6 Commonest Liver Lesions & When to Worry: (Benign vs. Malignant).

The commonest liver lesions are primarily benign, such as hepatic hemangioma and focal nodular hyperplasia. Less common liver lesions include hepatic adenoma, hepatocellular carcinoma, liver metastases, and cholangiocarcinoma.

Worrisome symptoms of liver lesions include progressive pain, jaundice, weight loss, clay-colored stools, itching, and the presence of risk factors such as cirrhosis or chronic hepatitis B.

1 . Hepatic Hemangioma.

Type: benign lesion.

Frequency: Most common incidental liver lesion.

Prognosis: excellent

Liver hemangioma is the most common primary tumor of the liver. However, it has an excellent prognosis (typically, they don’t turn malignant).

If you’re a healthy person (without liver disease), hepatic hemangioma is the most likely diagnosis of an accidentally discovered liver lesion.

Hepatic hemangiomas affect all ages, but it is most common between ages 20-60 years. In addition, females are three times more likely to have hemangioma than males (reference).

Up to 20% of people have hepatic hemangiomas (reference). Most of them are small-sized.

Symptoms (characteristics):

• Most liver hemangiomas are small-sized and asymptomatic.
• People discover it accidentally when they undergo abdominal imaging, such as abdominal ultrasound.
• Larger or multiple hemangiomas may cause dull-aching liver pain in the right upper quadrant.
• In rare cases, thrombosis inside the hemangioma may cause severe acute abdominal pain.
• Liver hemangioma may grow over time (especially during pregnancy).
• Complications such as rupture or thrombosis are also very rare.
• Hemangiomas don’t have malignant potential, So you shouldn’t worry about them.

Hemangiomas are diagnosed mainly by abdominal ultrasound and appear as hyperechoic (whitish) lesions in the liver. Hemangiomas are not a cause of concern if you don’t have liver cirrhosis or a history of cancers.

Treatment:

• Most hemangiomas are small and asymptomatic and require NO treatment.
• If the lesion is larger than 5 Cm in diameter, your doctor may request a follow-up imaging after 6 or 12 months.
• In larger hemangiomas or symptomatic patients, surgery (resection) or radiological intervention may be needed.

2. Focal Nodular Hyperplasia

Type: benign lesion.

Frequency: the second most common benign liver lesion.

Prognosis: Excellent.

Focal nodular hyperplasia is a common benign liver lesion formed by excess liver cells forming a nodule.

Symptoms and diagnosis:

• They are more common in women than in men.
• Most cases of FNH (focal nodular hyperplasia) are asymptomatic.
• Symptomatic cases often complain of vague (dull) liver pain in the right upper abdomen.
• Patients with FNH may have a predisposing disease such as cirrhosis.
• FNH is suspected by ultrasound or CT findings. A definitive diagnosis requires a contrast-enhanced MRI.

Treatment and prognosis:

• Most focal nodular hyperplasia (FNH) cases are asymptomatic and require NO treatment.
• Moreover, some lesions may regress over time without any intervention.
• In symptomatic cases, surgical resection may be rarely required.
• Complications (such as bleeding) are extremely rare.

3. Hepatic adenoma.

Type: benign lesion.

Frequency: rare.

Prognosis: malignant transformation occurs in 5%.

Hepatic adenomas (also known as hepatocellular adenomas) is uncommon to begin liver lesion. The occurrence of hepatocellular adenomas is associated with several factors such as (reference):

• The use of estrogen-containing medications.
• Anabolic androgens.
• Obesity.
• People with metabolic syndrome (fatty liver, diabetes, hypertension, increased blood lipids).
• People with glycogen storage diseases.

Symptoms and diagnosis:

• The size of adenomas ranges from a few millimeters to several centimeters.
• Smaller adenomas are entirely asymptomatic (discovered accidentally).
• Larger adenomas may cause complications such as rupture and hemorrhage (intraabdominal) with severe abdominal pain and shortness of breath.
• The diagnosis of hepatic adenoma is based on a contrast-enhanced MRI or liver biopsy.

