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Everything you need to know about Computed Tomography (CT) & CT Scanning

Liver: Malignant Tumors Imaging Pearls - Educational Tools | CT Scanning | CT Imaging | CT Scan Protocols - CTisus
Imaging Pearls ❯ Liver ❯ Malignant Tumors

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  • "Cholangiocarcinoma (CC) is the second most common primary malignant liver tumor in adults, accounting for 10%-25% of primary liver malignancies. CC is more frequently seen in patients with primary sclerosing cholangitis in North America (often seen in conjunction with inflammatory bowel disease) and in patients with parasitic infections in other parts of the world. Additional risk factors include hepatolithiasis, cirrhosis, and diabetes.”
    Imaging and Management of Liver Cancer
    Abdullah O.Alenezi et al.
    Seminars in Ultrasound, CT and MRI
    Volume 41, Issue 2, April 2020, Pages 122-138
  • "Angiosarcoma and epithelioid hemangioendotheliomas are additional primary liver neoplasms which may occur in adult patients. Angiosarcoma arises from endothelial cells and account for only 2% of primary liver malignancies. It is a vascular tumor on cross-sectional imaging and is not easily differentiated from adenoma or HCC. It is associated with remote exposure to polyvinyl, radium, and arsenic and prognosis is poor.”
    Imaging and Management of Liver Cancer
    Abdullah O.Alenezi et al.
    Seminars in Ultrasound, CT and MRI
    Volume 41, Issue 2, April 2020, Pages 122-138
  • “Hepatoblastoma is the most common malignancy of the liver in infants and children. Generally, it is diagnosed in children aged 100 ng/ml) in most children with hepatoblastoma; < 10% have low or normal AFP levels. Generally, hepatoblastomas, which always manifest as a large multinodular expansile mass in the right lobe, are heterogeneously enhanced in the arterial phase with washout in the portal venous phase or delayed phase and demarcate well from the liver parenchyma.”
    Hepatic nodules with arterial phase hyperenhancement and washout on enhanced computed tomography/magnetic resonance imaging: how to avoid pitfalls
    Mimi Tang et al.
    Abdominal Radiology https://doi.org/10.1007/s00261-020-02560-0
  • “Hepatic epithelioid angiomyolipoma (HEAML) is a subtype of hepatic angiomyolipoma with low malignancy rate. Angiomyolipoma is a type of mesenchymal liver tumor composed of adipose tissue, smooth muscle (spindled or epithelioid), and thick-walled blood vessels. The proportions of these three components may vary. The ratio of men to women is nearly 1:5. Most of these tumors are asymptomatic and occur in the absence of liver disease. The common tumor markers are almost all negative.”
    Hepatic nodules with arterial phase hyperenhancement and washout on enhanced computed tomography/magnetic resonance imaging: how to avoid pitfalls
    Mimi Tang et al.
    Abdominal Radiology https://doi.org/10.1007/s00261-020-02560-0 
  • “Hepatoblastoma is the most common primary malignant liver tumor in children, accounting for approximately two-thirds of liver tumors. It usually arises before 2 years of age, although it can rarely appear in adults . The majority of hepatoblastomas are diagnosed before the age of 5 years. Hepatoblastoma is classified into epithelial type (56–67%) and mixed epithelial and mesenchymal type (33–44%) . The fetal subtype has a better prognosis than the small-cell undifferentiated subtype . Hepatoblastoma can be associated with other conditions such as Gardner syndrome, Beckwith-Weideman syndrome and familial adenomatous polyposis.”
    Imaging of primary malignant tumors in non-cirrhotic liver
    G.Mamone et al.
    Diagn Interv Imaging 2020 Feb 3;S2211-5684
  • "On imaging, hepatoblastoma presents as a multilobulated and well-demarcated mass. Amorphous calcifications are observed in 20–50% of tumors and more common in the mixed form. On dynamic contrast-enhanced CT and MRI, hepatoblastoma demonstrates heterogeneous enhancement, which is more evident in the mixed form, to a lesser degree than the surrounding liver, during both arterial and portal venous/delayed phases. Sometimes, areas of subtle hypervascularization may be present during the arterial phase of enhancement.”
    Imaging of primary malignant tumors in non-cirrhotic liver
    G.Mamone et al.
    Diagn Interv Imaging 2020 Feb 3;S2211-5684
  • “Fibrolamellar hepatocellular carcinoma (FLHCC) is a rare tumor, accounting for less than 1% of primary hepatic malignancies. Clinical and pathological features of FLHCC significantly differ from conventional hepatocellular carcinoma (HCC). Unlike conventional HCC, FLHCC typically develops in young patients less than 40 years of age, without any history of underlying liver disease. Serum alfa-feto proteins are not useful as tumor markers in FLHCC. Imaging plays an important role in diagnosis and staging of FLHCC.”
    Fibrolamellar hepatocellular carcinoma: multiphasic CT features of the primary tumor on pre-therapy CT and pattern of distant metastases. 
    Ganeshan, D., Szklaruk, J., Kaseb, A. et al. 
    Abdom Radiol 43, 3340–3348 (2018).
  • "Central stellate scar within the tumor was present in 73% (24/33). Of the 24 patients with central scar, the presence of radiating septal bands extending to the periphery and central calcification within the scar was seen in 21 patients. Overall, the combination of central stellate scar with central calcifications was seen in 67% of the tumors (21/33). Other studies have reported that central scar may be seen in 20–71% of FLHCC. Similarly, central calcification in FLHCC has been reported in 35–68%.”
    Fibrolamellar hepatocellular carcinoma: multiphasic CT features of the primary tumor on pre-therapy CT and pattern of distant metastases.
    Ganeshan, D., Szklaruk, J., Kaseb, A. et al.
    Abdom Radiol 43, 3340–3348 (2018).
  • "In summary, FLHCC is a rare hepatic tumor which occurs predominantly in young individuals under the age of 40 years, without any predisposing factors such as cirrhosis or hepatitis. On CT, these tend to be large, solitary, and often well-defined lesions. FLHCC typically demonstrates heterogeneous hypervascular enhancement in the arterial phase images and variable enhancement in the portal venous phase. Often, these tumors are hypodense on delayed phase images. Central stellate scar with internal calcifications is a useful imaging feature that may help in the diagnosis.”
    Fibrolamellar hepatocellular carcinoma: multiphasic CT features of the primary tumor on pre-therapy CT and pattern of distant metastases.
