The continuous development of highly sensitive clinical imaging increased the detection of focal lesions of the liver. These accidentally detected liver tumors without liver-specific symptoms such as cholestasis have been named “incidentalomas.” Diagnostic tools such as sonography, computed tomography, or magnetic resonance imaging are used increasingly in asymptomatic individuals without defined suspected diagnoses in the setting of general prevention or followup after a history of malignancy. But despite continuous improvement of diagnostics, some doubt regarding the benign or malign behavior of a tumor remains. In case an asymptomatic hemangioma or FNH can be preoperatively detected with certainty, the indication for surgery must be very strict. In case of symptomatic liver lesions surgical resection should only be indicated with tumor-specific symptoms. In the remaining cases of benign lesions of the liver, a “watch and wait” strategy is recommended. In case of uncertain diagnosis, especially in patients with positive history of a malignant tumor or the suspected diagnosis of hepatocellular adenoma, surgical resection is indicated. Due to the continuous improvement of surgical techniques, liver resection should be done in the laparoscopic technique. Laparoscopic surgery has lower morbidity and shorter hospitalization than open technique. 1. Introduction In recent years the rapid development of highly sensitive clinical imaging has led to the detection of focal lesions of the liver more frequently. In addition, diagnostic tools are used increasingly in asymptomatic individuals without defined suspected diagnoses in the setting of general prevention or followup after a history of malignancy [1–4]. Unfortunately, the histological nature of a hepatic tumor is rarely proven by one method of imaging, and even sophisticated technologies some doubt regarding the benign or malign behavior of a tumor remain in 10–40% [5, 6]. These accidentally detected liver tumors without liver-specific symptoms such as cholestasis or portal hypertension have been named “incidentalomas” [4]; the reported incidence of these findings ranges from 10.2 to 52% [7, 8]. Autopsy studies have demonstrated up to 52% benign liver lesions in the western population [9, 10]. Other authors could demonstrate an incidence of incidentalomas of 10.2–14.3% of CT scans [7–9]. Generally, these tumors can be true benign or malign neoplasms or so-called tumor-like lesions [3]. Malignant tumors of the liver become usually only in stages of an advanced disease symptomatic. In case of metastases
References
[1]
N. Assy, G. Nasser, A. Djibre, Z. Beniashvii, S. Elias, and J. Zidan, “Characteristics of common solid liver lesions and recommendations for diagnostic workup,” World Journal of Gastroenterology, vol. 15, no. 26, pp. 3217–3227, 2009.
[2]
S. Delorme, “Radiologische diagnostik der leber,” Radiologe, vol. 40, no. 10, pp. 904–915, 2000.
[3]
M. Galanski, S. J？rdens, and J. Weidemann, “Diagnosis and differential diagnosis of benign liver tumors and tumor-like lesions,” Chirurg, vol. 79, no. 8, pp. 707–721, 2008.
[4]
M. Loss, C. Zülke, A. Obed, O. St？ltzing, and H. J. Schlitt, “Surgical therapy of benign liver tumors,” Chirurg, vol. 79, no. 8, pp. 722–728, 2008.
[5]
T. Skalicky, V. T？e？ka, A. Sutnar et al., “Surgical treatment of benign liver tumours—indications and results,” Zentralblatt fur Chirurgie, vol. 134, no. 2, pp. 141–144, 2009.
[6]
D. Strobel and T. Bernatik, “Diagnostik bei fokalen Leberl？sionen-Stellenwert der Kontrastmittelsonografie,” Deutsches ？rzteblatt, vol. 103, pp. 789–793, 2006.
[7]
B. S. Kuszyk, D. A. Bluemke, B. A. Urban et al., “Portal-phase contrast-enhanced helical CT for the detection of malignant hepatic tumors: sensitivity based on comparison with intraoperative and pathologic findings,” American Journal of Roentgenology, vol. 166, no. 1, pp. 91–95, 1996.
[8]
L. H. Schwartz, E. J. Gandras, S. M. Colangelo, M. C. Ercolani, and D. M. Panicek, “Prevalence and importance of small hepatic lesions found at CT in patients with cancer,” Radiology, vol. 210, no. 1, pp. 71–74, 1999.
[9]
P. J. Karhunen, A. Penttila, and K. Liesto, “Benign bile duct tumours, non-parasitic liver cysts and liver damage in males,” Journal of Hepatology, vol. 2, no. 1, pp. 89–99, 1986.
[10]
K. Hoffmann and P. Schemmer, “Benigne solide Tumoren der Leber,” Allgemein- und Viszeralchirurgie Up2date, vol. 5, pp. 135–146, 2011.
