Hepatic adenoma rupture following portal vein embolization

Abstract

Hepatic adenomas are benign liver tumors typically found in females of reproductive age. Though benign, hepatic adenomas are highly vascularized tumors, thus rupture and consequent hemorrhage present a feared complication. We report a case of a 31-year-old woman with hepatic adenoma who underwent preoperative portal vein embolization and subsequently suffered a rupture of her tumor. We postulate that the change in blood flow after portal vein embolization, a phenomenon known as the hepatic artery buffer response, may have contributed to the tumor rupture, though the possibility that the rupture was purely incidental remains. There is currently no prior report of such rupture occurring following portal vein embolization, and this case brings to light a potentially fatal complication of a generally safely regarded procedure in patients with hepatic adenoma.

Keywords: Adenoma rupture; Bleed; Hepatic adenoma; Portal vein embolization.

Fig. 1

Axial (a) and coronal (b) contrast-enhanced CT images demonstrate a large, hyperenhancing adenoma in the right lobe of the liver. Pre-embolization portal venogram (c) demonstrates decreased portal venous perfusion in the right lobe in the region of the hepatic adenoma. Postembolization portal venogram (d) shows redirection of the entire portal venous flow to the left hepatic lobe and absent portal venous flow in the embolized right lobe.

Fig. 2

Axial (a, c) and coronal (b) contrast-enhanced CT images demonstrate large intratumoral hemorrhage with multiple foci of active extravasation (black arrows) and intraperitoneal hemorrhage (white arrows). Hepatic artery angiogram (d) confirmed foci of arterial extravasation (black arrows).

Fig. 3

Photographs show the resected right liver lobe specimen (a) and the bisected right lobe of the liver with exposed adenoma (b). Low power (20×) view of hematoxylin and eosin staining of the resected right liver lobe specimen demonstrates embolization beads in a portal microvessel (c). Axial contrast-enhanced CT image 4 months after right lobe resection demonstrates enlarged left liver lobe (d).