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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]

CEUS has increased the capability of ultrasonography for the detection of focal liver lesions (FLL). The differential diagnosis between hepatocellular carcinoma (HCC) and other malignant tumors may be limited by similarities in the appearance of CEUS. The aim of this study was to evaluate the role of combination of LR-4 and LR-5 by adding ancillary features (AFs) in the CEUS LI-RADS v2017 algorithm for the diagnosis of definite HCC. This retrospective single- center study included 143 patients with 191 FLL detected by abdominal ultrasound from a total of 823 consecutive patients. The risk factors were liver cirrhosis of any etiology and non-cirrhotic HBV patients. Diagnosis was established either through histopathology or based on CT/MRI scan. CEUS recordings were assessed by an EFSUMB level 3 sonographer, with more than 10 years experience in CEUS and who was blinded to clinical data and to the final diagnosis. All lesions have been categorized according to the CEUS LI-RADS® described by The American College of Radiology scheme. The AFs were taken into account. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy were calculated. PPV for primitive malignancy (LR-4 + LR-5) was 95.7% (95CI%: 90.7–98%), with 88.07% sensitivity, 89.3% specificity and 88.4% accuracy for HCC (95CI%: 82.8–92.6%). LR4 + LR5 had 81.8% sensitivity for HCCs over 2 cm (n = 127), and 78.57% sensitivity for HCCs less than 2 cm (n = 14). Both sensitivity and accuracy of LR-4 + LR-5 for the diagnosis of definite HCC considerably raised to 88.07% and 88.4%, unlike the sensitivity and accuracy for LR-5 of only 60.45% and 69%, respectively. NPV also improved (73.4% vs. 46.6%), while similar high PPVs (95.7% vs. 96.2%) and quite similar specificity (89.3% vs. 93.6%) were maintained. Higher sensitivity than estimated for the diagnosis of HCCs smaller than 2 cm was achieved for CEUS LR-4 and LR-5. The use of AFs might improve the overarching goal of CEUS LR-5 + LR-4 diagnosis of high specificity for HCC and exclusion of non-HCC malignancy, despite the size of the lesion. [ABSTRACT FROM AUTHOR]