Download PDF
Dtsch Med Wochenschr 2012; 137(41): 2099-2116
DOI: 10.1055/s-0032-1305302
CME | Review article
Hepatologie, Onkologie, Radiologie
© Georg Thieme Verlag KG Stuttgart · New York

Der zufällig entdeckte Leberrundherd

Focal liver lesion, incidental finding
C. F. Dietrich
1   Med. Klinik 2, Caritas-Krankenhaus Bad Mergentheim
,
C. Jenssen
2   Klinik für Innere Medizin, Krankenhaus Märkisch Oderland
› Author Affiliations
Further Information

Publication History

06 July 2012

17 August 2012

Publication Date:
02 October 2012 (online)

Also available at
    Permissions and Reprints

Zusammenfassung

Der zufällig entdeckte Leberrundherd ist ein häufiges Problem, über dessen Abklärung nicht die Einigkeit besteht, die man eigentlich erwarten würde. Dies liegt auch daran, dass es mit Ausnahme von Patienten mit bekannter Leberzirrhose kein Vorsorgeprogramm zur frühzeitigen Detektion von Lebertumoren gibt.

Zur Abklärung (Detektion und Differenzialdiagnose) von Lebertumoren gehören theoretische Überlegungen, Anamnese, körperliche Untersuchung, laborchemische Untersuchungen, konventionelle Sonographie, dopplersonographische Techniken, kontrastverstärkte Sonographie (CEUS), Computertomographie (CT) und Magnetresonanztomographie (MRT) sowie die bildgebend gestützte Biopsie.

Als aussagekräftigste Methode haben sich kontrastverstärkte Ultraschalltechniken etabliert. Kontrastverstärkte Ultraschalltechniken wurden vor ca. 10 Jahren in die klinische Routine eingeführt und werden für vielfältige Indikationen im klinischen Alltag genutzt. Die kontrastverstärkte Sonographie ist in vielen Fällen die erste und auch entscheidende Technik zur Detektion und Charakterisierung von Lebertumoren. Diese Entwicklung wird durch vielfältige CEUS-Leitlinien reflektiert, beispielsweise durch die EFSUMB-Leitlinien 2004, 2008 und 2012 sowie die WFUMB-EFSUMB-Leitlinien 2012.

In dem CME-Artikel werden Überlegungen dargelegt, die eine geordnete Abklärung von inzidentellen Lebertumoren ermöglichen.

Abstract

The differential diagnosis of incidentally found Focal Liver Lesions (FLL) is complex. Screening procedures so far are only defined for patients with liver cirrhosis. Characterization of a FLL begins as soon as it is detected. Taking patients history and thorough clinical examination are essential. An imaging procedure that is used to detect liver masses should also allow the examiner to determine whether the lesion is benign or malignant. Conventional B-mode US and colour Doppler imaging are effective at detecting and characterizing typical liver cysts and calcifications. Laboratory data, computed tomography, magnetic resonance imaging and imaging guided liver biopsy are complementary methods.

Contrast Enhanced Ultrasound (CEUS) is a well established diagnostic imaging technique for a variety of indications and applications. One of the most important applications is in the liver where it is frequently a first-line technique for the detection and diagnosis (characterization) of focal liver lesions (FLL). In this setting the accurate differentiation of benign from malignant lesions is critical to ensure the patient undergoes the appropriate therapeutic option. This has been documented in recently published guidelines, in particular in terms of the enhancement patterns of the most common FLL hemangioma, focal nodular hyperplasia hepatocellular adenoma and their differentiation from malignant lesions. In this article the role of CEUS in the characterization of incidentally found FLL is described.

Schlüsselwörter

Echosignalverstärkte Sonographie - Leitlinien - Hämangiom - Fokal noduläre Hyperplasie - Lebermetastasen - Hepatozelluläres Karzinom - Computertomographie - Magnetresonanztomographie

Keywords

contrast enhanced ultrasonography - guidelines - hemangioma - focal nodular hyperplasia - liver metastases - hepatocellular carcinoma - computed tomography - magnetic resonance imaging
 