[11]
C. Zülke, M. Loss, I. Iesalnieks et al., “Benign liver lesions: indication for surgery and postoperative results,” Viszeralchirurgie, vol. 39, no. 2, pp. 86–97, 2004.
[12]
J. Belghiti, D. Pateron, Y. Panis et al., “Resection of presumed benign liver tumours,” British Journal of Surgery, vol. 80, no. 3, pp. 380–383, 1993.
[13]
A. Blachar, M. P. Federle, J. V. Ferris et al., “Radiologists' performance in the diagnosis of liver tumors with central scars by using specific CT criteria,” Radiology, vol. 223, no. 2, pp. 532–539, 2002.
[14]
M. P. Federle and G. Brancatelli, “Imaging of benign hepatic masses,” Seminars in Liver Disease, vol. 21, no. 2, pp. 237–249, 2001.
[15]
A. M. Xu, H. Y. Cheng, D. Chen, Y. C. Jia, and M. C. Wu, “Plane and weighted tri-phase helical CT findings in the diagnosis of liver focal nodular hyperplasia,” Hepatobiliary and Pancreatic Diseases International, vol. 1, no. 2, pp. 219–223, 2002.
[16]
N. Corigliano, P. Mercantini, P. M. Amodio et al., “Hemoperitoneum from a spontaneous rupture of a giant hemangioma of the liver: report of a case,” Surgery Today, vol. 33, no. 6, pp. 459–463, 2003.
[17]
T. Terkivatan, J. H. W. de Wilt, R. A. de Man, R. R. van Rijn, H. W. Tilanus, and J. N. M. Ijzermans, “Treatment of ruptured hepatocellular adenoma,” British Journal of Surgery, vol. 88, no. 2, pp. 207–209, 2001.
[18]
H. J. Gassel, I. Klein, U. Steger, M. Simon, and A. Thiede, “Cavernous liver hemangioma: rational diagnostics and therapeutic approach,” Viszeralchirurgie, vol. 40, no. 1, pp. 37–44, 2005.
[19]
M. Donati, G. A. Stavrou, A. Donati, and K. J. Oldhafer, “The risk of spontaneous rupture of liver hemangiomas: a critical review of the literature,” Journal of Hepato-Biliary-Pancreatic Surgery. In press.
[20]
J. H. Sewell and K. Weiss, “Spontaneous rupture of hemangioma of the liver. A review of the literature and presentation of illustrative case,” Archives of Surgery, vol. 83, pp. 729–733, 1961.
[21]
S. I. Schwartz and W. C. Husser, “Cavernous hemangioma of the liver. A single institution report of 16 resections,” Annals of Surgery, vol. 205, no. 5, pp. 456–465, 1987.
[22]
O. Farges, S. Daradkeh, and H. Bismuth, “Cavernous hemangiomas of the liver: are there any indications for resection?” World Journal of Surgery, vol. 19, no. 1, pp. 19–24, 1995.
[23]
D. Erdogan, O. R. C. Busch, O. M. van Delden, F. J. W. Ten Kate, D. J. Gouma, and T. M. van Gulik, “Management of spontaneous haemorrhage and rupture of hepatocellular adenomas. A single centre experience,” Liver International, vol. 26, no. 4, pp. 433–438, 2006.
[24]
J. H. B. M. Stoot, R. J. S. Coelen, M. C. de Jong, and C. H. Dejong, “Malignant transformation of hepatocellular adenomas into hepatocellular carcinomas: a systematic review including more than 1600 adenoma cases,” HPB, vol. 12, no. 8, pp. 509–522, 2010.
[25]
P. Flemming, U. Lehmann, D. Steinemann, H. Kreipe, and L. Wilkens, “Leberzelladenom. Entartungspotenzial und abgrenzung vom HCC,” Pathologe, vol. 27, no. 4, pp. 238–243, 2006.
[26]
L. Chiche, T. Dao, E. Salamé et al., “Liver adenomatosis: reappraisal, diagnosis, and surgical managemen: 8 new cases and review of the literature,” Annals of Surgery, vol. 231, no. 1, pp. 74–81, 2000.
[27]
L. Grazioli, M. P. Federle, T. Ichikawa, E. Balzano, M. Nalesnik, and J. Madariaga, “Liver adenomatosis: clinical, histopathologic, and imaging findings in 15 patients,” Radiology, vol. 216, no. 2, pp. 395–402, 2000.
