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肝局灶性病变的放射学评估

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肝局灶性病变的放射学评估 November 2006 Kevin Kuo, HMS III Gillian Lieberman, MD The Focal Hepatic Lesion: Radiologic Assessment Kevin Kuo, Harvard Medical School Year III Gillian Lieberman, MD November 2006 Kevin Kuo, HMS III Gillian Lieberman, MD 2 Our Patient: PS  67 y/o fe...
肝局灶性病变的放射学评估
November 2006 Kevin Kuo, HMS III Gillian Lieberman, MD The Focal Hepatic Lesion: Radiologic Assessment Kevin Kuo, Harvard Medical School Year III Gillian Lieberman, MD November 2006 Kevin Kuo, HMS III Gillian Lieberman, MD 2 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 November 2006 Kevin Kuo, HMS III Gillian Lieberman, MD 3 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… November 2006 Kevin Kuo, HMS III Gillian Lieberman, MD 4 Liver Anatomy http://hopkins-gi.nts.jhu.edu/pages/latin/templates/index.cfm Couinaud Segments Portal Triad and Hepatic Veins  Based on vascular anatomy  Important for surgical planning  Hepatic veins delineate lobes of the liver: Left (lateral and medial) and Right (anterior and posterior) November 2006 Kevin Kuo, HMS III Gillian Lieberman, MD 5 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 November 2006 Kevin Kuo, HMS III Gillian Lieberman, MD 6 Hepatic VenousPortal Venous Triple Phase Helical CT Foley, WD. Multiphase Hepatic CT with a Multirow Detector CT Scanner. 2000 (175): 679-685. Axial C+ CT Arterial Phase Axial C+ CT Portal Venous Phase Axial C+ CT Hepatic Venous Phase Contrast Injection Arterial 0 15 30 45 60 75 Time (sec) November 2006 Kevin Kuo, HMS III Gillian Lieberman, MD 7 PS: Cirrhosis and Portal Hypertension PACS, BIDMC 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 Venous Maximum Intensity Phase Reconstruction Axial C+ CT Film Findings: November 2006 Kevin Kuo, HMS III Gillian Lieberman, MD 8 PS: Triple Phase CT PACS, BIDMC Axial C- CT Axial C+ CT: Arterial Phase  Nodular liver  No discrete lesions Film Findings:  EarlyEarly hyperenhancinghyperenhancing lesionlesion November 2006 Kevin Kuo, HMS III Gillian Lieberman, MD 9 PS: Triple Phase CT PACS, BIDMC Axial C+ CT: Portal Venous Phase Axial C+ CT: Delayed Phase  Quick washout of enhancing lesion Film Findings:  HypoenhancingHypoenhancing lesion with lesion with peripheral rim of enhancementperipheral rim of enhancement November 2006 Kevin Kuo, HMS III Gillian Lieberman, MD 10 PS: Preliminary Diagnosis  Triple Phase CT Findings:  Early arterial phase enhancementarterial phase enhancement  quick washoutquick washout  peripheral rim of enhancementrim of enhancement in the delayed phase  Highly suspicious for HCC  HCC is hypervascularhypervascular 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… November 2006 Kevin Kuo, HMS III Gillian Lieberman, MD 11 Early arterial enhancement, fast washout, delayed fibrous capsule enhancement Hepatocellular Carcinoma (HCC) Mostly multiple low attenuation lesions, rim enhancement without “filling in” Metastasis Variable, central changes due to hemorrhage often seen Hepatocellular Adenoma Early filling in arterial phase with central filling defect (scar) Focal Nodular Hyperplasia (FNH) Peripheral filling in of contrast over time “Light Bulb Sign” on T2 MRI Hemangioma Sharply demarcated wall, water density, non- enhancing Hepatic Cyst PSClassical CT FindingsLesions Abscess Well demarcated hypodense areas with peripheral enhancement, may see gas A Walk Through The Differential Diagnoses: November 2006 Kevin Kuo, HMS III Gillian Lieberman, MD 12 Hepatic Cyst http://bb.westernu.edu/web/Pathology/webpath60/webpath/radi ol/heparad/ Axial C+ CT Film Findings:  Sharply demarcated, non enhancing, water-dense cyst. November 2006 Kevin Kuo, HMS III Gillian Lieberman, MD 13 Early arterial enhancement, fast washout, delayed fibrous capsule enhancement Hepatocellular Carcinoma (HCC) Mostly multiple low attenuation lesions, rim enhancement without “filling in” Metastasis Variable, central changes due to hemorrhage often seen Hepatocellular Adenoma Early filling in arterial phase with central filling defect (scar) Focal Nodular Hyperplasia (FNH) Peripheral filling in of contrast over time “Light Bulb Sign” on T2 MRI Hemangioma xSharply demarcated wall, water density, non- enhancing Hepatic Cyst PSClassical CT FindingsLesions Abscess Well demarcated hypodense areas with peripheral enhancement, may see gas A Walk Through The Differential Diagnoses: November 2006 Kevin Kuo, HMS III Gillian Lieberman, MD 14 Hemangioma Axial C+ CT (Various phases) Film Findings:  Hypodense lesion with peripheral filling in of contrast over time http://www.radiologyassistant.nl/en/448eef3083354 November 2006 Kevin Kuo, HMS III Gillian Lieberman, MD 15 Early arterial enhancement, fast washout, delayed fibrous capsule enhancement Hepatocellular Carcinoma (HCC) Mostly multiple low attenuation lesions, rim enhancement without “filling in” Metastasis Variable, central changes due to hemorrhage often seen Hepatocellular Adenoma Early filling in arterial phase with central filling defect (scar) Focal Nodular Hyperplasia (FNH) Peripheral filling in of contrast over time “Light Bulb Sign” on T2 MRI Hemangioma xSharply demarcated wall, water density, non- enhancing Hepatic Cyst PSClassical CT FindingsLesions Abscess Well demarcated hypodense areas with peripheral enhancement, may see gas A Walk Through The Differential Diagnoses: x November 2006 Kevin Kuo, HMS III Gillian Lieberman, MD 16 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 November 2006 Kevin Kuo, HMS III Gillian Lieberman, MD 17 Early arterial enhancement, fast washout, delayed fibrous capsule enhancement Hepatocellular Carcinoma (HCC) Mostly multiple low attenuation lesions, rim enhancement without “filling in” Metastasis Variable, central changes due to hemorrhage often seen Hepatocellular Adenoma Early filling in arterial phase with central filling defect (scar) Focal Nodular Hyperplasia (FNH) Peripheral filling in of contrast over time “Light Bulb Sign” on T2 MRI Hemangioma xSharply demarcated wall, water density, non- enhancing Hepatic Cyst PSClassical CT FindingsLesions Abscess Well demarcated hypodense areas with peripheral enhancement, may see gas A Walk Through The Differential Diagnoses: x x November 2006 Kevin Kuo, HMS III Gillian Lieberman, MD 18 Hepatocellular Adenoma Axial C+ CT Film Findings:  Multiple hypoenhancing heterogenous lesions Enhancing hepatic veinsEnhancing hepatic veins UpToDate: Hepatic Adenoma November 2006 Kevin Kuo, HMS III Gillian Lieberman, MD 19 Early arterial enhancement, fast washout, delayed fibrous capsule enhancement Hepatocellular Carcinoma (HCC) Mostly multiple low attenuation lesions, rim enhancement without “filling in” Metastasis Variable, central changes due to hemorrhage often seen Hepatocellular Adenoma Early filling in arterial phase with central filling defect (scar) Focal Nodular Hyperplasia (FNH) Peripheral filling in of contrast over time “Light Bulb Sign” on T2 MRI Hemangioma xSharply demarcated wall, water density, non- enhancing Hepatic Cyst PSClassical CT FindingsLesions Abscess Well demarcated hypodense areas with peripheral enhancement, may see gas A Walk Through The Differential Diagnoses: x x x November 2006 Kevin Kuo, HMS III Gillian