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Focal hepatic intrinsically hyperattenuating lesions at unenhanced CT: Not always calcifications

      Highlights

      • A wide spectrum of liver lesions can appear hyperattenuating on unenhanced CT.
      • Hyperattenuating hepatic lesions can be divided in non-calcified and calcified.
      • Imaging pattern recognition may improve diagnostic confidence.

      Abstract

      Due to the growing use of CT, there has been an increase in the frequency of detecting focal liver lesions. Intrinsically hyperattenuating hepatic lesions or pseudolesions are not uncommon at unenhanced CT. Hyperattenuating hepatic lesions can be divided into non-calcified and calcified.
      Causes of intrinsic hyperattenuation include hemorrhage, thrombosis, and calcifications. Focal liver lesions can show hyperattenuation on unenhanced CT in case of severe liver steatosis.
      Recognition of etiologies associated with hyperattenuation on unenhanced CT can help the radiologist in characterizing focal liver lesions and pseudolesions. In this paper, we describe the spectrum of intrinsically hyperattenuating focal liver lesions and pseudolesions at unenhanced CT.

      Keywords

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      References

        • Berland L.L.
        • Silverman S.G.
        • Gore R.M.
        • et al.
        Managing incidental findings on abdominal CT: white paper of the ACR incidental findings committee.
        J Am Coll Radiol. 2010 Oct; 7: 754-773https://doi.org/10.1016/j.jacr.2010.06.013
        • Drebber U.
        • Kasper H.U.
        • Ratering J.
        • et al.
        Hepatic granulomas: histological and molecular pathological approach to differential diagnosis–a study of 442 cases.
        Liver Int. 2008 Jul; 28: 828-834https://doi.org/10.1111/j.1478-3231.2008.01695.x
        • Lagana S.M.
        • Moreira R.K.
        • Lefkowitch J.H.
        Hepatic granulomas: pathogenesis and differential diagnosis.
        Clin Liver Dis. 2010 Nov; 14: 605-617https://doi.org/10.1016/j.cld.2010.07.005
        • Patnana M.
        • Menias C.O.
        • Pickhardt P.J.
        • et al.
        Liver calcifications and calcified liver masses: pattern recognition approach on CT.
        AJR Am J Roentgenol. 2018 Jul; 211: 76-86https://doi.org/10.2214/AJR.18.19704
        • Gaya D.R.
        • Thorburn D.
        • Oien K.A.
        Hepatic granulomas: a 10 year single centre experience.
        J Clin Pathol. 2003 Nov; 56 (PMID: 14600131; PMCID: PMC1770104): 850-853https://doi.org/10.1136/jcp.56.11.850
        • Matheus T.
        • Muñoz S.
        Granulomatous liver disease and cholestasis.
        Clin. Liver Dis. 2004 Feb; 8 (ix) (PMID: 15062203): 229-246https://doi.org/10.1016/S1089-3261(03)00137-5
        • Dourakis S.P.
        • Saramadou R.
        • Alexopoulou A.
        • et al.
        Hepatic granulomas: a 6-year experience in a single center in Greece.
        Eur J Gastroenterol Hepatol. 2007 Feb; 19: 101-104https://doi.org/10.1097/01.meg.0000243882.09820.d2
        • Karaosmanoglu A.D.
        • Onur M.R.
        • Sahani D.V.
        • et al.
        Hepatobiliary tuberculosis: imaging findings.
        AJR Am J Roentgenol. 2016 Oct; 207: 694-704https://doi.org/10.2214/AJR.15.15926
        • Sah Shambhu Kumar
        • Zeng Chun
        • Li Xian
        • Mishra Ajay Kumar
        CT characterization of hepatic tuberculosis.
        Radiol Infect Dis. 2017; : 143-149https://doi.org/10.1016/j.jrid.2017.09.001
        • Stoupis C.
        • Taylor H.M.
        • Paley M.R.
        The Rocky liver: radiologic-pathologic correlation of calcified hepatic masses.
        Radiographics. 1998 May-Jun; 18 (quiz 726) (PMID: 9599391): 675-685https://doi.org/10.1148/radiographics.18.3.9599391
        • Pedrosa I.
        • Saíz A.
        • Arrazola J.
