The Focal Hepatic Lesion: Radiologic Assessment

Kevin Kuo, HMS III
Gillian Lieberman, MD
November 2006
The Focal Hepatic Lesion:
Radiologic Assessment
Kevin Kuo, Harvard Medical School Year III
Gillian Lieberman, MD
Kevin Kuo, HMS III
Gillian Lieberman, MD
November 2006
Our Patient: PS

67 y/o female w/ long history of alcohol use

Drinking since age 18, up to one bottle of
wine/day

Asymptomatic, denies abdominal distension,
hematemesis, ascites, encephalopathy
2
Kevin Kuo, HMS III
Gillian Lieberman, MD
November 2006
What Next?

Given PS’s extensive history of alcohol use,
we are clearly concerned about potential
cirrhosis and even hepatocellular carcinoma
(HCC).
However, we need to understand basic liver
anatomy to appreciate liver imaging…
3
Kevin Kuo, HMS III
Gillian Lieberman, MD
November 2006
Liver Anatomy
Couinaud Segments


Based on vascular anatomy
Important for surgical planning
Portal Triad and Hepatic Veins

Hepatic veins delineate lobes
of the liver: Left (lateral and
medial) and Right (anterior
and posterior)
http://hopkins-gi.nts.jhu.edu/pages/latin/templates/index.cfm
4
Kevin Kuo, HMS III
Gillian Lieberman, MD
November 2006
Screening for HCC: The Menu of Tests
Imaging
Modality
Accuracy*
Advantages
Disadvantages
US
Sens:60%
Spec:97%
Wide availability,
noninvasive, no radiation.
Assess vascular invasion.
Good for screening. Real
time images
Operator dependent,
low sensitivity, may not
always distinguish
between tumors
CT
Sens:68%
Spec: 93%
Improved sensitivity with
triple phase helical CT,
relatively fast
Increased radiation,
more costly
MRI
Sens: 81%
Spec: 85%
Most sensitive, especially
for smaller lesions. High
resolution, no radiation
Most expensive, takes
more time, patient
tolerance
*For HCC In patients with chronic liver disease
5
Kevin Kuo, HMS III
Gillian Lieberman, MD
November 2006
Triple Phase Helical CT
Axial C+ CT
Portal Venous
Phase
Axial C+ CT
Arterial Phase
Axial C+ CT
Hepatic Venous
Phase
Contrast Injection
Arterial
0
15
30
Portal Venous
Time (sec)
Hepatic Venous
45
60
Foley, WD. Multiphase Hepatic CT with a Multirow Detector CT Scanner. 2000 (175): 679-685.
75
6
Kevin Kuo, HMS III
Gillian Lieberman, MD
November 2006
PS: Cirrhosis and Portal Hypertension
Film Findings: Nodular, shrunken liver
Caudate and left lateral lobe enlargement
Esophageal Varices
Umbilical Recanalization
Enlarged Portal Vein
Splenomegaly, Ascites (neither present in our patient)
Axial C+ CT
PACS, BIDMC
Venous Maximum Intensity
Phase Reconstruction
Axial C+ CT
7
Kevin Kuo, HMS III
Gillian Lieberman, MD
November 2006
PS: Triple Phase CT
Axial C- CT
Film Findings:  Nodular liver
Axial C+ CT: Arterial Phase
 Early hyperenhancing lesion
 No discrete lesions
PACS, BIDMC
8
Kevin Kuo, HMS III
Gillian Lieberman, MD
November 2006
PS: Triple Phase CT
Axial C+ CT: Portal Venous Phase
Film Findings:
PACS, BIDMC
 Quick washout of
enhancing lesion
Axial C+ CT: Delayed Phase
 Hypoenhancing lesion with
peripheral rim of enhancement
9
Kevin Kuo, HMS III
Gillian Lieberman, MD
November 2006
PS: Preliminary Diagnosis

Triple Phase CT Findings:




Early arterial phase enhancement
quick washout
peripheral rim of enhancement in the delayed phase
Highly suspicious for HCC

