ct/mri of the liver and biliary tract

Why Liver Tumors Appear As They Do?:
Imaging-Pathologic Correlation
Pablo R. Ros, MD, MPH
University Hospitals of Cleveland
Case Western Reserve University
Cleveland, Ohio
USA
XLIV Curso Anual
Sociedad Mexicana de Radiologia e Imagen
Mexico, DF
El Por Que de la Correlacion
Anatomo-Radiologica:
Por que los Tumores Hepaticos
se Ven como Ven
Pablo R. Ros, MD, MPH
University Hospitals of Cleveland
Case Western Reserve University
Cleveland, Ohio
USA
XLIV Curso Anual
Sociedad Mexicana de Radiologia e Imagen
Mexico, DF
Imaging-Pathologic Correlation
Closes 2011
149 years of service
64 years of Rad-Path
Imaging-Pathologic Correlation
• Fundamental educational tool for
Radiology
• Underlying microscopic basis of disease
• Resulting gross features
• Learn imaging characteristics regardless
of technique
• Applicable to novel imaging: Optical and
molecular
• Essential to increase imaging’s accuracy
Imaging-Pathologic correlation
• Initiated in 1947 at AFIP
– Establishment of Radiologic Pathology
Branch
– Founded as Army Medical Museum (1862)
Imaging-Pathologic correlation
• Radiologic-Pathologic correlation
– Limited to plain films: Chest and Bone
(Elias Theros, MD)
– Imaging US, CT, MRI) expansion to solid
viscera (Brain, Liver, Heart, Kidney,…)
– Resident courses (Standard worldwide)
Imaging Pathologic
Correlation
Imaging Pathologic
Correlation: Liver Tumors
• Liver: key organ for imaging correlation
– large size
– homogeneous parenchyma
– variety of focal lesions (benign, malignant, nonsurgical)
– multiple imaging modalities
– imaging diagnosis possible
– impact in management
•
•
•
•
Basic pathological features
CT and MRI / Adult / Primary Neoplasms
Narrow differential diagnosis
Imaging Characterization
Imaging Pathologic
Correlation
Imaging Pathologic
Correlation
• Focal Nodular
Hyperplasia
• Fibrolamellar Carcinoma
• Intrahepatic
Cholangiocarcinoma
• Hemangioma
• Hepatocellular carcinoma
Imaging Pathologic
Correlation
•
•
•
•
•
•
Scar (fibrosis)
Blood (hemorrhage)
Contour (capsule)
Fat
Bubble (cystic nature)
Rock (calcification)
Scar: Focal Nodular Hyperplasia
- Central scar
- Vessels (result of AVM)
- Radiating fibrous septa, nodules
Scar: Focal Nodular Hyperplasia
- Central arteries
- Large size
- Edema
Scar: Focal Nodular Hyperplasia
- Edema, vessels
- Homogeneous, except for scar
- Red orange color, no bile stain
- Lobulated contour
Scar: Focal Nodular Hyperplasia
- CT: Low density
- T1 : Hypointense scar, septa
- T2 : Hyperintense scar
Scar: Focal Nodular Hyperplasia
- Very early enhancement
- Arteries in scar
- Enhancement in late phases
Scar: Focal Nodular Hyperplasia
- Isointense in Portal Phase
Scar: Focal Nodular Hyperplasia
- Early: rapid fill-in, homogeneous enhancement, vessels in scar
- Late: rapid wash-out, enhancement of scar
Scar: Focal Nodular Hyperplasia
- Large scar, mimics necrosis
Scar: Focal Nodular Hyperplasia
- GRE, Doppler : high signal in scar
- Central scar with large
arterial branches
Scar: Fibrolamellar Carcinoma
- Lamellar fibrosis
- Confluent centrally
- No vessels
- No edema
Scar: Fibrolamellar Carcinoma
- Central scar, Radiating Septa
- No vessels
- Calcification
Scar: Fibrolamellar Carcinoma
- Low signal in T2
- No enhancement
- Calcification
Scar: Fibrolamellar Carcinoma
- Ill defined scar
Scar: Intrahepatic
Cholangiocarcinoma
- Mucin producing neoplasm: marked fibrosis
- Fibrotic predominance (large central scars)
Scar: Intrahepatic
Cholangiocarcinoma
- Minimal arterial and portal enhancement
- Vascular encasement
Scar: Intrahepatic
Cholangiocarcinoma
- T1: Hypointense scar
- Early: No scar enhancement
- Late: Scar enhancement
Imaging-Pathologic correlation in
the Liver: Basic Pathologic Features
•
•
•
•
•
•
Scar (fibrosis)
Blood (hemorrhage)
Contour (capsule)
Fat
