Algorithm of Terkivatan et al for the Management of a Solitary Solid Liver Tumor

 

NOTE: The original algorithm does not specify a "solitary" hepatic lesion. I added this since the presence of multiple lesions (except hemangiomas) might favor a different approach.

 

Diagnosis from Imaging Studies	Other	Management
uncertain	complaints present	resect
uncertain	complaints absent	biopsy
adenoma	diameter > 5 cm	resect
adenoma	diameter <= 5 cm	stop steroid use and observe
focal nodular hyperplasia (FNH)	complaints severe	resect
focal nodular hyperplasia (FNH)	complaints none or minor	observe
hemangioma	complaints severe	resect
hemangioma	complaints none or minor	observe

 

where:

• Imaging studies include ultrasound, CT scan or MRI.

• The primary clinical complaints is usually abdominal pain. Others may include nonspecific complaints or a palpable mass.

 

Features of hemangiomas on imaging studies:

(1) ultrasound: 90% hyperechoic; a well-defined spherical or lobulated lesion; in 68% homogeneous signal

(2) CT scan: low density on unenhanced image; after delivery of contrast media peripheral nodular enhancement; fill-in of the lesion over 5-10 minutes

(3) MRI: round or lobulated mass; low signal intensity on T1 and high signal intensity on T2; typical peripheral nodular enhancement after the administration of gadolinium

 

Features of focal nodular hyperplasia on imaging studies:

(1) ultrasound: hypoechoic; well-defined lesion with smooth border

(2) CT scan: unenhanced well-defined hypodense or isodense lesion; after delivery of contrast media, homogeneous increase in density; presence of central scar

(3) MRI: slightly lower signal intensity on T1 and slightly higher signal intensity on T2; homogeneous enhancement after administration of gadolinium; may show a central scar

(4) scintigraphy: increased uptake within the lesion (due to presence of Kupffer cells)

 

Features of adenoma on imaging studies:

(1) ultrasound: hypoechoic; mostly localized at the periphery of the liver parenchyma; well-defined lesion with a smooth border

(2) CT scan: well-defined, hypodense lesion; rapid transient enhancement on dynamic CT; may show hemorrhage

(3) MRI: isointense signal intensity on T1 and T2; transient enhancement after the administration of gadolinium