Introduction

Ultrasound is frequently the first line of investigation for suspected liver pathology, and the decision to proceed to secondary investigative procedures, such as further radiology or histology, is determined by the findings of the initial ultrasound scan. It is used in the diagnosis, staging and monitoring of liver disorders.

Ultrasound has a much greater role, however, than that of a first line ‘exclusion’ test, and serves as a reliable tool for more focused, complex examinations. Developing technology and techniques now result in improved diagnostic accuracy and are increasingly obviating the need for further radiology. Ultrasound is used to both diagnose and treat conditions using ultrasound guided invasive procedures.

Intraoperative and laparoscopic ultrasound, using high frequency, direct contact techniques, set the standard for liver imaging in many cases.

Focal liver lesions

Focal liver lesions are common, and, once seen, require accurate characterization. In some cases – for example simple cysts – the ultrasound appearances are pathognomonic requiring no further investigation. In other cases, CEUS provides a rapid and definitive diagnosis, obviating the need for further investigation or follow-up. In other cases, ultrasound appropriately directs the patient’s further management (such as further radiological imaging for staging or characterization, or biopsy).

Simple cysts

One of the most frequently seen liver lesions, the simple cyst is either congenital (from abnormal development of a biliary radicle) or acquired (from trauma or previous infection). It is asymptomatic, unless large enough to cause a ‘mass effect’ – compressing and displacing adjacent structures – and is usually an incidental finding during the ultrasound scan. Frequently, small cysts are peripheral and therefore more likely to be missed on ultrasound than CT.

The simple cyst has three acoustic properties, which are pathognomonic: it is anechoic, has a well-defined smooth capsule and exhibits posterior enhancement (increased through-transmission of sound) (Fig. 4.1). Although theoretically it is possible to confuse a simple cyst with a choledochal cyst (see Chapter 3), the latter’s connection to the biliary tree is usually demonstrable on ultrasound. A radioisotope HIDA scan will confirm the biliary connection if doubt exists.

Fig. 4.1 • Typical liver cyst demonstrating a band of posterior enhancement, smooth capsule and fine septum. Note the ascites.

Complex cysts

Some cysts may contain a thin septum, which is not a significant finding. Occasionally haemorrhage or infection may occur in a simple cyst, giving rise to low level, fine echoes within it (Fig. 4.2). Such cysts are usually treated conservatively although the larger ones may be monitored with ultrasound, particularly if symptomatic. Percutaneous aspiration of larger cysts under ultrasound guidance may afford temporary decompression but is rarely performed, as they invariably recur, and there is a risk of infection. Laparoscopic fenestration (deroofing) in which part of the cyst wall is removed allowing drainage, provides a more permanent solution to large, symptomatic cysts.¹

Fig. 4.2 • Large, infected hepatic cyst containing low-level echoes.

A rare cause of a cystic lesion in the liver is the cystadenoma – a benign epithelial tumour which may appear uni- or multilocular. These have a pre-malignant potential, rarely progressing to form a cystadenocarcinoma. Close monitoring with ultrasound will demonstrate gradual increase in size, changes in the appearances of the wall of the cyst, such as thickening or papillary projections, and internal echoes in some cases, which may indicate malignant change. Cystic malignant liver lesions are uncommon, and the majority represent necrotic metastases, but it is extremely important to recognize suspicious malignant features such as solid nodules or thickened walls and septations (Fig. 4.3). A diagnostic aspiration may be performed under ultrasound guidance, and the fluid may contain elevated levels of carcinoembryonic antigen (CEA) if malignant.² Cystadenomas are usually surgically removed due to their malignant potential (Fig. 4.4).

Fig. 4.3 • Small cyst adjacent to the gallbladder containing a nodule. This was a mucinous metastasis from an ovarian carcinoma.

Fig. 4.4 • (A) Large cystadenoma containing echoes and a septum. The cyst was large enough to cause obstructive jaundice – the patient’s presenting symptom. The diagnosis was made by ultrasound-guided aspiration. A small nodule is present (arrow) which raises the suspicion for malignancy, and the cyst subsequently developed into a cystadenocarcinoma.

(B) A cystadenocarcinoma in a young woman presenting with altered LFTs, demonstrating the complex nature of the mass.

(C) MRI of the case in (B).

(Di) A rare primary neuroendocrine tumour of the liver, demonstrating a large complex mainly cystic lesion, diagnosed with US guided biopsy.

