Hepatobiliary Contrast Agents for Liver MRI

Transcription

1 Hepatobiliary Contrast Agents for Liver MRI Scott B. Reeder, MD, PhD International Society for Magnetic Resonance in Medicine Sociedad Mexicana de Radiologia e Imagen (SMRI) Mexico City June 4, 2014 Department of Radiology University of Wisconsin Madison, WI

2 Off-Label Disclosures Off-label uses of gadolinium based contrast agents (GBCAs) Off-label dosing of gadoxetic acid

3 Goals and Objectives Review available contrast agents for liver imaging Important Applications of Hepatobiliary agents Liver lesion detection and characterization Metastatic disease FNH vs Adenoma HCC and the Cirrhotic Liver Biliary Imaging

4 Goals and Objectives Review available contrast agents for liver imaging Important Applications of Hepatobiliary agents Liver lesion detection and characterization Metastatic disease FNH vs Adenoma HCC and the Cirrhotic Liver Biliary Imaging

5 What do Contrast Agents Offer For Liver MRI? Improved detection and confidence Characterization Staging Treatment monitoring T2W Pre-contrast Arterial Phase Portal Venous 20 minute Hepatobiliary

6 What are the choices? Extracellular GBCA s - Gadopentate dimeglumine (Magnevist) - Gadoteridol (Prohance) - Gadovertsetamide (Optimark) - Gadodiamide (Omniscan) - Gadobutrol (Gadavist) - Gadobenate dimeglumine (Multihance) - Hepatobiliary GBCA s - Gadobenate dimeglumine (Multihance) 3-5% hepatobiliary uptake, minute delay - Gadoxetic Acid (Eovist, Primovist) 50% hepatobiliary uptake, 20 minute delay

7 What are the choices? Extracellular GBCA s - Gadopentate dimeglumine (Magnevist) - Gadoteridol (Prohance) - Gadovertsetamide (Optimark) - Gadodiamide (Omniscan) - Gadobutrol (Gadavist) - Gadobenate dimeglumine (Multihance) - Hepatobiliary GBCA s - Gadobenate dimeglumine (Multihance) 3-5% hepatobiliary uptake, minute delay - Gadoxetic Acid (Eovist, Primovist) 50% hepatobiliary uptake, 20 minute delay

8 Dual Blood Supply to the Liver Aorta Liver HA Gut PV

9 Phases of Enhancement: Extracellular Contrast Agents Enhancement HA PV Liver Tumor Time inject

10 Dynamic Imaging of the Liver (Gadobenate Dimeglumine) Pre-contrast T1 Portal Venous Arterial

11 Case: 65yo Asian F, chronic hep B Arterial Phase Portal Venous Arterial Phase Portal Venous Hepatocellular Carcinoma Pre-contrast T2W with Fat-Sat In-phase Out of phase Typical Features on CT and MRI, Fat Detected with MRI

12 Hepatobiliary Gadolinium Agents Mangafodipir (Teslascan) Gadobenate dimeglumine (Gd-BOPTA, Multihance) All purpose contrast agent for liver imaging, MRA Also has 3-5% biliary excretion 0.1mmol/kg, Biliary phase imaging at 1-2 hours Gadoxetic Acid (Gd-EOB-DTPA, Eovist, Primovist) Primarily a hepatobiliary agent 50% hepatic excretion 0.05mmol/kg, imaging of bile ducts at 20 minutes

13 Gadoxetic Acid (Gd-EOB-DTPA, Eovist/Primovist) O EOB O O 3+ Gd + 2 Na N N O O N O O O O O DTPA O

14 Hepatobiliary Gadolinium Agents Intravenous administration ~50% Plasma, extracellular space OATP1 liver/ hepatocyte cmoat ~50% kidneyss urine bile/feces

15 Phases of Enhancement: Hepatobiliary Contrast Agents Enhancement HA PV Liver Time inject

16 Enhancement Time Course (Gadoxetic Acid): Optimum Hepatobiliary Phase Peak bile duct enhancement at 20-30minutes Nagle et al ISMRM 2009, in press JMRI 2012

17 Increase In Liver CNR (%) Liver Imaging: ECF vs Gadobenate Gadobenate (0.1 mmol/kg) Gadobenate (0.05 mmol/kg) Gadopentetate (0.1 mmol/kg) minutes postdose minutes postdose 10 Spinazzi A et al. Acad Radiol. 1998;5(suppl 1):S86-S89.

18 Hepatobiliary Dynamic Imaging Imaging of of thethe Liver Liver (Gadobenate Dimeglumine) Pre-contrast T1 Arterial Portal Venous Delayed

19 Phases of Enhancement: Hepatobiliary Contrast Agents Enhancement HA PV Liver Tumor Time inject

20 PET CT Showed One Met No se puede mostrar la imagen. Puede que su equipo no tenga suficiente memoria para abrir la imagen o que ésta esté dañada. Reinicie el equipo y, a continuación, abra el archiv o de nuev o. Si sigue apareciendo la x roja, puede que tenga que borrar la imagen e insertarla de nuev o. Case courtesy Claude Sirlin, MD

21 Detection of Metastases: DWI vs Gadoxetic Acid DWI (b =500 s/mm2) T1w Navigator Min IP (20 minutes) Gadoxetic acid enhanced imaging more robust

22 Case: Colorectal Metastases Diffusion Weighted Imaging Arterial Phase T1W Portal Venous Phase T1W T2W FSE with Fat-Sat 20 minute T1W 20 minute T1W (minip)

