Nodule in Liver: Investigations, Differential Diagnosis and Follow-up (original) (raw)
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Hepatology, 2007
This study prospectively evaluates the accuracy of contrast-enhanced ultrasound (CEUS) and dynamic magnetic resonance imaging (MRI) for the diagnosis of nodules 20 mm or smaller detected during ultrasound (US) surveillance. We included 89 patients with cirrhosis [median age, 65 years; male 53, hepatitis C virus 68, Child-Pugh A 80] without prior hepatocellular carcinoma (HCC) in whom US detected a small solitary nodule (mean diameter, 14 mm). Hepatic MRI, CEUS, and fine-needle biopsy (gold standard) (FNB) were performed at baseline. Non-HCC cases were followed (median 23 months) by CEUS/3 months and MRI/6 months. FNB was repeated up to 3 times and on detection of change in aspect/size. Intense arterial contrast uptake followed by washout in the delayed/venous phase was registered as conclusive for HCC. Final diagnoses were: HCC (n ؍ 60), cholangiocarcinoma (n ؍ 1), and benign lesions (regenerative/dysplastic nodule, hemangioma, focal nodular hyperplasia) (n ؍ 28). Sex, cirrhosis cause, liver function, and alpha-fetoprotein (AFP) levels were similar between HCC and non-HCC groups. HCC patients were older and their nodules significantly larger (P < 0.0001). First biopsy was positive in 42 of 60 HCC patients. Sensitivity, specificity, and positive and negative predictive values of conclusive profile were 61.7%, 96.6%, 97.4%, and 54.9%, for MRI, 51.7%, 93.1%, 93.9%, and 50.9%, for CEUS. Values for coincidental conclusive findings in both techniques were 33.3%, 100%, 100%, and 42%. Thus, diagnosis of HCC 20 mm or smaller can be established without a positive biopsy if both CEUS and MRI are conclusive. However, sensitivity of these noninvasive criteria is 33% and, as occurs with biopsy, absence of a conclusive pattern does not rule out malignancy. These results validate the American Association for the Study of Liver Disease (AASLD) guidelines.
Romanian journal of morphology and embryology = Revue roumaine de morphologie et embryologie, 2015
The incidence of hepatocellular carcinoma (HCC) has been constantly increasing over the last years mainly due to hepatitis C infection and cirrhosis. The new developments in imaging technology, including magnetic resonance imaging (MRI) and computed tomography (CT), allow a better diagnosis of HCC. Cirrhosis is characterized by formation of nodules from regenerative nodules to dysplastic nodules, followed by HCC. Thus, the differential diagnosis of hypervascular hepatic lesions is important, especially in the nodules smaller than 2 cm, although their characterization may be difficult even when histopathology is used. A multistep approach with the comparison of clinical data, pathological findings and imaging features is useful for a more accurate diagnosis. MRI has the ability to assess the same lesions features as CT and to better characterize the enhancement patterns of nodules combined with the lack of irradiation. Moreover, new liver specific contrast agents and imaging techniqu...
Small nodules (1–2cm) in liver cirrhosis: Characterization with contrast-enhanced ultrasound
European Journal of Radiology, 2009
Objective: To determine the diagnostic efficacy of arterial phase contrast-enhanced ultrasound (CEUS) for characterizing small hepatic nodules (1-2 cm) in patients with high-risk for hepatocellular carcinoma (HCC). Materials and methods: Over 12 months, CEUS was performed in 59 patients at high-risk for HCC with small hepatic nodules (1-2 cm; mean, 1.5 cm). Based only on arterial phase (<45 s) vascular intensity and pattern, lesions were prospectively diagnosed as HCC if there was hypervascularity without known features of hemangioma. The diagnosis of HCC was made regardless of the presence or absence of washout. Verification of diagnosis was made by liver transplantation (n = 13), biopsy (n = 12), resection (n = 3) or clinical and imaging follow-up for at least 12 months (n = 31). Results: At of the time of CEUS, the 59 nodules were diagnosed as HCC in 26 and benign lesions in 33, including 20 regenerative/dysplastic nodules (RN/DN), 11 hemangiomas, and 2 focal fat sparing. All 26 nodules with arterial phase hypervascularity without hemangioma-like features were HCC. However, CEUS misdiagnosed HCC as RN/DN in 4 cases with arterial iso-(n = 3) or hypovascularity (n = 1). CEUS correctly diagnosed all 11 hemangiomas. The sensitivity, specificity, and accuracy of CEUS for diagnosing HCC were 86.7, 100, and 93.2%. Conclusions: Arterial phase vascular intensity and pattern of CEUS are highly accurate for the diagnosis of small (1-2 cm) HCC and hemangioma in liver cirrhosis. On CEUS, arterial phase hypervascularity without a hemangioma-pattern alone may be sufficient for diagnosis of small HCC. Infrequent iso/hypovascular HCC may erroneously suggest RN/DN necessitating biopsy or close follow-up.
