Joon Koo Han, M.D. Department of Radiology

Seoul National University Hospital Seoul, Korea

True Incidence of Benign Liver Lesion: Unknown

French Statistics on Benign Liver Tumors ◦ Cyst and hemangiomas: most frequent ◦ FNH: 0.1% ◦ HCA: 0.03% (FNH:Adenoma = 3.3:1) ◦ M:F = 1:9 ◦ Obesity

Prevalance in Korea

How we manage in environment of high incidence

of HBV and HCV

Chronic Liver disease including Liver Cirrhosis: ◦ 8th cause of death in Korea in 2012 (13.5/100,000)

Liver cancer: ◦ 4th most common cancer (48.6/100,000) ◦ 2nd highest cancer mortality in Korean male in 2012

(33.7/100,000)

Lee SS et al. Clin Mol Hepatol 2012;18:309-315

M:F = 3.8:6.2 % (n=6,307)

Hemangioma 257 4.07

Cyst 166 2.63

Abscess 30 0.48

Eosinophilic Abscess (T. canis F. hepatica) 24 0.38

FNH and AML 15 0.24

Others 18 Calcification 16, peliosis 1, inflammatory pseudotumor 1

Lee SS et al. Clin Mol Hepatol 2012;18:309-315

No adenoma

Malignant Benign

HCC 422 TPL without HCC 23

CCC 72 IHD stone 11

HCC-CC 7 cyst 8

METS 154 ADPKD 7

EHD ca. 7 biliary cystadenoma 6

GB ca. 2 AML 4

angiosarcoma 1 IPMN 1 epithelioid hemangioendothelioma 1 FNH, biopsy only 1 Lympho-epithelioma like ca. 1 hemangioma, biopsy 1

NET 1 adenoma 1

Total 668 63

Very few adenoma Angiomyolipoma: major concern

8 cases (largest Korean HCA series in pathology) M:F = 4:4 ◦ HNF1α-mutated HA 3 (1:2) 35-40% ◦ β-Catenin mutated HA 1 (0:1) 10-15% ◦ Inflammatory HA 4 (3:1) >50% ◦ Unclassified HA 0

Few reported cases of HCA in Korea. ◦ Limited use of oral contraceptives in Korea due to Fear of side effects ◦ High prevalence of tubal ligation and vasectomy (1960~1980)

Kim H, Jang J, Kim D, Yeom BW, Won NH. Kor J Pathol 2013; 47: 411-417

* Paradis et al Gastroenterology 2004 * Bioulac-Sage et al Gastroenterology 2005 ; J Hepatol 2007

84 cases (1997-2009, single Korean center) ◦ M:F =39:45 (46.4%:53.6%) ◦ 77 FNH (HBV (+) in 2) ◦ 7 FNH like nodules: underlying LC (Budd-chiari 2, Cardiac LC 1)

◦ Surgical biopsy 28 (33.3%) ◦ Percutaneous biopsy 56 (66.7%) > 2 times: 7

◦ High-Low pattern in multiphasic CT: 10/78 (12.8%) Of 9 HBV or HCV (+), 3 were diagnosed as HCC by AASLD guideline

◦ Needle Bx: 6.5% (4/62) diagnosed as HCC

Choi JY, Lee HC, Yim JH et al. J Gastro Hepatol 2011;26:1004-1009

FNH: EOB uptake (+) ◦ > 95%

Adenoma: Usually not Malignant tumor: No EOB uptake

◦ Green HCC (5-10%): EOB uptake (+) : confusing

Hemangioma: No typical delayed enhancement ◦ Masked by strong parenchymal enhancement

Hyperintese HCCs more commonly show ◦ Focal defects in uptake ( 68.8 vs. 3.1%) ◦ Nodule in nodule appearance ( 75% vs. 0%) ◦ Internal septation (50% vs. 3.1%) ◦ Absence of a central scar (100% vs. 46.9%) ◦ Hypointense rim (75% vs. 15.6%)

Suh Y, et al. AJR 2011;197:W44-W52

Courtesy of Dr. Kim SH, SMC

30 sec 1 min 3 min 10 min 20 min Pre

Pre AP

PVP HBP

M/69 HBV (-)

liver mass found during Chest CT

69/M HBV(-)

2009-09 2012-10

2013-09 2013-09

?

Mild hypermetabolsm, SUV 3.0

Epithelioid AML

Korea: very low incidence of adenoma, M=F ◦ FNH / FNH like nodules: not so rare

MRI with hepatobiliary contrast agent: Helpful in differentiating Benign Hepatocellular masses from HCC (EOB uptake)

Benign hypervascular mass without EOB uptake (like AML) – diagnostic challenge