**7.4 Alternative treatment of HA**

Other options of treatment include: transarterial embolization or ablation and radiofrequency ablation. TAE is considered as a safe and effective mini-invasive

**139**

*Challenging Issues in Hepatic Adenoma DOI: http://dx.doi.org/10.5772/intechopen.87993*

reports of a reduction in tumor size.

**Figure 20.**

*bleeding.*

tumors that cannot be operated [78].

**7.5 Management of pregnant patient**

procedure to be used in both elective and emergency conditions. For small lesions, TAE can achieve complete resolution and thus avoidance of liver surgery entirely. TAE may be also used as means to shrink the tumors to a size that renders them approachable for subsequent surgical resection [76]. TAE can reduce the size of large adenomas, multiple adenomas, or adenomas that are in a surgical inaccessible localization alleviating the symptoms and reducing the risk of perioperative bleeding. It has a low rate of complications (8%). These complications associated with TAE include post-embolization syndrome, temporary renal failure, and cyst formation [77]. One pyogenic abscess after TAE was also reported as a complication after TAE for a large HA. No sufficient data exist until now to conclude that TAE reduces the risk of hemorrhage or malignant transformation of residual HA, despite

*Liver adenomatosis with a voluminous adenoma of the left liver in a 47-year-old male patient who had a liver transplantation. A-C. CECT of the liver with adenomatosis. D. Total hepatectomy specimen with numerous adenomas of various sizes, a voluminous adenoma in the left liver, and blood clots due to intratumoral* 

Radiofrequency ablation has its shortcomings, such as the need of many sessions in order to destruct the tumor completely, but it may be a very good option for

Medical treatment such as administration of the SRC inhibitor dasatinib or

Pregnancy is no longer considered a contraindication in hepatocellular adenoma less than 5 cm. Given the fact that the HA behaves as a hormone-dependent tumor that seems to grow or regress according to estrogen level increase or decrease, respectively, it is advised that patients with adenomas who contemplate pregnancy firstly resolve the liver tumor prior to remaining pregnant [80]. If HA was diagnosed in a fertile but nonpregnant woman, and if the tumor is greater than 5 cm or she has experienced adenoma-related complications, resection is indicated before pregnancy. If HA is incidentally identified during pregnancy, the best management varies from case to case. For the smaller lesions, a conservatory approach is feasible on the condition of ultrasound follow-up every 6 weeks.

JAK1/2 inhibitor ruxolitinib could be a new alternative in the future [79].

#### **Figure 20.**

*Liver Disease and Surgery*

adenomatosis, unless technically impossible or unsafe. Radiofrequency ablation or embolization in these patients was successful in some authors' experience [74]. Liver adenomatosis becomes an indication for liver transplantation if there is evidence of malignant transformation or complications [75]. Observing these changes is possible only if patients are carefully followed on a regular basis with imaging. Liver transplantation should be considered as the last resort for patients with adenomatosis. Patients with GSD should undergo transplantation earlier than other patients with HA because the literature considers this underlying disease as a risk factor for malignant transformation of adenomas [72]. Like in transplantation for HCC, imaging diagnosis of vascular invasion should be considered an absolute contraindication to transplantation. So all the efforts are directed to early diagnose a malignant transformation of HA, and any suspicion of malignancy has to be rapidly confirmed by biopsy. Discussion with the patients with liver adenomatosis about liver transplantation must be initiated when a major criterion or at least 3 minor criteria are identified. The only major criterion is the histological proof of malignancy in at least one adenoma. The minor criteria are: (1) more than 2 serious (life-threatening) hemorrhages, (2) more than 2 previous hepatectomies, (3) β mutated or inflammatory adenomas, (4) underlying liver disease (major steatosis and vascular abnormalities), and (5) age > 30 years [72]

*Upper left: massive liver adenomatosis that deforms the contour of the left lateral sector. Upper right: a left lateral sectionectomy is planned and a cotton loop around hepatic pedicle is placed for Pringle maneuver. Lower left: intraoperative aspect after left lateral sectionectomy. Lower right: sectioned surgical specimen with* 

Other options of treatment include: transarterial embolization or ablation and radiofrequency ablation. TAE is considered as a safe and effective mini-invasive

**138**

(**Figure 20**).

