Case Report # 1 Submitted by:James Korf, MS4 Faculty reviewer:Sandra Oldham, MD Date accepted:27 August 2014 Radiological Category:Principal Modality (1): Principal Modality (2): Gastrointestinal Angiography CT abdomen w/ and w/out contrast

Case History The patient is a 51 year old male with a past medical of HepC who presents for follow up imaging after a 2x 4 x4cm liver mass was noted on abdominal US evaluating previous abdominal distension.

Abdominal CT W/ and W/Out Contrast: Precontrast Phase

Arterial Phase

Venous Phase

Delayed Phase

Vascular Infection Neoplastic Degenerative Idiopathic Congenital Autoimmune/ Allergic Traumatic Endocrine Which one of the following is your choice for the appropriate diagnosis? Test Your Diagnosis

Vascular Infection Neoplastic Degenerative Idiopathic Congenital Autoimmune/ Allergic Traumatic Endocrine Which one of the following is your choice for the appropriate diagnosis? Test Your Diagnosis

Heterogeneous lesion found in segment 4 of the liver, diameter <20mm. Mass displays an area of low attenuation that does not enhance with contrast. Lesion exhibits Iso- density during pre-contrast phase, hyper-dense during arterial phase, iso-density with the venous phase, and hypo-density during delayed phase. Patchy enhancement of liver parenchyma can be noted especially on venous phase. Live edges show mild scalloping. Some evidence of portal hypertension with portal vein measuring 16 mm, and some splenomegaly noted. Right hepatic artery arises from superior mesenteric artery, and left hepatic artery arises from celiac axis. Cyst Hemangioma Metastasis Primary Malignancy Findings: Differentials: Findings and Differentials

Algorithm for potentially cancerous liver lesions. Discussion American College of Radiology. Liver Imaging Reporting and Data System version Accessed August 2014, from

Cysts Believed to be congenital in origin Benign avascular fluid filled lesion Low attenuation relative to liver parenchyma Does not enhance with contrast Tend to be solitary and homogenous Discussion

Liver Cysts Mortelé, Koenraad J. and Ros, Pablo R. Cystic Focal Liver Lesions in the Adult: Differential CT and MR Imaging Features. RadioGraphics :4,

Our patient

Hemangiomas Benign vascular tumor Low attenuation on unenhanced CT scans Have a characteristic nodular enhancement beginning the periphery that progresses centrally The contrast is retained, causing hemangiomas to be enhanced and hyper dense on delayed phase Discussion

Liver Hemangioma Precontrast Arterial phase Venous phase Uptodate.com. Courtesy of Jonathan Kruskal, MD. Graphic Version 3.0

Our Patient

Metastasis Tend to be multiple, but can occasionally present as a solitary nodule. Typical present as low attenuating masses. Most commonly GI in origin, and spread via portal venous system Therefore these metastases often enhance during venous contrast phase Discussion

RCC Metastasis: Venous phase

Our Patient

Primary Malignancy Hepatocellular Carcinoma is the common primary malignancy of liver Frequently seen in the setting of liver cirrhosis Also must consider Colangiocarcinoma Defining features of HCC –Arterial hyper enhancement –Washout vs. Fading –Capsule or Corona enhancement –Threshold growth –Invasion of portal vein Other features that are often found –Central necrosis –Calcifications Discussion

Algorithm for potentially cancerous liver lesions. Discussion American College of Radiology. Liver Imaging Reporting and Data System version Accessed August 2014, from

Capsule and Corona Enhancement in HCC American College of Radiology. Liver Imaging Reporting and Data System version Accessed August 2014, from

Washout and Fading in HCC American College of Radiology. Liver Imaging Reporting and Data System version Accessed August 2014, from

Our Patient

Hepatocellular Carcinoma mass with a LI-RAD 4B classification Diagnosis: Hepatocellular Carcinoma American College of Radiology. Liver Imaging Reporting and Data System version Accessed August 2014, from

LR1: Continued routine surveillance usually is appropriate. LR2: Continued routine surveillance usually is appropriate. LR3: Appropriate management is variable, depending mainly on size, stability, and clinical considerations. LR4: Close follow up, additional imaging, biopsy, or treatment (loco-regional treatment, sub-total hepatic resection) may be appropriate. LR5: Treatment without biopsy is appropriate. Management

Case Followup Case Follow Up : Attempted T.A.C.E

American College of Radiology. Liver Imaging Reporting and Data System version Accessed August 2014, from Safety/Resources/LIRADS/ Herring, William. Learning Radiology: Recognizing the Basics, Second Edition. Pp © 2012 Mosby, Inc. Lise M, Da Pian PP, Nitti D. Colorectal metastases to the liver: present results and future strategies. J Surg Oncol Suppl. 1991;2: Mortelé, Koenraad J. and Ros, Pablo R. Cystic Focal Liver Lesions in the Adult: Differential CT and MR Imaging Features. RadioGraphics :4, Uptodate.com. Courtesy of Jonathan Kruskal, MD. Graphic Version 3.0 References