  • Literatur

  • 1 Albrecht T, Blomley M, Bolondi L et al. Guidelines for the use of contrast agents in ultrasound. January 2004. Ultraschall Med 2004; 25: 249-256
    Thieme ConnectPubMedSearch in Google Scholar
  • 2 Anderson SW, Kruskal JB, Kane RA. Benign hepatic tumors and iatrogenic pseudotumors. Radiographics 2009; 29: 211-229
    CrossrefPubMedSearch in Google Scholar
  • 3 Barreiros AP, Piscaglia F, Dietrich CF. Contrast enhanced ultrasound for the diagnosis of hepatocellular carcinoma (HCC): Comments on AASLD guidelines. J Hepatol 2012; ePub ahead of print
    PubMedSearch in Google Scholar
  • 4 Bernatik T, Seitz K, Blank W et al. Unclear focal liver lesions in contrast-enhanced ultrasonography-lessons to be learned from the DEGUM multicenter study for the characterization of liver tumors. Ultraschall Med 2010; 31: 577-581
    Thieme ConnectPubMedSearch in Google Scholar
  • 5 Biecker E, Fischer HP, Strunk H et al. Benign hepatic tumours. Z Gastroenterol 2003; 41: 191-200
    Search in Google Scholar
  • 6 Bruix J, Sherman M. Management of hepatocellular carcinoma: an update. Hepatology 2011; 53: 1020-1022
    CrossrefPubMedSearch in Google Scholar
  • 7 Claudon M, Cosgrove D, Albrecht T et al. Guidelines and good clinical practice recommendations for contrast enhanced ultrasound (CEUS) – update 2008. Ultraschall Med 2008; 29: 28-44
    Thieme ConnectPubMedSearch in Google Scholar
  • 8 Cui XW, Ignee A, Braden B et al. Biliary Papillomatosis and New Ultrasound Imaging Modalities. Z Gastroenterol 2012; 50: 226-231
    Thieme ConnectPubMedSearch in Google Scholar
  • 9 Devine AS, Jackson CS, Lyons L et al. Frequency of incidental findings on computed tomography of trauma patients. West J Emerg Med 2010; 11: 24-27
    PubMedSearch in Google Scholar
  • 10 Dietrich CF. Liver tumor characterization – comments and illustrations regarding guidelines. Ultraschall (Suppl) 2012; 33: S22-S30
    PubMedSearch in Google Scholar
  • 11 Dietrich CF, Cui XW, Barreiros AP et al. EFSUMB Guidelines 2011: Comment on emergent indications and visions. Ultraschall (Suppl) 2012; 33: S39-S47
    PubMedSearch in Google Scholar
  • 12 Dietrich CF, Cui XW, Boozari B et al. Contrast-enhanced ultrasound (CEUS) in the diagnostic algorithm of hepatocellular and cholangiocellular carcinoma. Ultraschall (Suppl) 2012; 33: S57-S66
    PubMedSearch in Google Scholar
  • 13 Dietrich CF, Cui XW, Ignee A. EFSUMB Guidelines 2011: Comments and illustrations. Ultraschall (Suppl) 2012; 33: S11-S21
    PubMedSearch in Google Scholar
  • 14 Dietrich CF, Maddalena ME, Cui XW et al. Liver tumor characterization – review of the literature. Ultraschall (Suppl) 2012; 33: S3-S10
    PubMedSearch in Google Scholar
  • 15 Dietrich CF, Nuernberg D. Lehratlas der interventionellen Sonographie. Stuttgart, New York: Thieme; 2011
    Search in Google Scholar
  • 16 Dietrich CF, Serra C, Jedrejczyk M. EFSUMB European Course Book. In: Dietrich CF, Hrsg. London: European Federation of Societies for Ultrasound in Medicine and Biology; 2012: 27-55
    Search in Google Scholar
  • 17 Dietrich CF, Averkiou MA, Correas JM et al. An EFSUMB Introduction into Dynamic Contrast-Enhanced Ultrasound (DCE-US) for Quantification of Tumour Perfusion. Ultraschall Med 2012; 33: 344-351
    Thieme ConnectPubMedSearch in Google Scholar
  • 18 Dietrich CF, Ignee A, Hocke M et al. Pitfalls and artefacts using contrast enhanced ultrasound. Z Gastroenterol 2011; 49: 350-356
    Thieme ConnectPubMedSearch in Google Scholar
  • 19 Dietrich CF, Ignee A, Trojan J et al. Improved characterisation of histologically proven liver tumours by contrast enhanced ultrasonography during the portal venous and specific late phase of SHU 508A. Gut 2004; 53: 401-405
