Malignant Focal Liver Lesions
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1 Malignant Focal Liver Lesions Other Than HCC Pablo R. Ros, MD, MPH, PhD Departments of Radiology and Pathology University Hospitals Cleveland Medical Center Case Western Reserve University
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3 Malignant Focal Liver Lesions Other than HCC HEPATOCELLULAR ORIGIN Fibrolamellar carcinoma (FLC) CHOLANGIOCELLULAR ORIGIN Cholangiocarcinoma (I-CAC) Cystadenocarcinoma
4 Malignant Focal Liver Lesions Other than HCC MESENCHYMAL ORIGIN Angiosarcoma Epithelioid Hemangioendothelioma Kaposi sarcoma Primary lymphoma METASTASIS
5 Malignant Focal Liver Lesions Unknown Case 56 yo man with jaundice and abdominal pain
6 T2 FS T1 FS arterial T1 FS delayed
7 What is the most likely diagnosis? A. Intrahepatic Cholangiocarcinoma B. Epithelioid Hemangioendothelioma C. Fibrolamellar carcinoma D. Metastasis E. Angiosarcoma
8 What is the most likely diagnosis? A. Intrahepatic Cholangiocarcinoma B. Epithelioid Hemangioendothelioma C. Fibrolamellar carcinoma D. Metastasis E. Ansgiosarcoma
9 Malignant Focal Liver Lesions Unknown Case 19 yo man with complex medical history, now with elevated liver function tests and palpable mid abdominal mass
10 T2 FS T1 FS T1 FS 2 min - Eovist T1 FS 20 min - Eovist
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12 What is the most likely diagnosis? A. Intrahepatic Cholangiocarcinoma B. Epithelioid Hemangioendothelioma C. Fibrolamellar carcinoma D. Metastasis E. Cystadenocarcinoma
13 What is the most likely diagnosis? A. Intrahepatic Cholangiocarcinoma B. Epithelioid Hemangioendothelioma C. Fibrolamellar carcinoma D. Metastasis E. Cystadenocarcinoma
14 What is the key finding? A.Size B. Lobular contour C. Small calcifications D.Hypodense
15 What is the key CT finding? A.Size B. Lobular contour C. Small calcifications D.Hypodense
16 Malignant Focal Liver Lesions Unknown Case 61 yo woman Intermittent abdominal pain and distension RUQ ultrasound, followed by CT Second abdominal CT scan, 8 months after initial one
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18 What is the most likely diagnosis? A. Intrahepatic Cholangiocarcinoma B. Epithelioid Hemangioendothelioma C. Fibrolamellar carcinoma D. Metastasis E. Angisarcoma
19 What is the most likely diagnosis? A. Intrahepatic Cholangiocarcinoma B. Epithelioid Hemangioendothelioma C. Fibrolamellar carcinoma D. Metastasis E. Angiosarcoma
20 Malignant Focal Liver Lesions Unknown Case 54 yo woman Abdominal pain Bloating Her two dogs died recently due to chronic arsenic intoxication
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22 What is the most likely diagnosis? A. Intrahepatic Cholangiocarcinoma B. Epithelioid Hemangioendothelioma C. Fibrolamellar carcinoma D. Metastasis E. Angisarcoma
23 What is the most likely diagnosis? A. Intrahepatic Cholangiocarcinoma B. Epithelioid Hemangioendothelioma C. Fibrolamellar carcinoma D. Metastasis E. Angisarcoma
24 Malignant Focal Liver Lesions Unknown Case 55 yo woman with liver mass on ultrasound
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27 What is the most likely diagnosis? A. Intrahepatic Cholangiocarcinoma B. Epithelioid Hemangioendothelioma C. Fibrolamellar carcinoma D. Metastasis E. Angiosarcoma
28 What is the most likely diagnosis? A. Intrahepatic Cholangiocarcinoma B. Epithelioid Hemangioendothelioma C. Fibrolamellar carcinoma D. Metastasis E. Cystadenocarcinoma
29 Metastasis 10 times more frequent than primary malignant liver neoplams Multiple If solitary, likely from Colon Adenocarcinoma HCC, 10 times more frequent than other primary liver tumors
30 Fibrolamellar Carcinoma - Malignant Hepatocytes - Lamellar fibrosis - Confluent centrally - AFP negative
