European Journal of Cardiovascular Medicine

Hepatobiliary masses encompass a wide spectrum of benign and malignant lesions involving the liver, gallbladder, and biliary tree. Accurate and timely diagnosis is crucial for effective management and improved patient outcomes. The liver, due to its dual blood supply and complex parenchymal architecture, poses diagnostic challenges, especially in differentiating between lesions with overlapping imaging characteristics (1).

Imaging plays a pivotal role in the detection, characterization, staging, and follow-up of hepatobiliary masses. Among various imaging modalities, multidetector computed tomography (MDCT) has gained prominence due to its rapid acquisition, high spatial resolution, and capacity for multiphasic evaluation (2). Triple-phase MDCT, comprising arterial, portal venous, and delayed phases, enables dynamic evaluation of lesion vascularity, which is particularly useful in identifying hypervascular tumors like hepatocellular carcinoma (HCC) and hypovascular tumors such as cholangiocarcinoma and metastases (3,4).

The arterial phase helps in visualizing hypervascular lesions, while the portal venous and delayed phases assist in detecting washout patterns, lesion margins, and associated vascular or biliary involvement. These imaging characteristics are often diagnostic and can eliminate the need for invasive procedures in many cases (5). Moreover, MDCT aids in assessing the resectability of lesions by providing detailed anatomical mapping of hepatic vasculature and biliary structures.

Given the increasing burden of hepatic and biliary malignancies, especially in regions with high prevalence of chronic liver disease, there is a need for precise and non-invasive diagnostic tools. This study aims to evaluate the diagnostic accuracy and clinical utility of triple-phase MDCT in the assessment of hepatobiliary mass lesions, correlating imaging findings with histopathological diagnosis or clinical follow-up.

This prospective observational study was conducted in the Department of Radiodiagnosis over a period of 24 months. A total of 60 patients with clinical suspicion of hepatobiliary mass lesions were enrolled after obtaining informed consent.

Inclusion criteria consisted of patients aged above 18 years presenting with right upper quadrant pain, jaundice, weight loss, abdominal mass, or abnormal liver function tests suggestive of hepatobiliary pathology. Patients who had undergone ultrasonography showing space-occupying lesions in the liver or biliary tract were also included.

Exclusion criteria were patients with known contrast allergies, renal insufficiency (serum creatinine >1.5 mg/dL), pregnant women, and those who had previously undergone hepatobiliary surgery or interventional procedures.

All patients underwent triple-phase contrast-enhanced MDCT using a 64-slice scanner. The scanning protocol included unenhanced, arterial, portal venous, and delayed phases. Non-ionic iodinated contrast (approximately 1.5 mL/kg body weight) was administered intravenously using a power injector at a rate of 3–4 mL/s. Bolus tracking was employed with the region of interest placed on the abdominal aorta to initiate the arterial phase at optimal enhancement. The portal venous phase was acquired at 60–70 seconds post-injection and the delayed phase at approximately 180 seconds.

Images were reconstructed in axial, coronal, and sagittal planes and analyzed by two experienced radiologists independently. The following imaging features were evaluated: lesion size, number, location, enhancement pattern across all phases, margins, vascular invasion, biliary obstruction, calcifications, and presence of satellite nodules or metastasis.

Final diagnoses were confirmed by histopathological examination (biopsy or surgical specimen) or clinical follow-up in cases where biopsy was not feasible. The diagnostic performance of triple-phase MDCT was assessed by calculating sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and overall accuracy using standard statistical methods.

A total of 60 patients were evaluated, comprising 37 males (61.7%) and 23 females (38.3%), with a mean age of 52.4 ± 12.1 years (range: 25–78 years). The majority of the patients (n=38; 63.3%) had malignant hepatobiliary lesions, while 22 cases (36.7%) were benign in nature.

The most common malignant lesion identified was hepatocellular carcinoma (HCC), accounting for 52.6% (n=20) of the malignant cases. Other malignant lesions included cholangiocarcinoma (n=10; 26.3%) and hepatic metastases (n=8; 21.1%). Among benign lesions, hemangiomas (n=9; 40.9%) and simple hepatic cysts (n=7; 31.8%) were predominant (Table 1).

