Management Of Focal Liver Lesions Research Articles

Imaging features and management of focal liver lesions

Notably, the number of incidentally detected focal liver lesions (FLLs) has increased dramatically in recent years due to the increased use of radiological imaging. The diagnosis of FLLs can be made through a well-documented medical history, physical examination, laboratory tests, and appropriate imaging methods. Although benign FLLs are more common than malignant ones in adults, even in patients with primary malignancy, accurate diagnosis of incidental FLLs is of utmost clinical significance. In clinical practice, FLLs are frequently evaluated non-invasively using ultrasound (US), computed tomography (CT), and magnetic resonance imaging (MRI). Although US is a cost-effective and widely used imaging method, its diagnostic specificity and sensitivity for FLL characterization are limited. FLLs are primarily characterized by obtaining enhancement patterns through dynamic contrast-enhanced CT and MRI. MRI is a problem-solving method with high specificity and sensitivity, commonly used for the evaluation of FLLs that cannot be characterized by US or CT. Recent technical advancements in MRI, along with the use of hepatobiliary-specific MRI contrast agents, have significantly improved the success of FLL characterization and reduced unnecessary biopsies. The American College of Radiology (ACR) appropriateness criteria are evidence-based recommendations intended to assist clinicians in selecting the optimal imaging or treatment option for their patients. ACR Appropriateness Criteria Liver Lesion-Initial Characterization guideline provides recommendations for the imaging methods that should be used for the characterization of incidentally detected FLLs in various clinical scenarios. The American College of Gastroenterology (ACG) Clinical Guideline offers evidence-based recommendations for both the diagnosis and management of FLL. American Association for the Study of Liver Diseases (AASLD) Practice Guidance provides an approach to the diagnosis and management of patients with hepatocellular carcinoma. In this article, FLLs are reviewed with a comprehensive analysis of ACR Appropriateness Criteria, ACG Clinical Guideline, AASLD Practice Guidance, and current medical literature from peer-reviewed journals. The article includes a discussion of imaging methods used for the assessment of FLL, current recommended imaging techniques, innovations in liver imaging, contrast agents, imaging features of common nonmetastatic benign and malignant FLL, as well as current management recommendations.

ACG Clinical Guideline: Focal Liver Lesions.

Focal liver lesions (FLLs) have become an increasingly common finding on abdominal imaging, especially asymptomatic and incidental liver lesions. Gastroenterologists and hepatologists often see these patients in consultation and make recommendations for management of multiple types of liver lesions, including hepatocellular adenoma, focal nodular hyperplasia, hemangioma, and hepatic cystic lesions including polycystic liver disease. Malignancy is important to consider in the differential diagnosis of FLLs, and healthcare providers must be familiar with the diagnosis and management of FLLs. This American College of Gastroenterology practice guideline uses the best evidence available to make diagnosis and management recommendations for the most common FLLs.

Sonographische Differenzialdiagnostik fokaler Leberläsionen

Rapid diagnostic assessment is crucial for the clinical management of focal liver lesions. In addition to standard B‑mode sonography, color-coded Doppler sonography and contrast-enhanced ultrasound are widely used for the classification of liver tumors. In gastroenterology, clinical sonography plays an important role in the detection of tumors, in the follow-up of oncological patients and for the screening for hepatocellular carcinoma. Thereby, correctly classifying focal liver lesions essentially requires the interpretation of ultrasound findings in the clinical context (e.g., incidental finding, known risk factors, history of liver cirrhosis or malignant disease). In this review, we summarize the available ultrasound techniques for the characterization of focal liver lesions and discuss their importance and relevance for the differential diagnosis and further diagnostic and therapeutic management.

Elastography for characterization of focal liver lesions: current evidence and future perspectives.

Focal liver lesions (FLLs) are a common finding during routine abdominal ultrasound (US). The differential diagnosis between diverse types of FLLs, especially between benign and malignant ones, is extremely important and can often be particularly challenging. Radiological techniques with contrast administration and/or liver biopsy are mostly necessary for establishing diagnosis, but they have several contraindications or complications. Due to limitations of these tools, there is urgent and still unmet need to develop a first line, non-invasive and simple method to diagnose FLLs. Elastography is an US-based imaging modality that provides information about the physical parameter corresponding to the tissue stiffness and can be considered a virtual biopsy. Several elastographic approaches have been developed, such as transient elastography, strain imaging and share wave imaging, which include point shear wave elastography and 2D shear wave elastography. These tools are already in use for evaluating liver fibrosis and in the assessment of focal lesions in other organs, like breast and thyroid gland. This review aims to assess the current evidence of different techniques based on elastography in the setting of FLLs, in order to evaluate accuracy, limitations and future perspectives. In particular, we focused on two contexts: the ability of discriminating between benign and malignant lesions, especially hepatocellular carcinoma and liver metastasis, and the surveillance after percutaneous therapy. This could have a high clinical impact making elastography crucial to identify the appropriate management of FLLs.