HCC is hypervascular receives ~80% of its blood
flow from hepatic arteries and only ~20% from the
portal vein (exact opposite of normal liver
parenchyma)
Nonetheless, we need to consider the full differential diagnosis…
10
Kevin Kuo, HMS III
Gillian Lieberman, MD
November 2006
A Walk Through The Differential Diagnoses:
Lesions
Classical CT Findings
Hepatic Cyst
Sharply demarcated wall, water density, nonenhancing
Hemangioma
Peripheral filling in of contrast over time
“Light Bulb Sign” on T2 MRI
Focal Nodular
Hyperplasia (FNH)
Early filling in arterial phase with central filling
defect (scar)
Hepatocellular
Adenoma
Variable, central changes due to hemorrhage
often seen
Metastasis
Mostly multiple low attenuation lesions, rim
enhancement without “filling in”
Abscess
Well demarcated hypodense areas with
peripheral enhancement, may see gas
Hepatocellular
Carcinoma (HCC)
Early arterial enhancement, fast washout,
delayed fibrous capsule enhancement
PS
11
Kevin Kuo, HMS III
Gillian Lieberman, MD
November 2006
Hepatic Cyst
Axial C+ CT
Film Findings:
 Sharply demarcated,
non enhancing, water-dense
cyst.
http://bb.westernu.edu/web/Pathology/webpath60/webpath/radi
ol/heparad/
12
Kevin Kuo, HMS III
Gillian Lieberman, MD
November 2006
A Walk Through The Differential Diagnoses:
Lesions
Classical CT Findings
PS
Hepatic Cyst
Sharply demarcated wall, water density, nonenhancing
x
Hemangioma
Peripheral filling in of contrast over time
“Light Bulb Sign” on T2 MRI
Focal Nodular
Hyperplasia (FNH)
Early filling in arterial phase with central filling
defect (scar)
Hepatocellular
Adenoma
Variable, central changes due to hemorrhage
often seen
Metastasis
Mostly multiple low attenuation lesions, rim
enhancement without “filling in”
Abscess
Well demarcated hypodense areas with
peripheral enhancement, may see gas
Hepatocellular
Carcinoma (HCC)
Early arterial enhancement, fast washout,
delayed fibrous capsule enhancement
13
Kevin Kuo, HMS III
Gillian Lieberman, MD
November 2006
Hemangioma
Axial C+ CT (Various phases)
Film Findings:
 Hypodense lesion with
peripheral filling in of
contrast over time
http://www.radiologyassistant.nl/en/448eef3083354
14
Kevin Kuo, HMS III
Gillian Lieberman, MD
November 2006
A Walk Through The Differential Diagnoses:
Lesions
Classical CT Findings
PS
Hepatic Cyst
Sharply demarcated wall, water density, nonenhancing
x
Hemangioma
Peripheral filling in of contrast over time
“Light Bulb Sign” on T2 MRI
x
Focal Nodular
Hyperplasia (FNH)
Early filling in arterial phase with central filling
defect (scar)
Hepatocellular
Adenoma
Variable, central changes due to hemorrhage
often seen
Metastasis
Mostly multiple low attenuation lesions, rim
enhancement without “filling in”
Abscess
Well demarcated hypodense areas with
peripheral enhancement, may see gas
Hepatocellular
Carcinoma (HCC)
Early arterial enhancement, fast washout,
delayed fibrous capsule enhancement
15
Kevin Kuo, HMS III
Gillian Lieberman, MD
November 2006
Focal Nodular Hyperplasia
Axial C+ CT
Film Findings:
 Enhancing lesion with
central filling defect (central
scar)
http://uuhsc.utah.edu/rad/medstud/BodyCaseStudies/BodyCa
se6a.htm
16
Kevin Kuo, HMS III
Gillian Lieberman, MD
November 2006
A Walk Through The Differential Diagnoses:
Lesions
Classical CT Findings
PS
Hepatic Cyst
Sharply demarcated wall, water density, nonenhancing
x
Hemangioma
Peripheral filling in of contrast over time
“Light Bulb Sign” on T2 MRI
x
Focal Nodular
Hyperplasia (FNH)
Early filling in arterial phase with central filling
defect (scar)
x
Hepatocellular
Adenoma
Variable, central changes due to hemorrhage
often seen
Metastasis
Mostly multiple low attenuation lesions, rim
enhancement without “filling in”
Abscess
Well demarcated hypodense areas with
peripheral enhancement, may see gas
Hepatocellular
Carcinoma (HCC)
Early arterial enhancement, fast washout,
delayed fibrous capsule enhancement
17
Kevin Kuo, HMS III
Gillian Lieberman, MD
November 2006
