Diagnosis and Management of Benign Liver Tumors

Laurence Chiche; Jean-Philippe Adam

Semin Liver Dis. 2013;33(3):236-247.

Conclusion

Practitioners are increasingly presented with BLTs and the need to make clinical decisions as to their treatment. The diagnostic workup identifies the tumors that must be removed, the tumors that should be monitored, and the tumors that may be ignored, and this analysis requires extensive knowledge of the characteristics of the various tumors.^[97] The goal of surgery depends on the symptoms and on the nature of the tumor. The clinical challenge is to perform safe symptomatic surgery, to justify preventive surgery, and to decrease the rate of diagnostic surgery.

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Acknowledgments
We wish to thank Professor Paulette Bioulac-Sage (CHU Bordeaux, Department of Pathology, Hôpital Pellegrin) for the critical review of this manuscript.

Table 1. Ten benign liver tumor aphorisms
Male sex and benign liver tumor: an a priori suspicious combination. The major risk of a benign liver tumor is … that it is not benign. Benign does not always mean without risk. To reassure a patient, you have to be sure. Your best partner in the management of benign liver tumors is the radiologist. An asymptomatic patient is likely to become symptomatic after surgery. It is not because the tumor is easy to remove that it has to be removed. Sometimes, it is easier to remove a benign liver tumor from the liver than from the mind. Liver surgery should always be justified and safe; however, in the case of benign liver tumors, be even more stringent. The five characteristics of ideal liver surgery for benign liver tumors include useful, liver-parenchyma preserving, 0 mortalities, 0 transfusions, and 0 adverse effects.

Table 2. .Imaging studies of the most common benign liver tumors
	US	CEUS	CT	MRI	Best diagnostic yield	Differential diagnoses
Hemangioma	Small: Well-defined hyperechoic (90%), homogeneous (70%) mass Giant: heterogeneous, hypoechoic if hemorrhage, fibrosis or calcifications) Doppler: low flow	Arterial phase: Discontinuous peripheral nodular enhancement Portal and late phases: Progressive and centripetal fill in	Low density on unenhanced images Discontinuous peripheral nodular enhancement after IV contrast medium Progressive contrast fill-in	T1: Hypointense T2: Hyperintense Discontinuous peripheral enhancement with progressive centripetal fill-in (Se > 95%-Sp = 95%) Atypical: 10%	US ± MRI (95%)	Angiosarcoma, angiomyolipoma, neuroendocrine metastases, metastases from renal, breast carcinoma
Focal nodular hyperplasia	Isoechoic, homogeneous, not encapsulated, Central hyperechoic area Central arterial signal (60%) Doppler: high flow (Se < 70%)	Arterial phase: Hyperenhancement Portal and late phases: isoenhancement	Unenhanced well-defined hypo- or isodense lesion, central scar (50%) Arterial phase: homogeneous hyperenhancement Portal and late phases: isoenhancement	T1: Isointense T2: Isointense or slightly hyperintense Hyperintense central scar after enhancement during delayed phase (Se, Sp > 95%)	US + MRI (80%)	Fibrolamellar HCC (calcified central scar), HCA
Hepatocellular adenoma	Unspecific Heterogeneous Hyperechoic if steatotic anechoic if hemorrhage	Arterial phase: Hyperenhancement; Portal phase: Hypoenhancement Late phase: No enhancement	Unspecific Unenhanced well-defined hypo or isodense lesion, no central scar Arterial phase: Homogeneous hyperenhancement or Necrotic/hemorrhagic areas	HNF1-α: Signal lost on chemical shift; homogeneous, discrete arterial enhancement without persistence during delayed phase	?	HCC FNH
				Inflammatory: Hyperintense T2 with strong peripheral signal, persistent enhancement and delayed washout
				Beta-catenin/unclassified: No specific sign
Hepatic cyst	Homogeneous anechoic fluid-filled space, no borders, posterior acoustic enhancement	No enhancement	Isodense to water, well-defined, without borders	T1: Hypointense T2: Isointense to fluid	US ± MRI	Hydatic cyst
Hepatobiliary cystadenoma	Anechoic, irregular borders, internal septations	Arterial phase: Hyperenhancement of cystic wall, internal septations and solid portion, progressive washout; Portal and late phases: Hypoenhancement	Isodense with thick wall, mural nodules, and internal septations	T1: Multilocular mass with homogeneous hypointensity	US + MRI	Cystadenocarcinoma

Abbreviations: CEUS, contrast-enhanced ultrasound; CT, computed tomography; HCA, hepatocellular adenoma; HCC, hepatocellular carcinoma; HNF1-α, hepatocyte nuclear factor-1 α; FNH, focal nodular hyperplasia; IV, intravenous; MRI, magnetic resonance imaging; Se, sensitivity; Sp, specificity; US, ultrasound.

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Diagnosis and Management of Benign Liver Tumors

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