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RESUMEN La captación de 18 FDG en PET-TC por un adenoma hepatocelular (HCA) es poco frecuente. Esta situación genera dudas en cuanto a los diagnósticos diferenciales y tratamiento. El objetivo de este artículo fue realizar una mini revisión de los últimos 37 años de HCA con avidez por el 18FDG y presentar un nuevo caso. Sobre la base de un estudio realizado por otros autores entre 1984 y 2014, se amplía la búsqueda utilizando las mismas palabras clave hasta el año 2021. Se analizan los datos relevantes. Entre 1984 y 2021 detectamos 38 casos en 37 años. Fue más frecuente en mujeres en edad reproductiva. Los subtipos H-HCA e I-HCA fueron los más frecuentes. El tratamiento quirúrgico fue el más empleado. La diferenciación celular y los trastornos metabólicos de la glucosa y de los lípidos favorecerían la captación de 18FDG. La resección hepática ofrecería mayores garantías permitiendo el estudio completo de la lesión.
ABSTRACT Hepatocellular adenoma (HCA) uptake of 18FDG uptake on PET-CT is rare. This situation poses doubts about the differential diagnoses and treatment. The aim of this article is to perform a mini review of 18FDG avid HCA over the past 37 years and to describe a new case presentation. Based on a study conducted by other authors between 1984 and 2014, we extended the search until 2021 using the same keywords. The relevant data were analyzed. Between 1984 and 2021 we detected 38 cases in 37 years. HCAs were more common in women of childbearing age. The most common types were H-HCA an I-HCA. Surgical resection was the treatment most used. Cell differentiation and glucose and lipid metabolic diseases would favor 18FDG uptake. Liver resection provides better outcomes, allowing for a complete examination of the lesion.
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ABSTRACT Introduction: hepatocellular adenoma - AHC - is a rare benign neoplasm of the liver more prevalent in women at reproductive age and its main complication is hemorrhage. In the literature, case series addressing this complication are limited. Methods: between 2010 and 2022, 12 cases of bleeding AHC were attended in a high-complexity university hospital in southern Brazil, whose medical records were retrospectively evaluated. Results: all patients were female, with a mean age of 32 years and a BMI of 33kg/m2. The use of oral contraceptives was identified in half of the sample and also half of the patients had a single lesion. The mean diameter of the largest lesion was 9.60cm and the largest lesion was responsible for bleeding in all cases. The presence of hemoperitoneum was documented in 33% of the patients and their age was significantly higher than the patients who did not have hemoperitoneum - 38 vs 30 years, respectively. Surgical resection of the bleeding lesion was performed in 50% of the patients and the median number of days between bleeding and resection was 27 days. In only one case, embolization was used. The relation between ingrowth of the lesions and the time, in months, was not obtained in this study. Conclusion: it is concluded that the bleeding AHC of the present series shows epidemiological agreement with the literature and may suggest that older patients trend to have hemoperitoneum more frequently, a fact that should be investigated in further studies.
RESUMO Introdução: o Adenoma Hepatocelular - AHC - é uma neoplasia benigna rara do fígado associada a mulheres com idade reprodutiva. Sua principal complicação é o sangramento,mas as séries de casos direcionadas a esta intercorrência são limitadas. Métodos: entre os anos de 2010 e 2022 foram registrados 12 casos de AHC sangrante em um hospital universitário de alta complexidade no sul do Brasil, cujos prontuários foram retrospectivamente avaliados. Resultados: todos os pacientes eram do sexo feminino, com média de idade de 32 anos e de IMC de 33kg/m2. O uso de anticoncepcionais foi identificado em metade da amostra e também metade das pacientes apresentava lesão única. O diâmetro médio da maior lesão foi de 9,60cm e a maior lesão foi responsável pelo sangramento em todos os casos. Hemoperitôneo foi documentado em 33% das pacientes e a idade destas foi significativamente maior do que as pacientes que não apresentaram hemoperitôneo - 38 vs 30 anos, respectivamente. A ressecção cirúrgica da lesão sangrante foi realizada em 50% das pacientes e a mediana de dias entre o sangramento e a ressecção foi de 27 dias. Em apenas um caso foi lançado mão da embolização da lesão. Não se demonstrou correlação entre a taxa de redução das lesões e o passar dos meses, nos casos em que foi adotado tratamento conservador. Conclusão: conclui-se que aos AHC sangrantes da presente série apresentam concordância epidemiológica com a literatura e pode sugerir que as pacientes com maior idade tendem a apresentar hemoperitôneo mais frequentemente, fato que deve ser investigado em maiores estudos.
