A 42-year-old woman undergoes ultrasound for right upper-quadrant discomfort. The scan reveals a 2.5 cm, round, uniformly hyperechoic, well-demarcated lesion in segment VII (marked **A** in the diagram) with mild posterior acoustic enhancement and no internal vascularity on colour Doppler. Liver function tests and AFP are normal. What is the most likely diagnosis and the most appropriate management?
A. Hepatocellular carcinoma; urgent CECT with arterial phase imaging and AFP monitoring
B. Hepatic adenoma; counsel on discontinuation of oral contraceptives and consider resection
C. Focal nodular hyperplasia; MRI with hepatobiliary contrast for confirmation
D. Hepatic cavernous hemangioma; no treatment required, reassurance and discharge
Explanation
Why "Hepatic cavernous hemangioma; no treatment required, reassurance and discharge" is right
The lesion marked A exhibits the classic ultrasound hallmark of a hepatic cavernous hemangioma: uniformly hyperechoic, well-demarcated, round morphology with posterior acoustic enhancement and absent internal vascularity on Doppler. According to AASLD Practice Guidelines and Sabiston Surgery, hepatic cavernous hemangioma is the commonest benign liver tumor (prevalence 0.5–7% in autopsy series), composed of blood-filled, endothelium-lined vascular spaces with slow flow. The normal AFP and liver function tests exclude HCC and other malignancies. Incidental asymptomatic hemangiomas require no treatment—only reassurance and discharge; surveillance is reserved for giant lesions (>5 cm).
Why each distractor is wrong
Focal nodular hyperplasia; MRI with hepatobiliary contrast for confirmation: FNH typically shows a central scar and homogeneous arterial enhancement on CECT, not uniform hyperechogenicity on ultrasound. While FNH is benign, the imaging appearance here is classic for hemangioma, not FNH.
Hepatic adenoma; counsel on discontinuation of oral contraceptives and consider resection: Hepatic adenoma is associated with oral contraceptive or anabolic steroid use and carries risk of rupture, bleeding, and malignant transformation. The ultrasound appearance and normal AFP do not support adenoma; adenomas are often heterogeneous and may show arterial enhancement without centripetal fill-in.
Hepatocellular carcinoma; urgent CECT with arterial phase imaging and AFP monitoring: HCC occurs in cirrhotic livers, presents with elevated AFP, and shows washout on delayed-phase imaging. This patient has normal AFP, no mention of cirrhosis, and a benign imaging pattern inconsistent with HCC.
High-YieldNEET PG
A uniformly hyperechoic, well-demarcated lesion <3 cm with posterior acoustic enhancement and no Doppler flow in a non-cirrhotic liver with normal AFP = hepatic hemangioma = reassure and discharge; no biopsy (bleeding risk).
AASLD Practice Guidelines; Sabiston Surgery
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