the focal hepatic lesion: radiologic assessment

November 2006Kevin Kuo, HMS IIIGillian Lieberman, MD

The Focal Hepatic Lesion: Radiologic Assessment

Kevin Kuo, Harvard Medical School Year IIIGillian Lieberman, MD


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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


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What Next?

Given PS’s extensive 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…


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Liver Anatomy

http://hopkins-gi.nts.jhu.edu/pages/latin/templates/index.cfm

Couinaud Segments

Portal Triad and Hepatic Veins

Based on vascular anatomy

Important for surgical planning

Hepatic veins delineate lobes of the liver: Left (lateral and medial) and Right (anterior and posterior)


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Screening for HCC: The Menu of TestsImaging 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 expensive, takes more time, patient tolerance

*For HCC In patients with chronic liver disease


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Hepatic VenousPortal Venous

Triple Phase Helical CT

Foley, WD. Multiphase Hepatic CT with a Multirow Detector CT Scanner. 2000 (175): 679-685.

Axial C+ CT Arterial Phase

Axial C+ CT Portal Venous

Phase

Axial C+ CT Hepatic Venous

Phase

Contrast Injection

Arterial

0 15 30 45 60 75Time (sec)


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PS: Cirrhosis and Portal Hypertension

PACS, BIDMC

Nodular, shrunken liverCaudate and left lateral lobe enlargementEsophageal VaricesUmbilical RecanalizationEnlarged Portal VeinSplenomegaly, Ascites (neither present in our patient)

Axial C+ CT Venous Maximum Intensity Phase Reconstruction Axial C+ CT

Film Findings:


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PS: Triple Phase CT

PACS, BIDMC

Axial C-

CT Axial C+ CT: Arterial Phase

Nodular liver

No discrete lesions

Film Findings: EarlyEarly

hyperenhancinghyperenhancing

lesionlesion


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PS: Triple Phase CT

PACS, BIDMC

Axial C+ CT: Portal Venous Phase Axial C+ CT: Delayed Phase

Quick washout of enhancing lesion

Film Findings:

HypoenhancingHypoenhancing

lesion with lesion with peripheral rim of enhancementperipheral rim of enhancement


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PS: Preliminary Diagnosis

Triple Phase CT Findings:

Early arterial phase enhancementarterial phase enhancement

quick washoutquick washout

peripheral rim of enhancementrim of enhancement

in the delayed phase

Highly suspicious for HCC

HCC is hypervascularhypervascular

receives ~80% of its blood flow from hepatic arteries and only ~20% from the portal vein (exact opposite of normal liver parenchyma)

Nonetheless, we need to consider the full differential diagnosis…


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Early arterial enhancement, fast washout, delayed fibrous capsule enhancement

Hepatocellular Carcinoma (HCC)

Mostly multiple low attenuation lesions, rim enhancement without “filling in”

Metastasis

Variable, central changes due to hemorrhage often seen

Hepatocellular Adenoma

Early filling in arterial phase with central filling defect (scar)

Focal Nodular Hyperplasia (FNH)

Peripheral filling in of contrast over time“Light Bulb Sign”

on T2 MRIHemangioma

Sharply demarcated wall, water density, non-

enhancing

Hepatic Cyst

PSClassical CT FindingsLesions

AbscessWell demarcated hypodense areas with peripheral enhancement, may see gas

A Walk Through The Differential Diagnoses:


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Hepatic Cyst

http://bb.westernu.edu/web/Pathology/webpath60/webpath/radi

ol/heparad/

Axial C+ CT

Film Findings:

Sharply demarcated,

non enhancing, water-dense cyst.


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Metastasis






on T2 MRIHemangioma

xSharply demarcated wall, water density, non-

enhancing

Hepatic Cyst





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Hemangioma

Axial C+ CT (Various phases)

Film Findings:

Hypodense

lesion with

peripheral filling in of contrast over time

http://www.radiologyassistant.nl/en/448eef3083354


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Metastasis






on T2 MRIHemangioma


enhancing

Hepatic Cyst




x


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Focal Nodular HyperplasiaAxial C+ CT

Film Findings:

Enhancing lesion with

central filling defect (central scar)

http://uuhsc.utah.edu/rad/medstud/BodyCaseStudies/BodyCa

se6a.htm


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Metastasis






on T2 MRIHemangioma


enhancing

Hepatic Cyst




x

x


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Hepatocellular AdenomaAxial C+ CT

Film Findings:

Multiple hypoenhancing

heterogenous

lesions

Enhancing hepatic veinsEnhancing hepatic veins

UpToDate: Hepatic Adenoma


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Metastasis






on T2 MRIHemangioma


enhancing

Hepatic Cyst




x

x

x


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Liver Metastasis (Colonic Adenocarcinoma)

Axial C+ CT

Film Findings:

Multiple hypoenhancing

heterogenous

lesions

http://www.mypacs.net/repos/mpv3_repo/viz/full/11724/586248.

jpg


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Metastasis






on T2 MRIHemangioma


enhancing

Hepatic Cyst




x

x

xx


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Liver Abscess

Axial C+ CT

Film Findings:

Well demaracated

hypoenhancing

lesion

Rim of increased Rim of increased

enhancement relative to enhancement relative to central regioncentral region

http://www.e-radiography.net/ibase5/Hepatic/index.htm


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Metastasis






on T2 MRIHemangioma


enhancing

Hepatic Cyst




x

x

xx

x


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PS: Hepatocellular Carcinoma

