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Abdominal imaging hcc t loke

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  • 1. Diagnostic imaging of small HCC in liver cirrhosis : The current approach Dr.Tony Loke United Christian Hospital
  • 2. Disclosure No conflict of interest
  • 3. Contents •  Step wise progression of hepatocarcinogenesis •  MR I can image this histhopathological process - Gadoxetic enhanced MRI + DWI •  Definite Criteria for HCC – Low sensitivity •  Gadoxetic enhanced MRI alone - ↑sensitivity •  Diffusion weighted MRI -↑ specificity •  Combined Ga MRI and DWI – current approach •  Proposed Algorithm – Best diagnostic accuracy
  • 4. Multistep progression of Hepatocarcinogenesis Kudo M Oncology 2010;78:87-93
  • 5. Intranodular blood supplyunpaired arteries / portal tracts Tajima T AJR 2002:178;885
  • 6. Histopathological pathway of Carcinogenesis •  Replacement of normal liver cells by abnormal liver malignant cells -↓ OATP8 expression •  Hypointensity – HBP Primovist enhanced MRI •  Unpaired arteries ↑ + Portal tract ↓ •  Wash in/ Wash out – Dynamic CT and MRI •  Increased cell density with progressive undifferentiated nodules •  Hyperintensity - DWI
  • 7. Process of Hepatocarcinogenesis Kudo M J gastroenterology and hepatology 2010;25:439-452
  • 8. Diagnostic criteria for typical HCC Bruix J, Sherman M Hepatology 2011;53:1020-1022
  • 9. Definite HCC • Wash in (arterial phase hyperenhancement) / Wash out– AASLD, EASL criteria (>1 cm) and JSH (any size) •  Dynamic MDCT, MRI (Primovist enhanced MRI), CEUS • Only 71% - have ‘wash in’ and ‘wash out’ on more than one test Marrero JA et al Liver Transpl 2005;11:281-289
  • 10. ↑ Sensitivity - Malignant liver nodules •  Absence of OATP8 expression / kupffer cells •  Liver specific contrast agents •  Primovist MRI, SPIO-MRI, Sonazoid- CEUS •  Restricted diffusion •  Diffusion weighted MRI
  • 11. Ancillary MRI criteria -
 Malignant liver nodules •  T2W Hyperintensity •  Capsular enhancement – LI RADS •  T1 hypointensity •  Lesion size •  Lesional fat •  Lesion growth on follow up •  ‘Nodule in nodule’ pattern
  • 12. PRIMOVIST alone has higher sensitivity -? Compromised specificity •  Comparing primovist and magnevist, •  Significant increased sensitivity with primovist. •  Hepatocellular phase imaging with Primovist improves HCC detection. •  Primovist MRI has higher diagnostic accuracy (0.88 vs 0.74, p<. 001) and higher sensitivity (0.85 vs0.69, p<.001) than triple phase MDCT •  Particularly in smaller lesions (<2cm) •  MRI with primovist has equal accuracy as dual-contrast MRI for HCC detection •  Combined use of extracellular gadolinium and SPIO. Marin D et al Radiology 2009;251:85-95 Park G et al BJR 2010;83:1010-1016 Kim YK et al Invest Radiol 2010:45:740-746 Martino et al Radiology 2010;256:806
  • 13. Hypervascular nodule Size does not matter! Hypervascular nodule without washout Primovist Negative uptake HCC Positive uptake Biopsy or Follow up Kudo M Oncology 2010;78:87-93
  • 14. Hypovascular Nodule- size matters! Hypovascular nodule Primovist Negative uptake ≥1.5cm HCC – 98% LGDN – 2% Positive uptake <1.5cm ≥1.5cm <1.5cm Follow up Biopsy or FU Follow up 17% progress to HCC in 1 year HCC LGDN
  • 15. PRIMOVIST (GD-EOB-DTPA) GADOXETIC ACID HCC-Hypointense at 20 min HBP (e)
  • 16. DIFFUSION WEIGHTED MRI - ↑ Specificity •  SI ratio significantly differentiates malignant and benign lesions at all b-values. •  Optimal threshold b=600 •  SI ratio 1.25. •  For detection of HCC, DWI with b=600 has •  sensitivity of 95.2% compared to 80.6% for conventional MRI (p=0.023) •  specificity of 82.7% compared to 65.4% (p=0.064%). •  The improved accuracy was most beneficial for differentiating lesions smaller than 2cm. Vandecaveye V Eur Radiol 2009;may:1431
