Gastroenterol Res

Gastroenterology Research, ISSN 1918-2805 print, 1918-2813 online, Open Access

Article copyright, the authors; Journal compilation copyright, Gastroenterol Res and Elmer Press Inc

Journal website http://www.gastrores.org

Review

Volume 2, Number 5, October 2009, pages 259-267

Approach to Solid Liver Masses in the Cirrhotic Patient

**Table 1.** Accuracy and key features of imaging techniques in the diagnosis of most common liver masses in cirrhosis
Lesions	US- US Doppler, Contrast ultrasound	Triphasic Dynamic CT	MRI	PET SCAN	CT-Angiography
+, degree of accuracy; SS sensitivity; SP specificity; a; Intraoperatrive ultrasound, contrast ultrasound and EUS are highly sensitive to detect liver mass; From Assy N, World J Gastroenterol. 2009;15:3217-27.
HCC	+ Hypo or hyper echoic Doppler: hyper vascular. index and flow high, spectral broadening	+++ hyper vascular, often irregular borders Heterogeneous> Homogeneous abnormal internal vessel Hallmark feature is arterial hypervascular- and venous wash-out SS 52-54%	+++ hyper vascular Poor different: Hypo intense T-1, Hyper intense T2; Well different: Hype intense T-1, Iso intense T-2 SS 53-78%	+ Increased uptake. but many HCC do not show uptake at PET	++++ Hyper vascular Av shunting angiogenesis
Cholangio -CA	Bile duct dilatation if major ducts are involved Intrahepatic CCC: no bile dilatation	Hypo dense lesion Delayed enhancement	Hypo intense T1 Hyper intense T2 MRCP is useful	SS 93% Increase uptake	Hyper vascular
Metastasis	+ SS 40-70 % hypo echoic to hyper echoic; Doppler; low index and flow; presence of spectral broadening	+++ SS 49-74 % complete ring enhancement	+++ SS 68 -90 % Low intensity T-1 High intensity T-2	+++++ SS 90-100% colon, pancreas	++++ SS 88-95% hyper vascular
Haemangioma	++ Hyper echoic Doppler: low flow, low index, absence of spectral broadening	+++ Peripheral puddles, fill in from periphery, enhancement on delayed scan	++++ Peripheral enhancement centripetal progression HyperintenseT2, hypo intense T1 SS >95%, SP 95%	No uptake	+++ Cotton wool pooling of contrast, normal vessels without AV shunt, persistent enhancement
Focal fatty liver	+ hyper echoic, no mass effect, no vessel displacement	++ Sharp interface Low density (<40u)	+++	No uptake	normal finding
Adenoma	+ Heterogeneous Hyper echoic If haemorrhage: anechoic centre. Doppler: variable flow and spectral broadening	++ Homogenous>Heterogeneous, Peripheral feeders filling in from periphery	++ Capsule, Hyper intense T1 (intra lesion fat )	no uptake uptake if degeneration to HCC	++ Hyper vascular Large peripheral Vessel. Central scar if haemorrhage

Table 1. Accuracy and key features of imaging techniques in the diagnosis of most common liver masses in cirrhosis

Lesions

US- US Doppler, Contrast ultrasound

Triphasic Dynamic CT

MRI

PET SCAN

CT-Angiography

+, degree of accuracy; SS sensitivity; SP specificity; a; Intraoperatrive ultrasound, contrast ultrasound and EUS are highly sensitive to detect liver mass; From Assy N, World J Gastroenterol. 2009;15:3217-27.

HCC

+
Hypo or hyper echoic
Doppler: hyper vascular.
index and flow high, spectral broadening

+++
hyper vascular, often irregular borders
Heterogeneous> Homogeneous
abnormal internal vessel
Hallmark feature is arterial hypervascular-
and venous wash-out
SS 52-54%

+++
hyper vascular
Poor different: Hypo intense T-1, Hyper intense T2;
Well different: Hype intense T-1, Iso intense T-2
SS 53-78%

+
Increased uptake. but many HCC do not show uptake at PET

++++
Hyper vascular
Av shunting
angiogenesis

Cholangio -CA

Bile duct dilatation if major ducts are involved
Intrahepatic CCC: no bile dilatation

