Indikation und Ergebnisse nach Resektion gutartiger Lebertumoren

Zusammenfassung

Die Diagnosestellung sowie Festlegung und Durchführung der geeigneten Therapie bei benignen Leberläsionen stellen für den Viszeralchirurgen eine besondere Herausforderung dar.
Trotz Ausschöpfung verschiedener radiologischer und nuklearmedizinischer Methoden, verbessertem Verständnis der individuellen Tumorbiologie sowie des zu erwartenden klinischen Verlaufes stellen nicht operationswürdige Läsionen wie das asymptomatische Hämangiom oder die fokal noduläre Hyperplasie (FNH) noch einen erheblichen Anteil der resezierten benignen Lebertumoren dar. Bei der operativen Therapie gelten die Forderungen einer möglichst geringen perioperativen Morbidität bei minimaler Mortalität, so dass bezüglich der zugrunde liegenden Indikationsstellung ein Höchstmaß an Transparenz bestehen muss. Die Resektion eines symptomatischen benignen Lebertumors führt in der überwiegenden Mehrzahl der Fälle zur unmittelbaren Behebung der tumorassoziierten Beschwerden.
Große Fallserien und Kasuistiken bestätigen eine betont zurückhaltende OP-Indikation bei fraglich symptomatischen Hämangiomen und FNH eindeutiger Dignität. Eine großzügige Indikation besteht weiterhin für die weitaus häufiger symptomatischen hepatozellulären Adenome, auch aufgrund der unbestrittenen Entartungsgefahr. Seltene Tumoren epithelialen oder mesenchymalen Ursprungs wie biliäre Zystadenome, Angiomyolipome oder Gallengangsadenome („Cholangiome”) erfordern im Falle der Zystadenome eine elektive Resektion bei nachgewiesener Entartungsgefahr, beim Angiomyolipom mit oftmals fehlender präoperativer Zuordnung ebenfalls die Resektion, beim inzidentell anzutreffenden Cholangiom eine konservative Vorgehensweise.
Letztlich obliegt dem Chirurgen die Verantwortung, nach möglichst eindeutiger präoperativer Diagnosesicherung in Kenntnis des zu erwartenden klinischen Verlaufes und unter Berücksichtigung patienten-spezifischer Kriterien die korrekte Entscheidung bezüglich der individuellen Therapie zu treffen.

Abstract

Diagnosis and decision making in regard to benign liver lesions still pose a major challenge for visceral surgeons.
Despite the use of complementary radiologic and scintigraphic diagnostic procedures as well as improved understanding of the essential tumour biology and expected clinical course both haemangiomas and focal nodular hyperplasia (FNH) still represent a large proportion of resected benign liver tumours. Acceptable perioperative morbidity and minimal mortality are prerequisites in connection with the surgery of benign liver lesions, supporting the demand for utmost transparency in the indication for surgery. The resection of a symptomatic liver lesion will lead to immediate relief in the majority of cases.
Both large series and individual reports have supported a critical appraisal of surgery in cases of questionable symptoms associated to a given liver lesion such as haemangioma or FNH. A generous approach should be followed in the case of hepatic-cell adenoma, which more often tend to become acutely symptomatic and also harbour the danger of malignant transformation. Seldom tumours of epithelial or mesenchymal origin such as biliary cystadenoma, angiomyolipoma or bile-duct adenoma (“cholangioma”), demand surgical resection in the case of cystadenoma due to the risk of malignant transformation and due to diagnostic insecurity in the majority of angiomyolipoma, whereas the often intraoperatively encountered cholangioma should be treated conservatively.
The surgeon alone bears final responsibility for the correct therapeutic decision regarding a supposedly benign liver lesion, supported by appropriate diagnostic measures and profound knowledge of the underlying tumour biology and expected clinical course.

