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MR of Liver imaging: How I do it?
Laurence BARANES, Pierre ZERBIB, Frédéric PIGNEUR, Alain LUCIANI, Alain RAHMOUNI
CHU HENRI MONDOR, CRETEIL, FRANCE
MR of Liver imaging :How I do it?
AFIIM -ISRA 2016
AIM
• To propose a method of interpretation of a liver
nodule discovered on MRI with clinical cases
Mrs J…
• 38 yo
• Discovery of a liver mass
Clinical features
• Fever
• Right upper quadrant pain
• Hypereosinophilia
Alveolar ecchinococcosis
Mr R
• 55 yo
• …
T1 fat sat
T1 in phase
T1 Fat sat arterial phase
T2 fat sat 2nd écho
T1 Fat sat portal phase
Fluid-fluid level
This is not a typical biliary cyst
Mr R
• 55 yo
• The context was : characterization of liver
nodules in a context of gastrointestinal
stromal tumor
GIST metastasis
Clinical context
no chronic liver disease
chronic liver disease
- vascular features
- Nodule size
- T2 wi signal?
(Sex, neoplasia, infection..)
Global liver signal analysis
HCC?
Eliminate a pseudo lésion
- Artifact
- focal fat
- perfusion disorders
Multiple nodules
metastasis
Inflammatory
infectious
Single nodule
- Angioma
- FNH
- Biliary cyst
Diagnostic ranges
Cystic nodules Hypervascular nodules
Fibrous nodules T1 hyperintense nodules
Mr G, 64 yo
• Alcoholic liver cirrhosis
• Caracterization of a liver nodule discovered
on US follow up
T2 fat sat
T1 iv-
T1 iv+ arterial
T1 iv+ venous
HCC on a cirrhotic liver
What should be always searched for on a liver MRI ?
• Liver dysmorphia
– Irregular contours
– Segment 4 hypotrophy
– Segment 1 hypertrophy
– Left lobe hypertrophy
– Right lobe hypotrophy
• Portal hypertension signs
– Ascitis
– splenomegaly
– Porto-portal and porto-systemic shunts
Search for liver dysmorphia and portal hypertension signs
• segment 1 hypertrophy
• segment 4 atrophy
In the chronic liver diseases, the aim is to detect HCC
Nodules on a cirrhotic liver
• Regenerative nodule
• Dysplastic nodule
• Hepatocellular carcinoma
• Pseudo lésion: trouble de perfusion
• Fibrose confluente
Gamme cirrhose et nodule
Anatomical Continuum
• Regenerative nodule
• Dysplastic nodule
• Hepatocellular carcinoma
Anatomical continuum
- Size
- Hypersignal on T2 wi
- Arterial enhancement of the nodule
- No portal enhancement
These transitions go with an increasing of:
- size
- cellularity
- neoangiogenesis
Takayama Annals of Surgical Oncology 2007; 15:972-978
Anatomical continuum
- Size
- Hypersignal on T2 wi
- Arterial enhancement =ofWash-in
the nodule
- No portal enhancement = Wash-out
Typical
enhancement
These transitions go with an increasing of:
- size
- cellularity
- neoangiogenesis
Takayama Annals of Surgical Oncology 2007; 15:972-978
Anatomical continuum
- Size
- Hypersignal on T2 wi
- Arterial enhancement =ofWash-in
the nodule
- No portal enhancement = Wash-out
Typical
enhancement
+
Wash-in
Wash-out
Clinical context
no chronic liver disease
chronic liver disease ?
- Vascular features
- Nodule size
- T2 wi signal?
(Sex, neoplasia, infection..)
Global liver signal analysis
HCC?
Eliminate a pseudo lésion
- Artifact
- focal fat
- perfusion disorders
Multiple nodules
metastasis
Inflammatory
infectious
Single nodule
- Angioma
- FNH
- Biliary cyst
Diagnostic ranges
Cystic nodules Hypervascular nodules
Fibrous nodules T1 hyperintense nodules
Mrs V
• 38 yo
• with hepatic angiosarcoma resected
droite)
• 34 liver nodules found on a follow-up CT scan
• Bilan avant prise en charge thérapeutique
 MRI assessment
MRI confirmed tumor recurrence
What about the 34 liver nodules described on the CT scan report?
