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Sparing of Fatty Infiltration Around Focal Hepatic Lesions in Patients with Hepatic Steatosis: Sonographic Appearance with CT and MRI Correlation

¹ Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 388-1, Pungnap 2-dong, Songpa-ku, Seoul 138-736, Korea.
² Department of Radiology, National Cancer Center, Gyeonggi-do, Korea.
³ Department of Diagnostic Radiology, Kyung Hee University Hospital, Seoul, South Korea.

Received July 12, 2007; accepted after revision October 10, 2007.

 
Address correspondence to K. W. Kim (kimkw{at}amc.seoul.kr).

Abstract

Top Abstract Introduction Hepatic Hemangioma Hepatocellular Carcinoma Cholangiocarcinoma Metastatic Lesions Nonneoplastic Lesions Conclusion References

 
OBJECTIVE. The purposes of this study were to illustrate the sonographic features of focal hepatic lesions with peritumoral sparing of fatty infiltration in patients with hepatic steatosis, to correlate the sonographic findings with CT and MRI findings, and to discuss the possible mechanisms.

CONCLUSION. Various focal hepatic lesions can accompany peritumoral sparing of fatty infiltration in patients with hepatic steatosis, and they can manifest with an atypical sonographic appearance.

Keywords: Doppler study • fatty liver • liver neoplasms • sonography

Introduction

Top Abstract Introduction Hepatic Hemangioma Hepatocellular Carcinoma Cholangiocarcinoma Metastatic Lesions Nonneoplastic Lesions Conclusion References

 
Focal sparing of fatty infiltration frequently occurs around various hepatic space-occupying lesions in patients with hepatic steatosis [1]. Opposed-phase gradient-echo MRI is the best method for depicting peritumoral sparing of fatty infiltration under these circumstances [2–5]. At sonography, the sparing of infiltration can obscure the presence of focal hepatic lesions or at least modify the sonographic appearance, leading to diagnostic confusion. Sonography is the first-line radiologic investigation for patients with suspected liver lesions. It therefore is important for radiologists both to recognize peritumoral sparing of fatty infiltration so that it can be identified as a sign of adjacent focal lesions and to be familiar with the sonographic appearance of various focal hepatic lesions with peritumoral sparing of fatty infiltration. The purposes of this article are to illustrate the sonographic features of various focal hepatic lesions with peritumoral sparing of fatty infiltration in patients with hepatic steatosis, to correlate the features with the CT and MRI findings, and to discuss the possible mechanisms of peritumoral sparing of fatty infiltration.

Hepatic Hemangioma

Top Abstract Introduction Hepatic Hemangioma Hepatocellular Carcinoma Cholangiocarcinoma Metastatic Lesions Nonneoplastic Lesions Conclusion References

 
Peritumoral sparing of fatty infiltration frequently occurs around hepatic hemangiomas, appearing as a hyperattenuating rim on unenhanced CT [6] and as a hyperintense peritumoral rim on chemical shift MRI [2, 3]. Chen et al. [2] found that areas of peritumoral sparing of fatty infiltration around hemangiomas on chemical shift MRI were well correlated with those of temporal peritumoral enhancement during the arterial phase of dynamic contrast-enhanced studies. Dilution of portal blood flow by non-lipid-rich arterial blood through the arterioportal shunt is considered the cause of peritumoral sparing of fatty infiltration around hemangiomas [2, 7].

In patients with hepatic steatosis, peritumoral sparing of fatty infiltration can modify the sonographic appearance of hemangiomas. Given that hepatic steatosis causes an echo-poor appearance of hemangiomas and that high-flow hemangiomas with arterioportal shunt are commonly seen as hypoechoic lesions, it is not surprising that hemangiomas with peritumoral sparing of fatty infiltration tend to have a hypoechoic appearance with or without a hyperechoic rim [8] (Figs. 1A, 1B, 1C, 1D, and 1E). In addition, these tumors are surrounded by geographic hypoechoic areas representing peritumoral sparing of fatty infiltration that are similar to the hyperattenuating areas on unenhanced CT and to the hyperintense areas on opposed-phase gradient-echo MR images. In a previous study [9], we compared sonography and chemical shift MRI of patients with hepatic hemangioma. We found that among 40 hemangiomas with a hyper intense peritumoral rim on opposed-phase gradient-echo MR that represented peritumoral sparing of fatty infiltration, a geographic peritumoral hypoechoic area was correspondingly seen in 27 (68%) of the tumors. Although the results may indicate that sonography is less sensitive than chemical shift MRI in depicting this finding, it seems that the value of sonography may have been underestimated because it is operator-dependent. In other words, the peritumoral hypoechoic area might have been neglected if sonographers were unaware of the importance of this finding. Color Doppler sonography can depict intratumoral blood flow, large feeding arteries, and sometimes reversed blood flow in the portal branch parallel to the feeding arteries [8, 10] (Figs. 2A, 2B, 2C, and 2D).

