Liver Lesion Imaging

Christopher Mejias
MS3
• Pt. presents with a 2cm “lesion” seen
incidentally on a CT scan.
• Pt. is asymptomatic
• What’s the differential?
 Masses Seen on Imaging
• Benign
- Cyst
- Focal Nodular Hyperplasia (FNH)
- Hemangioma
- Adenoma
• Malignant
- Hepatocellular Carcinoma (HCC)
- Metastases
 Imaging Overview
• Ultrasound, CT and MRI are the most common
imaging modalities in evaluating liver lesions.
• CT and MRI are much more useful when contrast
is used.
• Due to the dual blood supply of the liver, there
are multiple contrast phases – arterial, portal
venous and delayed phase.
• Depending on the blood supply to a lesion, it will
differently on the various phases.
 Cysts
• Most common liver lesion (2-7% prevalence).
• Increased prevalence with PCKD (polycystic
kidney disease).
• Simple cysts are most common.
• Numerous cysts throughout the liver is a
feature of polycystic liver disease.
 US features
• Anechoic homogenous lesion without
wall thickening.
• May have septa
 CT findings
• Round hypodense lesion without contrast
enhancement
 Hydatid cysts
• A cyst with multiple septations suggests a
hydatid cyst caused by echinococcus.
 FNH
• A common benign liver lesion with no
malignant potential.
• Usually found incidentally
 CT findings
• Classically presents as a hypodense to
isodense lesion with a cental scar (hypodense)
 CT Findings
• Contrast enhances in the arterial phase
• Isodense in portal venous phase and delayed
phase
• Central scar is non-enchancing in the arterial
and portal venous phases, but may have
delayed enhancement
 CT

A – non-contrast, B – arterial phase, C – portal venous phase, D – delayed phase

 MRI
• FNH central scar is hypointense on T1 and
hyperintense on T2.

T1 T2
 Hemangioma
• Another common benign lesion.
• Proliferation of vascular tissue
 US findings
• Hyperechoic (in contrast to cysts)
 CT findings
• Hypodense lesion or lesions with no central
scar

CT non-contrast
 CT findings
• Enhances peripherally in the arterial phase
with further enhancement in portal venous
phase.

arterial Portal venous

 Adenoma
• A rare benign lesion.
• Associated with oral contraceptive use in
women.
• Highly variable presentation on CT, MRI and
US
 CT findings
• A common presentation is a well demarcated mass with
hemorrhage. Tends to be contrast enhancing on arterial and
early portal venous phase, but presentation is variable.

CT – non-contrast
 Hepatocellular Carcinoma
• Most common primary malignancy of the liver
• Associated with hepatitis B (10% risk at 5
years) and hepatitis C (30% risk at 5 years).
• Also associated with cirrhosis of any cause.
• Less common causes include
hemochromatosis, Wilson’s disease, alpha-1
anti-trypsin deficiency
 Gross features
• Can be large with calcifications, necrosis
and/or fat
• Can be multifocal
• Can be infiltrative/diffuse
 US
• Hypoechoic, heterogenous mass
 CT
• Hypodense to isodense. Contrast enhancing on arterial phase
with rapid washout on portal venous phase because they are
supplied mostly be the hepatic artery

Non-contrast
 CT

Arterial phase
 CT

Portal venous phase

 MR
• Hypointense on T1 with contrast
enhancement and rapid washout.

T1
 MR

T1 contrast - arterial
 MR

T1 contrast – portal venous

 MR
• May also show a peripheral hypoattenuation in the delayed
venous phase (termed peripheral washout). This is highly
specific for malignancy
 MR
• May also have a rim of enhancement due to presence of a
capsule or pseudocapsule. This is fairly specific for HCC.
 Tumor Thrombus
• Tumor thrombus – tumor within a blood
vessel can occur with malignant lesions
(usually HCC and metastases)
• Transplantation is contraindicated.
Tumor thrombus
 Fibrolamellar carcinoma
• Rare form of HCC that presents as a large lobulated
mass with calcifications and a central scar.
• Occurs in livers without underlying cirrhosis
 Liver Metastasis
• The most common malignant liver lesion.
• Common primary tumors include GI, breast,
lung. Essentially any solid malignancy may
show up.
• More commonly show up as multiple liver
lesions.
 US
• Generally hypoechoic, round, well defined masses. (can be
hyperechoic)
• Compression of nearby vasculature is concerning for a met.
 CT
• Tend to be hypointense with less contrast enhancement than
the surrounding liver.
• Enhancement tends to be peripheral

CT with contrast – portal venous phase

 LI-RADS
• Image classification system for stating the
likelihood of malignancy (L1 is benign and L5 is
definitely malignant).
• Most important factors are size, arterial
enhancement, washout, rim enhancement in
portal venous phase (more likely cancer), and
size progression.
 Cirrhosis
• This is irreversible fibrosis of the liver due to chronic liver
disease
• Common etiologies include alcohol, hep B, hep C,
steatohepatitis.
• Some less common include primary sclerosing cholangitis,
primary biliary cirrhosis, hemochromatosis, Wilson’s disease
• May or may not present with sequelae of liver disease
(ascites, portal venous congestion, jaundice,
encephalopathy).
• Presence of cirrhosis and a lesion suggests primary
malignancy over metastases.
 US
• Better than CT for diagnosing cirrhosis.
• Presents with heterogenous texture, surface nodularity and
sometimes ascites

Normal liver
cirrhosis
 US
• Caudate lobe hypertrophy is highly specific,
but not sensitive.
 CT
• Not as sensitive in early cirrhosis
• Late cirrhosis will show heterogeneity, surface nodularity, and
regenerative nodules
 Regenerative Nodule
• Supplied by portal venous system, hence they enhance on
portal venous phase

CT with contrast – portal venous phase

 Child Pugh Scoring System
• The severity of cirrhosis can not be determined solely on the
basis of imaging findings.
• The Child Pugh scoring system is used to determine severity.
A is least severe, C is the most severe.
• Factors used – total bilirubin, albumin, INR, ascites, hepatic
encephalopathy
• Generally, patients may undergo liver resection for class A
cirrhosis but not class B or C.
• For malignancy in the presence of class B or C cirrhosis,
options include chemotherapy, transplantation, ablative
therapies, portal venous embolization.
 Criteria for Resection
• Briefly, resection depends on features of the tumor,
extent of disease and underlying liver pathology.
• Child Pugh class B and C livers are generally not able
to be resected
• Tumors that are metastatic or invade vasculature
can’t be resected
• There needs to be enough liver volume after
resection for residual function (up to 70-80% of a
healthy liver can be resected).
 Criteria for Transplant
• Some patients with unresectable masses may be a
candidate for transplant
• Milan criteria:
1. single tumor < 5cm or up to three tumors <3cm
2. No extra hepatic involvement
3. No major vessel involvement
• Alternative therapies can be used in patients awaiting
transplant or who cannot be transplanted – a few
include chemo-embolization, portal vein ablation,
microwave ablation
 Summary
• Liver lesions can be evaluated by multiple imaging
modalities.
• Features suggesting a benign lesion include a central scar
(FNH), peripheral enhancement on arterial phase with
further enhancement on portal venous phase
(hemangioma).
• Features suggesting malignancy include arterial
enhancement followed by washout, presence of a capsule,
threshold growth over time.
• Underlying cirrhosis points to primary HCC. Multiple lesions
in a healthy liver point to metastases.
 Summary cont.
• Prognosis and treatment are determined by
characteristics of the lesion, extent of disease,
underlying liver pathology
 References
• Radiopaedia.org
• Radiologyassisstant.nl
• Uptodate.com