A 29-year-old woman taking combined oral contraceptives for 5 years presents with sudden right upper quadrant pain and hypotension. CT shows a 7 cm hepatic mass with hemoperitoneum. Histology shows sheets of normal-appearing hepatocytes supplied by thick-walled unpaired arteries, with no portal tracts and no bile ducts within the lesion. The most likely diagnosis is:

• A Focal nodular hyperplasia
• B Hepatic hemangioma
• C Well-differentiated hepatocellular carcinoma
• D Hepatocellular adenoma ✓

Explanation

Hepatocellular adenoma is a benign neoplasm of hepatocytes strongly linked to estrogen exposure. It lacks portal tracts and bile ducts, which distinguishes it from regenerative nodules and focal nodular hyperplasia. The abnormal thick-walled arteries make it prone to rupture, causing life-threatening intraperitoneal hemorrhage, particularly during pregnancy or with large lesions. Focal nodular hyperplasia has a central stellate scar with arteriovenous malformation-like vessels and proliferating ductules, and it does not bleed. Management of large or bleeding adenomas includes resection and stopping estrogens.

Reference: Robbins and Cotran Pathologic Basis of Disease, 10th ed.

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Written and medically reviewed by the StethoPrep medical team.