Focal Nodular Hyperplasia: Causes, Symptoms, Treatment and Cost

Focal nodular hyperplasia (FNH) is a benign tumour that grows in the liver. It is made up of a type of abnormal cell called hepatic stellate cells and is composed of clumps of tissue that form a nodule (lump).

FNH is the most common benign lesion in the liver, occurring mostly in young women between 20 to 40 years old. It happens when new tissue develops in response to an injury or infection.

There are three types of FNH:

• Classical Type: This is the most common type found and is usually one solid solitary nodule with a prominent central feeding vessel (stellate artery). It may also have radiating vessels around it but does not contain any fat. It is usually composed of normal mature hepatocytes without the presence of bile ducts.
• Plateau Type: This is made up of many small nodules that form a plateau-like configuration when seen on imaging studies such as ultrasounds or CT scans. They can also have radiating vessels, but do not typically contain any fat or bile ducts within them like the classical type does.
• Mixed Type: As its name implies, this type contains elements of both classical and plateau types combined together with some atypical components present as well, such as fat or bile duct elements located within some or all of the nodules making up this type of FNH growth pattern.

• The exact cause of FNH is unknown. It's likely caused by a combination of genetic and environmental factors such as chronic inflammation, hormonal imbalances, and certain medications.
• Rarely, it is linked to inherited genetic diseases such familial adenomatous polyposis.
• FNH may also occur in patients with cirrhosis or diabetes.

• Focal nodular hyperplasia (FNH) usually produces no symptoms, and is often discovered during imaging tests done for other purposes.
• When symptoms do manifest, they may include abdominal pain, a sense of fullness in the abdomen, and possibly blood in the stool.
• Unexplained weight loss or anaemia may be present in some cases as well.
• Very rarely, people with FNH can experience liver failure due to rapid growth of the nodules and excessive amounts of blood flowing into them from the liver vasculature, leading to congestion and eventual cirrhosis of the liver.

• Avoid exposure to toxins like alcohol and cigarette smoke.
• Keep your weight at a healthy level.
• Participate in regular physical activity and maintain a healthy diet that includes an abundance of fresh fruits and vegetables.
• Your doctor should do routine examinations to detect any underlying medical issues that may raise your risk for FNH.
• Talk to your doctor about taking medications (such as hormone therapy) that can reduce the likelihood of developing FNH if you are at increased risk due to certain medical conditions.

• CT or MRI scans: CT scans are generally the best method for diagnosing Focal Nodular Hyperplasia. MRI scans may sometimes be used to evaluate the extent of the lesion or any nearby structures. CT scans are preferred because they provide a more comprehensive view of the lesions and any surrounding tissue.
• Biopsy: Biopsy is the best way to figure out if someone has FNH. During a biopsy, a small piece of tissue from the lesion is taken and looked at under a microscope.
• Ultrasound: Ultrasound imaging is a noninvasive exam used to diagnose FNH and is the most preferred and cost-effective way to detect the lesion. Ultrasound examination can provide detailed information on FNH including its size, shape, location, wall thickness, internal structure and calcifications, if any.
• Blood tests: Although blood tests are not used to diagnose FNH, they may be used to rule out comorbid conditions that can present with similar symptoms. A complete blood count (CBC), liver function tests, and pancreatic enzyme levels are examples of blood tests that can be done.

• Bleeding: When the lesion is disturbed, it can cause bleeding in the organ.
• Obstruction: Focal Nodular Hyperplasia can cause obstruction of bile ducts or blood vessels in rare cases.
• Infection: If the lesion is open, there may be a risk of developing an infection which can be dangerous.
• Cancerous transformation: Although rare, Focal Nodular Hyperplasia has potential to transform into malignant tissue and become cancerous.

• Herbal teas: Drink herbal teas such as chamomile, ginger or peppermint to reduce inflammation and digestion issues.
• Aromatherapy: Practice aromatherapy with essential oils like lavender or cedarwood to reduce stress and relax the mind and body.
• Guggul supplements: Guggul is an Ayurvedic herb which possesses anti-inflammatory properties which can be used for treating Focal Nodular Hyperplasia.

• Consume a balanced, nutrient-rich diet that includes plenty of fruits and vegetables, lean protein sources, whole grains, low-fat dairy products and healthy fats.
• Eat fatty fish, like salmon or tuna, 2 to 3 times per week for omega-3 fatty acids.
• Get adequate fiber from fiber-rich foods, such as legumes and whole grains.

