This presentation is about radiological features of hepatic benign and malignant mass lesions.

1. ULTRASONOGRAPHY OF
HEPATIC MASS LESION
DR.ABHILASHA SINGH
DNB RESIDENT
RADIO-DIAGNOSIS
RAMKRISHNA CARE HOSPITAL

3.  Characterization of a known liver lesion (what is it?)
 Detection (is it there?)
Focused examination

4. Liver mass characterisation
 Based on the appearance of the mass on gray- scale imaging
and vascular information derived from spectral, color, and
power Doppler sonography.
 Gray-scale : Differentiation of cystic and solid masses, and
characteristic appearances
 Vascular information obtained on conventional Doppler ultra-
sound examination.
 However, Contrast-enhanced CT (CECT) or MRI required for
definitive characterization.

5.  To address a failed Doppler ultrasound examination of a focal liver lesion, the
two basic remedies are :
(1) inject a microbubble contrast agent to enhance the Doppler signal from blood
(2) use a specialized imaging technique such as pulse inversion sonography, which
allows preferential detection of the signal from the contrast agent with suppression
of the signal from back- ground tissue.
 Ultrasound contrast agents currently in use are second-generation agents
comprising tiny bubbles of a perfluorocarbon gas contained within a stabilizing
shell.
 Liver lesion characterization with microbubble contrast agents is based on :
1. lesional vascularity
2. lesional enhancement in the arterial and portal venous phase.

6.  Lesional vascularity assessment depends on continuous imaging of the agents
while they are within the vascular pool. We document the presence, number,
distribution, and morphology of any lesional vessels
 Lesional enhancement is best determined by comparing the echogenicity of the
lesion to the echogenicity of the liver at a similar depth on the same frame and
requires knowledge of liver blood flow.
 Vascularity and enhancement patterns of a liver lesion, by comparison, will therefore
reflect the actual blood flow and hemodynamics of the lesion in question, such that :
 A hyperarterialized mass will appear more enhanced against a less enhanced liver on
an arterial phase sequence
 A hypoperfused lesion will appear as a dark or hypoechoic region within the
enhanced liver on an arterial phase sequence.

9. Liver Mass Detection
 Not size but echogenicity that determines lesion conspicuity on a sonogram.
 Tiny mass of only a few millimeters will be easily seen if it is increased or decreased in
echogenicity compared with the adjacent liver parenchyma.
 Effective method to date to improve lesion visibility is to perform contrast-enhanced
liver ultrasound
 First technique :
 1rst-generation contrast agent Levovist (Schering AG, Berlin).
 After clearance of the contrast agent from the vascular pool, the micro- bubble persisted
in the liver, probably within the Kupffer cells on the basis of phagocytosis.
 Liver metastases, lacking Kupffer cells, do not enhance and therefore show as black or
hypoechoic holes within the enhanced parenchyma.

10.  Second technique :
 CEUS with a perfluorocarbon contrast agent and low-MI scanning in both the
arterial and the portal venous phase.
 Virtually all metastases and HCCs will be unenhanced relative to the liver in the
portal phase because the liver parenchyma is optimally enhanced in this phase.
 Hypervascular liver masses (e.g., HCC, metastases) : will show as hyperechoic
masses relative to the liver parenchyma in the arterial phase because they are
predominantly supplied by hepatic arterial flow.
 Enhancement of benign lesions, FNH, and hemangioma generally equals or
exceeds liver enhancement in the portal venous phase.

12.  Significant lesion , requiring confirmations of their diagnoses :
1. A hypoechoic halo identified around an echogenic or isoechoic liver mass is
an ominous sonographic sign necessitating definitive diagnosis.
2. A hypoechoic and solid liver mass is highly likely to be significant and also
requires definitive diagnosis.
3. Multiple solid liver masses may be significant and suggest metastatic or
multifocal malignant liver disease. However, hemangiomas are also frequently
multiple.
4. Clinical history of malignancy, chronic liver disease or hepatitis, and
symptoms referable to the liver are requisite information for interpretation of
a focal liver lesion.

13. Tumors
(I) Benign :
1-Cavernous Hemangioma
2-Focal nodular hyperplasia
3-Adenoma
4-Hemangioendothelioma
5-Mesenchymal Hamartoma
6-Fatty tumors
(II) Malignant :
1-Hepatocellular Carcinoma (HCC)
2-Mets
3-Lymphoma
4-Hepatoblastoma

14. Benign Hepatic
Tumors

15. Incidence :
-Most common benign tumor of the liver
-80% in females , hemangiomas may enlarge particularly during
pregnancy or estrogen administration
Two types :
1. Typical Hemangioma : Common
Small , asymptomatic
Discovered incidentally
2 . Giant Hemangioma : > 5 cm
Uncommon
1 . Cavernous Hemangioma :

16. Ultrasonographic Features :
-Small < 3 cm , well defined , homogenous and hyperechoic
-Giant hemangiomas are heterogeneous
-Posterior acoustic enhancement is common
-Extremely slow blood flow that will not routinely be detected by
either color or duplex Doppler sonography.
Histologically :
-Hemangiomas consist of multiple vascular channels that are
lined by a single layer of endothelium and separated and
supported by fibrous septa.
-The vascular spaces may contain thrombi.

