Erros comuns

Common mistakes in the diagnosis of hepatic lesions

Francisco Capinha

Serviço de Gastrenterologia e Hepatologia, Unidade Local de Saúde de Santa Maria

Helena Cortez-Pinto

Serviço de Gastrenterologia e Hepatologia, Unidade Local de Saúde de Santa Maria

Clínica Universitária de Gastrenterologia, Faculdade de Medicina, Universidade de Lisboa, Portugal

Overestimate the accuracy of abdominal ultrasound in hepatocellular carcinoma (HCC) diagnosis.

A semestral ultrasound (US) is recommended for HCC screening in a specific target population.1 However, US is an operator dependent technic, with limitations that could compromise HCC detection, especially in those who are obese, have very fatty or heterogeneous livers, and/or have difficulties collaborating during the exam.2

Think that every nodule in cirrhotic liver is from hepatic origin

In cirrhotic patients, in the absence of an extra-hepatic tumor previously identified, any hepatic lesion could be assumed wrongly as hepatic origin. It is important to consider the possibility of metastasis, that in most cases can be confirmed by CT scan or MRI, although a broader evaluation can be necessary to discard extra-hepatic tumors.

Nodules in steatotic liver

Hepatic steatosis is very frequent in the general population. Focal fat deposits with a mass-like or nodular appearance, as well as steatosis spared areas, can mimic focal solid liver lesions, and be difficult to diagnose when evaluated by US and/or CT-scan. MRI is mandatory in these case.3

Misdiagnosed haemangiomas as a malignant lesion and vice-versa

Haemangiomas are the most frequent benign hepatic tumors. Sometimes they present with atypical features and can be hard to distinguish from malignant lesions. In these cases, MRI can be very helpful. It is important to establish a definitive diagnosis, because due to its benign course, imaging follow-up is not required for typical haemangioma.4

Adenomas, haemangiomas and focal nodular hyperplasia in the “same pocket”

Adenomas should be distinguished from the rest of benign hepatic tumors, because of their potential to be malignant or become malignant. Due to the pathophysiology involved, it is indicated the active surveillance in all adenoma cases, suspension of hormonotherapy in women, and surgical approach based on dimension (>5cm in women) and gender (males).5

  1. Galle PR, Forner A, Llovet JM, et al. EASL Clinical Practice Guidelines: Management of hepatocellular carcinoma. J Hepatol. 2018;69(1):182-236. doi:10.1016/j.jhep.2018.03.019
  2. Simmons O, Fetzer DT, Yokoo T, et al. Predictors of adequate ultrasound quality for hepatocellular carcinoma surveillance in patients with cirrhosis. Aliment Pharmacol Ther. 2017;45(1):169-177. doi:10.1111/apt.13841
  3. Vilgrain V, Ronot M, Abdel-Rehim M, et al. Hepatic steatosis: A major trap in liver imaging. Diagn Interv Imaging. 2013;94(7-8):713-727. doi:10.1016/j.diii.2013.03.010
  4. Colombo M, Forner A, Ijzermans J, et al. EASL Clinical Practice Guidelines on the management of benign liver tumours. J Hepatol. 2016;65(2):386-398. doi:10.1016/j.jhep.2016.04.001
  5. Tsilimigras DI, Rahnemai-Azar AA, Ntanasis-Stathopoulos I, et al. Current Approaches in the Management of Hepatic Adenomas. J Gastrointest Surg. 2019;23(1):199-209. doi:10.1007/s11605-018-3917-4