What is the appropriate workup for a 2.4cm liver lesion found on computed tomography (CT) scan?

From the Guidelines

A 2.4 cm liver lesion found on CT scan requires immediate further evaluation with a dedicated multiphasic contrast-enhanced MRI of the liver to determine if it is benign or malignant, as recommended by the most recent and highest quality study 1. The recommended next steps include blood tests, such as liver function tests, hepatitis serologies, alpha-fetoprotein (AFP), CEA, and CA 19-9 tumor markers.

• If you have a history of cancer, this information should be shared with your doctor as it may influence the evaluation approach.
• Depending on the MRI findings, a liver biopsy may be necessary for definitive diagnosis.
• Common benign lesions include hemangiomas, focal nodular hyperplasia, and hepatic adenomas, while concerning findings could suggest hepatocellular carcinoma or metastatic disease.
• The size of 2.4 cm is significant enough to warrant thorough investigation, as lesions larger than 2 cm have a higher risk of being clinically significant, as noted in previous studies 1. You should schedule this follow-up imaging promptly, ideally within 1-2 weeks, and discuss the results with a hepatologist or oncologist if abnormalities are detected.
• The American College of Radiology recommends MRI abdomen without and with IV contrast, CT abdomen with IV contrast multiphase, or US abdomen with IV contrast for the imaging of an indeterminate >1 cm liver lesion on initial imaging with US in a normal liver with no suspicion or evidence of extrahepatic malignancy or underlying liver disease 1.
• It is essential to prioritize the evaluation of this liver lesion to determine the best course of action and to minimize potential morbidity and mortality.

From the Research

Diagnostic Approach for Liver Lesion

• A 2.4cm liver lesion found on CT scan requires a thorough diagnostic workup to determine its nature and appropriate management 2.
• The likely diagnoses for a solid liver lesion include hepatocellular carcinoma, hemangioma, focal nodular hyperplasia, and hepatic adenoma 2.
• MRI with gadolinium can differentiate between these lesions in 70% of cases, and fine needle core biopsy or aspiration may be required in doubtful cases 2.

Role of Imaging Modalities

• Ultrasonography, computed tomography, and magnetic resonance imaging (MRI) are commonly used imaging modalities for detecting and characterizing liver lesions 2, 3, 4.
• MRI is preferred for characterizing indeterminate hepatic masses, and contrast-enhanced MRI with extra-cellular gadolinium chelates can provide valuable information 3.
• The diagnostic sensitivity and specificity of imaging procedures vary, with MRI having the highest sensitivity and specificity (100% and 85.7%, respectively) 4.

Biopsy and Histology

• Liver biopsy is indicated in cases with inconclusive radiologic features and a history of malignancy or underlying liver disease 5.
• Bleeding is a potential complication of biopsy in hemangiomas, but the risk may be overstated 5.
• Histology is required only when the nature of the liver lesion is doubtful, especially in patients with a primary malignancy 2.

Considerations for Liver Disease

• The presence of liver disease, such as fibrosis or cirrhosis, can affect the characteristics of hepatic hemangiomas on MRI 6.
• Smaller lesion size and less T2 shine-through effect are observed in hemangiomas developed on cirrhosis, which is an important finding to highlight in patients at risk of developing hepatocellular carcinoma 6.