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Sclerosed hepatic hemangioma. A Axial unenhanced CT shows partially exophytic lesion in the left liver, with small internal calcifications (arrowhead). B On axial fat suppression T2-weighted MR image, the lesion is hypointense with internal central hyperintensity (arrow). C Axial gadolinium-enhanced T1-weighted during arterial phase shows hypointense lesion, with no enhancement. D At 7-min delayed phase the lesion shows mild, irregular, spotty enhancement. CT-guided biopsy was consistent with fibrotic tissue in hemangioma
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Frequently encountered on abdominal imaging studies, the majority of common benign liver lesions are asymptomatic, confidently diagnosed by imaging, and do not require further workup, follow-up, or treatment. The increasing use of multimodality liver imaging, has allowed the recognition of uncommon evolutions of common benign liver lesions such as...
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BACKGROUND
The effect of vessel wall magnetic resonance imaging (VW-MRI) enhancement in partially thrombosed aneurysms has previously indicated aneurysmal instability and a rupture risk. However, whether the contrast effect of the wall changes before or after flow diversion treatment is still under investigation.
OBSERVATIONS
The authors report a...
Citations
... The prevalence of hepatic hemangiomas is lower in cirrhotic livers than in non-cirrhotic ones [63]. While hepatic hemangiomas may retain their characteristic imaging features, in advanced stages of cirrhosis, they often lose these distinctive traits, complicating diagnostic efforts [63,64]. Magnetic resonance imaging (MRI) is regarded as the preferred modality for evaluating hepatic hemangiomas due to its superior contrast resolution. ...
... The diagnostic sensitivity of MRI is further enhanced by T2-weighted sequences. In ultrasonography (US), both dysplastic nodules and hepatocellular carcinoma may appear as hyperechoic nodules, which can mimic the sonographic appearance of hepatic hemangiomas [64]. ...
Hepatic hemangiomas are the most common benign liver tumors. Typically, small- to medium-sized hemangiomas are asymptomatic and discovered incidentally through the widespread use of imaging techniques. Giant hemangiomas (>5 cm) have a higher risk of complications. A variety of imaging methods are used for diagnosis. Cavernous hemangioma is the most frequent type, but radiologists must be aware of other varieties. Conservative management is often adequate, but some cases necessitate targeted interventions. Although surgery was traditionally the main treatment, the evolution of minimally invasive procedures now often recommends transarterial chemoembolization as the treatment of choice.
... Imaging diagnosis of the most benign focal liver lesions is oftentimes straightforward through US, CT, and MRI. However, in case of an atypical presentation or uncommon evolutions of benign liver lesions, current imaging techniques may not be considered definitive and further work-up, sometimes including biopsy, may be needed [82]. With regard to malignancies, HCC is the only neoplasm that can be confidently diagnosed through imaging without the need for biopsy confirmation whenever specific imaging criteria are present on contrast-enhanced CT or MRI in patients at high risk of HCC [81]. ...
Recently, medical radiology has undergone significant improvements in patient management due to advancements in image acquisition by the last generation of machines, data processing, and the integration of artificial intelligence. In this way, cardiovascular imaging is one of the fastest-growing radiological subspecialties. In this study, a compressive review was focused on addressing how and why CT and MR have gained a I class indication in most cardiovascular diseases, and the potential impact of tissue and functional characterization by CT photon counting, quantitative MR mapping, and 4-D flow. Regarding rectal imaging, advances in cancer imaging using diffusion-weighted MRI sequences for identifying residual disease after neoadjuvant chemoradiotherapy and [18F] FDG PET/MRI were provided for high-resolution anatomical and functional data in oncological patients. The results present a large overview of the approach to the imaging of diffuse and focal liver diseases by US elastography, contrast-enhanced US, quantitative MRI, and CT for patient risk stratification. Italy is currently riding the wave of these improvements. The development of large networks will be crucial to create high-quality databases for patient-centered precision medicine using artificial intelligence. Dedicated radiologists with specific training and a close relationship with the referring clinicians will be essential human factors.
... FNH is defined as a nodule composed of benign-appearing hepatocytes occurring in a liver that is otherwise histologically normal or nearly normal [26]. Although FNH may increase in size in 3-15% of cases, these lesions do not evolve to malignancy and their management is conservative [27,28]. ...
