1. BENIGN FOCAL LESIONS IN
LIVER
DR.SAJITH .S

2. CELL OF ORIGIN
• Hepatocellular.
• Cholangiocellular.
• Mesenchymal.

3. Hepatocellular origin
• Adenoma
• Focal Nodular Hyperplasia ( FNH )
• Hepatocellular Nodules in Cirrhosis.
• Nodular Regenerative Hyperplasia ( NRH ).

4. Cholangiocellular origin
• Hepatic Cyst.
• Biliary Hamartomas.
• Peribiliary Cyst.
• Biliary adenoma.
• Biliary Cystadenoma.
• Caroli Disease.
• Biliary Papillomatosis.

5. Mesenchymal origin
• Cavernous Hemangioma.
• Hemangioendothelioma( adult, infantile )
• Focal Fat.
• Angiomyolipoma.
• Lipoma.
• Peliosis Hepatis.
• Paraganglioma.

6. Cavernous hemangioma
• Most common primary
liver tumor.
• All age groups.
• females >> males.
• Size less than 1 cm to 30
cm (giant hemangioma).

7. Clinical presentation
• No signs and symptoms.
• When tumor exceeds 4 cm ,abdominal
pain/discomfort or a palpable mass.
• Rupture occurs rarely.

8. characteristics
• Usually solitary.
• Borders are clear.
• Not encapsulated.
• Various degenerative changes are seen in its
centre.
– Old and new thrombus formation.
– Necrosis, scarring, hemorrhage & calcification.

9. usg
• Focal, homogenous, hypo vascular and
hyperechoic lesions.

10. ct
• Hypodense area with same density of aorta.
• Arterial phase-peripheral enhancement is seen
first, followed by gradual filling towards the
centre.
• Equilibrium phase-prolonged enhancement.
• In precontrast, arterial, equilibrium phases
tumor density is similar to that of aorta.

13. mri
• Hypointense on T1.
• Hyperintense on T2.
• In T2 signal intensity is higher than that of
spleen.

14. Focal nodular hyperplasia
• Second common benign lesion.
• Female >> male. 8:1
• Reactive change to abnormal circulation.
• Well defined lesion characterized by a central
fibrous scar.

15. Clinical presentation
• Usually asymptomatic.
• Epigastric pain and hepatomegaly are seen
frequently.

16. characteristics
• Well-demarcated.
• Solitary mass without a capsule.
• Often located beneath the surface of liver.
• In central scar - feeding arteries, draining veins
connecting to hepatic vein.
• Necrosis and hemorrhage usually not seen.

17. usg
• Iso to hypoechoic.
• Colour doppler-central vascularity.

18. ct
• Homogenous hypodense mass with a central
scar showing more marked hypodense.
• Arterial phase- brisk homogenous
enhancement.
• Portal phase-early wash out.
• Delayed phase-barely visible.
• If vessels radiating from central scar to the
periphery of the tumor is visualized , a near
definite diagnosis of FNH.

22. mri
• Iso - hypointense on T1.
• Hyper - isointense on
T2.
• Central scar
– Hypointense on T1.
– Hyperintense on T2.

23. Adenoma
• Rare benign tumor in younger age group
compared to FNH.
• Solitary (80%).
• Females (90%).
• Predisposing factors-oral contraceptives,
anabolic steroids and glycogen storage disease.

24. Clinical presentation
• Abdominal mass.
• Recurrent abdominal pain.
• Acute abdomen (tumor rupture).

25. Characteristics
• Clear border
• No capsule (fibrous capsule in some cases)
• Core - bleeding, necrosis, scar tissue
• Contains-fat & glycogen
• Neither portal vein nor bile ducts

26. usg
• May be hypo, iso, hyperechoic.
• Typically heterogenous with areas of fluid
component.
• Variable degrees of hemorrhage, necrosis &
fat.
• Calcification rare.

27. ct
• Hypodense mass.
• Hyper attenuation areas in
case of ruptured.
• Area of necrotic foci and
scar tissue – hypodense
areas
• Calcification is rare.
• Moderate tumor
enhancement in atrerial
phase.

