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January 2024

Should We Report Incidental Low-Density Liver Lesions with Benign Features?
Journal Watch by Helen O’Brien

Should We Report Incidental Low-Density Liver Lesions with Benign Features? A Retrospective Single-Centre Analysis of Trauma CT scans

Bob Zhang,Prasanna Ratnakanthan, Maryam Shekarforoush, Warren Clements

Journal of Gastrointestinal and Abdominal Radiology 2021; 04(01): 024-027.

DOI: 10.1055/s-0040-1718250

Increasingly cross-sectional imaging detects incidental liver lesions. While many have characteristic benign imaging appearances, some are indeterminate which pose a dilemma for follow up and further management. Over investigation can have a significant impact on patients and health care systems.   This study investigated the frequency of incidental liver lesions on trauma CT scans, the additional imaging investigations performed for hypodense lesions with benign imaging features, and whether differences in reporting influenced follow-up.

A retrospective single-centre analysis of 3,595 body trauma CT scans was performed over a 15-month period in a major Australian centre. Incidental liver lesions were identified in 527 (15%) patients, with 347 (10%) fulfilling the inclusion criteria of low-density liver lesions. 311 of 347 (90%) were reported likely benign with 36 (10% ) either indeterminate or with no diagnosis offered. Additional imaging was requested by the referring doctor for 43 out of 285 patients (15%) when lesions were mentioned only in the body of the report, compared with 41 out of 62 patients (66%) when mentioned in the conclusion (odds ratio [OR] = 10.99, p < 0.0001). When additional imaging was recommended in the report, follow-up was arranged for 36 out of 52 patients (69%), compared with 48 out of 295 patients with liver lesions (16%) when it was not suggested (OR = 11.58, p < 0.0001).

Follow up was incomplete because of local referral practices. While 84/347 patients had some follow-up imaging arranged, only 24 had local reports available for review. It is unclear how many of the ‘indeterminate’ group were evaluated for outcomes.

The paper concludes that significantly higher rate of follow up occurred if; the liver lesion is mentioned in conclusion (66% vs 18%, OR = 10.99, p < 0.0001); if further investigations are suggested in the report (69% vs 16%, OR = 11.58, p < 0.0001); and that small nonaggressive lesions less than 30 HU should not be followed-up in the absence of known extra-hepatic malignancy or preexisting hepatic risk factors.

Limitations apply to generalisability from this retrospective study and the high rate of lesions lost to follow up, particularly for the ‘indeterminate/no diagnosis offered’ group. A central expert assessment of the liver lesions detected on CT could have determined whether local radiology assessment was accurate. It would have also been attractive to use this data to influence local radiology and clinical practice and to reaudit the outcomes to look for quality improvement.

In conclusion, this paper indicates that radiologists should report benign liver lesions clearly and unequivocally to prevent over investigation and wasted resource. This is a particular risk when such lesions are included inappropriately in the conclusion of reports or where additional investigations are recommended for benign irrelevant liver lesions by radiologists. Radiologists must be responsible to prevent inappropriate over investigation.


Helen O’Brien graduated MBChB from the University of Aberdeen in Scotland. She completed radiology training in the Severn Deanery in England and in Aberdeen in the Scotland North Deanery. She achieved her Fellowship of the Royal College of Radiologists and certificate for completion of training (CCT) in radiology. During training, she developed a love for abdominal radiology and non-vascular intervention and is completing a Fellowship in GI Radiology at St James’s University Hospital in Leeds, England.