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  Table of Contents    
CASE REPORT  
Year : 2011  |  Volume : 54  |  Issue : 4  |  Page : 822-824
Multiple focal nodular hyperplasia, an incidental finding on autopsy


Department of Pathology, T.N. Medical College and B Y L Nair Ch. Hospital, Mumbai, India

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Date of Web Publication6-Jan-2012
 

   Abstract 

Focal nodular hyperplasia (FNH) is a benign condition of the liver often discovered incidentally on radiological investigation. Although FNH is a well-described lesion in the literature considerable diagnostic problems regarding this entity still remains. We report a case of multiple FNH in a 23-year-old male patient detected as an incidental finding in autopsy. On gross examination FNH was not suspected because of the multiple lesions and the lack of central scar which is characteristically described in FNH. The diagnosis was established on histopathology after examination of multiple sections of the lesions.

Keywords: Autopsy, liver focal nodular hyperplasia, multiple FNH

How to cite this article:
Shetty JB, Amrapurkar AD, Shenoy AS. Multiple focal nodular hyperplasia, an incidental finding on autopsy. Indian J Pathol Microbiol 2011;54:822-4

How to cite this URL:
Shetty JB, Amrapurkar AD, Shenoy AS. Multiple focal nodular hyperplasia, an incidental finding on autopsy. Indian J Pathol Microbiol [serial online] 2011 [cited 2019 Jun 16];54:822-4. Available from: http://www.ijpmonline.org/text.asp?2011/54/4/822/91538



   Introduction Top


Focal nodular hyperplasia (FNH) is a benign tumor of the liver accounting for approximately 8% of all the primary hepatic tumors. [1] It is commonly described in premenopausal women and only 10% of the cases occur in males. [2] FNH commonly presents as a solitary mass in 60-70% of the cases and with multiple lesions in 30% of the cases. [3] Grossly it is characterized by the presence of well-circumscribed vascular tan nodule with a typical central fibrous scar. [1],[2] Histologically this lesion shows a nodular hyperplastic parenchyma composed of normal hepatocytes arranged in 1-2 cell thick plate. [2],[4] Bile duct proliferation is seen at the interface between hepatocytes and fibrous regions. [3],[4] The fibrous scar contains irregular arteries with thickened walls, veins and capillaries. Discrete inflammatory infiltrate is seen in the fibrous septa surrounding the hepatocyte nodules. [1],[4],[5] We highlight some of the unusual clinical, gross and microscopical features of FNH. The present case was detected as an incidental finding in a non-smoker male who died of bronchopneumonia. Grossly there were multiple lesions in the liver without the central scar. Microscopically apart from the ectatic and thickened vessels within the fibrous scar of the lesions of liver, large cavernous type of vessels were also seen in the submucosa of the stomach. The present case is unique because there is no case of FNH reported in literature with liver showing such great number of nodules as was seen in the present case. Furthermore, these lesions were detected on autopsy. The incidence of FNH detected on autopsy in one of the studies carried out on 50,000 autopsy cases was only 0.02%. [6]


   Case Report Top


A 23-year-old male patient who presented with history of fever and cough of 10-15 days duration expired after short hospital stay. A complete postmortem examination was done. Lungs showed features of confluent bronchopneumonia. Liver weighed 1200 g. Right lobe of liver showed a nodular subcapsular lesion measuring 4 ×3×2 cm in size with central umbilication. On cut section the mass was solid pale yellow. No central scar was seen on naked eye examination [Figure 1]. Similar multiple tiny yellow nodules were seen throughout the entire liver parenchyma ranging from 1 to 2 cm. Nodules were slightly raised above the surface [Figure 2]. There was no evidence of necrosis or hemorrhage. Surrounding liver showed chronic venous congestion. Biliary system was unremarkable. No space-occupying lesions were seen in the other organs. Lymph nodes were not enlarged. On gross examination of liver possibility of infective etiology was considered. Since the patient died of bilateral bronchopneumonia we suspected these lesions to be multiple abscesses probably of bacterial or fungal etiology. Microscopical examination of the large nodule of the liver showed normal hepatocytes arranged in 2-3 cell plate thickness surrounded by fibrous septa. Central fibrous scars consisting of large dilated thick-walled blood vessels [Figure 3]a with proliferating bile ductules and moderate inflammation [Figure 3]b were appreciated only on microscopical examination). Massons Trichrome stain was done which highlighted the fibrous tissue around the liver nodule and the thickened blood vessels. Retic stain done on the liver demonstrated the two cell plate thickness of the hepatocytes [Figure 3]d. Few nodules showed presence of large ectatic blood vessels at the periphery of the nodule. Surrounding liver parenchyma showed changes of chronic venous congestion. There was no evidence of adenoma or hepatocellular carcinoma. Sections from the stomach showed large dilated cavernous type of vessels in the submucosa [Figure 4].
Figure 1: Gross picture of the liver showing a large subcapsular nodule. Inset showing closer view of the nodule

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Figure 2: Closer view of the liver showing tiny nodules scattered throughout the parenchyma

