1. The document discusses magnetic resonance imaging of focal hepatic lesions. It provides details on liver anatomy, MRI techniques including different pulse sequences and contrast agents, and classifications of common focal hepatic lesions. 2. Key focal hepatic lesions discussed include hemangioma, focal nodular hyperplasia (FNH), hepatocellular adenoma, and hepatocellular carcinoma. Characteristic imaging features of each lesion on different MRI sequences and contrast phases are provided. 3. Other imaging modalities for evaluating focal hepatic lesions mentioned include nuclear scintigraphy, angiography, and positron emission tomography (PET), along with their applications.

1. MAGNETIC RESONANCE
IMAGING OF FOCAL HEPATIC
LESIONS
Presenter: MOZAMMIL RABBANI
Moderator: DR. DIPU BHUYAN
(ASSOCIATE PROFESSOR)

2. ANATOMY
 Largest gland in the body weighing about 1.4kg in adult
 Occupies right hypochondrium and part of epigastrium
 Covered by peritonium except bare area on
posterosuperior surface, fossa for GB and IVC
 Blood supply – Portal vein 80%, Hepatic artery 20%
Drained by three hepatic veins into IVC

3. SEGMENTAL ANATOMY
COUINAUD CLASSIFICATION
 The Couinaud classification of liver anatomy divides the
liver into eight functionally independent segments.
 Each segment has its own vascular inflow, outflow and
biliary drainage.
 In the centre of each segment there is a branch of the
portal vein, hepatic artery and bile duct.
In the periphery of each segment there is vascular
outflow through the hepatic veins

4.  Right hepatic vein divides the right lobe into anterior
and posterior segments.
 Middle hepatic vein divides the liver into right and left
lobes (or right and left hemiliver). This plane runs from
the inferior vena cava to the gallbladder fossa.
 The Falciform ligament divides the left lobe into a
medial- segment IV and a lateral part - segment II and
III.
 The portal vein divides the liver into upper and lower
segments.

6. How to separate liver segments
on cross sectional imaging

7. MR IMAGING
 Liver imaging is ideally done on a high field
system(>1.0 T) with fast gradients. Phased
array multicoils are used which provide high
signal to noise ratio.
 Fast gradient echo sequences such as
FLASH is generally used to obtain T1
weighted sequences.
 Echo-train sequences such as turbo spin
echo is used for T2 weighted images

8.  Fat suppression is frequently used with these echo-
train sequences because fat has very high signal
intensity on these images.
 T1 weighted 2D gradient echo sequences are used to
perform post contrast imaging of liver.
 The liver parenchyma appears homogenous on both
T1 and T2 weighted scans.
 The liver shows moderate signal intensity on T1W
images, similar to pancreas but brighter than spleen
and kidneys.
 T2W scans the liver appears dark and has low signal
intensity and has signal intensity less than that of
spleen.

9. POST CONTRAST: TRIPHASIC
STUDY
 The three phases of enhancement are based on the
location of gadolinium enhancement within the various
hepatic vessels.
 The arterial dominant phase ---contrast material is
present in the arteries and in the main portal vein but not
in the hepatic veins.
 The portal venous phase ---contrast material in the
arteries as well as in the portal and hepatic veins.
 The delayed phase --- 2–3 min after contrast
administration.

10.  In the arterial dominant phase --
 hypervascular lesion ---if its enhancement is greater
than that of liver parenchyma
 hypovascular lesion ---if its enhancement is less than
or equal to that of the liver parenchyma.

11. MR imaging contrast agents
 MR contrast agents are currently used to accentuate
the difference in signal intensity between the liver
lesions and adjacent normal tissue and to highlight
different enhancement patterns.
 According to biodistribution, the contrast agents are
divided into three categories
1. Extracellular contrast agents
2. Hepatobiliary contrast agents
3. Resticuloendothelial system targeted contrast agents

12.  Extracellular contrast agents are hydrophilic, small
molecular gadolinium chelates. Gd-DTPA , Gd-DOTA
and the more recent non-ionic agents such as
gadodiamide ,gadobutrol and gadoteridol provide
information on vascularization and perfusion similar to
that of iodinated contrast media at CT examination.
 Using breath-hold T1W GRE sequences , a dynamic
contrast enhanced study of liver is performed during the
arterial phase(20-30 sec after injection) , portal venous
phase (70-80 sec after injection) and the delayed
phase (2-3 min after injection).

