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Liver lesions
- 1. Powerpoint Templates Page 1 Liver lesions Dr. Aftab Qadir
- 2. Powerpoint Templates Page 2 Benign Liver lesions • Hemangioma • Focal nodular hyperplasia • Hepatic adenoma • Liver cyst • Liver abscess
- 3. Powerpoint Templates Page 3 Malignant • Hepatocellular carcinoma • Heptoblastoma Rare malignant: • Fibrosarcoma • Angiosarcoma • Leiomyosarcoma • Lymphoma
- 4. Powerpoint Templates Page 4 Hypervascular lesions Benign • Heamangioma • Adenoma • FNH Malignant • HCC • Hypervascular metastasis
- 5. Powerpoint Templates Page 5 Hypovascular lesions • Hypovascular liver tumors are more common. • Most hypovascular lesions are metastases.
- 6. Powerpoint Templates Page 6 Multiphasic CT For detection of liver lesions • Non enhance CT • Arterial phase • Portal venous phase • Delayed
- 7. Powerpoint Templates Page 7 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
- 8. Powerpoint Templates Page 8 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
- 9. Powerpoint Templates Page 9 Portal venous phase • To detect hypovascular tumors • Scanning is at about 75 seconds
- 11. Powerpoint Templates Page 11 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)
- 13. Powerpoint Templates Page 13 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
- 14. Powerpoint Templates Page 14 T1W T2W Gadolinium Hepatocellular Ca ,iso or (fat degeneration) Metastasis Haemanigioma ++ (like CT) Adenoma often FNH + delayed MRI of Liver
- 15. Powerpoint Templates Page 15 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
- 16. Powerpoint Templates Page 16 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
- 18. Powerpoint Templates Page 18 Clinical presentation Presentation is variable may include: • constitutional symptoms • jaundice • portal hypertension from invasion of the portal vein • hepatomegally / mass
- 19. Powerpoint Templates Page 19 • Majority of patient have cirrhosis • More than 80% of patients with HCC have cirrhosis • May be Focal, multiple or diffusely infiltrative
- 20. Powerpoint Templates Page 20 Investigation • alpha-fetoprotein (AFP) levels are elevated in 50-75 % of cases • Radiological investigation including ultrasound, CT and MRI • Biopsy
- 21. Powerpoint Templates Page 21 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
- 25. Powerpoint Templates Page 25 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
- 26. Powerpoint Templates Page 26 Enhancement pattern • Transient early arterial enhancement and then washes out
- 30. Powerpoint Templates Page 30 MRI T1(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
- 33. Powerpoint Templates Page 33 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
- 34. Powerpoint Templates Page 34 Ultrasound • Usually large heterogeneous predominantly hyperechoic lesion, calcification may be seen(40%)
- 35. Powerpoint Templates Page 35 CT • Large solitary well circumscribed • Heterogeneous arterial enhancement • 30-40% have central scar • Calcification can be seen on non enhanced CT
- 39. Powerpoint Templates Page 39 Hepatic metastasis • More common than primary • May be solitary but usually multiple • Majority are hypovascular • Extremely variable appearance on ultrasound
- 40. Powerpoint Templates Page 40 Hypervascular metastases • Carcinoids • Leiomyosarcomas • Neuroendocrine tumors • Renal carcinomas • Thyroid carcinomas • Choriocarcinomas • Occasionally pancreas, ovary, or breast
- 41. Powerpoint Templates Page 41 Ultrasound Hypoechoic metastasis • Lymphoma • Sarcoma • Most adenocarcinoma(breast, lung, pancreas)
- 43. Powerpoint Templates Page 43 Hyperechoic • Colorectal carcinoma and other GIT • Carcinoid, Renal cell carcinoma, islet cell tumor
- 45. Powerpoint Templates Page 45 Cystic metastasis • Ovarian carcinoma • Cystadenocarcinoma of pancreas • squamous cell carcinoma Calcified metastasis • Mucinous adenocarcinoma of colon
- 48. Powerpoint Templates Page 48 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
- 50. Powerpoint Templates Page 50 MRI • Most metastase are hypointense on T1 • Hyperintense on T2
- 52. Powerpoint Templates Page 52 Interactive cases
- 53. Powerpoint Templates Page 53 Liver calcification causes??
Notes de l'éditeur
- Hypervascular metastasis:neuroendocrine,renal cell ca,melanoma
- WHY? Metastases are 20% more common and most are hypovascular
- Only a minority of tumors contain calcifications, cystic components, fat or hemorrhage and will be detected on a NECT.
- Tumors enhance in arterial phase. Liver will enhance in the portal venous phase
- Will be visible as hyperdense lesions in a relatively hypodense liver
- also called the hepatic phase because there already must be enhancement of the hepatic veins
- HCC Cirrhotic liver with a single nodule in the right lobe showing marked arterial phase enhancement and early wash off in the portovenous phase are diagnostic features of a HCC.
