the Management of Benign Liver Lesions

Section1: General:

·       In patients with a focal liver lesion of uncertain aetiology, we recommend multiphasic contrast-enhanced imaging, preferably MRI or CT, performed with late arterial, portal venous, and delayed phases, (Strong recommendation, low certainty evidence, ^(6)).

Section 2: Hepatic haemangioma:

·       In patients with a normal or healthy liver, a hyperechoic lesion, in ultrasonography, is very likely to be a liver haemangioma. With typical radiology (homogeneous hyperechoic, sharp margin, posterior enhancement, and absence of halo sign) in a lesion less than 3 cm, we advise performing ultrasound for the diagnosis, (Conditional recommendation, moderate certainty evidence, ⁽⁴⁾)^.

·       We recommend the diagnosis of haemangioma by contrast enhanced imaging, (CT and/or MRI). It is based on a typical vascular profile characterized by peripheral and globular enhancement on arterial phase followed by a central enhancement on delayed phases. MRI provides additional findings such as lesion signal on T1-, T2- weighted sequences, and diffusion imaging, (Strong recommendation, moderate certainty evidence, ⁽⁴⁾)^.

·       Pregnancy and oral contraceptives are not contraindicated, (Conditional recommendation, low certainty evidence, ⁽⁴⁾)^.

·       We recommend conservative management for typical cases of haemangioma, (Strong recommendation, moderate certainty evidence, ⁽⁴⁾)^.

·       In patients with asymptomatic haemangioma < 10 cm we suggest no imaging follow-up, due to its benign course, (Conditional recommendation, moderate certainty evidence, ⁽⁴⁾)^.

·        In symptomatic patients or with haemangiomas > 10 cm we advise follow-up, due to possible complications, (Conditional recommendation, very low certainty evidence, ⁽⁷⁾)^.

·       When indicated, we advise to follow-up with ultrasound in view of non-invasiveness, low costs, and absence of biological risk, (Conditional recommendation, moderate certainty evidence, ⁽⁴⁾)^.

·        In haemangiomas > 15 cm, due to the difficulty of assessing dimensional variations by means of ultrasound, we advise performing magnetic resonance, (Conditional recommendation, very low certainty evidence, ⁽⁷⁾)^.

·       In patients with symptomatic haemangiomas (Kasabach- Merritt syndrome or bulk symptoms) or pedunculated haemangiomas or haemangiomas with a diameter of 10 cm or more, we advise performing surgical treatment, (Conditional recommendation, very low certainty evidence, ⁽⁷⁾)^.

·       For symptomatic haemangiomas less than 10 cm, we advise performing loco-regional ablation techniques initially. In case of unfavourable clinical evolution or volume increase after treatment, we advise performing resection, (Conditional recommendation, very low certainty evidence, ^{(4 &7})^.

·       In symptomatic patients with unresectable giant hepatic haemangioma or multiple haemangiomas, we advise performing liver transplantation as a feasible treatment, (Conditional recommendation, very low certainty evidence, ⁽⁷⁾)^.

 Section 3: Focal nodular hyperplasia:

·       We recommend CEUS, CT, or MRI for diagnosing FNH with nearly 100% specificity. MRI has the highest diagnostic performance overall, (Strong recommendation, moderate certainty evidence, ⁽⁴⁾).

·       We advise evaluating patients with focal liver lesions that are suspicious for focal nodular hyperplasia using multiphase MRI with contrast agents to distinguish focal nodular hyperplasia from hepatocellular adenoma, (Conditional recommendation, low certainty evidence,  ⁽⁶⁾).

·       For a lesion typical of FNH, we advise against routine follow-up, (Conditional recommendation, low certainty evidence, ⁽⁴⁾).

·       We do not advise routinely discontinuing oral contraceptives in patients diagnosed with focal nodular hyperplasia, (Conditional recommendation, low certainty evidence, ⁽⁷⁾).

·       We recommend against treatment, if imaging is typical, or the patient is asymptomatic, (Strong recommendation, low certainty evidence, ⁽⁴⁾).

·       In symptomatic adults with focal nodular hyperplasia, we advise performing surgical treatment of the lesion, as it might improve the quality of life. However, follow-up does not appear associated with the occurrence of major complications, (Conditional recommendation, very low certainty evidence,  ⁽⁷⁾).

Section 4: Hepatocellular adenoma:

·       We recommend MRI for diagnosing HCA as it is superior to all other imaging modalities and due to its intrinsic properties to detect fat and vascular spaces. It offers an opportunity to subtype HCA up to 80%, (Strong recommendation, moderate certainty evidence, ⁽⁴⁾).

