Download PDF
Ultraschall Med 2023; 44(01): 81-88
DOI: 10.1055/a-1579-9457
Original Article

Contrast-Enhanced Ultrasound Findings in Patients with Rare Solitary Necrotic Nodule of the Liver – a Multicenter Report

Befunde im kontrastverstärkten Ultraschall bei Patienten mit seltenen solitären nekrotischen Knoten der Leber – ein Multicenterbericht
Giampiero Francica 
1   Interventional Ultrasound Unit, Pineta Grande Srl, Castel Volturno, Italy
,
Maria Franca Meloni
2   Radiology, Casa di Cura Igea, Milano, Italy
3   Radiology, University of Wisconsin-Madison, United States
,
Laura Riccardi
4   Internal Medicine and Gastroenterology, Catholic University of the Sacred Heart Faculty of Medicine and Surgery, Roma, Italy
,
Ilario de Sio
5   Hepatogastroenterology, University of Campania Luigi Vanvitelli School of Medicine and Surgery, Napoli, Italy
,
Eugenio Caturelli
6   Gastroenterology, Belcolle Hospital, Viterbo, Italy
,
Fulvia Terracciano
7   Gastroenterology, IRCCS Ospedale Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
,
Francesco Giangregorio
8   Hepatogastroenterology, Guglielmo da Saliceto Hospital, Piacenza, Italy
,
Jason Chiang
9   Radiology, Ronald Reagan UCLA Medical Center, Los Angeles, United States
,
Roberta Danzi
10   Radiology, Pineta Grande Srl, Castel Volturno, Italy
,
Antonella Marra
7   Gastroenterology, IRCCS Ospedale Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
,
Marco Niosi
5   Hepatogastroenterology, University of Campania Luigi Vanvitelli School of Medicine and Surgery, Napoli, Italy
,
Teresa Valentina Ranalli
11   Pathology, Belcolle Hospital, Viterbo, Italy
,
Maurizio Pompili
4   Internal Medicine and Gastroenterology, Catholic University of the Sacred Heart Faculty of Medicine and Surgery, Roma, Italy
› Author Affiliations
› Further Information
Also available at
    Permissions and Reprints

Abstract

Purpose This multicenter retrospective study highlights the contrast-enhanced ultrasound (CEUS) findings in a series of histologically proven solitary necrotic nodules (SNN) of the liver, a poorly understood pathologic entity of uncertain origin that mimics malignancy.

Materials and Methods 22 patients (M/F 13/9; mean age 59.4 years, SD ± 10.7, range 35–81) with histological diagnosis of SNN and CEUS were selected from clinical, imaging, and pathological archives of 7 US interventional centers, each of which provided 1 to 6 cases (mean 2.8). Pathological diagnosis was made on 20 US-guided biopsies and 2 surgical specimens. 2 patients had 2 SNNs with identical CEUS findings so that imaging analysis was carried out on 24 nodules.

Results SNN was an incidental finding in healthy people in 10 cases (45.5 %), and it was discovered during follow-up for either known extrahepatic malignancies (9 cases = 41 %) or chronic liver disease (3 cases = 13.5 %). SNNs had a mean size of 19.3 mm (SD ± 6.5, range 9–40). On B-mode US, SNNs appeared hypoechoic in 14 cases (66.7 %), “target-like” in 7 cases (29.2 %), and homogeneously hyperechoic in 1 case (4.1 %). On CEUS, all lesions appeared devoid of contrast enhancement (“punched out” aspect) in the arterial, portal venous, and late phases after US contrast agent injection. A uniformly thin, hyperenhancing ring in the early arterial phase and isoenhanced with the surrounding parenchyma in the portal venous and late phases was found in 10 nodules (41.6 %). Clinical and imaging follow-up (mean duration 42.2 months, SD ± 34.9, range 2–108) was available in 15 patients with 16 SNNs: no changes in size and echostructure were seen.