        • Ferreirós J.
        • Pedrosa C.S.
        Hydatid disease: radiologic and pathologic features and complications.
        Radiographics. 2000 May-Jun; 20 (PMID: 10835129): 795-817https://doi.org/10.1148/radiographics.20.3.g00ma06795
        • Alghofaily K.A.
        • Saeedan M.B.
        • Aljohani I.M.
        • et al.
        Hepatic hydatid disease complications: review of imaging findings and clinical implications.
        Abdom Radiol (NY). 2017 Jan; 42: 199-210https://doi.org/10.1007/s00261-016-0860-2
        • Chouhan M.D.
        • Wiley E.
        • Chiodini P.L.
        • Amin Z.
        Hepatic alveolar hydatid disease (Echinococcus multilocularis), a mimic of liver malignancy: a review for the radiologist in non-endemic areas.
        Clin Radiol. 2019 Apr; 74: 247-256https://doi.org/10.1016/j.crad.2019.01.007
        • Alghofaily K.A.
        • Saeedan M.B.
        • Aljohani I.M.
        • et al.
        Hepatic hydatid disease complications: review of imaging findings and clinical implications.
        Abdom Radiol (NY). 2017 Jan; 42: 199-210https://doi.org/10.1007/s00261-016-0860-2
        • Vilanova J.C.
        • Barceló J.
        • Smirniotopoulos J.G.
        Hemangioma from head to toe: MR imaging with pathologic correlation.
        Radiographics. 2004 Mar-Apr; 24 (PMID: 15026587): 367-385https://doi.org/10.1148/rg.242035079
        • Klotz T.
        • Montoriol P.F.
        • Da Ines D.
        • et al.
        Hepatic haemangioma: common and uncommon imaging features.
        Diagn Interv Imaging. 2013 Sep; 94: 849-859https://doi.org/10.1016/j.diii.2013.04.008
        • Hao F.
        • Yang X.
        • Tian Y.
        • Wang W.
        • Ge M.
        Spontaneous internal hemorrhage of a giant hepatic hemangioma: a case report.
        Medicine (Baltimore). 2017 Nov; 96 (PMID: 29381955; PMCID: PMC5708954)e8702https://doi.org/10.1097/MD.0000000000008702
        • Bioulac-Sage P.
        • Laumonier H.
        • Couchy G.
        • et al.
        Hepatocellular adenoma management and phenotypic classification: the Bordeaux experience.
        Hepatology. 2009 Aug; 50: 481-489https://doi.org/10.1002/hep.22995
        • Bioulac-Sage P.
        • Rebouissou S.
        • Sa Cunha A.
        • et al.
        Clinical, morphologic, and molecular features defining so-called telangiectatic focal nodular hyperplasias of the liver.
        Gastroenterology. 2005 May; 128: 1211-1218https://doi.org/10.1053/j.gastro.2005.02.004
        • Bioulac-Sage P.
        • Balabaud C.
        • Zucman-Rossi J.
        Subtype classification of hepatocellular adenoma.
        Dig Surg. 2010; 27: 39-45https://doi.org/10.1159/000268406
        • van Aalten S.M.
        • de Man R.A.
        • Jzermans J.N.
        • Terkivatan T.
        Systematic review of haemorrhage and rupture of hepatocellular adenomas.
        Br J Surg. 2012 Jul; 99: 911-916https://doi.org/10.1002/bjs.8762
        • European Association for the Study of the Liver (EASL)
        EASL clinical practice guidelines on the management of benign liver tumours.
        J Hepatol. 2016 Aug; 65 (PMID: 27085809): 386-398https://doi.org/10.1016/j.jhep.2016.04.001
        • Wanless I.R.
        • Mawdsley C.
        • Adams R.
        On the pathogenesis of focal nodular hyperplasia of the liver.
        Hepatology. 1985 Nov-Dec; 5 (PMID: 4065824): 1194-1200https://doi.org/10.1002/hep.1840050622
        • Shanbhogue A.K.
        • Prasad S.R.
        • Takahashi N.
        • et al.
        Recent advances in cytogenetics and molecular biology of adult hepatocellular tumors: implications for imaging and management.
        Radiology. 2011 Mar; 258: 673-693https://doi.org/10.1148/radiol.10100376
        • Caseiro-Alves F.
