30 seconds after injection. Coarse calcifications are seen in only 5% of patients. Your mildly heterogeneous pancreas can be as a result of a fatty liver, or chronic pancreatitis. mild and high-grade dysplastic nodules with moderate or severe cellular atypia, but For example, a dermoid cyst has heterogeneous attenuation on CT. ideal diet is plant based diet. CEUS exploration is indicated when a nodule is malignancy. Doppler circulation signal. The tumor's Cholangiocarcinoma usually presents as a mass of 5-20cm. Even on delayed images the density of a hemangioma must be of the same density as the vessels. CEUS represents a useful method in clinical practice for differentiating between malignant and benign FLLs detected on standard ultrasonography, and the results are in concordance with previous multicenter studies: DEGUM (Germany) and STIC (France). CEUS examination shows central tumor filling of compare the tumor diameter before therapy with the ablation area. and the tumor diameter is unchanged. occurs. Unable to process the form. fruits salads green vegetables. 4 An abdominal aortic . well defined lesion, with sizes of 23cm or less, showing increased echogenity and, when also has a low sensitivity in differentiating dysplastic nodules from early HCC. Fatty liver is a reversible condition that can be brought on by bad diet or high alcohol consumption. It can be a constricting or an expanding lesion, because it can have a fibrous or a glandular stroma. It is composed of multiple vascular channels lined by endothelial cells. [citation needed], It is a benign tumor made up of normal or atypical hepatocytes. metastases have non-characteristic Doppler vascular pattern, with few exceptions (carcinoid parenchyma reconstruction, as occurs in cirrhosis, steatosis accumulation or in case of acute However in 20% of patients the scar is hypointense. [citation needed], It consists of localized accumulation of fat-rich liver cells. The specification of these data is important for staging liver tumors and prognosis. Imaging features of FLC overlap with those of other scar-producing lesions including FNH, HCC, Hemangioma and Cholangiocarcinoma. ranges between 4080% . At US, metastases may appear cystic,hypoechoic, isoechoic or hyperechoic. have distinct delineation (hydatid cyst), lack of vascularization or show a characteristic The finding of hemorrhage as an area of high attenuation can be seen in as many as 40% of adenomas. At the time the article was last revised Jeremy Jones had no recorded disclosures. Low density, so it may be cystic i.e fluid containing. (the result of intratumoral circulatory disorders, consequence of hemorrhage or necrosis) treatment results, while other studies have shown the limitations of CEUS especially [citation needed] characterized by decrease until absence of portal venous input and by increase of arterial normal parenchyma in a shining liver. The ultrasonographic appearance of splenic neoplasia is variable and can include splenomegaly or focal mass lesions, which are commonly poorly defined, anechoic, hypoechoic, targetlike, 22 or complex, similar to those of the liver. Hypovascular metastases are the most common and occur in GI tract, lung, breast and head/neck tumors. reverberations backwards. CEUS exploration, by circulatory pattern, displace normal liver structures and even neighboring organs (in case of Rim enhancement is a feature of malignant lesions, especially metastases. Difficulties in CEUS examination result from post-lesion Spectral Doppler examination detects central arterial vessels and CFM resection and liver transplantation and they are indicated for early tumor stages in patients presence of fatty liver) or lack of patient's cooperation (immediately after therapy). Generally, both nodules enhances identically with the surrounding liver parenchyma after [citation needed], In the first days after RFA both CEUS and spiral CT have low sensitivity in assessing During this phase the center of the lesion becomes hypoechoic, enhancing the tumor types of benign liver tumors. vessels having a characteristic location in the center of the tumor, within a fibrotic scar. Unfortunately, this homogeneous enhancement in the late arterial phase is not specific to adenomas, since small HCC's and hemangiomas as well as hypervascular metastases and FNH can demonstrate similar enhancement in the arterial phase. performance are: excessive obesity, fatty liver disease, hypomobility of the diaphragm, and validated indications at this time, but with proved efficacy in extensive clinical trials Computed tomography angiography revealed that this large vessel was a spontaneous extrahepatic portocaval shunt draining portal flow to the iliac veins through the inferior epigastric veins ( Fig. after the procedure, including CEUS, can show apart from the character of the lesion any So any cystic structure near the biliary tract in a patient, who recently has undergone a biliary procedure, is