19 hours ago · Liver lesions have a broad spectrum of pathologies ranging from benign liver lesions such as hemangiomas to malignant lesions such as primary hepatocellular carcinoma and metastasis. Imaging is a crucial step in diagnosing these conditions as liver enzymes can be elevated in up to 9% of individuals in the USA. >> Go To The Portal
In contrast to survey examinations, liver staging examinations are performed in patients with known hepatic malignancy (primary or secondary) when liver resection is being considered.
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3. Is the patient having symptoms that could be attributed to the lesion? Magnetic resonance imaging (MRI) is the recommended imaging modality to most accurately characterize suspected benign liver lesions.
Accurate characterization of liver masses by cross-sectional imaging is particularly dependent on an understanding of the unique phasic vascular perfusion of the liver and the characteristic behaviors of different lesions during multiphasic contrast imaging.
Assessment of liver lesions takes into consideration their appearance and vascularity on a variety of imaging modalities: The differential diagnosis for pediatric liver lesions is different to that for an adult.
Metastatic liver lesions are usually hypointense on T1-weighted imaging and hyperintense on T2-weighted images. Most metastatic liver tumors are hypovascular, and the portal venous phase is the best time frame to be visualized. Some metastatic tumors, including renal cell carcinoma, melanoma, and sarcoma, are hypervascular.
Magnetic resonance imaging (MRI) MRI scans can be very helpful in looking at liver tumors. Sometimes they can tell a benign tumor from a malignant one. They can also be used to look at blood vessels in and around the liver to see any blockages, and can help show if liver cancer has spread to other parts of the body.
The differential diagnosis of a liver mass is large and requires understanding of the clinical and imaging features of liver lesions. A detailed history, physical examination, hepatic biochemical tests, and imaging studies are all essential in making the diagnosis.
Recent work indicates that with colorectal liver metastases, careful MRI or CT should detect 95% or more of lesions larger than about 15 mm. The real issue now is the accuracy of detection for lesions smaller than this.
Liver lesions are groups of abnormal cells in your liver. Your doctor may call them a mass or a tumor. Noncancerous, or benign, liver lesions are common. They don't spread to other areas of your body and don't usually cause any health issues. But some liver lesions form as a result of cancer.
Noncancerous (benign) tumors are quite common and usually do not produce symptoms. Often, they are not diagnosed until an ultrasound, computed tomography scan, or magnetic resonance imaging scan is performed.
Malignant liver lesions are diagnosed in a myriad of ways. If your healthcare provider suspects you have liver cancer, any of these may be ordered: Blood tests like alpha-fetoprotein (AFP) tumor marker and liver function tests (LFTs) Imaging tests like ultrasounds, computerized tomography (CT) scans, and MRIs.
Mass > 2 cm Enhancement in the arterial phase and washout in the portal venous phase is essential for the diagnosis of a liver lesion > 2 cm in a cirrhotic liver. More than 80% of masses > 2 cm in a cirrhotic liver are HCC[33,34]. An elevated AFP confirms the diagnosis.
Stage 2: One liver tumor is present, and cancer has spread to nearby blood vessels; or there is more than one tumor in the liver, but none are larger than 5 centimeters (cm).
Liver lesions are abnormal growths that may be noncancerous (benign) or cancerous. Benign lesions occur for a variety of reasons and are typically not cause for concern. Liver cancer is less common but more serious.
The majority of liver lesions are noncancerous, or benign. Many lesions are detected during imaging tests for unrelated health conditions. Although most lesions aren't harmful, it's still critical to receive a proper diagnosis.
The majority of liver lesions are noncancerous, harmless, and can be left untreated. Liver hemangiomas are the most common type of benign liver mass, occurring in an estimated 5% of adults in the US. Other common noncancerous liver lesions include focal nodular hyperplasias and hepatic adenomas.
The estimated time needed for a HCC to grow from 1 cm to 2 cm was 212 days in patients with HBV infection and 328 days in those with HCV infection.
It is helpful to subclassify lesions into three clinical categories. First are benign mass lesions for which no treatment is needed; second are benign mass lesions for which treatment is required; and third are malignant mass lesions for which treatment is always required if feasible 1.
Specialized imaging studies such as Octreotide scans, used in the diagnosis of neuroendocrine tumors, and positron emission tomography (PET) scans , used for detection of metastatic disease or cholangiocarcinoma, are also valuable adjuncts for clinical diagnosis and management. Surveillance for Hepatocellular Carcinoma.
