Download Imaging Hepatocellular Carcinoma: The Role of Radiology in Diagnosis Treatment

Imaging Hepatocellular Carcinoma:
The Role of Radiology in Diagnosis & Treatment
Rachel Jimenez
Gillian Lieberman, MD
March 2008
Clinical Presentation
50 year old man with chronic Hepatitis C &
cirrhosis, awaiting transplant
What is the role of imaging in the pre-transplant patient?
Monitoring of a liver transplant candidate includes:
Blood tests to determine liver & kidney function
EKG, Echocardiogram, & Cardiac stress test to assess heart function
Chest X-ray (CXR) and pulmonary function test to assess lung health
Abdominal ultrasound (US) to view the liver & evaluate vessel patency
Computed Tomography (CT) to assess liver size and anatomy
Magnetic Resonance Imaging (MRI) to evaluate for lesions
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Ultrasound (US)
• Best FIRST test in pre-transplant surveillance
• Performed every 3-6 months to look for new lesions or
changes to vessel patency
• Advantages:
High availability
Low cost
Non-invasive
High Specificity
Bialecki, E. & Di Bisceglie, HPB , 2005.
Limitations:
Operator experience
Obese patients
Low sensitivity)
Limited differentiation of soft tissue
Our Patient: Screening Liver Ultrasound
Sagittal View
PACS, BIDMC
Isoechoic mass in Segment VIII
Our Patient: Screening Liver Ultrasound
Transverse View
PACS, BIDMC
A hypoechoic rim is visible around the mass
Our Patient: Screening Liver Ultrasound
Doppler
PACS, BIDMC
Portal vein & major vessels are patent
Anatomy: Couinaud Classification
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Differential diagnosis:
• Solitary liver mass in US
Benign:
Adenoma
Hemangioma
Hamartoma
Fatty Infiltration
Focal Nodular Hyperplasia
Regenerative nodular hyperplasia
Malignant:
Hepatocellular carcinoma
Hepatoblastoma
Hemangiosarcoma
Cholangiocarcinoma
Leiomyosarcoma
Hemangiopericytoma
Metastases
M. M. Reeder and B Felson, Gamuts in Radiology, Springer-Verlag Telos, 3rd edition, 1993.
Differential diagnosis:
• Solitary liver mass in US
• Isoechoic
Benign:
Adenoma
Hemangioma
Hamartoma
Fatty Infiltration
Focal Nodular Hyperplasia
Regenerative nodular hyperplasia
Malignant:
Hepatocellular carcinoma
Hepatoblastoma
Hemangiosarcoma
Cholangiocarcinoma
Leiomyosarcoma
Hemangiopericytoma
Metastases
M. M. Reeder and B Felson, Gamuts in Radiology, Springer-Verlag Telos, 3rd edition, 1993.
Differential diagnosis:
• Solitary liver mass in US
• Isoechoic
• Hypoechoic rim
Benign:
Adenoma
Hemangioma
Hamartoma
Fatty Infiltration
Focal Nodular Hyperplasia
Regenerative nodular hyperplasia
Malignant:
Hepatocellular carcinoma
Hepatoblastoma
Hemangiosarcoma
Cholangiocarcinoma
Leiomyosarcoma
Hemangiopericytoma
Metastases
Herbay, A., Frieling, T., Niederau, C., & Hussinger, D. (1997) AJR, 169(9): 1539.
M. M. Reeder and B Felson, Gamuts in Radiology, Springer-Verlag Telos, 3rd edition, 1993.
Magnetic Resonance Imaging (MRI)
• BEST test for evaluating abnormal ultrasound in patients
with known liver disease
• Useful in distinguishing benign from malignant masses
using T2 non-contrast & T1 phase-contrast sequences
• Advantages:
High sensitivity (82-96)%
High resolution
Bialecki, E. & Di Bisceglie, HPB , 2005.
Limitations:
Expensive
Time Intensive
Patient Dependent
Our Patient: Liver Mass on T1 Abdominal MRI
PACS, BIDMC
Non-contrast T1
A cirrhotic liver, enlarged spleen, and ascites
Our Patient: Liver Mass on T2 Abdominal MRI
PACS, BIDMC
Non-contrast T2
Ill-defined round 5cm lesion with increased signal
Our Patient: 3 Phase Contrast Enhanced T1 MRI
PACS, BIDMC
Arterial Phase
Portal Venous Phase
Delayed Phase
Lesion demonstrates enhancement during the arterial phase
and washout during the venous phase
Comparison Patient: Focal Nodular Hyperplasia on MRI
Contrast our patient’s MRI with this patient’s. MRI demonstrating
the typical appearance of FNH on C+ MRI
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Non-contrast T2
Delayed phase T1
Hyperintense
Hypointense
Enhancement of stellate scar
Enhancement of stellate scar
MRI Summary
• 5 cm mass in segment VIII of liver
• No lymphadenopathy or vessel involvement
• Increased signal intensity during arterial phase
• Decreased signal intensity during venous phase
• No evidence of stellate scar
• Patient history
Diagnosis: Hepatocellular Carcinoma*
* Pathology confirmed diagnosis of HCC
Hepatocellular Carcinoma
Hepatocellular carcinoma (HCC) is a primary tumor of
hepatocytes that develops in the setting of chronic liver disease.
