FOCAL HEPATIC LESIONS IMAGING DIAGNOSIS

FOCAL HEPATIC LESIONS IMAGING DIAGNOSIS

W.MNARI, M. GOLLI

MONASTIR-TUNISIA

5th ARAB RADIOLOGY CONGRESS25th - 28th April 2012

Objective :

1. Identify the most important imaging

features of common benign liver tumors

2. Identify the most important imaging

features of malignant lesions

3. Know the diagnosis of hepatocellular

carcinoma

Introduction

• Extensive use of imaging studies has

increased the detection rates of hepatic

lesions

• A mass can be found either incidentally

or during screening for liver cancer in

patients with cirrhosis

• These can be benignant or malignant and

thus the right approach for assessing

these masses is important

Hemangioma

Focal nodular

hyperplasia

Adenoma

Liver cysts …

Primary liver cancers• Hepatocellular

carcinoma• Fibrolamellar

carcinoma• Cholangiocarcinoma

Metastases

Benign Malignant

Classification:

• Symptomatic or Incidentally detected

• History of Hepatitis or extra hepatic

malignant tumor

• Liver function tests

• Cirrhotic or Non cirrhotic

Things to consider usually.....

FortuitousNon

cirrhotic

Symptomatic

Non cirrhotic

Chronic diseaseCirrhosis

Benign Malignant

HémangiomaFNH

Adénoma

Metastasis FLC

HCCDNRN

Circumstances of discovery

BENIGN LIVER LESIONS

Hepatic Hemangiomas • Benign vascular lesions of liver.

• The commonest liver tumor

• Autopsy studies : 0.4-20 percent

• 3-5 decades

• Thought to arise from congenital hamartomas

(abnormal growth of normal tissue), it can also

develop from dilatation of blood vessels in a

normal tissue

• Usually asymptomatic

• Incidental discovry: US++

Hepatic Hemangiomas

Hemangiomas are

composed of many

endothelium-lined

vascular spaces

separated by fibrous

septa

Cavernous angiomas

Hepatic Hemangiomas US: well-defined, uniformly hyperechoic liver mass

with peripheral feeder vessels that are characteristic

of a hemangioma.

Cavernous angiomas

Hepatic Hemangiomas US Diagnosis

In practice:

. Us characteristic feature

. No context of neoplastic diesease

. Normal liver function tests

Hemangioma

NO

CT or MRI

YES

Hepatic Hemangiomas CT: The pathognomonic features of caverneous

hemangioma: peripheral nodular and discontinuous

enhancement and progressive centripetal fill-in

IV-

HAP

PVP

DP

Hepatic Hemangiomas Diagnosis

CT: venous enhancement from periphery to center


MRI:

. Hypointense and well defined in T1

. Marked hyperintensity that increases with

echo time on T2

. The same caracteristic pattern of enhacement

as is seen at CT


MRI:

Focal Nodular Hyperplasia (FNH)

. Benign nodule formation of normal liver tissue

. 2nd most common benign hepatic lesion

. More common in young and middle age women

. Male to female :5-17

. Usually asymptomatic

. May cause minimal pain

. Response of parenchyma to a vascular malformation

or portal duct injury.


. Hyperplasia with a central stellate scar radiating in to distinct nodules.

. Ductular diffentiation and malformed vessels.

. Rarely- encapsulated and pedunculated.

. Biliary structures


Diagnosis:

US: Nodule with varying echogenicity

Color Doppler imaging may show

central vessels


Diagnosis: CT

. Central scar

. Brisk homogeneous enhancement

. Well defined

. Early homogenesation

. Hypodense fibrous bands and septa that arise from

the scar

. On delayed phase images the central scar may remain

hyperattenuating

. Without capsule

Focal Nodular Hyperplasia (FNH)Diagnosis: CT

HAP

PVP

DP

IV-

Focal Nodular Hyperplasia (FNH)Diagnosis: CT


Diagnosis:MRI typical finding

. Isointense to hypointense on T1-weighted images

. Slightly hyperintense to isointense on T2-weighted

images

. Brisk homogeneous enhancement

. Delayed enhancement of the central scar


Diagnosis:MRI typical finding


20% of FNH cases are classified as nonclassic

Biopsy

Attal P et al. Radiology 2003;228:465-472

Hepatic Adenoma

. Rare hepatic tumor

. Women aged 20 to 40 years

. Association with oral contraceptive use

. Solitary (70%–80%)