(Dii) CT is valuable in indicating the extent of the disease.

Rarely, cystic lesions in the liver may be due to other causes. These include pancreatic pseudocyst (within an interlobular fissure) in patients with acute pancreatitis or mucin-filled metastatic deposits in primary ovarian cancer. An AV malformation – a rare finding in the liver – may look like a septated cystic lesion. Doppler, however, will demonstrate flow throughout the structure.

Polycystic liver

There is a fine dividing line between a liver that contains multiple simple cysts and ‘polycystic liver disease’. The latter usually occurs with polycystic kidneys, a common autosomal dominant condition readily recognizable on ultrasound (see Chapter 7), but rarely may affect the liver alone, sparing the kidneys (Fig. 4.5). The appearances are of multiple, often septated cysts, of varying sizes throughout the liver. The cumulative enhancement behind the numerous cysts imparts a highly irregular echogenicity to the liver texture and may make it extremely difficult to pick up other focal lesions which may be present.

Fig. 4.5 • Multiple cysts enlarging the left lobe of liver in autosomal dominant polycystic kidney disease.

The polycystic liver is usually asymptomatic, but easily palpable, and if the kidneys are also affected the abdomen can look very distended. As with cysts in the kidneys, haemorrhage or infection in a cyst can cause localized pain. Treatment of the cysts by drainage is not successful, and in rare cases, hepatic transplantation offers the only viable option in patients with intractable symptoms.

Hydatid (echinococcal) cyst

Hydatid disease comes from a parasite, Echinococcus granulosus, which is endemic in the Middle East and in sheep-farming areas but rare in the UK. The worm lives in the alimentary tract of infected dogs, which excrete the eggs. These may then be ingested by cattle or sheep and subsequently complete their lifecycle in a human. The parasite spreads via the bloodstream to the liver, where it lodges, causing an inflammatory reaction. The resulting cyst can be slow growing and asymptomatic and they may be single or multiple, depending on the degree of infestation.

Ultrasound may demonstrate a spectrum of appearances, from cystic through to solid, and the diagnosis can be made by looking carefully at the wall and contents; the hydatid cyst has two layers to its capsule, which may appear thickened, separated or detached on ultrasound. Daughter cysts may arise from the inner capsule – the honeycomb or cartwheel appearance (Fig. 4.6) and the cyst may contain floating membranes and fine sand or debris.³ A calcified rind around a cyst is usually associated with an old, inactive hydatid lesion.

Fig. 4.6 • Hydatid cyst demonstrating surrounding daughter cysts.

The diagnosis of hydatid, as opposed to a simple cyst, is an important one, as any attempted aspiration may spread the parasite further by seeding along the needle track if the operator is unaware of the diagnosis. Hydatids may be treated successfully using percutaneous ultrasound guided aspiration with sclerotherapy although surgical resection is necessary for some cases.⁴

Abscesses

Liver abscesses result from bacterial, fungal or parasitic infection. The most common are pyogenic abscesses secondary to abdominal infection – for example cholangitis (via the biliary tree), diverticulitis or appendicitis (via the portal vein). Diabetic patients and those with compromised immune response are particularly prone to such infections.

Ultrasound appearances

Hepatic abscesses may display a spectrum of acoustic features. Their internal appearances vary considerably; in the very early stages there is a zone of infected, oedematous liver tissue which appears on ultrasound as a hypoechoic, solid focal lesion. As the infection develops, the liver tissue becomes necrotic and liquefaction takes place. The abscess may still appear full of homogeneous echoes from pus and can be mistaken for a solid lesion, but as it progresses, the fluid content may become apparent, usually with considerable debris within it. Because they are fluid-filled, abscesses demonstrate posterior enhancement (Fig. 4.7A). The margins of an abscess are irregular, often ill-defined and frequently thickened. The inflammatory capsule of the abscess may demonstrate vascularity on colour or power Doppler, but this is not invariable, and depends on equipment sensitivity and size of the lesion. Infection with gas-forming organisms may account for the presence of gas within some liver abscesses (Fig. 4.7B).

Fig. 4.7 • (A) Early stages of a pyogenic abscess in a transplanted liver. The lesion looks quite solid, but note the posterior enhancement.

(B) The gas contained within this large abscess in the right lobe of the liver obscures the full extent of the lesion. (Large abscesses like this, which contain gas, may mimic the acoustic appearances of normal bowel.)

