First look at the images on the left and look at the enhancement patterns. [citation needed], It consists of localized accumulation of fat-rich liver cells. conditions) and tumoral (HCC). oncologists since 2003 because it involves no irradiation and has no hepatic or renal toxicity, [citation needed], B-mode ultrasonography is unable to distinguish between regenerative nodules and degree of tumor necrosis is not correlated with tumor diameter, therefore simple Correlate . CEUS exploration is indicated when a nodule is 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). absent. ADVERTISEMENT: Supporters see fewer/no ads. Vascular complications include thrombosis and stenosis of the hepatic artery, portal vein, or inferior vena cava, as well as hepatic artery pseudoaneurysms and celiac artery stenosis. During the arterial phase, the signal is weak or The imaging findings will be non-specific. This means that at times the differential between FNH and FLC will not be possible. uncertain results or are contraindicated. out at the end of arterial phase. In the portal venous phase the lesion is again isodense to the surrounding liver parenchyma and you can't see it. [1], Tumor detection is based on the performance of the method and should include morphometric information (three axes dimensions, volume) and topographic information (number, location specifying liver segment and lobe/lobes). Hypovascular metastases have to be differentiated from focal fatty infiltration, abscesses, atypical hypovascular HCC and cholangiocarcinoma. examination. (the result of intratumoral circulatory disorders, consequence of hemorrhage or necrosis) [citation needed], 2D ultrasound, Doppler ultrasound and especially CEUS can play an important role in pretherapeutic Although malignant transformation is rare, for this reason, surgical resection is advocated in most patients with presumed adenomas. In 60% of cases more than one hemangioma is present. diagnostic methods currently in use because of the known limitations of the ultrasound It has an incidence of 0.03%. Clinical correlation in such cases is most helpful. Larger HCC lesions typically have a mosaic appearance due to hemorrhage and fibrosis. First, histologic studies may lead to misdiagnosis when differentiating HA from FNH. Peripheral enhancement 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. This article is based on a presentation given by Richard Baron and adapted for the Radiology Assistant by Robin Smithuis. Although it is difficult to see, there is also portal venous thrombosis on the left. 2 A distended or enlarged organ. It is a heterogeneous disease encompassing a broad spectrum of histologic states characterized universally by macrovesicular hepatic steatosis. stages, which include very early stage (single nodule <2cm), curable by surgical resection Asked for Male, 58 Years. Monitoring limited by the presence of Lipiodol (iodine oil), therefore the evaluation of therapeutic During late phase the appearance is isoechoic or Does this help you? cholangiocarcinomas so complementary diagnostic procedures should be considered. CT will show FNH as a vascular tumor, that will be hyperdens in the arterial phase, except for the central scar. This articleand the rest of the serieswill discuss ultrasound evaluation of specific abdominal organs/systems, including scanning principles, normal sonographic appearance, and identification of common abnormalities seen during ultrasound examination. addition, the method can incidentally detect metastases in asymptomatic patients. [citation needed], Baseline 2D ultrasound has an important role in surveillance programs for patients at risk to interval for ultrasound screening of at risk population is 6 months as it results from status, as tumors are often asymptomatic, being incidentally discovered. therapeutic efficacy. During the late phase the tumor remains isoechoic to the liver, which strengthens the techniques, CEUS is the one that brought a significant benefit not only by increasing the What is a heterogeneous liver? In the portal venous phase however, the enhancement is not as bright as the enhancement of the portal vein. This is consistent with fatty liver. However in 20% of patients the scar is hypointense. Finally most hemangiomas show complete fill in with contrast. Rim enhancement is continuous peripheral enhancement and is never hemangioma. CEUS examination is insufficient, requiring morphologic diagnostic procedures, use of other diagnostic imaging Malignant lesions however have a tendency to loose their contrast faster than the surrounding liver, so they may become relatively hypodense in later phases. Fibrolamellar carcinoma (FLC) has a dark scar on T2WI and FNH has a brigth scar on T2WI in 80% of the cases. It displays a mix of densities due to various factors including alcohol damage and obesity. [citation needed], It develops on non cirrhotic liver. The presentation of liver abcesses is very much dependend on the way the bacteria have entered the liver. Low density, so it may be cystic i.e fluid containing. [citation needed], Transarterial chemoembolization (TACE) is part of palliative therapies for HCC used in well defined lesion, with sizes of 23cm or less, showing increased echogenity and, when CEUS increased accuracy is due to the different behavior of normal liver parenchyma Given the CEUS limitations, currently some authors consider CT and hypoechoic appearance during late phase. However, continued high alcohol consumption can result in fatty liver disease, which can cause cirrhosis of the liver, an irreversible condition. Small HCC and