1
Jessica Y. Leung, HMS 2004
Gillian Lieberman, MD
Radiographic evaluation of hepatocellular
carcinoma
Jessica Y. Leung, Harvard Medical School, Year III
Gillian Lieberman, MD
January 2003
2
Jessica Y. Leung, HMS 2004
Gillian Lieberman, MD
Mr. B.HPI:•
71 yo
man with mild diarrhea and R sided rib
discomfort PMH:•
Prostatectomy in 1995 for early stage prostate CA
•
Superficial melanoma removed in 1998•
Hx
of benign colon polyps
•
No risk factors for liver disease
? Liver metastases from melanoma or prostate cancer
3
Jessica Y. Leung, HMS 2004
Gillian Lieberman, MD
Mr. B. –
RUQ ultrasound
Large lesion in R hepatic lobe, solid with heterogeneous echotexture
BIDMC PACS
4
Jessica Y. Leung, HMS 2004
Gillian Lieberman, MD
DDx
of Solid Liver MassWhat types of cells are in the liver?
http://mycourses.med.harvard.edu/
collection_display.asp, HMS #61
•
Invading cells•
Metastases•
Lymphoma•
Carcinoid
•
Hepatocytes•
Adenoma, hepatoblastoma•
Focal nodular hyperplasia•
Hepatocellular
carcinoma•
Bile ducts •
Cholangioma•
Cholangiocarcinoma•
Blood vessels•
Hemangioma, hemangioendothelioma
•
Angiosarcoma
Normal liver histology
5
Jessica Y. Leung, HMS 2004
Gillian Lieberman, MD
DDx
of Liver Mass in Adult
> 50 yo
(Mr. B.)•
Common•
Hemangioma•
Metastases
•
Uncommon•
Angiosarcoma•
Hepatocellular
carcinoma•
Intrahepatic
cholangiocarcinoma
< 50 yo•
Common•
Focal nodular hyperplasia
•
Uncommon•
Fibrolamellar
carcinoma•
Hepatocellular
carcinoma
Reeder MMM. Reeder and Felson’s
Gamuts
in Radiology. 1993.
6
Jessica Y. Leung, HMS 2004
Gillian Lieberman, MD
Mr. B.’s
diagnosis
•
Ultrasound-guided biopsy demonstrated hepatocellular
carcinoma
http://www.kumc.edu/instruction/medicine/pathology/ed/ch_14/c14_s35a.html
Example of HCC on liver biopsy
7
Jessica Y. Leung, HMS 2004
Gillian Lieberman, MD
Hepatocellular
carcinoma•
Epidemiology:•
Most common primary cancer worldwide•
↑
incidence: China, Sub-Saharan Africa•
↓
incidence: N and S America, Europe, Australia•
4:1 (M:F)•
Risk factors: •
Cirrhosis, HBV, HCV, alcohol, hemochromatosis, environmental toxins, etc.
•
Growth patterns:•
Solitary mass, multifocal masses, diffuse infiltrating•
Treatment: •
Surgical resection, local ablation (chemo, alcohol, radio)•
Prognosis: •
5 yr survival < 5%•
High mortality due to late clinical presentationSchwartz JM, Carithers
RL. UpToDate
Online 10.3
Kamel
IR, Bluemke
DA. J Vasc
Interv
Radiol
2002; 13:S173
8
Jessica Y. Leung, HMS 2004
Gillian Lieberman, MD
Imaging modalities for HCC
•
Ultrasound•
Most frequently used for detection of HCC•
Appearance of HCC is non-specific•
Small tumors hypoechoic
and homogeneous•
Large tumors isoechoic
or hyperechoic
and heterogeneous with coarse-irregular internal echoes
•
Doppler used to evaluate tumor vascularity, not always accurate
•
Sensitivity 71%, specificity 93% (noncirrhotics)•
Sensitivity 47%, specificty
98% (cirrhotics)•
New contrast agents may improve accuracy of diagnosis of HCC
Sherman M, Peltekian
KM, Lee C. Hepatology
1995; 22:432
Kim TK, Kim AY, Choi
BI. Abdominal Imaging 2002; 27:129
Kamel
IR, Bluemke
DA. J Vasc
Interv
Radiol
2002; 13:S173
9
Jessica Y. Leung, HMS 2004
Gillian Lieberman, MD
Imaging modalities for HCC (cont’d)
•
CT •
Often performed secondary to abnormality seen on U/S•
May be used as primary screening modality in cirrhotics•
Features of HCC more specific than U/S•
Hypodense
lesions, hypervascular, enhance in arterial phase, hypodense
in equilibrium phase •
Sensitivity of helical CT may be as high as 90%•
3 mm HCCs
detectable•
Biphasic CT –
CTHA and CTAP
Schwartz JM, Carithers
RL. UpToDate
Online 10.3
Hollett
MD, Jeffrey RB Jr, Nino-Murcia M et al. AJR Am J Roentgenol
1995; 164:879
10
Jessica Y. Leung, HMS 2004
Gillian Lieberman, MD
Mr. B. –
Abdominal CT1. Multiple hypoattenuating
lesions pre-contrast
3. Hypodense
in portal venous and equilibrium phases
2. Early arterial enhancementBIDMC PACS
11
Jessica Y. Leung, HMS 2004
Gillian Lieberman, MD
•
MRI •
High resolution image w/o nephrotoxic
contrast agents•
T1: hyperintensity
(35%), isointensity
(25%), hypointensity
(40%) •
Contrast-enhanced dynamic MRI has similar sensitivity for diagnosis as helical CT
•
Better than CT at differentiating dysplastic nodules from HCC
•
New hepatocyte-specific contrast agents
•
Angiography•
Used for chemoembolization
of tumors and to control bleeding of ruptured HCC
Imaging modalities for HCC (cont’d)
Schwartz JM, Carithers
RL. UpToDate
Online 10.3
Kamel
IR, Bluemke
DA. J Vasc
Interv
Radiol
2002; 13:S173
12
Jessica Y. Leung, HMS 2004
Gillian Lieberman, MD
Patient 2 -
HCC on MRI
BIDMC PACSCentral area of T2 hyperintensity
suggestive of necrosis
13
Jessica Y. Leung, HMS 2004
Gillian Lieberman, MD
Mr. B. -
Angiography
BIDMC PACS
R hepatic artery angiogram –
Hypervascularity
of HCC
14
Jessica Y. Leung, HMS 2004
Gillian Lieberman, MD
Mr. B. –
Post-chemoembolization
BIDMC PACS
1.
