Benign Tumors
Liver Cysts
Simple/congenital cysts
Simple cysts are the most common benign lesions found in the liver. Simple cysts are made up of bile duct cells that are not connected with the bile duct system. They rarely are symptomatic unless they are large, in which case patients may complain of pain, epigastric fullness or a mass, or early satiety related to gastric compression.
Treatment
Simple aspiration (emptying the cyst through a needle placed by a radiologist) is not recommended as an initial therapy because the cysts almost always recur. If the cyst is drained then injected and reaspirated with absolute alcohol (PAIRS) the success rate is as high as 80 percent.
If PAIRS fails or is not possible to perform, then laparoscopic surgery – wide unroofing is usually the next step. The recurrence rate after wide cyst fenestration is usually less than 5 percent. The excised cyst wall is evaluated by the pathologists to confirm the diagnosis.
Polycystic liver disease
Polycystic liver disease (PCLD) is a genetic disorder that occurs over a wide spectrum of clinical and anatomic presentations (few small cysts to innumerable and often very large cysts) is seen in. Symptoms include fullness, trouble eating, and pain which is often chronic and unrelenting. Other causes of such symptoms should be evaluated before considering cyst drainage or surgery.
As with simple cysts, PAIRS or laparoscopic unroofing are the treatment options if there are a few large cysts that are causing specific complaints. Occasionally resection (removing part of the liver) is appropriate when there is diffuse cyst disease and a markedly enlarged liver. Liver transplantation is reserved when the other treatments are not possible, often when there is liver failure as well.
Biliary cystadenoma
Biliary cystadenomas are uncommon cysts that result from abnormal growth of cells in the liver (neoplasia). The symptoms are the same as with other liver cysts and are often seen in women older than 40 years of age. CT and MRI are usually accurate in making the diagnosis. These tumors have a small risk of becoming malignant, so complete removal is recommended.
Treatment
BCAs need to be removed completely in order to prevent recurrence. This can usually be done by enucleation (shelling the tumor out of the liver), which can be less traumatic than a formal liver resection.
Infectious cysts – liver abscess
Liver abscesses are collections of pus and bacteria in the liver .They are caused by seeding from an infection elsewhere (like colon inflammation or heart valve infections) or they can occur after endoscopic bile duct studies (ERCP). They are rarely difficult to diagnose as symptoms can include right upper quadrant abdominal pain, fever, sweats and chills. Abscesses are detected by ultrasound, CT and MRI.
Treatment
Intravenous antibiotics and radiologic drainage are usually effective. Surgery is rarely necessary.
Benign Solid Liver Tumors
Benign, solid liver tumors are being seen more frequently as the number of ultrasounds and CTs increases.
Hepatic adenoma
Hepatic adenomas (e.g., liver cell adenoma, hepatocellular adenoma) are the most important benign liver tumors. They occur in reproductive age woman and are more common in women who use oral contraceptives (OCPs). The tumors are composed of pure sheets of hepatocytes (liver cells). Pain is the most common presenting symptoms. However, adenomas are significant because they can rupture and as many as 25 percent of these lesions are found as a result of an acute bleed.
The diagnosis is often made with CT and MRI. Occasionally it may be difficult to confidently make the diagnosis with these tests and a nuclear medicine liver scan may be necessary. Biopsy is rarely necessary.
Treatment
Since most patients with adenomas are taking OCPs, stopping these drugs is the first line of therapy. Small adenomas (<4 cm) can be followed and if they regress may not require further treatment. Tumors that do not regress or tumors larger than 4 cm should be considered for removal (resection) as there is a risk of rupture and a small risk of cancer. Resection can be laparoscopic or open depending on the location of the tumor. Laparoscopic RFA is a potentially effective treatment option especially in patients with multiple adenomas.
Focal nodular hyperplasia
In contrast to hepatic adenomas, focal nodular hyperplasia typically is not associated with symptoms. FNH is an overgrowth of normal liver cell types and as such does not pose a risk of bleeding/rupture or malignant degeneration. These lesions have characteristic findings on CT or MRI, but a nuclear medicine scan may be necessary to confirm the diagnosis.
Treatment
Because FNH is rarely symptomatic surgery is rarely recommended. In patients with symptoms related to FNH, resection is indicated and can be performed open or laparoscopically.
Hemangiomas
Hemangiomas, also known as cavernous hemangiomas, are common benign liver lesions generally discovered incidentally on X-ray studies. They arise as a disorganized collection of small blood vessels. Symptoms may include chronic low-intensity right upper-quadrant abdominal pain and problems with eating, especially when the lesions are quite large. Hemangiomas of the liver pose a very small risk of bleeding. Hemangiomas rarely cause blood disorders (including platelet problems). Ultrasound, CT and MRI are usually diagnostic. If the diagnosis is unclear, a nuclear medicine liver red blood cell SPECT scan may be necessary. Rarely an angiogram is needed for diagnosis.
Treatment
As with the other benign lesions, if symptoms are present other causes of abdominal pain should always be sought before considering surgery. When indicated by symptoms, hemangiomas can be resected by enucleation or more standard formal liver resection.
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