Lieberman, MD 20 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 November 2006 Kevin Kuo, HMS III Gillian Lieberman, MD 21 Early arterial enhancement, fast washout, delayed fibrous capsule enhancement Hepatocellular Carcinoma (HCC) Mostly multiple low attenuation lesions, rim enhancement without “filling in” Metastasis Variable, central changes due to hemorrhage often seen Hepatocellular Adenoma Early filling in arterial phase with central filling defect (scar) Focal Nodular Hyperplasia (FNH) Peripheral filling in of contrast over time “Light Bulb Sign” on T2 MRI Hemangioma xSharply demarcated wall, water density, non- enhancing Hepatic Cyst PSClassical CT FindingsLesions Abscess Well demarcated hypodense areas with peripheral enhancement, may see gas A Walk Through The Differential Diagnoses: x x x x November 2006 Kevin Kuo, HMS III Gillian Lieberman, MD 22 Liver Abscess Axial C+ CT Film Findings:  Well demaracated hypoenhancing lesion  Rim of increased Rim of increased enhancement relative to enhancement relative to central regioncentral region http://www.e-radiography.net/ibase5/Hepatic/index.htm November 2006 Kevin Kuo, HMS III Gillian Lieberman, MD 23 Early arterial enhancement, fast washout, delayed fibrous capsule enhancement Hepatocellular Carcinoma (HCC) Mostly multiple low attenuation lesions, rim enhancement without “filling in” Metastasis Variable, central changes due to hemorrhage often seen Hepatocellular Adenoma Early filling in arterial phase with central filling defect (scar) Focal Nodular Hyperplasia (FNH) Peripheral filling in of contrast over time “Light Bulb Sign” on T2 MRI Hemangioma xSharply demarcated wall, water density, non- enhancing Hepatic Cyst PSClassical CT FindingsLesions Abscess Well demarcated hypodense areas with peripheral enhancement, may see gas A Walk Through The Differential Diagnoses: x x x x x November 2006 Kevin Kuo, HMS III Gillian Lieberman, MD 24 PS: Hepatocellular Carcinoma Axial CT (various phases) Film Findings:  Early arterial enhancementEarly arterial enhancement  Quick washoutQuick washout  Peripheral rim of Peripheral rim of enhacementenhacement PACS, BIDMC November 2006 Kevin Kuo, HMS III Gillian Lieberman, MD 25 Early arterial enhancement, fast washout, delayed fibrous capsule enhancement Hepatocellular Carcinoma (HCC) Mostly multiple low attenuation lesions, rim enhancement without “filling in” Metastasis Variable, central changes due to hemorrhage often seen Hepatocellular Adenoma Early filling in arterial phase with central filling defect (scar) Focal Nodular Hyperplasia (FNH) Peripheral filling in of contrast over time “Light Bulb Sign” on T2 MRI Hemangioma xSharply demarcated wall, water density, non- enhancing Hepatic Cyst PSClassical CT FindingsLesions Abscess Well demarcated hypodense areas with peripheral enhancement, may see gas A Walk Through The Differential Diagnoses: x x x x x √ November 2006 Kevin Kuo, HMS III Gillian Lieberman, MD 26 PS: The Final Diagnosis  Ultrasound guided biopsy confirmed the diagnosis… Hepatocellular CarcinomaHepatocellular Carcinoma November 2006 Kevin Kuo, HMS III Gillian Lieberman, MD 27 HCC: MR Imaging Ito, K. Hepatocellular carcinoma: Conventional MRI findings including gadolinium-enhanced dynamic imaging. 2006 (58): 196-199. 