Hepatic capsular retraction: spectrum of benign and malignant etiologies

Retraction of the liver capsule may be associated with a diverse spectrum of benign and malignant hepatic abnormalities. These include primary malignant neoplasms (epithelioid hemangioendothelioma, hepatocellular carcinoma, cholangiocarcinoma), secondary malignant neoplasms before and after treatment, and hepatic hemangioma, especially in cirrhotic livers. Other etiologies include confluent fibrosis in cirrhotic livers, chronic biliary obstruction (as can be seen in primary sclerosing cholangitis), and traumatic hepatic injury (iatrogenic and noniatrogenic). Because several recent studies have incorrectly reported hepatic capsular retraction as a specific sign of hepatic malignancy, it is important to understand the imaging appearances of the various etiologies associated with this sign to avoid misdiagnosis that may adversely affect the therapeutic approach.