British Journal of Radiology 75 (2002),994-1002 © 2002 The British Institute of Radiology
Various causes of hepatic capsular retraction: CT and MR findings
D M Yang, MD
H S Kim, MD
S W Cho, MD
and
H S Kim, MD
Department of Radiology, Gachon Medical College Gil Medical Center, 1198, Guwol-Dong, Namdong-Gu, Incheon 405-760, South Korea
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Abstract
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Hepatic capsular retraction adjacent to hepatic tumour is rare, although this finding has been described in a variety of malignant tumours and haemangioma. The authors have seen various causes of hepatic capsular retraction associated with hepatic tumours, including a variety of malignant tumours, haemangioma and post-treatment of malignant tumours, as well as cases not associated with a hepatic tumour, including confluent hepatic fibrosis, oriental cholangiohepatitis and bile duct necrosis. Furthermore, causes of pseudoretraction of the hepatic capsule, including accessory fissure and normal liver parenchyma between the protruded masses, are described.
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Introduction
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Retraction of the liver capsule is an unusual CT or MR finding associated with a variety of tumours [1–6] (Table 1
). The prevalence of capsular retraction adjacent to hepatic tumour has been reported as 2–2.8% [1, 2]. This capsular retraction is due to necrosis and desmoplastic reaction within the tumour, which distorts the tumour margin and adjacent liver capsule [3]. Retraction of the liver capsule has been emphasized only in patients with hepatic tumour. However, this finding can be found in patients without a hepatic tumour, such as those with confluent hepatic fibrosis [7, 8]. Furthermore, the authors have seen a variety of causes of hepatic capsular retraction not associated with a hepatic tumour, including confluent hepatic fibrosis, oriental cholangiohepatitis and bile duct necrosis. In addition, pseodoretraction of the hepatic capsule, owing to invagination of the liver by the diaphragm and normal parenchyma between the protruded hepatic masses, is described. Therefore the authors suggest that two types of capsular retraction of the liver are possible: capsular retraction adjacent to a hepatic tumour; and capsular retraction not associated with a hepatic tumour. This article offers CT and MR findings of various causes of capsular retraction of the liver.
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Hepatic capsular retraction associated with hepatic tumour
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Malignant tumour
Retraction of the liver capsule adjacent to a hepatic tumour was first described in epithelioid haemangioendothelioma of the liver [4]. However, this finding has been reported in a variety of malignant tumours: hepatocellular carcinoma (Figure 1); fibrolamellar hepatocellular carcinoma; intrahepatic cholangiocarcinoma (Figure 2); and metastases [1–3]. In hepatic metastatic disease, a wide variety of primary tumours are associated with hepatic capsular retraction; including colon cancer (Figure 3), breast cancer (Figure 4), carcinoid tumour, lung cancer and gallbladder cancer [1–3]. Furthermore, the authors have encountered stomach cancer and pancreas cancer (Figure 5) as primary tumours with hepatic capsular retraction. Outwater [3] suggested that capsular retraction adjacent to a tumour reflects internal necrosis and desmoplasia within the tumour. Soyer et al [1] asserted that retraction of the liver capsule adjacent to a hepatic tumour is specific to malignant tumours.
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Figure 1. CT scan of a 66-year-old woman with hepatocellular carcinoma, obtained during the (a) arterial and (b) delayed phase of enhancement after injection of contrast material. This shows a heterogeneously enhanced mass with capsular retraction in the right hepatic lobe.
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Figure 2. Portal phase CT scan of a 56-year-old man with an intrahepatic cholangiocarcinoma shows a hypodense mass in the left hepatic lobe. There is a focal capsular retraction adjacent to the mass (arrow).
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Figure 3. Portal phase CT scan of a 74-year-old man with liver metastases from colon cancer shows multiple hypodense masses in both hepatic lobes. Hepatic capsular retraction is seen adjacent to the right hepatic mass.
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Figure 4. Portal phase CT scan of a 32-year-old woman with liver metastases from breast cancer shows focal hepatic capsular retraction adjacent to a right hepatic mass.
