Baron pitfalls in liver imaging cirrhosis_rsna 2014
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1) Cirrhosis of the liver complicates imaging due to the increased risk of hepatocellular carcinoma (HCC) and the presence of other lesions that can mimic HCC. 2) While most HCCs enhance on arterial phase imaging, up to 15% are hypovascular and imaging techniques must be optimized to properly detect tumors. 3) Benign lesions like regenerative nodules, focal fibrosis, and vascular abnormalities are common in cirrhotic livers and can appear similar to HCC, so attention to characteristics on all phases is important to avoid misdiagnosis.
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Baron pitfalls in liver imaging cirrhosis_rsna 2014
- 1. Pitfalls in Liver Imaging: Cirrhosis Richard Baron, M.D. University of Chicago Slides online: https://www.radiology.uchicago.edu/page/faculty-lectures URL address in RSNA Meeting On-Line Program
- 2. Background: HCC in Cirrhosis • 10 – 14% of advanced cirrhosis harbors HCC • 25% of Hepatitis B/C patients develop HCC within 10 years • Compare to risk of colon cancer in 50 y.o.: < 1% prevalence, 7% lifetime incidence
- 3. How Good Are We at Imaging Cirrhotic Liver? • Triaging patient care now with noninvasive imaging diagnosis of HCC • Most HCC are hypervascular and well seen on arterial phase imaging: But 10 – 15% of HCC are hypovascular • What are implications of finding more lesions? ►Reliance on accuracy, specificity • Up to 75% of small arterially enhancing lesions in cirrhosis are benign!
- 4. Pitfalls in Cirrhotic Liver Imaging • Technical – Optimizing HCC detection • Pathology and Natural History of HCC – Regenerative nodule transformation to HCC – Unusual imaging variants of HCC • Simulators of HCC and other adverse conditions – Benign vascular lesions – Cirrhotic processes ►Focal Confluent Fibrosis ►Infarcted Regenerative Nodules ►Arterio-portal shunts ►Peribiliary cysts – …
- 5. Siderotic Nodules: CT Non Contrast Portal Venous Phase
- 6. Pitfall: Mistaking siderotic nodule for enhancing HCC Case courtesy of Giuseppe Brancatelli, M.D.
- 8. MR Excels in Detecting Siderotic Regenerating Nodules T2 MR T1 SPGR MR + C Pitfall: Mistaking iron susceptibility for areas of tumoral decreased perfusion!
- 9. HCC Dx: AASLD CRITERIA > 10 mm Liver Lesion, chronic liver disease One imaging technique with typical HCC (AP hypervascularity & PV/EQ washout) If atypical on CT or MR, recommends utilizing the other for possible characterization UNOS/OPTN and LI-RADS accepts capsule formation American Association for the Study of Liver Diseases (AASLD) Practice Guideline. 2010 AP PV EQ
- 10. Arterial Phase Imaging: Pitfall: Inadequate Rate of Contrast infusion 2.5 ml/sec 5.0 ml/sec 75th cc 60th cc ?? cc
- 11. Pitfall: Timing for arterial phase tumor enhancement 18 sec 35 sec Bolus Tracking: 100 – 150 HU aorta, + add 18 secs
- 12. 01/22/2008 Pitfall: Inadquate attention to EQ Phase 10/30/2007 Pre Portal EquilibriumLate ArterialEarly Arterial
- 13. HCC Enhancement Pitfall: Assuming all enhance and washout similarly • Majority show classic pattern ……. BUT • 10 – 15% are hypovascular at presentation • Occasionally HCC can demonstrate peliotic changes and delayed enhancement • Technical pitfall: PV Phase scan may be too early and simulate retained contrast enhancement
- 14. AP PVP DP DN low Grade HCC Gr I HCC Gr I DN HCC simulating blood pool enhancement Case courtesy of Dr. Hyun-Jung Jang , University of Toronto
- 15. T2 T1 Gadolinium Pitfall -- Regenerating nodules enhance
- 17. HCC: Best Visualized with MR Gadolinium Contrast?
- 18. HCC: MRI signal intensities AP EQ Delay T1 T2 DWI Hepatobiliary agent Pt #1 Pt #2 Pitfall: Assuming there is a specific constellation of MR signal intensities to characterize HCC nodule!
- 19. HCC Benign Nodule AP Hyperintensity 84% 42% T2 Hyperintensity 60% 16% Washout 79% 65% Hepatobiliary Delay Hypointensity 79% 51% All 4 signs 42% 0% < 1 sign 9% 64% Cirrhotic Nodule MRI signal intensities: 1 - 2 cm Kim TK, Radiology, 2011 DWI Hyperintensity 81% 27% Lee MH, AJR, 2011
- 20. Diagnosing HCC: Value of T2 characteristics AP EQ
- 21. Pitfall: T2 characteristics are NOT seen on SSFSE T2 Fat Sat SSFSE T2 Fat Sat SSFSEAP
- 22. Pitfall: Biological Variation July, 2007 December, 2007 2010 Arterial Phase Delay Phase
- 23. Pitfall: Other malignancies in Hepatitis C Follicular Hepatic Lymphoma: Associated with hepatitis C, usually polyclonal, but can progress to monoclonal malignancy AP PV T1T2
- 24. Hemangioma in cirrhosis: Uncommon! AP 2003 20052004 T2 2006 T2 T2
- 25. Pitfall in cirrhosis: Think twice before suggesting hemangioma AP1 PVP1AP2 PVP2 EQ T2 Close attention to EQ and T2 will show characteristics diagnosing HCC! 509 Consecutive transplant specimens Pathology: 9 patients Imaging: 3 patients ( < 1%) Miller et al, Radiology, 1994
- 26. HCC and Hemangioma in Cirrhosis Screening
- 27. HEMANGIOMA LIKE LESIONS IN CIRRHOSIS DYSPLASTIC NODULE HCC HEMANGIOMA From Caturelli et al, Radiology, 2001; 220:337-342 • 1982 patients • 44 hemangioma like lesions • 22 hemangiomas; 22 HCC • 1648 patients followed • 26 hemangioma like lesions • 22 HCC; 4 dysplastic nod.
- 28. Parenchymal Cysts in Cirrhosis are Uncommon HCC Cyst
- 30. Peribiliary Cysts Pitfall: Simulate Biliary Obstruction
- 31. Avoiding Pitfall: Septations separate Cysts
- 32. Avoiding Pitfall: Cysts on Both Sides of Portal Vein
- 33. False Positive CT Diagnosis HYPERVASCULAR Reg/Dysplastic Nodules Focal Fibrosis Peliosis A-P Shunting/THAD HYPOVASCULAR Focal Fibrosis Reg Nodules (and infarcted nodules) Fibrosed Hemangiomas
- 34. Focal Confluent Fibrosis • Characteristic Location Segs 8, 4 & 5 Wedge Shaped • Capsular Retraction • Trapped/crowded vessels
- 36. Focal Confluent Fibrosis T2 MR
- 37. Focal Confluent Fibrosis: Enhancement
- 38. • Cirrhosis truly complicates liver imaging! Cirrhotic Liver: TAKE HOME POINTS • Incidence and prevalence of HCC puts imagers on high alert for suspicious findings • Remember decreasing prevalence of hemangiomas and cysts • Be aware of characteristics of benign lesions to avoid misdiagnosis of HCC and biliary obstruction • Attention to imaging techniques are critical for detection of HCC Contrast infusion rate; AP timing; Importance of T2 FSE c/w SSFSE Not all HCC follow classic early enhancement pattern or show a specific MR signal intensity pattern!