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Mahesh Kumar, Palbha Khanna, Raja Kollu, R P Bansal
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Original Article
Ultrasonography and computed tomography
evaluation in hepatic mass lesions
Mahesh Kumar
1*
, Palbha Khanna
1,2
Resident,
3
Assistant Professor,
4
Professor and HOD, Department of Ra
Email: maheshverma2708@gmail.com
Abstract
Background:
Ultrasonography and computed
Evaluate the role of Ultrasonography (USG) and Computed Tomography (CT) in detection and characterization of
hepatic mass lesions and
correlation with the histopathology.
voluson 730 pro machine with convex probe of frequency 3
“SIEMENS” 16 slice spiral CT scanner. Hepatic Triple
of hepatic masses in our study includes infective (36%), primary benign tumours (20%), primary malignant tumours
(16%), and metastasis (28%). Most common benign and malignant lesions were hemangioma and metastasis.
Conclusion:
Infective masses are the
most common malignant lesions. Ultrasonography is initial imaging modality of choice as it is noninvasive, free of
radiation hazards, quick and cost effective. CT narrows the
Key Words:
Ultrasonography, tomography, hepatic mass lesions.
*
Address for Correspondence:
Dr.
Mahesh Kumar, Department of Radiodiagnosis and Imaging, NIMS Medical College, Jaipur
Email: maheshverma2708@gmail.com
Received Date: 10/01/2017 Revised Date: 12/0
2
INTRODUCTION
Liver diseases are amongst the common causes of
morbidity and mortality in India, which are encountered
frequently in day-to-day practice.
Focal liver lesions
(FLL) have been a common reason for consultation faced
by gastroenterologists and hepatologists. The increasing
and widespread use of imaging studies has led to an
increase in detection of incidental FLL.
characterization
of focal liver lesions is one of the most
confusing and controversial challenges in imaging today.
Ultrasonography allow full liver scanning and accurate
detection of focal lesions of liver parenchyma. Ultrasound
examinations are the most frequently used i
method for evaluation of focal liver lesions.
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DOI: 18
March 2017
Mahesh Kumar, Palbha Khanna, Raja Kollu, R P Bansal
.
Ultrasonography and computed tomography evaluation
International Medical Journal.
March 2017; 4(3): 351-356.
http://www.medpulse.in
Ultrasonography and computed tomography
evaluation in hepatic mass lesions
, Palbha Khanna
2
, Raja Kollu
3
, R P Bansal
4
Professor and HOD, Department of Ra
diodiagnosis and Imaging,
NIMS Medical College,
Ultrasonography and computed
tomography evaluation of hepatic mass lesions
Evaluate the role of Ultrasonography (USG) and Computed Tomography (CT) in detection and characterization of
correlation with the histopathology.
Materials and Methods:
USG was performed by using GE
voluson 730 pro machine with convex probe of frequency 3
-
5 MHz and high frequency probe of 7
“SIEMENS” 16 slice spiral CT scanner. Hepatic Triple
-
Phase Contrast MDCT Protocol was followed.
of hepatic masses in our study includes infective (36%), primary benign tumours (20%), primary malignant tumours
(16%), and metastasis (28%). Most common benign and malignant lesions were hemangioma and metastasis.
Infective masses are the
most common entity among all hepatic mass lesions and Metastatic masses are the
most common malignant lesions. Ultrasonography is initial imaging modality of choice as it is noninvasive, free of
radiation hazards, quick and cost effective. CT narrows the
list of differential diagnosis.
Ultrasonography, tomography, hepatic mass lesions.
Mahesh Kumar, Department of Radiodiagnosis and Imaging, NIMS Medical College, Jaipur
-
Delhi highway, Jaipur Rajasthan, INDIA.
2
/2017 Accepted Date: 02/03/2017
Liver diseases are amongst the common causes of
morbidity and mortality in India, which are encountered
Focal liver lesions
(FLL) have been a common reason for consultation faced
by gastroenterologists and hepatologists. The increasing
and widespread use of imaging studies has led to an
increase in detection of incidental FLL.
Detecting and
of focal liver lesions is one of the most
confusing and controversial challenges in imaging today.