FNH are composed of normal hepatocytes and behave like a regenerative mass of variable size. They lack a terminal central hepatic vein and characteristically show capillarization of sinusoids derived from a feeding artery that is usually larger than normal 43, 44. On ultrasound, FNH may show very slight changes in echogenicity compared to the surrounding parenchyma and usually appear hypo- or isoechoic and slightly inhomogeneous due to the central scar 45. FNH are usually isodense with the surrounding liver on CT and isointense on MRI. This feature may make them undetectable on unenhanced imaging and has earned them the label “stealth lesions”. They are fairly homogeneous except for the central scar when it is present which is typically hypodense on CT and T2 bright on MRI. A central scar, when present, is quite specific 46, 47. In multiphasic CT or MR imaging studies, FNHs typically show rapid homogeneous uptake of contrast in the early arterial phase with rapid return to near-normal enhancement in the portal venous and delayed phases. With MRI contrast agents such as gadoxetate disodium (Eovist) or gadobenate dimeglumine (MultiHance) that have both renal and biliary excretion, FNHs show active hepatocyte uptake and look similar to or brighter than the surrounding liver tissue in the hepatocyte phase of imaging 48, 49 ( Figure 4 ). The central scar is often absent and, rarely, FNH may contain fat or appear heterogeneous with atypical features, making the differentiation from hepatic adenomas, fibrolamellar hepatocellular carcinoma and HCCs difficult. Demonstration of the uptake of hepatocyte-specific contrast agents is most useful in such situations 48, 49. Biopsy may be required for a definitive diagnosis.
A common thread in the etiological factors for cholangiocarcinoma are inflammatory conditions of the liver and biliary tract, and factors such as diabetes and smoking that contribute to genomic instability through oxidative stress and faulty DNA repair mechanisms. These tumors can present as a single mass, a large mass with satellite nodules, or multiple nodules within the liver. Microscopically cholangiocarcinomas are usually well-differentiated adenocarcinomas and resemble other glandular carcinomas of extrahepatic origin. The diagnosis of cholangiocarcinoma often depends on clinical and radiological exclusion of other primary sites. Cholangiocarcinomas are often scirrhous, with islands of malignant cells surrounded by dense stroma, which can make cytological diagnosis difficult. When cholangiocarcinomas develop in bile duct strictures, the demonstration of chromosomal polysomy in cytologic specimens using fluorescence in situ hybridization has proven more sensitive than cytology, while maintaining high specificity 23. Molecular analyses of cholangiocarcinomas show mutations in the KRAS, p53, IDH1/2, BRAF, EGFR, MET, and PIK3CA genes.
Hepatic adenomas are relatively uncommon benign liver masses most commonly seen in women but also increasingly found in men, particularly those with metabolic syndrome. There are different subtypes of hepatic adenomas differentiated by their histologic, genetic, and radiologic phenotypes and by their epidemiologic characteristics. Major etiologic factors for hepatic adenomas include oral contraceptive use, anabolic steroids in males, the metabolic syndrome, and excessive alcohol use 52 - 57. Newer generation contraceptive pills with lower estrogen content are likely associated with a lower risk of hepatic adenomas. Despite that, the overall incidence of hepatic adenomas has not decreased 58. This can perhaps be explained by the increasing rates of obesity worldwide and an associated increase in metabolic syndrome, with a subset of those patients being diagnosed with hepatic adenomas, particularly the inflammatory and telangiectatic variant 55, 59. This suggests that obesity and metabolic syndrome increase the risk of developing adenomas. The presence of multiple hepatic adenomas in the liver, typically greater than 5 or greater than 10 adenomas, depending on the particular definition, is referred to as hepatic adenomatosis. Adenomatosis is associated with glycogenosis type Ia or III, Klinefelter syndrome, familial diabetes or familial adenomatosis 60 - 62. Clinically, hepatic adenomas are characterized by their responsiveness to estrogen and their tendency towards intratumoral hemorrhage with scarring and, rarely, hepatic rupture with hemoperitoneum. Adenomas also have a small, but real, risk of malignant transformation into HCCs.