13.  Hepatobiliary agents are either only hepatocyte
selective ,such as mangafodipir trisodium (Mn-DPDP)
or are Gd chelates(gadobenate dimeglumine GD-
BOPTA and Gd-ethoxybenzyl Gd-EOB that are
distributed in the extracellular space and also
hepatocyte selective.
 Mn-DPDP is injected at the dose of 0.5 mmol/kg as a
slow intravenous infusion and maximum liver
enhancement is observed within 15-20 minutes of
infusion,.
 On post contrast images, most tumours of non
hepatocellular origin including metastasis , benign liver
cysts and hemangioma remains hypo intense relative to

14.  RES contrast agents are superparamagnatic particles
of iron oxide(SPIO) , which produce loss of signal on
T2W images.
 Kupffer cells take up more than 80% of these particles
allowing liver specific phase imaging 10 min after
injection.
 Malignant focal lesions usually do not contain Kupffer
cells and therefore appear as bright nodules against the
markedly hypo intense liver parenchyma

15. Angiography
 The high quality of images provided by cross sectional
imaging techniques has led to a dramatic change in the
indications for hepatic angiography.
 This technique is now seldom used for diagnostic
purpose but is widely used for vascular interventions
used in the management of liver lesions.

16.  Prior to the procedure, coagulation profile and serum
creatinine are obtained.
 Angiography of liver is performed by selective injections
of the celiac axis and superior mesenteric artery or one
or more of their branches.

17.  A 5 french right angle or reverse curve angle catheter
such as Cobra is used.
 The volume of the contrast usd is about 20-30 cc
injected at the rate of 5-6 cc per second.
 Visualization of portal venous system is done by
injecting the splenic artery or SMA coupled with
prolonged filming.

18. Positron emisson tomography
 PET is an imaging modality that uses positron emitters
,such as flourine-18 to visualize the tissue, such as
cancers with increased glucose metabolism.
 The most commonly used radiotracer for PET is 2-(18F)
fluoro-2 deoxy-d –glucose.
 FDG-PET has been proved to be highly sensitive in
detecting hepatic metastases from various primaries.

19.  The ability of FDG-PET quantitatively to establish
metabolic rates makes it a potential valuable tool for
monitoring response to the therapy.
 For benign lesions like hemangioma , adenoma and
FNH , FDG-PET is not suitable.
 PET has limited spatial resolution compared with CT
and MR imaging and the intrinsic heterogenous activity
in normal background liver limits the ability of FDG-PET
to show small malignant lesions.

20. Radionuclide Imaging
 In this technique,hepatocyte and kupffer cells can be
investigated with Tc 99m labelled tracers.
 Radiopharmaceuticals based on imidodiacetic acid(IDA)
are taken up by functioning hepatocytes ,excreted
unchanged in bile and not absorbed from gut.
 Studies with IDA compounds allow imaging of
functioning liver prenchyma and also trace the flow of
bile in the ducts,gall bladder and bowel.

21.  Labelled colloids demostrate the distribution of
functioning tissue by targeting the RE cells of liver,
spleen and bone marrow.
 Mass lesions which contain no functioning RE cells(the
vast majority of pathologies) are shown as non-
functioning areas.

22. Applications
 Application of hepatobiliary scintigraphy in liver disease
include the assessment of regional liver function
,demostration of bile leaks in liver trauma and the
differential diagnosis of hepatocellular tumours.
 In differntiating benign hepatocellular tumours from
metastasis or primary malignancies,the radionuclide
imaging using IDA or labelled colloids is sufficiently
specific to allow biopsy to be avoided in the majority of
the cases.

23. CLASSIFICATION OF FOCAL
LESIONS
 BENIGN TUMORS AND TUMOR LIKE
CONDITIONS
 MALIGNANT TUMORS
 CYSTS
 INFECTIONS/ INFLAMMATION
 TRAUMA
 OTHERS

25. MALIGNANT LESIONS
 Hepatocellular carcinoma
 Fibrolamellar hepatocellular carcinoma
 Metastasis
 Lymphoma
 Sarcomas ( Angiosarcoma, Mesenchymal sarcomas)
 Intrahepatic Cholangicarcinoma
 Hepatoblastoma
 Biliary Cystadenocarcinoma