Ultrasonography allow full liver scanning and accurate
detection of focal lesions of liver parenchyma. Ultrasound
examinations are the most frequently used i
maging
method for evaluation of focal liver lesions.
1,2
Hepatic
sonographic main strengths include its ability to
characterize common benign lesions like cysts,
Haemangiomas, its safety and low cost. Ultrasound is
used as first line imaging investigation i
jaundice, right upper quadrant pain and hepatomegaly.
Sonography, because of its ability to image in any oblique
plane is equal or superior to CT and MRI in localizing
lesions to an anatomic segment or sub segment of the
liver. Sonography i
s unexcelled in showing the
relationship of liver tumors to critical structures such as
veins, bile ducts and arteries.
indispensable imaging tool for the evaluation of hepatic
masses. It can help in determining the respectability of
hepatic
masses, planning of treatment and following the
response to therapy. Biopsy can be done under CT
control.
Spiral computed tomography has rapidly gained
acceptance as the preferred technique for routine liver
evaluation because it provides image acquisitio
enhancement of the liver parenchyma during a single
breath hold.
3,4
In addition, the fast data acquisition allows
successive scanning of the entire liver at different
moments after injection of contrast material, thus creating
the possibility of
multiphasic liver CT. Triphasic Spiral
computed tomography technique allows imaging of the
entire liver in three phases, from the time of
administration of contrast. Though ultrasonography also
www.medpulse.in
March 2017
Ultrasonography and computed tomography evaluation
http://www.medpulse.in
Ultrasonography and computed tomography
NIMS Medical College,
Jaipur, Rajasthan.
tomography evaluation of hepatic mass lesions
. Aims and Objectives:
Evaluate the role of Ultrasonography (USG) and Computed Tomography (CT) in detection and characterization of
USG was performed by using GE
5 MHz and high frequency probe of 7
-10 Mhz. CT done on
Phase Contrast MDCT Protocol was followed.
Result: Spectrum
of hepatic masses in our study includes infective (36%), primary benign tumours (20%), primary malignant tumours
(16%), and metastasis (28%). Most common benign and malignant lesions were hemangioma and metastasis.
most common entity among all hepatic mass lesions and Metastatic masses are the
most common malignant lesions. Ultrasonography is initial imaging modality of choice as it is noninvasive, free of
Delhi highway, Jaipur Rajasthan, INDIA.
sonographic main strengths include its ability to
characterize common benign lesions like cysts,
Haemangiomas, its safety and low cost. Ultrasound is
used as first line imaging investigation i
n patients with
jaundice, right upper quadrant pain and hepatomegaly.
Sonography, because of its ability to image in any oblique
plane is equal or superior to CT and MRI in localizing
lesions to an anatomic segment or sub segment of the
s unexcelled in showing the
relationship of liver tumors to critical structures such as
veins, bile ducts and arteries.
CT has been an
indispensable imaging tool for the evaluation of hepatic
masses. It can help in determining the respectability of
masses, planning of treatment and following the
response to therapy. Biopsy can be done under CT
Spiral computed tomography has rapidly gained
acceptance as the preferred technique for routine liver
evaluation because it provides image acquisitio
n at peak
enhancement of the liver parenchyma during a single
In addition, the fast data acquisition allows
successive scanning of the entire liver at different
moments after injection of contrast material, thus creating
multiphasic liver CT. Triphasic Spiral
computed tomography technique allows imaging of the
entire liver in three phases, from the time of
administration of contrast. Though ultrasonography also

MedPulse – International Medical Jo urnal, ISSN: 2348-2516, EISSN: 2348-1897, Volume 4, Issue 3, March 2017 pp 351-356
MedPulse – International Medical Jo urnal, ISSN: 2348-2516, EISSN: 2348-1897, Volume 4, Issue 3, March 2017 Page 352
having similar accuracy in detecting the lesions, CT is
preferred because it out-performs US and MRI for
evaluating the extra-hepatic abdomen.
5
The present study
was planned to investigate the role of conventional
contrast enhanced CT along with ultrasonography in
detection and characterization of hepatic mass lesions.
