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FOCAL HEPATIC LESIONS IMAGING DIAGNOSIS

5th ARAB RADIOLOGY CONGRESS 25 th - 28 th April 2012. FOCAL HEPATIC LESIONS IMAGING DIAGNOSIS. W.MNARI, M. GOLLI MONASTIR-TUNISIA. Objective :. Identify the most important imaging features of common benign liver tumors Identify the most important imaging features of malignant lesions

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FOCAL HEPATIC LESIONS IMAGING DIAGNOSIS

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

  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 Chronicdisease 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 : 0.4-20 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 Cavernousangiomas 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. Cavernousangiomas

  11. Hepatic Hemangiomas US Diagnosis Hemangioma In practice: . Us characteristicfeature . No context of neoplasticdiesease . Normal liver function tests YES NO CT or MRI

  12. Hepatic Hemangiomas CT: The pathognomonic features of caverneoushemangioma: 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. .Ductulardiffentiation 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;228:465-472

  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: . Nonspecific, adenomas may be hypo, iso, or hyperechoic but are typically heterogeneous CT: . Wellcircumscribedwithoutlobulation . 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 cirrhoticliver • 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. Hepatocellular Carcinoma (HCC) Jeong et al. AJR:185, October 2005

  36. Regenerating Nodules Usually too small to detect by imaging –May be surrounded by fibrotic septa –May containiron, copper Sideroticregenerating 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) oftenwell-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 . OtherFeatures: Focal fat

  44. Hepatocellular Carcinoma (HCC) MRI

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

  46. 2010 AASLD AlgorithmforInvestigation of SmallNodules Found On Screening in PatientswithCirrhosis 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 Othercontrastenhanced Study (CT or MRI) No Yes Arterial hypervascularity AND venous or delayed phase washout Biopsy HCC Investigate according to size Yes No Bruix J and Sherman M. AASLD Practice Guidelines , Management of Hepatocellular Carcinoma Hepatology November 2011

  47. 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

  48. 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.

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

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