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Pediatric Applications at CEUS: Focal Liver Lesions
M. Beth McCarville, MD
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KEY FACTS

  • Terminology

    • Clinical Implications

      • IMAGING

        TERMINOLOGY

        • Abbreviations

          • Focal liver lesion (FLL)
        • Definitions

          • FLLs are common lesions found incidentally in clinical practice and in 20-50% of autopsies
            • These "incidentalomas" increase in frequency with age and occur in 7.2-33.0% of patients imaged by CT, 10.2-34.5% by MR, and 2.3-6.2% by B-mode US
            • Majority are benign and, in children, include focal nodular hyperplasia (FNH), adenoma, nodular regenerative hyperplasia, and infantile hepatic hemangioma (IHH)
            • Lesions < 1 cm are likely to be benign in patients with no history of cancer
              • Risk of malignancy increases in patients with history of cancer
          • FNH is nodule composed of benign-appearing hepatocytes with bile duct proliferations and vascular anomalies occurring in healthy liver parenchyma
          • Adenoma is spherical or ovoid neoplasm composed of hepatocytes in liver that is otherwise normal or near normal
          • Nodular regenerative hyperplasia [regenerative nodule (RN)] is rare benign process in which normal hepatic architecture is entirely replaced by small, diffuse RNs of hepatocytes surrounded by atrophic liver in absence of fibrosis
          • IHHs may be solitary or multifocal, are composed of large, endothelial-lined vascular channels, and occur in fetuses and neonates accounting for ~ 12% of pediatric liver tumors
          • Metastasis is secondary malignant growth at distance from primary site of cancer
            • Most common tumors to metastasize to liver in children are neuroblastoma and Wilms tumor

        Clinical Implications

        • Presentation

          • Natural History and Prognosis

            • Treatment

              CEUS Technique

              • CEUS Protocol Advice

                Imaging

                • General Features

                  • MR Findings

                    • US Findings

                      • CEUS Findings

                        Differential Diagnosis

                        • Benign vs. Malignant Liver Lesions

                          Practical Considerations

                          • Pearls and Pitfalls

                            Selected References

                            1. Fang C et al: Contrast enhanced ultrasound (CEUS) in the diagnosis of pediatric focal nodular hyperplasia and hepatic adenoma: inter-observer reliability. Pediatric Radiology. 49(1): 82–90, 2019
                            2. Masand PM: Magnetic resonance imaging features of common focal liver lesions in children. Pediatr Radiol. 48(9):1234-1244, 2018
                            3. Piorkowska MA et al: Characterization of a hepatic haemangioma with contrast-enhanced ultrasound in an infant. Ultrasound. 26(3):178-181, 2018
                            4. Wu M et al: Contrast-enhanced US for characterization of focal liver lesions: a comprehensive meta-analysis. Eur Radiol. 28(5):2077-2088, 2018
                            5. Xu M et al: The value of clinical and ultrasound features for the diagnosis of infantile hepatic hemangioma: comparison with contrast-enhanced CT/MRI. Clin Imaging. 51:311-317, 2018
                            6. Zarzour JG et al: Contrast-enhanced ultrasound of benign liver lesions. Abdom Radiol (NY). 43(4):848-860, 2018
                            7. Anupindi SA et al: Contrast-enhanced US assessment of focal liver lesions in children. Radiographics. 37(6):1632-1647, 2017
                            8. Beyer LP et al: Characterization of focal liver lesions using CEUS and MRI with liver-specific contrast media: experience of a single radiologic center. Ultraschall Med. 38(6):619-625, 2017
                            9. Burrowes DP et al: Contrast-enhanced US approach to the diagnosis of focal liver masses. Radiographics. 37(5):1388-1400, 2017
                            10. Chavhan GB et al: Liver MR imaging in children: current concepts and technique. Radiographics. 36(5):1517-32, 2016
                            11. Chiorean L et al: Focal masses in a non-cirrhotic liver: the additional benefit of CEUS over baseline imaging. Eur J Radiol. 84(9):1636-43, 2015
                            12. Chiorean L et al: Vascular phases in imaging and their role in focal liver lesions assessment. Clin Hemorheol Microcirc. 62(4):299-326, 2015
                            13. Chiorean L et al: Benign liver tumors in pediatric patients - review with emphasis on imaging features. World J Gastroenterol. 21(28):8541-61, 2015
                            14. Chou R et al: Imaging Techniques for the diagnosis of hepatocellular carcinoma: a systematic review and meta-analysis. Ann Intern Med. 162(10):697-711, 2015
                            15. Dhingra S et al: Update on the new classification of hepatic adenomas: clinical, molecular, and pathologic characteristics. Arch Pathol Lab Med. 138(8):1090-7, 2014
                            16. Jacob J et al: Contrast Enhanced Ultrasound (CEUS) Characterization of Grey-scale Sonographic Indeterminate Focal Liver Lesions in Paediatric Practice. Ultraschall in der Medizine. 34:529-540, 2013
                            17. Smith EA et al: Incidence and etiology of new liver lesions in pediatric patients previously treated for malignancy. AJR Am J Roentgenol. 199(1):186-91, 2012
                            18. Chung EM et al: From the archives of the AFIP: Pediatric liver masses: radiologic-pathologic correlation. Part 2. Malignant tumors. Radiographics. 31(2):483-507, 2011
                            19. Seale MK et al: Hepatobiliary-specific MR contrast agents: role in imaging the liver and biliary tree. Radiographics. 29(6):1725-48, 2009
                            20. International Working Party: terminology of nodular hepatocellular lesions. Hepatology. 22(3):983-93, 1995
                            Related Anatomy
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                            Related Differential Diagnoses
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                            References
                            Tables