27. HEMANGIOMA
 MC benign hepatic tumor
 Tumor composed of multiple vascular channels lined by
a single layer of endothelial cells supported by a thin
fibrous stroma
 Small-<3 cm, large- >3cm ,giant ->10 cm
 M:F= 1:5
 Most are asymptomatic, incidental findings on imaging

28.  Hemangiomas are usually solitary but are multiple in
approximately 10% of cases. Their borders are clear, but
they are not encapsulated.
 As the hemangioma grows, various degenerative
changes are seen in its center, including old and new
thrombus formation, necrosis, scarring, hemorrhage,
and calcification.When degeneration and fibrous
changes become more prominent, the lesion is referred
to as a sclerosed hemangioma

29.  To diagnose Hemangioma, 3 conditions have to be
fulfilled :
1. Enhancement equal or more than the Aorta
2. Enhancement persists on delayed imaging
3. Appears in a globular or nodular in discontinuous
fashion

30.  T1-hypointense
 T2- Significantly hyperintense ( light bulb )
 T1 with IV Gd – DTPA shows enhancement similar to
that seen on CT examination.
HAEMANGIOMA-MRI

33.  Rapidly filling hemangiomas are not very frequent (16%
of all hemangiomas). However, rapid filling seems to
occur significantly more often in small hemangiomas
(42% of hemangiomas .
 MR imaging show a particular enhancement pattern:
immediate homogeneous enhancement.
 D/D- hypervacular mets hemangioma remain
hyperintense on delayed scans whereas mets are
hypointense on delayed scans.

34. Nuclear Scintigraphy
 Tagged RBC blood pool scans are virtually diagnostic
with defect on early scans and prolonged and
persistent filling in, on delayed scans
 Many vascular tumors like HCC, adenoma, FNH may
have a persistent uptake but in the early scans have
uptake rather than defect

35. Angiography
 Early pooling of
contrast in the late
arterial phase
 Contrast retained well
beyond venous phase
-cotton wool
appearance
 Angio- important when
coexist with metastasis
as differentiation is
important when
planning resection

36. FOCAL NODULAR
HYPERPLASIA(FNH)
 Tumor like condition characterized by a central stellate
fibro vascular scar with surrounding nodules of
hyperplastic hepatocytes, Kupffer cells and small bile
ductules
 Vessels present in the central stellate scar
 Usually smaller than 5cm
 2nd MC benign liver tumor
 MC in women
 Age- 20-40yrs

37.  Calcification, necrosis and haemorrhage are extremely
rare, as even large FNH lesions do not usually outgrow
their blood supply.
 Both Kupffer cell activity and the central scar have been
used to characterize FNH,
 The histologically important distinguishing features are
the lack of normal architecture with absent portal tracts
and no connecting bile duct drainage.

38.  If vessels radiating from the central scar to the
periphery of the tumor are visualized, a near-definitive
diagnosis of FNH can be made.
 This spoke-wheel pattern is most sensitively delineated
by contrast-enhanced ultrasonography.

39.  The central scar is not a specific finding of FNH and can
be seen in a variety of other focal liver lesions such as
giant hemangiomas and HCCs.
 The central scar in giant hemangiomas is typically larger
and brighter on T2-weighted images. In addition, the
lesions have homogeneous high signal intensity on T2-
weighted images and show peripheral nodular
enhancement in most cases.
 Some HCCs may contain a central scar, the central scar
in HCC shows low signal intensity on T2- and T1-
weighted images and does not enhance much on
contrast-enhanced images.

40. MRI
 T1-iso to hypointense, scar is hypointense
 T2-iso to hyperintense, scar is hyperintense
 Gd-DTPA-
 Early-homogeneous enhancement of FNH
 Late-enhancement of scar
 T2 with SPIO ( coated crystalline particles taken up by
phagocytes), uniform decrease in intensity throughout
liver due to T2 signal loss.

43. Nuclear Scintigraphy
 Sulfur colloid-due to presence of Kupffer cells, uptake in
60%
 Hepatobiliary scans-HIDA-uptake and excretion due to
presence of biliary ductules

44. Angiography
 Hypervascular mass possessing a centrifugal
or spoke wheel pattern of vascular supply.

45. HEPATOCELLULAR ADENOMA
 Rare benign tumour
 M.C in women of child bearing age
 Four times high risk with OCP’s
 Usually solitary, 8- 15 cm in size
 Contains fat and glycogen
 Associated with GSD type I, when multiple lesions are
present

46.  Tumor composed of fatty hepatocytes arranged in cords
that occasionally form bile.
 Vascular lesions composed mainly hepatocytes with no
portal tracts or bile ducts.
 Thrombosis, necrosis, hemorrhage is common
 Can rupture leading to hemoperitonium
 Small, but definite risk (1%) of malignant change
 Hence surgical resection is usually preferred.

