Liver lesions SYMPOSIUM RADIOLOGY
-
Upload
satyendra-raghuwanshi -
Category
Health & Medicine
-
view
601 -
download
2
description
Transcript of Liver lesions SYMPOSIUM RADIOLOGY
![Page 1: Liver lesions SYMPOSIUM RADIOLOGY](https://reader036.fdocuments.us/reader036/viewer/2022062514/5592372b1a28ab37158b46ca/html5/thumbnails/1.jpg)
LIVER LESIONSMaj Satyendra
Ref : Manorama berry
Gore Levine
Radiology assistant
Radiopedia
![Page 2: Liver lesions SYMPOSIUM RADIOLOGY](https://reader036.fdocuments.us/reader036/viewer/2022062514/5592372b1a28ab37158b46ca/html5/thumbnails/2.jpg)
OBJECTIVE1. Identify the most important features of common
liver tumors
![Page 3: Liver lesions SYMPOSIUM RADIOLOGY](https://reader036.fdocuments.us/reader036/viewer/2022062514/5592372b1a28ab37158b46ca/html5/thumbnails/3.jpg)
LIVER LESIONS MALIGNANT Metastasis Hepatocellular carcinoma
(hepatoma) Fibrolamellar carcinoma Intrahepatic
cholangiocarcinoma Hepatoblastoma Infantile
hemangioendothelioma Biliary cystadenoma
/cystadenocarcinoma Angiosarcoma Epithelioid
hemangioendothelioma Lymphoma
BENIGN Liver cysts Cyst adenoma Biliary hamartomas Hemangioma Focal nodular
hyperplasia Hepatic adenoma Regenerative nodules Atypical regenerative
nodules
![Page 4: Liver lesions SYMPOSIUM RADIOLOGY](https://reader036.fdocuments.us/reader036/viewer/2022062514/5592372b1a28ab37158b46ca/html5/thumbnails/4.jpg)
LIVER LESIONS MALIGNANT Metastasis Hepatocellular carcinoma
(hepatoma) Fibrolamellar carcinoma Intrahepatic
cholangiocarcinoma Hepatoblastoma Infantile
hemangioendothelioma Biliary cystadenoma
/cystadenocarcinoma Angiosarcoma Epithelioid
hemangioendothelioma Lymphoma
BENIGN Liver cysts Cyst adenoma Biliary hamartomas Hemangioma Focal nodular
hyperplasia Hepatic adenoma Regenerative nodules Atypical regenerative
nodules
![Page 5: Liver lesions SYMPOSIUM RADIOLOGY](https://reader036.fdocuments.us/reader036/viewer/2022062514/5592372b1a28ab37158b46ca/html5/thumbnails/5.jpg)
HYPERVASCULAR LESIONSBenign
Hemangioma Adenoma FNH
Malignant HCC FLC
Metastasis RCC Melanoma NET
![Page 6: Liver lesions SYMPOSIUM RADIOLOGY](https://reader036.fdocuments.us/reader036/viewer/2022062514/5592372b1a28ab37158b46ca/html5/thumbnails/6.jpg)
IMAGING TECHNIQUES plain radiography : gross hepatomegaly
calcification USG / CE-USG CT MRI Angiography Scintigraphy:
Sulfur colloid , Tc99m labelled RBC’s PET
![Page 7: Liver lesions SYMPOSIUM RADIOLOGY](https://reader036.fdocuments.us/reader036/viewer/2022062514/5592372b1a28ab37158b46ca/html5/thumbnails/7.jpg)
CT SCAN
Non contrast study:
Contrast study: arterial phase: 20-40secs Portal phase : 60-80secs Early delayed: > 180 sec
, best at 4 mins Late delayed : 4-6hrs
![Page 8: Liver lesions SYMPOSIUM RADIOLOGY](https://reader036.fdocuments.us/reader036/viewer/2022062514/5592372b1a28ab37158b46ca/html5/thumbnails/8.jpg)
UNDERSTANDING THE PHASES Liver -dual blood
supply Normal parenchyma
- 80% portal vein 20% -hepatic artery All liver tumors
blood supply from hepatic artery
![Page 9: Liver lesions SYMPOSIUM RADIOLOGY](https://reader036.fdocuments.us/reader036/viewer/2022062514/5592372b1a28ab37158b46ca/html5/thumbnails/9.jpg)
ARTERIAL PHASE
20- 40 sec Hypervascular
tumors enhance via the hepatic artery
Normal liver parenchyma not yet enhanced
Hypervascular tumors enhance optimally at 35 sec
