Rare hepatic lesions and uncommon patterns of common hepatic lesions on dynamic multiphasic MDCT studies

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1 Rare hepatic lesions and uncommon patterns of common hepatic lesions on dynamic multiphasic MDCT studies Poster No.: C-1324 Congress: ECR 2011 Type: Educational Exhibit Authors: C. Kakkar, P. Koteshwara, A. M. Polnaya, K. Rajagopal, N. M Mulimani, V. R. K. Rao ; Manipal, Karnataka/IN, Mangalore, Karnataka/IN Keywords: Abdomen, Liver, Biliary Tract / Gallbladder, CT, Diagnostic procedure, Infection, Neoplasia, Tropical diseases DOI: /ecr2011/C-1324 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 40

2 Learning objectives To illustrate the imaging patterns of uncommon hepatic lesions on dynamic multiphasic studies. To emphasize on uncommon patterns of common hepatic lesions leading to diagnostic dilemma. Background Primary or secondary hepatic lesions have a varying patterns of enhancement on multiphasic MDCT studies which are helpful in diagnosis however there are group of lesions such as coexisting hepatocellular and cholangiocarcinoma, hepatic tuberculosis, oriental cholangiohepatitis etc which may not be diagnosed on imaging due to overlapping patterns and final result depends on histopathology. Rupture of primary hepatic tumors is a rare but catastrophic entity and most patients succumb to this emergency. We came across a few cases of "bloody liver" secondary to a ruptured haemangioma and heptomas. "Lumps and bumps" of the liver surface secondary to entities like cirrhosis is quiet common however certain entities like pseudocirrhosis can also have a similar appearance. Malignant lesions like haemangioendothelioma, peripherally placed hepatoma can cause extreme degree of capsular retraction which can cause a bumpy surface of liver. Alpha fetoprotein is a marker of hepatoma however we in our experience observed a few cases which did not show any elevation of this tumor marker and a retrospective analysis showed that all these tumors were encapsulated hepatoma and histopathology showed all these lesions to be well differentiated form of hepatocelullar carcinoma. Imaging findings OR Procedure details The imaging pattern are described based on either the gross morphological pattern of the lesion like lumpy bumpy liver, rocks in liver, gas in liver, fat in liver. Page 2 of 40

3 Enhancement pattern in the form of filling lesions showing overlapping patterns such as hepatocholangiocarcinoma and metastases.capsular enhancement pattern in hepatoma which has served a very specific feature in our review. Bloody liver secondary to ruptured neoplasms. Images for this section: Fig. 1 Fig. 2: Cirrhosis with Hepatocellular carcinoma and significant capsular retraction. A : Plain CT image shows an ill defined hypodense lesion in the right lobe with marked retraction of the hepatic capsule. B and C : There is intense enhancement in the subcapsular location(arrow)with heterogeneous arterial enhancement more inferiorly. Gross free fluid noted in perihepatic location. Page 3 of 40

4 Fig. 3: D, E and F( contd.) : Portovenous phase images show infiltrative pattern of the lesion which appears hypodense suggestive of washout. G )There is persistence of contrast enhancement in region of capsular retraction which is relatively hyperdense to the adjacent lesion and hepatic parenchyma. A close mimic of such an appearance in cirrhosis can be confluent hepatic fibrosis. Page 4 of 40

5 Fig. 4: Malignant Haemangioendolthelioma: A and B ) Plain CT image shows a hypodense lesion (arrows)in the right lobe. The lesion is deriving blood supply from the right hepatic artery (dotted arrow) and shows predominantly a peripheral enhancement Fig. 5: C and D (contd.) Arterial phase image shows another homogenously enhancing focus adjacent to the primary lesion.the primary lesion shows a focal area of capsular retraction(arrowhead)which is better appreciated on magnified view. Page 5 of 40

6 Fig. 6: E and F (contd.) : Portovenous phase the lesion is heterogeneous and largely isodense to rest of hepatic parenchyma. Delayed phase the lesion is isodense to rest of hepatic parenchyma. Fig. 7: Pseudocirrhosis : Known case metastatic carcinoma breast post chemotherapy. A and B) Axial portovenous phase images show surface nodularity (arrowhead) with hypodense branching pattern involving the hepatic parenchyma diffusely. Page 6 of 40

