Synopsis
Liver lesions in the non
cirrhotic liver may be observed on healthy liver or in patients with
extrahepatic cancer.
On healthy liver, most
liver lesions are found incidentally consequent to the widespread use of imaging
tests and the vast majority is benign. These benign liver tumours are a
heterogeneous group of lesions with different cellular origins. However, some
malignant tumors may also be found incidentally. MRI is indicated because MRI
is the best imaging technique for tissue characterization. Interestingly, the
most common benign liver lesions are hemangiomas and focal nodular hyperplasia,
both diagnosed with high sensitivity and very high specificity on MRI. MRI is
the key imaging modality in liver hemangiomas by showing typical findings on
pre-contrast imaging (hypointense on T1-weighted sequences and strongly
hyperintense on heavily T2-weighted sequences) and on contrast-enhanced
sequences with a peripheral and globular enhancement of the lesion followed by
a central enhancement on delayed phases. On diffusion-weighted MR sequences,
the signal of an hemangioma drops with increasing b-values. Consequently the
Apparent Diffusion Coefficient (ADC) value is high. The two most common imaging
atypias are giant hemangiomas and rapidly filling hemangiomas. Both are easily
diagnosed on MRI.
On MRI, FNH usually associates several
findings: i) lesion homogeneity except the central scar, ii) slightly different
from the adjacent liver on precontrast US, CT or MRI [48, 49], iii) strong and
homogeneous enhancement on arterial phase CEUS, CT or MR with a central
vascular supply, which becomes similar to adjacent liver on portal and delayed
phases [32, 50, 51] iv) central scar best seen on MRI (hypointense on
precontrast T1-weighted images, strongly hyperintense on T2-weighted images,
and becoming hyperintense on delayed phase using extracellular MR contrast
agents because of the accumulation of contrast material in the fibrous tissue
[52, 53] ), and v) lack of capsule with often lobulated contours. The diagnosis
of FNH is based on a combination of these imaging features but none of them is
completely specific of FNH. On diffusion-weighted MRI, FNH may appear
hyperintense on high b values corresponding to mild diffusion restriction.
Nevertheless, ADC values are usually close to that of the liver FNH
usually associates several findings: i) lesion homogeneity except the central
scar, ii) slightly different from the adjacent liver on precontrast T1- and
T2-weighted MRI, iii) strong and homogeneous enhancement on arterial phase with
a central vascular supply, which becomes similar to adjacent liver on portal
and delayed phases iv) central scar that is hypointense on precontrast
T1-weighted images, strongly hyperintense on T2-weighted images, and becoming
hyperintense on delayed phase using extracellular MR contrast agents because of
the accumulation of contrast material in the fibrous tissue, and v) lack of
capsule with often lobulated contours. The diagnosis of FNH is based on a combination
of these imaging features but none of them is completely specific of FNH. On
diffusion-weighted MRI, FNH may appear hyperintense on high b values
corresponding to mild diffusion restriction. Nevertheless, ADC values are
usually close to that of the liver. Hepatobiliary MR contrast agents can be
used to highlight the hepatocellular origin of the FNH. Most FNHs are iso or
hyperintense on hepatobiliary phase, some having rim-accentuated enhancement.
With hepatobiliary MR contrast agents, the sensitivity for diagnosing FNH has
increased up to 90%.
Hepatocellular adenomas
(HCA) are less common than hemangioma or FNH but their prevalence is increasing
likely due to the increase of the metabolic syndrome. Based on genomic
analysis, three main molecular subtypes of HCA have been clearly identified so
far, with a fourth class presently uncharacterised. Interestingly the two common, which represent
80% of all HCAs are well recognized on MRI. As the most striking pathologic
features are the presence of fat or telangiectatic component, MRI is the most
accurate technique. HNF-1α inactivated HCAs are characterized by the presence
of marked steatosis on pathology. They appear homogeneous on MRI and have a variable
signal on T2-sequences.The striking finding is a diffuse and homogeneous signal
dropout on chemical shift T1-weighted sequences. They are usually moderately
hypervascular and often show wash-out on portal and/or delayed phase using
extracellular MR contrast agents. On high-b values diffusion-weighted MRI, they
are iso-or moderately hyperintense. Using the diffuse and homogeneous signal
dropout on chemical shift T1-weighted sequences, the sensitivity of MRI ranges
from 87% to 91% and the specificity ranges from 89% to 100% for diagnosing
HNF-1α inactivated HCA. Inflammatory HCAs are characterized on MRI by their
telangiectatic features. They show a strong hyperintense signal on T2-weighted
images (as strong as the signal of the spleen), which may be either diffuse or
as a rimlike band in the periphery of the lesion and defines the atoll sign. On
T1-weighted sequences, lesion signal intensity is variably iso- to
hyperintense. When present, hyperintensity persists on fat suppressed and
opposed-phase sequences. They are markedly hypervascular and show persistent
enhancement on delayed phase using extracellular MR contrast agents. Using the
two striking imaging findings (strong hypersignal on T2-weighted MR images and
the persistent enhancement on delayed phase), the sensitivity of MRI ranges
from 85% to 88% and the specificity ranges from 88% to 100% for diagnosing
inflammatory HCA with extracellular contrast agents. Most HCAs are hypointense on
hepatobiliary MR phase and this feature is helpful for differentiating HCA from
FNH. However, recent studies have shown that nearly half of the inflammatory
HCAs are iso-or hyperintense on hepatobiliary MR phase.
In patients with
extrahepatic cancer, liver lesions may be attributed to liver metastases or may
be unrelated and are mostly benign. In these patients, it is estimated that
approximately half of the liver lesions smaller than 2cm are benign. Therefore
the goals of imaging are twofold: first lesion characterization and second
intrahepatic staging if some lesions are liver metastases. MRI is also helpful
for differentiating benign liver lesions from liver metastases. MRI findings of
the latter are not unique and may vary with the primary cancer. However most
liver metasases are hypovascular surrounded by a peripheral halo on
contrast-enhanced sequences. For intrahepatic tumor staging, many original
works and three meta-analyses have shown that MR imaging is significantly more
sensitive for detecting liver metastases on a per-lesion basis than helical CT
and FDG-PET. More recently, the sensitivity of MR imaging in liver metastases
has increased compared to conventional sequences as a result of two improvements:
diffusion-weighted MR sequences and the hepatospecific phase using gadoxetic
acid (Gd-EOB-DTPA). Combined DW-MR and gadoxetic acid-enhanced MR imaging has
the highest sensitivity for detecting liver metastases on a per-lesion basis.
Acknowledgements
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