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Solid liver lesions: Differential diagnosis and evaluation

INTRODUCTION

The differential diagnosis of solid liver lesions is broad, but many can be diagnosed noninvasively. In some cases, predominantly solid liver lesions may have cystic components, as may be seen with hemangiomas or tumors that have areas that are necrotic. Conversely, predominantly cystic liver lesions may have solid areas, particularly in the setting malignancy.

This topic will review the differential diagnosis of solid liver lesions, outline an approach to their evaluation, and discuss the radiographic findings associated with common solid liver lesions. The approach to patients with cystic liver lesions and liver abscesses are discussed elsewhere. (See "Diagnosis and management of cystic lesions of the liver" and "Pyogenic liver abscess" and "Extraintestinal Entamoeba histolytica amebiasis", section on 'Amebic liver abscess'.)

DIFFERENTIAL DIAGNOSIS

There are numerous causes of solid liver lesions, both benign and malignant. It is important to establish a correct diagnosis, especially when the potential for therapy exists. The diagnosis requires consideration of the clinical history, risk factors, laboratory test findings, imaging studies, and in some cases, pathologic examination of the lesion. (See 'Diagnostic approach' below.)

While most of these lesions present as solitary masses, multiple lesions may be seen in patients with hepatic hemangiomas, idiopathic noncirrhotic portal hypertension, regenerative nodules, hepatocellular carcinoma, and metastatic disease.

Common benign liver lesions include [1]:

                       

