Diagnostic Imaging Pathways - Liver Lesion (Incidental)
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Population Covered By The Guidance
This pathway provides guidance on the imaging of adult patients with a focal liver lesion discovered incidentally on imaging for unrelated indications, who have no history of malignancy or risk factors for hepatocellular carcinoma.
Date reviewed: February 2015
Date of next review: 2017/2018
Published: July 2015
Quick User Guide
Move the mouse cursor over the PINK text boxes inside the flow chart to bring up a pop up box with salient points.
Clicking on the PINK text box will bring up the full text.
The relative radiation level (RRL) of each imaging investigation is displayed in the pop up box.
SYMBOL | RRL | EFFECTIVE DOSE RANGE |
![]() | None | 0 |
![]() | Minimal | < 1 millisieverts |
![]() | Low | 1-5 mSv |
![]() | Medium | 5-10 mSv |
![]() | High | >10 mSv |
Images
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
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Hepatic haemangioma (HH) |
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Focal nodular hyperplasia (FNH) |
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Hepatic adenoma (HA) |
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