suspicious of a liver abces. An echogenic liver is an ultrasound reading that indicates a higher level of fat in the liver. Findings of heterogeneous liver echogenicity and irregular surface correlated to liver cirrhosis with a sensitivity of 70.6%, specificity of 100%, positive and negative predictive values of 100% and 82.1% respectively, and accuracy of 87.5%. Rarely, sizes can reach several centimeters, leading up to the substitution of a whole liver vascularization is typical for HCC and is the key to imaging diagnosis. In moderate or poorly differentiated HCC (classic HCC) tumor nutrition is HCC may be solitary, multifocal or diffusely infiltrating. clinical suspicion of abscess. What can an ultrasound of the liver detect? The described changes have diagnostic value in liver nodules larger than 2cm. Appendicitis - Pitfalls in US and CT diagnosis, Acute Abdomen in Gynaecology - Ultrasound, Transvaginal Ultrasound for Non-Gynaecological Conditions, Bi-RADS for Mammography and Ultrasound 2013, Coronary Artery Disease-Reporting and Data System, Contrast-enhanced MRA of peripheral vessels, Vascular Anomalies of Aorta, Pulmonary and Systemic vessels, Esophagus I: anatomy, rings, inflammation, Esophagus II: Strictures, Acute syndromes, Neoplasms and Vascular impressions, TI-RADS - Thyroid Imaging Reporting and Data System, How to Differentiate Carotid Obstructions. Although adenomas are benign lesions, they can undergo malignant transformation to hepatocellular carcinoma (HCC). (single nodule of 25cm, or up to 3 nodules <3cm) which can be treated by vasculature changes progressively, correlated with the degree of malignancy, and it is It is just a siderotic iron containing hyperdense nodule. both arterial and portal phases, while early HCC nodules may have similar In addition sensitivity and specificity of ultrasound in detecting liver metastases, but also by assessing cholangiocarcinomas so complementary diagnostic procedures should be considered. phase and seeing metastases in contrast to normal liver parenchyma during the sinusoidal conditions) and tumoral (HCC). therapies initially after one month then after every 3 months post-TACE. There are four routes for bacteria to get into the liver. with the medical history, the patient's clinical and functional (biochemical and greatly reduced, reaching approx. active bleeding). Adenomas typically measure 8-15 cm and consist of sheets of well-differentiated hepatocytes. metastases). As a result of the risk of intraperitoneal hemorrhage and the rare occurrence of malignant transformation to HCC, surgical resection has been advocated in most patients with presumed HA. Inconclusive ultrasound results warranted a CT scan of the chest, abdomen and pelvis with contrast, which showed a heterogeneous low-density lesion within the right lobe of the liver that extended to the left lobe (Figure 5). Among ultrasound The patient has a good general Fatty liver disease . arterial hyperenhancement and portal and late wash-out. studies showing that between 5994% of newly diagnosed liver nodules in cirrhotic patients Rarely, HCC may appear isoechoic, consist of a tumor type with a higher degree of but it is an expensive method and still difficult to reach. Thus, a possible residual In addition, discrimination of synchronous lesions that have a The upper images show a lesion that is isodens to the liver on the NECT. status, as tumors are often asymptomatic, being incidentally discovered. In the portal venous phase however, the enhancement is not as bright as the enhancement of the portal vein. On the left pathologic specimens of FLC and FNH. every 6 months combined with alpha fetoprotein (AFP) determination is an effective The spatial distribution of the vessels is irregular, disordered. During late phase the appearance is isoechoic or different against the general pattern of restructured liver either by different echogenity or by with good liver function. Routine use of CEUS examination to At Doppler examination, circulation represented by a reduced arterial bed compared to that of the surrounding useful to exclude an active lesion at the moment of exploration but does not have absolute conjunction with contrast CT/MRI and to assess the effectiveness of treatment when using an antiangiogenic therapy for hypervascular metastases . With color doppler sometimes the vessels can be seen within the scar. 4. In sepsis the spread will be via the arterial system as in patients with endocarditis and there will be multiple abscesses spread out through the periphery of the liver. At conventional B-mode ultrasound, diffuse fatty infiltration results in increased echogenicity of the liver when compared to other organs such as the renal cortex (Fig. Got fatty liver disease? arterial phase, with washout during the portal venous phase and hypoechoic pattern Oliver JH, Baron RL: State of the art, helical biphasic contrast enhanced CT of the liver: Technique, indications, interpretation, and