DETECTING EARLY LIVER METASTASIS: THE POWER OF MRI WITH LIVER SPECIFIC CONTRAST
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1 DETECTING EARLY LIVER METASTASIS: THE POWER OF MRI WITH LIVER SPECIFIC CONTRAST LINDA PANTONGRARG-BROWN, MD ADVANCED DIAGNOSTIC IMAGING, RAMATHIBODI HOSPITAL, BANGKOK, THAILAND
2 OUTLINE Choice of imaging modalities Role of gadoxetic MRI Imaging pearls Conclusions
3 BALANCING ACT PHOTOGRAPH BY MARCO MARCONE, NATIONAL GEOGRAPHIC YOUR SHOT
4 SENSITIVITY OF NON-INVASIVE IMAGING MODALITIES FOR LIVER METASTASES Modalities Sensitivity US 55% CT 72% MRI 76% FDG PET 90% Meta analysis: Kinket et al. Radiology 2002; 224:
5 DO WE NEED TO PERFORM PET BEFORE LIVER RESECTION? Not routinely because of uncertain clinical value, restricted availability, high cost, and additional radiation exposure
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8 VALLEY DUSTING PHOTOGRAPH BY TYLER LEKKI, NATIONAL GEOGRAPHIC YOUR SHOT
9 WHAT ABOUT GADOXETIC-ENHANCED MRI (PRIMOVIST) Several studies show superiority of gadoxetic-mri over ECCM-MRI and CT. (Lafaro et al. International Journal of Hepatology. Volume 2013) Eventhough gadoxetic-mri is expensive, it is required less additional imagings. It was in fact cost saving when reimaging, and the cost of modified and unnecessary surgical procedures was factored into the equation. (Zech et al. European Radiology, vol.19, supplement 3, pp. S753 S763, 2009)
10 CT HB phase gadoxetic-mri
11 GADOXETIC MRI VS PET/CT IN METASTATIC CRC Gadoxetic acid-enhanced liver MRI detected more metastatic nodules compared with PET/CT, especially for small ( <2cm) nodules. The newly detected nodules induced management plan change in 43.8% of patients.
12 Ji-WonOh, BioMed Research International, 2016
13 Modalities Overall sensitivity <10 mm sensitivity CT 68% 16% Gadoxetic MRI 90% 74% PET/CT 61% 9%
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15 CASE 1 56-year-old man with primary colon cancer, S/P surgery. US shows liver lesions. Gadoxetic-MRI (primovist) was performed.
16 plain arterial venous T2W Simple cysts or cystic metastasis 20 min HB phase
17 Bx confirms adenocarcinoma, mucin producing
18 SEGMENTECTOMY: MUCINOUS ADENOCA
19 IMAGING PEARL OF CASE 1 Cystic metastasis from mucin-producing adenoca may mimic simple cysts. Different shade of hyposignal intensity in 20 m HB phase of Gadoxetic MRI could be a clue.
20 CASE 2 57-year-old man with primary colon cancer, S/P surgery. Presenting with rising CEA, concerned for metastasis.
21 MRI FROM OUTSIDE: NEGATIVE
22 GADOXETIC-MRI (PRIMOVIST): 20 MIN HB PHASE AND DWI 1000
23 IMAGING PEARL OF CASE 2 Combination of HB phase gadoxetic- MRI and DWI pulse sequence is very useful tool for accurate detection of small lesions. Radiology, Oct
24 CASE 3 A 65F with sigmoid cancer MRI to evaluate liver metastasis
25 20 M HB PHASE OF GADOXETIC MRI Are these lesions all metastatic nodules?
26 DWI T2 T2 Only single metastasis, Others are cysts. A phase A phase
27 20 M HB phase COMPANION CASE S All these nodules metastases? Yes, they are. DWI Companion case of value of 20 m HB phase and DWI
28 IMAGING PEARL OF CASE 3 20 m HB phase Gadoxetic MRI is sensitive for liver metastasis, but not specific. Cysts and metastases may look the same. Interpretaion in conjunction with other pulse sequences is important, particularly with DWI, dynamic contrast study, and sometimes T2.
29 CASE 4 25F, underlying FAP and CA colon, S/P total colectomy and CMT
30 A phase Are these hypervascular nodules metastases?? No, these are not metastatic nodules. They are NRH. 20 m HB phase
31 NODULAR REGENERATIVE HYPERPLASIA NRH commonly occurs in normal liver parenchyma. It is associated with immunosuppressive or antineoplastic medicines. NRH is considered to be a reaction to heterogeneous portal blood flow.
32 IMAGING PEARL OF CASE 4 Nodules in the liver with primary CRC are not always metastasis. Hypervascular liver metastasis is unusual for primary CRC, and NRH should be considered. 20 M HB phase of Gadoxetic MRI will help diagnose NRH.
33
34 CONCLUSIONS Liver is the most common metastatic site for primary colorectal cancer. Surgical resection for cure is possible for isolated liver metastasis. Imaging plays an important role for accurate diagnosis and assessment of liver metastasis.
35 CONCLUSIONS Both CT and MRI are imaging of choice for assessment. MRI is better than CT for detection of small lesions, particularly a combination of HB phase gadoxetic-mri and DWI. FDG-PET is reserved for selected cases.
36 LIFE ON MARS PHOTOGRAPH BY BRYAN GEIGER, NATIONAL GEOGRAPHIC YOUR SHOT
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