![Page 10: Liver lesions SYMPOSIUM RADIOLOGY](https://reader036.fdocuments.us/reader036/viewer/2022062514/5592372b1a28ab37158b46ca/html5/thumbnails/10.jpg)
PORTAL VENOUS PHASE
60- 80 sec To detect
hypovascular tumors
![Page 11: Liver lesions SYMPOSIUM RADIOLOGY](https://reader036.fdocuments.us/reader036/viewer/2022062514/5592372b1a28ab37158b46ca/html5/thumbnails/11.jpg)
DELAYED PHASE
Begins at about > 180 sec
Best done at 10 minutes
![Page 12: Liver lesions SYMPOSIUM RADIOLOGY](https://reader036.fdocuments.us/reader036/viewer/2022062514/5592372b1a28ab37158b46ca/html5/thumbnails/12.jpg)
Pre contrast Arterial Phase Portal venous phase
Delayed
Hepatocelluar Ca Low attenuation Homogenous enhancement
Washout of lesion
Isodense
Adenoma Low attenuation Homogenous enhancement 85%
Iso or hypodense
Iso or hypodense
Haemangioma Low attenuation Peripheral puddles Partial Fill in Complete fill in
FNH Iso/Low attenuation
Homogenous enhancement
Hypodense Isodense
Hypervascular Mets Low attenuation Homogenous enhancement
Hypodense
Metastasis Low attenuation Hypodense Hypodense
Cyst Low attenuation No enhancement
Abscess Low attenuation may have irregular margins
Transient regional enhancement
Ring enhancement
Multiphasic CT of Liver
![Page 13: Liver lesions SYMPOSIUM RADIOLOGY](https://reader036.fdocuments.us/reader036/viewer/2022062514/5592372b1a28ab37158b46ca/html5/thumbnails/13.jpg)
T1W T2W Gadolinium Hepatocellular Ca
,iso or (fat degeneration) Metastasis Haemanigioma ++ (like CT) Adenoma
often FNH + delayed
FLC + delayed
MRI of Liver
![Page 14: Liver lesions SYMPOSIUM RADIOLOGY](https://reader036.fdocuments.us/reader036/viewer/2022062514/5592372b1a28ab37158b46ca/html5/thumbnails/14.jpg)
LIVER CYSTS
Developmental - ? Origin from hamatomatous tissue
Do no communicate with biliary tree
Thin walled 1mm Unilocular Anechoic Water density 0-15 HU Non enhancing >10 consider ADPKD
![Page 15: Liver lesions SYMPOSIUM RADIOLOGY](https://reader036.fdocuments.us/reader036/viewer/2022062514/5592372b1a28ab37158b46ca/html5/thumbnails/15.jpg)
![Page 16: Liver lesions SYMPOSIUM RADIOLOGY](https://reader036.fdocuments.us/reader036/viewer/2022062514/5592372b1a28ab37158b46ca/html5/thumbnails/16.jpg)
![Page 17: Liver lesions SYMPOSIUM RADIOLOGY](https://reader036.fdocuments.us/reader036/viewer/2022062514/5592372b1a28ab37158b46ca/html5/thumbnails/17.jpg)
HEMANGIOMA
Commonest benign tumor
Asymptomatic Large vascular
channels filled with slowly flowing blood
F> M (5:1) Multiple in 10%
cases 2-4cms-typical
characteristic
![Page 18: Liver lesions SYMPOSIUM RADIOLOGY](https://reader036.fdocuments.us/reader036/viewer/2022062514/5592372b1a28ab37158b46ca/html5/thumbnails/18.jpg)
USG
Sharply defined Hyperechoic Homogenous Faint acoustic
enhancement >2.5cm Cystic and fibrotic
regions
Doppler : Filling vessel in the
periphery of the tumor but no significant colour flow.
![Page 19: Liver lesions SYMPOSIUM RADIOLOGY](https://reader036.fdocuments.us/reader036/viewer/2022062514/5592372b1a28ab37158b46ca/html5/thumbnails/19.jpg)
PLAIN CT: HYPODENSE MASS
![Page 20: Liver lesions SYMPOSIUM RADIOLOGY](https://reader036.fdocuments.us/reader036/viewer/2022062514/5592372b1a28ab37158b46ca/html5/thumbnails/20.jpg)
CECT: Early peripheral lesion
enhancement Progressive centripetal
opacification Isodense fill in on
delayed scans (<15 mins)
Central scar may be present
Upto 90% of hemangiomas meet these criteria.
