pediatic liver benign leisions radiology

1. Pediatric Liver Masses:
Part 1. Benign Tumors
DR SIDRA AFZAL
PGR
NEW RADIOLOGY DEPT
SERVICES HOSPITAL LAHORE

2. • Benign hepatic tumors in children include
leisions that are unique to the pediatric age
group.
• About one third of the primary liver tumors in
children are benign.

3. Infantile Hemangioendothelioma
• Or infantile hepatic hemangioma is a vascular
neoplasm and the most common benign
hepatic tumor of infancy
• About half of them are solitary and half are
multifocal
• Nearly 90 percent of them are diagnosed in
the first 6 months of life and one third in the
first month.
• There is slight female predominance.

4. Clinical features
• Asymptomatic abdominal mass
• Serious complications may occur which
include,
1. High output CHF due to associated large AV
shunts
2. ‘Kassabach Merritt syndrome’ of
coagulopathy due to intratumoral platelet
sequestration.

5. Imaging features
• Depend upon whether leisions are focal,
multifocal or diffuse.
• Typically evidence of high flow is apparent as
manifest by enlargement of hepatic arteries
and veins.
• Owing to the risk of bleeding, biopsy of these
masses is avoided and diognosis is made on
the basis of typical imaging findings.

6. Multifocal infantile hemangioendothelioma in a 6-month-old girl
Transverse US image shows several small, well-demarcated,
homogeneous hypoechoic lesions (arrowheads) in the liver.

7. Color Doppler image shows peripheral flow around some of the
lesions.

8. Computed tomographic (CT) image obtained without
intravenous contrast material shows that the lesions
(arrowheads) are hypoattenuating relative to the liver

9. Contrast material–enhanced CT image shows that the nodules enhance
intensely and uniformly (arrowheads).

10. Coronal fat-saturated T2-weighted magnetic resonance (MR) image shows
numerous well-defined hyperintense nodules in the liver. Arrow =
gallbladder.

11. Coronal T1-weighted MR image shows that the nodules
(arrowheads) are hypointense relative to the liver.

12. Coronal gadolinium-enhanced fat-saturated T1-weighted MR image
shows uniform enhancement of the nodules (arrowheads).

13. This is Plain radio-graph of the chest and abdomen of a 12 day old girl born
prematurely at 31 weeks, shows an enlarged cardiac silhouette, paucity of bowel gas
with lateral deviation of the stomach, and body wall edema.

14. Axial T2-weighted MR image shows a predominantly hyperintense
mass (arrow) with a central hypointense area and adjacent flow voids
(arrowhead), which represent enlarged hepatic veins.

15. Axial nonenhanced T1-weighted spoiled gradient-echo MR image
shows that the mass (T) is hypointense relative to the liver.

16. Arterial phase gadolinium-enhanced T1-weighted MR image
shows intense, peripheral, papillary enhancement (arrowheads)
of the mass

17. Delayed phase gadolinium-enhanced T1- weighted MR image shows
centripetal enhancement of the mass with a persistent hypointense area
(arrowhead

18. Diffuse form of hemangioendothelioma in a 10-week-old girl with
severe hypo-thyroidism.
Transverse US images show numerous large masses (* )
replacing the liver and compressing the inferior vena cava
(arrow ). AO ,aorta.

19. Longitudinal color Doppler image shows a
direct portal vein–to–hepatic vein shunt.

20. Contrast-enhanced CT image, obtained in the early portal venous
phase, shows peripheral corrugated enhancement of the masses
(arrowheads) and compression of the inferior vena cava (arrow).

21. Delayed phase CT image shows centripetal
enhancement of the masses

22. Mesenchymal Hemartoma
• Is the second most common benign liver mass
in children
• It is most commonly discovered in children
younger than 2 yrs of age with nearly all
lesions discovered by age 5.
• There is slight male predominance.

23. Clinical features
• The most common presentation, is painless
abdominal distention. The abdominal
enlargement is usually gradual, although
distention can develop fairly rapidly .

24. Imaging features
• The gross appearance, which ranges from
predominantly cystic to predominantly solid,
determines the imaging features. The vast
majority of mesenchymal hamartomas contain
cysts.
• Cystic portions are avascular and stromal
portions are relatively hypovascular.

25. Mesenchymal hamartoma in a 16-month-old girl.
Transverse US image shows cystic (arrowheads) and solid (T)
portions of the tumor and adjacent normal liver (*).

26. Longitudinal color Doppler image shows no flow to the cystic
component, which contains low-level echoes (arrowhead).
Minimal flow is seen in the solid component (arrows).

27. Coronal CT image obtained with intravenous and oral
contrast material shows the mixed cystic (arrowheads)
and solid (T) tumor replacing the left hepatic lobe. * =
normal liver.

28. Mesenchymal hamartoma of the liver in a 2-year-old boy.
* normal liver,
Trans-verse US image shows a well-defined cystic mass with multiple
septa in the liver.

