Episode one of the Liver Tumors and Transplant chapter runs the benign masses on a single decision: imaging appearance plus hormonal or drug context usually settles the diagnosis, and biopsy enters only when the imaging is atypical or the lesion has real malignant potential. Peripheral nodular enhancement filling inward is a hemangioma, hepatobiliary-phase retention is focal nodular hyperplasia, and hepatobiliary-phase darkening is an adenoma. From the adenoma you stratify by sex, size, growth, and beta-catenin status, because that subtype is what turns a benign mass into a resection case. The two edge entities, nodular regenerative hyperplasia and peliosis hepatis, round out the pattern-recognition set. Topics covered Imaging-plus-context decision rule Cavernous hemangioma and its enhancement pattern Kasabach-Merritt syndrome Focal nodular hyperplasia and the central scar Hepatic adenoma and oral contraceptives Adenoma molecular subtypes and beta-catenin Adenoma resection versus surveillance Nodular regenerative hyperplasia and peliosis hepatis Key decisions A cavernous hemangioma shows peripheral nodular enhancement in the arterial phase that fills inward over the venous phase, and that classical pattern means no biopsy and no surveillance. Treat a hemangioma only when it is giant and symptomatic, causes Kasabach-Merritt syndrome with thrombocytopenia and consumptive coagulopathy, or drives high-output heart failure. Focal nodular hyperplasia retains a hepatobiliary contrast agent like gadoxetate because it has functioning hepatocytes and bile ductules, while an adenoma goes dark in that phase, so no needle is needed and the pill is not stopped when imaging is classical. Resect any hepatic adenoma in a man regardless of size, plus any lesion five centimeters or larger, any growing lesion, any beta-catenin-positive lesion, any that has bled, and resect before a planned pregnancy. Small adenomas in young women on the pill can be watched: stop the pill first, then image every six months for two years and annually thereafter. Hepatic adenomatosis, meaning more than ten lesions, is a rare reason to transplant when the disease is unresectable. A near-normal biopsy behind non-cirrhotic portal hypertension is nodular regenerative hyperplasia revealed on reticulin stain, and blood-filled cavities in a drug-exposed patient is peliosis hepatis managed by removing the offending agent. For the full chapter with MCQs, tables, and primary-guideline references, visit www.boardpearls.com. Questions or feedback: [email protected].

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