What are the treatment and management options for hepatic adenoma?

Management of Hepatic Adenoma

Surgical resection is the recommended first-line treatment for hepatic adenomas to reduce risks of hemorrhage and malignant transformation, particularly for adenomas >5 cm, those with concerning features, or in high-risk patients. 1

Diagnostic Evaluation

• Initial imaging should include contrast-enhanced CT or MRI to characterize the lesion(s), with MRI being preferred for better characterization of adenoma subtypes 2
• Regular monitoring with ultrasound is reasonable in the pediatric population, with baseline imaging followed by repeat studies every 12-24 months 2
• Once adenomas are detected, contrast-enhanced CT/MRI should be performed every 6-12 months or earlier based on clinical findings 2
• Laboratory testing should include liver function tests (transaminases, albumin, bilirubin) every 6 months in patients with adenomas 2
• Alpha-fetoprotein and carcinoembryonic antigen levels are often normal even with malignant transformation and cannot reliably predict HCA-to-HCC transformation 2

Treatment Algorithm

Conservative Management

• Consider in selected cases:
  • Adenomas <5 cm without concerning features 3
  • Cessation of oral contraceptives or exogenous hormones, which may lead to regression 3
  • Weight loss in patients with metabolic syndrome 3

Indications for Intervention

• Adenomas >5 cm in diameter 4
• Male patients (higher risk of malignant transformation) 5
• Patients with symptoms (especially abdominal pain) 1
• Beta-catenin activated subtype (higher risk of malignant transformation) 5
• Evidence of growth on follow-up imaging 2
• Increasing number of lesions 2
• Increased vascularity (concerning for malignant transformation) 2

Treatment Options

Surgical Resection

• First-line treatment for most hepatic adenomas that meet intervention criteria 1
• Anatomical resections are recommended when feasible 2
• Laparoscopic approach can be safely used in selected cases 1, 4
• Perioperative mortality for liver resection in appropriate candidates is expected to be 2-3% 2

Minimally Invasive Treatments

• Transarterial embolization:

  • First-line treatment for ruptured adenomas with active bleeding 6
  • Can be considered as a bridge to elective surgery 6
  • May be definitive treatment in selected cases, particularly poor surgical candidates 6

• Percutaneous ablative therapies:

  • Percutaneous ethanol injection and radiofrequency ablation are options for adenomas (especially if increasing in size or number) 2
  • Best for lesions <5 cm in diameter 2

Liver Transplantation

• Consider for patients with:
  • Multiple, growing lesions that do not regress with improved dietary regimens 2
  • No evidence of distant metastatic disease 2
  • Glycogen storage disease with multiple adenomas 2
  • High-risk genetic/molecular features suggesting potential for malignant transformation 2

Management of Complications

Hemorrhage

• Immediate hemodynamic stabilization 6
• Transarterial embolization as first-line treatment 6
• Consider elective resection after stabilization 1

Malignant Transformation

• High suspicion needed as no reliable biomarker exists 2
• Warning signs include:
  • Sudden increase in size or number of adenomas 2
  • Increased vascularity 2
  • Changes in imaging characteristics 2
• Treat according to oncologic resection principles if malignant transformation is confirmed 3

Special Considerations

Pregnancy

• Pregnancy is a risk factor for tumor growth and complications but is not an absolute contraindication 3
• Close monitoring with ultrasound during pregnancy is recommended 3

Glycogen Storage Disease

• Patients with glycogen storage disease require special consideration due to higher risk of adenoma development 2
• Good metabolic control may modify adenoma formation and progression, but adenomas can occur despite good control 2
• Consider liver transplantation for patients with multiple, growing lesions 2

Follow-up Protocol

• Regular imaging surveillance every 6-12 months with contrast-enhanced MRI or CT 2
• Liver function tests every 6 months 2
• Lifelong follow-up is recommended due to risk of recurrence or development of new lesions 2