30. mri
• Hyper to isointense on T1
• Hypo to hyperintense on T2
• Hemorrhagic tumor hyperintense on T1 & T2

32. Hepatocellular nodules in cirrhosis
• Classified as regenerative nodule, dysplastic
nodule.
• Regenerative nodules:
– USG and CT –too small to detect.
– When regenerative nodules contain iron, they are
termed siderotic nodules.
– Siderotic nodules- hyperdense on UECT and
hypointense on both T1 and T2.

34. • Dysplastic nodules :
– Rarely diagnosed by USG or CT
– MRI- Isointense with hyperintense foci on T1
– Hypo on T2.(opposite to HCC).

35. angiomyolipoma
• Rare benign tumor.
• Composed of mature fat, blood vessels and
smooth muscle cells.
• It is not capsulated.
• Tuberous sclerosis is a known association of
hepatic angiomyolipoma.

36. usg
• Circumscribed hyperechoic lesion.

37. ct
• Solid mass containing markedly hypodense
area.
• Arterial phase- partially enhancement often
with visualization of large central vessels.

38. mri
• Hyperintense on both T1 & T2.
• Decreased intensity with fat suppression.
T1 Fat sup T1

39. Hepatic cyst
• Single/multiple.
• Lined by single layer of cuboidal epithelium.
• Older adults
• Clinical presentation
– Asymptomatic
– Compressive symptoms (massive).

40. usg
• Fine cystic lesion
with partial or
complete septa are
often visualized.
• In case of
complications –
debris, thickened
septa and complex
internal fluid.

41. ct
• Smooth rimmed
hypodense mass.
• HU value near zero.
• No enhancement at all
on CECT.

42. mri
• Hypointense on T1.
• Extremely hypointense on T2.

43. Infantile hemangioendothelioma
• Common infant benign lesion.
• Resembles capillary hemangioma seen in
infantile skin and mucosa.
• With in 6 months of birth.
• Solitary mass but may be multifocal.
• Typically large (1-20 cm).

44. Clinical presentation
• Hepatomegaly.
• Abdominal mass.
• congestive heart failure.
• Bleeding,anemia,thrombocytopenia.
• Cutaneous hemangioma.
• Occasionally jaundice.

45. ct
• Hypodense area.
• 16%- calcification and hemorrhage.
• CECT – similar to that of cavernous
hemangiomas.
• MRI-Resemble those of hepatic hemangioma.

46. Biliary cystadenoma
• Multi locular cystic liver mass.
• Originates from bile duct.
• Usually right hepatic lobe.
• Adults, Females >> males.
• Malignant transformation to cystadenocarcinoma
is not uncommon.
• Clincal presentation
– Chronic abdominal pain.

47. usg
• Hypoechoic cystic lesion .
• Intracystic soft tissue components may be
present.
• Focal calcification can occur.

48. ct
• UECT – well defined hypodense lesion.
• Wall and internal septations are often
visualized (differentiate from simple cyst).
• CECT – cyst wall and soft tissue component
typically enhance.

49. Hepatic abscess
• Commonly – pyogenic,amebic and fungal.
• Via – portal vein, hepatic artery or bile duct.
• Solitary or multiple.

50. ct
• Pyogenic – double structured hypodense area.
– CECT : double target sign.( arterial phase)
• Thick ring like stain (portal and venous phase)
• Amoebic – CECT- enhanced mural structure
with hypodense area at its lateral side owing to
the presence of oedema.
• Fungal – CECT – faint ring like enhancement
(arterial phase )
– Hypodense (venous phase).

52. Hydatid cyst
• All age group.
• Caused by larva stage of adult tape worm.

53. Ct and mri
• Thick walled cystic lesions with internal round
periphery daughter cysts.
• Attenuation and signal intensity in mother
cyst is more than daughter cyst.

54. Common Benign lesions in liver
Common
benign lesions
Scar Caps Ca++ Fat Blood Cystic
Hemangioma + + +
FNH + +
Adenoma + + +
Abscess +
Cystadenoma + +
Angiomyolipoma
+

56. benign lesions
• Hyper vascular
– Hemangioma.
– Adenoma.
– FNH.
• Scar
– FNH
– Hemangioma