. Can be associated with right upper-quadrant pain

. Risk of rupture, hemorrhage, or malignant

transformation

. 5-10cm

. Benign neoplasm composed of normal hepatocytes no

portal tract, central veins, or bile ducts

. Surrounded by a capsule

. Surgical resection is generally advised

Hepatic AdenomaUS:

. Nonspecific, adenomas may be hypo, iso, or hyperechoic but

are typically heterogeneous

CT:

. Well circumscribed without lobulation

. Heterogeneous because of their mixed components of fat,

hemorrhage, and necrosis

. Diffuse heterogeneous arterial enhancement and iso

attenuated on delayed scan

MRI:

. Hyper to isointense on T1 (hemorrhage) and slightly

hyperintense on T2 weighted images

. Same appearance on contrast-enhanced image as CT scan

Hepatic Adenoma

Liver cysts:

. May be single or multiple

. May be part of polycystic kidney disease

. Patients often asymptomatic

. No specific management required

Liver cysts:

. US is sufficient to diagnose

. On CT scan or MRI hepatic cysts are typically

discovered incidentally

Liver cysts:

Liver cysts: HYDATID CYST

MALIGNANT LIVER LESIONS

Hepatocellular Carcinoma (HCC)

•The fifth most common tumor

•Rarely occurs before age of 40 and peaks at 70 years

•Male to female: 4/1

•Cirrhosis is the strongest predisposing factor for HCC

•80% of cases of HCC developing in a cirrhotic liver

•Causes of cirrhosis: hepatitis (B and C virus infection),

alcohol, Hemochromatosis and biliary cirrhosis

Most HCCs develop by means of a multistep progression: from

a low-grade dysplastic nodule to a high-grade dysplastic

nodule, to a dysplastic nodule with a focus of HCC, and finally

to overt carcinoma.Willatt et al Radiology: Volume 247: Number 2—May 2008


Jeong et al. AJR:185, October 2005

Usually too small to detect by imaging

–May be surrounded by fibrotic septa

–May contain iron, copper

Siderotic regenerating nodules

–Hyperdense on NCCT, disappear on HAP & PVP

–Variable on T1, Hypointense on T2 MR, “bloom” on GRE

Regenerating Nodules

Importance of NC imaging

Dysplastic Nodules

Rarely diagnosed by US or CT

Iso to hyperintense on T1 (copper)

Iso to Hypo on T2 (opposite of HCC)

Should not enhance much on HAP

Several morphological forms

Massive(>3cms)

Nodular (<3cms)

Diffuse


AFP (Alfa feto protein)

Is an HCC tumor marker

Values more than 100ng/ml are highly suggestive of

HCC

Elevation seen in more than 70%


US : hyperechoic, smaller tumors are hypoechoic.

Heterogeneous, hypervascular

US sensitivity about 75%.

Arterial Phase:

liver(30-35 sec)

HCC as supplied by arterial branch/neovascularization


Venous Phase:

HCC which is enhanced during arterial phase has

lost its contrast, hence no enhancement of the

tumor but rest of the liver enhances.

Contrast in brightness of the lesion with respect to

surrounding liver.

Enhancement

Wash out phenomenan

CT or MR

Hepatocellular Carcinoma (HCC)Delayed Phase :

Wash -out phenomenan persists and often

exaggerated in smaller lesions.

