II. Epidemiology

  1. Hepatic Incidentalomas are identified on 15% of CT studies
  2. Benign Hepatic Lesions are identified in >50% of autopsies in patients without cancer

III. Evaluation

  1. Lesions requiring no further evaluation
    1. Hepatic Lesion <5 mm OR
    2. Low attenuation (20 Hounsfield Units or less)
    3. Benign imaging features
    4. Flash-filling (strongly enhancing) lesions consistent with benign Hemangiomas
  2. Suspicious findings
    1. Solid Hepatic Lesions >5mm
    2. Poorly defined margins
    3. Greater attenuation (>20 Hounsfield Units)
    4. Interval growth
    5. Heterogenous lesions

IV. Differential Diagnosis

  1. Hepatic Adenoma
    1. Benign tumor in women on Oral Contraceptives (and exacerbated during pregnancy)
    2. Larger Hepatic Adenomas may bleed or rupture
    3. Discontinuation of Oral Contraceptives results in regression of tumor
      1. Switch to nonhormonal Contraception
      2. Monitor regression with serial liver Ultrasound
    4. Surgical resection may be considered in some cases
      1. Large or persistent lesions are associated with an increased risk of malignant transformation
  2. Focal Nodular Hyperplasia
    1. Benign Liver Lesions in young women
    2. Appear as central liver scar on imaging
  3. Hepatic Cysts
    1. Simple Liver Cysts often require no further evaluation
    2. Indeterminate lesions may be followed with serial liver Ultrasound
  4. Hepatic Cystadenoma
    1. Rare, benign Liver Lesions that uncommonly undergo malignant transformation
    2. Consider further evaluation as imaging may not differentiate benign from malignant
  5. Hepatic Cavernous Hemangioma
    1. Most common benign Liver Incidentalomas
    2. Peripheral Nodule enhancement on CT
    3. Low risk of rupture if <11 cm
    4. No treatment needed in asymptomatic Liver Hemangiomas

V. Imaging

  1. Multiphasic Abdominal CT
    1. Single-phase Abdominal CT can not differentiate Liver Lesions adequately
  2. Multiphasic Adominal MRI

VI. Diagnostics

  1. Percutaneous Liver biopsy
    1. Complication rate <5%

VII. Management

  1. Surgical resection indications
    1. Liver Lesions suspicious for Hepatocellular Carcinoma
    2. Large Liver Lesions at risk for malignant transformation or rupture (e.g. large Hepatic Adenoma)

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