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Literature review current through: Jul 2014. | This topic last updated: Apr 2, 2014.
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References
Top
  1. Bonder A, Afdhal N. Evaluation of liver lesions. Clin Liver Dis 2012; 16:271.
  2. Uchimura K, Nakamuta M, Osoegawa M, et al. Hepatic epithelioid hemangioendothelioma. J Clin Gastroenterol 2001; 32:431.
  3. Emile JF, Azoulay D, Gornet JM, et al. Primary non-Hodgkin's lymphomas of the liver with nodular and diffuse infiltration patterns have different prognoses. Ann Oncol 2001; 12:1005.
  4. Page RD, Romaguera JE, Osborne B, et al. Primary hepatic lymphoma: favorable outcome after combination chemotherapy. Cancer 2001; 92:2023.
  5. Rougemont AL, McLin VA, Toso C, Wildhaber BE. Adult hepatoblastoma: learning from children. J Hepatol 2012; 56:1392.
  6. Farges O, Daradkeh S, Bismuth H. Cavernous hemangiomas of the liver: are there any indications for resection? World J Surg 1995; 19:19.
  7. Gandolfi L, Leo P, Solmi L, et al. Natural history of hepatic haemangiomas: clinical and ultrasound study. Gut 1991; 32:677.
  8. Grieco MB, Miscall BG. Giant hemangiomas of the liver. Surg Gynecol Obstet 1978; 147:783.
  9. Wanless IR, Mawdsley C, Adams R. On the pathogenesis of focal nodular hyperplasia of the liver. Hepatology 1985; 5:1194.
  10. Kerlin P, Davis GL, McGill DB, et al. Hepatic adenoma and focal nodular hyperplasia: clinical, pathologic, and radiologic features. Gastroenterology 1983; 84:994.
  11. Mathieu D, Kobeiter H, Maison P, et al. Oral contraceptive use and focal nodular hyperplasia of the liver. Gastroenterology 2000; 118:560.
  12. Saul SH. Masses of the liver. In: Diagnostic Surgical Pathology, 3rd ed, Sternberg SS (Ed), Lippincott Williams & Wilkins, Philadelphia 1999. p.1553.
  13. Rooks JB, Ory HW, Ishak KG, et al. Epidemiology of hepatocellular adenoma. The role of oral contraceptive use. JAMA 1979; 242:644.
  14. Edmondson HA, Henderson B, Benton B. Liver-cell adenomas associated with use of oral contraceptives. N Engl J Med 1976; 294:470.
  15. Grossman H, Ram PC, Coleman RA, et al. Hepatic ultrasonography in type I glycogen storage disease (von Gierke disease). Detection of hepatic adenoma and carcinoma. Radiology 1981; 141:753.
  16. Furuya K, Nakamura M, Yamamoto Y, et al. Macroregenerative nodule of the liver. A clinicopathologic study of 345 autopsy cases of chronic liver disease. Cancer 1988; 61:99.
  17. Kew MC. Tumors of the liver. In: Hepatology: A Textbook of Liver Disease, 3rd ed, Zakim D, Boyer T (Eds), WB Saunders, Philadelphia 1996. p.1513.
  18. Paley MR, Ros PR. Hepatic metastases. Radiol Clin North Am 1998; 36:349.
  19. Reddy KR, Schiff ER. Approach to a liver mass. Semin Liver Dis 1993; 13:423.
  20. Torzilli G, Minagawa M, Takayama T, et al. Accurate preoperative evaluation of liver mass lesions without fine-needle biopsy. Hepatology 1999; 30:889.
  21. Bruix J, Sherman M, American Association for the Study of Liver Diseases. Management of hepatocellular carcinoma: an update. Hepatology 2011; 53:1020.
  22. Schwartz LH, Gandras EJ, Colangelo SM, et al. Prevalence and importance of small hepatic lesions found at CT in patients with cancer. Radiology 1999; 210:71.
  23. Hagspiel KD, Neidl KF, Eichenberger AC, et al. Detection of liver metastases: comparison of superparamagnetic iron oxide-enhanced and unenhanced MR imaging at 1.5 T with dynamic CT, intraoperative US, and percutaneous US. Radiology 1995; 196:471.
  24. Robinson PJ. Imaging liver metastases: current limitations and future prospects. Br J Radiol 2000; 73:234.
  25. Kruskal JB, Kane RA. Intraoperative ultrasonography of the liver. Crit Rev Diagn Imaging 1995; 36:175.
  26. Borzio M, Borzio F, Macchi R, et al. The evaluation of fine-needle procedures for the diagnosis of focal liver lesions in cirrhosis. J Hepatol 1994; 20:117.
  27. Fornari F, Filice C, Rapaccini GL, et al. Small (< or = 3 cm) hepatic lesions. Results of sonographically guided fine-needle biopsy in 385 patients. Dig Dis Sci 1994; 39:2267.
  28. Limberg B, Höpker WW, Kommerell B. Histologic differential diagnosis of focal liver lesions by ultrasonically guided fine needle biopsy. Gut 1987; 28:237.
  29. Yu SC, Lau WY, Leung WT, et al. Percutaneous biopsy of small hepatic lesions using an 18 gauge automated needle. Br J Radiol 1998; 71:621.
  30. Tsou MH, Lin YM, Lin KJ, et al. Fine needle aspiration cytodiagnosis of liver tumors. Results obtained with Riu's stain. Acta Cytol 1998; 42:1359.
  31. Evans GH, Harries SA, Hobbs KE. Safety of and necessity for needle biopsy of liver tumours. Lancet 1987; 1:620.