18.  When a hyper-echoic lesion typical of a cavernous
hemangioma is incidentally discovered, no further
examination is usually necessary, or at most, a repeat
ultrasound is performed in 3 to 6 months to document lack of
change.
 In a patient with a known malignancy, an increased risk for
hepatoma, abnormal results of LFTs, clinical symptoms
referable to the liver, or an atypical sonographic pattern, one
of the following additional imaging techniques is generally
recommended to confirm the suspicion of hemangioma:
microbubble- enhanced sonography, CT, red blood cell
(RBC) scintigraphy, or MRI.

21. Incidence :
- The 2 most common benign liver mass after
hemangioma
- More common in women in childbearing Period
(Hormonal influences may be a factor)
nd
2-Focal Nodular Hyperplasia :

22.  Microscopically :
• Include normal hepatocytes, Kupffer cells, biliary ducts, and the
components of portal triads, although no normal portal venous structures
are found.
• As a hyperplastic lesion, there is proliferation of normal, nonneoplastic
hepatocytes that are abnormally arranged.
• Bile ducts and thick-walled arterial vessels are prominent, particularly in
the central fibrous scar.
• The excellent blood supply makes hemorrhage, necrosis, and
calcification rare.
 These lesions often produce a contour abnormality to the surface of the
liver or may displace the normal blood vessels within the parenchyma.

23. Ultrasonographic Features :
-Often a subtle liver mass that is difficult to differentiate from in
echogenicity from the adjacent liver parenchyma
-The central scar may be seen as a hypoechoic linear or stellate
area within the central portion of the mass , on occasion may be
hyperechoic
-Doppler ultrasound highly suggestive, in that well developed
peripheral and central blood vessel larger are seen , the blood
vessels can be seen to course within the central scar which either
a linear or stellate configuration (spoke-wheel vascularity)

28. Incidence :
-Less common than FNH
-More common in women , increase incidence now due to
usage of oral contraceptive agents
-Anabolic steroids (typically young men) , Glycogen storage
disease
-The tumor may be asymptomatic , but often the patient or
the physician feels a mass in the right upper quadrant
-Pain may occur as a result of bleeding or infarction within
the lesion , the most alarming manifestation is shock caused
by tumor rupture and hemoprotineum
3-Adenoma

29.  Pathologically : a hepatic adenoma is usually solitary,
8 to 15 cm, and well encapsulated.
 Microscopically : the tumor consists of normal or
slightly atypical hepatocytes. Bile ducts and Kupffer cells
are few or absent.
 Hepatic adenomas may show either calcification or fat ,
both of which appear echogenic on sonography, making
their gray-scale appearance suggestive in some cases.

30. Ultrasonographic Features :
-Solitary and large at the time of diagnosis (5-15cm)
-Non specific , the echogenicity may be hyperechoic
(most common) , hypoechoic , isoechoic or mixed
-With hemorrhage , a fluid component may be evident
within or around the mass and free intraperitoneal blood
may be seen
-A hypoechoic halo of focal fat sparing is also frequently
seen
-Colour Doppler may show perilesional sinusoid

32. Hepatic adenoma Vs FNH
 Differentiation of hepatic adenomas from FNH is often not
possible by their gray-scale or Doppler characteristics
 Hepatic adenomas are substantially less vascular than most FNH
masses and certainly do not show either the intralesional or
perilesional vascular tortuosity associated with FNH.
 Most adenomas are cold on technetium- 99m sulfur colloid
imaging as a result of absent or greatly decreased numbers of
Kupffer cells.
 Hepatobiliary scans : These lesions do not contain bile ducts, the
tracer is not excreted, and the mass persists as a photon-active
region.
 CEUS; hepatic adenoma is characterized by centripetal filling and
non- homogeneity.

