Large unclassified hepatocellular adenoma with spontaneous haemorrhage and necrosis in a young woman: Surgical management and post-operative surveillance challenges

Title : Large unclassified hepatocellular adenoma with spontaneous haemorrhage and necrosis in a young woman: Surgical management and post-operative surveillance challenges

Abstract:

Hepatocellular adenomas (HCA) are rare benign liver tumours predominantly affecting young women of reproductive age, strongly associated with oral contraceptive pill (OCP) use. Spontaneous haemorrhage and necrosis are recognised but uncommon complications, occurring in larger lesions. The unclassified subtype of HCA is particularly rare and its clinical behaviour is poorly understood.

Case Presentation: We report a case of a 27-year-old woman who presented acutely on 17th August 2025 with right upper quadrant (RUQ) tenderness, pyrexia, and raised inflammatory markers with deranged liver enzymes. Computed tomography of the abdomen and pelvis (CTAP) revealed a large exophytic solid lesion in segment 6 of the liver with hyperdense areas consistent with internal haemorrhage, without evidence of rupture. The radiological features were suggestive of a benign aetiology, with hepatocellular adenoma considered the most likely diagnosis. The case was discussed with the hepatopancreatobiliary (HPB) team at King’s College Hospital (KCH), and the patient was transferred to KCH where she subsequently underwent a right posterior liver sectionectomy of segments 6 and 7.

Outcome: Histopathological analysis confirmed a hepatocellular adenoma of unclassified type (105mm in total size) with extensive necrosis and intratumoural haemorrhage, with no evidence of malignancy or beta-catenin activation. The resection margins were tumour free. Post-operative recovery was uneventful. Surveillance MRI with hepatobiliary contrast performed in December 2025 demonstrated multiple bilobar hepatic lesions — the largest in segment 2/3 (7cm) consistent with focal nodular hyperplasia (FNH), with remaining smaller lesions consistent with adenomas. Conservative surveillance is ongoing.

Conclusion: This case highlights the diagnostic and surgical challenges posed by large unclassified HCAs presenting with acute haemorrhage in young women. Multidisciplinary collaboration with specialist HPB centres is essential. Post-operative surveillance with MRI hepatobiliary contrast is critical given the risk of residual and de novo lesions.

Keywords: hepatocellular adenoma; liver resection; spontaneous haemorrhage; unclassified HCA; focal nodular hyperplasia; hepatobiliary MRI; young women

Biography:

Sukanya Lakshmi Mahendran MBBS, MRCS (England) after completing her medical training in India, Sukanya developed a passion for surgery while working in remote and underserved communities, including the Andaman and Nicobar Islands and Northeast India, where she witnessed its transformative, permanent impact on patients’ lives. She moved to the UK, joining Medway Maritime NHS Trust in 2022, progressing through CT1 and CT2 equivalent posts, obtaining her MRCS, and rising to Trust Grade Surgical Registrar. She has built a strong clinical and academic foundation, with a long-term goal of specialising in Colorectal Surgery. In August 2026, she takes up a Clinical Research Fellowship at Wirral University Teaching Hospital.