Practice
Rational Imaging
Investigating focal liver lesions
Cite this as:
BMJ
2012;344:e657
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2 April 2012
The responses by Dunne et al and Aspinall are welcomed for their contributions to this important topic.
Our article, as part of the "Rational Imaging" Series, was intended to provide a fundamental overview of the imaging options available for the characterisation of an incidental focal liver lesion. It was aimed principally at the primary care setting and, as Dr Aspinall rightly points out, a different investigative algorithm should be applied to a more select population of patients at high risk of hepatocellular carcinoma (HCC) (1). In our practice the role of contrast-enhanced ultrasound (CEUS) would be to initially characterise an incidental lesion into broadly "non-malignant" vs "malignant" and to guide further investigation if required. In the case of HCC vs intrahepatic cholangiocarcinoma (IHC), the enhancement patterns obtained using CEUS would typically show initial arterial enhancement and then usually some degree of contrast washout. While IHC often demonstrates a distinctive pattern of peripheral enhancement in the arterial phase, it is acknowledged that there can be an overlap in its enhancement pattern with HCC (2); in which case MR imaging would then be recommended to further characterise such lesions and obtain local staging information.
We fully endorse the view of Dunne et al in terms of liver biopsy and its risks. Such an invasive procedure obviously should not be undertaken without due thought and ideally preceding MDT discussion. However, situations do occur where, despite thorough radiological and biochemical investigation, lesions remain indeterminate and not fully characterised, particularly in cases of co-existent pathologies: biopsy remains in the current updated algorithm for suspected HCC in cirrhosis (1). Such a situation is reducing in the HPB setting with the increasing use of hepatocyte specific MR contrast agents: although these agents may not be routinely available or familiar in all centres. We re-iterate Dunne et al's comments about the risks of percutaneous liver biopsy and as displayed in our original article (Figure 2), it is considered a "last resort" option.
Dhruv Patel
Specialist Registrar Radiology
Victoria Scott
Foundation Year 2
James Pilcher
Consultant Radiologist
References
1. Bruix J, Sherman M. Management of hepatocellular carcinoma: An update. Hepatology 2011; 53: 1020-1022
2. Chen LD, Xu HX, Xie XY, Xie XH, Xu ZF, Liu GJ, Wang Z, Lin MX, Lu MD. Intrahepatic cholangiocarcinoma and hepatocellular carcinoma: differential diagnosis with contrast-enhanced ultrasound. Eur Radiol. 2010;20:743-53
Competing interests: None declared
St Georges Healthcare NHS Trust, London, SW17 0QT
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21 February 2012
I was surprised that the “Rational Imaging” feature by Patel et al[1] did not discuss hepatocellular carcinoma (HCC) or intrahepatic cholangiocarcinoma (IHC) in an article on focal liver lesions, particularly in a patient with apparent chronic liver disease.
Several of the authors’ statements deserve further 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 may 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 substantially different from those incidentally found in low risk populations.[3]
For example, in one study of 1,982 cirrhotic patients, 50% of lesions characterised radiologically as typical haemangiomas were subsequently revealed to be hyperechogenic HCC.[4]
Similarly, Patel et al’s enthusiasm for contrast-enhanced ultrasound should be balanced by recent data showing the technique fails to discriminate between HCC and IHC in patients with chronic liver disease, unlike contrast enhanced MRI.[5]
It should therefore be emphasised that Patel et al’s algorithm for investigating focal liver lesions applies to patients at low risk of HCC. In those with cirrhosis of any aetiology or in cases of chronic viral hepatitis B or C, I would suggest following the diagnostic algorithms advised by international liver societies.[6]
References:
[1] Patel DV, Scott V, Pilcher J. Investigating focal liver lesions. BMJ. 2012;344:41-44
[2] Saverymuttu SH, Joseph AE, Maxwell JD. Ultrasound scanning in the detection of hepatic fibrosis and steatosis. Br Med J(Clin Res Ed) 1986;292:13-15
[3] Yang JD, Roberts LR. Hepatocellular carcinoma: a global view. Nat. Rev. Gastroenterol. Hepatol. 2010; 7: 448–458
[4] Caturelli E, Pompili M, Bartolucci F, Siena DA, Sperandeo M, Andriulli A, Bisceglia M. Hemangioma-like lesions in chronic liver disease: diagnostic evaluation in patients. Radiology. 2001;220:337-42
[5] Vilana R, Forner A, Bianchi L, García-Criado A, Rimola J, de Lope CR, Reig M, Ayuso C, Brú C, Bruix J. Intrahepatic peripheral cholangiocarcinoma in cirrhosis patients may display a vascular pattern similar to hepatocellular carcinoma on contrast-enhanced ultrasound. Hepatology. 2010;51:2020-9
[6] Bruix J, Sherman M. Management of hepatocellular carcinoma: An update. Hepatology 2011; 53: 1020-1022
Competing interests: None declared
Portsmouth Hospitals NHS Trust, Queen Alexandra Hospital, Portsmouth PO6 3LY
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21 February 2012
Editor
British Medical Journal
Dear Sir,
Investigating focal liver lesions. Patel DV et al. BMJ 2012; 344: 41-44
We welcome this interesting article by Patel and colleagues on what is an increasing problem in clinical practice: the management of liver lesions detected incidentally during investigation of other symptoms. As the authors point out, the vast majority are entirely benign and the prevalence of such benign incidental lesions is 10% in the general adult population.
