From the Guidelines
No follow-up imaging is recommended for this 66-year-old female patient. The ultrasound findings reveal only benign hepatic cysts with internal septations but no solid components or vascularity, which are common incidental findings that do not require additional imaging 1. The geographic hypoechoic region near the hepatic hilum likely represents focal fat sparing, another benign finding in the setting of mild hepatic steatosis (fatty liver). These findings adequately explain the low-density nodules initially seen and do not suggest any malignant or concerning lesions that would warrant further investigation. Simple hepatic cysts are fluid-filled structures that occur in approximately 2.5-18% of the population and typically remain stable over time. Since the ultrasound has characterized these lesions as benign cysts without suspicious features, and no solid hepatic lesions were identified, routine surveillance is unnecessary. The patient can be reassured about the benign nature of these findings.
The guidelines for the management of hepatocellular carcinoma, as outlined in the 2022 KLCA-NCC Korea practice guidelines 1, do not apply to this patient's situation, as the ultrasound findings do not meet the criteria for "definite" or "probable" HCC. The patient's lesions do not exhibit any of the ancillary imaging features that would suggest malignancy, such as mild-to-moderate T2 hyperintensity, restricted diffusion, or threshold growth. Therefore, based on the most recent and highest quality evidence, no further imaging or follow-up is necessary.
It is worth noting that older guidelines, such as those from the American Association for the Study of Liver Diseases (AASLD) in 2005 1, may have recommended more frequent surveillance or biopsy for certain types of lesions. However, these guidelines are outdated and have been superseded by more recent evidence. In this case, the patient's benign ultrasound findings and lack of suspicious features make further imaging or follow-up unnecessary.
From the Research
Follow-up Imaging Recommendations
The patient's ultrasound results showed diffuse increased echogenicity related to mild cytosis, multiple cysts with internal septation, and a geographic hypoechoic region adjacent to the hepatic hilum, likely representing focal fat sparing. Given these findings, follow-up imaging may be recommended to monitor the patient's condition and detect any potential development of hepatocellular carcinoma (HCC).
Imaging Modalities
- MRI is considered a valuable imaging modality for assessing cirrhosis and its complications, including HCC 2, 3, 4.
- MRI provides better intrinsic soft-tissue contrast and can characterize lesions more accurately than other imaging modalities 3, 5.
- Dynamic contrast-enhanced MRI can help differentiate benign from malignant lesions based on enhancement patterns 3, 4.
Risk of Progression to HCC
- New arterial phase enhancing nodules in patients with cirrhosis frequently progress to HCC 6.
- Factors such as serum α-fetoprotein level, hepatitis B or C virus infection, and presence of other HCCs are strong predictors of progression to HCC 6.
- LI-RADS classification can help categorize nodules and predict the risk of progression to HCC 6.