        • Zins M.
        • Mahfouz A.-E.
        • et al.
        Calcification in focal nodular hyperplasia: a new problem for differentiation from fibrolamellar hepatocellular carcinoma.
        Radiology. 1996 Mar; 198: 889-892https://doi.org/10.1148/radiology.198.3.8628888
        • Weiss S.W.
        • Enzinger F.M.
        Epithelioid hemangioendothelioma: a vascular tumor often mistaken for a carcinoma.
        Cancer. 1982 Sep 1; 50: 970-981https://doi.org/10.1002/1097-0142(19820901)50:5<970::aid-cncr2820500527>3.0.co;2-z
        • Bruegel M.
        • Muenzel D.
        • Waldt S.
        • et al.
        Hepatic epithelioid hemangioendothelioma: findings at CT and MRI including preliminary observations at diffusion-weighted echo-planar imaging.
        Abdom Imaging. 2011 Aug; 36: 415-424https://doi.org/10.1007/s00261-010-9641-5
        • Makhlouf H.R.
        • Ishak K.G.
        • Goodman Z.D.
        Epithelioid hemangioendothelioma of the liver: a clinicopathologic study of 137 cases.
        Cancer. 1999 Feb 1; 85: 562-582https://doi.org/10.1002/(sici)1097-0142(19990201)85:3<562::aid-cncr7>3.0.co;2-t
        • Gan L.U.
        • Chang R.
        • Jin H.
        • Yang L.I.
        Typical CT and MRI signs of hepatic epithelioid hemangioendothelioma.
        Oncol Lett. 2016 Mar; 11: 1699-1706https://doi.org/10.3892/ol.2016.4149
        • European Association for the Study of the Liver
        EASL clinical practice guidelines: management of hepatocellular carcinoma.
        J Hepatol. 2018 Jul; 69 (PMID: 29628281): 182-236https://doi.org/10.1016/j.jhep.2018.03.019
        • Omata M.
        • Cheng A.L.
        • Kokudo N.
        • et al.
        Asia-Pacific clinical practice guidelines on the management of hepatocellular carcinoma: a 2017 update.
        Hepatol Int. 2017 Jul; 11 (PMID: 28620797; PMCID: PMC5491694): 317-370https://doi.org/10.1007/s12072-017-9799-9
        • Arslanoglu A.
        • Seyal A.R.
        • Sodagari F.
        • et al.
        Current guidelines for the diagnosis and management of hepatocellular carcinoma: a comparative review.
        AJR Am J Roentgenol. 2016 Nov; 207: W88-W98https://doi.org/10.2214/AJR.15.15490
        • Marrero J.A.
        • Kulik L.M.
        • Sirlin C.B.
        • et al.
        Diagnosis, staging, and management of hepatocellular carcinoma: 2018 practice guidance by the American Association for the Study of Liver Diseases.
        Hepatology. 2018 Aug; 68: 723-750https://doi.org/10.1002/hep.29913
        • Murakami T.
        • Morioka D.
        • Takakura H.
        • Miura Y.
        • Togo S.
        Small hepatocellular carcinoma with ring calcification: a case report and literature review.
        World J Gastroenterol. 2013 Jan 7; 19 (PMID: 23326175; PMCID: PMC3542747): 129-132https://doi.org/10.3748/wjg.v19.i1.129
        • Yoshida H.
        • Mamada Y.
        • Taniai N.
        • Uchida E.
        Spontaneous ruptured hepatocellular carcinoma.
        Hepatol Res. 2016 Jan; 46: 13-21https://doi.org/10.1111/hepr.12498
        • Shriki J.E.
        • Seyal A.R.
        • Dighe M.K.
        • et al.
        CT of atypical and uncommon presentations of hepatocellular carcinoma.
        AJR Am J Roentgenol. 2015 Oct; 205: W411-W423https://doi.org/10.2214/AJR.14.14000
        • Graham R.P.
        Fibrolamellar carcinoma: what is new and why it matters.
        Surg Pathol Clin. 2018 Jun; 11: 377-387https://doi.org/10.1016/j.path.2018.02.006
        • Han J.K.
        • Choi B.I.
        • Kim A.Y.