29. Axial T2-weighted MR image shows the markedly hyperintense mass
containing thin septa (arrows)

30. Coronal nonenhanced T1-weighted MR image shows
that the mass (arrows) is homogeneously hypointense
relative to the liver.

31. Coronal contrast-enhanced T1-weighted MR image obtained at
the same level shows that enhancement is limited to the septa
(arrows).

32. Focal Nodular Hyperplasia
• FNH is most often seen in adult women but
uncommonly occurs in young children and
adolescents.
• it represents 2% of all primary hepatic tumors
in children from birth to age 20 years . In the
pediatric population, the lesion is typically
diagnosed between the ages of 2 and 5 years
• A marked female predominance of the lesion
is reported

33. Clinical features
• FNH is most commonly an incidental finding at
imaging
• Symptoms of a mass lesion are described in
20% of cases .
• Abdominal pain is another common symptom
• Tumor rupture and hemorrhage are rare

34. Imaging features
• Because the mass is composed predominantly
of hepatocytes, it appears similar to normal
liver, and the lesion may be inapparent except
for mass effect on adjacent structures.
• The presence of the central scar may aid
identification of the mass on nonenhanced
scans

35. FNH in a 6-year-old girl.
Transverse US image shows the well-circumscribed, homogeneous, slightly
hypoechoic mass (arrows) in the liver.

36. Color Doppler image shows flow in vessels radiating outward from
the central scar.

37. On a duplex US image, the Doppler spectrum of the intratumoral
vessels shows an arterial waveform.

38. Arterial phase coronal CT image shows the tumor (arrow)
enhancing more than the adjacent liver and lack of
enhancement of the central scar (arrowhead).

39. Coronal CT delayed image, shows intensely enhancing vessels
(arrow) adjacent to the tumor.

40. Hepatocellular Adenoma
• Hepatocellular adenoma, or hepatic adenoma, is
a rare benign hepatic neoplasm that is
etiologically associated with the use of steroids,
especially oral contraceptives.
• Pediatric patients mainly consist of girls over 10
years old, most of whom have a history of oral
contraceptive use
• It is also associated with androgen steroid
therapy in fanconi anemia, glycogen storage
disease types I and III, and also galactosemia and
familial diabetes mellitus in pediatric patients.

41. Clinical features
• More commonly, patients are asymptomatic
or present with an abdominal mass.
• Chronic and acute abdominal pain are other
reported symptoms.
• The main clinical concern is intratumoral
hemorrhage, which occurs in approximately
10% of patients.

42. Imaging features
• The appearance of hepatocellular adenoma
varies depending on its pathologic
composition.
• Those without hemorrhage are homogeneous
and similar in appearance to adjacent normal
liver.
• The presence of intratumoral hemorrhage or
intracellular fat produces distinguishing
imaging features.

43. Multiple hepatocellular adenomas in a 16-year-old girl
In-phase axial T1-weighted gradient-echo MR image shows a
heterogeneous, predominantly hypointense mass (arrowheads) with a
small hyperintense focus consistent with hemorrhage. In addition,
there is also an isointense mass (arrow).

44. Out-of-phase axial MR image shows a decrease in the signal intensity of
both masses (arrowheads, arrow), a finding indicative of intralesional fat.

45. Nonenhanced axial T1-weighted spoiled gradient-echo MR image
shows the well-defined masses (T). One is slightly hypointense
relative to the liver; the other is isointense.

46. Arterial phase axial T1-weighted MR image shows that both masses (T)
enhance slightly more than the liver. An additional smaller lesion is
visible (arrow

47. Portal venous phase MR image shows that the masses (T) are
isointense to slightly hypointense relative to the liver. Straight arrow
= additional smaller lesion, curved arrow = adjacent enlarged vein.

48. Nodular Regenerative Hyperplasia
• NRH may occur in patients of any age and has
infrequently been reported in children
• NRH is characterized by regenerative nodules
surrounded by atrophic liver in the absence of
fibrosis. The nodules vary in size from a few
millimeters to several centimeters.

49. Clinical features
• One-half of cases are found incidentally during
studies performed for other indications, but
one-half have signs and symptoms of portal
hypertension
• NRH should be considered in young patients
with portal hypertension and no evidence of
portal vein thrombosis.

50. Imaging features
• The appearance of NRH at imaging is variable
and depends in part on the size of the
nodules.
• Diffuse tiny nodules are not detected, and the
imaging appearance of the liver is normal.
• Nodules have a propensity to coalesce and
may then become evident at imaging.

51. NRH, US image shows a well-circumscribed,
homogeneous, hypoechoic hepatic mass
(arrow).

52. On a contrast-enhanced CT image, the mass (arrow) diffusely
enhances more than adjacent liver.

53. Axial T1-weighted MR image shows that the mass (arrow) is ill
defined and slightly hypointense relative to the liver with a slightly
hyperintense partial rim

54. Axial T2-weighted MR image shows the ill-defined
hyperintense mass (arrow).

55. Thankyou