    Ganeshan, D., Szklaruk, J., Kaseb, A. et al.
    Abdom Radiol 43, 3340–3348 (2018).
  • Purpose: High mortality rate due to liver cirrhosis has been reported over the globe in the previous years. Early detection of cirrhosis may help in controlling the disease progression toward hepatocellular carcinoma (HCC). The lack of trained CT radiologists and increased patient population delays the diagnosis and further management. This study proposes a computer- aided diagnosis system for detecting cirrhosis and HCC in a very efficient and less time-consuming approach.
    Conclusions: The proposed computer-aided diagnosis system for detecting cirrhosis and hepatocellular carcinoma (HCC) showed promising results and can be used as effective screening l in medical image analysis.
    Computer-aided diagnosis of cirrhosis and hepatocellular carcinoma using multi-phase abdomen CT
    Akash Nayak et al.
    International Journal of Computer Assisted Radiology and Surgery (2019) 14:1341–1352
  • “This study has developed a standalone CAD system with promising results for semi-automated liver segmentation using a novel modified region-growing algorithm in axial CT acquisition, followed by classification of subjects to healthy and diseased using histogram analysis and logistic regression and finally detection of the diseased subjects as cirrhosis or HCC using temporal features extracted using the proposed novel multiphasic analysis of contrast-enhanced CT and SVM classifier.”
    Computer-aided diagnosis of cirrhosis and hepatocellular carcinoma using multi-phase abdomen CT
    Akash Nayak et al.
    International Journal of Computer Assisted Radiology and Surgery (2019) 14:1341–1352
  • Hepatic Angiosarcoma: Risk Factors
    - vinyl chloride       
    --- used to make polyvinyl chloride (PVC) pipes, wire coatings, plastic kitchen ware, and insulation
    - arsenic
    - anabolic steroids
    - radiation
    - thorium dioxide
  • “Hepatic angiosarcoma is uncommon and accounts for only 2% of all primary hepatic malignancies, but it is the most common malignant mesenchymal tumour of the liver. It predominantly affects patients aged 50–70 years, with a slight male predilection.  In the majority of cases of primary hepatic angiosarcoma, no obvious risk factor can be identified. However, it is reported that the tumour has an association with environmental, iatrogenic and occupational exposure to certain carcinogens. These include thorium dioxide, vinyl chloride, arsenic and radiation. Haemochromatosis and von Recklinghausen disease are also known to be linked to angiosarcoma.”
    “Angiosarcoma: clinical and imaging features from head to toe.” 
    Gaballah, Ayman H et al.
    The British journal of radiology vol. 90,1075 (2017): 20170039. doi:10.1259/bjr.20170039
  • "The gross pathology and imaging findings of hepatic angiosarcoma can show four different patterns: multiple nodules a large dominant mass , a combination of dominant mass and smaller nodules, and rarely, a diffusely infiltrating micronodular tumour.The two predominant patterns are large solitary mass and multifocal lesions.”
    “Angiosarcoma: clinical and imaging features from head to toe.”
    Gaballah, Ayman H et al.
    The British journal of radiology vol. 90,1075 (2017): 20170039. doi:10.1259/bjr.20170039
  • “The CT appearance of angiosarcoma of the liver is consistent with that of an aggressive vascular tumour .Unenhanced CT demonstrates a predominantly hypoattenuating mass when compared with the surrounding liver parenchyma, with or without hyperattenuating foci, known to reflect haemorrhage.Hepatic angiosarcoma resulting from thorium dioxide exposure produces distinct imaging findings of a hypoattenuating mass on unenhanced CT with hyperattenuating linear meshwork appearance characteristic of residual Thorotrast, as well as a dense spleen and lymph nodes resulting from the agent .On contrast-enhanced CT, large dominant masses exhibit heterogeneous enhancement, which indicates central necrosis and fibrotic change Small nodular lesions usually appear as hypoattenuating areas with some enhancing foci .Irregular or ring enhancement can also be seen .The enhancement is usually less than that of the aorta in the early phases with delayed progressive enhancement.
    “Angiosarcoma: clinical and imaging features from head to toe.” 
    Gaballah, Ayman H et al.
    The British journal of radiology vol. 90,1075 (2017): 20170039. doi:10.1259/bjr.20170039
  • “The hepatic angiosarcoma is a tumour of mesenchymal origin, representing 0.1–2% of all primary tumours of the liver and generally appearing during the sixth or seventh decade of life.”
    Liver Angiosarcoma: Rare tumour associated with a poor prognosis, literature review and case report
    Mauricio Millan et al.
    International Journal of Surgery Case Reports 28 (2016) 165–168
  • “Liver Angiosarcoma may manifest as a single mass with satellite nodules or as a diffuse infiltrative mass throughout the liver tissue due to the atypical proliferation of endothelial cells in the hepatic sinusoids. Creating a high mortality rate due to haemorrhages (secondary to tumour rupture) or acute liver failure with a 2 years survival rate of 3%.”
    Liver Angiosarcoma: Rare tumour associated with a poor prognosis, literature review and case report
    Mauricio Millan et al.
    International Journal of Surgery Case Reports 28 (2016) 165–168
  • “Liver Angiosarcoma is a rare tumour with a poor long-term prognosis due to massive haemorrhages and its high recurrence rate. Hence partial hepatectomy of the affected liver tissue with adjuvant therapy has been recognized to improve patients’ survival when compared to liver transplant.”
    Liver Angiosarcoma: Rare tumour associated with a poor prognosis, literature review and case report
    Mauricio Millan et al.
    International Journal of Surgery Case Reports 28 (2016) 165–168
  • Hepatic Angiosarcoma: E
    - vinyl chloride
    - chronic intake of arsenic
    - anabolic steroids
    - androgens
    - cyclophosphamide
    - oral contraceptives
    - Seventy five percent of the cases are of unknown aetiology
  • “It is classically associated with exposure to thorium dioxide, vinyl chloride, arsenic, and radiation; hemochromatosis; and von Recklinghausen disease, but most lesions encountered in clinical practice are without such associated factors. Clinical presenta- tion includes nonspecic symptoms such as abdominal pain, weight loss, and fatigue.” 


