Sex: female
Age: 51 years
History
This patient was admitted to hospital complaining of right upper quadrant pain radiating to the right side and back, nausea and vomitting.
Laboratory data
Unremarkable.
Physical findings
Unremarkable.
Case text
During the work up for right upper quadrant pain, an ill-defined, slightly low-echogenicity mass was found in the right liver lobe at ultrasound. CT showed an intermediate attenuation mass, with slight contrast enhancement. Laparoscopic biopsy of the lesion was said to show it to be cystic.
Image1-4
MRI of the upper abdomen, T2-weighted sequence.
In the right liver lobe.
Image 5-8
MRI, T1-weighted sequence.
T1-weighted TSE images, respiratory compensated TR 550, TE 15. 10 mm thick slices.
Image 9-13
MRI, multi-echo.
T2-weighted images with increasing TE. The sequence is formed of eight echoes at the same location, TR 2000, TE 40, 80, 120, 160, 200, 240, 280 and 320. Here, the first, fifth and seventh echoes are left out (images 9-13).
Image 14-18
MRI. Dynamic T1-weighted sequence after contrast injection with Gadolinium.
T1-weighted gradient echo (TFE) images, TR 15,TE 4, flip angle 25 degrees. Breath hold images every 20 seconds. Here, the images nr. 14-18 are shown (20 seconds, 1 minute, 1 min 40 sec, 2 min 20 sec and 3 minutes after contrast injection). The same slice through part of the lesion (images 14-18).
Image 19-22
MRI. T1-weighted late sequence after contrast enhancement.
T1-weighted TSE, respiratory compensated, TR 550, TE 15. Images after 10 minutes.
Image 1-4
1. Where is the lesion located?
In the right liver lobe.
2. What are the characteristic features based on this sequence?
Lobulated lesion, uncertain whether one or two contiguous lesions. High signal intensity, rather homogeneous.
3. What are the differentials?
The most common incidental finding in an otherwise healthy person without history of malignancy, is cavernous hemangioma or cyst of the liver. Abscess is also possible. Adenoma and focal nodular hyperplasia (FNH) are not as common but possible. Malignancy must always be ruled out.
Image 5-8
4. What are the characteristic features based on this sequence?
Intermediate signal intensity, lobulated, rather well circumscribed.
5. What are the differentials left?
Cyst can be ruled out on the signal intensity. Abscess is often more patchy. Adenomas and FNH most likely not as low signal intensity on T1-, neither as high on T2-weighted images.
6. What should further be done?
Multi-echo imaging to get further support to the diagnosis of hemangioma, being the most common lesion in the liver
Image 9-13
7. What can be said about the signal intensity on this series of images?
On echoes with increasing TE, the signal intensity decreases only marginally, compared to the signal intensity of the spinal canal
8. What conclusion can be drawn on the basis of this sequence alone?
A hemangioma should have almost the same signal intensity throughout the series. In this case there is a very small drop out of signal but not as much as should be the case with a malignant lesion.
9. How confident can you be about the diagnosis?
The features of the signal intensity pattern on a multi-echo is only indicative. When there is no loss of signal intensity, there is very high confidence on the lesion to be a cavernous hemangioma, but this is often only the case with rather small hemangiomas, whereas the medium or large ones can have atypical patterns.
10. What should further be done?
Contrast injection with Gadolinium.
11. Is there anything specific to think about, when setting up the next sequence?
Important to image dynamically, because the enhancement pattern changes depending on the time phase you image. The first images should be performed as soon as possible after (or even during) the injection.
Image 14-18
12. Describe the enhancement pattern.
There is a successive filling of the lesion with contrast material from the periphery, being almost homogeneous after 3 minutes
13. What conclusion can be drawn on the basis of the contrast enhancement?
This is a typical contrast enhancement pattern for a cavernous hemangioma.
14. What is the most likely diagnosis?
Cavernous hemangioma, the signal pattern on multi-echo and the enhancement pattern on dynamic imaging are both almost pathognomonic for cavernous hemangioma.
15. What can be done to further increase your confidence?
Late imaging after contrast injection. It would not really be necessary in this case but is included to show the typical pattern.
Image 19-22
16. Describe the enhancement pattern after 10 minutes.
There is a homogeneous enhancement of the lesion.
17. What is your final diagnosis?
Cavernous hemangioma of the liver.
18. How about your confidence in the diagnosis?
If there was complete confidence after the multi-echo and dynamic Gd-images, this late enhancement of the lesion could be considered not as typical. It can, however, take quite a long time for the contrast to be washed out of the liver, so that its enhancement equals that of normal liver parenchyma.
Final diagnosis
Cavernous hemangioma of the liver.
Differential diagnosis
- Malignancy (rim enhancement)
- Cyst (low signal intensity on T1-weighted images, no enhancement)
- Adenoma (not as high signal on T2-, not as low on T1-weighted images)
- FNH (idem)
- Abscess (rim enhancement, patchy)
Discussion
Cavernous hemangiomas are very common hepatic lesions (up to 25% of the population is being reported as having hemangiomas in the liver at autopsy), almost always being found incidentally, while investigating some unrelated symptoms, for example with ultrasound. They very rarely become symptomatic, and then because of bleeding in a very big hemangioma. The problem is to differentiate this purely accidental finding from other lesions in the liver which can require surgery, such as metastasis or adenomas. This is especially true in a patient with a known history of malignant disease.
The ultrasound features are often very typical with high echogenicity, well circumscribed and a diameter most commonly not passing 2 cm. In an otherwise healthy person this should not require further investigations. If this, however, is considered to be necessary, liver scintigraphy with blood pool imaging is a very sensitive and specific modality if the lesion is over 2 cm in size. The large hemangiomas can be very atypical, though, and the very small ones (< 2cm) are not always detected.
CT with contrast injection and dynamic imaging is a good imaging modality to get further support for a lesion being a hemangioma and in many centers it is considered that if two of the mentioned modalities support the diagnosis of hemangioma, no further work up is necessary.
MRI is very sensitive in detecting lesions in the liver. Multi-echo imaging as described is considered to be diagnostic if the signal intensity pattern is typical and then no other investigation is required. Only a benign cyst can have the same signal pattern and these are ruled out on the basic signal features. If, however, the multi-echo does not provide a typical signal pattern, then contrast injection of Gadolinium with dynamic imaging is a very sensitive tool. Late imaging can sometimes further increase the conspicuity of the lesion. As is the case with the mentioned imaging modalities, the very big hemangiomas are atypical even in this case.