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 enhancementarterial phase enhancement  Quick washout  Rim enhancementRim enhancement of fibrous capsule in portal/delayed phases November 2006 Kevin Kuo, HMS III Gillian Lieberman, MD 28 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 November 2006 Kevin Kuo, HMS III Gillian Lieberman, MD 29 HCC: Treatment Options X RFA more appropriate Large unresectable tumors not amenable to RFA. Absence of portal vein thrombosis or encephalopathy Chemo- embolization √Do not meet resectability/transplant criteria but disease confined to liver Radiofrequency Ablation √…Unresectable patients w/ solitary lesion < 5cm or <3 lesions of <3 cm. No vascular invasion or metastases Transplant X Cirrhotic, poor hepatic reserve Solitary lesion, no vascular invasion, preserved hepatic function Resection Patient PSOptimal Candidate:Treatment: X EtOH found at transplant eval. November 2006 Kevin Kuo, HMS III Gillian Lieberman, MD 30 Radiofrequency Ablation: Guidance http://hopkins-gi.nts.jhu.edu/pages/latin/templates/index.cfm http://www.ijri.org/articles/ARCHIVES/2003-13-3/phy315.htm US Guidance CT Guidance Axial C- CT  RFA needle in tumorFilm Findings: November 2006 Kevin Kuo, HMS III Gillian Lieberman, MD 31 PS: RFA Ultrasound PACS, BIDMC Axial US: Lesion Pre-RFA Axial US: Lesion Post-RFA  Hypoechoic lesion with poorly defined borders.  HyperechoicHyperechoic region with dirty region with dirty shadowing (air bubbles from RF shadowing (air bubbles from RF procedure)procedure) Film Findings: November 2006 Kevin Kuo, HMS III Gillian Lieberman, MD 32 PS: Post-RFA Images PACS, BIDMC Axial CT C+ Immediately after RFA Procedure Axial CT C+ 5 months after RFA Procedure  Post-Ablational Hyperemia  Lesion no longer enhancesLesion no longer enhances  No new enhancing lesions Film Findings: November 2006 Kevin Kuo, HMS III Gillian Lieberman, MD 33 PS: The Outcome While not definitively cured, RF ablation was considered to be successful and our patient is doing relatively well. November 2006 Kevin Kuo, HMS III Gillian Lieberman, MD 34 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 November 2006 Kevin Kuo, HMS III Gillian Lieberman, MD 35 Acknowledgements:  Fabio Komlos, MD  Andrew Bennett, MD  Andrew Hines-Peralta, MD  Gillian Lieberman, MD  Pamela Lepkowski  Larry Barbaras November 2006 Kevin Kuo, HMS III Gillian Lieberman, MD 36 References:  Fernandez MP, Redvanly RD. “Primary Hepatic Malignant Neoplasms.” Radiologic Clinics of North America. (1998) 36:333-346.  Ferrucci JT. “Liver Tumor Imaging.” Radiologic Clinics of North America. (1994) 32:39-52.  Foley DW, Mallisee TA, Taylor AJ. “Multiphase Hepatic CT with a Multirow Detector CT Scanner.” American Journal of Radiology. (2000) 175:679-685.  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 gadolinium- enhanced dynamic imaging.” European Journal of Radiology (2006) 58:186-199.  Kamel IR, Bluemke DA. “Imaging Evaluation of Hepatocellular carcinoma.”Journal of Vascular Interventional Radiology. (2002) 13:173-183.  Kamel IR, Bluemke DA. “MR Imaging of liver tumors.” Radiologic Clinics of North America. (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 The Focal Hepatic Lesion:�Radiologic Assessment Our Patient: PS What Next? Liver Anatomy Screening for HCC: The Menu of Tests Triple Phase Helical CT PS: Cirrhosis and Portal Hypertension PS: Triple Phase CT PS: Triple Phase CT PS: Preliminary Diagnosis Slide Number 11 Hepatic Cyst Slide Number 13 Hemangioma Slide Number 15 Focal Nodular Hyperplasia Slide Number 17 Hepatocellular Adenoma Slide Number 19 Liver Metastasis (Colonic Adenocarcinoma) Slide Number 21 Liver Abscess Slide Number 23 PS: Hepatocellular Carcinoma Slide Number 25 PS: The Final Diagnosis HCC: MR Imaging Hepatocellular Carcinoma: Background HCC: Treatment Options Radiofrequency Ablation: Guidance PS: RFA Ultrasound PS: Post-RFA Images PS: The Outcome Summary Acknowledgements: References:
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