MATERIALS AND METHODS
A prospective study was conducted in the
DEPARTMENT OF RADIODIAGNOSIS, NIMS
MEDICAL COLLEGE and HOSPITAL, SHOBHA
NAGAR JAIPUR From 1
st
January 2013 to October
2014. The study group included 100 patients referred with
strong clinical doubt of having hepatic mass lesion,
incidentally detected hepatic mass lesion on routine
ultrasonography or CT scanning, known hepatic mass
lesion for further evaluation and patients referred for
USG or CT guided FNAC or aspiration. Patients with
proven hepatic invasion by adjacent malignancies (GB,
hepatic flexure, antral etc.) were excluded.
Diagnostic criteria included the morphology of lesion, its
enhancement patterns and associated findings with
clinical correlation. The results were then compared with
previous studies in the literature.
RESULTS
Minimum age of the patient was 2 years and the
maximum age was 89 years. The maximum numbers of
patients in between 61 to 70 years constituted 20% of all
patients. Males accounted for larger group compared to
females with M:F being 1.2:1. Age group and gender
involvement varied according with the type of lesion.
Spectrum of hepatic masses in our study includes
infective (36%), primary benign tumours (20%), primary
malignant tumours (16%), and metastasis (28%). Of the
all malignant lesions, most common were metastasis
(28%) and most common primary malignant lesion was
hepatocellular carcinoma (8%) and Most common benign
lesion was hemangioma (12%).
Table 1: Spectrum of major varities of Hepatic Masses
Sr.
No. Lesions Number of
Cases Percentage
1 Primary benign tumors 20 20
2 Primary malingnant
tumors 16 16
3 Metastasis 28 28
4 Infective 36 36
Total 100 100
Infective hepatic lesions were the most common hepatic
mass lesions which included pyogenic (16%), amoebic
(8%), hydatid (85%), tubercular (4%) of total cases.
Table 2: Distribution of patients with infective hepatic lesions
Sr.
No. Lesions Number
of Cases
% of patients
with infective
lesions
% age of
total
cases
1 Pyogenic
abscess 16 44.45 16
2 Amoebic liver
abscess 8 22.22 8
3 Hydatic cyst 8 22.22 8
4 Tubercular
infection 4 11.11 4
Total 36 100 36%
USG and CT gave the diagnosis and characterization of
abscess but definitive diagnosis is made by HPE and
culture studies. Second largest group was metastasis,
Majority cases with primary in GIT. Majority Of
metastatic deposits include hypoechoic (16%) rest are
hyperechoic and mixed.
Table 3: Distribution of pattern echogenicity of hepatic metastaces
Sr.
No.
Echogenicity Number of
Cases
Percentage
1 Hypoechoic 16 57.15
2 Hyperechoic 8 28. 57
3 Hypoechoic and
Hyperechoic
4 14.28
Total 28 100

Mahesh Kumar, Palbha Khanna, Raja Kollu, R P Bansal
Copyright © 2017, Medpulse Publishing Corporation, MedPulse – International Medical Journal, Volume 4, Issue 3 March 2017
Hypervascular metastases may become iso-attenuating
and thus difficult to detect during the redistribution phase
of enhancement, therefore, patients with a known
vascular primary malignancy should be evaluated with
triple-phase helical CT. Sonographic appearance of HCC
was variable, it may be hypoechoic, complex or
echogenic. A thin peripheral halo can be seen.
Hepatocellular carcinoma was more easily identified and
better characterized on dynamic contrast-enhanced CT
because of its arterial supply. On dynamic CECT, HCC
characteristically appears as transiently hyperattenuating
mass during hepatic arterial phase. Vascular invasion in
our study was significantly associated with primary
hepatic malignancies, most commonly seen with HCC.
Intrahepatic-cholangio-carcinoma (IHCC) was the 2nd
most common primary malignant tumor (4%),
Presentation depends on the location of the mass. Dilated
IHBRD and lobar atrophy were common findings.
Hepatoblastoma (4%) was most common primary
malignant tumor of childhood. In benign group,
Hemangioma was the most common benign tumor of
liver (12%).and most of the time it was an incidental
finding. Simple cysts were also incidental finding (8%) in
this study.