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RESUMEN: El hematoma subcapsular del hígado (HSH), es una entidad poco frecuente. La mayoría de casos reportados se asocian al embarazo, en el contexto de síndrome de recuento bajo de plaquetas, elevación de enzimas hepáticas, y hemólisis. Otras patologías relacionadas son ruptura de carcinoma hepatocelular, adenoma, hiperplasia nodular focal; y amilosis. El objetivo de este artículo fue reportar morfología y resultados del tratamiento quirúrgico observados en una serie de pacientes con HSH, en términos de morbilidad postoperatoria (MPO). Serie de casos retrospectiva de pacientes con HSH intervenidos de forma consecutiva en Clínica RedSalud Mayor Temuco, entre 2004 y 2019. La variable resultado fue MPO. Otras variables de interés fueron edad, sexo, etiología, diámetro, necesidad de transfusión y tiempo de hospitalización. Se utilizó estadística descriptiva. Se trató a 7 pacientes (71,4 % mujeres), con una mediana de edad de 46 años. La mediana del diámetro del HSH, tiempo quirúrgico y estancia hospitalaria fueron 11 cm, 105 min y 5 días, respectivamente. No hubo necesidad de reintervenciones. Con una mediana de seguimiento de 31 meses, no se verificó MPO ni mortalidad. El HSH es una condición poco frecuente, y la evidencia disponible escasa. Puede asociarse a condiciones benignas y malignas. Requiere un alto índice de sospecha para un diagnóstico oportuno.Su pronóstico depende de la etiología.
SUMMARY: Subcapsular hematoma of the liver (SHL) is a rare entity. The majority of cases are associated with pregnancy, in the context of low platelet count syndrome, elevated liver enzymes, and hemolysis. Other related pathologies are ruptured hepatocellular carcinoma, adenoma, focal nodular hyperplasia, and amyloidosis. The aim of this article was to report morphology and results of the surgical treatment observed in a series of patients with SHL, in terms of postoperative morbidity (POM). Retrospective case series of patients with SHL who were intervened consecutively at Clínica RedSalud Mayor Temuco, between 2004 and 2019. The results variable was MPO. Other variables of interest were age, sex, etiology, diameter, need for transfusion, and length of hospitalization. Descriptive statistics were used; 7 patients (71.4% women) were treated with a median age of 46 years. The median diameter of SHL, surgical time, and hospital stay were 11 months, no POM and mortality were verified. SHL is a rare condition, and the available evidence is scarce. It can be associated with benign and malignant diseases. It requires a high index of suspicion for a timely diagnosis. Its prognosis depends on the etiology.