Schlüsselwörter

Benigne Lebertumore - Resektion - Indikation

Key words

Benign liver lesions - resection - indication

Literatur

• 1 Adam Y G, Huvos A G, Fortner J G. Giant hemangiomas of the liver.  Ann Surg. 1970;  172 239-245
• 2 Arblade S, Vilgrain V, Terris B, Zins M, Vullierme M P, Flejou J F, Belghiti J, Menu Y. [Hepatic angiomyolipoma simulating hepatocytic tumor. 3 cases].  Gastroenterol Clin Biol. 1996;  20 1022-1026
• 3 Baer H U, Dennison A R, Mouton W, Stain S C, Zimmermann A, Blumgart L H. Enucleation of giant hemangiomas of the liver. Technical and pathologic aspects of a neglected procedure.  Ann Surg. 1992;  216 673-676
• 4 Becker Y T, Raiford D S, Webb L, Wright J K, Chapman W C, Pinson C W. Rupture and hemorrhage of hepatic focal nodular hyperplasia.  Am Surg. 1995;  61 210-214
• 5 Belghiti J, Hiramatsu K, Benoist S, Massault P, Sauvanet A, Farges O. Seven hundred forty-seven hepatectomies in the 1990s: an update to evaluate the actual risk of liver resection.  J Am Coll Surg. 2000;  191 38-46
• 6 Belghiti J, Pateron D, Panis Y, Vilgrain V, Flejou J F, Benhamou J P, Fekete F. Resection of presumed benign liver tumours.  Br J Surg. 1993;  80 380-383
• 7 Blachar A, Federle M P, Ferris J V, Lacomis J M, Waltz J S, Armfield D R, Chu G, Almusa O, Grazioli L, Balzano E, Li W. Radiologists' performance in the diagnosis of liver tumors with central scars by using specific CT criteria.  Radiology. 2002;  223 532-539
• 8 Brouwers M A, Peeters P M, de Jong K P, Haagsma E B, Klompmaker I J, Bijleveld C M, Zwaveling J H, Slooff M J. Surgical treatment of giant haemangioma of the liver.  Br J Surg. 1997;  84 314-316
• 9 Charny C K, Jarnagin W R, Schwartz L H, Frommeyer H S, DeMatteo R P, Fong Y, Blumgart L H. Management of 155 patients with benign liver tumours.  Br J Surg. 2001;  88 808-813
• 10 Cherqui D, Rahmouni A, Charlotte F, Boulahdour H, Metreau J M, Meignan M, Fagniez P L, Zafrani E S, Mathieu D, Dhumeaux D. Management of focal nodular hyperplasia and hepatocellular adenoma in young women: a series of 41 patients with clinical, radiological, and pathological correlations.  Hepatology. 1995;  22 1674-1681
• 11 Chouillard E, Cherqui D, Tayar C, Brunetti F, Fagniez P L. Anatomical bi- and trisegmentectomies as alternatives to extensive liver resections.  Ann Surg. 2003;  238 29-34
• 12 Closset J, Veys I, Peny M O, Braude P, Van Gansbeke D, Lambilliotte J P, Gelin M. Retrospective analysis of 29 patients surgically treated for hepatocellular adenoma or focal nodular hyperplasia.  Hepatogastroenterology. 2000;  47 1382-1384
• 13 Corigliano N, Mercantini P, Amodio P M, Balducci G, Caterino S, Ramacciato G, Ziparo V. Hemoperitoneum from a spontaneous rupture of a giant hemangioma of the liver: report of a case.  Surg Today. 2003;  33 459-463
• 14 Craig J R. Mesenchymal tumors of the liver. Diagnostic problems for the surgical pathologist.  Pathology (Phila). 1994;  3 141-160
• 15 D’Halluin V, Vilgrain V, Pelletier G, Rocher L, Belghiti J, Erlinger S, Buffet C. [Natural history of focal nodular hyperplasia. A retrospective study of 44 cases].  Gastroenterol Clin Biol. 2001;  25 1008-1010
• 16 Delorme S. [Radiological diagnosis of the liver].  Radiologe. 2000;  40 904-915