  32. Navarro F, Taourel P, Michel J, et al. Diaphragmatic and subcutaneous seeding of hepatocellular carcinoma following fine-needle aspiration biopsy. Liver 1998; 18:251.
  33. Takamori R, Wong LL, Dang C, Wong L. Needle-tract implantation from hepatocellular cancer: is needle biopsy of the liver always necessary? Liver Transpl 2000; 6:67.
  34. Durand F, Regimbeau JM, Belghiti J, et al. Assessment of the benefits and risks of percutaneous biopsy before surgical resection of hepatocellular carcinoma. J Hepatol 2001; 35:254.
  35. Silva MA, Hegab B, Hyde C, et al. Needle track seeding following biopsy of liver lesions in the diagnosis of hepatocellular cancer: a systematic review and meta-analysis. Gut 2008; 57:1592.
  36. Nicolau C, Brú C. Focal liver lesions: evaluation with contrast-enhanced ultrasonography. Abdom Imaging 2004; 29:348.
  37. Assy N, Nasser G, Djibre A, et al. Characteristics of common solid liver lesions and recommendations for diagnostic workup. World J Gastroenterol 2009; 15:3217.
  38. Ohnishi K, Nomura F. Ultrasonic Doppler studies of hepatocellular carcinoma and comparison with other hepatic focal lesions. Gastroenterology 1989; 97:1489.
  39. Perkins AB, Imam K, Smith WJ, Cronan JJ. Color and power Doppler sonography of liver hemangiomas: a dream unfulfilled? J Clin Ultrasound 2000; 28:159.
  40. Yasuhara K, Kimura K, Ohto M, et al. Pulsed Doppler in the diagnosis of small liver tumours. Br J Radiol 1988; 61:898.
  41. Tanaka S, Kitamura T, Fujita M, et al. Color Doppler flow imaging of liver tumors. AJR Am J Roentgenol 1990; 154:509.
  42. Cherqui D, Rahmouni A, Charlotte F, et al. Management of focal nodular hyperplasia and hepatocellular adenoma in young women: a series of 41 patients with clinical, radiological, and pathological correlations. Hepatology 1995; 22:1674.
  43. Shamsi K, De Schepper A, Degryse H, Deckers F. Focal nodular hyperplasia of the liver: radiologic findings. Abdom Imaging 1993; 18:32.
  44. Bartolozzi C, Lencioni R, Paolicchi A, et al. Differentiation of hepatocellular adenoma and focal nodular hyperplasia of the liver: comparison of power Doppler imaging and conventional color Doppler sonography. Eur Radiol 1997; 7:1410.
  45. Wang LY, Wang JH, Lin ZY, et al. Hepatic focal nodular hyperplasia: findings on color Doppler ultrasound. Abdom Imaging 1997; 22:178.
  46. Sandler MA, Petrocelli RD, Marks DS, Lopez R. Ultrasonic features and radionuclide correlation in liver cell adenoma and focal nodular hyperlasia. Radiology 1980; 135:393.
  47. Ishiguchi T, Shimamoto K, Fukatsu H, et al. Radiologic diagnosis of hepatocellular carcinoma. Semin Surg Oncol 1996; 12:164.
  48. Colli A, Cocciolo M, Mumoli N, et al. Peripheral intrahepatic cholangiocarcinoma: ultrasound findings and differential diagnosis from hepatocellular carcinoma. Eur J Ultrasound 1998; 7:93.
  49. Choi BI, Lee JM, Han JK. Imaging of intrahepatic and hilar cholangiocarcinoma. Abdom Imaging 2004; 29:548.
  50. Sheiner PA, Brower ST. Treatment of metastatic cancer to the liver. Semin Liver Dis 1994; 14:169.
  51. Yamashita Y, Ogata I, Urata J, Takahashi M. Cavernous hemangioma of the liver: pathologic correlation with dynamic CT findings. Radiology 1997; 203:121.
  52. Mergo PJ, Ros PR. Benign Lesions of the Liver. In: The Radiologic Clinics of North America, 2, W.B. Saunders, Philadelphia 1998. Vol 36, p.319.
  53. Carlson SK, Johnson CD, Bender CE, Welch TJ. CT of focal nodular hyperplasia of the liver. AJR Am J Roentgenol 2000; 174:705.
  54. Welch TJ, Sheedy PF 2nd, Johnson CM, et al. Focal nodular hyperplasia and hepatic adenoma: comparison of angiography, CT, US, and scintigraphy. Radiology 1985; 156:593.
  55. Grattagliano A, Rapaccini GL, Caturelli E, et al. Nodular regenerative hyperplasia of the liver: ultrasonographic appearance and echo-guided bioptic diagnosis. Ital J Gastroenterol 1994; 26:349.
  56. Mahamid J, Miselevich I, Attias D, et al. Nodular regenerative hyperplasia associated with idiopathic thrombocytopenic purpura in a young girl: a case report and review of the literature. J Pediatr Gastroenterol Nutr 2005; 41:251.
  57. Marin D, Furlan A, Federle MP, et al. Imaging approach for evaluation of focal liver lesions. Clin Gastroenterol Hepatol 2009; 7:624.
  58. Ros PR, Davis GL. The incidental focal liver lesion: photon, proton, or needle? Hepatology 1998; 27:1183.
  59. Mahfouz AE, Hamm B, Mathieu D. Imaging of metastases to the liver. Eur Radiol 1996; 6:607.
  60. Semelka RC, Schlund JF, Molina PL, et al. Malignant liver lesions: comparison of spiral CT arterial portography and MR imaging for diagnostic accuracy, cost, and effect on patient management. J Magn Reson Imaging 1996; 6:39.
  61. Ferrucci JT. Liver tumor imaging: current concepts. AJR Am J Roentgenol 1990; 155:473.
