Acknowledgements. Update of Focal Liver Lesions Goals. Focal Liver Lesions. Imaging Choices For Liver Lesions. Focal Liver Lesions

Transcription

1 Acknowledgements Update of Focal Liver Lesions 2012 Giles Boland Massachusetts General Hospital Harvard Medical School No disclosures Dushyant Sahani Mukesh Harisinghani Goals Focal liver lesions Imaging strategies CT vs. MRI vs. PET Benign lesions Malignant lesions Contrast agents DWI Focal Liver Lesions Non-cirrhotic Cyst Biliary hamartoma/cystadenoma Abscess Hemangioma FNH Adenoma Cirrhotic RGN DSN Focal Liver Lesions Non-cirrhotic Cyst Biliary hamartoma/cystadenoma Abscess Hemangioma FNH Adenoma Metastases Fibro Lamellar HCC Lymphoma Cirrhotic RGN DSN Imaging Choices For Liver Lesions MDCT MR US FDG-PET/PET-CT 1

2 Why use CT for Liver Imaging? Assess Lesion/tumor burden Number Size Location Treatment Response Why use CT for Liver Imaging? Assess Lesion/tumor burden Number Size Location Treatment Response Evaluate Vasculature Tumor involvement Variations that may alter surgical resection Why use CT for Liver Imaging? Assess Lesion/tumor burden Number Size Location Treatment Response Evaluate Vasculature Tumor involvement Variations that may alter surgical resection Evaluate Functional Reserve Post-surgical residual volume Steatosis Why use CT for Liver Imaging? Assess Lesion/tumor burden Number Size Location Treatment Response Evaluate Vasculature Tumor involvement Variations that may alter surgical resection Evaluate Functional Reserve Post-surgical residual volume Steatosis Evaluate for other sites of metastases May preclude surgical resection Monitoring Response to Chemotherapy Conventional method of monitoring treatment response is change in tumor size CT Disadvantage: Lesion contrast Lesion Is Too Small To Characterize RECIST Target Lesions (>1-2 cm) 5 max in an organ Non-target lesions 59 mm WHO RECIST RECIST Target Lesions (>1 cm) 2 max in an organ Short-axis of LN>15 mm Therasse P et al. JNCI 2000 Therasse P et al. EJC 2006 Eisenhauer EA et al. EJC mm 18 mm RECIST= Response Evaluation Criteria in Solid Tumors WHO = World Health Organization CT Vs. MRI Lesions > 1.5 cm can be routinely characterized on a MDCT 2

3 Small Lesion Detection: CT vs. MR B Liver Mets: MR vs. FDG-PET PET Sensitivity Lesions > 2 cm=100%, 30-60% lesions < 1 cm Post-ChemoTx : 63% overall sensitivity? CT MR MRI can detect lesions < 1 cm In fatty liver, hypovascular lesions are less conspicuous on CT FDG-PET Metastases: 65 Lesions <1cm: 12 Kinkel. Radiology Sahani. AJR Akhurst T. JCO Coenegrachts K. Radiology MRI Metastases: 88 Lesions <1cm 33 Liver Blood Supply Arterially Enhancing Lesions: Benign Normal Parenchyma 20-25% blood supply from hepatic arteries 75-80% blood supply from portal vein Liver Tumors Blood supply preferentially from hepatic arteries Benign Hemangioma (< 1cm) Focal nodular hyperplasia Hepatocellular Adenoma Dual-phase scanning Dachman and Freedman 1994 Arterially Enhancing Lesions: Malignant Hemangioma FNH Adenoma Primary Metastases Carcinoid Islet cell tumors RCC Melanoma GIST Breast? Dachman and Freedman

4 Arterially Enhancing Lesions: Malignant Portal Venous Phase Primary Metastases Carcinoid Islet cell tumors RCC Melanoma GIST Breast? Dachman and Freedman 1994 Portal Venous Phase Portal Venous Phase Focal Liver Lesions Non-cirrhotic Cyst Biliary hamartoma/cystadenoma Abscess Hemangioma FNH Adenoma Metastases Fibro Lamellar HCC Lymphoma Cirrhotic RGN DSN Simple cysts 4