Hepatology, 2005
In a prospective study, we examined the impact of arterial hypervascularity, as established by the European Association for the Study of the Liver (EASL) recommendations, as a criterion for characterizing small (1-3 cm) nodules in cirrhosis. A total of 72 nodules (1-2 cm, n ؍ 41; 2.1-3 cm, n ؍ 31) detected by ultrasonography in 59 patients with cirrhosis were included in the study. When coincidental arterial hypervascularity was detected at contrast perfusional ultrasonography and helical computed tomography, the lesion was considered to be hepatocellular carcinoma (HCC) according to EASL criteria. When one or both techniques showed negative results, ultrasound-guided biopsy was performed. In cases with negative results for malignancy or highgrade dysplasia, biopsy was repeated when an increase in size was detected at the 3-month follow-up examination. Coincidental hypervascularity was found in 44 of 72 nodules (61%; 44% of 1-2-cm nodules and 84% of 2-3-cm nodules). Fourteen nodules (19.4%) had negative results with both techniques (hypovascular nodules). Biopsy showed HCC in 5 hypovascular nodules and in 11 of 14 nodules with hypervascularity using only one technique. All nodules larger than 2 cm finally resulted to be HCC. Not satisfying the EASL imaging criteria for diagnosis were 38% of HCCs 1 to 2 cm (17% hypovascular) and 16% of those 2 to 3 cm (none hypovascular). In conclusion, the noninvasive EASL criteria for diagnosis of HCC are satisfied in only 61% of small nodules in cirrhosis; thus, biopsy frequently is required in this setting. Relying on imaging techniques in nodules of 1 to 2 cm would miss the diagnosis of HCC in up to 38% of cases. Any nodule larger than 2 cm should be regarded as highly suspicious for HCC. (HEPATOLOGY 2005;42: 27-34.)
Internal and Emergency Medicine, 2020
Ultrasound (US) detection of liver nodules in cirrhotic patients requires further radiological examinations and often a followup with repeated short-term evaluations to verify the presence of hepatocellular carcinoma (HCC). Aims of the study were to assess the rate of HCC diagnosis and to identify HCC predictors in a cohort of cirrhotics followed-up after US detection of the liver nodule(s). One-hundred-eighty-eight consecutive cirrhotic patients (124 males, mean age 64.2 years) with liver nodule(s) detected by US were enrolled. All patients underwent second-level imaging [computed tomography (TC) or magnetic resonance (MR)], and those without a definite diagnosis of HCC were followed-up with TC and/or RM repeated every 3-6 months up to 18 months if HCC was not diagnosed. After 18 months, non-HCC patients came back to routine US surveillance. HCC was diagnosed in 73/188 cases (38.8%). In 66/73 patients (90.4%) HCC was identified at first radiological evaluation after US, while in the remaining seven subjects it was diagnosed at the subsequent imaging examination. Age (p = 0.001) and nodule dimension (p = 0.0001) were independent predictors of HCC at multivariate analysis. Fourty-nine/188 patients were lost at follow up after 18 months. Twenty/139 remaining patients developed HCC and 3/139 cholangiocarcinoma; 77 died between 3 and 110 months from the beginning of the study (61 for end-stage liver disease, 8 for extrahepatic causes, eight for unknown causes). Patients who developed liver cancer earlier during the follow up had the shortest overall survival. US-detected liver nodules are not neoplastic in more than half of cirrhotic patients. A definite diagnosis may be obtained at the time of the first radiologic evaluation after US in the vast majority of the cases. Patients in whom nodules are found not to be tumoral may return to the US surveillance program routinely applied to all cirrhotics.
The American Journal of Gastroenterology, 2002
The aim of our study was to evaluate the nature of focal liver lesions detected during the ultrasound follow-up of a population (prevalently anti-hepatitis C virus [anti-HCV] positive) with chronic liver disease. METHODS: The study population consisted of 1827 consecutive newly diagnosed chronic liver disease cases without liver nodules at enrollment. Patients were screened at 4-month intervals by ultrasound and serum ␣-fetoprotein assessment. All lesions detected on imaging studies (except those accompanied by diagnostic ␣-fetoprotein levels) were subjected to biopsy (histology and cytology). RESULTS: During the 7-yr follow-up period (mean ϭ 43.1 months), one or more solid focal lesions were found in 287 patients. ␣-Fetoprotein was diagnostic for hepatocellular carcinoma in 51 patients. Ultrasound-guided fine-needle biopsy was performed in the remaining 236 patients, yielding a diagnosis in 214: 198 hepatocellular carcinomas, 11 dysplastic nodules, and five B-cell non-Hodgkin's lymphomas (all confined to the liver and all in patients with chronic HCV infection). Twenty-two patients with nondiagnostic biopsies received diagnoses of hepatocellular carcinoma (20) or dysplastic nodules (two) based on arteriography or surgical biopsy. CONCLUSIONS: Focal lesions arising in patients with HCVrelated chronic liver disease can be other than hepatocellular carcinoma, and ultrasound-guided fine-needle biopsy plays an important role in their diagnosis. The prevalence of non-Hodgkin's lymphoma in this selected population was 0.31%. The fact that all five lymphoma patients had cirrhosis related to hepatitis C strengthens the hypothesis of an etiological correlation between the latter infection and Bcell lymphoproliferative disorders.
