Benign liver tumours

Liver tumours are benign or malignant; malignant tumours can be primary or secondary. In Europe and the USA, a solitary lesion in the liver is more likely to be a metastatic carcinoma than a primary liver tumour.

Risk factors for liver cancer¹

The major risk factors for liver cancer are infection with hepatitis B and C and heavy alcohol consumption, all of which can cause cirrhosis. Smokers and those with diabetes are also at increased risk, while consumption of foods contaminated with aflatoxin is a cause of liver cancer in many developing countries.

See also the separate Primary Liver Cancer and Secondary Liver Cancer articles.

Haemangioma

• The most common benign liver tumour in adults and children. They are more common in the right lobe of the liver than in the left lobe.

• Hepatic haemangiomas can occur as part of a clinical syndrome - eg, Klippel-Trénaunay-Weber syndrome, Osler-Weber-Rendu syndrome and Von Hippel-Lindau disease.

• The vast majority of hepatic haemangiomas are asymptomatic and most often discovered incidentally during imaging investigations for unrelated health concerns.²

• Large cavernous haemangiomas may reach 8-10 cm in diameter.

• They are thought to be congenital and may enlarge under the influence of oral contraceptives.³ However, they usually regress when oral contraceptives are stopped. They can also grow during pregnancy.

• Hepatic haemangiomas may be seen in up to 10% of children aged 1 year but they usually regress within the first two years of life.

Haemangioma symptoms⁴

• Usually small and asymptomatic; they most often present as incidental findings at the time of imaging of the liver, laparotomy or post-mortem.

• Right upper quadrant pain or fullness is the most common symptom.

• Examination is usually normal but there may be hepatomegaly and/or an arterial bruit over the right upper quadrant.

• Rare presentations include a large abdominal mass, high-output cardiac failure, obstructive jaundice, gastrointestinal haemorrhage or fever. Thrombocytopenia, hypofibrinogenaemia and microangiopathic haemolytic anaemia may rarely occur.

• Large lesions may cause obstruction to gastric emptying and so present with vomiting.

• Rupture is rare but may occur spontaneously, following trauma or at the time of attempted biopsy.

Investigations

• Imaging techniques include ultrasound, contrast-enhanced CT scanning, nuclear medicine studies using technetium ^99m Tc-labelled red blood cells, MRI, hepatic arteriography and digital subtraction angiography.

Haemangioma treatment⁵

• If asymptomatic they may be left alone. Surgical resection is the treatment of choice if necessary. Minimally invasive therapies include arterial embolisation, radiofrequency ablation and hepatic irradiation. Liver transplantation is required on rare occasions. Steroids and interferon treatment are other treatment options.

Hepatic adenoma

• Hepatic adenomas are rare, benign liver tumours. Approximately 90% of cases occur in females, mostly aged 15-45 years. They occur most often in women of childbearing age and are strongly associated with the use of oral contraceptives.

• Usually asymptomatic but may cause slight abdominal pain in the epigastrium and in the right hypochondrium, and also bloating. May cause elevations of gamma GT and alkaline phosphatase. The possibility of malignant transformation can be monitored with serum alpha-fetoprotein (AFP).⁶

• Other conditions associated with hepatic adenomas include:

  • Anabolic steroids.⁷

  • Beta-thalassaemia.

  • Tyrosinaemia.

  • Type 1 diabetes mellitus.

  • Glycogen storage diseases (types 1 and 3). Multiple hepatic adenomas are more common in glycogen storage disease.

• The risk of malignant transformation is not completely known and may be as high as 13%.

Hepatic adenoma symptoms⁸

• Often asymptomatic and found incidentally on physical examination or during imaging for another reason.

• May present with pain in the right upper quadrant or the epigastric region.

• A palpable mass may be noticed by the patient.

• May present with severe, acute abdominal pain with bleeding into the abdomen, leading to shock.

• Other rare presentations include obstructive jaundice.

Investigations

• Liver function is not usually affected but aminotransferase levels may be mildly elevated or there may be features suggestive of obstructive jaundice.

• The most appropriate imaging investigation is contrast-enhanced MRI.⁹

• Immediate abdominal imaging is required for patients with hepatocellular adenomas who present with new or worsened abdominal pain or signs of haemodynamic instability.

Hepatic adenoma treatment¹⁰

• Patients should be managed in referral centres with access to an MDT. They should be advised to stop using oral contraceptives or anabolic steroids. Pregnancy should be avoided until resection of the tumour because of the risk of growth and rupture.

• Symptomatic tumours should be resected. Due to the increased risk of spontaneous life-threatening haemorrhage and the possible malignant transformation associated with larger-sized tumours, asymptomatic hepatic adenomas approaching 4 cm and those requiring hormonal therapy should also be resected.¹¹

• Yearly ultrasound imaging and serum AFP levels for patients with hepatocellular adenomas who do not have a resection of the tumour.

• Emergency hepatic arteriography and embolisation should be considered to control bleeding in high-risk surgical candidates.

Focal nodular hyperplasia¹²

• Focal nodular hyperplasia is the second most common benign liver tumour.

• It is a benign condition of the liver that is often discovered incidentally on radiological investigation. It is more common in women.

• It is not prone to malignant change.¹³

• It is rarely symptomatic and surgical intervention is almost never required. However, symptomatic focal nodular hyperplasia does occur, may have rapid growth and may require resection.¹⁴

• Duplex Doppler ultrasound may be sufficient but further confirmation may be required using CT, MRI, MR angiography or radionuclide imaging.

• Rupture and haemorrhage have occasionally been reported. Therefore, some authorities advocate excision but most patients can be monitored with imaging.

Other benign liver tumours

They are very rare. They include fibroma, lipoma, leiomyoma and cystadenoma.