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Focal hepatic lesions

focal liver lesions

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Focal hepatic lesions

  1. 1. FOCAL HEPATIC LESIONS •Yasser Asiri R1
  2. 2. Objective : 1. Identify the most important imaging features of common benign liver tumors 2. Identify the most important imaging features of malignant lesions 3. Know the diagnosis of hepatocellular carcinoma
  3. 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. 4. Hemangioma Focal nodular hyperplasia Adenoma Liver cysts Primary liver cancers •Hepatocellular carcinoma •Fibrolamellar carcinoma •Cholangiocarcinoma Metastases Benign Malignant Classification:
  5. 5. • Symptomatic or Incidentally detected • History of Hepatitis or extra hepatic malignant tumor • Liver function tests • Cirrhotic or Non cirrhotic
  7. 7. Hepatic Hemangiomas • Benign vascular lesions of liver. • The commonest liver tumor • More common in female • May range in size from 1cm to >10 cm • 3-5 decades • Usually asymptomatic • Incidental discovry: US
  8. 8. Hepatic Hemangiomas Hemangiomas are composed of many endothelium-lined vascular spaces separated by fibrous septa Cavernous angiomas
  9. 9. Hepatic Hemangiomas US: well-defined, uniformly hyperechoic liver mass with peripheral feeder vessels that are characteristic of a hemangioma. Posterior acoustic enhancment. Cavernous angiomas
  10. 10. Hepatic Hemangiomas CT: The pathognomonic features of caverneous hemangioma: peripheral nodular and discontinuous enhancement and progressive centripetal fill-in The attenuation of the enhancement is similar to the aorta. IV- HAP PVP DP
  11. 11. Hepatic Hemangiomas Diagnosis CT: venous enhancement from periphery to center
  12. 12. 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
  13. 13. Hepatic Hemangiomas Diagnosis MRI:
  14. 14. Hepatic Hemangiomas Diagnosis
  15. 15. Focal Nodular Hyperplasia (FNH) . Benign nodule formation of normal liver tissue with no malignant potential. . 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.
  16. 16. Focal Nodular Hyperplasia (FNH) . Hyperplasia with a central stellate scar radiating in to distinct nodules. .the scar is due to Ductular diffentiation and malformed vessels. . Rarely- encapsulated and pedunculated. .
  17. 17. Focal Nodular Hyperplasia (FNH) Diagnosis: US: usually non- specific, Nodule with varying echogenicity commonly isoechoicto to normal liver. The scar is not usually seen on US. Color Doppler imaging may show central vessels with spoke wheel configuration
  18. 18. Focal Nodular Hyperplasia (FNH) Diagnosis: CT . Central scar formed by a ductules and venules rather than a true fibrous scar. . Brisk homogeneous enhancement with quick wash out. In the portovenous phase it will only shows unenhanced scar. Usually th e scar shows late enhancment . 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
  19. 19. Focal Nodular Hyperplasia (FNH) Diagnosis: CT HAP PVP DP IV-
  20. 20. Focal Nodular Hyperplasia (FNH) Diagnosis: CT
  21. 21. 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
  22. 22. Focal Nodular Hyperplasia (FNH) Diagnosis:MRI typical finding
  23. 23. 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 . they are usually resected . Benign neoplasm composed of normal hepatocytes scattered kupffer cells and no bile ducts. “negative in hIDA scan”. Surrounded by a psuedocapsule tends to enhance late
  24. 24. Hepatic Adenoma US: . Nonspecific, adenomas may be hypo, iso, or hyperechoic but are typically heterogeneous CT: . Non specific apperance , usually Well circumscribed hypoense mass which shows hetrogenous enhancment hetrougenous lesion without lobulation . 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
  25. 25. Hepatic Adenoma
  26. 26. Liver cysts: . May be single or multiple . May be part of polycystic kidney disease or Biliary hamartomas . Patients often asymptomatic . No specific management required
  27. 27. Liver cysts: . US is sufficient to diagnose . On CT scan or MRI hepatic cysts are typically discovered incidentally Well defined and low in densitywith internal attenuation of water. No enhancment on any phase of the post contrast scans.
