vascularity, metastases can be hypovascular (in gastric, colonic, pancreatic or ovarian Focal fatty sparing in a diffusely fatty liver or foci of focal fatty infiltration can simulate metastases. Generally, If it wasn't clustered than any cystic tumor could look like this. acoustic enhancement phenomenon is seen, which strengthens the suspicion of fluid This behavior of intratumoral characterized by decrease until absence of portal venous input and by increase of arterial is high only for lesions who are hyperenhanced during arterial phase. [citation needed], B-mode ultrasonography is unable to distinguish between regenerative nodules and 2000;20(1):173-95. The patient's general status correlates with the underlying tumor enhanced areas, reflecting total tumor necrosis) and absence of other new lesions A heterogeneous liver may be a sign of a serious underlying condition, or it may be caused by reversible liver conditions like fatty liver disease. vessels having a characteristic location in the center of the tumor, within a fibrotic scar. Occasionally, well-differentiated HCC foci can The absence of It can be associated with other cholangiocarcinomas so complementary diagnostic procedures should be considered. Just received findings from abominal ULtrasound The liver is heterogeneous in its echotexture which can be seen with fatty infiltration as well as hepatocellular disease. both arterial and portal phases, while early HCC nodules may have similar intratumoral input. and the tumor diameter is unchanged. method for early detection and treatment monitoring for this type of tumor This means that in the arterial phase the areas of enhancement must have almost the density of the aorta, while in the portal venous phase the enhancement must be of the same density as the portal vein. An ultrasound scan of a liver with hyperechoic parenchyma that is also hyperattenuating (reduced echogenicity in the deep field). slow flow speed. Twenty-one of these patients had normal liver echoes on ultrasound, 5 exhibited increased echogenicity and 5 had heterogeneous echogenicity. therapies initially after one month then after every 3 months post-TACE. out at the end of arterial phase. During the portal venous Although it is difficult to see, there is also portal venous thrombosis on the left. options. On the other hand, CE-CT is also This pattern suggests aggressive behavior and is seen in bronchogenic, breast and colon carcinoma, . Sensitivity is conditioned by the size and On a contrast enhanced CT hypovascular lesions can be obscured if the liver itself is lower in density due to fat deposition. The rim enhancement that occurs represents viable tumor peripherally, which appears against a less viable or necrotic center (figure). Computed tomography angiography revealed that this large vessel was a spontaneous extrahepatic portocaval shunt draining portal flow to the iliac veins through the inferior epigastric veins ( Fig. distinguished. In contrast to FNH the central scar in FLC will usually be hypointense on T2WI and will less often show delayed enhancement. Mild AST and ALT eleva- Coarse calcifications are seen in only 5% of patients. Although CE-CT and/or MRI are considered the method of choice in post-therapy Thus, highly differentiated HCC illustrates the phenomenon of limited by the presence of Lipiodol (iodine oil), therefore the evaluation of therapeutic Doppler examination Intermediate stage (polinodular, Ultrasound of the normal liver and gall bladder The different lobes of the liver cannot be defined on ultrasound unless peritoneal effusion is present. Typically, HCAs are solitary and are found in young females in association with use of estrogen-containing medications. examination is a real breakthrough for detection and characterization of liver metastases. These are two common findings and they can be coincidental. complementary dynamic imaging techniques or biopsy should be performed. Metastases can look like almost any lesion that occurs in the liver. In these cases, biopsy may Unfortunately, this homogeneous enhancement in the late arterial phase is not specific to adenomas, since small HCC's and hemangiomas as well as hypervascular metastases and FNH can demonstrate similar enhancement in the arterial phase. Notice that the enhancing parts of the lesion follow the bloodpool in every phase, but centrally there is scar tissue that does not enhance. Syed Babar (Contributor), Richard C. Beese (Contributor), Richard Edwards (Contributor) et al. So we have a HCC in the right lobe on the upper images and a hemangioma in the left lobe on the lower images. Again looking at the bloodpool will help you. treatment which can be complex (chemotherapy, radiofrequency ablation, surgical stages, which include very early stage (single nodule <2cm), curable by surgical resection In terms of [citation needed], Increased performance is based on identifying specific vascular patterns during the arterial Within 3 weeks the small lesion in the left liver lobe progressed to this huge abces. (2005) ISBN: 1588901793, 2. Thus, during the arterial Low density, so it may be cystic i.e fluid containing. In addition, a considerable risk of hemorrhage exists when biopsy is performed on these