- Metastasis
- after lung and stomach cancer
- HCC are typically diagnosed in adults in late middle age or elderly
- HCC may present with jaundice, bloating from ascites, easy bruising from blood clotting abnormalities or as loss of appetite, unintentional weight loss, abdominal pain, especially in the right upper quadrant, nausea, emesis, or fatigue weight loss, fevers, fatigue, and malaise
- a combination of alfa fetoprotein, imaging, and background cirrhosis is used to make the diagnosis of HCC Imaging should be used instead of biopsy to diagnose HCC
- Heterogeneous due to necrosis and hemorrhage The larger the lesion the more heterogeneous the enhancement
- Well defined low echogenicity mass in segment 4 of the liver, with peri and intralesional vascularity
- A 60 year old male patient with known chronic hepatitis C and liver cirrhosis. On surveillance US, a hypoechoic lesion was noted in segment 3 of the liver and demonstrated vascularity on Doppler study.
- focal, multiple or diffusely infiltrating A capsule is usually best seen in the delayed phase as a relative hyperdense structure.
- the larger the lesion the more heterogeneous the enhancement becoming indistinct or hypodense compared to the rest of the liver at the portal phase Area of necrosis -> low density non enhancing Tumor thrombosis of portal vein will also shows enhancement
- Small HCC seen only in arterial phase in a patient with cirrhosis
- NECT, arterial and portal venous phase in a patient with Hepatitis C with two lesions in the liver (arrows)
- CT scan of the abdomen with quadrephasic liver protocol was performed which confirmed the presence of a hyper-vascular lesion in segment 3, demonstrating washout on portovenous phase.
- This is on account of the supply to HCCs being from the hepatic artery rather than portal vein iso or hyperintense(T1) Early arterial enhancement and rapid washout becoming hypointense to the liver Superparamagnetic iron oxide based MRI
- A 3-cm lesion is seen near the porta hepatis within the right lobe of the liver. It is mildly hyperintense on T2-weighted imaging with fat suppression and is hypointense on precontrast T1-weighted imaging. The lesion demonstrates heterogeneous arterial-phase enhancement and subsequent washout on the portal venous phase. Delayed 20-minute hepatobiliary-phase imaging shows marked hypointensity of this lesion relative to the adjacent liver. HCC can have multiple and varied appearances. Typically, a focal HCC shows arterial-phase enhancement with subsequent washout on portal-venous-phase imaging, which is highly specific for HCC in the correct clinical setting. Dynamic enhanced imaging of HCC is extremely important for both detection and characterization of these lesions. Other useful imaging features to help characterize HCC include rim enhancement on portal-venous-phase imaging (and 5- to 10-minute delayed imaging using a conventional extracellular gadolinium-based contrast agent); hypointensity on precontrast T1 imaging; and isointensity or mild hyperintensity on T2 imaging. Moderate and poorly differentiated HCCs do not contain normal functioning hepatocytes and typically appear hypointense on delayed hepatobiliary-phase imaging, as in this case. There are reports of hepatobiliary gadolinium-based contrast uptake in well-differentiated hepatocellular carcinoma; however, this effect is uncommon and not entirely understood. As in this example, the best contrast between lesion and the adjacent liver is achieved on the delayed hepatobiliary phase. However, delayed hepatobiliary-phase imaging is inadequate for characterization of HCC, which requires the constellation of imaging findings from all sequences for diagnosis. Thus, the utility of delayed hepatobiliary phase is to provide additional characterization as well as detection of these lesions, particularly smaller lesions. In general, the diagnosis of HCC should be made in the appropriate clinical setting, such as a high-risk patient with viral hepatitis or other risk factors for HCC. single-shot fast spin-echo MRI
- A 1.8-cm lesion is seen within segment 2/3 adjacent to the porta hepatis (yellow arrow). It is slightly hypointense on precontrast T1 imaging and slightly hyperintense on T2 imaging. The lesion demonstrates minimal but definite restricted diffusion. Dynamic-phase imaging shows brisk and uniform arterial enhancement with subsequent washout and rim enhancement on portal-venous-phase imaging. Ninety-minute delayed hepatobiliary-phase imaging shows hypointensity relative to the adjacent liver.
- FLC characteristically manifests as a 10-20 cm large hepatic mass in adolescents or young adults. The typical risk factors for HCC such as cirrhosis, elevated alphafetoprotein, viral hepatitis, alcohol abuse are absent.
- In contrast to FNH the central scar in FLC will usually be hypointense on T2WI and will less often show delayed enhancement. While FNH is always very homogeneous, FLC is usually heterogeneous following contrast administration.
- Transverse US image through the dome of the liver helps confirm that the hepatic lesion is a soft tissue mass. (b) Spectral Doppler US image reveals low resistance arterial flow in the lesion, which indicates a hypervascular tumor with arteriovenous shunting.
- Fibrolamellar HCC On the left CT- and MR-images of a left-lobe fibrolamellar HCC in a 19-year-old man. A. Non-enhanced transverse CT scan shows calcification (curved arrow) within the hypoattenuating tumor (straight arrows). B. Hepatic arterial contrast-enhanced transverse CT scan shows heterogeneous hypervascularity within the tumor (arrows). C. Ten-minute delayed transverse CT scan demonstrates subtle areas of hyperattenuation that represent fibrous tissue within the central scar, radiating septa, and capsule (open arrows). Curved arrow = calcification. D. Transverse T2-weighted MR image (5,000/105) also demonstrates the central scar and septa (open arrow). The tumor itself (straight arrows) is nearly isointense to liver
- In children, most common primary sites for metastatic lesions to the liver are: Neuroblastoma Wilms tumor Leukemia
- Lung ca target appearance
- Hypoechoic liver metastases of a colon carcinoma Hypoechoic liver metastases of a melanoma
- Liver metastasis of a colon carcinoma with a hyperechoic lesion in the left liver lobe with a halo.
