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Focal liver lesions are common, with a prevalence up to 20%. The lesions must be evaluated in context of risk factors associated with malignancy. Risk factors include age >40 years, known current or past malignancy, presence of liver cirrhosis or chronic liver disease (i.e. suspected by elevated liver elastography measurement ≥8 kPa or FIB-4 score ≥1.3), unintentional weight loss, fever or night sweats, newly detected focal liver lesions, documented growth of focal liver lesions, current or past use of androgens (e.g. testosterone, oxymetholone, danazol), increased serum tumour markers (i.e. alpha-fetoprotein, carbohydrate antigen 19-9 [CA19-9], carcinoembryonic antigen [CEA]) and family history of malignancy.

In patients without risk factors of malignancy, regional (non-)fatty changes, simple liver cysts and typical haemangiomas can be diagnosed by conventional ultrasound (without contrast). Conventional ultrasound Doppler is recommended to rule out vascular malformations such as portosystemic shunts.

In all other cases of focal liver lesions, contrast-enhanced imaging is indicated for differentiation in benign and malignant dignity.

Contrast-enhanced ultrasound (CEUS) as a first diagnostic step and contrast-enhanced magnetic resonance imaging (MRI) are accurate tests to diagnose haemangioma and focal nodular hyperplasia.

Hepatocellular adenoma is diagnosed by contrast-enhanced MRI and/or histology.

“Wash out” on CEUS is highly suspicious for a malignant focal liver lesion. Additional investigations aimed at identifying the primary tumour, as well as staging-computed tomography, MRI and/or histology may be necessary and should be decided on a case-by-case basis.

A biopsy of focal liver lesions is indicated in cases of unclear dignity, malignant aspect and focal liver lesions of unclear origin as well as for guiding surgical and oncological management.