Nonspecific Abnormal Findings on Radiological please help

2/2011 I had chest pain under my breast near the heart which felt like high rib pain. I was on the birth control pill at that time (since discontinued them) and my Endo.(hypothyroidism) recommended that I see my PCP. for an x-ray. I got the x-ray and PCP ordered CT/CT Angio Chest I was having Dyspnea. Everything came back OK except: There is an 18mm low attenuation lesion in the right lobe of the liver with peripheral enhancement. The pattern is suggestive of a hemangioma. Right lobe liver lesion question hemangioma. A follow-up MRI is suggested to confirm this.
I did not want to have the injection for the MRI because I read about NSF and I'm scared about the gadolinium even though I currently have no kidney issues.  I asked my primary Dr. if there were any other imaging tests or do I absolutely need the MRI. Two days after the CT scan we did an ultrasound report is below:

Limited abdominal ultrasound
HISTORY: Chest CT performed reported 18-mm peripheral enhancing lesioin right lobe of liver felt likely to represent hemangioma but not completely evaluated on the study of the chest by report.
A rounded well circumscribed mass with sharply demarcated margins is present in the right lobe of the liver. The mass is hyperechoic to the surrounding hepatic parenchyma and measures approximately 1.8 cm in maximal dimension. No other hepatic lesions are seen.

CONCLUSION: Well circumscribed hyperechoic mass right lobe of the liver measuing 18mm in maximal dimension. The appearance is typical for hemangioma. A follow-up ultrasound could be obtained in 6 months time to document ongoing stability.----

I have ultrasound coming up I'm wondering if I should do the MRI or is having the ultrasound to monitor this  lesion a safe option? Should I  seek a second opinion? My last office visit with my primary Dr. when asked if it was thought to be a cancerous lesion I was told they can't rule out cancer at this time but it's probably not. Not sure what I should do at this point.

[Thomas D Schiano, MD]

i think that this is a hemangioma from what you describe.  the test of choice is a contrast MRI--I am not aware frankly of anyone developing (extremely rare overall)NSF with having normal renal function.  for peace of mind i would encourage you to get the MRI.

[bccb]

Thank you for taking the time to respond to my post Doctor. I would be very grateful if you could shed some light on my other questions.

My last ultrasound from this week states:
History: Echogenic mass right lobe of the liver demonstrated on earlier studies.

The visualized hepatic parenchyma demonstrates a well circumscribed hypoechoic mass right lobe of the liver measuring 1.9 x 1.7cm. This is without significant change in size and appearance compared with the ultrasound in February.

The gallbladder appears normal without stones. No gallbladder wall edema or pericholecystic fluid collections are present. The common bile duct measures 3 milimeters.
Right kidney appears grossly normal without hydronephrosis. No fluid collections are present in the right upper quadrunt.

The pancreas is not completely visualized but where seen appears normal.

IMPRESSION: Well-circumscribed hyperechoic mass measuring 1.9x 1.7 cm right lobe of the liver without significant change compared with the ultrasound from February. This likely represents an incidental hemangioma. A follow-up study in 6 months time recommended
.------------------end report
Is says hypoechoic above but in the IMPRESSION part of the report it then says hyperechoic? Which one is correct? In the past it was always hyperechoic. Also it seems it has grown at last ultrasound I was told it was 18mm but now the new ultrasound says its 1.9 x 1.7 cm. Is this just because there's a margin of error with ultrasound measurements? Or has the hemangioma grown? Am I correct in thinking it has grown but not significantly?

Is a MRI still a good idea? And if I seek a second opinion if so what type of Doctor do I seek a second opinion from?
Thank You

[bccb]

Forgot to mention above that my last blood test came back high as Bilirubin Total 1.6 (range:0.2-1.0)

Direct Bilirubin 0.3 (range:0.0-0.3)

Is this related or something to be concerned about? I've never had high values with bilirubin in the past. I was fasting for this blood test for about 14 hours.

[Thomas D Schiano, MD]

the hemangioma is hyperechoic and from the measurements it seems that it is actually the same size---18mm=1.8cm.  i wouldn't worry about the size.  get the MRI for peace of mind.  i would seek the opinion of a hepatologist if you need a 2nd opinion.  the elevated bilirubin while fasting is most likely Gilbert"s disease, a benign enzyme defect of the liver.

[bccb]

Thank you so much for answering my post Doctor I truly appreciate it. I'm a bit concerned and confused because I was first told that on CT scan it was 1.8 cm which equals 18mm in maximal dimension and I was given no other dimension on the CT scan. The first ultrasound that I had in February stated that it was approximately 1.8cm which equals 18mm, so no change there. But now this most recent ultrasound says 1.9 x 1.7 cm. Am I missing something? I thought 1.9 cm=19 mm? Does this mean it grew or does it mean it's a better measurement now? Can you tell me what maximal dimension means?

