Multiple Liver Lesions of Unusual Benign Etiology Mimicking Metastatic Disease

Question: A 41-year-old woman was referred to our outpatient clinic after routine transabdominal ultrasonography revealing multiple liver nodules, up to 13 mm in diameter, scattered throughout both lobes, with hypoechoic to isoechoic center and hyperechoic peripheral halo, interpreted as suspicious for metastatic disease (Figure A). Abdominal computed tomography confirmed multiple widespread liver lesions, characterized by a hypodense donut-shaped appearance with a normodense center. No further pathologic findings were seen. Her past medical history was unremarkable. There were no relevant findings on physical examination. Laboratory investigation was only pertinent for mild iron overload (hyperferritinemia, 265.1 mg/mL; transferrin saturation, 57.5%). HFE gene mutation analysis revealed H63D homozygosity. Suspecting malignant disease, she had already been submitted to a thorough diagnostic workup with chest x-ray, gastroscopy, colonoscopy, and gynecologic examination that were unrevealing; tumor markers were within normal range. Subsequent magnetic resonance imaging confirmed the presence of multiple nodular, well-delineated lesions throughout the liver. On T2-weighted sequences these lesions appeared hyperintense to the surrounding liver parenchyma (Figure B), whereas no lesions could be seen on fat-suppressed T2-weighted images (Figure C). Furthermore, no signs of focal lesions on fat-suppressed T1-weighted sequence were found, after intravenous gadolinium-DTPA administration. To aid the differential diagnosis, ultrasound-guided percutaneous needle biopsy was held. Histologic examination revealed macrovesicular or microvesicular steatosis, chronic inflammatory infiltrate, pericellular fibrosis, or siderosis (Figure D, E). There was no evidence of malignancy. What is the diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.