  • 17. Classic HCC -SI ratio 1.83 for b600 (g)
  • 18. Small HCC -No lesion seen on T1, T2 or enhanced MRI. SI ratio=1.5 at b600
  • 19. CURRENT APPROACH •  Combined Primovist enhanced MRI and Diffusion weighted imaging – able to image the step wise pathogenesis of HCC •  Dynamic Primovist MRI - Wash in / Wash out •  Hepatobiliary phase Primovist enhanced MRI - OATP8 expression •  DWI - cell density •  Ancillary features
  • 20. COMBINED PRIMOVIST MRI AND DWI •  Criteria for HCC •  Hypervascular nodules with washout •  Hypervascular nodules without washout, hypointense on HBP phase (irrespective of DWI) •  Hypervascular nodules without wash out, iso/hyperintense on HBP phase + Hyperintense DWI •  Hypovascular nodules, hypointense on HBP phase + Hyperintensity DWI •  Combined Primovist and DWI has better diagnostic accuracy and sensitivity (93.3%) in detection of HCC < 2cm •  False positive – HGDN Park MJ et al Radiology 2012:264;761-770
  • 21. COMBINED PRIMOVIST AND DWI Park MJ et al Radiology 2012:264;761-770
  • 22. COMBINED PRIMOVIST AND DWI Park MJ et al Radiology 2012:264;761-770
  • 23. Typical small HCC Small hypervascular HCC –DWI b=100, 800
  • 24. Segment 6 hypervascular HCC < 1.5 CM
  • 25. Atypical small HCC Hypervascular HCC- hypointense on HBP but DWI normal
  • 26. Hypervascular HCC – and DN (DWI and HBP-Normal)
  • 27. CT hypervascular lesionSegment 5 pseudolesion
  • 28. Hypovascular HCC < 1.5 CM Hypointense HBP + Hypertintense DWI
  • 29. SEGMENT 2/3 HCC Hypo/hypervascular component (HBP+DWI = +ve)
  • 30. HGDN simulating HCC Hypovascular DN- hypointense on HBP and DWI hyperintense
  • 31. Segment 5 HGDN – Hypointense HBP (DWI-Normal)
  • 32. DN > 1.5CM HBP + DWI = negative
  • 33. Summary - Current Approach •  Nodule detected on USG •  Dynamic CT •  Hypervascular with washout (>1cm) •  Atypical features •  Combined Primovist enhanced MRI and DWI •  Hypervascular without washout, hypointense on HBP phase •  Hypervascular without washout, isointense on HBP phase + Hyperintense DWI •  Hypovascular nodules, hypointense on HBP phase + Hyperintensity DWI •  Ancillary features •  Higher diagnostic accuracy and sensitivity •  Particularly for HCC < 2cm •  False positive for HGDN
  • 34. Conclusion - Current Approach •  Combined Primovist and DWI •  Higher diagnostic accuracy and sensitivity •  Particularly for HCC < 2cm •  false positive include HGDN •  Combined Primovist enhanced MRI and DWI •  Hypervascular without washout, hypointense on HBP phase •  Hypervascular nodules, isointense on HBP phase + Hyperintense DWI •  Hypovascular nodules, hypointense on HBP phase + Hyperintensity DWI
  • 35. SEG 2/3 HYPERVASCULAR HCC WITH PARADOXICAL UPTAKE (DWI-hyperintense)
  • 36. SEGMENT 6 HCC WITH NORMAL ARTERIAL, T2W AND DWI
  • 37. FOCAL NODULAR LIVER LESIONS: 1994 INTERNATIONAL CLASSIFICATION •  Regenerative nodule •  Cirrhotic nodule •  Low grade dysplastic nodule (adenomatous hyperplasia) •  High grade dysplastic nodule (adenomatous hyperplasia with atypia) •  Dysplastic nodule with subfoci of HCC (early HCC) •  HCC (overt HCC) International Working Party. Hepatology 1995;22:983-993
  • 38. DEVELOPMENT OF HCC IN CIRRHOTIC LIVER •  Temporal progression from regenerative nodules to dysplastic nodules to well differentiated HCC. •  HCC may develop independently of RN and DN.
