Download - Benign focal lesions in liver
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BENIGN FOCAL LESIONS IN LIVER
DR.SAJITH .S
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CELL OF ORIGIN
• Hepatocellular.• Cholangiocellular.• Mesenchymal.
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Hepatocellular origin
• Adenoma• Focal Nodular Hyperplasia ( FNH )• Hepatocellular Nodules in Cirrhosis.• Nodular Regenerative Hyperplasia ( NRH ).
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Cholangiocellular origin
• Hepatic Cyst.• Biliary Hamartomas.• Peribiliary Cyst.• Biliary adenoma.• Biliary Cystadenoma.• Caroli Disease.• Biliary Papillomatosis.
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Mesenchymal origin
• Cavernous Hemangioma.• Hemangioendothelioma( adult, infantile )• Focal Fat.• Angiomyolipoma.• Lipoma.• Peliosis Hepatis.• Paraganglioma.
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Cavernous hemangioma
• Most common primary liver tumor.
• All age groups. • females >> males.• Size less than 1 cm to 30
cm (giant hemangioma).
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Clinical presentation
• No signs and symptoms.• When tumor exceeds 4 cm ,abdominal
pain/discomfort or a palpable mass.• Rupture occurs rarely.
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characteristics
• Usually solitary.• Borders are clear.• Not encapsulated.• Various degenerative changes are seen in its
centre.– Old and new thrombus formation.– Necrosis, scarring, hemorrhage & calcification.
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usg
• Focal, homogenous, hypo vascular and hyperechoic lesions.
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ct
• Hypodense area with same density of aorta.• Arterial phase-peripheral enhancement is seen
first, followed by gradual filling towards the centre.
• Equilibrium phase-prolonged enhancement.• In precontrast, arterial, equilibrium phases
tumor density is similar to that of aorta.
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mri• Hypointense on T1.• Hyperintense on T2.• In T2 signal intensity is higher than that of
spleen.
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Focal nodular hyperplasia
• Second common benign lesion.• Female >> male. 8:1• Reactive change to abnormal circulation.• Well defined lesion characterized by a central
fibrous scar.
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Clinical presentation
• Usually asymptomatic.• Epigastric pain and hepatomegaly are seen
frequently.
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characteristics
• Well-demarcated.• Solitary mass without a capsule.• Often located beneath the surface of liver.• In central scar - feeding arteries, draining veins
connecting to hepatic vein.• Necrosis and hemorrhage usually not seen.
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usg• Iso to hypoechoic.• Colour doppler-central vascularity.
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ct
• Homogenous hypodense mass with a central scar showing more marked hypodense.
• Arterial phase- brisk homogenous enhancement.• Portal phase-early wash out.• Delayed phase-barely visible.• If vessels radiating from central scar to the
periphery of the tumor is visualized , a near definite diagnosis of FNH.
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mri
• Iso - hypointense on T1.• Hyper - isointense on
T2.• Central scar– Hypointense on T1.– Hyperintense on T2.
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Adenoma
• Rare benign tumor in younger age group compared to FNH.
• Solitary (80%).• Females (90%).• Predisposing factors-oral contraceptives,
anabolic steroids and glycogen storage disease.
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Clinical presentation
• Abdominal mass.• Recurrent abdominal pain.• Acute abdomen (tumor rupture).
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Characteristics
• Clear border• No capsule (fibrous capsule in some cases)• Core - bleeding, necrosis, scar tissue• Contains-fat & glycogen• Neither portal vein nor bile ducts
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usg
• May be hypo, iso, hyperechoic.• Typically heterogenous with areas of fluid
component.• Variable degrees of hemorrhage, necrosis &
fat.• Calcification rare.
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ct
• Hypodense mass.• Hyper attenuation areas in
case of ruptured.• Area of necrotic foci and
scar tissue – hypodense areas
• Calcification is rare.• Moderate tumor
enhancement in atrerial phase.