5 Focal Liver Lesions Non-cirrhotic Cyst Biliary hamartoma/cystadenoma Abscess Hemangioma FNH Adenoma Metastases Fibro Lamellar HCC Lymphoma Cirrhotic RGN DSN Biliary cystadenoma Ovarian Metastases Biliary cystadenoma Biliary hamartoma Peri-biliary cysts 5

6 Biliary hamartoma Peri-biliary cysts Biliary hamartoma Peri-biliary cysts Focal Liver Lesions Non-cirrhotic Cyst Biliary hamartoma/cystadenoma Abscess Hemangioma FNH Adenoma Metastases Fibro Lamellar HCC Lymphoma Cirrhotic RGN DSN Amebic Fungal Hydatid Pyogenic Focal Liver Lesions Non-cirrhotic Cirrhotic Cyst RGN Biliary Hamartoma/cystadenoma DSN Abscess Hemangioma FNH Adenoma Metastases Fibro Lamellar HCC Lymphoma 6

7 Hemangioma - Pathology Hemangioma: CECT Capillary Cavernous Sclerosing Sclerosed Arterial Portal Equilibrium Hemangioma: MRI Hemorrhage? T2WI Arterial Portal Equilibrium Hemorrhage? Hemangioma - MR sensitivity specificity > 95% heavily T2-weighted images Gadolinium-enhanced dynamic gradient echo T1-weighted images 7

8 Sclerosing and Sclerosed Hemangioma Sclerosed Hemangioma Focal Liver Lesions Non-cirrhotic Cirrhotic Cyst RGN Biliary Hamartoma/cystadenoma DSN Abscess Hemangioma FNH Adenoma Metastases Fibro Lamellar HCC Lymphoma Focal Nodular Hyperplasia MR criteria: Homogeneous lesion (except scar) Iso/slightly hyperintense on T2-WI Hyperintense scar on T2-WI Strong arterial enhancement (gd chelates) Delayed enhancement of the scar on T1-WI absence of capsule Focal Nodular Hyperplasia Focal Nodular Hyperplasia: Gd-DTPA MRI FSE T2WI NCCT Arterial Arterial Phase PVP Portal Venous Delayed Equilibrium Phase 8

9 Focal Nodular Hyperplasia: MRI Tissue Characterization: Morphologic Overlap (Central Scar) Characterization Sensitivity : 74% Specificity : 100% Fibrolamellar FNH HCC Mathieu D, Kobeiter H, Maison P, Rahmouni A, Cherqui D, Zafrani ES, Dhumeaux D. RSNA Oral contraceptive use and focal nodular hyperplasia of the liver. Gastroenterology 2000 Mar;118(3): Metastasis Carcinoid Hemangioma Hepatocellular Adenoma: MR Hepatocellular Adenoma 50-60% of hepatocellular adenomas are hyperintense on T1-WI Fat accumulation Hemorrhage Sinusoidal dilatation or peliosis Capsule CT Hemorrhage Mathieu D, Paret M, Mahfouz AE, et al..hyperintense benign liver lesions on spin-echo T1-weighted MR images: pathologic correlations. Abdom Imaging. 1997; 22 : MRI Adenoma Adenomatosis: Intratumoral fat IP OOP IP OOP T2WI Gd- DTPA T2WI Gd- DTPA 9

10 FNH vs. Adenoma Hepatobiliary Contrast Agents Supporting FNH Supporting Adenoma Scar Lipid (OP drop in SI) Homogenous enhancement Hemorrhage Capsule Dual agents extracellular and hepatocyte Hepatocyte uptake Excreted in bile Improve lesion detection (staging) Characterize as hepatocellular or non-hepatocellular Specifically characterize some lesions (FNH) Evaluate biliary tree Hepatobiliary Contrast Agents Properties MnDPDP Gd-BOPTA Gd-EOB-DTPA (Teslascan) (Multihance) (Eovist) FNH Dynamic H-B phase +++ Biliary Excretion FDA Examples >10 min-hours + > 60 min-2 hrs +++ <10 min-hrs 50% 6% 50% Approval removed Approved in US and EU Approved in US and EU Arterial Phase Hepatobiliary Phase Adenoma T1 T1 Fat Sat Arterial Adenoma Fat Arterial enhancement No scar T2 Sahani et al. Radiographics 2009 Delayed 10