The tumor capsule

IV-

HAP

PVP

DP

capsule

MRI

. Variable intensity of HCC on T1

. 35% hyper, 25% iso-, 40 % hypo

. Hyperintense (T1) often well-differentiated,

contain fat, copper, glycogene

. Almost always hyperintense on T2 MR

. The tumor capsule is hypointense on both T1-

and T2-weighted images in most cases

. Other Features: Focal fat



MRI

Hepatocellular Carcinoma (HCC)Hypovascular HCC +/- 30%

Liver nodule

< 1 cm > 1 cm

Reapeat US at 3 months

Growing/changing character

Stable

Investigate according to size

4 – phase MDCT/dynamicContrast enhanced MRI

Arterial hypervascularity AND venous or delayed phase washout

Other contrast enhancedStudy (CT or MRI)

Arterial hypervascularity AND venous or delayed phase washout

Yes No

Yes No

HCC Biopsy

2010 AASLD Algorithm for Investigation of Small Nodules

Found On Screening in Patients with Cirrhosis

Bruix J and Sherman M. AASLD Practice Guidelines , Management of Hepatocellular Carcinoma Hepatology November 2011

DIAGNOSIS : patients with cirrhosis or chronic hepatitis (even without cirrhosis)

Fibro-Lamellar Carcinoma

. Presents in young pt (5-35)

. Not related to cirrhosis, AFP is normal

. CT/MRI shows large mass with peripheral enhancement and

typical stellate scar with radial septa showing persistant

enhancement

. Calcifications

Metastatic disease

. Most common malignant hepatic tumor

. Presence of extrahepatic malignancy should be

sought in patients with characteristic liver lesions

per imaging studies. Physical exam and history is

very helpful.

. Common primaries : colon, breast, lung, stomach,

pancreases, and melanoma

. Mild cholestatic picture (ALP, LDH) with preserved

liver function

. CT or US guided biopsy provides definitive diagnosis

but not always required.

Metastatic diseaseVariable US features+++

Iso, hyper or hypo echoic++

Contrast-enhanced US (CEUS)

(84% accuracy)

Intraoperative US (IOUS) (96%

accuracy)

Typical feature

Metastatic disease. MDCT are the most commonly used imaging

modalities

for detection and characterization of hepatic metastases

. Most liver metastases are hypovascular and are best

imaged during the portal venous phase (colon, stomach

and pancreas)

. Hypervascular metastases enhancing on the arterial

phase (neuroendocrine tumors, renal cell, breast,

melanoma, thyroid)

. Calcification may be present with metastases from

mucinous

gastrointestinal tract tumors and from primary ovarian,

breast, lung, renal, and thyroid cancer

. Other features : Hemorrhagic or cystic metastases

Metastatic disease

. On MRI, metastases are variable but are usually hypo- to

isointense on T WI and iso- to hyperintense on T2 WI

. Metastatic tumors with liquefactive necrosis or cystic

neoplasms show higher signal intensity on T2 WI

. Metastases may show central hypointensity on T2WI

(coagulative necrosis, fibrin, and mucin)

. High T1 signal intensity can be seen with metastases from

melanoma, colonic adenocarcinoma, ovarian adenocarcinoma,

multiple myeloma and pancreatic mucinous cystic tumor

. Comparing T2-weighted (TE 90) and T2-weighted (TE 160)

sequences, metastases become less intense Characterization

. T1-weighted 3D dynamic contrast-enhanced MRI Detection

Metastatic disease

Metastatic disease

HB Agents

USPIO Agents

T1

T2

Multihance* Primovist*

Endorem*

. Liver-specifc contrast agent: hepatobiliary agent(T1) or

reticuloendothelial agent (superparamagnetic agent; T2)

Metastatic diseaseDiffusion MRI imaging Detection++

+

Taouli and Koh Radiology 2010; 254:47–66

Conclusion :

. MDCT and MRI are the most commonly used

imaging modalities for detection and

characterization of focal hepatic lesion

. Imaging modalities can make diagnosis for:

Hepatic cyst

Caverneous hemangioma

Typical FNH

HCC

. For others lesions biopsy will be often

necessary

Monastir

FOCAL HEPATIC LESIONS IMAGING DIAGNOSIS

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