Maria Franca Meloni1 *, Debora Cidoni2 , Giacomo Gazzano1, and Sandro Sironi2 ,
1 Casa di Cura Igea: Department of Radiology, Milano, Italy
2 Department of Radiology, University of Milano-Bicocca, Papa Giovanni XXIII Hospital Bergamo- Italy
2 Instituto Auxologico Italiano, Department of Pathology, Milano, Italy
* Correspondence: meloni.mariafranca@gmail.com
Clinical history
A 55-year-old healthy female, without a history of cirrhosis or cancer had undergone a follow-up MRI for renal angiomyolipoma with contrast agent and diffusion weighted sequences at a different hospital. She had not taken any estrogen or progesterone drugs in the past. The MRI incidentally identified a focal lesion in liver segment III measuring 16 mm with intense diffusion restriction.
Images
Image 1a, 1b, 1c -The lesion was hyperintense on T2 weighted images (image 1a), with intense arterial enhancement and perilesional vascularization (image 1b). The central portion of the lesion was hypointense in the late phase with a hyperintense rim. Laboratory tests were normal and tumor markers were negative. The patient was referred to our hospital for further evaluation with ultrasound including contrast enhanced ultrasound (CEUS).
Image 2 - On gray scale ultrasound imaging a hypoechoic lesion was identified in segment III measuring 1.6 cm (white arrow).
Video 1 – CEUS shows transient arterial enhancement and early wash-out 22 seconds after injection.
Image 3 - CEUS with 1.2ml of Sonovue at 15 sec, 20 sec, 120 sec and 180 sec post-injection, respectively. The lesion (white arrow) shows early enhancement at 15 seconds after injection, with early wash-out at 22 seconds, which becomes progressive and intense at 120 and 180 seconds
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Question 1 of 2
1. Question
Question 1: What is the most likely diagnosis?
Correct
CORRECT ANSWER EXPLAINED BELOW
Correct answer to Q1 is: Other
Discussion
The vascular behavior on CEUS could indicate a malignant lesion, but the absence of symptoms or a history of cancer along with negative laboratory tests including tumor markers lead us to continue the clinical investigations.
Incorrect
CORRECT ANSWER EXPLAINED BELOW
Correct answer to Q1 is: Other
Discussion
The vascular behavior on CEUS could indicate a malignant lesion, but the absence of symptoms or a history of cancer along with negative laboratory tests including tumor markers lead us to continue the clinical investigations.
Question 2 of 2
2. Question
Question 2: Is the information we have enough for a diagnosis?
Correct
CORRECT ANSWER EXPLAINED BELOW
Correct answer to Q2 is: Biopsy is strongly recommended.
Additional Imaging
Video 2 – Ultrasound guided biopsy performed with an 18 G semi-automatic needle of the liver lesion in segment III.
Image 4 – Histological sample.
Image 5 – Hematoxylin-Eosin staining. Epitheloid microgranuloma and lymphocytic infiltration. The histological diagnosis was compatible with atypical mycobacteriosis.
Additional discussion
Hepatic granulomas are rare benign lesions. They are found in approximately 2-15% of liver biopsies. The causes can be infectious and non-infectious. Infectious granulomas are linked to primary biliary cirrhosis, tuberculosis, viral hepatitis B and C, bacterial, fungal, and parasitic infections, while non-infectious ones are usually linked to drugs or sarcoidosis (1).
Hepatic granulomas may be found incidentally in asymptomatic patients or patients with vague or non-specific symptoms. The do not have a specific enhancement pattern in CT or MRI, and can in fact present without enhancement, with hyper-enhancement or with peripheral rim-like enhancement (2).
The CEUS behavior of granuloma is described as highly variable, making the differential diagnosis with malignant neoplasms difficult (3-5).
In our case the patient was asymptomatic, and the detection of the liver lesion was incidental. CEUS, performed after B-mode ultrasonography, showed a rapid and fleeting arterial enhancement followed by an early (22 sec) and progressively intense wash-out. The CEUS behavior was compatible with a malignant lesion, but in the absence of a clinical history of cancer, a biopsy was necessary, which correctly led to the benign diagnosis.
