Extrahepatic Metastases of Hepatocellular Carcinoma: A Spectrum of Imaging Findings  Annalisa K. Becker, MD, FRCPC, David K. Tso, MD, Alison C. Harris, MD, FRCPC, David Malfair, MD, FRCPC, Silvia D. Chang, MD, FRCPC  Canadian Association of Radiologists Journal  Volume 65, Issue 1, Pages 60-66 (February 2014) DOI: 10.1016/j.carj.2013.05.004 Copyright © 2014 Canadian Association of Radiologists Terms and Conditions

Figure 1 (A) A 54-year-old man with hepatocellular carcinoma. Axial contrast-enhanced computed tomography images in portal venous phase, demonstrating a portion of the primary lesion (white arrow) that is causing thrombosis of the posterior branch of the right portal vein (black arrow); complicated perihepatic and perisplenic fluid (24 HU) raises the possibility of capsular rupture; the nodular contour of the liver is consistent with a background of cirrhosis. (B) A 66-year-old man with hepatocellular carcinoma; an axial contrast-enhanced computed tomography in portal venous phase, demonstrating left portal vein tumour thrombosis with extension into the right portal vein confluence (white arrow). Canadian Association of Radiologists Journal 2014 65, 60-66DOI: (10.1016/j.carj.2013.05.004) Copyright © 2014 Canadian Association of Radiologists Terms and Conditions

Figure 2 A 58-year-old man with hepatocellular carcinoma and direct invasion of hepatic veins. Axial contrast-enhanced computed tomography in the (A) arterial phase and (B) portal venous phase, demonstrating a large hepatic mass with central low attenuation that involves segments VII and VIII, and obliterates the right hepatic vein (white arrows). The mass demonstrates enhancement in the arterial phase and portal venous washout, characteristic of hepatocellular carcinoma, which was confirmed at biopsy. Canadian Association of Radiologists Journal 2014 65, 60-66DOI: (10.1016/j.carj.2013.05.004) Copyright © 2014 Canadian Association of Radiologists Terms and Conditions

Figure 3 A 58-year old man with hepatocellular carcinoma. (A, B) Axial contrast-enhanced computed tomography in the portal venous phase, demonstrating invasion of the intrahepatic inferior vena cava (A and B, white arrow). Portions of the primary tumour are visualized within the right lobe (black arrows). (C) Axial contrast-enhanced computed tomography images in the portal venous phase, demonstrating invasion of the right hepatic vein (white arrow) with the primary lesion seen again in the right lobe (black arrows). Canadian Association of Radiologists Journal 2014 65, 60-66DOI: (10.1016/j.carj.2013.05.004) Copyright © 2014 Canadian Association of Radiologists Terms and Conditions

Figure 4 A 42-year-old man with hepatocellular carcinoma and metastatic lung nodules. (A) Posteroanterior radiograph, demonstrating metastatic lung nodules with a lower lobe predominance. (B) Axial contrast-enhanced computed tomography image, demonstrating multiple, nonspecific pulmonary nodules at the lung bases (arrows). Canadian Association of Radiologists Journal 2014 65, 60-66DOI: (10.1016/j.carj.2013.05.004) Copyright © 2014 Canadian Association of Radiologists Terms and Conditions

Figure 5 A 68-year-old woman with hepatocellular carcinoma and metastatic lung nodules. Axial T1-weighted gadolinium-enhanced image, demonstrating a metastatic nodule at the right lung base (white arrow). Canadian Association of Radiologists Journal 2014 65, 60-66DOI: (10.1016/j.carj.2013.05.004) Copyright © 2014 Canadian Association of Radiologists Terms and Conditions

Figure 6 A 55-year-old man with hepatocellular carcinoma treated with hepatic embolization with invasion of regional lymph nodes. Axial contrast-enhanced computed tomography in the (A) arterial phase and (B) portal venous phase, demonstrating portal and peripancreatic necrotic lymphadenopathy with peripheral enhancement (white arrows); the inferior margin of the hepatocellular carcinoma primary tumour is visualized after embolization (black arrows). Locules of gas are expected after treatment, up to 7-10 days. Canadian Association of Radiologists Journal 2014 65, 60-66DOI: (10.1016/j.carj.2013.05.004) Copyright © 2014 Canadian Association of Radiologists Terms and Conditions

