Liver Lesions With Hepatic Capsular Retraction

The Natural History and Management of Hepatic Hemangioma

BACKGROUND

Knowledge of the natural history and management of hepatic hemangiomas is lacking. The aim of this study was to investigate the natural history of hemangiomas and to elucidate the factors that determine tumor growth and optimal management.

METHODS

A total of 211 adult patients were enrolled, with follow-up for more than three years. Follow-up was performed with repeated ultrasonography (US) and laboratory tests for liver function and coagulation factors (platelets, prothrombin time (PT), fibrinogen, thrombin-antithrombin III complex (TAT), D-dimer, and fibrin and fibrinogen degradation products (FDP)).

RESULTS

Tumor size decreased in 38.9% of patients, showed no change in 31.3%, and increased in 29.8%. The incidence of a size increase was very high in patients under 40 years of age and decreased gradually with age, whereas the incidence of a size decrease increased with age and increased markedly over 60 years of age. The incidence of an increase in size decreased gradually with size enlargement, whereas the incidence of a decrease in size increased markedly with tumor size and further increased rapidly when hemangiomas became larger than 60 mm. Values of TAT, D-dimer, FDP, and Mac-2 binding protein glycosylation isomer (M2BPGi) were closely related to the change in size of hemangiomas.

CONCLUSIONS

Hemangiomas in older patients (>60 years of age) and larger tumors (>60 mm in size) had a tendency to decrease in size, resulting from the reduction in coagulation disorders and the progression of liver fibrosis. Therefore, the majority of patients with hemangiomas can be safely managed by clinical observation.

Liver Metastases: Correlation between Imaging Features and Pathomolecular Environments

A wide range of imaging manifestations of liver metastases can be encountered, as various primary cancers preferably metastasize to the liver (organ-specific metastases), with the imaging characteristics largely depending on various primary tumor-specific factors such as histopathologic category, degree of tumor differentiation, histologic behavior, and intratumor alterations. Characteristic imaging features potentially can help provide a more precise diagnosis in some clinical settings. These settings include those of (a) primary cancers of hollow organs such as gastrointestinal organs, the lungs, and the bladder, owing to the appearance of metastases that cannot be applied to the liver, which is a parenchymal organ; (b) unknown primary tumors; (c) more than one primary tumor; (d) another emergent malignancy; and (e) transformation to a different histopathologic tumor subtype. The characteristic features include the target sign on T2-weighted MR images or during the hepatobiliary phase of hypovascular metastasis, the peripheral rim washout sign on delayed phase images, peritumor hyperintensity during the hepatobiliary phase, hypervascular metastasis, a cystic appearance with marked hyperintensity on T2-weighted images, marked hyperintensity on T1-weighted images, calcification, capsular retraction, absence of the vessel-penetrating sign, distribution of liver metastases, and rare intraductal forms of metastases. In addition to various factors associated with the primary cancer, desmoplastic reactions around the tumor-which can be observed in adenocarcinomas with peripheral and peritumor enhancement, distinct arterioportal shunts with metastases from pancreatic ductal carcinoma, and pseudocirrhosis-also can affect these findings. The authors review the characteristic imaging findings of liver metastases from various primary cancers, with a focus on the mechanisms that underlie organ-specific liver metastases. Online supplemental material is available for this article. ^©RSNA, 2022.

Hepatic tuberculosis masquerading as malignancy

BACKGROUND AND AIMS

Hepatic tuberculosis (HTB) is rare and mimics neoplastic liver lesions clinico-radiologically leading to misdiagnosis and even unnecessary surgery.

METHODS AND MATERIAL

We analysed 43 cases of HTB diagnosed at a referral cancer centre over 10 years. Clinical details, investigations and treatment received were noted.

