J Liver Cancer.  2025 Mar;25(1):67-78. 10.17998/jlc.2025.03.06.

Insights into hepatocellular adenomas in Asia: molecular subtypes, clinical characteristics, imaging features, and hepatocellular carcinoma risks

• Heo S
• Song IH
• Reizine E
• Ronot M
• Nault JC
• Kim HY
• Choi SH
• Kim SY

• KMID: 2567065
• DOI: http://doi.org/10.17998/jlc.2025.03.06

Abstract

Hepatocellular adenomas (HCAs) are benign monoclonal liver tumors. Advances in molecular studies have led to the identification of distinct subtypes of HCA with unique pathways, clinical characteristics, and complication risks, underscoring the need for precise diagnosis and tailored management. Malignant transformation and bleeding remain significant concerns. Imaging plays a crucial role in the identification of these subtypes, offering a non-invasive method to guide clinical decision-making. Most studies involving patients with HCAs have been conducted in Western populations; however, the number of studies focused on Asian population has increased in recent years. HCAs exhibit distinct features in Asian population, such as a higher prevalence among male patients and specific subtypes (e.g., inflammatory HCAs). Current clinical guidelines are predominantly influenced by Western data, which may not fully capture these regional differences in epidemiology and subtype distribution. Therefore, this review presents the updated molecular classification of HCAs and their epidemiologic differences between Asian and Western populations, and discuss the role of imaging techniques, particularly magnetic resonance imaging using hepatobiliary contrast agents, in classifying the subtypes and predicting the risk of hepatocellular carcinoma.

Keyword

Adenoma, liver cell; Liver neoplasms; Diagnostic imaging; Magnetic resonance imaging

Figure

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  Figure 1. Representative case of HNF1-α inactivated subtype of hepatocellular adenoma. Gadoxetic acid-enhanced liver MR images of a 39-year-old female revealed a 3 cm mass in liver segment 8 (white arrow). The tumor exhibits a homogeneous signal drop on the opposedphase image (A) compared with that of the in-phase image (B), suggesting diffuse fat deposition. On dynamic phases of liver MR imaging, compared with that of the background liver, the lesion shows lower signal intensity on pre-contrast image (C), similar signal intensity on arterial phase (D), and lower signal intensity on portal venous phase (E), and hepatobiliary phase (F). Over ten other sub-centimeter-sized hepatic lesions with similar characteristics are detected (arrowheads), suggesting adenomatosis. HNF1-α, hepatocyte nuclear factor 1α; MR, magnetic resonance.

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  Figure 2. Representative case of an inflammatory subtype of hepatocellular adenoma. Gadoxetic acid-enhanced liver MR images of a 40-year-old male revealed a 2.8 cm mass (white arrow) in liver segment 6. The background liver shows signal drop on opposed-phase image (A) compared with that on the in-phase (B), suggesting background hepatic steatosis. The tumor exhibits higher signal intensity compared with that of the background liver on T2 weighted image (C) and pre-contrast T1 weighted image (D), strong arterial phase hyperenhancement (E), and maintains a higher signal intensity than that of the liver on portal venous phase (F). MR, magnetic resonance.

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  Figure 3. Representative case of a β-catenin-activated inflammatory subtype of hepatocellular adenoma. Gadoxetic acid-enhanced liver MR images of a 21-year-old female revealed a 4.3 cm-sized mass in liver segment 1 (white arrow). The background liver shows signal drop on opposed-phase image (A) compared with that on the in-phase image (B), suggesting background hepatic steatosis. The tumor exhibits no evidence of an internal fat component. The tumor shows higher signal intensity compared with that of the background liver on T2 weighted image (C), demonstrates strong arterial phase hyperenhancement (D), and maintains a higher signal intensity than that of the liver on portal venous phase (E) and hepatobiliary phase (F). MR, magnetic resonance.

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  Figure 4. Representative case of a β-catenin-activated subtype of hepatocellular adenoma. Gadoxetic acid-enhanced liver MR images of a 25-year-old female revealed a 15 cm-sized mass in the right hemi-liver (white arrow). The tumor exhibits heterogeneous iso to high signal intensity on T2-weighted image (A). The tumor contains internal bright signal intensity foci (white arrowhead) on the pre-contrast T1 weighted image (B) suggestive of hemorrhage. The solid portion of the tumor demonstrates arterial hyperenhancement compared with that of the background liver (C), no washout on portal venous phase (D) and transitional phase (E), and shows higher signal intensity than that of the liver on hepatobiliary phase (F). MR, magnetic resonance.

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  Figure 5. Representative case of a sonic hedgehog subtype of hepatocellular adenoma. Extracellular fluid agent-enhanced liver MR images of a 46-year-old female/male revealed a 8.5 cm-sized mass in liver segment 3 (white arrow). The background liver shows signal drop on opposed-phase image (A) compared with that on the in-phase image (B), suggesting background hepatic steatosis. The tumor exhibits fluidfilled cavities (arrowhead) on the T2 weighted image (C), which does not show enhancement on portal venous phase image (D). MR, magnetic resonance.

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  Figure 6. Representative case of an unclassified subtype of hepatocellular adenoma. Gadoxetic acid-enhanced liver MR images of a 32-year-old female revealed a 3.8 cm mass (white arrow) in liver segment 6. The tumor exhibits slightly high signal intensity on the T2 weighted image (A). The tumor shows iso-signal intensity on the pre-contrast T1 weighted image (B), faint arterial hyper-enhancement (C), iso-signal intensity on the portal venous (D) and transitional (E) phases, and slightly low signal intensity on the hepatobiliary phase image (F), defined as a signal intensity lower than that of the liver but higher than that of the vessels. The tumor exhibits ill-defined margins across all MR imaging sequences. MR, magnetic resonance.

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