Table 1: Distribution of Hepatobiliary Lesions (n = 60)

Triple-phase MDCT revealed characteristic enhancement patterns aiding diagnosis. Arterial phase hyperenhancement followed by washout in the portal phase was observed in 85% of HCC cases. Cholangiocarcinomas showed peripheral or delayed enhancement in 80% of cases, while hemangiomas typically exhibited peripheral nodular enhancement with progressive centripetal fill-in (Table 2).

Table 2: Enhancement Patterns of Hepatobiliary Lesions on Triple-Phase MDCT

The diagnostic performance of MDCT was evaluated by comparing imaging findings with histopathology or clinical follow-up. Triple-phase MDCT demonstrated a sensitivity of 92.1%, specificity of 86.3%, positive predictive value (PPV) of 90%, negative predictive value (NPV) of 84%, and overall accuracy of 89% in detecting malignant lesions (Table 3).

Table 3: Diagnostic Accuracy of Triple Phase MDCT

These findings underscore the utility of triple-phase MDCT in providing detailed vascular and morphological evaluation of hepatobiliary masses, aiding in early differentiation between benign and malignant lesions (Table 1, Table 2, Table 3).

Triple-phase multidetector computed tomography (MDCT) has become a cornerstone in the non-invasive diagnosis and characterization of hepatobiliary mass lesions. The present study demonstrated that MDCT provides high sensitivity and specificity in differentiating between benign and malignant liver and biliary tract lesions, with an overall diagnostic accuracy of 89%. These findings are consistent with prior research emphasizing the clinical utility of multiphasic imaging in liver lesion assessment (1,2).

Hepatocellular carcinoma (HCC), the most frequent primary hepatic malignancy, typically exhibits arterial phase hyperenhancement followed by portal venous phase washout—features that were evident in 85% of the HCC cases in our study. This classical enhancement pattern remains a key radiological criterion for HCC diagnosis, especially in cirrhotic livers, as endorsed by the Liver Imaging Reporting and Data System (LI-RADS) (3,4). Previous studies have reported similar enhancement patterns in 70–90% of HCC cases, supporting our findings (5,6).

Cholangiocarcinoma, the second most common primary hepatic malignancy, usually appears hypovascular on arterial phase imaging and demonstrates progressive or delayed enhancement due to its fibrous stroma (7,8). In our study, 80% of cholangiocarcinoma cases exhibited delayed enhancement, aligning with previous literature suggesting that this feature can aid in distinguishing it from HCC and metastases (9,10).

Hepatic metastases, especially from colorectal or breast primaries, displayed variable enhancement depending on the origin. Our findings indicated rim enhancement and irregular margins in most metastatic lesions, which is in agreement with earlier observations that such patterns are typical of hypovascular metastases (11,12). Hemangiomas, the most common benign liver tumors, were readily identified by their peripheral nodular enhancement with centripetal fill-in—seen in 100% of cases in our series. This enhancement behavior remains pathognomonic and has been consistently reported across multiple studies (13,14).

The strength of MDCT lies in its ability to provide high-resolution multiphasic imaging, which enables visualization of both morphological and hemodynamic characteristics of hepatic lesions. Its role extends beyond diagnosis to include surgical planning, particularly in assessing vascular invasion, lobar involvement, and biliary obstruction (15).

Despite its advantages, MDCT does have limitations. Small lesions (<1 cm), especially in cirrhotic livers, may be missed or remain indeterminate. Additionally, radiation exposure and contrast nephropathy are important considerations, particularly in elderly or renally compromised patients (3,6). Nevertheless, with appropriate patient selection and adherence to scanning protocols, these risks can be minimized.

In conclusion, the findings of this study support the established role of triple-phase MDCT as a reliable, rapid, and non-invasive modality for the comprehensive evaluation of hepatobiliary lesions. Its diagnostic accuracy, especially in differentiating benign from malignant lesions, highlights its significance in routine clinical practice.