• 17 Di Carlo I, Urrico G S, Ursino V, Russello D, Puleo S, Latteri F. Simultaneous occurrence of adenoma, focal nodular hyperplasia, and hemangioma of the liver: are they derived from a common origin?.  J Gastroenterol Hepatol. 2003;  18 227-230
• 18 Federle M P, Brancatelli G. Imaging of benign hepatic masses.  Semin Liver Dis. 2001;  21 237-249
• 19 Foster J H, Berman M M. The malignant transformation of liver cell adenomas.  Arch Surg. 1994;  129 712-717
• 20 Fulcher A S, Sterling R K. Hepatic neoplasms: computed tomography and magnetic resonance features.  J Clin Gastroenterol. 2002;  34 463-471
• 21 Gaffey M J, Iezzoni J C, Weiss L M. Clonal analysis of focal nodular hyperplasia of the liver.  Am J Pathol. 1996;  148 1089-1096
• 22 Gedaly R, Pomposelli J J, Pomfret E A, Lewis W D, Jenkins R L. Cavernous hemangioma of the liver: anatomic resection vs. enucleation.  Arch Surg. 1999;  134 407-411
• 23 Gordon S C, Reddy K R, Livingstone A S, Jeffers L J, Schiff E R. Resolution of a contraceptive-steroid-induced hepatic adenoma with subsequent evolution into hepatocellular carcinoma.  Ann Intern Med. 1986;  105 547-549
• 24 Gratz K F, Weimann A. [Diagnosis of liver tumors - when is scintigraphy of value?].  Zentralbl Chir. 1998;  123 111-118
• 25 Grimm J, Muller-Hulsbeck S, Blume J, Biederer J, Heller M. [Comparison of biphasic spiral CT and MnDPDP-enhanced MRI in the detection and characterization of liver lesions].  Rofo Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr. 2001;  173 266-272
• 26 Hanazaki K, Kajikawa S, Matsushita A, Monma T, Koide N, Nimura Y, Yazawa K, Watanabe H, Nishio A, Adachi W, Amano J. Hepatic resection of giant cavernous hemangioma of the liver.  J Clin Gastroenterol. 1999;  29 257-260
• 27 Harisinghani M G, Hahn P F. Computed tomography and magnetic resonance imaging evaluation of liver cancer.  Gastroenterol Clin North Am. 2002;  31 759-776
• 28 Helmberger T K, Laubenberger J, Rummeny E, Jung G, Sievers K, Dohring W, Meurer K, Reiser M F. MRI characteristics in focal hepatic disease before and after administration of MnDPDP: discriminant analysis as a diagnostic tool.  Eur Radiol. 2002;  12 62-70
• 29 Hotokezaka M, Kojima M, Nakamura K, Hidaka H, Nakano Y, Tsuneyoshi M, Jimi M. Traumatic rupture of hepatic hemangioma.  J Clin Gastroenterol. 1996;  23 69-71
• 30 Hung C H, Changchien C S, Lu S N, Eng H L, Wang J H, Lee C M, Hsu C C, Tung H D. Sonographic features of hepatic adenomas with pathologic correlation.  Abdom Imaging. 2001;  26 500-506
• 31 Isozaki T, Numata K, Kiba T, Hara K, Morimoto M, Sakaguchi T, Sekihara H, Kubota T, Shimada H, Morizane T, Tanaka K. Differential diagnosis of hepatic tumors by using contrast enhancement patterns at US.  Radiology. 2003;  229 798-805
• 32 Issa P. Cavernous haemangioma of the liver: the role of radiotherapy.  Br J Radiol. 1968;  41 26-32
• 33 Ito M, Sasaki M, Wen C Y, Nakashima M, Ueki T, Ishibashi H, Yano M, Kage M, Kojiro M. Liver cell adenoma with malignant transformation: a case report.  World J Gastroenterol. 2003;  9 2379-2381
• 34 Kuo P C, Lewis W D, Jenkins R L. Treatment of giant hemangiomas of the liver by enucleation.  J Am Coll Surg. 1994;  178 49-53
