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BENIGN

TUMORS OF
THE LIVER
MARIA THERESA M. NAVARRO, MD
4th Year Radiology Resident
Department of Medical Imaging
Quirino Memorial Medical Center
Hepatic
Hemangioma
s
HEPATIC HEMANGIOMAS
 CAVERNOUS HEMANGIOMA – most common
benign neoplasm of the liver
 second most common hepatic tumor, exceeded
only by metastases
 affects all age groups
 women > men
 within the right lobe of the liver
 few millimeters to greater than 20 cm diameter
HEPATIC
HEMANGIOMAS
 mesodermal in origin
 histologically : blood-filled cavernous
vascular spaces of variable size and
shape lined single layer of flat endothelium
 stable lesions, rarely increase or decrease
in size
IMAGING FEATURES OF
CAVERNOUS HEMANGIOMAS

 PLAIN FILMS
 mostly, too small to be identified on plain films of
the abdomen
 very large lesions, nonspecific findings :

hepatomegaly or a large upper abdominal mass


IMAGING FEATURES OF CAVERNOUS
HEMANGIOMAS

 CHARACTERISTIC (but rarely seen)


 presence of multiple calcified phleboliths
 numerous calcified “trabeculations and spicules”

that arise from a central point and radiate out


toward the periphery of the lesion
IMAGING FEATURES OF CAVERNOUS
HEMANGIOMAS

 ULTRASOUND
 well-circumscribed, homogenous, densely
echogenic masses with posterior acoustic
enhancement
 differential diagnosis:

 hepatocellular ca

 metastatic disease

 hepatic adenoma

 focal nodular hyperplasia


IMAGING FEATURES OF CAVERNOUS
HEMANGIOMAS

 ULTRASOUND
 demonstrate varying internal complexity,
depending on the degree of thrombosis, fibrosis,
hemorrhagic necrosis, or calcification
 sonographic heterogeneity – more common in
larger lesions.
 hyperechoic pattern (67% to 70%) – presence of
multiple vascular interfaces between the walls of
the cavernous sinuses and the blood within
them
IMAGING FEATURES OF
CAVERNOUS HEMANGIOMAS

 COMPUTED TOMOGRAPHY
 CT diagnosis is based on the understanding of
the neoplasm’s vascular hemodynamics
 blood typically circulates slowly within the the

dilated cavernous spaces of this tumor and


tends to flow from peripherally located sinusoids
toward those at the lesion center.
IMAGING FEATURES OF
CAVERNOUS HEMANGIOMAS
 COMPUTED TOMOGRAPHY
 series of noncontrast-enhanced CT scans to localize
suspected hemangioma
 rapid-sequence, single-level dynamic CT scan are

obtained to the largest segment of the lesion during an


IV bolus injection of
 150 ml of 60% contrast agent (42g of iodine)

 sequential delayed scans acquired for up to 30 minutes

after injection
 or until lesion is isodense with normal hepatic

parenchyma so that the lesion’s contrast enhancement


profile can be evaluated.
IMAGING FEATURES OF
CAVERNOUS HEMANGIOMAS
 DYNAMIC PHASE OF BOLUS CONTRAST INJECTION
 show peripheral enhancement at the margins of the
hemangioma
 initial enhancement need not encircle the entire lesion

but may appear as :


 well defined focal regions of intense nodular

enhancement at or near the lesion periphery


 during the arterial phase of hepatic enhancement (10 to

30 seconds after bolus initiation) - mural nodules


 represent as feeding vascular nidus
IMAGING FEATURES OF
CAVERNOUS HEMANGIOMAS
 DYNAMIC PHASE OF BOLUS CONTRAST
INJECTION
 centripetal pattern of hemangioma with fill-in
occuring from the periphery toward the lesion
center
 the most intense enhancement is seen early and
involves those vascular spaces that received the
iodinated contrast first
 the degree of lesion enhancement then
gradually decreases as the concentration of
iodine in the bloodstream falls
(Left) Axial NECT shows large mass in lateral segment,
most of which is isodense to blood except for hypodense
foci of scar. (Right) Axial CECTin venous parenchymal
phase shows cloud-like peripheral enhancement that is
isodense to vessels
(Left) Sagittal sonogram shows uniformly hyperechoic lesion in
peripheral right lobe.
(Right) Axial CECT in venous phase shows typical large
hemangioma with nodular peripheral enhancement and
nonenhancing scar (arrow).
Capillary hemangioma (curved arrow) isodense to vessels in all
phases.
 “Even though CT is highly accurate
in the diagnosis of hemangiomas,
it does not consistently yield
characteristic enhancement
patterns, thus limiting is clinical
usefulness.”
IMAGING FEATURES OF
CAVERNOUS HEMANGIOMAS

