Acta Chirurgica Austriaca

, Volume 26, Issue 2, pp 109–112 | Cite as

Focal nodular hyperplasia of the liver

A single institution experience
  • A. D. Dagradi
  • G. L. Mangiante
Originalarbeiten

Abstract

Background: Focal nodular hyperplasia (FNH), an expansive neoplasm of the liver, was regarded as a rare condition in the past but is nowadays more frequently identified. This can be attributed to the widespread use of uninvasive screening and diagnosing techniques, like imaging by ultrasonography. In our study, all patients with FNH were retrospectively analyzed with regard to diagnostic and therapeutic techniques, and the influence of surgical and conservative therapies was presented.

Methods: We diagnosed 41 FNH in 39 patients over a period of 20 years. All patient histories, laboratory, radiological, and anatomo-pathological data were evaluated.

Results: Clinical symptoms attributable to FNH were found in 16 out of 39 patients (41%). 11 of 30 women were under oral contraceptives (OC). The hormone status of all patients was within the normal range. An increase in gamma-glutamyl transpeptidase in 15 out of 32 patients (46.8%) was the only biochemical clue to FNH; alpha-fetoprotein and carcinoembryonic antigen values were normal. It is possible to obtain a reliable preoperative diagnosis by combining different imaging techniques, such as computerized axial tomography, Tc-99m-colloid scintigraphy and Tc-99m-diisopropyl iminodiacetic acid scintigraphy. Cytologic examinations by ultrasonic fine needle aspiration of the liver proved to be helpful. 32 FNH were excised in 31 patients, in 4 patients biopsy was performed. Postoperative mortality was 0. In 5 FNH in 4 patients malignant changes were cytologically excluded after radiological results had pointed to FNH; the radiologic and biochemical follow-up examinations of these patients every 6 months did not reveal any increase in FNH size.

Conclusions: Only patients with symptomatic forms of FNH or those risking a rupture or torsion should be surgically treated. In asymptomatic patients, short-term follow-ups are an adequate method of monitoring. In case the lesion grows, a total removal is indicated.

Key-words

Benign liver tumors focal nodular hyperplasia liver resection liver surgery 

Fokal noduläre Hyperplasie der Leber: Erfahrungen unseres Instituts

Zusammenfassung

Grundlagen: Die fokal noduläre Hyperplasie (FNH), eine expansive Leberneoplasie, die in der Vergangenheit als seltene Erscheinung galt, wird heute mit zunehmender Häufigkeit diagnostiziert. Dies ist hauptsächlich durch die Verbreitung nichtinvasiver Diagnosetechniken, wie Ultraschallsonographie, möglich. Alle Patienten mit FNH wurden erneut durchgesehen und nach Diagnose- und Therapietechniken, die in unserem Institut Verwendung fanden, analysiert.

Methodik: Im Zeitraum von 20 Jahren wurden 41 Fälle von FNH bei 39 Patienten beobachtet. Die Krankengeschichten, Labordaten, Röntgenuntersuchungsergebnisse und die anatomischpathologischen Befunde aller Patienten wurden erneut überprüft.

Ergebnisse: Bei 41% der Patienten waren klinische Symptome, die auf FNH zurückzuführen waren, präsent. 11 von 30 Frauen nahmen orale Antikonzeptiva. Die Hormonuntersuchungen der 14 untersuchten Patienten lagen im Normbereich. Als einziger Wert erwies sich im Falle der FNH der Anstieg der Gamma-Glutamyltranspeptidase von Bedeutung (bei 19 von 39 Patienten; =46,8% der Fälle), während das Alphaprotein (AFP) und die karzino-embryogenetischen Antigene (CEA) normal waren. Bei 37 Patienten (48,8%) basiert die sichere präoperative Diagnose auf der Kombination verschiedener Untersuchungsverfahren, wie der axialen Computertomographie, der Tc-99m-Kolloidszintigraphie und der Tc-99m-markierten Diisopropyl-Imino-di-Essigsäurederivate-Szintigraphie.

