Solitary Necrotic Nodules of the Liver: Histology and Diagnosis With CT and MRI

Solitary necrotic nodule of the liver: imaging features, differential diagnosis and management

Solitary necrotic nodule of the liver (SNNL) is a rare and benign liver lesion often discovered incidentally. Despite its occurrence, the exact cause of SNNL remains unknown, with various theories proposing traumatic, infectious, degenerative or transformative origins. The variable imaging characteristics of SNNLs frequently lead to misdiagnosis as malignant tumors, prompting patients to undergo unnecessary and high-risk procedures such as biopsies and surgeries. Moreover, biopsies often yield inconclusive results due to the presence of necrotic tissue within the lesion, posing challenges for accurate histologic diagnosis. This review aims to offer guidance on differentiating SNNLs from other liver lesions using multimodality imaging approaches. It will analyze essential imaging steps that should be performed and highlight those that should be avoided to enhance diagnostic accuracy and prevent unnecessary interventions.

Multiparametric MRI manifestations of the spontaneous intratumoral coagulative necrosis in HCC

PURPOSE

To investigate the MRI manifestations of the spontaneous intratumoral coagulative necrosis (iCN) in patients with hepatocellular carcinoma (HCC) and its value in predicting the postoperative early recurrence (≤ 2 years).

METHODS

Patients with HCC who underwent preoperative multiparametric MRI between January 2015 and February 2019 were enrolled in this retrospective study. The MRI manifestations of iCNs on TIWI, T2WI, and ADC were recorded. The sensitivity and specificity of MRI for the detection of iCNs were also evaluated. A multivariable Cox proportional hazards model and the Kaplan-Meier method were used to verify the value of histologically-confirmed and MRI-identified iCNs, respectively, in predicting early recurrence.

RESULTS

A total of 163 patients (median age, 56 years; interquartile range, 49-64 years; 139 men) with HCCs were evaluated, of whom 27(16.6%) had histologically-confirmed iCNs. MRI identified 92.6% (25 of 27; 95% confidence interval [CI] 74.2%, 98.7%) of iCNs (sensitivity), with a specificity of 79.4% (78 of 136; 95% CI 71.4%, 85.7%), based on non-enhancement on post-contrast MRI. And the MRI-identified iCNs were characterized by a similar appearance to surrounding tumour tissue shown on pre-contrast MRI but not enhanced on post-contrast MRI. The multivariable Cox proportional hazards model revealed that only the presence of histologically-confirmed iCN was independently associated with early HCC recurrence (hazard ratio = 2.73; 95% CI 1.20, 6.21; P = 0.017). The Kaplan-Meier curve showed that the presence of MRI-identified iCN was also associated with early recurrence (P < 0.001).

CONCLUSION

Multiparametric MRI identified iCNs with high sensitivity and modest specificity. The presence of iCNs is associated with early HCC recurrence.

Solitary Necrotic Nodule of the Liver: A Benign Mimicker of Malignancy

Solitary necrotic nodule (SNN) of the liver is an uncommon and benign finding in liver pathology. Typically, it appears as a single and asymptomatic lesion, primarily located at the subcapsular region of the right lobe of the liver. Unfortunately, it is easy to mistake this benign lesion for a primary or secondary neoplastic lesion, making it a potential diagnosis pitfall for liver malignancies. The diagnosis of SNN can be difficult to determine as the imaging findings frequently lack specificity. This brings out the importance of histomorphological examination to accurately identify this lesion, and to rule out any possible malignancies. We report here the case of a 35-year-old woman with a history of squamous cell carcinoma of the cervix, who presented a solitary nodule on her liver that was falsely diagnosed as a metastatic lesion in the liver at imagery. The aim of this article is to highlight the importance of using special stains and immunohistochemical staining for diagnosing SNN and excluding any necrotic metastases of the liver. We demonstrated that the absence of a reticulin meshwork in the necrotic core should prompt consideration of a necrotic metastasis in the liver, rather than a solitary necrotic nodule.

