Diagnosis of liver nodules within and outside screening programs

Evaluation of a liver nodule detected with ultrasound includes the recovery of a detailed medical history, a physical exam, appropriate contrast imaging examinations and, in selected cases, histopathology. In this setting, identification of liver disease accompanying a liver nodule helps distinction between benign nodules and metastatic malignant nodules from primary liver cancer, as recommended by scientific liver societies. Diagnostic algorithms for a liver nodule in patients with liver disease involve contrast CT scan, magnetic resonance imaging or contrast enhanced ultrasounds to show the typical neoplastic pattern of early arterial hyperenhancement wash-in followed by hypoenhancement in the late portal phase wash out. The flow charts developed by western societies utilize the discriminant criterion of tumor size i.e. the radiological diagnosis being endorsed in a nodule equal or greater than 1 cm whereas eastern societies rely on the recognition of a typical vascular pattern of the node, independently of size. Differential diagnosis should be obtained to differentiate liver related nodules like regenerative macronodules (more than 20% of the cases) and the less frequent intrahepatic cholangiocarcinoma (~2% of the cases) from liver disease unrelated nodules like hemangioma (~4%), neuroendocrine metastatic nodules (~1%) and focal nodular hyperplasia. In patients without liver disease, the most common liver nodules in the liver are hemangioma (~1.5%), focal nodular hyperplasia (0.03%) and hepatocellular adenoma (up to 0.004% in long term users of oral contraceptives). Optimization of management of patients with a liver nodule requires establishment of a multidisciplinary clinic.