Conclusion CEUS can contribute to the diagnosis of SNN when a “punched out” appearance in all vascular phases with or without thin rim enhancement in the very early arterial phase is present in healthy subjects in whom a focal liver lesion is incidentally found. In patients with a history of chronic liver disease or malignancy, US-guided biopsy represents the unavoidable first-line diagnostic modality.

Zusammenfassung

Ziel Diese multizentrische retrospektive Studie beleuchtet die Befunde des kontrastverstärkten Ultraschalls (CEUS) bei histologisch nachgewiesenen solitären nekrotischen Knoten (SNN) der Leber, einer schlecht verstandenen pathologischen Entität ungewisser Entstehung, die eine bösartige Erkrankung vortäuscht.

Material und Methoden 22 Patienten (M/F 13/9; mittleres Alter 59,4 Jahre, SD ± 10,7, Bereich 35–81) mit histologischer SNN-Diagnose und CEUS wurden aus den klinischen, bildgebenden und pathologischen Archiven von 7 US-amerikanischen Interventionszentren ausgewählt, von denen jedes Zentrum 1–6 Fälle (Mittelwert 2,8) zur Verfügung stellte. Die pathologische Diagnosestellung erfolgte mittels 20 US-gestützten Biopsien und 2 chirurgischen Proben. Zwei Patienten hatten 2 SNNs mit identischen CEUS-Befunden, sodass die bildgebende Analyse an 24 Knoten durchgeführt wurde.

Ergebnisse SNN waren ein Zufallsbefund bei Gesunden in 10 Fällen (45,5 %), während sie bei der Nachsorge von bekannten extrahepatischen Malignomen in 9 Fällen (41 %) oder von chronischen Lebererkrankungen in 3 Fällen (13,5 %) entdeckt wurden. Die SNNs hatten eine mittlere Größe von 19,3 mm (SD ± 6,5, Bereich 9–40). Im Graustufen-Ultraschall zeigten sich die SNN in 14 Fällen (66,7 %) hypoechogen, in 7 Fällen (29,2 %) „zielähnlich“ und in einem Fall (4,1 %) homogen hyperechogen. Bei der CEUS-Untersuchung erschienen alle Läsionen ohne Kontrastanreicherung („ausgestanztes“ Aussehen) in der arteriellen, portalvenösen und späten Phase nach US-Kontrastmittelinjektion. Ein gleichmäßig dünner Ring mit Hyperenhancement in der frühen arteriellen Phase und Isoenhancement zum umgebenden Parenchym in der portalvenösen und späten Phase wurde bei 10 Knoten (41,6 %) gefunden.

Eine klinische und bildgebende Nachbeobachtung (mittlere Dauer 42,2 Monate, SD ± 34,9, Bereich 2–108) stand bei 15 Patienten mit 16 SNNs zur Verfügung. Es wurden keine Veränderungen in Größe und Echostruktur festgestellt.

Schlussfolgerung CEUS kann zur Diagnose von SNN beitragen, wenn bei gesunden Probanden, bei denen zufällig eine fokale Leberläsion gefunden wird, ein „ausgestanztes“ Erscheinungsbild in allen vaskulären Phasen mit oder ohne dünnem Randsaum in der sehr frühen arteriellen Phase vorhanden ist. Bei Patienten mit chronischer Lebererkrankung oder einer Tumorerkrankung in der Anamnese ist die US-gestützte Biopsie unweigerlich die First-Line-Diagnostik.

