Liver Lesion (Incidental)

Pathway

Images

Image Gallery Note: These images open in a new page
1		Hepatic Haemangioma Image 1 (Computed Tomography): Post-contrast images demonstrating initial peripheral enhancement, followed by delayed filling of the lesion with contrast. These features are typical of a haemangioma.
2a		Hepatic Haemangioma Image 2a, 2b and 2c (Triphasic Computed Tomography): Non-contrast scan (Image 2a) demonstrates a subtle low attenuation lesion in segment 6 of the liver (arrow). There is globular peripheral enhancement of the lesion in the post contrast arterial phase scan (Image 2b) with delayed filling in of the lesion in the portal venous phase (Image 2c).
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2d		Image 2d (Ultrasound): Ultrasound scan demonstrating the liver lesion in same patient.
3a		Hepatic Haemangioma Image 3a (H&E, x2.5): Histological section of a hepatic haemangioma showing variously sized, dilated and congested blood vessels set in a fibrous stroma with residual islands of liver parenchyma.
4a		Hepatic Adenoma Image 4a and 4b (Computed Tomography): Coronal and axial views demonstrating several enhancing liver lesions.
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4c		Image 4c (Ultrasound): Ultrasound scan demonstrating the liver lesions in same patient.
5a		Hepatic Focal Nodular Hyperplasia Image 5a and 5b (Triphasic Computed Tomography): The arterial phase scan (Image 5a) shows a hyperattenuating nodular lesion (narrow arrow) with the typical central scar (broad arrow) in segment 4 of the liver. On the delayed portal venous phase (Image 5b), the lesion becomes isoattenuating (arrow).
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6a		Hepatic Focal Nodular Hyperplasia Image 6a, 6b, 6c and 6d (Magnetic Resonance Imaging): Gadolinium-enhanced T1-weighted MRI (Image 6a) demonstrates an ill-defined low-signal intensity mass in segment 4 of the liver with intense enhancement in the arterial phase (Image 6b). Minor enhancement persists in the portal venous phase (Image 6c) and the lesion becomes isointense with enhancement of the central scar (arrow) on the delayed image (Image 6d).
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7		Simple Hepatic Cyst Image 7 (Ultrasound): Simple-appearing cyst in the left lobe of liver.
8a		Hepatocellular Carcinoma Image 8a and 8b (Ultrasound): Within segment 6 of the liver, there is an approximately 2cm subcapsular hypoechoic lesion (arrow) which does not demonstrate any increased vascularity.
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8c		Image 8c, 8d, 8e and 8f (Triphasic Computed Tomography): CT of the same patient shows a cirrhotic liver with patent hepatic and portal veins as well as ascites. Within segment 6, there is a nodular area which demonstrates slight enhancement corresponding to the lesion identified on ultrasound (arrow). This lesion could represent either a dysplastic cirrhotic nodule or an early hepatocellular carcinoma.
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8g		Image 8g, 8h, 8i and 8j (Magnetic Resonance Imaging): MRI of the same patient demonstrates a lesion measuring approximately 2.5 cm in diameter on the inferomedial aspect of segment 5 in a subcapsular location. This is bulging the capsule of the liver at the level of the upper pole of the right kidney. The lesion is essentially isointense to the rest of the liver on T1 weighted imaging (out of phase) but is slightly hyperintense on in-phase imaging suggesting that the rest of the liver has some fatty infiltration. The lesion is slightly hyperintense on first echo T2 but is not clearly visible on more heavily weighted T2 imaging. The lesion shows arterial enhancement but washes out in the portal venous phase, with the rim of the lesion remaining enhanced. The appearances are consistent with a hepatocellular carcinoma.
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9a		Hepatocellular Carcinoma Image 9a and 9b : Hepatectomy specimens showing a multifocal hepatocellular carcinoma with areas of necrosis and haemorrhage arising in a cirrhotic liver.
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9c		Image 9c (H&E, x2.5) and 9d (H&E, x10): Histological sections of a hepatocellular carcinoma arising on a background of cirrhosis. The usual lobular architecture is replaced by irregular and thickened trabeculae of malignant hepatocytes. There is mild nuclear pleomorphism.
9d