7 Fig. 8: C(contd.) Hepatomegaly with hypoattenuating branching pattern in the entire liver. Page 7 of 40

8 Fig. 9 Page 8 of 40

9 Fig. 10: Ruptured Haemangioma: A and B ) Plain CT reveals a large hypodense lesion in the right lobe of liver with fuzziness of hepatic margins inferiorly(arrowhead) and adjacent fluid collection(arrow). Fig. 11: C and D (contd.) : Post contrast arterial phase lesion shows peripheral enhancement (black arrow)with suspicious site of rupture(arrowhead) and associated perihepatic fluid (dotted arrow). Page 9 of 40

10 Fig. 12: E and F (contd.): The lesion shows progressive centripetal filling in the portovenous phase (arrows)associated fluid collection (arrowhead). The lesion is isodense to the liver in delayed phase. Page 10 of 40

11 Fig. 13: Ruptured Hepatoma: A) Well defined isodense lesion in the right lobe of liver ( arrows) with central hypodense area. Hyperdense collection noted in the lesser sac (asterisk) suggestive of haemoperitoneum. Page 11 of 40

12 Fig. 14: B and C (contd.) : Lesion shows arterial enhancement (arrows) with adjacent haematoma extending inferiorly anterior to the pancreas in lesser sac. Fig. 15: D and E (contd.) : Lesion shows some areas of washout in the periphery with a sharply defined capsule showing delayed enhancement (arrowhead). Another lesion hypodense lesion noted in the left lobe (arrow). Haematoma in the lesser sac (asterisk). Fig. 16: F and G (contd.) : The primary lesion shows a significant blush on selective right hepatic artery angiography (arrows) with multiple smaller lesions detected in the adjacent parenchyma (arrowhead). Post embolisation there is significant reduction in the tumor blush. Page 12 of 40

13 Fig. 17: Hepatoma with rupture and atretic suprahepatic Inferior vena cava: A) Plain CT shows hyperdense fluid in the left lumbar region suggestive of haemoperitoneum. B :Arterial phase there is an ill defined lesion (arrows) deriving blood supply from the branch of left hepatic artery. Lesion shows solid enhancement in the arterial phase. Fig. 18: C and D (contd.) : Portovenous phase the liver shows nodular surface with markedly enlarged caudate lobe(asterisk).the lesion is hypodense to the rest of hepatic parenchyma suggestive of washout. Page 13 of 40

14 Fig. 19: E and F (contd.): Portovenous phase there is abrupt change in the calibre of inferior vena cava with non visualization of suprahepatic segment of infeiror vena cava. The supradiaphragmatic segment was receiving the venous drainage through enlarged collaterals. Page 14 of 40

15 Fig. 20: G and H : Marked hypertrophy of the caudate lobe with main portal vein arching across it.dilated and enlarged azygous and hemiazygous veins due to atresia of inferior vena cava. Multiple perisplenic collaterals noted secondary to portal hypertension. Fig. 21 Page 15 of 40

16 Fig. 22: Hepatocellular carcinoma: A) Plain CT study shows a large lesion in the right lobe with calcific focus(arrowhead). B,C and D) Arterial phase shows a prominent vascular channel in periphery of lesion(arrow)with intensely enhancing areas in the centre of lesion (dotted arrow). Lesion shows solid enhancement in the periphery on inferior sections. Page 16 of 40

17 Fig. 23: C and D (contd.) : Lesion shows enhancing areas of contrast puddling in the centre of lesion suggestive of arterioportal shunting (arrowhead). Fig. 24: G (contd.) : Delayed phase lesion shows peripheral capsular enhancement (arrowhead)with enhancing vascular channels in the centre.serum AFP:Not elevated. Page 17 of 40

18 Fig. 25: Encapsulated Hepatoma with normal AFP levels: A ) A large well defined lesion with solid peripheral enhancement and central non enhancing area suggestive of necrosis. B)Coronal portovenous phase there is appreciation of capsular enhancement (arrowhead). Fig. 26: C and D (contd.) Lesion is largely hypodense to rest of the hepatic parenchyma in portovenous and delayed phase (at 180 seconds). The capsular enhancement and delineation is best appreciated on delayed phase. Page 18 of 40

19 Fig. 27 Page 19 of 40

20 Fig. 28: Well defined lesion in the right lobe of liver showing central (arrow) and peripheral calcification(arrowhead).no enhancement in the arterial and portovenous phases. Final Diagnosis :Hydatid disease.close differential can be a chronic abscess. Page 20 of 40

