Transcript FOCAL HEPATIC LESIONS IMAGING DIAGNOSIS

5th ARAB RADIOLOGY CONGRESS
25th - 28th April 2012
FOCAL HEPATIC LESIONS IMAGING
DIAGNOSIS
W.MNARI, M. GOLLI
MONASTIR-TUNISIA
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
Classification:
Benign
Malignant

Hemangioma


Focal nodular
•
hyperplasia

Adenoma

Liver cysts …
Primary liver cancers
•
Hepatocellular
carcinoma
Fibrolamellar carcinoma
Cholangiocarcinoma

Metastases
•
Things to consider usually.....
•
Symptomatic or Incidentally detected
•
History of Hepatitis or extra hepatic malignant
tumor
•
Liver function tests
•
Cirrhotic or Non cirrhotic
Circumstances of discovery
Fortuitous
Non cirrhotic
Symptomatic
Non cirrhotic
Benign
Malignant
Hémangioma
FNH
Metastasis
Adénoma
FLC
Chronic disease
Cirrhosis
HCC
DN
RN
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
Cavernous
angiomas
Hemangiomas are
composed of many
endothelium-lined
vascular spaces
separated by fibrous
septa
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
Hemangioma
In practice:
. Us characteristic feature
YES
. No context of neoplastic diesease
. Normal liver function tests
NO
CT or MRI
Hepatic Hemangiomas
CT: The pathognomonic features of caverneous hemangioma:
peripheral nodular and discontinuous enhancement and
progressive centripetal fill-in
IVHAP
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
IVHAP
PVP
DP
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 Adenoma
US:
. 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 lowgrade 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
Regenerating Nodules
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
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
Hepatocellular Carcinoma (HCC)
Several morphological forms
Massive(>3cms)
Nodular (<3cms)
Diffuse
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%.
Hepatocellular Carcinoma (HCC)
Arterial Phase:
CT or MR
liver(30-35 sec)
HCC as supplied by arterial branch/neovascularization
Enhancement
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.
Wash out phenomenan
Hepatocellular Carcinoma (HCC)
Delayed Phase :
Wash -out phenomenan persists and often exaggerated in
smaller lesions.
The tumor capsule
capsule
IVHAP
PVP
DP
Hepatocellular Carcinoma (HCC)
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)
MRI
Hepatocellular Carcinoma (HCC)
Hypovascular HCC +/- 30%
2010 AASLD Algorithm for Investigation of Small Nodules
Found On Screening in Patients with Cirrhosis
DIAGNOSIS : patients with cirrhosis or chronic hepatitis (even without cirrhosis)
Liver nodule
< 1 cm
> 1 cm
4 – phase MDCT/dynamic
Contrast enhanced MRI
Reapeat US at 3 months
Arterial hypervascularity AND
venous or delayed phase washout
Growing/changing
character
Stable
Yes
Investigate
according to size
HCC
Other contrast enhanced
Study (CT or MRI)
Arterial hypervascularity AND
venous or delayed phase washout
Yes
No
Biopsy
No
Bruix J and Sherman M. AASLD Practice Guidelines , Management of Hepatocellular Carcinoma Hepatology November 2011
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 disease
Variable 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
. Liver-specifc contrast agent: hepatobiliary agent(T1) or
reticuloendothelial agent (superparamagnetic agent; T2)
T1
Multihance*
Primovist*
HB Agents
T2
Endorem*
USPIO Agents
Metastatic disease
Diffusion 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