Teaching Points

Teaching Points

• The great majority of incidentally-detected liver nodules are benign 1
• Even in patients with known extrahepatic primary malignancy, small liver lesions, if single or very few in number, are more likely to be benign than malignant 1
• The problem of incidental lesions, in the liver and elsewhere, is an important component of the burgeoning issue of over diagnosis and the potential harming of healthy people 2
• It is fairly important to distinguish hepatic adenomas HA from focal nodular hyperplasia FNH as the former can present acutely due to rupture and consequent haemoperitoneum in addition to the risk of malignant transformation up to 10% of these tumours 1
• Contrast enhanced ultrasound CEUS has been found to improve the characterisation of focal liver lesions 3,4 with enhancement patterns generally similar to CECT 5 and CEMRI 6, and can be utilized in the presence of renal impairment 7
• CEUS can be performed at the same attendance as the ultrasound at which the lesion was discovered, with resultant early reassurance of the patient and his / her doctors in the majority of cases 8
• Breath hold T1 and fast spin-echo T2 weighted MR images are used for the evaluation of a liver nodule with gadolinium-enhanced dynamic MRI imaging improving liver lesion characteristics
• Technetium-99m-labelled red blood cell scan has a high specificity and positive predictive value for hepatic haemangiomas but a negative test result does not indicate a diagnosis for which further imaging investigation is then required
• In the absence of risk factors, the role for biopsy in the diagnosis of hepatic incidentalomas is limited
• Typical imaging appearances of common clinically encountered benign, non-cystic hepatic incidentalomas 1,6,7,9-16

References

References

Date of literature search: February 2015

The search methodology is available on request. Email

References are graded from Level I to V according to the Oxford Centre for Evidence-Based Medicine, Levels of Evidence. Download the document

