Benign focal liver lesions-from diagnosis to treatment

Focal liver lesions in a noncirrhotic liver often present as incidental finding during routine abdominal imaging as part of a general check-up, or during work-up in case of a known malignancy. Only in some cases, liver tumors may be symptomatic. The most important diagnostic challenge involves differentiating benign tumors from pre-malignant or malignant lesions. Especially during work-up of a known malignancy a correct diagnosis of a liver lesion is essential for an adequate staging, thereby preventing an over-, or undertreatment of malignant disease. However, there are still patients who do undergo unnecessary biopsy or surgery because of a presumed malignancy or because of uncertainty in the diagnosis despite an extensive work-up. However, these interventions are not always to the benefit of the patient. Even after having diagnosed a benign lesion, the most appropriate treatment still may remain controversial, as in case of a hepatocellular adenoma. This thesis emphasizes the need for a clear management strategy in case of a presumed benign liver lesion, and formulates guidelines for diagnostic work-up and the indications for surgery

Giant solitary fibrous tumour of the liver

BACKGROUND: Solitary fibrous tumour (SFT) is an uncommon mesenchymal neoplasm that most frequently affects the pleura, although it has been reported with increasing frequency in various other sites such as in the peritoneum, pericardium and in non-serosal sites such as lung parenchyma, upper respiratory tract, orbit, thyroid, parotid gland, or thymus. Liver parenchyma is rarely affected. Clinically, SFTs cause symptoms after having reached a certain size or when vital structures are involved. In recent years, SFTs are more often identified and distinguished from other tumours with a similar appearance due to the availability of characteristic immunohistochemical markers. CASE PRESENTATION: In this manuscript we report the case of a large tumour of the liver, which was histologically diagnosed as a SFT, and showed involvement of a single hepatic segment. Because of the patient's presentation and clinical course, it may represent a radiation-induced lesion. CONCLUSION: When a SFT has been diagnosed, surgery is the treatment of choice. The small number of patients with a SFT of the liver and its unknown natural behaviour creates the need to a careful registration and follow-up of all identified case

Antegrade balloon dilatation as a treatment option for posttransplant ureteral strictures: Case series of 50 patients

Objectives: The aim of this study was to investigate the effects of antegrade balloon dilatation on ureteral strictures that developed after kidney transplant. Materials and Methods: The hospital databases of the Erasmus Medical Center (Rotterdam, The Netherlands) and the Academic Medical Center (Amsterdam, The Netherlands) were retrospectively screened for patients who underwent balloon dilatation after kidney transplant. Balloon dilatation was technically successful whenever it was able to pass the strictured segment with the guidewire followed by balloon inflation; the procedure was clinically successful if no further interventions (for example, surgical revision of the ureteroneocystostomy or prolonged double J placement) were necessary. Results: Fifty patients (2.4%) of 2075 kidney transplant recipients underwent antegrade balloon dilatation because of urinary outflow obstruction. Median time between transplant and balloon dilatation was 3 months (range, 0-139 mo). In 43 patients (86%), balloon dilatation was technically successful. In the remaining 7 patients (14%), it was impossible to pass the strictured segment with the guidewire. In 20 of 43 patients (47%) having a technically successful procedure, the procedure was also clinically successful, with median follow-up after balloon dilatation of 35.5 months (range, 0-102 mo). We did not identify any patient o

Independent risk factors for urological complications after deceased donor kidney transplantation

Urological complications after kidney transplantation are mostly related to the ureteroneocystostomy, often requiring interventions with additional costs, morbidity and mortality. Our aim was to assess risk factors for urological complications in deceased donor kidney transplantation. Between January 2000 and December 2011, 566 kidney transplantations were performed with deceased donor kidneys. Recipients were divided in a group with, and a group without urological complications, defined as the need for a percutaneous nephrostomy catheter or surgical revision of the ureteroneocystostomy. Univariate and multivariate analyses were performed. Univariate analysis showed increased number of male donors (p = 0.041), male recipients (p = 0.002), pre-emptively transplanted recipients (p = 0.007), and arterial reconstructions (p = 0.004) in the group with urological complications. Less urological complications occurred in recipients on hemodialysis (p = 0.005). More overall surgical interventions (p<0.001), surgical site infections (p = 0.042), urinary tract infections (p<0.001) and lymphoceles (p<0.001) occurred in the group with urological complications. Multivariate analysis showed that male recipients (p = 0.010) and arterial reconstructions (p = 0.019) were independent risk factors. No difference was found between both groups in patient or graft survival. In conclusion, recipient male gender and arterial reconstruction are independent risk factors for urological complications after deceased donor kidney transplantation. Nevertheless, graft and recipient survival is not different between both groups

