Hepatic adenoma assessment: Wait longer to avoid overtreatment?

LAS VEGAS – For women with larger hepatic adenomas, current guidelines suggest reassessment at 6 months after oral contraceptive withdrawal to determine whether resection is warranted.

However, emerging data show reassessing at that time point may lead to overtreatment, according to Laura M. Kulik, MD, professor of medicine (gastroenterology and hepatology), radiology and surgery (organ transplantation), Northwestern University, Chicago.

“There’s been some controversy that 6 months may be too short,” Dr. Kulik said at the inaugural Perspectives in Digestive Diseases meeting held by Global Academy for Medical Education.

Unlike other benign liver lesions, hepatic adenomas can hemorrhage and transform to hepatocellular carcinoma. Current guidelines from the European Association for the Study of the Liver state that larger lesions (i.e., 5 cm or greater on baseline imaging) are associated with a higher risk of complications. According to one systematic review cited in the document, almost all cases of hemorrhage or spontaneous rupture occur in lesions 5 cm or larger.

Oral contraceptive use has been associated with a 30- to 40-fold increase in hepatic adenoma incidence, according to the guidelines.

All men with hepatic adenomas should undergo resection or curative treatment, the guidelines say, since they have a significantly higher risk of hepatocellular carcinoma.

By contrast, women with hepatic adenomas larger than 5 cm should discontinue oral contraceptives – which may lead to tumor regression in some cases – and should be reassessed 6 months later with contrast-enhanced MRI; if the lesion is still greater than 5 cm at that time, they should be considered for resection or curative treatment, the guidelines say.

However, authors of a retrospective cohort study have challenged that advice, suggesting that a 6-month follow-up may not always be long enough to see adequate tumor regression (HPB 2017 Apr;19[Suppl 1]:S3).

 

In the study, researchers from Erasmus MC University Medical Center, Rotterdam, the Netherlands, reviewed records for patients who were diagnosed with a hepatic adenoma of at least 5 cm and followed for at least 6 months after oral contraceptives were stopped.

Of that group, 104 underwent surgical treatment for a lesion larger than 5 cm, while the remaining 86 were conservatively treated.

The researchers found that in the conservatively treated group, 61 lesions (71%) regressed below the 5-cm cutoff after a median of 85 weeks (95% confidence interval, 52-110 weeks), with larger lesions taking significantly longer to regress.

Based on those findings, the investigators said the 6-month cutoff may lead to overtreatment, and that for some patients with particularly large tumors, it may be justified to wait up to 24 months.

 

“The study does suggest that, potentially, 6 months may be too short,” Dr. Kulik told attendees at the meeting. “They do caution that beta-catenin mutated adenomas should probably be removed without waiting longer because of the risk of developing cancer.”

Dr. Kulik reported disclosures related to Bayer, BMS, BTG, and Eisai. Global Academy and this news organization are owned by the same parent company.

LAS VEGAS – For women with larger hepatic adenomas, current guidelines suggest reassessment at 6 months after oral contraceptive withdrawal to determine whether resection is warranted.

However, emerging data show reassessing at that time point may lead to overtreatment, according to Laura M. Kulik, MD, professor of medicine (gastroenterology and hepatology), radiology and surgery (organ transplantation), Northwestern University, Chicago.

“There’s been some controversy that 6 months may be too short,” Dr. Kulik said at the inaugural Perspectives in Digestive Diseases meeting held by Global Academy for Medical Education.

Unlike other benign liver lesions, hepatic adenomas can hemorrhage and transform to hepatocellular carcinoma. Current guidelines from the European Association for the Study of the Liver state that larger lesions (i.e., 5 cm or greater on baseline imaging) are associated with a higher risk of complications. According to one systematic review cited in the document, almost all cases of hemorrhage or spontaneous rupture occur in lesions 5 cm or larger.

Oral contraceptive use has been associated with a 30- to 40-fold increase in hepatic adenoma incidence, according to the guidelines.

All men with hepatic adenomas should undergo resection or curative treatment, the guidelines say, since they have a significantly higher risk of hepatocellular carcinoma.

By contrast, women with hepatic adenomas larger than 5 cm should discontinue oral contraceptives – which may lead to tumor regression in some cases – and should be reassessed 6 months later with contrast-enhanced MRI; if the lesion is still greater than 5 cm at that time, they should be considered for resection or curative treatment, the guidelines say.

