What is the most common malignancy in the liver, and how does it present sonographically?

• A. Metastatic liver disease: may appear with hypoechoic ring, irregular shape, heterogeneous
• B. Hepatocellular carcinoma (HCC): hypoechoic and heterogeneous with halo
• C. Cholangiocarcinoma: hypoechoic mass
• D. Hepatic hemangioma: hyperechoic lesion

Answer: (A)

Metastatic disease is the most common malignant involvement of the liver. The liver’s role as a filter for bloodstream from many primaries makes it a frequent site for metastases. On ultrasound, these lesions are often multiple and show variable echogenicity. A common pattern is hypoechoic lesions with irregular, sometimes lobulated margins and a heterogeneous internal texture due to necrosis, hemorrhage, or varying tumor components. A surrounding hypoechoic halo can be seen around necrotic metastases as well. This combination—multiplicity, irregular shape, and heterogeneous appearance—best fits the typical ultrasound presentation of the most common malignant liver tumors.

Primary liver cancers and benign entities have different typical patterns, but they are less common than metastases: hepatocellular carcinoma can appear as a vascular, heterogeneous mass with possible halo; cholangiocarcinoma often presents as a hypoechoic or heterogeneous mass; hepatic hemangioma is usually a well-defined, bright (hyperechoic) benign lesion.