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Nodular Hyperplasia of 
the Liver 
By 
Dr. Ihab Samy 
Surgical Oncology Dept. 
National Cancer Institute-Cairo Unversity 
2014
 Benign liver cell tumors (BLCT) are common and their clinical management 
remains controversial. 
 The differential diagnosis of liver tumors requires understanding of the 
clinical and imaging features of the liver lesions.
FOCAL NODULAR HYPERPLASIA 
 This is the second most prevalent benign liver lesion (after hemangioma), with a woman 
preponderance, in 80–90% of the cases, in third or fourth decade and a global incidence 
of about 0.6–3% of the general population. 
 There is no identifiable etiologic factor. It is, however, associated with a condition 
having local or systemic vascular anomalies. 
 The most accepted theory posits a congenital vascular malformation as the trigger 
event; however, it is thought to arise as a result of larger-than-expected pre-existing 
spider-like arterial structures with heterogeneous blood flow in the liver cellular 
architecture, resulting a hyperplastic hepatocytic response
 FNH is a benign idiopathic fleshy tumour of the liver, ten times more common 
than adenoma and is found at any age but mainly in adults. 
 Most of the patients are not symptomatic and the diagnosis is made 
incidentally during surgery, autopsy or imaging procedures for others 
symptoms. 
 The liver function tests are normal. 
 Complications, as the rupture, bleeding or malignant transformation, 
although rare, are described in literature
 Tumour is more or less rounded, lobulated and well demarcated but not 
encapsulated with a diameter ranging from one to several centimetres. 
 When the tumour is large, it may be painful. 
 Other symptoms described are loss of appetite, nausea, vomiting and weight 
loss.
 Usually occurs in non-cirrhotic livers. 
 A central fibrous scar with prominent arterial branches is typically observed 
at the histological examination. 
 Some cases reported of FNH complications mention dilatation of intrahepatic 
bile duct, compression of portal vein, compression of stomach, compression 
of inferior vena cava, intra-tumor bleeding and intra-peritoneal rupture.
Diagnosis: Imaging 
 The diagnosis of FNH can be made using imaging techniques in 90% of cases in 
experienced centers. 
 The characteristic radiologic findings of FNH have been well documented, but 
the exact distinction of FNH from other hypervascular hepatic tumors is not 
easy, especially in cases of small lesions.
 Contrast-enhanced ultrasonography (CEUS) is the first modality of 
choice for FNH:FNH typically shows arterial increase enhancement, 
very marked in the first few seconds. 
 Centrifugal (70%) or eccentric (30%) enhancement through one 
afferent correspondingly situated arteries is a diagnostic pointer. 
 Recently in 2013, Wang et al. from the University of Guangzhou 
(Republic of China) confirmed that the contrast-enhanced computed 
tomography (CECT) have similar diagnostic performance for FNH and 
CEUS should be the first imaging technique for the diagnosis of FNH.
 Gadoxetic acid (Gd-EOB-DTPA, Primovist®, Bayer Schering Pharma AG, Berlin, Germany) 
is a hepatocyte-specific magnetic resonance (MR) contrast agent that is increasingly 
used for liver MR imaging. 
 Gadoxetic acid is actively taken up by hepatocytes and excreted along the bile duct and 
kidney. 
 It is known to be specific for the diagnosis of FNH, showing hyperintense or isointense 
regions compared to the liver during the delayed hepatobiliary phase
 On dynamic contrast-enhanced MR images, FNH usually shows homogeneous 
enhancement during the arterial phase, compartmentalized by radiate fibrous 
septae, arising from the nonenhancing central scar. 
 The central scar of FNH usually shows a high SI on T2WI and delayed 
enhancement because it is mainly a vascular and inflammatory scar.
CT with contrast
Management and Treatment of FNH 
 If the patient is female with typical FNH on imaging, normal liver tests and no 
medical history of cancer, the diagnosis of FNH is considered and the biopsy is 
not necessary. 
 If the patient is a male, biopsy is proposed. In the case of atypical FNH on 
imaging biopsy is necessary. 
 FNH is often asymptomatic and the surgery is not indicated even if the lesion 
is large.
 However, the patients with a large lesions can to develop abdominal pain or 
compression of adjacent structures and liver resection may be indicated. 
 Cherqui D,2008 published a short report on clinical management of benign 
liver cell tumors and it is proposed for FNH monitoring by an MRI six and 
twelve months, then MRI or CEUS each year for three years after then stop 
monitoring.
ACG Clinical Guideline 2014 for FNH 
 An MRI or CT scan should be obtained to confirm a diagnosis of FNH. A liver 
biopsy is not routinely indicated to confirm the diagnosis (strong 
recommendation, low quality of evidence). 
 Pregnancy and the use of oral contraceptives or anabolic steroids are not 
contraindicated in patients with FNH (conditional recommendation, low 
quality of evidence). 
 Asymptomatic FNH does not require intervention (strong recommendation, 
moderate quality of evidence). 
 Annual US for 2 – 3 years is prudent in women diagnosed with FNH who wish to 
continue OCP use. Individuals with a firm diagnosis of FNH who are not using 
OCP do not require follow-up imaging (conditional recommendation, low 
quality of evidence).