Hepatocellular Adenoma
Axial C+ CT
Film Findings:
 Multiple hypoenhancing
heterogenous lesions
Enhancing hepatic veins
UpToDate: Hepatic Adenoma
18
Kevin Kuo, HMS III
Gillian Lieberman, MD
November 2006
A Walk Through The Differential Diagnoses:
Lesions
Classical CT Findings
PS
Hepatic Cyst
Sharply demarcated wall, water density, nonenhancing
x
Hemangioma
Peripheral filling in of contrast over time
“Light Bulb Sign” on T2 MRI
x
Focal Nodular
Hyperplasia (FNH)
Early filling in arterial phase with central filling
defect (scar)
x
Hepatocellular
Adenoma
Variable, central changes due to hemorrhage
often seen
x
Metastasis
Mostly multiple low attenuation lesions, rim
enhancement without “filling in”
Abscess
Well demarcated hypodense areas with
peripheral enhancement, may see gas
Hepatocellular
Carcinoma (HCC)
Early arterial enhancement, fast washout,
delayed fibrous capsule enhancement
19
Kevin Kuo, HMS III
Gillian Lieberman, MD
November 2006
Liver Metastasis (Colonic Adenocarcinoma)
Axial C+ CT
Film Findings:
 Multiple hypoenhancing
heterogenous lesions
http://www.mypacs.net/repos/mpv3_repo/viz/full/11724/586248.
jpg
20
Kevin Kuo, HMS III
Gillian Lieberman, MD
November 2006
A Walk Through The Differential Diagnoses:
Lesions
Classical CT Findings
PS
Hepatic Cyst
Sharply demarcated wall, water density, nonenhancing
x
Hemangioma
Peripheral filling in of contrast over time
“Light Bulb Sign” on T2 MRI
x
Focal Nodular
Hyperplasia (FNH)
Early filling in arterial phase with central filling
defect (scar)
x
Hepatocellular
Adenoma
Variable, central changes due to hemorrhage
often seen
x
Metastasis
Mostly multiple low attenuation lesions, rim
enhancement without “filling in”
x
Abscess
Well demarcated hypodense areas with
peripheral enhancement, may see gas
Hepatocellular
Carcinoma (HCC)
Early arterial enhancement, fast washout,
delayed fibrous capsule enhancement
21
Kevin Kuo, HMS III
Gillian Lieberman, MD
November 2006
Liver Abscess
Axial C+ CT
Film Findings:
 Well demaracated
hypoenhancing lesion
 Rim of increased
enhancement relative to
central region
http://www.e-radiography.net/ibase5/Hepatic/index.htm
22
Kevin Kuo, HMS III
Gillian Lieberman, MD
November 2006
A Walk Through The Differential Diagnoses:
Lesions
Classical CT Findings
PS
Hepatic Cyst
Sharply demarcated wall, water density, nonenhancing
x
Hemangioma
Peripheral filling in of contrast over time
“Light Bulb Sign” on T2 MRI
x
Focal Nodular
Hyperplasia (FNH)
Early filling in arterial phase with central filling
defect (scar)
x
Hepatocellular
Adenoma
Variable, central changes due to hemorrhage
often seen
x
Metastasis
Mostly multiple low attenuation lesions, rim
enhancement without “filling in”
x
Abscess
Well demarcated hypodense areas with
peripheral enhancement, may see gas
x
Hepatocellular
Carcinoma (HCC)
Early arterial enhancement, fast washout,
delayed fibrous capsule enhancement
23
Kevin Kuo, HMS III
Gillian Lieberman, MD
November 2006
PS: Hepatocellular Carcinoma
Axial CT (various phases)
Film Findings:
 Early arterial enhancement
 Quick washout
 Peripheral rim of
enhacement
PACS, BIDMC
24
Kevin Kuo, HMS III
Gillian Lieberman, MD
November 2006
A Walk Through The Differential Diagnoses:
Lesions
Classical CT Findings
PS
Hepatic Cyst
Sharply demarcated wall, water density, nonenhancing
x
Hemangioma
Peripheral filling in of contrast over time
“Light Bulb Sign” on T2 MRI
x
Focal Nodular
Hyperplasia (FNH)
Early filling in arterial phase with central filling
defect (scar)
x
Hepatocellular
Adenoma
Variable, central changes due to hemorrhage
often seen
x
Metastasis
Mostly multiple low attenuation lesions, rim
enhancement without “filling in”
x
Abscess
Well demarcated hypodense areas with
peripheral enhancement, may see gas
x
Hepatocellular
Carcinoma (HCC)
Early arterial enhancement, fast washout,
delayed fibrous capsule enhancement
√
25
Kevin Kuo, HMS III
Gillian Lieberman, MD
November 2006
PS: The Final Diagnosis