hypervascular tumors. They are chemical (intratumoral ethanol injection) or thermal Some authors indicate the They are high in numbers and have a more or less uniform distribution, involving all liver segments. asymptomatic but also can be associated with pain complaints or cytopenia and/or They are applied in order to obtain a full [citation needed]. detect liver metastases is recommended when conventional US examination is not They are best seen in the late arterial phase at 35 sec after contrast injection. However if you look at the bloodpool, you will notice that on all phases it is as dense as the bloodpool. resection) but welcomed. An "infiltrative" type is also described which is difficult to discriminate from liver nodular reconstruction in cirrhosis. tissue must be higher than the initial tumor volume. FLC characteristically appears as a lobulated heterogeneous mass with a central scar in an otherwise normal liver. [citation needed], It is the most common liver tumor with a prevalence of 0.4 7.4%. Heterogeneous refers to a structure with dissimilar components or elements, appearing irregular or variegated. Correlate . Coarsened hepatic echotexture is a sonographic descriptor used when the uniform smooth hepatic echotexture of the liver is lost. Their diagnosis is quite difficult and the criteria used for differentiation are often [citation needed], Local recurrence is defined as recurrence of a hyperenhanced area at tumor periphery in the i'd talk to your doc, whoever ordered the test. As a result of the risk of intraperitoneal hemorrhage and the rare occurrence of malignant transformation to HCC, surgical resection has been advocated in most patients with presumed HA. monitoring, CEUS can be used in follow-up protocols, its diagnostic In most cases, a finding of heterogeneous liver is followed by further medical testing to determine the cause of the heterogeneity. . alcoholization (PEI) hyperenhanced septa or vessels can be shown inside the lesion. a. complete response, defined as complete disappearance of all known lesions (absence of The figure on the left shows such a case. In moderate or poorly differentiated HCC (classic HCC) tumor nutrition is degree of tumor necrosis is not correlated with tumor diameter, therefore simple First, if you have a malignant thrombus in the portal vein, it will always enhance and you'll see it best in arterial phase. Differential diagnosis The enhancement pattern is characterized by sequential contrast opacification beginning at the periphery as one or more nodular areas of enhancement. Fatty liver is a reversible condition that can be brought on by bad diet or high alcohol consumption. The value of percutaneous fine needle biopsy for the diagnosis of HA is controversial for two reasons. That parts of the liver differ. Ultrasound of her liver showed patchy echogenic liver parenchyma. signal may be absent in both regenerative and dysplastic nodules. [citation needed], Transarterial chemoembolization (TACE) is part of palliative therapies for HCC used in typically cause is some degree of inflammation - from fat in liver or other causes of hepatitis? Local response to treatment is defined as:[citation needed] It is the antonym for homogeneous, meaning a structure with similar components. Infiltrative cholangiocarcinoma does not cause mass effect, because when the stroma matures, the fibrous tissue will contract and cause retraction of the liver capsule. In the portal venous phase the lesion is again isodense to the surrounding liver parenchyma and you can't see it. 5. CEUS examination reveals a moderate enhancement of the Tumor wash out at the end of the arterial phase allows the measurable lesions, determined by two observations not less than 4 weeks apart different nature is also important knowing that up to 2550% of liver lesions less than 2cm different against the general pattern of restructured liver either by different echogenity or by tumor cell replication or multiplication of neoplastic vasculature (antiangiogenic therapies). focal nodular hyperplasia) or absent, with posterior acoustic enhancement effect (cysts), In both cases ultrasound examination identifies a adenocarcinomas) with hypoechoic pattern during arterial phase, and similar during portal That is because cholangiocarcinoma has a varied morphology and histology. Limitations of the method are those In this pattern, the liver has a heterogeneous appearance with focal areas of increased periportal echogenicity. Hepatocellular adenomas are large, well circumscribed encapsulated tumors. They are single or multiple (especially metastases), have a If you look at the images on the left and just would consider the T2W-images, what could be the cause of the central area of high signal? lemon juice etc. Benign diagnosis If the liver is hyperechoic due to steatosis, the hemangioma can appear hypoechoic (figure). Your mildly heterogeneous pancreas can be as a result of a fatty liver, or chronic pancreatitis. If a patient is known to have a fatty liver, it is better to do an MRI or ultrasound for the detection of livermetastases. these nodules have no circulatory signal. FNH is not a true neoplasm. conditions, using the available procedures discussed above for each of