Real Time Ultrasonography Evaluation of Focal Liver Lesions: A

Origi na l A r tic le
Real Time Ultrasonography Evaluation of Focal
Liver Lesions: A Cross-sectional Study
S Gopalakrishnan1,
Sethurajan2,
Adaikappan3,
Palanisamy Gunasekaran2,
R Vivek1
Post-Graduate Student, Department of Radiology, Rajah Muthiah Medical College and Hospital,
Chidambaram, Tamil Nadu, India, 2Assistant Professor, Department of Radiology, Rajah Muthiah
Medical College and Hospital, Chidambaram, Tamil Nadu, India, 3Associate Professor, Department of
Radiology, Rajah Muthiah Medical College and Hospital, Chidambaram, Tamil Nadu, India
1
Corresponding Author: Dr. S. Gopalakrishnan, No. 3, 6th Cross Street, Jaya Nagar,
Tiruvallur - 602 001, Tamil Nadu, India. Phone: +91-8939228976. E-mail: [email protected]
Abstract
Introduction: Focal liver lesions can be congenital or acquired and may be benign or malignant. Sonography, in spite of the
advent of advanced imaging modalities has prevailed as the preferred modality for evaluation of liver lesions as it is readily
accessible, cost effective and allows real time evaluation.
Aim: To establish the efficacy of the diagnostic ultrasound to detect various focal liver lesions and provide necessary information,
aiding their appropriate management.
Materials and Methods: Patients, who are referred for sonography at Radiology Department, clinically suspected of having
focal hepatic lesions with clinical features like abdominal pain, fever, loss of weight and appetite, mass per abdomen, jaundice,
abdominal distension and urticaria were included in this study.
Results: Ultrasonography is highly sensitive and specific in the diagnosis of focal liver lesions like hemangioma, fatty liver,
cirrhosis, cystic and hydatid lesions, malignant liver tissue and metastasis.
Conclusion: Ultrasonography is a safe and effective method of detecting focal liver lesions. It’s easy availability, portability,
flexibility, lack of dependence on organ function and lack of ionizing radiation makes it ideal for imaging the liver.
Keywords: Carcinomas, Cyst, Doppler, Hemangioma, Ultrasonography
INTRODUCTION
Focal liver lesions are common on pathologic or imaging
evaluation of the liver and include a variety of malignant
and benign neoplasms, as well as congenital and acquired
masses of inflammatory and traumatic nature. Evaluation
of focal liver lesions is a complex issue which is often the
major focus of the cross sectional imaging study.1
Sonography is widely accessible, relatively inexpensive,
portable, noninvasive, nonionizing, allows imaging in
multiple planes and can frequently be repeated. It assists
in real time evaluation of organ under examination,
especially the liver which is situated just below the
ribcage without intervening gas, has a high sensitivity and
reasonable specficity.2 Sonography has excellent spatial
and contrast resolution,3 hence gray-scale morphology
of a mass allows for differentiation of cystic and solid
masses and in many instances, characteristic recognized
appearances may suggest the correct diagnosis without
further evaluation. Characterization of a liver mass on
conventional sonography is based on the appearance of
the mass on gray scale imaging.4
MATERIALS AND METHODS
A prospective study of 40 cases of focal liver lesions diagnosed
by ultrasonography in Department of Radiodiagnosis.
Inclusion Criteria
Patients in the age group above 18 years and focal liver
lesion of diameter >10.0 mm.
Exclusion Criteria
Patients with diffuse liver disease like steatosis, cirrhosis,
hepatitis, storage diseases. Diffuse malignancies and also
the post-operative and post-traumatic patients.
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Gopalakrishnan, et al.: Focal Liver Lesions Sonography
Patient Preparation and Scanning Technique
Once the patient agrees to participate in the study, informed
consent was taken prior to ultrasound examination,
followed by detailed history and brief clinical examination.
Patients were kept nil by mouth for few hours prior to
ultrasound examination. In some cases, clinical condition
of the patient demanded an ultrasound examination
without prior preparation.