    Primary Hepatic Neoplasms of Vascular Origin: Key Imaging Features and Differential Diagnoses With Radiology-Pathology Correlation 
Hailey Hye-In Choi et al.
AJR 2017; 209:W350–W359
  • Risk factors for Hepatic Angiosarcoma
    • exposure to thorium dioxide,
    • vinyl chloride
    • Arsenic
    • radiation
    • hemochromatosis
    • von Recklinghausen disease
  • “Angiosarcoma shows progressive but incomplete enhancement in an irregular flame-shaped pattern. Although previously, attenuation of the enhancement was described as being less than that of the aortic blood pool, a more recent, larger study found that the attenuation followed blood pool, much like hemangiomas. The disordered morphology of the enhancement, however, enables distinction from hemangiomas.” 


    Primary Hepatic Neoplasms of Vascular Origin: Key Imaging Features and Differential Diagnoses With Radiology-Pathology Correlation 
Hailey Hye-In Choi et al.
AJR 2017; 209:W350–W359
  • “The Liver Imaging Reporting and Data System (LI-RADS) is the American College of Radiology standardized reporting and data collection system for patients with cirrhosis, chronic liver disease, or other risk factors for development of HCC. This guideline is based on an algorithm with which lesions are classified into categories that determine the probability that the lesion is a benign lesion or HCC on the basis of CT or MRI findings.”