[28]
L. Grazioli, M. P. Bondioni, H. Haradome et al., “Hepatocellular adenoma and focal nodular hyperplasia: value of gadoxetic acid-enhanced MR imaging in differential diagnosis,” Radiology, vol. 262, no. 2, pp. 520–529, 2012.
[29]
J. Neuberger, B. Portmann, H. B. Nunnerley, M. Davis, J. W. Laws, and R. Williams, “Oral-contraceptive-associated liver tumours: occurrence of malignancy and difficulties in diagnosis,” The Lancet, vol. 1, no. 8163, pp. 273–276, 1980.
[30]
L. C. Tao, “Oral contraceptive-associated liver cell adenoma and hepatocellular carcinoma: cytomorphology and mechanism of malignant transformation,” Cancer, vol. 68, no. 2, pp. 341–347, 1991.
[31]
B. Y. Choi and M. H. Nguyen, “The diagnosis and management of benign hepatic tumors,” Journal of Clinical Gastroenterology, vol. 39, no. 5, pp. 401–412, 2005.
[32]
C. Zülke and H. J. Schlitt, “Incidentalomas of the liver and gallbladder : evaluation and therapeutic procedure,” Chirurg, vol. 78, no. 8, pp. 698–712, 2007.
[33]
P. J. Mergo, J. D. Engelken, T. Helmberger, and P. R. Ros, “MRI in focal liver disease: a comparison of small and ultrasmall superparamagnetic iron oxide as hepatic contrast agents,” Journal of Magnetic Resonance Imaging, vol. 8, no. 5, pp. 1073–1078, 1998.
[34]
A. J. Ruppert-Kohlmayr, M. M. Uggowitzer, C. Kugler, D. Zebedin, G. Schaffler, and G. S. Ruppert, “Focal nodular hyperplasia and hepatocellular adenoma of the liver: differentiation with multiphasic helical CT,” American Journal of Roentgenology, vol. 176, no. 6, pp. 1493–1498, 2001.
[35]
T. Isozaki, K. Numata, T. Kiba et al., “Differential diagnosis of hepatic tumors by using contrast enhancement patterns at US,” Radiology, vol. 229, no. 3, pp. 798–805, 2003.
[36]
D. Strobel, S. Raeker, P. Martus, E. G. Hahn, and D. Becker, “Phase inversion harmonic imaging versus contrast-enhanced power Doppler sonography for the characterization of local liver lesions,” International Journal of Colorectal Disease, vol. 18, no. 1, pp. 63–72, 2003.
[37]
D. G. D. Wight, Atlas of Liver Pathology, Kluwer Academic Publishers, Dordrecht, The Netherlands, 2nd edition, 1993.
[38]
K. F. Gratz and A. Weimann, “Diagnosis of liver tumors—when is scintigraphy of value?” Zentralbl Chir, vol. 123, pp. 111–118, 1998.
[39]
J. Grimm, S. Müller-Hülsbeck, J. Blume, J. Biederer, and M. Heller, “Comparison of biphasic spiral CT and MnDPDP-enhanced MRI in the detection and characterization of liver lesions,” Rofo Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr, vol. 173, pp. 266–272, 2001.
[40]
P. Herman, V. Pugliese, M. A. C. Machado et al., “Hepatic adenoma and focal nodular hyperplasia: differential diagnosis and treatment,” World Journal of Surgery, vol. 24, no. 3, pp. 372–376, 2000.
[41]
S. Shimizu, T. Takayama, T. Kosuge et al., “Benign tumors of the liver resected because of a diagnosis of malignancy,” Surgery Gynecology and Obstetrics, vol. 174, no. 5, pp. 403–407, 1992.
[42]
A. Weimann, B. Ringe, J. Klempnauer et al., “Benign liver tumors: differential diagnosis and indications for surgery,” World Journal of Surgery, vol. 21, no. 9, pp. 983–991, 1997.
[43]
G. T. Huang, J. C. Sheu, P. M. Yang, H. S. Lee, T. H. Wang, and D. S. Chen, “Ultrasound-guided cutting biopsy for the diagnosis of hepatocellular carcinoma—a study based on 420 patients,” Journal of Hepatology, vol. 25, no. 3, pp. 334–338, 1996.
[44]
E. H. Smith, “Complications of percutaneous abdominal fine-needle biopsy: review,” Radiology, vol. 178, no. 1, pp. 253–258, 1991.
[45]
N. Corigliano, P. Mercantini, P. M. Amodio et al., “Hemoperitoneum from a spontaneous rupture of a giant hemangioma of the liver: report of a case,” Surgery Today, vol. 33, no. 6, pp. 459–463, 2003.
