1. FOCAL HEPATIC LESIONS IMAGING DIAGNOSIS
5th ARAB RADIOLOGY CONGRESS
25th - 28th April 2012
FOCAL HEPATIC LESIONS IMAGING DIAGNOSIS
W.MNARI, M. GOLLI
MONASTIR-TUNISIA

2. Objective :
Identify the most important imaging features of common benign liver tumors
Identify the most important imaging features of malignant lesions
Know the diagnosis of hepatocellular carcinoma

3. 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

4. Classification: Benign Malignant Hemangioma Focal nodular hyperplasia
Adenoma
Liver cysts …
Primary liver cancers
Hepatocellular carcinoma
Fibrolamellar carcinoma
Cholangiocarcinoma
Metastases

5. Things to consider usually.....
Symptomatic or Incidentally detected
History of Hepatitis or extra hepatic malignant tumor
Liver function tests
Cirrhotic or Non cirrhotic

6. Circumstances of discovery
Fortuitous
Non cirrhotic
Symptomatic
Non cirrhotic
Chronic disease
Cirrhosis
Benign
Malignant
Hémangioma
FNH
Adénoma
Metastasis
FLC
HCC DN RN

7. Benign Liver Lesions

8. Hepatic Hemangiomas Benign vascular lesions of liver.
The commonest liver tumor
Autopsy studies : 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++

9. Hepatic Hemangiomas Cavernous angiomas
Hemangiomas are composed of many endothelium-lined vascular spaces separated by fibrous septa

10. Hepatic Hemangiomas
US: well-defined, uniformly hyperechoic liver mass with peripheral feeder vessels that are characteristic of a hemangioma.
Cavernous angiomas

11. Hepatic Hemangiomas US Diagnosis Hemangioma In practice:
. Us characteristic feature
. No context of neoplastic diesease
. Normal liver function tests
YES NO
CT or MRI

12. Hepatic Hemangiomas
CT: The pathognomonic features of caverneous hemangioma: peripheral nodular and discontinuous enhancement and progressive centripetal fill-in
IV-
HAP
PVP DP

13. Hepatic Hemangiomas Diagnosis
CT: venous enhancement from periphery to center

14. Hepatic Hemangiomas Diagnosis 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

15. Hepatic Hemangiomas
Diagnosis
MRI:

16. Hepatic Hemangiomas
Diagnosis

17. 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.

18. Focal Nodular Hyperplasia (FNH)
. Hyperplasia with a central stellate scar radiating in to distinct nodules.
. Ductular diffentiation and malformed vessels.
. Rarely- encapsulated and pedunculated.
. Biliary structures

19. Focal Nodular Hyperplasia (FNH)
Diagnosis:
US: Nodule with varying echogenicity
Color Doppler imaging may show central vessels

20. Focal Nodular Hyperplasia (FNH)
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

21. Focal Nodular Hyperplasia (FNH)
Diagnosis: CT
IV-
HAP
PVP DP

22. Focal Nodular Hyperplasia (FNH)
Diagnosis: CT

23. Focal Nodular Hyperplasia (FNH)
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

24. Focal Nodular Hyperplasia (FNH)
Diagnosis:MRI typical finding

25. Focal Nodular Hyperplasia (FNH)
20% of FNH cases are classified as nonclassic
Biopsy
Attal P et al. Radiology 2003;228:

26. 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

27. Hepatic Adenoma US: CT: MRI:
. 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

28. Hepatic Adenoma

29. Liver cysts: . May be single or multiple
. May be part of polycystic kidney disease
. Patients often asymptomatic
. No specific management required

30. Liver cysts: . US is sufficient to diagnose
. On CT scan or MRI hepatic cysts are typically discovered incidentally

31. Liver cysts:

32. Liver cysts:
HYDATID CYST

33. Malignant Liver Lesions

34. 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

35. Jeong et al. AJR:185, October 2005
Hepatocellular Carcinoma (HCC)
Jeong et al. AJR:185, October 2005

36. Importance of NC imaging
Regenerating Nodules
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
Importance of NC imaging

37. 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

38. Hepatocellular Carcinoma (HCC)
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%

39. Hepatocellular Carcinoma (HCC)
US : hyperechoic, smaller tumors are hypoechoic.
Heterogeneous, hypervascular
US sensitivity about 75%.

40. Hepatocellular Carcinoma (HCC)
Arterial Phase:
liver(30-35 sec)
HCC as supplied by arterial branch/neovascularization
CT or MR
Enhancement
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.
Wash out phenomenan

41. Hepatocellular Carcinoma (HCC)
Delayed Phase :
Wash -out phenomenan persists and often exaggerated in smaller lesions.
The tumor capsule
capsule
IV-
HAP
PVP DP

42. Hepatocellular Carcinoma (HCC)

43. Hepatocellular Carcinoma (HCC)
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

44. Hepatocellular Carcinoma (HCC)
MRI

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

47. 2010 AASLD Algorithm for Investigation of Small Nodules
Found On Screening in Patients with Cirrhosis
DIAGNOSIS : patients with cirrhosis or chronic hepatitis (even without cirrhosis)
Liver nodule
< 1 cm
> 1 cm
4 – phase MDCT/dynamic
Contrast enhanced MRI
Reapeat US at 3 months
Arterial hypervascularity AND
venous or delayed phase washout
Growing/changing
character
Stable
Other contrast enhanced
Study (CT or MRI)
Yes No
Arterial hypervascularity AND
venous or delayed phase washout
Biopsy
Investigate
according to size
HCC
Yes No
Bruix J and Sherman M. AASLD Practice Guidelines , Management of Hepatocellular Carcinoma Hepatology November 2011

48. 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

49. 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.

50. Metastatic disease Typical feature Variable US features+++
Iso, hyper or hypo echoic++
Contrast-enhanced US (CEUS) (84% accuracy)
Intraoperative US (IOUS) (96% accuracy)
Typical feature

51. 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

52. 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

53. Metastatic disease

54. Metastatic disease

55. Metastatic disease
. Liver-specifc contrast agent: hepatobiliary agent(T1) or reticuloendothelial agent (superparamagnetic agent; T2) T1
Multihance*
Primovist*
HB Agents T2
Endorem*
USPIO Agents

56. Metastatic disease Detection+++ Diffusion MRI imaging
Taouli and Koh Radiology 2010; 254:47–66

57. 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

58. Monastir