    Current Guidelines for the Diagnosis and Management of Hepatocellular Carcinoma: A Comparative Review 
Arslanoglu A et al.
AJR 2016; 207:W88–W98
  • “In the current clinical scenario of noncirrhotic HCV-positive liver disease, the differential diagnosis includes HCC, CCA, lymphoma, and benign lesions. The sensitivity of PET for the identification of primary hepatic tumors is not high enough to rule out malignancy.”
    Positron Emission Tomography Scan for a Hepatic Mass
    Blechacz B, Gores GJ
    Hepatology Vol 52, No 6. pp 2186-2191 2010
  • “Because the approaches to the management of HCC, CCA, lymphoma, and benign lesions are all radically different, the need for a specific diagnosis is absolute. Therefore, we would not perform a diagnostic 18F-FDG PET scan in this situation. Even if this lesion is HCC on biopsy, the role of a PET scan in determining the prognosis is unclear, and it is not recommended.”
    Positron Emission Tomography Scan for a Hepatic Mass
    Blechacz B, Gores GJ
    Hepatology Vol 52, No 6. pp 2186-2191 2010
  • “In summary, because of the variable glucose metabolism of HCCs, FDG PET has shown mixed utility in the detection of HCCs, with sensitivities of 55–64% and with larger tumors visualized better than smaller tumors. FDG PET appears to provide insight into the metabolic activity of the tumor, with higher FDG uptake correlating with higher grade cancers and predicting prognosis.”
    Value of PET/CT in the Management of Primary Hepatobiliary Tumors, Part 2
    Sacks A et al
    AJR 2011; 197:W260-W265
  • “In summary, the sensitivity of FDG PET and FDG PET/CT in diagnosing cholangiocarcinoma appears to be dependent on both the morphologic characteristics and location of the lesion, with nodular forms and peripherally located lesions being easier to detect than infiltrating and hilar lesions. FDG PET and FDG PET/CT have been shown to be very beneficial in detecting regional and distal metastases from cholangiocarcinoma, which can affect patient management.”
    Value of PET/CT in the Management of Primary Hepatobiliary Tumors, Part 2
    Sacks A et al
    AJR 2011; 197:W260-W265
  • “In summary, the sensitivity of FDG PET and FDG PET/CT in diagnosing cholangiocarcinoma appears to be dependent on both the morphologic characteristics and location of the lesion, with nodular forms and peripherally located lesions being easier to detect than infiltrating and hilar lesions.”
    Value of PET/CT in the Management of Primary Hepatobiliary Tumors, Part 2
    Sacks A et al
    AJR 2011; 197:W260-W265
  • “In summary, liver metastases are generally FDG avid and therefore are detected easily by FDG PET. This sensitivity has been found to be equal or superior to that of both CT and MRI. Furthermore, FDG PET has been found to be able to detect extrahepatic metastases that were missed by conventional imaging.”
    Value of PET/CT in the Management of Liver Metastases, Part 1
    Sacks A et al
    AJR 2011; 197:W256-W259
  • “FDG PET/CT has been shown to be very accurate and sensitive in the detection of liver metastases derived from a wide range of primary cancers. D’Souza et al. showed the superiority of PET/CT over contrast-enhanced CT in the detection of untreated hepatic metastases in a prospective study evaluating 45 patients with suspected liver metastases from various primary cancers.”
    Value of PET/CT in the Management of Liver Metastases, Part 1
    Sacks A et al
    AJR 2011; 197:W256-W259
  • MRI of Liver Tumors: Technical Advances
    - 3T imaging with advantages like
    - Higher signal to noise ratio (SNR)
    - Higher spatial resolution
    - Faster imaging time
  • MRI of Liver Tumors: Acquisition Protocols
    - Non contrast image acquisitions
    - Contrast enhanced (Gadolinium) images at arterial, venous and delyed phase
    - Liver specific contrast agents (Eovist, Multihance) to detect and distinguish various benign and maignant tumors
    - Diffusion weighted imaging (DWI)
    - MR elastography
  • “With a combination of basic T1 and T2 weighted sequences, diffusion weighted imaging, DWI, and hepatobiliary gadolinium contrast agents, that is gadobenate dimeglumine (Gd-BOPTA) and gadoxetic acid (Gd-EOB), most liver lesions can be adequately diagnosed. Benign lesions, as cyst, hemangioma, focal nodular hyperplasia, FNH or adenoma, can be distinguished from malignant lesions.”
    MRI of Focal Liver Lesions
    Albiin N
    Crr Med Imaging Rev 2012 May; 8(20:107-116
  • “ With modern magnetic resonance imaging (MRI), spatial resolution and robustness increased dramatically. Beside the evaluation of neovascularization by means of gadolinium-enhanced early dynamic MRI, the main advantages of MRI are additional information on tissue composition and liver-specific function. With diffusion-weighted imaging or plain T(1)- and T(2)-weighted sequences, different tissue elements like fat, hemorrhage, glycogen, edema and cellular density can be evaluated. Liver-specific contrast agents give insight into the Kupffer cell density or the hepatocellular function. The integration of all these parts into the MR examination allows for a very high detection rate for overt HCC nowadays, although very small HCCs are still a challenge.”
    Imaging of hepatocellular carcinoma by computed tomography and magnetic resonance imaging: State of the Art
    Zech CJ et al.
    Dig Dis 2009;27(2):114-24
  • “ With modern magnetic resonance imaging (MRI), spatial resolution and robustness increased dramatically. Beside the evaluation of neovascularization by means of gadolinium-enhanced early dynamic MRI, the main advantages of MRI are additional information on tissue composition and liver-specific function. With diffusion-weighted imaging or plain T(1)- and T(2)-weighted sequences, different tissue elements like fat, hemorrhage, glycogen, edema and cellular density can be evaluated. Liver-specific contrast agents give insight into the Kupffer cell density or the hepatocellular function.”
    Imaging of hepatocellular carcinoma by computed tomography and magnetic resonance imaging: State of the Art
    Zech CJ et al.
    Dig Dis 2009;27(2):114-24
  • “Dynamic multiphasic multidetector-row CT (MDCT) and magnetic resonance imaging (MRI) are the standard diagnostic methods for the noninvasive diagnosis of HCC, which can be made based on hemodynamic features (arterial enhancement and delayed washout). The technical development of MDCT and MRI has made possible the fast scanning with better image quality and resolution, which enables an accurate CT hemodynamic evaluation of hepatocellular tumor, as well as the application of perfusion CT and MRI in clinical practice. Perfusion CT and MRI can measure perfusion parameters of tumor quantitatively and can be used for treatment response assessment to anti-vascular agents. Besides assessing the hemodynamic or perfusion features of HCC, new advances in MRI can provide a cellular information of HCC. Liver-specific hepatobiliary contrast agents, such as gadoxetic acid, give information regarding hepatocellular function or defect of the lesion, which improves lesion detection and characterization. Diffusion-weighted imaging (DWI) of the liver provides cellular information of HCC and also has broadened its role in lesion detection, lesion characterization, and treatment response assessment to chemotherapeutic agents.”
    Diagnosis of hepatocellular carcinoma: newer radiological tools
    Lee Jm, Yoon JH, Kim KW
    Semin Oncol 2012 Aug  39(4):399-409
  • “Dynamic multiphasic multidetector-row CT (MDCT) and magnetic resonance imaging (MRI) are the standard diagnostic methods for the noninvasive diagnosis of HCC, which can be made based on hemodynamic features (arterial enhancement and delayed washout). The technical development of MDCT and MRI has made possible the fast scanning with better image quality and resolution, which enables an accurate CT hemodynamic evaluation of hepatocellular tumor, as well as the application of perfusion CT and MRI in clinical practice.”
    Diagnosis of hepatocellular carcinoma: newer radiological tools
    Lee Jm, Yoon JH, Kim KW
    Semin Oncol 2012 Aug  39(4):399-409
  • “Perfusion CT and MRI can measure perfusion parameters of tumor quantitatively and can be used for treatment response assessment to anti-vascular agents. Besides assessing the hemodynamic or perfusion features of HCC, new advances in MRI can provide a cellular information of HCC. Liver-specific hepatobiliary contrast agents, such as gadoxetic acid, give information regarding hepatocellular function or defect of the lesion, which improves lesion detection and characterization. Diffusion-weighted imaging (DWI) of the liver provides cellular information of HCC and also has broadened its role in lesion detection, lesion characterization, and treatment response assessment to chemotherapeutic agents.”
    Diagnosis of hepatocellular carcinoma: newer radiological tools
    Lee Jm, Yoon JH, Kim KW
    Semin Oncol 2012 Aug  39(4):399-409
  • Hepatic Lymphoma
    - Primary hepatic lymphoma is extraordinarily rare (NHL)
    - Usually secondary lymphomatous involvement
    - Poorly enhancing solitary or multiple masses
    - Look for lymphadenopathy
  • Epithelioid Hemangioendothelioma
    - Rare tumor of vascular origin
    - Low-to-intermediate grade malignancy
    - More favorable prognosis compared to other hepatic malignancies
  • Epithelioid Hemangioendothelioma
    - Multiple hypodense lesions at periphery
    - Confluent lesions
    - Capsular retraction
    - Peripheral enhancement with a “ring” or “target” morphology
  • Biliary Cystadenoma/Cystadenocarcinoma
    - Cystic lesion with multiple internal loculations
    - Encapsulated and well circumscribed
    - Even if benign, can have malignant potential
    - Very difficult to completely resect
    - Female predominance
  • Cholangiocarcinoma
    1. Tumor arises from the bile duct epithelium
    2. 95% adenocarcinoma
    3. Associated with:
    - PSC
    - Choledochal cysts
    - Drug exposures (such as thoratrast)
    - Congenital hepatic fibrosis
    - Viral hepatitis
  • Cholangiocarcinoma
    1. Intrahepatic
    - Mass forming intrahepatic cholangiocarcinoma
    - Periductal infiltrating cholangiocarcinoma
    - Intraductal cholangiocarcinoma
    2. Hilar Cholangiocarcinoma
    3. Extrahepatic Cholangiocarcinoma
  • Hepatic Lymphoma
    1. Primary hepatic lymphoma is extraordinarily rare (NHL)
    2. Usually secondary lymphomatous involvement
    3. Poorly enhancing solitary or multiple masses
    4. Look for lymphadenopathy
  • Epithelioid Hemangioendothelioma
    - Rare tumor of vascular origin
    - Low-to-intermediate grade malignancy
    - More favorable prognosis compared to other hepatic malignancies
  • Epithelioid Hemangioendothelioma
    - Multiple hypodense lesions at periphery
    - Confluent lesions
    - Capsular retraction
    - Peripheral enhancement with a “ring” or “target” morphology
  • "Preliminary assessment of this approach shows excellent retrieval results for three types of liver lesions visible on portal venous CT images, warranting continued development and validation in larger and more comprehensive database"

