What are the next steps for a patient with a history of type 1 diabetes and gastroparesis who has two liver lesions, one measuring 3.4 x 3.0 x 2.7 cm in the left hepatic lobe segment 2 and the other measuring 1.4 x 1.7 x 1.4 cm in the left hepatic dome segment 4A, as shown on CT results?

Management of Two Liver Lesions in a Patient with Type 1 Diabetes and Gastroparesis

The smaller 1.4 cm lesion in segment 4A with homogeneous persistent enhancement including hepatobiliary phase uptake is consistent with focal nodular hyperplasia (FNH) and requires no further workup, while the larger 3.4 cm heterogeneous lesion in segment 2 with atypical features warrants either contrast-enhanced ultrasound (CEUS) or repeat MRI with hepatobiliary contrast agent for definitive characterization. 1

Lesion-Specific Analysis and Risk Stratification

The 1.4 cm Segment 4A Lesion

• This lesion demonstrates classic imaging features of FNH: isointense on T1 and T2, early arterial enhancement, persistent enhancement through all phases, and critically, uptake on hepatobiliary phase imaging, which is pathognomonic for FNH. 1
• No further imaging or biopsy is needed for this lesion - the hepatobiliary phase uptake provides 88-99% diagnostic accuracy for FNH, and this benign lesion requires no treatment or surveillance. 1
• FNH occurs in up to 15% of the general population with normal liver and carries no malignant potential. 1

The 3.4 cm Segment 2 Lesion - Requires Further Characterization

• This larger lesion has concerning atypical features: heterogeneous enhancement pattern, "subtle eccentric hypoenhancing region indeterminate for early scar development," and persistent delayed enhancement that is more intense than arterial phase. 1
• While the persistent enhancement could suggest hemangioma, the heterogeneity and hypointense T1 signal are atypical - classic hemangiomas are markedly hyperintense on T2 and show peripheral nodular enhancement with centripetal fill-in. 1, 2
• The description raises concern for atypical hemangioma, hepatocellular adenoma, or less likely, a hypervascular malignancy, though the lack of washout argues against malignancy. 1

Recommended Next Step for the Indeterminate Lesion

Proceed with contrast-enhanced ultrasound (CEUS) as the next diagnostic step for the 3.4 cm lesion. 1, 3

Rationale for CEUS Over Other Modalities

• CEUS reaches a specific diagnosis in 83% of indeterminate lesions and distinguishes benign from malignant in 90% of cases, correctly characterizing 90% of hemangiomas and 90% of FNH. 1, 4
• CEUS provides real-time evaluation of enhancement patterns and acts as a purely intravascular contrast agent, making washout detection more reliable than CT or MRI where interstitial contrast shift may conceal washout. 3
• For this patient with type 1 diabetes, CEUS avoids additional gadolinium exposure and is particularly useful when MRI findings are equivocal. 3
• CEUS can definitively differentiate hemangioma (peripheral nodular enhancement with centripetal fill-in and persistent enhancement) from hepatocellular adenoma (arterial hyperenhancement with washout in portal venous phase). 3

Alternative: Repeat MRI with Hepatobiliary Contrast

• If CEUS is unavailable or inconclusive, repeat MRI with gadoxetate (Eovist/Primovist) is the alternative, which achieves 95-99% accuracy for hemangioma characterization. 1
• The current MRI appears to have used extracellular contrast based on the description - hepatobiliary agents provide additional functional information about hepatocyte uptake that can distinguish FNH from adenoma. 2

When to Consider Biopsy

Biopsy should only be pursued if CEUS or repeat MRI with hepatobiliary contrast cannot establish a confident benign diagnosis. 1

Critical Biopsy Considerations

• Avoid biopsy of suspected hemangiomas due to 9-12% bleeding risk with hypervascular lesions. 1
• If biopsy becomes necessary, use CEUS guidance which increases technical success from 74% to 100%. 1
• The lack of restricted diffusion on the current MRI argues strongly against malignancy, making biopsy less urgent. 1

Clinical Context: Impact of Diabetes and Gastroparesis

• The patient's type 1 diabetes and gastroparesis are not directly relevant to liver lesion management but may affect contrast administration timing and patient tolerance of procedures. 5, 6
• Ensure optimal glycemic control before any procedure, as gastroparesis patients often have erratic glucose control. 6
• The gastroparesis does not increase risk of hepatic lesions or alter the diagnostic approach. 5

What NOT to Do - Common Pitfalls

• Do not order CT imaging - the patient already has superior MRI characterization, and CT would provide no additional diagnostic value while adding radiation exposure. 1, 7
• Do not proceed directly to biopsy without attempting CEUS or repeat MRI with hepatobiliary contrast first. 1
• Do not order Tc-99m sulfur colloid scan - this has no role in modern evaluation of indeterminate liver lesions. 4
• Do not ignore the smaller lesion - while it requires no further workup, document that it represents FNH to prevent future unnecessary investigations. 1