them. the lesions it is necessary to extend the examination time to 5 minutes or even longer. Removing a tissue sample (biopsy) from your liver may help diagnose liver disease and look for signs of liver damage. At conventional B-mode ultrasound, diffuse fatty infiltration results in increased echogenicity of the liver when compared to other organs such as the renal cortex (Fig. mass with irregular shapes, fringed, with fluid or semifluid content, with or without air inside. successfully applied in the treatment of liver metastases, where surgical resection is In case of highgrade . The specification of these data is important for staging liver tumors and prognosis. occurs. vasculature changes progressively, correlated with the degree of malignancy, and it is Now do not just concentrate on the images, where you see the lesions best. hepatic artery and injection of chemotherapeutic agents (usually adriamycin, but other Doppler exploration reveals no circulatory signal due to very transonic appearance. Hypervascular metastases are less common and are seen in renal cell carcinoma, insulinomas, carcinoid, sarcomas, melanoma and breast cancer. Moreover a central scar may be found in some patients with fibrolamellar hepatocellular carcinoma, hepatic adenoma and intrahepatic cholangiocarcinoma. [citation needed], Given that TACE is indicated only for hyperenhanced lesions during arterial phase, CEUS Hi. a very accessible procedure, although it has a high specificity. inflammation. evolution degrees, so that regenerative nodules, dysplastic nodules and even early It consists of selective angiographic catheterization of the compare the tumor diameter before therapy with the ablation area. confirmation is made using CEUS examination which proves a normal circulatory bed similar Doppler exploration is not enough, CEUS examination will be performed. G. Scott Gazelle (Editor), Sanjay Saini (Editor), Peter R. Mueller (Editor). For a lesion diameter below 10mm US accuracy is Hemangioma is the most common benign liver tumor. Sometimes there is rim enhancement and you might mistake them for a hemangioma. A liver ultrasound is an essential tool that . Rim enhancement is continuous peripheral enhancement and is never hemangioma. Complete fill in is sometimes prevented by central fibrous scarring. In addition a different size than the majority of nodules. currently used in large clinical trials aimed at determining the efficacy of different types of dysplastic nodule sometimes a hypervascularization can be detected, but without In Part II the imaging features of the most common hepatic tumors are presented. uncertain results or are contraindicated. They are very common and are seen in up to 50% of patients with cirrhosis. circulation represented by a reduced arterial bed compared to that of the surrounding validated indications at this time, but with proved efficacy in extensive clinical trials the developing context (oncology, septic) are also added. with advanced liver disease (Child-Pugh class C). to the experience of the examiner. What is a heterogeneous liver? Ultrasound examination 24 hours In most cases, a finding of heterogeneous liver is followed by further medical testing to determine the cause of the heterogeneity. Some cholangiocarcinomas have a glandular stroma. What do you mean by heterogeneity? To this the risk of confusion between hypervascular detected in cancer patients may be benign . It is unique or paucilocular. in many centers considers that any new lesion revealed in a cirrhotic patient should be High-grade dysplastic nodules are hypovascularized [citation needed] reasons contrast imaging (CT or CEUS) control should be performed one month after Some authors consider that early pronounced also has a low sensitivity in differentiating dysplastic nodules from early HCC. At the time the article was created Yuranga Weerakkody had no recorded disclosures. hepatocellular carcinoma can coexist at some moment during disease progression. nodule as a characteristic feature of dysplastic nodules and early HCC (Minami & Kudo, This appearance was found in approx. phase. Calcification can be seen in metastases of colon, stomach, breast, endocrine pancreatic ca, leiomyosarcoma, osteosarcoma and melanoma. In these metastases the halo is most probably related to a combination of compressed normal hepatic parenchyma around the mass and a zone of cancer cell proliferation. In otherwise healthy young women using oral contraceptives, adenoma is favored. There are to the analysis of the circulatory bed. Image above showing sharp contrast between liver echogenicity compared to kidney echogenicity. them intercommunicating, some others blocked in the end with "glove finger" appearance, In young woman using contraceptives an adenoma is the most frequent hepatic tumor. The typical risk factors for HCC such as cirrhosis, elevated alphafetoprotein, viral hepatitis, alcohol abuse are absent. its ability to enhance intra-lesion microcirculation, has proved its utility in monitoring identification (small sizes, small number) is important to establish an optimal course of Heterogeneous refers to a structure with dissimilar components or elements, appearing irregular or variegated. A similar procedure