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We read with interest the study of Luciani and colleagues (Gut 2002;50:877–80) comparing focal nodular hyperplasia (FNH) of the liver in men and women. The major findings of this very large study conducted by an expert team in this field were that mean age at diagnosis was higher in men (p<0.01), mean FNH size smaller (p<0.001), and surgery more often performed (p<0.001) in men (n=18) than in women (n=216). Interestingly, perhaps because of the relatively small number of men (although very large in terms of the rare occurrence of FNH in men), no cases of multiple FNH were noted in the male population.
We report here a case of multiple FNH in a 74 year old patient with a biopsy proven prostatic cancer. This patient had not received any treatment. He was referred to our liver unit in March 2001 for evaluation of multiple liver masses discovered on abdominal ultrasonography during the staging of his cancer. Bone scintigraphy disclosed no metastases. Liver biochemistry was normal except for a mild increase in gamma glutamyl transferase activity. Prothrombin index was 100%. Serological search for hepatitis B or hepatitis C virus infection was negative. Genetic (haemochromatosis, alpha 1 antitrypsin deficiency) and autoimmune liver diseases were carefully excluded, and alcohol consumption was below 10 g/day. Upper gastrointestinal endoscopy and colonoscopy were normal. Tumour markers of malignant primitive or secondary liver lesions were within the normal range. Liver Doppler ultrasonography disclosed multiple heterogeneous lesions with a hypoechoic pattern and without an arterial signal. Abdominal tomodensitometry before and after contrast enhancement showed multiple lesions with rapid contrast enhancement during the arterial phase. The largest lesion was located between the left liver and segment IV and measured 75 mm.
Because there was no magnetic resonance imaging (MRI) in our centre, ultrasound guided liver biopsy in both tumoral and non-tumoral areas was performed. The diagnosis of typical FNH was made in several of the lesions whereas non-tumoral liver was normal. The patient received hormonal treatment from April 2001. In October 2001, MRI confirmed a diagnosis of FNH with a central stellate area in the largest lesion. In December 2002, he was in good health with unchanged ultrasonography.
This case report is unique in that there were multiple lesions of FNH in a man who had not received any previous treatments or portacaval shunt. Although from a literature search it is difficult to determine the exact number of men with multiple FNH, the numbers are probably very low. In this report, the discrepancy between normal bone scintigraphy and multiple liver lesions made the diagnosis of liver metastasis probable. Nevertheless, histological examination of several hepatic lesions, retrospective MRI, and outcome made the diagnosis of multiple FNH certain. This report, in common with the large series of Luciani et al, indicates that FNH diagnosis may be very difficult in men
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