Discussion

Hepatocellular adenomas are uncommon benign hepatocellular tumors occurring predominantly in women of reproductive age and are strongly associated with prolonged exposure to estrogen-containing oral contraceptives [1,2]. Their main complications are hemorrhage and malignant transformation. Hemorrhagic risk is influenced by lesion size and molecular subtype and is generally higher in lesions larger than 5 cm [2,3]. In the present case, however, intralesional hemorrhage was demonstrated in both the 12-cm lesion involving segments VII and VIII and the separate 3-cm lesion in segment V.

The current molecular classification includes HNF1A-inactivated, inflammatory, β-catenin–activated, mixed β-catenin–activated inflammatory, sonic hedgehog, and unclassified hepatocellular adenomas [2,3]. Inflammatory adenomas, which account for approximately 40% of cases, are characterized by sinusoidal dilatation, inflammatory infiltrates, and vascular ectasia and may have a marked hemorrhagic tendency [3,5]. Sonic hedgehog adenomas are also strongly associated with symptomatic bleeding, whereas HNF1A-inactivated adenomas generally have a lower hemorrhagic risk. β-catenin activation, particularly involving exon 3, is mainly associated with malignant transformation [2,3]. Histopathological examination confirmed the inflammatory subtype in the sampled lesion, but this classification cannot necessarily be extrapolated to all additional adenomas.

Multimodality imaging was essential for demonstrating lesion multiplicity and characterizing the hemorrhagic components. On unenhanced CT, the 2 largest lesions contained spontaneously hyperattenuating areas consistent with intralesional hemorrhage. The larger lesion was additionally associated with a subcapsular hematoma. On contrast-enhanced CT, the hemorrhagic components remained hypoattenuating relative to the surrounding liver parenchyma, without definite active contrast extravasation. MRI further characterized the blood products and demonstrated arterial enhancement within the viable portions of both lesions. Identification of the separate segment V adenoma on unenhanced CT, coronal MRI, and dynamic MRI confirmed the multifocal nature of the disease [1,2,5].

Mild hepatic steatosis was present but was not a predominant feature of this case. Although an association between hepatic steatosis and multiple hepatocellular adenomas has been reported [6,7], obesity and metabolic dysfunction were not documented in our patient. The onset of pain immediately after vigorous physical exertion represents a notable temporal association, although a direct causal relationship cannot be established.

Management of hemorrhagic hepatocellular adenomas depends on hemodynamic status, clinical progression, laboratory findings, and imaging features. Although the patient remained hemodynamically stable and no active contrast extravasation was identified on CT, persistent hemoglobin decline and worsening abdominal pain raised concern for ongoing or intermittent bleeding. Selective arterial embolization was therefore performed, resulting in clinical and biological stabilization while preserving uninvolved liver parenchyma. Follow-up imaging demonstrated regression of the subcapsular hematoma and reduction in lesion size, consistent with previously reported outcomes following transarterial embolization [4].