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Radiologists face challenges distinguishing benign liver nodules from hepatocellular carcinoma (HCC) in congested livers. Standard diagnostic algorithms like LI-RADS are unreliable due to overlapping imaging features in liver congestion.

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Area of Science:

  • Radiology
  • Hepatology
  • Medical Imaging

Background:

  • Liver congestion presents diagnostic challenges due to altered hemodynamics.
  • Congestion causes diffuse parenchymal changes and nodule development, mimicking malignancy.
  • Distinguishing benign focal nodular hyperplasia (FNH)-like nodules from hepatocellular carcinoma (HCC) is difficult.

Purpose of the Study:

  • To discuss the pathophysiology of liver congestion and nodule formation.
  • To review imaging findings and mimics of liver congestion and hypervascular lesions.
  • To propose a diagnostic algorithm for hypervascular liver lesions in congested livers.

Main Methods:

  • Review of complex liver macro- and microhemodynamics in congestion.
  • Analysis of imaging features differentiating benign from malignant nodules.
  • Evaluation of the limitations of the Liver Imaging Reporting and Data System (LI-RADS) in congested livers.

Main Results:

  • FNH-like nodules and HCC share overlapping imaging features in congested livers.
  • Standard LI-RADS criteria lack specificity in this setting.
  • Morphologic changes and increased liver stiffness complicate cirrhosis diagnosis.

Conclusions:

  • Liver congestion requires a tailored approach to imaging diagnosis.
  • Radiologists must be aware of diagnostic pitfalls in congested livers.
  • A new conceptualization and diagnostic algorithm are needed for hypervascular lesions in congested livers.