- cystic squamous cell carcinoma ovarian cancer pancreatic adenocarcinoma colorectal carcinoma (CRC)
- Calcified liver metastases of a sigmoid carcinoma with hyperechoic lesions causing acoustic shadowing Liver metastases with central necrosis
- Large solitary metastasis of an ovarian cancer
- liver metastases may display slight peripheral enhancement with a hypoattenuating center Hyperattenuating lesions are uncommon On the portal venous phase of scanning, some highly vascular primary tumors such as renal cell carcinomas, pancreatic islet cell tumors, pheochromocytomas, melanomas, and breast carcinomas, may appear as isoattenuating to normal liver
- Liver metastases, contrast-enhanced CT. Multiple hypoattenuating lesions of varying sizes are seen in both the left and right lobes of the liver, some with indistinct margins. The patient had colorectal carcinoma. CT scan showing extensive liver metastases
- Rapid washout is a feature of malignant lesion Most lesion shows less enhancement than surrounding liver
- Two lesions are seen within the lateral segment of the left lobe of the liver (yellow arrows). They appear mildly hyperintense on T2 images and mildly hypointense on precontrast T1 images. On arterial-phase and portal-venous-phase images, the lesions demonstrate rim enhancement; they appear hypointense on 5-minute and 20-minute delayed hepatobiliary-phase imaging. Thin-slab MinIP of the 20-minute delayed images showed no other lesions. This is a straightforward example of the detection and characterization of metastatic disease in the liver. Metastases such as those from colorectal cancer are typically hyperintense on T2 imaging and show rim enhancement on contrast-enhanced T1 imaging. As metastatic lesions contain no functioning hepatocytes, they appear hypointense on delayed hepatobiliary-phase imaging. It is important to review the precontrast T1 images, which often depict these lesions well. Diffusion-weighted imaging showed restricted diffusion within these lesions (not shown).
- calcifications are hyperdense on CT and hypointense on T1 and T2 MR images Calcified metastasis in a patient with colon cancer.
- Biopsy proven bilobed HCC in segment 8 of liver peripherally located with invasion of hepatic vein pulse Doppler demonstrate arterial flow
- Innumerable lesions are seen throughout the liver, appearing mildly hyperintense on T2 imaging and hypointense on precontrast T1 imaging with progressive rim enhancement on arterial-phase and portal-venous-phase imaging. In addition, there is a distinct 2-cm mass within the posterior aspect of the right lobe of the liver (yellow arrow). It is moderately hyperintense on T2 imaging and hypointense on precontrast T1 imaging. The lesion shows subtle peripheral discontinuous nodular enhancement that progressively fills in on subsequent imaging with homogeneous signal that matches the blood pool at 6 minutes. Ninety-minute delayed hepatobiliary-phase imaging demonstrates isointensity of this single lesion with the blood pool. All other lesions appear hypointense relative to the liver, with a hypointense rim and isointense ring within the lesion in a characteristic target pattern. The colorectal metastases in this example are highly typical: mildly hyperintense on T2 with slow rim enhancement on dynamic-phase imaging. The target appearance seen on the delayed hepatobiliary phase is also typical of metastases. The presence of a both cavernous hemangioma and colorectal metastases in the same patient presents an opportunity for direct comparison of the appearance of these lesions on both T2 and contrast-enhanced T1 imaging. As seen in previous examples, the signal within hemangioma follows the blood pool on steady-state imaging (beyond a few minutes).
- Echogenic nodular lesion in segment 7 of liver in a known case of RCC, represents metastatic nodule.
- Metastatic sacral cordoma Two large lesions are seen within segments 7 and 8 of the liver. The larger lesion (segment 8) has a lobulated border. Both lesions appear moderately hyperintense on T2 imaging and hypointense on precontrast T1 imaging. Minimal rim enhancement is seen on the arterial-phase and portal-venous-phase images. Profound hypointensity relative to the adjacent liver parenchyma is seen on the 20-minute delayed hepatobiliary-phase images. The lesions exhibit restricted diffusion on diffusion-weighted imaging. Other lesions were identified on other slices (not shown). This case shows typical MRI findings of metastatic disease within the liver. Delayed hepatobiliary-phase imaging is not necessary to either detect or characterize lesions of this size, although the best contrast between lesion and liver is seen on the delayed images. We have found that high-resolution delayed hepatobiliary-phase images provide accurate means of measuring the dimensions of metastatic lesions and therefore may be useful for follow-up studies where accurate size measurements are necessary. High contrast offered by delayed-phase imaging may be a useful means of volumetric measurements of these lesions as well, although further research is needed to demonstrate this.