liver cancer vs atypical hemangioma - proper long term diagnosis/course of action?

[concerned_ibs_sufferer]

I apologize if this is incorrect forum as there is no liver/hepatology forum.  

On a prior CT scan done 3 mo ago, 3 liver lesions were discovered. The most recent scan noted the same lesions. Largest lesion is mildly lobulated & demonstrates peripheral enhancement & central low attenuation.  Appearance is slightly different than prior study likely due to timing differences between IV contrast material injection and scanning. It measures 23x17x20mm vs 24x15x20mm on prior study.  Impression: Central liver heterogenous mass, with similar measurements but slightly different CT enhancement pattern compared to prior study; the appearance remains nonspecific but compatible with an atypical hemangioma.  

A 2nd lesion in inferior right lobe is ~11x10x17mm vs 13x11x6mm from prior scan; no significant interval change, nonspecific but compatible with hemangioma. 3rd lesion is 3-5mm, very small, unchanged.

My ALT test remains at 48, same as 3mos ago, but higher than 25 level from 9 mos ago; lab limit is 36.

What is proper ongoing course of action?   Radiologist and dr suggest a 3rd CT scan in 3-6 months.  It seems that they can not diagnose definitively that it's a hemangioma due to atypical appearance.  So I need to do repeat scans to ensure no growth.  Still even if next scan shows no growth, Dr said, we should still follow up with subsequent scans (periodic ultrasound), but for how long?

What is the proper course of action for determing if lesion is atypical hemangioma?  It seems nobody can be definitive. So, I'm in constant worry which is bad as I have an anxiety disorder.  With lesions that look like atypical hemangioma & slightly elevated ALT, is there no other way to confirm it's not cancer?  I don't know if I can handle more scans.

Prior CT &lab data:
http://www.medhelp.org/posts/Liver-Transplant/Poorly-defined--hypodense--left-medial-segment-liver-lesion---Do-I-need-to-worry-about-cancer/show/1353219?personal_page_id=1799698#post_6182467

[Thomas D Schiano, MD]

good luck

[concerned_ibs_sufferer]

thanks for all the recommendations. I feel more comfortable understanding the different options.  I thank you for all the comments. I'll cross my fingers in the meantime and follow up in 5 months to let you know the outcome.  Hopefully my elevated ALT will have returned to normal and hopefully there will be no growth of the liver lesion!

[Thomas D Schiano, MD]

i think having all of the imaging performed at the same facility is the way to go, and ideally at a hospital or university based one at that.  getting the baseline U/S and thereafter repeating is reasonable. there is no formal recommendation but i think annually for a while to insure that there is no interval growth.  these lesions do not transform into other things so no growth for a while should be reassuring.

[concerned_ibs_sufferer]

Thank you for all your great information.  I think I have a better understanding of the issues with your info.  For now, I just have to hope my 3rd CT in June does not show any growth.  If it does, then a liver biopsy (which has its risks) may be necessary, so I'm hoping for no growth.

Staying positive, assuming lesion/atypical hemangioma is stable, then longer term, how long does one generally continue monitoring these liver lesions on an ongoing basis?  Semi-annually for the rest of one's life, or annually for a few years?  Is there a recommended frequency and term to continue monitoring?  At some time horizon, can it actually be diagnosed that the lesion is an atypical hemangioma?

Also, I'll be switching medical insurance at the end of this year.  Given the emphasis you indicated about minimizing variability when using U/S scans, does this mean that a follow up surveillance U/S at a different facility/provider would not be reliable.  

In other words, if I have a new provider/facility change, then would an appropriate course of action be to obtain a new followup CT/MRI scan (in conjunction with a new U/S to establish a new baseline).  Thereafter, periodic ongoing U/S scans at this facility and with same radiologist would be adequate for monitoring the lesion.

I apologize for all the questions as my anxiety is getting to me about all the issues while I wait another 5 months for CT.  I am very greatful for all your helpful comments.

[Thomas D Schiano, MD]

it varies from center to center but MRI and CT scan should more or less be equivalent in following these lesions.  i think getting another one is reasonable and if they want to get a sonogram at the same time to establish a baseline, its not unreasonable to follow on an ongoing basis with U/S as long as the imaging studies are being performed at the same place and preferably read by the same radiologist.

[concerned_ibs_sufferer]

Dr Schiano, thanks for comments.  Yes, I have been pushing for an MRI follow up scan. Unfortunately, at the Kaiser facility where I am a patient, the preference is for CT over MRI at this location for some reason.  My follow up CT scan this June would be my 3rd CT in 9 months.

Given recent research studies about lifetime exposure from CT scans and cancer estimates , is 3 CT scans in a 9 month period for a liver lesion (suspected to be atypical hemangioma) considered excessive radiation exposure for a 34 year old male?  

If so, what then is the proper standard of care for long term follow up on a liver lesion/suspected atypical hemangioma?  

In my situation, if the 3rd CT scan is stable, they have recommended periodic ultrasound scans to monitor lesion over longer term. Longer term, they don't want to do too many more CTs due to radiation exposure, so they have suggested longer term follow up with Ultrasound (assuming 3rd scan shows no growth).  

However, you indicated that an ultrasound may not be adequate surveillance modality longer term once one has better confidence that a lesion is more probable to be a atypical hemangioma.  Does this then really only leave an MRI scan as the longer term option for surveillance of the lesion?  Or can periodic CT scans be done longer term despite the cumulative radiation exposure risks?  And if so, at what frequency?  Every year?  Every 3 years?  

What then is the proper longer term standard of care for monitoring atypical hemangioma lesions.  It seems that if ultrasounds are not adequate surveillance  modality, and that if longer term periodic CTs are considered excessive radiation, is MRI really the only longer term surveillance option?

[Thomas D Schiano, MD]

i think that over the short term if there is interval growth, it is not consistent with a hemangioma so the lesion would need to be removed or biopised.  Once everyone feels a bit better that this is in fact a hemangioma then the frequency of scans can be lessened.  i do not think that the ultrasound is an adequate surveillance modality for this.

[Thomas D Schiano, MD]

the elevated ALT is not ascribable to hemangiomas so we also need to asess why this is high.  They should perform a scan with eovist contrast for better delineation.  the first lesion described sounds like a hemangioma, the second one not as characteristic.  following with ultrasound I believe will not be helpful.  i agree that interval growth would warrant more aggressive action. Following with scans is not unreasonable--they should also try MRI instead of CT scan to decrease radiation exposure.

[concerned_ibs_sufferer]

Is that the proper long term course of action?

Do a 3rd CT scan in 6 months to ensure no growth.  After that, follow up with ultra sound scans every 6 months?  When can one stop the scans?  i.e. When can one finally say that it is definitively not cancer?

If one of the scans does show growth, then does that mean the likelihood of the lesion being cancerous has increased significantly?