![Page 21: Liver lesions SYMPOSIUM RADIOLOGY](https://reader036.fdocuments.us/reader036/viewer/2022062514/5592372b1a28ab37158b46ca/html5/thumbnails/21.jpg)
![Page 22: Liver lesions SYMPOSIUM RADIOLOGY](https://reader036.fdocuments.us/reader036/viewer/2022062514/5592372b1a28ab37158b46ca/html5/thumbnails/22.jpg)
MR
Marked hyperintensity on T2 WI
Light bulb sign
Low intensity areas- fibrosis/ myxoid tissue/ thrombus
![Page 23: Liver lesions SYMPOSIUM RADIOLOGY](https://reader036.fdocuments.us/reader036/viewer/2022062514/5592372b1a28ab37158b46ca/html5/thumbnails/23.jpg)
<2 cm - uniform
early enhancement
peripheral nodular Centripetally
enhancement. large (>5cms)
peripheral nodular enhancement
Centre remains hypointense.
![Page 24: Liver lesions SYMPOSIUM RADIOLOGY](https://reader036.fdocuments.us/reader036/viewer/2022062514/5592372b1a28ab37158b46ca/html5/thumbnails/24.jpg)
GIANT CAVERNOUS HEMANGIOMA 5 – 20 CMS.
CAN BE CONFUSED WITH METS /HCC
![Page 25: Liver lesions SYMPOSIUM RADIOLOGY](https://reader036.fdocuments.us/reader036/viewer/2022062514/5592372b1a28ab37158b46ca/html5/thumbnails/25.jpg)
![Page 26: Liver lesions SYMPOSIUM RADIOLOGY](https://reader036.fdocuments.us/reader036/viewer/2022062514/5592372b1a28ab37158b46ca/html5/thumbnails/26.jpg)
HEPATIC ADENOMA
Solitary >10 cm Pathology: absence of
kupffer cells, bile ducts ? malignant potential Female : age 20 – 40
yrs. H/o OCP/ anabolic
steroids
Central hge/ necrosis Thin capsule -30 %
![Page 27: Liver lesions SYMPOSIUM RADIOLOGY](https://reader036.fdocuments.us/reader036/viewer/2022062514/5592372b1a28ab37158b46ca/html5/thumbnails/27.jpg)
USG: Large
hyperechoic lesion- glycogen / fat Central anechoic areas: zones of internal haemorhage
![Page 28: Liver lesions SYMPOSIUM RADIOLOGY](https://reader036.fdocuments.us/reader036/viewer/2022062514/5592372b1a28ab37158b46ca/html5/thumbnails/28.jpg)
PLAIN CT: Low density lesion (fat)High density
lesion ( hge ) CECT:
Hypervascular lesion , rapid washout
Calcification +/- 5 %
![Page 29: Liver lesions SYMPOSIUM RADIOLOGY](https://reader036.fdocuments.us/reader036/viewer/2022062514/5592372b1a28ab37158b46ca/html5/thumbnails/29.jpg)
MRI
Heterogenous Increased T1
signal Fat/ glycogenLow signal –
hemorrhage/ necrosis/ scar
Hypointense capsule T1 and T2
- 1/3rd CSI –loss of signal
![Page 30: Liver lesions SYMPOSIUM RADIOLOGY](https://reader036.fdocuments.us/reader036/viewer/2022062514/5592372b1a28ab37158b46ca/html5/thumbnails/30.jpg)
FOCAL NODULAR HYPERPLASIA
Asymptomatic/incidental Etiology- unkn/ ? Cong
vascular malformation Female -20-50 yrs. Typical central stellate
fibrovascular scar - 50%
Hyper vascular Normal liver elements
Hepatocytes Non communicating bile
ducts, Kupffer cells Fibrous septa
![Page 31: Liver lesions SYMPOSIUM RADIOLOGY](https://reader036.fdocuments.us/reader036/viewer/2022062514/5592372b1a28ab37158b46ca/html5/thumbnails/31.jpg)
USG: Well defined
isoechoic massHomogenous
echotextureCentral hypo scarCalcification seen
in 1.4 % .
DOPPLER: stellate flow pattern CEUS : central A with
centrifugal filling
![Page 32: Liver lesions SYMPOSIUM RADIOLOGY](https://reader036.fdocuments.us/reader036/viewer/2022062514/5592372b1a28ab37158b46ca/html5/thumbnails/32.jpg)
NECT: Well defined with mass effect Attenuation same as that of
liver parenchyma/ less - fat Central scar common.