RESULTS

The median age was 46 years with a female preponderance (58%). HTB was diagnosed incidentally in 28% cases during surveillance imaging for a previous cancer. Constitutional symptoms (31, 72%), abdominal pain (25, 58%), fever (12, 28%), hepatomegaly (22, 51%), elevated alkaline phosphatase (34, 79%), elevated aminotransferases (18, 42%) and hypoalbuminemia (19, 45%) were common features. All cases had negative HIV serology and normal tumor markers. Twenty-two (52.5%) had solitary liver lesion and lesions > 2 cm in 28 (65%). Ultrasound showed hypoechoic lesions in 31 of 33 cases. Computed tomography showed hypodense lesions (43,100%) with mild peripheral enhancement (32, 74%). Calcifications (5, 12%) and capsular retraction (8, 19%) was uncommon. MRI was performed in seven cases commonly showed T1 hypointense, T2 hyperintense lesions with restricted diffusion. Histopathology showed granulomatous inflammation (42, 97.5%), Langhan's giant cells (41, 95%) and caseation necrosis (35, 85%). Acid-fast stain and PCR positivity was uncommon. Extrahepatic organs were involved in 20 (46.5%). HTB mimicked cholangiocarcinoma (25, 58%), liver metastasis (11, 26%) and lymphoma (3, 7%). Six patients underwent liver resection with a presumptive diagnosis of cancer without a preoperative biopsy. All patients received antitubercular therapy, 37 had clinico-radiological response, there were 3 deaths and 3 patients were lost to follow-up.

CONCLUSION

HTB is rare and can mimic a malignancy clinico-radiologically. Calcifications and pseudocapsule appearance on multiphase CT scan may help in differentiating HTB from hepatic malignancy. Tumor markers are normal while histopathology is generally diagnostic. A high index of suspicion is required to avoid unnecessary surgery as the patients respond well to ATT.

TRIAL REGISTRATION

This is a retrospective and observational study hence clinical trial registration is not applicable.

A case of focal confluent hepatic fibrosis in the patient with hepatitis C virus-related liver cirrhosis: a mimic of cholangiolocellular carcinoma

During routine ultrasound examination, a hyperechoic mass was detected in the anterior segment of the liver in an 80-year-old woman with hepatitis C virus-related cirrhosis. Computed tomography and magnetic resonance imaging findings suggested a malignant tumor with abundant fibrous stroma, similar to cholangiolocellular carcinoma. However, subsequent partial hepatectomy revealed a mass characterized by abundant fibrosis without tumor cells, dilated blood vessels, and marginal ductular reaction. Accordingly, focal confluent fibrosis was diagnosed. Generally, the diagnosis of focal confluent fibrosis is straightforward because of its well-established imaging characteristics. However, its differentiation from a malignant tumor can occasionally be difficult because of variation in presentation depending on the amount of fibrous stroma and the degree of inflammatory cell infiltration. In the present case, diagnosis was difficult because the lesion was more localized than usual, presenting a mass-like shape, and there was obvious hyperintensity on T2-weighted imaging and ring-shaped hyperintensity on diffusion-weighted imaging. Moreover, hepatic capsular retraction was indistinct, which can be one of the key findings of focal confluent fibrosis. When a hepatic mass is associated with a fibrous lesion, focal confluent fibrosis should be considered in the differential diagnosis, even though the lesion is associated with several atypical findings.

Causes of hepatic capsular retraction: a pictorial essay

Abstract

Hepatic capsular retraction refers to the loss of the normal convex hepatic contour, with the formation of an area of flattening or concavity. This can result from myriad causes, including intrinsic hepatic conditions such as cirrhosis, biliary obstruction, benign tumours, malignancy and infections, as well as extrahepatic causes such as trauma. This article aims to provide familiarity with this wide spectrum of conditions, including mimics of hepatic capsular retraction, by highlighting the anatomic, pathologic and imaging features that help distinguish these entities from one another.

Teaching Points

• Hepatic capsular retraction can occur due to various intrinsic or extrinsic hepatic causes.

