Evaluation and Management of Incidental Liver Lesions
Understanding the natural history, evaluation, and management of benign liver lesions is crucial for diagnosing incidental liver findings. Common benign liver lesions include hepatic hemangioma, focal nodular hyperplasia, hepatic adenoma, and hepatic cyst. Differential diagnosis plays a key role in identifying these lesions. This article explores clinical scenarios and imaging findings to aid in the proper assessment and management of incidental liver lesions.
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Incidentolomas - Evaluation and Management of Incidental Liver Lesions Patrick M. Horne, MSN, ARNP, FNP-BC Assistant Director of Hepatology Clinical Research Division of Gastroenterology, Hepatology and Nutrition University of Florida Health
Disclosures Financial relationships to disclose within the past 12 months: Grant support with Bayer/Onyx
Objectives Discuss natural history of benign liver lesions. Discuss Evaluation and management of FNH, Hemangioma, Liver Cyst, Adenoma
Background Causes of focal liver lesions are diverse and can range widely. Typically are clinically silent and detected incidentally while undergoing evaluation for unrelated symptoms. Understanding the clinical circumstances surrounding the presence of liver lesions aids in better diagnosis.
Differential diagnosis Common benign liver lesions include: Hepatic hemangioma Focal nodular hyperplasia (FNH) Hepatic adenoma Hepatic cyst Idiopathic noncirrhotic portal hypertension Focal nodular hyperplasia Regenerative nodules Bonder A & Afdhal N. Clin. Liver Dis. 2012
Case 1 40 year old Caucasian female presents to her PCP s office intermittent nonspecific abdominal pain and nausea. Physical exam negative but abdominal ultrasound ordered which notes a possible lesion. Follow up imaging obtained
Case 1 Persistent enhancement throughout imaging phases
Hemangioma Most common benign hepatic tumor 60-80% diagnosed in people between the ages of 30-50. Ratio of occurrence in women to men, 3:1. More common in young women Choi BY & Nguyen MH. J Clin Gastroenterol. 2005
Hemangioma-Diagnosis On ultrasound appear well-defined, lobulated, homogeneous hyperechoic mass. The accuracy of US is reported to be 70% to 80%. CT and/or MRI was best options With MRI having sensitivity and specificity around 85-95%. Descottes B et al. Surg. Endosc. 2003. Unai O et al. Clin Imaging. 2002.
Hemangioma-Management Treatment is usually not indicated in the setting of no symptoms with a firm diagnosis and confirmed stability on imaging at least 6 months apart. Lesions less than 5 cm Larger lesions may require closer monitoring and if symptoms develop may need to treatment. Blecker E et al. Z. Gastroenterol. 2003
Hemangioma-Management Treatment options include Surgery Resection Hepatic irradiation or transarterial catheter chemoembolization
Case 2 25 year old Hispanic female undergoing work up for elevated liver function tests (LFTs). Noted to have multiple liver lesions on abdominal ultrasound, the largest measuring 13 cm in diameter. Follow up imaging including CT and MRI completed.
Case 2-Imaging CT scan
Case 2-Imaging MRI
Focal Nodular Hyperplasia (FNH) Second most common liver tumor Incidence is on the rise due to better imaging. Can occur in both men and women 80-95% of cases seen in women, ratio 5:1 Bartolotta TV et al. La Radiologia Medica. 2013.
FNH-features Class findings include: Presence of a central scar on contrast enhanced imaging Present in about 1/3 of patients Lesions typically become hyperdense during arterial phase imaging. Due to arterial origin of the blood supply Isodense during portal venous phase Though central scar may be hyperdense Bartolotta TV et al. La Radiologia Medica. 2013.
FNH-Diagnosis Sulfur colloid scanning Due to prevalence of Kupffer cells, 80% of FNHs will show active uptake
FNH-Management Typically conservative. Typically stable lesions and do not change over time No evidence to suggest malignant transformation Enlargement and/or development in the setting of OCP?
Case 3 30 year old Caucasian female presents with chronic abdominal pain. Has been on oral contraception therapy for 5 years Otherwise healthy, no significant medical history.
Case 3 MRI
Hepatic adenoma Uncommon lesions Mostly in young women (22-40) Commonly in the right lobe of the liver Grazioli L. Radiographics. 2001
Hepatic adenoma Strong association with: Oral contraceptives and hormones Anabolic steroids Glycogen storage disease Less common association: Pregnancy Diabetes mellitus
Hepatic adenoma Prognosis not well established There is an association with: Malignant transformation Spontaneous hemorrhage Rupture
Hepatic adenoma-Diagnosis Typically made clinically with imaging. Biopsy of the lesion is not indicated or recommended due to risk of bleeding. Imaging techniques: US-limited CT and/or MRI
Hepatic adenoma-Diagnosis CT: Well demarcated and have low attenuation or are isodense on noncontrast imaging and show peripheral enhancement early with centipedal flow during portal venous. MRI: usually well demarcated and typically hyperintense on T1. Enhancement on T2 images that enhance further with gadolinium administration is highly suggestive. Grazioli L. Radiographics. 2001 Chung. KY AJR. 1995
Hepatic adenoma-Management Dependent on size of lesion and symptoms If asymptomatic and lesion is small (less than 5 cm) Stop OCP if taking Can monitor with imaging and possibly AFP If symptomatic and/or lesion is large (greater than 5 cm) Surgical resection is recommended. Liver transplantation rare Dokmak S. et al. Gastroenterology. 2009
Case 4 60 year old female presents to a local ER with severe abdominal pain with a palpable mass on physical examination. No known history of liver disease or GI symptoms
Hepatic cyst-Prevalence Dependent on origin Simple: More common in right lobe. More in women, ratio of 1.5:1. Distinction between simple and other types of cysts is difficult to make but very important for management. Huge cysts found often in women over age 50.
Hepatic cyst-Diagnosis Ultrasound: Good at distinguishing between simple and other cystic lesions CT scan: Well demarcated lesion with no enhancement after administration of IV contrast. MRI: No enhancement with contrast. T1-weighted images the cyst shows a low signal, whereas a very high intensity signal is shown on T2-weighted images.
Simple cyst Cystic echinococcosis Alveolar Echinococcosis Cystadenoma And cystadenocarino ma Border Sharp and smooth Laminated Irregular Irregular Shape Spherical or oval Round or oval Irregular Round or oval Echo pattern Anechoic Anechoic or atypical Hyperechogenic outer ring and hypoechogenic center Hypoechogenic with hyperechogenic septations Appearance No septa multiseptated multivesicular Septated and/or sold structures Wall Strong posterior wall echoes Wall enhancement Posterior acoustic feature Relative accentuation of echoes Dorsal shadowing (calcified areas) Doral shadowing (calcified areas) Lantinga MA. 2013. World Journal of Gastro.
Hepatic cyst-Management Symptoms and type of cyst drive the management Majority do not require intervention (if simple). Would consider monitoring large cysts over 4 cm with interval imaging. Minor and major surgical options available for large cysts and/or symptoms
Hepatic cyst-Management Interventions: Needle aspiration (though associated with high failure rate and rapid recurrence) Deroofing Liver resection If infectious, treat appropriately. Yasawry MI. World J Gastroenterol. 2011
Conclusion Liver lesions are common and proper diagnosis is important. A combination of medical history as well as appropriate imaging is essential. Most liver lesions are benign but in certain situations must be addressed or treated.