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Figure 5. (a) Portal and (b) delayed phase CT scans of a 65-year-old man with liver metastases from pancreas cancer show a hypodense mass with capsular retraction in the right hepatic lobe (arrow).
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Post-emblization of hepatocellular carcinoma
Transcatheter arterial chemoembolization (TACE) plays an important role in the treatment of hepatocellular carcinoma. Subsegmental TACE with a large amount of iodized oil evoked massive necrosis of the tumour and atrophy of surrounding liver parenchyma [9]. This tumour necrosis and severe atrophy of surrounding liver parenchyma caused capsular retraction of the liver (Figure 6).
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Figure 6. CT scan of a 62-year-old woman with hepatocellular carcinoma obtained 2 months post transcatheter arterial chemoembolization shows a focal capsular retraction of the right hepatic lobe and dense accumulation of iodized oil in the tumour.
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Post-chemotherapy of malignant tumour
The hepatotoxic effects of systemic chemotherapy include fatty infiltration of the liver, focal hepatitis, portal fibrosis, cirrhosis and hepatic necrosis [10]. Capsular retraction adjacent to tumour has been described in patients with hepatic metastases from carcinoid tumour treated by systemic chemotherapy [1]. Young et al [10] also reported hepatic capsular retraction in patients with metastatic breast carcinoma treated by chemotherapy. Additionally, they suggest that nodular regenerative hyperplasia is a possible mechanism for the development of a lobular hepatic contour [10]. In one patient with Hodgkin's disease, capsular retraction adjacent to tumour was noted following systemic chemotherapy 5 months later (Figure 7). The authors suggest that this finding is due to necrosis and fibrosis of the tumour by chemotherapy.
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Figure 7. 47-year-old man with Hodgkin's disease. (a) Portal phase CT scan shows a hypodense mass in the liver. (b) CT scan obtained 7 months after systemic chemotherapy shows capsular retraction of the liver. The size of the hepatic mass is decreased.
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Benign tumour
Retraction of the liver capsule adjacent to a hepatic tumour has been reported to be a specific sign for malignant hepatic tumours [1]. However, in recent reports, this finding has also been found in hepatic haemangioma, which is the most common benign tumour of the liver [5, 6]. Capsular retraction associated with hepatic haemangioma is due to central thrombosis and fibrosis of large vascular channels of this tumour [6], which is seen more often in larger haemangioma (Figure 8). All reported cases of haemangioma with capsular retraction were larger than 4 cm and were classified as giant haemangioma [5, 6].
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Figure 8. 51-year-old woman with a hepatic hemangioma. (a) Portal phase CT scan shows a hypodense mass with peripheral nodular enhancement in the right hepatic lobe. (b) Delayed phase CT scan shows progressive centripetal enhancement of the mass. Focal retraction of the liver capsule is seen adjacent to the hepatic mass (arrow).
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Hepatic capsular retraction not associated with hepatic tumour
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Confluent hepatic fibrosis
Focal confluent fibrosis can occur in the cirrhotic liver as a hepatic mass in approximately 14% of cases [7]. This fibrosis is accompanied by atrophy of the affected liver parenchyma and retraction of the overlying liver capsule (Figure 9). Confluent hepatic fibrosis usually appears as wedge-shaped with capsular retraction and usually involves the medial segment of the left lobe, the anterior segment of the right lobe, or both [7]. Confluent hepatic fibrosis is revealed on unenhanced CT as a low attenuated lesion that becomes isoattenuated or minimally hypoattenuated post contrast enhancement [8]. The differential diagnosis of confluent fibrosis includes hepatic infarction, hepatocellular carcinoma, cholangio- carcinoma and epithelioid haemangioendothelioma. An awareness of their characteristic location, shape and enhancement may be helpful in differentiating them from hepatic tumours [7, 8].