Figure 1 a Figure 1 b
Figure 2 a Figure 2 b

MedPulse – International Medical Jo urnal, ISSN: 2348-2516, EISSN: 2348-1897, Volume 4, Issue 3, March 2017 pp 351-356
MedPulse – International Medical Jo urnal, ISSN: 2348-2516, EISSN: 2348-1897, Volume 4, Issue 3, March 2017 Page 354
Figure 3 a Figure 3 b
Legend:
Figure 1(a): Hepatocellular Carcinoma: Sonogram in a 70year male patient showing a large slightly echogenic mass with peripheral halo sign
in Right lobe of liver; Figure 1(b): Hepatocellular Carcinoma: Axial CECT scan in the same patient. on arterial phase showing
Heterogeneously enhancing mass lesion with central nonenhancing hypodense area s/o necrosis.
Figure 2(a): Pyogenic Liver Abscess: Right and left lobe of liver showing multiple cystic lesions with thick shaggy walls and having internal
echoes and septae; Figure 2(b): Pyogenic Liver Abscess: Axial CECT scan in the same pt. showing multiple oval to spherical, peripherally
enhancing hypodense lesions.
Figure 3(a): Hepatic Metastases: sonogram in 60 year old patient of Ca colon showing innumerate rounded to oval hypoechoic lesions
diffusely scattered in both lobes of liver; Figure 3(b): Hepatic Metastases: Axial Contrast Enhanced CT scan in the same patient showing the
liver studded with mild peripherally enhancing hypodense lesions.
DISCUSSION
Primary benign hepatic tumors accounted for 20 (20%)
out of 100 cases in this study with 12 cases (60%) of
hemangiomas and 8 cases (40%) of simple hepatic cysts.
There were 74 (73.3%) females and 27 (26.7%) males.
Mean age was 50.7 years (range 25 to 77).
6,7
Size of
cavernous hemangiomas was 2-3 cm, which was
consistent with study of cherqui D
8
who showed that
these lesions are incidental findings and mostly less than
3 cm in size and these lesions shows homogenous
echogenic pattern on ultrasound. The feature of globular
enhancement was found to be more specific for
differentiating hepatic hemangiomas from hypervascular
metastases on single-pass, contrast enhanced
CT
9
.Imaging findings in this study were comparable to
that of Nelson and Judith et al
6
, Taseva A, Tasev
V, Bulanov D et al.
7
Most simple cysts were diagnosed
incidentally on USG. The CT appearance of hepatic cysts
are well-circumscribed, homogenous mass of near-water
attenuation value (20<HU), which shows no enhancement
after IV contrast material administration.
10
In this study,
there were only 8 cases of simple hepatic cysts, as these
lesions are asymptomatic and usually detected
incidentally. All the lesions were anechoic structure
having thin imperceptible wall with posterior acoustic
enhancement on usg and there was no enhancement on
contrast CT. HCC is the most common primary liver
cancer comprising of 80% of primary liver malignancies.
1
Ignee a et al (2005)
11
al in their study, evaluated the
appearances of HCC on ultrasound. In their study, HCC
are hypoechoic in 48 % of the cases, isoechoic in 9 %,
hyperechoic in 19 %, and in 25 % a mixture between
hyper- and hypoechoic appearance was found compared
to the surrounding liver tissue. In this study, on USG, in 4
(50%) patients, the lesions were hypoechoic. In another 3
(33%) patients, the lesion were mixed echogenic and in 1
patent (10%) the lesion was isoechoic. No calcifications
noted in all the lesions. On colour flow Doppler, high
velocity signals were seen. On CECT scan, all patients
followed the same pattern of enhancement in arterial and
porto-venous phases. We observed portal venous and
hepatic venous invasion in 3 (33 %) cases in whom the
tumors were large and infiltrative. Intrahepatic
cholangiocarcinoma is an adenocarcinoma that arises
from the epithelium of small intrahepatic bile ducts. It is
much less common than hepatocellular carcinoma,
accounting for only approximately 10% of all primary
hepatic malignancies.