47.  T1-heterogeneous
 with increased signal areas due to fat and
hemorrhage
 T2- heterogeneous appearance
 1/3 rd have rim which is hypointense on T1 and T2
 Gadolinium enhanced MRI – Heterogenous
enhancement in the arterial phase but rapidly fades on
subsequent images.
 Hepatocellular adenomas imaged with CT, lipid
deposition seen in only 7% of lesions. In contrast, 35%–
77% of adenomas demonstrate steatosis at chemical
shift MR imaging

51. Nuclear scintigraphy
 Sulfur colloid-Very few kupffer cells hence uptake in only
20%
 Hepato biliary agents HIDA scans-uptake due to
hepatocytes but no excretion due to lack of bile ductules

52. Nodular Regenerative Hyperplasia
 Presence of diffuse, multiple regenerative nodules, not
associated with fibrosis
 Multiple nodules varying in size from few mm to cms on
the liver surface
 Rare condition.
 Usually associated with portal hypertension and portal
vein thrombosis

53.  MRI
T1- Hyperintese
T2- Hypointense
 Nuclear scintigraphy: Abnormal hepatocytes with kupfer
cells, hence uptake of Tc 99m sulfur colloid

55. Mesenchymal Hamartoma
 <2 years, 7 % of childhood tumors
 Benign cystic developmental lesions
 Gelatinous mesenchymal tissue
 Large – 15 cms or more
 Mass effect – Respiratory distress and lower limb
edema
 T1 – hypointensity. T2 – slightly hyperintense

57. Angiomyolipoma
 10% of patients with tuberous sclerosis & renal
angiolipomas have hepatic fatty tumors either lipoma,
angiomyolipoma.
MR
◦ Fat is high signal on T1 & T2
◦ MR with fat Suppression-same lesions are
hypointense

59. Infantile Hemangioendothelioma
 M/c liver tumor for first 6 months.
 Vascular tumor derived from endothelial cells that
proliferate and form vascular channels
 Solitary or multinodular. Nodules from few mm to
15cm or more
 Hemorrhage, fibrosis, thrombosis, calcification are
common
 90% discovered in first 6months.
 F>M, appearance similar to multiple
hemangiomas
 Hepatomegaly, CHF due to AV shunts,
thrombocytopenia caused by trapping of platelets
 Occasional rupture- hemoperitoneum

60. MRI
 Heterogenous appearance on both T1 & T2WI because
of presence of necrosis , hemorrahage and fibrosis.
 Peripheral enhancement and central fillin is noted after
administration of gadolinium.

61. Simple Cyst
 Arise from bile duct epithelium ,lined by cuboidal
epithelium. Multiple cysts as part of ADPKD and Caroli
disease .
 Hepatic cysts appear markedly hypointense on T1-
weighted MR images and markedly hyperintense on T2-
weighted images.
 Hepatic cysts have well-defined margins and are usually
oval or round. The presence of thick walls or enhancing
internal components suggests the diagnosis of hepatic
abscess or neoplasm rather than a simple cyst.

62.  When haemorrhage or inflammation occurs in the centre
of these cysts, the signal intensity on MRI undergoes a
variety of changes. Such lesions are referred to as
complicated cysts

64. Biliary Hamartoma
 Bile duct hamartomas, also called von Meyenburg
 complexes, are uncommon benign biliary malformations.
 asymptomatic and are typically discovered incidentally.
 Bile duct hamartomas are usually less than 1 cm in
diameter and are often numerous.

65. MRI
 T1- hypo
 T2 – hyper.
 contrast-enhanced images- no internal enhancement

67. Focal Hepatic Steatosis
 Focal steatosis is often easily recognized on
the basis of the typical periligamentous or
periportal location, and the presence of
nondistorted, traversing blood vessels.
 Patchy focal fat deposition or sparing may be
mistaken for an infiltrative neoplasm.

