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APPROACH TO THE APPROACH TO THE DIAGNOSIS OF THE DIAGNOSIS OF THE DIFFICULT LIVER DIFFICULT LIVER LESION WITHLESION WITH MRIMRI

Richard C. SemelkaRichard C. Semelka

Clinical historyClinical history

HistoryHistory

Chronic Primary No KnownChronic Primary No KnownLiver Malignancy DiseaseLiver Malignancy DiseaseDiseaseDisease

Chronic Liver DiseaseChronic Liver DiseaseHCC most common malignant lesion HCC most common malignant lesion Regenerative/Regenerative/dysplasticdysplastic nodulesnodulesIndependently worrisome features:Independently worrisome features:

Mild Mild hyperintensityhyperintensity on T2on T2Early intense enhancementEarly intense enhancementWashout with late capsuleWashout with late capsuleAlpha Alpha fetofeto proteinprotein

HemangiomaHemangioma not rarenot rareCysts/Cysts/hamartomahamartoma not rarenot rare

Fatty HCCHypovascular HCC

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Hypervascular HCC

Multiple HCC

Diffuse HCC

Regenerative nodules

Low grade dysplastic nodule High grade dysplastic nodule

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Acute on Chronic Hepatitis Portal vein thrombosis

Acute Budd-Chiari

Primary MalignancyPrimary Malignancy

HistologicHistologic type and locationtype and locationClues to Clues to vascularityvascularity of liver metastasesof liver metastases

Chemotherapy administration and whenChemotherapy administration and whenLiver metastases can adopt a variety of Liver metastases can adopt a variety of appearances in acute, appearances in acute, subacutesubacute and and chronic response to chemotherapychronic response to chemotherapy

Hypervascular carcinoid metastases

Hypervascular liver metastases

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Colon Cancer Metastases Colon Cancer Metastases

No Known DiseaseNo Known DiseaseBBenign lesions 10x to 100x more common enign lesions 10x to 100x more common than malignant, based on actuarial data than malignant, based on actuarial data BBenign lesions are common (20% population)enign lesions are common (20% population)Normal background liver?Normal background liver?Could the patient have cirrhosis?Could the patient have cirrhosis?

MRI appearance of background liverMRI appearance of background liverHCC uncommon in the absence of HCC uncommon in the absence of underlying chronic disease(< 1 in 100)underlying chronic disease(< 1 in 100)

Could the patient have an unsuspected Could the patient have an unsuspected primary malignancy?primary malignancy?

Uncommon (< 1 in 200Uncommon (< 1 in 200))

Biliary hamartoma

CystTiny Type 1 hemangioma

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Small Type 2 hemangioma Type 3 hemangioma

FNHUnsuspected primary malignancyUnsuspected primary malignancyIslet cell tumor metastases

Unsuspected primary malignancyUnsuspected primary malignancyIslet cell tumor metastases

Liver metastases from Liver metastases from unsuspected colon cancerunsuspected colon cancer

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MRI findingsMRI findingsLesion appearance onLesion appearance on::

T1, T2, T1, T2,

early and late postearly and late post--GdGd images images

hepatocytehepatocyte uptakeuptake

MRI appearanceMRI appearanceMarginsMarginsSI on SI on noncontrastnoncontrast imagesimages

Qualify Qualify SISI e.g. mild, mod, marked S1e.g. mild, mod, marked S1e.g. HCC mild T2, never mod or markede.g. HCC mild T2, never mod or markede.g. e.g. hemangiomahemangioma mod or marked T2mod or marked T2

Cyst

Hemangioma

Adenoma

FNH

HCC

T2 appearances of HCC

UniformUniformRingRingDiffuse heterogeneousDiffuse heterogeneousNodularNodularNone (cyst, None (cyst, hypovascularhypovascular lesion)lesion)

Enhancement early Enhancement early post gadpost gad

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Uniform

Ring

Heterogenous

Adenoma

Pancreatic cancer

HCCHCC

Nodular

No enhancement

Hemangioma

Cyst

Enhancement late Enhancement late post gadpost gad

Enlargement + Enlargement + coallescencecoallescence nodules (nodules (hemangiomahemangioma))Fading (to background liver) (adenoma, FNH, high Fading (to background liver) (adenoma, FNH, high grade grade dysplasticdysplastic nodules, nodules, metsmets) ) Washout (lower than liver) (HCC, Washout (lower than liver) (HCC, hypervascularhypervascularmetsmets))CentripedalCentripedal ((hemangiomahemangioma or or metsmets) ) Progressive intensified of enhancement (fibrosis, Progressive intensified of enhancement (fibrosis, chemo chemo txtx metsmets))None (cyst)None (cyst)

Hemangioma

FNH

Adenoma

Coalescence ofnodular enhancement

Fading

Fading

Carcinoid

Wash out

HCC

Wash out

Progressive enhancement

Abscess

Cirrhosis

Chemotherapytreated metastases

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HemangiomaHemangioma always bright on T2always bright on T2HCC never bright on T2HCC never bright on T2Background fatty liver: FNH, Background fatty liver: FNH, metsmetsFatty lesions: focal fat, adenoma, HCCFatty lesions: focal fat, adenoma, HCCCirrhotic liver, never describe FNH or Cirrhotic liver, never describe FNH or adenoma, describe RN/DN/HCCadenoma, describe RN/DN/HCCCould this liver be cirrhotic? Could this liver be cirrhotic?