  • 39. PRIMOVIST MRI MOST SENSITIVE TECHNIQUE IN DETECTING EARLY HEPATOCARCINOGENESIS
  • 40. CONSENSUS STATEMENTSJAPAN SOCIETY OF HEPATOLOGY •  Typical HCC can be diagnosed by imaging regardless of the size if a typical vascular pattern is obtained on dynamic CT, dynamic MRI, CEUS or a combination of CTHA and CTAP. •  Different from Western guidelines, only one dynamic study showing the typical pattern is sufficient to diagnose HCC. •  The typical imaging pattern include hypervascularity in the arterial phase and washes-out in the portal venous phase.
  • 41. CONSENSUS STATEMENTSJAPAN SOCIETY OF HEPATOLOGY •  Sonazoid-enhanced ultrasound is more sensitive for detection of intranodular hypervascularity than MDCT or dynamic MRI. Therefore to confirm true hypovascularity, sonazoid-enhanced CEUS is recommended. •  Nodules with hypovascularity and negative findings on SPIO-MRI, Kupffer imaging of Sonazoid CEUS, primovist MRI are likely to be benign. They can be followed up without treatment.
  • 42. JAPAN SOCIETY OF HEPATOLOGY
  • 43. JAPAN SOCIETY OF HEPATOLOGY
  • 44. 2ND INTERNATIONAL FORUM LIVER MRI
  • 45. PRIMOVIST CONTRAST ENHANCED MRI- PROTOCOL OPTIMIZATION AND EVALUATION OF HEPATIC NODULES IN LIVER CIRRHOSIS Dr. Tony Loke Consultant Radiologist United Christian Hospital
  • 46. PRIMOVIST - GADOLINIUM-ETHOXYBENZYLDIETHYLENETRIAMINEPENTAACETIC ACID (GDEOB-DTPA) •  Combined extracellular hepatobiliary gadolinium based contrast agents with liver specific properties •  Multihance and Primovist •  These agents able to assess both vascularity and hepatocellular function.
  • 47. PROTOCOL OPTIMIZATION - PHARMACOKINETIC AND PHARMACODYNAMIC PROPERTIES OF PRIMOVIST IN LIVER CIRRHOSIS. •  Patients with advanced cirrhosis, three important differences are present. •  Diminished and delayed liver parenchyma enhancement •  diminished parenchymal enhancement in the hepatocyte phase •  time to peak enhancement may be delayed. •  Diminished and delayed biliary excretion. •  In the noncirrhotic liver, primovist produces intense biliary tree enhancement beginning as early as 5 minutes after contrast injection. •  Enhancement of bile ducts in the cirrhotic liver is delayed and of limited intensity
  • 48. PROTOCOL OPTIMIZATION - PHARMACOKINETIC AND PHARMACODYNAMIC PROPERTIES OF PRIMOVIST IN LIVER CIRRHOSIS. •  Patients with advanced cirrhosis, three important differences are present. •  Prolonged blood pool enhancement. •  50% of primovist is cleared by the liver and 50% via the kidneys. •  Patients with advanced cirrhosis, the hepatic elimination pathway is impaired and the blood vessels appear hyperintense for a longer duration. •  The relatively low contrast enhancement in portal and hepatic veins is relevant because it reduces the sensitivity for detecting venous obstruction and invasion.
