Hepatic tumors in the pediatric population are rare entities representing about 5% of all intra-abdominal masses in such age group. The presentation of benign and malignant tumors is quite similar with a palpable mass and/or abdominal pain as the chief complaints, as reported previously [6, 12]. Diagnosis is often based on radiological criteria and tumor markers or tissue biopsy in cases with doubtful imaging features.

The diagnosis of benign liver neoplasms is sometimes a challenge in spite of the advances in radiological studies in the recent era. In our study, only 33% of patients with benign lesions were diagnosed by classic imaging criteria. Similarly, Qureshi et al. reported that 38% of patients in their series were diagnosed as per radiological features [13]. In contradiction, Kochin et al. declared that definitive diagnosis using imaging was achieved in 58.5% of the patients in their study [14]. These data confirm that ultrasound-guided biopsy is imperative in cases with equivocal criteria to establish a precise tissue diagnosis for proper management. Serum AFP is often elevated in patients with hepatoblastoma and has a key role in the diagnosis of those patients [10]. In contrast, it is not elevated in the majority of children with benign tumors. However; serum AFP may be elevated in some patients with MH and the levels return to normal values within months after tumor resection [15, 16]. This was in line with our findings as three patients with MH were presented with elevated tumor marker at diagnosis that was normalized post-resection.

Management of pediatric benign liver tumors includes several components, and hepatectomy is the sole modality in certain patients as documented by a recent report [4]. In the current study, operative resection was the treatment of choice for all pathological subtypes except IHH/hemangioma. Additionally, a patient with a huge IHH/hemangioma that did not respond to medical therapy or embolization technique was successfully managed by surgery. Our findings report that medical therapy is the first and an effective strategy for IHH/hemangioma as well as declared by Gnarra et al. [17]. However, surgery is reserved for cases with failed or progressive courses. Following IHH/hemangioma, MH is the second most commonly encountered benign liver tumor among children. Surgical resection is always performed for MH due to several causes as such tumors grow in sizes reaching huge sizes and malignant transformation to embryonal sarcoma could occur in addition to the rarity of spontaneous regression [16]. In our study, all patients with MH were exclusively managed by surgery and the same results were declared by others [1, 13, 14]. Liver adenoma is an extremely rare tumor in pediatric age. Intra-tumoral or intra-abdominal bleeding and malignant transformation can occur; consequently, operative management is fundamental in cases with adenomas more than 5 m in size [4]. In this study, the two patients with adenomas had tumor sizes of 12 and 7.5 cm, and both of them were treated by surgery to avoid the occurrence of the aforementioned complications. FNH is usually encountered in children between 7 and 14 years, with approximately 200 cases diagnosed per annum according to a literature report [4]. Surgical resection is the treatment of choice for symptomatic patients with FNH as documented by our study and others [1, 3, 13, 14]. Consequently, the authors of this study believe that surgery is a crucial modality of management for pediatric benign liver tumors as well as hepatoblastomas.

The complications of hepatectomy are several, and intraoperative or early postoperative bleeding is the most life-threatening complication [7]. This can be attributed to small blood volumes in pediatric patients in addition to the excision of tumors on normal liver tissue that leads to more hemorrhage when compared to adults with cirrhotic liver. In our study, none of the included patients had bleeding or other major complications, and only 3 cases received blood transfusion post-resection. Similar results regarding safe tumor resection without significant complications and reduced intraoperative blood loss were reported by previous studies [13, 18]. Definitely, the adoption of neoadjuvant chemotherapy in hepatoblastoma with huge sizes leads to tumor downsizing and easier resections [8, 9], which is not applicable in benign liver neoplasms. Therefore, surgical resection for benign hepatic tumors may be a critical procedure in some children with extensive lesions and we believe that tumor resection should be performed in dedicated centers with a high flow of pediatric liver surgeries. The outcomes of surgical resection for benign hepatic tumors are deficient in the pediatric literature. Nevertheless, few studies reported favorable results as well as our findings [1, 4, 13, 14].