Student SYB Chet Cunha MS IV January 22, 2009

History 61 y/o M with known HCV x 5 yrs. presenting with vague abdominal discomfort. Outside CT showed single suspicious lesion in liver. US guided bx shows mild chronic hepatitis with no evidence of malignancy or cirrhosis. PE and ROS unremarkable.

DDx Hepatic mass lesions Malignancy - HCC, lymphoma, hemangiosarcoma, intrahepatic cholangiocarcinoma, mets (GI, GU, ovarian, pancreatic) Benign tumors - hemangioma, adenoma Cysts - hepatic cysts, hydatid cysts, polycystic liver disease Abscesses - pyogenic, amebic, fungal Focal fatty infiltration Caroli’s disease

Labs CBC/BMP unremarkable. No LFT abnormalities. Elevated Alpha-fetoprotein. HAV/HBV serologies negative.

W/U of hepatic lesion CT with contrast MRI US Tc-99m Lipiodol Angiography with CT f/u US, CT guided, or open bx for definitive dx

Imaging - Lipiodol Angiogram

Imaging - Triphasic CT 2 weeks after Angiography

Periportal lymphadenopathy

Imaging - Triphasic CT 2 weeks after Angiography Smaller middle lobe but no frank evidence of cirrhosis

HCC Most often seen in presence of cirrhosis (EtOH, HBV, HCV, hemochromatosis, aflatoxin, alpha 1 antitrypsin) AFP often, but not always elevated 3 growth patterns: Solitary mass (often large) Multifocal/nodular Diffuse

HCC Radiographically US appearance variable MR - hypo in T1, hyper in T2 Unenhanced CT - hypoattenuated lesions CT with contrast - hyper in arterial phase Often invades portal vasculature

HCC - Treatment Options Surgical resection Chemoembolization Radiofrequency ablation Chemotherapy Liver transplantation (If pt has 1 lesion <5cm or 3 lesions <3cm*) *N.B. these measurements can be reevaluated following neoadjuvant therapy

Further Reading Gourtsoyiannis, N.C., Ros, P.R. Radiologic-Pathologic Correlations from Head to Toe. Springer Publishing, Berlin Grossman, Z.D., Katz, D. S., et al. Cost-Effective Diagnostic Imaging. Mosby Elsevier, Philadelphia, Weinstein, W.M., Hawkey, C.J., Bosch, J. Clinical Gastroenterology and Hepatology. Mosby Elsevier, Philadelphia, 2005.