21 Fig. 29: Middle aged man with history of recurrent abdominal pain and jaundice. A and B: Plain CT reveals multiple small hyperdensities in the right lobe suggestive of calcification(arrow).biliary radical dilatation in the left lobe (arrowheads) Fig. 30: C and D (contd.) : Contrast sequences. Coronal CT reveals a branching pattern of the calcifications suggestive of intraductal calculi. Curved reformatted image shows soft tissue density within the CBD. Dilated biliary radicals in the left lobe. Possibility of worm infestation (ascariasis) causing oriental cholangiohepatitis considered. Further work up and follow up : No evidence of malignancy / progression of disease. Close mimic can be an intraductal cholangiocarcinoma. Page 21 of 40

22 Fig. 31: Tubercular Cholangitis : A and B)Unenhanced axial CT section shows linear calcifications along the biliary radicals(arrow).ill defined soft tissue density along the biliary radicals (dotted arrow). Fig. 32: C and D): Arterial and portovenous phase shows wall calcifications along the dilated radicals (discontinuous arrow) and minimal enhancement of the soft tissue in the periportal location (arrow). Page 22 of 40

23 Fig. 33: E) Coronal CT section in portovenous phase shows minimal enhancing soft tissue density along the walls of the common bile duct which appears mildly prominent. Page 23 of 40

24 Fig. 34: F)Conglomerated low attenuation paraortic lymph nodal mass(arrow)with biliary radical dilatation (dotted arrow). Page 24 of 40

25 Fig. 35: Calcified Hydatid: Densely calcified lesion in the right lobe of liver in subcapsular location. Page 25 of 40

26 Fig. 36 Page 26 of 40

27 Fig. 37: Hepatoma with intratumoral pseudoaneurysm: A)A large well define lesion(arrows)in the right lobe which is isodense to rest of hepatic parenchyma. The lesion shows a well defined hyperdensity within (arrowhead). Page 27 of 40

28 Fig. 38: B (contd.) : Arterial phase lesion is showing significant enhancement with intense enhancement (similar to aorta noted in the region of hyperdensity (refer previous image) suggestive of pseudoaneurysm. C)The lesion shows area of washout on portovenous phase. Fig. 39: D (contd.) : Coronal portovenous image shows fluid level in the region of pseudoaneurysm. Non - enhancing area noted in the lesion (asterisk) suggestive of necrosis. E: Delayed phase there is capsular enhancement. Final Diagnosis : Well differentiated Hepatocellular carcinoma. AFP levels : Within normal limits. Page 28 of 40

29 Fig. 40 Fig. 41: A and B : Plain and contrast enhanced CT shows a large well defined encapsulated lesion in the right lobe showing multiple hypodense areas suggestive of air pockets. Coronal sections reveals multiple small satellite lesions adjacent to the larger lesion with associated stranding in the perihepatic space inferiorly. Final Diagnosis: Hydatid disease. Other possibility can be a cholangitic abscesses. Page 29 of 40

30 Fig. 42 Fig. 43: Hepatic Lipoma in patient with multiple renal angiomyolipomas: Well defined fat density lesion in the right lobe of liver(arrowhead). Page 30 of 40

31 Fig. 44 Fig. 45: Tubercular Abscess:A)Axial contrast enhanced CT study shows a well defined lesion in the right lobe with thick enhancing rim (arrow) with central area of caseous necrosis in a case of nodular isolated hepatic tuberculosis Page 31 of 40

32 Fig. 46: Multiple microabscesses in the right lobe of the liver forming complex mass lesion. (B) Arterial phase reveals a minimally enhancing lesion in the right lobe with an artery traversing through the lesion. Area of necrosis noted in the periphery. C) Portovenous phase reveals the mass to be well circumscribed composed of multiple tiny abscesses Fig. 47: Lymphoma with extensive necrosis: Middle aged male patient with fever and upper abdominal pain.hiv status negative. A)Gray scale image shows a large hypoechoic lesion in the right lobe mimicking an abscess. B)Arterial phase the lesion shows peripheral solid and centrally liquefied ( asterisk)lesion in the right lobe.geographic hypodense area(arrows)in the spleen. Page 32 of 40