    Automated Retrieval of CT Images of Liver Lesions on the Basis of Image Similarity: Method and preliminary reults
    Napel SA et al.
    Radiology 2010; 256;243-252

  • "When used individually, groups of semantic, texture, and boundary features resulted in various levels of performance in retrieving relevant lesions. However, combining all features produced the best overall results. Mean precision was greater than 90% at all values of recall, and mean, best and worst case retrieved accuracy was greater than 95%, 100% and greater than 78% respectively with NDGC."

    Automated Retrieval of CT Images of Liver Lesions on the Basis of Image Similarity: Method and preliminary reults
    Napel SA et al.
    Radiology 2010; 256;243-252

  • "To develop a system to facilitate the retrieval of radiologic images that contain similar appearing lesions and to perform a preliminary evaluation of this system with a database of computed tomographic (CT) images of the liver and an external standard of image similarity."

    Automated Retrieval of CT Images of Liver Lesions on the Basis of Image Similarity: Method and preliminary reults
    Napel SA et al.
    Radiology 2010; 256;243-252

     

  • "Our data emphasize that 3D and multiphase fusion images may be an accurate and routinely applicable tool for the diagnosis and therapeutic management of patients with biliary system abnormalities."

    Hilar and Suprapancreatic Cholangiocarcinoma: Value of 3D Angiography and Multiphase Fusion Images Using MDCT
    Uchida M et al.
    AJR 2005; 184:1572-1577

  • " The degree of enhancement on delayed phase CT is a useful indicator for prediction of the prognosis of patients with mass forming Intrahepatic Cholangicarcinoma (ICC)."

    Delayed-Phase Dynamic CT Enhancement as a Prognostic Factor for Mass-forming Intrahepatic Cholangiocarcinoma
    Asayama Y et al.
    Radiology 238:150-155

  • "In nonoperated patients, there was excellent agreement between Magnetic Resonance Cholangiography and direct cholangiography in evaluating biliary ductal extension, with agreement up to 94.7% "

    Biliary Ductal Involvement of Hilar Cholangiocarcinoma: Multidetector Computed Tomography Versus Magnetic Resonance Cholangiography
    Cho et al.
    J Comput Assist Tomogr 2007; 31:72-78

  • Hilar Cholangiocarcinoma: Facts
    - AKA Klatskin tumors
    - Adenocarcinoma of the duct bifurcation in the porta but now include CBD cancers
    - These tumors can spread locally with vascular invasion, adenopathy, peritoneal infiltration not uncommon.
  • MDCT vs MRI  

    " In evaluating the biliary duct extension of hilar cholangiocarcinoma, MDCT and MRC (Magnetic Resonance Cholangiography) showed similar accuracies and agreement."

    Biliary Ductal Involvement of Hilar Cholangiocarcinoma: Multidetector Computed Tomography Versus Magnetic Resonance Cholangiography
    Cho et al.
    J Comput Assist Tomogr 2007; 31:72-78

  • Diagram illustrates a suggested algorithm for the diagnosis and treatment of cholangiocarcinomas.  

    http://radiographics.rsna.org/content/28/5/1263.full.pdf

    Sainani N I et al.
    Radiographics 2008;28:1263-1287

  • MRI Imaging of the Liver: Cholangiocarcinoma
    - T2 weighted MR cholangiography is excellent for defining site of ductal obstruction and upstream biliary obstruction
    - The lesions may be hypo- or hyperintense on MR cholangiography.
  • MRI Imaging of the Liver: Cholangiocarcinoma
    - Mass forming cholangiocarcinoma are hypointense to isointense on T1 weighted MR images and hyperintense on T2 weighted images
    - With Gd enhancement the periphery of the lesion may enhance early and the central portion of the lesion will enhance on delayed phase images
  • MDCT Technique for the Liver

    Dual phase imaging protocol
    - Arterial phase imaging (30 sec)
    - Venous phase imaging (60-65 sec)
    - Delayed phase imaging (4 minute delay) 