T2 fat sat
T1 iv-
T1 iv+ arterial
T1 iv+ venous
T2 fat sat
T1 iv-
Normal liver
T1 iv+ arterial
T1 iv+ veinous
T2 fat sat
T1 iv-
Diseased liver
T1 iv+ arterial
T1 iv+ veinous
The nodules described on CT scan are actually
residual normal liver
Message
Remember to analyze the global signal of the liver before
interpreting the intrinsic signal of liver nodules
Normal liver
Disease liver
T2 fat sat
Bone marrow infiltration
Clinical context
No chronic liver disease
Chronic liver disease ?
- Vascular features
- Nodule size
- T2 wi signal?
(Sex, neoplasia, infection..)
Global signal of the liver
(steatosis, iron overload…)
HCC?
Eliminate a pseudo lésion
- Artifact
- focal fat
- perfusion disorders
Multiple nodules
metastasis
Inflammatory
infectious
Single nodule
- Angioma
- FNH
- Biliary cyst
Diagnostic ranges
Cystic nodules Hypervascular nodules
Fibrous nodules T1 hyperintense nodules
Mr H, 54 yo
• Colorectal cancer
• Metastases on segment 1 and 5
• MRI assessment before surgery
Additionnal metastasis on segment 8
Diffusion sequences are the most sensitive sequences
The optimal b value for detection is about 100
Clinical context
no chronic liver disease
chronic liver disease ?
- vascular features
- Nodule size
- T2 wi signal?
(Sex, neoplasia, infection..)
Global signal of the liver analysis
(steatosis, iron overload…)
HCC?
Detection of the lesions: Diffusion sequences++
Rule out a pseudo lésion
- Artifact
- focal fat
- perfusion disorder
Multiple nodules
metastasis
Inflammatory
infectious
Single nodule
- Angioma
- FNH
- Biliary cyst
Diagnostic ranges
Cystic nodules Hypervascular nodules
Fibrous nodules T1 hyperintense nodules
Mr C.,
• Colorectal cancer with liver metastases
• Follow-up
How many nodules do you see?
How many nodules do you see?
Pseudo-nodule
nodule
This pseudo nodule is due to a movement artifact in the phase
encoded direction
The distance between all the images in the encoded phase is the same
Any hyperintense structure on T1 or T2 wi
can cause an artifact (not only gallbladder or aorta)
Clinical context
no chronic liver disease
chronic liver disease ?
- vascular features
- Nodule size
- T2 wi signal?
(Sex, neoplasia, infection..)
Global signal of the liver analysis
(steatosis, iron overload…)
HCC?
Detection of the lesions: Diffusion sequences++
Rule out a pseudo lesion
- Artifact
- focal fat
- perfusion disorder
Multiple nodules
metastasis
Inflammatory
infectious
Single nodule
- Angioma
- FNH
- Biliary cyst
Diagnostic ranges
Cystic nodules Hypervascular nodules
Fibrous nodules T1 hyperintense nodules
Mrs L.,
• No medical history
• Discovery of multiple hepatic nodules on US
In phase
Out of phase
Focal steatosis
Clinical context
No chronic liver disease
Chronic liver disease ?
- Vascular features
- Nodule size
- T2 wi signal?
(Sex, neoplasia, infection..)
Global signal of the liver analysis
(steatosis, iron overload…)
HCC?
Detection of the lesions: Diffusion sequences++
Rule out a pseudo lesion
- Artifact
- focal fat / normal fat in a steatotic liver
- perfusion disorder
Multiple nodules
metastasis
Inflammatory
infectious
Single nodule
- Angioma
- FNH
- Biliary cyst
Diagnostic ranges
Cystic nodules Hypervascular nodules
Fibrous nodules T1 hyperintense nodules
Mrs A.,
• History of portal thrombosis and coagulation
disorders
• Liver nodule on US
 Characterization with MRI
Perfusion disorder
Clinical context
no chronic liver disease
Chronic liver disease ?
- Vascular features
- Nodule size
- T2 wi signal?
(Sex, neoplasia, infection..)
Global signal of the liver analysis
(steatosis, iron overload…)
HCC?