12
IHCC was the second most
common primary malignant neoplasm in this study as
well 4 (25%) cases out of 16. Biliary ductal dilatation
Peripheral to the mass is a common finding
13
seen in all
case (100%) in our study and portal venous encasement
by cholangiocarcinoma may lead to hepatic lobar
atrophy.
14
On USG, the lesion is hypovascular solid mass
with heterogenous echotexture and may appear hypo, iso
or hyperechoic.
15
The usual CT appearance is that of a
hypo-attenuating mass with irregular margins that shows
mild peripheral enhancement and pooling of contrast
material on delayed images.
12
Similar findings were seen
in cases including in this study. 4 cases of hepatoblastoma
in our study three were upto 3 year of age and one was 6

Mahesh Kumar, Palbha Khanna, Raja Kollu, R P Bansal
Copyright © 2017, Medpulse Publishing Corporation, MedPulse – International Medical Journal, Volume 4, Issue 3 March 2017
year old. The USG appearance is of large mixed
echogenic mass with poor margins of having small cysts.
Rounded or irregular shaped calcify deposits are
commonly seen within the lesion.
16
The CT appearance of
hepatoblastoma and hepatocellular carcinoma are similar.
Imaging features in the 4 cases of our study were
consistent with those mentioned in literature and 3 cases
showed calcifications within. Hepatic metastatic disease
is the most common malignancy of the non-cirrhotic
liver. Metastases occur 20 times more often than other
malignancies in the non-cirrhotic liver.
17
In this study
metastatic disease comprised of 28 cases (28%) as
compared to 16 (16%) of cases of primary malignancy,
which was consistent with other studies in literature.
Incidence of primaries from GIT was low in our study as
contrary to incidence mentioned in literature according to
which the most common source of hepatic metastases is
gastro-intestinal tumors (65%).
18
The cause for this
discrepancy could be explained by less number of
patients included in this study.
Table 4: comparision of echopatterns of Metastasis in our study
with literature
Echo
pettern
Present
study
Jain AK et
al (%)
Viscomi GN
et al (%)
Timmariah
et al (%)
Hypoechoic 57.15 34.60 37. 50 38. 50
Hyperechoic 28. 57 13.30 25.0 19.20
Mixed 14.28 4.0 37. 50 23.10
Others 33. 5
Most metastases are hypodense relative to normal liver
because these are hypovascular. Some metastatic lesions
have a predominantly cystic appearance. This occurs
characteristically, with ovarian tumours, carcinoma of the
colon, teratoma and metastatic squamous tumours with an
attenuation of <20 HU (e.g. Ca colon and ovary).
19
Other
neoplasms having rapid growth leading to necrosis and a
cystic appearance (e.g. Ca lung and sarcomas). 4 cases of
smooth walled cystic metastases resembling simple cysts
two were from ca Colon and two were from Ca ovary
were seen. Therefore, patients with a known vascular
primary malignancy should be evaluated with triple-phase
helical CT. Ultrasonography is the preferred initial
method of imaging for liver abscess as it is non-invasive,
cost effective and can be used to guide aspiration to
identify the causative organisms. Ultrasound will usually
show a spherical oval or slightly irregular echo poor
lesions with distal enhancement. This pattern is present in
75% of cases. In a study of 32 cases of hepatic abscess by
Abdelouafi A, Ousehal A, Vuzidane, Kadiri R et al 1993
20
16 cases were found to be pyogenic liver abscess and
remaining 16 cases to be amoebic liver abscess. All the
patients initially underwent ultrasonographic
examination. The confirmation of ultrasonographic
diagnosis was made by ultrasound guided percutaneous
aspiration in 30 cases and laparotomy in 2 cases. In this
study 24 cases of hepatic abscess, 16 cases (44.45%) were
of pyogenic liver abscesses and 8 case were of amoebic
liver abscesses comprising of 66.67% of total infective
lesions and 24% focal hepatic lesions.12 (75%) cases
were having complaints of fever and pain abdomen. In
this study also Pyogenic abscesses were multiple in 9
cases and all amoebic liver abscesses were solitary.