Arterial phase : Lesion enhance markedly and uniformly with the exception of central scar.
Portal phase : Isodense with liver
parenchyma Scar- low.
Delayed imaging : iso dense Scar may show enhancement.
![Page 33: Liver lesions SYMPOSIUM RADIOLOGY](https://reader036.fdocuments.us/reader036/viewer/2022062514/5592372b1a28ab37158b46ca/html5/thumbnails/33.jpg)
MRI T1: Isointense T2: Slightly
hyperintense to isointense.
central scar is hypointense on T1 and hyperintense on T2.
Early homogenous enhancement of FNH , late enhancement of the central scar.
![Page 34: Liver lesions SYMPOSIUM RADIOLOGY](https://reader036.fdocuments.us/reader036/viewer/2022062514/5592372b1a28ab37158b46ca/html5/thumbnails/34.jpg)
T2 WITH SPIO: FNH shows loss of signal due to
uptake of iron oxide particles by kupffer cells within the lesion. The degree of signal loss is greater than normal liver
T1 WITH Mn DPDP/ BOPTA FNH contains hepatocytes that take
up these agents resulting in hyperintensity of the lesion relative to the liver.
![Page 35: Liver lesions SYMPOSIUM RADIOLOGY](https://reader036.fdocuments.us/reader036/viewer/2022062514/5592372b1a28ab37158b46ca/html5/thumbnails/35.jpg)
FOCAL FAT Diagnostic confusion
with tumors Common sites
Periportal region of the medial segment of left lobe (segment IV)
Either side of falciform ligament
Cranial aspect of GB fossa
Characteristic features: Geographic appearance Lack of mass effect Vessels through the
lesion
![Page 36: Liver lesions SYMPOSIUM RADIOLOGY](https://reader036.fdocuments.us/reader036/viewer/2022062514/5592372b1a28ab37158b46ca/html5/thumbnails/36.jpg)
CSI in-and out-of phase
Signals of fat and water cancel each other in “out of phase” image
![Page 37: Liver lesions SYMPOSIUM RADIOLOGY](https://reader036.fdocuments.us/reader036/viewer/2022062514/5592372b1a28ab37158b46ca/html5/thumbnails/37.jpg)
HEPATOCELLULAR CARCINOMA
Most common primary malignancy of the liver
Rising incidence, attributed to a rise in hepatitis B and C infection
![Page 38: Liver lesions SYMPOSIUM RADIOLOGY](https://reader036.fdocuments.us/reader036/viewer/2022062514/5592372b1a28ab37158b46ca/html5/thumbnails/38.jpg)
RISK FACTORS: hepatitis B (HBV) infection hepatitis C (HCV) infection alcoholism biliary cirrhosis food toxins e.g. aflatoxins congenital biliary atresia inborn errors of metabolism
haemochromatosis
alpha-1 antitrypsin deficiency
type 1 glycogen storage disease
Wilson disease
![Page 39: Liver lesions SYMPOSIUM RADIOLOGY](https://reader036.fdocuments.us/reader036/viewer/2022062514/5592372b1a28ab37158b46ca/html5/thumbnails/39.jpg)
USG Small HCC’s
(<3cms)hypoechoic
with posterior acoustic enhancement
>3cms- mosaic or mixed pattern
![Page 40: Liver lesions SYMPOSIUM RADIOLOGY](https://reader036.fdocuments.us/reader036/viewer/2022062514/5592372b1a28ab37158b46ca/html5/thumbnails/40.jpg)
CT SCAN
3 patterns: SolitaryMulticentricDiffuse
Large hypodense mass
Central low attenuation due to necrosis
![Page 41: Liver lesions SYMPOSIUM RADIOLOGY](https://reader036.fdocuments.us/reader036/viewer/2022062514/5592372b1a28ab37158b46ca/html5/thumbnails/41.jpg)
Focal calcification -7.5%
Majority - hypervascular arterial phase
Heterogenous enhancement due to central necrosis
Isodense on delayed images
Angioinvasive: portal vein /IVC
![Page 42: Liver lesions SYMPOSIUM RADIOLOGY](https://reader036.fdocuments.us/reader036/viewer/2022062514/5592372b1a28ab37158b46ca/html5/thumbnails/42.jpg)
ARTERIAL PHASE
Demonstration of arterial branches tumour
Arterio portal shunts
![Page 43: Liver lesions SYMPOSIUM RADIOLOGY](https://reader036.fdocuments.us/reader036/viewer/2022062514/5592372b1a28ab37158b46ca/html5/thumbnails/43.jpg)
![Page 44: Liver lesions SYMPOSIUM RADIOLOGY](https://reader036.fdocuments.us/reader036/viewer/2022062514/5592372b1a28ab37158b46ca/html5/thumbnails/44.jpg)
Portal venous invasion by hepatocellular carcinoma. portal phase-expanded low attenuation focus in right portal vein.
