Post on 07-May-2015
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Benign Liver lesions
• Hemangioma• Focal nodular hyperplasia• Hepatic adenoma• Liver cyst• Liver abscess
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Malignant• Hepatocellular carcinoma• Heptoblastoma
Rare malignant:• Fibrosarcoma• Angiosarcoma• Leiomyosarcoma• Lymphoma
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Hypervascular lesions
Benign• Heamangioma• Adenoma• FNH
Malignant• HCC• Hypervascular metastasis
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Hypovascular lesions
• Hypovascular liver tumors are more common.
• Most hypovascular lesions are metastases.
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Multiphasic CT
For detection of liver lesions• Non enhance CT• Arterial phase• Portal venous phase• Delayed
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Understanding the phases• Liver has dual blood supply• Normal parenchyma is supplied for 80%
by the portal vein and only for 20% by the hepatic artery
• All liver tumors get 100% of their blood supply from the hepatic artery
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Arterial phase • In the arterial phase hypervascular tumors
will enhance via the hepatic artery, when normal liver parenchyma does not yet enhances, because contrast is not yet in the portal venous system.
• Hypervascular tumors will enhance optimally at 35 sec after contrast injection
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Portal venous phase• To detect hypovascular tumors • Scanning is at about 75 seconds
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Delayed Phase• Begins at about 3-4 minutes after contrast
injection and imaging is best done at 10 minutes• Valuable for washout of contrast(HCC),retention
of contrast(heamangioma),retention of contrast in fibrous tissue (capsule of HCC, central scar of FNH)
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Pre contrast Arterial Phase Portal venous phase
Delayed
Hepatocelluar Ca Low attenuation Homogenous enhancement
Washout of lesion
Isodense
Adenoma Low attenuation Homogenous enhancement 85%
Iso or hypodense
Iso or hypodense
Haemangioma Low attenuation Peripheral puddles Partial Fill in Complete fill in
FNH Iso/Low attenuation
Homogenous enhancement
Hypodense Isodense
Metastasis(hypervascular) Low attenuation Homogenous enhancement
Hypodense
Metastasis Low attenuation Hypodense Hypodense
Cyst Low attenuation No enhancement
Abscess Low attenuation may have irregular margins
Transient regional increase enhancement
Ring enhancement
Multiphasic CT of Liver
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T1W T2W Gadolinium Hepatocellular Ca
,iso or (fat degeneration) Metastasis Haemanigioma ++ (like CT) Adenoma
often FNH + delayed
MRI of Liver
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Hepatocellular Carcinoma• Most common primary malignancy of the
liver• Third most common cause of cancer-
related death• The incidence of HCC is rising, largely
attributed to a rise in hepatitis C infection
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Risk factors:• hepatitis B (HBV) infection • hepatitis C (HCV) infection • alcoholism • biliary cirrhosis • food toxins e.g. aflatoxins• congenital biliary atresia• inborn errors of metabolism
haemochromatosis
alpha-1 antitrypsin deficiency
type 1 glycogen storage disease
Wilson disease
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Clinical presentation
Presentation is variable may include:• constitutional symptoms• jaundice• portal hypertension from invasion of the portal vein• hepatomegally / mass
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• Majority of patient have cirrhosis• More than 80% of patients with HCC have
cirrhosis• May be Focal, multiple or diffusely
infiltrative
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Investigation• alpha-fetoprotein (AFP) levels are
elevated in 50-75 % of cases• Radiological investigation including
ultrasound, CT and MRI• Biopsy
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Ultrasound• Variable appearance• Small <3cm usually hypoechoic• Larger tumors often are heterogeneous• May invade the portal vein• Most tumors will show central vascularity
on Doppler study
Larger tumors often are heterogeneous
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CT• Focal HCC
large usually hypodense mass
may have necrosis / fat / calcification• Multifocal HCC
multiple masses of variable attenuation may also have central hypodense necrotic portions• Diffuse HCC
may be difficult to distinguish from associated cirrhosis
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Enhancement pattern
• Transient early arterial enhancement and then washes out
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MRIT1(variable)
T1 C+ (Gd)
Enhancement similar to CT
Rim enhancement may persist
T2 –Hyperintense
Post SPIO (Iron oxide) - increases sensitivity in diagnosing small HCC’s
Enhancement similar to CT
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Fibrolamellar hepatocellular carcinoma
• Variant of HCC• Younger age group(20-40years)• Not associated with cirrhosis• No association with HCC risk factors• Usually present with constitutional
symptoms• Fibrolamellar carcinomas typically are
single large tumours
Not associated with cirrhosis
Fibrolamellar carcinomas typically are single large tumours
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Ultrasound• Usually large heterogeneous
predominantly hyperechoic lesion, calcification may be seen(40%)
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CT• Large solitary well circumscribed• Heterogeneous arterial enhancement• 30-40% have central scar• Calcification can be seen on non
enhanced CT
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Hepatic metastasis• More common than primary • May be solitary but usually multiple• Majority are hypovascular• Extremely variable appearance on
ultrasound
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Hypervascular metastases• Carcinoids• Leiomyosarcomas• Neuroendocrine tumors• Renal carcinomas• Thyroid carcinomas• Choriocarcinomas• Occasionally pancreas, ovary, or breast
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UltrasoundHypoechoic metastasis• Lymphoma• Sarcoma• Most adenocarcinoma(breast, lung, pancreas)
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Hyperechoic• Colorectal carcinoma and other GIT• Carcinoid, Renal cell carcinoma, islet cell
tumor
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Cystic metastasis• Ovarian carcinoma• Cystadenocarcinoma of pancreas• squamous cell carcinoma
Calcified metastasis• Mucinous adenocarcinoma of colon
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CT• On unenhanced CT -> Hypodense• On Enhanced CT -> non enhancing
hypodense• The margin of the lesions can vary from
well defined to ill defined• Hyperattenuating lesions are uncommon
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MRI• Most metastase are hypointense on T1• Hyperintense on T2