Hepatic Neoplasms:

Features on Grayscale and

Contrast
Enhanced Ultrasound
Tae Kyoung Kim, MD, HyunJung Jang, MD,
Stephanie R. Wilson, MD

- An overview
- Benign hepatic neoplasms
Cavernous hemangioma
Focal nodular hyperplasia
Hepatic adenoma
Fatty lesions of the liver
-Malignant hepatic neoplasms
Hepatocellular carcinoma
Hepatic epithelioid
hemangioendothelioma
Metastatic disease
- Summary
- References

Fig. 1. Small homogeneous echogenic nodules in the liver: two different

diagnoses. (A) Transverse ultrasound image in a 46-year-old woman
shows multiple well-defined homogeneous echogenic nodules in the liver.
These nodules were confirmed as hemangiomas. (B) Oblique ultrasound
image in a 58-year-old man who had chronic
hepatitis B shows a small homogeneous echogenic nodule in the liver.
This nodule turned out to be an HCC at biopsy. (From Withers CE, Wilson
SR. The liver. In: Rumack C, Wilson SR, Charboneau JW, et al, editors.
Benign hepatic neoplasm
Diagnostic Ultrasound. Philadelphia: Mosby; 2005. p. 77147; with

Fig. 2. Large atypical hemangioma in a 43-year-old man. (A) Oblique

ultrasound image shows a large heterogeneous hyperechoic mass
(arrows) in the right lobe of the liver. (B) CEUS image 22 seconds after
injection demonstrates multifocal areas of nodular enhancement in the
periphery of the mass. (C) At 39 seconds after injection, there is
centripetal progression of peripheral nodular enhancement of the mass.
(D) CEUS image at 133 seconds after injection shows further progression
of centripetal enhancement without evidence of washout.

Fig. 3. Hemangioma in a 57-year-old woman. (A) Transverse ultrasound

image shows a heterogeneous mass with central hypoechoic portion and
peripheral thick echogenic rind in the right lobe of the liver. (B) CEUS image
58 seconds after injection demonstrating peripheral nodular enhancement
of the mass. (C) At 115 seconds after injection there is central progression
of nodular enhancement, producing a bridging of these enhancing nodules

Fig. 4. Hypoechoic hemangioma with rapid enhancement in a 51-year-old

woman. (A) Transverse ultrasound image shows a homogeneous
hypoechoic mass in the right lobe of the liver. (B) CEUS image 9 seconds
after injection shows peripheral nodular enhancement of the mass. (C) At
11 seconds after injection the mass shows homogeneous enhancement. (D)
The mass shows persistent positive enhancement at 120 seconds after

Fig. 5. Focal nodular hyperplasia in a 33-year-old woman. (A) Transverse

ultrasound image shows a subtle isoechoic mass (arrows) in the right lobe
of the liver. CEUS image at (B) 9 seconds and (C) 10 seconds after
injection shows early filling of stellate arteries, followed by strong
homogeneous enhancement of the mass. The enhancement direction is
from the center to the periphery (centrifugal). (D) CEUS image at 253
seconds after injection shows persistent positive enhancement of the

Fig. 6. Hepatic adenoma in a 47-year-old woman who

had glycogen storage disease. Oblique ultrasound image shows a markedly
heterogeneous mass with multifocal bright echogenic areas representing
intratumoral fat.

Fig. 7. Hepatic adenoma in a 48-year-old woman. (A) Transverse ultrasound

image shows a heterogeneous hyperechoic mass (arrows) in the left lobe of
the liver. CEUS image at (B) 8 seconds and (C) 10 seconds after injection
shows diffuse hypervascularity of the mass (arrowheads) with small,
irregular, nonenhancing areas (arrows in C) representing necrosis or
hemorrhage. (D) CEUS image at 115 seconds after injection shows washout
of the mass (arrowheads).

