Hypervascular Hepatic Focal Lesions: Spectrum of Imaging Features

doi:10.1067/j.cpradiol.2006.12.004

Current Problems in Diagnostic Radiology

Volume 36, Issue 3, May–June 2007, Pages 107-123

https://doi.org/10.1067/j.cpradiol.2006.12.004 Get rights and content

Detection and characterization of liver lesions often present a diagnostic challenge to the radiologists. Liver lesions may be classified as hypovascular and hypervascular based on degree of hepatic arterial blood supply. Common hypervascular liver lesions include hemangioma, focal nodular hyperplasia, hepatocellular adenoma, hepatocellular carcinoma, fibrolamellar carcinoma, and metastases from primary tumors such as islet cell tumor, carcinoid, renal cell carcinoma, melanoma, and thyroid carcinoma. In this review article, we discuss the spectrum of imaging features of hypervascular liver lesions.

Section snippets

Imaging Modalities

Ultrasound is an inexpensive and easily available imaging test for evaluation of liver lesions. It is highly sensitive for differentiation of solid from cystic liver lesion. However, routine transabdominal ultrasound is not as sensitive as computed tomography (CT) or magnetic resonance imaging (MRI) for detection and characterization of liver lesions.² Conversely, intraoperative ultrasound and laparoscopic ultrasound are highly sensitive for detecting liver lesions that are not seen on routine

Hypervascular Lesions

Common hypervascular liver lesions include hemangioma, focal nodular hyperplasia (FNH), hepatocellular adenoma (HCA), hepatocellular carcinoma (HCC), fibrolamellar carcinoma (FLC), and metastases from primary tumors such as islet cell tumor, carcinoid, renal cell carcinoma, melanoma, and thyroid carcinoma. Rare lesions that may present as hypervascular liver lesions include angiosarcoma, infantile hemangioendothelioma, peliosis hepatis, and intrahepatic splenosis. Other conditions that could

Hemangioma

Hemangioma is the most common benign liver neoplasm. Hemangiomas are more common in young adult females and can be multiple in 15 to 20% of cases. Histology shows a series of vascular lakes and channels, with larger lesions developing areas of thrombosis and fibrosis. Ultrasound reveals well-delineated, uniform, hyperechoic mass with faint acoustic enhancement (Fig 1).⁶ Larger lesions (> 6 cm) can become heterogenous and hypoechoic due to thrombosis, necrosis, and cystic degeneration.

Conclusion

In summary, hypervascular liver lesions include a spectrum of benign and malignant tumors and tumor-like liver conditions. MRI is gradually emerging as the imaging modality of choice for detection and characterization of liver lesions. Identification of contrast enhancement patterns is crucial for characterization of hypervascular liver lesions. A properly timed arterial phase scanning is critical to avoid imaging pitfalls for detection of hypervascular liver lesions with more delayed images

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Cited by (33)