Die zytologischen Untersuchungen mittels ultraschallgesteuerter transkutaner Leberpunktion erwiesen sich als hilfreich, aber nicht entscheidend in der diagnostischen Definition.

32 FNH bei 31 Fällen wurden operativ komplett entfernt, in 4 Fällen erfolgte operativ eine Biopsie. Die postoperative Mortalität war 0. 5 FNH von 4 Patienten wurden röntgenologisch und der Ausschluß einer malignen Veränderung zytologisch in periodischen Abständen von 6 Monaten kontrolliert. Es wurde keine Größenzunahme beobachtet.

Schlußfolgerungen: Wir sind der Meinung, daß nur die symptomatischen Fälle und jene von FNH mit dem Risiko einer Ruptur oder Torsion einer chirurgischen Therapie unterzogen werden müssen. Nach dem Erstellen einer sicheren Diagnose ist für asymptomatische Fälle eine kurzfristige Kontrolle ausreichend. Bei Größenzunahme der Läsion ist eine komplette Entfernung indiziert.

Schlüsselwörter

Lebertumoren gutartige Hyperplasie fokal noduläre Leberteilresektion Leberchirurgie 
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References

  1. (1).
    Edmondson HA: Tumors of the liver and intrahepatic bile ducts. Atlas of Tumors Pathology 1958;sect VII, fasc 25, 13, AFIP, Washington D.C.Google Scholar
  2. (2).
    Wanless IR, Mawdsley C, Adams R: On the pathogenesis of Focal Nodular Hyperplasia of the Liver. Hepatology 1985;5,6:1194–1200.CrossRefGoogle Scholar
  3. (3).
    Kerlin P, Davis GL, McGill DB, Weiland LM, Adson MA, Sheedy PF: Hepatic Adenoma and Focal Nodular Hyperplasia: clinical, pathological and radiologic features. Gastroenterology 1983;73:386–394.Google Scholar
  4. (4).
    Klatskin G: Hepatic Tumors:possible relationship to use of oral contraceptives. Gastroenterology 1983;73:994–1002.Google Scholar
  5. (5).
    Knowles DM, Casarella WI, Johnson PM, Wolff M: The clinical, radiologic and pathologic characterization of benign hepatic neoplasms. Alleged association with oral contraceptives. Medicine (Baltimore) 1978;57:223–237.Google Scholar
  6. (6).
    Brady MS, Coit DG: Focal Nodular Hyperplasia of the liver. Surg Gyn Obs 1990;171:377–381.Google Scholar
  7. (7).
    Huguet C, Mouiel J: Tumeurs du foie chez l’adulte. Paris, Masson, 1983.Google Scholar
  8. (8).
    Ishak KG, Rabin L: Benign Tumors of the Liver. Med Clin North Am 1975;59:995–1013.PubMedGoogle Scholar
  9. (9).
    Pain JA, Gimson AES, Williams R, Howard ER: Focal nodular hyperplasia of the liver: results of treatment and options in management. Gut 1991;32:524–527.PubMedGoogle Scholar
  10. (10).
    Nime F, Pickeren JW, Vana J, Aronoff BL, Baker HW, Murphy GP: The histology of liver tumors in oral contraceptive users observed during a National Survey by the American College of Surgeons Commission of Cancer. 1979;44:1481–1489.Google Scholar
  11. (11).
    Karhunen PJ: Benign Hepatic Tumors and Tumor-like conditions in Men. J Clin Pathol 1986;39:183–188.PubMedGoogle Scholar
  12. (12).
    Kunstlinger F: Decouverte echographique fortuite des lesions focalisèes du foie. Gastroenterol Clin Biol 1983;7:951–954.PubMedGoogle Scholar
  13. (13).
    Rogers JV, Mack LA, Freeny PC, Johnson ML, Sones PJ: Hepatic focal nodular hyperplasia. Angiography, CT, Sonography, and Scintigraphy. AJR 1981;137:983–990.PubMedGoogle Scholar
