A comparative study of contrast enhanced ultrasound and contrast enhanced magnetic resonance imaging for the detection and characterization of hepatic hemangiomas

ACG Clinical Guideline: Focal Liver Lesions

Focal liver lesions (FLLs) have become an increasingly common finding on abdominal imaging, especially asymptomatic and incidental liver lesions. Gastroenterologists and hepatologists often see these patients in consultation and make recommendations for management of multiple types of liver lesions, including hepatocellular adenoma, focal nodular hyperplasia, hemangioma, and hepatic cystic lesions including polycystic liver disease. Malignancy is important to consider in the differential diagnosis of FLLs, and healthcare providers must be familiar with the diagnosis and management of FLLs. This American College of Gastroenterology practice guideline uses the best evidence available to make diagnosis and management recommendations for the most common FLLs.

Benign liver lesions 2022: Guideline for clinical practice of Associazione Italiana Studio del Fegato (AISF), Società Italiana di Radiologia Medica e Interventistica (SIRM), Società Italiana di Chirurgia (SIC), Società Italiana di Ultrasonologia in Medicina e Biologia (SIUMB), Associazione Italiana di Chirurgia Epatobilio-Pancreatica (AICEP), Società Italiana Trapianti d'Organo (SITO), Società Italiana di Anatomia Patologica e Citologia Diagnostica (SIAPEC-IAP) - Part I - Cystic lesions

Benign liver lesions are increasingly diagnosed in daily clinical practice due to the growing use of imaging techniques for the study of the abdomen in patients who have non-specific symptoms and do not have an increased risk of hepatic malignancy. They include simple or parasitic cysts and solid benign tumors which differ widely in terms of prevalence, clinical relevance, symptoms and natural history and often lead to significant clinical problems relating to diagnosis and clinical management. Following the need to have updated guidelines on the management of benign focal liver lesions, the Scientific Societies mainly involved in their management have promoted the drafting of a new dedicated document. This document was drawn up according to the present Italian rules and methodologies necessary to produce clinical, diagnostic, and therapeutic guidelines based on evidence. Here we present the first part of the guideline, concerning the characterization of focal hepatic lesions detected by ultrasound, and the diagnosis and clinical management of simple and parasitic hepatic cysts, and of polycystic liver disease.

When Benign Behaves Badly: Atypical Hemangiomas on Contrast-Enhanced Ultrasonography

ABSTRACT

Hemangioma is the most common benign liver tumor and is frequently encountered as an incidental finding on imaging. The classic enhancement pattern of hemangioma is diagnostic on contrast-enhanced ultrasound (CEUS), and it follows the same pattern of enhancement on computed tomography and magnetic resonance imaging. However, there is a subset of hemangiomas that demonstrate atypical enhancement patterns on CEUS. The ability to recognize the different enhancement patterns and discern when additional imaging or biopsy may be necessary is essential to accurately interpret an atypical hemangioma on CEUS. This article reviews various enhancement patterns of hemangioma on CEUS to avoid pitfalls in characterization of focal liver lesions on CEUS.

A Nomogram Model for Predicting the Response to Transcatheter Arterial Embolization in Patients With Symptomatic Hepatic Hemangioma

Background: Transcatheter arterial embolization (TAE) is regarded as an effective treatment for patients with symptomatic hepatic hemangioma. However, few studies have evaluated the efficacy of TAE alone for treating hepatic hemangioma. The aim of this study was to identify the factors that influence the response to TAE and formulate a quantitative nomogram to optimize the individualized management of hepatic hemangioma.

Methods: We retrospectively studied 276 patients treated with TAE for hepatic hemangioma at our center from January 2011 to December 2019. The full cohort was randomly divided into training and validation cohorts. After assessing the potential predictive factors for the efficacy of TAE in the training cohort, a nomogram model was established and evaluated by discrimination and calibration.

Results: During follow-up, the symptom relief rate was 100%. The tumor blood supply (p < 0.001), tumor number (p = 0.004), and tumor size (p = 0.006) were identified as significant predictors of the failure of tumor shrinkage in response to TAE. The nomogram model showed favorable discrimination and calibration, with a C-index of 0.775 (95% CI, 0.705–0.845) in the training cohort, which was further confirmed in the validation cohort (C-index 0.768; 95% CI, 0.680–0.856). The side effects of TAE were relatively minor and included mainly abdominal pain, nausea, vomiting, fever, and the presence of elevated hepatic transaminases.

Conclusion: TAE is a safe and effective treatment for symptomatic hepatic hemangioma. The established nomogram performed well for the estimation of the effect of TAE in patients with hepatic hemangioma and can facilitate the selection of patients who would benefit most from the treatment.

Contrast-Enhanced Ultrasound as a Main Radiological Diagnostic Method for Primary Liver Neoplasms and Hemangiomas

Contrast-enhanced ultrasound (CEUS) is a relatively new approach for the definitive diagnosis of focal liver lesions (FLL). The essential advantages of CEUS are affordability, absence of radiation, and negligible nephrotoxicity-making this diagnostic approach more preferable.

This review includes data from 39 different research studies published during the last 10 years, selected through the MeSH strategy in PubMed.

