Hepatic Adenomas in Men: Diagnostic Considerations and Management in the Modern Era

Hepatic adenomas (HAs) are rare benign liver tumors traditionally associated with young women, yet contemporary epidemiologic trends reveal increasing recognition among men. Historically, universal resection in males has been recommended because of a nearly tenfold increased risk of malignant transformation as reported by Farges et al. in a single-institution surgical series; however, advances in molecular profiling and imaging have challenged this paradigm. β-catenin-activated and inflammatory subtypes account for most cases in men, often associated with anabolic steroid exposure, obesity, or metabolic syndrome. β-catenin-activated adenomas-particularly those harboring CTNNB1 exon 3 mutations-demonstrate the strongest correlation with malignant potential. Magnetic resonance imaging with hepatobiliary contrast agents can suggest subtype but lacks perfect accuracy; biopsy offers improved diagnostic precision and enables molecular confirmation. Current ACG and EASL guidelines still endorse routine resection for all hepatic adenomas in males; however, available retrospective data suggest that malignant transformation appears to be uncommon in small (5 cm) lesions lacking exon 3 CTNNB1 mutations; however, this observation is derived from limited, predominantly retrospective data and does not exclude the possibility of malignant transformation in this subgroup. These data support selective, biopsy-guided surveillance for small, indeterminate tumors within experienced multidisciplinary centers where longitudinal follow-up is reliable. Resection remains the standard recommendation for large or β-catenin-mutated adenomas, with minimally invasive surgery demonstrating excellent outcomes. Modern management of hepatic adenomas in men should be individualized, integrating molecular subtype, size, risk factors, and patient context. A multidisciplinary and molecularly informed strategy is essential to optimize outcomes while avoiding unnecessary intervention.