        • An S.K.
        Cholangiocarcinoma: pictorial essay of CT and cholangiographic findings.
        Radiographics. 2002 Jan-Feb; 22 (PMID: 11796906): 173-187https://doi.org/10.1148/radiographics.22.1.g02ja15173
        • Vanderveen K.A.
        • Hussain H.K.
        Magnetic resonance imaging of cholangiocarcinoma.
        Cancer Imaging. 2004 Apr 6; 4: 104-115https://doi.org/10.1102/1470-7330.2004.0018
        • Liver Cancer Study Group of Japan
        he General Rules for the Clinical and Pathological Study of Primary Liver Cancer.
        4th Edition. Kanehara, Tokyo2000
        • Chung Y.E.
        • Kim M.J.
        • Park Y.N.
        Varying appearances of cholangiocarcinoma: radiologic-pathologic correlation.
        Radiographics. 2009 May-Jun; 29 (PMID: 19448110): 683-700https://doi.org/10.1148/rg.293085729
        • Lim J.H.
        Cholangiocarcinoma: morphologic classification according to growth pattern and imaging findings.
        AJR Am J Roentgenol. 2003 Sep; 181: 819-827https://doi.org/10.2214/ajr.181.3.1810819
        • Zulfiqar M.
        • Shetty A.
        • Tsai R.
        Diagnostic approach to benign and malignant calcifications in the abdomen and pelvis.
        Radiographics. 2020 May-Jun; 40 (PMID: 32302263): 731-753https://doi.org/10.1148/rg.2020190152
        • Zhou Y.
        • Zhang J.
        • Pu Dan
        Tumor calcification as a prognostic factor in cetuximab plus chemotherapy-treated patients with metastatic colorectal cancer.
        Anti-Cancer Drugs. 2019 Feb; 30 (PMID: 30570508; PMCID: PMC6365256): 195-200https://doi.org/10.1097/CAD.0000000000000726
        • Easson A.M.
        • Barron P.T.
        • Cripps C.
        • Hill G.
        • Guindi M.
        • Michaud C.
        Calcification in colorectal hepatic metastases correlates with longer survival.
        J Surg Oncol. 1996 Dec; 63: 221-225https://doi.org/10.1002/(SICI)1096-9098(199612)63:4<221::AID-JSO2>3.0.CO;2-E
        • Bosman F.T.
        • Carneiro F.
        • Hruban R.H.
        • Theise N.D.
        WHO Classification of Tumours of the Digestive System.
        Fourth Edition. 2010
        • Borhani A.A.
        • Wiant A.
        • Heller M.T.
        Cystic hepatic lesions: a review and an algorithmic approach.
        AJR Am J Roentgenol. 2014 Dec; 203: 1192-1204https://doi.org/10.2214/AJR.13.12386
        • Lee C.W.
        • Tsai H.I.
        • Lin Y.S.
        • et al.
        Intrahepatic biliary mucinous cystic neoplasms: clinic radiological characteristics and surgical results.
        BMC Gastroenterol. 2015 Jun10; 15: 67https://doi.org/10.1186/s12876-015-0293-3
        • Fragulidis G.P.
        • Vezakis A.I.
        • Konstantinidis C.G.
        • et al.
        Diagnostic and therapeutic challenges of intrahepatic biliary cystadenoma and cystadenocarcinoma: a report of 10 cases and review of the literature.
        Int Surg. 2015 Jul; 100: 1212-1219https://doi.org/10.9738/INTSURG-D-15-00025.1
        • National Comprehensive Cancer Network (NCCN)
        NCCN Guidelines, Version 2.2016.
        NCCN, Fort Washington, PA2016
        • Agnello F.
        • Salvaggio G.
        • Cabibbo G.
        • et al.
        Imaging appearance of treated hepatocellular carcinoma.
        World J Hepatol. 2013 Aug 27; 5: 417-424https://doi.org/10.4254/wjh.v5.i8.417
        • Mahnken A.H.
        • Pereira P.L.
        • de Baère T.
        Interventional oncologic approaches to liver metastases.
        Radiology. 2013 Feb; 266: 407-430https://doi.org/10.1148/radiol.12112544
        • Marin D.
        • Cappabianca S.
        • Serra N.