36. Incidence :
-It is a rare tumor that may occur as a solitary lesion or
multifocal nodules ranging in size from few mm upto
15 cm
-Most common benign pediatric liver tumor
-85% present at < 6 months
-Associated cutaneous hemangiomas in 50%
4-Infantile Hepatic Hemangioendothelioma

37. Sonographic Features :
-Appears as a complex, mostly solid hepatic lesion with variable
hypo- and hyperechoic echotexture
-In cases of significant arteriovenous shunting,dilated hepatic
vasculature with prominent blood flow at Doppler US is typical
-If large vascular spaces are present, anechoic regions with
detectable flow may be seen
-The lesions are often well demarcated from the surrounding
liver parenchyma

38. Transverse US image shows several small, well-demarcated,
homogeneous hypoechoic lesions (arrowheads) in the liver

39. Color Doppler image shows peripheral flow around some of
the lesions

40. Incidence :
-2 most common benign tumor in pediatric
population
nd
-It typically occurs in children and neonates,
with most cases presenting within the first
two years of life
-Male predominance (2:1)
5-Mesenchymal Hamartoma

41. Sonographic Features :
-Mesenchymal hamartomas can show a wide spectrum of
radiological features, from being :
1-Predominantly cystic tumor, to
2-Multiseptated cystic tumor, to
3-Mixed solid and cystic tumor, to
4-Even a completely solid tumor
-The dominant radiographic pattern, however, is a large
(often around 12-15 cm), predominantly cystic mass with
internal septations, there can be considerable variation in
the size of septae and cystic spaces

42. (a) Transverse US image shows cystic (arrowheads) and
solid (T) portions of the tumor and adjacent normal liver (*),
(b) Longitudinal color Doppler image shows no flow to the cystic
component, which contains low-level echoes (arrowhead), minimal
flow is seen in the solid component (arrows)

44. Mesenchymal hamartoma in a 2-year-8-month-old boy, A. US shows a large,
multiseptated cystic tumor in the right lobe of the liver. The septa of the
tumor (arrows) are very thin and regular in thickness, B. CT+C shows a
large cystic tumor with fine enhancing septa (arrows) in the liver, there is no
solid portion or calcification within the tumor

45.  Hepatic lipomas are extremely rare.
 There is an association between hepatic lipomas and renal
angiomyolipomas and tuberous sclerosis.
 The lesions are asymptomatic.
 CT confirms the diagnosis and reveals the fatty nature of the mass
 Angiomyolipomas, by comparison, may also appear echogenic on
sonography, although they may have insufficient fat to appear
consistently with fatty attenuation on CT, making diagnostic confirmation
more difficult without biopsy.
6- Fatty Tumors : Hepatic Lipomas and Angiomyolipoma

47. Malignant Hepatic
Neoplasms

48. Incidence :
-One of the most common malignant tumors
-More in men (M:F - 5:1)
-Incidence : Alcoholic cirrhosis
Hepatitis B & C
Clinical presentation :
Often delayed until the tumor reaches an advanced
stage. Symptoms include RUQ pain, weight loss, and
abdominal swelling when ascites is present.
1-Hepatocellular Carcinoma

49.  Pathologically, HCC occurs in the following three forms:
1. Solitary tumor
2. Multiple nodules
3. Diffuse infiltration
 There is a propensity toward venous invasion. The portal
vein is involved in 30% to 60% of cases and more often than
the hepatic venous system

50. Ultrasonographic Features :
-Typically a small focal HCC appears hypoechoic compared to
normal liver
-Larger lesions are heterogeneous due to fibrosis , fatty change ,
necrosis and calcification
-A peripheral halo of hypoechogenicity may be seen with focal
fatty sparing
-Small tumors may appear diffusely hyperechoic, secondary to
fatty metamorphosis or sinusoidal dilation, making them
indistinguishable from focal fatty infiltration, cavernous
hemangiomas, and lipomas.

52.  Studies evaluating focal liver lesions with duplex Doppler
and CDFI suggest HCC has characteristic high-velocity
signals
 Doppler sonography is excellent for detecting
neovascularity within tumor thrombi within the portal veins,
diagnostic of HCC even without demonstration of the
parenchymal lesion
 CEUS : Lesions are hypervascular, often showing
dysmorphic vessels and frequently showing unenhanced
regions representing either necrosis or scarring .
In the portal venous phase, lesions show washout.

57. Incidence :
-Typically these tumors occur in young
adults (20 to 40 years of age)
-Unlike HCC they do not have an
association with cirrhosis, alcoholism or
hepatitis B / C infection, i.e. it occurs in a
non-cirrhotic liver
Fibrolamellar HCC :

58. Ultrasonographic features :
-Fibrolamellar HCCs have nonspecific
sonographic features and are seen as
well-defined masses of variable
echogenicity on ultrasound
-Multiphasic CT using a liver protocol or
dynamic contrast-enhanced MRI is usually
required for further characterization

59. Fibrolamellar hepatocellular carcinoma (HCC) in 23-year-old woman,
transverse gray-scale ultrasound image shows large heterogeneous
echogenic lesion (curved arrow) in liver, echogenic strands in center
of lesion (straight arrow) represent central scar, ultrasound features
of fibrolamellar HCC are usually nonspecific

60. Differential Diagnosis :
From liver lesions with a central scar
1-FNH
2-Hemangioma (especially if large)
3-HCC (Fibrolamellar type)
4-Cholangiocarcinoma (peripheral type)
5-Hepatic adenoma , metastases
(occasionally)

61. Hemangiosarcoma
(Angiosarcoma)
 Extremely rare malignant tumor.
 Association with specific carcinogens: Thorotrast, arsenic,
and polyvinyl chloride.
 Sonographic appearance : Large mass of mixed
echogenicity.