We conclude that CEUS is a promising approach for diagnosing primary liver neoplasms and it is an excellent radiological approach for children and pregnant women because of the absence of radiation and nephrotoxicity. Studies showed that CEUS is a very good approach for the differentiation of a variety of hemangiomas and for a detailed description of those findings. Therefore, CEUS is an important and progressive method for the diagnosis of liver neoplasms. The regular use of CEUS will facilitate the diagnosis of primary liver lesions.

ACR Appropriateness Criteria® Liver Lesion-Initial Characterization

Incidental liver masses are commonly identified on imaging performed for other indications. Since the prevalence of benign focal liver lesions in adults is high, even in patients with primary malignancy, accurate characterization of incidentally detected lesions is of paramount clinical importance. This document reviews utilization of various imaging modalities for characterization of incidentally detected liver lesions, discussed in the context of several clinical scenarios. For each clinical scenario, a summary of current evidence supporting the use of a given diagnostic modality is reported. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Differentiation of atypical hepatic hemangioma from liver metastases: Diagnostic performance of a novel type of color contrast enhanced ultrasound

BACKGROUND

In clinical practice, the diagnosis is sometimes difficult with contrast-enhanced ultrasound (CEUS) when the case has an atypical perfusion pattern. Color parametric imaging (CPI) is an analysis software for CEUS with better detection of temporal differences in CEUS imaging using arbitrary colors. It measures the differences in arrival time of the contrast agent in lesions so that the perfusion features of atypical hemangioma and colorectal cancer (CRC) liver metastasis can be distinguished.

AIM

To evaluate the role of a novel type of CPI of CEUS in the differential diagnosis of atypical hemangioma from liver metastases in patients with a history of CRC.

METHODS

From January 2016 to July 2018, 42 patients including 20 cases of atypical hemangioma and 22 cases of liver metastases from CRC were enrolled. These patients had a mean age of 60.5 ± 9.3 years (range: 39-75 years). All patients received ultrasound, CEUS and CPI examinations. Resident and staff radiologists independently and retrospectively reviewed CEUS and CPI images. Two sets of criteria were assigned: (1) Routine CEUS alone; and (2) CEUS and CPI. The diagnostic sensitivity, specificity, accuracy and receiver operating characteristic (ROC) curve of resident and staff radiologists were analyzed.

RESULTS

The following CPI features were significantly different between liver hemangioma and liver metastases analyzed by staff and resident radiologists: Peripheral nodular enhancement (65%-70.0% vs 4.5%-13.6%, P < 0.001, P = 0.001), mosaic/chaotic enhancement (5%-10% vs 68.2%-63.6%, P < 0.001, P < 0.001) and feeding artery (20% vs 59.1%-54.5%, P = 0.010, P = 0.021). CPI imaging offered significant improvements in detection rates compared with routine CEUS in both resident and staff groups. By resident radiologists, the specificity and accuracy of CEUS+CPI were significantly increased compared with that of CEUS (77.3% vs 45.5%, P = 0.030; 78.6% vs 50.0%, P = 0.006). In addition, the area under the curve (AUC) of CEUS+CPI was significantly higher than that of CEUS (0.803 vs 0.757, P = 0.036). By staff radiologists, accuracy was improved in CEUS+CPI (81.0% vs 54.8%, P = 0.010), whereas no significant differences in specificity and sensitivity were found (P = 0.144, P = 0.112). The AUC of CEUS+CPI was significantly higher than that of CEUS (0.890 vs 0.825, P = 0.013) by staff radiologists.

CONCLUSION

Compared with routine CEUS, CPI could provide specific information on the hemodynamic features of liver lesions and help to differentiate atypical hemangioma from liver metastases in patients with CRC, even for senior radiologists.

High-frequency ultrasonography and contrast-enhanced ultrasound for the evaluation of testicular capillary hemangioma: A case report

RATIONALE

Testicular capillary hemangioma (TCH) is a rare benign tumor of the testis. To the authors' knowledge, there is currently only a few literatures describing the use of contrast-enhanced ultrasound (CEUS) to diagnose TCH. Accurate preoperative diagnosis of benign tumors can avoid orchiectomy. A case of TCH evaluated using high-frequency ultrasound and CEUS is presented.

PATIENT CONCERNS

A 21-year-old male presented with a right testicular mass during a routine physical examination, and was admitted to the authors' hospital for definitive diagnosis and treatment.

DIAGNOSES

Combined gray-scale, color Doppler ultrasonography, and CEUS did not exclude the possibility that the right testicular lesion may be a benign tumor. Combined with morphological and immunohistochemical staining results, a pathological diagnosis of TCH was considered.

INTERVENTIONS

The patient underwent right orchiectomy under general anesthesia, which proceeded smoothly.

OUTCOMES

At the 12-month follow-up, the patient was completely asymptomatic and resumed all daily activities.

LESSONS

TCH is a rare benign tumor and lacks extensive previous data in imaging findings. If TCH can be diagnosed accurately before surgery, excessive or inappropriate treatment of benign lesions can be minimized, which will be beneficial to the physical and psychological health of patients.