Hepatic adenoma
Introduction
Introduction to hepatic adenoma Hepatic adenoma, also known as hepatocellularadenoma (HCA), is a rare benign tumor of the liver. The reason may be related to the increase in the use of contraceptives. It is reported that the incidence of the disease is long-term use of contraceptives ( 3 to 4) / 10,000, and the incidence of the disease is only 1 in 1 million for women who do not take birth control pills and take birth control pills for less than 2 years. Hepatic adenomas may be single or multiple. The biliary cystadenoma can undergo malignant transformation. basic knowledge The proportion of illness: 0.003% Susceptible people: no specific population Mode of infection: non-infectious Complications: hemorrhagic shock
Cause
Hepatic adenoma
Oral contraceptives (30%)
At present, oral contraceptives are considered to be the main cause of acquired hepatic adenomas. It is thought to have a close relationship with oral contraceptives: in the 1950s and 1960s, oral contraceptives were not common; more than 90% Patients with hepatic adenoma occur in young women, and at least 75% of patients have a history of taking birth control pills. Women over the age of 30 taking the pill have an increased risk of developing the disease; the incidence of hepatic adenomas and the time of taking birth control pills There is a direct relationship with the dose; the patient can see atrophy after stopping the contraceptive.
Endocrine disorders (30%)
The true cause of this disease is unknown, the incidence may be related to sexual endocrine disorders, infant and child cases may be related to abnormal development of congenital embryos, Henson believes that acquired factors may be closely related to liver cirrhosis, hepatocyte nodular hyperplasia.
Androgen (20%)
Tumor enlargement can be seen during pregnancy; hepatic adenomas rarely occur in postmenopausal women, and hepatic adenomas in men may be associated with diabetes, glycogen storage and the use of androgens.
Pathogenesis
1. Pathogenesis There are currently three theories:
(1) Isolated hepatic embryonic cell mass, which may be derived from the embryonic development stage, is almost completely isolated from normal liver tissue in tissue and function, and is in an isolated state, which is more common in infants and young children.
(2) Henson et al proposed that this disease is closely related to secondary liver cirrhosis or other damage, such as syphilis, infection, and compensatory hepatocyte nodular hyperplasia caused by venous congestion.
(3) At present, most scholars believe that long-term oral combination of norethisterone and contraceptives can induce the occurrence of hepatocellular adenomas. Clinical observations show that the time of contraceptive use and dosage of drugs have a certain role in the development of hepatocellular adenomas. When the drug is taken for more than 1 year and more than 5 years, the prevalence rate is increased by 20 to 100 times, but the exact pathogenesis caused by the drug is still unclear.
2. Pathological changes Liver adenoma is pathologically divided into hepatocellular adenoma, cholangiocarcinoma (including bile duct adenoma and biliary cystadenoma), mixed adenoma, hepatocellular adenoma is more common in the right lobe (67%), 70 % is a single nodule, the diameter is generally greater than 10cm, the maximum can reach 20 ~ 30cm, occasionally the tumor can have multiple nodules, the tumor boundary is clear, often there is incomplete fibrous envelope, the tumor on the cut surface is slightly uplifted, texture and surrounding liver The tissue is similar but the color is slightly shallow, bleeding and infarction can be seen. The tumor cells are arranged in a cable shape. The cell cord is composed of 1 to 2 rows of hepatocytes. These cells are slightly more enlarged than normal liver cells, but the atypia is not obvious. Seeing or lacking, occasionally cell atypia, this situation is common in long-term use of anabolic steroids or oral contraceptives, sometimes tumor cells arranged in a glandular tube, biliary embolus in the lumen, cystic sinusoids in the tumor Hepatic purpura is formed when a large number of cystic sinusoids appear.
Biliary adenomas are rare, often single, mostly located under the liver capsule, with a diameter of less than 1 cm, and occasionally as large as 2 cm. A few cases are multiple nodules distributed in the left and right lobe of the liver. However, the realm is clear. The tumor is located in the portal area and consists of small bile duct-like adenomatoid-like cells. The size of the tumor cells is uniform, the cytoplasm is rich, the nucleus is deep-stained, the mitotic figures are rare, and the collagen fibers between the glandular ducts are interstitial. Inflammatory cells such as lymphocytes may also be infiltrated, and the tumor may extend along the portal area without destroying the hepatic cord.
A biliary cystadenoma is a multi-atrial tumor that occurs in the liver and contains a clear liquid or mucus, which occurs in the right lobe. The tumor has a clear boundary. The cyst is lined with a single layer of cubic epithelium or a ciliated columnar epithelium. Fine granular, lightly stained, the size and shape of the nucleus is equivalent, located in the center of the cell.
Mixed adenoma is a kind of adenoma with both liver adenoma and biliary adenoma. It is more common in children and develops faster.