• Hepatic capsular retraction is observed in both benign and malignant conditions.

• Recognising associated imaging features can help elicit causes of hepatic capsular retraction.

Diagnosis and management of intrahepatic cholangiocarcinoma: a comprehensive update for the radiologist

There is increasing focus on intrahepatic cholangiocarcinoma (IHCC) due to its rising incidence worldwide and relatively poor prognosis, with the revised TNM classification (2009) introducing a separate staging system for IHCC for the first time. In this article, we comprehensively review the current role of the radiologist in the diagnosis and management of patients with IHCC.

Magnetic resonance imaging in cirrhosis: what's new?

Cirrhosis is the main risk factor for the development of hepatocellular carcinoma (HCC). The major causative factors of cirrhosis in the United States and Europe are chronic hepatitis C infection and excessive alcohol consumption with nonalcoholic steatohepatitis emerging as another important risk factor. Magnetic resonance imaging is the most sensitive imaging technique for the diagnosis of HCC, and the sensitivity can be further improved with the use of diffusion-weighted imaging and hepatocyte-specific contrast agents. The combination of arterial phase hyperenhancement, venous or delayed phase hypointensity "washout feature," and capsular enhancement are features highly specific for HCC with reported specificities of 96% and higher. When these features are present in a mass in the cirrhotic liver, confirmatory biopsy to establish the diagnosis of HCC is not necessary. Other tumors, such as cholangiocarcinoma, sometimes occur in the cirrhotic at a much lower rate than HCC and can mimic HCC, as do other benign lesions such as perfusion abnormalities. In this article, we discuss the imaging features of cirrhosis and HCC, the role of magnetic resonance imaging in the diagnosis of HCC and other benign and malignant lesions that occur in the cirrhotic liver, and the issue of nonspecific arterially hyperenhancing nodules often seen in cirrhosis.

Contrast enhanced liver MRI in patients with primary sclerosing cholangitis: inverse appearance of focal confluent fibrosis on delayed phase MR images with hepatocyte specific versus extracellular gadolinium based contrast agents

RATIONALE AND OBJECTIVES

To assess the enhancement pattern of focal confluent fibrosis (FCF) on contrast-enhanced hepatic magnetic resonance imaging (MRI) using hepatocyte-specific (Gd-EOB-DTPA) and extracellular (ECA) gadolinium-based contrast agents in patients with primary sclerosing cholangitis (PSC).

MATERIALS AND METHODS

After institutional review board approval, 10 patients with PSC (6 male, 4 female; 33-61 years) with 13 FCF were included in this retrospective study. All patients had a Gd-EOB-DTPA-enhanced liver MRI exam, and a comparison ECA-enhanced MRI. On each T1-weighted dynamic dataset, the signal intensity (SI) of FCF and the surrounding liver as well as the paraspinal muscle (M) were measured. In the Gd-EOB-DTPA group, hepatocyte phase images were also included. SI FCF/SI M, SI liver/SI M, and [(SI liver - SI FCF)/SI liver] were compared between the different contrast agents for each dynamic phase using the paired Student's t-test.

RESULTS

There was no significant difference in SI FCF/SI M in all imaging phases. SI liver/SI M was significantly higher for the Gd-EOB-DTPA group in the delayed phase (P < .001), whereas there was no significant difference in all other imaging phases. In the Gd-EOB-DTPA group, mean [(SI liver - SI FCF)/SI liver] were as follows (values for ECA group in parentheses): unenhanced phase: 0.26 (0.26); arterial phase: 0.01 (-0.31); portal venous phase (PVP): -0.05 (-0.26); delayed phase (DP): 0.14 (-0.54); and hepatocyte phase: 0.26. Differences were significant for the DP (P < .001).

CONCLUSIONS

On delayed phase MR images the FCF-to-liver contrast is reversed with the lesions appearing hyperintense on ECA enhanced images and hypointense on Gd-EOB-DTPA-enhanced images.