A Comprehensive Narrative Review on the Evolving Role of Endoscopic Ultrasound in Focal Solid Liver Lesions Diagnosis and Management.

The implications of endoscopic ultrasound (EUS) have expanded considerably in recent years to cover more fields in invasive gastroenterology practice, as both an investigative and therapeutic modality. The utility of EUS in the diagnosis and management of focal liver lesions has gained a special attractiveness recently. The EUS probe proximity to the liver and its excellent spatial resolution enables real-time images coupled with several enhancement techniques, such as contrast-enhanced (CE) EUS. Aside from its notable capability to execute targeted biopsies and therapeutic interventions, EUS has developed into a hopeful therapeutic tool for the management of solid liver lesions. Herein, we provide a comprehensive state-of-the-art review on the efficacy and safety of EUS in the diagnosis and management of focal solid liver lesions. Medline/PubMed and Embase database searches were conducted by two separate authors (T.K. and W.S.), all relevant studies were assessed, and relevant data was extracted and fully reported. EUS-guided diagnosis of focal liver lesions by sonographic morphologic appearance and cytological and histopathological finding of biopsies obtained via fine needle aspiration/biopsy have been shown to significantly improve the diagnosis of solid liver lesions compared with traditional imaging tools. Similarly, EUS-guided treatment has been shown to consistently have excellent technical success, high efficacy, and minor adverse events. The evolving valuable evidences of EUS utility might satisfy the unmet need of optimizing management of focal solid liver lesions.

Elastography for characterization of focal liver lesions: current evidence and future perspectives.

Focal liver lesions (FLLs) are a common finding during routine abdominal ultrasound (US). The differential diagnosis between diverse types of FLLs, especially between benign and malignant ones, is extremely important and can often be particularly challenging. Radiological techniques with contrast administration and/or liver biopsy are mostly necessary for establishing diagnosis, but they have several contraindications or complications. Due to limitations of these tools, there is urgent and still unmet need to develop a first line, non-invasive and simple method to diagnose FLLs. Elastography is an US-based imaging modality that provides information about the physical parameter corresponding to the tissue stiffness and can be considered a virtual biopsy. Several elastographic approaches have been developed, such as transient elastography, strain imaging and share wave imaging, which include point shear wave elastography and 2D shear wave elastography. These tools are already in use for evaluating liver fibrosis and in the assessment of focal lesions in other organs, like breast and thyroid gland. This review aims to assess the current evidence of different techniques based on elastography in the setting of FLLs, in order to evaluate accuracy, limitations and future perspectives. In particular, we focused on two contexts: the ability of discriminating between benign and malignant lesions, especially hepatocellular carcinoma and liver metastasis, and the surveillance after percutaneous therapy. This could have a high clinical impact making elastography crucial to identify the appropriate management of FLLs.

Contrast-enhanced ultrasound (CEUS) prediction of focal liver lesions in patients after liver transplantation in comparison to histopathology results.

To investigate the value of contrast-enhanced ultrasound (CEUS) in histologic prediction of focal liver lesions after liver transplantation. 10 focal liver lesions in 10 patients after liver transplantation were scanned using CEUS and the CEUS results were compared with the histopathological results. Among 10 focal liver lesions, 7 proofed to be histopathological benign and 3 lesions proofed to be histopathological malignant. All lesions (100%) were correctly report as benign or malignant in the report of the CEUS examination. CEUS can be helpful in the differentiation of benign and malignant focal liver lesions in patients after liver transplantation and can be used in clinical management of focal liver lesions.

Recommendations of ACG clinical guideline: the diagnosis and management of focal liver lesions

Recommendations of ACG clinical guideline: the diagnosis and management of focal liver lesions

Description of focal liver lesions with Gd-EOB-DTPA enhanced MRI.