• 35 Lapeyre M, Mathieu D, Tailboux L, Rahmouni A, Kobeiter H. Dilatation of the intrahepatic bile ducts associated with benign liver lesions: an unusual finding.  Eur Radiol. 2002;  12 71-73
• 36 Laurent C, Trillaud H, Lepreux S, Balabaud C, Bioulac-Sage P. Association of adenoma and focal nodular hyperplasia: experience of a single French academic center.  Comp Hepatol. 2003;  2 6
• 37 Luciani A, Kobeiter H, Maison P, Cherqui D, Zafrani E S, Dhumeaux D, Mathieu D. Focal nodular hyperplasia of the liver in men: is presentation the same in men and women?.  Gut. 2002;  50 877-880
• 38 Marino I R, Scantlebury V P, Bronsther O, Iwatsuki S, Starzl T E. Total hepatectomy and liver transplant for hepatocellular adenomatosis and focal nodular hyperplasia.  Transpl Int. 1992;  5 (Suppl 1) 201-205
• 39 Mergo P J, Engelken J D, Helmberger T, Ros P R. MRI in focal liver disease: a comparison of small and ultra-small superparamagnetic iron oxide as hepatic contrast agents.  J Magn Reson Imaging. 1998;  8 1073-1078
• 40 Mergo P J, Ros P R. Benign lesions of the liver.  Radiol Clin North Am. 1998;  36 319-331
• 41 Neuberger J, Portmann B, Nunnerley H B, Laws J W, Davis M, Williams R. Oral-contraceptive-associated liver tumours: occurrence of malignancy and difficulties in diagnosis.  Lancet. 1980;  1 273-276
• 42 Nufer M, Stuckmann G and Decurtins M. [Benign liver tumors: diagnosis and therapy - a review].  Schweiz Med Wochenschr. 1999;  129 1257-1264
• 43 Ott R, Hohenberger W. [Focal nodular hyperplasia and liver cell adenoma: operation or observation?].  Zentralbl Chir. 1998;  123 145-153
• 44 Paley M R, Mergo P J, Torres G M, Ros P R. Characterization of focal hepatic lesions with ferumoxides-enhanced T₂-weighted MR imaging.  AJR Am J Roentgenol. 2000;  175 159-163
• 45 Paradis V, Bieche I, Dargere D, Laurendeau I, Nectoux J, Degott C, Belghiti J, Vidaud M, Bedossa P. A quantitative gene expression study suggests a role for angiopoietins in focal nodular hyperplasia.  Gastroenterology. 2003;  124 651-659
• 46 Paradis V, Laurent A, Flejou J F, Vidaud M, Bedossa P. Evidence for the polyclonal nature of focal nodular hyperplasia of the liver by the study of X-chromosome inactivation.  Hepatology. 1997;  26 891-895
• 47 Perkins A B, Imam K, Smith W J, Cronan J J. Color and power Doppler sonography of liver hemangiomas: a dream unfulfilled?.  J Clin Ultrasound. 2000;  28 159-165
• 48 Petri A, Hohn J, Wolfard A, Laszlo Kokai E, Kocsis Savanya G, Boros M, Balogh A. [Surgery of benign liver tumors: indications for treatment. Personal experience and review of the literature].  Magy Onkol. 2003;  47 391-395
• 49 Pietrabissa A, Giulianotti P, Campatelli A, Di Candio G, Farina F, Signori S, Mosca F. Management and follow-up of 78 giant haemangiomas of the liver.  Br J Surg. 1996;  83 915-918
• 50 Ren N, Qin L X, Tang Z Y, Wu Z Q, Fan J. Diagnosis and treatment of hepatic angiomyolipoma in 26 cases.  World J Gastroenterol. 2003;  9 1856-1858
• 51 Ruppert-Kohlmayr A J, Uggowitzer M M, Kugler C, Zebedin D, Schaffler G, Ruppert G S. Focal nodular hyperplasia and hepatocellular adenoma of the liver: differentiation with multiphasic helical CT.  AJR Am J Roentgenol. 2001;  176 1493-1498
• 52 Schunk K, Schadmand-Fischer S, Thelen M. [Diagnostic imaging of benign and malignant liver tumors: computerized tomography or magnetic resonance tomography?].  Zentralbl Chir. 1998;  123 124-130