• Median age group is 50-70 & predominates in men
• HBV & HCV cause > 90% of HCC's worldwide
• Patients with HCC usually have no physical symptoms
• Common sites of metastasis include lung & bone
• Median survival is 5% at 5 years
Hagop et al., MD Anderson Manual of Medical Oncology, 2006.
Staging of HCC
American Joint Committee on Cancer-TNM System
Stage
TNM
Scheme
I
T1N0M0
Single tumor <2cm
II
T2N0M0
>2cm or single tumor <2cm + vascular invasion
IIIA
T3N0M0
Single tumor >5cm or >2cm + vascular invasion
IIIB
T1-3N1M0
Positive Regional Lymph Node
IVA
T4N0-1M0
Multiple tumors involving major vessels/multiple lobes
IVB
T1-4N0-1M1
Vauthey et al., J Clin Oncol, 2002.
Remote Metastasis
Our Patient: Normal CXR
“The lungs are clear.”
PACS, BIDMC
AP view of the thorax
Left lateral view of the thorax
Our Patient: Normal RN Bone Scan
“No evidence of MDP avid osseous metastases.”
PACS, BIDMC
Anterior
Posterior
Bone Scintigraphy: Technetium, 99Tcm
Staging of HCC
American Joint Committee on Cancer-TNM System
Stage
TNM
Scheme
I
T1N0M0
Single tumor <2cm
II
T2N0M0
>2cm or single tumor <2cm + vascular invasion
IIIA
T3N0M0
Single tumor >5cm or >2cm + vascular invasion
IIIB
T1-3N1M0
Positive Regional Lymph Node
IVA
T4N0-1M0
Multiple tumors involving major vessels/multiple lobes
IVB
T1-4N0-1M1
Vauthey et al., J Clin Oncol, 2002.
Remote Metastasis
Treatment
Liver transplantation
5 year survival 60-70%, limited to Stage I & II
HCC
Surgical resection
5 year survival 40-50%, limited to single, welldemarcated, and anatomically accessible
lesions
Percutaneous destruction
e.g. Radiofrequency ablation
5 year survival ~40%, limited to lesions
measuring <3cm
Transcatheter Arterial
Chemoembolization (TACE)
OUR PATIENT
Modest survival benefit, Treatment of choice for
single intrahepatic lesions >5cm
Hagop et al., MD Anderson Manual of Medical Oncology, 2006.
Our Patient: Transcatheter Arterial Chemoembolization
PACS, BIDMC
A catheter is inserted into the hepatic artery via the femoral artery
Our Patient: Transcatheter Arterial Chemoembolization
PACS, BIDMC
Contrast is injected to confirm proper placement of catheter
Our Patient: Transcatheter Arterial Chemoembolization
PACS, BIDMC
Chemotherapy & embolic agents are mixed & injected together.
Our Patient: CT Post-procedure Imaging
Used within 24 hours of procedure to assess for effective
delivery of chemotherapy to mass
PACS, BIDMC
“…successful chemoembolization of the…hypervascular mass”
Bialecki, E. & Di Bisceglie, HPB , 2005.
Our Patient: CT at 3 Month Follow-up
BEST test for evaluation of known hepatic malignancy &
for detecting extra- hepatic metastases
PACS, BIDMC
“Interval decrease in mass size…no new liver lesions.”
Oliva & Saini, Cancer Imaging, 2004.
Summary
Radiology vital in the medical management, diagnosis, &
therapy of Hepatocellular Carcinoma
• Ultrasound - Assessing for lesion & vessel patency
• Magnetic resonance imaging - Characterizing known
lesion
• Nuclear Scintigraphy/Plain Film - Tumor staging
• Hepatic Angiography - Visualization for interventional
therapy
• Computed tomography (CT) - Evaluation of tumor
progression post-therapy
Acknowledgments
Gillian Lieberman, MD
Maria Levantakis
Andrew Hines-Peralta, MD
Diana Ferris, MD
Alice Lee, MD
References
M. M. Reeder and B Felson, Gamuts in Radiology, 3rd edition, Springer-Verlag Telos, 1993.
Bialecki, E. & Di Bisceglie, A. Diagnosis of hepatocellular carcinoma. HPB (Oxford). 2005; 7(1): 26–34.
Bruix J, Sherman M, Lloret JM, Beaugrand M, Lencioni R, Burroughs AK, et al. Clinical management of
hepatocellular carcinoma. Conclusions of the Barcelona-2000 EASL conference. European
Association for the Study of the Liver. J Hepatol. 2001;35:421
Hagop M. Kantarjian, Robert A. Wolff, Charles A. Koller (Eds.) The MD Anderson Manual of Medical
Oncology. Chapter 15, Pancreatic Cancer and Hepatobiliary Malignancies. New York, McGrawHill, 2006.
Herbay, A., Frieling, T., Niederau, C., & Hussinger, D. (1997) Solitary Hepatic Lesions with a
Hypoechoic Rim: Value of Color Doppler Sonography. AJR, 169(9): 1539.
Maria Raquel Oliva, M. & Saini, S. Liver cancer imaging: role of CT, MRI, US and PET. Cancer Imaging.
2004; 4. S42-S46.
M. M. Reeder and B Felson, Gamuts in Radiology, 3rd edition, Springer-Verlag Telos, 1993.
Vauthey JN, Lauwers GY, Esnaola NF. Simplified staging for hepatocellular carcinoma. J Clin Oncol
2002;20:1527–1536.
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