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Humanos , Masculino , Feminino , Adulto , Pessoa de Meia-Idade , Hematoma/cirurgia , Hematoma/patologia , Hepatopatias/cirurgia , Hepatopatias/patologia , Estudos Retrospectivos , Seguimentos , Resultado do Tratamento , HepatectomiaRESUMO
BACKGROUND: Hepatocellular adenoma (HA) is a rare benign liver tumor with increasing incidence affecting young women. In the last years, much has changed in diagnosis, classification, and treatment, due to the identification of different molecular subtypes. With the evolving knowledge, especially on molecular characteristics of the disease, we are far from a consensus of how to deal with such a multifaceted benign disease METHODS: In the last 20 years, we have treated 134 patients with HA with a mean age of 28 years, being 126 women. Fifty patients had a history of abdominal pain and 13 patients had an acute episode of pain due to rupture and bleeding. Until 2009, adenomas larger than 4 cm in diameter were resected, regardless of gender. From 2010 to 2016, only adenomas larger than 5 cm were referred for surgical treatment. Since 2016, resection was indicated in all female patients with non-steatotic adenomas larger than 5 cm and all adenomas in men. RESULTS AND DISCUSSION: One hundred twenty-four patients were submitted to resection, being in 21 major resections. Since 2010, 74% of resections were done laparoscopically. Patients with ruptured adenomas were treated with transarterial embolization. Morbidity rate was 8.1% with no mortality. Authors discuss point-by-point all the aspects and presentations of the disease and the best approach. We proposed a therapeutic guideline based on the best available evidence and in our experience. CONCLUSIONS: Due to the complexity of the disease, the treatment of HA is one the best examples of an individualized approach.
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Adenoma de Células Hepáticas , Carcinoma Hepatocelular , Neoplasias Hepáticas , Cirurgiões , Adenoma de Células Hepáticas/cirurgia , Adulto , Feminino , Humanos , Neoplasias Hepáticas/cirurgia , Masculino , Biologia MolecularRESUMO
Systemic symptoms such as fever and fatigue are non-specific manifestations spanning from inflammation to neoplasia. Here we report the case of a 34 year-old man who presented with systemic symptoms for four months. CT-scan and MRI revealed a 3.4 cm arterialized hepatic lesion and a 7 cm paraduodenal mass. Surgical resection of both lesions and histological examination revealed an inflammatory hepatocellular adenoma and a unicentric plasma cell type of Castleman disease. Moreover, a diffuse AA amyloid deposition in the liver was observed. Resection of both lesions was associated with an improvement of the symptoms. To our knowledge, this is the first report of a synchronous presentation of a unicentric plasma cell type of Castleman disease, inflammatory hepatocellular adenoma and AA amyloidosis.
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Adenoma de Células Hepáticas/complicações , Hiperplasia do Linfonodo Gigante/complicações , Neoplasias Hepáticas/complicações , Adenoma de Células Hepáticas/diagnóstico , Adenoma de Células Hepáticas/cirurgia , Adulto , Biópsia com Agulha de Grande Calibre , Hiperplasia do Linfonodo Gigante/diagnóstico , Diagnóstico Diferencial , Hepatectomia , Humanos , Neoplasias Hepáticas/diagnóstico , Neoplasias Hepáticas/cirurgia , Imageamento por Ressonância Magnética , Masculino , Tomografia Computadorizada por Raios XRESUMO
BACKGROUND: Hepatocellular adenoma (HCA) is a rare benign liver tumor usually affecting young women with a history of prolonged use of hormonal contraception. Although the majority is asymptomatic, a low proportion may have significant complications such as bleeding or malignancy. Despite responding to the hormonal stimulus, the desire for pregnancy in patients with small HCA is not contraindicated. However, through this work we demonstrate that intensive hormonal therapies such as those used in the treatment of infertility can trigger serious complications. CASE SUMMARY: A 33-year-old female with a 10-year history of oral contraceptive use was diagnosed with a hepatic tumor as an incidental finding in an abdominal ultrasound. The patient showed no symptoms and physical examination was unremarkable. Laboratory functional tests were within normal limits and tests for serum tumor markers were negative. An abdominal magnetic resonance imaging (MRI) was performed, showing a 30 mm × 29 mm focal lesion in segment VI of the liver compatible with HCA or Focal Nodular Hyperplasia with atypical behavior. After a total of six years of follow-up, the patient underwent ovulation induction treatment for infertility. On a following MRI, a suspected malignancy was warned and hence, surgery was decided. The surgical specimen revealed malignant transformation of HCA towards trabecular hepatocarcinoma with dedifferentiated areas. There was non-evidence of tumor recurrence after three years of clinical and imaging follow-up. CONCLUSION: HCAs can be malignant regardless its size and low-risk appearance on MRI when an ovultation induction therapy is indicated.