(C) A percutaneous drain put into a liver abscess under ultrasound guidance.

(D) A resolving abscess (arrows) demonstrates calcification, with no liquefied content.

(E) Two abscesses in a patient on immunosuppression.

(F) CEUS of the case in E demonstrates a third smaller abscess (arrow) not visible pre-contrast.

(G) CT confirms multiple abscesses.

There are three main types of abscess.

Pyogenic abscess

These form as a result of infection entering the liver through the portal venous system. Most commonly, appendiceal or diverticular abscesses are responsible, but intrahepatic abscesses are also seen in immunosuppressed patients and following post-operative infection.

Pyogenic abscesses are frequently multiple, and the patient must be closely monitored after diagnosis to prevent rapid spread. They are still considered a lethal problem, which has increased in recent years due to increasingly aggressive surgical approaches to many abdominal neoplasms.⁵

Amoebic abscess

This is a parasitic infection which is rare in the UK, but found frequently in parts of Africa, India and the southern parts of the USA. Increasing worldwide travel means a more frequent recognition of such lesions with ultrasound,⁶ and suspicion should be raised when the patient has visited these countries. It is usually contracted by drinking contaminated water and infects the colon, ulcerating the wall and subsequently being transported to the liver via the portal venous system.

About 25% of infected patients form hepatic abscesses and the infection may spread to other sites in the abdomen. Following initial ultrasound, CT is necessary to identify extrahepatic disease.

Candidiasis abscess

This is a fungal infection which may be seen in immunosuppressed patients. It is a rare cause of abscess formation and is usually bloodborne. The resulting abscesses are likely to be small but multiple on presentation.

Management of hepatic abscesses

An ultrasound guided aspiration to obtain pus for culture is useful for identifying the responsible organism. Aspiration combined with antibiotic therapy is usually highly successful for smaller abscesses, and ultrasound is used to monitor the resolution of the abscesses in the liver. Ultrasound-guided drainage is used for large lesions, and surgical removal is rarely required.

Further radiology may be indicated to establish the underlying cause and extent of infection, e.g. barium enema or CT, particularly if amoebic infection is suspected.

Haematoma

A haematoma is the result of trauma (usually, therefore, via the emergency department) but the trauma may also be iatrogenic, e.g. following a biopsy procedure (hence the value of using ultrasound guidance to avoid major vessels in the liver) or surgery. The liver haematoma may have similar acoustic appearances to those of an abscess but does not share the same clinical features or history (Fig. 4.8).

Fig. 4.8 • (A) Intrahepatic haematoma following a road traffic accident with rib fractures. The lesion is relatively fresh and contains some low level echoes.

(B) A subphrenic haematoma displaces the liver inferiorly.

The acoustic appearances depend upon the timing – a fresh haematoma may appear liquid and hypoechoic, but rapidly becomes more ‘solid’ looking and hyperechoic, as the blood clots. As it resolves the haematoma liquefies and may contain fibrin strands. It will invariably demonstrate a band of posterior enhancement and has irregular, ill-defined walls in the early stages. Later on it may encapsulate, leaving a permanent cystic ‘space’ in the liver, and the capsule may calcify. Injury to the more peripheral regions may cause a subcapsular haematoma which demonstrates the same acoustic properties. The haematoma outlines the surface of the liver and the capsule can be seen surrounding it. This may be the cause of a palpable ‘enlarged’ liver (Fig. 4.8B).

Intervention is rarely necessary and monitoring with ultrasound confirms eventual resolution. More serious hepatic ruptures, however, causing haemoperitoneum, may require surgery. CEUS is useful in demonstrating the extent of injury and is particularly useful in the absence of a haemoperitoneum (see Chapter 10, Fig. 10.1) (Table 4.1).

Table 4.1 Cystic focal liver lesions – differential diagnoses

Haemangioma

This is the most common, solid benign tumour found in the liver. Haemangiomas are highly vascular, composed of a network of tiny blood vessels. They may be solitary or multiple. Most haemangiomas are small and found incidentally. They are rarely symptomatic but do cause a diagnostic dilemma, as they can be indistinguishable from liver metastases.

Their acoustic appearances vary; the majority are hyperechoic, rounded well-defined lesions, but they may also be hypoechoic or of mixed echogenicity. In patients with fatty livers, the haemangioma frequently looks hypoechoic relative to the background of the hyperechoic hepatic parenchyma. Larger ones can demonstrate a spectrum of reflectivity depending on their composition, and may demonstrate pools of blood and central areas of degeneration. They frequently exhibit slightly increased through-transmission, with posterior enhancement, particularly if large. This is probably due to the increased blood content compared with the surrounding liver parenchyma (Fig. 4.9).

