This document discusses various malignant liver lesions including primary and secondary tumors. For primary liver cancers, it describes hepatocellular carcinoma (HCC) as the most common type, risk factors such as hepatitis, and imaging features. It also discusses cholangiocarcinoma, hepatoblastoma, and rare tumors such as fibrolamellar carcinoma. Secondary cancers and criteria for staging HCC are also summarized.

1. MALIGNANT LESIONS
OF LIVER
Dr. Harshita Saxena
Department of Radiodiagnosis
Sir Ganga Ram Hospital
New Delhi

2. PRIMARY
 Hepatocytes
o Hepatocellular carcinoma
(HCC)
o Fibrolamellar HCC
o Hepatoblastoma
 Biliary epithelium
o Cholangiocarcinoma
o Cystadenocarcinoma
 Mesenchymal origin
o Angiosarcoma
o Epitheloid
hemangioendothelioma
o Leiomyosarcoma
o Lymphoma
SECONDARY
o Metastatic deposits
o Lymphoma
METASTASIS IS COMMONEST MALIGNANT HEPATIC LESION

3. In paediatric age group most common malignant
tumors in decreasing order of frequency
 Hepatoblastoma,
 Hepatocellular carcinoma (HCC),
 Undifferentiated (embryonal) sarcoma (UES),
 Angiosarcoma, and
 Embryonal rhabdomyosarcoma.
 Epithelioid hemangioendothelioma (EHE) may also occur in
adolescents.
RadioGraphics 2011; 31:483–507
In a study of 716 cases of pediatric liver tumors submitted to the
Armed Forces Institute of Pathology between 1970 and 1999, Ishak
et al (1)

4. Hepatocellular Carcinoma
 Most common primary malignancy of the liver
 Male : female > 4 : 1
 Rising incidence, attributed to a rise in hepatitis B and C infection

5. Risk factors
 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

6. Clinical presentation
 HCC are typically diagnosed in adults in late middle age or elderly
 Patients with cirrhosis usually present earlier.
 less aggressive - pyrexia of unknown origin, abdominal pain,
malaise, weight loss, and hepatomegaly. Jaundice is rare.
 Aggressive - hemoperitoneum.

7. Investigation
 alpha-fetoprotein (AFP) levels are elevated in 50-75 % of cases
 Radiological investigation including ultrasound, CT and MRI
 Biopsy

8. USG
• 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.

9. CT
 Focal calcification -7.5%
 Majority – hyperdense on
arterial phase, as HCCs take
supply from the hepatic artery
rather than portal vein
 Heterogenous enhancement
due to central necrosis

11.  Arterio portal shunts

12. Tumour thrombus shows enhancement on arterial phase, it causes expansion of vessel &
will often show continuity with primary tumour.

14. In phase
Out phase
If HCC is containing fat :- loss of signal on the out-of-phase image compared with the in-phase image can be seen.

15. T1 T2
SPIO
RES SPECIFIC CONTRAST
ADMINISTRATION
Ferucarbotran (after 20min)

16. Pathologically, there are several
variant types of HCC
 clear cell type HCC,
 fibrolamellar HCC,
 sarcomatoid HCC,
 combined HCC–cholangiocarcinoma, and
 sclerosing HCC
Hepatocellular carcinoma variants: radiologic-pathologic
correlation. AJR Am J Roentgenol. 2009 Jul;193(1):W7-13.

17. Clear cell type HCC
 Abundant cytoplasmic fat is present resulting increased
echogenicity on USG and decreased attenuation on CT.
 Signal drop on opposed-phase T1-weighted MR images.

18. Sarcomatoid HCC
 is an aggressive variant that grow rapidly, resulting in central
necrosis or hemorrhage
 shows peripheral enhancement with an unenhanced central
portion

19. Combined HCC-cholangiocarcinoma
 composed of elements from both entities.
 On contrast-enhanced CT and MRI :- the HCC-dominant tumor is
well enhanced in the early phase and washed out in the late phase,
and the cholangiocarcinoma-dominant tumor shows peripheral
and delayed enhancement.

20. Sclerosing HCC
 characterized by intense fibrosis.
 With remarkable progressive and prolonged enhancement

21. Fibrolamellar Carcinoma
 usually presents as a single, large, well-demarcated, but
nonencapsulated tumor with fibrous bands and a central
fibrous scar.
 adolescents or young adults.
 The typical risk factors for HCC such as cirrhosis, elevated
alphafetoprotein etc are absent.
On histopathology it is characterized by
laminated fibrous layers, interspersed
between the tumor cells.