23 Detection of Metastases to Liver Mounting evidence that hepatobiliary agents improve the sensitivity of met detection - Chan et al Ir J Med Sci 2012 Bashir et al JMRI 2012 Motosugi et al Radiology 2011 Huppertz et al al Radiology 2005 Bluemke et al Radiology 2005 Limited data on outcomes Multiple sequences required to characterize lesions Challenge: new respiratory triggered sequences - Very spatial resolution and optimized liver-lesion CNR - may be the only sequence on which lesion detected

24 Optimized T1 Weighting: High Flip Angle Increasing flip angle leads to tremendous improvements in.. Liver-lesion contrast (~30o) Liver-biliary contrast (~45o) Nagle et al JMRI 2012

25 Hepatobiliary Agents: Focal Nodular Hyperplasia (Gadobenate) FNH retains contrast on delayed phase imaging

26 Small Hypervascular Mass Focal nodular hyperplasia

27 Gadobenate-Enhanced MRI: FNH vs Adenoma Arterial Late FNH Grazioli L et al. Radiology. 2005;236: Adenoma

28 Gadobenate-Enhanced MRI: FNH vs Adenoma Grazioli et al Radiology mmol/kg of gadobenate dimeglumine Hepatic Adenoma/Adenomatosis (32 HA, 75 LA) 107/107 (100%) of HA or LA were hypointense FNH (128) 124/128 (97%) of FNH were iso- or hyper-intense

29 FNH: Pathological Proven (Gadoxetic Acid) T2 FSE Late Arterial 20 minute delayed

30 Adenoma: Pathological Proven (Gadoxetic Acid) Opposed Phase Late Arterial In-Phase 20 minute delayed

31 Adenoma vs FNH: Experience with Gadoxetic Acid Appears to follow same rules as gadobenate Increasing data with (path proof) - Grazioli et al Radiology Zech et al Investigative Radiology Huppertz et al Radiology 2005 University of Wisconsin experience - 34 FNH: 100% iso- or hyperintense - 6 HA: 100% hypointense - Mohajer et al, JMRI 2012 Data are promising but more data needed

32 Hemangioma: Hepatobiliary Contrast Agents T2W FSE Late Arterial 20 minute delay Behaves as expected follows blood pool Images courtesy Raj Gupta, MD & Elmar Merkle, MD

33 Hemangioma: Hepatobiliary Contrast Agents Gadobenate Dimeglumine

34 Hepatobiliary Agents: HCC? Delayed imaging clearly helpful if Background liver is relatively normal (ie: not cirrhotic) HCC does not take up agent Problems Most HCC in US arise in cirrhotic liver HCC can take up hepatocyte specific agents Most experience in Asia Promising results for both Gd-BOPTA and Gd-EOB

35 Patterns of Enhancement: Hepatobiliary GBCA s Normal Liver Cirrhotic Liver Tumor How well will these agents perform in cirrhotic livers?

36 Case: Hepatitis B T2W FSE with Fat-Sat Pre-contrast T1W Arterial Phase T1W Coronal T2W SSFSE Portal Venous Phase T1W 20 minute T1W

37 Hepatobiliary Agents: HCC? Arterial Phase Gadoxetic Acid Same accuracy as CT Gadoxetic acid MRI better for small HCC Portal Venous Delayed Phase 0.8cm moderately differentiated HCC (segment VII) SH Kim et al AJR 2009

38 Gall Bladder Trauma 45 yo F with cirrhosis and directed Blunt Trauma to the Gall Bladder

39 Gall Bladder Trauma Directed Blunt Trauma to the Gall Bladder Functional, but very poor spatial resolution

40 MR Cholangiography: Gadobenate Heavily T2 Weighted 3D-MRCP Anatomy T1 Weighted MRC Anatomy + Function

41 MR Cholangiography: Gadoxetic Acid Heavily T2 Weighted 3D-MRCP Anatomy T1 Weighted MRC Anatomy + Function

42 Case: Bile Leak s/p Cholecystectomy Frydrychowicz et al JMRI 2011

43 Case: r/o stricture s/p Liver Tx

44 Case: r/o stricture s/p Liver Tx Frydrychowicz et al JMRI 2011

45 Primary Sclerosing Cholangitis Jedynak et al JMRI 2012

46 Primary Sclerosing Cholangitis Nagle et al JMRI 2012

47 Primary Sclerosing Cholangitis Jedynak et al JMRI 2012 s

48 Primary Sclerosing Cholangitis T1W MR cholangiography vs T2W MRCP (n=34) T2W MRCP prefered and performed better (IQ) T1 MRC highly complementary Second look at anatomy Does not overcall strictures like T2W MRCP Functional information Jedynak et al JMRI 2012

49 Are Liver Specific Agents Helpful? Metastatic Disease HA vs FNH More data needed, but highly promising HCC Data strong in Asia, more Western data needed Biliary

50 UW-Madison Algorithm (not universally accepted) Cirrhotic Liver Extracellular GBCA (eg. gadobenate dimeglumine) Dynamic phase vascular complications of portal hypertension Data unclear on gadoxetic acid in the Western cirrhotic Focal liver lesion Default = Gadoxetic acid eg. mets, adenoma/fnh, etc Consider extracellular GBCA for known vascular lesions eg. hemangioma, peliosis MRCP (biliary pathology) Gadoxetic acid

51 Goals and Objectives Review available contrast agents for liver imaging Important Applications of Hepatobiliary agents Liver lesion detection and characterization Metastatic disease FNH vs Adenoma HCC and the Cirrhotic Liver Biliary Imaging

52 Thank you! Alex Frydrychowicz, MD Scott Nagle, MD, PhD Jeff Weinreb, MD Claude Sirlin, MD