LIVER IMAGING TIPS IN VARIOUS MODALITIES. M.Vlychou, MD, PhD Assoc. Professor of Radiology University of Thessaly

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1 LIVER IMAGING TIPS IN VARIOUS MODALITIES M.Vlychou, MD, PhD Assoc. Professor of Radiology University of Thessaly

2 Hepatocellular carcinoma is a common malignancy for which prevention, screening, diagnosis, treatment, and surveillance demand a multidisciplinary approach Knowledge of the underlying pathophysiology as well as advances in clinical management should be employed by radiologists to effectively communicate with hepatologists, surgeons, and oncologists Imaging and image-directed therapies are key components of effective management of patients with HCC

3 Efremidis et al (2007) Eur Radiol 17:

4 Ultrasound Gray scale and color Doppler ultrasound Contrast enhanced Ultrasound Intraoperative US Elastography detection and characterization of focal liver lesions Fusion imaging American Association for the Study of Liver Diseases (AASLD) guidelines: HCC surveillance with non contrast-enhanced abdominal ultrasound for several well-defined subsets of the population: cirrhosis, chronic hepatitis B

5 Contrast enhanced Ultrasound Hepatocellular carcinoma Courtesy Dr. Kyriakopoulou, Medical Center of Athens

6 Contrast enhanced Ultrasound Hepatocellular carcinoma, portal vein thrombosis Courtesy Dr. Kyriakopoulou, Medical Center of Athens

7 Contrast enhanced Ultrasound Heterogeneous hyperenhancement of intra-hepatic cholangiocaricnoma during arterial phase Courtesy Dr. Kyriakopoulou, Medical Center of Athens

8 AASLD guidelines management of HCC (2011) Surveillance of (high risk) patients has to be based on ultrasound examination Diagnosis of HCC should be based on imaging techniques and/or biopsy Contrast-enhanced US may offer false positive HCC diagnosis in patients with cholangiocarcinoma and thus, has been dropped from the diagnostic techniques

9 Intra- operative US Liver Cancer. 2013

10 US elastography The stiffness of a lesion can be correlated with histology; however, Its role remains to be determined

11 After identification of a concerning observation via abdominal ultrasound, use of dynamic contrast enhanced computed tomography(ct), magnetic resonance imaging(mri), or biopsy is indicated for diagnosis

12 Keep in mind.. Radiol Clin N Am 53 (2015)

13 Dynamic protocol of CT in non-enhanced, arterial (25 sec), portal (60 sec) and late phase Typical HCC, nodule in nodule appearance

14 Dynamic protocol of CT in non-enhanced, arterial (25 sec), portal (60 sec) and late phase Atypical HCC

15 Dynamic protocol of CT in cirrhosis Possible diffuse HCC

16 Dynamic CT follow up Recurrence of a previously treated HCC by ablation. Next to the necrotic lesion the is a solid component, HCC

17 What can an MRI scan offer? Dynamic scan similar to CT, with improved diagnostic efficacy Diffusion-weighted imaging Liver-specific contrast agents Multiple studies have demonstrated excellent sensitivity and specificity of MRI for the detection and characterization of HCC, particularly for smaller tumors, 1 2 cm in size with sensitivity up to 84% and 47% with MRI and CT, respectively

18 MR imaging Dynamic gadolinium-enhanced MR imaging in a patient with HCC

19 MR imaging T2FS and DWI weighted images in a patient with HCC

20 Liver- specific gadoxetic acid MRI The use of this type of contrast agent enables lesions that contain hepatocytes to be distinguished from those that do not Malignant lesions composed of non-functioning hepatocytes (high-grade dysplastic nodules and HCC) or that have no hepatocytes (metastasis) do not show uptake of this type of contrast in the hepatobiliary phase Likewise, these agents also have been used to distinguish focal nodular hyperplasia from fibrolamellar carcinoma and from hepatic adenoma These contrast media could be especially useful in those patients with hepatic lesions that do not have the classic vascular behavior of HCC

21 arterial portal delayed T2FS Lesions visible only in arterial phase of dynamic protocol (LAVA)

22 arterial portal 10 min post 20 min post Dynamic protocol with liver specific agent, includes 10min and 20min scans post injection

23 LAVA LATE 20 min post contrast (Gd-EOB-DTPA, Primovist) Diagnosis: multiple FNHs

24 LAVA arterial phase, 3T MR LAVA 20min post, 3T MR Scanning protocol includes dynamic scanning 10min and 20 min after iv administration of liver-specific contrast agent- HCC

25 Cor T2 T2FS 33 yo male patient with liver cirrhosis and ascites

26 arterial phase 20min late 33 yo male patient with liver cirrhosis and ascites, dynamic scan with liver specific contrast confluent fibrosis

27 DWI 10min late Combination of diffusion weighted imaging and liver specific contrast shows no evidence of HCC

28 arterial arterial 60 yo male HBV: LAVA, primovist, arterial phase, multifocal HCC

29 Portal 10min late 60 yo male HBV: LAVA, primovist, arterial phase, multifocal HCC

30 60 yo male HBV: LAVA, primovist, arterial phase, multifocal HCC

31 PRIMOVIST NON CIRROTIC LIVER AJR Am J Roentgenol Jul;195(1):13-28

32 PRIMOVIST CIRROTIC LIVER AJR Am J Roentgenol Jul;195(1):29-41

33 LI-RADS currently applies to CT and MRI performed with extracellular contrast agents LI-RADS soon will be expanded to apply to hepatobiliary contrast agents

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35 In conclusion HCC is a common malignancy with increasing world wide prevalence The varied clinical scenarios in which HCC may be seen may reflect underlying pathophysiological heterogeneity in the disease Knowledge of current treatment regimens as well as the various extant diagnostic and post-therapeutic imaging criteria can maintain the radiologist's central role in the multidisciplinary management of HCC

36 Thank you for your attention