30
25
25
22.5
15
12.5
5
5
0
2.5
18-20
RESULTS
In our study, Out of 40 patients, the youngest patient was
19 years of age and the oldest was 84 years of age with a
mean age of 52 years. Majority of the patients were in the age
group between 50 and 60 years (Table 1 and Graph 1). Out
of the 40, majority were males who numbered 26 (65%) and
14 (35%) were females with the male to female ratio being
1.8:1 (Table 2 and Graph 2). Out of the 40 patients, 24 (60%)
patients had abdominal pain. 18 (45%) patients had fever,
16 (40%) had loss of weight and appetite, 14 (35%) patients
complained of mass per abdomen, 9 (23%) had jaundice and
7 (18%) patients complained of abdominal distension and
urticaria. Out of 40 patients, 10 (25%) had hemangiomas
65
21-30
31-40
41-50
51-60
61-70
>70
Graph 1: Age distribution of focal liver lesions
Liver was scanned in various planes like sagittal, parasagittal,
transverse, oblique, subcostal, intercostal and coronal
planes. Comprehensive scanning of other upper abdominal
organs was done.
Apart from the above observations related to lesion
several other important observations were made which
include the overall assessment of liver size, portal and
hepatic veins involvement, biliary tract and gall bladder,
lymphadenopathy and ascites.
10
10
Patients were examined in the supine position to begin with
and then in decubitus (right or left) and sitting position if
needed.
Various ultrasonographic features of focal liver lesions
were observed, which include:
1. Number of lesions - Single or multiple
2. Location within liver - Lobar distribution (right lobe,
left lobe, both lobes)
3. Echogenicity - (by comparing with that of normal liver
parenchyma), Hyperechoic, hypoechoic, anechoic or
mixed echogenic
4. Size, shape and margins: Exact size of the lesion
was measured with a note on shape of the lesion
like round, oval or irregular. Margins of lesion were
studied whether well-defined, poorly defined, regular
or irregular
5. Acoustic characteristics of lesions.
22.5
20
35
Male
65
Female
Graph 2: Sex distribution of focal liver lesions
Table 1: Age distribution of focal liver lesions
Age group (years)
Number of cases
Percentage
1
2
5
9
10
9
4
105
2.5
5
12.5
22.5
25
22.5
10
100
18-20
21-30
31-40
41-50
51-60
61-70
More than 70
Total
Table 2: Sex distribution of focal liver lesions
Sex
Male
Female
Total
Number of cases
Percentage
26
14
40
65
35
100
and male to female ratio of 1:1.8 (Table 3 and Graph 3),
which is in close correlation to the study of Gandolfi et
al.5 and Trastek et al.6 However this is lower than reported
by the other workers who noted a female prevalence up to
5:1,7,8 8 (20%) had metastases. It was most commonly seen
in the age group of 51-60 years (Graph 4). The age group
ranged from 51 to 68 years with a mean age of 58.2 years.
Males constituted majority (75%) and females the remainder,
7 (17.5%) had abscess the age group was in the range of 1962 years with a mean age of 47 years. Hepatic abscess was
predominantly seen in males 6 (85.7%) and 1 (14.3%) female
patient. Male to female ratio was 6:1. 6 (15%) had cystic lesion
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Gopalakrishnan, et al.: Focal Liver Lesions Sonography
Table 3: Sex distribution of individual focal liver lesions
Sex
Male
Female
Total
Liver
abcess
PMLT
Metas
tases
Hemangioma
Cystic
lesion
Hydatid
lesion
Cholangiocarcinoma
Total
6
1
7
4
1
5
6
2
8
5
5
10
3
3
6
2
1
3
1
1
26
14
40
PMLT: Primary malignant liver tumor
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
1
DISCUSSION
1
2
5
6
3
1
Haemangioma
1
4
6
5
3
2
Female
Male
Graph 3: Sex distribution of individual focal liver lesions
It is the most common benign liver lesion, cavernous type
with incidence ranging from 0.4% to 20%. Common in
females ratio being 5:1.
Sonography
Typically the lesions are small, <3 cm in diameter,
well defined, homogenous and hyperechoic (Figure 1).
Increased echogenicity has been related to numerous
interfaces between the walls of the cavernous sinuses
and the blood within them. Larger lesions tend to be
heterogeneous with central hypoechoic foci corresponding
to fibrous collagen scars.
