Overall Bottom Line

The medical evaluation of liver lesions is often challenging to clinicians. When a patient is diagnosed with a liver lesion, it is important to consider the clinical situation in which it was discovered.
Careful history taking and physical examination often give important clues to diagnosis.
The laboratory evaluation and morphological features on radiological imaging frequently lead to diagnosis without a biopsy.
Primary hepatic neoplasm should be high on the list of differential diagnoses in patients with chronic liver diseases presenting with new focal liver lesions.

Section 1: Background

Disease classification

Liver (hepatic) lesions are classified into non-malignant (benign) lesions, primary malignant neoplasms and secondary malignant (metastatic) neoplasms.
The most common benign hepatic lesions are hepatic hemangioma, hepatic cysts and hepatic adenoma and FNH. Common infectious lesions include pyogenic and amebic liver abscesses and echinococcal cyst.
Common primary hepatic neoplasms include HCC and cholangiocarcinoma.
The liver is a common organ for metastatic disease. The secondary or metastatic neoplasm sources include malignancies from colon, breast, lymphoma, thyroid, pancreas, melanoma, lungs and neuroendocrine tumors.

The most common benign solid hepatic tumor is hemangioma and its prevalence is 3–10%. Hepatic hemangioma is often found in the right lobe of the liver and in females predominantly.
Simple hepatic cysts are discovered in 5–10% of asymptomatic adults. These are benign and often are found in the right lobe of the liver. Large cysts are found frequently in women over 50 years of age.
The second most common of primary solid liver tumor is FNH.
Prevalence of FNH and hepatic adenoma are 3–8% and less than 1%, respectively. Both are more common in females. FNH is benign; however, the hepatic adenomas is associated with malignant transformation and spontaneous hemorrhage.
The prevalence of HCC and metastatic lesions are less than 1% of the general population. It develops in patients with chronic liver disease, is the fourth leading cause of cancer-related death among males and its incidence is on the rise worldwide.

The increased use of radiological tests such as CT scan, MRI and ultrasound has increased incidental findings of liver lesions. Many of these are benign and are found incidentally during the investigation of unrelated matters. These lesions frequently cause diagnostic dilemmas and challenges to physicians.
Liver lesions found incidentally often lead to several blood and radiological tests and occasionally invasive tests such as biopsy which may impact overall economic cost. However, there is no clear data on the precise economic impact of liver lesions found incidentally.

There are no clear risk factors for hemangioma, hepatic cyst and FNH.
The risk of developing hepatic adenoma is associated with estrogen, oral contraceptive pills, anabolic steroid use and glycogen storage disease.
The risk of developing a hepatic neoplasm such as HCC is associated with exposure to aflatoxins and cirrhosis of the liver from hepatitis C, NASH and chronic hepatitis B infection. The risk of developing HCC in cirrhotic patients is roughly 3–5% yearly.

Bottom Line/Clinical Pearls

There is no preventive measure for benign hepatic hemangioma, cyst and FNH.
The primary prevention should be focused on identifying and screening patients at risk of developing a primary hepatic neoplasm such as HCC.
Hepatitis A and hepatitis B vaccinations should be offered routinely to those patients with chronic liver diseases who are not immune.

For asymptomatic patients without any underlying liver disease, a routine liver lesion screening is not recommended. However, serum liver function should be offered to patients during a routine physical check-up to identify patients at risk of developing chronic liver diseases.
For patients with liver cirrhosis and/or chronic hepatitis B infection, HCC screening such as ultrasound should be offered every 6 months to detect the cancer at an early stage.

Bottom Line/Clinical Pearls

Clinical context is very important in diagnosis of focal liver lesions. For healthy patients with no evidence of chronic liver disease, malignant hepatic neoplasm is less likely.
For patients with a focal liver lesion and with evidence of chronic liver diseases such as cirrhosis and/or hepatitis B infection, primary hepatic neoplasm such as HCC should be ruled out with further blood and radiological tests.
The diagnosis requires evaluation of clinical situations, performing appropriate blood tests and radiological tests.

Most commonly, benign hepatic cyst, hemangioma and FNH are found incidentally. Most commonly the patients have no symptoms from the liver lesions. However, some patients may complain of vague RUQ discomfort when the lesions are complex and large.
Patients with pyogenic abscess or amebic abscess may have fever, chills and abdominal pain associated with infection.
Patients with small adenomas are asymptomatic. Those with larger adenomas (>5 cm) infrequently present with acute abdominal pain due to tumor rupture and intratumor hemorrhage.
Cirrhotic patients with small HCC often have no specific symptoms. As the HCC grows, the patient tends to experience vague RUQ discomfort from the space-occupying lesion. As the tumor becomes more advanced, the patients may present with new hepatic decompensation such as variceal bleed, jaundice, ascites and hepatic encephalopathy.

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