1. Incidentolomas - Evaluation and Management of Incidental Liver Lesions
Patrick M. Horne, MSN, ARNP, FNP-BC
Assistant Director of Hepatology Clinical Research
Division of Gastroenterology, Hepatology and Nutrition
University of Florida Health

2. Disclosures
Financial relationships to disclose within the past 12 months:
Grant support with Bayer/Onyx

3. Objectives Discuss natural history of benign liver lesions.
Discuss Evaluation and management of FNH, Hemangioma, Liver Cyst, Adenoma

4. 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.

5. 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

6. 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

7. Case 1
Persistent enhancement throughout imaging phases

8. Hemangioma Most common benign hepatic tumor
60-80% diagnosed in people between the ages of
Ratio of occurrence in women to men, 3:1.
More common in young women
Choi BY & Nguyen MH. J Clin Gastroenterol

9. 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
Unai O et al. Clin Imaging

10. 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

11. Hemangioma-Management
Treatment options include
Surgery
Resection
Hepatic irradiation or transarterial catheter chemoembolization

12. 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.

13. Case 2-Imaging
CT scan

14. Case 2-Imaging
MRI

15. 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

16. 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

17. FNH-Diagnosis Sulfur colloid scanning
Due to prevalence of Kupffer cells, 80% of FNHs will show active uptake

18. 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?

19. 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.

20. Case 3
MRI

21. Hepatic adenoma Uncommon lesions Mostly in young women (22-40)
Commonly in the right lobe of the liver
Grazioli L. Radiographics

22. Hepatic adenoma Strong association with: Less common association:
Oral contraceptives and hormones
Anabolic steroids
Glycogen storage disease
Less common association:
Pregnancy
Diabetes mellitus

23. Farges O. Gut

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

25. 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

26. 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
Chung. KY AJR

27. 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

28. 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

29. Case 4

30. Hepatic cyst-Differential

31. 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.

32. 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.

33. Simple cyst
Cystic echinococcosis
Alveolar
Echinococcosis
Cystadenoma
And cystadenocarinoma
Border
Sharp and smooth
Laminated
Irregular
Shape
Spherical or oval
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 World Journal of Gastro.

34. 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

35. 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

36. 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.

37. Thank you