Diagnostic Ultrasound - Abdomen and Pelvis
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Diagnostic Ultrasound - Abdomen and Pelvis

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Ciliated Hepatic Foregut Cyst TERMINOLOGY Abbreviations • Ciliated hepatic foregut cyst (CHFC) Definitions • Foregut developmental malformation in liver IMAGING General Features • Best diagnostic clue ○ Subcapsular cystic lesion located within or close to segment IV of liver • Location ○ Within or near medial segment of left lobe of liver (segment IV) ○ Either subcapsular or beneath Glisson capsule • Size ○ Average: 3.6 cm (range: 1.1-13 cm) • Morphology ○ Typically unilocular, rarely multilocular ○ Round or ovoid cystic lesion with smooth, well-defined walls Ultrasonographic Findings • Single unilocular cyst • May contain internal echogenic foci • Posterior acoustic enhancement CT Findings • NECT:Variable depending on fluid composition ○ Mostly hypoattenuating; sometimes iso- or hyperattenuating • CECT:No enhancement MR Findings • T1WI:Frequently hyperintense due to mucin ○ Depends on viscosity, mucin density, presence or absence of cholesterol and calcium crystals • T2WI:Brightly hyperintense Imaging Recommendations • Best imaging tool ○ Ultrasound is suggestive of diagnosis; correlation with CT or MR may be helpful DIFFERENTIAL DIAGNOSIS Complicated Hepatic Cyst • May contain thin septa, internal debris, or fluid-debris level Biliary Cystadenoma/Cystadenocarcinoma • Usually multilocular or with complex septations or mural nodules • Predominantly seen in women Biloma • Usually results from trauma, including prior surgery Hematoma • Due to hepatic trauma • Echogenicity evolves over time PATHOLOGY General Features • Etiology ○ Thought to arise from detached outpouching of hepatic diverticulum or adjacent enteric foregut – Share common embryological origin with bronchial cyst and esophageal cyst Gross Pathologic & Surgical Features • Cyst contents:Mostly viscous or mucinous ○ Infantile form: Bilious fluid with direct communication with bile ducts Microscopic Features • Similar to bronchogenic and esophageal cysts • Lined, ciliated, pseudostratified, mucin-secreting columnar epithelium • Cyst wall contains abundant smooth muscle fibers CLINICAL ISSUES Presentation • Most common signs/symptoms ○ Asymptomatic and incidentally found by imaging • Other signs/symptoms ○ Right upper quadrant pain – Small cyst: Subcapsular location may stretch Glisson capsule ○ Abdominal mass secondary to enlarged cystic swelling ○ Large cysts may cause obstructive jaundice or portal hypertension secondary to compression effects Demographics • Age:Middle-aged • Gender:Slight male predominance (1.1:1) • Prevalence:Very rare but increasingly diagnosed Natural History & Prognosis • Slowly growing congenital cyst • Clinical course usually benign • 3% risk of malignant transformation: Squamous cell carcinoma, usually in setting of large cyst Treatment • Surgical excision or enucleation irrespective of size so as to eliminate subsequent cancer risk • Infantile CHFC: Liver resection and closure of biliary communication DIAGNOSTIC CHECKLIST Consider • Rule out other cystic lesions and solid hypovascular tumorous lesions in liver Image Interpretation Pearls • Single subcapsular unilocular cystic lesion in or near hepatic segment IV with variable internal contents SELECTED REFERENCES http://radiologyebook.com/ 1. Sharma S et al: Ciliated hepatic foregut cyst: an increasingly diagnosed condition. Hepatobiliary Pancreat Dis Int. 7(6):581-9, 2008 Diagnoses: Liver 231

