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Focal Liver Lesions that can be safely managed and monitored at the primary care setting (Part 1)
2018-02-15

Introduction

Whether initiated by clinicians or patients, imaging of the abdomen had been more and more often performed for various indications. A study in the U.S. found that during the period 1996- 2010, the use of CT examinations had tripled and that of MRI had quadrupled. With high prevalence of hepatitis B virus infection in Hong Kong and better public education on surveillance of the carriers, the need and increment in the use of liver imaging is probably even more so than the above figures. On the other hand, the imaging modalities and methods had also gotten more sophisticated over the years thus increasing their diagnostic yield.

All these factors meant that the discovery of a focal liver lesion (FLL) in an asymptomatic patient, or with irrelevant complaints, is now encountered by our general practitioners at an unprecedented rate.  It is therefore important for them to make the correct decision about what to do about these patients and when to refer them to a specialist.

 

Evaluation of patients with a FLL

A detailed history and physical examination is mandatory—the gender and age, hepatitis B carrier status, the use of oral contraceptive pills, alcohol consumption and personal or family history of liver disease or primary tumours all help to identify the subgroup of high risk patients. History of weight loss is always significant. These riskl factors should prompt further investigation and specialist referral at a lower threshold.

Regarding liver imaging findings, the author finds it of upmost importance to personally review the films, it is even of more relevance nowadays that many cross border patients would bring along films of variable, sometimes of dubious quality and each must be individually appraised.

A satisfactory CT for the investigation of a FLL meant a triple phase one using multidetector scanner (MDCT) with high injection rate of contrast which allows faster scanning with more uniform hepatic enhancement. (2,3) “Triple phase” refers to the plain, late arterial, portovenous and delayed phases for characterization of liver lesions. Of note is that sometimes abdominal CT examination (for example plain or double phase contrast CT) was ordered for other complaints and incidental detection of FLL warrants a dedicated triple phase CT or even an MRI for diagnosis.

MRI for liver should include the same triple phases as a CT examination; the intravenous contrast agent used, however, differs—gadolinium is commonly employed but newer generation hepatospecific agent like gadoxetate disodium (PrimovistTM) provides more information regarding the nature of the FLL. MRI is also superior in diagnosing fatty infiltration which can sometimes masquerade as a liver lesion on USG or CT. Magnetic Resonance Cholangio- Pancreaticography (MRCP) is also valuable for appraising suspected biliary lesion or to define the relationship between a liver mass and the biliary tree.

More sophisticated or invasive investigative tools should be initiated by a specialist rather than at a primary care setting. They should be reserved for high risk patients with ambiguous findings.

References:

  1. Smith-Bindman R, Miglioretto DI, Johnson E et al. Use of diagnostic imaging studies and associated radiation exposure for patients enrolled in large integrated health care systems. 1996-2010. JAMA 2012;307:2004-9.
  2. Lee KH, O'Malley ME, Haider MA, Hanbidge A.AJR Am J Roentgenol. 2004 Mar;182(3):643-9. Triple-phase MDCT of hepatocellular carcinoma.
  3. Marrero JA, Ahn J, Rajender Reddy K. ACG clinical guideline: the diagnosis and management of focal liver lesions. Am J Gastroenterol. 2014; 109(9): 1328-47
  4. Shaked O, Siegelman ES, Olthoff K et al. Biologic and clinical features of benign solid and cystic lesions of the liver. Clini Gastroenterol Hepatol 2011;9:547-62
  5. Hernandez- Nieto L, Brugeuera M, Bombi J et al. Benign liver-cell adenoma associated with long-term administration of an androgenic- anabolic steroid(methandienone). Cnacer 1977;40:1761-4
  6. Labrune P, Trioche P, Duvaltier I et al. Hepatocellular adenomas in glycogen storage disease type I and III: a series of 43 patients and review of the literature. J Paediatr Gastroenterol Nutr 1997;24:276-9
  7. Bunchorntavakul C, Bahirwani R, Drazek D et al. Clinical features and natural history of hepatocellular adenomas: the impact of obesity. Aliment Pharmacol Ther 2011;34:664-74
  8. Bioulac-Sage P, Taouji S, Possenti L et al. Hepatocellular adenoma subtypes:the impact of overweight and obesity. Liver Int 2012;32:1217-21
  9. Karhunen PJ. Benign hepatic tumours and tumour like condition in men. C Clin Pathol 1986;39:183-9
  10. Oto A, Tamm EP, Szklaruk J. Multidetector row CT of the liver. Radiol Clin North Am 2005;43:827-48

The above information is provided by Dr Chik Hsia Ying, Barbara