  • 49. PROTOCOL OPTIMIZATION – PRIMOVIST ENHANCED MRI IN CIRRHOTIC LIVER •  Problems with on-label approved dose Gd-EOB-DTPA of 0.025mmol/kg. •  Selecting the appropriate scan delay is difficult from low dose and small amount of on-label approved dose •  Studies have shown the signal intensity of vessels in the arterial phase is less with primovist than extracellular gadolinium-based agents using on-label approved dose. •  Standard dose provide low sensitivity for detection of hypervascular HCC/lesions despite its higher T1 relaxivitiy Cruite I et al AJR 2010;195:29-41
  • 50. PROTOCOL OPTIMIZATION-SOLUTION FOR ACHIEVING OPTIMAL ARTERIAL PHASE •  Optimal arterial phase increases sensitivity for detection of hypervascular lesions •  Perform consecutive arterial phase data sets. •  Administer the agent at a higher off-label dose (0.0375 – 0.05 mmol/kg). •  This is 50%-100% higher than the approved dose. •  Injecting all 10ml (20ml if patient exceeds the dose rate calculation) -rounded up to the nearest bottle •  For patients with estimated GFR of less than 60mL/min, a weightadjusted dose is administered without rounding. •  Inject contrast at slower rate of 1cc/second followed by 20ml of saline chaser at 2cc/second. •  2cc/sec with higher dose
  • 51. PRIMOVIST PROTOCOL - DIFFERENCE WITH CONVENTIONAL GD
  • 52. UCH PROTOCOL - PRIMOVIST ENHANCED MRI LIVER •  MRCP performed before contrast injection •  Bolus timing method is used •  Contrast seen at LVOT or ascending aorta, patient asked to take 2 breath holds (8 -10 seconds) and 2 consecutive arterial phases imaging is acquired using 3D VIBE (15 seconds). •  late arterial phase is performed after 2 breath holds. •  Hepatic phase is performed after another 2 breath holds •  Equilibrium phase is performed at 120 minutes. •  Diffusion weighted imaging and 2D axial SPAIR is performed while waiting for delayed 20 mins hepatocyte phase. •  Hepatocyte phase - 20 minutes delay. •  Hepatocyte phase - 40 minutes delay •  if hepatic veins and portal veins not cleared •  contrast not visible in biliary tree. •  Hepatocyte phase - 60 minutes delay may be necessary.
  • 53. UCH PROTOCOL – PRIMOVIST ENHANCED MRI LIVER
  • 54. WHEN TO USE PRIMOVIST IN PATIENTS WITH LIVER CIRRHOSIS •  Primovist is routinely use in cirrhosis except for: •  Assessment of ablated lesions for residual or recurrent disease. •  Reduced vascularity •  Patients whose bilirubin is above 3 mg/dL. •  Sensitivity for lesion detection reduced from diminished liver enhancement •  Evaluation of vascular patency •  PV and HV remains hyperintense from prolonged blood pool •  Evaluation of hemangiomas •  Appearance same as HCC
  • 55. IS PRIMOVIST BETTER FOR DETECTING HCC? -COMPARED WITH OTHER AGENTS /IMAGING MODALITIES •  Combined dynamic and hepatocyte phase of Primovist has greater diagnoctic accuracy for HCC detection than either dynamic or MDCT alone •  Comparing primovist and magnevist, significant increase in sensitivity was achieved with primovist. •  Hepatocellular phase imaging with Primovist improves HCC detection compared with conventional extracellular gadolinium chelates. •  MRI with primovist has equal accuracy as dual-contrast MRI for HCC detection (simultaneous use of conventional extracellular gadolinium and superparamagnetic iron oxide agent). Marin D et al Radiology 2009;251:85-95 Park G et al BJR 2010;83:1010-1016 Kim YK et al Invest Radiol 2010:45:740-746
  • 56. PRIMOVIST UPTAKE BY HEPATOCYTE BY OATP1 EXCRETION TO BILE JUICE REGULATED BY MRP2 Kudo M J gastroenterology and hepatology 2010;25:439-452
  • 57. Kudo M Oncology 2010;78:87-93
  • 58. HCC (87 lesions) Hepatobiliary phase In one study Hypointense 92% Isointense 6% Hyperintense 2% WDHCC (39 lesions) Hepatobiliary phase Another study Hypointense 35 Isointense 2 Hyperintense 2 DN (8) Hypointense 3 Isointense 3 Hyperintense 2 Kudo M J gastroenterology and hepatology 2010;25:439-452
  • 59. CRITERIA FOR HCC •  Reading Hepatobiliary phase alone insufficient •  Result in false positives and negatives •  Hepatocyte phase •  Post contrast EOB ratio •  Read the whole exam •  T1 (hypointense) •  T2 (hyperintense) •  Dynamic contrast (hypervascularity +/- washout) •  DWI (restricted diffusion)
  • 60. CRITERIA FOR HCC DIAGNOSIS •  A nodule with increased enhancement on arterial phase and washout on late venous or equilibrium phase •  A nodule with arterial enhancement and hyperintensity on T2WI (and/or DWI) •  A nodule with isointensity during contrast enhanced arterial phase, hyperintensity on T2WI (and/or DWI) and no uptake of contrast on hepatobiliary phase (even < 1.5cm) •  Nodule > 1.5cm with no uptake of contrast agent on hepatobiliary phase images.
