The value of liver resection for focal nodular hyperplasia: resection yes or no?

BACKGROUND: Focal nodular hyperplasia (FNH) are benign lesions in the liver. Although liver resection is generally not indicated in these patients, rare indications for surgical approaches indeed exist. We here report on our single-center experience with patients undergoing liver resection for FNH, focussing on preoperative diagnostic algorithms and quality of life (QoL) after surgery. METHODS: Medical records of 100 consecutive patients undergoing liver resection for FNH between 1992 and 2012 were retrospectively analyzed with regard to diagnostic pathways and indications for surgery. Quality of life (QoL) before and after surgery was evaluated using validated assessment tools. Student's t test, one-way ANOVA, χ (2), and binary logistic regression analyses such as Wilcoxon-Mann-Whitney test were used, as indicated. RESULTS: A combination of at least two preoperative diagnostic imaging approaches was applied in 99 cases, of which 70 patients were subjected to further imaging or tumor biopsy. In most patients, there was more than one indication for liver resection, including tumor-associated symptoms with abdominal discomfort (n = 46, 40.7 %), balance of risk for malignancy/history of cancer (n = 54, 47.8 %/n = 18; 33.3 %), tumor enlargement/jaundice of vascular and biliary structures (n = 13, 11.5 %), such as incidental findings during elective operation (n = 1, 0.9 %). Postoperative morbidity was 19 %, with serious complications (>grade 2, Clavien-Dindo classification) being evident in 8 %. Perioperative mortality was 0 %. Liver resection was associated with a significant overall improvement in general health (very good-excellent: preoperatively 47.4 % vs. postoperatively 68.1 %; p = 0.015). CONCLUSIONS: Liver resection remains a valuable therapeutic option in the treatment of either symptomatic FNH or if malignancy cannot finally be ruled out. If clinically indicated, liver resection for FNH represents a safe approach and may lead to significant improvements of QoL especially in symptomatic patients.

Laparoscopic versus open liver resection for benign and malignant solid liver tumors: a case-matched study.

BACKGROUND: Laparoscopic liver resection (LLR) is proposed as an alternative to open liver resection (OLR) for treatment of liver tumors. The aim of this study was to compare the surgical and oncological outcomes of LLR versus OLR in benign and malignant solid liver tumors. STUDY DESIGN: In this case-matched study, charts of 497 patients with liver lesions who had LLR or OLR in our center were retrospectively reviewed. Among them, 54 consecutive patients with benign or malignant solid liver tumors who had LLR were matched with a similar number of patients with OLR based on the pathology and extent of liver resection. Additionally, the surgical and oncological outcomes such as operating room time, amount of blood transfusion requirement, free resection margin rate, length of hospital stay, complication rate, perioperative mortality, and survival were compared between the two groups. RESULTS: Demographics, pathological characteristics of the tumor, and extent of liver resection were similar between the two groups. Twenty-nine (54%) patients in each group had malignant lesions. There were no statistically significant differences between the two groups in terms of operating room time, amount of blood transfusion requirement, free resection margin, or postoperative complication rate or survival. However, hospital stay was significantly shorter in the laparoscopic group (5.9 versus 9 days, P=.006). Although no perioperative mortality was observed in patients with benign tumors, among the patients with malignant tumors, 2 died perioperatively in each group. CONCLUSIONS: Our results in accordance with previous studies demonstrated that although the oncological outcomes of LLR and OLR were comparable, LLR patients had a shorter hospital stay.

Insulin-like growth factor II mRNA-binding protein 3 (IMP3) expression in hepatocellular carcinoma. A clinicopathological analysis with emphasis on diagnostic value.

AIMS: Patients with hepatocellular carcinoma (HCC) usually present with advanced disease and rarely qualify for curative therapy. Immunohistochemical markers that help to discriminate benign from malignant processes early, and that have prognostic significance, would be useful. Expression of the oncofetal protein insulin-like growth factor II mRNA-binding protein 3 (IMP3) in malignant cells of different tumour types correlates with reduced overall survival. METHODS AND RESULTS: Tissue microarrays (TMAs) containing 55 normal liver samples, 365 HCCs (122 with corresponding non-tumorous liver), 10 hepatocellular adenomas, 13 focal nodular hyperplasias and nine dysplastic nodules from western European patients were stained for IMP3. IMP3 was analysed in 61 core needle biopsies and findings were compared to glypican-3 and CD34. HCCs in TMAs were strongly positive for IMP3 in 18.4% of cases compared to absent expression in normal and non-tumorous liver tissue and benign liver tumours. Patients with IMP3 expression in HCCs showed significantly poorer overall survival in multivariate analysis (P = 0.044). Of the 61 core needle biopsies analysed, 32 (52.5%) of the HCCs were IMP3-positive. CONCLUSIONS: In core needle biopsies, IMP3 expression seems to be of limited use as a single marker for the diagnosis of HCC, given a sensitivity of 52%, but it may be helpful in combination with other markers.

