Inflammatory hepatic adenoma

Last revised by Dr Jeremy Jones on 20 Sep 2021

Inflammatory hepatic adenomas are a genetic and pathological subtype of hepatic adenoma. Their appearance and prognosis is different than other subtypes and has the highest incidence of hemorrhage amongst hepatic adenoma subtypes.

Most common subtype of hepatic adenoma (40-50%). Occur most commonly in women with oral contraceptive pill (OCP) usage. It is also seen in older patients with hepatic steatosis or metabolic syndrome 6. For that reason, is not a common lesion in young patients with no history of OCP usage.

Fever, leukocytosis, elevated CRP, and elevated liver function tests (LFTs) are compatible with an inflammatory hepatic adenoma.

  • T1: isointense or mildly hyperintense relative to liver
  • T1 C+ (Gd): ​marked arterial enhancement that fades in the portal venous phase and delayed phase
  • T1 C + (hepatobiliary contrast, Eovist) 5:
    • unlike the other subtypes of adenomas, inflammatory adenomas can show enhancement after administration of hepatospecific contrast (although they do not contain liver cells or bile duct epithelium)
      • this occurs because inflammatory adenomas express OATP membrane receptors (where hepatospecific contrast molecules bind and normally present in cells derived from hepatocytes or bile duct epithelium)
      • differential diagnosis with focal nodular hyperplasia can be tricky, as both lesions show enhancement after administration of hepatospecific contrast — FNH because it contains cells derived from hepatocytes and bile duct epithelium, and inflammatory adenoma because it expresses OATP membrane receptors
  • IP/OP: no hypointensity on the out-of-phase sequence
  • T2
    • ​usually hyperintense
    • an atoll sign may be seen: peripheral rim of high T2 signal intensity with the center of the lesion appearing isointense to the background liver; this is considered a characteristic sign

Inflammatory hepatic adenomas have a higher risk of bleeding than other subtypes (hemorrhage occurs in ~30% of this subtype). Adenomas larger than 5 cm are also at increased risk of hemorrhage.

If imaging shows an inflammatory hepatic adenoma subtype, then patients usually stop any oral contraceptive and the lesion regresses.

If it does not regress, then one treatment pathway suggests:

  • ≥5 cm: resection
  • <5 cm: biopsy

Tissue diagnosis then confirms or changes the adenoma subtype. If inflammatory pathologic subtype, then:

  • clinical and imaging follow up of any remaining adenomas until menopause
  • resection or thermal ablation of enlarging adenomas that grow ≥5 cm

There is a very small risk that a hepatic adenoma may develop into a hepatocellular carcinoma (HCC).

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Cases and figures

  • Figure 1: histology (H&E)
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  • Case 1
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  • Case 2
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  • Case 3
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  • Case 4: with atoll sign
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