  62. Grazioli L, Bondioni MP, Haradome H, et al. Hepatocellular adenoma and focal nodular hyperplasia: value of gadoxetic acid-enhanced MR imaging in differential diagnosis. Radiology 2012; 262:520.
  63. Grazioli L, Morana G, Kirchin MA, Schneider G. Accurate differentiation of focal nodular hyperplasia from hepatic adenoma at gadobenate dimeglumine-enhanced MR imaging: prospective study. Radiology 2005; 236:166.
  64. Zech CJ, Herrmann KA, Reiser MF, Schoenberg SO. MR imaging in patients with suspected liver metastases: value of liver-specific contrast agent Gd-EOB-DTPA. Magn Reson Med Sci 2007; 6:43.
  65. Van Beers BE, Pastor CM, Hussain HK. Primovist, Eovist: what to expect? J Hepatol 2012; 57:421.
  66. McFarland EG, Mayo-Smith WW, Saini S, et al. Hepatic hemangiomas and malignant tumors: improved differentiation with heavily T2-weighted conventional spin-echo MR imaging. Radiology 1994; 193:43.
  67. Goshima S, Kanematsu M, Kondo H, et al. Hepatic hemangioma: correlation of enhancement types with diffusion-weighted MR findings and apparent diffusion coefficients. Eur J Radiol 2009; 70:325.
  68. Semelka RC, Brown ED, Ascher SM, et al. Hepatic hemangiomas: a multi-institutional study of appearance on T2-weighted and serial gadolinium-enhanced gradient-echo MR images. Radiology 1994; 192:401.
  69. Kim T, Federle MP, Baron RL, et al. Discrimination of small hepatic hemangiomas from hypervascular malignant tumors smaller than 3 cm with three-phase helical CT. Radiology 2001; 219:699.
  70. Mattison GR, Glazer GM, Quint LE, et al. MR imaging of hepatic focal nodular hyperplasia: characterization and distinction from primary malignant hepatic tumors. AJR Am J Roentgenol 1987; 148:711.
  71. Buetow PC, Pantongrag-Brown L, Buck JL, et al. Focal nodular hyperplasia of the liver: radiologic-pathologic correlation. Radiographics 1996; 16:369.
  72. Irie H, Honda H, Kaneko K, et al. MR imaging of focal nodular hyperplasia of the liver: value of contrast-enhanced dynamic study. Radiat Med 1997; 15:29.
  73. Mahfouz AE, Hamm B, Taupitz M, Wolf KJ. Hypervascular liver lesions: differentiation of focal nodular hyperplasia from malignant tumors with dynamic gadolinium-enhanced MR imaging. Radiology 1993; 186:133.
  74. Mathieu D, Rahmouni A, Anglade MC, et al. Focal nodular hyperplasia of the liver: assessment with contrast-enhanced TurboFLASH MR imaging. Radiology 1991; 180:25.
  75. Rummeny E, Weissleder R, Sironi S, et al. Central scars in primary liver tumors: MR features, specificity, and pathologic correlation. Radiology 1989; 171:323.
  76. Paley MR, Ros PR. MR imaging of the liver--a practical approach. Magn Reson Imaging Clin N Am 1997; 5:415.
  77. Chung KY, Mayo-Smith WW, Saini S, et al. Hepatocellular adenoma: MR imaging features with pathologic correlation. AJR Am J Roentgenol 1995; 165:303.
  78. Outwater EK, Blasbalg R, Siegelman ES, Vala M. Detection of lipid in abdominal tissues with opposed-phase gradient-echo images at 1.5 T: techniques and diagnostic importance. Radiographics 1998; 18:1465.
  79. Manfredi R, Barbaro B, Masselli G, et al. Magnetic resonance imaging of cholangiocarcinoma. Semin Liver Dis 2004; 24:155.
  80. Drane WE, Krasicky GA, Johnson DA. Radionuclide imaging of primary tumors and tumor-like conditions of the liver. Clin Nucl Med 1987; 12:569.
  81. Rogers JV, Mack LA, Freeny PC, et al. Hepatic focal nodular hyperplasia: angiography, CT, sonography, and scintigraphy. AJR Am J Roentgenol 1981; 137:983.
  82. Boulahdour H, Cherqui D, Charlotte F, et al. The hot spot hepatobiliary scan in focal nodular hyperplasia. J Nucl Med 1993; 34:2105.
  83. Tamm EP, Rabushka LS, Fishman EK, et al. Intrahepatic, extramedullary hematopoiesis mimicking hemangioma on technetium-99m red blood cell SPECT examination. Clin Imaging 1995; 19:88.
  84. Isla C, Ceballos C, Córdoba E, et al. Cavernous hemangioma of the liver. Diagnostic value of 99mTc-labeled red cell scintigraphy: results in 28 patients. Rev Esp Enferm Dig 1997; 89:29.
  85. Moinuddin M, Allison JR, Montgomery JH, et al. Scintigraphic diagnosis of hepatic hemangioma: its role in the management of hepatic mass lesions. AJR Am J Roentgenol 1985; 145:223.
  86. Farlow DC, Chapman PR, Gruenewald SM, et al. Investigation of focal hepatic lesions: is tomographic red blood cell imaging useful? World J Surg 1990; 14:463.
  87. Salvatori M, Meduri G, Manfredi R, et al. [A false negative scintigram in hepatic cavernous hemangioma with extensive thrombotic fibrosis. A case report]. Radiol Med 1994; 88:337.
  88. el-Desouki M, Mohamadiyeh M, al-Rashed R, et al. Features of hepatic cavernous hemangioma on planar and SPECT Tc-99m-labeled red blood cell scintigraphy. Clin Nucl Med 1999; 24:583.