pitfalls. US will show a FNH as a non specific ill-defined lesion. Doppler examination Sensitivity is conditioned by the size and clinical trials that investigated the tumor size doubling time (Bruix, 2005; Maruyama et al., Patients with glycogen storage disease, hemochromatosis, acromegaly, or males on anabolic steroids also are more prone to developing hepatic adenomas. Doppler exploration is not enough, CEUS examination will be performed. You have to look at all the other images, because they give you the clue to the diagnosis. Many patients with cirrhosis have portal venous thrombosis and many patients with HCC have thrombosis. During late (sinusoidal) phase, if However if you look at the delayed phase, you will notice that this area enhances. All the normal constituents of the liver are present but in an abnormally organized pattern. and are firm to touch, even rigid. parenchymal hyperemia. related to US penetration (pronounced fatty liver disease, deep lesion, excessive obesity) and tumor may appear more evident. Using CEUS examination to detect metastases a sensitivity of 8095% is obtained, similar to conclusive, when precise information on some injuries (number, location) is necessary in For a lesion diameter below 10mm US accuracy is of circumscribed lesions, with clear, imprecise or "halo" delineation, with homogeneous or signal may be absent in both regenerative and dysplastic nodules. On the left a typical FNH with a central scar that is hypodens in the portal venous phase and hyperdens in the equilibrium phase. The lesion can have different forms, most cases being oval and The If you look at the images on the left and just would consider the T2W-images, what could be the cause of the central area of high signal? Infiltrative cholangiocarcinoma does not cause mass effect, because when the stroma matures, the fibrous tissue will contract and cause retraction of the liver capsule. The lesion is hyperdense in the equilibrium phase indicating dens fibrous tissue. Radiographics. post-therapy), while monitoring of systemic therapies of HCC and metastases are not a very accessible procedure, although it has a high specificity. : this is a common ultrasound finding, echogenic or heterogenous liver - meaning not all of liver tissue looks exactly the same. Typically HCC invades liver vessels, primarily the portal veins but also the hepatic veins . An "infiltrative" type is also described which is difficult to discriminate from liver nodular reconstruction in cirrhosis. required. acoustic impedance of the nodules. the procedure increases its performance even if it does not have a decisive contribution to CEUS. [citation needed], Gadolinium MRI examination is a procedure used more and more often, and its advantages Image above showing sharp contrast between liver echogenicity compared to kidney echogenicity. So we have a HCC in the right lobe on the upper images and a hemangioma in the left lobe on the lower images. That is because cholangiocarcinoma has a varied morphology and histology. area showing a peripheral homogeneous hyperenhanced rim due to post-procedure Then we look at liver enzymes, the patients history, do blood tests for various liver diseases. [1], Tumor detection is based on the performance of the method and should include morphometric information (three axes dimensions, volume) and topographic information (number, location specifying liver segment and lobe/lobes). attenuation which make US examination more difficult. Heterogeneous steatosis MRI Definition Steatosis is defined as the accumulation of fatty acids in the form of triglycerides in the cytoplasm of hepatocytes. These early HCC's are very different from the large ones that we see in the non-cirrhotic patients. The most common cause would be central necrosis in a tumor. Benign diagnosis FNH is not a true neoplasm. considered complementary methods to CT scan. On dynamic contrast-enhanced MRi the characteristics of metastases are the same as for CECT. For example, a dermoid cyst has heterogeneous attenuation on CT. Ultrasound Cirrhotic liver monitoring, Early hepatocellular carcinoma (Early HCC), Techniques for evaluating the efficiency of therapy, Ultrasound monitoring ablative therapies (alcoholization PEI, radiofrequency ablation RFA), Ultrasound monitoring of TACE therapy (transarterial chemoembolization), Ultrasound monitoring of systemic therapies, "[Sonographic diagnostics of liver tumors]", "Contrast-enhanced ultrasonography parameters in neural network diagnosis of liver tumors", https://en.wikipedia.org/w/index.php?title=Ultrasonography_of_liver_tumors&oldid=1076573293, detection and characterization of hepatic tumors, This page was last edited on 11 March 2022, at 20:00. Hepatobiliary and Pancreatic Radiology: Imaging and Intervention. Thus, during the arterial If you only had the portal venous phase you surely would miss this lesion. CEUS Typically, HCAs are solitary and are found in young females in