Thank you

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Nodular hyperplasia of the liver

  • 1. Nodular Hyperplasia of the Liver By Dr. Ihab Samy Surgical Oncology Dept. National Cancer Institute-Cairo Unversity 2014
  • 2.  Benign liver cell tumors (BLCT) are common and their clinical management remains controversial.  The differential diagnosis of liver tumors requires understanding of the clinical and imaging features of the liver lesions.
  • 3. FOCAL NODULAR HYPERPLASIA  This is the second most prevalent benign liver lesion (after hemangioma), with a woman preponderance, in 80–90% of the cases, in third or fourth decade and a global incidence of about 0.6–3% of the general population.  There is no identifiable etiologic factor. It is, however, associated with a condition having local or systemic vascular anomalies.  The most accepted theory posits a congenital vascular malformation as the trigger event; however, it is thought to arise as a result of larger-than-expected pre-existing spider-like arterial structures with heterogeneous blood flow in the liver cellular architecture, resulting a hyperplastic hepatocytic response
  • 4.  FNH is a benign idiopathic fleshy tumour of the liver, ten times more common than adenoma and is found at any age but mainly in adults.  Most of the patients are not symptomatic and the diagnosis is made incidentally during surgery, autopsy or imaging procedures for others symptoms.  The liver function tests are normal.  Complications, as the rupture, bleeding or malignant transformation, although rare, are described in literature
  • 5.  Tumour is more or less rounded, lobulated and well demarcated but not encapsulated with a diameter ranging from one to several centimetres.  When the tumour is large, it may be painful.  Other symptoms described are loss of appetite, nausea, vomiting and weight loss.
  • 6.  Usually occurs in non-cirrhotic livers.  A central fibrous scar with prominent arterial branches is typically observed at the histological examination.  Some cases reported of FNH complications mention dilatation of intrahepatic bile duct, compression of portal vein, compression of stomach, compression of inferior vena cava, intra-tumor bleeding and intra-peritoneal rupture.
  • 7.
  • 8.
  • 9. Diagnosis: Imaging  The diagnosis of FNH can be made using imaging techniques in 90% of cases in experienced centers.  The characteristic radiologic findings of FNH have been well documented, but the exact distinction of FNH from other hypervascular hepatic tumors is not easy, especially in cases of small lesions.
  • 10.  Contrast-enhanced ultrasonography (CEUS) is the first modality of choice for FNH:FNH typically shows arterial increase enhancement, very marked in the first few seconds.  Centrifugal (70%) or eccentric (30%) enhancement through one afferent correspondingly situated arteries is a diagnostic pointer.  Recently in 2013, Wang et al. from the University of Guangzhou (Republic of China) confirmed that the contrast-enhanced computed tomography (CECT) have similar diagnostic performance for FNH and CEUS should be the first imaging technique for the diagnosis of FNH.
  • 11.  Gadoxetic acid (Gd-EOB-DTPA, Primovist®, Bayer Schering Pharma AG, Berlin, Germany) is a hepatocyte-specific magnetic resonance (MR) contrast agent that is increasingly used for liver MR imaging.  Gadoxetic acid is actively taken up by hepatocytes and excreted along the bile duct and kidney.  It is known to be specific for the diagnosis of FNH, showing hyperintense or isointense regions compared to the liver during the delayed hepatobiliary phase
  • 12.  On dynamic contrast-enhanced MR images, FNH usually shows homogeneous enhancement during the arterial phase, compartmentalized by radiate fibrous septae, arising from the nonenhancing central scar.  The central scar of FNH usually shows a high SI on T2WI and delayed enhancement because it is mainly a vascular and inflammatory scar.
  • 13.
  • 15. Management and Treatment of FNH  If the patient is female with typical FNH on imaging, normal liver tests and no medical history of cancer, the diagnosis of FNH is considered and the biopsy is not necessary.  If the patient is a male, biopsy is proposed. In the case of atypical FNH on imaging biopsy is necessary.  FNH is often asymptomatic and the surgery is not indicated even if the lesion is large.
  • 16.  However, the patients with a large lesions can to develop abdominal pain or compression of adjacent structures and liver resection may be indicated.  Cherqui D,2008 published a short report on clinical management of benign liver cell tumors and it is proposed for FNH monitoring by an MRI six and twelve months, then MRI or CEUS each year for three years after then stop monitoring.
  • 17. ACG Clinical Guideline 2014 for FNH  An MRI or CT scan should be obtained to confirm a diagnosis of FNH. A liver biopsy is not routinely indicated to confirm the diagnosis (strong recommendation, low quality of evidence).  Pregnancy and the use of oral contraceptives or anabolic steroids are not contraindicated in patients with FNH (conditional recommendation, low quality of evidence).  Asymptomatic FNH does not require intervention (strong recommendation, moderate quality of evidence).  Annual US for 2 – 3 years is prudent in women diagnosed with FNH who wish to continue OCP use. Individuals with a firm diagnosis of FNH who are not using OCP do not require follow-up imaging (conditional recommendation, low quality of evidence).