HCCs are thought to arise as a consequence of premature hepatocyte senescence caused by repeated cycles of cell injury, regeneration and repair, occurring in an inflammatory environment that leads to genetic and epigenetic aberrations. HCCs show significant molecular heterogeneity; a substantial percentage of HCCs have mutations in the p53 and CTNNB1 genes, as well as in genes regulating chromatin remodeling 84. At least 5 molecular subclasses have been identified thus far, including a proliferative subclass characterized by PI3 kinase/Akt kinase activation, a β-catenin mutated subclass, interferon related, polysomy 7, and undefined classes, however they are not routinely used in clinical practice 85. Most HCCs in the United States arise within a cirrhotic liver. Microscopically HCC cells resemble normal hepatocytes to a variable extent in well to moderately differentiated tumors. The tumor is characterized by naked or unaccompanied arteries, absence of normal portal tracts, and hepatic cord thickness more than 3 cells thick which can be highlighted by a reticulin stain. Mitoses are usually present ( Figure 9 ). Histologic patterns of HCC include trabecular (the most common pattern), acinar (pseudoglandular), solid, and scirrhous patterns. These patterns do not appear to have prognostic significance. Immunohistochemical stains such as HepPar-1, Glypican-3 and polyclonal CEA are useful for confirming the diagnosis of HCC 86.
A common thread in the etiological factors for cholangiocarcinoma are inflammatory conditions of the liver and biliary tract, and factors such as diabetes and smoking that contribute to genomic instability through oxidative stress and faulty DNA repair mechanisms.
To determine the outcomes after initial therapy in patients with chronic liver disease and retrospectively assigned Liver Imaging Reporting and Data System (LI-RADS; version 2014) category 4 (LR-4) and 5 (LR-5) nodules at gadoxetate disodium–enhanced MR imaging.
In this retrospective study, 260 patients with a single LR-4 ( n = 132) or LR-5 ( n = 128) nodule who were assigned a LI-RADS category were included.
Patients with LR-4 nodules had ILRs and IDRs similar to patients with LR-5 nodules when stratified by treatment type. RFS was also similar between patients with LR-4 and LR-5 nodules. Among the four initial treatments, liver transplant and resection showed better local tumor control, with longer RFS than RFA or TACE.
Hepatocellular carcinoma (HCC) is the fifth most common malignant tumor worldwide, and the third most frequent cause of cancer-related deaths ( 1, 2 ).
This study was approved by the review board of our institution. The requirement for informed consent was waived because of the retrospective analysis nature of the study.
On the basis of the major imaging features, 75 nodules were initially assigned as LR-3, but 69 (92.0%) of these were upgraded to LR-4 because of the presence of ancillary features. By excluding the remaining six LR-3 and three LR-M nodules, we analyzed 132 LR-4 nodules in 132 patients, and 128 LR-5 nodules in 128 patients ( Figs 2 and 3 ).
In our study we attempted to identify the clinical outcomes of LR-4 and LR-5 nodules, including ILR, IDR, and RFS, after initial treatment according to the BCLC staging system, which is widely accepted in clinical practice.
When evaluating a lesion that is concerning for malignancy, determining the presence of underlying liver disease , specifically cirrhosis, is important as cirrhosis predisposes patients to HCC as well as iCCA. Other malignant lesions are unrelated to the presence of cirrhosis.
Magnetic resonance imaging (MRI) is the recommended imaging modality to most accurately characterize suspected benign liver lesions. Hepatic hemangioma, a blood filled cavity lined by a single layer of epithelial cells that derives its blood supply from the hepatic artery, is the most common benign liver lesion.
HCC is the leading cause of mortality in patients with cirrhosis with an estimated 1/3 of patients developing HCC in their lifetime. The diagnosis of HCC with known cirrhosis can be made based on radiographic findings without the need for a pathologic confirmation with a biopsy.
The European Association for the Study of the Liver (EASL) has comprehensive guidelines on the management of benign liver lesions. 1 When considering if surgical resection is warranted in a patient with a benign liver lesion, there are key questions to consider: 1.
The most common primary liver cancer is HCC, with 80 – 90% of cases occurring in patients with cirrhosis. In 2016, data from the CDC showed a 43% increase in mortality in the United States during the period of 2000-2016. This is thought to be due to the rising incidence of HCC with fairly steady 10-year mortality rates due to HCC.
While the incidence of HA is declining related to oral contraceptive pill (OCP) use, it is rising due to obesity and the metabolic syndrome, often leading to multiple HA. For males, resection is recommended for HA regardless of size.
Angiosarcoma carries a dismal prognosis with two-year survival of only 3%. Mortality is generally due to tumor rupture (high vascularity) or liver failure due to replacement of the liver with tumor. Risk factors include vinyl chloride, arsenic, cyclophosphamide, anabolic steroids, and OCP.