Tchelepi H. Ralls PW. Ultrasound Quarterly. 20(4):155-69, 2004 Dec. Journal Reading Ultrasound of Focal Liver Masses-Image Finding in Common Liver Lesions Int 許致博 Tchelepi H. Ralls PW. Ultrasound Quarterly. 20(4):155-69, 2004 Dec.

Outline Simple hepatic cysts Carvenous hemangioma Hepatic metastasis Hepatocellular carcinoma Cholangiocarcinoma Liver abscess Focal nodular hyperplasia / liver cell adenoma

Simple hepatic cysts Male : Female = 1 : 4 Frequency increases with age < 60 y/o  < 1% of pt > 60 y/o  3% ~ 7% S/S: rare. May occur from mass effect, rupture, hemorrhage, infection Gaines PA, Sampson MA. The prevalence and characterization of simple hepatic cysts by ultrasound examination. Br J Radiol. 1988;62:335–337.

Simple hepatic cysts A cyst is found in a young pt: Polycystic liver disease Autosomal dominant polycystic kidney disease von Hippel-Lindqu disease Other: echinococcal disease, residua from inflammatory disease, cystic neoplasia

Sonographic appearances Well defined, thin epithelial lining and imperceptible wall Watery fluid, echo-free lesion Distal sonic enhancement Usually solitary Round or oval Size from < 1 cm to > 20 cm

Simple hepatic cysts Sonography: the best tool, better than CT Rarely simulate clinically significant lesions  require no further evaluation Polycystic disease: different from simple hepatic cysts: more irregular and more often internal debris Thick septations or solid component: biliary cystadenomas Equivocal : biopsy

Polycystic disease Debris (+) Multiple Irregular Septation (+)

Biliary cystadenoma Irregular Thicker septations

Cavernous hemangioma Commonest benign hepatic neoplasm: 1~4% of individuals Female > Male S/S: Rare. Mass effect may occur Rupture with hemorrhage and thrombocytopenia has been reported

Sonographic appearances Small hemangioma Echogenic Well-defined Distal sonic enhancement

Sonographic appearances Large hemangiomas Thrombosis, necrosis: mixed echogenicity or even hypoechoic Circumferential echogenic rim contifuous to normal liver  strongly suggestive of hemangioma Moody AR, Wilson SR. Atypical hepatic hemangioma: a suggestive sonographic morphology. Radiology. 1993;188:413–417.

Delay-phase CT Incomplete filling Well-defined echogenic rim Hypoechoic Well-defined echogenic rim

Sonographic appearances Color Doppler: internal flow is in common. Hypervascularity is rare  Need further evaluation  MR + c or CT + c Internal flow is more common in larger lesions

Further evaluation Typical hemangioma usually do not require further evaluation Atypical hemangiomas may require further evaluation  especially in pt with known malignancy Biopsy may be necessary

Hepatic metastasis In the U.S.: Incidence: 18~20 times than HCC Produce S/S: 10 times than HCC In a autopsy series, 38% of pt with ca had hepatic metastases Most common ca include: lung, colon, pancrease, breast, stomach Edmonson HA, Craig JR. Neoplasms of the liver. In: Shiff L, Shiff ER, (eds). Diseases of the Liver. 5th ed. Philadelphia:Lippincott;1987:1147.

Sonographic appearances 90% of pt: multifocal Any appearance may occur Usually inhomogeneous A target or bull’s eye with varying rings of hypo- and hyperechogenicity are common Ill-defined infiltrative dz with focal nodularity Simulate simple cysts or classic hemagiomata: uncommon

Sonographic appearances Liver meta from pancreatic ca Predominantly hypoechoid Liver meta from colon ca Halo appearance: bull’s eye sign

Where is the primary ca? Sonographic appearance is a poor predictor Unlike simple cyst  irregular wall Cystic lesion  SCC or GIST (liver meta from esophageal ca) Sonographic appearance is a poor predictor Certain patterns may be suggest: Necrotic metastases: SCC and sarcomas (especially GIST) Cystic lesions: SCC Lesions with fluid-fluid levels: GIST (leiomyosarcoma) Large to moderate-sized hyperechoic with microcalcifications: colonic primary

Hepatocellular carcinoma Commonest primary liver cancer: 80% primary liver malignancies in the U.S. Less common than hepatic metastases Associated with HBV and HCV. HCV > HBV 85% of pt with HCC: cirrhosis or pre-cirrhotic conditions Alcoholic cirrhosis related HCC: 10% of autopsied pt Sonar is a part of screening for HCC

Sonographic appearances Findings are variable for advanced HCC Small HCCs (< 5 cm): 75% hypoechoic As HCCs enlarge: hypoechoic peripheral rims Further progression: numerous and heterogeneous HCCs present clinically: usually multifocal Screen situation: usually small lesions

