What are the next steps in managing two rounded hypoattenuating lesions, one measuring up to 2.9 cm and the other measuring 0.7 cm, found in the liver?

From the Guidelines

The next steps in managing two rounded hypoattenuating liver lesions (2.9 cm and 0.7 cm) should include further characterization with contrast-enhanced MRI with liver-specific contrast agents, as this is the most sensitive imaging modality for liver lesion characterization, as recommended by the American College of Radiology 1.

Initial Assessment

The presence of two rounded hypoattenuating liver lesions, one measuring up to 2.9 cm and the other measuring 0.7 cm, necessitates a thorough evaluation to determine their nature and potential impact on the patient's health. The initial assessment should consider the patient's clinical history, including age, risk factors for liver disease, and any history of malignancy, as these factors can influence the likelihood of benign versus malignant lesions.

Diagnostic Approach

The diagnostic approach should involve:

• Blood tests, including liver function tests, tumor markers (AFP, CEA, CA 19-9), and hepatitis serology, to gather more information about the patient's liver health and potential underlying conditions.
• Contrast-enhanced MRI with liver-specific contrast agents for further characterization of the lesions, as it is the most sensitive imaging modality for liver lesion characterization 1.
• Depending on the imaging results, a liver biopsy may be necessary, particularly for the larger 2.9 cm lesion if malignancy cannot be excluded, to obtain a definitive diagnosis.

Considerations

• The patient's clinical history and risk factors should be thoroughly reviewed to determine the likelihood of benign versus malignant lesions.
• Common benign diagnoses include hemangiomas, focal nodular hyperplasia, and simple cysts, while concerning findings would prompt referral to hepatology or surgical oncology.
• The approach to patients with mass lesions will vary depending on the patient’s overall clinical picture, and imaging plays a critical role in evaluating essentially all liver mass lesions, as emphasized by the American College of Radiology 1.

Management

The management of the patient should be based on the results of the diagnostic evaluation and should consider the potential risks and benefits of each treatment option. The patient should be closely monitored, and any changes in their condition should be promptly addressed. Referral to a specialist, such as a hepatologist or surgical oncologist, may be necessary if the lesions are suspected to be malignant or if the patient's condition worsens.

Key Points

• Further characterization with contrast-enhanced MRI with liver-specific contrast agents is recommended for the two rounded hypoattenuating liver lesions.
• Blood tests, including liver function tests, tumor markers, and hepatitis serology, should be ordered to gather more information about the patient's liver health.
• A liver biopsy may be necessary, particularly for the larger lesion, if malignancy cannot be excluded.
• The patient's clinical history and risk factors should be thoroughly reviewed to determine the likelihood of benign versus malignant lesions.
• Common benign diagnoses include hemangiomas, focal nodular hyperplasia, and simple cysts, while concerning findings would prompt referral to hepatology or surgical oncology, as supported by the evidence from the American College of Radiology 1 and other studies 1.

From the Research

Next Steps in Managing Liver Lesions

The presence of two rounded hypoattenuating lesions in the liver, one measuring up to 2.9 cm and the other measuring 0.7 cm, requires further evaluation to determine their nature and appropriate management.

• Imaging Strategies: According to 2, liver imaging strategies should incorporate liver lesion detection and characterization. For patients with a known extra-hepatic malignancy, a contrast-enhanced computed tomography (CT) examination is typically used to exclude hepatic and extra-hepatic involvement.
• Characterization of Lesions: The use of contrast-enhanced magnetic resonance imaging (MRI) with tissue-specific contrast agents is preferred for characterizing indeterminate hepatic masses 2. Additionally, 3 highlights the importance of imaging characterization of non-hepatocellular carcinoma (HCC) lesions in cirrhosis to formulate an accurate diagnosis and appropriate management.
• Role of PET/CT: 4 suggests that 18F-fluorodeoxyglucose (FDG) PET/CT is invaluable in managing liver lesions, particularly in evaluating suspected liver metastases. It is both sensitive and specific in detecting liver metastases from a wide range of primary cancers.
• Monitoring and Follow-Up: For hypoattenuating nodular lesions in chronic liver disease, periodic follow-up with helical CT is recommended 5. This allows for the detection of attenuation conversion, which may indicate progression to hepatocellular carcinoma.
• Biopsy and Histological Examination: In cases where tissue diagnosis is needed, liver biopsy may be necessary 2. This is particularly important for lesions that are suspicious for malignancy or have atypical imaging features.
• Treatment Planning: The management of liver lesions depends on their nature and the patient's underlying condition. For example, 6 discusses the use of neoadjuvant therapy with Bevacizumab and Irinotecan for patients with colorectal cancer and liver metastases planned for metastasectomy. FDG-PET/CT can be used to evaluate treatment response and predict pathologic outcome.