The Focal Hepatic Lesion: Radiologic Assessment Kevin Kuo, Harvard Medical School Year III
Our Patient: PS 67 y/o female w/ long history of alcohol use Drinking since age 18, up to one bottle of wine/day Asymptomatic, denies abdominal distension, hematemesis, ascites, encephalopathy 2
What Net? Given PS s etensive history of alcohol use, we are clearly concerned about potential cirrhosis and even hepatocellular carcinoma (HCC). However, we need to understand basic liver anatomy to appreciate liver imaging 3
Liver Anatomy Couinaud Segments Based on vascular anatomy Important for surgical planning Portal Triad and Hepatic Veins Hepatic veins delineate lobes of the liver: Left (lateral and medial) and Right (anterior and posterior) http://hopkins-gi.nts.jhu.edu/pages/latin/templates/inde.cfm 4
Screening for HCC: The Menu of Tests Imaging Modality Accuracy* Advantages Disadvantages US Sens:60% Spec:97% Wide availability, noninvasive, no radiation. Assess vascular invasion. Good for screening. Real time images Operator dependent, low sensitivity, may not always distinguish between tumors CT Sens:68% Spec: 93% Improved sensitivity with triple phase helical CT, relatively fast Increased radiation, more costly MRI Sens: 81% Spec: 85% Most sensitive, especially for smaller lesions. High resolution, no radiation Most epensive, takes more time, patient tolerance *For HCC In patients with chronic liver disease 5
Triple Phase Helical CT Aial C+ CT Arterial Phase Aial C+ CT Portal Venous Phase Aial C+ CT Hepatic Venous Phase Contrast Injection Arterial Portal Venous Hepatic Venous 0 15 30 45 60 75 Time (sec) Foley, WD. Multiphase Hepatic CT with a Multirow Detector CT Scanner. 2000 (175): 679-685. 6
PS: Cirrhosis and Portal Hypertension Film Findings: Nodular, shrunken liver Caudate and left lateral lobe enlargement Esophageal Varices Umbilical Recanalization Enlarged Portal Vein Splenomegaly, Ascites (neither present in our patient) PACS, BIDMC Aial C+ CT Venous Maimum Intensity Phase Reconstruction Aial C+ CT 7
PS: Triple Phase CT Aial C- CT Aial C+ CT: Arterial Phase Film Findings: Nodular liver No discrete lesions Early hyperenhancing lesion PACS, BIDMC 8
PS: Triple Phase CT Aial C+ CT: Portal Venous Phase Aial C+ CT: Delayed Phase Film Findings: Quick washout of enhancing lesion Hypoenhancing lesion with peripheral rim of enhancement PACS, BIDMC 9
PS: Preliminary Diagnosis Triple Phase CT Findings: Early arterial phase enhancement quick washout peripheral rim of enhancement in the delayed phase Highly suspicious for HCC HCC is hypervascular receives ~80% of its blood flow from hepatic arteries and only ~20% from the portal vein (eact opposite of normal liver parenchyma) Nonetheless, we need to consider the full differential diagnosis 10
A Walk Through The Differential Diagnoses: Lesions Classical CT Findings PS Hepatic Cyst Hemangioma Focal Nodular Hyperplasia (FNH) Hepatocellular Adenoma Metastasis Abscess Hepatocellular Carcinoma (HCC) Sharply demarcated wall, water density, nonenhancing Peripheral filling in of contrast over time Light Bulb Sign on T2 MRI Early filling in arterial phase with central filling defect (scar) Variable, central changes due to hemorrhage often seen Mostly multiple low attenuation lesions, rim enhancement without filling in Well demarcated hypodense areas with peripheral enhancement, may see gas Early arterial enhancement, fast washout, delayed fibrous capsule enhancement 11
Hepatic Cyst Aial C+ CT Film Findings: Sharply demarcated, non enhancing, water-dense cyst. http://bb.westernu.edu/web/pathology/webpath60/webpath/radi ol/heparad/ 12
A Walk Through The Differential Diagnoses: Lesions Hepatic Cyst Hemangioma Focal Nodular Hyperplasia (FNH) Hepatocellular Adenoma Metastasis Abscess Hepatocellular Carcinoma (HCC) Classical CT Findings Sharply demarcated wall, water density, nonenhancing Peripheral filling in of contrast over time Light Bulb Sign on T2 MRI Early filling in arterial phase with central filling defect (scar) Variable, central changes due to hemorrhage often seen Mostly multiple low attenuation lesions, rim enhancement without filling in Well demarcated hypodense areas with peripheral enhancement, may see gas Early arterial enhancement, fast washout, delayed fibrous capsule enhancement PS 13