Hepatic Cavernous Hemangioma Diagnoses: Liver TERMINOLOGY • Benign tumor composed of dilated vascular channels lined by single layer of endothelial cells and supported by thin fibrous stroma IMAGING • Well-defined, uniformly hyperechoic mass • Internal vascularity often undetectable with color Doppler • May see posterior acoustic enhancement • "Typical atypical" hemangioma: Hyperechoic rim with hypoechoic center • Contrast-enhanced imaging ○ Arterial hyperenhancement: "Flash fill" homogeneous hypervascularity or nodular discontinuous hyperenhancement ○ Centripetal fill-in on later images ○ Enhancement follows blood pool KEY FACTS TOP DIFFERENTIAL DIAGNOSES • Focal steatosis • Hepatocellular carcinoma • Hypervascular metastases PATHOLOGY • Large vascular channels lined by single layer of endothelial cells supported by thin fibrous septa • Most common benign tumor of liver DIAGNOSTIC CHECKLIST • Small hepatocellular carcinoma (HCC) or metastasis can mimic hemangioma • Hemangioma may vary in echogenicity at different times of scanning due to rate of blood flow within lesion • May see posterior acoustic enhancement (Left) Transverse graphic shows a solitary hemangioma, illustrating the lobular contour and multiple internal fibrous septa ſt, which are separating vascular channels st. (Right) Transverse US of the right lobe of the liver shows a homogeneously echogenic hemangioma st. This is a typical appearance of a hemangioma. (Left) Color Doppler US of a hemangioma st shows no detectable internal vascularity, likely related to flow that is too slow to be sonographically detected. (Right) Transverse US of the right lobe of the liver shows a typical hemangioma st, which is homogeneously echogenic with well-defined margins. 232 http://radiologyebook.com/

Hepatic Cavernous Hemangioma<br />

Diagnoses: Liver<br />

TERMINOLOGY<br />

• Benign tumor composed of dilated vascular channels lined<br />

by single layer of endothelial cells <strong>and</strong> supported by thin<br />

fibrous stroma<br />

IMAGING<br />

• Well-defined, uniformly hyperechoic mass<br />

• Internal vascularity often undetectable with color Doppler<br />

• May see posterior acoustic enhancement<br />

• "Typical atypical" hemangioma: Hyperechoic rim with<br />

hypoechoic center<br />

• Contrast-enhanced imaging<br />

○ Arterial hyperenhancement: "Flash fill" homogeneous<br />

hypervascularity or nodular discontinuous<br />

hyperenhancement<br />

○ Centripetal fill-in on later images<br />

○ Enhancement follows blood pool<br />

KEY FACTS<br />

TOP DIFFERENTIAL DIAGNOSES<br />

• Focal steatosis<br />

• Hepatocellular carcinoma<br />

• Hypervascular metastases<br />

PATHOLOGY<br />

• Large vascular channels lined by single layer of endothelial<br />

cells supported by thin fibrous septa<br />

• Most common benign tumor of liver<br />

DIAGNOSTIC CHECKLIST<br />

• Small hepatocellular carcinoma (HCC) or metastasis can<br />

mimic hemangioma<br />

• Hemangioma may vary in echogenicity at different times of<br />

scanning due to rate of blood flow within lesion<br />

• May see posterior acoustic enhancement<br />

(Left) Transverse graphic<br />

shows a solitary hemangioma,<br />

illustrating the lobular<br />

contour <strong>and</strong> multiple<br />

internal fibrous septa ſt,<br />

which are separating vascular<br />

channels st. (Right)<br />

Transverse US of the right lobe<br />

of the liver shows a<br />

homogeneously echogenic<br />

hemangioma st. This is a<br />

typical appearance of a<br />

hemangioma.<br />

(Left) Color Doppler US of a<br />

hemangioma st shows no<br />

detectable internal<br />

vascularity, likely related to<br />

flow that is too slow to be<br />

sonographically detected.<br />

(Right) Transverse US of the<br />

right lobe of the liver shows a<br />

typical hemangioma st, which<br />

is homogeneously echogenic<br />

with well-defined margins.<br />

232<br />

http://radiologyebook.com/

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