Benign liver tumors present diagnostic challenges due to overlap between lesions on imaging and clinical features. Hemangiomas are typically the only clearly diagnosed tumors without biopsy. Biopsy or laparoscopy are reasonable invasive approaches for diagnostic uncertainty. The predominant treatment is observation, except for adenomas which often require surgery due to malignant potential. Diagnostic uncertainty is an acceptable indication for surgical intervention.

1. BENIGN LIVER
TUMORS
Department of Surgical Gastroenterology
King George’s Medical University
Lucknow

2. Background
• Unexpectedly or incidentally diagnosed
– Malignant to benign- 1: 2
• Different treatment and prognosis
• Diagnostic uncertainty- An acceptable indication for operative
intervention in 40 %
» Kammula US et al Int J Gatrointest Cancer 2001

3. Concerns
• Diagnostic confusion and management
• Imaging of choice
• Role of
– Biopsy
– Laparoscopy
• Observe or Treat

4. Liver mass
Incidental / Asymptomatic
Imaging
Non diagnostic / Inconclusive
Biopsy
Eventful / False negativity
Observation / Operative intervention

5. Benign Tumors of Liver
Mesenchymal Tumors
• Adipose tissue
Lipoma
Myelolipoma
Angiomyolipoma
• Muscle Tissue
Leiomyoma
• Blood vessel
Hemangioendothelioma
Hemangioma
• Mixed mesenchymal/epithelial
Mesenchymal hamartoma
Benign teratoma
• Others
Inflammatory pseudotumor
Focal fat sparing
Infectious lesions
Epithelial tumors
• Hepatocellular
NRH
FNH
Hepatic Adenoma
• Cholangiocellular
Bile adenoma
Biliary cystadenoma

6. John T et al Ann Surg 1994

7. Clinical Evaluation
Clinical context
History
Medications (eg OCPs)
Symptoms : Constitutional, GI
Complete physical
Stigmata of CLD
Rectal bleeding (hemoccult)
Breast and pelvic examination
Laboratories
CBC
LFTs
Hep B/C Serology
Tumor markers: AFP, CEA, CA19.9

8. Hemangioma
• Most common
• 0.4% - 20% (autopsy)
» Rubin R et al Med Clin North Am 1996
» Karhunen et al J Clin Path 1986
• Variable size
• Giant hemangioma - > 4cm
• Diagnosed more in female
• Third to fifth decade

9. • Pathogenesis
• Benign congenital hamartoma (Ectasia)
• Increase in growth or symptoms
– Pregnancy
– Oral contraceptive
– Estrogen may have role
» Nichols E et al SCNA 1989
• Pathology
• Compressible cystic lesion
• Histology
– Vascular space, endothelial lining, fibrous seta

10. • Clinical features
• Mostly asymptomatic
• Abdominal fullness, early satiety, anorexia
• Pain- Thrombosis. Infarcts, Necrosis, Pressure
• Size
– 40 % >4 cm & 90% >10cm are symptomatic
» Goodman Z et al Neoplasm of Liver 1987
• Spontaneous rupture- rare (Reported 28 case /100
year)
» Farge O et al Word J Surg 1995
• Physical findings unremarkable
• Biochemical analysis usually normal

11. • Consumption coagulopathy
(Kasaback Merrit Syndrome
– Giant hemangioma with feature of DIC
• Clinical course
• Benign
• May grow during pregnancy or OCP
• 8 out of 158 were symptomatic during 60 months
follow-up ( All > 5 cm)
» Gandolfi L et al Gut 1991

12. Imaging
• USG
• Well demarcated Homogenous Hypoechoic
• Posterior acoustic shadow

13. Plain
Hypodense mass,
Central scar
Arterial phase
Peripheral nodular enhancement
Portal venous phase
Centripetal filling

14. T1
Hypointense
T2
Hyperintense
Post contrast T1
Peripheral nodular enhancement
Post contrast T2
Centripetal filling with central scar
<2cm, multiple lesion, 90 % sensitivity

