What are the next steps for a patient with moderate hepatic (liver) steatosis and two new liver lesions, including one measuring 2.7 cm in segment 4A, with a differential diagnosis including benign and malignant etiologies?

From the Guidelines

For a patient with moderate hepatic steatosis and two new liver lesions, including a 2.7 cm lesion in segment 4A with an uncertain diagnosis, the next steps should include a comprehensive diagnostic workup with a multiphasic contrast-enhanced MRI with liver-specific contrast agents, as recommended by the most recent guidelines 1. This approach is crucial for characterizing the lesions and determining the appropriate management strategy. The patient's history and clinical examination should also be considered, including risk factors for chronic liver disease and symptoms attributable to the liver, as outlined in the guidelines for hepatocellular carcinoma diagnosis and treatment 1.

Some key points to consider in the diagnostic workup include:

• The use of MRI with liver-specific contrast agents, such as gadoxetate disodium/Eovist, to better characterize the lesions 1
• Laboratory tests, including liver function tests (ALT, AST, bilirubin, albumin), alpha-fetoprotein (AFP), and other tumor markers like CA 19-9 and CEA 1
• Consultation with a hepatologist and possibly a multidisciplinary liver tumor board to discuss the findings and determine the best course of action 1
• Consideration of a CT-guided or ultrasound-guided liver biopsy of the 2.7 cm lesion if the MRI findings remain inconclusive, as recommended by the guidelines for liver lesion characterization 1

While awaiting the results of these diagnostic tests, the patient should be counseled on lifestyle modifications to address the hepatic steatosis, including weight loss if overweight, limiting alcohol consumption, controlling diabetes if present, and reducing intake of processed foods and sugars. These diagnostic steps are crucial because the 2.7 cm lesion could represent various conditions ranging from benign (like focal nodular hyperplasia or adenoma) to malignant (hepatocellular carcinoma or metastasis), and proper management depends entirely on an accurate diagnosis, as emphasized in the guidelines for management of incidental liver lesions 1.

From the Research

Next Steps for Moderate Hepatic Steatosis with Liver Lesions

The patient has been diagnosed with moderate hepatic steatosis and two new liver lesions, including one measuring 2.7 cm in segment 4A, with a differential diagnosis that includes both benign and malignant etiologies. Given this information, the next steps should focus on further assessment and characterization of these lesions.

Importance of Dedicated Cross-Sectional Liver Imaging

• Dedicated cross-sectional liver imaging is recommended for further assessment of the liver lesions 2, 3.
• This approach can help in detecting and characterizing hepatic masses, especially in the setting of diffuse hepatic steatosis, where computed tomography (CT) and sonography may have decreased sensitivity and specificity 2.
• Magnetic Resonance Imaging (MRI) may be the imaging procedure of choice for the detection and characterization of both hepatic steatosis and coexistent hepatic masses due to its ability to demonstrate intratumoral lipid, which can add specificity in characterizing hepatocellular neoplasms 2.

Role of Advanced Imaging Techniques

• Advanced imaging techniques such as proton-density fat fraction (PDFF) on MRI can enable easy and reproducible quantification of hepatic fat and are useful for follow-up and assessment of treatment response in patients with nonalcoholic fatty liver disease (NAFLD) 4.
• Multiecho gradient-echo techniques can simultaneously calculate T2* maps, which is important for ruling out coexisting hepatic iron overload 4.
• MRI elastography and functional evaluation with Gd-EOB-DTPA are becoming important for monitoring the progression of NAFLD to steatohepatitis and cirrhosis 4.

Diagnostic Accuracy of CT for Hepatic Steatosis

• CT plays a significant role in the opportunistic identification of hepatic steatosis, with noncontrast CT (NCCT) showing high performance for the detection of at least moderate steatosis 5.
• The diagnostic accuracy of CT for hepatic steatosis detection can vary, and reliable cutoffs for measures such as liver attenuation, liver-spleen attenuation difference, and liver to spleen attenuation ratio have been suggested 5.

Considerations for Focal Steatosis and Fatty Sparing

• Focal steatosis and fatty sparing can mimic solid lesions and are frequent findings in liver imaging 6.
• Knowledge of CT and MRI appearance of focal steatosis and fatty sparing is crucial for an accurate diagnosis and to rule out other pathologic processes 6.