Download Radiographic Evaluation of Hepatocellular Carcinoma

Jessica Y. Leung, HMS 2004
January 2003
Gillian Lieberman, MD
Radiographic evaluation of
hepatocellular carcinoma
Jessica Y. Leung, Harvard Medical School, Year III
Gillian Lieberman, MD
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Jessica Y. Leung, HMS 2004
Gillian Lieberman, MD
Mr. B.
HPI:
• 71 yo man with mild diarrhea and R sided rib
discomfort
PMH:
• Prostatectomy in 1995 for early stage prostate CA
• Superficial melanoma removed in 1998
• Hx of benign colon polyps
• No risk factors for liver disease
? Liver metastases from melanoma or prostate cancer
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Jessica Y. Leung, HMS 2004
Gillian Lieberman, MD
Mr. B. – RUQ ultrasound
Large lesion in R hepatic lobe,
solid with heterogeneous
echotexture
BIDMC PACS
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Jessica Y. Leung, HMS 2004
Gillian Lieberman, MD
DDx of Solid Liver Mass
What types of cells are in the liver?
• Hepatocytes
• Adenoma, hepatoblastoma
• Focal nodular hyperplasia
• Hepatocellular carcinoma
• Bile ducts
• Cholangioma
• Cholangiocarcinoma
• Blood vessels
• Hemangioma,
hemangioendothelioma
• Angiosarcoma
• Invading cells
Normal liver histology
http://mycourses.med.harvard.edu/
collection_display.asp, HMS #61
• Metastases
• Lymphoma
• Carcinoid
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Jessica Y. Leung, HMS 2004
Gillian Lieberman, MD
DDx of Liver Mass in Adult
> 50 yo (Mr. B.)
• Common
• Hemangioma
• Metastases
• Uncommon
• Angiosarcoma
• Hepatocellular
carcinoma
• Intrahepatic
cholangiocarcinoma
< 50 yo
• Common
• Focal nodular hyperplasia
• Uncommon
• Fibrolamellar carcinoma
• Hepatocellular carcinoma
Reeder MMM. Reeder and Felson’s Gamuts in Radiology. 1993.
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Jessica Y. Leung, HMS 2004
Gillian Lieberman, MD
Mr. B.’s diagnosis
• Ultrasound-guided biopsy demonstrated
hepatocellular carcinoma
Example of HCC on liver biopsy
http://www.kumc.edu/instruction/medicine/pathology/ed/ch_14/c14_s35a.html
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Jessica Y. Leung, HMS 2004
Gillian Lieberman, MD
Hepatocellular carcinoma
• Epidemiology:
•
•
•
•
Most common primary cancer worldwide
↑ incidence: China, Sub-Saharan Africa
↓ incidence: N and S America, Europe, Australia
4:1 (M:F)
• Risk factors:
• Cirrhosis, HBV, HCV, alcohol, hemochromatosis, environmental
toxins, etc.
• Growth patterns:
• Solitary mass, multifocal masses, diffuse infiltrating
• Treatment:
• Surgical resection, local ablation (chemo, alcohol, radio)
• Prognosis:
• 5 yr survival < 5%
• High mortality due to late clinical presentation
Schwartz JM, Carithers RL. UpToDate Online 10.3
Kamel IR, Bluemke DA. J Vasc Interv Radiol 2002; 13:S173
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Jessica Y. Leung, HMS 2004
Gillian Lieberman, MD
Imaging modalities for HCC
• Ultrasound
• Most frequently used for detection of HCC
• Appearance of HCC is non-specific
• Small tumors hypoechoic and homogeneous
• Large tumors isoechoic or hyperechoic and heterogeneous
with coarse-irregular internal echoes
• Doppler used to evaluate tumor vascularity, not always
accurate
• Sensitivity 71%, specificity 93% (noncirrhotics)
• Sensitivity 47%, specificty 98% (cirrhotics)
• New contrast agents may improve accuracy of diagnosis
of HCC
Sherman M, Peltekian KM, Lee C. Hepatology 1995; 22:432
Kim TK, Kim AY, Choi BI. Abdominal Imaging 2002; 27:129
Kamel IR, Bluemke DA. J Vasc Interv Radiol 2002; 13:S173
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Jessica Y. Leung, HMS 2004
Gillian Lieberman, MD
Imaging modalities for HCC (cont’d)
• CT
• Often performed secondary to abnormality seen on U/S
• May be used as primary screening modality in cirrhotics
• Features of HCC more specific than U/S
• Hypodense lesions, hypervascular, enhance in arterial phase,
hypodense in equilibrium phase
• Sensitivity of helical CT may be as high as 90%
• 3 mm HCCs detectable
• Biphasic CT – CTHA and CTAP
Schwartz JM, Carithers RL. UpToDate Online 10.3
Hollett MD, Jeffrey RB Jr, Nino-Murcia M et al. AJR Am J Roentgenol 1995; 164:879
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Jessica Y. Leung, HMS 2004
Gillian Lieberman, MD
Mr. B. – Abdominal CT
1. Multiple hypoattenuating lesions pre-contrast
2. Early arterial enhancement
BIDMC PACS
3. Hypodense in portal venous and equilibrium phases
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Jessica Y. Leung, HMS 2004
Gillian Lieberman, MD
Imaging modalities for HCC (cont’d)
• MRI
• High resolution image w/o nephrotoxic contrast agents
• T1: hyperintensity (35%), isointensity (25%),
hypointensity (40%)
• Contrast-enhanced dynamic MRI has similar sensitivity
for diagnosis as helical CT
• Better than CT at differentiating dysplastic nodules
from HCC
• New hepatocyte-specific contrast agents
• Angiography
• Used for chemoembolization of tumors and to control