15. Tc 99 m Pertechnate / RBC
• Initial hypoperfusion with increase
tracer uptake in 30 minute
• False negative: Thrombosis / Fibrosis
• False Positivity: HCC /
Angiosarcoma
• Sensitivity - 80 %,
• Specificity – 100% for lesion >2
cm
» Kinnard M et al
Semin
Roentgenol
1995
SPECT
• Better spatial resolution
• Sensitivity & Specificity – 90 to 95%
Kudo M et al AJR 1989
• Lesion <2 cm & close to major vessels-
MRI > SPECT
Angiography
• Diagnostics confusion & Coexisting
pathology
– Cotton wool appearance
» Rapid filling of large
space, > 40 min)
– Absent AV shunt
– D/D: Vascular lesion
Combination USG, CT, SPECT has
86% sensitivity,
100 specificity,
91% accuracy

16. Treatment
Indication
• Symptomatic
• Complication
• ? Rupture
• Diagnostic doubt
Option
• Enucleation or Resection
Equally effective
Less complication in enucleation
Gedaly et al Arch Surg 1999
• Angioembolization/ Vascular
ligation
– Steroid & Radiation
– Interferon α 2a

17. Focal Nodular Hyperplasia
• Second most common
• 2.5- 8% in autopsy
• Female predominance
• 20-50 year
• Etiology: ? OCPs
• Clinical feature
Asymptomatic,
incidental
Pain, Rupture,
Hemorrhage – rare
Coexist
– Hemangioma
– Adenoma
– GSD
Pathogenesis
• ? Neoplastic / Hamartoma / Response to injury
• Response to hypo or hyper perfusion
Haber M et al Gastroenterology 1995
• Coexisting hemangioma ( Vascular Pathology)
Pathology
• Demarcated, well encapsulated
• Usually solitary
• Radial scar with central septa
• Preserved hepatic parenchyma with Kupfer cell
over activity

18. Imaging
Contrast enhanced USG
Spoke wheel pattern
Early phase
Isoechoic to normal liver
delayed phase
s/o Benign etiology

19. Precontrast
Isodense, central scar
Arterial Phase
Homogenous enhancement
Portal phase
No pooling

20. TI
Isointense to hypointense
T2 – Hyperintense,
Hyperintense central scar
Post contrast T1
Uniformly enhancing

21. • Tc 99m sulfur colloid scan
• Increased uptake with colloid concentration
• Angiography
• Central feeding artery
• Spoke wheel pattern
• Capillary blush
– FLC- Central scar with hypointense in T2
– Adenoma- No central scar

22. Treatment
• Observation / Surgical treatment
• Indication
– Symptomatic
– Increase in size
– Diagnostic uncertainty
• Enucleation / Resection
• Angioembolisation / Hepatic artery ligation
– Un-resectable lesion

23. Liver cell adenoma
• Rare tumor
• Women, child bearing age
• Malignant potential
• Pathogenesis
– OCP
– Hepatocyte transformation
» Edmondson H et al Ann
Intern Med 1977
» Wanless I et al Lab
Invest 1982
– Insulin - Glucagon
imbalance
• DM
• Glycogen storage disease
– Pregnancy
• ER / PR receptor usually
absent
» Massod S et al Arch
Pathol Lab Med
1989

24. • Pathology
• Large,
circumscribed,
partial
encapsulated
• Absent hepatic
architecture
• Reduced
Kupfer cell
activity
• Feeder -
Hepatic artery
• Peliosis
hepatitis
• Clinical feature
• Asymptomatic
• Pain – Most common
• Bleeding
• Mass
• Malignant
transformation
(2-7% years)
• Adenomatosis
– > 10 adenomas
– More potential
malignant
propensity

25. Unenhanced- Iso or hypodense
Arterial phase- Hyperdense,
irregular enhancement
Portal phase- Isodense

26. • USG
• Well defined lesion with variable echogenicity
• MRI
• T1
– Well defined hyper intense
• T2
– Heterogenous enhancement
• Sulfur colloid scan
• Reduced uptake (d/t reduced Kupffer cells)