association with use of estrogen-containing medications. Therefore, some authors argue that screening Large hemangiomas can have an atypical appearance. tool in the evaluation of liver enzyme abnormalities is abdominal ultrasound (US), with more in-depth evalua-tion by computed tomography (CT), magnetic resonance imaging (MRI)/magnetic resonance cholangiopancreatog-raphy (MRCP), or cholescintigraphy as detailed later. nodule, with distinct pattern, developed on cirrhotic liver. immediately post-procedure (with the possibility of reintervention in case of partial response) a. complete response, defined as complete disappearance of all known lesions (absence of Deviations from the He has been president of the Society of Computed Body Tomography and Magnetic Resonance. or cysts inside is suggestive for parasitic, hydatid nature. The pathogenesis is believed to be related to a generalized vascular ectasia that develops due to exposure of the liver to oral contraceptives and related synthetic steroids. [citation needed], Please review the contents of the article and, Pseudotumors and inflammatory masses of the liver, Preneoplastic status. paucilocular), have distinct delineation, with increased echogenity (hemangiomas, benign Calcification is rare and seen in less than 10%, usually in the central scar of giant hemangioma. [citation needed], These lesions are well defined, with isoechoic or hypoechoic appearance and sizes less than treatment which can be complex (chemotherapy, radiofrequency ablation, surgical CEUS examination is Nevertheless, chronic Budd-Chiari syndrome may be difficult to differentiate from cirrhosis ( 8 ). PubMed Google . Some authors consider that early pronounced walls, without circulatory signal at Doppler or CEUS investigation. The nodule's It Adenomas may rupture and bleed, causing right upper quadrant pain. <2cm (from <5% in the 90s in Europe to > 30% today in Japan) with curative therapy Some authors indicate the In the arterial phase we see a hyperdense structure in the lateral segment of the left lobe of the liver. It is They are divided into low-grade dysplastic nodules, where cellular atypia are No, not in the least. However, a typical central scar may not be visible in as many as 20% of patients (figure). In most cases, a finding of heterogeneous liver is followed by further medical testing to determine the cause of the heterogeneity. lobe (acquired, parasitic). 3 Left untreated, continued fibrotic changes can lead to multilobular cirrhosis. Heterogeneous Liver on Research Ultrasound Identifies Children with Cystic Fibrosis at High Risk of Advanced Liver Disease: Interim Results of a Prospective Observational Case-Controlled Study Marilyn J. Siegel MD 1 , A. Jay Freeman MD 2 , Wen Ye PhD 3 , Joseph J. Palermo MD 4 , Jean P. Molleston MD 5 , Shruti M. Paranjape MD 6 , Janis Stoll MD 7 , the developing context (oncology, septic) are also added. [citation needed], Increased performance is based on identifying specific vascular patterns during the arterial Another important feature of hemangiomas is the increased sound transmission. This can be caused by mild fibrosis of fatty liver disease. to adjacent liver parenchyma in all three phases of investigation. Fifty-four patients undergoing endoscopic ultrasound . (Claudon et al., 2008). Abstract Purpose: To assess the value of contrast-enhanced ultrasound (CEUS) for differentiating malignant from benign focal liver lesions (FLLs . scar. out at the end of arterial phase. to bloating, in cancer patients post-therapy steatosis occurs, which prevent deep visibility. Following are the characteristic features of some splenic neoplasias: exploration reveals their radial position. Radiology 1996; 201:1-14. has a hereditary, autosomal dominant transmission (von Hippel Lindau disease). Also they are These lesions are multiple, but not spread out through the liver. [3], They can be single or multiple, with variable size, generally less than 20mm (congenital). is therefore mandatory to analyze all these three phases of CEUS examination for a proper neovascularization is enhanced in a chaotic and explosive way, while normal, arterial and Their diagnosis is quite difficult and the criteria used for differentiation are often The content is Within 3 weeks the small lesion in the left liver lobe progressed to this huge abces. It means that the liver isn't homogeneous. [citation needed], The substrate on which the tumor condition develops (if the liver is normal or if there is evidence of diffuse liver disease) and The bacteria will fall down into the dependent portion of the right lobe. They tend to be very large with a mozaic pattern, a capsule, hemorrhage, necrosis and fat evolution. Moreover a central scar may be found in some patients with fibrolamellar hepatocellular carcinoma, hepatic adenoma and intrahepatic cholangiocarcinoma. Ultrasound revealed a hypertrophic, heterogeneous liver and a large shunt between a patent umbilical vein and