33 Fig. 48: C and D (contd.):portovenous phase the lesion shows a hepatic lesion with peripheral solid enhancement (arrows) and central necrosis (asterisk).splenomegaly with a necrotic lesion(asterisk) involving large part of splenic parenchyma. Enlarged enhancing lymph node in the left inguinal region(arrowhead). Fig. 49 Page 33 of 40

34 Fig. 50: Amoebic Abscess : A)Plain CT image shows a well defined hypodense lesion in the right lobe of liver. B)Arterial phase lesion shows minimal enhancement in the periphery and in the centre. Fig. 51: C (contd.): In portovenous phase the lesion is showing increasing enhancement centripetally(asterisk.) Minimal perihepatic fluid noted posteriorly(arrowhead). D: Delayed phase there is significant filling up of the lesion. Page 34 of 40

35 Fig. 52: Multiple haemangiomas with a large exophytic lesion : Well defined hypodense lesion in the right lobe (arrow) with a large hypodense lesion in the peritoneum (arrow). There is a rim of hepatic tissue around the lesion(arrowhead). B and C: Arterial phase the lesion shows a peripheral nodular enhancement(arrowhead). Page 35 of 40

36 Fig. 53: E,F,G and H(contd.): Portovenous phase the lesion shows progressive filling(arrowhead)with complete filling in the delayed phase. Fig. 54: Hepatocholangiocarcinoma: A and B) The lesion shows intense enhancement in the arterial phase an is hyperdense to hepatic parenchyma. Page 36 of 40

37 Fig. 55: C and D (contd.): There is no washout in the portovenous phase with lesion being hyperdense to the hepatic parenchyma on portovenous and delayed phase. Fig. 56: Hepatocholangiocarcinoma : A)On plain scan the lesion is isodense to the rest of parenchyma(arrowhead). B:Intense enhancement noted in the lesion on arterial phase (arrowhead) with central non-enhancing area. Page 37 of 40

38 Fig. 57: C and D(contd.): Coronal portovenous phase the lesion is hyperdense (arrowhead) to the hepatic parenchyma. Delayed phase the lesion is hyperdense to the rest of hepatic parenchyma (arrowhead). Fig. 58: Colorectal Metastases: A ) Isodense lesion with central hypodensity in the right lobe. B) Arterial phase lesions shows more enhancement relative to hepatic parenchyma C and D) Portovenous and delayed phase there is increasing enhancement of the lesion suggestive of progressive filling pattern. Page 38 of 40

39 Fig. 59: E(contd.) :Coronal portovenous image shows sharply demarcated lesion in the right lobe. F: A large proliferative growth noted in the region of rectum. Final Diagnosis : Metastasis from adenocarcinoma. Page 39 of 40

40 Conclusion Multiphasic analysis permits diagnosis of a lot of hepatic lesions such as hepatomas, haemangiomas, adenomas, metastases etc however we observed there are a few lesions like hepatocholangiocarcinoma,metastases, infective pathologies which can cause a diagnostic dilemma and may mimic other pathologies. Capsular retraction can be seen in multiple pathologies and is not specific for a single entity. Personal Information References Lipson JA, Qayyum A, Avrin DE, et al. CT and MRI of hepatic contour abnormalities. Am J Roentgenol. 2005;184: Meghan Lubner, Christine Menias, Creed Rucker, et al. Blood in the Belly: CT Findings of Hemoperitoneum. RadioGraphics 2007,27, Levy AD. Malignant liver tumors. Clin Liver Dis. 2002;6: Kanematsu M, Kondo H, Goshima S, et al. Imaging liver metastases: review and update. Eur J Radiol. 2006;58: Prasad SR, Wang H, Rosas H, et al. Fat-containing lesions of the liver: radiologic-pathologic correlation.radiographics 2005;25: D M Yang, H S Kim, S W Cho,et al. Various causes of hepatic capsular retraction: CT and MR #ndings. The British Journal of Radiology, 2002,75: Vilgrain V, Boulos L, Vullierme MP, et al. Imaging of atypical hemangiomas of the liver with pathologic correlation. Radiographics 2000; 20: Vishal Bhagat, Milind Javale, Jihnhee Yu, et al. Combined hepatocholangiocarcinoma. Case-series and review of literature.international Journal of Gastrointestinal cancer,2006 Volume 37 (1), Mortele KJ, Segatto E, Ros PR. The infected liver: radiologic-pathologic correlation. Radiographics 2004; 24: Page 40 of 40