bleeding of ruptured HCC
Schwartz JM, Carithers RL. UpToDate Online 10.3
Kamel IR, Bluemke DA. J Vasc Interv Radiol 2002; 13:S173
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Jessica Y. Leung, HMS 2004
Gillian Lieberman, MD
Patient 2 - HCC on MRI
Central area of T2
hyperintensity suggestive of
necrosis
BIDMC PACS
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Jessica Y. Leung, HMS 2004
Gillian Lieberman, MD
Mr. B. - Angiography
R hepatic artery angiogram – Hypervascularity of HCC
BIDMC PACS
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Jessica Y. Leung, HMS 2004
Gillian Lieberman, MD
Mr. B. – Post-chemoembolization
1. 1% lidocaine
2. Chemotherapeutic
(doxorubicin, lipiodol)
+ contrast
BIDMC PACS
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Jessica Y. Leung, HMS 2004
Gillian Lieberman, MD
Other imaging modalities
• FDG PET – useful for determining histologic
differentiation of HCC, and HCC mets
• 99mTc-labeled AFP (experimental)
Schwartz JM, Carithers RL. UpToDate Online 10.3
Kamel IR, Bluemke DA. J Vasc Interv Radiol 2002; 13:S173
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Jessica Y. Leung, HMS 2004
Gillian Lieberman, MD
Findings associated with HCC
• Mass effect or local invasion
• Often secondary to underlying cirrhosis
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Jessica Y. Leung, HMS 2004
Gillian Lieberman, MD
Patient 2 - Mass effect
Compression of portal vein
BIDMC PACS
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Jessica Y. Leung, HMS 2004
Gillian Lieberman, MD
Patient 3 - Vascular invasion
Ascites
Portal vein
invasion
BIDMC PACS
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Jessica Y. Leung, HMS 2004
Gillian Lieberman, MD
Patient 2 - Portal hypertension
Caput Medusae seen on CT reconstruction
BIDMC PACS
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Jessica Y. Leung, HMS 2004
Gillian Lieberman, MD
Patient 3 - Portal hypertension (cont’d)
Varices
BIDMC PACS
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Jessica Y. Leung, HMS 2004
Gillian Lieberman, MD
Non-HCC liver masses
DO NOT BE FOOLED!
• Metastases
• Spectrum of appearances, usually low attenuation on CT,
contrast may or may not enhance
• Hemangioma
• Focal nodular hyperplasia
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Jessica Y. Leung, HMS 2004
Gillian Lieberman, MD
Patient 4 - Hemangioma
Peripheral enhancement
during bolus phase of IV
contrast
Hypodense on precontrast scan
BIDMC PACS
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Jessica Y. Leung, HMS 2004
Gillian Lieberman, MD
Patient 5 - Focal Nodular Hyperplasia
Hyperdense lesion in
setting of fatty liver
Enhances in arterial
phase, accentuates
central fibrous scar
Scar enhances during
late arterial phase…
enhancement washes
out during portal venous
and equilibrium phase
BIDMC PACS
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Jessica Y. Leung, HMS 2004
Gillian Lieberman, MD
Summary
• Incidence of HCC is increasing in the U.S.
• Due to high mortality, early detection is essential
• U/S
• Cheap, primary mode of detection, lower sensitivity and
specificity compared to CT
• Aids in obtaining pathological diagnosis
• CT
• higher sensitivity with advances in speed of imaging and dual
phase imaging
• MRI
• useful for differentiating dyplastic nodules from HCC
• IR
• useful for local ablation of HCC in non-surgical candidates
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Jessica Y. Leung, HMS 2004
Gillian Lieberman, MD
References
1.
Schwartz JM, Carithers RL Jr. Clinical features, diagnosis, and screening for primary hepatocellular
carcinoma. UpToDate Online 10.3.
2.
Hollett MD, Jeffrey RB Jr, Nino-Murcia M, et al. Dual-phase helical CT of the liver: Value of arterial
phase scans in the detection of small (<1.5 cm) malignant hepatic neoplasms. AJR Am J Roentgenol
1995; 164:879.
3.
Sherman M, Peltekian KM, Lee C. Screening for hepatocellular carcinoma in chronic carriers of
hepatitis B virus: Incidence and prevalence of hepatocellular carcinoma in a North American urban
population. Hepatology 1995; 22:432.
4.
Kim TK, Kim AY, Choi BI. Hepatocellular carcinoma: harmonic ultrasound and contrast agent. Abd
Imaging 2002; 27:129.
5.
Murakami T, Kim T, Takahashi S, Nakamura H. Hepatocellular carcinoma: multidetector row helical
CT. Abd Imaging 2002; 27:139.
6.
Kamel IR, Bluemke DA. Imaging evaluation of hepatocellular carcinoma. J Vasc Interv Radiol 2002;
13(9 Pt 2):S173.
7.
Reeder MMM. Reeder and Felson's Gamuts in Radiology: Comprehensive Lists of Roentgen
Differential Diagnosis. New York: Springer-Verlag New York Inc, 1993.
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Jessica Y. Leung, HMS 2004
Gillian Lieberman, MD
Acknowledgements
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Vassilios Raptopoulos, MD
Don (Buddy) Wiese, MD
Robert Kane, MD
Gillian Lieberman, MD
Pamela Lepkowski
Larry Barbaras and Cara Lyn D’amour
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