Fig. 8. Angiomyolipoma in a 47-year-old woman. (A) A transverse ultrasound

image shows a bright echogenic mass in the right lobe of the liver. (B) On
unenhanced CT scan the mass demonstrates marked hypoattenuation similar
to subcutaneous fat. (From Withers CE, Wilson SR. The liver. In: Rumack C,
Wilson SR, Charboneau JW, et al, editors. Diagnostic Ultrasound. Philadelphia:
Mosby; 2005. p. 77147; with permission.)

Fig. 9. Focal fat deposition in a 24-year-old woman. Oblique ultrasound

images obtained with simultaneous dual-imaging display technique
demonstrate an irregular echogenic focal lesion in the right lobe of the liver
on grayscale image (right side), which demonstrates complete isovascularity
relative to normal liver on CEUS image (left side). The lesion demonstrated
isoechogenicity during all phases of contrast enhancement (not shown).

Fig. 10. Typical encapsulated HCC in a 53-year-old man. (A) Oblique

ultrasound image shows a heterogeneous mass with hypoechoic halo in the
right lobe of the liver. (B) CEUS image 11 seconds after injection
demonstrates heterogeneous hypervascularity of the mass. (C) At 18
seconds after injection the mass shows diffuse enhancement with
nonenhancing areas representing necrosis. (D) The mass shows washout
(negative enhancement) relative to normal liver 148 seconds after
injection.

Fig. 11. Infiltrative HCC in a 49-year-old man. (A) Transverse ultrasound

image of the right lobe and (B) sagittal ultrasound image of the left lobe
show multiple ill-defined hypoechoic lesions throughout the liver. (From
Withers CE, Wilson SR. The liver. In: Rumack C, Wilson SR, Charboneau JW,
et al, editors. Diagnostic Ultrasound. Philadelphia: Mosby; 2005. p. 77
147; with permission.)

Fig. 12. HCC with portal vein thrombosis.

(A)Transverse ultrasound image in a 44-year-old man shows a large
infiltrative mass with invasion into the right and main portal veins, forming
a tumor thrombi expanding the venous lumen (arrows).
(B)Oblique ultrasound image and
(C)color Doppler image of a 66-year-old man show hypoechoic thrombi in
the right portal vein (arrows) with internal vascularity characteristic of
tumor thrombosis.

Fig. 13. Small HCC with late washout in a 56-year-old man. (A) Oblique
ultrasound image shows a homogeneous hypoechoic mass in the right
lobe of the liver. (B) CEUS image 8 seconds after injection shows
homogeneous hypervascularity of the mass. (C) At 130 seconds after
injection the mass (arrows) is not clearly seen because of isovascularity
relative to adjacent liver. (D) The mass (arrows) shows slight washout at
221 seconds after injection.

Fig. 14. Dysplastic nodule in a 59-year-old man.

(A)Oblique ultrasound image shows a slightly hypoechoic nodule (arrows) in
the right lobe of the liver. The liver is cirrhotic and there is a small amount
of ascites.
(B)CEUS image at 12 seconds after injection shows slight hypovascularity of
the nodule (arrows) relative to adjacent liver.
(C) The nodule (arrows) is not clearly seen at 90 seconds after injection
because of isovascularity.

Fig. 15. Residual viable HCC after radiofrequency ablation in a 72-year-old

man. (A) Oblique ultrasound image shows an exophytic mass in the right lobe
of the liver representing an HCC treated with radiofrequency ablation.
(B) Arterial-phase CEUS image obtained at 22 seconds after injection shows
evidence of residual viable HCC that is seen as an eccentric area of
enhancement in the anterior aspect of the mass (arrows). The remaining area
of the mass is avascular because of necrosis. (C) At 55 seconds after injection
the area of arterial enhancement shows washout relative to normal liver

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Fig. 16. Hepatic metastases with target pattern in
17.
a 56-year-old woman. Transverse ultrasound image
shows numerous liver masses with alternating
hypoechoic
and hyperechoic rings around an internal hypoechoic
center, a target-like appearance.
Fig. 17. Calcified hepatic metastasis from colon cancer in a 62-year-old
man. Transverse ultrasound image shows a large echogenic mass
containing central areas with posterior shadowing representing
calcifications. There is a hypoechoic halo (arrows) surrounding the mass.