Additional value of superb microvascular imaging of ultrasound examinations to evaluate focal liver lesions
2022, European Journal of Radiology
Citation Excerpt :
The current diagnostic challenge is how to effectively differentiate between benign and malignant FLLs because the management strategy and clinical outcomes are different between them [3]. However, because FLLs show various echogenicity and appearances on US images with considerable overlaps in US imaging findings, accurate characterization using US images is often challenging [4,5]. Tumor vascularity with an enhancement pattern often provides crucial information to characterize FLLs [6].
To evaluate the additional value of superb microvascular imaging (SMI) to characterize focal liver lesions (FLLs).
Between July 2020 and December 2020, 70 patients (39 men and 31 women; mean age [± standard deviation], 61.1 ± 10.1 years) with FLLs were prospectively enrolled and underwent B-mode ultrasound (US), color Doppler imaging (CDI), power Doppler imaging (PDI), and SMI examinations on the same day. All the malignant FLLs were confirmed by histological diagnosis, while the benign FLLs were confirmed by typical imaging features at contrast-enhanced CT and/or MRI. Tumor vascularity scores in CDI, PDI, and SMI were graded using a 5-point scale. For tumors in which vascularity was detected on SMI, tumor vascular pattern on SMI was assessed in each lesion. The diagnostic performance of a combination of B-mode US and SMI, based on vascular pattern on SMI, was compared to B-mode US alone to diagnose malignant lesions; and hemangiomas.
Seventy FLLs (34 benign [31 hemangiomas, 3 focal nodular hyperplasias] and 36 malignant tumors [16 hepatocellular carcinomas, 10 cholangiocarcinomas, 10 metastases]) were enrolled. Tumor vascularity score in SMI was significantly higher than those in CDI and PDI (P < 0.001). Using a combination of B-mode US and SMI, the diagnostic performance was improved from 0.867 and 0.834 to 0.945 and 0.921 (P = 0.035 and 0.112) to diagnose malignant tumors and from 0.896 and 0.853 to 0.975 and 0.987 (P = 0.027 and 0.006) to diagnose hemangiomas by reviewers 1 and 2, respectively.
SMI provides higher sensitivity than CDI and PDI to detect tumor vascularity, and a combination of B-mode US and SMI can improve the characterization of FLLs when vascular pattern of tumor is considered.
Diagnostic Value of High Frame Rate Contrast-enhanced Ultrasonography and Post-processing Contrast Vector Imaging for Evaluation of Focal Liver Lesions: A Feasibility Study
2020, Ultrasound in Medicine and Biology
Citation Excerpt :
Besides, US is typically used to post-operatively monitor hepatic metastasis from common malignancies such as colorectal (Mishima et al. 2016; Schneider et al. 2019) or breast cancer (Mishima et al. 2016). However, its accuracy in the characterization of focal liver lesions is limited (Namasivayam et al. 2007; D’Onofrio et al. 2015) and further evaluation using other imaging modalities is needed in most cases. Contrast-enhanced US (CEUS) is a real-time dynamic imaging technique that plays an important role in this setting by providing information regarding the vascularities and enhancement patterns of focal liver lesions (Schellhaas et al. 2016; Terzi et al. 2018).
This study evaluated the feasibility of contrast vector imaging (CVI) to characterize focal liver lesions. From July to October 2019, we prospectively enrolled 30 patients with focal liver lesions (hepatocellular carcinoma [HCC] [n = 19], metastasis [n = 8], combined HCC-cholangiocarcinoma [CC] [n = 1], intra-hepatic CC [n = 1] and sclerosed hemangioma [n = 1]). Contrast-enhanced ultrasound (CEUS) was performed with high frame rate contrast harmonic imaging technique by one radiologist, and post-processing CVI was obtained and analyzed by two radiologists. On combined CVI with CEUS, the staining pattern was significantly predominant in HCCs (9/11, 81.8%), while peripheral rim was frequent in non-HCCs (5/8, 62.5%) (p = 0.020). HCCs exhibited feeding arteries (8/11, 45.5%) and high velocity variance (10/11, 90.9 %), whereas non-HCCs showed detour pattern (4/8, 50.0%) with either a high or low velocity variance (4/8, 50.0%, both), with no significant inter-group differences (p = 0.052 and 0.080, respectively). In conclusion, CVI was feasible and provided quantitative and multi-parametric information of different types of hepatic tumors.
Superb microvascular imaging technology for ultrasound examinations: Initial experiences for hepatic tumors
2016, European Journal of Radiology
Citation Excerpt :
Therefore, the detection and characterization of focal liver lesions on US are crucially important in clinical practice. However, the exact characterization of focal liver lesions using US images is often difficult due to the variable echogenicities and appearances of focal liver lesion [7–9]. Information regarding vascularity with an enhancement pattern provides an important clue for the exact characterization of a focal liver lesion.