Fibrosis on short TE T1W imagesFibrosis on short TE T1W imagesEarly negligible, late progressive Early negligible, late progressive

enhancementenhancement

ImagingImaging Pearls:Pearls: Carcinoid metastasesBackground fatty liver

Moderate fibrosis Cirrhotic liverCirrhotic liver

Imaging PearlsImaging PearlsBenign liver lesions are common Benign liver lesions are common (especially if there is no underlying liver (especially if there is no underlying liver disease)disease)In cirrhotic liver, malignant lesions are In cirrhotic liver, malignant lesions are HCC (HCC (metsmets uncommon when coexistent uncommon when coexistent other primary tumor is present)other primary tumor is present)Could this be a chemo Could this be a chemo txtx met?met?

Liver metastases Post-chemotherapy

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Imaging Pearls:Imaging Pearls:Distinguish hemorrhage/protein from Distinguish hemorrhage/protein from enhancement (enhancement (noncontrastnoncontrast T1)T1)Distinguish fat effects from washout Distinguish fat effects from washout (look at all non suppressed and fat (look at all non suppressed and fat suppressed images)suppressed images)Confluent fibrosis or Confluent fibrosis or fibroticfibrotic lesions, lesions, minimal early enhancement with minimal early enhancement with progressive increased enhancementprogressive increased enhancement

Hemorrhage secondary to RFA

Fat suppression vs wash-out effect Multiple focal fat

DonDont start with clinical historyt start with clinical history Clinical Clinical history is always important, start with thathistory is always important, start with thatUncommon appearance of common lesions is Uncommon appearance of common lesions is more common than common appearance of more common than common appearance of uncommon lesionsuncommon lesions over simplificationover simplification--how how common is common, how uncommon is common is common, how uncommon is uncommonuncommonSequence Sequence X X is not neededis not needed, T1, T2, early and , T1, T2, early and late post gad are always importantlate post gad are always important

Modifying MythsModifying MythsConclusionConclusion

MRI is by far the most diagnostically MRI is by far the most diagnostically accurate approach for liver lesions accurate approach for liver lesions Radiation hazards of CT must be Radiation hazards of CT must be considered when deciding on which considered when deciding on which modality to usemodality to useMRI is relatively safeMRI is relatively safeLogical approachLogical approach

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ConclusionConclusionLogical approachLogical approach

Clinical historyClinical historyLesion appearance: T1, T2, Lesion appearance: T1, T2, Early and late post Early and late post GdGdBenign lesions commonBenign lesions commonCould this be a chemoCould this be a chemo--txtx metmetCould this be a cirrhotic liver Could this be a cirrhotic liver

Table of Contents2006 Annual Meeting Program CommitteeContinuing EducationDeclaration of Speaker Financial Interests or Relationships================Saturday, 6 May 2006MR Physics for Physicists - Day 1 - 08:30 to 18:00 ~ Room 6EOrigins of the Equations of Magnetization Dynamics Numerical Implementation of the Bloch Equation to Simulate Magnetization Dynamics and ImagingAlternate Mechanisms for Spin PolarizationImaging Strategies for Hyperpolarized Elements and Molecules Contrast Mechanisms in Molecular Imaging - No syllabus contribution availableQuantum Mechanical and Semi-Classical Theory of RelaxationRelaxation and Contrast Mechanisms in Living Tissue Fast SE/TSE/RARE, Refocusing with Low Flip Angle PulsesFast Gradient Echo Including SSFPPulse Sequence Design for EPI and Non-Cartesian SamplingLimits of SNR and Practical Consequences

Quantitative Image and Data Analysis - Day 1 - 09:00 to 17:40 ~ Room 613-614Introduction to Quantitative Analysis Mapping of Quantitative MR ParametersStatistical Analysis of Quantitative MR Data: Basic MethodsArtifacts, Noise, Filtering and Compensation Techniques Image Registration and Motion Correction Feature Extraction, Shape Fitting, and Image SegmentationQuantitative Morphology: Volumes, Shapes, and Voxel-Based MeasuresMotion Estimation, Modeling, and Compensation Bulk Flow Measurements and Angiography

