Imaging features and management of focal liver lesions

Abstract

Notably, the number of incidentally detected focal liver lesions (FLLs) has increased dramatically in recent years due to the increased use of radiological imaging. The diagnosis of FLLs can be made through a well-documented medical history, physical examination, laboratory tests, and appropriate imaging methods. Although benign FLLs are more common than malignant ones in adults, even in patients with primary malignancy, accurate diagnosis of incidental FLLs is of utmost clinical significance. In clinical practice, FLLs are frequently evaluated non-invasively using ultrasound (US), computed tomography (CT), and magnetic resonance imaging (MRI). Although US is a cost-effective and widely used imaging method, its diagnostic specificity and sensitivity for FLL characterization are limited. FLLs are primarily characterized by obtaining enhancement patterns through dynamic contrast-enhanced CT and MRI. MRI is a problem-solving method with high specificity and sensitivity, commonly used for the evaluation of FLLs that cannot be characterized by US or CT. Recent technical advancements in MRI, along with the use of hepatobiliary-specific MRI contrast agents, have significantly improved the success of FLL characterization and reduced unnecessary biopsies. The American College of Radiology (ACR) appropriateness criteria are evidence-based recommendations intended to assist clinicians in selecting the optimal imaging or treatment option for their patients. ACR Appropriateness Criteria Liver Lesion-Initial Characterization guideline provides recommendations for the imaging methods that should be used for the characterization of incidentally detected FLLs in various clinical scenarios. The American College of Gastroenterology (ACG) Clinical Guideline offers evidence-based recommendations for both the diagnosis and management of FLL. American Association for the Study of Liver Diseases (AASLD) Practice Guidance provides an approach to the diagnosis and management of patients with hepatocellular carcinoma. In this article, FLLs are reviewed with a comprehensive analysis of ACR Appropriateness Criteria, ACG Clinical Guideline, AASLD Practice Guidance, and current medical literature from peer-reviewed journals. The article includes a discussion of imaging methods used for the assessment of FLL, current recommended imaging techniques, innovations in liver imaging, contrast agents, imaging features of common nonmetastatic benign and malignant FLL, as well as current management recommendations.

Keywords: Focal liver lesions, Imaging, Ultrasonography, Computed tomography, Magnetic resonance imaging, Management

Core Tip: The incidence of incidentally detected focal liver lesions (FLL) has risen significantly due to increased radiological imaging use. While benign FLLs are more common, even in patients with primary malignancy, accurate diagnosis is clinically significant. Non-invasive evaluation, such as ultrasound, computed tomography, and magnetic resonance imaging (MRI), is common in clinical practice. MRI, particularly with hepatobiliary-specific contrast agents, has enhanced FLL characterization, reducing unnecessary biopsies. Guidelines from the American College of Radiology, American College of Gastroenterology, and American Association for the Study of Liver Diseases offer evidence-based recommendations for optimal imaging and management. This article provides a comprehensive review of FLL, covering imaging methods, current techniques and modalities, innovations in imaging, contrast agents, features of nonmetastatic benign and malignant FLLs, and current management recommendations.