Imaging findings of fibrolamellar hepatocellular carcinomas on ultrasonography: A comparison with conventional hepatocellular carcinomas

WFUMB Review Paper. Incidental Findings in Otherwise Healthy Subjects, How to Manage: Liver

An incidental focal liver lesion (IFLL) is defined as a hepatic lesion identified in a patient imaged for an unrelated reason. They are frequently encountered in daily practice, sometimes leading to unnecessary, invasive and potentially harmful follow-up investigations. The clinical presentation and the imaging aspects play an important role in deciding if, and what further evaluation, is needed. In low-risk patients (i.e., without a history of malignant or chronic liver disease or related symptoms), especially in those younger than 40 years old, more than 95% of IFLLs are likely benign. Shear Wave liver Elastography (SWE) of the surrounding liver parenchyma should be considered to exclude liver cirrhosis and for further risk stratification. If an IFLL in a low-risk patient has a typical appearance on B-mode ultrasound of a benign lesion (e.g., simple cyst, calcification, focal fatty change, typical hemangioma), no further imaging is needed. Contrast-Enhanced Ultrasound (CEUS) should be considered as the first-line contrast imaging modality to differentiate benign from malignant IFLLs, since it has a similar accuracy to contrast-enhanced (CE)-MRI. On CEUS, hypoenhancement of a lesion in the late vascular phase is characteristic for malignancy. CE-CT should be avoided for characterizing probable benign FLL and reserved for staging once a lesion is proven malignant. In high-risk patients (i.e., with chronic liver disease or an oncological history), each IFLL should initially be considered as potentially malignant, and every effort should be made to confirm or exclude malignancy. US-guided biopsy should be considered in those with unresectable malignant lesions, particularly if the diagnosis remains unclear, or when a specific tissue diagnosis is needed.

Kontrastmittelsonografie eines fibrolamellären hepatozellulären Karzinoms

Wir berichten über einen 24-jährigen Patienten, der sich mit anhaltenden Oberbauchschmerzen, Übelkeit und Völlegefühl ohne Erbrechen seit 5 Monaten zur ambulanten endoskopischen Diagnostik vorstellte. Bei der körperlichen Untersuchung fiel eine Verhärtung im Epigastrium ohne Druckschmerzhaftigkeit auf. Endoskopisch zeigte sich lediglich eine Impression des Bulbus duodeni bei intakter Duodenalschleimhaut. Darüber hinaus lagen unauffällige Befunde in Gastroskopie und Ileokoloskopie vor. Abdomensonografisch zeigte sich im linken Leberlappen eine große inhomogene Raumforderung mit scharfer, unregelmäßiger Begrenzung. Der rechte Leberlappen wies eine komplett unauffällige Sonomorphologie auf, insbesondere keine Zeichen des Parenchymschadens oder einer Leberzirrhose. Entlang der oberen mesenterialen Gefäße stellten sich mehrere vergrößerte Lymphknoten mit Kontakt zum Bulbus duodeni dar. In der Kontrastmittelsonografie (CE-US) zeigte die Leberläsion das typische Perfusionsmuster eines hepatozellulären Karzinoms. Zur Klärung des malignitätsverdächtigen Befunds wurde eine sonografisch gesteuerte Stanzbiopsie durchgeführt. Die histopathologische Aufarbeitung ergab den Befund eines hepatozellulären Karzinoms vom fibrolamellären Subtyp.

Mit diesem Fallbericht möchten wir zeigen, dass das HCC vom fibrolamellären Subtyp, trotz einer starken kollagenreichen bindegewebigen Stromakomponente in der Histopathologie, ein HCC-typisches Perfusionsmuster in der KM-Sonografie aufweist.

[Contrast-Enhanced Ultrasound of Fibrolamellar Hepatocellular Carcinoma]

We present the case of a 24-year-old male patient, who was admitted for endoscopy due to sustained pain in the upper abdomen with nausea and postprandial fullness without vomiting for more than 5 months. In the physical examination, an epigastric induration was found. Endoscopy revealed an external impression of the proximal duodenum. Beyond that, normal findings could be ascertained in gastroscopy and ileo-colonoscopy. Abdominal ultrasound identified a large hypoechoic lesion in the left liver lobe with a sharp delineation. Along the upper mesenteric vessels, enlarged lymphnodes were visible with contact to the proximal duodenum. Contrast-enhanced ultrasound (CE-US) was conducted and revealed the typical perfusion pattern of hepatocellular carcinoma. For further assessment, an ultrasound-guided core-biopsy of the lesion was performed. The histopathological evaluations resulted in the diagnosis of a hepatocellular carcinoma of fibrolamellar subtype.With the present case, we want to illustrate the perfusion pattern of a fibrolamellar hepatocellular carcinoma in contrast-enhanced ultrasound. Even though the tumor tissue is surrounded by lamellar bands of fibrosis with collagen-rich fibers, the perfusion pattern is consistent with the previously known appearance of HCC in CE-US.

Role of contrast-enhanced ultrasound guidance in core-needle biopsy for diagnosis of cervical tuberculous lymphadenitis

OBJECTIVE

To investigate the diagnostic value of core-needle biopsy (CNB) guided by contrast-enhanced ultrasound (CEUS) in cervical tuberculous lymphadenitis (CTL).

METHODS

178 patients with pathological confirmation of CTL were retrospectively enrolled. All of them had undergone CNB prior to the final surgery. According to the different ways of puncture guidance, they were divided into two groups: conventional ultrasound (US) group (n = 81) and CEUS group (n = 97). The comparison of diagnostic efficacy between two groups was compared and analyzed.

RESULTS

Among the 178 patients, 146 were directly diagnosed as CTL by CNB, including 59 patients in CEUS group and 87 patients in US group. The diagnostic accuracy were 89.7% (87/97) and 72.8% (59/81), respectively (P < 0.01). For subgroup analyses, differences among diagnostic efficacy ascribed to the different guiding methods were significant in medium size group (>2.0 cm and ≤3.0 cm) and large size group (>3.0 cm), 91.7% for CEUS group vs. 69.0% for US group (P < 0.05) and 84.4% for CEUS group vs. 57.7% for US group (P < 0.05), respectively.

CONCLUSIONS

In the diagnosis of CTL, compared with the US-guided CNB, CEUS-guided CNB have certain advantages, especially for larger lymph nodes.