69. Focal Hepatic Infections
 HYDATID DISEASE
 PYOGENIC ABSCESS
 AMOEBIC ABSCESS
 CANDIDIASIS

70. Hydatid Cyst
 Caused by Echinococcus
 Right lobe of liver is most commonly involved.
 Cyst structure-
PERICYST: Dense connective tissue capsule
around the cyst
ECTOCYST: Middle laminated layer
ENDOCYST: Inner germinal layer that gives rise
to brood capsules

71.  Demonstrates pericyst, the matrix & daughter cysts.
 Pericyst- Hypointense rim on both T1 & T2 WI.
 Hydatid matrix – Hypointense on T1WI & markedly
hyperintense on T2WI.
 Daughter cysts- slightly hypointense when compared to
matrix on T2WI.

72.  Precetti S et al 2007 classified Hydatid disease into four
types on the basis of their radiologic appearance.
 Type Ⅰ: Simple cyst
 Type Ⅱ: Cyst with daughter cysts and matrix
 Type Ⅲ: Calcified cyst
 Type Ⅳ
 Hydatid complications include rupture and superinfec-
tion

73.  A solitary type cyst may be difficult to distinguish from a
simple epithelial cyst. The hydatid cysts are
hyperintense on DWI, whereas none of the simple cysts
show significant hyperintensity. The mean ADCs of the
hydatid cysts is significantly lower (2.5 × 10-3 ± 0.9) than
that of the simple cysts(3.5 × 10-3 ± 0.5)

78.  Complications
 Rupture and superinfections
 Rupture can be:
1. Contained type: only endocyst ruptures & cyst
contents confined by pericyst
2. Communicating type : when cyst contents escape into
biliary or bronchial radicles that are incorporated into
pericyst
3. Direct type:when both endo & pericyst tear & spill
contents into pleural, peritoneal or pericardial cavities

79.  Biliary Communications:
 Direct sign: Visualisation of cyst wall defect or
a communication between the cyst and biliary
radicle.
 Indirect sign: Fluid levels and signal intensity
changes.

80. Pyogenic Abscess
 ETIOLOGY.
 50% caused by anaerobic, mixed anaerobic-aerobic
 E. coli- MC in adults
 Staph- MC in children
 PATHOGENESIS
1. Biliary- MC because of ascending cholangitis from
benign or malignant biliary obstructions.
2. Portal vein - abscesses of biliary origin are often
multiple , whereas from portal vein source are often
solitary.
3. Hepatic art
4. Direct from adj organs

81. MRI
 T1-Hypo
 T2-Hyper
 DWI: tends to to have high signal within the abscess
cavity
 ADC: tends to have low signal within the abscess cavity
 Gd-DTPA-rim enhancement which persist in thickness
and intensity over time.
 Perilesional edema -hyper on T2 seen in 1/3 & diff from
cysts & hemangiomas

83. Differentiating hepatic abscess
from malignant mimickers
 No hepatic abscesses shows peripheral washout on 3-
min late phase compared with malignant tumors.
 Both shows hyperintense rims on DWI, but abscesses
have rims with high ADC values compared with one
malignant tumor.
 Mean ADC values of abscesses (1.47 × 10-3 mm2 /s) is
significantly higher than malignancies (0.68 × 10-
3 mm2 /s ).

84. Amoebic Liver Disease
 Caused by E.histolytica
 Mostly solitary
 MC in right lobe
 After intestinal infection is established, amoeba is
carried to the liver by the portal vein.
 Centrally the cavity is filled by a thick fluid that
resembles anchovy paste.

85. MR
 Hypo-T1
 Hyper-T2
 T2-edema
 They are difficult to differentiate from other liver
abscesses. They generally tend to be round or oval in
shapes in 82 verses 60% of pyogenic abscesses.

87. Hepatic Candiasis
 Uncommon ,caused by candid species
 Seen in immuno compromised patients
 Candida species may evoke
- little or no inflammatory response.
- cause the usual suppurative response
- occasionally produce granulomas

88. MRI
 Untreated nodules
1. Rounded lesions less than 1 cm in diameter
2. Minimally hypointense on T1-weighted and
gadolinium-enhanced images and markedly
hyperintense on T2-weighted images .
In the subacute presentation after treatment
1. Lesions appear mildly to moderately hyperintense on
T1- and T2-weighted images and demonstrate
enhancement on gadolinium-enhanced images.
2. A dark ring is usually seen around these lesions with
all sequences.