Advanced Body Imaging - 08:30 to 18:15 ~ Room 6DApproach to Diagnosis of the Difficult Liver Lesion with MRILiver Specific Contrast Agents: An UpdateAssessing Tumor Response in Liver TherapyPancreas: From Structure to FunctionMRCP and MRI in the Evaluation of Bile Duct ObstructionMRI of Ano-Rectal DiseasesMRI of Prostate Cancer: Diagnosis, Staging, and Treatment The Role of MRI in Evaluating Benign Uterine DiseaseDiagnosing, Staging and Stratifying Patients with Malignant Uterine DiseaseCharacterizing Adnexal Masses: Pearls and PitfallsOptimizing Your Breast MRI TechniqueMRI Criteria to Diagnose Breast Cancer MRI Screening of High Risk WomenMR Guided Breast Interventions

Clinical MRI: From Physical Principles to Practical Protocols - 08:00 to 17:45 ~ Room 615-617Overview of MR PhysicsMusculoskeletal MR Principles (Spin-Echo, FSE, Gradient Echo)Musculoskeletal MR Practical Protocols Body MR Principles (STIR, Gradient Echo, Fast Imaging Tricks)Body ProtocolsVascular MR Principles (TOF, 3D GRE)Vascular ProtocolsNeuro MR Principles (FLAIR, EPI-Perfusion, Diffusion)Neuro Protocols Cardiac MR Principles (Gating, True FISP, Phase Contrast) Cardiac Protocols

Diffusion and Perfusion Methodology - 08:30 to 18:15 ~ Room 6CTheory of DiffusionBiophysical Underpinnings of DiffusionTensor Encoding / DecodingSequences for Diffusion MRIArtifacts and Pitfalls in Diffusion MRI - No syllabus contribution availableDSI/ Qball/ GDTI and TractographyTheory of Perfusion MeasurementsDSC Perfusion (with Pitfalls)ASL Perfusion - Pulsed/ContinuousNew Ideas in PerfusionExchangeClinical Applications of Diffusion/Perfusion MRI: A Review

Molecular Imaging - 08:00 to 17:50 ~ Room 602-604IntroductionImaging Technologies I: Physical Principles, Technical IssuesImaging Technologies II: Comparison of Techniques, Strengths/Weaknesses, FusionCombined Technologies: MRI/PET, PET/CT, MRI/Optical Instrumental Aspects - No syllabus contribution availableConcepts of Probe Design I: Physical Principles of Reporter MoietiesConcepts of Probe Design II. Design of Target-Specific ProbesCombined Technologies: Multimodal ProbesNon-Invasive Imaging of Cell SignalingImaging the Function of Gene ProductsMonitoring Cell MigrationMolecular Imaging in Drug Research Molecular Imaging and AtherosclerosisMolecular Imaging in Experimental Therapeutics of Cancer

MR Spectroscopy in Clinical Practice - 08:30 to 18:00 ~ Room 611-612Basics of MR Spectroscopy for the Practicing Clinician1D, 2D and 3D Localization Techniques and ShimmingData Processing and Interpretation1D and 2D Quantification MethodsQuality Assurance and ArtifactsClinical Potential of C- and P-MRSMRS in Congenital Metabolic DisordersMRS in Pediatric TumorsMRS in Perinatal AsphyxiaMRS, MRI & fMRI in Epilepsy SurgeryMRS in Therapy Planning and Follow-up of Adult Brain TumorsMRS in Stroke, MS and Infectious DiseasesMRS in Neurodegenerative DiseasesMRS in Psychiatric DiseasesP31-MRS of Muscle DiseasesMRS of Prostate Diseases

RF Systems Engineering - 08:30 to 18:15 ~ Room 618-620Overview of Signal Detection and the RF ChainPrinciples and Modeling of the Signal Detection by a CoilIntroduction to the World of RF; Transmission Lines, Impedence Transformers, and RF ComponentsRF Measurements: The Network Analyzer and Smith ChartPreamp Design and Characterization T/R Switchs, Baluns, Traps, and Active Detuning ElementsVolume Coil Types and Design PrinciplesArray Coil Types and Design PrinciplesModeling the EM Wave Interaction with the Body and SAR Transmit SENSE Coil

===============Sunday, 7 May 2006MR Physics for Physicists - Day 2 - 08:30 to 18:00 ~ Room 6EMR ElastographyVelocity Encoding and Flow ImagingGridding for Non-Cartesian k-Space SamplingReconstruction for Multi-Coil AcquisitionGeneralized Spatial and Temporal Interpolation, Limited Data ReconstructionOverview of the Technical ChallengesOptimized Pulse Sequences at High Field Principles of Parallel TransmissionPhysical Principles for the Assessment of MRI Safety at High Field

