Symptomatic Focal Nodular Hyperplasia Research Articles

Outcomes of transarterial embolization for large symptomatic focal nodular hyperplasia in 17 pediatric patients.

To evaluate the safety and the long-term outcomes of transarterial embolization (TAE) with lipiodol-bleomycin emulsion (LBE) plus N-Butyl cyanoacrylate (NBCA) in the treatment of children with large symptomatic focal nodular hyperplasia (FNH). This is a retrospective case serial study. Children (aged <18 years) with FNH were treated. Indications for TAE were patients who were presenting with FNH related abdominal pain and the maximum diameter of FNH is more than 7cm, and who were not candidates for surgical treatment. Technical success, adverse events, symptoms relief rate, and changes in the lesion size after TAE were evaluated. Between January 2003 and February 2018, 17 pediatric patients were included. Technical success was achieved in all patients. Mean follow-up was 67.5 months. All patients had complete resolution of abdominal symptom. The mean largest diameter of the lesions decreased from 10.5cm to 1.9cm (P<0.01). The mean volume reduction rate was 96.9%. The complete resolution of the FNH was observed in 16 patients. No further therapy was needed for all patients. TAE with LBE plus NBCA appears to be a safe and effective treatment in pediatric patients with large symptomatic FNH. It could be considered as the first-line treatment for symptomatic large FNH.

Resection of symptomatic focal nodular hyperplasia of the liver with pre-operative angioembolization

Focal nodular hyperplasia (FNH) is a rare benign liver tumor in children. Treatment is only mandatory if the tumor is symptomatic and/or large. Transarterial embolization offers a safe alternative to surgery, but above all the possibility of performing limited hepatectomies. We report 2 cases, of 10 years old girl and 11 years old boy, who have a focal nodular hyperplasia affecting the left liver for the first one and the right liver for the second one. They were managed successfully by preoperative transarterial embolization followed by surgery.

Long-term outcomes of transarterial embolization with lipiodol-bleomycin emulsion plus polyvinyl alcohol particles versus the particles alone for large symptomatic focal nodular hyperplasia: a propensity score-matched analysis.

To compare the efficacy of transarterial embolization (TAE) with polyvinyl alcohol (PVA) particles alone and lipiodol-bleomycin emulsion (LBE) plus PVA particles for patients with unresectable large symptomatic focal nodular hyperplasia (FNH). We performed a retrospective analysis of patients who underwent TAE either with PVA particles alone (group A, n = 46) or LBE plus PVA particles (group B, n = 35) for large (≥ 7 cm) symptomatic FNH between January 2002 and February 2019. Propensity score matching (PSM) (1:1) was performed to adjust for potential baseline confounders. Technical success, adverse events (AEs), symptom relief, and changes in the lesion size after TAE were evaluated. Statistical analysis included Wilcoxon rank sum test and χ2 test. After PSM, no significant differences in baseline characteristics were found between the groups (31 in group A and 31 in group B, with a mean age of 31 years). Technical success was achieved in all patients (100%), without major AEs in both groups. Complete resolution of the abdominal symptoms was reported in 77.4% in group A and 100% in group B (p = 0.037) during a mean follow-up period of 72 months; complete resolution (CR) of the FNH rate was significantly higher in group B than in group A (93.6% vs. 67.7%; p = 0.019). Compared with the use PVA particles alone, TAE with LBE plus PVA particles in the treatment of patients with large symptomatic FNH had a significantly higher rates of CR of the FNH and complete relief of the symptoms. • Transarterial embolization (TAE) with lipiodol-bleomycin emulsion (LBE) plus PVA particles for the large symptomatic FNH yielded better results than with PVA particles alone, in terms of complete resolution of FNH lesions (93.6% vs 67.7%) and complete relief of the abdominal symptoms (100% vs 77.4%) during a mean follow-up period of 72 months (38-170 months). • No major complications were recorded in both groups, and no significant difference in the incidence of postembolization syndrome were observed between the two groups.

