Diagnostic Imaging Pathways - 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
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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
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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
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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
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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
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