22.  USG:
 as a solitary, well-defined,
lobulated mass with
variable echotexture
 calcification may be
seen(50%)

23. CT:
 Hypodense mass
 Central scar – Calcification
 Predominant heterogenous enhancement

24. MRI
ON MRI FLC SHOWS HETEROGENOUS ENHANCEMENT
WITH HYPOINT SCAR WHICH SHOWS DELAYED ENHANCEMENT

25. FNH v/s FLC
 Central scar of FNH -hyperintense on T2.
 FNH rarely has calcification within the scar.
 While FNH is always very homogeneous, FLC is usually
heterogeneous following contrast administration.
 Fibrolamellar carcinomas do not show significant
enhancement on delayed hepatobiliary phase images after
administration of Gd-BOPTA however FNH appears
hyperintense.
 FLC has relative lack of Kupffer cells, resulting in a photopenic
defect at 99mTc labeled sulfur colloid scanning
 Biopsy
 normal hepatocytes with bile ductules in FNH
 Malignant, eosinophilic hepatocytes in FLC

26. * American College of Radiology (ACR).
LIRADS
A system of standardized
terminology and criteria to
interpret and report
imaging examinations of
the liver.
LR-3 Intermediate probability
of being HCC
LR-4 Probably HCC
LR-5 Definitely HCC.

27. OM: Other Malignancy
Cholangiocellular carcinoma
(CCC)
•Metastasis
•Lymphoma,
•Post-transplant
lymphoproliferative disorder
(PTLD)

28. LR5V: Definitely HCC with
Tumor in vein
The term tumor in vein is
preferred over the term tumor
thrombus

29. reduction in enhancement resulting in portal
venous phase or delayed phase hypo-
enhancement relative to liver.
Delayed phase
usually should be
acquired at around
3-5 mints

30. Peripheral rim of smooth hyper-
enhancement in the portal venous
phase or delayed phase that
unequivocally is thicker or more
conspicuous than the rims
surrounding background nodules.

31. increase in diameter of a mass by a minimum of 5mm AND, depending on the
time interval between examinations, by the following amounts:
o Time interval Diameter increase ≤ 6 months ≥ 50%
o > 6 months ≥ 100%
o A new ≥10mm mass also represents threshold growth, regardless of the time
interval.

32. AASLD
Criteria
Hepatocellular carcinoma: illustrated guide to systematic radiologic diagnosis and staging according to guidelines of the American Association for the Study of
Liver Diseases. Radiographics. 2013 Oct;33(6):1653-68.

33. Staging of
Hepatocellular Carcinoma
AASLD advocates use of the BCLC (Barcelona Clinic Liver Cancer )
staging system because it is the only system that encompasses the three
factors that have been shown to be independent predictors of survival :-
 radiologic tumor extent,
 liver function { by using the Child-Turcotte-Pugh (CTP) score} and
 patient’s performance status { by using the Eastern Cooperative Oncology
Group (ECOG) scale}

34. Radiologic BCLC stage 0 disease is a solitary lesion
that measures less than 2 cm in diameter
portal
hypertension or
hyperbilirubinemia
ABSENT
RESECTION
portal
hypertension or
hyperbilirubinemia
PRESENT
TRANSPLANTATION
Associated
comorbidities
RFA

35. Radiologic BCLC stage A disease is a solitary lesion that measures
more than 2 cm in diameter or early multifocal disease that consists
of up to three lesions, none of which measure more than 3 cm in
diameter
portal
hypertension or
hyperbilirubinemia
ABSENT
RESECTION
portal
hypertension or
hyperbilirubinemia
PRESENT
TRANSPLANTATION
Associated
comorbidities
RFA

36. Radiologic BCLC stage B disease is advanced
multifocal disease that consists of more than one
lesion, with at least one that is larger than 3 cm, or
of more than three lesions regardless of size
TACE

37. Radiologic BCLC stage C disease is
hepatocellular carcinoma with either vascular
invasion or nodal or metastatic disease.
SORAFENIB

38. BCLC stage D disease is not a radiologic stage. It
is determined only on the basis of poor liver
function and poor patient performance (CTP = C,
ECOG > 2).
Management consist of only supportive therapies

39. Transplantation criteria widely used
Milan criteria
 presence of a solitary hepatocellular carcinoma <5 cm, or
 up to three separate lesions, each <3 cm.
 no extrahepatic involvement
 no major vessel involvement

40. HEPATOBLASTOMA
 Most common primary liver tumor in childhood.
 Usually occurs in first 3 yrs of life.
 Present as painless abdominal mass, anorexia, wt loss, pain &
jaundice.
 S.AFP is usually elevated.
 Usually unifocal but multiple nodules or diffuse liver
involvement may be seen. calcification in about 33%.
 Epithelial hepatoblastomas demonstrate a more
homogeneous appearance, while mixed tumors are more
heterogeneous in attenuation.

