Incidentolomas - Evaluation and Management of Incidental Liver Lesions

Patrick M. Horne, MSN, ARNP, FNP-BCAssistant Director of Hepatology Clinical Research

Division of Gastroenterology, Hepatology and Nutrition

University of Florida Health

Disclosures• Financial relationships to disclose within

the past 12 months:

• Grant support with Bayer/Onyx

Objectives• Discuss natural history of benign liver

lesions.• Discuss Evaluation and management of

FNH, Hemangioma, Liver Cyst, Adenoma

Background• Causes of focal liver lesions are diverse and

can range widely.• Typically are clinically silent and detected

incidentally while undergoing evaluation for unrelated symptoms.

• Understanding the clinical circumstances surrounding the presence of liver lesions aids in better diagnosis.

Differential diagnosis• Common benign liver lesions include:– Hepatic hemangioma– Focal nodular hyperplasia (FNH)– Hepatic adenoma– Hepatic cyst– Idiopathic noncirrhotic portal hypertension• Focal nodular hyperplasia

– Regenerative nodules

Bonder A & Afdhal N. Clin. Liver Dis. 2012

Case 1• 40 year old Caucasian female presents to

her PCP’s office intermittent nonspecific abdominal pain and nausea.

• Physical exam negative but abdominal ultrasound ordered which notes a possible lesion.

• Follow up imaging obtained

Case 1

Persistent enhancement throughout imaging phases

Hemangioma• Most common benign hepatic tumor• 60-80% diagnosed in people between the

ages of 30-50.• Ratio of occurrence in women to men, 3:1.– More common in young women

Choi BY & Nguyen MH. J Clin Gastroenterol. 2005

Hemangioma-Diagnosis• On ultrasound appear well-defined,

lobulated, homogeneous hyperechoic mass. • The accuracy of US is reported to be 70% to

80%.• CT and/or MRI was best options– With MRI having sensitivity and specificity

around 85-95%.

Descottes B et al. Surg. Endosc. 2003.

Unai O et al. Clin Imaging. 2002.

Hemangioma-Management• Treatment is usually not indicated in the

setting of no symptoms with a firm diagnosis and confirmed stability on imaging at least 6 months apart. – Lesions less than 5 cm

• Larger lesions may require closer monitoring and if symptoms develop may need to treatment.

Blecker E et al. Z. Gastroenterol. 2003

Hemangioma-Management• Treatment options include– Surgery• Resection

– Hepatic irradiation or transarterial catheter chemoembolization

Case 2• 25 year old Hispanic female undergoing

work up for elevated liver function tests (LFTs).

• Noted to have multiple liver lesions on abdominal ultrasound, the largest measuring 13 cm in diameter.

• Follow up imaging including CT and MRI completed.

Case 2-Imaging• CT scan

Case 2-Imaging• MRI

Focal Nodular Hyperplasia (FNH)• Second most common liver tumor• Incidence is on the rise due to better

imaging.• Can occur in both men and women– 80-95% of cases seen in women, ratio 5:1

Bartolotta TV et al. La Radiologia Medica. 2013.

FNH-features• Class findings include:– Presence of a “central scar” on contrast

enhanced imaging– Present in about 1/3 of patients– Lesions typically become hyperdense during

arterial phase imaging.• Due to arterial origin of the blood supply

– Isodense during portal venous phase• Though central scar may be hyperdense

Bartolotta TV et al. La Radiologia Medica. 2013.

FNH-Diagnosis• Sulfur colloid scanning– Due to prevalence of Kupffer cells, 80% of FNHs

will show active uptake

FNH-Management• Typically conservative. • Typically stable lesions and do not change

over time• No evidence to suggest malignant

transformation• Enlargement and/or development in the

setting of OCP?

Case 3• 30 year old Caucasian female presents with

chronic abdominal pain.• Has been on oral contraception therapy for

5 years• Otherwise healthy, no significant medical

history.

Case 3

MRI

Hepatic adenoma• Uncommon lesions• Mostly in young women (22-40)• Commonly in the right lobe of the liver

Grazioli L. Radiographics. 2001

Hepatic adenoma• Strong association with:– Oral contraceptives and hormones– Anabolic steroids– Glycogen storage disease

• Less common association:– Pregnancy– Diabetes mellitus

Farges O. Gut. 2011

Hepatic adenoma• Prognosis not well established• There is an association with:– Malignant transformation– Spontaneous hemorrhage– Rupture

Hepatic adenoma-Diagnosis• Typically made clinically with imaging.• Biopsy of the lesion is not indicated or

recommended due to risk of bleeding.• Imaging techniques:– US-limited– CT and/or MRI

Hepatic adenoma-Diagnosis• CT: Well demarcated and have low

attenuation or are isodense on noncontrast imaging and show peripheral enhancement early with centipedal flow during portal venous.

• MRI: usually well demarcated and typically hyperintense on T1. Enhancement on T2 images that enhance further with gadolinium administration is highly suggestive.Grazioli L. Radiographics. 2001

Chung. KY AJR. 1995

Hepatic adenoma-Management• Dependent on size of lesion and symptoms• If asymptomatic and lesion is small (less

than 5 cm)– Stop OCP if taking– Can monitor with imaging and possibly AFP

• If symptomatic and/or lesion is large (greater than 5 cm)– Surgical resection is recommended.– Liver transplantation rare Dokmak S. et al. Gastroenterology.

2009

Case 4• 60 year old female presents to a local ER

with severe abdominal pain with a palpable mass on physical examination.

• No known history of liver disease or GI symptoms

Case 4

Hepatic cyst-Differential

Hepatic cyst-Prevalence• Dependent on origin– Simple:• More common in right lobe.• More in women, ratio of 1.5:1.• Distinction between simple and other types of cysts

is difficult to make but very important for management.

– Huge cysts found often in women over age 50.

Hepatic cyst-Diagnosis• Ultrasound:– Good at distinguishing between simple and other

cystic lesions

• CT scan:– Well demarcated lesion with no enhancement after

administration of IV contrast.

• MRI:– No enhancement with contrast. T1-weighted images

the cyst shows a low signal, whereas a very high intensity signal is shown on T2-weighted images.

Simple cyst Cystic echinococcosis

AlveolarEchinococcosis

CystadenomaAnd cystadenocarinoma

Border Sharp and smooth

Laminated Irregular Irregular

Shape Spherical or oval Round or oval Irregular Round or oval

Echo pattern Anechoic Anechoic or atypical

Hyperechogenic outer ring and hypoechogenic center

Hypoechogenic with hyperechogenic septations

Appearance No septa multiseptated multivesicular Septated and/or sold structures

Wall Strong posterior wall echoes

Wall enhancement

Posterior acoustic feature

Relative accentuation of echoes

Dorsal shadowing (calcified areas)

Doral shadowing (calcified areas)

Lantinga MA. 2013. World Journal of Gastro.

Hepatic cyst-Management• Symptoms and type of cyst drive the

management– Majority do not require intervention (if simple).– Would consider monitoring large cysts over 4

cm with interval imaging.– Minor and major surgical options available for

large cysts and/or symptoms

Hepatic cyst-Management• Interventions:– Needle aspiration (though associated with high

failure rate and rapid recurrence)– Deroofing– Liver resection– If infectious, treat appropriately.

Yasawry MI. World J Gastroenterol. 2011

Conclusion• Liver lesions are common and proper

diagnosis is important.• A combination of medical history as well as

appropriate imaging is essential.• Most liver lesions are benign but in certain

situations must be addressed or treated.

Thank you