 MAGNETIC RESONANCE IMAGING


 Most sensitive modality for detecting hepatic
cavernous hemangioma
 high signal characterics similar to those of fluids

 Hypointense on T1 images and significantly


hyperintense on T2 images
 Retain their marked signal intensity on heavily
T2-weighted multiecho images
(“light bulb sign”)
IMAGING FEATURES OF
CAVERNOUS HEMANGIOMAS

 MAGNETIC RESONANCE IMAGING


 Well-circumscribed, smoothly marginated
lesions and appear spheroid, ovoid, or lobulated
 Low-signal-intensity clefts and septation – larger

hemangiomas and correspond to hypodense


regions on dynamic bolus CT studies
IMAGING FEATURES OF
CAVERNOUS HEMANGIOMAS
 MAGNETIC RESONANCE IMAGING
HEMANGIOMAS METASTASES

Homogenous hyperintense Heterogenous amorphous


pattern appearance
Well-circumscribed Ringed morphology

Smoothly marginated Indistinct margination

Surrounding peritumoral
edema
IMAGING FEATURES OF
CAVERNOUS HEMANGIOMAS

 RED BLOOD CELL


SCINTIGRAPHY
 typically display a “hot spot”
appearance on delayed
labeled-RBC scans, reflecting
the circulatory characteristics
of these neoplasms
IMAGING FEATURES OF
CAVERNOUS HEMANGIOMAS
 ANGIOGRAPHY
 Has long been considered gold standard in the
diagnosis of hepatic hemagioma
 Classic Finding :
 normal main and feeding hepatic artery
 early contrast accumulation within the lesion
during the late arterial phase
 Prolonged, delayed stain that persists throughout
the capillary phase and well into the late venous
phase
IMAGING FEATURES OF
CAVERNOUS HEMANGIOMAS
 ANGIOGRAPHY
 Atypical angiographic features:
 Hypovascular mass
 Or a dense, homogeneous hypervascular

mass
 Arterial-portal venous shunting
 Identification of a persistent pool of
contrast puddling within such
lesions may be the only means of
diagnosing these complicated
hemangiomas short of performing
a biopsy or surgical resection
APPROACH TO IMAGING OF
SUSPECTED HEMANGIOMAS
 (Modification scheme by Freeny)
 GROUP I
 Patients who have well-circumscribed, homogeneous,
hyperechoic lesions
 No clinical symptoms referable to the liver
 Normal liver function results
 No known primary neoplasm
 Patients who have lesions with atypical sonographic
patterns
 Abnormal clinical findings
 Known primary neoplasm
Group I Patients
 Labeled-RBC scintigraphy with SPECT
tomographic imaging is the preferred procedure
of definitive lesion characterization due to its
relative low cost and near 100% specificity and
positive predictive value.
 (1.5 cm to 2.0 cm lesions)
Group I Patients
 Magnetic Resonance Imaging
 reserved for lesions smaller than1.5 to 2.0 cm
 lesions 2.5 cm or smaller located adjacent to the
heart or major intrahepatic vessels
 Both modalities – useful in patients with multiple
suspected hemangiomas
Group I Patients
 MRI is not advocated if the patient has
a known primary hypervascular
endocrine neoplasm
 If these studies yield undeterminate
findings for hemangioma

angiography or
percutaneous needle
APPROACH TO IMAGING OF SUSPECTED
HEMANGIOMAS
 (Modification scheme by Freeny)
 GROUP II
 Patients who have focal hepatic lesions detected on
routine dynamic-incremental bolus CT studies

HEMANGIOM
Peripheral A
Delayed
contrast Images
enhancemen Show
t Isodense Fill-
APPROACH TO IMAGING OF SUSPECTED
HEMANGIOMAS

 GROUP II

ATYPICAL KNOWN ABNORMAL


CT PRIMARY LIVER
FEATURES TUMOR FINDINGS

ADDITIONAL MRI using the size


IMAGING WITH and specific criteria
LABELED-RBC already outlined
SPECT
APPROACH TO IMAGING OF
SUSPECTED HEMANGIOMAS
 GROUP III
 Whose hepatic lesions are first detected on MRI

