1. 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

2. 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.

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

4. Arterial Phase

6. Venous Phase

9. Delayed Phase

10. 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

11. 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

12. 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

13. Algorithm for potentially cancerous liver lesions. Discussion American College of Radiology. Liver Imaging Reporting and Data System version 2013.1. Accessed August 2014, from http://www.acr.org/Quality-Safety/Resources/LIRADS/.

14. 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

15. Liver Cysts Mortelé, Koenraad J. and Ros, Pablo R. Cystic Focal Liver Lesions in the Adult: Differential CT and MR Imaging Features. RadioGraphics 2001 21:4, 895-910

16. Our patient

17. 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

18. Liver Hemangioma Precontrast Arterial phase Venous phase Uptodate.com. Courtesy of Jonathan Kruskal, MD. Graphic 70560 Version 3.0

19. Our Patient

20. 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

21. RCC Metastasis: Venous phase

22. Our Patient

23. 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

24. Algorithm for potentially cancerous liver lesions. Discussion American College of Radiology. Liver Imaging Reporting and Data System version 2013.1. Accessed August 2014, from http://www.acr.org/Quality-Safety/Resources/LIRADS/.

25. Capsule and Corona Enhancement in HCC American College of Radiology. Liver Imaging Reporting and Data System version 2013.1. Accessed August 2014, from http://www.acr.org/Quality-Safety/Resources/LIRADS/.

26. Washout and Fading in HCC American College of Radiology. Liver Imaging Reporting and Data System version 2013.1. Accessed August 2014, from http://www.acr.org/Quality-Safety/Resources/LIRADS/.

27. Our Patient

28. Hepatocellular Carcinoma mass with a LI-RAD 4B classification Diagnosis: Hepatocellular Carcinoma American College of Radiology. Liver Imaging Reporting and Data System version 2013.1. Accessed August 2014, from http://www.acr.org/Quality-Safety/Resources/LIRADS/.

29. 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

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

32. American College of Radiology. Liver Imaging Reporting and Data System version 2013.1. Accessed August 2014, from http://www.acr.org/Quality- Safety/Resources/LIRADS/ Herring, William. Learning Radiology: Recognizing the Basics, Second Edition. Pp 183- 190. © 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;2:69-73. Mortelé, Koenraad J. and Ros, Pablo R. Cystic Focal Liver Lesions in the Adult: Differential CT and MR Imaging Features. RadioGraphics 2001 21:4, 895-910 Uptodate.com. Courtesy of Jonathan Kruskal, MD. Graphic 70560 Version 3.0 References