Color Doppler
Hemangiomas are characterized by extremely slow blood
flow, which is imperceptible.
Hepatic Adenoma
They are benign, well encapsulated; true hepatic neoplasms
composed entirely of hepatocytes. These are solitary tumors
occurring predominantly in women of child bearing age
and is strongly associated with use of oral contraceptives.
Graph 4: Age distribution of individual focal liver lesions
in the age group of 36-75 years with a mean age of 48.3
distributed equally in both males and females as compared
to previous study which showed female preponderance,9
5 (12.5%) had primary malignant liver tumor with age range
of 49-84 years, with a mean age of 66.8 years. These were
more common in 61-70 years. Majority of the patients were
males 4 (80%) and 1 (20%) female, 3 (7.5%) had hydatid cyst
in the age group of 28-54 years of age with a mean age of
38.6 years. Males were the predominant group compromising
2 (66.6%) and 1 (33.3%) female patient, and 1 (2.5%)
had cholangiocarcinoma in a female aged 75 years (Table
4). Diagnosis of hemangioma, cystic and hydatid lesions
showed specificity of 97.8%, 98.9% and 98.9% respectively.
In 28 (70%) patients the lesions were in the right lobe, in
7 (17.5%) involved both lobes and in 5 (12.5%) in the left
lobe. In 30 (75%) patients had solitary lesions and 10 (25%)
had multiple lesions.
Sonography
An echogenic mass with halo is one of its presentations
(Figure 2), but adenomas may be hypoechoic, isoechoic
or mixed. With hemorrhage, a fluid component may be
evident within or around the mass and free intra-peritoneal
blood may be seen. Compression of the surrounding liver
may cause a hypoechoic halo.10
Focal Nodular Hyperplasia (FNH)
It is a benign congenital hamartomatous vascular
malformation or reparative process in areas of focal injury
characterized by a central fibrous scar surrounded by
nodules of hyperplastic hepatocytes and small bile ductules.
Common in women of reproductive age group.11
Sonography
These lesions are typically a well circumscribed, most
often solitary mass with a central scar, subtle contour
abnormalities and displacement of vascular structures.
Lesions may be hypo, is or hyperechoic homogeneous mass
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Gopalakrishnan, et al.: Focal Liver Lesions Sonography
Table 4: Age distribution of individual focal liver lesions
Age group
(years)
18-20
21-30
31-40
41-50
51-60
60-70
>70
Total
Liver
abscess
PMLT
Metas
tatses
Hemangioma
Cyti
lesion
Hydatid
lesian
Cholangiocarcinoma
Total
1
1
1
2
5
9
10
9
4
40
1
1
2
1
2
7
5
3
1
1
4
2
2
8
10
1
2
2
5
1
1
2
2
1
1
1
6
3
PMLT: Primary malignant liver tumor
Figure 3: Focal nodular hyperplasia
Figure 1: Hemangioma
Doppler confi rms mainly arterial signals within the
FNH lesion.
Simple Liver Cyst
It is the second most common benign hepatic lesion,
incidence being 22%. Although the cyst is thought to be of
congenital, developmental origin, usually, it is discovered in
adults more frequent in women with the size varying from
1.0 cm to >20.0 cm in diameter.
Sonography
Simple hepatic cysts are anechoic with a well demarcated,
thin wall and posterior acoustic enhancement (Figure 5).12
Polycystic Liver Disease
lesions. Central scar is seen as hypoechoic linear or stellate
area within the central portion of the mass (Figure 3).
In patients with polycystic liver disease, hepatic tissue
surrounding the cysts is not normal and commonly contain
Von Meyenburg’s complexes and increased fibrous tissue.
Hepatic involvement occurs in approximately 57-74% of
patients with autosomal dominant (adult) polycystic kidney
disease.13
Color Doppler
Sonography
FNH is extremely hyper vascular with a dominant
feeding artery and stellate vascular pattern. Spectral
When more than 10 cysts are present, the diagnosis of
polycystic disease should be considered.14 Hepatic cysts are
Figure 2: Hepatic adenoma
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Gopalakrishnan, et al.: Focal Liver Lesions Sonography
anechoic with a well demarcated, thin wall and posterior
acoustic enhancement (Figure 4).