Hemangioma Aial C+ CT (Various phases) Film Findings: Hypodense lesion with peripheral filling in of contrast over time http://www.radiologyassistant.nl/en/448eef3083354 14
A Walk Through The Differential Diagnoses: Lesions Hepatic Cyst Hemangioma Focal Nodular Hyperplasia (FNH) Hepatocellular Adenoma Metastasis Abscess Hepatocellular Carcinoma (HCC) Classical CT Findings Sharply demarcated wall, water density, nonenhancing Peripheral filling in of contrast over time Light Bulb Sign on T2 MRI Early filling in arterial phase with central filling defect (scar) Variable, central changes due to hemorrhage often seen Mostly multiple low attenuation lesions, rim enhancement without filling in Well demarcated hypodense areas with peripheral enhancement, may see gas Early arterial enhancement, fast washout, delayed fibrous capsule enhancement PS 15
Focal Nodular Hyperplasia Aial C+ CT Film Findings: Enhancing lesion with central filling defect (central scar) http://uuhsc.utah.edu/rad/medstud/bodycasestudies/bodyca se6a.htm 16
A Walk Through The Differential Diagnoses: Lesions Hepatic Cyst Hemangioma Focal Nodular Hyperplasia (FNH) Hepatocellular Adenoma Metastasis Abscess Hepatocellular Carcinoma (HCC) Classical CT Findings Sharply demarcated wall, water density, nonenhancing Peripheral filling in of contrast over time Light Bulb Sign on T2 MRI Early filling in arterial phase with central filling defect (scar) Variable, central changes due to hemorrhage often seen Mostly multiple low attenuation lesions, rim enhancement without filling in Well demarcated hypodense areas with peripheral enhancement, may see gas Early arterial enhancement, fast washout, delayed fibrous capsule enhancement PS 17
Hepatocellular Adenoma Aial C+ CT Film Findings: Multiple hypoenhancing heterogenous lesions Enhancing hepatic veins UpToDate: Hepatic Adenoma 18
A Walk Through The Differential Diagnoses: Lesions Hepatic Cyst Hemangioma Focal Nodular Hyperplasia (FNH) Hepatocellular Adenoma Metastasis Abscess Hepatocellular Carcinoma (HCC) Classical CT Findings Sharply demarcated wall, water density, nonenhancing Peripheral filling in of contrast over time Light Bulb Sign on T2 MRI Early filling in arterial phase with central filling defect (scar) Variable, central changes due to hemorrhage often seen Mostly multiple low attenuation lesions, rim enhancement without filling in Well demarcated hypodense areas with peripheral enhancement, may see gas Early arterial enhancement, fast washout, delayed fibrous capsule enhancement PS 19
Liver Metastasis (Colonic Adenocarcinoma) Aial C+ CT Film Findings: Multiple hypoenhancing heterogenous lesions http://www.mypacs.net/repos/mpv3_repo/viz/full/11724/586248. jpg 20
A Walk Through The Differential Diagnoses: Lesions Hepatic Cyst Hemangioma Focal Nodular Hyperplasia (FNH) Hepatocellular Adenoma Metastasis Abscess Hepatocellular Carcinoma (HCC) Classical CT Findings Sharply demarcated wall, water density, nonenhancing Peripheral filling in of contrast over time Light Bulb Sign on T2 MRI Early filling in arterial phase with central filling defect (scar) Variable, central changes due to hemorrhage often seen Mostly multiple low attenuation lesions, rim enhancement without filling in Well demarcated hypodense areas with peripheral enhancement, may see gas Early arterial enhancement, fast washout, delayed fibrous capsule enhancement PS 21
Liver Abscess Aial C+ CT Film Findings: Well demaracated hypoenhancing lesion Rim of increased enhancement relative to central region http://www.e-radiography.net/ibase5/hepatic/inde.htm 22