27. Treatment
• Surgical removal
– Malignant transformation
– Bleeding and Necrosis
– Rapid increase in size in pregnancy
• Enucleation / Resection / Transplantation
• Angioembolization
• Follow-up
– USG & AFP
– Small, asymptomatic lesion after discontinuing OCP

28. Rare lesions
• Nodular regenerative hyperplasia
– Thoroughly distributed
– Usually <0.5 cm size
– Pathogenesis
• Vascular obstruction , atrophy and regenerative
hyperplasia
• Atrophy in central zone, regeneration around
periphery
» Altmann H et al 1989

29. • Association
• Chronic liver disease
(Cirrhosis, PHN)
• Chronic systemic disease
• Budd Chiari syndrome
• Felty syndrome
• Crest syndrome
• Collagen disorder
• Imaging
– USG
• Hypo or iso-echoic
– CT
• Hyperdense in
arterial phase while
imperceptible on
Portal phase
• Clinical feature
– Presentation as of
chronic liver disease

30. Adenomatous hyperplasia
• Compensatory lobular hyperplasia in response to
parenchyma collapse
• Macro-regenerative nodule
– In cirrhosis, lesion > 1 cm
– Type I- without atypia
– Type II- Associated with atypia

31. • Infantile bile duct adenoma
• Solitary subcapsular lesion
– D/D cholagiocarcinoma
• Non-neoplastic lesion
• Focal injury to bile duct
• Biliary hamartoma
– von Meyenberg Complex
• Anomalous bile duct proliferation
• Small nodular lesion, In elderly
• Precursor of cystic hepatic lesion of polycystic
kidney disease

32. • Infantile Hemangioendothelioma
– MC benign liver tumor in children and infancy
– Presentation
• Solitary or multiple mass with ill-defined margin
• Hepatomegaly, Vascular mass, Cardiac failure
• Consumption coagulopathy, Microangioathic
hemolytic anemia
• Coexisting cutaneous hemangioma, Cardiac defect,
Neural tube defect

33. • Imaging
• USG & CT s/o vascular lesion
• Treatment
– Management of CHF
– Operative intervention
• Progressive enlargement
• Symptomatic
• Resection / Enucleation
• Angioembolization / Hepatic artery ligation

34. • Inflammatory pseudotumor
• Acquired lesion, post inflammatory, >3cm size
• Solitary or multiple
• Show inflammatory infiltrates
• Presentation
– Jaundice, Pain, Fever, Hepatomegaly
• Imaging
– USG- Mosaic pattern
– CT- Non-enhancing irregular lesion
• Treatment
– Observation
– Resection if diagnostic dilemma

35. • Peliosis hepatitis
• Small multiple blood filled spaces
• Associated with steroid, OCP,
immunocompromised patient
D/D
Diffuse metastatic disease
Granulomatous lesion
(Sarcoidosis, extra intestinal
inflammatory bowel disease)
Diffuse coalescing hypodense lesion

36. Biopsy in Benign Lesions
– Indication
• Diagnostic uncertainty
– Contraindication
• Uncooperative patient
• Bleeding tendency
– PT > 3 second over normal after correction
– Platelet count <60,000 after correction
– Aspirin within 7 days
– Anatomical unsuitability, vascular lesion, Massive ascites

37. • Pitfalls
• Safety
– Mortality 0.3%
• Sampling error
– False negative rate up to 30 %
– USG guided FNAC showed 90% accuracy
– Transjugular liver biopsy
• Massive ascites, Coagulopathy, Vascular liver lesion
• Higher complication rate

38. Role of Laparoscopy
– Better surface tomography
– Guide biopsy at desired site
– Lap Ultrasound further increases sensitivity
(98%)

39. Approach to patient

40. Summary
Benign liver tumor represents a diagnostic dilemma -
both radiological and clinical
Significant overlap seen in lesion other than
hemangioma
Invasive approach reasonable
Biopsy / Laparoscopy
Predominant treatment is observation except in
adenoma
Diagnostic uncertainty is acceptable indication of
surgery