91. MALIGNANT LESIONS

92. Hepatocellular Carcinoma
 MC primary malignant tumor of liver
 Can develop in Cirrhotic and Non-Cirrhotic liver
 Wide geographical variation in incidence
 Present with - dull pain, fever, malaise, jaundice
 Elevated AFP values
 Hepatitis (B& C) and cirrhosis (particularly post necrotic
& haemochromotosis)-main risk factors. Others are
aflotoxins, steroids

93. THREE MAJOR PATTERNS
1. Large solitary mass
 Associated with massive necrosis and hemorrhage
2. Multifocal/nodular
 Multiple, well demarcated nodules similar to
metastasis
3. Diffuse infiltrative
 Multiple small foci through out liver

94.  Highly vascular and receives blood supply from the
hepatic artery.
 Vascular invasion of the Portal vein is more common
than the hepatic vein.
 Vascular invasion is a typical feature of HCC but tends
to occur in larger lesions, which can cause portal vein
invasion and thrombosis.
 The hyperintenense signal on T2WI is highly suggestive
of tumor thrombosis. The malignant thrombus also
causes portal vein dilatation (>23 mm)where as bland
thrombus rarely does. Identification is important because
malignant thrombus is a contraindication to liver
transplantation.

95. HCC-MRI
 T1WI- Hypointense
 T2WI- Hyperintense
 Capsule - hypointense on T1W and Hyperintense on
T2W
 Post contrast- Intensely enhance on arterial phase,
wash out of tumor signal below liver at 2min with late
enhancemnt of pseudocapsule.
 In contradistinction to the uniform fat deposition in
adenomas, fat deposition in HCCs is usually patchy.
Macroscopic fat within HCC is well demonstrated on CT
scans.

96.  The term transient hepatic intensity difference (THID), a
modification of the CT term transient hepatic attenuation
difference, is also used to describe peritumoral
enhancement, which is seen around HCC as an area of
hypervascularity in the arterial phase.
 In the cirrhotic liver if the lesion demonstrates
characteristic features of hepatocellular carcinoma—that
is, arterial phase hyperenhancement and portal venous
or delayed phase washout—with a single modality, the
diagnosis can be made and no further investigation is
required.

100. Focal Nodule In a Cirrhotic Liver
 Regenerating nodule
Hypointense on T1WI, T2WI, similar enhancement to
rest of liver.
 Dysplastic nodule
Hyperintense on T1WI, Hypointense on T2WI due to
iron accumulation ( siderotic nodule). Variable
enhancement
 HCC
Hypointense on T1WI, Hyperintense on T2WI
Enhances on arterial phase with washout of tumour
signal below liver at 2 min post contrast.
Peripheral pseudocapsule may enhance

101. Role of DWI in the characterization of
hepatocellular carcinomas and dysplastic
nodules in cirrhotic liver.
 HCC have slightly high or strongly high SI on
DWI, where as DNs have iso-SI or low SI. The
mean (SD) ADC and ADC ratio (lesion to
liver)for HCCs (1.28 x 10 [0.25] mm/s and 0.88
[0.15], respectively) is significantly lower than
those for DNs (1.53 x 10 [0.33] mm/s and 1.00
[0.08], respectively).

102. Regenerating nodules

104. NUCLEAR SCINTIGRAPHY
 Sulfur colloid- Heterogeneous uptake. Defect with
prominent left lobe & caudate lobe in cirrhosis
 HIDA-50% uptake due to ability of neoplastic
hepatocytes to produce bile
ANGIO
 Tumor blush due to presence of neovascularity and
shunts.
 If extension into veins → threads & streaks pattern can
be seen

105. Fibrolamellar Ca
 Solitary, lobulated,well defined tumor containing a
central fibrous scar.
 Younger age,5-35yrs
 M:F=1:1
 Non-cirrhotic, No increase in AFP
 Relatively good prognosis, mean survival-60
months(HCC-6mo)
 Hemorrhage and necrosis are rare.
 Central stellate calcification in 55% cases.