Axial CT (various phases)

Film Findings:

Early arterial enhancementEarly arterial enhancement

Quick washoutQuick washout

Peripheral rim of Peripheral rim of

enhacementenhacement

PACS, BIDMC


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Metastasis






on T2 MRIHemangioma


enhancing

Hepatic Cyst




x

x

xx

x

√


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PS: The Final Diagnosis

Ultrasound guided biopsy confirmed the diagnosis…

Hepatocellular CarcinomaHepatocellular Carcinoma


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HCC: MR Imaging

Ito, K. Hepatocellular carcinoma: Conventional MRI findings including gadolinium-enhanced dynamic imaging. 2006 (58): 196-199.

Axial T1 Weighted MR Precontrast

Axial T1 Weighted MR Arterial Phase

Axial T1 Weighted MR Portal-phase

Variable intensity on T1 and T2 weighted imaging

Early arterial phase enhancementarterial phase enhancement

Quick washout

Rim enhancementRim enhancement

of fibrous capsule in portal/delayed phases


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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, Aflatoxins, 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


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HCC: Treatment Options

X RFA more appropriate

Large unresectable tumors not amenable to RFA. Absence of portal vein thrombosis or encephalopathy

Chemo-

embolization

√Do not meet resectability/transplant criteria but disease confined to liver

Radiofrequency Ablation

√…Unresectable patients w/ solitary lesion < 5cm or <3 lesions of <3 cm. No vascular invasion or metastases

Transplant

X

Cirrhotic, poor hepatic reserve

Solitary lesion, no vascular invasion, preserved hepatic function

Resection

Patient PSOptimal Candidate:Treatment:

X EtOH found at transplant eval.


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Radiofrequency Ablation: Guidance

http://hopkins-gi.nts.jhu.edu/pages/latin/templates/index.cfmhttp://www.ijri.org/articles/ARCHIVES/2003-13-3/phy315.htm

US Guidance CT Guidance

Axial C-

CT RFA needle in tumorFilm Findings:


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PS: RFA Ultrasound

PACS, BIDMC

Axial US: Lesion Pre-RFA Axial US: Lesion Post-RFA

Hypoechoic lesion with poorly defined borders.

HyperechoicHyperechoic

region with dirty region with dirty shadowing (air bubbles from RF shadowing (air bubbles from RF procedure)procedure)

Film Findings:


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PS: Post-RFA Images

PACS, BIDMC

Axial CT C+Immediately after RFA Procedure

Axial CT C+5 months after RFA Procedure

Post-Ablational Hyperemia Lesion no longer enhancesLesion no longer enhances No new enhancing lesions

Film Findings:


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PS: The Outcome

While not definitively cured, RF ablation was considered to be successful and our patient is

doing relatively well.


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Summary

Several modalities available for hepatic imaging (US, CT, MRI)

Differential Dx for focal hepatic lesion

Use of different enhancement patterns to distinguish between lesions

Treatment options available for HCC

Radiofrequency Ablation


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Acknowledgements:

Fabio Komlos, MD

Andrew Bennett, MD

Andrew Hines-Peralta, MD

Gillian Lieberman, MD

Pamela Lepkowski

Larry Barbaras


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References:

Fernandez MP, Redvanly RD. “Primary Hepatic Malignant Neoplasms.”

Radiologic Clinics of North America. (1998) 36:333-346.

Ferrucci JT. “Liver Tumor Imaging.”


Foley DW, Mallisee TA, Taylor AJ. “Multiphase Hepatic CT with a Multirow Detector CT Scanner.”

American Journal of Radiology. (2000) 175:679-685.

Hoon J, McTavish J, Mortele JK, Wiesner W, Ros PR. “Hepatic Imaging with Multidetector CT.”

Radiographics. (2001) 21:71-80.

Ito K. “Hepatocellular Carcionma: Conventional MRI findings including gadolinium-

enhanced dynamic imaging.”

European Journal of Radiology (2006) 58:186-199.

Kamel IR, Bluemke DA. “Imaging Evaluation of Hepatocellular carcinoma.”Journal of Vascular Interventional Radiology. (2002) 13:173-183.

Kamel IR, Bluemke DA. “MR Imaging of liver tumors.”


Kamel IR, Liapi E, Fishman EK. “Multidetector CT of hepatocellular carcinoma.”

Best Practice and Research Clinical Gastroenterology. (2005) 19:63-89.

Patel N. “Portal Hypertension.”

Seminars in Roentgenology. (2002) 37:293-302.

Taylor HM, Ros PR. “Hepatic Imaging: An Overview.”


http://hopkins-gi.nts.jhu.edu/pages/latin/templates/index.cfm

http://www.ijri.org/articles/ARCHIVES/2003-13-3/phy315.htm

http://bb.westernu.edu/web/Pathology/webpath60/webpath/radiol/heparad/

http://www.radiologyassistant.nl/en/448eef3083354

http://uuhsc.utah.edu/rad/medstud/BodyCaseStudies/BodyCase6a.htm

http://www.e-radiography.net/ibase5/Hepatic/index.htm

the focal hepatic lesion: radiologic assessment

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