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Hepatic adenoma

Key sources
The following summarized guidelines for the evaluation and management of hepatic adenoma are prepared by our editorial team based on guidelines from the Enhanced Recovery After Surgery Society (ERASS 2023), the European Association for the Study of the Liver (EASL 2023; 2019; 2016), the European Federation of Societies for Ultrasound (EFSU 2020), the American College of Radiology (ACR 2020), and the American College of Gastroenterology (ACG 2016; 2014).
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Guidelines

1.Classification and risk stratification

Risk factors: recognize that oral contraceptives may be considered risk factors for the development of hepatic adenoma.
B
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2.Diagnostic investigations

Contrast-enhanced ultrasound
As per ACR 2020 guidelines:
Obtain contrast-enhanced abdominal ultrasound of an indeterminate > 1 cm liver lesion on initial ultrasound in patients with a normal liver with no suspicion or evidence of extrahepatic malignancy or underlying liver disease.
B
Obtain contrast-enhanced abdominal ultrasound of an incidental liver lesion > 1 cm on initial ultrasound, non-contrast or single-phase CT, or non-contrast MRI in patients with known chronic liver disease.
B

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  • Cross-sectional imaging

3.Diagnostic procedures

Liver biopsy: perform a liver biopsy in patients with inconclusive imaging findings and if a biopsy is deemed necessary to make treatment decisions.
B

4.Medical management

Indications for treatment
As per EASL 2016 guidelines:
Decide on the treatment based on gender, size, and pattern of progression.
B
Decide on the management of patients with multiple hepatocellular adenomas based on the size of the largest tumor.
B

5.Therapeutic procedures

Embolization: perform embolization of a bleeding hepatocellular adenoma with hemodynamic instability.
B

6.Perioperative care

Preoperative care, counseling
Provide preoperative information and counseling regarding the upcoming liver surgery. Consider using brochures and multimedia support to improve verbal counseling.
B
Advise preoperative smoking cessation at least 4 weeks before hepatectomy. Advise alcohol cessation in heavy drinkers (> 24 g/day for females or > 36 g/day for males) 4-8 weeks before surgery.
A

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  • Preoperative care (nutrition)

  • Preoperative care (rehabilitation)

  • Preoperative care (biliary drainage)

  • Preoperative care (antibiotic prophylaxis)

  • Preoperative care (corticosteroids)

  • Preoperative care (preanesthetic medication)

  • Intraoperative care (anesthesia and analgesia)

  • Intraoperative care (temperature management)

  • Intraoperative care (fluid management)

  • Postoperative care (thromboprophylaxis)

  • Postoperative care (early mobilization)

  • Postoperative care (nutrition)

  • Postoperative care (antiemetics)

  • Postoperative care (laxatives)

7.Surgical interventions

Surgical resection, indications: perform resection in patients with hepatocellular adenoma irrespective of size in males and in any instance of proven β-catenin mutation.
B
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  • Liver transplantation

  • Surgical resection (technical considerations)

8.Specific circumstances

Pregnant patients
As per EASL 2023 guidelines:
Do not offer additional interventions in female patients with hepatic adenomas with a diameter < 5 cm, as pregnancy does not increase the risk of complications related to the tumor. Obtain ultrasound assessment as some tumors may increase in size.
D
Offer treatment before pregnancy where possible in patients planning a pregnancy with a hepatic adenoma with a diameter > 5 cm, as these tumors are associated with an increased risk of enlargement and hemorrhage.
B

9.Patient education

General counseling: as per EASL 2016 guidelines, advise lifestyle changes such as discontinuation of oral contraceptives as well as weight loss upon hepatocellular adenoma diagnosis.
B

10.Follow-up and surveillance

Serial imaging assessment: as per EASL 2016 guidelines, reassess female patients with lesions < 5 cm at 1 year, and annually thereafter.
B