Nodular regenerative hyperplasia of the liver: survival and associated features in a UK case series.

AIMS: Nodular regenerative hyperplasia (NRH) is a rarely identified liver disorder. It is characterized histologically by nodular hepatocyte regeneration without significant fibrosis, and clinically by portal hypertension and abnormal liver function tests (LFTs). Survival data in an unselected cohort after diagnosis of NRH have not been previously described. This study aims to identify a regional cohort with NRH, to determine survival after diagnosis and to assess the relative frequency of associated conditions. METHODS: Patients were identified retrospectively from liver biopsy reports within pathology databases, over a 13-year period from Glasgow, Scotland, UK. Case notes were retrieved, clinical information extracted and survival was determined. RESULTS: Forty-two patients were identified (19 males). Common presenting features were abnormal LFTs (predominantly cholestatic) (76%) and portal hypertension (9.5%). None had severe liver dysfunction (Child-Pugh score A: 81%, B: 19%, C: 0%). Varices were detected in 26%, and portal hypertension was detected in 31%. There were five (12%) variceal bleeds, one fatal. The patients were subdivided into four groups according to associated clinical conditions: malignancy (29%), prothrombotic (21%), rheumatological (24%) and idiopathic/other (26%). Mean survival was 8.1 years, although survival was highly variable, and was associated with age and associated disease, but not with portal hypertension or varices. No patients in the rheumatological subgroup died. CONCLUSION: NRH is usually associated with malignant, prothrombotic or rheumatological conditions. Survival is highly variable and related to age and the underlying disease process, but not to portal hypertension overall. Liver function remains well preserved.

Focal nodular hyperplasia of the liver in longterm survivors of neuroblastoma: how much diagnostic imaging is necessary?

OBJECTIVES: Focal nodular hyperplasia of the liver is a tumor-like lesion, uncommon in children, but it has recently been more frequently observed in children treated for malignant diseases, especially neuroblastoma. The aetiology is unclear, the pathogenesis remains controversial. Focal nodular hyperplasia of the liver is suspected to be a sequela of tumor therapy. METHODS: Besides the clinical data we evaluated the imaging modalities needed to diagnose focal nodular hyperplasia of the liver in children with neuroblastoma who have been followed in our institution for more than 5 years. RESULTS: Out of 60 children six developed focal nodular hyperplasia at a median time of 10.5 years after diagnosis of neuroblastoma and 9.4 years after the end of treatment. The diagnosis of focal nodular hyperplasia was based on imaging criteria which are variable in ultrasonography and specific in MRI. Only one child underwent surgical biopsies to rule out liver metastases. CONCLUSIONS: Longterm survivors of neuroblastoma are at risk of developing focal nodular hyperplasia, especially if they underwent toxic chemotherapy and/or radiotherapy to the liver during initial treatment. The recommended diagnostic imaging tools are ultrasonography for detecting liver lesions and MRI for confirming and characterizing these lesions as focal nodular hyperplasia.

Isolated resection of the caudate lobe: indications, technique and results.

BACKGROUND/AIMS: This paper reports a series of 24 isolated caudate lobe resections (ICLR), performed for 13 benign tumors (10 hemangiomas, 2 focal nodular hyperplasias, 1 adenoma) and 11 malignant tumors (3 hepatocarcinomas, 1 peripheral cholangiocarcinoma and 7 metastatic - 5 colorectal carcinomas, 1 breast carcinoma, 1 adrenal carcinoma). Klatskin tumors were excluded. METHODOLOGY: There were 10 hemangioma enucleations, 7 Spiegel lobe resections and 7 high dorsal resections. Total vascular exclusion was performed in 7 cases. Vascular resection with reconstruction was necessary in 5 cases. RESULTS: Complications occurred in 7 cases (3 bile leaks, 3 abdominal fluid collections and one liver failure leading to death). From the 10 patients with malignant tumors who survived the operation, 7 developed recurrences: 2 intrahepatic, 1 retroperitoneal, 4 systemic. Five patients are alive (3 without recurrence). One patient died of multiple complications after a repeat hepatectomy and colectomy. Three patients died from generalized disease. Another patient, with generalized disease, was lost from follow-up. CONCLUSIONS: ICLR is a difficult operation, especially with malignant tumors. Total vascular exclusion of the liver is routinely recommended in high dorsal resection. Malignant tumors located in the caudate lobe have a poor prognosis; local and, especially, distant metastases are frequent. Aggressive chemotherapy and follow-up are recommended.