    CrossrefPubMedSearch in Google Scholar
  • 20 Dietrich CF, Kratzer W, Strobe D et al. Assessment of metastatic liver disease in patients with primary extrahepatic tumors by contrast-enhanced sonography versus CT and MRI. World J Gastroenterol 2006; 12: 1699-1705
    CrossrefPubMedSearch in Google Scholar
  • 21 Dietrich CF, Mertens JC, Braden B et al. Contrast-enhanced ultrasound of histologically proven liver hemangiomas. Hepatology 2007; 45: 1139-1145
    CrossrefPubMedSearch in Google Scholar
  • 22 Dietrich CF, Riemer-Hommel P. Challenges for the German Health Care System. Z Gastroenterol 2012; 50: 557-572
    Thieme ConnectPubMedSearch in Google Scholar
  • 23 Dietrich CF, Schuessler G, Trojan J et al. Differentiation of focal nodular hyperplasia and hepatocellular adenoma by contrast-enhanced ultrasound. Br J Radiol 2005; 78: 704-707
    CrossrefPubMedSearch in Google Scholar
  • 24 Guang Y, Xie L, Ding H et al. Diagnosis value of focal liver lesions with SonoVue(R)-enhanced ultrasound compared with contrast-enhanced computed tomography and contrast-enhanced MRI: a meta-analysis. J Cancer Res Clin Oncol 2011; 137: 1595-1605
    CrossrefPubMedSearch in Google Scholar
  • 25 Hirche TO, Ignee A, Hirche H et al. Evaluation of hepatic steatosis by ultrasound in patients with chronic hepatitis C virus infection. Liver Int 2007; 27: 748-757
    CrossrefPubMedSearch in Google Scholar
  • 26 Hirche TO, Russler J, Schroder O et al. The value of routinely performed ultrasonography in patients with Crohn disease. Scand J Gastroenterol 2002; 37: 1178-1183
    CrossrefPubMedSearch in Google Scholar
  • 27 Ignee A, Piscaglia F, Ott M et al. A benign tumour of the liver mimicking malignant liver disease – cholangiocellular adenoma. Scand J Gastroenterol 2009; 44: 633-636
    CrossrefPubMedSearch in Google Scholar
  • 28 Ignee A, Weiper D, Schuessler G et al. Sonographic characterisation of hepatocellular carcinoma at time of diagnosis. Z Gastroenterol 2005; 43: 289-294
    Thieme ConnectPubMedSearch in Google Scholar
  • 29 Karhunen PJ. Benign hepatic tumours and tumour like conditions in men. J Clin Pathol 1986; 39: 183-188
    Search in Google Scholar
  • 30 Mork H, Ignee A, Schuessler G et al. Analysis of neuroendocrine tumour metastases in the liver using contrast enhanced ultrasonography. Scand J Gastroenterol 2007; 42: 652-662
    CrossrefPubMedSearch in Google Scholar
  • 31 Nguyen BN, Flejou JF, Terris B et al. Focal nodular hyperplasia of the liver: a comprehensive pathologic study of 305 lesions and recognition of new histologic forms. Am J Surg Pathol 1999; 23: 1441-1454
    CrossrefPubMedSearch in Google Scholar
  • 32 Nuernberg D, Ignee A, Dietrich CF. Aktueller Stand der Sonographie in der Gastroenterologie – Leber und Milz. Z Gastroenterol 2006; 44: 991-1000
    Thieme ConnectPubMedSearch in Google Scholar
  • 33 Piscaglia F, Nolsoe C, Dietrich CF et al. The EFSUMB Guidelines and Recommendations on the Clinical Practice of Contrast Enhanced Ultrasound (CEUS): update 2011 on non-hepatic applications. Ultraschall Med 2012; 33: 33-59
    Thieme ConnectPubMedSearch in Google Scholar
  • 34 Schlottmann K, Klebl F, Zorger N et al. Contrast-enhanced ultrasound allows for interventions of hepatic lesions which are invisible on convential B-mode. Z Gastroenterol 2004; 42: 303-310
    Thieme ConnectPubMedSearch in Google Scholar
  • 35 Schuessler G, Fellbaum C, Fauth F et al. Der inflammatorische Pseudotumor – eine schwierige Differenzialdiagnose. Ultraschall Med 2006; 27: 273-279