Ultrasound guided biopsy confirmed the
diagnosis…
Hepatocellular Carcinoma
26
Kevin Kuo, HMS III
Gillian Lieberman, MD
November 2006
HCC: MR Imaging
Axial T1 Weighted MR
Precontrast




Axial T1 Weighted MR
Arterial Phase
Axial T1 Weighted
MR Portal-phase
Variable intensity on T1 and T2 weighted imaging
Early arterial phase enhancement
Quick washout
Rim enhancement of fibrous capsule in portal/delayed
phases
Ito, K. Hepatocellular carcinoma: Conventional MRI findings including gadolinium-enhanced dynamic
imaging. 2006 (58): 196-199.
27
Kevin Kuo, HMS III
Gillian Lieberman, MD
November 2006
Hepatocellular Carcinoma: Background

Incidence: 2.5/100,000 in US vs. 50/100,000 in East Asia,

Median survival after diagnosis: ~ 12 months




Projected to be the worldwide leading cause of cancer
mortality by 2010 (WHO)
Causes: Hepatitis B and/or C, Cirrhosis, Aflatoxins,
Hemochromatosis
Diagnosis of HCC gives bonus points for transplantation
evaluation based on the Model for End Stage Liver Disease
(MELD)
May be a focal lesion, dominant lesion with satellites, or
diffusely infiltrating
28
Kevin Kuo, HMS III
Gillian Lieberman, MD
November 2006
HCC: Treatment Options
Treatment:
Optimal Candidate:
Patient PS
Resection
Solitary lesion, no vascular invasion,
preserved hepatic function
X Cirrhotic, poor
hepatic reserve
Transplant
Unresectable patients w/ solitary lesion
< 5cm or <3 lesions of <3 cm. No
vascular invasion or metastases
√…
X EtOH found at
transplant eval.
Radiofrequency
Ablation
Do not meet resectability/transplant
criteria but disease confined to liver
√
Chemoembolization
Large unresectable tumors not
amenable to RFA. Absence of portal
vein thrombosis or encephalopathy
X RFA more
appropriate
29
Kevin Kuo, HMS III
Gillian Lieberman, MD
November 2006
Radiofrequency Ablation: Guidance
US Guidance
CT Guidance
Axial C- CT
Film Findings:
http://hopkins-gi.nts.jhu.edu/pages/latin/templates/index.cfm
http://www.ijri.org/articles/ARCHIVES/2003-13-3/phy315.htm
 RFA needle in tumor
30
Kevin Kuo, HMS III
Gillian Lieberman, MD
November 2006
PS: RFA Ultrasound
Axial US: Lesion Pre-RFA
Film Findings:
PACS, BIDMC
 Hypoechoic lesion
with poorly defined
borders.
Axial US: Lesion Post-RFA
 Hyperechoic region with dirty
shadowing (air bubbles from RF
procedure)
31
Kevin Kuo, HMS III
Gillian Lieberman, MD
November 2006
PS: Post-RFA Images
Axial CT C+
Immediately after RFA Procedure
Axial CT C+
5 months after RFA Procedure
Film Findings:  Post-Ablational Hyperemia
 Lesion no longer enhances
 No new enhancing lesions
PACS, BIDMC
32
Kevin Kuo, HMS III
Gillian Lieberman, MD
November 2006
PS: The Outcome
While not definitively cured, RF ablation was
considered to be successful and our patient is
doing relatively well.
33
Kevin Kuo, HMS III
Gillian Lieberman, MD
November 2006
Summary

Several modalities available for hepatic
imaging (US, CT, MRI)

Differential Dx for focal hepatic lesion

Use of different enhancement patterns to
distinguish between lesions

Treatment options available for HCC

Radiofrequency Ablation
34
Kevin Kuo, HMS III
Gillian Lieberman, MD
November 2006
Acknowledgements:

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

Fabio Komlos, MD
Andrew Bennett, MD
Andrew Hines-Peralta, MD
Gillian Lieberman, MD
Pamela Lepkowski
Larry Barbaras
35
Kevin Kuo, HMS III
Gillian Lieberman, MD
November 2006
References:
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Hoon J, McTavish J, Mortele JK, Wiesner W, Ros PR. “Hepatic Imaging with Multidetector
CT.” Radiographics. (2001) 21:71-80.
Ito K. “Hepatocellular Carcionma: Conventional MRI findings including gadoliniumenhanced dynamic imaging.” European Journal of Radiology (2006) 58:186-199.
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(2003) 41:51-65.
Kamel IR, Liapi E, Fishman EK. “Multidetector CT of hepatocellular carcinoma.” Best
Practice and Research Clinical Gastroenterology. (2005) 19:63-89.
Patel N. “Portal Hypertension.” Seminars in Roentgenology. (2002) 37:293-302.
Taylor HM, Ros PR. “Hepatic Imaging: An Overview.” Radiologic Clinics of North America.
(1998) 36:237-244.
http://hopkins-gi.nts.jhu.edu/pages/latin/templates/index.cfm
http://www.ijri.org/articles/ARCHIVES/2003-13-3/phy315.htm
http://bb.westernu.edu/web/Pathology/webpath60/webpath/radiol/heparad/
http://www.radiologyassistant.nl/en/448eef3083354
http://uuhsc.utah.edu/rad/medstud/BodyCaseStudies/BodyCase6a.htm
http://www.e-radiography.net/ibase5/Hepatic/index.htm
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