  • 61. HYPOVASCULAR NODULE – SIZE MATTERS •  Hypovascular nodules (on arterial phase) with negative uptake on hepatobiliary phase are thought to represent DN or WDHCC •  Lesion > 1.5 will progress to hypervascular nodules in 80% in 1 year •  Lesion < 1.5 will progress to hypervascular nodules in 17% in 1 year Kudo M Oncology 2010;78:87-93
  • 62. DN > 1.5CM - POSITIVE UPTAKE
  • 63. DN > 1.5 CM - POSITIVE UPTAKE
  • 64. DN - NEGATIVE UPTAKE
  • 65. SEGMENT 3 HCC – LESION DEMARCATION BETTER
  • 66. HYPERVASCULAR RECURRENT HCC – OTHER DN +VE UPTAKE
  • 67. SEG 2/3 HYPERVASCULAR HCC WITH PARADOXICAL UPTAKE
  • 68. HYPERVASCULAR SEG 7 DN - POSITIVE UPTAKE
  • 69. HYPOVASCULAR < 1.5 CM HCC – T2/DWI BRIGHT
  • 70. DN –NOT VISIBLE IN OTHER SEQUENCES EXCEPT HEPATOCYTE PHASE
  • 71. SEGMENT 6 HCC WITH NORMAL ARTERIAL, T2W AND DWI
  • 72. CT SEGMENT 6 HYPOENHANCING NODULE - HCC IN HEPATOCYTE PHASE > 1.5 CM
  • 73. CT HYPERVASCULAR LESIONS – SEG 5 HCC
  • 74. SEGMENT 6 HCC < 1.5 CM
  • 75. CT HYPERVASCULAR LESION – SEG 5 PSEUDOLESION
  • 76. SMALL HYPERVASCULAR HCC
  • 77. SEGMENT 6 HCC & 2 HEMANGIOMAS
  • 78. SEGMENT 5 – DN FEATURES ON T1/2
  • 79. SEGMENT 5 HCC – NEGATIVE UPTAKE
  • 80. COMBINED PRIMOVIST AND DWI Park MJ et al Radiology 2012:264;761-770
  • 81. FALSE POSITIVE – HEPATOBILIARY PHASE •  Hypointense lesions seen only on hepatobiliary phase (without arterial enhancement and T2 hyperintensity) can either be WDHCC or Cirrhotic nodules •  HCC tend to be larger(>1.5cm) than benign nodules(0.5-1.2cm) •  Lesions <1.5cm seen on hepatobiliary phase can still be well-differentiated HCC and should not be ignored. •  Close monitoring, biopsy or resected in patients with coexisting overt HCC. •  Hypervascular pseudolesions •  15% shows negative uptake on hepatobiliary phase •  13% showed T2 hyperintensity •  DWI normal
  • 82. FALSE NEGATIVE - HEPATOBILIARY PHASE •  HCC which are T1 hyperintense may be isointense on hepatobiliary phase. •  Look for hypervascularity on arterial phase, T2/DWI hyperintensity •  Hepatic dysfunction or hyperbilirubinemia reduces hepatic uptake of the contrast agent •  lesion conspicuity on hepatobiliary phase images is decreased, although false-negative cases can occur in patients with normal bilirubin level. •  Lesions are less conspicuous in fatty liver •  do 20 min delay without fat sat •  Paradoxical uptake – Green hepatomas •  2.5 to 8.5% of HCC appear iso/hyperintense •  Altered transporter mechanism
  • 83. SUMMARY- CRITERIA FOR HCC •  Hypervascular nodules with washout – irrespective of delayed phase •  Hypervascular nodules and hyperintensity on T2WI (and/or DWI) – irrespective of delayed phase •  Isointense nodule (arterial phase) with hyperintensity on T2WI (and/or DWI) and negative uptake of contrast on hepatobiliary phase (even < 1.5cm) •  Nodule > 1.5cm with no uptake of Primovist on hepatobiliary phase images– irrespective of vascularity
  • 84. SUMMARY •  Negative uptake in hypovascular lesions <1.5 cm can still be HCC •  FU required as 17% becomes hypervascular in 1 year •  Positive uptake can still be HCC •  DWI (+/- hepatocyte SI ratio) to exclude pseudolesion •  Hypointense rim and/or focal defect on delayed phase •  Nodule in nodule and internal septation helps •  FU(+/-biopsy) necessary