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Difficulty: MediumGastroenterology and Hepatology

A radiologist is reviewing multiphasic computed tomography (CT) scans of the liver for several adult patients. Match each clinical and radiologic presentation with its most likely diagnosis.

  • A 62-year-old man with a history of alcohol use disorder has a 3.5-cm liver mass demonstrating early arterial hyperenhancement and rapid contrast washout during the portal venous phase.Hepatocellular carcinoma
  • A 29-year-old asymptomatic woman is found to have an incidental 4-cm liver lesion showing peripheral nodular enhancement on the arterial phase with progressive centripetal fill-in on delayed imaging.Hepatic hemangioma
  • A 34-year-old woman on long-term oral contraceptives presents with acute abdominal pain; imaging reveals a 6-cm subcapsular liver lesion with heterogeneous enhancement and evidence of recent internal hemorrhage.Hepatic adenoma
  • A 31-year-old healthy woman undergoes imaging for atypical abdominal pain, revealing a 5-cm liver mass with intense, uniform arterial enhancement and a central stellate scar.Focal nodular hyperplasia

Answer

The 62-year-old with early enhancement and venous washout matches Hepatocellular carcinoma. The asymptomatic 29-year-old with centripetal fill-in matches Hepatic hemangioma. The 34-year-old oral contraceptive user with a hemorrhaging subcapsular lesion matches Hepatic adenoma. The 31-year-old with a uniformly enhancing mass and a central stellate scar matches Focal nodular hyperplasia.
Accurate identification of solid liver lesions requires integrating patient demographics and risk factors with classic multiphasic imaging patterns. Hepatocellular carcinoma exhibits early arterial enhancement and rapid venous washout, typically in a cirrhotic liver. Hepatic hemangiomas show peripheral nodular, centripetal fill-in over time. Hepatic adenomas are heterogeneous, prone to hemorrhage, and linked to exogenous estrogen. Focal nodular hyperplasia features a hypervascular mass organized around a classic central stellate scar.

Step-by-Step Solution

1
Analyze the first vignette: a male with a history of alcohol use disorder and a mass with arterial hyperenhancement and venous washout.
Matches Hepatocellular carcinoma.
Alcohol use disorder predisposes to cirrhosis, the primary risk factor for HCC. HCC derives its blood supply from the hepatic artery, causing early enhancement, while the surrounding cirrhotic liver tissue enhances later via the portal vein, resulting in apparent rapid washout of the tumor.
2
Evaluate the second vignette: an asymptomatic young woman with a lesion showing peripheral nodular enhancement and progressive centripetal fill-in.
Matches Hepatic hemangioma.
This 'outside-in' contrast filling pattern is pathognomonic for cavernous hemangiomas due to the slow velocity of blood flow through their large vascular spaces.
3
Assess the third vignette: a young woman taking oral contraceptives who presents with acute pain and a hemorrhaging subcapsular lesion.
Matches Hepatic adenoma.
Hepatic adenomas are benign epithelial tumors strongly linked to estrogen exposure. They carry a significant risk of spontaneous rupture and bleeding, presenting with acute abdominal pain and heterogeneous imaging due to internal hemorrhage.
4
Examine the fourth vignette: a healthy young woman with an intensely enhancing mass and a central stellate scar.
Matches Focal nodular hyperplasia.
FNH is a hyperplastic response to a congenital vascular anomaly. The central scar represents a large anomalous artery with radiating fibrotic septa, which is the classic diagnostic hallmark on imaging.

Key Concept

Diagnosis of solid liver lesions using multiphasic CT/MRI contrast enhancement patterns and patient risk factors.
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Topics

Gastroenterology and Hepatology

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