From the Guidelines
The correct answer is (a) usually occurs in women of reproductive age. Hepatic focal nodular hyperplasia (FNH) is a benign liver lesion that predominantly affects women between the ages of 20-50 years, with a female-to-male ratio of approximately 8:1, as reported in a study published in the Journal of Hepatology in 2023 1. Despite common misconception, FNH is not causally related to oral contraceptive use (option b is incorrect), although hormones may influence its growth in some cases. Most patients with FNH are asymptomatic, with the lesion often discovered incidentally during imaging performed for unrelated reasons. Only about 20% of patients present with abdominal pain (option c is incorrect). FNH has a characteristic central stellate scar with radiating fibrous septa and is considered a stable lesion with minimal risk of complications. Unlike hepatic adenomas, FNH rarely undergoes spontaneous rupture or hemorrhage (option d is incorrect), making it a lesion that typically requires no intervention unless symptomatic, as supported by a study published in Hepatology in 2021 1. The benign nature and low complication rate of FNH generally allow for conservative management with periodic imaging surveillance rather than surgical resection.
Some key points to consider in the management of FNH include:
- The association of FNH with estrogen is not well established, and pregnancy is not contraindicated in women with FNH, as stated in the EASL clinical practice guidelines on the management of liver diseases in pregnancy 1.
- Imaging is not routinely recommended to monitor FNH during pregnancy, unless there are specific concerns or symptoms, as recommended in the guidelines 1.
- The risk of spontaneous rupture or hemorrhage is extremely low, and FNH is considered a stable lesion with minimal risk of complications, as reported in the study published in Hepatology in 2021 1.
Overall, the management of FNH should prioritize a conservative approach, with periodic imaging surveillance and monitoring for symptoms, rather than surgical intervention, in order to minimize morbidity, mortality, and improve quality of life.
From the Research
Hepatic Focal Nodular Hyperplasia Characteristics
- Hepatic focal nodular hyperplasia (FNH) usually occurs in women of reproductive age, as stated in the study 2.
- The condition is related to oral contraceptive use, although the influence of female hormones on the course of FNH is still controversial, as mentioned in 2 and 3.
- FNH typically presents as an asymptomatic liver mass, with abdominal pain not being a common symptom, as indicated in 3 and 4.
- The risk of spontaneous rupture is extremely rare for FNH, as stated in 3 and 5.
Clinical Behavior and Pathologic Features
- FNH is distinct from hepatic adenoma in its clinical behavior and pathologic features, as mentioned in 3 and 5.
- The two conditions can usually be differentiated radiographically using a combination of radionuclide scanning and angiography, as stated in 5.
- FNH may be a precursor for fibrolamellar hepatocellular carcinoma, although it is a truly benign lesion without any potential for malignant transformation, as indicated in 5 and 4.
Treatment and Management
- Discontinuation of oral contraceptives can reduce the size of FNH, as shown in the case report 2.
- Systematic follow-up remains the gold standard in asymptomatic patients with FNH, as stated in 4 and 6.
- Elective surgery should be considered in symptomatic patients, in those with marked enlargement, and in case of uncertainty of diagnosis, as mentioned in 4 and 6.
- Surgery for FNH is a safe procedure with low morbidity and very good long-term results, as indicated in 4 and 6.