    Thieme ConnectPubMedSearch in Google Scholar
  • 36 Seitz K, Bernatik T, Strobel D et al. Contrast-enhanced ultrasound (CEUS) for the characterization of focal liver lesions in clinical practice (DEGUM Multicenter Trial): CEUS vs. MRI – a prospective comparison in 269 patients. Ultraschall Med 2010; 31: 492-499
    Thieme ConnectPubMedSearch in Google Scholar
  • 37 Seitz K, Greis C, Schuler A et al. Frequency of tumor entities among liver tumors of unclear etiology initially detected by sonography in the noncirrhotic or cirrhotic livers of 1349 patients. Results of the DEGUM multicenter study. Ultraschall Med 2011; 32: 598-603
    Thieme ConnectPubMedSearch in Google Scholar
  • 38 Seitz K, Strobel D, Bernatik T et al. Contrast-Enhanced Ultrasound (CEUS) for the characterization of focal liver lesions – prospective comparison in clinical practice: CEUS vs. CT (DEGUM multicenter trial). Parts of this manuscript were presented at the Ultrasound Dreilandertreffen 2008, Davos. Ultraschall Med 2009; 30: 383-389
    Thieme ConnectPubMedSearch in Google Scholar
  • 39 Strobel D, Bernatik T, Blank W et al. Diagnostic accuracy of CEUS in the differential diagnosis of small (</= 20 mm) and subcentimetric (</= 10 mm) focal liver lesions in comparison with histology. Results of the DEGUM multicenter trial. Ultraschall Med 2011; 32: 593-597
    Thieme ConnectPubMedSearch in Google Scholar
  • 40 Strobel D, Seitz K, Blank W et al. Contrast-enhanced ultrasound for the characterization of focal liver lesions – diagnostic accuracy in clinical practice (DEGUM multicenter trial). Ultraschall Med 2008; 29: 499-505
    Thieme ConnectPubMedSearch in Google Scholar
  • 41 Strobel D, Seitz K, Blank W et al. Tumor-specific vascularization pattern of liver metastasis, hepatocellular carcinoma, hemangioma and focal nodular hyperplasia in the differential diagnosis of 1,349 liver lesions in contrast-enhanced ultrasound (CEUS). Ultraschall Med 2009; 30: 376-382
    Thieme ConnectPubMedSearch in Google Scholar
  • 42 Trillaud H, Bruel JM, Valette PJ et al. Characterization of focal liver lesions with SonoVue-enhanced sonography: international multicenter-study in comparison to CT and MRI. World J Gastroenterol 2009; 15: 3748-3756
    CrossrefPubMedSearch in Google Scholar
  • 43 Trojan J, Hammerstingl R, Engels K et al. Contrast-enhanced ultrasound in the diagnosis of malignant mesenchymal liver tumors. J Clin Ultrasound 2010; 38: 227-231
    PubMedSearch in Google Scholar
  • 44 Volk M, Strotzer M, Lenhart M et al. Frequency of benign hepatic lesions incidentally detected with contrast-enhanced thin-section portal venous phase spiral CT. Acta Radiol 2001; 42: 172-175
    CrossrefPubMedSearch in Google Scholar
  • 45 Wermke W. Sonographische Differenzialdiagnose. Leberkrankheiten. Köln: Deutscher Ärzteverlag; 2005
    Search in Google Scholar
  • 46 Xie L, Guang Y, Ding H et al. Diagnostic value of contrast-enhanced ultrasound, computed tomography and magnetic resonance imaging for focal liver lesions: a meta-analysis. Ultrasound Med Biol 2011; 37: 854-861
    CrossrefPubMedSearch in Google Scholar
  • 47 Young NA, Mody DR, Davey DD. Misinterpretation of normal cellular elements in fine-needle aspiration biopsy specimens: observations from the College of American Pathologists Interlaboratory Comparison Program in Non-Gynecologic Cytopathology. Arch Pathol Lab Med 2002; 126: 670-675
    PubMedSearch in Google Scholar
  • 48 Zech CJ. Mit welcher Methode? Sichere Diagnose bei einem Zufallsbefund in der Leber. MMW Fortschr Med 2011; 153: 41-44
    PubMedSearch in Google Scholar