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5th ARAB RADIOLOGY CONGRESS 25 th - 28 th April 2012. FOCAL HEPATIC LESIONS IMAGING DIAGNOSIS. W.MNARI, M. GOLLI MONASTIR-TUNISIA. Objective :. Identify the most important imaging features of common benign liver tumors Identify the most important imaging features of malignant lesions - PowerPoint PPT Presentation
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FOCAL HEPATIC LESIONS IMAGING DIAGNOSIS
W.MNARI, M. GOLLI
MONASTIR-TUNISIA
5th ARAB RADIOLOGY CONGRESS25th - 28th April 2012
Objective :
1. Identify the most important imaging
features of common benign liver tumors
2. Identify the most important imaging
features of malignant lesions
3. Know the diagnosis of hepatocellular
carcinoma
Introduction
• Extensive use of imaging studies has
increased the detection rates of hepatic
lesions
• A mass can be found either incidentally
or during screening for liver cancer in
patients with cirrhosis
• These can be benignant or malignant and
thus the right approach for assessing
these masses is important
Hemangioma
Focal nodular
hyperplasia
Adenoma
Liver cysts …
Primary liver cancers• Hepatocellular
carcinoma• Fibrolamellar
carcinoma• Cholangiocarcinoma
Metastases
Benign Malignant
Classification:
• Symptomatic or Incidentally detected
• History of Hepatitis or extra hepatic
malignant tumor
• Liver function tests
• Cirrhotic or Non cirrhotic
Things to consider usually.....
FortuitousNon
cirrhotic
Symptomatic
Non cirrhotic
Chronic diseaseCirrhosis
Benign Malignant
HémangiomaFNH
Adénoma
Metastasis FLC
HCCDNRN
Circumstances of discovery
BENIGN LIVER LESIONS
Hepatic Hemangiomas • Benign vascular lesions of liver.
• The commonest liver tumor
• Autopsy studies : 0.4-20 percent
• 3-5 decades
• Thought to arise from congenital hamartomas
(abnormal growth of normal tissue), it can also
develop from dilatation of blood vessels in a
normal tissue
• Usually asymptomatic
• Incidental discovry: US++
Hepatic Hemangiomas
Hemangiomas are
composed of many
endothelium-lined
vascular spaces
separated by fibrous
septa
Cavernous angiomas
Hepatic Hemangiomas US: well-defined, uniformly hyperechoic liver mass
with peripheral feeder vessels that are characteristic
of a hemangioma.
Cavernous angiomas
Hepatic Hemangiomas US Diagnosis
In practice:
. Us characteristic feature
. No context of neoplastic diesease
. Normal liver function tests
Hemangioma
NO
CT or MRI
YES
Hepatic Hemangiomas CT: The pathognomonic features of caverneous
hemangioma: peripheral nodular and discontinuous
enhancement and progressive centripetal fill-in
IV-
HAP
PVP
DP
Hepatic Hemangiomas Diagnosis
CT: venous enhancement from periphery to center
Hepatic Hemangiomas Diagnosis
MRI:
. Hypointense and well defined in T1
. Marked hyperintensity that increases with
echo time on T2
. The same caracteristic pattern of enhacement
as is seen at CT
Hepatic Hemangiomas Diagnosis
MRI:
Hepatic Hemangiomas Diagnosis
Focal Nodular Hyperplasia (FNH)
. Benign nodule formation of normal liver tissue
. 2nd most common benign hepatic lesion
. More common in young and middle age women
. Male to female :5-17
. Usually asymptomatic
. May cause minimal pain
. Response of parenchyma to a vascular malformation
or portal duct injury.
Focal Nodular Hyperplasia (FNH)
. Hyperplasia with a central stellate scar radiating in to distinct nodules.
. Ductular diffentiation and malformed vessels.
. Rarely- encapsulated and pedunculated.