View larger version (83K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1A —50-year-old woman with hepatic steatosis and hemangioma. Peritumoral sparing of fatty infiltration is present around hemangioma. Transverse sonogram shows increased liver echogenicity suggestive of hepatic steatosis. Well-defined hypoechoic mass with thick hyperechoic rim is surrounded by geographic hypoechoic area (arrowheads).

View larger version (113K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1B —50-year-old woman with hepatic steatosis and hemangioma. Peritumoral sparing of fatty infiltration is present around hemangioma. Unenhanced CT scan shows low hepatic attenuation suggestive of hepatic steatosis and pericaval mass with profoundly low attenuation. Geographic hyperdense area (arrowheads) around tumor corresponds to peritumoral hypoechoic area in A, suggesting presence of peritumoral sparing of fatty infiltration.

View larger version (99K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1C —50-year-old woman with hepatic steatosis and hemangioma. Peritumoral sparing of fatty infiltration is present around hemangioma. Contrast-enhanced hepatic arterial phase CT scan shows temporal peritumoral enhancement (arrowheads) around hemangioma possibly caused by arterioportal shunt.

View larger version (103K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1D —50-year-old woman with hepatic steatosis and hemangioma. Peritumoral sparing of fatty infiltration is present around hemangioma. In-phase gradient-echo T1-weighted MR image shows hypointense pericaval mass.

View larger version (110K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1E —50-year-old woman with hepatic steatosis and hemangioma. Peritumoral sparing of fatty infiltration is present around hemangioma. Opposed-phase gradient-echo T1-weighted MR image shows low signal intensity of hepatic parenchyma, suggesting hepatic steatosis. Geographic peritumoral hyperintense area (arrowheads) corresponds to peritumoral hypoechoic area in A. Finding indicates presence of peritumoral sparing of fatty infiltration.

View larger version (123K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2A —70-year-old woman with hepatic steatosis and high-flow hemangioma with arterioportal shunt. Peritumoral sparing of fatty infiltration is present around hemangioma. Oblique sagittal sonogram shows increased liver echogenicity suggestive of hepatic steatosis. Small hypoechoic mass with thick hyperechoic rim (arrows) is surrounded by wedge-shaped hypoechoic area (arrowheads).

View larger version (83K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2B —70-year-old woman with hepatic steatosis and high-flow hemangioma with arterioportal shunt. Peritumoral sparing of fatty infiltration is present around hemangioma. Color Doppler sonogram shows vigorous intratumoral blood flow (long arrows). Reversed blood flow in portal branch (short arrows) parallel to feeding artery suggests presence of high-flow hemangioma with arterioportal shunt.

View larger version (115K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2C —70-year-old woman with hepatic steatosis and high-flow hemangioma with arterioportal shunt. Peritumoral sparing of fatty infiltration is present around hemangioma. Unenhanced CT scan shows inhomogeneously low hepatic attenuation suggestive of mild hepatic steatosis. Subtle hyperdense area (arrowheads) around tumor (arrow) suggests presence of peritumoral sparing of fatty infiltration.

View larger version (146K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2D —70-year-old woman with hepatic steatosis and high-flow hemangioma with arterioportal shunt. Peritumoral sparing of fatty infiltration is present around hemangioma. Contrast-enhanced hepatic arterial phase CT scan shows strong homogeneous enhancement of tumor (arrow) and peritumoral parenchymal enhancement (arrowheads) suggestive of high-flow hemangioma with arterioportal shunt.