MRI APPEARANCE IS
CLASSIC HEMANGIOM
A
NO
KNOWN
PRIMARY
NEOPLAS
APPROACH TO IMAGING OF
SUSPECTED HEMANGIOMAS
 GROUP III
ATYPICAL MRI
APPEARANCE
KNOWN PRIMARY NEOPLASM
(hypervascular endocrine
tumor)
ADDITIONAL SPECT CTAngiography or
IMAGING WITH FINDINGS Percutaneous
LABELED-RBC NEGATIVENeedle Biopsy
SPECT
LESIONS TOO
SMALL
APPROACH TO IMAGING OF SUSPECTED
HEMANGIOMAS
Lesions less than 1 cm are
difficult to consistently
characterize using any
noninvasive modality
Follow-up
ultrasound
or MRI at 6
unchanged inmonthschanged in size
size and and morphology
morphology
no further percutaneous biopsy
evaluation
Hepatocellular
Adenoma,
Focal Nodular
Hyperplasia,
and Others
Hepatocellular
Adenoma,
 Uncommon solid primary liver tumor
 Related to the use of oral contraceptives in women
and anabolic steroids in men
 Pathology : large (usually > 10 cm) solitary lesions
with a thin tumor capsule
 maybe rich in fat or glycogen
 Ultrasound : well-delineated heterogenous but
primarily echogenic hepatic mass
 Hyperechogenicity – attributed to the presence of
intratumoral fat and glycogen
Hepatocellular
Adenoma,
 Non-contrast-enhanced CT
 Predominantly isodense with liver but may appear
either uniformly hypodense due to extensive
steatosis
 Or heterogeneous with foci of hypodensity caused by
tumor necrosis and areas of hyperdensity secondary
to recent intratumoral hemorrhage
Hepatocellular
Adenoma,

 Distinctive perfusion characteristic of HA


 arterial phase of contrast infusion (15 to 25 seconds
after bolus injection of contrast media) - consists of
dense enhancement
 maybe homogenous in small tumors or
heterogeneous in a larger mass
 The lesion become hyperdense relative to normal

liver, which has enhanced minimally at this time.


Hepatocellular
Adenoma,
 portal venous phase (45 to 180 seconds after the injection of
contrast media)
 tumoral enhancement diminishes rapidly and the
tumors become isodense to normal liver during the

Radionuclide Scintigraphy
Most HAs are devoid of Kupffer cells, they
appear cold on sulfur colloid scintigraphy
Show uptake of the tracer
Because of the lack of bile ductules, the tracer
is not excreted, and delayed scans therefore
depict HAs as areas of markedly increased
Hepatocellular
Adenoma,
Hepatocellular
Adenoma,
 Magnetic Resonance Imaging
 Mimic malignant liver tumors, with the non-necrotic,
nonhemorrhagic solid component showing
 Hypointense appearance on T1 images and slight
hyperintense on T2 images
 However, the high fat or glycogen content, or both, of these
tumors can render them isointense or even hyperintense on
T1 images
 Hypointense tumor capsule best seen on T1 images
 Intratumoral bleeding – hyperintense on T1 images and
hypointense on T2 images
(Left) Axial T1WI MR shows hypointense encapsulated mass
with hyperintense foci (hemorrhage or fat).
(Right) Axial T2WI MR shows mass nearly isointense to liver
with
central focus of hyperintensity (hemorrhage).
Hepatocellular
Adenoma,

 Angiograms
 Hypervascular tumors with large peripheral vessels
 Centripetal flow
 Usually there is no arteriovenous shunting or vascular
invasion, as is often seen in hepatocellular carcinoma
 No specific diagnostic specificity can be gained
Hepatocellular
Adenoma,
 CONCLUSION
 Hypervascular tumors with large peripheral vessels
 Centripetal flow
 Usually there is no arteriovenous shunting or
vascular invasion, as is often seen in hepatocellular
carcinoma
 No specific diagnostic specificity can be gained
FOCAL NODULAR
HYPERPLASIA
 Clinical Background
 most common solid benign tumor of the liver
 usually found incidentally
 etiology unknown, but postulated that a congenital
vascular malformation may trigger the development
of hepatocyte hyperplasia
 hormonal influence  more common in women on
their 3rd to 5th decades
 controversy regarding its association with the use of
oral contraceptives
FOCAL NODULAR HYPERPLASIA
 Pathology
 well-circumscribed, usually solitary mass, no capsule
 with centrally located scar tissue surrounded by nodules of
hyperplastic hepatocytes
 nodules divided by thin septae that radiate from the central
scar, when there is one
 no normal portal venous structures
 usually located at the liver surface  bulge in the liver contour
 or pedunculated mass
 1 cm to > 15 cm
 hemorrhage, necrosis, and calcification are rare
FOCAL NODULAR HYPERPLASIA
 Radiology