. Biliary structures
Focal Nodular Hyperplasia (FNH)
Diagnosis:
US: Nodule with varying echogenicity
Color Doppler imaging may show
central vessels
Focal Nodular Hyperplasia (FNH)
Diagnosis: CT
. Central scar
. Brisk homogeneous enhancement
. Well defined
. Early homogenesation
. Hypodense fibrous bands and septa that arise from
the scar
. On delayed phase images the central scar may remain
hyperattenuating
. Without capsule
Focal Nodular Hyperplasia (FNH)Diagnosis: CT
HAP
PVP
DP
IV-
Focal Nodular Hyperplasia (FNH)Diagnosis: CT
Focal Nodular Hyperplasia (FNH)
Diagnosis:MRI typical finding
. Isointense to hypointense on T1-weighted images
. Slightly hyperintense to isointense on T2-weighted
images
. Brisk homogeneous enhancement
. Delayed enhancement of the central scar
Focal Nodular Hyperplasia (FNH)
Diagnosis:MRI typical finding
Focal Nodular Hyperplasia (FNH)
20% of FNH cases are classified as nonclassic
Biopsy
Attal P et al. Radiology 2003;228:465-472
Hepatic Adenoma
. Rare hepatic tumor
. Women aged 20 to 40 years
. Association with oral contraceptive use
. Solitary (70%–80%)
. Can be associated with right upper-quadrant pain
. Risk of rupture, hemorrhage, or malignant
transformation
. 5-10cm
. Benign neoplasm composed of normal hepatocytes no
portal tract, central veins, or bile ducts
. Surrounded by a capsule
. Surgical resection is generally advised
Hepatic AdenomaUS:
. Nonspecific, adenomas may be hypo, iso, or hyperechoic but
are typically heterogeneous
CT:
. Well circumscribed without lobulation
. Heterogeneous because of their mixed components of fat,
hemorrhage, and necrosis
. Diffuse heterogeneous arterial enhancement and iso
attenuated on delayed scan
MRI:
. Hyper to isointense on T1 (hemorrhage) and slightly
hyperintense on T2 weighted images
. Same appearance on contrast-enhanced image as CT scan
Hepatic Adenoma
Liver cysts:
. May be single or multiple
. May be part of polycystic kidney disease
. Patients often asymptomatic
. No specific management required
Liver cysts:
. US is sufficient to diagnose
. On CT scan or MRI hepatic cysts are typically
discovered incidentally
Liver cysts:
Liver cysts: HYDATID CYST
MALIGNANT LIVER LESIONS
Hepatocellular Carcinoma (HCC)
•The fifth most common tumor
•Rarely occurs before age of 40 and peaks at 70 years
•Male to female: 4/1
•Cirrhosis is the strongest predisposing factor for HCC
•80% of cases of HCC developing in a cirrhotic liver
•Causes of cirrhosis: hepatitis (B and C virus infection),
alcohol, Hemochromatosis and biliary cirrhosis
Most HCCs develop by means of a multistep progression: from
a low-grade dysplastic nodule to a high-grade dysplastic
nodule, to a dysplastic nodule with a focus of HCC, and finally
to overt carcinoma.Willatt et al Radiology: Volume 247: Number 2—May 2008
Hepatocellular Carcinoma (HCC)
Jeong et al. AJR:185, October 2005
Usually too small to detect by imaging
–May be surrounded by fibrotic septa
–May contain iron, copper
Siderotic regenerating nodules
–Hyperdense on NCCT, disappear on HAP & PVP
–Variable on T1, Hypointense on T2 MR, “bloom” on GRE
Regenerating Nodules
Importance of NC imaging
Dysplastic Nodules
Rarely diagnosed by US or CT
Iso to hyperintense on T1 (copper)
Iso to Hypo on T2 (opposite of HCC)
Should not enhance much on HAP
Several morphological forms
Massive(>3cms)
Nodular (<3cms)
Diffuse
Hepatocellular Carcinoma (HCC)
AFP (Alfa feto protein)
Is an HCC tumor marker
Values more than 100ng/ml are highly suggestive of
HCC
Elevation seen in more than 70%
Hepatocellular Carcinoma (HCC)
US : hyperechoic, smaller tumors are hypoechoic.
Heterogeneous, hypervascular
US sensitivity about 75%.
Arterial Phase:
liver(30-35 sec)
HCC as supplied by arterial branch/neovascularization
Hepatocellular Carcinoma (HCC)
Venous Phase:
HCC which is enhanced during arterial phase has
lost its contrast, hence no enhancement of the
tumor but rest of the liver enhances.
Contrast in brightness of the lesion with respect to
surrounding liver.
Enhancement
Wash out phenomenan
CT or MR
Hepatocellular Carcinoma (HCC)Delayed Phase :
Wash -out phenomenan persists and often
exaggerated in smaller lesions.