Top Abstract Introduction Hepatic Hemangioma Hepatocellular Carcinoma Cholangiocarcinoma Metastatic Lesions Nonneoplastic Lesions Conclusion References

On sonography, a hypoechoic halo, a possible indicator of hepatic malignancy, may not be discernible around HCCs with peritumoral sparing of fatty infiltration (Figs. 3A, 3B, and 3C). Because the tumor may be believed to be larger than it actually is, targeting the periphery of the lesion during sonographically guided percutaneous biopsy may result in erroneous tissue sampling. In contrast to the descriptions of hemangioma, the sonographic literature in English has little information about the prevalence of peritumoral sparing of fatty infiltration around HCC. A well-designed prospective study is warranted to determine the frequency of peritumoral sparing of fatty infiltration around HCCs on sonography and to better describe the sonographic appearance of HCCs with peritumoral sparing of fatty infiltration. Color Doppler sonography may show large feeding arteries and intratumoral flow, but corona-like enhancement and hemodynamic alteration around HCC are usually below the sensitivity limits of the examination.

View larger version (75K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3A —79-year-old man with hepatic steatosis and hepatocellular carcinoma. Peritumoral sparing of fatty infiltration is present around hepatocellular carcinoma. Transverse sonogram shows increased liver echogenicity suggestive of hepatic steatosis. Hypoechoic mass (arrow) and wedge-shaped hypoechoic area (arrowheads) are present in right hepatic lobe.

View larger version (99K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3B —79-year-old man with hepatic steatosis and hepatocellular carcinoma. Peritumoral sparing of fatty infiltration is present around hepatocellular carcinoma. Unenhanced CT scan shows low hepatic attenuation suggestive of hepatic steatosis and well-defined hypoattenuating mass. Ill-defined hyperdense rim (arrowheads) surrounds tumor, which corresponds to peritumoral hypoechoic area in A. Finding represents peritumoral sparing of fatty infiltration.

View larger version (115K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3C —79-year-old man with hepatic steatosis and hepatocellular carcinoma. Peritumoral sparing of fatty infiltration is present around hepatocellular carcinoma. Contrast-enhanced hepatic arterial phase CT scan shows enhancing tumor surrounded by wedge-shaped parenchymal enhancement (arrowheads) in right hepatic lobe. It is not definite whether this type of temporal enhancement indicates arterioportal shunt or corona-like enhancement. Diagnosis of hepatocellular carcinoma was made after percutaneous biopsy of tumor.

Top Abstract Introduction Hepatic Hemangioma Hepatocellular Carcinoma Cholangiocarcinoma Metastatic Lesions Nonneoplastic Lesions Conclusion References

View larger version (83K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4A —65-year-old woman with hepatic steatosis and cholangiocarcinoma. Peritumoral sparing of fatty infiltration surrounds cholangiocarcinoma. Transverse sonogram shows increased liver echogenicity suggestive of hepatic steatosis and slightly hypoechoic mass in right hepatic lobe. Mass is surrounded by wedge-shaped hypoechoic areas (arrowheads). Capsular retraction adjacent to mass (arrows) is evident.

View larger version (116K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4B —65-year-old woman with hepatic steatosis and cholangiocarcinoma. Peritumoral sparing of fatty infiltration surrounds cholangiocarcinoma. Unenhanced CT scan shows low hepatic attenuation suggestive of hepatic steatosis and low-attenuation mass in right hepatic lobe. Wedge-shaped peritumoral hyperdense area (arrowheads) corresponds to peritumoral hypoechoic area in A. Finding represents peritumoral sparing of fatty infiltration.

View larger version (125K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4C —65-year-old woman with hepatic steatosis and cholangiocarcinoma. Peritumoral sparing of fatty infiltration surrounds cholangiocarcinoma. Contrast-enhanced hepatic arterial phase CT scan shows tumor encasing right anterior segmental portal vein (arrow). Rimlike and wedge-shaped parenchymal enhancement (arrowheads) surrounds tumor. Right hepatectomy was performed; pathologic diagnosis of mass was cholangiocarcinoma.

Top Abstract Introduction Hepatic Hemangioma Hepatocellular Carcinoma Cholangiocarcinoma Metastatic Lesions Nonneoplastic Lesions Conclusion References

View larger version (172K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5A —57-year-old man with hepatic steatosis and metastasis from gallbladder carcinoma. Peritumoral sparing of fatty infiltration surrounds metastatic lesion. Oblique sagittal sonogram shows increased liver echogenicity suggestive of hepatic steatosis and slightly hypoechoic mass with subtle hyperechoic rim (long arrow) in right hepatic lobe. Mass is surrounded by large hypoechoic areas (arrowheads). Tram track–like hypoechoic lesion (short arrows) surrounding small tubular structure, presumed to be thrombosed portal branch, is adjacent to mass.