A Walk Through The Differential Diagnoses: Lesions Hepatic Cyst Hemangioma Focal Nodular Hyperplasia (FNH) Hepatocellular Adenoma Metastasis Abscess Hepatocellular Carcinoma (HCC) Classical CT Findings Sharply demarcated wall, water density, nonenhancing Peripheral filling in of contrast over time Light Bulb Sign on T2 MRI Early filling in arterial phase with central filling defect (scar) Variable, central changes due to hemorrhage often seen Mostly multiple low attenuation lesions, rim enhancement without filling in Well demarcated hypodense areas with peripheral enhancement, may see gas Early arterial enhancement, fast washout, delayed fibrous capsule enhancement PS 23
PS: Hepatocellular Carcinoma Aial CT (various phases) Film Findings: Early arterial enhancement Quick washout Peripheral rim of enhacement PACS, BIDMC 24
A Walk Through The Differential Diagnoses: Lesions Hepatic Cyst Hemangioma Focal Nodular Hyperplasia (FNH) Hepatocellular Adenoma Metastasis Abscess Hepatocellular Carcinoma (HCC) Classical CT Findings Sharply demarcated wall, water density, nonenhancing Peripheral filling in of contrast over time Light Bulb Sign on T2 MRI Early filling in arterial phase with central filling defect (scar) Variable, central changes due to hemorrhage often seen Mostly multiple low attenuation lesions, rim enhancement without filling in Well demarcated hypodense areas with peripheral enhancement, may see gas Early arterial enhancement, fast washout, delayed fibrous capsule enhancement PS 25
PS: The Final Diagnosis Ultrasound guided biopsy confirmed the diagnosis Hepatocellular Carcinoma 26
HCC: MR Imaging Aial T1 Weighted MR Precontrast Aial T1 Weighted MR Arterial Phase Aial T1 Weighted MR Portal-phase Variable intensity on T1 and T2 weighted imaging Early arterial phase enhancement Quick washout Rim enhancement of fibrous capsule in portal/delayed phases Ito, K. Hepatocellular carcinoma: Conventional MRI findings including gadolinium-enhanced dynamic imaging. 2006 (58): 196-199. 27
Hepatocellular Carcinoma: Background Incidence: 2.5/100,000 in US vs. 50/100,000 in East Asia, Median survival after diagnosis: ~ 12 months Projected to be the worldwide leading cause of cancer mortality by 2010 (WHO) Causes: Hepatitis B and/or C, Cirrhosis, Aflatoins, Hemochromatosis Diagnosis of HCC gives bonus points for transplantation evaluation based on the Model for End Stage Liver Disease (MELD) May be a focal lesion, dominant lesion with satellites, or diffusely infiltrating 28
HCC: Treatment Options Treatment: Resection Optimal Candidate: Solitary lesion, no vascular invasion, preserved hepatic function Patient PS X Cirrhotic, poor hepatic reserve Transplant Radiofrequency Ablation Chemoembolization Unresectable patients w/ solitary lesion < 5cm or <3 lesions of <3 cm. No vascular invasion or metastases Do not meet resectability/transplant criteria but disease confined to liver Large unresectable tumors not amenable to RFA. Absence of portal vein thrombosis or encephalopathy X EtOH found at transplant eval. X RFA more appropriate 29
Radiofrequency Ablation: Guidance US Guidance CT Guidance Aial C- CT Film Findings: RFA needle in tumor http://hopkins-gi.nts.jhu.edu/pages/latin/templates/inde.cfm http://www.ijri.org/articles/archives/2003-13-3/phy315.htm 30
PS: RFA Ultrasound Aial US: Lesion Pre-RFA Aial US: Lesion Post-RFA Film Findings: Hypoechoic lesion with poorly defined borders. Hyperechoic region with dirty shadowing (air bubbles from RF procedure) PACS, BIDMC 31
PS: Post-RFA Images Aial CT C+ Immediately after RFA Procedure Aial CT C+ 5 months after RFA Procedure Film Findings: Post-Ablational Hyperemia Lesion no longer enhances No new enhancing lesions PACS, BIDMC 32
PS: The Outcome While not definitively cured, RF ablation was considered to be successful and our patient is doing relatively well. 33
Summary Several modalities available for hepatic imaging (US, CT, MRI) Differential D for focal hepatic lesion Use of different enhancement patterns to distinguish between lesions Treatment options available for HCC Radiofrequency Ablation 34
Acknowledgements: Fabio Komlos, MD Andrew Bennett, MD Andrew Hines-Peralta, MD Pamela Lepkowski Larry Barbaras 35
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