Liver lesion found by chance: follow-up scans

The main guidance

ACG 2024 (American College of Gastroenterology): diagnosis and management of the most common liver spots, including adenoma, focal nodular hyperplasia (FNH), haemangioma and liver cysts. It updates the ACG 2014 guideline. (ACG 2024)
EASL 2016 (European Association for the Study of the Liver): benign liver tumours, meaning haemangioma, FNH and adenoma. (EASL 2016)(Haring 2021)
ACR 2017 white paper (American College of Radiology): liver spots found by chance on CT, sorted by the person's risk and the look of the spot. (ACR 2017)
LI-RADS: the ACR system for reading liver spots in people at high risk of liver cancer, built into AASLD guidance. (Elsayes 2019)

The full texts of ACG 2024, EASL 2016 and ACR 2017 are behind a paywall. The details below come from open-access reviews that set them side by side, and name the guideline each point comes from. (Haring 2021)(Granata 2025)(Kahraman 2024)

Your risk group comes first

ACR 2017 sorts people before it sorts spots. Low risk means no history of cancer, no liver disease and no liver risk factors; within that group, people over 40 are at higher risk than younger people. High risk means a known cancer that often spreads to the liver, cirrhosis or other liver risk factors. (Granata 2025) EASL 2016 says contrast imaging is needed for a likely haemangioma in people with cancer or liver disease, where ultrasound alone may be enough in a healthy liver. (Haring 2021)

Findings that usually need no follow-up

Simple cyst: no evidence-based follow-up rules exist, and follow-up is not recommended. (Kahraman 2024)
Typical haemangioma: ACG 2014 and EASL 2016 both say follow-up imaging is not needed. EASL says a typical one under 3 cm in a healthy liver can be diagnosed on ultrasound alone. (Haring 2021)
Typical FNH: EASL 2016 says follow-up is not needed unless there is a vascular liver disease. ACG 2014 says no follow-up imaging for a firm diagnosis, except yearly ultrasound for 2 to 3 years in women who keep taking the contraceptive pill. (Haring 2021)
Small spot in a low-risk person: ACR 2017 says a spot under 1 cm with no suspicious features needs no further tests. (Granata 2025)

When a contrast scan is advised

Unclear spot over 1 cm in a healthy liver, first seen on ultrasound: the ACR Appropriateness Criteria list contrast ultrasound, multiphase CT or contrast MRI. (Granata 2025)(Kahraman 2024)
Unclear spot under 1 cm with a past cancer: contrast MRI if it was first seen on ultrasound; contrast MRI or multiphase CT if it was first seen on a plain CT or MRI. (Granata 2025)
Spot with suspicious features: ACR 2017 says MRI should be considered for one under 1 cm, and one of 1 cm or more needs more tests. (Granata 2025)
Likely haemangioma or FNH: ACG 2014 confirms with MRI or CT. EASL 2016 calls MRI the most accurate test for FNH, with contrast ultrasound most accurate for FNH under 3 cm. (Haring 2021)

Adenoma checks and how often

Follow-up imaging for a hepatocellular adenoma that is being watched (simplified)
Guidance	How often
ACG 2014	CT or MRI every 6 to 12 months; how long depends on growth and stability
EASL 2016	In women, adenomas under 5 cm are reassessed at 1 year, then imaged yearly
SBH 2015 (Brazil)	Imaging every 6 months, with no end point given

Source for the table: the side-by-side tables in Haring 2021. (Haring 2021) Adenomas of 5 cm or more, and in some guidelines adenomas in men or certain subtypes, move beyond follow-up scans to a specialist decision. (Haring 2021)

When LI-RADS applies

LI-RADS is used for adults with cirrhosis, chronic hepatitis B, or current or past liver cancer. It is not used for children, or for cirrhosis caused by a vascular disorder or congenital hepatic fibrosis. Each spot gets a category from LR-1 (definitely benign, such as a cyst or haemangioma) to LR-5 (definitely liver cancer). (Elsayes 2019) On a surveillance ultrasound, a spot under 10 mm that is not clearly benign (US-2) gets a repeat ultrasound every 3 to 6 months, and back to the usual 6-monthly schedule once stable for 2 years; a spot of 10 mm or more (US-3) gets a contrast scan. (Elsayes 2019) For the surveillance schedule itself, see liver cancer surveillance.

Routine age-based screening

A liver spot found by chance does not replace the routine screenings for your age. For liver scarring see the FIB-4 score, and for blood tests see liver function test results. For other findings on a scan, see gallbladder polyp found by chance, pancreatic cyst found by chance, kidney cyst found by chance and adrenal mass found by chance.

Where they differ:

Confirming a haemangioma. EASL 2016 accepts ultrasound alone for a typical one under 3 cm in a healthy liver; ACG 2014 and SBH 2015 recommend confirming it with CT or MRI. (Haring 2021)
Large haemangiomas. SBH 2015 lists ultrasound every 6 to 12 months for those over 5 cm; ACG 2014 and EASL 2016 list no follow-up for typical ones. (Haring 2021)
FNH. SBH 2015 lists scans every 6 months to 2 years; EASL 2016 and ACG 2014 list none for a typical one, with the exceptions above. (Haring 2021)
Adenoma intervals. SBH every 6 months, ACG 6 to 12 months, EASL yearly after the first year. (Haring 2021)
Who gets more tests. ACR 2017 sets the plan by risk group first, while LI-RADS is only for people at high risk of liver cancer. (Granata 2025)(Elsayes 2019)

Your doctor decides what your result means for you.

Questions people ask

Are most liver spots found by chance cancer?

No. Haring 2021 notes that liver spots found by chance are seen in about 15% of people, up to 30% over 40, and that most are benign, such as cysts, areas of fat sparing and benign tumours. (Haring 2021)

Does a simple liver cyst need follow-up?

Usually not. The Kahraman 2024 review says follow-up and treatment of simple liver cysts found by chance is not recommended. (Kahraman 2024)

Does a haemangioma need repeat scans?

Not when it is typical. ACG 2014 and EASL 2016 both say follow-up imaging is not needed for a typical haemangioma; SBH 2015 lists ultrasound every 6 to 12 months for those over 5 cm. (Haring 2021)

What if I have cirrhosis or hepatitis B?

Then a new liver spot is read with LI-RADS, the system for people at high risk of liver cancer, and is linked to your regular liver cancer surveillance. (Elsayes 2019) (Kahraman 2024)

Is a very small spot checked further?

In a low-risk person, ACR 2017 says a spot under 1 cm with no suspicious features needs no further tests. With a past cancer or liver disease, a contrast MRI or CT may be used. (Granata 2025) (Kahraman 2024)