Who manages liver adenomas?

Management of Liver Adenomas

Liver adenomas should be managed by a multidisciplinary hepatobiliary team led by a hepatologist, with essential involvement of hepatobiliary surgeons, interventional radiologists, diagnostic radiologists, pathologists, and oncologists.

Multidisciplinary Team Approach

The management of liver adenomas requires specialized expertise from multiple disciplines to ensure optimal patient outcomes regarding morbidity, mortality, and quality of life. According to current guidelines, the following specialists should be involved:

Core Team Members:

• Hepatologist: Serves as the primary coordinator who first diagnoses and manages the underlying liver disease 1
• Hepatobiliary/Transplant Surgeons: At least two specialists trained in liver resection surgery who can demonstrate high-level skills in this area 1
• Interventional Radiologist: Expert in hepatobiliary disease for potential embolization procedures 1
• Diagnostic Radiologist: Specialized in liver imaging for accurate characterization of lesions 1
• Pathologist: Expert in liver pathology for tissue diagnosis when needed 1
• Clinical Nurse Specialist: For patient education and care coordination 1

Additional specialists may include:

• Medical Oncologist: For cases with malignant transformation 1
• Psychologist/Social Worker: For patient support 1

Decision-Making Process

The multidisciplinary team should follow a structured approach to management:

1. Initial Assessment:

   • Complete imaging workup (contrast-enhanced CT or MRI is preferred over ultrasound with 68-91% detection rates) 1
   • Risk stratification based on:
     • Size (>5 cm increases risk of complications)
     • Molecular subtype (β-catenin activated subtypes have higher malignancy risk)
     • Gender (males have higher risk of malignant transformation)
     • Presence of symptoms 2, 3

2. Treatment Decision Algorithm:

   • Observation: For small (<5 cm), asymptomatic adenomas in low-risk patients
   • Surgical Resection: Indicated for:
     • Symptomatic patients
     • Adenomas >5 cm
     • Male patients
     • β-catenin activated subtype
     • Evidence of growth despite hormone cessation 2, 3
   • Embolization: For acute hemorrhage before definitive management 3

Pitfalls and Considerations

• Avoid Delayed Referral: General surgeons should recognize their limitations and refer complex cases to hepatobiliary centers early 4
• Pregnancy Considerations: While pregnancy can increase risk of adenoma growth and complications, the presence of an adenoma alone is not a contraindication to pregnancy 3
• Hemorrhage Risk: 29% of adenomas may present with hemorrhage, requiring prompt intervention 2
• Malignant Transformation: Approximately 5% risk, necessitating oncologic principles for resection 2

Surgical Approach

When surgery is indicated, the approach should be determined by the hepatobiliary surgical team:

• Laparoscopic resection is increasingly preferred for accessible lesions with 70% lower morbidity compared to open procedures 5, 2
• Open resection may be necessary for larger, less accessible, or multiple adenomas 2

The management of liver adenomas has evolved significantly with improved imaging and surgical techniques, shifting toward earlier surgical intervention in high-risk cases rather than prolonged observation, especially given the favorable risk-benefit ratio of modern minimally invasive approaches 5, 2.