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E³ 218 - Benign liver tumours: daily questions

Wednesday, March 1, 10:30 - 12:00 Room: M 4 Session Type: E³ - ECR Academies: Tips and Tricks in Liver, Bile Ducts and Pancreas Imaging Topics: Imaging Methods, Abdominal Viscera Moderator: S. M. Ertürk (Istanbul/TR) Add session to my schedule In your schedule (remove)


Chairman's introduction

S. M. Ertürk; Istanbul/TR

Learning Objectives



The session will focus on the imaging features of the cystic and solid liver lesions. The new classification system of the hepatic adenomas will be discussed in detail. Sample cases of haemangiomas and FNHs will be another focus of the session since these lesions are very frequently encountered in imaging studies of the liver. Imaging strategies to increase accuracy regarding the detection and characterisation of focal hepatic lesions will be summarised.


A. Cystic lesions: always biliary cysts?

O. Benjaminov; Petach Tikva/IL

Learning Objectives

1. To be able to list the different conditions that may present as cystic liver masses.
2. To understand the diagnostic multimodality strategy.
3. To become familiar with assessment challenges.


Liver cysts are increasingly found on abdominal imaging studies. They cause a diagnostic challenge. There are no current management guidelines that help in their management. In most cases they are asymptomatic and follow a benign course. However, it is essential to differentiate between benign and malignant liver cysts. The majority are of a biliary origin. Others are non-biliary and include hydatid and other infectious cystic lesions, cystic neuroendocrine lesions and cystic metastases. Other lesions which contain a fluid attenuation component may mimic liver cysts such as necrotic changes within lesions following chemotherapeutic treatment. Clinical history, laboratory findings and previous imaging may help in reaching an accurate diagnosis. An important step in narrowing the differential diagnosis is in determining the presence of complex structures within the lesions.


B. Solid benign lesions: how to solve the conundrum?

F. Caseiro-Alves; Coimbra/PT

Learning Objectives

1. To become familiar with the recent classification of liver cell adenoma and its justification.
2. To learn about the typical and atypical appearance of focal nodular hyperplasia.
3. To understand the treatment strategy and the modalities of follow-up when appropriate.


Benign hepatocellular neoplasms are being recognized with increased frequency using cross-sectional imaging. One of the main goals is to be able to make a clear-cut differential diagnosis between focal nodular hyperplasia (FNH) and hepatocellular adenoma (HCA) since patient management is substantially different. Despite the sound knowledge acquired in the last few years about the morphological features of FNH using various cross-sectional imaging techniques, new players in the field have arisen such as diffusion-weighted MR imaging (DWI) and use of hepatobiliary contrast agents. These new biomarkers offer a different view over FNH and allow a more accurate characterization even in more atypical cases. Concerning HCA, current knowledge implies that the sub-types of this neoplasm should be known since, again, patient management differs and these patients are no longer seen as compulsory surgical candidates. These sub-types will be further discussed and the role of imaging for risk stratification (haemorrhage and malignant transformation) will be addressed. Further, illustrative cases of combined FNH/HCA cases will be demonstrated along with the main imaging clues for a successful differential diagnosis.


C. From images to strategy: tough cases of benign liver tumours

M. Nadrljanski; Belgrade/RS

Learning Objectives

1. To be able to define a diagnostic strategy when facing an unknown case of solid liver lesion, likely to be benign.
2. To become familiar with the unusual appearance of common lesions like focal nodular hyperplasia or haemangioma.


Benign liver tumours are often diagnosed incidentally. The most common lesions include haemangioma, focal nodular hyperplasia (FNH) and hepatocellular adenoma (HCA). Liver nodule(s), often detected on the initial abdominal ultrasound (US), are characterized by contrast-enhanced imaging studies: contrast-enhanced US (CEUS), computed tomography (CT) and magnetic resonance imaging (MRI). Clinical context determines the association with the development of liver disease. Lesions with atypical features (“tough cases”) require additional attention. The most common atypical findings in haemangioma - rapidly filling and giant haemangiomas - may be diagnosed on MRI. In case of the slow-filling and calcified lesions - sclerosing haemangiomas - the diagnostic imaging is less reliable. In case of the growing lesions, the lesion management is made according to multidisciplinary team (MDT). The diagnosis of FNH is based on the combined radiological features, not considered as lesion specific. Atypical forms (FNH without a central scar, FNH with significant steatosis) require particular attention, as the sensitivity of MRI is lower, especially in the absence of the central scar. The use of the specific hepatobiliary contrast agents may contribute to the increase of MRI sensitivity. HCA, not considered the unique entity, reflects the subtype radiological features. The presence of fat and telangiectatic features requires the appropriate imaging technique(s) - MRI for fat and dilated vascular spaces visualization. MRI lesion subtyping is important, as MRI is considered superior to other modalities. In case of atypical benign lesions, MDT will decide on the patient management, including the indication for biopsy/resection.

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