Treatment and prognosis:

• The risk of malignant transformation is about 5% (reference).
• Risk factors for malignant transformation include size >5cm and being male.
• Surgical treatment is the first line in patients with large lesions or those who have symptoms or complications.
• Recurrence after surgical resection is uncommon.

4. Liver metastases (spread from other cancers).

Type: malignant lesion.

Frequency: uncommon.

Prognosis: generally bad, depends on the primary tumor.

One of the characteristics of cancer is that it can spread to distant organs (metastasis). The liver is one of the commonest sites of cancer metastasis.

A malignant cell or group of cells from the primary tumor (breast cancer or pancreatic cancer) travels through the blood vessels to settle in the liver.

The malignant cells grow into liver lesions (or lesions) in the liver in a process called distant metastasis.

People with liver metastasis are often diagnosed with a primary tumor elsewhere.

Symptoms and diagnosis:

• History of the primary tumor (breast, colon, pancreatic cancer).
• Sometimes, the first presentation is liver lesions (metastasis) before discovering the primary tumor.
• Early metastasis is asymptomatic.
• Larger and multiple metastatic lesions cause severe liver pain and altered liver functions (such as jaundice).
• There is a sense of hard mass in the right upper abdomen (in advanced cases).
• The diagnosis is based on abdominal imaging (abdominal ultrasound, CT, MRI) or tumor scan (PET scan).

The presence of liver metastasis is, unfortunately, a bad prognosis. Liver Mets mean that the tumor is in a late stage, limiting the options for treatment.

The one-year survival rate in patients with synchronous liver metastasis is about 15% (reference).

5. Hepatocellalar carcinoma (HCC).

Type: malignant lesion.

Frequency: sixth common cancer worldwide.

Prognosis: bad (1-year survival rate is about 49%, the 5-year survival rate is about 19.5%)

Hepatocellular carcinoma is one of the commonest cancers worldwide. Often, for HCC to occur, people must have risk factors such as (reference):

• Liver cirrhosis.
• Chronic hepatitis B (or less commonly, hepatitis C).
• Alcohol intake.
• Smoking.
• Non-alcoholic fatty liver disease.
• Diabetes mellitus.
• Ingestion of some toxins such as aflatoxin (contaminates some products such as corn).
• Betel nut chewing.
• Iron overload.
• Drinking contaminated water.

Symptoms:

• Presence of one or more of the above risk factors (most commonly liver cirrhosis or hepatitis B virus infection).
• Early HCC is asymptomatic.
• Weight loss.
• Liver pain (in the right upper abdomen).
• Late cases may present with complications such as jaundice, intraabdominal bleeding, etc.

The diagnosis is based on contrast-enhanced abdominal CT or MRI.

Several treatment options depending on the size and the number of lesions:

• Surgical resection.
• Blocking the artery that feeds the malignant lesion (trans-arterial chemoembolization or TACE).
• Radiofrequency ablation.

6. Intrahepatic Cholangiocarcinoma.

Type: malignant lesion.

Frequency: rare.

Prognosis: bad.

Cholangiocarcinoma refers to the malignant tumor of the bile ducts. When cholangiocarcinoma occurs in the part of bile ducts inside the liver, it is called intrahepatic cholangiocarcinoma.

Symptoms include:

• Jaundice (yellowish skin and eye whites).
• Itchy skin (often intense).
• Clay-colored stool and dark urine.
• Abdominal pain (often in the right upper quadrant of your abdomen).
• Fatigue.
• Weight loss.
• Night sweats.

When should you worry about liver lesions?

It would help if you are worried about liver lesion when there are:

• Liver cirrhosis.
• Chronic hepatitis B or C.
• A long history of alcoholic hepatitis.
• A long history of non-alcoholic fatty liver disease.
• Progressive weight loss.
• Jaundice, clay stools, or dark urine.
• Progressive or severe liver pain.
• Fever.