41. USG
 large, inhomogeneous echogenic mass sometime
with calcification.

42. CT
 well defined heterogeneous
hypodense mass. Frequently
with areas of necrosis,
haemorrhage and
calcification.
 Like HCC, hepatoblastoma
can invade the portal or
hepatic veins
Arterial neovascularity can be seen with washout
on delayed scans.

43. MRI:
 T1: generally hypointense
 C+ (Gd): can show heterogeneous enhancement
 T2 : generally hyperintense compared to liver
 areas of necrosis and haemorrhage are common

44. Cholangiocarcinoma
 second most common primary hepatic tumour
 usually in the elderly (7th decade).
 There is slight male predilection.
 Elevated tumor markers: CA19-9, CEA

45. Risk factors • primary sclerosing cholangitis (PSC)
• recurrent pyogenic cholangitis
• liver flukes
• Opisthorchis viverrini
• Clonorchis sinensis (clonorchiasis)
• Caroli's disease/choledochal cysts
• toxins
• thorotrast
• dioxin
• polyvinyl chloride
• heavy alcohol use
• viral infection(s)
• HIV
• hepatitis B and hepatitis C
• EBV

46. According to
macroscopic growth pattern
 mass-forming
 periductal infiltrating: most common at the hilum
 intraductal: slow growing with better prognosis
Cholangiocarcinoma: pictorial essay of CT and cholangiographic findings. Radiographics. 2002 Jan-Feb;22(1):173-87.

47. Ultrasound
 Mass-forming intrahepatic: tumours will be homogeneous mass of
intermediate echogenicity with a peripheral hypoechoic halo of
compressed liver.
 are often associated with capsular retraction
 Periductal infiltrating:
 altered calibre bile duct (narrowed or dilated) without a well-
defined mass.
 Intraductal:
 usually ductectasia with or without a visible mass. If a polypoid mass
is seen, it is usually hyperechoic.

48.  Mass-forming cholangiocarcinomas: are typically homogeneously
low in attenuation on non-contrast scans, and demonstrate
heterogeneous peripheral enhancement with gradual
enhancement centrally.
 capsular retraction may be seen.
 The bile ducts distal to the mass are typically dilated.
 unlike HCC, cholangiocarcinoma only rarely forms a tumour
thrombus .
The lesion appears hyperdense in the
equilibrium phase due to dens fibrous tissue
retaining contrast

49. Appears hypoint on T1 and hyperint on T2 WI & Shows Heterogeneous predominantly peripheral enhancement which becomes more extensive
and central on the delayed images.

50. Cystadenocarcinoma
 rare, usually slow growing, multilocular cystic tumors
 in middle-aged women
 Symptoms are related to the mass effect of the
lesion and consist of intermittent pain or biliary
obstruction.

51. Imaging features
 USG & CT: it appears as a solitary cystic mass with a
well-defined thick fibrous capsule, mural nodules,
internal septa, and rarely capsular calcification.
 Polypoid, pedunculated excrescences

52. MRI
 fluid-containing multilocular mass, with homogeneous low
signal intensity on T1-weighted images and homogeneous
high signal intensity on T2-weighted images.
PV-phase Gd - enhanced T1w MR
shows enhancement of the capsule
and septa.

53. ANGIOSARCOMA
 Rare tumor seen in adults of 5th to 7th decade, more common in
men than in women.
 associated with chemical carcinogens exposure including
Thorotrast.
 Metastases are seen in 60% of patients at presentation, the
median survival is only 6 months.
 On USG, either multiple nodules or a solitary mass can be
demonstrated.
 The echotexture of an angiosarcoma varies according to the
degree of internal necrosis and hemorrhage.
Malignant vascular tumors of the liver: radiologic-pathologic correlation.
Radiographics. 1994 Jan;14(1):153-66.

54. CT
 either single or multiple masses
that are predominantly
hypoattenuating & may contain
foci of calcification
 Dynamic CT findings may mimic
a large hemangioma,
 incomplete filling with contrast
material is the rule.