Bubble (cystic nature)
Rock (calcification)
Blood: Hepatocellular
Adenoma
- Large size, poor vascularity
- Necrosis and hemorrhage
- Contained bleeding or hemoperitoneum
Blood: Hepatocellular Adenoma
Blood: Hepatocellular Adenoma
Blood: Hepatocellular Adenoma
- Heterogeneous
- Hemosiderin rings
Blood: Hepatocellular Carcinoma
Blood: Angiosarcoma
- Most vascular malignant tumor
- Internal hemorrhage
- Blood-fluid levels
Blood: Angiosarcoma
Blood: Hemangioma
- Occasionally
- Necrosis
Blood: Hemangioma
Imaging-Pathologic correlation in the
Liver: Basic Pathologic Features
•
•
•
•
•
•
Scar (fibrosis)
Blood (hemorrhage)
Contour (capsule)
Fat
Bubble (cystic nature)
Rock (calcification)
Basic Pathologic Features:
Contour (capsule)
• Hepatocellular Adenoma
• Hepatocellular Carcinoma
• Cystadenoma/Cystadeno
carcinoma
Capsule: Hepatocellular
Adenoma
- Thin fibrous capsule
- Well defined contour
- Subcapsular vessels
Capsule: Hepatocellular
Adenoma
Capsule: Hepatocellular
Carcinoma
Capsule: Hepatocellular
Carcinoma
Imaging-Pathologic correlation in the
Liver: Basic Pathologic Features
•
•
•
•
•
•
Scar (fibrosis)
Blood (hemorrhage)
Contour (capsule)
Fat
Bubble (cystic nature)
Rock (calcification)
Fat: Hepatocellular Adenoma
- Predominantly fatty
- Also blood, capsule
Fat: Hepatocellular Adenoma
- Predominantly fatty by CT
Fat: Hepatocellular Adenoma
- Central fat
Fat: Hepatocellular
Carcinoma
Fat: Hepatocellular Carcinoma
- Fat, Capsule
- Non-cirrhotic liver
Fat: Angiomyolipoma
- Fat attenuation
- Septa
- Multiple
Fat: Angiomyolipoma
Post gad - aneurysms
Fat: Focal Nodular Hyperplasia
Imaging-Pathologic correlation in the
Liver: Basic Pathologic Features
•
•
•
•
•
•
Scar (fibrosis)
Blood (hemorrhage)
Contour (capsule)
Fat
Bubble (cystic nature)
Rock (calcification)
Bubble:
Cystadenoma/Cystadenocarcinom
a
Bubble:
Cystadenoma/Cystadenocarcinom
a
Bubble: Microbiliary
Hamartoma
- Small size
- Multiple
- Diffuse
Bubble: Abscess
Bubble: Abscess
Clustering
Rim enhancement
Bubble: Echinoccocal cyst
Bubble: Echinoccocal cyst
Imaging-Pathologic correlation in the
Liver: Basic Pathologic Features
•
•
•
•
•
•
Scar (fibrosis)
Blood (hemorrhage)
Contour (capsule)
Fat
Bubble (cystic nature)
Rock (calcification)
Rock: Fibrolamellar
Carcinoma
Rock: Hemangioma
- Up to 20 % of cases
- Large fibrotic areas
Imaging-Pathologic correlation
in the Liver: Basic Pathologic
Features
•
•
•
•
•
•
Scar (fibrosis)
Blood (hemorrhage)
Contour (capsule)
Fat
Bubble (cystic nature)
Rock (calcification)
Imaging-Tissue
Correlation:Micro MRI
Imaging-Tissue Correlation
Protease imaging
BT20
DU4475
Bremer et al. Radiology, 2002
Fluorescence mediated
tomography
Ntziachristos, NatMed 2002
Radiolabeled monoclonal antibody targeting
Prostate Specific Membrane Antigen (PSMA)
Prostate
(green)
Tumor
(red)
Correlation/Validation
Proof of Concept in BCS: Preliminary Trial Results
a
Tumor Associated
Proteases
1 cm
b
Path.
Neg.
margin
5x Mag.
1 cm
c
d
e
Path.
Pos.
margin
Anterior
Posterior
1.25x Mag.
1.25x
Mag.
Future: “Missed” Tumor Tissue After Resection
cavity
a
b
cavity
cavity
Nuclei
GB119
c
Nuclei
Vimentin
normal
brain
normal
brain
Tumor
Tumor
resection cavity
Nuclei
GB119
resection cavity
Nuclei
Vimentin
Imaging-Pathologic Correlation
• Fundamental educational tool for
Radiology
• Underlying microscopic basis of disease
• Resulting gross features
• Learn imaging characteristics regardless
of technique
• Applicable to novel imaging: Optical and
molecular
• Essential to increase imaging’s accuracy
Imaging-Tissue Correlation
• Essential to increase imaging’s accuracy
• Payors not able to sustain current
reimbursement at low specificity
• Value proposition:
–
–
–
–
–
Characterization (diagnosis)
Resectability
Staging
Response to therapy (Angiogenesis, DWI,…)
Prognosis
• Tissular, Cellular and Molecular correlation