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Figure 9. 39-year-old man with confluent hepatic fibrosis. (a) Arterial phase CT scan shows a wedge-shaped, low attenuated lesion with retraction of the liver capsule in the right hepatic lobe (arrow). (b) On delayed phase CT, the lesion is isoattenuated to the liver parenchyma. (c) On T1 weighted MRI the lesion is lower signal intensity than the adjacent liver parenchyma. (d) On T2 weighted MRI, the lesion is hyperintense.
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Oriental cholangiohepatitis
Oriental cholangiohepatitis, also known as recurrent pyogenic cholangitis and intrahepatic pigment stone disease, is characterized by recurrent abdominal pain, fever and jaundice. Hepatic parenchymal atrophy is common. Kusano et al [11] described that hepatic atrophy is attributed to diminished portal venous flow, and the degree of portal vein obstruction in patients with oriental cholangiohepatitis has been correlated with the severity of liver atrophy. These changes usually involve the lateral segment of the left hepatic lobe and the posterior segment of the right hepatic lobe. We suggest that focal parenchymal atrophy in patients with oriental cholangiohepatitis may show capsular retraction of the liver (Figure 10).
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Figure 10. 63-year-old woman with oriental cholangiohepatitis. (a) Unenhanced CT scan shows high-attenuated stones in the bile ducts of the right hepatic lobe. (b) Arterial phase CT scan shows transient parenchymal enhancement and dilatation of the bile duct in the right hepatic lobe. Focal capsular retraction of the liver is noted (arrow). (c) On portal phase CT scan, the right hepatic parenchyma is homogeneous.
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Bile duct necrosis
Transcatheter arterial chemoembolization has been widely used in the treatment of hepatic tumours, particularly when the tumours are not surgically resectable. Various complications associated with TACE for hepatic tumours have been described. Bile duct necrosis is one of the complications arising from repeated TACE procedures. Yu et al [12] described ischaemic bile duct injury causing bile duct dilatation, marked narrowing or obliteration of the adjacent intrahepatic portal vein branches and subsequent parenchymal atrophy (Figure 11). Additionally, they stated that the mean time between TACE and the appearance of atrophic changes on CT was 20 weeks.
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Figure 11. 53-year-old man with hepatocellular carcinoma post-transcatheter arterial chemoembolization (TACE). (a) Portal phase CT scan shows dense accumulation of iodized oil in the right hepatic mass (arrow). (b, c) T2 weighted MR images obtained 5 months post-TACE with an emulsion of 30 mg of adriamycin and 3 ml of iodized oil, shows a dilatation of right intrahepatic bile ducts. This finding suggests bile duct necrosis as a complication of TACE. The right hepatic mass, with retention of iodized oil, is hypointense (arrow). (d, e) On dynamic fast low angle shot (FLASH) MR images obtained 30 s after injection of contrast media, the right hepatic mass is not enhanced (arrow). (f) Portal phase CT scan obtained 19 months post-TACE shows severe atrophy of hepatic parenchyma and a capsular retraction in the right hepatic lobe (arrow).
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Pseudoretraction of the hepatic capsule
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Invagination of the liver by the diaphragm may mimic capsular retraction of the liver [13] (Figure 12). These accessory fissures are limited to the superior aspect of the liver, near the diaphragmatic dome. Furthermore, the normal liver parenchyma between the protruded masses may mimic capsular retraction of the liver (Figure 13).
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Figure 12. CT scan of a 49-year-old woman with pseudoretraction of the hepatic capsule by accessory fissure shows a shallow indentation of the right hepatic lobe, which mimics capsular retraction of the liver (arrow).
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Figure 13. CT scan of a 55-year-old man with hepatocellular carcinoma shows multiple hypodense masses in the right hepatic lobe. The normal liver parenchyma (arrow) between the masses mimics capsular retraction of the liver.
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Conclusion
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This pictorial review shows that retraction of the liver capsule is not a finding specifically associated with a hepatic tumour but may be seen in patients without a hepatic tumour, including those with confluent hepatic fibrosis, oriental cholangiohepatitis and bile duct necrosis.
Received for publication December 13, 2001.
Revision received May 7, 2002.
Accepted for publication May 20, 2002.
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References
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Abstract
Introduction
