Diagnostic Ultrasound - Abdomen and Pelvis

Hepatic Mass With Central Scar
Differential Diagnoses: Liver
DIFFERENTIAL DIAGNOSIS
Common
• Focal Nodular Hyperplasia
• Fibrolamellar Carcinoma
• Hepatocellular Carcinoma
• Hepatic Adenoma
• Hepatic Metastases
Less Common
• Atypical Hemangioma
• Hepatic Echinococcus Cyst
ESSENTIAL INFORMATION
Helpful Clues for Common Diagnoses
• Focal Nodular Hyperplasia
○ Mass: Typically homogeneous and isoechoic to liver
– Occasionally hypoechoic or hyperechoic
○ Central scar: Typically hypoechoic (18% hyperechoic)
– Contains central feeding artery
○ Color Doppler: "Spoke-wheel" pattern
– Prominent central feeding artery with multiple small
vessels radiating peripherally
– Large draining veins at tumor margins
• Fibrolamellar Carcinoma
○ Presents in otherwise healthy young adults
– Background cirrhosis or hepatitis in < 5% of patients
○ Well-defined, partially/completely encapsulated large
mass
○ Prominent central fibrous scar
○ Calcification within scar common
○ Intralesional necrosis/hemorrhage
○ Vascular, biliary, and nodal invasion may be present
• Hepatocellular Carcinoma
○ Background cirrhosis ± signs of portal hypertension
○ Central tumor necrosis/fibrosis produces apparent
central scar
○ Color Doppler may show irregular tumor
hypervascularity or tumor thrombus in portal vein
• Hepatic Adenoma
○ Well-defined round or mildly lobulated contour
○ Hypo-/iso-/hyperechoic mass
○ Central fat, hemorrhage, necrosis, and calcification
– May simulate central scar
○ Color Doppler shows hypervascular tumor supplied by
hepatic artery
• Hepatic Metastases
○ Necrotic or treated metastases with necrotic center may
simulate central scar
○ Necrotic center may be lined with irregular walls and
contain debris
○ Color Doppler may not show vascularity as many
metastases are hypovascular
Helpful Clues for Less Common Diagnoses
• Atypical Hemangioma
○ Hypoechoic center with hyperechoic rim may simulate
central scar
– "Typical atypical" hemangioma (up to 40%)
○ Posterior acoustic enhancement
○ No visible color Doppler flow in center of lesion
– Flow too slow to be sonographically detected
• Hepatic Echinococcus Cyst
○ Honeycombed cyst
– Multiple septations between daughter cysts in mother
cyst
○ "Spoke-wheel" appearance of septa simulating central
scar
SELECTED REFERENCES
1. Kong WT et al: Contrast-Enhanced Ultrasound in Combination with Color
Doppler Ultrasound Can Improve the Diagnostic Performance ofFocal
Nodular Hyperplasia and Hepatocellular Adenoma. Ultrasound Med Biol.
41(4):944-51, 2015
2. Kim T et al: Liver masses with central or eccentric scar. Semin Ultrasound CT
MR. 30(5):418-25, 2009
(Left) Intraoperative
abdominal US using a highfrequency
transducer shows a
hypoechoic focal nodular
hyperplasia (FNH) in the liver
ſt with a hyperechoic central
scar . (Right) Transverse
abdominal ultrasound shows a
pedunculated FNH ſt with a
slightly hyperechoic central
scar arising from the
lateral segment of the left
lobe of the liver.
Focal Nodular Hyperplasia
Focal Nodular Hyperplasia
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