Trans-arterial Embolization of Focal Nodular Hyperplasia in a Teenager: Beyond Pain Control

Abstract

Background: Focal nodular hyperplasia (FNH) is the most common benign non-vascular liver tumor. It is predominantly found in women (9:1 ratio) between ages 30 to 50 years. Intervention is usually reserved for symptomatic FNH lesions. Trans-arterial embolization has been shown to be a reasonable alternative to surgical resection. Budd-Chiari syndrome is a potentially deadly phenomenon in which the hepatic venous outflow tract is obstructed, which can lead to liver failure. Secondary Budd-Chiari is caused by compression of the hepatic veins or inferior vena cava (IVC) by lesions originating outside of the vein (e.g. tumors). Case: A 19 year old girl was referred to Hepatology Clinic for management of symptomatic FNH, progressive in size and associated right upper quadrant pain and fullness over a period of five years. At the time of presentation she had two MRIs of the abdomen over a three month interval, showing an 3.5 X 5.7 cm enlarging mass abutting the IVC involving segment VIII, extending into the caudate lobe. Physical exam was significant for reproducible right upper quadrant tenderness. Labs including liver function tests were normal. After an unremarkable EGD was performed to evaluate for alternative causes of abdominal pain, and Hepatobiliary Surgery had deemed resection a highrisk intervention, the patient was referred to Interventional Radiology for embolization of her FNH. During the procedure, by arteriogram, a hypertrophied branch of right hepatic artery was found to be the primary vascular supply of the FNH. This branch was embolized with lipiodiol and ethanol which until cessation of flow into the artery supplying the targeted mass. Follow up MRI imaging of abdomen at 6 months post-procedure show positive response with progressively diminishing size of residual FNH (2.8 X 1.7 cm). At 6 month post-procedural follow up patient reported complete resolution of symptoms at rest. Discussion: Although typically presenting in adult women ages 30-50, this case highlights the need to recognize FNH as a potential cause for right upper quadrant in teenage girls. In this case the medical teams decided to pursue embolization not only because of the mass effect, but also because of the abutment on the hepatic veins and IVC. Early recognition and therapeutic embolization of FNH can not only safely lead to significant symptomatic pain relief, it can also decrease risk of venous outflow obstruction and by extension prevent secondary Budd-Chiari syndrome.