1. Gore RM, Newmark GM, Thakrar KH, Mehta UK, Berlin JW. Hepatic incidentalomas. Radiol Clin North Am. 2011;49(2):291-322. (Review article). View the reference
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3. Schillaci O, Danieli R, Manni C, Capoccetti F, Simonetti G. Technetium-99m-labelled red blood cell imaging in the diagnosis of hepatic haemangiomas: the role of SPECT/CT with a hybrid camera. Eur J Nucl Med Mol Imaging. 2004;31(7):1011-5. (Level III evidence). View the reference
4. Klein D, Jenett M, Gassel HJ, Sandstede J, Hahn D. Quantitative dynamic contrast-enhanced sonography of hepatic tumors. Eur Radiol. 2004;14(6):1082-91. (Level III evidence). View the reference
5. Seitz K, Strobel D, Bernatik T, Blank W, Friedrich-Rust M, Herbay A, et al. Contrast-Enhanced Ultrasound (CEUS) for the characterization of focal liver lesions - prospective comparison in clinical practice: CEUS vs. CT (DEGUM multicenter trial). Parts of this manuscript were presented at the Ultrasound Dreilandertreffen 2008, Davos. Ultraschall Med. 2009;30(4):383-9. (Level II evidence). View the reference
6. Claudon M, Dietrich CF, Choi BI, Cosgrove DO, Kudo M, Nolsøe CP, et al. Guidelines and good clinical practice recommendations for contrast enhanced ultrasound (CEUS) in the liver – update 2012. Ultraschall Med. 2013;34(1):11-29. (Guideline). View the reference
7. Sporea I, Martie A, Bota S, Sirli R, Popescu A, Danila M. Characterization of focal liver lesions using contrast enhanced ultrasound as a first line method: a large monocentric experience. J Gastrointestin Liver Dis. 2014;23(1):57-63. (Level III evidence). View the reference
8. Won SY, Singh N, Lim BG, Stella D, Gibson R. Hepatic contrast-enhanced ultrasound: impact of its introduction in the Australian context . J Med Imaging Radiat Oncol. 2014;58(1):38-45. (Level III evidence). View the reference
9. Whitney WS, Herfkens RJ, Jeffrey RB, McDonnell CH, Li KC, Van Dalsem WJ, et al. Dynamic breath-hold multiplanar spoiled gradient-recalled MR imaging with gadolinium enhancement for differentiating hepatic hemangiomas from malignancies at 1.5 T . Radiology. 1993;189(3):863-70. (Level III evidence). View the reference
10. Boutros C, Katz SC, Espat NJ. Management of an incidental liver mass. Surg Clin North Am. 2010;90(4):699-718. (Review article). View the reference
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12. Buell JF, Tranchart H, Cannon R, Dagher I. Management of benign hepatic tumors. Surg Clin North Am. 2010;90(4):719-35. (Review article). View the reference
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14. Yamashita Y, Ogata I, Urata J, Takahashi M. Cavernous hemangioma of the liver: pathologic correlation with dynamic CT findings. Radiology. 1997;203(1):121-5. (Level III evidence). View the reference
15. Royal HD, Brown ML, Drum DE, Nagle CE, Sylvester JM, Ziessman HA. Procedure guideline for hepatic and splenic imaging. Society of nuclear medicine. J Nucl Med. 1998;39(6):1114-6. (Guideline). View the reference
16. Federle MP, Filly RA, Moss AA. Cystic hepatic neoplasms: complementary roles of CT and sonography. AJR Am J Roentgenol. 1981;136(2):345-8. (Level III evidence). View the reference
17. Margolis NE, Shaver CM, Rosenkrantz AB. Indeterminate liver and renal lesions: comparison of computed tomography and magnetic resonance imaging in providing a definitive diagnosis and impact on recommendations for additional imaging. J Comput Assist Tomogr. 2013;37(6):882-6. (Level III evidence). View the reference
18. Cogley JR, Miller FH. MR imaging of benign focal liver lesions. Radiol Clin North Am. 2014;52(4):657-82. (Review article). View the reference
19. Rode A, Bancel B, Douek P, Chevallier M, Vilgrain V, Picaud G, et al. Small nodule detection in cirrhotic livers: evaluation with US, spiral CT, and MRI and correlation with pathologic examination of explanted liver . J Comput Assist Tomogr. 2001;25(3):327-36. (Level II evidence). View the reference
20. Purysko AS, Remer EM, Coppa CP, Obuchowski NA, Schneider E, Veniero JC. Characteristics and distinguishing features of hepatocellular adenoma and focal nodular hyperplasia on gadoxetate disodium-enhanced MRI. AJR Am J Roentgenol. 2012;198(1):115-23. (Level III evidence). View the reference
21. Grieser C, Steffen IG, Seehofer D, Kramme IB, Uktolseya R, Scheurig-Muenkler C, et al. Histopathologically confirmed focal nodular hyperplasia of the liver: gadoxetic acid-enhanced MRI characteristics. Magn Reson Imaging. 2013;31(5):755-60. (Level III evidence). View the reference
22. Jang HJ, Kim TK, Lim HK, Park SJ, Sim JS, Kim HY, et al. Hepatic hemangioma: atypical appearances on CT, MR imaging, and sonography. AJR Am J Roentgenol. 2003;180(1):135-41. (Review article). View the reference
23. Ziessman HA, Silverman PM, Patterson J, Harkness B, Fahey FH, Zeman RK, et al. Improved detection of small cavernous hemangiomas of the liver with high-resolution three-headed SPECT. J Nucl Med. 1991;32(11):2086-91. (Level III evidence). View the reference
24. Birnbaum BA, Weinreb JC, Megibow AJ, Sanger JJ, Lubat E, Kanamuller H, et al. Definitive diagnosis of hepatic hemangiomas: MR imaging versus Tc-99m-labeled red blood cell SPECT. Radiology. 1990;176(1):95-101. (Level III evidence). View the reference
25. Wee A. Fine-needle aspiration biopsy of hepatocellular carcinoma and related hepatocellular nodular lesions in cirrhosis: controversies, challenges, and expectations . Patholog Res Int. 2011;2011:17. (Review article). View the reference
26. Torzilli G, Minagawa M, Takayama T, Inoue K, Hui A-M, Kubota K, et al. Accurate preoperative evaluation of liver mass lesions without fine-needle biopsy. Hepatology. 1999;30(4):889-93. (Level II evidence). View the reference
27. Silva MA, Hegab B, Hyde C, Guo B, Buckels JA, Mirza DF. Needle track seeding following biopsy of liver lesions in the diagnosis of hepatocellular cancer: a systematic review and meta-analysis. Gut. 2008;57(11):1592-6. (Level II/III evidence). View the reference
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29. Chang S, Kim SH, Lim HK, Lee WJ, Choi D, Lim JH. Needle tract implantation after sonographically guided percutaneous biopsy of hepatocellular carcinoma: evaluation of doubling time, frequency, and features on CT . AJR Am J Roentgenol. 2005;185(2):400-5. (Level III evidence). View the reference

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