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: