Liverlesions
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Liverlesions Begins at about 3-4 minutes after contrast injection and imaging is best done at 10 minutes Valuable for washout of contrast(HCC),retention of contrast(heamangioma),retention of contrast in fibrous tissue (capsule of HCC, central scar of FNH)
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Liverlesions
- 1. Powerpoint Templates Liver lesions Page 1 Dr. Vrishit Saraswa Resident Department of Radiodiagnosis
- 2. Powerpoint TemplatesBenign Liver lesions Page 2 • Hemangioma • Focal nodular hyperplasia • Hepatic adenoma • Liver cyst • Liver abscess
- 3. Powerpoint TemplatesMalign ant Page 3 •Hepatocellular carcinoma •Heptoblastoma Rare malignant: •Fibrosarcoma •Angiosarcoma •Leiomyosarcoma •Lymphoma
- 4. Powerpoint TemplatesHypervascular lesions Page 4 Benign •Heamangioma •Adenoma •FNH Malignant •HCC •Hypervascular metastasis
- 5. Powerpoint Templates Hypovascular lesions Page 5 • Hypovascular liver tumors are more common. • Most hypovascular lesions are metastases.
- 6. Powerpoint TemplatesMultiphasic CT Page 6 For detection of liver lesions • Non enhance CT • Arterial phase • Portal venous phase • Delayed
- 7. Powerpoint Templates Understanding the phases Page 7 • Liver has dual blood supply • Normal parenchyma is supplied for 80% by the portal vein and only for 20% by the hepatic artery • All liver tumors get 100% of their blood supply from the hepatic artery
- 8. Powerpoint Templates Arterial phase Page 8 • In the arterial phase hypervascular tumors will enhance via the hepatic artery, when normal liver parenchyma does not yet enhances, because contrast is not yet in the portal venous system. • Hypervascular tumors will enhance optimally at 35 sec after contrast injection
- 9. Powerpoint TemplatesPortal venous phase Page 9 • To detect hypovascular tumors • Scanning is at about 75 seconds
- 11. Powerpoint TemplatesDelayed Phase Page 11 • Begins at about 3-4 minutes after contrast injection and imaging is best done at 10 minutes • Valuable for washout of contrast(HCC),retention of contrast(heamangioma),retention of contrast in fibrous tissue (capsule of HCC, central scar of FNH)
- 13. Powerpoint Templates Precontrast ArterialPhase Portalvenous phase Delayed Hepatocelluar Ca Lowattenuation Homogenous enhancement Washoutof lesion Isodense Adenoma Lowattenuation Homogenous enhancement 85% Isoor hypodense Iso or hypodense Haemangioma Lowattenuation Peripheral puddles Partial Fill in Complete fill in FNH Iso/Low attenuation Homogenous enhancement Hypodense Isodense Metastasis(hypervascular) Lowattenuation Homogenous enhancement Hypodense Metastasis Lowattenuation Hypodense Hypodense Cyst Lowattenuation Noenhancement Abscess Low attenuation may have irregular margins Transient regional increaseenhancement Ring enhancement Multiphasic CT of Liver Page 13
- 14. Powerpoint Templates T1W T2W Gadolinium HepatocellularCa ,isoor (fatdegeneration) Metastasis Haemanigioma ++ (likeCT) Adenoma often FNH + delayed MRI of Liver Page 14
- 15. Powerpoint Templates Hepatocellular Carcinoma Page 15 • Most common primary malignancy of the liver • Third most common cause of cancer- related death • The incidence of HCC is rising, largely attributed to a rise in hepatitis C infection
- 16. Powerpoint Templates Risk factors: Page 16 • hepatitis B (HBV) infection • hepatitis C (HCV) infection • alcoholism • biliary cirrhosis • food toxins e.g. aflatoxins • congenital biliary atresia • inborn errors of metabolism haemochromatosis alpha-1 antitrypsin deficiency type 1 glycogen storage disease Wilson disease
- 18. Powerpoint Templates Clinical presentation Page 18 Presentation is variable may include: • constitutional symptoms • jaundice • portal hypertension from invasion of the portal vein • hepatomegally / mass
- 19. Powerpoint Templates • Majority of patient have cirrhosis • More than 80% of patients with HCC have cirrhosis • May be Focal, multiple or diffusely infiltrative Page 19
- 20. Powerpoint TemplatesInvestiga tion Page 20 • alpha-fetoprotein (AFP) levels are elevated in 50-75 % of cases • Radiological investigation including ultrasound, CT and MRI • Biopsy
- 21. Powerpoint TemplatesUltrasou nd Page 21 • Variable appearance • Small <3cm usually hypoechoic • Larger tumors often are heterogeneous • May invade the portal vein • Most tumors will show central vascularity on Doppler study
- 25. Powerpoint TemplatesC T Page 25 • Focal HCC large usually hypodense mass may have necrosis / fat / calcification • Multifocal HCC multiple masses of variable attenuation may also have central hypodense necrotic portions • Diffuse HCC may be difficult to distinguish from associated cirrhosis
- 26. Powerpoint TemplatesEnhancement pattern Page 26 • Transient early arterial enhancement and then washes out
- 30. Powerpoint Templates MR I Page 30 T1(variable) T1 C+ (Gd) Enhancement similar to CT Rim enhancement may persist T2 –Hyperintense Post SPIO (Iron oxide) - increases sensitivity in diagnosing small HCC’s
- 33. Powerpoint Templates Fibrolamellar hepatocellular carcinoma • Variant of HCC • Younger age group(20-40years) • Not associiated with cirrhosis • No association with HCC risk factors • Usually present with constitutional symptoms • Fibrollamellllar carcinomas typically are singlle llarge ttumours Page 33
- 34. Powerpoint TemplatesUltrasou nd Page 34 • Usually large heterogeneous predominantly hyperechoic lesion, calcification may be seen(40%)
- 35. Powerpoint Templates C T Page 35 • Large solitary well circumscribed • Heterogeneous arterial enhancement • 30-40% have central scar • Calcification can be seen on non enhanced CT
- 39. Powerpoint TemplatesHepatic metastasis Page 39 • More common than primary • May be solitary but usually multiple • Majority are hypovascular • Extremely variable appearance on ultrasound
- 40. Powerpoint Templates Hypervascular metastases Page 40 • Carcinoids • Leiomyosarcomas • Neuroendocrine tumors • Renal carcinomas • Thyroid carcinomas • Choriocarcinomas • Occasionally pancreas, ovary, or breast
- 41. Powerpoint Templates Ultrasou nd Page 41 Hypoechoic metastasis • Lymphoma • Sarcoma • Most adenocarcinoma(breast, lung, pancreas)
- 43. Powerpoint Templates Page 43 Hyperechoic Colorectal carcinoma and other GIT Carcinoid, Renal cell carcinoma, islet cell tumor
- 45. Powerpoint Templates Cystic metastasis • Ovarian carcinoma • Cystadenocarcinoma of pancreas • squamous cell carcinoma Calcified metastasis • Mucinous adenocarcinoma of colon Page 45
- 48. Powerpoint Templates C T Page 48 • On unenhanced CT -> Hypodense • On Enhanced CT -> non enhancing hypodense • The margin of the lesions can vary from well defined to ill defined • Hyperattenuating lesions are uncommon
- 50. Powerpoint Templates MR I Page 50 • Most metastase are hypointense on T1 • Hyperintense on T2
- 52. Powerpoint Templates Interactive cases Page 52
- 53. Powerpoint Templates Liver calcification causes?? Page 53