Malignant Focal Liver Lesions

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Malignant Focal Liver Lesions Other Than HCC Pablo R. Ros, MD, MPH, PhD Departments of Radiology and Pathology University Hospitals Cleveland Medical Center Case Western Reserve University Pablo.Ros@UHhospitals.org

Malignant Focal Liver Lesions Other than HCC HEPATOCELLULAR ORIGIN Fibrolamellar carcinoma (FLC) CHOLANGIOCELLULAR ORIGIN Cholangiocarcinoma (I-CAC) Cystadenocarcinoma

Malignant Focal Liver Lesions Other than HCC MESENCHYMAL ORIGIN Angiosarcoma Epithelioid Hemangioendothelioma Kaposi sarcoma Primary lymphoma METASTASIS

Malignant Focal Liver Lesions Unknown Case 56 yo man with jaundice and abdominal pain

T2 FS T1 FS arterial T1 FS delayed

What is the most likely diagnosis? A. Intrahepatic Cholangiocarcinoma B. Epithelioid Hemangioendothelioma C. Fibrolamellar carcinoma D. Metastasis E. Angiosarcoma

What is the most likely diagnosis? A. Intrahepatic Cholangiocarcinoma B. Epithelioid Hemangioendothelioma C. Fibrolamellar carcinoma D. Metastasis E. Ansgiosarcoma

Malignant Focal Liver Lesions Unknown Case 19 yo man with complex medical history, now with elevated liver function tests and palpable mid abdominal mass

T2 FS T1 FS T1 FS 2 min - Eovist T1 FS 20 min - Eovist

What is the most likely diagnosis? A. Intrahepatic Cholangiocarcinoma B. Epithelioid Hemangioendothelioma C. Fibrolamellar carcinoma D. Metastasis E. Cystadenocarcinoma

What is the most likely diagnosis? A. Intrahepatic Cholangiocarcinoma B. Epithelioid Hemangioendothelioma C. Fibrolamellar carcinoma D. Metastasis E. Cystadenocarcinoma

What is the key finding? A.Size B. Lobular contour C. Small calcifications D.Hypodense

What is the key CT finding? A.Size B. Lobular contour C. Small calcifications D.Hypodense

Malignant Focal Liver Lesions Unknown Case 61 yo woman Intermittent abdominal pain and distension RUQ ultrasound, followed by CT Second abdominal CT scan, 8 months after initial one

What is the most likely diagnosis? A. Intrahepatic Cholangiocarcinoma B. Epithelioid Hemangioendothelioma C. Fibrolamellar carcinoma D. Metastasis E. Angisarcoma

What is the most likely diagnosis? A. Intrahepatic Cholangiocarcinoma B. Epithelioid Hemangioendothelioma C. Fibrolamellar carcinoma D. Metastasis E. Angiosarcoma

Malignant Focal Liver Lesions Unknown Case 54 yo woman Abdominal pain Bloating Her two dogs died recently due to chronic arsenic intoxication

What is the most likely diagnosis? A. Intrahepatic Cholangiocarcinoma B. Epithelioid Hemangioendothelioma C. Fibrolamellar carcinoma D. Metastasis E. Angisarcoma

What is the most likely diagnosis? A. Intrahepatic Cholangiocarcinoma B. Epithelioid Hemangioendothelioma C. Fibrolamellar carcinoma D. Metastasis E. Angisarcoma

Malignant Focal Liver Lesions Unknown Case 55 yo woman with liver mass on ultrasound

What is the most likely diagnosis? A. Intrahepatic Cholangiocarcinoma B. Epithelioid Hemangioendothelioma C. Fibrolamellar carcinoma D. Metastasis E. Angiosarcoma

What is the most likely diagnosis? A. Intrahepatic Cholangiocarcinoma B. Epithelioid Hemangioendothelioma C. Fibrolamellar carcinoma D. Metastasis E. Cystadenocarcinoma

Metastasis 10 times more frequent than primary malignant liver neoplams Multiple If solitary, likely from Colon Adenocarcinoma HCC, 10 times more frequent than other primary liver tumors

Fibrolamellar Carcinoma - Malignant Hepatocytes - Lamellar fibrosis - Confluent centrally - AFP negative

Fibrolamellar Carcinoma - Poorer vascularity, Bile stained - Central scar, Radiating Septa - No vessels in scar - Calcification