[46]
T. Terkivatan, J. H. de Wilt, R. A. de Man et al., “Indications and long-term outcome of treatment for benign hepatic tumors: a critical appraisal,” Archives of Surgery, vol. 136, no. 9, pp. 1033–1038, 2001.
[47]
C. K. Charny, W. R. Jarnagin, L. H. Schwartz et al., “Management of 155 patients with benign liver tumours,” British Journal of Surgery, vol. 88, no. 6, pp. 808–813, 2001.
[48]
V. D'Halluin, V. Vilgrain, G. Pelletier et al., “Natural history of focal nodular hyperplasia. A retrospective study of 44 cases,” Gastroenterologie Clinique et Biologique, vol. 25, no. 11, pp. 1008–1010, 2001.
[49]
R. Gedaly, J. J. Pomposelli, E. A. Pomfret, W. D. Lewis, and R. L. Jenkins, “Cavernous hemangioma of the liver: anatomic resection versus enucleation,” Archives of Surgery, vol. 134, no. 4, pp. 407–411, 1999.
[50]
B. Descottes, D. Glineur, F. Lachachi et al., “Laparoscopic liver resection of benign liver tumors: results of a multicenter European experience,” Surgical Endoscopy and Other Interventional Techniques, vol. 17, no. 1, pp. 23–30, 2003.
[51]
H. G. Rau, E. Buttler, G. Meyer, H. M. Schardey, and F. W. Schildberg, “Laparoscopic liver resection compared with conventional partial hepatectomy—a prospective analysis,” Hepatogastroenterology, vol. 45, no. 24, pp. 2333–2338, 1998.
[52]
H. G. Rau, A. Zimmermann, C. Wardemann, and F. W. Schildberg, “Standards of surgical techniques in liver metastases,” Chirurgische Gastroenterologie Interdisziplinar, vol. 19, no. 4, pp. 333–339, 2003.
[53]
A. Petri, J. H？hn, A. Wolfárd et al., “Surgery of benign liver tumors: indications for treatment. Personal experience and review of the literature,” Magyar Onkologia, vol. 47, no. 4, pp. 391–395, 2003.
[54]
T. Terkivatan, J. H. de Wilt, R. A. de Man et al., “Indications and long-term outcome of treatment for benign hepatic tumors: a critical appraisal,” Archives of Surgery, vol. 136, no. 9, pp. 1033–1038, 2001.
[55]
S. C. Gordon, K. J. Reddy, and A. S. Livingstone, “Resolution of a contraceptive-steroid-induced hepatic adenoma with subsequent evolution into hepatocellular carcinoma,” Annals of Internal Medicine, vol. 105, no. 4, pp. 547–549, 1986.
[56]
H. Tesluk and J. Lawrie, “Hepatocellular adenoma. Its transformation to carcinoma in a user of oral contraceptives,” Archives of Pathology and Laboratory Medicine, vol. 105, no. 6, pp. 296–299, 1981.
[57]
N. Ren, L. X. Qin, Z. Y. Tang, Z. Q. Wu, and J. Fan, “Diagnosis and treatment of hepatic angiomyolipoma in 26 cases,” World Journal of Gastroenterology, vol. 9, no. 8, pp. 1856–1858, 2003.
[58]
C. N. Yeh, M. F. Chen, C. F. Hung, T. C. Chen, and T. C. Chao, “Angiomyolipoma of the liver,” Journal of Surgical Oncology, vol. 77, no. 3, pp. 195–200, 2001.
[59]
O. Katsuhisa, O. Kazuo, Y. Kadokawa et al., “Comparison of the grade evaluated by “Liver damage” of Liver Cancer Study Group of Japan and Child-Pugh classification in patients with hepatocellular carcinoma,” Hepatology Research, vol. 34, no. 4, pp. 266–272, 2006.
[60]
J. I. Tsao, J. P. Loftus, D. M. Nagomey, M. A. Adson, and D. M. Ilstrup, “Trends in morbidity and mortality of hepatic resection for malignancy: a matched comparative analysis,” Annals of Surgery, vol. 220, no. 2, pp. 199–205, 1994.
[61]
M. Abu Hilal, A. Badran, F. di Fabio, and N. W. Pearce, “Pure laparoscopic en bloc left hemihepatectomy and caudate lobe resection in patients with intrahepatic cholangiocarcinoma,” Journal of Laparoendoscopic and Advanced Surgical Techniques A, vol. 21, no. 9, pp. 845–849, 2011.
