Hepatic Adenoma
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2005.Incidence of HCC in adenomas-8 to 14%
1993. “The surgeon is tempted to operate. However in
most uncomplicated cases of adenoma it is advisable to be
conservative.” Sheila Sherlock. D of Liver & Biliary
System.
1995. “Malignant progression of adenomas have been
reported , but it is rare” International Working Party on
classification of nodular hepatocellular lesions. Hepatology
1997.”The author cannot find a single report of definite
malignant transformation during follow up of an
unresected adenoma” John Foster.Surgery of the Liver. Ed
LH Blumgart.
Hepatic Adenoma
• What is the truth?
Hepatic adenoma
• 2006. Zucman-Rossi et al. Hepatology 43;515: 2006
• Retrospective, multicentre, pathological study
• 96 tumors from13 French university hospitals over 12
years = < 1 tumor/ hospital /year =rare!
• Inclusion criteria=definite (87) or possible (9) diagnosis of
adenoma (HA) from hepatectomy! (95) or Tx (1 )
• Final Diagnosis by Panel of 22 pathologists:
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HA……...68
HA/HCC..11(14%)
HA/FNH…14
HCC……….1
Hepatic Adenoma
• Zucman-Rossi (2006).”hepatic adenomas
may bleed, and rarely undergo malignant
transformation!
• What is going on?
Hepatic Adenoma
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85 female:11male
61 females on OC
18 hepatic adenomatosis
27multiple adenomata <10 (? Forme fruste hepatic
adenomatosis)
• Hemorrhage ( 55 micro and 32 macro) 87 cases
• 60 rest of liver normal
• 36 abnormal liver-F2/F3 fibrosis(4);sinusoidal
dilatation(5);steatosis (23);iron(2);polycystic(2)
Hepatic Adenoma
• In order to clarify and try and classify the tumors the authors used
mutations of 2 genes
• HNF1 and -catenin
• Non-HNF1 tumors-size of tumor  hemorrhage;
• NB.Bleed, mean 8cm v no bleed 5cm diameter
.NB.-catenin mutation was significantly associated with
malignancy. Of the 11 cases, 5cases were male. All but one of the
women were on OC
The authors did not describe any association between size and
malignancy
Hepatic Adenoma
• My conclusions from Zucman-Rossi 2006 (State of the
Art?)
• Clinicians, radiologists and pathologists are not great at
diagnosing liver adenomas
• The size of the adenoma may only be important as a
predictor of bleeding
• In general malignant transformation of single adenomas
may indeed be rare
• However there appears to be a subgroup, especially in
men in which associated malignancy is more common
• The finding of adenoma and HCC in the same tumor,
even with the same genetic mutation, may indicate an
association, and not necessarily transformation. i.e.
both may be primary neoplastic growths due to the
Hepatic Adenoma
• Recommendations in patients diagnosed
as adenoma:• Try and confirm diagnosis in any way
possible; history ( female on OC),
radiographically, biochemically (eg AFP,
sensitivity 20%, specificity 96%)
• Increase suspicion of HCC in males
• Increase suspicion in multiple adenomas
Hepatic Adenoma
• Should you perform a biopsy?
• Higher risk of bleeding
• Pathologists have difficulty differentiating
adenoma from well differentiated HCC
Hepatic Adenoma
• What about surgery?
• Resect all single adenomas in men, because of a
higher risk of malignancy?
• Resect all adenomas >8cm (very high risk of
bleeding)?
• Resect all adenomas >5cm ( risk of clinical
bleeding 20-40%)?
• Resect all adenomas with history of pain over the
liver and/or evidence of previous bleed?
Hepatic adenoma
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What about surgery?
1970’s mortality rate 9%
1980’s mortality rate 4%
>1990 mortality rate 1%
How would we feel if a young mother with
an asymptomatic 5cm adenoma died postoperatively?
Hepatic Adenoma
• My conclusion-we should have a good
indication for resecting an asymptomatic
adenoma