    3D Post Processing protocol 
    - Volume rendering
    - MIP imaging 

  • MDCT Technique for the Liver
    - Study Protocol
    - 100-120 ml of Omnipaque-350
    - Injection rate 4-5 cc/sec thru 18g needle
  • MDCT/CTA: Evaluation of Cholangiocarcinoma
    - Ideal for initial evaluation of suspected cholangiocarcinoma
    - Cholangiocarcinoma may appear hypodense on early phase imaging and may become hyperdense on later phase imaging
    - Provides CTA angiographic map of the liver used for therapy planning
    - Excellent for detecting extrahepatic disease
  • Transabdominal Ultrasound: Evaluation of Cholangiocarcinoma
    - Good screening technique to detect biliary obstruction and defining level of obstruction
    - Cause of obstruction (tumor) may be difficult to see
    - Mass forming cholangiocarcinoma may be hard to visualize and echo pattern can be hyperechoic, hypoechois or mxed echogenicity
    - Limited value for staging extent of disease in porta and extraportal zones
  • Noninvasive Imaging techniques
    - Ultrasonography
    - MDCT
    - MDCT with PET CT
    - MRCP
    - PET scanning
  • Cholangiocarcinoma: Role of Imaging
    - Noninasive diagnosis and characterization of Cholangiocarcinoma
    - Confirmation of diagnosis
    - Pretherapeutic staging and assessment of resectability
    - Screening of high risks patients
  • Cholangiocarcinoma: Classification
    - Intrahepatic (peripheral)
    - Perihilar
    - Extrahepatic
  • Cholangiocarcinoma: Facts
    - Arises from bile duct epithelium
    - 2nd most common primary hepatobiliary cancer after hepatoma
    - Usually an adenocarcinoma (95% of cases)
    - Peak prevalence in 7th decade of life
    - More common in patients with PSC, choledochal cyst, familial polyposis, congenital hepatic fibrosis and exposure to thorotrast
  • Cholangiocarcinoma: Facts
    - Second most common primary malignancy of the liver (10-20% of all primary tumors)
    - Highest prevalence in Southeast Asia
    - Usually adenocarcinoma Usually hypovascular mass on CT although it may have a vascular rim
    - Can arise in a congenital choledochal cyst with a lifetime risk of 10-15%
  • Cholangiocarcinoma: Risk Factors
    - Liver flukes
    - Primary sclerosing cholangitis
    - Viral infection (hepatitis B, C virus)
    - Caroli's disease
    - Environmental or occupational toxin (thorotrast, dioxin, polyvinyl chloride)
    - Heavy alcohol consumption
  • "Familiarity with both expected and unexpected imaging appearances of common benign hepatic tumors, less commonly encountered benign hepatic tumors, and iatrogenic abnormalities potentially masquerading as hepatic tumors allows the radiologist to achieve an informed differential diagnosis."

    Benign Hepatic tumors and Pseudotumors
    Anderson SW, Kruskal JB, Kane RA
    RadioGraphics 2009; 29:211-229

  • "MDCT has reasonable sensitivity in the detection of hepatocellular carcinoma in patients with cirrhosis who undergo liver transplantation. Attention should be paid, however, to avoiding overestimation of the extent of disease."


    Role of MDCT in the Diagnosis of Hepatocellular Carcinoma in Patients with Cirrhosis Undergoing Orthotopic Liver Transplantation
    Ronzoni A et al
    AJR 2007;189;792-798

  • "With 64-MDCT, the addition of isotrophic coronal reformations to transverse images significantly improved reader confidence for the detection of HCC, with no statistically significant improvement in sensitivity, positive predictive value, or diagnostic accuracy. This improvement comes at the cost of a longer interpretation time."

    Detection of Hepatocellular Carcinoma in Patients with Cirrhosis: Added Value of Coronal Reformations from Isotrophic Voxels with 64-MDCT
    Marin D et al.
    AJR 2009; 192:180-187
  • "The more accurate and detailed pretreatment evaluation of HCC progression using a unified CTA system contributed to the improvement of survival of patients with HCC."

    Impact of a Unified CT Angiography System on Outcome of Patients with Hepatocellular Carcinoma
    Toyoda H et al.
    AJR 2009; 192:766-774

  • "The more accurate and detailed pretreatment evaluation of HCC progression using a unified CTA system contributed to the improvement of survival of patients with HCC. In addition it contributed to the improved efficacy of TACE with an increased survival rate."

    Impact of a Unified CT Angiography System on Outcome of Patients with Hepatocellular Carcinoma
    Toyoda H et al.
    AJR 2009; 192:766-774

  • Fibrolamellar Hepatocellular Carcinoma: facts

    - Per age of occurrence is 24.8 years
    - More common in caucasians but no m-f dominance
    - Patients may present with abdominal pain, malaise and weight loss.
    - Median survival for resectable tumor is 37-56% at 5 years, unresectable tumor is 0%
  • Fibrolamellar Hepatocellular Carcinoma: CT Findings

    - 80 % have a lobulated surface
    - Calcification is seen in 35-68% of tumors and is usually small but central
    - Lesion are hypervascular in 80% of cases, often with central scar
    - Adenopathy very common
  • Cholangiocarcinoma: facts

    - 2nd most common primary hepatic malignancy
    - Accounts for 15% of liver cancers
    - Increased incidence with
    –Liver fluke infestation
    –Cirrhosis
    –Primaring sclerosisng cholangitis
    –Hepatitis B and C infection
  • Primary Sclerosing Cholangitis: facts

    - Male predominance
    - 60-80% of patients have associated IBD especially ulcerative colitis
    - Cholangiocarcinoma develops in 10% of patients with PSC
  • CT Evaluation of a Liver Mass

    - Enhancement characterization
    –Arterial phase
    - Is the lesion vascular?
    - If vascular, how vascular (i.e. like aorta or IVC)?
    - If it enhances is it best described as homogeneous or irregular?
  • CT Evaluation of a Liver Mass

    - Enhancement characterization
    –Arterial phase
    - Does it have a feeding artery and if does would you describe it as smooth or irregular?
    - Is the feeding vessel enlarged?
    - Is there neovascularity?
  • "Twenty eight (17%) of the 169 enhancing lesions were hepatocellular carcinoma. All of the 43 wedge-shaped subcapsular lesions were benign."

