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Parenchymal pseudolesions include focal fatty change, focal sparing, inflammatory pseudotumor, confluent fibrosis, pseudotumor hypertrophy and hepatic peliosis. Focal fatty changes are the most frequent of them. Approximately 30-40% of fatty liver infiltration cases occur focally, either as solitary areas, or as multiple areas with a more widespread distribution and lead to differential diagnosis with liver neoplasm. We present several cases of hepatic parenchymal pseudolesions, exemplified by 2D and contrast enhanced ultrasound imaging We report the case of a 72-year-old Caucasian man, who presented with a three- day history of right upper quadrant abdominal pain. He also complained of anorexia and significant weight loss in one month. The ultrasound exam showed an imprecisely- defined heterogeneous mass situated in his right hepatic lobe measuring 68 mm × 46 mm. Diffuse homogeneous hyperenhancement in the arterial phase and washout during the delayed phase was observed at contrast- enhanced ultrasound (CEUS), therefore malignancy was suspected. Because the MRI scan showed suspicious appearance of malignant lesion, liver biopsy was performed. Microscopic examination revealed nonspecific benign characteristics The metastatic work- up was also negative. After 3 months, the patient was in good condition. The case of a patient with neoplastic history and pseudotumoral fatty free infiltration and three other cases of atypical localisation of focal fatty infiltration or focal fatty sparing are also detailed. Non- neoplastic abnormalities are clearly depicted with modern imaging techniques such as CEUS. CEUS has high accuracy in the diagnosis of liver focal fatty infiltration or sparing. [ABSTRACT FROM AUTHOR]

Hepatic pseudolesions are non- neoplastic abnormalities of the liver which may be sub- divided into parenchymal pseudolesions and vascular pseudolesions. Vascular pseudolesions include non- neoplastic hepatic pseudolesions such as intrahepatic shunts and vascular abnormalities associated with Budd- Chiari syndrome or portal vein thrombosis. We present several cases of hepatic vascular pseudolesions, exemplified by 2D and contrast- enhanced ultrasound imaging (CEUS), to be considered in the differential diagnosis of real liver tumors. First case belongs to a 63-year-old patient who was diagnosed with a liver abscess (LA) two years ago. Significant resolution of the LA was observed in the follow- up evaluation. In the vicinity of the residual abscess, Doppler US examination revealed a blood flow pattern with arterial and venous communication suggestive of arterio- portal shunt (APS). CEUS showed a homogeneous enhancement of this area and it also indicated the presence of the APS. Furthermore, an imprecisely delimited area with late and incomplete wash out was depicted in the late phase which led to differential diagnostic challenges with malignant tumors. Another case of a 74- years- old man with vascular abnormalities associated with Budd- Chiari syndrome secondary to multicentric hepatocellular carcinoma is illustrated in this topic. three cases with enhancement anomalies caused by portal vein thrombosis are also detailed in this paper. The main clinical difficulty is to detect the non- neoplastic lesions and to discriminate between them and benign and malignant hepatic neoplasms. CEUS may be an useful tool for the characterization of hepatic vascular pseudolesions. [ABSTRACT FROM AUTHOR]

Hemangiomas are among the most common benign solid lesions that can occur in the liver. Generally, they occur as a single lesion less than 3 cm diameter, but there are also described cases with multiple or bigger lesions (up to 20 cm). The diagnosis is confirmed by using imaging methods, thus their incidence has increased due to the recent improvement and widespread use of imaging. The aim of this study was to evaluate the usefulness of CEUS in clinical practice. We performed a retrospective study for the year 2021 in the Gastroenterology Department of Emergency County Hospital of Craiova, Romania, including patients with diagnosed hepatic hemangioma. It is based on a group of 35 patients, 12 men and 18 women, ages ranged from 34 to 85 years. There were detected 65 focal liver lesions (21 patients with single lesion, 14 patients with 2 or more lesions) suspected as hemangiomas after performing standard abdominal US, which were further investigated by CEUS and/or contrast-enhanced CT or MRI and diagnosed as hepatic hemangiomas due to the typical enhancement pattern identified, consistent with EFSUMB guidelines. Out of the 35 patients included in our study, 25 had no pre-existing liver damage, 8 had moderate diffuse steatosis and 2 had ethanolic liver cirrhosis. Within standard B-mode US of the 65 lesions, there were found 12 cases (18,5%) with a hypoechoic appearance, 52 cases (80%) with a hyperechoic appearance and 1 case (1,5%) with an isoechoic appearance. None of them showed intralesional vessels at color or power Doppler exam. Out of the 65 FLL, 47 cases (72,3%) were diagnosed as hepatic hemangiomas by CEUS, after presenting typical enhancing pattern: centripetal fill-in in the arterial phase (all 47 cases), partial (20 cases) or complete (27 cases) centripetal filling and sustained enhancement in portal and late phases; 1 case (1,6%) showed no enhancement in any on the vascular phases of CEUS, therefore it was also performed a contrast enhanced CT which confirmed the diagnosis of sclerosed hemangioma (atypical variant); 14 cases (21,5%) were investigated and diagnosed only by contrast-enhanced CT/MRI due to their associated pathology which required detailed investigations (without performing CEUS); 3 cases (4,6%) had typical aspect at standard B-mode US, being diagnosed without the necessity of any other investigations. Contrast enhanced imaging has an unmatched value for HH diagnosis due to their typical enhancement pattern of the contrast agent, therefore CEUS could be considered the first-line investigation in all the patients with suspected hemangioma after performing a standard B-mode US. [ABSTRACT FROM AUTHOR]

Clinical utility of ancillary features (AFs) in contrast-enhanced ultrasound (CEUS) Liver Imaging Reporting and Data System (LI-RADS®) is yet to be established. In this study, we assessed the diagnostic yield of CEUS LI-RADS and AFs in hepatocellular carcinoma (HCC). We retrospectively included patients with risk factors for HCC and newly diagnosed focal liver lesions (FLL). All lesions have been categorized according to the CEUS LI-RADS v2017 by an experienced sonographer blinded to clinical data and to the final diagnosis. From a total of 143 patients with 191 FLL, AFs favoring HCC were observed in 19.8% cases as hypoechoic rim and in 16.7% cases as nodule-in nodule architecture. From the total of 141 HCC cases, 83.6% were correctly classified: 57.4%- LR-5 and 26.2%- LR-4. In 9.21% cases, CEUS indicated LR-M; 2.12% cases- LR-3. The LR-5 category was 96.2% predictive (PPV) of HCC. LR-5 had 60.4% sensitivity and 93.6% specificity. PPV for primitive malignancy (LR-4 + LR-5) was 95.7%, with 88% sensitivity, 89.3% specificity and 88.4% accuracy for HCC. LR-4 category had 94.8% PPV and 26.2% sensitivity. CEUS LR4 + LR5 had 81,8% sensitivity for HCCs over 2 cm and 78.57% sensitivity for smaller HCCs. CEUS LR-5 remains an excellent diagnostic tool for HCC, despite the size of the lesion. The use of AFs might improve the overarching goal of LR-5 + LR-4 diagnosis of high specificity for HCC and exclusion of non-HCC malignancy. [ABSTRACT FROM AUTHOR]