Sonographic appearances Some HCC (even small): fatty metamorphosis  ↑echogenicity Vascular invasion is common: portal vein > hepatic vein Bile duct obstruction: extrinsic compression > duct invasion HCC 3 x 1.5 cm Hypoechoid Internal flow

HCC arising in normal liver HCCs arise in normal liver: uncommon Occur at a younger age Single, well circumscribed lesions, lobulated margins, fibrolamellar HCCs 2% of HCC 25% ~ 50% HCC in young adults Echogenicity: variable Central scar: nonspecific High prevalence of calcification: also common in all varieties of HCC (20 ~ 25%) HCC with center scar

Hepatic metastasis and HCC May be impossible to distinguish Distinguish from lab data Underlying liver dz favors HCC Invasion of the portal or hepatic veins favors HCC  < 5% of pt with portal venous invasion occur in metastatic dz Biopsy

Cholangiocarcinoma Arise from the bile ducts 10% of all primary liver cancers Peripheral (PCC) and hilar (Klatskin tumor) PCC is 3 times > hilar cholangiocarcinoma in the U.S. PCC is usually a large tumor

Cholangiocarcinoma Hilar cholangiocarcinoma: early ductal obstruction Associated with: Hemochromatosis Ulcerative colitis Caroli disease Choledochal cyst Hemochromatosis: 9% of PCC and 18% of hilar cholangiocarcinoma

Cholangiocarcinoma Hard to visualized with all modalities Sonography is superior to multiphase helical CT about hilar cholangiocarcinoma Sonographic findings are variable: Hypoechoid? Hyperechoid? Author: slightly hypoechoic lesions are more frequent Cholangiocarcinoma Invade left protal vein

Liver abscess Incidence: worldwide, pyogenic liver abscess < amebic liver abscess In U.S. Pyogenic > amebic.

Pyogenic liver abscess Mild and vague S/S Pyogenic: usually as a complication of other condition (ex immunocompromised, older pt, cholecystitis, bile duct obstruction, trauma, surgery) E. coli is most common Polymicrobial infections are common: 50% of pt

Sonographic appearances Typical appearance: Poorly defined Irregularly marginated Hypoechoid Irregular areas of increased echogenicity are frequent Gas present. Diffusely hyperechoic appearance may be noted due to large amounts of gas Variable sonographic appearance Clusters of small lesions: “cholangitic” abscesses Usually can’t D/D with tumor necrosis

Fluid-debris level Solid –appearing mass R/O malignancy Hyperechoic region in the center  Air bubble

Pyogenic liver abscess Tx: percutaneous image-guided abscess drainage better than surgery Multiloculated abscess also can be drained with one catheter

Amebic liver abscess Provoking S/S High-risk populations: Young Hispanic males HIV-positive pt

Sonographic appearances Hypoechoic appearance with fine, homogenous, low-level echoes throughout Tend to well-defined than pyogenic abscess Tend to have a round or oval shape Difficult to D/D

Amebic liver abscess Tend to be more well-defined ???

Initially, multiseptate fluid collection 2 weeks later after treatment Decrease size Development of a thick wall 3 months later after treatment

Pyogenic v.s. amebic abscesses Confusion  aspiration for D/D Percutaneous driagnostic aspiration: 15% of amebic abscess pt Percutaneous drainage of amebic liver abscess is not indicated

Focal nodular hyperplasia (FNH) Liver cell adenoma (LCA) Rare benign liver tumors Unknown cause LCA is associated with oral contraceptives Other factors associated with LCA: glycogen storage dz, androgen administration, tyrosinemia, galactosemia, diabetes, cirrhosis FNH v.s. oral contraceptives: controversial Male < Female S/S FNH is a clinically insignificant lesion LCA can cause morbidity and mortality related to hemorrhage or malignant change A focal lesion may show both FNH and LCA

Sonographic appearances FNH: Echogenicity close to normal liver High flow Central scar: also seen in other lesions Lesions present high flow: Focal nodular hyperplasia HCC Metastatic lesions

Focal nodular hyperplasia Echogenicity close to normal liver High flow Stellate area of low density typical of focal nodular hyperplasia

Sonographic appearances Similar to FNH Variable appearance. If bleeding  hypoechoid (if old) or hyperechoid Usually solitary, marginated, encapsulate mass

Liver cell adenoma Focal nodular hyperplasia

Sonographic appearances FNH: More homogeneous LCA: More inhomogeneous Usually hypoechoic D/D Technetium sulfur colloid liver spleen scanning FNH: liver exhibits normal or increased uptake

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