Table 4

Comparison of guideline recommendations on HCA

	ACG (2014)27		SBH (2015)26		EASL (2016)28
Diagnostics	t	Although CT can be used to diagnose HCA, recent findings suggest that MRI can be used to diagnose HCA andt it can identify the subtypes of HCA based on the imaging patterns, obviating the need for biopsy to distinguish these subtypes. MRI enhanced with gadobenate dimeglumine or gadoxetate disodium can be very effective in differentiating HCA from FNH and other lesions. (Specific MRI findings of H-HCA, I-HCA and b-HCA are described).	R	The imaging modality of choice for suspected cases of HCA is MRI, which may also define subtype. (mentions H-HCA, I-HCA and b-HCA to have specific MRI findings).	S	MRI is superior to all other imaging modalities and due to its intrinsic properties to detect fat and vascular spaces it offers an opportunity to subtype HCA up to 80%.
					S	The positive identification of H-HCA or inflammatory HCA is achievable with MRI with >90% specificity. By contrast, identification of b-HCA and its distinction with U-HCA and hepatocellular carcinoma is not possible by any imaging technique.
					S	Identification of b-HCA and distinction from unclassified HCA or HCC is not possible with any current imaging technique.
	S	Obtaining a biopsy should be reserved for cases in which imaging is inconclusive and biopsy is deemed necessary to make treatment decisions.	R	Percutaneous liver biopsy should be reserved for cases of diagnostic uncertainty in which definition of management is dependent on biopsy findings.	t	Biopsy may be considered within a BLT-MDT* to exclude malignancy. Resection is advised in case of b-HCA.
Management	W	In HCA ≥5 cm, intervention through surgical or non-surgical modalities is recommended, as there is a risk of rupture and malignancy. (no explicit mentioning of indication for resection in all men).	t	The high risk of malignant transformation of HCA in male patients means that surgical resection is always indicated, regardless of tumour size.	W	Treatment decisions are based on gender, size and pattern of progression.
					W	Base management of multiple HCA on the size of the largest tumour progression.
					W	In women, a period of 6 months observation after lifestyle change is advised and resection is indicated for nodules equal or greater than 5 cm and those continuing to grow.
					W	HCA resection is recommended irrespective of size in men and in any instance of proven β-catenin mutation.
					W	A bleeding HCA with haemodynamic instability should be embolised and residual viable lesion on follow-up imaging is an indication for resection.
					W	The management of patients with multiple HCA should be based on the size of the largest tumour.
					W	Hepatic resection might be considered in unilobular disease, and in those cases with more widespread HCA, resection of the largest adenomas may be an option.
					W	Liver transplantation is not recommended in multiple HCA but might be considered in individuals with underlying liver disease.
	S	CP, hormone-containing IUD, and anabolic steroids are to be avoided in patients with HCA.	R	CP or anabolic androgenic steroids should be discontinued if in use.	S	On HCA diagnosis, lifestyle changes such as discontinuation of CP as well as weight loss should be advised. (No IUD mentioned).
	W	Pregnancy is not generally contraindicated in cases of HCA <5 cm and an individualised approach is advocated for these patients.	R	Surgical resection is indicated in women of childbearing age with lesions >5 cm and in men, regardless of lesion size. As gestation may lead to growth of HCA, resection should be offered to women with large nodules (even if <5 cm) who wish to become pregnant.	t	Monitor HCA in pregnant women by US every 6–12 weeks. Pursue vaginal delivery in case of non exophytic HCA <5 cm. Consider embolisation for growing lesions. Prior to 24 weeks, surgery may be preferred, especially in peripherally located smaller lesions.
Follow-up	W	If no therapeutic intervention is pursued, lesions suspected of being HCA require follow-up CT or MRI at 6-month to 12-month intervals. The duration of monitoring is based on the growth patterns and stability of the lesion over time.	R	If surgical intervention is not indicated, the progression of HCA should be monitored by follow-up imaging every 6 months. (No end mentioned).	W	In women, lesions less than 5 cm should be reassessed at 1 year, and annual imaging adopted thereafter.
Follow-up	W		R		t	There is no robust data on the timeline to define stable disease.

Green = Moderate level of evidence, Orange = Low level of evidence, Red = Very low level of evidence.
*BLT-MDT should consist of a hepatologist, hepatopancreatobiliary surgeon, diagnostic and interventional radiologist, and a pathologist.
ACG, American College of Gastroenterology; b-HCA, beta catenin mutated HCA; BLT-MDT, benign liver tumour dedicated multidisciplinary team; CP, contraceptive pills; CT, computed tomography; EASL, European Association for the Study of the Liver; FNH, focal nodular hyperplasia; HCA, hepatocellular adenoma; HCC, hepatocellular carcinoma; H-HCA, hepatocyte nuclear factor 1a inactivated HCA; I-HCA, inflammatory HCA; IUD, intrauterine device; MRI, magnetic resonance imaging; R, recommendation without definition of strength; S, strong recommendation; SBH, Brazilian Society of Hepatology; t, in text advice; U-HCA, unclassified HCA; US, ultrasound; W, weak recommendation/conditional recommendation.