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Abdomen » Hepatobiliary
Hepatic Focal Nodular Hyperplasia
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Author(s) :
Danilo Sirigu, MD
 
Presentation A 35 -year-old woman with a history of oral contraception presents with right upper quadrant pain.
 
 
Caption: B-mode gray scale imaging
Description: Transabdominal ultrasound shows a mass in the right lobe of the liver. The mass is isoechoic to the surrounding liver parenchyma and is causing contour deformity.
 
 
Caption: Color Doppler
Description: Transverse Color Doppler ultrasound shows a "central spider" pattern with multiple vessels radiating peripherally from the centre of the lesion.
 
 
Caption: Contrast Enhanced Ultrasound (CEUS)
Description: Transverse arterial phase image after injection of microbubble contrast agent (SonoVue) shows small central enhancement of the lesion with a “ spoke wheel “ appearance. CEUS image in portal venous phase and late phase shows persistent positive homogeneous enhancement with iso-enhancing appearance.
 
 
 
Caption: 
Description: 
 
Differential Diagnosis Focal nodular hyperplasia,
Hemangioma,
Hepatic adenoma
Fibrolamellar Hepatocellular Carcinoma
 
Final Diagnosis Focal Nodular Hyperplasia
 
Discussion Focal Nodular Hyperplasia is the second most common benign liver mass after hemangioma.  It is thought to be a benign hyperplastic response to a congenital arteriovenous malformation.  FNH is not seen in patients with cirrhosis. There is usually a peripheral pseudo-capsule and a central or eccentric fibrous scar radiating to the periphery and containing arteries.
Differentiation from hepatic adenoma is important. In contrast to hepatic adenoma, conservative management can be performed safely in patients who have FNH irrespective of their size, because FNH neither undergoes malignant degeneration nor is likely to bleed or rupture.  Oral contraceptives don’t cause FNH , but have trophic effect on growth.
FNH is consistently accurately diagnosed with the use of microbubble contrast agents ( CEUS ).
In arterial phase, the lesion are hypervascular, and two highly suggestive morphologic patterns include the presence of stellate vessels within the lesion and a tortuous feeding artery .
During the portal venous phase and late phase the lesions remains iso- hyper perfused to normal liver tissue with central scar visibile in 2/3rd of large FNH .
 
Case References
  1. T. K. Kim, et alt.Focal Nodular Hyperplasia and Hepatic Adenoma: Differentiation with Low-Mechanical-Index Contrast-Enhanced Sonography Am. J. Roentgenol., January 1, 2008; 190(1): 58 - 66.
  2. Dietrich CF, Schuessler G, Trojan J, Fellbaum C, Ignee A. Differentiation of focal nodular hyperplasia and hepatocellular adenoma by contrast-enhanced ultrasound. Br J Radiol2005; 78:704 -707
  3. O. Catalano, et al.Real-Time Harmonic Contrast Material-specific US of Focal Liver Lesions RadioGraphics, March 1, 2005; 25(2): 333 – 349
  4. Migaleddu V, et al.( SMIRG); Characterization of focal liver lesions in real time using harmonic imaging with high mechanical index and contrast agent Levovist. AJR Am J Roentgenol 2004; 182:1505–1512
  5. Herman P, Pugliese V, Machado MA, et al. Hepatic adenoma and focal nodular hyperplasia: differential diagnosis and treatment. World J Surg 2000;24:372–6.
  6. Kim TK, Jang HJ, Wilson SR. Benign liver masses: imaging with microbubble contrast agents.  Ultrasound Q 2006;22:31–9.
 
Follow Up Patient was referred to a neonatal intensive care unit and treated without surgery. No further compications developed and the child is now doing fine