Hepatobiliary MRI contrast agents are increasingly being used for liver imaging. In clinical practice, most focal liver lesions do not uptake hepatobiliary contrast agents. Less commonly, hepatic lesions may show variable signal characteristics on hepatobiliary phase. This pictorial essay reviews a broad spectrum of benign and malignant focal hepatic observations that may show hyperintensity on hepatobiliary phase in various clinical settings. In non-cirrhotic patients, focal hepatic observations that show hyperintensity in the hepatobiliary phase are usually benign and typically include focal nodular hyperplasia. In patients with primary or secondary vascular disorders, focal nodular hyperplasia-like lesions arise as a local hyperplastic response to vascular alterations and tend to be iso- or hyperintense in the hepatobiliary phase. In oncologic patients, metastases and cholangiocarcinoma are hypointense lesions in the hepatobiliary phase; however, occasionally they may show a diffuse, central and inhomogeneous hepatobiliary paradoxical uptake with peripheral rim hypointensity. Post-chemotherapy focal nodular hyperplasia-like lesions may be tricky, and their typical hyperintense rim in the hepatobiliary phase is very helpful for the differential diagnosis with metastases. In cirrhotic patients, hepatocellular carcinoma may occasionally appear hyperintense on hepatobiliary phase.
... On magnetic resonance imaging, they are hyperintense on T2-weighted sequences. Giant hemangiomas (greater than 10 cm in diameter) may contain extensive fibrous changes as well as calcifications [2,3]. ...
... On magnetic resonance imaging, FNH lesions have a lobulated border, are generally isointense on T2-and T1-weighted non-contrast imaging, show hyperenhancement on the arterial phase, and are relatively isointense to the liver on portal venous phase and delayed imaging. In about half of all FNH lesions, a central scar is identified which can demonstrate delayed enhancement due to fibrous tissue [2,3]. ...
... The imaging characteristics vary according to the subtype. Magnetic resonance imaging is often the best imaging modality for diagnostic purposes due to the ability to assess the signal intensity of T1-and T2weighted imaging, the presence of fat, hemorrhage or necrosis, and the enhancement pattern on multiphase imaging [2,3]. ...
Transarterial embolization has shown promise as a safe, effective, and less invasive treatment modality for benign liver lesions (hemangioma, focal nodular hyperplasia (FNH), and hepatic adenoma (HA)) with fewer complications compared to surgical intervention. There is no consensus regarding the most appropriate embolization material(s) for the treatment of benign liver tumors. The purpose of this study was to review the current literature regarding the transarterial embolization of benign liver tumors and to share our single center experience. This was a non-blinded, retrospective, single-institution review of the bland embolization of benign liver tumors. Clinical data and imaging before and after embolization were used to evaluate lesion response to transarterial embolization. Twelve patients were included in the study. Five patients with six hemangiomas were treated. Pain was a presenting complaint in all five of these patients. The median change in tumor volume was −12.4% and ranged from −30.1% to +42.3%. One patient with two FNH lesions was treated, and both lesion volumes decreased by more than 50%. Six patients with 10 adenomas were treated. Pain was a presenting complaint in three patients, and five patients had a lesion >5 cm. The median change in tumor volume was −67.0% and ranged from −92.9% to +65.8%. Bland transarterial embolization of liver hemangiomas, FNH, and HA can be an effective and minimally invasive treatment modality to control the size and/or symptoms of these lesions. There is a variable response depending on tumor type and the embolization materials used.
... Spontaneous hemorrhage and Kasabach-Merritt syndrome are rare [22,23]. In the current study, there was no spontaneous or traumatic intraperitoneal hemorrhage occurred, no recorded Kasabach-Merritt syndrome as it is recorded in children and our cases were adult. ...
Background
Generally, hemangiomas are asymptomatic and most lesions are incidentally diagnosed on abdominal ultrasonography. The indications for surgery are still debated mainly due to limited data about the natural history of hepatic hemangiomas. The aim of this study is to investigate the natural history of hepatic hemangiomas, the effects of age and sex on their growth, and their tendency to increase in size or causing symptoms or complications as a guide for surgical indication. In this current study, combined retrospective and prospective analysis was conducted on 186 Egyptian adult patients having 244 hepatic hemangiomas who attended to the outpatient clinics. Follow-up was performed to observe the accurate site, size, number, rate of growth of the lesions, and their tendency to cause symptoms or complications.
Results
Ninety-one percent of patients were asymptomatic and 9% were symptomatic. During follow-up, 48% of patients showed an increase in tumor diameter, 22% decreased, and 30% were stable. The growth rate at 18–45-year group showed an increasing trend that was higher in females; it was 3.3 ± 2 mm/year for males and 3.9 ± 1.8 mm/year for females. At ˃ 45 year group, the female patients showed a decreasing trend (− 2.1 ± 1.1 mm/year) while in males showed an increasing trend that was slower than in 18–45-year group (2.6 ± 1.7 mm/year).