    Small Hypervascular Enhancing Lesions on Arterial Phase Images of Multiphase Dynamic Computed Tomography in Cirrhotic Liver: Fate and Implications
    Hwang SH et al.
    J Comput Assist Tomogr 2008;32:39-45
    note: these were all vascular lesions that then become isodense onvenous/delayed phase
  • "When small hepatic arterial phase enhancing lesions on dynamic CT are observed, a serial, close follow-up of the lesions is still essential for correct diagnosis( 4 months)."

    Small Hypervascular Enhancing Lesions on Arterial Phase Images of Multiphase Dynamic Computed Tomography in Cirrhotic Liver: Fate and Implications
    Hwang SH et al.
    J Comput Assist Tomogr 2008;32:39-45
  • Hepatic Adenoma: Facts

    Increased frequency with

    - Oral contraceptive use
    - Androgen steroid therapy
    - Type 1 Glycogen Storage Disease
    - Iron overload with beta thalassemia - Diabetes mellitus
  • Hepatic Adenoma: Facts

    - 10% of cases present with acute abdomen due to lesion rupture and/or bleed
    - Malignant transformation risk is 10% but increases with males and with larger tumors
  • "Hepatic adenoma is a rare benign epithelial tumor that is usually encountered in young woman who use oral contraceptives.It is clinically significant because of the risk of hemorrhage and its low-grade malignancy potential."

    CT and MR Imaging Evaluation of Hepatic Adenoma Brancatelli G et al J Comput Assist Tomogr 2006:30;745-750
  • Hepatic Adenoma: CT Findings

    - Hypoattenuating on non-contrast CT
    - Heterogeneous and hypervascular on contrast enhanced CT
    - Areas of hemorrage may be seen in or near the lesion on any phase of imaging
  • Hepatic Adenoma vs FNH

    - Hepatic adenomas have a smooth surface, intratumoral hemorrhage, and a tumor capsule (25%)
    - FNH enhances far greater than an Hepatic adenoma and hepatic adenomas don't have central scars.
  • "Our results indicate that the intensity and heterogeneity of hepatic artery enhancement of HCC’s on CT hepatic arteriography correlated with the degree of VEGF expression in HCC’s."

    Expression of Vascular Endothelial Growth Factor in Hepatocellular carcinoma and the Surrounding Liver: Correlation with Angiographically Assisted CT Kanematsu M et al. AJR 2004; 183:1585-1593
  • " Sixteen slice MDCT allows robust evaluation of the hepatic parenchyma, with the potential for improved detection and characterization of focal liver lesions."

    Comprehensive Analysis of Hypervascular Liver Lesions Using 16-MDCT and Advanced Image Processing Kamel IR, Lawler LP, Fishman EK AJR 2004; 183:443-452 (August 2004)
  • Hepatic Epithelioid Hemangioendothelioma: Facts

    - Vascular liver tumor
    - May present with RUQ pain, Budd Chiari syndrome or liver failure
    - Often low grade malignacy on pathology
  • Hepatic Epithelioid Hemangioendothelioma: CT Findings

    - Tumor nodules ranging in size from 0.5 to 12 cm
    - May be multifocal or diffuse
    - Tumor may calcify
    - Tumor may become isodense following IV contrast injection
    - Metastases to lymph nodes not uncommon
  • " Helical CT screening for hepatocellular carcinoma in patients with cirrhosis has a substantive false positive detection rate. Although most of the lesions were hypoattenuating a few hyperenhancing arterial phase lesions were proven not to be hepatocellular carcinoma."

    Helical CT Screening for Hepatocellular Carcinoma in Patients with Cirrhosis: Frequency and Causes of False Positive InterpretationBrancatelli G et al.AJR 2003; 180:1007-1014
  • Hyperattenuating Lesions in the Cirrhotic Liver: Differential Diagnosis

    - Hepatoma
    - Transient benign hepatic enhancement
    - Hemangiomas
    - Fibrosis
    - Peliosis
    - Volume averaging
    - Low grade dysplastic nodule
  • Hypervascular Lesions of the Liver on Arterial phase Mapping

    - Hepatoma
    - Metastatic islet cell tumors
    - Metastatic renal cell carcinoma
    - FNH
    - Hepatic adenoma
    - Hemangioma
    - AVM /aneurysm /pseudoaneurysm
  • " Combined CT during arterial portography and CT hepatic arteriography is useful for the preoperative evaluation of patients with known or suspected hepatocellular carcinoma."

    Preoperative Evaluation of Hepatocellular Carcinoma: Combined Use of CT with Arterial Portography and Hepatic Arteriography
    Kim HC et al.
    AJR 2003;180:1593-1599
  • " The average sensitivity and positive predictive values for the detection of HCC 88.5% and 93.4% for images from all three phases.Analysis of the combination of late arterial and portal venous phase images resulted in the highest sensitivity values."

    Hepatocellular Carcinoma: Detection with Triple Phase Multi-Detector Row Helical CT in Patients with Chronic Hepatitis Laghi A et al. Radiology 2003; 226:543-549
  • " The acquisition of images during two arterial contrast phases does not provide additional benefit over timed conventional biphasic technique."

    Hepatocellular Carcinoma: Detection with Triple Phase Multi-Detector Row Helical CT in Patients with Chronic Hepatitis Laghi A et al. Radiology 2003; 226:543-549
  • " Mean sensitivity and positive predictive values of CT for hypervascular hepatocellular carcinoma (66% and 97% respectively) were higher than those for MR imaging 963% and 96% respectively) but there was no significant difference in detecting sensitivity among the observors."

    Detection of Hepatocellular Carcinoma: Comparison of Dynamic MR Imaging with Dynamic Double Arterial Phase Helical CT Noguchi Y et al. AJR 2003;180;455-460
  • " CT,US and MR imaging performed similarly on a lesion by lesion basis. Small tumor nodules were the most common cause of missed HCCs with all tests. PET did not depict any HCC’s."

