Multiple hepatocellular adenomas associated with long-term administration of androgenic steroids for aplastic anemia

Abstract

Introduction: Anabolic steroids are widely administered to patients with aplastic anemia (AA) and are associated with numerous medical complications. To assist with future diagnoses, we report about a young boy with multiple hepatocellular adenomas (HAs) induced by long-term use of anabolic androgenic steroids (AAS) for AA and present a related literature review. Patient concern: A 15-year-old boy who was diagnosed with AA in 2011 had been treated with stanozolol (6 mg per day) and ciclosporin A (120–150 mg per day) for almost 4 years. He presented with epigastric pain and fever, and abdominal computed tomography showed a lesion of heterogenous density measuring 13.5 × 13.0 × 8.0 cm in the left hepatic lobe, which was initially misdiagnosed as a liver abscess. Diagnosis: The patient went into hemorrhagic shock twice after invasive manipulation that aimed at diagnosis and was finally diagnosed with HA using fine needle aspiration. Interventions: The patient discontinued AAS and only reserved ciclosporin A for AA treatment. Outcomes: Follow-up abdominal computed tomography performed 4 years after AAS discontinuation showed obvious regression of the hepatic lesions. Conclusion: It is of great importance for hematologists to completely understand that the long-term use of AAS may cause HA, which carries a great risk of hemorrhage and malignant transformation.

Hepatotoxicity of anabolic androgenic steroids in sport

“…It seems that AAS usually induces formation of multiple adenomas rather than one [37][38][39][40]. HCA may rupture which can lead to lifethreatening hemorrhagic shock and hemoperitoneum, demanding an urgent surgical intervention [8,11,37,39]. That is why a biopsy of HCAs should be performed under extreme caution or should not be done at all [37].…”

“…HCA may rupture which can lead to lifethreatening hemorrhagic shock and hemoperitoneum, demanding an urgent surgical intervention [8,11,37,39]. That is why a biopsy of HCAs should be performed under extreme caution or should not be done at all [37]. HCC is hardly ever induced by AAS abuse [40].…”

“…It appears that it is linked to a better prognosis than HCC caused by hepatitis C, B or cirrhosis hepatis [8,13,40,41]. The symptoms of liver tumours are: sensation of pain and palpable masses in the right upper quadrant of the stomach, radiological evidence of a tumour [8,13,37,41], occasionally followed by cholestasis [37,42]. As long as there are neither additional liver injuries nor tumour related emergencies, the hepatic enzymes and αfetoprotein levels are not elevated [8,13,37,41].…”

“…The symptoms of liver tumours are: sensation of pain and palpable masses in the right upper quadrant of the stomach, radiological evidence of a tumour [8,13,37,41], occasionally followed by cholestasis [37,42]. As long as there are neither additional liver injuries nor tumour related emergencies, the hepatic enzymes and αfetoprotein levels are not elevated [8,13,37,41]. While establishing a treatment strategy it is important to keep in mind that HCAs (especially when detected early) may undergo a spontaneous regression [5,8,11,37,39].…”

“…As long as there are neither additional liver injuries nor tumour related emergencies, the hepatic enzymes and αfetoprotein levels are not elevated [8,13,37,41]. While establishing a treatment strategy it is important to keep in mind that HCAs (especially when detected early) may undergo a spontaneous regression [5,8,11,37,39]. Progression of HCAs as well as their recurrence have been reported in patients who did not withdraw AAS [8].…”