What is the recommended management for a patient with a suspected liver hemangioma, a Bosniak class 2F lesion in the left kidney, and a small wedge-shaped area of cortical thinning adjacent to a calcification in the left kidney?

Management of Suspected Liver Hemangioma, Bosniak 2F Renal Lesion, and Cortical Thinning

For this patient with a suspected 2.9 cm liver hemangioma, obtain a contrast-enhanced MRI with hepatobiliary contrast agent (gadoxetate disodium) to definitively characterize the lesion, perform surveillance imaging at 6-12 months for the Bosniak 2F renal lesion, and no specific intervention is needed for the cortical thinning with calcification which represents chronic scarring. 1

Liver Lesion Management

Definitive Characterization Required

• The peripherally enhancing 2.9 cm lesion requires definitive characterization rather than simple follow-up, as hemangiomas can occasionally mimic malignant lesions 1
• Order MRI abdomen with gadoxetate disodium (Eovist) including dynamic multiphase imaging (late arterial and portal venous phases) plus diffusion-weighted imaging 2
• This protocol provides 95-99% accuracy for hemangioma diagnosis and establishes definitive diagnosis in 95% of liver lesions 1, 2
• Only 1.5% of patients require additional imaging after MRI versus 10% with CT alone 1, 2

Why MRI Over Simple Follow-up

• While typical hemangiomas (capillary type) ranging from millimeters to 3 cm are well-defined and stable, this 2.9 cm lesion approaches the threshold where definitive characterization becomes critical 3
• Atypical hemangiomas can mimic hepatocellular carcinoma, cholangiocarcinoma, or other malignancies, making confident diagnosis essential 4, 5, 6
• The hepatobiliary phase with gadoxetate provides superior differentiation from other lesions including focal nodular hyperplasia and adenomas 2

After Definitive Diagnosis

• If confirmed as typical hemangioma on MRI: no further follow-up is required for lesions <3 cm in asymptomatic patients with normal liver 3, 6
• If atypical features persist: consider biopsy or short-interval (3-6 month) follow-up imaging 1

Bosniak 2F Renal Lesion Management

Surveillance Protocol

• Bosniak 2F lesions require active surveillance with imaging at 6-12 month intervals initially 1
• The 2.2 cm lesion with coarse central calcification fits the 2F category (minimally complex cyst requiring follow-up) 1
• Active surveillance is appropriate as these lesions have low but non-negligible malignancy risk (approximately 5-10%) 1

Surveillance Strategy

• Perform contrast-enhanced CT or MRI at 6 months, then annually for at least 5 years if stable 1
• Monitor for interval growth, development of enhancing solid components, or increasing complexity 1
• Consider renal mass biopsy if lesion demonstrates growth or develops concerning features during surveillance 1

Risk-Benefit Considerations

• For Bosniak 2F lesions, surveillance with potential delayed intervention is preferred over immediate intervention given the low malignancy risk and competing mortality risks 1
• Shared decision-making should incorporate patient age, comorbidities, and risk tolerance 1

Cortical Thinning with Calcification

No Active Management Required

• The wedge-shaped cortical thinning adjacent to calcification represents chronic scarring, likely from prior infection, infarction, or inflammatory process 1
• This is a benign finding requiring no specific follow-up or intervention 1
• Document the finding but do not pursue additional imaging specifically for this abnormality 1

Critical Pitfalls to Avoid

For Liver Lesion

• Never accept "follow-up recommended" without definitive characterization for lesions approaching 3 cm - atypical hemangiomas and malignancies can have similar appearances 4, 5, 6
• Do not order MRI without contrast or without hepatobiliary phase - diagnostic yield is insufficient 2
• Inflammatory adenomas can mimic hemangiomas; hepatobiliary phase helps differentiate (adenomas show low signal) 2

For Renal Lesion

• Do not dismiss Bosniak 2F lesions as simple cysts - they require structured surveillance 1
• Avoid over-aggressive intervention for stable 2F lesions in elderly patients with significant comorbidities 1
• Do not extend surveillance intervals beyond 12 months in the first 2-3 years 1

For Cortical Thinning

• Do not confuse chronic cortical scarring with active pathology requiring intervention 1
• Avoid unnecessary additional renal imaging focused solely on this benign finding 1