![Page 45: Liver lesions SYMPOSIUM RADIOLOGY](https://reader036.fdocuments.us/reader036/viewer/2022062514/5592372b1a28ab37158b46ca/html5/thumbnails/45.jpg)
MRI
Small HCC’s v/s regenerative Cirrhotic nodule: hyper on T1 , iso / hypo on T2
HCC : hyperintense on T2
HCC arising in a siderotic nodule: “nodule within a nodule” appearance
HCC - a small focus of high signal intensity within the low signal intensity nodule.
![Page 46: Liver lesions SYMPOSIUM RADIOLOGY](https://reader036.fdocuments.us/reader036/viewer/2022062514/5592372b1a28ab37158b46ca/html5/thumbnails/46.jpg)
Hepatocellular carcinoma and regenerative nodule. T1w MRI (A) and T2w MRI (B) demonstrating a hepatocellular carcinoma (white arrowhead) and an adjacent atypical regenerative nodule (black arrowhead).
Majority of hepatomas have decreased signal intensity on T1WI -increased signal -fat or glycogen content
![Page 47: Liver lesions SYMPOSIUM RADIOLOGY](https://reader036.fdocuments.us/reader036/viewer/2022062514/5592372b1a28ab37158b46ca/html5/thumbnails/47.jpg)
FIBROLAMELLAR CARCINOMA
Age group: 5 - 35yrs Spontaneous
No predisposing factor
Solitary lobulated well defined tumor containing a central fibrous scar.
Punctate calcification- in scar >50% cases
![Page 48: Liver lesions SYMPOSIUM RADIOLOGY](https://reader036.fdocuments.us/reader036/viewer/2022062514/5592372b1a28ab37158b46ca/html5/thumbnails/48.jpg)
Moderate enhancement.
Delayed enhancement of scar
Prognosis - good.
![Page 49: Liver lesions SYMPOSIUM RADIOLOGY](https://reader036.fdocuments.us/reader036/viewer/2022062514/5592372b1a28ab37158b46ca/html5/thumbnails/49.jpg)
FNH V/S FLC
Central scar of FNH -hyperintense on T2.
FNH rarely has calcification within the scar.
FNH - usually asymptomatic.
Biopsy normal hepatocytes with bile ductules in FNH Malignant, eosinophilic hepatocytes in FLC
![Page 50: Liver lesions SYMPOSIUM RADIOLOGY](https://reader036.fdocuments.us/reader036/viewer/2022062514/5592372b1a28ab37158b46ca/html5/thumbnails/50.jpg)
METASTASIS
Most common Most common metastatic
site , after nodes Multiple lesions – common
Hypervascular mets DD -hemangiomas, FNH,
adenoma and HCC.
Hypovascular mets DD-focal fatty infiltration,
abscesses, atypical hypovascular HCC
![Page 51: Liver lesions SYMPOSIUM RADIOLOGY](https://reader036.fdocuments.us/reader036/viewer/2022062514/5592372b1a28ab37158b46ca/html5/thumbnails/51.jpg)
Hypervascular mets: RCC, Thyroid, carcinoid, melanoma, islet cell tumor, choriocarcinom.
Calcified mets: Mucinous CA of GI tract (colon, stomach, rectum), melanoma ovarian ca.
![Page 52: Liver lesions SYMPOSIUM RADIOLOGY](https://reader036.fdocuments.us/reader036/viewer/2022062514/5592372b1a28ab37158b46ca/html5/thumbnails/52.jpg)
Cystic mets: mucinous ovarian
ca, colonic ca
![Page 53: Liver lesions SYMPOSIUM RADIOLOGY](https://reader036.fdocuments.us/reader036/viewer/2022062514/5592372b1a28ab37158b46ca/html5/thumbnails/53.jpg)
THANK U
![Page 54: Liver lesions SYMPOSIUM RADIOLOGY](https://reader036.fdocuments.us/reader036/viewer/2022062514/5592372b1a28ab37158b46ca/html5/thumbnails/54.jpg)