Liver Tumor

[LauraLM]

I had a CT scan 6/04 for some RUQ pain.  They found a mass in my liver (4.5 cm x 4.0 cm) but it was believed benign (Focal Nodular Hyperplasia) and not causing the pain. I d/c'd birth control pills 6/04 per Dr. LFT and AFP were normal.  F/U CT Scan 10/04 revealed mass had grown to 5.6 cm x 4.5 cm. CT still saying consistent with FNH.  It is in the dead center of my liver, right on top of the hepatic vein and portal vein.  It has began to compress the intra hepatic bile duct.  I am told this is a tricky area and biopsy is not normally recommended.  I want to follow this conservatively, but obviously I am worried by the change in size.  My Dr. says this should not be causing any pain - that it is too deep in the liver and there are no nerve endings there.  I am 38 yrs old and otherwise healthy with no history of liver disease.  I am a tiny person so I would think something this size would eventually cause some problems.  My questions are as follows:  1)  Do FNH tumors typically continue to grow after stopping BCP's?  2)  How can you know it is not malignant w/out biopsy? Should I really just not worry about it? 3) Should LFT's and tumor markers be repeated at this time?  4) how large can a benign liver tumor get before it becomes a problem by its size alone?  Thank you.

[taymack]

My husband (47yo) was recently found to have a liver tumor, incidentally diagnosed while in the hospital for RUQ abd pain. He has had an abdominal/pelvic CT w/contrast and an MRI w/contrast as well as an Ultrasound. The tumor is 6.8cm x 4.3cm but has not been Dx as benign or malignant at this point. Our PCP has discussed 3 posibilities==> Hemangioma-which has been ruled out, FNH which as discussed is vary rare in males or a malignancy, however, the tumor is located in the posterior region of the liver and we are told that a "primary site" liver tumor is rare. AFP and Hepititis testing have been completed but is at this point are pending results. We have been told that if Hep B positive, this would increase the risk of a positive malignancy. Liver scan has been discussed but not ordered yet. RUQ pain does persist on a daily bases. After my husband andI discussed this pain we did realize that the pain has been an on going problem for approximately 18 months. Our PCP has discussed possible Needle Bx, Open Bx but has stated that because he feels at this time, there is a low chance of this being malignant, he would defer to a surgeon. We are seeing a local surgennext week. My questions are these:
1. Is it that difficult to Dx a malignant tumor in the posterior region of the liver?
2. Is it possible for a tumor of this size to cause this pain.
3. If this is a benign tumor should we still be concerned?

[lorig234]

did you have an MRI? i don't know if it is an appropriate test for what your diagnosis is , but really helped me.  i had 2 tests a few months apart with slightly elevated ast,alt and ggt.  my gi suggested an ultrasound because i also have ulcerative colitis and the association between uc and a liver disease called psc.  on my ultrasound they found a 1.5 cm echogenic mass so i had a follow up ct scan in which several small lesions were found. some couldn't be characterized at all because of size and the 3 that were big enough had some characteristics of hemangiomoas , but radiology couldn't definitively characterize.  i had a choice of  serial ct scans over months to check for stability or an mri.  i decided to have my mri in manhattan at a private facility and have it read by a radiologist who used to be a head radiologist sloane-kettering prior to going into private practice. i figured that i was better off having someone who has read thousands of abdominal mri's read mine. i don't ususally leave our local group , but my cousin who practices medicine in manhattan really pushed for getting the mri read by someone who has seen tons of liver lesions.  they we able to characterize them as hemangiomas .  i guess i go back periodically to check for size.

i know how awful it is finding out you have a lesion on your liver. it was probably the scariest thing  i have ever been through. I'm sure everything will be fine.

[surgeon]

1) They may continue to grow; however, growth is indeed of concern. It might be useful to find out from your doctors whether, based on the CT scan, what is the possibility that it could be something else.
2) You can't know with absolute certainty without biopsy. If biopsy is strongly felt inadvisable, you might consider getting a PET scan which likely would give more information to distinguish between FNH and tumor. Open biopsy is a consideration as well, if the lesion can be seen on ultrasound, which could be used to guide a surgical biopsy needle intraoperatively.
3) Wouldn't hurt
4) A benign growth can be quite large without causing problems, depending on location. Size, per se, is less important than the actual diagnosis.

[debi9218]

I too was diagnosed with FNH recently and was just as concerned as you sound, I am a nurse and let my training go out the window and assumed the worst.  Fortunately, my nodules have not grown in the past four months.  I was not on BCP, but do know that taking them is strongly linked to FNH.  The only way to truly be definitive regarding a diagnosis is a biopsy (I was also told it was difficult to biopsy).  In the absence of high risk factors such as alcoholism or hepatitis, and your age (assuming you obviously are child bearing age because of the BCP) it is very unlikely that it is malignant.  Take comfort in knowing that the radiologist reading your CT most likely has seen thousands of films of livers and can usually tell what liver tumors are by the way tumors present themselves.  Also, after doing a little research on the web, I found that FNH is not associated with any fatalities.  Good luck!

[Kevin Pho, MD]

To answer your questions:
1) Normally the diagnosis of FNH can be made in the abscence of a biopsy.  The imaging studies should be good enough.  Although in most cases stopping OCPs should help, it does not happen in 100% of cases.

2) Normally FNH does not grow, so if the liver lesion continues to grow, then you have to question the diagnosis.  I would consider an MRI for further evaluation.  The decision of a biopsy should be made after further imaging.

3) You can consider LFTs and tumor markers (i.e. alpha fetoprotein).  However, they will be non-diagnostic if abnormal, and you would have to consider further imaging tests or a biopsy anyways.  

4) There is no "set" size before a tumor becomes a problem.  It the tumor continues to grow, then a more definitive diagnosis should be considered.

You may want to consider a referral to a GI physician for further evaluation.

Followup with your personal physician is essential.

This answer is not intended as and does not substitute for medical advice - the information presented is for patient education only. Please see your personal physician for further evaluation of your individual case.

Kevin, M.D.
Medical Weblog:
kevinmd_b

[GallbladderBaby]

I think you're going to be just fine...  Hang in there and don't stress out.  Good luck and may God bless!