31 Fibrolamellar Carcinoma - Poorer vascularity, Bile stained - Central scar, Radiating Septa - No vessels in scar - Calcification
32 Fibrolamellar Carcinoma
33 Fibrolamellar Carcinoma: Scar - Low signal in T2 - No enhancement - Calcification
34 Fibrolamellar Carcinoma - Heterogeneous - Poor vascularity - Ill defined scar
35 Fibrolamellar Carcinoma Heterogeneous No Calcifications No FDG activity
36 Fibrolamellar Carcinoma
37 Fibrolamellar Carcinoma Homogeneous, but Calcifications
38 Fibrolamellar Carcinoma
39 MALIGNANT HEPATIC NEOPLASMS CHOLANGIOCELLULAR ORIGIN Cholangiocarcinoma (I-CAC) Cystadenocarcinoma
40 Intrahepatic Cholangiocarcinoma (I-CAC) Microscopy Adenocarcinoma: mucin rich, no bile Abundant fibrous stroma Calcification
41 I-CAC - Large (5-20 cm), - Solid (Hemorrhage/necrosis rare) - Fibrous, scar, calcifications - Satellite nodules (20%) - Local extension, no tumor thrombus
42 I-CAC Pathogenesis/Associations Thorotrast Hepatolithiasis (5% - 20%) Clonorchis sinensis Sclerosing Cholangitis Caroli Disease Congenital Hepatic Fibrosis
43 I-CAC Hypodense, homogeneous, irregular borders Capsular Retraction Satellite nodules No Cirrhosis
44 I-CAC Biliary dilatation, segmental
45 I-CAC
46 I-CAC T1: Hypointense Early: Peripheral enhancement
47 I-CAC Late: central enhancement in scar
48 I-CAC Vascular encasement, no invasion Extrahepatic local extension
49 MALIGNANT HEPATIC NEOPLASMS MESENCHYMAL ORIGIN Angiosarcoma Epithelioid Hemangioendothelioma Kaposi sarcoma Primary lymphoma
50 Risk Factors: Thorotrast, Vinyl chloride, Arsenicals
51 Angiosarcoma Pathologic Findings Foci of malignant endothelial cells Along vascular spaces Thorotrast granules displaced peripherally
52 Angiosarcoma Pathologic Findings - Multinodular (70%) - Solitary - Thorotrast peripherally displaced reticulated surface fibrosis
53 Angiosarcoma - Thorotrast, liver, spleen, lymph nodes peripherally displaced
54 Angiosarcoma
55 Angiosarcoma
56 Angiosarcoma
57 Angiosarcoma
58 Epithelioid Hemangioendothelioma Slow, peripheral (subcapsular) growth Hypertrophy of uninvolved liver
59 Epithelioid Hemangioendothelioma
60 Epithelioid Hemangioendothelioma Nonspecific symptoms or asymptomatic (20%) Slow, peripheral (subcapsular) growth Hypertrophy of uninvolved liver
61 Epithelioid Hemangioendothelioma Peripheral, globular enhancement Intratumoral shunting Invasive
62 Regarding Primary Hepatic Lymphoma? A. The liver is commonly involved B. Its contour is ill defined C. It is typically Hodgkin Disease D. Typically has calcifications E. Solitary, multiple and diffuse forms
63 Regarding Primary Hepatic Lymphoma? A. The liver is commonly involved B. Its contour is ill defined C. It is typically Hodgkin Disease D. Typically has calcifications E. Solitary, multiple and diffuse forms
64 Lymphoma Primary lymphoma, extremely rare NHL, diffuse large cell type Immunocompromised (transplant, IDS, ) Solitary, Multiple, Diffuse Low attenuation, well defined MRI preferred for diffuse form
65 Lymphoma NHL, Hemosiderosis Multiple, well defined nodules Hypodense, No enhancement
66 Lymphoma Diffuse Geographic involvement Spleen deposit
67 Malignant Focal Liver Lesions Other than HCC HEPATOCELLULAR ORIGIN Fibrolamellar carcinoma (FLC) CHOLANGIOCELLULAR ORIGIN Cholangiocarcinoma (I-CAC) Cystadenocarcinoma
68 Malignant Focal Liver Lesions Other than HCC MESENCHYMAL ORIGIN Angiosarcoma Epithelioid Hemangioendothelioma Kaposi sarcoma Primary lymphoma METASTASIS
69 Malignant Focal Liver Lesions More than Metastasis and HCC Gamut of primary malignant neoplasms Different cellular lines and appearances Imaging: Benign vs. Malignant Primary vs. Secondary Resectable vs. Unresectable Imaging guided Biopsy Percutaneous therapy
70 Surgical vs. Nonsurgical Lesions Cyst Focal Fat Flow Phenomenon Abscess Hemangioma FNH Unresectable metastasis
71
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