Spontaneous hepatic rupture during late pregnancy in a patient with solitary necrotic nodule of the liver: A case report

Background

Spontaneous hepatic rupture (SHR) during pregnancy is a rare and life-threatening event, which usually occurs together with preeclampsia, eclampsia, HELLP syndrome, or liver tumors. However, SHR resulting from solitary necrotic nodule of the liver (SNNL) is extremely rare.

Case presentation

We report the case of a 32-year-old pregnant woman who presented at 33 weeks of gestation with abdominal pain and emesis. Transabdominal ultrasound and magnetic resonance imaging revealed massive hemoperitoneum and lesions in the left lobe of the liver. An emergency cesarean section was performed and the hepatic rupture was managed surgically via left lateral lobectomy. The postprocedural course was uneventful. The premature baby successfully survived, and the patient was discharged 8 days after admission without complications. Histological examination revealed a diagnosis of SNNL, which resulted in the hepatic hematoma and SHR.

Conclusion

To our knowledge, this is the first case of SHR resulting from SNNL during late pregnancy. Multidisciplinary collaboration and surgical management are important cornerstones for improving the perinatal outcomes when SHR is suspected in a pregnant patient.

Solitary necrotic nodules of the liver with "ring"-like calcification: A case report

BACKGROUND

Solitary necrotic nodule of the liver (SNNL) is a rare benign lesion with a complete necrotic core and a clear fibrous capsule containing elastic fibers. We present the case of a patient with a radiographic computed tomography (CT) finding of "ring"-like annular calcification within the lesion and postoperative pathologic diagnosis of necrotic nodules wrapped by dense fibers in liver tissue, as well as the patient's subsequent management and outcome.

CASE SUMMARY

A 38-year-old Chinese woman with a history of systemic lupus erythematosus treated with prednisone and hydroxychloroquine, without any symptoms, was found to have hepatic space-occupying lesions by imaging examination at a health examination. A subsequent CT scan suggested a space-occupying lesion of the liver with annular calcification, which was not defined to be benign or malignant. After that, a laparoscopic hepatic space-occupying resection was performed. The postoperative pathological diagnosis was necrotic nodules wrapped by dense fibers in the liver tissue, and the final diagnosis was SNNL. The patient had an uneventful postoperative recovery.

CONCLUSION

There is a "ring"-like calcification in SNNL. This patient had a history of systemic lupus erythematosus, without a history of parasite infection, trauma, or tumor. Therefore, whether the etiology and pathological changes of SNNL are related to rheumatic immune diseases remains to be investigated.

Huge solitary necrotic nodule of the liver: a rare case report with review of literature

Solitary necrotic nodule of the liver (SNNL) is an uncommon disease in clinical practice, and its pathogenesis is still unclear. Here, we report the case of a 35-year-old woman. After physical examination, the patient was found to have a liver neoplasm, and there were no other physical complaints. Abdominal contrast-enhanced computed tomography (CT) showed the presence of a hypodense lesion. The patient opted for surgery to eliminate the lesion. Pathologic examination revealed an isolated necrotic nodular lesion with a size of 12 cm×10 cm×10 cm. The patient had a history of hepatitis B infection. To our knowledge, this is the largest SNNL ever reported and the first case with a history of hepatitis B infection.

A Challenging Case of Solitary Necrotic Nodules of the Liver Mimicking Hepatic Metastases: CT, MRI, and PET-CT Findings

Main teaching point: Solitary necrotic nodules of the liver can be multiple and usually appear as hypovascular nodules mimicking hepatic metastases, but they are relatively small and located in the subcapsular areas of the liver.

