Teaching Points
- The great majority of incidentally-detected liver nodules are benign
- Even in patients with known extrahepatic primary malignancy, small liver lesions (if single or very few in number) are more likely to be benign than malignant.
- If the patient has a known primary malignancy, further imaging is needed if management will be affected.
- If there is a high risk of metastatic disease, image-guided fine needle aspiration (FNA) biopsy.
- If there is a low risk of malignancy, follow-up imaging may be the chosen course.
- If there is an intermediate risk, further imaging such as PET scan, MRI or FNA may be indicated.
- If there are risk factors for primary hepatic malignancy (hepatocellular carcinoma - HCC):
- Lesions <1cm are usually followed by serial imaging.
- Lesions >1cm should be investigated further with either 4-phase MDCT or dynamic contrast enhanced MRI. If the appearances are typical of HCC, the lesion should be treated as HCC. If the appearances are atypical, a second contrast enhanced study with the other imaging modality should be performed, or the lesion should be biopsied.
- If biopsy is negative, the lesion should be followed by imaging every 3-6 months until the nodule disappears. If the lesion enlarges but remains atypical for HCC a repeat biopsy is recommended.
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