• 53 Srivastava D N, Gandhi D, Seith A, Pande G K, Sahni P. Transcatheter arterial embolization in the treatment of symptomatic cavernous hemangiomas of the liver: a prospective study.  Abdom Imaging. 2001;  26 510-514
• 54 Strobel D, Raeker S, Martus P, Hahn E G, Becker D. Phase inversion harmonic imaging versus contrast-enhanced power Doppler sonography for the characterization of focal liver lesions.  Int J Colorectal Dis. 2003;  18 63-72
• 55 Stroszczynski C, Gaffke G, Gretschel S, Rambow A, Jost D, Schlecht I, Schneider U, Schicke B, Hohenberger P, Gebauer B, Felix R. [Use of SPIO-enhanced T₁- and T₂-weighted images for the differentiation of liver lesions: an ROC analysis].  Rofo Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr. 2003;  175 1368-1375
• 56 Suzuki H, Nimura Y, Kamiya J, Kondo S, Nagino M, Kanai M, Miyachi M. Preoperative transcatheter arterial embolization for giant cavernous hemangioma of the liver with consumption coagulopathy.  Am J Gastroenterol. 1997;  92 688-691
• 57 Tannapfel A and Wittekind C. [Preneoplasia of the liver. Definition - differential diagnosis - clinical consequences].  Pathologe. 2001;  22 399-406
• 58 Tao L C. Oral contraceptive-associated liver cell adenoma and hepatocellular carcinoma. Cytomorphology and mechanism of malignant transformation.  Cancer. 1991;  68 341-347
• 59 Tepetes K, Selby R, Webb M, Madariaga J R, Iwatsuki S, Starzl T E. Orthotopic liver transplantation for benign hepatic neoplasms.  Arch Surg. 1995;  130 153-156
• 60 Terkivatan T, de Wilt J H, de Man R A, van Rijn R R, Tilanus H W, Jn I J. Treatment of ruptured hepatocellular adenoma.  Br J Surg. 2001;  88 207-209
• 61 Terkivatan T, de Wilt J H, de Man R A, van Rijn R R, Zondervan P E, Tilanus H W, Ijzermans J N. Indications and long-term outcome of treatment for benign hepatic tumors: a critical appraisal.  Arch Surg. 2001;  136 1033-1038
• 62 Tesluk H, Lawrie J. Hepatocellular adenoma. Its transformation to carcinoma in a user of oral contraceptives.  Arch Pathol Lab Med. 1981;  105 296-299
• 63 Trampert L, Benz P, Ruth T, Oberhausen E. [Nuclear medicine diagnosis of focal liver lesions].  Nuklearmedizin. 1993;  32 174-177
• 64 Weimann A, Ringe B, Klempnauer J, Lamesch P, Gratz K F, Prokop M, Maschek H, Tusch G, Pichlmayr R. Benign liver tumors: differential diagnosis and indications for surgery.  World J Surg. 1997;  21 983-990
• 65 Welch T J, Sheedy P F2, Johnson C M, Stephens D H, Charboneau J W, Brown M L, May G R, Adson M A, McGill D B. Focal nodular hyperplasia and hepatic adenoma: comparison of angiography, CT, US, and scintigraphy.  Radiology. 1985;  156 593-595
• 66 Xu A M, Cheng H Y, Chen D, Jia Y C, Wu M C. Plane and weighted tri-phase helical CT findings in the diagnosis of liver focal nodular hyperplasia.  Hepatobiliary Pancreat Dis Int. 2002;  1 219-223
• 67 Yamagata M, Kanematsu T, Matsumata T, Utsunomiya T, Ikeda Y, Sugimachi K. Management of haemangioma of the liver: comparison of results between surgery and observation.  Br J Surg. 1991;  78 1223-1225
• 68 Yeh C N, Chen M F, Hung C F, Chen T C, Chao T C. Angiomyolipoma of the liver.  J Surg Oncol. 2001;  77 195-200