LIVER IMAGING TIPS IN VARIOUS MODALITIES M.Vlychou, MD, PhD Assoc. Professor of Radiology University of Thessaly
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
Efremidis et al (2007) Eur Radiol 17:2969-2982
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
Contrast enhanced Ultrasound Hepatocellular carcinoma Courtesy Dr. Kyriakopoulou, Medical Center of Athens
Contrast enhanced Ultrasound Hepatocellular carcinoma, portal vein thrombosis Courtesy Dr. Kyriakopoulou, Medical Center of Athens
Contrast enhanced Ultrasound Heterogeneous hyperenhancement of intra-hepatic cholangiocaricnoma during arterial phase Courtesy Dr. Kyriakopoulou, Medical Center of Athens
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
Intra- operative US Liver Cancer. 2013
US elastography The stiffness of a lesion can be correlated with histology; however, Its role remains to be determined
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
Keep in mind.. Radiol Clin N Am 53 (2015) 919 931
Dynamic protocol of CT in non-enhanced, arterial (25 sec), portal (60 sec) and late phase Typical HCC, nodule in nodule appearance
Dynamic protocol of CT in non-enhanced, arterial (25 sec), portal (60 sec) and late phase Atypical HCC
Dynamic protocol of CT in cirrhosis Possible diffuse HCC
Dynamic CT follow up Recurrence of a previously treated HCC by ablation. Next to the necrotic lesion the is a solid component, HCC
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
MR imaging Dynamic gadolinium-enhanced MR imaging in a patient with HCC
MR imaging T2FS and DWI weighted images in a patient with HCC
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
arterial portal delayed T2FS Lesions visible only in arterial phase of dynamic protocol (LAVA)
arterial portal 10 min post 20 min post Dynamic protocol with liver specific agent, includes 10min and 20min scans post injection
LAVA LATE 20 min post contrast (Gd-EOB-DTPA, Primovist) Diagnosis: multiple FNHs
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
Cor T2 T2FS 33 yo male patient with liver cirrhosis and ascites
arterial phase 20min late 33 yo male patient with liver cirrhosis and ascites, dynamic scan with liver specific contrast confluent fibrosis
DWI 10min late Combination of diffusion weighted imaging and liver specific contrast shows no evidence of HCC
arterial arterial 60 yo male HBV: LAVA, primovist, arterial phase, multifocal HCC
Portal 10min late 60 yo male HBV: LAVA, primovist, arterial phase, multifocal HCC
60 yo male HBV: LAVA, primovist, arterial phase, multifocal HCC
PRIMOVIST NON CIRROTIC LIVER AJR Am J Roentgenol. 2010 Jul;195(1):13-28
PRIMOVIST CIRROTIC LIVER AJR Am J Roentgenol. 2010 Jul;195(1):29-41
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
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
Thank you for your attention