Imaging procedures play a fundamental role in the therapeutic management of focal liver lesions. The goals of imaging are to detect and correctly characterize focal liver lesions. This review highlights the performances of newer, liver-specific, contrast media in the diagnosis of focal liver lesions, particularly Gd-EOB-DTPA (Primovist), the most frequently used liver specific contrast media.It has been shown, in different papers, that Gd-EOB-DTPA has better performances compared to either triphasic contrast enhanced computed tomography or dynamic MRI in both detection and characterization of hepatocellular carcinoma on the cirrhotic liver. Therefore liver MRI with Primovist is considered, in many centers, the “state-of-the-art” imaging examination of the liver before surgery or liver transplantation.Gd-EOB-DTPA is also useful in the differential diagnosis of benign hypervascular focal liver lesions such as adenomas or focal nodular hyperplasias.

ACG clinical guideline: the diagnosis and management of focal liver lesions.

Focal liver lesions (FLL) have been a common reason for consultation faced by gastroenterologists and hepatologists. The increasing and widespread use of imaging studies has led to an increase in detection of incidental FLL. It is important to consider not only malignant liver lesions, but also benign solid and cystic liver lesions such as hemangioma, focal nodular hyperplasia, hepatocellular adenoma, and hepatic cysts, in the differential diagnosis. In this ACG practice guideline, the authors provide an evidence-based approach to the diagnosis and management of FLL.

Diagnostic efficacy of gadoxetic acid (Primovist)-enhanced MRI and spiral CT for a therapeutic strategy: comparison with intraoperative and histopathologic findings in focal liver lesions

A multicenter study has been employed to evaluate the diagnostic efficacy of magnetic resonance imaging (MRI) using the new liver-specific contrast agent gadoxetic acid (Gd-EOB-DTPA, Primovist), as opposed to contrast-enhanced biphasic spiral computed tomography (CT), in the diagnosis of focal liver lesions, compared with a standard of reference (SOR). One hundred and sixty-nine patients with hepatic lesions eligible for surgery underwent Gd-EOB-DTPA-enhanced MRI as well as CT within 6 weeks. Pathologic evaluation of the liver specimen combined with intraoperative ultrasound established the SOR. Data sets were evaluated on-site (14 investigators) and off-site (three independent blinded readers). Gd-EOB-DTPA was well tolerated. Three hundred and two lesions were detected in 131 patients valid for analysis by SOR. The frequency of correctly detected lesions was significantly higher on Gd-EOB-DTPA-enhanced MRI compared with CT in the clinical evaluation [10.44%; 95% confidence interval (CI): 4.88, 16.0]. In the blinded reading there was a trend towards Gd-EOB-DTPA-enhanced MRI, not reaching statistical significance (2.14%; 95% CI: -4.32, 8.6). However, the highest rate of correctly detected lesions with a diameter below 1 cm was achieved by Gd-EOB-DTPA-enhanced MRI. Differential diagnosis was superior for Gd-EOB-DTPA-enhanced MRI (82.1%) versus CT (71.0%). A change in surgical therapy was documented in 19 of 131 patients (14.5%) post Gd-EOB-DTPA-enhanced MRI. Gd-EOB-DTPA-enhanced MRI was superior in the diagnosis and therapeutic management of focal liver lesions compared with CT.

Clinical management of focal liver lesions: the key role of real-time contrast-enhanced US

Ultrasonography (US) is the most commonly used liver imaging modality worldwide. Unfortunately, it has limited sensitivity in the detection of small tumor nodules. Moreover, US findings are often nonspecific, as appearances of benign and malignant liver lesions overlap. The introduction of microbubble contrast agents and the development of contrast-specific techniques have opened new prospects in liver US. The advent of second-generation agents that enable continuous real-time contrast-enhanced imaging has been instrumental in improving the acceptance and reproducibility of the examination. With the publication of guidelines for the use of contrast agents in liver US by the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB), contrast-enhanced US has entered clinical practice. The guidelines define the indications and recommendations for the use of contrast agents in focal liver lesion detection, characterization, and posttreatment follow-up. Recently, the clinical value of contrast US as a reliable alternative to CT or MR imaging in characterizing hepatocellular carcinoma in cirrhosis has been endorsed by the practice guideline document issued by the American Association for the Study of Liver Diseases and the 2005 Monothematic Conference on Hepatocellular Carcinoma of the European Association for the Study of the Liver. In this article, the current role of contrast US in the diagnostic management of focal liver lesions is discussed with regard to the following clinical scenarios: (1) characterization of incidental findings; (2) diagnosis of hepatocellular carcinoma in patients with cirrhosis; and (3) identification of hepatic metastases in oncology patients; (4) guidance and monitoring of tumor ablation procedures.