62. Hepatic Epithelioid
Hemangioendothelioma
 Rare malignant tumor of vascular origin that occurs in adults.
 Soft tissues, lung, and liver are affected.
 Begins as multiple hypoechoic nodules, which grow and coalesce
over time, forming larger, confluent masses that tend to involve the
periphery of the liver. Foci of calcification may be present.
 The hepatic capsule overlying the lesions of EHE may be retracted
inward, secondary to fibrosis incited by the tumor; this unusual
feature is highly suggestive of the diagnosis.
 Diagnosis of hepatic EHE is made by percutaneous liver biopsy and
immunohistochemical staining.

63. Incidence :
-18 to 20 times more common than HCC
-The most common primary tumor sites :GB , Colon , Stomach , Pancreas ,
Breast & Lung
-Patients with short- term survival (<1 year) after initial detection of liver
metastases:HCC and carcinomas of the pancreas, stomach, and
esophagus.
-Patients with longer- term survival : Head and neck carcinomas and
carcinoma of the colon
2-Metastases

64. Ultrasonographic Features :
• Multiple solid lesions of varying size and a hypoechoic halo
surrounding a liver mass.
• A halo around the periphery of a liver mass on sonography is an
ominous sign strongly associated with malignancy, particularly
metastatic disease but also HCC
• Different appearances :
a) Echogenic metastases
b) Hypoechoic
c) Target
d) Calcified
e) Cystic
f) Diffuse

66. a) Hyperechoic :
-Gastrointestinal origin or from HCC
-The more vascular the tumor , the more
likely the lesion to be echogenic
-Renal cell carcinoma , carcinoid ,
choriocarcinoma , vascular primaries &
islet cell carcinoma
-Mimic a hemangioma on sonography

68. b) Hypoechoic :
-Hypovascular
-Untreated metastatic breast or lung cancer ,
as well as gastric, pancreatic, and esophageal tumors
-Multiple hypoechoic hepatic masses is more
typical of primary NHL of the liver or lymphoma
associated with AIDS , however lymphomatous
masses may appear anechoic & septated ,
mimicking hepatic abscesses

71. c) Bull’s eye (target pattern) :
-Peripheral hypoechoic zone
-The appearance is nonspecific & common ,
although it is frequently identified in
metastases from bronchogenic carcinoma

73. d) Calcified metastases :
-Marked echogenicity & distal acoustic shadowing
-Mucinous adenocarcinoma , osteosarcoma ,
chondosarcoma , teratocarcinoma ,
neuroblastoma
-Calcium may appear as large , echogenic &
shadowing foci or more often shows
innumerable tiny punctate echogenicities without
clear shadowing

76. e) Cystic metastases :
- Ubiquitous benign hepatic cyst, including mural nodules,
thick walls, fluid- fluid levels, and internal septations
-Necrosis in sarcoma , cystic growth pattern as in
cystadenocarcinoma of ovary & pancreas & mucinous carcinoma of
colon

78. f) Diffuse (infiltrative) :
-Reflects infiltrative metastatic disease and is the most difficult
to appreciate on sonography, probably because of the loss of the
reference normal liver for comparison
-- Breast ,lung carcinomas and malignant melanomas
shows this pattern.
-The diagnosis can be difficult if the patient has a fatty liver from
chemotherapy

81. 3-Lymphoma
-Secondary involvement occurs in up to 50
% of patients with systemic lymphoma ,
but it frequently occult , primary hepatic
lymphoma is very rare
-Multiple hypoechoic hepatic masses + solid
masses at the spleen , kidney , chest …
+ lymphadenopathy

83. NHL in a 16-year-old girl, (a) US scan shows a large hypoechoic
nodule (M) in the right hepatic lobe, K = kidney, L = liver, (b) CT+C
shows low-attenuation nodular lesions (arrowheads), a few discrete
lesions are evident in both hepatic lobes, with small nodules in the
spleen and right kidney

84. Incidence :
-Most common primary malignant liver
tumor in children
-Age : < 2 years
Ultrasonographic Features :
-Large hepatic mass
-Mixed echogenicity (US), often hyperechoic relative to
adjacent liver
4-Hepatoblastoma

85. Transverse US image shows the hyperechoic mass with a lobular
margin and hypoechoic septa (arrowheads), arrow = portal vein

87. THANK YOU