Diagnosis and treatment of hepatocellular adenoma in the Netherlands: Similarities and differences

Background: The diagnosis of hepatocellular adenoma (HA) has a great impact on the lives of young women and may pose clinical dilemmas to the clinician since there are no standardized protocols to follow. We aimed to establish expert opinions on diagnosis and treatment of HA by collecting data from a nationwide questionnaire in the Netherlands. Methods: A questionnaire was sent to 20 Dutch hospitals known to offer hepatologic and surgical experience on liver tumours. Results: 17 hospitals (85%) responded to the questionnaire. Annually, a median of 52 patients presented with a solid liver tumour. In 15 (88%) hospitals, hepatic adenomas were diagnosed with contrast-enhanced, multiphase spiral CT or MRI. In 2 (12%) hospitals, histology was required as part of a management protocol. Surveillance after withdrawal of oral contraceptives was the initial policy in all clinics. MRI, CT or ultrasound was used for follow-up. Criteria for surgical resection were a tumour size >5 cm and abdominal complaints. In 5 (29%) hospitals, patients were dismissed from follow-up after surgery. In complex cases (e.g. large, multiple or centrally localized lesions, a wish for pregnancy), the tre

Management of hepatocellular adenoma during pregnancy

Background & Aims: Hepatocellular adenoma in pregnant women requires special considerations because of the risk of hormone induced growth and rupture. To prevent these potential lethal complications, pregnancy is either often discouraged or the surgical resection of large adenomas is recommended. It may be questioned whether it is justified to deny a young woman a pregnancy, as the biological behaviour of hepatocellular adenoma may be less threatening than presumed. In this study we establish the management of hepatocellular adenoma during pregnancy based on our own experience and literature. Methods: Twelve women with documented hepatocellular adenoma were closely monitored during a total of 17 pregnancies between 2000 and 2009. Their files were reviewed. Results: In four cases, hepatocellular adenomas grew during pregnancy, requiring a Caesarean section in one patient (two pregnancies) at 36 and 34 weeks because of an assumed high risk of rupture. In one case radiofrequency ablation therapy was applied in the first trimester to treat a hormone sensitive hepatocellular adenoma, thereby excluding potential growth later in pregnancy. No intervention was performed in the other 14 cases and all pregnancies had an uneventful course with a successful maternal and fetal outcome. Conclusions: A "wait and see" management may be advocated in pregnant women presenting with a hepatocellular adenoma. In women with large tumours or in whom hepatocellular adenoma had complicated previous pregnancies, surgical resection may be recommended. In women with smaller adenomas it may no longer be necessary to discourage pregnancy

Hepatocellular adenoma: When and how to treat? Update of current evidence

Hepatocellular adenoma (HCA) is a rare, benign liver tumor. Discovery of this tumor is usually as an incidental finding, correlated with the use of oral contraceptives, or pregnancy. Treatment options have focused on conservative management for the straightforward, smaller lesions (5 cm) that pose a greater risk of hemorrhage or malignant progression. In recent years, a new molecular subclassification of HCA has been proposed, associated with characteristic morphological features and loss or increased expression of immunohistochemical markers. This subclassification could possibly provide considerable benefits in terms of patient stratification, and the selection of treatment options. In this review we discuss the decision-making processes and associated risk analyses that should be made based on lesion size, and subtype. The usefulness of this subclassification system in terms of the procedures instigated as part of the diagnostic work-up of a suspected HCA will be outlined, and suitable treatment schemes proposed

Learning curves of minimally invasive donor nephrectomy in a high-volume center: A cohort study of 1895 consecutive living donors

Background: Few studies have investigated the learning curves of minimally invasive donor nephrectomy (MIDN) using the cumulative sum (CUSUM) analysis. In addition, no study has compared the learning curves of the different surgical MIDN techniques in one cohort study using the CUSU