Conclusion
Growth pattern of liver hemangiomas is affected by age and sex. The majority of hemangiomas are asymptomatic and complications are rare. Hemangioma size alone is not an indication for surgery in asymptomatic patients. Surgical indications are limited to patients with severe symptoms, complications, or suspicious lesions. Most hemangiomas can be managed conservatively even giant hemangiomas.
... On contrast-enhanced CT and MRI, FNHs typically undergo immediate, intense, homogeneous enhancement on arterial phase and enhancement similar to the liver on portal venous and delayed phases ( fig. 1) (30). The central scar is characterized by a delayed enhancement due to fibrotic content (32,33). ...
... Therefore, hepatobiliary (HB) contrast-enhanced MRI is mandatory to differentiate FNHs from HCAs. MRI performed with HB contrast agent (the most common are Gd-BOPTA, MultiHance, Bracco, Milan, Italy and Gd-EOB-DTPA, Primovist; Bayer Schering Pharma, Germany) is considered the gold standard in imaging FNH (32,34). Furlan A. et al., in their study on FNHs occurred after chemotherapy treatment, demonstrated that typical MRI In the hepatocyte phase, FNH shows isointensity with the central scar hypointense (F) appearance might avoid unnecessary biopsy or surgery (36). ...
... The central fibrous scar is not specific for FNH, and other lesions, such as haemangiomas and fibrolamellar HCCs, may show it (32). Fibrolamellar HCC is a variant that usually occurs in young adults without chronic liver disease. ...
On computed tomography (CT) and magnetic resonance imaging (MRI), hepatocellular tumors are characterized based on typical imaging findings. However, hepatocellular adenoma, focal nodular hyperplasia, and hepatocellular carcinoma can show uncommon appearances at CT and MRI, which may lead to diagnostic challenges. When assessing focal hepatic lesions, radiologists need to be aware of these atypical imaging findings to avoid misdiagnoses that can alter the management plan. The purpose of this review is to illustrate a variety of pitfalls and atypical features of hepatocellular tumors that can lead to misinterpretations providing specific clues to the correct diagnoses.
... However, they may change in size over time, demonstrating enlargement or shrinkage. About enlargement, it consists of few millimeters per year, with higher growth rate in giant hemangiomas, and seems to be gender independent [48]. When enlarged, the HHs usually maintain their typical US, CT, and MR imaging findings. ...
... By contrast, the shrinkage of HHs is more often encountered in the context of liver cirrhosis, as above mentioned (Fig. 21). However, a size reduction may be observed spontaneously, probably because changes in the inner structure of HHs, such as fibrosis in sclerosing hemangioma (Fig. 9), thrombosis or hemorrhage [48]. Again, a decrease in size might be observed in patients underwent to systemic chemotherapy, although this condition remains currently controversial [48]. ...
... However, a size reduction may be observed spontaneously, probably because changes in the inner structure of HHs, such as fibrosis in sclerosing hemangioma (Fig. 9), thrombosis or hemorrhage [48]. Again, a decrease in size might be observed in patients underwent to systemic chemotherapy, although this condition remains currently controversial [48]. ...
The hemangioma is the most common solid lesion of the liver. Therefore, radiologists must know the typical and atypical imaging findings of this lesion in order to reach a correct diagnosis and avoid diagnostic errors. However, only few papers have comprehensively described the entire spectrum of atypical and uncommon imaging features. In this updated review, we provide the imaging features of hepatic hemangioma, in both typical and atypical forms, as well as its association with abnormalities in the adjacent hepatic parenchyma and other hepatic lesions, and its complications.
... Related studies have found that estrogen receptors are expressed in hepatic hemangioma and that high estrogen conditions (such as pregnancy and use of oral contraceptives) can promote their growth (Gemer et al. 2004;Au and Liu 2005;El-Hashemite et al. 2005;Yeh et al. 2007b;van Malenstein et al, 2011). Although there have been reports on the natural growth history of hepatic hemangioma, no consensus has been reached (Glinkova et al. 2004;Yeh et al. 2007a;Hasan et al. 2014;Vernuccio et al, 2018). This study investigated the epidemiological characteristics of and the factors affecting the growth of hemangioma, such as age and sex, by analyzing the case data of 534 patients, and hope that our results can provide a theoretical basis for the development of personalized treatment and follow-up programs. ...
