Liver Transplantation for Treatment of Unresectable Spontaneous Ruptured Hepatocellular Adenoma: A Rare Indication

Abstract

Hepatocellular Adenomas (HA) are rare benign tumors of the liver which occur predominantly in young women. Although benign, HA may have complications such as hemorrhage and malignant transformation. So, sometimes conservative management is not enough. We report a case of a 26-year-old woman on oral contraceptives who presented with acute abdominal pain and signs of hemodynamic shock. She underwent transarterial embolization due to the presence of multiple HA with rupture and active hemorrhage. This minimally invasive treatment failed to control the disease. The patient presented a progressive increase in the size of the masses with signs of recent hemorrhage, and the HA became unresectable, so she underwent liver transplantation. Liver transplantation is rarely indicated for the treatment of HA; however, in unresectable masses, it should be considered to prevent potential rupture with hemorrhage or malignant transformation.

Keywords: adenoma rupture; haemorrhage; hepatocellular adenoma; liver transplantation; transarterial embolization.

Figure 1. Computed tomography (CT) of the abdomen on the day of presentation.

Axial (A) and coronal (B) contrast-enhanced CT images demonstrated heterogeneously hyper-enhancing hepatic masses. The largest was one in the right lobe, which measured 11 cm and one in the left lobe, which measured 6.7 cm. The CT also showed a right subcapsular haematoma with signs of active hemorrhage (arrows) measuring 22x16x10 cm.

Figure 2. Computed tomography (CT) of the abdomen hours after first transarterial embolization.

Axial (A) and coronal (B) CT angiography images demonstrated an increase to 13 cm of the mass in the right lobe, with signs of active hemorrhage and intraperitoneal effusion. Also, the CT showed two other hyperenhancing masses in the right lobe (arrows), various masses in the left lobe (arrows), the largest measuring 9.1 cm, and the right subcapsular hematoma, without signs of active hemorrhage.

Figure 3. Computed tomography (CT) of the abdomen twenty-four days after second transarterial embolization.

Axial (A) and coronal (B) CT angiography images demonstrated various heterogeneously hepatic masses with signs of recent hemorrhage, and increased measures (arrows). The largest were two in the right lobe, which measured 14 and 11 cm and one in the left lobe, which measured 10 cm. Also, the right subcapsular hematoma showed signs of recent hemorrhage and increased measures to 27x20x12cm.