the left branch of the portal vein. 24 hours after the procedure the inflammatory peripheral rim is thinning and This includes lesions developed on liver A heterogeneous liver appears to have different masses or structures inside it when imaged via ultrasound. characteristic appearance is enough for positive diagnostic. techniques, CEUS is the one that brought a significant benefit not only by increasing the 1 ). hyperemia, presence of intratumoral air, ultrasound limitations (too deep lesion or the Echogenity is variable. ADVERTISEMENT: Supporters see fewer/no ads. avoid oily fatty foods etc including milk and derivatives. MRI usually is more sensitive in detecting fat and hemorrhage. In addition, a considerable risk of hemorrhage exists when biopsy is performed on these hypervascular tumors. First, if you have a malignant thrombus in the portal vein, it will always enhance and you'll see it best in arterial phase. TACE therapeutic results by contrast imaging techniques is performed as for ablative heterogeneous echo pattern. Ultrasonography of liver tumors involves two stages: detection and characterization. You have to realize however, that this simply means that the lesion is hyperechoic to normal liver. [citation needed]. that of contrast CT and MRI . increases with the tumor size. arterio-venous shunts. In this situation a pronounced hepatomegaly occurs. Sometimes, especially for HCC treated by (2002) ISBN: 1588901017. Therefore, current practice In most cases, a finding of heterogeneous liver is followed by further medical testing to determine the cause of the heterogeneity. Another common aspect is "bright Liver cirrhosis was confirmed in 111 participants; therefore, ultrasound had a 94% sensitivity and 49% specificity for the detection of liver cirrhosis [ 41 ]. totally "filled" with CA, hemangioma appears isoechoic to the liver. vascularity, metastases can be hypovascular (in gastric, colonic, pancreatic or ovarian On CEUS examination both RN and DN may have quite a variable enhancement pattern. the lesions it is necessary to extend the examination time to 5 minutes or even longer. Any imaging test done like ct mri or ULTRASOUND etc and it also depends on what cause lead to present disease. establish a differential diagnosis with hepatocellular carcinoma. degree of tumor necrosis is not correlated with tumor diameter, therefore simple hyperenhancement during arterial phase close to the lesion, this being suggestive of a liver presence of venous type Doppler flow which reflects the portal venous nutrition of the slow flow speed. hematological) status are important elements that should also be considered. categories of cirrhotic liver nodules: regenerative, dysplastic (considered as premalignant The presentation of liver abcesses is very much dependend on the way the bacteria have entered the liver. The left lobe (with lateral and medial divisions) encompasses a third to half of the parenchyma. investigations with other diagnostic procedures; at a size between 10 20mm two CEUS increased accuracy is due to the different behavior of normal liver parenchyma Neoformation vessels occur with increasing degree of dysplasia. single, solid consistency with inhomogeneous structure. ** TECHNIQUE **: Ultrasound images of the liver acquired. The key to the diagnosis in the lesion on the left is the fact that it is isoattenuating to normal liver in the portal venous phase and stays that way without a wash out on the delayed phase (not shown). In these metastases the halo is most probably related to a combination of compressed normal hepatic parenchyma around the mass and a zone of cancer cell proliferation. and a normal resistivity index. Hemangioma is the most common benign liver tumor. mimic a liver tumor. normal liver (metastases). Metastases can look like almost any lesion that occurs in the liver. This can occur due to a number of reasons which include: Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. associating "wash out" during portal and late CEUS phases. This suggested underlying liver fibrosis, although the liver contour was smooth. (well differentiated HCC) or increased RI (moderately or poorly differentiated HCC). You see it on the NECT and you could say it is hypodens compared to the liver. Ultrasound examination of the liver is performed with patients in a supine position. different nature is also important knowing that up to 2550% of liver lesions less than 2cm with heterogeneous structure, poorly delineated, often with peripheral location and weak dynamic imaging techniques and recognized by the presence of intratumoral non-enhanced If a patient is known to have a fatty liver, it is better to do an MRI or ultrasound for the detection of livermetastases. located in contact with the diaphragm, a "mirror image" phenomenon can be seen. What is the cause of course liver and so high BILIRUBIN. Typically, these tumors are more difficult to see than fatty deposits because the difference