We report a very rare case of multiple solitary necrotic nodules of the liver mimicking hepatic metastases in a patient with previous history of lung cancer. The lesions appeared as low-attenuated or low-signal intensity nodules with thin rim enhancement on both contrast-enhanced computed tomography (CT) and magnetic resonance (MR) imaging, making them difficult to differentiate from hepatic metastases. This rare benign entity should be kept in mind, especially when lesions are small and located in the subcapsular areas of the liver.

Causes, consequences, and therapy of tumors acidosis

While cancer is commonly described as "a disease of the genes," it is also associated with massive metabolic reprogramming that is now accepted as a disease "Hallmark." This programming is complex and often involves metabolic cooperativity between cancer cells and their surrounding stroma. Indeed, there is emerging clinical evidence that interrupting a cancer's metabolic program can improve patients' outcomes. The most commonly observed and well-studied metabolic adaptation in cancers is the fermentation of glucose to lactic acid, even in the presence of oxygen, also known as "aerobic glycolysis" or the "Warburg Effect." Much has been written about the mechanisms of the Warburg effect, and this remains a topic of great debate. However, herein, we will focus on an important sequela of this metabolic program: the acidification of the tumor microenvironment. Rather than being an epiphenomenon, it is now appreciated that this acidosis is a key player in cancer somatic evolution and progression to malignancy. Adaptation to acidosis induces and selects for malignant behaviors, such as increased invasion and metastasis, chemoresistance, and inhibition of immune surveillance. However, the metabolic reprogramming that occurs during adaptation to acidosis also introduces therapeutic vulnerabilities. Thus, tumor acidosis is a relevant therapeutic target, and we describe herein four approaches to accomplish this: (1) neutralizing acid directly with buffers, (2) targeting metabolic vulnerabilities revealed by acidosis, (3) developing acid-activatable drugs and nanomedicines, and (4) inhibiting metabolic processes responsible for generating acids in the first place.

[Solitary necrotic nodule of the liver: about two cases]

Les lésions hépatiques nodulaires sont majoritairement tumorales. Le nodule nécrotique solitire du foie est rare. Le diagnostic preopératoire est difficile. Il s'agit d'une femme âgée de 43 ans qui était opérée d'un adénocarcinome du rectum métastatique au foie opéré. Le scanner abdominal de surveillance a révélé un nodule hépatique d'allure métastatique. Le second cas est celui d'un homme de 56 ans, admis pour cholécystectomie avec découverte per-opératoire d'un nodule hépatique. Dans les deux cas, le nodule hépatique était sous capsulaire et a été réséqué. L'examen anatomopathologique posait le diagnostic de nodule nécrotique solitaire du foie. Le nodule nécrotique non spécifique du foie est une lésion qui doit être évoquée, même dans un contexte néoplasique. Une caractérisation par l'imagerie et une ponction biopsie des lésions hépatiques peut être utile.

Specific imaging characteristic of solitary necrotic nodule of the liver: Marked peripheral rim-like enhancement with internal hypointensity on longer delayed MRI

OBJECTIVES

To obtain specific imaging findings of solitary necrotic nodule of the liver (SNNL) using longer delayed contrast-enhanced MRI and compare them with those of three mimic hepatic diseases.

METHODS

Sixteen patients with SNNL underwent plain and contrast-enhanced triphasic CT and multiphasic MRI with delayed time prolonged to 2 h after contrast bolus injection. Twenty-three patients with mimic lesions including seven with eight HCCs, five with five iCCs and 11 with metastatic lesions served as the control group. Those patients also received plain and multiphasic contrast-enhanced MRI. Imaging features of lesions such as peripheral wash-out time were evaluated.

RESULTS

Among the 16 SNNLs, with a prolonged delayed MRI time, the enhancement degree of tumour periphery increased gradually. When it was up to 1 h, all lesions represented moderate/marked peripheral enhancement with internal hypointensity. However, the peripheral wash-out in seven HCCs (87.5%) and all metastatic lesions except three appeared at 10 or 15 min, one iCC (20%) at 30 min and the other lesions at 1 h.