Key words

CEUS - liver - solitary necrotic nodule - ultrasound - biopsy


Publication History

Received: 09 January 2021

Accepted: 17 July 2021

Article published online:
25 August 2021

© 2021. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 

  • References

  • 1 Strobel D, Seitz K, Blank W. et al. Contrast-enhanced ultrasound for the characterization of focal liver lesions--diagnostic accuracy in clinical practice [DEGUM multicenter trial]. Ultraschall in Med 2008; 29: 499-505
    Article in Thieme ConnectPubMedGoogle Scholar
  • 2 Seitz K, Bernatik T, Strobel D. et al. Contrast-enhanced ultrasound [CEUS] for the characterization of focal liver lesions in clinical practice [DEGUM Multicenter Trial]: CEUS vs. MRI – a prospective comparison in 269 patients. Ultraschall in Med 2010; 31: 492-499
    Article in Thieme ConnectPubMedGoogle Scholar
  • 3 Dietrich CF, Nolsøe CP, Barr RG. et al. Guidelines and Good Clinical Practice Recommendations for Contrast Enhanced Ultrasound [CEUS] in the Liver – Update 2020 – WFUMB in Cooperation with EFSUMB, AFSUMB, AIUM, and FLAUS. Ultraschall in Med 2020; 41: 562-585
    Article in Thieme ConnectPubMedGoogle Scholar
  • 4 Yang HK, Burns PN, Jang HJ. et al. Contrast-enhanced ultrasound approach to the diagnosis of focal liver lesions: the importance of washout. Ultrasonography 2019; 38: 289-301
    CrossrefPubMedGoogle Scholar
  • 5 Burrowes DP, Kono Y, Medellin A. et al. Contrast-enhanced US Approach to the Diagnosis of Focal Liver Masses. Radiographics 2020; 40: E16-E20
    CrossrefPubMedGoogle Scholar
  • 6 Wildner D, Bernatik T, Greis C. et al. CEUS in hepatocellular carcinoma and intrahepatic cholangiocellular carcinoma in 320 patients – early or late washout matters: a subanalysis of the DEGUM multicenter trial. Ultraschall in Med 2015; 36: 132-139
    Article in Thieme ConnectPubMedGoogle Scholar
  • 7 Jang HJ, Kim TK, Burns PN. et al. Enhancement patterns of hepatocellular carcinoma at contrast-enhanced US: comparison with histologic differentiation. Radiology 2007; 244: 898-906
    CrossrefPubMedGoogle Scholar
  • 8 Shepherd NA, Lee G. Solitary necrotic nodules of the liver simulating hepatic metastases. J Clin Pathol 1983; 36: 1181-1183
    CrossrefPubMedGoogle Scholar
  • 9 Berry CL. Solitary necrotic nodule of the liver: a probable pathogenesis. J Clin Pathol 1985; 38: 1278-1280
    CrossrefPubMedGoogle Scholar
  • 10 Tsui WM, Yuen RW, Chow LT. et al. Solitary necrotic nodule of the liver: parasitic origin?. J Clin Pathol 1992; 45: 975-978
    CrossrefPubMedGoogle Scholar
  • 11 Zhou Y, Li B, Xu F. et al. Clinical features of solitary necrotic nodule of the liver. Hepatobiliary Pancreat Dis Int 2008; 7: 485-489
    PubMedGoogle Scholar
  • 12 Alfieri S, Carriero C, Doglietto GB. et al. Solitary necrotic nodule of the liver: diagnosis and treatment. Hepato-Gastroenterol 1997; 44: 1210-1211
    PubMedGoogle Scholar
  • 13 De Luca M, Luigi B, Formisano C. et al. Solitary necrotic nodule of the liver misinterpreted as malignant lesion: considerations on two cases. J Surg Oncol 2000; 74: 219-222
    CrossrefPubMedGoogle Scholar
  • 14 Kondi-Pafiti AI, Grapsa DS, Kairi-Vasilatou ED. et al. “Solitary” necrotic nodule of the liver: an enigmatic entity mimicking malignancy. Int J Gastrointest Cancer 2006; 37: 74-78
