Outline : Imaging Jewels Jewels of hepatobiliary cancer imaging : what to look for? Hepatocellular carcinoma Cholangiocarcinoma Surachate Siripongsakun, M.D. Chulabhorn Cancer Center Imaging characteristics of HCC A wash-in, V wash-out Intracellular fat: in/out phase Fibrous capsule Hypo T1, T2, delay enh Heterogenous enh. (Mosaic pattern) Central scar Fat Blood Cal Scar Capsule High DN + - - - + HCC + + - + + Hemangioma - + + + - FNH + - - + - (psuedo) Adenoma + + - - - (psuedo) Mets - + + - - Rare Imaging characteristics AML lipoma Angiosarc Fibrolamellar HCC Fibrolamellar HCC Fibrolamellar HCC Fatty mass Fatty mass Cirrhosis High grade DN HCC Non-cirrhosis HCC Adenoma FNH (rare) Fatty changes late hepatocarcinogenesis 1. HG-DN 2. HCC Gross fat AML (rare) Lipoma (rare) Yu et al, AJR 2007 1
Fatty HCC 1. Larger size 2. Wash in/out 3. Capsule NC 30 Sec 60 Sec 90 Sec 38 F, chronic hepatitis B, segment 8 dome lesion Small fatty nodule = favor high-dn Jewels : fatty nodule in cirrhosis Fatty nodule in cirrhosis = high DN and HCC Look for other HCC features if so HCC (wash in/out, fibrous capsule) No HCC features size < 1.5 cm favor DNs FU size 1.5 cm trend HCC close FU Characteristics : capsule, scar Central Scar Fibrous Capsule High DN - + HCC + + FL-HCC + + Hemangioma + - FNH + - (pseudo) Adenoma - - (pseudo) NC A PV EQ T2 A D reg Gd HB GdEOB D-Reg Gd 1 2 2 HBP-Gd-EOB T2 1 2 3 4 A 45 Year old male with imaging of Typical FNH 3 4 5 1. Homogenous arterial enh. 2. Isointense, no V or D wash out 3. Delayed enh. Scar (extracellular Gd) 4. Uptake hepatocyte specific agent on HBP 5. Scar hyper T2WI 1. Hyper T2 mass with central scar (hyper T2) 2. Homogenous arterial enhancement 3. Non complete delayed-enhanced scar + capsule 4. Non-uptake primovist on hepatobiliary phase Dx HCC mimics FNH 2
Fibrous Capsule - Hypo T1, T2 - Delayed enh. Central scar - Hyper T2 - Non enh. HCC with central scar and capsules Imaging Jewels Hepatocellular carcinoma Cholangiocarcinoma Hussein : liver MRI, springer 2005 Evolution of cholangiocarcinoma Infection, inflammation, hyperplasia ( predisposing factors ) Cholangiocarcinoma Growth patterns Premalignant changes of bile duct epithelium (current concept) - Biliary Intraepithelial Neoplasia (Bil-IN) - Intraductal Papillary Neoplasm of Biliary Tract (IPN-B) Invasive Tubular Adenocarcinoma Intraductal type Periductal type Mass forming type Nakanuma et al, WHO classification IPNB Bil-IN Biliary intraepithelial neoplasia (Bil-IN) Bil-IN I Case I Precancerous lesion of cholangiocarcinoma Multistep-carcinogenesis classified into 3 grades (cellular atypia) - Bil-IN I (low grade) - Bil-IN II (intermediate grade) - Bil-IN III (high grade, carcinoma in situ) Bil-IN II - Typical cholangiocarcinoma (MC - periductal type) Bil-IN III Nakanuma et al, WHO classification Nakanuma et al,world J Hepatol. 2009 October 31; 1(1): 35-42. 3
Case I S57-421 Mildly dilated and thickening wall of right main hepatic duct and proximal part of large intrahepatic duct of right lobe Rt. main hepatic duct S57-421 Rt. hepatic duct: Biliary Intraepithelial Neoplasia II-III (BilIN II-III) Intraductal Papillary Neoplasm of Biliary Tract (IPNB) Biliary Papilloma Papillary Carcinoma of bile duct Mucin producing bile duct tumor Intraductal growth-type Cholangiocarcinoma Intraductal Papillary Neoplasm of Biliary Tract (IPNB) Nakanuma et al, WHO classification 4
friable Equivalent to pancreas IPMN Mucin producing 5
Mass forming CCA Typical CCA enhancement 1.Arterial rim enh. 2.Reticular internal enhancement Noted : associte bile duct dilatation Mass forming CCA NC 30 s 60 s 90 s 180 s Hypervascular mass forming CCA Key Can be seen upto 20 % (mimick shcc) Common in cirrhosis, HCV (increase risk) 5mins 10 mins T2 NC A PV Characteristics : 1. rim enhancement with slow filling in 2. internal reticulation (fibrotic stroma) Kang et al, radiology2012 Case I A hypoechoic mass with possible internal calcification (arrow) CT : hypovascalar mass with internal calcifications with gradual faint internal enhancement CCA possible arising form OV infection (granulomas) 6
Typical gradual faint internal enhancement on delayed phase Subcapsular retraction Suggesting Intrahepatic CCA CCA favors Vascular encasement T2 A Independent features small CCA vs HCC Target appearance : DWI - Restriction -Rim - Non restriction Center - Target on HBP (Gd-BOPTA, multihance) HBP DWI Park et al, abdominal imaging 2012 Mamone et al, abdominal imaging 2015 Target appearance CCA AdenoCA mets CCA : Target appearance on HBP (Gd-BOPTA) Large CCA : Target appearance on HBP (Gd-BOPTA) 7
Summary : CCA & premalignant lesions Bil-IN IPNB CCA Growth pattern Intraepithelial Intraductal Invasive, transmural Obstruction Narrowing Non complete complete Mucin production (inside bile duct) no 30-40% no Imaging appearance Non specific Smooth thickened Irregular bile duct Intraductal polypoid Isolated IHD dilatation Connect to BD Periductal Mass forming Intraductal with parenchymal extension 8