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Case Reports
. 2013 Dec;11(4):524-7.
doi: 10.1590/s1679-45082013000400021.

Minimally invasive treatment of hepatic adenoma in special cases

[Article in English, Portuguese]
Felipe Nasser, Breno Boueri Affonso, Francisco Leonardo Galastri, Bruno Calazans Odisio, Rodrigo Gobbo Garcia
Case Reports

Minimally invasive treatment of hepatic adenoma in special cases

[Article in English, Portuguese]
Felipe Nasser et al. Einstein (Sao Paulo). 2013 Dec.

Abstract
in English, Portuguese

Hepatocellular adenoma is a rare benign tumor that was increasingly diagnosed in the 1980s and 1990s. This increase has been attributed to the widespread use of oral hormonal contraceptives and the broader availability and advances of radiological tests. We report two cases of patients with large hepatic adenomas who were subjected to minimally invasive treatment using arterial embolization. One case underwent elective embolization due to the presence of multiple adenomas and recent bleeding in one of the nodules. The second case was a victim of blunt abdominal trauma with rupture of a hepatic adenoma and clinical signs of hemodynamic shock secondary to intra-abdominal hemorrhage, which required urgent treatment. The development of minimally invasive locoregional treatments, such as arterial embolization, introduced novel approaches for the treatment of individuals with hepatic adenoma. The mortality rate of emergency resection of ruptured hepatic adenomas varies from 5 to 10%, but this rate decreases to 1% when resection is elective. Arterial embolization of hepatic adenomas in the presence of bleeding is a subject of debate. This observation suggests a role for transarterial embolization in the treatment of ruptured and non-ruptured adenomas, which might reduce the indication for surgery in selected cases and decrease morbidity and mortality. Magnetic resonance imaging showed a reduction of the embolized lesions and significant avascular component 30 days after treatment in the two cases in this report. No novel lesions were observed, and a reduction in the embolized lesions was demonstrated upon radiological assessment at a 12-month follow-up examination.

O adenoma hepatocelular é um tumor benigno raro, que apresentou aumento do número de diagnósticos nas décadas de 1980 e 1990, o que foi atribuído à difusão dos contraceptivos hormonais orais, e à melhor disponibilização e ao avanço dos exames radiológicos. Apresentamos aqui o relato de dois pacientes com grandes adenomas hepáticos submetidos ao tratamento minimamente invasivo por meio de embolização arterial. O primeiro caso foi submetido à embolização eletiva, por apresentar múltiplos adenomas, além de hemorragia recente de um desses nódulos. O segundo, caracterizado por vítima de trauma abdominal fechado e rotura de adenoma hepático, foi realizado em caráter de urgência, tendo a paciente sinais clínicos de choque hemodinâmico secundário à hemorragia intra-abdominal. O desenvolvimento de terapias minimamente invasivas locorregionais, como a embolização arterial, trouxe um novo horizonte para pacientes com adenomas hepáticos. Na ressecção emergencial de um adenoma hepático roto, as taxas de mortalidade são de 5 a 10%, enquanto que a ressecção eletiva reduz a 1% esse desfecho. A embolização arterial dos adenomas hepáticos na vigência de hemorragia é tema de debate. Essa constatação aponta para um possível papel da embolização transarterial desses tumores rotos e não rotos, visto que tal conduta poderá limitar a indicação cirúrgica em casos selecionados, resultando na redução da morbimortalidade. O seguimento das pacientes tratadas foi realizado por meio de ressonância magnética e, após 30 dias, já havia diminuição das lesões embolizadas bem como a presença de significativo componente avascular. O controle radiológico, após 12 meses, mostrou ausência de novas lesões e diminuição daquelas embolizadas.

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Figures

Figure 1
Figure 1. Angiography of the liver before and after embolization. Hypervascular lesions compatible with hepatic adenomas were observed in the liver right lobe, and these lesions are absent in the angiography after embolization
Figure 2
Figure 2. Magnetic resonance imaging before embolization and one year later. Hypervascular lesions in the liver right lobe. The largest one is located in the caudate lobe with central necrosis and external compression of the inferior vena cava. The control magnetic resonance imaging exam performed one year after embolization shows a reduced hypervascular lesion in the caudate lobe, no external compression of the inferior vena cava, and no growth of the remaining hypervascular lesions
Figure 3
Figure 3. Angiography of the liver before and after embolization. A large hypervascular lesion compatible with hepatic adenoma was observed in the liver right lobe, and the amputation of the intrahepatic arterial branches in the control exam after embolization is shown
Figure 4
Figure 4. Tomography of the abdomen before embolization and control magnetic resonance imaging one year later. A large hypervascular lesion is observed in the right liver lobe with a heterogeneous aspect suggestive of local hematoma, hypervascular lesions in the left liver lobe, and free fluid in the peritoneal cavity suggestive of abdominal hemorrhage. The magnetic resonance imaging exam one year later showed a significant reduction of the embolized lesions and the absence of new lesions
See this image and copyright information in PMC

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