Embolization of a rare case of focal nodular hyperplasia in an adolescent boy

This report highlights a special case of focal nodular hyperplasia (FNH) in a 14-year-old boy. FNH is a benign liver lesion which typically presents in middle-aged women. Symptomatic FNH lesions, lesions of large size, or lesions in problematic locations are often surgically resected. Surgical treatment options such as resection or liver transplantation were discussed in our case, however the mass was deemed unresectable due to its central location and proximity to vascular structures. Super-selective particle embolization of this hypervascular benign mass proved to be an effective treatment resulting in complete resolution of symptoms and significant reduction of the size of the mass, with no post-procedural complications.

2226 Hot Spot Sign on Tc-99m DISIDA Nuclear Hepatobiliary Scan

INTRODUCTION: Hepatic Focal Nodular Hyperplasia (FNH) can be an unusual cause of abdominal pain. Prior to the advent of readily accessible diagnostic imaging techniques, patients with FNH primarily presented with vague symptoms of abdominal pain, then proceeded to imaging, which led to diagnosis. Today, most cases are found incidentally on imaging, in often asymptomatic patients. Here, we present a patient with significant symptoms in whom an identified FNH was considered inconsequential, but is eventually proven otherwise. CASE DESCRIPTION/METHODS: A previously healthy 31-year-old male presented with a one-month history of persistent postprandial right upper quadrant abdominal pain. Ultrasound showed cholelithiasis. MRI revealed FNH of the anteroinferior subsegment of the liver. Tc-99m DISIDA Cholescintigraphy showed a normal functioning gallbladder, but an abnormal delayed clearance of tracer from a focal area in inferior tip of the liver, corresponding to the FNH seen on MRI, consistent with a “hot spot sign”. Due to suspicion for symptomatic cholelithiasis, he underwent elective cholecystectomy. Symptoms persisted post-op, thus, his pain was thought to be from symptomatic FNH. After subsequent elective FNH resection, symptoms subsided. DISCUSSION: While cholescintigraphy typically evaluates for biliary tree dysfunction, it can also reveal abnormality in hepatic parenchymal tissue. Previously, Tc-99m Sulfur Colloid Liver-Spleen scans were used for diagnosis of FNH. However, the “hot spot sign” on cholescintigraphy has also been described as diagnostic for FNH. This case illustrates that a focal area of delayed tracer washout, or “hot spot”, can also be seen with Tc-99m DISIDA. Although the significance of delayed tracer washout is unclear, this finding suggests liver parenchyma’s inability to effectively clear bile from an FNH. This inability to adequately clear bile, may result in pain. The severity of impaired clearance may even correlate with the severity of symptoms. Although further investigation is necessary, cholescintigraphy may prove a useful tool in functional imaging for differentiating between symptomatic and asymptomatic FNH.

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

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.

Percutaneous Microwave Coagulation for the Treatment of Small Solitary Focal Nodular Hyperplasia of Liver

Background: Whether percutaneous microwave coagulation (PMC) is safe and effective for the treatment of symptomatic focal nodular hyperplasia (FNH) of the liver remains unknown. Methods: Between January 2006 and September 2015, sixteen patients with solitary symptomatic FNHs in the liver (the largest diameter less than 5 cm) were treated by PMC. The safty and effectiveness were analyzed. Results: There were 4 males and 12 females. All these patients suffered from upper abdominal pain. The FNHs ranged in size from 3.2 cm to 5.0 cm (3.9 cm ± 0.12 cm). All the PMC procedures were performed successfully. All 16 patients had symptomatic improvement after the treatment with no procedure-related morbidity or mortality. Among 16 patients, 15 (93.8%) patients with FNHs were assessed to be ablated completely by CT examination performed within four weeks after PMC treatment. One patient failed to follow up regularly, but showed up 2 years and 7 months later for suffering upper abdominal pain again with original FNH enlargement, and the patient received surgical resection of the FNH and achieved asymptomatic aftermath. Conclusion: PMC is safe and effectiveness for symptomatic liver FNHs. PMC should be considered to be an alternative modality for those solitary FNHs with less than 5 cm in diameter.