However, authors of a retrospective cohort study have challenged that advice, suggesting that a 6-month follow-up may not always be long enough to see adequate tumor regression (HPB 2017 Apr;19[Suppl 1]:S3).

 

In the study, researchers from Erasmus MC University Medical Center, Rotterdam, the Netherlands, reviewed records for patients who were diagnosed with a hepatic adenoma of at least 5 cm and followed for at least 6 months after oral contraceptives were stopped.

Of that group, 104 underwent surgical treatment for a lesion larger than 5 cm, while the remaining 86 were conservatively treated.

The researchers found that in the conservatively treated group, 61 lesions (71%) regressed below the 5-cm cutoff after a median of 85 weeks (95% confidence interval, 52-110 weeks), with larger lesions taking significantly longer to regress.

Based on those findings, the investigators said the 6-month cutoff may lead to overtreatment, and that for some patients with particularly large tumors, it may be justified to wait up to 24 months.

 

“The study does suggest that, potentially, 6 months may be too short,” Dr. Kulik told attendees at the meeting. “They do caution that beta-catenin mutated adenomas should probably be removed without waiting longer because of the risk of developing cancer.”

Dr. Kulik reported disclosures related to Bayer, BMS, BTG, and Eisai. Global Academy and this news organization are owned by the same parent company.

LAS VEGAS – For women with larger hepatic adenomas, current guidelines suggest reassessment at 6 months after oral contraceptive withdrawal to determine whether resection is warranted.

However, emerging data show reassessing at that time point may lead to overtreatment, according to Laura M. Kulik, MD, professor of medicine (gastroenterology and hepatology), radiology and surgery (organ transplantation), Northwestern University, Chicago.

“There’s been some controversy that 6 months may be too short,” Dr. Kulik said at the inaugural Perspectives in Digestive Diseases meeting held by Global Academy for Medical Education.

Unlike other benign liver lesions, hepatic adenomas can hemorrhage and transform to hepatocellular carcinoma. Current guidelines from the European Association for the Study of the Liver state that larger lesions (i.e., 5 cm or greater on baseline imaging) are associated with a higher risk of complications. According to one systematic review cited in the document, almost all cases of hemorrhage or spontaneous rupture occur in lesions 5 cm or larger.

Oral contraceptive use has been associated with a 30- to 40-fold increase in hepatic adenoma incidence, according to the guidelines.

All men with hepatic adenomas should undergo resection or curative treatment, the guidelines say, since they have a significantly higher risk of hepatocellular carcinoma.

By contrast, women with hepatic adenomas larger than 5 cm should discontinue oral contraceptives – which may lead to tumor regression in some cases – and should be reassessed 6 months later with contrast-enhanced MRI; if the lesion is still greater than 5 cm at that time, they should be considered for resection or curative treatment, the guidelines say.

However, authors of a retrospective cohort study have challenged that advice, suggesting that a 6-month follow-up may not always be long enough to see adequate tumor regression (HPB 2017 Apr;19[Suppl 1]:S3).

 

In the study, researchers from Erasmus MC University Medical Center, Rotterdam, the Netherlands, reviewed records for patients who were diagnosed with a hepatic adenoma of at least 5 cm and followed for at least 6 months after oral contraceptives were stopped.

Of that group, 104 underwent surgical treatment for a lesion larger than 5 cm, while the remaining 86 were conservatively treated.

The researchers found that in the conservatively treated group, 61 lesions (71%) regressed below the 5-cm cutoff after a median of 85 weeks (95% confidence interval, 52-110 weeks), with larger lesions taking significantly longer to regress.

Based on those findings, the investigators said the 6-month cutoff may lead to overtreatment, and that for some patients with particularly large tumors, it may be justified to wait up to 24 months.

 

“The study does suggest that, potentially, 6 months may be too short,” Dr. Kulik told attendees at the meeting. “They do caution that beta-catenin mutated adenomas should probably be removed without waiting longer because of the risk of developing cancer.”

Dr. Kulik reported disclosures related to Bayer, BMS, BTG, and Eisai. Global Academy and this news organization are owned by the same parent company.