·       Treatment decisions should be based on gender, and size and pattern of progression of adenoma, (Strong recommendation, moderate certainty evidence, ⁽⁴⁾).

·       We recommend discontinuation of oral contraceptives or intrauterine devices that are hormone impregnated in patients with hepatic adenomas, (Strong recommendation, low certainty evidence, ^{(4, 6 &7)).}

·       We advise encouraging weight loss in overweight or obese patients with hepatic adenomas, (Conditional recommendation, very low certainty of evidence, ⁽⁶⁾).

·   HCA resection is advised in any instance of proven β-catenin mutation in both sexes, (Conditional recommendation, low certainty evidence,  ⁽⁴⁾).

·  HCA resection is advised irrespective of size in men, (Conditional recommendation, low certainty evidence,  ⁽⁴⁾).

·   In women with lesions less than 5 cm, we advise annual imaging reassessment. (Conditional recommendation, very low certainty of evidence, ^{(4 & 6)}).

·    In women with nodules equal or greater than 5 cm and those continuing to grow, we advise resection, (Conditional recommendation, low certainty evidence,  ⁽⁴⁾).

·     In bleeding HCA with hemodynamic instability, we advise performing embolization. Resection is advised for residual viable lesions on follow-up imaging, (Conditional recommendation, very low certainty of evidence, ⁽⁴⁾).

·     In patients with hepatic adenomas requiring treatment who are unable to undergo surgical resection, we advise performing embolization or ablation as alternative treatment approaches, (Conditional recommendation, low certainty of evidence, ⁽⁴⁾).

·    In patients with ruptured hepatic adenomas, we advise hemodynamic stabilization followed by embolization and/or surgical resection, (Conditional recommendation, very low certainty of evidence, ⁽⁶⁾).

Section 5: Multiple lesions:

·       In patients with multiple HCA, management is advised to be based on the size of the largest tumor, (Conditional recommendation, very low certainty of evidence, ⁽⁶⁾).

·       We advise performing hepatic resection in unilobular disease.  In those cases with more widespread HCAs, resection of the largest adenomas may be an option, (Conditional recommendation, very low certainty of evidence, ⁽⁶⁾).

·       Liver transplantation is not advised in multiple HCA, but may be advised in individuals with underlying liver disease, (Conditional recommendation, very low certainty of evidence, ⁽⁶⁾).

Section 6: Simple hepatic cysts:

·       In patients with asymptomatic simple hepatic cysts, regardless of size, we recommend expectant management without need for routine surveillance or intervention, (Strong recommendation, low certainty evidence, ⁽⁶⁾).

·       In patients with simple hepatic cysts with specific high-risk features seen on ultrasound (e.g. septations, calcifications, mural thickening or nodularity, heterogeneity, and presence of daughter cysts), we recommend further investigation with CT or MRI, (Strong recommendation, low certainty evidence, ⁽⁶⁾).

·       We advise performing surgical cyst fenestration or aspiration with sclerotherapy for management of patients with symptomatic simple hepatic cysts, (Conditional recommendation, low certainty evidence, ⁽⁶⁾).

·       We recommend chemical and cytological examination for aspirated fluid, (Good practice statement).

·       We advise discontinuation of exogenous oestrogen use in women with polycystic liver disease, (Conditional recommendation, very low certainty evidence, ⁽⁶⁾).

·       For patients with PCLD with numerous small- to medium-sized cysts throughout the liver not amenable to surgical resection, we advise performing cyst fenestration, or aspiration sclerotherapy, (Conditional recommendation, moderate certainty evidence, ⁽⁶⁾).

·        For patients with symptomatic ADPKD with concurrent PCLD, we advise medical management using somatostatin analogues, (Conditional recommendation, moderate certainty evidence, ⁽⁶⁾).

Section 7: Hydatid (echinococcal) cysts:

·       Antihelmenthic treatment is recommended for all viable cysts disregarding any further surgical or non-surgical modality of treatment, (Good practice statement).

·       We advise surgical management in patients with complicated hydatid cysts (i.e., those with biliary fistulas or cysts communicating with the biliary tree, multiseptated cysts, rupture or haemorrhage, secondary infection, or percutaneously inaccessible cysts) provided there is no contraindication to surgery, (Conditional recommendation, very low certainty evidence, ⁽⁶⁾).

·       In patients with uncomplicated hydatid cysts in whom surgery is not an option, we advise performing percutaneous treatment with PAIR with adjunct antihelminthic therapy, (Conditional recommendation, low certainty evidence, ⁽⁶⁾).