"Incidentaloma" of the liver: management of a diagnostic and therapeutic dilemma

Abstract

The continuous development of highly sensitive clinical imaging increased the detection of focal lesions of the liver. These accidentally detected liver tumors without liver-specific symptoms such as cholestasis have been named "incidentalomas." Diagnostic tools such as sonography, computed tomography, or magnetic resonance imaging are used increasingly in asymptomatic individuals without defined suspected diagnoses in the setting of general prevention or followup after a history of malignancy. But despite continuous improvement of diagnostics, some doubt regarding the benign or malign behavior of a tumor remains. In case an asymptomatic hemangioma or FNH can be preoperatively detected with certainty, the indication for surgery must be very strict. In case of symptomatic liver lesions surgical resection should only be indicated with tumor-specific symptoms. In the remaining cases of benign lesions of the liver, a "watch and wait" strategy is recommended. In case of uncertain diagnosis, especially in patients with positive history of a malignant tumor or the suspected diagnosis of hepatocellular adenoma, surgical resection is indicated. Due to the continuous improvement of surgical techniques, liver resection should be done in the laparoscopic technique. Laparoscopic surgery has lower morbidity and shorter hospitalization than open technique.

Figure 1

Two hemangiomas in gadolinium enhanced MRI (contrast medium: gadoxetic acid; disodium salt (Primovist, Eurokontrast GmbH, Heidelberg), scanner: GE Signa HDxt 1,5T (General Electric Company, USA)): peripheral nodular enhancement in T1 FS early arterial contrast phase (upper left): (T1 LAVA FS dynamic FA80, TR 185 TE 4,2), progressive centripetal enhancement in T1 FS late arterial (upper right): (T1 LAVA FS dynamic FA80, TR 185 TE 4,2) and portal-venous phase (lower left): (T1 LAVA FS dynamic FA80, TR 185 TE 4,2). Typical ill-shaped intermediate (less than in cysts) hyperintensity in T2 (lower right): (T2 FRFSE FS FA 90 TR 2500 TE 94,16). Lesion in left lobe is partially clotted with thrombosis and shows less enhancement.

Figure 2

Focal nodular hyperplasia in gadolinium-enhanced MRI (contrast medium: gadoxetic acid; disodium salt (Primovist, Eurokontrast GmbH, Heidelberg), scanner: GE Signa HDxt 1,5T (General Electric Company, USA)): inhomogeneous hyperintensity on T1 FS in portal-venous contrast phase (T1 FSPGR FS FA12, TR 4,24 TE 2,04, TI 7).

Figure 3

Segment 1 adenoma in gadolinium-enhanced MRI (contrast medium: gadoxetic acid; disodium salt (Primovist, Eurokontrast GmbH, Heidelberg), scanner: GE Signa HDxt 1,5T (General Electric Company, USA)): hyperintens. in T1 FS arterial contrast phase (upper left): (T1 LAVA FS dynamic FA80, TR 185 TE 4,2), partial equilibration to liver isointensity in T1 FS late portal-venous phase (upper right): (T1 FSPGR FS FA12, TR 4,24 TE 2,04, TI 7), slight hyperintensity on T2 FS (lower left): (T2 FRFSE FS FA 90 TR 2500 TE 94,16), and isointensity in unenhanced T1 fat sat. (lower right): (T1 LAVA FS dynamic FA80, TR 185 TE 4,2).

Figure 4

Waterjet dissector (Helix Hydro-Jet; Erbe Elektromedizin GmbH, Tübingen, Germany).

Figure 5

Algorithm for management of solid liver lesions (mod. from Terkivatan et al. [54]).