 Diagnostic : presence of hepatocellular


reticuloendothelial function in liver tumors that
possess a cental scar containing vessels and bile
ducts
FOCAL NODULAR HYPERPLASIA
 Ultrasound
 as much as 2/3 appear homogenous and isoechoic
to normal liver and may be visible only because of
the mass effect they exert on adjacent hepatic
vessels
 some cases, FNH appear as inhomogenous mass
 central scar maybe detected as hyperechoic area but
often cannot be differentiated from other hypoechoic
or isoechoic areas
FOCAL NODULAR HYPERPLASIA

 Color-coded Doppler Ultrasound


 the hypervascular nature of FNH take on the
appearance of numerous scattered arterial and
venous Doppler signals exhibiting a “comet tail”
appearance throughout the tumor
FOCAL NODULAR HYPERPLASIA
 Computed Tomography
 with the exception of a central scar, the
appearance of FNH on CT scans is usually
indistinguishable from that of HA
 generally isodense to normal liver on
noncontrast-enhanced CT studies
 can be identified only if they deform the liver
contours or possess a prominent stellate-
shaped central scar
FOCAL NODULAR HYPERPLASIA
 Dynamic CT scan
 arterial phase (approximately the first 30
seconds) - rapid enhancement, appearing
hyperdense relative to liver
 portal phase – steady decrease in attenuation,
so they appear relatively isodense or
hypodense to uninvolved liver tissue
 delayed CT scan – vascular scar tissue
appear hyperdense
 perfusion profile also seen in both
hepatocellular carcinoma and adenoma
(Left) Axial CECTin arterial phase shows intense homogeneous
enhancement
of mass with central scar with thin radiating septa. Typical FNH
appearance
resembles cross section of an orange.
(Right) Axial CECT in venous phase shows mass (arrow) isodense to
liver
with delayed enhancement of central scar.
FOCAL NODULAR HYPERPLASIA
 Nuclear Scintigraphy
 technetium sulfur colloid scans, which portray
reticuloendothelial cellular function, the uptake of
tracer is normal approximately 50% of FNHs and
 uptake is increased in approximately 10%
 as many of 40% of the FNHs do not possess
reticuloendothelial cellular function, the presence of
a “cold lesion” does not exclude the possibility of
FNH.
FOCAL NODULAR HYPERPLASIA
 MRI Scan
 suggested if the liver tumor appears isointense on
both T1 and T2 images and has a central scar
 some cases, detected only by their mass effect on
normal hepatic vasculature plus the presence of
central scar (hypointense on T1 and hyperintense on
T2 images)
 uncommonly FNH may mimic other solid tumors by
being hypointense on T1 and hyperintense on T2
images.
(Left) Axial T1 C+ MR in arterial phase shows intense homogeneous
enhancement of mass with central hypointense scar.
(Right) Axial T2WI MR shows mass is minimally hyperintense, scar
(arrow) is hyperintense.
FOCAL NODULAR HYPERPLASIA

 Hepatic scars are also not specific for FNH

 “Thus differentiation of FNH from other


malignant or benign (solid) tumors is
frequently not possible with MRI”
FOCAL NODULAR HYPERPLASIA

 Dynamic T1 MRI studies


 arterial phase (first 30 seconds) – dense
enhancement
 60 seconds after injection – rapid washout
of the agent leading to isointensity of the
FNH to normal liver
 similar tumoral enhancement in
differentiated hepatocellular carcinoma
FOCAL NODULAR HYPERPLASIA

 Angiography
 seldom performed for the tissue
characterization of focal liver tumors
 hypervascular mass possessing a centrifugal
or “spoke wheel” pattern of vascular supply
MACROREGENERATIVE NODULE AND
NODULE REGENERATIVE
HYPERPLASIA

 Clinical Background
 MACROREGENERATIVE NODULE (MRN)
 10%-14% of the patients with chronic liver
disease, such as advanced cirrhosis
 Severe hepatic injury such as aftermath of
massive hepatic necrosis
MACROREGENERATIVE NODULE AND
NODULE REGENERATIVE
HYPERPLASIA
 Clinical Background
 NODULAR REGENERATIVE HYPERPLASIA
(NRH)
 much rarer condition
 arises without any hepatic injury or fibrosis
 but is associated with a variety of systemic
diseases such as rheumatoid arthritis and
polyarteritis nodosa.
MACROREGENERATIVE NODULE (MRNs)

 Pathology
 Well-circumscribed nodules composed of
hepatocytes that are arranged in normal cords
and contain portal areas
 Fibrosis is absent or slight
 Multiple
 1 to 6 cm in diameter
 Necrosis and hemorrhage (rare)
NODULAR REGENERATIVE HYPERPLASIA
(NRH)

