Letters Focal liver lesions

Algorithm for investigating focal liver lesions doesn’t apply to patients at high risk of hepatocellular carcinoma

BMJ 2012; 344 doi: http://dx.doi.org/10.1136/bmj.e2558 (Published 10 April 2012) Cite this as: BMJ 2012;344:e2558
  1. Richard J Aspinall, consultant hepatologist1
  1. 1Portsmouth Hospitals NHS Trust, Queen Alexandra Hospital, Portsmouth PO6 3LY, UK
  1. richard.aspinall{at}porthosp.nhs.uk

I was surprised that Patel and colleagues’ article on focal liver lesions in a patient with apparent chronic liver disease did not discuss hepatocellular carcinoma (HCC) or intrahepatic cholangiocarcinoma.1

Several of the authors’ statements deserve clarification. Firstly, an ultrasound scan suggestive of fatty infiltration in a South Asian man with raised liver enzymes does not mean the patient has non-alcoholic fatty liver disease. This non-specific radiological appearance can also be found in chronic hepatitis, ethanol misuse, drug induced liver injury, and autoimmune liver disease.2

Most cases of HCC arise on a background of chronic liver disease and the risk of malignancy in focal lesions in this setting is very different from that seen in low risk populations.3 For example, in one study of 1982 patients with cirrhosis, 50% of lesions characterised radiologically as typical haemangiomas were subsequently shown to be hyperechogenic HCC.4

Similarly, the authors’ enthusiasm for contrast enhanced ultrasound should be balanced by recent data showing that, unlike contrast enhanced magnetic resonance imaging, the technique fails to discriminate between HCC and intrahepatic cholangiocarcinoma in patients with chronic liver disease.5

Thus, Patel and colleagues’ algorithm for investigating focal liver lesions applies only to patients at low risk of HCC. In those with cirrhosis of any cause or in cases of chronic viral hepatitis B or C, the diagnostic algorithms advised by international liver societies should be followed.6


Cite this as: BMJ 2012;344:e2558


  • Competing interests: None declared.