  28. 28. Liver cysts:
  30. 30. Hepatocellular Carcinoma (HCC) •The most common primary tumour liver 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 •HCC is locally invasive and tends to invade the portal vien, IVC and bile ducts. •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 convert carcinoma.
  31. 31. Usually too small to detect by imaging –May be surrounded by fibrotic septa –May contain iron, copper Siderotic regenerating nodules –Hyperdense on NCCT, disappear on HAP & PVP –Variable on T1, Hypointense on T2 MR, “bloom” on GRE -completely supplied by portal vein and it’s not premalignant. Regenerating Nodules
  32. 32. Dysplastic Nodules A premalignant lesion. No arterial enhancement Iso to hyperintense on T1 (copper) Iso to Hypo on T2 (opposite of HCC) Should not enhance much on hypervascular liver lesions
  33. 33. Hepatocellular Carcinoma (HCC) 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%
  34. 34. Hepatocellular Carcinoma (HCC) US : hyperechoic, smaller tumors are hypoechoic. Heterogeneous, hypervascular US sensitivity about 75%.
  35. 35. Arterial Phase: liver(30-35 sec) HCC as supplied by arterial branch/neovascularization Hepatocellular Carcinoma (HCC) 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. Enhancement Wash out phenomenan CT or MR
  36. 36. Hepatocellular Carcinoma (HCC) Delayed Phase : Wash -out phenomenan persists and often exaggerated in smaller lesions. The tumor capsule IV- HAP PVP DP capsule
  37. 37. Hepatocellular Carcinoma (HCC)
  38. 38. MRI . Variable intensity of HCC on T1 . 35% hyper, 25% iso-, 40 % hypo . Hyperintense (T1) often well-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 . Other Features: Focal fat Hepatocellular Carcinoma (HCC)
  39. 39. Hepatocellular Carcinoma (HCC) MRI
  40. 40. Hepatocellular Carcinoma (HCC) Hypovascular HCC +/- 30%
  41. 41. 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
  42. 42. 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.
  43. 43. Metastatic disease Variable US features+++ Iso, hyper or hypo echoic++ Contrast-enhanced US (CEUS) (84% accuracy) Intraoperative US (IOUS) (96% accuracy) Typical feature
  44. 44. Metastatic disease . Most liver metastases are hypovascular and are best imaged during the portal venous phase (colon, stomach and pancreas) . Hypervascular metastases enhancing on the arterial phase (neuroendocrine tumors, renal cell, breast, melanoma, thyroid) . Calcification may be present with metastases from mucinous gastrointestinal tract tumors and from primary ovarian, breast, lung, renal, and thyroid cancer . Other features : Hemorrhagic or cystic metastases
  45. 45. Metastatic disease . On MRI, metastases are variable but are usually hypo- to isointense on T WI and iso- to hyperintense on T2 WI . Metastatic tumors with liquefactive necrosis or cystic neoplasms show higher signal intensity on T2 WI . Metastases may show central hypointensity on T2WI (coagulative necrosis, fibrin, and mucin) . High T1 signal intensity can be seen with metastases from melanoma, colonic adenocarcinoma, ovarian adenocarcinoma, multiple myeloma and pancreatic mucinous cystic tumor . Comparing T2-weighted (TE 90) and T2-weighted (TE 160) sequences, metastases become less intense Characterization . T1-weighted 3D dynamic contrast-enhanced MRI Detection
  46. 46. Wide spectrum of apperance on CT depends on the primary neoplasm •Well defined , low density soli mass with peripheral enhancement e.g. Colon cancer •Hypervascular metastasis show diffused enhancement on arterial phase. •Can be calcified when the primary neoplasm is mucinous adenocarcinomas, osteocarcinoma, chondrosarcoma. •Cystic metastasis from mucinous colon carcinoma, carcinoid or lung.
  47. 47. Metastatic disease
  48. 48. Conclusion : . MDCT and MRI are the most commonly used imaging modalities for detection and characterization of focal hepatic lesion . Imaging modalities can make diagnosis for: Hepatic cyst Caverneous hemangioma Typical FNH HCC . For others lesions biopsy will be often necessary