Hepatocellular Carcinoma (HCC)
It is one of the most common malignant tumors and one
of the 10 most common cancers in the world. It peaks in
5th 6th decade. It occurs predominantly in men, with sex
ratio of about 2.5:1.
Several growth patterns appear; most common is of the
trabecular pattern. Grossly three major patterns of growth
are
1. A large solitary mass
2. Nodular or multifocal masses
3. Diffuse or cirrhotomimetic HCC.
Sonography
The masses may be hypoechoic, complex or echogenic.
Most small (<5.0 cm) HCC’s are hypoechoic, corresponding
to solid tumor. A thin peripheral halo corresponding to
the fibrous capsule is seen most often in small HCC.
Calcification is uncommon. HCC of mixed echogenicity
is due to non-liquefactivenecrosis (Figure 6).
Color Doppler
HCC has characteristic high velocity signals (>250 cm/s).
Doppler is excellent in detecting neovascularity within
tumor thrombi within the portal veins, diagnostic of HCC.15
Fibrolamellar Carcinoma (FLC)
Most commonly seen in younger patients. The alphafetoprotein body inclusions that are, usually, seen in HCC are
absent in FLC. A fibrous central scar is seen in larger lesions.16
Grossly, FLC, usually, arises in the normal liver; only 20%
of patients have cirrhosis. It has more potential for cure
(40%) after surgical resection.17
Sonography
The echogenicity of FLC is variable. Punctuate calcification
and central echogenic scar are common than in hepatomas.
Intrahepatic Cholangiocarcinoma
An adenocarcinoma that originates in the second or
higher order intra hepatic ducts represents 10% of all
cholangiocarcinomas.
The tumors are large, firm with abundant fibrous tissue.
Figure 4: Polycystic liver disease
Sonography
Hypovascular solid mass with heterogeneous echotexture,
may appear hypo, iso or hyperechoic. Has a higher incidence
of ductal obstruction (31%) than HCC (2%).18
Figure 5: Simple liver cyst
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Figure 6: Hepatocellular carcinoma
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Gopalakrishnan, et al.: Focal Liver Lesions Sonography
Metastatic Disease
It is the most common malignancy of the non-cirrhotic
liver. The highest percentages of liver metastases occur
in primary carcinomas of gall bladder, pancreas, colon,
stomach and breast.19,20 Most metastases to the liver are
blood-borne via the hepatic artery or portal vein.
Lesions may be infiltrative, expansile or military.
A zone of venous stasis may be observed to surround a
metastatic lesion, extending up to 1 cm, in approximately
25% of patients. Tumor thrombi that occlude the portal
or hepatic vein may be seen in approximately 7-15% of
patients with hepatic metastatic disease.
Diagnostic challenges in the radiologic evaluation of
metastatic disease include staging and follow-up in patients
with a known malignancy and the evaluation of resectability
in patients with solitary or few metastases.
Sonography
identified in metastases from the bronchogenic
carcinoma.
Calcified metastases are distinctive by virtue of their
marked echogenicity and distal acoustic shadowing.
Mucinous adenocarcinoma of the colon is the most
common primary associated with it.21
Cystic metastases are uncommon, usually, have mural
nodules, thick walls, fluid-fluid levels and internal septations.
Infectious Lesions
Bacterial (pyogenic) liver abscess
The liver abscess most commonly develops via the biliary
tree, secondary to ascending cholangitis from benign or
malignant biliary obstruction.22,23
In adults, Escherichia coli is most commonly isolated, while
Staphylococcus is most often isolated from pediatric liver
abscess.24,25
More commonly they present with multiple focal liver
masses. Sonographic appearances vary like; echogenic,
hypoechoic, target, calcified cystic and diffuse.
Leucocytosis elevated serum alkaline phosphatase,
hypoalbuminemia and prolonged prothrombin time are
the most common laboratory findings.26
Echogenic metastases (Figure 7) tend to arise from the
gastrointestinal primary or from HCC. More vascular the
tumor, more likely the lesion to be echogenic. Therefore,
metastases from the renal cell carcinoma, carcinoid,
choriocarcinoma and islet cell carcinoma tend to be
echogenic.