The Risk of Hepatocellular Carcinoma in Cirrhotic Patients with Small Liver Nodules on MRI
The American Journal of Gastroenterology, 2006
BACKGROUND The presence of hepatocellular carcinoma (HCC) has important implications for patients with AND AIM: cirrhosis. Studies have not compared the risk of cancer in cirrhotic patients with small liver nodules to cirrhotic patients without nodules. Our aim was to determine the risk of HCC in cirrhotic patients with small liver nodules on MRI compared to those without nodules. METHODS: We conducted a prospective study to determine the rate of HCC in cirrhotic patients with and without liver nodules. Cases were patients with liver nodule(s) less than 2 cm on MRI and controls were cirrhotic patients without nodules. Kaplan-Meier estimates and multivariate analysis were performed to estimate the risk of HCC in the two groups. RESULTS: A total of 310 liver transplant candidates with a mean follow-up of 663 days were included in the study and 133 underwent liver transplant during follow-up. The 1-yr incidence of HCC in the liver nodule group and control group was 11% and 0.5%, respectively, p < 0.001. The adjusted risk for HCC in the liver nodule group was 25 times higher compared to the control group, HR = 25.1 [95% CI 8.0, 78.9]. In 133 candidates who underwent transplant with and without liver nodules the rate of HCC was 11 (50%) and 4 (3.6%), respectively, p < 0.001. CONCLUSION: The incidence of HCC in patients with small liver nodules is significantly higher compared to patients with cirrhosis without liver nodules. The presence of small liver nodules warrants increased imaging surveillance for HCC.
Ultraschall in der Medizin
Purpose: To assess the impact of different vascular patterns at contrast-enhanced ultrasound (CEUS) on the characterization of small liver nodules (10 - 30 mm) in cirrhosis and to determine whether primary nodules and recurrent nodules (after a previously treated hepatocellular carcinoma) display variations in enhancement pattern.Materials and Methods: A total of 135 cirrhotic patients were evaluated. A diagnosis of hepatocellular carcinoma (HCC) was established according to AASLD Guidelines, based on imaging (computed tomography and/or magnetic resonance) or liver biopsy. All patients underwent CEUS. Different CEUS patterns were evaluated in terms of diagnostic accuracy: HYPER-HYPO: Arterial hyperenhancement followed by washout (hypoechoic appearance compared with surrounding parenchyma) in late phase; HYPER-ISO: Arterial hyperenhancement followed by isoenhancement (isoechoic appearance) in late phase; ISO-ISO: Isoenhancement in all vascular phases.Results: A total of 155 consecuti...
Imaging of Liver Tumors in Patients with Chronic Liver Disease
Current Radiology Reports, 2014
Imaging techniques have become the accepted mainstay for the assessment of liver lesions in cirrhosis and, thanks to the improvement of their diagnostic capabilities in recent years, have further limited the need to resort to bioptic sampling. Hepatocellular carcinoma (HCC) is the most common cause of de-novo liver nodules in cirrhosis, and its diagnosis relies on noninvasive contrast-enhanced imaging studies. Diagnostic criteria have been extensively validated, and the vascular pattern deemed typical for HCC is an arterial hyperenhancement of the nodule followed by washout in the portal or late phase. This pattern provides a positive predictive value for the diagnosis of HCC of about 97 % in nodules in cirrhosis according to the literature. However, the need for a more precise differentiation from other malignancies arising in cirrhosis, making up the remaining about 3 %, and specifically intrahepatic cholangiocarcinoma, has over time led to changes in the recommendations for the noninvasive diagnosis of HCC in cirrhosis. The present review aims to report recently published interesting studies that have brought new insights into the problem of the characterization and differential diagnosis of liver tumors in chronic liver diseases.
Journal of Hepatology, 2010
POSTERS surgery. However, surgery was considered curative in 50/116 IH-CCA (43%) vs 17/102 (17%) EH-CCA. 18% of IH-vs 4% of EH-CCA received no treatment. In conclusion, in Italy IH-CCA is managed as frequently as EH-CCA. In comparison with EH-CCA, IH-CCA occurs at younger age, is more frequently associated with smoking habits, cirrhosis and/or hepatitis virus infection and with an incidental asymptomatic presentation. In contrast, most EH-CCA are jaundiced at the diagnosis. CCA diagnostic management is cost-and timeconsuming with a curative surgical treatment applicable in 43% IHvs 17% EH-CCA.