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MR of Liver imaging: How I do it?

MR of Liver imaging: How I do it?. Laurence BARANES, Pierre ZERBIB, Frédéric PIGNEUR, Alain LUCIANI, Alain RAHMOUNI CHU HENRI MONDOR, CRETEIL, FRANCE. AIM. To propose a method of interpretation of a liver nodule discovered on MRI with clinical cases. Mrs J…. 38 yo

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MR of Liver imaging: How I do it?

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  1. MR of Liver imaging: How I do it? Laurence BARANES, Pierre ZERBIB, Frédéric PIGNEUR, Alain LUCIANI, Alain RAHMOUNI CHU HENRI MONDOR, CRETEIL, FRANCE MR of Liver imaging :How I do it? AFIIM -ISRA 2016

  2. AIM • To propose a method of interpretation of a liver nodule discovered on MRI with clinical cases

  3. Mrs J… 38 yo Discovery of a liver mass

  4. Clinical features Fever Right upper quadrant pain Hypereosinophilia

  5. Alveolarecchinococcosis

  6. Mr R 55 yo …

  7. T1 in phase T2 fat sat 2nd écho T1 fat sat T1 Fat satarterial phase T1 Fat sat portal phase

  8. Fluid-fluid level This is not a typical biliary cyst

  9. Mr R 55 yo The context was : characterization of liver nodules in a context of gastrointestinal stromal tumor

  10. GIST metastasis

  11. (Sex, neoplasia, infection..) Clinical context chronic liver disease no chronic liver disease Global liver signal analysis - vascular features - Nodule size - T2 wi signal? HCC? • Eliminate a pseudo lésion • Artifact • focal fat • perfusion disorders Multiple nodules Single nodule - Angioma - FNH - Biliary cyst metastasis Inflammatory infectious Diagnostic ranges Fibrous nodules T1 hyperintense nodules Cystic nodules Hypervascular nodules

  12. Mr G, 64 yo • Alcoholic liver cirrhosis • Caracterization of a liver nodule discovered on US follow up

  13. T2 fat sat T1 iv- T1 iv+ venous T1 iv+ arterial

  14. HCC on a cirrhotic liver

  15. What should be always searched for on a liver MRI ? Liver dysmorphia Irregular contours Segment 4 hypotrophy Segment 1 hypertrophy Left lobe hypertrophy Right lobe hypotrophy Portal hypertension signs Ascitis splenomegaly Porto-portal and porto-systemic shunts

  16. Search for liver dysmorphia and portal hypertension signs • segment 1 hypertrophy • segment 4 atrophy In the chronic liver diseases, the aim is to detect HCC

  17. Nodules on a cirrhotic liver • Regenerative nodule • Dysplastic nodule • Hepatocellular carcinoma • Pseudo lésion: trouble de perfusion • Fibrose confluente

  18. Gamme cirrhose et nodule • Regenerative nodule • Dysplastic nodule • Hepatocellular carcinoma Anatomical Continuum

  19. Anatomical continuum • Size- Hypersignal on T2 wi- Arterial enhancement of the nodule - No portal enhancement These transitions go with an increasing of: - size - cellularity - neoangiogenesis Takayama Annals of Surgical Oncology 2007; 15:972-978

  20. Anatomical continuum • Size- Hypersignal on T2 wi- Arterial enhancement of the nodule - No portal enhancement = Wash-in Typical enhancement = Wash-out These transitions go with an increasing of: - size - cellularity - neoangiogenesis Takayama Annals of Surgical Oncology 2007; 15:972-978

  21. Anatomical continuum • Size- Hypersignal on T2 wi- Arterial enhancement of the nodule - No portal enhancement = Wash-in Typical enhancement = Wash-out + Wash-in Wash-out

  22. (Sex, neoplasia, infection..) Clinical context chronic liver disease ? no chronic liver disease Global liver signal analysis - Vascular features - Nodule size - T2 wi signal? HCC? • Eliminate a pseudo lésion • Artifact • focal fat • perfusion disorders Multiple nodules Single nodule - Angioma - FNH - Biliary cyst metastasis Inflammatory infectious Diagnostic ranges Fibrous nodules T1 hyperintense nodules Cystic nodules Hypervascular nodules

