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Focal Liver Lesions that can be safely managed and monitored at the primary care setting (Part 2)

Confirmed FLL

When confronting a FLL, the following algorithm is useful as a guide:
algorithm for investigation of FLL

After excluding high risk patients and suspicious lesions like hepatocellular carcinoma, liver metastasis and cholangiocarcinoma, FLL would be either solid, cystic or haemangioma with classical appearance on imaging. All suspicious lesions should have been referred to a specialist at this stage.


Solid benign FLLs

Hepatocellular adenoma

Considered a rare benign liver tumour, the incidence varies from 0.007-0.012% with a prevalence in females taking oral contraceptive pills and often regress after cessation of OC pills. (4) There is a causal relationship between the development of liver adenomas and sex hormones disturbance. Along this line, usage of anabolic androgen steroids has also been implicated in the development of liver adenomas in male. (5) Specific diseases like glycogen storage disease (GSD) and metabolic syndrome are also more prone to developing hepatocellular adenoma. (6,7)

On CT scan, a hepatocellular adenoma should be well demarcated with peripheral enhancement and usually homogeneous rather than heterogeneous. It could be hypodense (if steatotic) or hyperdense (after haemorrhage). MRI (especially using hepatospecific contrast agent) has been shown to be superior in not just diagnosis of the adenoma but distinguishing different subtypes-- particular variant such as telangiectatic hepatocellular adenoma (THCA) was found to be more symptomatic with higher malignant potential. It is thus recommended that all hepatic adenomas should be referred to a specialist, if it was opined that THCA was the case, an aggressive approach would usually be adopted. (3)

The main concern about hepatocellular adenoma was its propensity to haemorrhage and malignant change. Most of such complications occurring in lesions larger than 5cm. Hence these benign tumours tend to be treated surgically, especially THCA. When managing such patients, it is important to advise on stopping all hormone use and weight reduction. After specialist consultation, those deemed low risk in haemorrhage, rupture and malignant transformation (<5cm) can be monitored at the primary care setting, with imaging every 6 months for 2 years then annually depending on growth and stability of the lesions.

Pregnancy in patients with hepatocellular adenoma is a more complicated issue—as the frequency is low and data lacking. Growth of the adenoma is to be expected but pregnancy is not absolutely contraindicated in all patients especially with smaller tumours. The treatment must be individually devised by a team of surgeon, obstetrician and hepatologist. (8)


  1. Smith-Bindman R, Miglioretto DI, Johnson E et al. Use of diagnostic imaging studies and associated radiation exposure for patients enrolled in large integrated health care systems. 1996-2010. JAMA 2012;307:2004-9.
  2. Lee KH, O'Malley ME, Haider MA, Hanbidge A.AJR Am J Roentgenol. 2004 Mar;182(3):643-9. Triple-phase MDCT of hepatocellular carcinoma.
  3. Marrero JA, Ahn J, Rajender Reddy K. ACG clinical guideline: the diagnosis and management of focal liver lesions. Am J Gastroenterol. 2014; 109(9): 1328-47
  4. Shaked O, Siegelman ES, Olthoff K et al. Biologic and clinical features of benign solid and cystic lesions of the liver. Clini Gastroenterol Hepatol 2011;9:547-62
  5. Hernandez- Nieto L, Brugeuera M, Bombi J et al. Benign liver-cell adenoma associated with long-term administration of an androgenic- anabolic steroid(methandienone). Cnacer 1977;40:1761-4
  6. Labrune P, Trioche P, Duvaltier I et al. Hepatocellular adenomas in glycogen storage disease type I and III: a series of 43 patients and review of the literature. J Paediatr Gastroenterol Nutr 1997;24:276-9
  7. Bunchorntavakul C, Bahirwani R, Drazek D et al. Clinical features and natural history of hepatocellular adenomas: the impact of obesity. Aliment Pharmacol Ther 2011;34:664-74
  8. Bioulac-Sage P, Taouji S, Possenti L et al. Hepatocellular adenoma subtypes:the impact of overweight and obesity. Liver Int 2012;32:1217-21
  9. Karhunen PJ. Benign hepatic tumours and tumour like condition in men. C Clin Pathol 1986;39:183-9
  10. Oto A, Tamm EP, Szklaruk J. Multidetector row CT of the liver. Radiol Clin North Am 2005;43:827-48

The above information is provided by Dr Chik Hsia Ying, Barbara