Radiographic evaluation of hepatocellular carcinoma

eradiology.bidmc.harvard.edu

Radiographic evaluation of hepatocellular carcinoma

Jessica Y. Leung, HMS 2004

Gillian Lieberman, MD

Radiographic evaluation of

hepatocellular

carcinoma

Jessica Y. Leung, Harvard Medical School, Year III

Gillian Lieberman, MD

January 2003

1


Jessica Y. Leung, HMS 2004

Gillian Lieberman, MD

HPI:


Mr. B.

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

2


Jessica Y. Leung, HMS 2004

Gillian Lieberman, MD

Mr. B. –

Large lesion in R hepatic lobe,

solid with heterogeneous

echotexture

RUQ ultrasound

BIDMC PACS

3


Jessica Y. Leung, HMS 2004

Gillian Lieberman, MD

DDx

What types of cells are in the liver?

Normal liver histology

http://mycourses.med.harvard.edu/

collection_display.asp, HMS #61

of Solid Liver Mass





Hepatocytes




Adenoma, hepatoblastoma

Focal nodular hyperplasia

Hepatocellular carcinoma

Bile ducts



Cholangioma

Cholangiocarcinoma

Blood vessels



Hemangioma,

hemangioendothelioma

Angiosarcoma

Invading cells

• Metastases

• Lymphoma

• Carcinoid

4


Jessica Y. Leung, HMS 2004

Gillian Lieberman, MD

DDx

> 50 yo (Mr. B.)

• Common




Hemangioma

Metastases

Uncommon




Angiosarcoma

Hepatocellular

carcinoma

Intrahepatic

cholangiocarcinoma

Reeder MMM. Reeder and Felson’s Gamuts in Radiology. 1993.

of Liver Mass in Adult

< 50 yo

• Common



Focal nodular hyperplasia

Uncommon



Fibrolamellar carcinoma

Hepatocellular carcinoma

5



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

6







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

7



Jessica Y. Leung, HMS 2004

Gillian Lieberman, MD

Ultrasound







Imaging modalities for HCC

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

8



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

9


Jessica Y. Leung, HMS 2004

Gillian Lieberman, MD

Mr. B. –

1. Multiple hypoattenuating

2. Early arterial enhancement

3. Hypodense

Abdominal CT

lesions pre-contrast

in portal venous and equilibrium phases

BIDMC PACS

10




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

11


Jessica Y. Leung, HMS 2004

Gillian Lieberman, MD

Patient 2 -

Central area of T2

hyperintensity suggestive of

necrosis

HCC on MRI

BIDMC PACS

12


Jessica Y. Leung, HMS 2004

Gillian Lieberman, MD

Mr. B. -

R hepatic artery angiogram –

Angiography

Hypervascularity

BIDMC PACS

of HCC

13


Jessica Y. Leung, HMS 2004

Gillian Lieberman, MD

Mr. B. –

Post-chemoembolization

1.

2.

1% lidocaine

Chemotherapeutic

(doxorubicin, lipiodol)

+ contrast

BIDMC PACS

14




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

15




Jessica Y. Leung, HMS 2004

Gillian Lieberman, MD

Findings associated with HCC

Mass effect or local invasion

Often secondary to underlying cirrhosis

16


Jessica Y. Leung, HMS 2004

Gillian Lieberman, MD

Patient 2 -

Compression of portal vein

Mass effect

BIDMC PACS

17


Jessica Y. Leung, HMS 2004

Gillian Lieberman, MD

Ascites

Portal vein

invasion

Patient 3 -

Vascular invasion

BIDMC PACS

18


Jessica Y. Leung, HMS 2004

Gillian Lieberman, MD

Patient 2 -

Caput Medusae

Portal hypertension

seen on CT reconstruction

BIDMC PACS

19


Jessica Y. Leung, HMS 2004

Gillian Lieberman, MD

Patient 3 -

Portal hypertension (cont’d)

BIDMC PACS

Varices

20


Jessica Y. Leung, HMS 2004

Gillian Lieberman, MD

DO NOT BE FOOLED!




Metastases


Non-HCC liver masses

Spectrum of appearances, usually low attenuation on CT,

contrast may or may not enhance

Hemangioma

Focal nodular hyperplasia

21


Jessica Y. Leung, HMS 2004

Gillian Lieberman, MD

Hypodense on precontrast

scan

Patient 4 -

Hemangioma

Peripheral enhancement

during bolus phase of IV

contrast

BIDMC PACS

22


Jessica Y. Leung, HMS 2004

Gillian Lieberman, MD

Patient 5 -

Hyperdense lesion in

setting of fatty liver

Enhances in arterial

phase, accentuates

central fibrous scar

Focal Nodular Hyperplasia

Scar enhances during

late arterial phase…

enhancement washes

out during portal venous

and equilibrium phase

BIDMC PACS

23








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

24


1.

2.

3.

4.

5.

6.

7.

Jessica Y. Leung, HMS 2004

Gillian Lieberman, MD

References

Schwartz JM, Carithers RL Jr. Clinical features, diagnosis, and screening for primary hepatocellular

carcinoma. UpToDate Online 10.3.

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 (








Jessica Y. Leung, HMS 2004

Gillian Lieberman, MD

Acknowledgements

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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