However we are concerned by their recommendations regarding liver biopsy, which may reflect their institution not hosting a cancer network designated specialist Hepatobiliary Specialist MDT. The Mersey and Cheshire HB SMDT sees on average up to 10 such newly detected lesions each week from across our cancer network. With the advent of high quality CT, MRI with hepatocyte specific contrast agent, and contrast ultrasound scanning it is now more than 5 years since we have had to resort to image guided percutaneous biopsy/fine needle aspiration to clarify the diagnosis of such lesions.
The authors cite the results from one eminent US centre to validate the safety of such a biopsy 1. It must be borne in mind that this paper reviewed the safety of random image guided liver biopsy in general, with only 81/539 biopsies being for diagnosis of a focal liver lesion, and no reporting on oncological complications (needle track tumour seeding)(see Figure 1). Since the vast majority of such incidental lesions are benign then the risk of tumour seeding remains low 2. However, when malignant liver tumours are biopsied in this manner there remains a small but real risk of tumour seeding for both potentially curable malignant primary 3 and resectable metastatic liver tumours 4. Indeed in the latter group, biopsy of colorectal liver metastases prior to hepatectomy with curative intent was associated with a 50% reduction in overall survival at 4 years after liver surgery 4.
While we fully endorse the authors’ views on the appropriate radiological imaging of these lesions, the reality is that in 2012 the diagnosis of such lesions will be made by a combination of these radiological investigations in combination with an accurate clinical history and appropriate biochemical investigations by an experienced cancer network designated specialist HB MDT. Image guided liver biopsy of focal liver lesion(s) should only be on the recommendation of such an SMDT, and usually only to obtain a histological diagnosis to guide appropriate palliative chemotherapy for patients with inoperable and incurable malignancy involving the liver.
Yours sincerely,
Declan FJ Dunne
Surgical Research Fellow
Hepatobiliary Surgical Service
Aintree University Hospital NHSFT
Liverpool L9 7AL
Robert P Jones
Surgical Research Fellow
Hepatobiliary Surgical Service
Aintree University Hospital NHSFT
Liverpool L9 7AL
Hassan Malik
Consultant Hepatobiliary Surgeon
Hepatobiliary Surgical Service
Aintree University Hospital NHSFT
Liverpool L9 7AL
Stephen Fenwick
Consultant Hepatobiliary Surgeon
Hepatobiliary Surgical Service
Aintree University Hospital NHSFT
Liverpool L9 7AL
David White
Consultant Radiologist
Aintree University Hospital NHSFT
Liverpool L9 7AL
Graeme Poston
Professor of Hepatobiliary Surgery
Hepatobiliary Surgical Service
Aintree University Hospital NHSFT
Liverpool L9 7AL
References:
1. Padia SA, Baker ME, Schaeffer CJ, Remer EM, Obuchowski NA, Winans C, Herts BR. Safety and efficacy of sonographic-guided random real-time core needle biopsy of the liver. J Clin Ultrasound 2009; 37: 138-43
2. Robertson EG, Baxter G. Tumour seeding following percutaneous needle biopsy: the real story! Clin Radiol 2011; 66: 1007-14
3. Ahn DW, Shim JH, Yoon JH, Kim CY, Lee HS, Kim YT, Kim YJ. Treatment and clinical outcome of needle-track seeding from hepatocellular carcinoma. Korean J Hepatol 2011; 17: 106-12
4. Jones OM, Rees M, John TG, Bygrave S, Plant G. Biopsy of resectable colorectal liver metastases causes tumour dissemination and adversely affects survival after liver resection. Brit J Surg 2005; 92: 1165-8
Legend
Figure One
Operative photograph of histologically proven implanted metastatic hepatocellular carcinoma on Glisson’s capsule of the liver of a patient with a resectable and potentially curable tumour at the site of an earlier ultrasound guided percutaneous biopsy of the tumour. The patient developed abdominal wall recurrence of disease one year after hepatectomy and died one year later from atypical widespread recurrence of their disease.
Competing interests: None declared
Aintree University Hospital, Lower Lane, Liverpool, L9 7AL
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