The tumor capsule
IV-
HAP
PVP
DP
capsule
Hepatocellular Carcinoma (HCC)
MRI
. Variable intensity of HCC on T1
. 35% hyper, 25% iso-, 40 % hypo
. Hyperintense (T1) often well-differentiated,
contain fat, copper, glycogene
. Almost always hyperintense on T2 MR
. The tumor capsule is hypointense on both T1-
and T2-weighted images in most cases
. Other Features: Focal fat
Hepatocellular Carcinoma (HCC)
Hepatocellular Carcinoma (HCC)
MRI
Hepatocellular Carcinoma (HCC)Hypovascular HCC +/- 30%
Liver nodule
< 1 cm > 1 cm
Reapeat US at 3 months
Growing/changing character
Stable
Investigate according to size
4 – phase MDCT/dynamicContrast enhanced MRI
Arterial hypervascularity AND venous or delayed phase washout
Other contrast enhancedStudy (CT or MRI)
Arterial hypervascularity AND venous or delayed phase washout
Yes No
Yes No
HCC Biopsy
2010 AASLD Algorithm for Investigation of Small Nodules
Found On Screening in Patients with Cirrhosis
Bruix J and Sherman M. AASLD Practice Guidelines , Management of Hepatocellular Carcinoma Hepatology November 2011
DIAGNOSIS : patients with cirrhosis or chronic hepatitis (even without cirrhosis)
Fibro-Lamellar Carcinoma
. Presents in young pt (5-35)
. Not related to cirrhosis, AFP is normal
. CT/MRI shows large mass with peripheral enhancement and
typical stellate scar with radial septa showing persistant
enhancement
. Calcifications
Metastatic disease
. Most common malignant hepatic tumor
. Presence of extrahepatic malignancy should be
sought in patients with characteristic liver lesions
per imaging studies. Physical exam and history is
very helpful.
. Common primaries : colon, breast, lung, stomach,
pancreases, and melanoma
. Mild cholestatic picture (ALP, LDH) with preserved
liver function
. CT or US guided biopsy provides definitive diagnosis
but not always required.
Metastatic diseaseVariable US features+++
Iso, hyper or hypo echoic++
Contrast-enhanced US (CEUS)
(84% accuracy)
Intraoperative US (IOUS) (96%
accuracy)
Typical feature
Metastatic disease. MDCT are the most commonly used imaging
modalities
for detection and characterization of hepatic metastases
. Most liver metastases are hypovascular and are best
imaged during the portal venous phase (colon, stomach
and pancreas)
. Hypervascular metastases enhancing on the arterial
phase (neuroendocrine tumors, renal cell, breast,
melanoma, thyroid)
. Calcification may be present with metastases from
mucinous
gastrointestinal tract tumors and from primary ovarian,
breast, lung, renal, and thyroid cancer
. Other features : Hemorrhagic or cystic metastases
Metastatic disease
. On MRI, metastases are variable but are usually hypo- to
isointense on T WI and iso- to hyperintense on T2 WI
. Metastatic tumors with liquefactive necrosis or cystic
neoplasms show higher signal intensity on T2 WI
. Metastases may show central hypointensity on T2WI
(coagulative necrosis, fibrin, and mucin)
. High T1 signal intensity can be seen with metastases from
melanoma, colonic adenocarcinoma, ovarian adenocarcinoma,
multiple myeloma and pancreatic mucinous cystic tumor
. Comparing T2-weighted (TE 90) and T2-weighted (TE 160)
sequences, metastases become less intense Characterization
. T1-weighted 3D dynamic contrast-enhanced MRI Detection
Metastatic disease
Metastatic disease
Metastatic disease
HB Agents
USPIO Agents
T1
T2
Multihance* Primovist*
Endorem*
. Liver-specifc contrast agent: hepatobiliary agent(T1) or
reticuloendothelial agent (superparamagnetic agent; T2)
Metastatic diseaseDiffusion MRI imaging Detection++
+
Taouli and Koh Radiology 2010; 254:47–66
Conclusion :
. MDCT and MRI are the most commonly used
imaging modalities for detection and
characterization of focal hepatic lesion
. Imaging modalities can make diagnosis for:
Hepatic cyst
Caverneous hemangioma
Typical FNH
HCC
. For others lesions biopsy will be often
necessary
Monastir
Recommended