Chapter 44 MASS IN THE LIVER

KEY POINTS

• Widespread use of modern imaging modalities has resulted in frequent identification of incidental focal liver masses/nodules.

• Advances in imaging techniques now allow most masses to be diagnosed without the need for surgical resection.

• Imaging techniques useful for differential diagnosis include ultrasound (with or without colour Doppler), triphasic contrastenhanced computed tomography (CT), CT angiography (with or without iodised oil), gadolinium-enhanced magnetic resonance imaging (MRI), and imaging-guided biopsy.

• Incidentally found liver masses usually represent benign pathology and many, particularly simple cysts and typical haemangiomas, can be successfully diagnosed with ultrasound alone.

• Liver masses in the cirrhotic patient have a high risk of being hepatocellular carcinoma and require thorough investigation.

• A multidisciplinary approach is recommended for difficult cases and for malignant masses.

APPROACHES TO THE LIVER MASS

The diagnostic approach to a mass in the liver differs according to the medical history of the patient. Patients can be separated into three groups:

• Previously well with a mass found incidentally on abdominal imaging

• A background of chronic liver disease or known cirrhosis

• A history of extrahepatic malignancy or symptoms suggestive of malignancy.

Incidental liver mass in the well patient

With the widespread use of ultrasound for the investigation of a wide range of abdominal symptoms, focal liver masses are frequently identified. Most of these represent benign pathology, and further imaging is only required if there is doubt as to the nature of the mass on the initial study. Patients with a simple cyst can be reassured and no further investigation is needed. A recent study has shown that if a focal mass has the typical appearance of a haemangioma on ultrasound the risk of missing a malignant lesion is less than 0.5%, so further imaging is not required. Other focal lesions usually require further investigation, depending on the initial form of imaging employed.

The patient with chronic liver disease or known cirrhosis

The risk of hepatocellular carcinoma (HCC) is greatly increased in the cirrhotic patient with lesions >3 cm diameter, having a >95% risk of being a HCC. All focal liver lesions in patients with significant chronic liver disease should be considered a HCC until proven otherwise and further investigation is always warranted.

The patient with extrahepatic malignancy or symptoms suggestive of malignancy

The liver is a common site for metastatic disease; the most common primary sites are within the gastrointestinal tract, lung, urogenital tract, breast followed by non-Hodgkin’s lymphoma. The finding of multiple lesions of differing sizes that involve both lobes of the liver is a typical presentation of hepatic metastases. Solitary liver lesions, unless clearly benign, require further imaging or image-guided biopsy.

BENIGN LIVER MASSES

Cavernous haemangioma

Cavernous haemangiomas are the most common benign hepatic tumour, occur in 5% of the population and are female predominant. On ultrasound they are well circumscribed, uniform, hyperechoic lesions without a peripheral halo. When found incidentally in the otherwise well patient, classical ultrasound features are usually sufficient to establish the diagnosis and further investigation or treatment is unnecessary. Atypical haemangiomas can present a diagnostic challenge but triphasic computed tomography (CT) or, preferably, gadolinium-enhanced magnetic resonance imaging (MRI) will confirm the diagnosis in the majority of cases and have largely replaced ^99mTc-labelled red blood cell studies (Table 44.1).

TABLE 44.1 Relative utility of imaging modalities in providing a diagnosis of a hepatic mass

Focal nodular hyperplasia

Focal nodular hyperplasia (FNH) is a well circumscribed mass that typically displays a central stellate scar, a feature that is best seen with triphasic CT or gadolinium-enhanced MRI (Table 44.1). FNH is female predominant, usually asymptomatic and does not progress to malignancy. Ultrasound displays an isoechoic or hypoechoic lesion and colour Doppler may display vessels radiating outward from the artery within the central scar. Most lesions are less than 5 cm diameter and solitary. Occasionally differentiation from fibrolamellar HCC may be difficult.

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