Abscesses from the portal vein sources are often solitary,
with 65% occurring in the right lobe, 12% in the left lobe
and 23% in both lobes.
Hypoechogenic metastases are generally hypovascular and
hypercellular without interstitial stroma. Typically seen in
untreated breast and lung cancer, as well as gastric, pancreatic
and esophageal tumors. Lymphomatous involvement of the
liver also manifest as hypoechoic masses.
Target or bulls eye pattern is characterized by a peripheral
hypoechoic zone. It is nonspecific, although frequently
Sonography
Frank purulent abscess appear cystic, with the fluid
ranging from echo free to highly echogenic. Regions of
early suppuration appear solid with altered echogenicity,
usually, hypoechoic related to necrosis. Well-defined round
lesion with echogenic rim, fluid-fluid interfaces, internal
septations, internal debris and gas artifacts. Distal acoustic
enhancement is also seen.
Fungal Abscess
Fungal microabscesses of the liver occur in immun
ocompromised patients, most commonly those with
hematologic malignancies.
Candidiasis, the most common frequently occurring
systemic fungal infection in immunocomprosied patients,
is most occurring with the increase in the incidence of
AIDS and bone marrow transplantation, chemotherapy
and radiation therapy. Detection may be difficult because
blood cultures are positive in only 50% of patients.27
Sonography
Figure 7: Metastasis
69
Sonographic features include - “Wheel within a wheel”
due to peripheral hypoechoic zone with an inner echogenic
wheel and central hypoechoicnidus. Seen early in the
disease.
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Gopalakrishnan, et al.: Focal Liver Lesions Sonography
Bull’s eye: 1-4 cm lesion having a hyperechoiccentre and
a hypoechoic rim.
Uniformly hypoechoic: Most common finding, corresponds
progressive fibrosis.
Echogenic: Variable calcification representing scar
formation.
Amoebic Abscess
Hepatic infection by the parasite entamoebahistolytica
is the most common extraintestinal manifestation of
amoebiasis.28-30 The parasite crosses the colonic mucosa
and enters the portal circulation (most commonly) or the
lymphatics or when it passes directly into the liver from
the hepatic flexure.31
The preferential occurrence of these lesions in the right
lobe is related to the venous drainage.32
Sonography
Round or oval shaped lesion with absence of a prominent
wall, hypoechogeni city compared to normal liver, fine
low-level internal echoes, distal sonic enhancement and
contiguity with the diaphragm (Figure 8).
Echinococcal Disease
Hydatid disease of the liver has two forms i.e. the cystic
form and alveolar form. The cysts may be solitary or
multiple, grow slowly to reach a large size. The wall of the
cyst contains three layers: (1) The pericyst, (2) the endocyst
and, (3) the ectocyst.
Calcification of the ectocyst alone may occur and when
the parasite dies, the true cyst wall (both the ectocyst
and endocyst) may also calcify or may separate from the
pericyst. Most complications from hydatid cysts are related
to rupture of the cyst into surrounding structures (biliary
tree, pleura and peritoneum).33,34
Sonography
Sonographic features of hepatic hydatid disease are
1. Simple cysts containing no internal architecture except
sand
2. Cysts with detached endocyst secondary to rupture
3. Cysts with daughter cysts matrix (echogenic material
between the daughter cysts), or both densely calcified
masses.35
CONCLUSION
Ultrasound showed the highest specificity for hydatid
cysts, cystic lesions, hemangioma. Besides the advantages
of ultra-sonogram over other modalities with cost
effectiveness and accessibility, the introduction of
microbubble contrast agents and the development of
contrast-specific techniques have opened new possibilities
in liver imaging. Initially, only intermittent imaging with
Doppler detection was available. Second-generation
contrast agents and low mechanical index real-time
scanning techniques are decisive advances that enable
convenient liver examinations with high sensitivity and
specificity.
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How to cite this article: Gopalakrishnan S, Sethurajan, Adaikappan, Gunasekaran P, Vivek R. Real Time Ultrasonography Evaluation of
Focal Liver Lesions: A Cross Sectional Study. Int J Sci Stud 2014;2(7):64-71.
Source of Support: Nil, Conflict of Interest: None declared.
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