The value of liver resection for focal nodular hyperplasia: resection yes or no?

BackgroundFocal nodular hyperplasia (FNH) are benign lesions in the liver. Although liver resection is generally not indicated in these patients, rare indications for surgical approaches indeed exist. We here report on our single-center experience with patients undergoing liver resection for FNH, focussing on preoperative diagnostic algorithms and quality of life (QoL) after surgery.MethodsMedical records of 100 consecutive patients undergoing liver resection for FNH between 1992 and 2012 were retrospectively analyzed with regard to diagnostic pathways and indications for surgery. Quality of life (QoL) before and after surgery was evaluated using validated assessment tools. Student’s t test, one-way ANOVA, χ2, and binary logistic regression analyses such as Wilcoxon–Mann–Whitney test were used, as indicated.ResultsA combination of at least two preoperative diagnostic imaging approaches was applied in 99 cases, of which 70 patients were subjected to further imaging or tumor biopsy. In most patients, there was more than one indication for liver resection, including tumor-associated symptoms with abdominal discomfort (n = 46, 40.7 %), balance of risk for malignancy/history of cancer (n = 54, 47.8 %/n = 18; 33.3 %), tumor enlargement/jaundice of vascular and biliary structures (n = 13, 11.5 %), such as incidental findings during elective operation (n = 1, 0.9 %). Postoperative morbidity was 19 %, with serious complications (>grade 2, Clavien–Dindo classification) being evident in 8 %. Perioperative mortality was 0 %. Liver resection was associated with a significant overall improvement in general health (very good–excellent: preoperatively 47.4 % vs. postoperatively 68.1 %; p = 0.015).ConclusionsLiver resection remains a valuable therapeutic option in the treatment of either symptomatic FNH or if malignancy cannot finally be ruled out. If clinically indicated, liver resection for FNH represents a safe approach and may lead to significant improvements of QoL especially in symptomatic patients.Electronic supplementary materialThe online version of this article (doi:10.1186/s40001-015-0181-x) contains supplementary material, which is available to authorized users.

Transarterial Embolization of Symptomatic Focal Nodular Hyperplasia

PurposeTo evaluate the effectiveness of small size trisacryl gelatin microsphere embolization as a minimally invasive treatment option for patients with symptomatic focal nodular hyperplasia (FNH). Materials and MethodsA retrospective review was performed of experience with transarterial bland embolization of FNH during the period 2006–2011 in 12 patients (10 women and 2 men; age range, 18–61 y) with a total of 17 lesions presenting with symptoms of pain. FNH was pathologically proven in 11 lesions from 10 patients; the remaining lesions exhibited the classic imaging appearance for FNH. All patients underwent superselective embolization with 100–300 μm trisacryl gelatin microspheres. Lesion size and contrast enhancement before and after treatment were compared to determine success of the procedure. Clinical response was determined by review of the electronic medical record. ResultsAfter embolization, seven patients showed complete resolution and five patients showed partial resolution of symptoms. Compared with imaging performed before the procedure, mean decrease in lesion size after embolization was 61% (range, 26%–90%) on cross-sectional imaging obtained 4–10 weeks after embolization and 87% (range, 54%–98%) on subsequent imaging. Diminished contrast enhancement was universally noted, with 5 of 17 lesions showing complete lack of residual enhancement. ConclusionsTransarterial bland embolization of FNH with trisacryl gelatin microspheres in symptomatic patients is a suitable treatment alternative to surgical resection.