  14. (14).
    Schild H, Kreitner KF, Thelen M, Groenninger J, Weber M, Boerner N, Stoerkel J, Eisser D: Fokal-noduläre hyperplasie der Leber bei 930 Patienten. Fortschr Röntgenstr 1987;147:612–618.Google Scholar
  15. (15).
    Welch TJ, Sheedy PF, Johnson CM, Stephens DH, Charboneau JW, Brown ML, May GR, Adson MA, McGill DB: Focal nodular hyperplasia and hepatic adenoma: comparison of Angiography, CT, US, and Scintigraphy. Radiology 1985;156:593–595.PubMedGoogle Scholar
  16. (16).
    Mathieu D, Bruneton JN, Drouillard J, Pointreau CC, Vasile N: Hepatic Adenomas and Focal Nodular hyperplasia: dynamic CT study. Radiology 1986;160:53–58.PubMedGoogle Scholar
  17. (17).
    Kier R, Rosenfield AT: Focal Nodular Hyperplasia of the Liver on delayed enhanced CT. AJR 1989;153:885–886.PubMedGoogle Scholar
  18. (18).
    Procacci C, Fugazzola C, Cinquino M, Mangiante G, Zonta L, Bergamo Andreis IA, Nicoli N, Pistolesi GF: Contribution of CT characterization of focal nodular hyperplasia of the liver. Gastrointest Radiol 1992;17:63–73.PubMedCrossRefGoogle Scholar
  19. (19).
    Casarella WJ, Knowles DM, Wolff M, Johnson PM: Focal nodular hyperplasia and liver cell adenoma: radiologic and pathologic differentiation. Am J Roentgenol 1978;131:393–402.Google Scholar
  20. (20).
    D’Ouza VJ, Sumner TE, Watson NE, Formanek AG: Focal nodular hyperplasia of the liver imaging by differing modalities. Pediatr Radiol 1983;13:77–81.CrossRefGoogle Scholar
  21. (21).
    Biersack HJ, Thelen M, Torres JF, Lackner K, Winkler CG: Focal nodular hyperplasia of the liver as established by 99mTc Sulfur Colloid and HIDA scintigraphy. Radiology 1980;137:187–190.PubMedGoogle Scholar
  22. (22).
    Marabini A, Giorgetti PG, Zamboni M, Cavaggioni M, Braggio P, Nicoli N, Mangiante G: Nuclear Medicine Identification of Hepatic Focal Nodular hyperplasia: experience of 10 cases. J Nucl Med All Sci 1989;4:154.Google Scholar
  23. (23).
    Kotzerke J, Schwarzrock R, Heintz P, Ringe B, Hundeshagen H: Gleichzeitiges Auftreten einer fokal nodulären Hyperplasie (FNH) and eines Haemangiomas der Leber-Schwierigkeiten bei Arztdiagnose. Fortschr Röntgenstr 1989;151:742–744.CrossRefGoogle Scholar
  24. (24).
    Horino N, Tanaka Y, Usui T, Yokoyama T: Focal nodular hyperplasia of the liver. The value of liver and biliary scintigraphy for differential diagnosis. Acta Pediatr Scand 1985;74:828–832.Google Scholar
  25. (25).
    Tanasescu D, Brachman M, Rigby J, Yadegar J, Ramanna L, Waxman A: Scintigraphic Triad in Focal Nodular Hyperplasia. Am J Gastroenterol 1984;79:61–64.PubMedGoogle Scholar
  26. (26).
    Lubbers PR, Ros PR, Goodman ZD, Ishak KG: Accumulation of Technetium 99m Sulfur Colloid by Hepatocellular Adenoma: Scintigraphic-pathological correlation. AJR 1987;148:1105–1108.PubMedGoogle Scholar
  27. (27).
    Vincent LM: Accumulation of Technetium-99m Sulfur Colloid in Hepatocellular Adenomas. AJR 1987;149:862–863 (letter).PubMedGoogle Scholar
  28. (28).
    Fornari F, Civardi G, Cavanna L, Rossi S, Buscarini E, Di Stasi M, Sbolli G, Buscarini L: Ultrasonically Guided Fine-Needle Aspiration Biopsy: A Highly Diagnostic Procedure for Hepatic Tumors. Am J Gastroenterol 1990;85:1009–1013.PubMedGoogle Scholar