1% lidocaine
2.
Chemotherapeutic (doxorubicin, lipiodol) + contrast
15
Jessica Y. Leung, HMS 2004
Gillian Lieberman, MD
Other imaging modalities
•
FDG PET –
useful for determining histologic differentiation of HCC, and HCC mets
•
99mTc-labeled AFP (experimental)
Schwartz JM, Carithers
RL. UpToDate
Online 10.3
Kamel
IR, Bluemke
DA. J Vasc
Interv
Radiol
2002; 13:S173
16
Jessica Y. Leung, HMS 2004
Gillian Lieberman, MD
Findings associated with HCC
•
Mass effect or local invasion •
Often secondary to underlying cirrhosis
17
Jessica Y. Leung, HMS 2004
Gillian Lieberman, MD
Patient 2 -
Mass effect
BIDMC PACS
Compression of portal vein
18
Jessica Y. Leung, HMS 2004
Gillian Lieberman, MD
Patient 3 -
Vascular invasion
BIDMC PACS
Ascites
Portal vein invasion
19
Jessica Y. Leung, HMS 2004
Gillian Lieberman, MD
Patient 2 -
Portal hypertension
BIDMC PACS
Caput Medusae
seen on CT reconstruction
20
Jessica Y. Leung, HMS 2004
Gillian Lieberman, MD
Patient 3 -
Portal hypertension (cont’d)
BIDMC PACS
Varices
21
Jessica Y. Leung, HMS 2004
Gillian Lieberman, MD
Non-HCC liver masses
DO NOT BE FOOLED!
•
Metastases •
Spectrum of appearances, usually low attenuation on CT, contrast may or may not enhance
•
Hemangioma•
Focal nodular hyperplasia
22
Jessica Y. Leung, HMS 2004
Gillian Lieberman, MD
Patient 4 -
Hemangioma
Hypodense
on pre-
contrast scan
Peripheral enhancement during bolus phase of IV contrast
BIDMC PACS
23
Jessica Y. Leung, HMS 2004
Gillian Lieberman, MD
Patient 5 -
Focal Nodular Hyperplasia
BIDMC PACS
Hyperdense
lesion in setting of fatty liver
Enhances in arterial phase, accentuates central fibrous scar
Scar enhances during late arterial phase… enhancement washes out during portal venous and equilibrium phase
24
Jessica Y. Leung, HMS 2004
Gillian Lieberman, MD
Summary
•
Incidence of HCC is increasing in the U.S.•
Due to high mortality, early detection is essential•
U/S•
Cheap, primary mode of detection, lower sensitivity and specificity compared to CT
•
Aids in obtaining pathological diagnosis•
CT •
higher sensitivity with advances in speed of imaging and dual phase imaging
•
MRI •
useful for differentiating dyplastic
nodules from HCC•
IR •
useful for local ablation of HCC in non-surgical candidates
25
Jessica Y. Leung, HMS 2004
Gillian Lieberman, MD
References1.
Schwartz JM, Carithers
RL Jr. Clinical features, diagnosis, and screening for primary hepatocellular
carcinoma. UpToDate
Online 10.3.
2.
Hollett
MD, Jeffrey RB Jr, Nino-Murcia M, et al. Dual-phase helical CT of the liver: Value of arterial phase scans in the detection of small (<1.5 cm) malignant hepatic neoplasms. AJR Am J Roentgenol
1995; 164:879.
3.
Sherman M, Peltekian
KM, Lee C. Screening for hepatocellular carcinoma in chronic carriers of hepatitis B virus: Incidence and prevalence of hepatocellular carcinoma in a North American urban population. Hepatology
1995; 22:432.
4.
Kim TK, Kim AY, Choi
BI. Hepatocellular carcinoma: harmonic ultrasound and contrast agent. Abd
Imaging 2002; 27:129.
5.
Murakami T, Kim T, Takahashi S, Nakamura H. Hepatocellular carcinoma: multidetector row helical CT. Abd
Imaging 2002; 27:139.
6.
Kamel
IR, Bluemke
DA. Imaging evaluation of hepatocellular carcinoma. J Vasc
Interv
Radiol
2002; 13(9 Pt 2):S173.
7.
Reeder MMM. Reeder and Felson's
Gamuts
in Radiology: Comprehensive Lists of Roentgen Differential Diagnosis.
New York: Springer-Verlag New York Inc, 1993.
26
Jessica Y. Leung, HMS 2004
Gillian Lieberman, MD
Acknowledgements
•
Vassilios
Raptopoulos, MD•
Don (Buddy) Wiese, MD
•
Robert Kane, MD •
Gillian Lieberman, MD
•
Pamela Lepkowski•
Larry Barbaras and Cara Lyn D’amour