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Hepatocellular adenomas (HCAs) are rare benign monoclonal hepatic tumors that commonly occur in females (3-4 per 100,000 women) due to the use of oral contraceptives, its primary risk factor. Recently, HCAs have been classified into 4 distinct subtypes according to genotypic and phenotypic characteristics and clinical features: inflammatory HCA (40-50%), which are hypervascular with marked peliosis and a tendency to bleed; hepatocyte nuclear factor 1α (HNF1A)-mutated HCA (H-HCA, 30-40%) that are diffusely steatotic and rarely undergo malignant transformation; ß-catenin activated HCA (10-15%), which frequently undergo malignant transformation and may seem hepatocellular carcinoma on imaging; and unclassified HCA (10-25%). In this study, we report the case of a 23-year-old female oral contraceptive user with H-HCA. Usually, H-HCA is considered to be nonsevere in most cases and often requires outpatient follow-up. However, in this case, the injury had substantially increased in volume and evolved with a major bleeding frame, which was an unusual finding for this subtype of adenoma. The therapeutic used for this patient was a laparoscopic left hepatic segmentectomy. Thus, the choice of treatment to be performed in a patient with H-HCA can depend on the tumor size (>5 cm), the outcome of previous bleeding, and the risk of bleeding recurrence.
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ABSTRACT Space-occupying lessions of the liver may be cystic or solid. Ultrasonography is an extremely useful method for initial screening, and suffices for diagnosis of simple hepatic cysts. Complex cysts and solid masses require computed tomography or magnetic resonance imaging for confirmation. Wide surgical excision is indicated in cystadenoma or cystadenocarcinoma. Clinical and epidemiological data are important, as nodules in noncirrhotic livers are more likely to be benign. Hemangiomas, the most common benign tumors, require no follow-up after diagnostic confirmation if they are small and asymptomatic. Patients with giant, symptomatic hemangiomas or compression of adjacent structures should be referred to hepatobiliary centers for potential surgery. The genetic heterogeneity of hepatocellular adenoms and their epidemiology and prognosis prompted classification of these tumors into four subtypes based on histology and immunohistochemistry. The major complications of hepatocellular adenoms are rupture with bleeding and malignant transformation. Rupture occurs in approximately 30% of cases. The main risk factors are tumors size >5 cm and inflammatory subtype. Hepatocellular adenoms may enlarge during pregnancy due to marked hormonal stimulation. As oral contraceptive pills and anabolic steroids have associated with hepatocellular adenoms growth, particularly of the hepatocyte nuclear factor-1 alfa subtype, these drugs should be discontinued. Focal nodular hyperplasia is the second most common benign tumor of hte liver. It is most frequent in women aged 20 to 60, and 70% to 90% of cases are asymptomatic. In the adsence of a central scar and/or other hallmarks of Focal nodular hyperplasia, with uncertainty between this diagnosis and hepatocellular adenoma, liver-specific contrast agentes are indicated.