 Pathology
 Not known
 May stem from occlusion of the intrahepatic
branches of the portal vein
 Few millimeter to 1 cm
 Scattered diffusely throughout the liver
MACROREGENERATIVE NODULE AND
NODULE REGENERATIVE HYPERPLASIA
 Cross sectional imaging – difficult because
 of the small size of NRH
 altered gross hepatic morphology that accompanies
cirrhosis and MRNs
 alteration in the echogenicity and MR signal intensity
of uninvolved hepatic tissue can interfere with lesion
detection
 No specific features on UTZ and CT, except for
round liver lesions up to several centimeters in
diameter in the setting of MRNs
MACROREGENERATIVE NODULE AND
NODULE REGENERATIVE HYPERPLASIA

 however on T2 MR images, MRNs may appear as


low-signal-intensity nodules
(Left) Axial CECT shows dysmorphic liver with collateral blood
vessels on the surface of the liver. Hypervascular lesion with
hypodense ring (arrow) represents a focus of nodular
regenerative hyperplasia
(Right) Axial CECTshows dysmorphic liver; intra and
extrahepatic collaterals bypassing occluded portal vein.
(Left) Axial T7 C+ MR shows numerous 2 cm hyperintense lesions in a
patient with
Budd-Chiari syndrome.
(Right) Axial T2WI MR demonstrates inconspicuous hypointense foci of
nodular
regenerative hyperplasia (arrow) in the right hepatic lobe.
HEPATIC CYSTS
 Clinical Background and Pathology
 maybe classified as:
 Developmental

 Infectious

 Traumatic

 arise from the bile duct epithelium


(cholangiocellular)
 unilocular
 solitary or multiple
HEPATIC CYSTS
 Clinical Background and Pathology
 Cyst wall – 1mm or less in thickness
 lined by a simple layer of cuboidal epithelium
 less commonly by squamous or columnar
epithelium
 adjacent liver tissue is normal and free of
fibrosis or inflammation
 5 to 14% of the population
 slightly more prevalent in women
HEPATIC CYSTS
 Ultrasound
 anechoic
 posterior wall is
well seen
 enhanced through
transmission
HEPATIC
CYSTS
 Computed Tomography
 thin-walled
 sharply marginated lesions
 water density ( 0 + 15 HU)
 non-enhancing
 versus HYDATID CYSTS
 possess septations, mural calcifications
and daughter cysts within the parent cyst
HYDATID CYST
HEPATIC CYSTS

 Magnetic Resonance Imaging


 long T1 and T2 relaxation
 hypointense on T1 and markedly
hyperintense on T2
 homogenous, sharply marginated
 signal intensity is indistinguishable from
hepatic hemangioma
 comparable to signal intensity of bile and
CSF
POLYCYSTIC LIVER DISEASE

 Clinical Background and Pathology


 numerous simple hepatic cysts
 adjacent liver tissue contains fibrotic
areas
(von Meyenberg complexes)
POLYCYSTIC LIVER
DISEASE
 Radiology
 multiple cysts of variable size and different
internal composition
 often in combination with PKD
 appearance of the cysts on ultrasound,
CT, and MRI studies can vary broadly as a
consequence of multiple episodes of
intracystic hemorrhage
 comparable to the cysts of PKD
MESENCHYMAL TUMORS AND
HETEROTOPIC RESTS
 Clinical Background and Pathology
 Hemangioma – most common
 prevalence of remaining mesenchymal benign
liver tumor is low
 no unique radiographic features
 exception are tumors that contain fat
 lipomas, angiomyolipomas, myelolipomas
 no malignant potential
MESENCHYMAL TUMORS AND HETEROTOPIC
RESTS
 Ultrasound
 fat-containing tumors are echogenic
 posterior acoustic enhancement in homogenous appearing
tumors (specifically lipomas)
 Computed Tomography
 low density = > 20 HU
 pure lipomas show no enhancement
 partial and inhomogenous contrast enhancement should
suggest angiomatous (angiomyolipoma) or myeloid
(myelolipoma)
MESENCHYMAL TUMORS AND HETEROTOPIC
RESTS
 combined use of ultrasound and CT may permit
the diagnosis and exclude other lipomatous
tumors of the liver
 Magnetic Resonance Imaging
 fat-containing tumors  high signal intensity on
T1 and T2 images
 comparable to the subcutaneous or
retroperitoneal fat
HEPATIC HEMANGIOMA
FOCAL NODULAR HYPERPLASIA
FOCAL NODULAR HYPERPLASIA