  23. Mrs V • 38 yo • withhepaticangiosarcomaresected droite) • 34 liver nodules found on a follow-up CT scan • Bilan avant prise en charge thérapeutique  MRI assessment

  24. MRI confirmed tumor recurrence What about the 34 liver nodules described on the CT scan report?

  25. T2 fat sat T1 iv- T1 iv+ venous T1 iv+ arterial

  26. T2 fat sat T1 iv- T1 iv+ veinous T1 iv+ arterial Normal liver

  27. T2 fat sat T1 iv- T1 iv+ veinous T1 iv+ arterial Diseased liver The nodules described on CT scan are actually residual normal liver

  28. Message Remember to analyze the global signal of the liver before interpreting the intrinsic signal of liver nodules Normal liver Disease liver Bone marrow infiltration T2 fat sat

  29. (Sex, neoplasia, infection..) Clinical context Chronic liver disease ? No chronic liver disease Global signal of the liver (steatosis, iron overload…) - Vascular features - Nodule size - T2 wi signal? HCC? • Eliminate a pseudo lésion • Artifact • focal fat • perfusion disorders Multiple nodules Single nodule - Angioma - FNH - Biliary cyst metastasis Inflammatory infectious Diagnostic ranges Fibrous nodules T1 hyperintense nodules Cystic nodules Hypervascular nodules

  30. Mr H, 54 yo • Colorectal cancer • Metastases on segment 1 and 5 • MRI assessment before surgery

  31. Additionnal metastasis on segment 8 Diffusion sequences are the most sensitive sequences The optimal b value for detectionis about 100

  32. (Sex, neoplasia, infection..) Clinical context chronic liver disease ? no chronic liver disease Global signal of the liver analysis (steatosis, iron overload…) - vascular features - Nodule size - T2 wi signal? HCC? • Detection of the lesions: Diffusion sequences++ • Rule out a pseudo lésion • Artifact • focal fat • perfusion disorder Multiple nodules Single nodule - Angioma - FNH - Biliary cyst metastasis Inflammatory infectious Diagnostic ranges Fibrous nodules T1 hyperintense nodules Cystic nodules Hypervascular nodules

  33. Mr C., Colorectal cancer withlivermetastases Follow-up

  34. How many nodules do you see?

  35. How many nodules do yousee? Pseudo-nodule nodule This pseudo nodule is due to a movement artifact in the phase encoded direction

  36. The distance between all the images in the encoded phase is the same

  37. Any hyperintense structure on T1 or T2 wi can cause an artifact (not only gallbladder or aorta)

  38. (Sex, neoplasia, infection..) Clinical context chronic liver disease ? no chronic liver disease Global signal of the liver analysis (steatosis, iron overload…) - vascular features - Nodule size - T2 wi signal? HCC? • Detection of the lesions: Diffusion sequences++ • Rule out a pseudo lesion • Artifact • focal fat • perfusion disorder Multiple nodules Single nodule - Angioma - FNH - Biliary cyst metastasis Inflammatory infectious Diagnostic ranges Fibrous nodules T1 hyperintense nodules Cystic nodules Hypervascular nodules

  39. Mrs L., • No medical history • Discovery of multiple hepatic nodules on US

  40. In phase Out of phase

  41. Focal steatosis

  42. (Sex, neoplasia, infection..) Clinical context Chronic liver disease ? No chronic liver disease Global signal of the liver analysis (steatosis, iron overload…) - Vascular features - Nodule size - T2 wi signal? HCC? • Detection of the lesions: Diffusion sequences++ • Rule out a pseudo lesion • Artifact • focal fat / normal fat in a steatotic liver • perfusion disorder Multiple nodules Single nodule - Angioma - FNH - Biliary cyst metastasis Inflammatory infectious Diagnostic ranges Fibrous nodules T1 hyperintense nodules Cystic nodules Hypervascular nodules

  43. Mrs A., • History of portal thrombosis and coagulation disorders • Liver nodule on US  Characterizationwith MRI

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