Detection of the lesions: Diffusion sequences++
Rule out a pseudo lesion
- Artifact
- focal fat / normal fat in a steatotic liver
- perfusion disorder
Multiple nodules
Metastases
Inflammatory
Infectious
Single nodule
- Angioma
- Focal
- Biliary cyst
Diagnostic features
Cystic nodules Hypervascular nodules
Fibrotic nodules
Steatotic nodules
Clinical context
no chronic liver disease
Chronic liver disease ?
- Vascular features
- Nodule size
- T2 wi signal?
(Sex, neoplasia, infection..)
Global signal of the liver analysis
(steatosis, iron overload…)
HCC?
Detection of the lesions: Diffusion sequences++
Rule out a pseudo lesion
- Artifact
- focal fat / normal fat in a steatotic liver
- perfusion disorder
Multiple nodules
Metastases
Inflammatory
Infectious
Single nodule
- Angioma
- Focal
- Biliary cyst
Diagnostic features
Cystic nodules Hypervascular nodules
Fibrotic nodules
Steatotic nodules
Clinical context
no chronic liver disease
Chronic liver disease ?
- Vascular features
- Nodule size
- T2 wi signal?
(Sex, neoplasia, infection..)
Global signal of the liver analysis
(steatosis, iron overload…)
HCC?
Detection of the lesions: Diffusion sequences++
Rule out a pseudo lesion
- Artifact
- focal fat / normal fat in a steatotic liver
- perfusion disorder
Multiple nodules
Metastases
Inflammatory
Infectious
Single nodule
- Angioma
- Focal
- Biliary cyst
Diagnostic features
Cystic nodules Hypervascular nodules
Fibrotic nodules
Steatotic nodules
Clinical context
no chronic liver disease
Chronic liver disease ?
- Vascular features
- Nodule size
- T2 wi signal?
(Sex, neoplasia, infection..)
Global signal of the liver analysis
(steatosis, iron overload…)
HCC?
Detection of the lesions: Diffusion sequences++
Rule out a pseudo lesion
- Artifact
- focal fat / normal fat in a steatotic liver
- perfusion disorder
Multiple nodules
Metastases
Inflammatory
Infectious
Single nodule
- Hemangioma
- Focal nodular hyperplasia
- Biliary cyst
Diagnostic features
Cystic nodules Hypervascular nodules
Fibrotic nodules
Steatotic nodules
3 benign nodules can be diagnosed on imaging
Hemangioma
FNH
Biliary cyst
These benign nodules with a high prevalence need
to be diagnosed with a high specificity
Clinical context
no chronic liver disease
Chronic liver disease ?
- Vascular features
- Nodule size
- T2 wi signal?
(Sex, neoplasia, infection..)
Global signal of the liver analysis
(steatosis, iron overload…)
HCC?
Detection of the lesions: Diffusion sequences++
Rule out a pseudo lesion
- Artifact
- focal fat / normal fat in a steatotic liver
- perfusion disorder
Multiple nodules
Metastases
Inflammatory
Infectious
Single nodule
- Hemangioma
- Focal
- Biliary cyst
Diagnostic features
Cystic nodules
Hypervascular nodules
Fibrotic nodules
T1 hyperintense nodules
Hypervascular nodules
– Focal nodular hyperplasia
– Adenoma
– Hepatocellular carcinoma
– Hypervascular metastasis
•
•
•
•
kidney
Neuro endocrine tumor
Sarcoma
Melanoma
– Vascular nodules
• Perfusion disorders
• Hemangioma
Fibrotic nodules
•
•
•
•
•
•
•
Cholangiocarcinoma
HCC
Metastases (NET, Colorectal, breast, Metastasis on chimiotherapy)
Granuloma
Inflammatory Pseudo-tumor
Lymphoma
Epithelioid hemangioendothelioma
T1 hyperintense nodules
• Due to fat
– Intra cellular fat: Hepatocellular nodules
–
–
–
–
(fat, blood, copper)
Adenoma
Hepatocellular carcinoma (well differenciated)
(dysplatic nodule)
(focal nodular hyperplasia)
– Extra cellular fat
• Angiomyolipoma
• Lipoma
• Metastasis (blood, intresecal nature): thyroid, kidney, melanoma, choriocarcinoma,
colorectal, breast, ovary, pancreatic cystadenocarcinoma
Before
After