... Hepatic hemangiomas are often found incidentally on abdominal ultrasonography (Adriana et al, 2014), and atypical lesions should be further investigated with contrast-enhanced imaging studies such as CT scan and MRI (Satoshi et al, 2009). Abdominal pain and discomfort caused by dilatation of the liver capsule are the most common clinical manifestations of symptomatic hepatic hemangioma, whereas spontaneous hemorrhage and Kasabach-Merritt syndrome are rare, but extremely dangerous (Trotter and Everson 2001;Vernuccio et al, 2018; Kamyab and Rezaei-Kalantari 2019), and the mortality rate of Kasabach-Merritt syndrome has been reported to be up to 40% (O'Rafferty et al. 2015). In our study, the majority of patients with hepatic hemangioma are asymptomatic, and most of the lesions were found due to physical examination, other gastrointestinal diseases and abdominal discomfort. ...
Background: The effects of gender and age on the growth of hepatic hemangioma remain inconclusive. This study aims to further explore the natural growth of hepatic hemangioma and its influencing factors.
Methods: From June 2014 to April 2019, 534 untreated patients who were diagnosed with hepatic hemangioma in our hospital were enrolled. The growth changes of hepatic hemangioma were observed at follow-up by ultrasound.
Results: During the median 18 (14,22) (months of follow-up, 215 (40.3%) patients showed an increase in tumor diameter, 217 (40.6%) tumor diameters decreased, and102 (19.1%) tumor diameters did not change. Before the age of 40, the diameter of hemangiomas in each group of men and women increased with age. After 40 years old, those in men continued to grow slowly, while those in women had a relatively downward trend. Therefore, by investigating annual changes in tumor, it was found that the diameter of female tumors showed a significant downward trend after the age of 40, the difference is most pronounced between 50–60 years old (the annual change is −0.39 (−0.87,0.40) cm).
Conclusion: In the natural growth process of hepatic hemangioma, male and female patients present different trends, which may be related to sex.
... However, the increase in size of a benign or non-HCC lesion, although uncommon, may occur [3,4], resulting in a false positive rate of 17% when using threshold growth as major imaging feature for the diagnosis of HCC in cirrhosis [2]. Conversely, hepatic malignancies may uncommonly show spontaneous shrinkage or disappearance without treatment [5]. ...
... While it is known that benign hepatic cysts may enlarge in the general population without chronic liver disease [4], there are no studies on the natural history of cysts in cirrhosis. In our experience, hepatic cysts in cirrhosis are usually stable or decrease in size over time (Fig. 3). ...
... Furthermore, the fibrotic degeneration may lead to peripheral capsular retraction or concavity over the lesion (Fig. 7), and loss of the typical imaging features of hemangiomas, including T2 hyperintensity, nodular peripheral enhancement with centripetal filling and the enhancement parallel to blood vessels [3,16,17]. Central fibrotic degeneration may result in central hypointensity on T2-weighted images and lack of T2-shine-through effect compared to lesions occurring in normal or mildly fibrotic liver [4,15]. Sclerosed hemangioma may appear as a hypoenhancing lesion or may show rim arterial phase hyperenhancement (Fig. 5). ...
Objective
The purpose of this article is to describe and illustrate uncommon imaging evolutions of benign (i.e., cyst, hemangioma, focal nodular hyperplasia-like nodules, and hepatic angiomyolipoma) and malignant (i.e., HCC and non HCC malignancies) lesions in a cirrhotic liver. The content highlights relevant pathogenesis and imaging clues for proper differential diagnosis. Revision of prior imaging and knowledge of these scenarios may help the abdominal radiologist to reach a noninvasive diagnosis and direct the patient to the most appropriate clinical management.
Conclusion
Uncommon imaging evolutions of focal liver lesions in cirrhosis may represent a challenge for the abdominal radiologist, with atypical changes in size, and internal vascularization changes that may lead to misdiagnoses.
Liver cancer represents one of the most common causes of cancer-related mortality worldwide. The imaging diagnosis of liver cancer is challenging because different malignant liver lesions can present with a combination of imaging features on contrast-enhanced CT and/or MRI. Hepatocellular carcinoma represents about 90% of all primary liver cancers and it can be diagnosed non-invasively when the combination of non-rim arterial phase hyperenhancement and washout are present in cirrhotic or high-risk patients. Cholangiocarcinoma is the second most common primary hepatic malignancy and may arise in any tract of the biliary system, including extrahepatic, hilar, or intrahepatic cholangiocarcinomas. Hepatic metastases are the most common malignant liver cancer and they may be hypervascular or hypovascular on post-contrast phases, depending on the primary cancer. Other rare tumors include combined hepatocellular-cholangiocarcinoma, mucinous cystic neoplasm, hepatic epithelioid hemangioendothelioma, hepatic angiosarcoma, hepatic lymphoma, and gallbladder carcinoma. The aims of this chapter are to describe the imaging features of the most common primary liver malignancies and liver metastases and to describe the imaging features biliary malignancies.
