What is the role of surgery in the treatment of hepatocellular adenoma (HCA)?

Updated: Feb 21, 2018
  • Author: Bradford A Whitmer, DO; Chief Editor: BS Anand, MD  more...
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Answer

Due to the increased risk of spontaneous life-threatening hemorrhage and the possible malignant transformation associated with larger-size tumors or in patients with GSD, elective surgical resection is considered for all lesions greater than 5 cm in diameter. [59] Elective resection should be undertaken only after a reasonable period of observation if OCPs have been discontinued only recently. However, several authorities recommend that all adenomas should be resected regardless of size due to rare cases of malignant transformation after adenomas have decreased in size or disappeared after discontinuation of OCPs.

In a multicenter study of 124 patients, Deneve et al reported that tumors that were more likely to rupture were larger tumors and in women with recent hormone use. [27] The investigators recommended surgical resection when HCAs approached 4 cm in size or if hormonal therapy was required.

All patients with significantly elevated AFP levels should undergo resection of the tumor regardless of size.

With regard to timing of resection, Klompenhouwer et al suggest that a 6-month cut-off point in women is too early for assessment of regression of hepatocellular adenomas larger than 5 cm to no more than 5 cm. [60]  Rather, they indicate that in women with typical, non-β-catenin-activated hepatocellular adenomas, regardless of the baseline diameter, the cut-off point may be extended to 12 months. [60]

The majority of tumors can be resected locally or with segmental partial lobectomy. Elective resection carries approximately 13% morbidity. Mortality is rare. Complication rates associated with emergency surgery are higher, including a mortality rate of approximately 5-8%.

Laparoscopic resection can be used in patients who have small tumors within the anterolateral liver segments and for pedunculated tumors.

In a retrospective (1989-2013) multi-institutional European study of all patients who had undergone open or laparoscopic hepatectomies for hepatocellular adenomas to investigate the effects of the surgical approach on postoperative morbidities, Landi et al found that open surgery and laparoscopy showed similar postoperative morbidity rates and severities. [61] However, laparoscopy was associated with significantly less blood loss, a reduced need for transfusion, and a shorter hospital stay. [61]

Cho et al reported their experience with the management and outcomes of 41 patients with hepatocellular adenomas treated at the University of Pittsburgh between 1988 and 2007. [26] The investigators reported that surgical resection was preferable to observation if patients comorbidities and anatomical location are acceptable due to risks of hemorrhage (29%) and malignancy (5%).

In rare patients with multiple adenomas or glycogen storage disease, liver transplantation may be the only intervention that may remove all lesions and cure the underlying metabolic defect. [11, 62] Liver transplantation has also been successfully performed for spontaneous intrapartum rupture of an hepatocellular adenoma. [63]

Radiofrequency (RF) ablation can be used effectively in the treatment of hepatocellular adenoma. [64] However, multiple sessions are often required, and signs of residual adenoma might persist in some patients despite repetitive treatment. RF ablation might be especially beneficial in cases not amenable to surgery or in patients who would require major hepatic resection. Cases not amenable to surgery would include centrally located lesions or multiple HCAs in both lobes of the liver.

In a retrospective single-arm study of 36 patients with 58 hepatocellular adenomas who underwent 44 procedures with percutaneous thermal ablation, investigators reported a primary efficacy of 88% and a secondary efficacy of 100%, with a major complication rate of 4.5% (postprocedural hemorrhage). [65] At a median follow-up of 1.7 years, there was 100% clinical efficacy with no reports of malignant transformation, adenoma-related hemorrhages, or deaths.


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