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Liver tumours — benign lesions, HCC and metastases
Most liver lesions in a healthy person are benign (haemangioma, FNH) and need no treatment; in a cirrhotic liver a lesion with arterial enhancement and washout is HCC even without biopsy, and treatment follows BCLC; colorectal liver metastases are resected when possible.
Why it matters in the exam
Questions on a liver lesion start with the background: a healthy young woman with an incidental lesion — usually a haemangioma (peripheral filling that progresses inwards) or FNH (central scar), neither of which needs treatment. A woman on the oral contraceptive pill or a man on anabolic steroids with a lesion — think of an adenoma, which can bleed and become malignant: stop the pill and resect an adenoma larger than 5 cm or any adenoma in a man. Biopsy of a haemangioma is dangerous and unnecessary.
In a cirrhotic liver or an HBV carrier, ultrasound surveillance is done every 6 months, sometimes with AFP. A lesion of 1 cm or more is assessed by multiphase CT or MRI, and arterial-phase enhancement with late washout diagnoses HCC without biopsy. Treatment follows BCLC: very early and early stage — resection (with preserved liver function and no portal hypertension), transplantation (Milan criteria: one lesion up to 5 cm, or up to three lesions up to 3 cm, without vascular invasion) or ablation; intermediate stage — TACE; advanced stage — systemic therapy. Colorectal metastases are resected when clear margins can be achieved and enough liver remains.
Key points
- Haemangioma and FNH — benign, no treatment.
- Adenoma — stop the pill; resect above 5 cm, in a man or if bleeding.
- HCC surveillance: ultrasound every 6 months in cirrhosis or HBV.
- Arterial enhancement and washout in a cirrhotic liver = HCC without biopsy.
- Milan: one lesion of 5 cm or less, or no more than 3 lesions up to 3 cm — transplantation.
Summary table
| Lesion | Features | Treatment |
|---|---|---|
| Haemangioma | The most common; peripheral filling that progresses inwards | No treatment and no biopsy |
| FNH | Young woman; central scar | No treatment |
| Adenoma | Contraceptive pill or anabolic steroids; risk of bleeding and malignancy | Stop the pill; resect above 5 cm, in any man or if bleeding |
| Early HCC | Cirrhotic liver; arterial enhancement and washout | Resection, transplantation (Milan) or ablation |
| Intermediate and advanced HCC | Multiple lesions, vascular invasion or metastases | TACE at the intermediate stage; systemic therapy at the advanced stage |
| Colorectal metastases | The most common liver metastases | Resection with chemotherapy when enough liver can be left |
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Sources
- EASL Clinical Practice Guidelines: Management of hepatocellular carcinoma, 2018 — Surveillance, diagnosis and BCLC-based treatment
- AASLD Practice Guidance on prevention, diagnosis and treatment of hepatocellular carcinoma, 2023 — Imaging diagnosis and treatment allocation
- EASL Clinical Practice Guidelines on the management of benign liver tumours, 2016 — Haemangioma, FNH and hepatocellular adenoma
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-02. The text may contain errors; when in doubt, check the source.