Fig. 4.9 • (A) A typical haemangioma in segment VI of the liver demonstrates hyperechogenicity with well-defined borders.

(Bi) Administration of contrast demonstrates characteristic peripheral nodular enhancement in the arterial phase.

(Bii) The lesion gradually takes up contrast to become isoechoic with background liver in the sinusoidal contrast phase confirming a benign haemangioma.

(C) An atypical haemangioma appears hypoechoic on a background of fatty liver. CEUS confirmed its benign nature.

(D) Multiple tiny haemangiomas throughout the liver.

As with many lesions, colour or power Doppler is too insensitive to pick up the slow flow in haemangiomas or to assist with lesion characterization. Microbubble contrast agents demonstrate a peripheral, globular enhancement with gradual centripetal filling to become isoechoic with the background liver in the sinusoidal phase.⁷ CEUS frequently provides a definitive diagnosis at the time of scanning, reassuring the patient and obviating the need for further imaging of follow-up (Fig. 4.9).

When found in children, haemangiomas tend to be large and do produce symptoms. These masses produce shunting of blood from the aorta via the main hepatic artery and, in extreme cases, present with resulting cardiac failure. They are often heterogeneous in appearance and larger vessels within them may be identified with Doppler. Although many regress over a period of time, others may have to be embolized with coils under radiological guidance to control the symptoms.

Focal nodular hyperplasia

Focal nodular hyperplasia (FNH) is the second most common solid, benign liver tumour. It is made up of a hyperplastic proliferation of liver cells with hepatocytes, Kupffer cells, biliary and fibrous elements. It is most commonly found in young women, and is usually discovered by chance, being asymptomatic. Its ultrasound characteristics vary, from hypo-, iso- to hyperechoic compared with background liver (Fig. 4.10) and it may be multifocal. As with the haemangioma, it presents a diagnostic dilemma when found on CT or ultrasound, as its characteristics vary. As with haemangioma, CEUS is extremely helpful in characterizing incidental FNH, as it usually displays rapid arterial stellate filling, followed by centripetal enhancement with contrast uptake isoechoic with background liver in the sinusoidal phase.⁸ It may, however, be difficult to differentiate from the rarer adenoma which also exhibits rapid arterialization on CEUS.⁹

Fig. 4.10 • FNH:

(A) In the left lobe (arrows). These are frequently almost isoechoic with normal liver tissue.

(B) Following administration of microbubble contrast agent, FNH displays a ‘spoked-wheel’ pattern of vascular enhancement during the early arterial phase.

(C) The same lesion seconds later, showing a central scar.

(Di) A tiny FNH (arrow) (Dii) blushes rapidly in the arterial phase of contrast administration and (Diii) becomes isoechoic with background liver in the sinusoidal phase.

(E) Another example of an FNH, almost isoechoic with background liver.

Management of this benign mass is usually conservative, but surgical resection may be necessary in larger lesions.

Adenoma

The hepatic adenoma is a benign focal lesion consisting of a cluster of atypical liver cells (Fig. 4.11). Within this, there may be pools of bile or focal areas of haemorrhage or necrosis. This gives rise to a heterogeneous, patchy echotexture. The smaller ones tend to be homogeneous with a smooth texture. Their lipid content causes a tendency to be hyperechoic, although usually less reflective than a haemangioma, and many have similar reflectivity to the surrounding liver parenchyma.

Fig. 4.11 • (A) Adenoma in segment V of the liver in a young woman on the contraceptive pill.

(B) An unusual example of cystic degeneration in a large adenoma.

Focal fatty change

Not a ‘lesion’ as such, but included here due to its focal appearance. It may pose a diagnostic dilemma on initial ultrasound.

Focal fatty infiltration

Fatty infiltration of the liver is a common occurrence which may affect the whole, or part of the liver. It is associated with obesity and alcoholism, and can also occur in pregnancy, diabetes and with certain drugs.