Prevention
Hepatic adenoma prevention
It is believed that HCA women have a close relationship with oral contraceptives; men are associated with diabetes, glycogen storage disease and the use of androgen. Therefore, prevention against a clear cause is the key to prevention.
For young and middle-aged women, those who regularly take oral contraceptives should check the liver regularly and observe the liver shape changes dynamically. Once the liver-occupying lesions are found, first stop taking the contraceptives and closely observe the changes in the tumor. If the tumor continues to increase, it should still be Strive for surgery.
Liver function should be checked regularly for long-term oral contraceptives.
Complication
Hepatic adenoma complications Complications, hemorrhagic shock, liver cancer
Intra-abdominal hemorrhage is the most serious complication and requires urgent treatment.
1. When a tumor ruptures and bleeds, the patient may have a sudden severe pain in the right upper quadrant. In severe cases, the patient may have hemorrhagic shock.
2. HCA has the potential to turn into hepatocellular carcinoma.
Symptom
Hepatic adenoma symptoms Common symptoms Abdominal pain, bloating, right upper abdominal pain, jaundice, nausea, severe pain, chills, intra-abdominal bleeding, abdominal muscle tension
Symptom
It is often asymptomatic in the early stage and is often found in other physical examinations or upper abdominal surgery. When the tumor is large and the adjacent organs are oppressed, there may be upper abdominal fullness, anorexia, nausea or dull pain.
2. Signs
A mass was found in the upper abdomen, the surface was smooth, the quality was hard, and there was no tenderness, which could move up and down with the breath. If it is a cystadenoma, it will be sexy. In intratumoral hemorrhage, there is paroxysmal right upper abdominal pain, accompanied by fever, occasionally jaundice or chills, nausea and vomiting. The right upper abdominal muscles are tense and tender. When the tumor ruptures and bleeds, sudden onset of right upper quadrant pain, peritoneal irritation, severe shock may occur.
Examine
Hepatic adenoma examination
The test showed that the liver function was normal or showed mild GGT or ALP elevation, and AFP was negative. If the AFP increased, it indicated that the liver adenoma was malignant.
1. B-ultrasound showed that the boundary of the lesion was clear, and the echo was different depending on the surrounding liver tissue. It was a hypoechoic mass. If there was bleeding and necrosis, there was a mixed echo, and the boundary was clear and there was no halo.
2. CT scan of the tumor is in a low-density area, which can show different densities after enhancement. Enhanced CT shows that the adenoma is generally of equal density or mild low density. Because the adenoma is rich in blood vessels, it is easier to obtain CT images in the angiographic period. Adenomas, patients with glycogen accumulation disease or other fat-induced infiltrates, tumors can be characterized by high density, central necrosis, and occasional calcification. Intratumoral hemorrhage is characterized by high density on non-enhanced CT examination, after venography Tumor enhancement is more uneven.
3. Hepatic artery angiography is very sensitive. The tumor is characterized by abundant blood supply and concentric blood supply. It can also be seen that the central region is a low blood transport area, which indicates that there is intratumoral hemorrhage. Liver biopsy can avoid bleeding due to hemorrhage.
4. MRI adenocarcinoma has a uniform enhanced signal on the T1 image and a clear low-density envelope. This image can also be seen in focal nodular hyperplasia and hepatocellular carcinoma. This lesion can also be found in T1. The image appears to have a lower density than normal. In this case, it is difficult to distinguish it from liver metastasis. For example, subacute hemorrhage occurs. In the T1 and T2 images, there is an enhanced focal area. The above examination lacks specific signs of adenoma. Therefore, the results of the auxiliary examination need to be combined with the clinical to make a correct diagnosis.
5. Radionuclide liver scan tumor diameter > 2 ~ 3cm, the liver can show radioactive sparse areas.
Diagnosis
Diagnosis and differentiation of hepatic adenoma
Differential diagnosis
1. Liver cancer should be differentiated from primary and secondary liver cancer, generally based on medical history, disease course, disease progression, AFP and B-ultrasound dynamic observation to help identify, hepatic adenoma should be differentiated from primary liver cancer Because liver adenoma is easily misdiagnosed as liver cancer, especially low-grade malignant liver cancer, it is difficult to distinguish between the naked eye. It requires multiple pathological sections, repeated careful microscopic examination, and multiple chronic hepatitis B and cirrhosis history of primary liver cancer. There is abnormal liver function and elevated AFP. If there is a history of oral contraceptives, the disease should be suspected.
2. Focal nodular hyperplasia of focal nodular hyperplasia, color Doppler showed increased blood flow, which can be shown from the central artery to the surrounding blood vessels, pathological macroscopic visible central stellate scar.
3. Acute abdomen.
