CASE 1 11/1/2016 HEPATOBILIARY IMAGING CASE PRESENTATIONS DECLARATION. Dr. Chirag Patel ORGAN IMAGING yr old lady

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1 HEPATOBILIARY IMAGING CASE PRESENTATIONS DECLARATION No financial disclosures or affiliations with commercial organisations No discussion of investigational or off-label use of medical devices, products or pharmaceuticals ORGAN IMAGING 2016 Dr. Chirag Patel Sunnybrook Health Sciences Centre University of Toronto CASE 1 33yr old lady Hx of renal stones & resected pituitary adenoma (nonfunctional) 2004 Total thyroidectomy 2014 Abdominal Pain CT Abdo/Pelvis requested CT - PV CT - PV CT - PV CT - U CT - A CT - PV 1

2 T2w T2FS T1-IP T1-OP T2w T2FS T1-IP T1-OP T1FS Pre Gad T1FS+Gad - Art PV Equilibrium 5min Q1 What is the likely hepatic diagnosis? A. Metastases B. Adenomas C. Hepatocellular carcinoma D. Multifocal Angiomyolipomas E. Multi-Nodular hepatic steatosis What is the likely hepatic diagnosis? A. Metastases B. Adenomas C. Hepatocellular carcinoma D. Multifocal Angiomyolipomas E. Multi-Nodular hepatic steatosis 2

3 Repeat Biopsy: - Metastatic, well-differentiated Neuroendocrine Tumour - Moderate surrounding hepatic steatosis FATTY CHANGE IN LIVER FAT?? GLUCAGON Normal chromogranin A, C-peptides, gastrin & glucagonoma Asymptomaic TUMOUR INSULIN Metastatic PNET - Insulinoma FOCAL FAT Pancreatic Neuroendocrine Tumour Pituitary Adenoma Renal stones Parathyroid adenoma MEN1 CT CT Insulinoma Subcapsular Hepatic Steatosis Wanless IR et al. Mod Pathol Khalili K et al. AJR 2002 COMPANION 1 CECT - Art CECT - PV CECT - Del CT 67yr old man. Abdo Pain post colonoscopy. CT 3

4 T1w-IP T2w T2w-FS T1w-OP T2w-FS T1w-OP * T1w-IP * T1w-FS + C CECT Dynamic contrast MULTIFOCAL NODULAR FATTY INFILTRATION (MNFI) Multiple Rounded/spherical Lack of Mass effect Lack of Vascular distortion Central hepatic signal/density MNFI CASE 2 59yr old lady. Struck in abdomen with shopping cart FAST +ve Haemodynamically stable Trauma CT Kronke TJ. Eur Radiol

5 10 H.U. CT -PV CT -PV CT -PV CT -PV 4 days later. Increased abdominal pain Q2 Day 1 Day 4 What is the most likely diagnosis? A. Pancreatic injury B. Acute haemorrhage from hepatic injury C. Duodenal injury D. Bile duct injury E. IVC injury What is the most likely diagnosis? A. Pancreatic injury B. Acute haemorrhage from hepatic injury C. Duodenal injury D. Bile duct injury E. IVC injury 5

6 What test would you do next? A. MRI Liver B. Ultrasound +/- aspiration C. HIDA D. ERCP E. Multiphasic CT What test would you do next? A. MRI Liver B. Ultrasound +/- aspiration C. HIDA D. ERCP E. Multiphasic CT MRCP Common bile duct injury T1FS + Primovist Laparotomy & exploration Severed CBD with length of contused CBD Pancreatic head contusion Hepaticojejunostomy created (just below the bifurcation) T1FS + Primovist COMPANION 2 54yr old gentleman. RUQ pain and fever PMH APLS (DVT/PE), HTN, CKD Urgent US 6

7 CT (Triphasic) CT CT Rt Anterior Sector Biliary Anatomic Variance MRI + Primovist Rt Posterior Sector CHD Lt Main Anomalous insertion of the cystic duct Rt posterior sector duct Low insertion of the Rt posterior sector duct into the CHD Cystic duct Post-Primo 20min Biliary Variance 30% (risk factor of bile duct injury) Cholangiogram Mortele KJ et al. AJR 2001 Surgical Exploration Bile leak from three separated ducts (left main, right posterior and right anterior) Three separate hepaticojejunal anastomoses Roux-en-Y reconstruction. 60min 60min Re-admitted with cholangitis (4 months post-op) 60min 7

8 CASE 3 Primo 5min Primo 10min Primo 20min 55yr old man SOB Right hilar mass with RLL collapse Bronchoscopy confirmed malignant lesion Staging CTs Primo 5min MRCP Primo 10min Primo 20min Lee NK et al. Radiographics 2009 CECT - Art CECT - PV CECT - Del T2w-FS T2w T1w-OP T1w-IP T1w-FS T1w-FS + C DWI b0 b750 ADC 8

9 What is the hepatic lesion? Q3 A. Focal Nodular Hyperplasia B. Adenoma C. HCC D. Haemangioma E. Metastasis What is the hepatic lesion? A. Focal Nodular Hyperplasia B. Adenoma C. HCC D. Haemangioma E. Metastasis METASTASIS LUNG PRIMARY COMPANION CASE 3 T2w T2w-FS T1w-FS SUMMARY METASTASIS COLONIC PRIMARY Semelka RC et al. Abdom Imaging

10 Benign hepatic lesions may mimic malignancy or vice-versa Differentiating features can be subtle Important to recognize atypical features, particularly in relation to apparently benign lesions. Further Reading Hepatobiliary anatomical variance is relatively common Pay attention to biliary and vascular variance 1. Fatty Liver: Imaging Patterns and Pitfalls Hamer OW et al, Radiographics Fat-containing Lesions of the Liver: Radiologic-Pathologic Correlation Prasad SR et al, Radiographics Biliary Imaging: Multi-modality approach to imaging biliary injuries and their complications Melamud K et al, Radiographics Biliary MR imaging with Primovist and its clinical applications - Lee NK, Radiographics Chemotherapy-treated ;iver metastases mimicking haemangiomas on MR Semelka RC, Abdominal Imaging