1. Stehlík L, Di Tommaso M, Del Signore F, Paninárová M, Terragni R, Magni T, et al. Triple-phase multidetector computed tomography in distinguishing canine hepatic lesions. Animals (Basel). 2020;11(1):11. doi:10.3390/ani11010011. PMID: 33374833.
2. Jones ID, Lamb CR, Drees R, Priestnall SL, Mantis P. Associations between dual-phase computed tomography features and histopathologic diagnoses in 52 dogs with hepatic or splenic masses. Vet Radiol Ultrasound. 2016;57(2):144–53. doi:10.1111/vru.12336. PMID: 26763951.
3. Leela-Arporn R, Ohta H, Shimbo G, Hanazono K, Osuga T, Morishita K, et al. Computed tomographic features for differentiating benign from malignant liver lesions in dogs. J Vet Med Sci. 2019;81(12):1697–704. doi:10.1292/jvms.19-0278. PMID: 31597816.
4. Kutara K, Seki M, Ishigaki K, Teshima K, Ishikawa C, Kagawa Y, et al. Triple-phase helical computed tomography in dogs with solid splenic masses. J Vet Med Sci. 2017;79(11):1870–7. doi:10.1292/jvms.17-0253. PMID: 28993600.
5. Francis IR, Cohan RH, McNulty NJ, Platt JF, Korobkin M, Gebremariam A, et al. Multidetector CT of the liver and hepatic neoplasms: effect of multiphasic imaging on tumor conspicuity and vascular enhancement. AJR Am J Roentgenol. 2003;180(5):1217–24. doi:10.2214/ajr.180.5.1801217. PMID: 12704026.
6. Colagrande S, Carmignani L, Pagliari A, Capaccioli L, Villari N. Transient hepatic attenuation differences (THAD) not connected to focal lesions. Radiol Med. 2002;104(1-2):25–43. PMID: 12386553.
7. Metser U, Haider MA, Dill-Macky M, Atri M, Lockwood G, Minden M. Fungal liver infection in immunocompromised patients: depiction with multiphasic contrast-enhanced helical CT. Radiology. 2005;235(1):97–105. doi:10.1148/radiol.2351031210. PMID: 15731367.
8. Kim SH, Lee WJ, Lim HK, Lim JH. Prediction of viable tumor in hepatocellular carcinoma treated with transcatheter arterial chemoembolization: usefulness of attenuation value measurement at quadruple-phase helical computed tomography. J Comput Assist Tomogr. 2007;31(2):198–203. doi: 10.1097/01.rct.0000236424.20514.2e. PMID: 17414753.
9. Gulpinar B, Peker E, Kul M, Elhan AH, Haliloglu N. Liver metastases of neuroendocrine tumors: is it possible to diagnose different histologic subtypes depending on multiphasic CT features? Abdom Radiol (NY). 2019;44(6):2147–55. doi:10.1007/s00261-019-01963-y. PMID: 30863999.
10. Azizaddini S, Mani N. Liver Imaging. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Feb 20–. PMID: 32491392.
11. Patel BN, Rosenberg M, Vernuccio F, Ramirez-Giraldo JC, Nelson R, Farjat A, et al. Characterization of small incidental indeterminate hypoattenuating hepatic lesions: added value of single-phase contrast-enhanced dual-energy CT material attenuation analysis. AJR Am J Roentgenol. 2018;211(3):571–9. doi:10.2214/AJR.17.19170. PMID: 30040464.
12. Hohmann J, Skrok J, Puls R, Albrecht T. Characterization of focal liver lesions with contrast-enhanced low MI real-time ultrasound and SonoVue. Rofo. 2003;175(6):835–43. doi:10.1055/s-2003-39923. PMID: 12811698.
13. Nakamura K, Takagi S, Sasaki N, Bandula Kumara WR, Murakami M, Ohta H, et al. Contrast-enhanced ultrasonography for characterization of canine focal liver lesions. Vet Radiol Ultrasound. 2010;51(1):79–85. doi:10.1111/j.1740-8261.2009.01627. x. PMID: 20166400.
14. Karmazanovsky GG, Buryakina SA, Kondratiev EV, Yang Q, Ruchkin DV, Kalinin DV. Value of two-phase dynamic multidetector computed tomography in differential diagnosis of post-inflammatory strictures from esophageal cancer. World J Gastroenterol. 2015;21(29):8878–87. doi:10.3748/wjg. v21.i29.8878. PMID: 26269677.
15. Kutara K, Seki M, Ishikawa C, Sakai M, Kagawa Y, Iida G, et al. Triple-phase helical computed tomography in dogs with hepatic masses. Vet Radiol Ultrasound. 2014;55(1):7–15. doi:10.1111/vru.12099. PMID: 24102918.