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mri
• Hyper to isointense on T1• Hypo to hyperintense on T2• Hemorrhagic tumor hyperintense on T1 & T2
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Hepatocellular nodules in cirrhosis
• Classified as regenerative nodule, dysplastic nodule.
• Regenerative nodules:– USG and CT –too small to detect.–When regenerative nodules contain iron, they are
termed siderotic nodules.– Siderotic nodules- hyperdense on UECT and
hypointense on both T1 and T2.
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• Dysplastic nodules :– Rarely diagnosed by USG or CT–MRI- Isointense with hyperintense foci on T1– Hypo on T2.(opposite to HCC).
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angiomyolipoma
• Rare benign tumor.• Composed of mature fat, blood vessels and
smooth muscle cells.• It is not capsulated.• Tuberous sclerosis is a known association of
hepatic angiomyolipoma.
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usg
• Circumscribed hyperechoic lesion.
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ct
• Solid mass containing markedly hypodense area.
• Arterial phase- partially enhancement often with visualization of large central vessels.
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mri
• Hyperintense on both T1 & T2.• Decreased intensity with fat suppression.
T1 Fat sup T1
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Hepatic cyst
• Single/multiple.• Lined by single layer of cuboidal epithelium.• Older adults
• Clinical presentation– Asymptomatic– Compressive symptoms (massive).
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usg
• Fine cystic lesion with partial or complete septa are often visualized.
• In case of complications – debris, thickened septa and complex internal fluid.
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ct• Smooth rimmed
hypodense mass.• HU value near zero.• No enhancement at all
on CECT.
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mri
• Hypointense on T1.• Extremely hypointense on T2.
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Infantile hemangioendothelioma
• Common infant benign lesion.• Resembles capillary hemangioma seen in
infantile skin and mucosa.• With in 6 months of birth.• Solitary mass but may be multifocal.• Typically large (1-20 cm).
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Clinical presentation
• Hepatomegaly.• Abdominal mass.• congestive heart failure.• Bleeding,anemia,thrombocytopenia.• Cutaneous hemangioma.• Occasionally jaundice.
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ct• Hypodense area.• 16%- calcification and hemorrhage.• CECT – similar to that of cavernous
hemangiomas.• MRI-Resemble those of hepatic hemangioma.
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Biliary cystadenoma
• Multi locular cystic liver mass.• Originates from bile duct.• Usually right hepatic lobe.• Adults, Females >> males.• Malignant transformation to cystadenocarcinoma
is not uncommon.
• Clincal presentation– Chronic abdominal pain.
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usg
• Hypoechoic cystic lesion .• Intracystic soft tissue components may be
present.• Focal calcification can occur.
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ct• UECT – well defined hypodense lesion.• Wall and internal septations are often
visualized (differentiate from simple cyst).• CECT – cyst wall and soft tissue component
typically enhance.
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Hepatic abscess
• Commonly – pyogenic,amebic and fungal.• Via – portal vein, hepatic artery or bile duct.• Solitary or multiple.
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ct
• Pyogenic – double structured hypodense area.– CECT : double target sign.( arterial phase)• Thick ring like stain (portal and venous phase)
• Amoebic – CECT- enhanced mural structure with hypodense area at its lateral side owing to the presence of oedema.
• Fungal – CECT – faint ring like enhancement (arterial phase )– Hypodense (venous phase).
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Hydatid cyst
• All age group.• Caused by larva stage of adult tape worm.
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Ct and mri
• Thick walled cystic lesions with internal round periphery daughter cysts.
• Attenuation and signal intensity in mother cyst is more than daughter cyst.
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Common Benign lesions in liver
Common benign lesions
Scar Caps Ca++ Fat Blood Cystic
Hemangioma + + +FNH + +Adenoma + + +Abscess +Cystadenoma + +Angiomyolipoma +
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benign lesions
• Hyper vascular– Hemangioma.– Adenoma.– FNH.
• Scar– FNH– Hemangioma