**Figure 19.**

*evidence of the largest HA.*

**7.4 Alternative treatment of HA**

*Liver adenomatosis with a voluminous adenoma of the left liver in a 47-year-old male patient who had a liver transplantation. A-C. CECT of the liver with adenomatosis. D. Total hepatectomy specimen with numerous adenomas of various sizes, a voluminous adenoma in the left liver, and blood clots due to intratumoral bleeding.*

procedure to be used in both elective and emergency conditions. For small lesions, TAE can achieve complete resolution and thus avoidance of liver surgery entirely. TAE may be also used as means to shrink the tumors to a size that renders them approachable for subsequent surgical resection [76]. TAE can reduce the size of large adenomas, multiple adenomas, or adenomas that are in a surgical inaccessible localization alleviating the symptoms and reducing the risk of perioperative bleeding. It has a low rate of complications (8%). These complications associated with TAE include post-embolization syndrome, temporary renal failure, and cyst formation [77]. One pyogenic abscess after TAE was also reported as a complication after TAE for a large HA. No sufficient data exist until now to conclude that TAE reduces the risk of hemorrhage or malignant transformation of residual HA, despite reports of a reduction in tumor size.

Radiofrequency ablation has its shortcomings, such as the need of many sessions in order to destruct the tumor completely, but it may be a very good option for tumors that cannot be operated [78].

Medical treatment such as administration of the SRC inhibitor dasatinib or JAK1/2 inhibitor ruxolitinib could be a new alternative in the future [79].

#### **7.5 Management of pregnant patient**

Pregnancy is no longer considered a contraindication in hepatocellular adenoma less than 5 cm. Given the fact that the HA behaves as a hormone-dependent tumor that seems to grow or regress according to estrogen level increase or decrease, respectively, it is advised that patients with adenomas who contemplate pregnancy firstly resolve the liver tumor prior to remaining pregnant [80]. If HA was diagnosed in a fertile but nonpregnant woman, and if the tumor is greater than 5 cm or she has experienced adenoma-related complications, resection is indicated before pregnancy. If HA is incidentally identified during pregnancy, the best management varies from case to case. For the smaller lesions, a conservatory approach is feasible on the condition of ultrasound follow-up every 6 weeks.

#### *Liver Disease and Surgery*

Adenomas greater than 5 cm that are discovered during pregnancy need individualized approach. Surgery is recommended during second trimester to minimalize the risks for both the mother and the fetus. Radiofrequency has been an option performed during the first and second trimester [18]. Angioembolization poses the radiation risk to the fetus early in pregnancy and must be avoided in the first trimester.

Pregnancy induces not only an increased level of endogenous hormones but also an increased liver vascularity that puts the patient at risk for adenoma rupture especially in the third trimester [81]. However, a ruptured HA discovered during pregnancy should be immediately resected by laparotomy or laparoscopy [28, 82, 83].

#### **7.6 Follow-up of the patients**

The great majority of nonresected uncomplicated HA remains stable, in few cases disappear, and in general do not grow. There is an observation that IHA may disappear more rapidly.

The follow-up of the patients with H-HA and IHA with complete resection can be stopped few years after surgery. In case of incomplete resection and with no significant change in HA size during the first years, the follow-up must be continued but at longer intervals.

Instead, the patients with β-HA resected or RF ablated must be followed-up very closely with AFP serum level check and repeated alternating imaging (US, CEUS, CT, and MRI) in order to early diagnose a possible recurrence and, in a much worse scenario, a possible malignancy with the same positioning in the liver [84].
