This page was last reviewed 15-05-20
GPs may receive radiology reports of incidental focal liver lesions (FLLs). Although FLLs are relatively common and the vast majority are benign, it is imperative to confidently exclude a malignancy. The radiological imaging and clinical context must always be considered together to form an accurate differential diagnosis (e.g. patients with chronic liver disease, and a solid FLL, are at high risk of having hepatocellular carcinoma (HCC)).
Hepatic haemangiomas are the commonest benign neoplasm of the liver (up to 20% in autopsy series). They affect all ages, but are commonest in women aged 30-50. They are usually <4cm and solitary; even when large, they are usually asymptomatic and stable in size. Spontaneous bleeding is rare.
Focal nodular hyperplasia (FNH) is the 2nd most frequent benign liver tumour. FNH is a polyclonal hepatocellular proliferation, considered as a hyperplastic reaction resulting from arterial malformation. 90% occur in young females with an average age at presentation of 35-50. FNH is multiple in 20-30%. The typical natural history of FNH is of stability. There is no malignant potential and complications are exceedingly rare.
Hepatocellular adenomas are rare benign tumours of hepatocellular origin.. Although they occur most frequently in women aged 35-40, the incidence has increased in males with increased use of anabolic substances. There are associations with theoral contraceptive pill (OCP), maturity onset diabetes of the young, glycogen storage diseases, polycystic ovary syndrome, acromegaly and androgen use. They are multiple in 20%. Although usually asymptomatic, they can bleed, rupture, and may undergo malignant transformation.
Benign liver cysts affect between 2-7% of the population. They are uncommon before the age of 40 years, with slight female preponderance. The overwhelming majority are ‘simple’ cysts
Focal fatty infiltration (hepatic steatosis) or focal fatty sparing, often reported on liver ultrasonography, is of no consequence.
GPs should refer patients to secondary care who are suspected of having advanced liver fibrosis/cirrhosis.
Patients from the City of Edinburgh, Midlothian and East Lothian should be referred to Hepatology at the Royal Infirmary of Edinburgh.
Patients from West Lothian should be referred to St John’s Hospital. It is helpful for elective patients to have both a basic liver screen and an ultrasound scan performed prior to referral.
Haemangiomas
Asymptomatic patients, <3cm, with classical haemangioma appearances can be reassured without imaging follow-up. Pregnancy and oral contraceptives are not contraindicated.
Focal Nodular Hyperplasia
Asymptomatic patients with a firm imaging diagnosis of FNH do not require follow-up, unless there is underlying vascular liver disease. There is no indication for discontinuing OCPs and follow-up during pregnancy is not necessary.
Hepatocellular Adenomas
Specialist treatment decisions (e.g. need for resection, imaging follow-up) are based on gender, size, molecular subtype if known, and pattern of progression. Lifestyle changes such as discontinuation of the oral contraceptive pill/ anabolic steroids, as well as weight loss, should be advised. Hepatocellular adenoma in a pregnant woman requires regular ultrasound follow-up (every 6–12 weeks) to monitor size.
Cystic Lesions
Incidentally identified asymptomatic ‘simple’ cysts need no follow-up or treatment
Information Leaflet from the The British Liver Trust on Benign Tumours and Cystic Disease
https://www.britishlivertrust.org.uk/liver-information/liver-conditions/benign-tumours-and-cystic-disease/.
A video discussing the physiology of Benign Liver Tumours in the liver at the following URL https://youtu.be/4f4H3xBhF9I.
Journal of Hepatology : EASL Clinical Practice Guidelines on the management of benign liver tumours. J Hepatol. 2016 Aug;65(2):386-98.