The deposition of fat confined to certain focal areas of the liver is related to the blood supply to that area. Fatty infiltration increases the reflectivity of the parenchyma, making it hyperechoic. This can simulate a focal mass, such as a metastasis. Unlike a focal lesion however, it does not display any mass effect and the course of related vessels remains constant. It tends to have a characteristic straight-edged shape, rectangular or ovoid, corresponding to the region of local blood supply (Fig. 4.12). Foci of fatty change may be multiple, or may affect isolated liver segments. The most common sites are in segment IV around the porta, in the caudate lobe (segment I) and in the posterior area of the left lobe (segment III).

Fig. 4.12 • (A) Focal fatty change (arrow) can mimic a focal lesion.

(B) Focal fatty sparing in a characteristic position just anterior to the gallbladder.

(Ci) Focal fatty change in the right lobe of liver demonstrates a hepatic vein passing through it, (Cii) with no mass effect.

(Di) An irregular focal lesion in segment VI in a patient with cirrhosis is suspicious for hepatocellular carcinoma (HCC). (Dii) CEUS demonstrates normal contrast take up in the arterial, portal and sinusoidal phases, with no mass seen, confirming focal fatty change.

CEUS is useful and accurate in differentiating focal fatty change from a true lesion, as the contrast uptake is identical to background liver, and the contrast convincingly demonstrates the lack of mass effect (Fig. 4.12D) This technique usually obviates the need for further imaging in focal fatty change.

Granuloma

Granulomas are benign liver masses which are associated with chronic inflammatory liver diseases. They have a particular association with primary biliary cirrhosis, sarcoidosis or tuberculosis. They may be multiple and small, in which case the liver often looks coarse and hyperechoic. More often they are small discrete lesions which may be hypo- or isoechoic, sometimes with a hypoechoic rim like a target, or calcified with distal shadowing (Fig. 4.13). They can undergo central necrosis.

Fig. 4.13 • A calcified granuloma demonstrates acoustic shadowing.

Differential diagnoses include metastases or regenerating nodules, and their appearance on ultrasound is non-specific.

Hepatic calcification

Calcification occurs in the liver as a result of some pathological processes, and may be seen following infection or parasitic infestation. It may be focal – usually the end stage of a previous abscess, haematoma or granuloma – which usually indicates that the lesion in question is no longer active. It may also be seen within some metastases. Calcification may also be linear in nature, following the course of the portal tracts. This can be associated with old tuberculosis or other previous parasitic infestations such as schistosomiasis¹¹ (Fig. 4.14).

Fig. 4.14 • Considerable deposits of calcification are seen in the liver in this patient with nephrotic syndrome.

Occasionally hepatic calcification is seen in children or in the fetus. This is usually not a significant finding but pre-natal infection should be excluded with a TORCH screen.

Calcification, which casts a strong and definite shadow should be distinguished from air in the biliary tree (Fig. 3.46), which casts a reverberative shadow and is usually associated with previous biliary interventions, such as ERCP, sphincterotomy or stent placement.

Metastases

The liver is one of the most common sites to which malignant tumours metastasize. Secondary deposits are usually bloodborne, spreading to the liver via the portal venous system (e.g. in the case of gastrointestinal malignancies) or hepatic artery (e.g. lung or breast primaries,) or spread via the lymphatic system. Some spread along the peritoneal surfaces – for example ovarian carcinoma. This demonstrates an initial invasion of the subserosal surfaces of the liver (see Fig. 4.16A below), as opposed to the more central distribution seen with a haematogenous spread (see Fig. 4.16B below). The former, peripheral pattern is more easily missed on ultrasound because small deposits are often obscured by near-field artefact or rib shadows. It is therefore advisable for the operator to be aware of the possible pattern of spread when searching for liver metastases.

Ultrasound appearances

The acoustic appearances of liver secondaries are extremely variable (Figs 4.15, 4.16). When compared with normal surrounding liver parenchyma, metastases may be hyperechoic, hypoechoic, isoechoic or of mixed pattern. It is not possible to characterize the primary source by the acoustic properties of the metastases.

Fig. 4.15 • The mass effect

(A) A large isoechoic lesion (arrows), displaces the middle hepatic vein (arrowhead).

(B) Colour flow of the same case.

Fig. 4.16 • Examples of liver metastases:

(A) Peripheral, hypoechoic secondary deposits due to peritoneal spread from a primary ovarian carcinoma.

(B) Bloodborne metastases from bowel carcinoma are distributed throughout the liver.

(C) Solitary isoechoic metastasis, confirmed on MRI. Isoechoic metastases are easy to miss, and the use of CEUS is invaluable in demonstrating them.