Hypo dense lesion
Delayed enhancement

Hypo intense T1
Hyper intense T2
MRCP is useful

SS 93%
Increase uptake

Hyper vascular

Metastasis

+
SS 40-70 %
hypo echoic to hyper echoic; Doppler; low index and flow; presence of spectral broadening

+++
SS 49-74 %
complete ring enhancement

+++
SS 68 -90 %
Low intensity T-1
High intensity T-2

+++++
SS 90-100%
colon, pancreas

++++
SS 88-95%
hyper vascular

Haemangioma

++
Hyper echoic
Doppler: low flow, low index, absence of spectral broadening

+++
Peripheral puddles, fill in from periphery, enhancement on delayed scan

++++
Peripheral enhancement centripetal progression
HyperintenseT2,
hypo intense T1
SS >95%,
SP 95%

No uptake

+++
Cotton wool pooling of contrast, normal vessels without AV shunt, persistent enhancement

Focal fatty liver

+
hyper echoic, no mass effect, no vessel displacement

++
Sharp interface
Low density (<40u)

+++

No uptake

normal finding

Adenoma

+
Heterogeneous
Hyper echoic
If haemorrhage: anechoic centre. Doppler: variable flow and spectral broadening

++
Homogenous>Heterogeneous,
Peripheral feeders filling in from periphery

++
Capsule,
Hyper intense T1
(intra lesion fat )

no uptake
uptake if degeneration to HCC

++
Hyper vascular
Large peripheral
Vessel. Central scar
if haemorrhage

**Table 2.** Accuracy of tumor markers in the diagnosis of HCC
	Normal value	Sensitivity %	Specificity %	PPV %	NPV %	Diagnostic accuracy %
Des-gamma-carboxy prothrombin (DCP). Tissue polypeptide antigen (TPA), alpha fetoprotein (AFP), carcinoembryonic antigen (CEA), From Grazi GL, liver transplantation and surgery 1995;1: 249-255.
AFP (ng/dL)	20	55	97	95	69	77
CEA (ng/dL)	7	22	78	48	51	51
TPA (U/L)	90	70	61	62	70	66
DCP (AU/ml)	0.09	53	88	88	66	71

Table 2. Accuracy of tumor markers in the diagnosis of HCC

Normal value

Sensitivity %

Specificity %

PPV %

NPV %

Diagnostic accuracy %

Des-gamma-carboxy prothrombin (DCP). Tissue polypeptide antigen (TPA), alpha fetoprotein (AFP), carcinoembryonic antigen (CEA), From Grazi GL, liver transplantation and surgery 1995;1: 249-255.

AFP (ng/dL)

CEA (ng/dL)

TPA (U/L)

DCP (AU/ml)

0.09

**Table 3.** Accuracy of magnetic resonance imaging (MRI) and spiral computed (CT) in the diagnosis of liver mass (nodule)
	MRI %	CT %
From: de Ledinghen: Eur J Gastroenterol Hepatol, 2002;14:159-165.
Sensitivity	85	70
Specificity	71	86
Positive predictive value	92	95
Negative predictive value	56	43
Diagnostic Accuracy	82	74

Table 3. Accuracy of magnetic resonance imaging (MRI) and spiral computed (CT) in the diagnosis of liver mass (nodule)

MRI %

CT %

From: de Ledinghen: Eur J Gastroenterol Hepatol, 2002;14:159-165.

Sensitivity

Specificity

Positive predictive value

Negative predictive value

Diagnostic Accuracy

**Table 4.** The sensitivity (%) of FNA cytology, needle core biopsy, and combined FNA/FNCB in malignant and in benign liver lesions
Biopsy Site	FNA %	FNCB %	Combined %
FNA, fine needle aspiration. FNCB, needle core biopsy, From: Stewart CJ; J Clin Pathol. 2002; 55: 93–97.
Liver Metastasis	86	83	88
Hepatocellular Carcinoma	100	89	100
Benign Liver Lesions	100	89	100

Table 4. The sensitivity (%) of FNA cytology, needle core biopsy, and combined FNA/FNCB in malignant and in benign liver lesions

Biopsy Site

FNA %

FNCB %

Combined %

FNA, fine needle aspiration. FNCB, needle core biopsy, From: Stewart CJ; J Clin Pathol. 2002; 55: 93–97.

Liver Metastasis

Hepatocellular Carcinoma

100

Benign Liver Lesions

100