New Guideline Addresses Management of Focal Liver Lesions

Laurie Barclay, MD

August 25, 2014

The American College of Gastroenterology has issued a new, evidence-based guideline on the diagnosis and management of focal liver lesions (FLLs), published online August 19 in the American Journal of Gastroenterology. The new recommendations target gastroenterologists and aim to facilitate appropriate and improved patient care.

"Because of the widespread clinical use of imaging modalities such as ultrasonography...computed tomography...and magnetic resonance imaging...previously unsuspected liver lesions are increasingly being discovered in otherwise asymptomatic patients," write Jorge A. Marrero, MD, from the University of Texas at Southwestern in Dallas, and colleagues from the American College of Gastroenterology Practice Parameters Committee. "More importantly, the evaluation of liver lesions has taken on greater importance because of the increasing incidence of primary hepatic malignancies, especially hepatocellular carcinoma...and cholangiocarcinoma."

Therefore, consulting gastroenterologists and hepatologists are now more likely to encounter FLLs. In addition to malignant liver lesions, these may include benign solid and cystic liver lesions such as hemangioma, focal nodular hyperplasia (FNH), hepatocellular adenoma, and hepatic cysts.

"Although most incidentally noted FLLs are benign, it may be difficult to differentiate benign lesions from those that are malignant amid the broad differential of FLLs," the authors write. "Furthermore, it is important to remember that some noncancerous lesions such as hepatocellular adenomas and biliary cystadenomas have malignant potential. These lesions may not necessarily present with symptoms attributable to the lesion and are frequently not associated with underlying liver disease."

The guideline recommendations include the following:

  • Clinical factors may help determine the cause of FLLs, including age, sex, oral contraceptive use, chronic liver disease history, and recent travel.

  • FLL size is crucial in guiding the workup, as those smaller than 1 cm are generally benign incidental findings.

  • Radiologic studies can easily differentiate cystic from solid lesions, and a quality imaging modality alone may precisely diagnose certain solid FLLs such as FNH and hemangiomas.

  • Liver biopsy has a high risk of causing bleeding and often adds no additional value to the radiologic diagnosis of many benign lesions, such as hemangiomas and hepatocellular adenomas.

  • Most FLLs presenting as incidentalomas are benign, requiring only patient reassurance and monitoring.

  • Patients with cirrhosis and ultrasound lesion larger than 1 cm should undergo magnetic resonance imaging or triple-phase computed tomography.

  • Patients with chronic liver disease, especially cirrhosis, and solid FLLs must be considered to have hepatocellular carcinoma until otherwise proven.

  • Patients with hepatocellular adenoma should avoid oral contraceptives, hormone-containing intrauterine devices, and anabolic steroids.

  • Asymptomatic FNH does not require intervention.

  • Management of nodular regenerative hyperplasia involves diagnosis and management of any underlying predisposing disease processes.

  • Asymptomatic simple hepatic cysts should be observed with expectant management.

  • Monotherapy with antihelminthic drugs is not recommended in symptomatic patients with suspected hydatid cysts who are surgical or percutaneous treatment candidates.

The authors have disclosed no relevant financial relationships.

Am J Gastroenterol. Published online August 19, 2014. Abstract

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