Treatment of Symptomatic Focal Nodular Hyperplasia with Percutaneous Radiofrequency Ablation

The authors report a case of a 21-year-old woman taking oral contraceptives for severe dysmenorrhea who presented with a hepatic mass and worsening right upper quadrant pain. The oral contraceptives could not be discontinued because of her pelvic symptoms, necessitating treatment of the liver lesion for symptomatic relief. Computed tomography and percutaneous biopsy demonstrated the mass to be focal nodular hyperplasia. The patient opted for radiofrequency ablation rather than surgical enucleation for symptomatic relief. The ablation proved to be a safe and effective alternative to surgery to treat the benign tumor, and permitted more aggressive therapy of the dysmenorrhea.

Inferior Caval Vein Thrombosis Owing to Compression of Focal Nodular Hyperplasia: Surgical Resection after Shrinkage by Hepatic Artery Embolization

The purpose of this study was to investigate the results of a staged treatment of symptomatic focal nodular hyperplasia (FNH), consisting of first embolization and then resection. A 36-year-old woman presented with pulmonary embolism caused by an inferior caval vein thrombosis owing to external compression by FNH in liver segment I (5.2 x 6.7 cm). She was treated with anticoagulants. The FNH lesion was first reduced by radiologic embolization of the feeding branch of the right hepatic artery. A 41% size reduction was obtained, and the symptoms disappeared. FNH resection was performed 5(1/2) months later. The thrombus had disappeared, and the anticoagulant therapy could be stopped perioperatively. A symptomatic FNH lesion was treated successfully in two stages.

Management of Unresectable Symptomatic Focal Nodular Hyperplasia with Arterial Embolization

Symptomatic focal nodular hyperplasia (FNH) of the liver can usually be treated safely with liver resection. However, in those patients in whom resection is not possible because of the location or size of the tumor or other patient factors, selective arterial embolization should be considered. Herein, the authors describe the use of arterial embolization to treat three women with symptomatic FNH and provide a review of the literature.

Focal nodular hyperplasia: what are the indications for resection?

Focal nodular hyperplasia (FNH) is a benign condition of the liver that is often discovered incidentally on radiological investigation. FNH has no malignant potential, is rarely symptomatic and surgical intervention is almost never required. However, eight patients with a diagnosis of FNH associated with upper abdominal pain or rapid growth were referred for surgery. All patients had been extensively investigated for other causes of pain and had been observed for between 1 and 7 years prior to surgical referral. The FNH lesions were between 1 cm and 8 cm in diameter. One FNH lesion 7.5 cm in diameter lay in segment VII/VIII and was related to the right and middle hepatic veins. All patients were resected with immediate and lasting control of their symptoms. Based on this experience FNH should be managed in a manner similar to haemangiomas with most lesions being safe to observe. However, it should be recognized that symptomatic FNH does occur, as well as FNH behaving in an unusual fashion such as rapid growth. Both of these findings are indications for resection.

Anemic Infarction in Focal Nodular Hyperplasia of the Liver: A Diagnostic Pitfall

The authors report on an unusual case of a large symptomatic focal nodular hyperplasia (FNH) of the liver with multiple well-demarcated areas of anemic infarction presenting diagnostic difficulties because of their size and special radiologic features. A classical radiologic work-up (sonography, CT scan, angiography) first led to an erroneous diagnosis of a malignant liver tumor. There was then magnetic resonance imaging with application of the new liver magnetic resonance contrast agent, Endorem® which rendered the presence of malignancy unlikely and suggested the correct diagnosis of a partly necrotic FNH. The liver mass was removed by resection of segment I. Histology confirmed the diagnosis of FNH and demonstrated large areas of infarction inside the lesion characterized by coagulation necrosis. Infarction in FNH is a rare event. Pathogenic mechanisms are suggested. Recent views concerning diagnosis and treatment of FNH are briefly discussed.

Focal nodular hyperplasia of the liver: a link with sickle cell disease?

Focal nodular hyperplasia is a benign liver tumour that is rare in children. We report the second case of a child with sickle cell disease presenting with symptomatic focal nodular hyperplasia. The possible pathogenesis of focal nodular hyperplasia and the association with sickle cell disease are discussed.