Conclusion
Hepatic granuloma are rare lesions in the liver, but they should be considered in the differential diagnosis of focal liver lesions. CEUS cannot differentiate granulomatous lesions from focal malignant lesions such as metastases or intrahepatic cholcangiocarcinoma. Biopsy plays a fundamental role in the diagnosis as it excludes malignant pathology.
Conflicts of Interest:
The author declares no conflict of interest.
References
Choi EK, Lamps LW. Granulomas in the liver with a Focus on Infectious Causes Surg Pathol Clin. 2018 Jun;11(2):231-250. doi: 10.1016/j.path.2018.02.008
Mortelé KJ, Segatto E, Ros PR. The infected liver: radiologic-pathologic correlation. Radiographics. 2004 Jul-Aug;24(4):937-55. doi: 10.1148/rg.244035719.
Dietrich CF, Nolsøe CP, Barr RG, et al., Guidelines and Good Clinical Practice Recommendations for Contrast Enhanced Ultra- sound (CEUS) in the Liver – Update 2020 – WFUMB in Cooper- ation with EFSUMB, AFSUMB, AIUM, and FLAUS Ultraschall Med 2020; 39:187–210.
Kong WT, Wang WP, Cai H, Huang BJ, Ding H, Mao F. The analysis of enhancement pattern of hepatic inflamma- tory pseudotumor on contrast-enhanced ultrasound. Abdom Imaging 2014;39:168-174.
Correct answer to Q2 is: Biopsy is strongly recommended.
Additional Imaging
Video 2 – Ultrasound guided biopsy performed with an 18 G semi-automatic needle of the liver lesion in segment III.
Image 4 – Histological sample.
Image 5 – Hematoxylin-Eosin staining. Epitheloid microgranuloma and lymphocytic infiltration. The histological diagnosis was compatible with atypical mycobacteriosis.
Additional discussion
Hepatic granulomas are rare benign lesions. They are found in approximately 2-15% of liver biopsies. The causes can be infectious and non-infectious. Infectious granulomas are linked to primary biliary cirrhosis, tuberculosis, viral hepatitis B and C, bacterial, fungal, and parasitic infections, while non-infectious ones are usually linked to drugs or sarcoidosis (1).
Hepatic granulomas may be found incidentally in asymptomatic patients or patients with vague or non-specific symptoms. The do not have a specific enhancement pattern in CT or MRI, and can in fact present without enhancement, with hyper-enhancement or with peripheral rim-like enhancement (2).
The CEUS behavior of granuloma is described as highly variable, making the differential diagnosis with malignant neoplasms difficult (3-5).
In our case the patient was asymptomatic, and the detection of the liver lesion was incidental. CEUS, performed after B-mode ultrasonography, showed a rapid and fleeting arterial enhancement followed by an early (22 sec) and progressively intense wash-out. The CEUS behavior was compatible with a malignant lesion, but in the absence of a clinical history of cancer, a biopsy was necessary, which correctly led to the benign diagnosis.
Conclusion
Hepatic granuloma are rare lesions in the liver, but they should be considered in the differential diagnosis of focal liver lesions. CEUS cannot differentiate granulomatous lesions from focal malignant lesions such as metastases or intrahepatic cholcangiocarcinoma. Biopsy plays a fundamental role in the diagnosis as it excludes malignant pathology.
Conflicts of Interest:
The author declares no conflict of interest.
References
Choi EK, Lamps LW. Granulomas in the liver with a Focus on Infectious Causes Surg Pathol Clin. 2018 Jun;11(2):231-250. doi: 10.1016/j.path.2018.02.008
Mortelé KJ, Segatto E, Ros PR. The infected liver: radiologic-pathologic correlation. Radiographics. 2004 Jul-Aug;24(4):937-55. doi: 10.1148/rg.244035719.
Dietrich CF, Nolsøe CP, Barr RG, et al., Guidelines and Good Clinical Practice Recommendations for Contrast Enhanced Ultra- sound (CEUS) in the Liver – Update 2020 – WFUMB in Cooper- ation with EFSUMB, AFSUMB, AIUM, and FLAUS Ultraschall Med 2020; 39:187–210.
Kong WT, Wang WP, Cai H, Huang BJ, Ding H, Mao F. The analysis of enhancement pattern of hepatic inflamma- tory pseudotumor on contrast-enhanced ultrasound. Abdom Imaging 2014;39:168-174.