CONCLUSIONS

Longer MRI with a delayed time of 1-2 h may be useful in diagnosis SNNL, revealing the specific imaging characteristic of SNNL as pronounced peripheral enhancement with internal hypointensity.

KEY POINTS

• Longer delayed MRI plays an important role in the diagnosis of SNNL. • Characteristic imaging feature of SNNL is pronounced peripheral enhancement with internal hypointensity. • Periphery wash-out time can differentiate SNNL from mimic diseases. • Imaging findings of SNNL on routine CT and MRI are unspecific.

MRI characteristics for the differential diagnosis of benign and malignant small solitary hypovascular hepatic nodules

PURPOSE

To compare the MRI findings of benign and malignant solitary hypovascular hepatic nodules and identify the differentiating features.

MATERIALS AND METHODS

A total of 135 patients with solitary hypovascular hepatic lesions up to 3 cm (mass forming intrahepatic cholangiocarcinoma, n=29; metastases, n=26; inflammatory pseudotumors and solitary necrotic nodule, n=48; and hemangioma, n=32) were assessed. MRI findings were analyzed, and lesions were scored for peripheral and intratumoral appearance and enhancement patterns.

RESULTS

Univariate and multivariate analyses showed that the most common findings for benign lesions were subcapsular, sharp margin, homogeneous, marked high signal on T2WI, mild hyperintensity on T2WI, increasing intensity of peripheral globular enhancement, and persistent central septum-like linear enhancement on delayed phase (P<0.05). An area under the curve of 0.955 was obtained for differentiating malignant from benign nodules using the combined imaging features of ill-defined margins, heterogeneity, decreasing intensity of peripheral rim-like enhancement, and central increasing intensity of patchy enhancement. Interobserver agreement was good, ranging from 0.72 to 1.00.

CONCLUSION

MRI may be a useful noninvasive method for determining whether hypovascular hepatic nodules are malignant or benign.

Diffusion-Weighted Imaging with Two Different b-Values in Detection of Solid Focal Liver Lesions

One hundred and eighty-two consecutive patients with suspected liver disease were recruited to receive diffusion-weighted imaging (DWI) with two different b-values, in comparison with T2-weighted imaging (T2WI). The detection rate of three MR sequences in solid focal liver lesions (FLLs) and subgroup analyses were performed. Our prospective study found that DWI600 was equivalent to DWI100 and T2WI for the detection of solid FLLs overall but was significantly more accurate in the detection of malignant solid FLLs and lesions larger than 10 mm.

Oxaliplatin toxicity presenting as a liver nodule - case report

Background

Oxaliplatin based chemotherapy is often used as adjuvant therapy in colon and rectal cancer. A reported side effect is Sinusoidal Obstruction Syndrome which is characterized by a spectrum of pathologic changes, from sinusoidal dilation, peri-sinusoidal haemorrhage, peliosis and nodular regenerative hyperplasia. Very rarely it can cause the development of liver nodules mimicking liver metastases. Herein, we report a case of Sinusoidal Obstruction Syndrome causing a liver nodule suspicious of liver metastasis on imaging. This is the third reported case of this complication of oxaliplatin toxicity, in which resection was performed and pathological diagnosis confirmed.

Case presentation

We report the case of a 59 year old man with stage III colon cancer who underwent sigmoidectomy followed by adjuvant chemotherapy with oxaliplatin. One year after surgery a liver nodule was detected and the patient underwent right hepatectomy. Pathology showed no liver nodule and diagnosed sinusoidal obstruction syndrome.

Conclusion

We describe the third reported case of a liver lesion mimicking a liver metastasis after oxaliplatin-based chemotherapy for colon cancer. We suggest that in patients heavily treated with oxaliplatin with de novo liver nodules, this differential diagnosis should be considered. In particular, in this population of patients an intense imagiologic evaluation and even a preoperative biopsy should be pursued to confirm the diagnosis of malignancy and avoid overtreatment.