  29. (29).
    Ruschenburg I, Droese M: Fine Needle Aspiration Cytology of Focal Nodular Hyperplasia of the Liver. Acta Cytologica 1989;33:857–860.PubMedGoogle Scholar
  30. (30).
    Saul SH, Titelbaum DS, Gansler TS, Varello M, Burke DR, Atkinson BF, Rosato EF: The Fibrolamellar Variant of Hepatocellular Carcinoma. Its Association with Focal Nodular Hyperplasia. Cancer 1987;60:3049–3055.PubMedCrossRefGoogle Scholar
  31. (31).
    Mathieu D, Zafrani ES, Anglade MC, Dhumeaux D: Association of Focal Nodular Hyperplasia and Hepatic Hemangioma. Gastroenterology 1989;97:154–157.PubMedGoogle Scholar
  32. (32).
    Ndimbie OK, Goodmann ZD, Chase RL, Ma CK, Lee MW: Hemangiomas with localized Nodular Proliferation of the Liver. A suggestion on the pathogenesis of Focal Nodular Hyperplasia. Am J Surg Pathol 1990;14:142–150.PubMedCrossRefGoogle Scholar
  33. (33).
    Albrecht S, Wanless IR, Bilbao J, Frei JV: Multiple focal nodular hyperplasia of the liver associated with vascular malformations and neoplasia of the brain and meninges: a new syndrome. Lab Invest 1989;60:2A.Google Scholar
  34. (34).
    Marks WH, Thompson N, Appleman H: Failure of Hepatic Adenomas (HCA) to Regress After Discontinuance of Oral Contraceptives. Ann Surg 1988;208:190–195.PubMedCrossRefGoogle Scholar
  35. (35).
    Grangé JD, Guéchot J, Legendre C, Giboudeau J, Darnis F, Poupon R: Liver Adenoma and Focal Nodular Hyperplasia in a Man with High Endogenous Sex Steroids. Gastroenterology 1987;93:1409–1413.PubMedGoogle Scholar
  36. (36).
    Porter LE, Elm MS, Van Thiel DH, Eagon PK: Hepatic estrogen receptors in human liver disease. Gastroenterology 1987;92:735–745.PubMedGoogle Scholar
  37. (37).
    Hunt RF, Sali A, Kune GA: Oestrogen receptors in Focal nodular Hyperplasia of the Liver. Med J Aust 1985;143:519–520.PubMedGoogle Scholar
  38. (38).
    Scott LD, Katz AR, Duke JH, Cowan DF, Makland LF: Oral contraceptives, pregnancy, and Focal Nodular Hyperplasia of the liver. JAMA 1984;251:1461–1468.PubMedCrossRefGoogle Scholar
  39. (39).
    Dagradi A, Mangiante G, Nicoli N: Trattamento chirurgico dei tumori benigni del fegato in Mazzeo F, Rendano F (eds): Diagnosi e terapia dei tumori del fegato e delle vie biliari. Roma, CIC Ed Int, 1986, pp 68–79.Google Scholar
  40. (40).
    Soucy P, Rasuli P, Carpenter B: Definitive Treatment of Focal Nodular Hyperplasia of the Liver by Ethanol Embolization. J Pediatr Surg 1989;10:1095–1097.CrossRefGoogle Scholar
  41. (41).
    Mangiante G, Pistacchi E, Marchiori L, Nicoli N, Dagradi A: Adenoma epatico ed iperplasia focale nodulare. Chir Ital 1989;41:117–128.PubMedGoogle Scholar
  42. (42).
    Trastek VG, Van Heerden JA, Sheedy PF, Adson MA: Cavernous Haemangiomas of the Liver: resect or observe? Am J Surg 1983;145:49–53.PubMedCrossRefGoogle Scholar

Copyright information

© Blackwell Scientific Publications Ltd 1994

Authors and Affiliations

  • A. D. Dagradi
    • 1
  • G. L. Mangiante
    • 1
  1. 1.From Surgical ClinicUniversity of VeronaItaly

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