Patients with Focal Nodular Hyperplasia should avoid processed and junk foods, saturated fats, fried foods, and refined sugar as much as possible.

• Non-invasive monitoring: Regular ultrasound and MRI scans are recommended to monitor the growth and stability of the lesion.
• Medications: A careful assessment of individual risk factors needs to be considered before starting medications such as steroids, cytotoxic agents, or other immunosuppressive medications, to shrink the size and slow progression of the FNH lesion.
• Transarterial Embolization: This procedure blocks the artery supplying blood to the Focal Nodular Hyperplasia (FNH) lesion and causes it to shrink.
• Open liver resection: An incision is made in the abdomen in order to open up the patient’s abdominal cavity, with an open liver resection, part of the liver containing the tumour is removed with a scalpel.
• Radiofrequency ablation: This procedure uses radio frequency energy to heat and destroy FNH lesions to prevent them from growing further or spreading elsewhere in the liver.
• Liver transplantation: If these treatments are unsuccessful, or if the FNH tumor is causing excessive pain and other complications, then liver transplantation may be considered as a possible option for treatment.

A doctor specializing in endocrinology or medical hepatology should be consulted for Focal Nodular Hyperplasia (FNH).

Depending on the severity of symptoms, primary care doctors, gastroenterologists and radiologists can also provide treatments.

• Steroids: Steroids can be used to make the nodule smaller or to relieve symptoms like pain. In general, these drugs are only administered when other treatments are ineffective or their side effects are too severe.
• Calcineurin inhibitors: FNH is usually treated with calcineurin inhibitors like cyclosporine and tacrolimus. Because calcineurin inhibitors block certain pathways within cells, they reduce overactive growth signals—thereby reducing production of tumor cells associated with FNH.
• Immunomodulators: Immunomodulators that may be effective in treating FNH include interferon-alpha, interleukin-2 and thalidomide. Interferon-alpha suppresses cell growth by blocking inflammation and activating genetic pathways involved in the control of proliferation.
• Chemotherapy agents: There are some cases where chemotherapy may be used to address FNH. In those situations, agents such as doxorubicin, cisplatin and 5-fluorouracil may be used to target the cells that cause FNH and shrink the lesion.

Recovery time for Focal Nodular Hyperplasia (FNH) can vary greatly depending on the person and their specific diagnosis.

Generally, however, people are able to resume normal activities shortly after diagnosis.

Most people with FNH will not need any medical treatment and no long-term effects have been reported with the condition.

The type of treatment used for Focal Nodular Hyperplasia (FNH) affects how well it works.

In cases where medication is used, the effects can be temporary and must be managed with regular follow-up visits and continued care.

Surgery is another option and often results in more permanent resolution of the FNH, though there is some risk of regrowth.

Post-treatment guidelines for focal nodular hyperplasia (FNH) include:

• Regular follow-up exams up to yearly intervals for asymptomatic individuals.
• Close monitoring of imaging findings such as US and MRI, allowing for immediate intervention if changes are seen.
• Rapid response to any symptoms reported, requiring urgent imaging and potentially biopsy or other intervention based on the results.
• For those opting for ablation, return visits are necessary depending on the type of treatment chosen and status of the FNH lesion post-ablation/excision.

• The cost of Focal Nodular Hyperplasia treatments in India depends on the location and type of treatment.
• Generally, initial consultation and biopsy may cost anywhere from 3000 to 10000 INR.
• Surgical treatments generally involve a higher cost from 15,000 to 50,000 INR.
• Lastly, laparoscopic or minimally invasive techniques for FNH can range from 40,000 to over 1 lakh INR.

• Surgery: Bleeding and infection are the most common side effects; other risks include nerve damage, damage to adjacent structures, and decreased liver function.
• Radiation therapy: Some of the most common side effects are skin reactions in the area being treated, tiredness, and nausea.
• Drug treatments (chemotherapy): Short-term side effects include nausea, hair loss, fatigue, or changes in appetite or taste; long-term side effects depend on the type of drug used and may include infertility or increased risk for certain types of cancer.

If you notice any symptoms that are associated with focal nodular hyperplasia, you should make an appointment with a medical professional as soon as possible. This condition can lead to complications such as 'bleeding, obstruction, and infection,' the treatments for which can last anywhere from a few months to several years depending on the seriousness of the condition.