106.  MRI
T1- iso-hypo, T2- iso-hyper
Scar is hypo on T1 & T2 (fibrous nature)
(DD –FNH scar hyperintense on T2w)

108. Intrahepatic CholangioCarcinoma
 2nd MC primary liver malignancy
 M>F ,usually in 60’s
 Tumor arising from biliary duct epithelium & tends to
spread by local infiltration, accounts for 10% of all
cholangio Ca
 Three types
1.Mass forming
2.Periductal infilrating
3. Intraductal growing

109. Cholangio ca - MRI
 T1-hypointense
 T2-hyperintense +/-central hypo due to scar
 CE-(>4cm)-peripheral enhancement which progresses
towards center and spares scar
 CE-(2-4cm)-enhances homogeneously

111.  There are no specific imaging feature of ICCA that truly
distuinguishes it from HCC & metastsis.
 Capsular retraction and biliary dilatation adjacent to the
mass are highly suggestive of ICCA.
 Lesion > 4 cm show thick peripheral enhancement with
centripetal progression , like hemangioma but portal vein
invasion, bile duct dilatation, and patchy restricted
diffusion favors ICCA.

112. Metastasis
 Mets are the most common cause of malignant focal
lesions out numbering primary by 18:1
 MC site of mets is Lymph Node, 2nd is liver
 Colon-42%
 Stomach-23%
 Pancreas-21%
 Breast -14%
 Lung –13%

113. MRI
 T1 – usually hypointense. Mucin, hemorrhage, fat and
melanin appear hyperintense
 T2 – hyperintense
 The peripheral ring pattern is considered a specific
enhancement pattern for liver metastases butobserved
more frequently in hypervascular metastases,
particularly in neuroendocrine and carcinoid tumors
.

114.  . Classically, metastases from colon carcinoma, bladder
carcinoma, prostate carcinoma, and pulmonary
carcinoma have been considered hypovascular, and
those from thyroid carcinoma, carcinoid tumor,
neuroendocrine tumor, and renal cell carcinoma have
been considered hypervascular

118.  Metastatic liver cancer forms nodules as a rule, and their
distribution and size vary to some extent according to
the type of underlying malignancy.
 For example, liver metastases from pancreatic cancer
are usually small and uniform and are distributed
throughout the liver, whereas those from gallbladder
cancer tend to cluster in the gallbladder fossa

119. Cystadenoma&Cystadenoma Ca
 Rare & represent only 5% of all intra hepatic cysts of bile
duct origin
 Usually in middle aged women
 Same disease with cyst adenoma transforming into
Cystadeno Ca
 Cystadenomas are typically large and multilocular.

120.  MR
T1- low intensity
T2- high intensity
Variable intensity on both T1 and T2 images depend on
presence of solid components, hemorrhage and protein
content and helps in diff from other cystic diseases.

122. Hepatoblastoma
 MC primary liver neoplasm under the age of 3 years.(
esp b/w18-24 months)
 3rd MC abdominal tumor in childhood
 MC in males
 Increased serum AFP
 Aggressive-lung mets usually at time of diagnosis

123.  MRI
T1-hypo + areas of hyper (hemorrhage)
T2-hyper + areas of linear hypo (septae)

124. Role of DW-MRI in evaluation of
hepatic focal lesions
 The lowest ADCs are found in metastases, CCA and
HCCs and the highest values are found in
hemangiomas. The difference between the mean ADC
values of benign and malignant lesions was significant.
No significant differences in ADC values among the
different benign lesions or among the different malignant
lesions at both sequences.

125. Female
patient aged
55 year
presented
with
jaundice,
epigastric
pain and
epigastric
swelling
with past
history of
cancer
colon
resection.
mean ADC
value = 0.9
× 10−3 s/mm
2

126. Male
patient
aged
66 year
with liver
cirrhosis
presented
with
clinically
palpable
epigastric
swelling.
mean ADC
value = 1.1
2 × 10−3 m
m2/s

127. Male patient
aged 55 years
presented with
obstructive
jaundice. mean
ADC
value = 1.2 × 1
0−3 s/mm2

128. Female patient
aged 51 year,
presented with
hyperechoic left
hepatic lobe focal
lesion during US
checkup. mean
ADC
value = 2.9 × 10−3 s
/mm2

129. Advanced and emerging modalities

134. Conclusion
 Dynamic contrast-enhanced MR imaging is excellent for
the evaluation of various focal hepatic lesions. A
comprehensive MR imaging examination can be used to
diagnose or at least narrow the differential diagnosis for
most of these lesions.