    Detection of Primary Hepatic Malignancy in Liver Transplant Candidates: Prospective Comparison of CT, MR Imaging, US, and PET Teefey SA et al. Radiology 2003; 226:533-542
  • " Acquiring both a first and second arterial phase set of images allows detection of small hepatocellular carcinomas with greater sensitivity than acquiring images with either single arterial phase scan."

    Small Hypervascular Hepatocellular Carcinoma Revealed by Double Arterial Phase CT Performed with Single Breath-Hold Scanning and Automatic Bolus Tracking Kim T et al. AJR 2002; 178:899-904
  • " Clinically unsuspected HCC is most prevalent with cirrhosis secondary to hepatitis B or C, and, when evaluated at CT, is best detected with triphasic contrast material enhanced helical imaging."

    Pretransplantation Surveillance for Possible Hepatocellular Carcinoma in Patients with Cirrhosis: Epidemiology and CT-based Tumor Detection Rate in 430 Cases with Surgical Pathologic Correlation. Peterson MS et al. Radiology 2000; 21:743-749
  • " Although the late arterial phase images (30-35 seconds) reveal more hypervascular HCC lesions than do the early phase images (20 seconds), review of images obtained during both arterial phases yields the greatest sensitivity and positive predictive value."

    Hypervascular Hepatocellular Carcinoma: Detection with Double Arterial Phase Multi-Detector Row Helical CT Murakami T et al. Radiology 2001; 218:763-767
  • " Additional early arterial phase imaging did not improve the detection of HCC compared with three phase CT images, including late arterial,portal venous, and delayed phase imaging."

    Detection of Hepatocellular Carcinoma: Comparison of Dynamic Three Phase CT and Four Phase CT Images Using MDCT Kim SW et al. J Comput Assist Tomogr 26(5):691-698; 2002
  • " Double arterial phase CT with multidetector CT showed no significant improvement in effectiveness compared with single late arterial phase CT used alone for detecting hypervascular hepatocellular carcinoma in the cirrhotic liver."

    Hypervascular Hepatocellular Carcinoma: Can Double Arterial Phase Imaging with Multidetector CT Improve Tumor Depiction in the Cirrhotic Liver Ichikawa T et al. AJR 2002;179:751-758
  • " The addition of delayed phase imaging to dual phase helical CT is valuable for the detection and characterization of hepatocellular carcinoma.Delayed phase images were helpful in the characterization of hepatocellular carcinoma in 14% of patients."

    Detection of Hepatocellular Carcinoma: Value of Adding Delayed Phase Imaging to Dual Phase Helical CT Lim HJ et al. AJR 2002; 179:67-73
  • " HCC developed in the absence of cirrhosis or known risk factors and typically appeared as a large symptomatic hepatic tumor with clinical, laboratory, and CT features that distinguish it from other hepatic masses."

    Hepatocellular Carcinoma in Noncirrhotic Liver: CT, Clinical, and Pathologic Findings in 39 U.S. Residents Brancatelli G et al. Radiology 2002;222:89-94
  • " Dual-phase CT has a sensitivity of 69-71% and high specificity (86-91%) in enabling the detection and characterization of focal liver lesions. Interpretation is highly reproducible, as there is minimal variation between experienced reviewers."

    Surgically Staged Focal Liver Lesions: Accuracy and Reproducibility of Dual Phase Helical CT for Detection and Characterization Kamel IR et al. Radiology 2003; 227:752-757
  • Inhomogeneous Hepatic Enhancement on Early Phase Imaging: Differential Dx

    - Cirrhosis
    - Budd Chiari syndrome
    - Hepatic congestion
    - CTPV
    - Acute cholecystitis
    - Liver abscess
    - Hepatic tumor
    - Acute cholangitis
  • Tumors of the Liver that may contain fat: Differential Dx

    - Hepatic adenoma
    - Focal nodular hyperplasia
    - Hepatoma
    - Lipoma
    - Angiomyolipoma
    - Teratoma
  • Hepatic Adenomas: Increased in two conditions

    - Type I glycogen storage disease
    - Use of anabolic steroids
  • "In 92.7%-96.9% of women with breast cancer and hepatic lesions deemed TSTC but no definite liver metastases at initial CT, the lesions represented a benign finding."

    Hepatic Lesions Deemed Too Small to Characterize at CT: Prevalence and Importance in Woman with Breast Cancer Khalil HI et al Radiology 2005; 235:872-878
  • - Hepatic Lesions Deemed Too Small to Characterize at CT: Prevalence and Importance in Woman with Breast Cancer Khalil HI et al Radiology 2005; 235:872-878
    - 1012 pts with CT of the liver
    - 277 of 941 pts has a lesion TSTC
    - 191 of 277 pts had f/u CT
    - In 175 pts the lesion was unchanged, in 8 it was gone, and larger in 6.
    - Of the 6, 4 were due to tumor (3 breast)
  • " At our institution we now recommend that interval follow-up imaging, rather than immediate imaging work-up or biopsy, be performed when at least one hepatic lesion deemed TSTC is discovered at CT."

    Hepatic Lesions Deemed Too Small to Characterize at CT: Prevalence and Importance in Woman with Breast Cancer Khalil HI et al Radiology 2005; 235:872-878
  • Hepatoma (HCC): Facts

    - Most common primary hepatic malignancy
    - Incidence in U.S.A. of 2.4 per 100,000 per year
    - HCC is leading cause of death in patients with cirrhosis
    - 5 year survival of untreated HCC is less than 5%
  • "The optimal scan window for arterial phase images in the detection of hepatoma seems to be approximately 14-30 seconds from the 100H threshold."

    Optimal Scan Window for Detection of Hypervascular Hepatocellular Carcinomas During MDCT Examination Kim MJ et al. AJR 2006; July 187:198-206.
  • "For the margin of safety, we recommend a 20 second delay from the 100-H threshold as optimal scan timing for 16 MDCT."

    Optimal Scan Window for Detection of Hypervascular Hepatocellular Carcinomas During MDCT Examination Kim MJ et al. AJR 2006; July 187:198-206.
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