Nodule in Liver: Investigations, Differential Diagnosis and Follow-up

Abstract

Conventional ultrasonogram of the abdomen being noninvasive, inexpensive and ubiquitously available is the first imaging modality that raises suspicion of HCC in a patient with chronic liver disease with or without cirrhosis. The lesions in liver particularly nodule are being recognized with increased frequency with the wide spread use of ultrasonogram as the initial investigation and computerized tomography and magnetic resonance imaging subsequently. Any nodule in a cirrhotic liver should be considered as hepatocellular carcinoma until otherwise proved. This approach certainly is helpful in diagnosing HCC at its earliest possible stage to offer meaningful curative measures be it transplant, resection or ablative therapy. After a nodule is detected on ultrasonogram the next imaging modality can be a contrast enhanced study (dynamic CT scan or an MRI) to see if are present or not. Two vital clues for diagnosis of HCC by contrast enhanced imaging are presence of arterial hypervascularity and washout which are considered as "classical imaging features". This sequence of events of arterial uptake followed by washout is highly specific for diagnosis of HCC by imaging. If the features are typical showing classical imaging features (i.e hypervascular in the arterial phase with washout in portal venous or delayed phase) the lesion should be treated as HCC biopsy is not necessary. Nodular lesions showing an atypical imaging pattern, such as iso-or hypovascular in the arterial phase or arterial hypervascularity alone without portal venous washout, should undergo further examinations with another contrast enhanced imaging. Biopsy is advisable for those lesions which do not show classical features on the imaging. ( J CLIN EXP HEPATOL 2014;4:S57-S62) T he diagnosis of HCC is predominantly by imaging modality. Conventional ultrasonogram of the abdomen being noninvasive, inexpensive and ubiquitously available is the first imaging modality that raises suspicion of HCC in a patient with chronic liver disease with or without cirrhosis. This could happen either on surveillance or de novo. At times, particularly in young patients with vertically transmitted HBV infection in Asia pacific and African continents it is not uncommon to come across advanced HCC at the time first presentation. The lesions in liver particularly nodule are being recognized with increased frequency with the wide spread use of ultrasonogram as the initial investigation and computerized tomography and magnetic resonance imaging subsequently. The most important question to be answered is to determine the nature of the nodule i.e. regenerating nodule, HCC, intrahepatic cholangiocarcinoma, metastatic lesion(s) or rarely an infective process. Any nodule in a cirrhotic liver should be considered as hepatocellular carcinoma until otherwise proved. This approach certainly is helpful in diagnosing HCC at its earliest possible stage to offer meaningful curative measures be it transplant, resection or ablative therapy. In this article we intend to answer two issues of ...

Percutaneous Treatment of Malignant Liver Lesions: Evaluation of Success Using Contrast- Enhanced Ultrasound (CEUS) and Perfusion Software

“…In the hands of an experienced examiner, CEUS is a useful diagnostic method to evaluate the dynamic micro-vascularization of malignant liver tumors [16,20] and to detect remaining tumor vascularization after interventional treatment [21,22]. Furthermore, it has proven to be as accurate as other contrast-enhanced imaging (ceCT/ceMRI) modalities for the assessment of technical success after RFA [23 -25].…”

Liver disease secondary to congenital heart disease in children

“…Capsule, heterogeneity, and mosaic pattern could be observed in HCC by MRI [124]. The combination of hypervascularity in the arterial phase with washout in the portal venous or delayed phase, which are 'classical imaging features,' is highly specific for the diagnosis of HCC [127]. However, the specificity is not 100%.…”

Natural history of nonenhancing lesions incidentally detected during the diagnosis of hepatocellular carcinoma

“…2 It has been reported previously that 41-62% of lesions <2 cm in diameter show either an absence of arterial hypervascularity or venous washout. 3 In addition, the malignant transformation rates at 5 years were estimated to be 30-80% for highand low-grade dysplastic nodules and 12% for regenerative nodules. 15,20,21 We also have examined the clinical course of 18 adenomatous hyperplasias of the liver and found that 9 developed into HCC during the 1-to 5-year follow-up periods.…”