RESUMO As lesões que ocupam espaço no fígado podem ser císticas ou sólidas. A ultrassonografia é extremamente útil como rastreamento inicial, bastando como método diagnósticos em casos de cistos simples. Em cistos complexos e em nódulos sólidos é necessária a complementação diagnóstica com tomografia computadorizada ou ressonância magnética. Em casos de cistadenoma ou cistadenocarcinoma, a ampla retirada cirúrgica está indicada. Dados clínico-epidemiológicos são importantes, já que nódulos em fígados não-cirróticos têm maiores probabilidades de serem benignos. Para os hemangiomas, tumores benignos mais frequentes, após a confirmação diagnóstica não existe necessidade de acompanhamento sistemático quando os nódulos são pequenos e assintomáticos. Hemangiomas gigantes sintomáticos ou comprimindo órgãos vizinhos devem ser encaminhados a centros de referência para avaliação de intervenção cirúrgica. A heterogeneidade genética nos adenomas hepatocelulares bem como características epidemiológicas e prognósticas motivou sua classificação em quatro subtipos, com base em achados histológicos e de imunohistoquímica. As principais complicações que ocorrem com o adenomas hepatocelulares são ruptura com hemorragia e transformação carcinomatosa. A primeira ocorre em cerca de 30% dos casos e o principal fator de risco para esta complicação são tumores maiores do que 5 cm, do subtipo hiperplasia nodular focal 1A, esses medicamentos devem ser suspensos. A hiperplasia nodular focal é o segundo tumor benigno mais frequente, mais comum nas mulheres entre 20 e 60 anos, sendo assintomáticos em 70% a 90% dos casos. Na ausência de lesão cicatricial central e/ou outros sinais sugestivos de hiperplasi nodular focal, havendo dúvida diagnóstica com adenoma hepatocelular, o uso de contraste hepatespecíficos está indicado.
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Feminino , Humanos , Gravidez , Neoplasias Hepáticas/diagnóstico , Neoplasias Hepáticas/terapia , Adenoma de Células Hepáticas/diagnóstico , Adenoma de Células Hepáticas/terapia , Brasil , Hiperplasia Nodular Focal do Fígado/diagnóstico , Hiperplasia Nodular Focal do Fígado/terapia , Hemangioma/diagnóstico , Hemangioma/terapia , Sociedades MédicasRESUMO
Objetivos: El enfoque terapéutico de los adenomas ha cambiado en los últimos años, en especial por las posibilidades de caracterización por medio de las imágenes diagnósticas, principalmente la resonancia magnética (RM), que en la mayoría de los casos ha permitido una aproximación al tipo de adenoma. Métodos: Se realizó una revisión de la literatura reciente con el fin de describir las características imagenológicas de los tipos de adenomas, en las diferentes técnicas de imágenes, con principal énfasis en los hallazgos imagenológicos en resonancia magnética, lo cual permite diferenciar entre los subtipos histológicos de adenomas y ayuda a orientar el manejo médico o quirúrgico. Resultados: En la literatura se describe la adenomatosis hepática como una entidad frecuente en mujeres, de características imagenológicas atípicas. Además, se mencionan las características de los hallazgos por RM y su correlación con los tipos de adenomas, variedad esteatósica, peliótica y mixta. Conclusión: De acuerdo con la clasificación basada en las características genéticas, histopatológicas e imagenológicas de los diferentes subtipos de AHC y según la sintomatología, se podría determinar la historia natural y definir el pronóstico y las opciones terapéuticas o de seguimiento imagenológico.
Objective: The therapeutic approach of adenomas has changed in recent years, especially because of the possibilities for characterization by means of diagnostic imaging methods, mainly magnetic resonance imaging, which allowed us, in most cases, to approach the type of adenoma. Methods: A review of the recent literature was conducted in order to describe the characteristic imaging features of the types of adenomas in the different imaging techniques, with an emphasis on MRI, which allows differentiation between histologic subtypes of adenomas. In addition, it also helps guide medical or surgical management. Results: In the literature, we described hepatic adenomatosis as an entity which is frequently found in women, with atypical imaging features. In addition, we mentioned the characteristics of MRI findings and their correlation with the types of adenomas, inflammatory, steatosic, ß-catenin mutated and mixed. Conclusion: According to the classification based on genetic, histopathological and imaging features of the different subtypes of AHC, we could determine the natural history, define prognosis and the therapeutic options or imaging follow-up.