View larger version (112K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5B —57-year-old man with hepatic steatosis and metastasis from gallbladder carcinoma. Peritumoral sparing of fatty infiltration surrounds metastatic lesion. Unenhanced CT scan shows low hepatic attenuation suggestive of hepatic steatosis and low-attenuation mass (long arrow) with ill-defined geographic peritumoral hyperdense area (arrowheads) corresponding to peritumoral hypoechoic area in A. Finding represents peritumoral sparing of fatty infiltration. Small dotlike low-attenuation lesion (short arrow) is adjacent to mass.

View larger version (118K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5C —57-year-old man with hepatic steatosis and metastasis from gallbladder carcinoma. Peritumoral sparing of fatty infiltration surrounds metastatic lesion. Contrast-enhanced hepatic arterial phase CT scan shows ill-defined tumor with poor contrast enhancement (long arrow), geographic peritumoral parenchymal enhancement (arrowheads), and lack of opacification of portal branch (short arrow). Diagnosis of metastasis from gallbladder carcinoma was made after percutaneous biopsy of tumor.

View larger version (138K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6A —55-year-old man with hepatic steatosis and metastasis from renal cell carcinoma. Peritumoral sparing of fatty infiltration is present around metastatic lesions. Oblique sagittal sonogram shows increased liver echogenicity suggestive of hepatic steatosis and hypoechoic mass (asterisk) surrounded by slightly hypoechoic area (arrowheads) in right hepatic lobe.

View larger version (125K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6B —55-year-old man with hepatic steatosis and metastasis from renal cell carcinoma. Peritumoral sparing of fatty infiltration is present around metastatic lesions. In-phase gradient-echo T1-weighted MR image shows multiple hypointense metastatic masses.

View larger version (146K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6C —55-year-old man with hepatic steatosis and metastasis from renal cell carcinoma. Peritumoral sparing of fatty infiltration is present around metastatic lesions. Opposed-phase gradient-echo T1-weighted MR image shows low parenchymal signal intensity in right hepatic lobe, suggesting hepatic steatosis. Subsegmental hyperintense area (arrowheads) surrounds metastatic lesions (arrows) corresponding to peritumoral hypoechoic area in A. Finding represents peritumoral sparing of fatty infiltration.

View larger version (106K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6D —55-year-old man with hepatic steatosis and metastasis from renal cell carcinoma. Peritumoral sparing of fatty infiltration is present around metastatic lesions. Contrast-enhanced CT scan shows diffuse tumoral enhancement (arrows) and arterial hyperperfusion around tumors (arrowheads) probably caused by siphoning effect of hypervascular metastatic lesions. Right hepatectomy was performed; pathologic diagnosis was metastasis from renal cell carcinoma.

Nonneoplastic Lesions

Top Abstract Introduction Hepatic Hemangioma Hepatocellular Carcinoma Cholangiocarcinoma Metastatic Lesions Nonneoplastic Lesions Conclusion References

 
It seems obvious that peritumoral sparing of fatty infiltration can occur around hepatic abscesses in patients with hepatic steatosis, considering that abscesses commonly accompany transient hepatic attenuation differences on CT owing to a decrease in portal flow with pylephlebitis and reciprocal arterial hyperperfusion [15]. On sonography, however, although the straight border between the parenchyma and the lesion may suggest the presence of associated peritumoral sparing of fatty infiltration, it is difficult to discriminate the peritumoral sparing of fatty infiltration and the peripheral part of the abscess composed of inflammatory and edematous parenchyma (Figs. 7A, 7B, 7C, 8A, 8B, and 8C).

View larger version (106K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7A —56-year-old man with hepatic steatosis and pyogenic abscess. Peritumoral sparing of fatty infiltration is present around abscess. Oblique sagittal sonogram shows increased liver echogenicity suggestive of hepatic steatosis and hypoechoic lesion (asterisk) surrounded by slightly hypoechoic area (arrowheads) in right hepatic lobe.

View larger version (146K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7B —56-year-old man with hepatic steatosis and pyogenic abscess. Peritumoral sparing of fatty infiltration is present around abscess. Unenhanced CT scan shows low hepatic attenuation suggestive of hepatic steatosis and low-attenuation mass (asterisk) in right hepatic lobe. Ill-defined peritumoral hyperdense area (arrowheads) corresponds to peritumoral hypoechoic area in A. Finding represents peritumoral sparing of fatty infiltration.