(D) Large hyperechoic metastasis occupying segment VII of the right lobe. Note also the right pleural effusion.

(E) A necrotic metastasis, demonstrating posterior acoustic enhancement.

(F) Calcified metastases from breast carcinoma.

(Gi, Gii), Pre- and Post CEUS. Following administration of microbubble contrast agent, numerous metastases are discovered. These appear hypoechoic in the late portal venous phase, with no contrast uptake.

(Hi, Hii) Pre- and Post CEUS of a solitary metastasis in a patient who has undergone surgery for bowel carcinoma.

(J) Normal CEUS in a patient at risk of liver metastases. Contrast take up is homogeneous throughout the liver in the sinusoidal phase with no evidence of lesions. CEUS greatly increases the confidence in a negative scan.

Metastases tend to be solid with ill-defined margins. Some metastases, particularly the larger ones, contain fluid as a result of central necrosis (Fig. 4.16E), or because they contain mucin, for example from some ovarian primaries. Occasionally, calcification is seen within a deposit, causing distal acoustic shadowing, and this may also develop following treatment with chemotherapy. In some diseases, for example lymphoma, the metastases may be multiple but tiny – not immediately obvious to the operator as discrete focal lesions but as a coarse-textured liver (Fig. 4.16F). This type of appearance is non-specific and could be associated with a number of conditions, both benign and malignant.

Diagnosis of focal liver lesions, such as metastases, is made more difficult when the liver texture is diffusely abnormal or when there are dilated intrahepatic ducts, because the altered transmission of sound through the liver masks small lesions. Other possible ultrasound features associated with metastases include a lobulated outline to the liver, hepatomegaly and ascites.

If the finding of liver metastases is unexpected, or the primary has not been identified, it is useful to complete a full examination to search for a possible primary carcinoma and to identify other sites of carcinomatous spread. Lymphadenopathy (particularly in the para-aortic, para-caval and portal regions) may be demonstrated on ultrasound, as well as invasion of adjacent blood vessels and disease in other extrahepatic sites including spleen, kidneys, omentum and peritoneum. CT is the usual next step, to identify a possible primary site and to stage the disease, in particular demonstrating extra-hepatic disease which is often not seen on ultrasound.

Doppler is unhelpful in characterizing liver metastases, most of which appear poorly vascular or avascular. Fundamental non-contrast ultrasound lacks sensitivity in the diagnosis of liver metastases, as many lesions are either isoechoic, or small (subcentimetre) rendering them almost invisible. The use of microbubble contrast agents radically improves both the characterization and detection of metastatic deposits on ultrasound.¹² The injection of a bolus of contrast agent when viewed using pulse-inversion demonstrates variable vascular phase enhancement in the arterial and portal phases, but the sinusoidal phase invariably lacks contrast uptake (Fig. 4.16G, H). This is a particularly useful technique as it increases the contrast resolution between metastasis and background liver, meaning that even subcentimetre lesions are reliably demonstrated.

CEUS also increases the operator’s confidence in the absence of metastases, particularly in cases with altered LFTs and prior history of malignancy (Fig. 4.16J). This is useful in obviating the need for further imaging in normal livers.

Clinical features and management

Many patients present with symptoms from their liver deposits, rather than the primary carcinoma. The demonstration of liver metastases on ultrasound may often prompt further radiological investigations for the primary. The symptoms of liver deposits may include non-obstructive jaundice, obstructive jaundice (which may occur if a large mass is present at the porta), hepatomegaly, right-sided pain, increasing abdominal girth from ascites and altered LFTs.

Ultrasound-guided biopsy may be useful in diagnosing the primary and complements further imaging such as X-rays and contrast bowel studies. Accurate staging of the disease is performed with CT, MRI and/or PET-CT,¹³ which have improved sensitivity for identifying extrahepatic and systemic disease, such as peritoneal deposits and lymphadenopathy, and which can more accurately demonstrate adjacent spread of primary disease.

The prognosis for most patients with liver metastases has traditionally been poor, particularly if multiple, and depends to a large extent on the origin of the primary carcinoma. A regime of surgical debulking (removal of the primary carcinoma, adjacent invaded viscera, lymphadenopathy etc.) together with chemotherapy can slow down the progress of the disease. Increasingly, however, there are treatment options which result in increased, good quality survival and, in some cases, cure. This makes it important that secondary disease is diagnosed early and accurately in order to offer patients a significant chance of survival.

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