Fibrolamellar Carcinoma

Fibrolamellar Carcinoma: Scar - Low signal in T2 - No enhancement - Calcification

Fibrolamellar Carcinoma - Heterogeneous - Poor vascularity - Ill defined scar

Fibrolamellar Carcinoma Heterogeneous No Calcifications No FDG activity

Fibrolamellar Carcinoma

Fibrolamellar Carcinoma Homogeneous, but Calcifications

Fibrolamellar Carcinoma

MALIGNANT HEPATIC NEOPLASMS CHOLANGIOCELLULAR ORIGIN Cholangiocarcinoma (I-CAC) Cystadenocarcinoma

Intrahepatic Cholangiocarcinoma (I-CAC) Microscopy Adenocarcinoma: mucin rich, no bile Abundant fibrous stroma Calcification

I-CAC - Large (5-20 cm), - Solid (Hemorrhage/necrosis rare) - Fibrous, scar, calcifications - Satellite nodules (20%) - Local extension, no tumor thrombus

I-CAC Pathogenesis/Associations Thorotrast Hepatolithiasis (5% - 20%) Clonorchis sinensis Sclerosing Cholangitis Caroli Disease Congenital Hepatic Fibrosis

I-CAC Hypodense, homogeneous, irregular borders Capsular Retraction Satellite nodules No Cirrhosis

I-CAC Biliary dilatation, segmental

I-CAC

I-CAC T1: Hypointense Early: Peripheral enhancement

I-CAC Late: central enhancement in scar

I-CAC Vascular encasement, no invasion Extrahepatic local extension

MALIGNANT HEPATIC NEOPLASMS MESENCHYMAL ORIGIN Angiosarcoma Epithelioid Hemangioendothelioma Kaposi sarcoma Primary lymphoma

Risk Factors: Thorotrast, Vinyl chloride, Arsenicals

Angiosarcoma Pathologic Findings Foci of malignant endothelial cells Along vascular spaces Thorotrast granules displaced peripherally

Angiosarcoma Pathologic Findings - Multinodular (70%) - Solitary - Thorotrast peripherally displaced reticulated surface fibrosis

Angiosarcoma - Thorotrast, liver, spleen, lymph nodes peripherally displaced

Angiosarcoma

Angiosarcoma

Angiosarcoma

Angiosarcoma

Epithelioid Hemangioendothelioma Slow, peripheral (subcapsular) growth Hypertrophy of uninvolved liver

Epithelioid Hemangioendothelioma

Epithelioid Hemangioendothelioma Nonspecific symptoms or asymptomatic (20%) Slow, peripheral (subcapsular) growth Hypertrophy of uninvolved liver

Epithelioid Hemangioendothelioma Peripheral, globular enhancement Intratumoral shunting Invasive

Regarding Primary Hepatic Lymphoma? A. The liver is commonly involved B. Its contour is ill defined C. It is typically Hodgkin Disease D. Typically has calcifications E. Solitary, multiple and diffuse forms

Regarding Primary Hepatic Lymphoma? A. The liver is commonly involved B. Its contour is ill defined C. It is typically Hodgkin Disease D. Typically has calcifications E. Solitary, multiple and diffuse forms

Lymphoma Primary lymphoma, extremely rare NHL, diffuse large cell type Immunocompromised (transplant, IDS, ) Solitary, Multiple, Diffuse Low attenuation, well defined MRI preferred for diffuse form

Lymphoma NHL, Hemosiderosis Multiple, well defined nodules Hypodense, No enhancement

Lymphoma Diffuse Geographic involvement Spleen deposit

Malignant Focal Liver Lesions Other than HCC HEPATOCELLULAR ORIGIN Fibrolamellar carcinoma (FLC) CHOLANGIOCELLULAR ORIGIN Cholangiocarcinoma (I-CAC) Cystadenocarcinoma

Malignant Focal Liver Lesions Other than HCC MESENCHYMAL ORIGIN Angiosarcoma Epithelioid Hemangioendothelioma Kaposi sarcoma Primary lymphoma METASTASIS

Malignant Focal Liver Lesions More than Metastasis and HCC Gamut of primary malignant neoplasms Different cellular lines and appearances Imaging: Benign vs. Malignant Primary vs. Secondary Resectable vs. Unresectable Imaging guided Biopsy Percutaneous therapy

Surgical vs. Nonsurgical Lesions Cyst Focal Fat Flow Phenomenon Abscess Hemangioma FNH Unresectable metastasis

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