                            Tables

                            KEY FACTS

                            • Terminology

                              • Clinical Implications

                                • IMAGING

                                  TERMINOLOGY

                                  • Abbreviations

                                    • Focal liver lesion (FLL)
                                  • Definitions

                                    • FLLs are common lesions found incidentally in clinical practice and in 20-50% of autopsies
                                      • These "incidentalomas" increase in frequency with age and occur in 7.2-33.0% of patients imaged by CT, 10.2-34.5% by MR, and 2.3-6.2% by B-mode US
                                      • Majority are benign and, in children, include focal nodular hyperplasia (FNH), adenoma, nodular regenerative hyperplasia, and infantile hepatic hemangioma (IHH)
                                      • Lesions < 1 cm are likely to be benign in patients with no history of cancer
                                        • Risk of malignancy increases in patients with history of cancer
                                    • FNH is nodule composed of benign-appearing hepatocytes with bile duct proliferations and vascular anomalies occurring in healthy liver parenchyma
                                    • Adenoma is spherical or ovoid neoplasm composed of hepatocytes in liver that is otherwise normal or near normal
                                    • Nodular regenerative hyperplasia [regenerative nodule (RN)] is rare benign process in which normal hepatic architecture is entirely replaced by small, diffuse RNs of hepatocytes surrounded by atrophic liver in absence of fibrosis
                                    • IHHs may be solitary or multifocal, are composed of large, endothelial-lined vascular channels, and occur in fetuses and neonates accounting for ~ 12% of pediatric liver tumors
                                    • Metastasis is secondary malignant growth at distance from primary site of cancer
                                      • Most common tumors to metastasize to liver in children are neuroblastoma and Wilms tumor

                                  Clinical Implications

                                  • Presentation

                                    • Natural History and Prognosis

                                      • Treatment

                                        CEUS Technique

                                        • CEUS Protocol Advice

                                          Imaging

                                          • General Features

                                            • MR Findings

                                              • US Findings

                                                • CEUS Findings

                                                  Differential Diagnosis

                                                  • Benign vs. Malignant Liver Lesions

                                                    Practical Considerations

                                                    • Pearls and Pitfalls

                                                      Selected References

                                                      1. Fang C et al: Contrast enhanced ultrasound (CEUS) in the diagnosis of pediatric focal nodular hyperplasia and hepatic adenoma: inter-observer reliability. Pediatric Radiology. 49(1): 82–90, 2019
                                                      2. Masand PM: Magnetic resonance imaging features of common focal liver lesions in children. Pediatr Radiol. 48(9):1234-1244, 2018
                                                      3. Piorkowska MA et al: Characterization of a hepatic haemangioma with contrast-enhanced ultrasound in an infant. Ultrasound. 26(3):178-181, 2018
                                                      4. Wu M et al: Contrast-enhanced US for characterization of focal liver lesions: a comprehensive meta-analysis. Eur Radiol. 28(5):2077-2088, 2018
                                                      5. Xu M et al: The value of clinical and ultrasound features for the diagnosis of infantile hepatic hemangioma: comparison with contrast-enhanced CT/MRI. Clin Imaging. 51:311-317, 2018
                                                      6. Zarzour JG et al: Contrast-enhanced ultrasound of benign liver lesions. Abdom Radiol (NY). 43(4):848-860, 2018
                                                      7. Anupindi SA et al: Contrast-enhanced US assessment of focal liver lesions in children. Radiographics. 37(6):1632-1647, 2017
                                                      8. Beyer LP et al: Characterization of focal liver lesions using CEUS and MRI with liver-specific contrast media: experience of a single radiologic center. Ultraschall Med. 38(6):619-625, 2017
                                                      9. Burrowes DP et al: Contrast-enhanced US approach to the diagnosis of focal liver masses. Radiographics. 37(5):1388-1400, 2017
                                                      10. Chavhan GB et al: Liver MR imaging in children: current concepts and technique. Radiographics. 36(5):1517-32, 2016
                                                      11. Chiorean L et al: Focal masses in a non-cirrhotic liver: the additional benefit of CEUS over baseline imaging. Eur J Radiol. 84(9):1636-43, 2015
                                                      12. Chiorean L et al: Vascular phases in imaging and their role in focal liver lesions assessment. Clin Hemorheol Microcirc. 62(4):299-326, 2015
                                                      13. Chiorean L et al: Benign liver tumors in pediatric patients - review with emphasis on imaging features. World J Gastroenterol. 21(28):8541-61, 2015
                                                      14. Chou R et al: Imaging Techniques for the diagnosis of hepatocellular carcinoma: a systematic review and meta-analysis. Ann Intern Med. 162(10):697-711, 2015
                                                      15. Dhingra S et al: Update on the new classification of hepatic adenomas: clinical, molecular, and pathologic characteristics. Arch Pathol Lab Med. 138(8):1090-7, 2014
                                                      16. Jacob J et al: Contrast Enhanced Ultrasound (CEUS) Characterization of Grey-scale Sonographic Indeterminate Focal Liver Lesions in Paediatric Practice. Ultraschall in der Medizine. 34:529-540, 2013
                                                      17. Smith EA et al: Incidence and etiology of new liver lesions in pediatric patients previously treated for malignancy. AJR Am J Roentgenol. 199(1):186-91, 2012
                                                      18. Chung EM et al: From the archives of the AFIP: Pediatric liver masses: radiologic-pathologic correlation. Part 2. Malignant tumors. Radiographics. 31(2):483-507, 2011
                                                      19. Seale MK et al: Hepatobiliary-specific MR contrast agents: role in imaging the liver and biliary tree. Radiographics. 29(6):1725-48, 2009
                                                      20. International Working Party: terminology of nodular hepatocellular lesions. Hepatology. 22(3):983-93, 1995