Evaluation and Management of Incidental Liver Lesions

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
Farges O.  Gut.  2011
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
Case 4
Hepatic cyst-Differential
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.
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.
Thank you
Slide Note
Embed
Share

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.

  • Liver Lesions
  • Hepatology
  • Incidental Findings
  • Benign Liver Lesions
  • Imaging Studies

Uploaded on Sep 08, 2024 | 0 Views


Download Presentation

Please find below an Image/Link to download the presentation.

The content on the website is provided AS IS for your information and personal use only. It may not be sold, licensed, or shared on other websites without obtaining consent from the author. Download presentation by click this link. If you encounter any issues during the download, it is possible that the publisher has removed the file from their server.

E N D

Presentation Transcript


  1. 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

  2. Disclosures Financial relationships to disclose within the past 12 months: Grant support with Bayer/Onyx

  3. Objectives Discuss natural history of benign liver lesions. Discuss Evaluation and management of FNH, Hemangioma, Liver Cyst, Adenoma

  4. 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.

  5. 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

  6. 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

  7. Case 1 Persistent enhancement throughout imaging phases

  8. 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

  9. 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.

  10. 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

  11. Hemangioma-Management Treatment options include Surgery Resection Hepatic irradiation or transarterial catheter chemoembolization

  12. 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.

  13. Case 2-Imaging CT scan

  14. Case 2-Imaging MRI

  15. 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.

  16. 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.

  17. FNH-Diagnosis Sulfur colloid scanning Due to prevalence of Kupffer cells, 80% of FNHs will show active uptake

  18. 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?

  19. 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.

  20. Case 3 MRI

  21. Hepatic adenoma Uncommon lesions Mostly in young women (22-40) Commonly in the right lobe of the liver Grazioli L. Radiographics. 2001

  22. Hepatic adenoma Strong association with: Oral contraceptives and hormones Anabolic steroids Glycogen storage disease Less common association: Pregnancy Diabetes mellitus

  23. Farges O. Gut. 2011

  24. Hepatic adenoma Prognosis not well established There is an association with: Malignant transformation Spontaneous hemorrhage Rupture

  25. 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

  26. 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

  27. 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

  28. 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

  29. Case 4

  30. Hepatic cyst-Differential

  31. 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.

  32. 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.

  33. 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.

  34. 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

  35. 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

  36. 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.

  37. Thank you

Related


More Related Content

giItT1WQy@!-/#giItT1WQy@!-/#giItT1WQy@!-/#giItT1WQy@!-/#