View larger version (162K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7C —56-year-old man with hepatic steatosis and pyogenic abscess. Peritumoral sparing of fatty infiltration is present around abscess. Contrast-enhanced hepatic arterial phase CT scan shows segmental hepatic arterial hyperperfusion (arrowheads) around large abscess (asterisk) in right hepatic lobe. Diagnosis of pyogenic abscess was made with percutaneous fine-needle aspiration of lesion.

View larger version (122K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 8A —63-year-old man with hepatic steatosis and parasitic abscess. Peritumoral sparing of fatty infiltration is present around abscess. Oblique coronal sonogram shows increased liver echogenicity suggestive of hepatic steatosis and slightly hypoechoic lesion with hyperechoic rim (arrows) surrounded by ill-defined hypoechoic area (arrowheads) in right hepatic lobe.

View larger version (121K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 8B —63-year-old man with hepatic steatosis and parasitic abscess. Peritumoral sparing of fatty infiltration is present around abscess. Unenhanced CT scan shows low hepatic attenuation suggestive of hepatic steatosis and small low-attenuation lesion (arrow) with peritumoral hyperdense area (arrowheads) corresponding to peritumoral hypoechoic area in A. Finding represents peritumoral sparing of fatty infiltration.

View larger version (122K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 8C —63-year-old man with hepatic steatosis and parasitic abscess. Peritumoral sparing of fatty infiltration is present around abscess. Contrast-enhanced CT scan shows ill-defined parenchymal enhancement (arrowheads) surrounding small necrotic lesion (arrow) in right hepatic lobe. Diagnosis of parasitic abscess was made after percutaneous needle biopsy of lesion. Enzyme-linked immunosorbent assay result was positive for Fasciola hepatica.

View larger version (107K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 9A —65-year-old woman with hepatic steatosis and simple cyst. Peritumoral sparing of fatty infiltration is present around cyst. Transverse sonogram shows increased liver echogenicity suggestive of hepatic steatosis and anechoic cystic lesion in left hepatic lobe. Ill-defined boundary (arrowheads) between hepatic parenchyma and lesion and focal dilatation of segmental intrahepatic duct (arrows) suggest complicated cyst or cystic tumor.

View larger version (141K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 9B —65-year-old woman with hepatic steatosis and simple cyst. Peritumoral sparing of fatty infiltration is present around cyst. Unenhanced CT scan shows low hepatic attenuation suggestive of hepatic steatosis and well-defined cystic lesion in left hepatic lobe surrounded by thin hyperdense rim (arrowheads). Focal dilatation of segmental intrahepatic duct (arrows) also is present.

View larger version (122K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 9C —65-year-old woman with hepatic steatosis and simple cyst. Peritumoral sparing of fatty infiltration is present around cyst. In-phase gradient-echo T1-weighted MR image shows cystic lesion with low signal intensity.

View larger version (122K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 9D —65-year-old woman with hepatic steatosis and simple cyst. Peritumoral sparing of fatty infiltration is present around cyst. Opposed-phase gradient-echo T1-weighted MR image shows low signal intensity of hepatic parenchyma suggestive of hepatic steatosis. Thin rim (arrowheads) of high signal intensity around cyst suggests peritumoral sparing of fatty infiltration. Because of mass effect of lesion, left hepatic lobectomy was performed for diagnosis of cystic tumor. Diagnosis of simple biliary cyst was made at pathologic examination. (H and E)

View larger version (153K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 9E —65-year-old woman with hepatic steatosis and simple cyst. Peritumoral sparing of fatty infiltration is present around cyst. Low-power photomicrograph shows mild fatty infiltration in hepatic parenchyma.

View larger version (153K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 9F —65-year-old woman with hepatic steatosis and simple cyst. Peritumoral sparing of fatty infiltration is present around cyst. Low-power photomicrograph shows peritumoral sparing of fatty infiltration in hepatic parenchyma surrounding cyst. (H and E)

Top Abstract Introduction Hepatic Hemangioma Hepatocellular Carcinoma Cholangiocarcinoma Metastatic Lesions Nonneoplastic Lesions Conclusion References

References

Top Abstract Introduction Hepatic Hemangioma Hepatocellular Carcinoma Cholangiocarcinoma Metastatic Lesions Nonneoplastic Lesions Conclusion References

 

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This Article Abstract Figures Only Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Kim, K. W. Articles by Lee, M.-G. Search for Related Content PubMed PubMed Citation Articles by Kim, K. W. Articles by Lee, M.-G. Social Bookmarking                      What's this? Hotlight (NEW!) What's Hotlight?