    CrossrefPubMedGoogle Scholar
  • 15 Wang Y, Yu X, Tang J. et al. Solitary necrotic nodule of the liver: contrast-enhanced sonography. J Clin Ultrasound 2007; 35: 177-181
    CrossrefPubMedGoogle Scholar
  • 16 Claudon M, Cosgrove D, Albrecht T. et al. Guidelines and good clinical practice recommendations for contrast enhanced ultrasound [CEUS] – update 2008. Ultraschall in Med 2008; 29: 28-44
    Article in Thieme ConnectPubMedGoogle Scholar
  • 17 Sundaresan M, Lyons B, Akosa AB. 'Solitary' necrotic nodules of the liver: an aetiology reaffirmed. Gut 1991; 32: 1378-1380
    CrossrefPubMedGoogle Scholar
  • 18 Koea J, Taylor G, Miller M. et al. Solitary necrotic nodule of the liver: a riddle that is difficult to answer. J Gastrointest Surg 2003; 7: 627-630
    CrossrefPubMedGoogle Scholar
  • 19 Clouston AD, Walker NI, Prociv P. Parasitic origin of a solitary necrotic nodule of the liver. J Clin Pathol 1993; 46: 578
    CrossrefPubMedGoogle Scholar
  • 20 Deniz K, Coban G. Solitary necrotic nodule of the liver: always benign?. J Gastrointest Surg 2010; 14: 536-540
    CrossrefPubMedGoogle Scholar
  • 21 Yoon KH, Yun KJ, Lee JM. et al. Solitary necrotic nodules of the liver mimicking hepatic metastasis: report of two cases. Korean J Radiol 2000; 1: 165-168
    CrossrefPubMedGoogle Scholar
  • 22 Colagrande S, Paolucci ML, Messerini L. et al. Solitary necrotic nodules of the liver: cross-sectional imaging findings and follow-up in nine patients. Am J Roentgenol 2008; 191: 1122-1128
    CrossrefPubMedGoogle Scholar
  • 23 Geng L, Lin C, Huang B. et al. Solitary necrotic nodule of the liver: MR findings in 33 pathologically proved lesions. Eur J Radiol 2012; 81: 623-629
    CrossrefPubMedGoogle Scholar
  • 24 Wang LW, Liu K, Lin GW. et al. Solitary Necrotic Nodules of the Liver: Histology and Diagnosis with CT and MRI. Hepat Mon 2012; 12: e6212
    PubMedGoogle Scholar
  • 25 Qian H, Li S, Ji M. et al. MRI characteristics for the differential diagnosis of benign and malignant small solitary hypovascular hepatic nodules. Eur J Gastroenterol Hepatol 2016; 28: 749-756
    CrossrefPubMedGoogle Scholar
  • 26 Fang J, Ma X, Yu D. et al. Specific imaging characteristic of solitary necrotic nodule of the liver: Marked peripheral rim-like enhancement with internal hypointensity on longer delayed MRI. Eur Radiol 2017; 27: 3563-3573
    CrossrefPubMedGoogle Scholar
  • 27 Murphy-Lavallee J, Jang HJ, Kim TK. et al. Are metastases really hypovascular in the arterial phase? The perspective based on contrast-enhanced ultrasonography. J Ultrasound Med 2007; 26: 1545-1556
    CrossrefPubMedGoogle Scholar
  • 28 Choi SH, Kwon HJ, Lee SY. et al. Focal hepatic solid lesions incidentally detected on initial ultrasonography in 542 asymptomatic patients. Abdom Radiol [NY] 2016; 41: 265-272
    CrossrefPubMedGoogle Scholar
  • 29 Imura S, Miyake K, Ikemoto T. et al. Rapid growing solitary necrotic nodule of the liver. J Med Invest 2006; 53: 325-329
    CrossrefPubMedGoogle Scholar
  • 30 Choi CS, Cho EY, Jeong JS. et al. Spontaneous regression of a solitary necrotic nodule of the liver. Hepatol Int 2010; 4: 649-652
    CrossrefPubMedGoogle Scholar