Correct answer to Q3 is: Hemangioma
Additional Discussion:
Although MRI is usually a good imaging modality to diagnose liver lesions, including hemangiomas, occasionally, it can misdiagnose with cholangiocarcinoma or vice versa as both lesions have rim enhancement and do not show washout on MRI or CT. The reason cholangiocarcinoma does not show “washout”, the hallmark for malignancy, is due to the leakage of the small molecule contrast agents for CT and MRI into the interstitium of this schirrous tumor. On CEUS, which utilizes pure intravascular microbubble contrast agent, this leakage does not happen, and thus cholangiocarcinoma would show washout. This discrepancy between CT/MRI and CEUS is an important and very useful feature for cholangiocarcinoma diagnosis (3).
CEUS is a great imaging modality for the diagnosis of hemangiomas (4). Hemangioma is typically hyperechoic on gray scale ultrasound, however, with increasing incidence of fatty liver disease, more hemangiomas and other lesions are hypoechoic on gray scale imaging.
Conclusion
CEUS is a useful tool for the diagnosis of focal liver lesions, especially for lesions indeterminate on CT or MRI as highlighted in this case. CEUS LI-RADS is a standardized system for HCC diagnosis, providing non invasive diagnosis for HCC, however, it cannot be applied on patients without high risk for HCC.
Conflicts of interest
Research support from Bracco Diagnostics Inc, Lantheus, and Cannon Medical Systems co.
References
- Wilson SR, Lyshchik A, Piscaglia F, Cosgrove D, Jang HJ, Sirlin C, et al. CEUS LI-RADS: algorithm, implementation, and key differences from CT/MRI. Abdom Radiol (NY). 2018;43(1):127-42.
- Chernyak V, Fowler KJ, Do RKG, Kamaya A, Kono Y, Tang A, et al. LI-RADS: Looking Back, Looking Forward. Radiology. 2023;307(1):e222801.
- Wilson SR, Kim TK, Jang HJ, Burns PN. Enhancement patterns of focal liver masses: discordance between contrast-enhanced sonography and contrast-enhanced CT and MRI. AJR Am J Roentgenol. 2007;189(1):W7-W12.
- Liu LP, Dong BW, Yu XL, Liang P, Zhang DK, An LC. Focal hypoechoic tumors of Fatty liver: characterization of conventional and contrast-enhanced ultrasonography. Journal of ultrasound in medicine : official journal of the American Institute of Ultrasound in Medicine. 2009;28(9):1133-42.
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