Multiple Liver Lesions
Alexander J. Towbin, MD
DIFFERENTIAL DIAGNOSIS
Common
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Hemangioendothelioma/Hemangioma
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Hepatic Pyogenic Abscess
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Metastases
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Neuroblastoma
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Wilms Tumor
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Lymphoma/Leukemia
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Hepatoblastoma
Less Common
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Mesenchymal Hamartoma
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Nodular Regenerative Hyperplasia
Rare but Important
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Caroli Disease
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Peliosis Hepatis
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Angiomyolipoma
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Echinococcosis
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Hepatocellular Carcinoma
ESSENTIAL INFORMATION
Key Differential Diagnosis Issues
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Various causes of multiple liver lesions
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Benign and malignant
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Primary hepatic neoplasms are uncommon
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0.5-2% of all pediatric neoplasms
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2/3 are malignant
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Overlap in imaging appearance
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Biopsy often required
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Differential diagnosis can be focused by age
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Lab tests may be helpful in forming differential diagnosis
Helpful Clues for Common Diagnoses
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Hemangioendothelioma/Hemangioma
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a.k.a. infantile hepatic hemangioma
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Most common benign hepatic tumor
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85% diagnosed in 1st 6 months
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Skin hemangiomas present in ˜ 50%
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Single, multiple, or diffuse lesions
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Diffuse lesions often have severe clinical course
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Can cause massive hepatomegaly leading to compression of inferior vena cava and thoracic cavity
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Mass effect can lead to abdominal compartment syndrome and multiorgan failure
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Can be associated with severe hypothyroidism
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Hepatic Pyogenic Abscess
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Associated with immunodeficiency, systemic infection, abdominal inflammatory processes, and chronic granulomatous disease
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S. aureus most common organism
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Fungal infections and B. henselae associated with microabscesses
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Can be solitary or multiple
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Multiple in 20-25% of children and up to 70% in neonates
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Risks in neonate include necrotizing enterocolitis and umbilical vein catheterization
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US useful for diagnosis and follow-up
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Metastases
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Neuroblastoma and Wilms tumor most common
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Neuroblastoma metastasizes to liver (15%)
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Wilms tumor metastasizes to liver (12%)
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Hepatic metastases more common overall than primary hepatic tumors
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Can appear as discrete nodules or diffuse hepatic involvement
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Hepatoblastoma
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Most common pediatric hepatic malignancy
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Majority of patients diagnosed are < 18 months of age
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More common in boys
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Associated with low birth weight, hemihypertrophy, Beckwith-Wiedemann, familial adenomatous polyposis, trisomy 18, and fetal alcohol syndrome
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90% have increased serum α-fetoprotein
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Most common in right lobe of liver
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Bilateral disease in 35%
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Calcifications in 40-55%
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Usually solitary solid mass
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Can be multifocal although there is usually 1 dominant mass
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Helpful Clues for Less Common Diagnoses
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Mesenchymal Hamartoma
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2nd most common benign hepatic mass
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Typically diagnosed in 1st 2 years of life
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Often presents as large RUQ mass
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75% in right lobe
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α-fetoprotein may be moderately elevated
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Multiloculated cystic mass
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Mixed cystic and solid
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May be small or large
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Multiple tiny cysts may appear solid
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On US, septae of cysts may be mobile
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Rare malignant transformation to undifferentiated embryonal sarcoma
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Treatment via excision
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Nodular Regenerative Hyperplasia
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Multiacinar regenerative lesion of liver in noncirrhotic liver
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Associated with systemic diseases, such as vasculitis, collagen disorders, cardiovascular disorders, and neoplasms
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Can cause portal hypertension
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Can occur after spontaneous portal vein thrombosis
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Radiologic findings not specific
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Helpful Clues for Rare Diagnoses
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Caroli Disease
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a.k.a. type 5 choledochal cyst
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May be associated with autosomal recessive polycystic kidney disease
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Congenital cystic dilation of intrahepatic bile ducts
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Patients present with recurrent cholangitis or portal hypertension
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Peliosis Hepatis
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Multiple blood-filled cavities
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Rare in children
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Associated with underlying chronic conditions, such as cystic fibrosis, malnutrition, Fanconi anemia, Marfan syndrome, and adrenal tumors
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Angiomyolipoma
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Associated with tuberous sclerosis
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Less common than renal angiomyolipoma
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Often multiple when present
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Lesions have imaging characteristics of fat
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Echinococcosis
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a.k.a. hydatid disease
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Most common in Mediterranean, Middle East, eastern Europe, Africa, South America, China, and Australia
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Generally asymptomatic
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Appears as single or multiple cysts
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Daughter cysts present in 75%
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Cysts slowly expand over years
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Hepatocellular Carcinoma
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2nd most common hepatic malignancy in children
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Rare before age 5
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More common in males
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Most pediatric cases not associated with prior liver disease (> 60%)
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Can be associated with preexisting cirrhosis due to biliary atresia, Fanconi syndrome, viral hepatitis, hereditary tyrosinemia, or glycogen storage disease
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Other risk factors: Prior androgen steroid treatment, oral contraceptives, methotrexate
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Metastases common at diagnosis
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Regional lymph nodes, lungs, bone
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Disease is multifocal in > 50%
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Multifocal tumors influence overall survival and possibility of surgical resection
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Image Gallery
![]() Axial T2WI MR shows innumerable hyperintense lesions throughout the liver. Only a small area of normal liver remains
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