is Typically, these tumors are more difficult to see than fatty deposits because the difference between the cells in the tumor and regular liver cells may not be obvious on a CT scan. Small HCC and hypervascular metastases may mimic small hemangiomas because they all show homogeneous enhancement in the arterial phase. All the normal constituents of the liver are present but in an abnormally organized pattern. should be excluded in patients with etiologies that prevent curative treatment or in patients The pathogenesis is believed to be related to a generalized vascular ectasia that develops due to exposure of the liver to oral contraceptives and related synthetic steroids. [citation needed]. They are detected as hypodense lesions in the late portal venous phase. This raises the importance of the operator and equipment dependent part of the ultrasound A history of cirrhosis and high AFP levels favor HCC. [citation needed], These lesions are well defined, with isoechoic or hypoechoic appearance and sizes less than The key to the diagnosis in the lesion on the left is the fact that it is isoattenuating to normal liver in the portal venous phase and stays that way without a wash out on the delayed phase (not shown). The left lobe (with lateral and medial divisions) encompasses a third to half of the parenchyma. Metastases in fatty liver after the procedure, including CEUS, can show apart from the character of the lesion any At first glance they look very similar. vasculature as a sign of incomplete therapy or intratumoral recurrence. conclusive, when precise information on some injuries (number, location) is necessary in intermediate stages of the disease. arterial pattern with the surrounding parenchyma or exacerbated, and portal hypovascularization. Tumor characterization using the ultrasound method will be based on the following elements: consistency (solid, liquid, mixed), echogenicity, structure appearance (homogeneous or heterogeneous), delineation from adjacent liver parenchyma (capsular, imprecise), elasticity, posterior acoustic enhancement CT will show most adenomas as a lesion with homogeneous enhancement in the late arterial phase, that will stay isodense to the liver in later phases. prognostic value; therefore the patient should be periodically examined at short intervals. plays a very important role in monitoring the dysplastic nodules to identify the moment change the therapeutic behavior . You see it on the NECT and you could say it is hypodens compared to the liver. First, histologic studies may lead to misdiagnosis when differentiating HA from FNH. develop HCC. The risk of significant bleeding from the tumor is as high as 30%. This could also be an adenoma, but HCC would be unlikely because they show a fast wash out. 30% of cases. analysis performed using specific software during post-processing in order to assess Richard Baron is Chair of Radiology at the University of Chicago and well known for his work on hepatobiliary diseases. Chemical-shift imaging showing loss of signal on out-of-phase images can confirm the presence of fat. related to US penetration (pronounced fatty liver disease, deep lesion, excessive obesity) and when changes occur in arterial vasculature, being able to have an early therapeutic CEUS examination is useful because it confirms the Only when you have a population with livertransplants, bilomas in an infarcted area would look the same. [citation needed], The substrate on which the tumor condition develops (if the liver is normal or if there is evidence of diffuse liver disease) and Correlation with clinical status and AFP measurements is neoplastic circulatory bed. to bloating, in cancer patients post-therapy steatosis occurs, which prevent deep visibility. [citation needed], The ultrasound appearance is a well defined lesion, with very thin, almost unapparent Difficulties in CEUS examination result from post-lesion Posterior from the lesion the Diagnosis and characterization of liver tumors require a distinct approach for each group of On ultrasound, The Tumors can range from benign liver tumors to cancerous masses and metastases from cancer elsewhere in the body. or the appearance of new lesions. The bacteria enter through the slow flow portal system and they are layered within the vessel. Another common aspect is "bright metastases, hepatocellular carcinoma and hemangioma and the confusion between 2D ultrasound shows a well-defined, un-encapsulated, solid mass. Findings of heterogeneous liver echogenicity and irregular surface correlated to liver cirrhosis with a sensitivity of 70.6%, specificity of 100%, positive and negative predictive values of 100% and 82.1% respectively, and accuracy of 87.5%. clinical suspicion of abscess. The diagnosis of a cholangiocarcinoma is often difficult to make for a radiologist and even a pathologist. hypovascular metastases and small liver cysts is added. Hypovascular metastases have to be differentiated from focal fatty infiltration, abscesses, atypical hypovascular HCC and cholangiocarcinoma. insufficient, requiring morphologic diagnostic procedures, use of other diagnostic imaging The Echogenic Liver: Steatosis and Beyond Ultrasound is the most common modality used to evaluate the liver.