56. Hepatic epithelioid
hemangioendothelioma
 Rare malignant hepatic vascular tumour often
incidentally discovered in adults.
Ultrasound
 predominantly hypoechoic; however, can also
have mixed echotexture.
Malignant vascular tumors of the liver: radiologic-pathologic correlation.
Radiographics. 1994 Jan;14(1):153-66.

57. CT
 Typically seen as multiple hypo-attenuating lesions that
coalesce to form larger confluent hypo-attenuating regions
in a peripheral or subcapsular distribution with peripheral and
progressive centripetal enhancement in larger lesions with
incomplete fill-in on delayed phase images.
 Subcapsular lesion often present with capsular retraction.

58. MRI
 T1: hypointense lesions
 T2: heterogeneously increased signal intensity.
 Lesions often shows peripheral halo or target
like appearance.

59. Hepatic lymphoma
can be broadly divided into:
 secondary hepatic involvement with lymphoma:
commonest by far, many tend to be non Hodgkin
lymphoma (NHL)
 primary hepatic lymphoma: extremely rare.
 It may be difficult to differentiate primary vs secondary from
analysis of the liver lesion alone.
CT
 Lesions are generally reported to be hypo attenuating on
CT.
MRI
 T1: hypointense (mild to moderate) relative to liver
 T2: hyperintense relative to liver
 C+ (Gd): transient increased perilesional enhancement is
common.

60. Metastasis
ADULTS
 Colon
 Stomach
 Pancreas
 Breast
 Lung
Children
 Neuroblastoma
 Wilms tumor
 Leukemia
Metastatic lesions are more common than primary in liver

61. Hypovascular metastases
 are the most common
 occur in GI tract, lung, breast and head/neck tumors.
 They are detected as hypodense lesions in the late portal venous
phase
 The rim enhancement that occurs represents viable tumor
peripherally.

62. Hypervascular
metastases
 Renal Cell Carcinoma,
 Thyroid,
 neuroendocrine tumors (islet cell tumors,
carcinoid, pheochromocytoma).
 Melanoma,
 Choriocarcinoma.

63. Hemorrhagic Liver Metastases
 Colon
 Thyroid
 Breast
 Choriocarcinoma
 Melanoma
 RCC
Metastatic tumor with internal fluid-fluid level (arrow)
suggesting intratumoral hemorrhage.
Published by the University of Washington in the public interest. ISSN
1930-0433

64. Calcified metastases
 Mucinous CA of GI tract (colon, stomach,
rectum),
 Melanoma
 Ovarian ca.

65. Cystic metastases
 Mucinous ovarian ca,
 Colonic ca

66. Main References
 Buetow PC, Buck JL, Ros PR, Goodman ZD. Malignant vascular tumors of the
liver: radiologic-pathologic correlation. Radiographics. 1994 Jan;14(1):153-66.
 McEvoy SH, McCarthy CJ, Lavelle LP, Moran DE, Cantwell CP, Skehan SJ et al.
Hepatocellular carcinoma: illustrated guide to systematic radiologic diagnosis
and staging according to guidelines of the American Association for the
Study of Liver Diseases. Radiographics. 2013 Oct;33(6):1653-68.
 Chung EM, Lattin GE Jr, Cube R, Lewis RB, Marichal-Hernández C, Shawhan R,
Conran RM. From the archives of the AFIP: Pediatric liver masses: radiologic-
pathologic correlation. Part 2. Malignant tumors. Radiographics. 2011 Mar-
Apr;31(2):483-507.
 Chung YE, Park MS, Park YN, Lee HJ, Seok JY, Yu JS, Kim MJ. Hepatocellular
carcinoma variants: radiologic-pathologic correlation. AJR Am J Roentgenol.
2009 Jul;193(1):W7-13.
 McEvoy SH, McCarthy CJ, Lavelle LP, Moran DE, Cantwell CP, Skehan SJ et al.
Hepatocellular carcinoma: illustrated guide to systematic radiologic diagnosis
and staging according to guidelines of the American Association for the
Study of Liver Diseases. Radiographics. 2013 Oct;33(6):1653-68.
 Han JK, Choi BI, Kim AY, An SK, Lee JW, Kim TK et al. Cholangiocarcinoma:
pictorial essay of CT and cholangiographic findings. Radiographics. 2002 Jan-
Feb;22(1):173-87.
 Liver Masses - Common Tumors. Richard Baron. Radiology Assistant.