Hepatic Adenoma

 Almost all in young women with high estrogen environment, including steatosis and oral contraceptive use

image Anabolic steroids, diabetes, and glycogen storage disease are other causes

• Key features (not always present): Hypervascularity, fat content, hemorrhage, encapsulation

• MR shows some elements better than CT (lipid and hemorrhage)

• Gadoxetate-enhanced MR (Eovist; Primovist)
image Adenoma shows no substantial uptake or retention

image Key distinction from FNH

• T1WI: Mass: Heterogeneous signal intensity
image Increased signal intensity (due to fat or recent hemorrhage)

image Decreased signal intensity (necrosis, calcification, old hemorrhage)

• Heterogeneous, hypervascular mass with foci of fat or hemorrhage in a young woman


• Hepatocellular carcinoma (HCC)
image HCC typically occurs in older, cirrhotic men

• Fibrolamellar HCC

• Focal nodular hyperplasia
image Homogeneously enhances; retains gadoxetate

• Hypervascular metastases


• Hepatic steatosis, pregnancy, anabolic steroids,  and oral contraceptives increase number and growth rate of adenomas


• Risk factors for HCC
image Large adenoma, male sex, glycogen storage disease, anabolic steroid use, CTNNB1 -mutated subtype of HA

(Left) Graphic shows a hypervascular mass image in the right lobe and spontaneous subcapsular bleeding image.

(Right) Axial CECT of a 40-year-old woman with sudden RUQ pain and syncope shows an intensely enhancing mass image in the right lobe of the liver. A lentiform heterogeneous collection of fluid indents the surface of the liver, and within this collection is a focus of higher density image likely representing a sentinel clot. A ruptured inflammatory hepatic adenoma was resected.

(Left) Photograph of a resected specimen shows a large adenoma image with central areas of rupture and hemorrhage image. (Courtesy M. Yeh, MD, PhD.)

(Right) Photomicrograph of a hepatic adenoma features a thin-walled unpaired vessel image surrounded by neoplastic hepatocytes with abundant steatosis. Imaging often reveals these features, directly or indirectly. (Courtesy M. Yeh, MD, PhD.)



• Hepatic adenoma (HA)


• Hepatocellular adenoma, liver cell adenoma


• Heterogeneous group of benign hepatocellular neoplasms with distinctive genetic, pathologic, and clinical features


General Features

• Best diagnostic clue
image Heterogeneous, hypervascular mass with foci of fat or hemorrhage in a young woman

• Location
image Subcapsular region of right lobe of liver (75%)

image Intraparenchymal or pedunculated (10%)

• Size
image Varies from 6-30 cm

• Key concepts
image Very uncommon relative to focal nodular hyperplasia (FNH) and hepatocellular carcinoma (HCC)

image 3 distinct subtypes with different genetics, pathology, clinical features

CT Findings

• Depending on HA subtype
image Encapsulation seen in ∼ 20%, best on delayed phase CECT

image Hemorrhage within tumor, best seen on NECT as hyperdense foci

image Intratumoral lipid, best seen on NECT as hypodense foci

image Hypervascularity
– Most intense and persistent in inflammatory subtype of HA

image Calcification: Focal, present in ∼ 5%

MR Findings

• T1WI
image Mass: Heterogeneous signal intensity
– Increased signal intensity (due to fat and recent hemorrhage), more evident on MR than CT

– Decreased signal intensity (necrosis, calcification, old hemorrhage)

image Rim (fibrous pseudocapsule): Hypointense

• T2WI
image Mass: Heterogeneous signal intensity
– Increased signal intensity (old hemorrhage, necrosis)

– Decreased signal intensity (fat, recent hemorrhage)

image Rim (fibrous pseudocapsule): Hypointense

• T1WI C+
image Gadolinium, arterial phase
– Heterogeneous hypervascular enhancement (especially in inflammatory subtype)

image Delayed phase
– Pseudocapsule: Hyperintense to liver and adenoma

• Gadoxetate-enhanced MR (Eovist, Primovist)
image Hepatocellular-specific contrast agent

image Adenoma shows no substantial uptake or retention on delayed imaging
– Key distinction from FNH

Ultrasonographic Findings

• Grayscale ultrasound
image Complex, hyper-/hypoechoic, heterogeneous mass with anechoic areas
– Due to fat, hemorrhage, necrosis, and calcification

– Capsule may be seen

• Color Doppler
image Hypervascular tumor

image Large peripheral arteries and veins

image Intratumoral veins present
– Absent in FNH; useful distinction for adenoma

Angiographic Findings

• Conventional
image Hypervascular mass with centripetal flow

image Enlarged hepatic artery with feeders at tumor periphery (50%)

image Hypovascular; avascular regions
– Due to hemorrhage and necrosis

Nuclear Medicine Findings

• Technetium sulfur colloid (TcSC)
image Usually “cold” (photopenic) (80%)

image Uncommonly “warm” (20%)
– Due to uptake in sparse Kupffer cells

• HIDA scan
image Increased activity in some

• Gallium scan
image No uptake

Imaging Recommendations

• Best imaging tool
image Gadoxetate-enhanced MR, including multiphasic and delayed imaging

image In- and opposed-phase GRE


Hepatocellular Carcinoma

• May be hard to distinguish on imaging or pathology

• Biliary, vascular, nodal invasion and metastases = malignancy

• HCC typically occurs in older, cirrhotic men
image Adenoma occurs in young, healthy women

Fibrolamellar HCC

• Large, lobulated mass with scar and septa

• Vascular, biliary invasion and metastases common

Nov 16, 2016 | Posted by in GASTROINTESTINAL IMAGING | Comments Off on Hepatic Adenoma

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