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Figure 3: (a) Photomicrograph of the liver showing the dilated vessels within the fibrous tissue surrounding the nodule (hematoxylin and eosin, ×100). (b) Photomicrograph of the liver showing proliferating bile ductules within the fibrous scar (hematoxylin and eosin, ×400). (c) Photomicrograph of Masson trichrome (MT) stain done on liver highlighting the fibrous tissue around the liver nodule and the thickened blood vessels (MT, ×100). (d) Photomicrograph of reticulin stain done on liver highlighting the two cell plate thickness of the hepatocytes (reticulin, ×400)

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Figure 4: Photomicrograph of the stomach showing large dilated cavernous type of vessels in the submucosa (hematoxylin and eosin, ×100)

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   Discussion Top


FNH is an uncommon lesion, reported only 14 times in one series of 50,000 autopsies. Multiple lesions are seen in only 30% of the cases. FNH has been considered to be a neoplasm, regenerative process, hamartoma or a combination of these processes. [6]

Seventy to ninety percent of the cases of FNH at presentation are asymptomatic and majority of them are diagnosed as an incidental finding on radiological investigation. [1],[7] In the present case it was an incidental finding on autopsy. It is commonly seen in women between the age group of 20-40 yrs, primarily being associated with the use of oral contraceptives. [7] In males cigarette smoking is a risk factor. [8] However, deviations from these usual presentations can been seen as was seen in our case. In the present case the patient was a male and a nonsmoker.

The pathogenesis of FNH is not clear. Wanless and colleagues after studying 36 cases and review of literature concluded that the lesion results from a hyperplastic response of the hepatic parenchyma to a developmental arterial malformation. [9] Hence the coexistence of vascular lesion like hemangioma with FNH is not surprising. Other vascular abnormalities i.e., telangiectasis hereditary hemorrhagic telangiectasia, A-V malformations and anomalous pulmonary drainage have occasionally been reported in association with FNH. [10] In the present case grossly there were no vascular lesions in any of the organs. However, large cavernous type of vessels were seen in the submucosa of stomach on histopathology. Liver adjacent to the nodules showed changes of chronic passive congestion. These findings further support the association of FNH and vascular malformations. In many of the reported cases, multiple FNH is more often associated with vascular malformations. However, most of these cases of multiple FNH which are reported had only 2-5 lesions in the liver. The present case had more than 30 lesions in the liver. This form with a very great number of nodules seems to be extremely rare. [5] Thus this case highlights some unusual features of FNH which a pathologist and radiologist should be aware of to avoid making an erroneous diagnosis.

 
   References Top

1.Farrugia P, Alaggio R, Cardella F, Tropia S, Trizzino A, Ferrara F, et al. Focal nodular hyperplasia of the liver: An unusual association with diabetes mellitus in a child and review of literature. Ital J Pediatr 2010;36:41-4.  Back to cited text no. 1
    
2.Hsee LC, McCall JL, Koea JB. Focal nodular hyperplasia: What are the indications for resection? HPB (Oxford) 2005;7:298-302.  Back to cited text no. 2
[PUBMED]  [FULLTEXT]  
3.Colle I, Beeck BO, Hoorens A, Hautekeete M. Multiple focal nodular hyperplasia. J Gastroenterol 1998;33:904-8.  Back to cited text no. 3
[PUBMED]  [FULLTEXT]  
4.Bioulac Sage P, Balabaud C, Wanless IR. Diagnosis of focal nodular hyperplasia, Not so easy. Am J Surg Pathol 2001;25:1322-5.  Back to cited text no. 4
    
5.Lepreux S, Laurent C, Balabaud C, Bioulac Sage. Focal nodular hyperplasia lacking some key histopathological features making the diagnosis difficult. Virchows Arch 2002;440:445-6.  Back to cited text no. 5
    
6.Everson RB, Fraumeni JF. Familial glioblastoma with hepatic focal nodular hyperplasia. Cancer 1976;38:310-3.  Back to cited text no. 6
    
7.Chang SK, Chung YF, Thng CH, Loo HW. Focal nodular hyperplasia presenting as acute abdomen. Singapore Med J 2005;46:90-2.  Back to cited text no. 7
[PUBMED]  [FULLTEXT]  
8.Scalori A, Tavani A, Gallus S, La Vecchia C, Colombo M. Risk factors for focal nodular hyperplasia of the liver: An Italian case-control study. Am J Gastroenterol 2002;97:2371-3.  Back to cited text no. 8
[PUBMED]  [FULLTEXT]  
9.Wanless IR, Mawdsley C, Adams R. On the pathogenesis of focal nodular hyperplasia of the liver. Hepatology 1985;5:1194-200.  Back to cited text no. 9
[PUBMED]    
10.Mathieu D, Zafrani ES, Anglade MC, Dhumeaux D. Association of focal nodular hyperplasia and hepatic hemangioma. Gastroenterology 1989;97:154-7.  Back to cited text no. 10
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Correspondence Address:
Jyothi B Shetty
Department of Pathology, B-2 Anand Bhavan, Lal Chimney Compound, Dr. A. Nair Road, Mumbai - 400 011
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0377-4929.91538

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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