Quantitative Image and Data Analysis - Day 2 - 09:00 to 17:40 ~ Room 613-614Perfusion/Permeability 1: Tracer Kinetic Modeling Using Contrast AgentsfMRI Modeling and AnalysisPerfusion/Permeability 2: Modeling of Arterial Spin Labeling SignalsSpectroscopy Modeling and AnalysisElastography Modeling and AnalysisData Presentation and Interpretation: Rendering, Data Fusion, and Surgical PlanningQuantitative Data in Clinical Practice - No syllabus contribution available

Experimental Methods in MR of Cancer - 08:30 to 17:15 ~ Room 6CEvaluating Pathways, Inhibition and Regulation Using MRSCholine Metabolism: Meaning and SignificanceClinical Applications of Magnetic Resonance SpectroscopyMeasuring Vascular Properties Using Contrast AgentsTracer Kinetic Models: Extracting Physiological Vascular InformationMeasuring Vascular Properties Using Intrinsic Contrast Mechanisms (inc BOLD)Hypoxia and its AssessmentClinical Applications of MR Methods That Assess Tumor Vascular FunctionalityAssociating MR Findings with MR Gene and Protein ExpressionDiagnosis of Cancer Using MASApoptosis: MR ConsequencesDiffusion MRI: A Biomarker for Cancer Treatment Response

Multi-Modal fMRI: Physiology, Acquisition, and Analysis - 08:30 to 18:15 ~ Room 611-612Brain Oscillations and Neural NetworksPhysiology, Hemodynamics, and BOLD SignalsfMRI Paradigm DesignPre-processing of BOLD fMRI DataGeneral Linear Model for BOLD fMRI AnalysisIndependent Component Analysis of BOLD fMRI DataDiffusion Tensor Imaging: Acquisition and ProcessingDTI/fMRI: Integration/SynergyLow-Frequency BOLD Fluctuations and Brain Functional ConnectivityPerfusion-Based fMRIBlood-Volume-Based fMRI

Demystifying Biomedical MR Spectroscopy: Challenges, Advanced Concepts, and Applications - 08:00 to 15:15 ~ Room 615-617The Art of RF Pulse Design for MRS Spectral Editing - Uncovering Hidden MetabolitesWhat is the "Hype" in Hyperpolarization?New Approaches to Spectral Processing and QuantificationEx Vivo Spectroscopy - Linking the Benchtop to the ClinicMulti-nuclear MRS of Metabolic Dynamics in the BrainNew Approaches to MRS of Cerebral DisordersSpectroscopic Window on Tumor MetabolismAdvances in MRS of Diabetes and Obesity

Musculoskeletal Imaging - 08:00 to 17:25 ~ Room 618-620Shoulder MR UpdateMRI of the ElbowMRI of Muscle InjuryMRI of the Wrist and HandKnee MR UpdateMRI of the AnkleMRI of the HipBone Marrow ImagingMRI of Soft Tissue Pseudotumors

Advanced Brain MR Imaging - 08:30 to 17:45 ~ Room 602-604Protocol Update: Stroke, Tumors, Epilepsy and MS - No syllabus contribution availableHigh-Resolution Cortical ImagingParallel Imaging: Concepts and ApplicationsBrain Imaging at 3T and Challenges at 7TMeasuring Brain Volume Changes: the ToolsVolumetrics of Brain DevelopmentVolumetrics of MS and AgingDSC Perfusion: Concepts and ApplicationsASL Perfusion: Concepts and ApplicationsDTI: Concepts, Quantification and Quality IssuesDTI of Brain DevelopmentFiber Tracking: Concepts and ApplicationsData Analysis, Reproducibility and Reliability, PitfallsClinical Applications: Surgical Planning in Tumors Clinical Applications: Neurodegenerative Disorders and MS

Cardiac MRI - 07:30 to 17:15 ~ Room 6DImaging of Coronary Artery Disease with MRI/MRAIschemia Detection Using Perfusion, BOLD, etc.Ischemia Detection Using Wall Motion, Strain, etc. - Late addition to program/no syllabus contribution availableMyocardial Viability: DE-MRI and LD-DobMESAICELAND MI: An Epidemiology Study of Unrecognized Myocardial Infarction - No syllabus contribution availableMR-IMPACT (Perfusion)Controversies and Approaches to Stem Cell Revascularization - Late addition to faculty/no syllabus contribution availableEvaluation (Function, Ischemia) of Stem Cell Therapy PatientsStem Cell Labeling, Tracking, and Delivery in Cardiovascular DiseaseStem Cell Therapy in Acute Myocardial InfarctionCardiac Imaging: 1.5T vs 3.0T - Where's the Benefit?Interventional CMRCardiac Intervention