        • et al.
        CT appearance of hepatocellular carcinoma after locoregional treatments: a comprehensive review.
        Gastroenterol Res Pract. 2015; 2015670965https://doi.org/10.1155/2015/670965
        • Brunt E.M.
        Pathology of fatty liver disease.
        Mod Pathol. 2007 Feb; 20: S40-S48https://doi.org/10.1038/modpathol.3800680
        • Park Y.S.
        • Park S.H.
        • Lee S.S.
        • et al.
        Biopsy-proven nonsteatotic liver in adults: estimation of reference range for difference in attenuation between the liver and the spleen at nonenhanced CT.
        Radiology. 2011 Mar; 258: 760-766https://doi.org/10.1148/radiol.10101233
        • Kodama Y.
        • Ng C.S.
        • Wu T.T.
        • et al.
        Comparison of CT methods for determining the fat content of the liver.
        AJR Am J Roentgenol. 2007 May; 188: 1307-1312https://doi.org/10.2214/AJR.06.0992
        • Dioguardi Burgio M.
        • Bruno O.
        • Agnello F.
        • et al.
        The cheating liver: imaging of focal steatosis and fatty sparing.
        Expert Rev Gastroenterol Hepatol. 2016 Jun; 10: 671-678https://doi.org/10.1586/17474124.2016.1169919
        • Murphy M.C.
        • Gibney B.
        • Gillespie C.
        • Hynes J.
        • Bolster F.
        Gallstones top to toe: what the radiologist needs to know.
        Insights Imaging. 2020 Feb 5; 11: 13https://doi.org/10.1186/s13244-019-0825-4
        • Everhart J.E.
        • Khare M.
        • Hill M.
        • Maurer K.R.
        Prevalence and ethnic differences in gallbladder disease in the United States.
        Gastroenterology. 1999 Sep; 117: 632-639https://doi.org/10.1016/s0016-5085(99)70456-7
        • Frank M.
        • Phillips R.
        • Aldin Z.
        • Ghosh D.
        Hepatic artery aneurysm: an unusual cause of upper gastrointestinal bleed.
        BMJ Case Rep. 2017 Aug 24; 2017 (PMID: 28838922)bcr2017219865https://doi.org/10.1136/bcr-2017-219865
        • Jesinger R.A.
        • Thoreson A.A.
        • Lamba R.
        Abdominal and pelvicaneurysms and pseudoaneurysms: imagingreview with clinical, radiologic, and treatment correlation.
        Radiographics. 2013 May; 33: E71-E96https://doi.org/10.1148/rg.333115036
        • Jablonski K.L.
        • Chonchol M.
        Vascular calcification in end-stage renal disease.
        Hemodial Int. 2013 Oct; 17 (PMID: 24134325; PMCID: PMC3813300)S17-21https://doi.org/10.1111/hdi.12084
        • Parvey H.R.
        • Raval B.
        • Sandler C.M.
        Portal vein thrombosis: imaging findings.
        AJR Am J Roentgenol. 1994 Jan; 162: 77-81https://doi.org/10.2214/ajr.162.1.8273695
        • Kawasaki T.
        • Kambayashi J.
        • Sakon M.
        • et al.
        Portal vein calcification: a clinical review of the last 50 years and report of a case associated with dysplasminogenemia.
        Surg. Today. 1993; 23: 176-181https://doi.org/10.1007/BF00311239
        • Wang C.E.
        • Sun C.J.
        • Huang S.
        • et al.
        Extensive calcifications in portal venous system in a patient with hepatocarcinoma.
        World J Gastroenterol. 2014 Nov 21; 20: 16377-16380https://doi.org/10.3748/wjg.v20.i43.16377
        • Verma V.
        • Cronin 2nd, D.C.
        • Dachman A.H.
        Portal and mesenteric venous calcification in patients with advanced cirrhosis.
        AJR Am J Roentgenol. 2001 Feb; 176: 489-492https://doi.org/10.2214/ajr.176.2.1760489
        • Yoon W.
        • Jeong Y.Y.
        • Kim J.K.
        CT in blunt liver trauma.
        Radiographics. 2005 Jan-Feb; 25 (PMID: 15653589): 87-104https://doi.org/10.1148/rg.251045079