hypervascular metastases may mimic small hemangiomas because they all show homogeneous enhancement in the arterial phase. [citation needed] The size varies from a few millimeters to more than 10 cm (giant hemangiomas). The importance of a non enhanced scan is demonstrated in the case on the left. [citation needed]. Calcifications occur in 30-60% of fibrolamellar tumors. The common route is through the portal vein as a result of abdominal infection. Neoformation vessels occur with increasing degree of dysplasia. The case on the left proved to be HCC. . concordant imaging procedures are necessary, supplemented if necessary by an ultrasound Hepatocellular adenomas are large, well circumscribed encapsulated tumors. In this phase the attenuation of the normal liver parenchyma increases, revealing the relatively hypoattenuating metastases, sometimes with peripheral enhancement. Using CEUS examination to detect metastases a sensitivity of 8095% is obtained, similar to However when you look carefully you will notice the lamellar and heterogenous structure of FLC compared to the homogeneous appearance of FNH. heterogeneous echo pattern. You have to realize however, that this simply means that the lesion is hyperechoic to normal liver. Ultrasound In addition, a considerable risk of hemorrhage exists when biopsy is performed on these hypervascular tumors. artery with gelfoam, alcohol or metal rings. In most clinical settings, increased liver echogenicity is i'd talk to your doc, whoever ordered the test. This may be improved by the use of contrast agents variable, generally imprecise delineation, may have a very pronounced circulatory signal treatment of hypervascular liver metastases. Ultrasound of Abdominal Transplantation. HCC becomes isodense or hypodense to liver in the portal venous phase due to fast wash-out. . During the portal venous venous and late phases, respectively hypervascular (neuroendocrine tumors, malignant A history of a primary hypervascular tumor favors metastases. Peritumoral edema makes lesions appear larger on T2WI and is very suggestive of a malignant mass. all cause this ultrasound picture. are the absence of irradiation and its high sensitivity in tumor vasculature detection, So this is fibrotic tissue and the diagnosis is FNH. [citation needed]. These therapies are based on the different nature is also important knowing that up to 2550% of liver lesions less than 2cm paucilocular), have distinct delineation, with increased echogenity (hemangiomas, benign Radiology 1996; 201:1-14. These lesions need to be differentiated from other lesions with a scar like FLC, FNH and Cholangiocarcinoma. 5. Moreover a central scar may be found in some patients with fibrolamellar hepatocellular carcinoma, hepatic adenoma and intrahepatic cholangiocarcinoma. In both cases ultrasound examination identifies a This pattern is commonly seen in colorectal cancer. currently used in large clinical trials aimed at determining the efficacy of different types of The bacteria will fall down into the dependent portion of the right lobe. Adenomas may rupture and bleed, causing right upper quadrant pain. Some authors indicate the tumor may appear more evident. lobe (acquired, parasitic). Doppler examination shows the lack of vessels within the lesion. to bloating, in cancer patients post-therapy steatosis occurs, which prevent deep visibility. Heterogeneous refers to a structure with dissimilar components or elements, appearing irregular or variegated. vasculature as a sign of incomplete therapy or intratumoral recurrence. Arterial and the tumor diameter is unchanged. Hemangioma is the most common benign liver tumor. (2005) ISBN: 1588901793, 2. Hepatocellular Injury Mild AST and ALT Elevations. ranges between 4080% . Typically, HCAs are solitary and are found in young females in association with use of estrogen-containing medications. anemia when it is very bulky. 2008). If you had to pick one word to characterize a hemangioma on US, you would probably say 'hyperechoic'. 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 regarded as malignant until otherwise proven. It may What does heterogeneous mean in ultrasound? Heterogenous refers to a structure having a foreign origin. The figure on the left shows such a case. determined by two observations not less than 4 weeks apart; The key is to look at all the phases. [citation needed], US examination is required to detect liver metastases in patients with oncologic history. Infiltrative cholangiocarcinoma does not cause mass effect, because when the stroma matures, the fibrous tissue will contract and cause retraction of the liver capsule. appetite and anemia with cancer). Doppler examination detects a high speed arterial flow and low impedance index (correlated with described changes in tumor angiogenesis). resection) but welcomed. adenocarcinomas) with hypoechoic pattern during arterial phase, and similar during portal While FNH is always very homogeneous, FLC is usually heterogeneous following contrast administration. In histological terms, this usually appears as macrovacuolar steatosis, with large intracytoplasmic vacuoles displacing the nucleus to the periphery of the cells. or cysts inside is suggestive for parasitic, hydatid nature. increases with the tumor size. and requires other imaging procedures, follow up and measurements of the tumor at provides an overview of tumor extension and it is not limited by bloating or steatosis. measurement of the tumor diameter (RECIST criteria) is not enough for therapy assessment. [citation needed], It is a benign tumor made up of normal or atypical hepatocytes.