Amoebic liver abscess were larger in size than pyogenic
abscess. Most of the lesions are hypoechoic (75% of
amoebic and 50% of pyogenic abscess). The
heterogenous aspect was found in 36% of amoebic and in
25% of pyogenic abscess. The anechogenic aspect was
found in only one case of pyogenic abscess. Irregular wall
was found in 75% of amoebic abscesses and in 50% of
pyogenic abscesses. All the ultrasonographic results of
this study were coinciding with studies in the literature.
The characteristic CT appearance of hepatic abscess is
that of a round or irregularly shaped hypo attenuating
mass with a peripheral capsule that undergoes contrast
enhancement.
21
All the cases in this study had thick,
intensely enhancing capsule. Hepatic abscesses may be
unilocular or multilocular. Smaller lesions <2cm may be
seen clustering together with apparent coalescence into a
large abscess (“cluster sign”), which is suggestive of their
pyogenic nature.
22
(50% of cases in this study were
positive for this finding and it appeared to be a strong
indicator of the pyogenic nature of the lesion. The CT
appearance of amoebic abscess is nonspecific. Extra-
hepatic abnormalities are common and include pleural
effusion, perihepatic fluid collection, gastric or colonic
involvement, and retroperitoneal extension.
23
Right sided
pleural effusion was detected in 50% of cases in our
study. With the help of clinical picture, typical location
and imaging appearances, a correct diagnosis was made
in all cases. In extrapulmonary tuberculosis, hepatic
tuberculosis has been regarded as a rare form of TB.
24
Only 4 cases (11.11%) of tubercular involvement of liver
and in 2 cases associated splenic involvement also noted.
3 lesions are hypoechoic on USG and one case shows
diffuse calcifications on CT. On Contrast CT
examination, ill-defined foci of low attenuation lesions
which were showing mild peripheral enhancement, seen
in both lobes of liver and also in spleen in 2 cases. In this
study we found 8 cases of hydatid cyst (22.22% of
infective cases) 4 case were showing densely calcified
wall. The 2 patients (50%) was diagnosed as rupture
hydatid cyst having perihepatic collection with floating
membranes seen in the collection and remaining 2 were
having daughter cysts giving spoke wheel appearance.
Imaging findings in hepatic hydatid disease depend on the
stage of cyst growth (i.e., whether the cyst is unilocular,
contains daughter vesicles, contains daughter cysts, is

MedPulse – International Medical Jo urnal, ISSN: 2348-2516, EISSN: 2348-1897, Volume 4, Issue 3, March 2017 pp 351-356
MedPulse – International Medical Jo urnal, ISSN: 2348-2516, EISSN: 2348-1897, Volume 4, Issue 3, March 2017 Page 356
partially calcified, or is completely calcified [dead]).
When detached from the pericyst the true cyst wall may
appear as a thin wavy membrane within the fluid filled
cyst.
25
This characteristic sign was appreciated in 50%
cases of hydatid disease in this study. In the presence of
typical imaging features like multiple daughter cysts,
floating membrane and peripheral calcification, it was
easy to diagnose hydatid cysts on USG and CT.
CONCLUSION
Infective masses are the most common entity among all
hepatic mass lesions that come to clinical attention.
Metastatic masses are the most common malignant
lesions of the liver. Primary benign lesions present
clinically only when they are large or are detected
incidentally on scanning for other reasons. Hemangioma
can be confidently diagnosed on the basis of their
characteristic echotexture and enhancement patterns.
Ultrasonography proved to be the initial imaging
modality of choice as it is noninvasive, free of radiation
hazards, quick and cost effective. It is easily accepted by
patient as it is not very expensive, carried out without any
discomfort to patient and needs no extra preparation. Due
to high sensitivity, noninvasiveness, availability, superb
resolution, ability to detect calcium and density
discrimination, CT is a comparatively better imaging
modality for evaluation of hepatic masses. The imaging
of hepatic mass lesions by USG and CT is an ideal. CT
narrows the list of differential diagnosis, may suggest
accurate diagnosis or can confirm the probable diagnosis
by identifying the exact location, number, nature,
enhancement pattern, extent and additional findings
among USG detected hepatic mass lesions.
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Source of Support: None Declared
Conflict of Interest: None Declared