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Radiologic-Pathologic Correlation and MR Analysis of Hepatocellular Adenoma Subtypes.
Daniel Kehler1, George Yang2, Christine Zwart1, Marcela Salomao3, and Alvin Silva1

1Radiology, Mayo Clinic Arizona, Scottsdale, AZ, United States, 2University of Pennsylvania, PA, United States, 3Pathology, Mayo Clinic Arizona, Scottsdale, AZ, United States

Synopsis

Hepatocellular adenomas (HCA) present as four genetic subtypes that vary greatly in their clinical behavior and MR appearance. Inflammatory HCA has the highest propensity for hemorrhage, is characterized by hyperintense T2 signal, and displays arterial hyper-enhancement that persists on portal venous and delayed phases. HNF1-alpha mutated HCA portends a good prognosis, and is characterized by diffuse intracellular lipid. Beta-catenin HCA is less common and difficult to diagnose on imaging, though arguably the most important because of its high likelihood for malignant transformation. Unclassified HCA is not well understood in terms of imaging or clinical significance.

Purpose and Background Information

Purpose

Hepatocellular adenomas are often considered "benign" tumors; however, their propensity to hemorrhage and undergo malignant degeneration significantly impacts patient management. Historically these tumors were diagnosed with percutaneous biopsy or surgery because of the widely variable imaging appearance. Furthermore, even with a pathologically proven diagnosis it was difficult to predict which tumors were "bad actors". Over the last decade, technical advances have permitted identification of specific histopathologic and genetic features that help predict tumor behavior. Based upon these findings, four subgroups of hepatocellular adenoma were characterized, each with a unique MRI appearance. Through a retrospective analysis of 65 patients with pathologically proven hepatocellular adenoma from 1/1/2010-present, we will demonstrate several MRI examples from each category and discuss the clinical implications of each subgroup.

Outline and content

Inflammatory HCA:

  1. Clinical features

    1. Most common subtype

    2. OCPs and obesity are risk factors

    3. Can present with syndrome including fever, leukocytosis, as well as elevated liver function tests and inflammatory markers

    4. Highest propensity for hemorrhage and small risk of malignant transformation (approx. 10%)

  2. Imaging features

    1. Noncontrast: Diffusely T2 hyperintense T1 iso to slightly hyperintense

    2. Intense arterial enhancement with persistent portal venous and delayed enhancement

    3. No diffuse signal drop on opposed phase (may have focal signal drop)

HNF1-alpha mutated HCA:

  1. Clinical features

    1. Second most common subtype

    2. Occurs exclusively in females, 90% with history of OCP use

    3. Most favorable prognosis (lowest risk for hemorrhage and malignancy of all adenomas)

  2. Imaging features

    1. Noncontrast: T2 isointense to slightly hyperintense T1 isointense or hyperintense

    2. Moderate arterial enhancement without persistent portal venous and delayed enhancement

    3. Diffuse signal drop on opposed phase

Beta-catenin HCA:

  1. Clinical features

    1. Third most common subtype

    2. Highest association with malignant transformation

    3. Occur more frequently in men and are associated with exogenous male hormone administration

    4. Association with glycogen storage disease and Familial Adenomatosis Polyposis syndrome

  2. Imaging features:

    1. No consistent imaging features

    2. May show vague central scar

    3. May mimic hepatocellular carcinoma (strong arterial enhancement with washout)

Unclassified HCA - No consistent clinical or imaging features (least common subtype)

Summary

By improving our ability to detect and sub-classify hepatocellular adenomas at MRI, we hope to better inform our hepatology and surgical colleagues and significantly impact patient management.

Acknowledgements

No acknowledgement found.

References

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Figures

Inflammatory HCA in segment VIII demonstrates T2 hyperintense rim compatible with "atoll sign". Approximately 1/3rd of Inflammatory HCAs demonstrate this finding.

Arterial phase. Beta-catenin mutated HCA with internal foci of HCC. The large HCA in the medial segment of the left lobe demonstrates hyper-enhancement.

Venous phase. Beta-catenin mutated HCA with internal foci of HCC. The large HCA in the medial segment of the left lobe demonstrates two nodular foci of contrast washout along the right anterior aspect of the lesion compatible with biopsy proven foci of well-differentiated HCC contained within a Beta-catenin mutated HCA.

In phase axial image. Barely perceptible T1 isointense HNF1-alpha mutated HCA in the right hepatic lobe marginating the IVC.

Out of phase axial image. Diffuse signal drop compared to in phase image (figure 4) compatible with HNF1-alpha mutated HCA.

Proc. Intl. Soc. Mag. Reson. Med. 25 (2017)
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