between the cells in the tumor and regular liver cells may not be obvious on a CT scan. Left posterior oblique positioning aids visualization of the right hepatic lobe, by allowing easier placement of the transducer along the right lateral or right posterior body wall. There are studies Complete response is locally proved Fibrolamellar carcinoma (FLC) has a dark scar on T2WI and FNH has a brigth scar on T2WI in 80% of the cases. . Then continue. Other elements contributing to lower US Doppler exploration reveals no circulatory signal due to very types of benign liver tumors. These masses may be benign genetic differences or a result of liver disease. These are small lesions that transiently enhance homogeneously. Biliary abscesses start small but can progress rapidly. Often, other diagnostic procedures, especially interventional ones are no longer necessary. Diagnostic criteria are the presence of membranes and sediment inside. In otherwise healthy young women using oral contraceptives, adenoma is favored. Characteristic 2D ultrasound appearance is that of a very well defined lesion, with sizes of 2-3 cm or less, showing increased echogenity and, when located in contact with the diaphragm, a "mirror image" phenomenon can be seen. A heterogeneous liver can be caused by fatty liver disease, tumors or cirrhosis. Removing a tissue sample (biopsy) from your liver may help diagnose liver disease and look for signs of liver damage. is high only for lesions who are hyperenhanced during arterial phase. examination is a real breakthrough for detection and characterization of liver metastases. develop HCC. [citation needed], Spectral Doppler characteristics of early HCC overlap those of the dysplastic nodule, as they The volume of damaged tumor is asymptomatic but may be associated with right upper quadrant pain in case of are represented by the presence of portal venous signal type or arterial type with normal RI Thus, highly differentiated HCC illustrates the phenomenon of neoplasm) or multiple. liver parenchyma of the cirrhotic patient. create a bridge to liver transplantation. dysplastic nodule sometimes a hypervascularization can be detected, but without Color Doppler neoplastic circulatory bed. However, this pattern is not specific for metastases as it can also be seen in primary malignant liver neoplasms (eg, HCC) and benign liver neoplasms (eg, adenoma in glycogen storage disease). guided biopsy; at a size over 20mm one single dynamic imaging technique with Residual tumor tissue is evidenced at the periphery of Ultrasound findings Ultrasound examination 24 hours cannot replace CT/MRI examinations which have well established indications in oncology. Significant overlap is noted between the CT appearances of adenoma, HCC, FNH, and hypervascular metastases, making a definitive diagnosis based on CT imaging criteria alone difficult and often not possible. In these cases, differentiation from a malignant tumor is difficult On the other hand a fatty liver can also obscure metastases. CE-MRI as complementary methods. above described behavior can occur in arterialized hemangiomas or those containing CT will show FNH as a vascular tumor, that will be hyperdens in the arterial phase, except for the central scar. {"url":"/signup-modal-props.json?lang=us"}, Weerakkody Y, Jones J, Bell D, et al. By looking at the other phases to see if the enhancing areas match the bloodpool, it is usually possible to differentiate these lesions. Hypervascular metastases are less common and are seen in renal cell carcinoma, insulinomas, carcinoid, sarcomas, melanoma and breast cancer. Only on the delayed images at 8-10 minutes after contrast injection a relative hyperdense lesion is seen. In contrast to FNH the central scar in FLC will usually be hypointense on T2WI and will less often show delayed enhancement. 2004;24(4):937-55. They are very common and are seen in up to 50% of patients with cirrhosis. 68F, referred for ultrasound due to recurrent upper abdominal pain. determined by two observations not less than 4 weeks apart; 4 Finally, the nodular pattern is thought to represent changes related to hepatic fibrosis; it is present in approximately 10% of CFLD patients. contraindicated. It is the antonym for homogeneous, meaning a structure with similar components. disease (vascular and parenchymal decompensation for liver cirrhosis, weight loss, lack of The most common tumor that causes retraction besides cholangiocarcinoma is metastatic breast cancer. NAFLD is now recognized as the hepatic manifestation of the metabolic syndrome and is a major cause of liver-related morbidity and mortality. During the late phase the tumor remains isoechoic to the liver, which strengthens the internal bleeding. HCC is the most frequent abdominal malignancy worldwide and is especially common in Asia and mediterrean countries. The typical risk factors for HCC such as cirrhosis, elevated alphafetoprotein, viral hepatitis, alcohol abuse are absent.