Karaciğer Kitleleri

 

For patients with incidental lesions but without risk factors for liver malignancy, the need for additional imaging depends on whether the lesion can be diagnosed based on the initial study. For example, the diagnosis of hepatic hemangioma can be made with noncontrast ultrasound if the following criteria are met :

●Typical features are present (ie, homogenous, hyperechoic, well-delineated margin)

●Lesion size is <3 cm

●Patient has no history of cirrhosis or extrahepatic malignancy

USG sonrası etiyolojisi belirli olmayan hastalarda görüntüleme yapılacaksa  kontrastlı MR tercih ediliyor.İleri inceleme ile tespit yapılamazsa biyopsi yada görüntüleme ile takip gerekebilir. 

Takip görüntüleme :  kontrastlı görüntülemelerde tanı konulamayan ancak biyopsiye uygun olmayan ( < 1cm altı  ) insidental   lezyonlar  büyümeyi ,görünüm değişimi ve yeni lezyon oluşumunu tespit açısından takip edilebilir. kontrol görüntülemeler  ,şüphelenilen tanı ve risk faktörlerine ( ör oral kontraseptif) göre genelde 6-12 arasında yapılır. 

HCC riskli hastalarda : 

1 cm'den küçük lezyonlar  — Çapı <1 cm olan lezyonlar ileri görüntüleme veya biyopsi ile kesin olarak teşhis edilemeyecek kadar küçüktür. İyi huylu olmaları muhtemeldir. Bunları iki yıla kadar kısa aralıklarla (örn. her üç ila altı ayda bir) izliyoruz. Lezyon kaybolursa veya 1 cm'den küçük kalırsa, hasta altı aylık aralıklarla rutin izleme  dönebilir. Lezyon 1 cm'yi geçerse veya ≥1 cm'lik yeni bir lezyon gelişirse veya alfa-fetoprotein seviyesi yükselirse, karaciğerin dinamik kontrastlı bilgisayarlı tomografisi (BT) veya manyetik rezonans görüntülemesi (MRG) çekeriz.

≥1 cm olan lezyonlar  —  Çapı ≥1 cm olan lezyonlar, intravenöz kontrast içeren diğer karaciğer görüntülemeleriyle daha ayrıntılı olarak değerlendirilmelidir 

HCC tanısı tek başına görüntüleme veya biyopsi ile konulabilir. Görüntüleme özellikleri arasında nodül boyutu, kinetik ve kontrast özelliği  ve seri görüntülemede büyüme yer alır. Görüntüleme ayrıca görüntüleme özelliklerine göre bazı lezyonları (örn. kist, hemanjiyom) kesin olarak iyi huylu olarak veya görüntüleme özelliklerine göre ve/veya uzun süreli (örn. >24 ay) takipte değişmeden kalırsa muhtemelen iyi huylu olarak teşhis edebilir.

Diagnosis of HCC can be made either with imaging alone or by biopsy. Imaging features include nodule size, kinetics and pattern of contrast enhancement, and growth on serial imaging. Imaging can also diagnose some lesions (eg, cyst, hemangioma) as definitively benign based on imaging features or as probably benign based on imaging features and/or if they remain unchanged in long-term (eg, >24 month) follow-up.

kistik lezyonlar

Ultrasonography is probably the most helpful initial test, since it can usually differentiate a simple cyst from other cystic lesions. 

Basit Kist 

Differential diagnosis — The differential diagnosis of a simple cyst includes a variety of hepatic lesions that can have a cystic appearance, such as a mucinous cystic neoplasm (with or without invasive carcinoma), a hepatic abscess, a necrotic malignant tumor, a hemangioma, and a hamartoma . As mentioned above, the distinction can usually be made based upon the clinical setting (eg, presence of symptoms) and radiographic findings. The presence of symptoms related to the cyst or increasing size should raise concern that the lesion could be a mucinous cystic neoplasm (with or without invasive carcinoma) or another rare cystic neoplasm, since most simple cysts generally remain stable in size

Asymptomatic patients — For asymptomatic patients with simple liver cysts, no intervention or follow-up imaging for cyst surveillance is needed. Limited published data and clinical experience suggest that asymptomatic simple cysts do not have malignant potential . If the patient develops symptoms that are attributed to the liver cyst, intervention may be indicated. 

Symptomatic patients — Patients with large, symptomatic simple liver cysts may require intervention . The causal relationship between abdominal pain and a simple cyst must be admitted with caution and accepted only if the cyst is large (eg, ≥4 cm) and other causes of symptoms have been excluded. These include cholelithiasis, gastroesophageal reflux disease, gastric dysmotility, peptic ulcer disease, and other causes of abdominal pain

NONINVASIVE MUCINOUS CYSTIC NEOPLASM (CYSTADENOMA)

The differential diagnosis includes MCN(müsinöz kistik neoplazm) with an associated invasive carcinoma (cystadenocarcinoma), echinococcal cyst, and a simple cyst. Simple cysts can usually be distinguished on imaging studies because of the absence of septations and papillary projections and the presence of serous cystic fluid. Echinococcal cysts are frequently associated with calcifications, septations and thickening of the cyst wall

Imaging : On ultrasonography, an MCN typically appears as a hypoechoic lesion with thickened, irregular walls and occasional internal echoes representing debris and wall nodularity.

Treatment — The preferred treatment for noninvasive MCNs is resection, which should be performed whenever possible

CYSTIC ECHINOCOCCOSIS

Ultrasonography — The sensitivity of ultrasonography for evaluation of Echinococcus is 90 to 95 percent [30,31]. The most common appearance on ultrasound is an anechoic, smooth, round cyst, which can be difficult to distinguish from a benign cyst. In the presence of liver cyst membranes, mixed echoes can be confused with an abscess or neoplasm. In the presence of daughter cysts, characteristic internal septation can be seen.