Alice Fung, MD Oregon Health and Science University

Alice Fung, MD Oregon Health and Science University

Disclosure Comments The speaker Alice Fung, MD Has relevant financial relationships to disclose. Received honorarium from (Guerbet). This individual s financial interest are not related to the content of the activity. The speaker/planner Atif Zaman, MD MPH have no relevant financial relationships to disclose. The speaker/planner Lauren Myers, MMSc, PA-C have no relevant financial relationships to disclose.

Ultrasound Computed Tomography Magnetic Resonance Imaging Nuclear Medicine

Uses high frequency sound waves and their echoes Advantages: Noninvasive Excellent screening tool Relatively inexpensive Disadvantages: Low sensitivity High FN rates for detection of liver metastases Operator dependent

Indications: RUQ pain Bile duct obstruction Gallstones Abnormal LFT s Assess for underlying liver disease, ie steatosis Suspected liver masses Cyst versus solid lesion Hepatic Vasculature Patency of hepatic and portal venous systems Flow direction Hepatopedal: toward the liver Hepatofugal: away from the liver Consider requesting dopplers when examining the liver

Ultrasound for HCC Screening Goal: detect HCC at early stage when amenable to curative therapy US every 6 months Sensitivity 65% US + AFP: 90% sensitivity for early stage HCC

Ultrasound Radiology Speak Patient Scanning Characteristics Hyperechoic and Heterogeneous hepatic parenchyma Fatty infiltration or fibrosis Hepatocellular dysfunction Hypo or Hyper-echoic lesions If not a cyst, then further work up is necessary! US LI-RADS

US Liver Imaging Reporting and Data System (LI-RADS) US Category US-1: Negative US-2: Subthreshold (<10 mm) US-3: Positive (>/= 10 mm) US Visualization Score US-A: No or minimal limitations US-B: Moderate limitations US-C: Severe limitations

Uses X-rays to acquire images displayed in axial, sagittal, and coronal planes Advantages: Quick exam with short breath-holds Relatively available High spatial resolution Disadvantages Ionizing radiation Iodinated IV contrast is mandatory Consider MRI if Iodinated IV contrast cannot be administered Except for specific scenarios, noncontrast CT to evaluate for liver pathologies is insufficient

Indications: Characterize lesion seen by ultrasound or single-phase CT Screening in patients whose ultrasounds are no longer diagnostic (cirrhotic patients) Treatment response Evaluation of degree of portal hypertension Ascites Varices Vascular patency, including TIPS Post-transplant complications

Hepatic Enhancement Noncontrast Arterial Phase (25 secs) Portal Venous Phase (70 secs) Equilibrium (Delayed) Phase

HCC Supplied by hepatic artery Enhance during the arterial phase before normal liver parenchyma Normal liver parenchyma Supplied by portal veins Maximally enhances during the portal venous phase

In contrast, hemangiomas exhibit slow, progressive enhancement.

Uses magnetic properties of protons Advantages: Spatial resolution High soft tissue contrast resolution Very sensitive No radiation or iodinated contrast Disadvantages Costly Not as readily available Longer exam times than CT Acquisition time Patient cooperation with exam Claustrophobia Longer breath-holds Gadolinium contrast

Indications Patients allergic to iodinated contrast Lesion detection & characterization Vascular patency Biliary tree assessment Similar indications as with CT Reliance on multiphase post contrast imaging and T1 and T2-weighted sequences for lesion detection and characterization

CT/MR Radiology Speak Appearance of cirrhosis Nodular hepatic contour Shrunken liver Left lateral segment/caudate lobe hypertrophy Expanded gallbladder fossa

Evidence of portal hypertension MPV diameter >12 mm Spleen size >12 cm Ascites Varices Recanalized paraumbilical vein Gallbladder wall edema often seen and not to be suggestive of cholecystitis Hypoalbuminemia Reactive to hepatitis

Perfusional abnormality/shunt Cavernous transformation of the portal vein Replaced hepatic arteries

Confluent fibrosis Bridging fibrosis

Geographic hepatic steatosis

MRI and Fat Evaluation

MRI and Iron Evaluation

Liver Imaging Reporting and Data System (LI-RADS) Lesions versus observations Observations assigned category codes based on size and suspicion of HCC LR-NC: Noncategorized LR-TIV: Tumor in Vein, irregardless of type of tumor LR1: definitely benign LR2: probably benign LR3: intermediate probability of HCC LR4: probably HCC LR5: definitely HCC near 100% PPV LR-M: Malignancy, not specifically HCC

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