To explore whether superb microvascular imaging (SMI) technology could be helpful for the evaluation of hepatic tumors.
Our institutional review board approved this study, and informed consent was obtained from all of the patients. Twenty-three patients with 29 hepatic tumors were enrolled in our study. The tumors consisted of hemangiomas (n = 15), focal nodular hyperplasias (FNHs) (n = 7), and hepatocellular carcinomas (n = 7). All lesions were pathologically (n = 2) or radiologically (n = 27) confirmed. The mean tumor diameter was 1.9 cm (range, 0.9 cm to 5.0 cm). Using SMI technology, all lesions were scanned and categorized into subgroups according to the flow pattern on the SMI.
The hemangiomas exhibited nodular rim patterns (33%) and spotty dot-like patterns (20%), and both of these findings were very specific for the diagnosis of hemangioma. The FNHs exhibited spoke-wheel patterns (43%) and radiating vessel patterns (29%) that were very specific findings for the diagnosis of FNH. The other tumors did not exhibit any specific patterns on SMI.
Evaluations of the inner vascularities of hepatic tumors with the SMI technique were feasible, and the SMI features were significantly different between the different types of hepatic tumors. These differences could aid the diagnoses of hepatic tumors with US.
DW-MRI of liver lesions: Can a single ADC-value represent the entire lesion?
2014, Clinical Radiology
Citation Excerpt :
Haemangiomas consist of a series of vascular lakes and channels. Areas of thrombosis, fibrosis, necrosis, and cystic degenerations can also be encountered within haemangiomas.11 These zones of different histopathological features and differential rates of perfusion within a haemangioma may explain the heterogeneity of haemangiomas on ADC maps.
To evaluate whether focal liver lesions (FLLs) exhibit a homogeneous appearance on apparent diffusion coefficient (ADC) maps and whether there is inter-section variation in the calculated ADC values of FLLs (inter-section range).
Eighty-eight patients with 128 FLLs (70 benign, 58 malignant) who underwent abdominal magnetic resonance imaging (MRI) including diffusion-weighted (DW)-MRI were included. Two observers evaluated variation of signal intensity of each FLL within each ADC map image (intra-section) and among different ADC map images through the lesion (inter-section). ADC values of each FLL and neighbouring liver parenchyma were measured on all sections. The inter-section range of FLLs was compared with the neighbouring liver parenchyma.
Intra-section inhomogeneity was noted in 39.8% (97/244 sections) and 38.9% (95/244) of benign lesions, and 61% (114/187 sections) and 61.5% (115/187) of malignant lesions, by observer 1 and observer 2, respectively. Inter-section inhomogeneity was noted in 25.7% (18/70) and 27.1% (19/70) of benign lesions, and 51.7% (30/58) and 50% (29/58) of malignant lesions, by observer 1 and observer 2, respectively. The inter-section range for both benign (0.28 × 10⁻³ mm²/s) and malignant (0.25 × 10⁻³ mm²/s) FLLs were significantly greater than that of liver parenchyma surrounding benign (0.16 × 10⁻³ mm²/s, p < 0.001) and malignant (0.14 × 10⁻³ mm²/s, p = 0.01) FLLs.
Due to intra-/inter-section variations in ADC values of benign and malignant FLLs, a single ADC value may not reliably represent the entire lesion.
Advanced stages of melanoma: Role of structural imaging
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Citation Excerpt :
However, CT is limited because of its association with radiation exposure and difficulty in characterizing lesions less than 1 cm in size. MR imaging has emerged as the imaging modality of choice for detection and characterization of liver lesions.26 MR imaging has a high lesion/liver contrast ratio and is not associated with a risk of radiation exposure.26
Characterization of Primary and Malignant Liver Lesions using Texture Analysis
2023, International Journal of Biomedicine

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Original articleHypervascular Hepatic Focal Lesions: Spectrum of Imaging Features

Section snippets

Imaging Modalities

Hypervascular Lesions

Hemangioma

Conclusion

Eur J Ultrasound

Radiol Clin North Am

Embryology, histology, gross anatomy, and normal imaging anatomy of the liver

Imaging the liver

Oncologist

Intraoperative ultrasonography versus helical computed tomography and computed tomography with arterioportography in diagnosing colorectal liver metastases: Lesion-by-lesion analysis

World J Surg

MR imaging of liver tumors

Radiol Clin North Am

Benign liver neoplasms and tumor-like conditions

Hepatic cavernous hemangiomas: Simple diagnostic sign with dynamic bolus CT

Radiology

Original article
Hypervascular Hepatic Focal Lesions: Spectrum of Imaging Features