Multiple Concomitant Liver Pathologies: A Rare Occurrence

Abstract

Introduction: The differential diagnosis of multiple liver lesions is broad. The lesions usually represent single pathology. It is extremely rare to find pathologically different lesions concomitantly in the liver. Case: A 41-year-old woman with history of asthma underwent a CT scan of abdomen for work-up of abdominal pain and fullness of 2 weeks duration. CT scan showed numerous liver cysts, three focal masses suspicious of hepatic adenomas (HA), and one large ill defined mass in the right lobe concerning for heptoma. The patient was then referred to our facility. She did not smoke tobacco or drink alcohol and had been taking oral contraceptive pills (OCPs) since she had hysterectomy 21 years ago. CT guided biopsy of the right lobe mass showed pathological features suggestive of HA. Initial MRI of abdomen showed multiple benign liver cysts, large complex lesion in right lobe with signal characteristics suggestive of adenoma with hemorrhage. In addition, she had three arterially enhancing lesions consistent with FNH. Repeat MRI exams performed 4 and 15 months later showed progressive reduction in the size of right lobe HA. This correlated with improvement in her symptoms. She was referred to gastrointestinal surgery for possible surgical resection of HA. Due to progressive reduction in size after stopping OCPs, surgical resection of the HA was not considered necessary and serial imaging studies were advised. Discussion: Simple cysts, FNH and hepatic adenomas are the most common benign lesions of liver. Though some patients can have two different pathological lesions in liver, finding of three pathologically different lesions concomitantly in the liver is highly unusual. Simple liver cysts are present in around 1% of normal individuals and are usually diagnosed incidentally on abdominal imaging as most of them are asymptomatic. FNH is more common and is considered to originate from hepatocyte hyperplasia in response to hyperperfusion due to anomalous arterial supply. Its origin is not considered to be related to OCPs use but the patients on OCPs tend to have larger and more vascular FNHs. HAs have strong correlation to OCP use and have been reported to have 8-13% risk of progression to hepatoma. Treatment of asymptomatic HAs less than 5 cm in size is usually conservative with OCP discontinuation and serial follow-up imaging. Symptomatic adenomas are usually treated with surgical resection. Conclusion: Though it is rare to have multiple pathological lesions in the liver, it is important to consider it as possibility in appropriate clinical settings. Differential diagnosis is important due to significant difference in treatment of various hepatic lesions.