The Liver Incidentaloma

The incidental finding of a liver lesion noted on ultrasound or CT scan is fairly common today. The worry and concern can be tremendous. One’s overall risk of the nodule being a medically significant lesion is highly dependent on whether or not cirrhosis is present or not. In the presence of cirrhosis, hepatocellular carcinoma (HCC) is much more likely-90%. Without cirrhosis, benign lesions are generally much more common.

Around 20% of individuals will have a lesion noted on imaging with the vast majority of these being benign. These lesions more commonly occur in females and usually pose no long-term detrimental health effects. Recognition is key to minimizing unneeded expensive and invasive workup. Fortunately, many lesions have characteristic radiographic findings that are diagnostic. Hemangiomas (an aberrant collection of blood vessels ) and simple liver cysts are the majority of common benign lesions found. Other benign lesions include focal nodular hyperplasia, an accumulation or sparing of fat focally, and hepatic adenomas. The latter lesion is potentially associated with oral contraception, and thusly discontinuation of these medications may be recommended.

The workup for a liver lesion can be arduous and usually ultimately diagnostic. Generally, CT or MRI scan with contrast specifically looking at liver lesions is used to evaluate the uptake pattern of the contrast agent and size. A lab test called alpha-fetoprotein (AFP) may also be ordered as elevation of this lab is characteristic of hepatocellular carcinoma. If imaging and blood work prove non-diagnostic, a liver biopsy may be recommended. If malignancy is felt to be a likely diagnosis, referral to a liver transplant center may be advised for resection, ablation or possible liver transplantation. On certain occasions, continued monitoring of a lesion via imaging every 3-6 months is recommended, especially for lesions less than 1 cm in size. Multiple liver lesions are suggestive of metastatic malignancy from elsewhere.

Individuals with cirrhosis should be screened via an imaging modality every 6 months as per guideline recommendations. An AFP lab tests may also be ordered at this time. Finding hepatocellular carcinoma earlier has been demonstrated to lead to a better prognosis and increases the chances potentially of liver transplantation as an option. Survival has been noted to be over 80% in many individuals after liver transplantation for hepatocellular carcinoma.

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