Figure 7 A 42-year-old man with hepatocellular carcinoma and metastases to distant lymph nodes. (A) Axial and (B) coronal contrast-enhanced computed tomography images, demonstrating a conglomerate mass of necrotic nodes below the level of the renal vessels (A and B, black arrow). It is causing compression and possible invasion of the cava (A and B, white arrow). (C) Subcarinal and (D) paraesophageal lymph node metastases are also identified (C and D, white arrow). Canadian Association of Radiologists Journal 2014 65, 60-66DOI: (10.1016/j.carj.2013.05.004) Copyright © 2014 Canadian Association of Radiologists Terms and Conditions

Figure 8 A 48-year-old man with hepatocellular carcinoma and multiple bony metastases secondary to hepatitis-related hepatoma. (A) Axial contrast-enhanced computed tomography image on soft-tissue windows, demonstrating a lytic, expansile lesion in the right rib, vertebral body, and posterior elements (white arrows). (B) Axial T2-weighted image, demonstrating the magnetic resonance appearance of the same lesions seen in (A) (white arrows). (C) Computed tomography bone window image, demonstrating further involvement of the right sacrum (white arrows). Canadian Association of Radiologists Journal 2014 65, 60-66DOI: (10.1016/j.carj.2013.05.004) Copyright © 2014 Canadian Association of Radiologists Terms and Conditions

Figure 9 A 48-year-old man with hepatocellular carcinoma and metastases to the thoracic spine. Coronal T2-weighted image, demonstrating near-complete collapse of T7 and T8 vertebral bodies (grey arrow). Extension into the spinal canal is causing severe cord compression, with high signal change, which extends from T6 to T9 (white arrow). Canadian Association of Radiologists Journal 2014 65, 60-66DOI: (10.1016/j.carj.2013.05.004) Copyright © 2014 Canadian Association of Radiologists Terms and Conditions

Figure 10 A 46-year-old man with hepatitis B and hepatocellular carcinoma. (A) Axial T1-weighted image, demonstrating low signal metastases that involves the right posterior superior iliac spine and the left sacral ala and body (thin arrows), with extension into the S1 and S2 neural foramina (curved arrow). (B) Axial T1-weighted image in the same patient, demonstrating invasion of the left acetabular roof (white arrow). Canadian Association of Radiologists Journal 2014 65, 60-66DOI: (10.1016/j.carj.2013.05.004) Copyright © 2014 Canadian Association of Radiologists Terms and Conditions

Figure 11 A 66-year-old man with hepatocellular carcinoma and peritoneal deposits. Axial contrast-enhanced computed tomography image in portal venous phase, demonstrating peritoneal deposits deep to the abdominal wall (white arrows). Canadian Association of Radiologists Journal 2014 65, 60-66DOI: (10.1016/j.carj.2013.05.004) Copyright © 2014 Canadian Association of Radiologists Terms and Conditions

Figure 12 A 65-year-old man with hepatocellular carcinoma and mesenteric deposits. (A) Axial contrast-enhanced computed tomography in the portal venous phase, demonstrating a large, lobulated metastatic soft-tissue nodule in the right hemi-abdomen, immediately posterior and inferior to the hepatic flexure (white arrow). (B) Axial contrast-enhanced computed tomography in the portal venous phase demonstrates a satellite nodule inferior to segment IVb of the liver (white arrow). Canadian Association of Radiologists Journal 2014 65, 60-66DOI: (10.1016/j.carj.2013.05.004) Copyright © 2014 Canadian Association of Radiologists Terms and Conditions

Figure 13 A 60-year-old man with hepatocellular carcinoma treated with radiofrequency ablation. (A) Axial contrast-enhanced computed tomography image in the portal venous phase, demonstrating a left retroperitoneal mass, biopsy proven to represent well-differentiated hepatocellular carcinoma (white arrow). (B) Arterial phase enhancement, demonstrating the claw sign, confirms that the mass is arising from the lateral limb of the left adrenal gland (white arrow). Canadian Association of Radiologists Journal 2014 65, 60-66DOI: (10.1016/j.carj.2013.05.004) Copyright © 2014 Canadian Association of Radiologists Terms and Conditions

Figure 14 A 71-year-old man with multifocal hepatocellular carcinoma who presented with a history of falls and dizziness. Axial contrast-enhanced computed tomography, demonstrating a large, rim-enhancing lesion in the left frontal lobe (grey arrow), with a significant amount of associated vasogenic oedema (white arrows). Canadian Association of Radiologists Journal 2014 65, 60-66DOI: (10.1016/j.carj.2013.05.004) Copyright © 2014 Canadian Association of Radiologists Terms and Conditions