Thank You

[Thomas D Schiano, MD]

i think in essence this is the same size and would not worry about a change of 1 mm

[bccb]

Thank you for answering my questions and concerns. I greatly appreciate your help and reassurance.

[Alex2509]

Hi My name is Alexandra.  I was diagnosed, during an employment health examination last October 2010 with latent TB.  I was encouraged by the TB specialist to undertake medication for this to eradicate it from my body.  

I started work as a Security Professional with St. Josephs Hospital, Hamilton, Ontario in the November and began treatment in the form of Isonaizid from Feb to April of 2011. In April I was experiencing what I thought was gall bladder pain and took myself to hospital.  I was told that although my liver levels were a little elevated, and the ultrasound showed a slightly inflamed gall bladder, I was fine and sent home with a prescription for Tylenol 3.  

Two days later, I was at work and one of the nurses suggested I triage myself as my skin colour was very yellow.  I did so and was subsequently admitted to hospital for a team to watch what they call to be extreme liver levels.  

I was seen by a doctor who immediately placed me on a strong cocktail of antibiotics and plenty of fluids.I encouraged to speak to the TB specialist Lori Whitehead within St. Joe's.  I wanted him to communicate to her what was happening as I knew she would be interested and possibly shed some light on the situation for the doctor.  This continued to request that the Doctor speak with Lori, but it just didn't get done. On the Tuesday morning, I knew Lori had Clinic this day and again when meeting with the doctor, asked that he please speak with Lori.  I was approached by one of the nurses with my TB meds, which I questioned if I should still be taking along with the current antibiotics.  The nurse went away with the TB medication and she asked the Doctor if he would speak to Lori Whitehead.  Doctor came in to see me and insisted that I took the medication, stating that I had come in to the hospital with a completely separate set of circumstances, which he believed to be unrelated to my liver, therefore, I should continue to take the Isonaizid.  I almost had to beg him to speak with Lori at this point and said that I would take the medication in the meantime.

I swallowed the medication with the nurse present and voiced my frustration to her, saying that I didn't see why he would not speak with Lori as I am sure she would want to know what has occured so far with me.

Moments later the Doctor appeared in my room and said, please do not take the medication, I have just spoken with Lori Whitehead and she said that under no circumstance should you take the Isonaizid!!  I was furious and very frustrated as to why I was placed in this situation.

Doctor stated that Lori wanted all copies of all blood tests and ultrasounds done to date and wants to keep a close eye on you from now on as the medication may spike the current condition even more.  From this moment on, I was very skeptical.  A final Ultrasound was done to confirm that I indeed had an inflamed gall bladder wall, which is beginning to return to normal, but have two mobile stones, measuring  up to 1.3cm and my pancreas was returning to normal after a bout of pancreatitis, following an investigatory camera session. Doctor also mentioned that I had a shadow on my liver that he wanted me to follow up with my family Doctor in six months time.

I remained in the hospital for the rest of the week until Sunday afternoon, when I was released and sent home to rest for a further two weeks. I am no longer on the Latent TB medication and will not be taking this again.

I have recently had the ultrasound appointment and all three ultrasounds have now been sent by Lori Whitehead, to a Radiologist at St. Joe's for his opinion.

I did meet with Lori Whitehead once released from hospital and she informed me how scarred she was at the levels my liver were showing on her chart.  She said that she was pleased Doctor had called, but very frustrated that he didn't call before.  I stressed to Lori how many times I asked him to speak to you, but he just came back saying he didn't think it was necessary right now.  Lori said that the phone call came through to her with the Doctor stating how sorry he was for bothering her, but had a patient who was insisting I call you regarding her admission into hospital!!

My family Doctor called me in for the reading of the ultrasound performed and announced that I had a slightly rounded echogenic area in the right lobe of the liver measuring 1.9 x 1.9 x 1.8 cm.  The written report that I have states that this finding is uncertain if this represents a hemangioma, but goes on to state that the liver is otherwise unremarkable.

I am concerned as we have many forms of cancer in my family, some being liver cancer and others pancreatic, stomach and bowel.  I am shortly due to leave the hospital security department following a relocation with my husband and his new post in Ottawa.  We will be living in Gatineau.  I have sent an email to Lori Whitehead to ask if I can be referred to a hospital for further follow-up appointments and or treatment if necessary as I feel very vulnerable moving with all this being very fresh and how much of a toll it took on my body.

Please can you make some suggestions and or help with what I can look to do with the current information regarding my liver.  I will let you know what the Radiologist reports back with as soon as I find out myself.

Thank you in advance for taking the time to read this very long email.

Kind Regards
Alexandra Parsons

[Thomas D Schiano, MD]

the isoniazid (INH) can definitely cause liver damage--whether it was that or the gallbladder causing the jaundice is unclear to me.  i think its best that you are off of it as it can cause an idiosyncratic drug toxicity. hemangiomas are very often commonly found and do not pose a problem.  my sense is that everything will be OK.  feel free to write back.