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Key Features

  • Cavernous hemangioma

    • Most common benign hepatic neoplasm

    • Often found incidentally on ultrasonography or CT

    • Hormonal therapy may cause these lesions to enlarge

  • Hepatocellular adenoma

    • Most common in women in the third and fourth decades of life

    • Usually caused by oral contraceptives

  • Focal nodular hyperplasia

    • Occurs at all ages and in both sexes

    • Probably not caused by oral contraceptives

Clinical Findings

  • Hepatocellular adenoma may present with acute abdominal pain if tumor undergoes necrosis or hemorrhage

  • Focal nodular hyperplasia is often asymptomatic

  • The only physical finding in both lesions is a palpable abdominal mass in a few cases

Diagnosis

  • Cavernous hemangioma

    • Must be differentiated from other liver lesions, usually by MRI

    • Rarely, fine-needle biopsy is needed

  • Hepatocellular adenoma

    • A hypovascular tumor

    • A cold defect on liver CT scan

  • Focal nodular hyperplasia

    • Appears as a hypervascular mass, occasionally with a central hypodense "stellate" scar on contrast-enhanced ultrasonography, CT, or MRI

    • Consists of hyperplastic units of hepatocytes that stain positively for glutamine synthetase

  • Contrast-enhanced ultrasonography, arterial-phase helical CT and especially multiphase dynamic MRI can distinguish a hepatocellular adenoma from focal nodular hyperplasia in 80–90% of cases

  • In both focal nodular hyperplasia and hepatocellular adenoma, the liver function is usually normal

Treatment

  • Surgical resection of cavernous hemangiomas is infrequently necessary but may be required

    • For abdominal pain or rapid enlargement

    • To exclude malignancy

    • To treat Kasabach-Merritt syndrome (consumptive coagulopathy complicating a hemangioma)

  • Focal nodular hyperplasia

    • Resection done only in the symptomatic patient

    • Annual ultrasonography for 2–3 years is advised in affected women who continue taking oral contraceptives to make sure the lesion is not enlarging

    • Prognosis is excellent

  • Hepatocellular adenoma

    • If asymptomatic, regression of hepatocellular adenomas may follow cessation of oral contraceptives

    • However, adenomas may undergo bleeding, necrosis, and rupture

    • Transarterial embolization is the initial treatment for adenomas complicated by hemorrhage

    • Resection is advised in all patients in whom the tumor causes symptoms or measures > 5 cm in diameter, even in the absence of symptoms

    • Resection is also recommended even for an adenoma measuring < 5 cm in diameter if a beta-catenin gene mutation is present in a biopsy sample

    • In selected cases, laparoscopic resection or percutaneous radiofrequency ablation may be feasible

    • Rarely, liver transplantation is necessary

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