11 Adenoma Hepatobiliary Phase Focal Liver Lesions Non-cirrhotic Cyst Biliary hamartoma/cystadenoma Abscess Hemangioma Cirrhotic RGN DSN FNH Adenoma T2 Metastases Fibro Lamellar HCC Lymphoma Focal Liver Lesions Non-cirrhotic Cyst Biliary hamartoma/cystadenoma Abscess Hemangioma FNH Adenoma Metastases Fibro Lamellar HCC Lymphoma Cirrhotic RGN DSN Cirrhotic Nodule to HCC complex Hussein et al. Radiographics 2002 Malignant Transformation In Cirrhosis Cirrhotic Nodules: Blood Supply RGN HCC 14-38% of cirrhotic liver have DNs DN is a premalignant lesion and a target for HCC prevention DSN Portal Vein Hepatic Artery Courtsey: Glenn Krinsky NYU 11

12 Cirrhosis: Nodules Dysplastic Nodule T2W T1W Dynamic CT MR HCC Arising in DN T2 HAP Triple phase MDCT vs. MRI Progression from DN to HCC over 6 months CT HAP CT PVP Nagouchi et al AJR 2003 SN PPV MDCT 66% 96% MRI 63% 97% Fibrolamellar HCC Young age No cirrhosis Heterogeneous lesion Necrosis and hemorrhage Fibrous/Calcified central scar Nodes Fibrolamellar HCC CT Heterogeneous lesion Calcified central scar 12

13 Fibrolamellar HCC Fibrolamellar HCC CT Heterogeneous lesion Calcified central scar MR Heterogeneous lesion Hypointense central scar on T2 WI Fibrolamellar HCC MR: Fibrolamellar HCC MR Gd-Art Heterogeneous lesion Hypointense central scar on T2 WI MR: Fibrolamellar HCC MR: Fibrolamellar HCC Gd-Art Gd-Art Gd-Port Gd-Port Gd-Equil 13

14 MR: Fibrolamellar HCC HCC Gd-Art Gd-Port Gd-Equil T2-WI HCC HCC Carcinoid Carcinoid 14

15 Metastases Metastases Metastases Metastases Metastases: Peripheral Wash-out Metastases: Peripheral Wash-out 15

16 Hepatobiliary agenets HCC well differentiated HCC poorly differentiated Arterial Phase Delayed Radiographics 2009 Metastases Portal Venous Phase Hepatobiliary Phase Radiographics 2009 PET/CT FDG-PET: Equivocal CT findings Adenoma Indeterminate Unresectable Resectable 16

17 Diffusion-weighting imaging Diffusion-weighting imaging: used to characterize tissue T2 DWI Uses of DWI: Lesion detection Tissue characterization: Functional Evaluation Biomarker of tumor treatment response Koh DM et al. Eur Radiol May;18(5): Bruegel M et al. Eur Radiol Mar;18(3): Laurent V et al. Eur J Radiol Jun 2 Catalano OA. Radiology Jan;254(1): Assesses tissue cellularity More tissue less diffusion (water) Less diffusion = reduction in apparent diffusion coefficient (ADC) Not all tissues with reduced diffusion are abnormal (endometrium/bowel) Diffusion sensitizing gradient (b value) DWI sec T2 breath hold sequences (quick) Different b values (diffusion gradients) High tissue cellularity H2O diffusion restricted much so can be re-phased DWI and ADC DWI: normal = increased diffusion = signal loss Abnormal = decreased diffusion = increased signal Even at high b values for tumor Restricted diffusion tumor, abscess, cytotoxic edema, fibrosis ADC (apparent diffusion coefficient) ADC: (slope of signal loss between high and low b values) High slope = normal diffusion Low slope = restricted diffusion Normal ADC map = high signal intensity Abnormal ADC map = low signal intensity Qayyum et al Radiographics

18 DWI ADC Bright Dark Qayyum et al Radiographics 2009 Advanced MR Techniques: Diffusion Weighted Imaging MALIGNANT LESIONS Metastases HCC Cholangio CA Conventional MALIGNANT LESIONS MALIGNANT LESIONS Conventional Conventional DWI 18

19 MALIGNANT LESIONS HEMANGIOMA DWI + ADC Post-gado DWI ADC Conventional DWI ADC Map Summary Benign vs. malignant lesions History CT vs. MRI vs. PET Specific lesion characteristics Hepatobiliary agents DWI Biopsy 19