Hepatobiliary Contrast Agents SCBT/MR Annual Meeting Salt Lake City September 21, 2016 Scott B. Reeder, MD, PhD Department of Radiology University of Wisconsin Madison, WI
Disclosures University of Wisconsin-Madison receives research support from GE Healthcare, and Bracco Diagnostics Founder Calimetrix, LLC Shareholder Elucent Medical Consulting - Parexel International Off-label use & dosing of gadolinium
Dual Blood Supply to the Liver Aorta Liver HA Gut PV
Enhancement Phases of Enhancement: Extracellular Contrast Agents HA PV Liver Tumor Time inject
Dynamic Imaging of the Liver (Gadobenate Dimeglumine) Pre-contrast T1 Arterial Portal Venous
Increase In Liver CNR (%) Liver Imaging: ECF vs Gadobenate 120 100 80 Gadobenate (0.1 mmol/kg) 60 40 20 0 Gadobenate (0.05 mmol/kg) Gadopentetate (0.1 mmol/kg) 0 10 minutes postdose 10 120 minutes postdose Spinazzi A et al. Acad Radiol. 1998;5(suppl 1):S86-S89.
Hepatobiliary Dynamic Imaging of of the the Liver Liver (Gadobenate Dimeglumine) Pre-contrast T1 Arterial Portal Venous Delayed
Gadoxetic Acid (Gd-EOB-DTPA, Eovist/Primovist) O EOB O O N N O Gd 3+ 2 Na + O N O O O O O O DTPA
Hepatobiliary Gadolinium Agents Intravenous administration Plasma, extracellular space ~50% OATP1 liver/ hepatocyte ~50% cmoat kidneys bile/feces urine
Enhancement Phases of Enhancement: Hepatobiliary Contrast Agents HA PV Liver Time inject
PET CT Showed One Met Case courtesy Claude Sirlin, MD
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
Optimized T1 Weighting: High Flip Angle Increasing flip angle leads to tremendous improvements in.. Liver-lesion contrast (~30 o ) Liver-biliary contrast (~45 o ) Nagle et al JMRI 2012
Detection of Metastases: DWI vs Gadoxetic Acid DWI (b =500 s/mm 2 ) T1w Navigator Min IP (20 minutes) Gadoxetic acid enhanced imaging more robust
Case: 50-year-old woman with an enhancing liver mass identified on CT with mass effect on the IVC Coronal T2W SSFSE Pre-contrast T1W Arterial Phase T1W T2W FSE with Fat-Sat Portal Venous Phase T1W 20 minute T1W Focal Nodular Hyperplasia
Slice 1 Slice 2 Slice 3 Case: 31-yo woman with 3 masses seen on CT T2W FSE with Fat-Sat Arterial Phase T1W 20 minute T1W
Adenoma: Pathological Proven (Gadoxetic Acid) Opposed Phase In-Phase Mohajer JMRI 2012 Late Arterial 20 minute delayed
Case: 44 yo man with progressive abdominal pain Pre-contrast T1W Arterial Phase T1W T2W FSE with Fat-Sat Portal Venous Phase T1W 90 minute T1W Coronal T2W SSFSE Fibrolamellar HCC
Case: Hepatitis B T2W FSE with Fat-Sat Pre-contrast T1W Arterial Phase T1W Coronal T2W SSFSE Portal Venous Phase T1W 20 minute T1W
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
Gall Bladder Trauma 45 yo F with cirrhosis and directed Blunt Trauma to the Gall Bladder
Gall Bladder Trauma Directed Blunt Trauma to the Gall Bladder Functional, but very poor spatial resolution
MR Cholangiography: Gadoxetic Acid Heavily T 2 Weighted 3D-MRCP T 1 Weighted MRC Anatomy Anatomy + Function
Case: Bile Leak s/p Cholecystectomy Frydrychowicz et al JMRI 2011
Primary Sclerosing Cholangitis Nagle et al JMRI 2012
Cirrhotic Liver UW-Madison Algorithm 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 http://www.radiology.wisc.edu/fileshelf/contrastcorner/files/eovist_guidelines.pdf
Gadoxetic Acid + Gadofosveset Trisodium Gadoxetic Acid Gadofosveset Trisodium 20 min 5min Dynamic T1WI, T2WI, DWI BH FA 12/15º GA alone FB FA 30º 24 sec 4-5 min GA + GT combined BH FA 12/15º FB FA 30º 24 sec 4-5 min Bannas et al, European Radiology, 2016
Gadoxetic Acid + Gadofosveset Trisodium Gadoxetic Acid Gadoxetic Acid + Gadofosveset Hemangioma Case Lieble Colorectal met Case Ormond Neuroendocrine met Case Lemke Bannas et al, European Radiology, 2016
Case: 52-yo man with colorectal cancer Gadoxetic Acid GA + Gadofosveset DWI
Gadolinium Calculator https://www.radiology.wisc.edu/contrastcorner/gadcalc.php GadCalc
Thank you! Alex Frydrychowicz, MD Scott Nagle, MD, PhD Jeff Weinreb, MD Claude Sirlin, MD