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Liver lesions
Dr. Aftab Qadir
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Benign Liver lesions
• Hemangioma
• Focal nodular hyperplasia
• Hepatic adenoma
• Liver cyst
•...
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Malignant
• Hepatocellular carcinoma
• Heptoblastoma
Rare malignant:
• Fibrosarcoma
• Angiosar...
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Hypervascular lesions
Benign
• Heamangioma
• Adenoma
• FNH
Malignant
• HCC
• Hypervascular met...
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Hypovascular lesions
• Hypovascular liver tumors are more
common.
• Most hypovascular lesions ...
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Multiphasic CT
For detection of liver lesions
• Non enhance CT
• Arterial phase
• Portal venou...
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Understanding the phases
• Liver has dual blood supply
• Normal parenchyma is supplied for 80%...
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Arterial phase
• In the arterial phase hypervascular tumors
will enhance via the hepatic arter...
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Portal venous phase
• To detect hypovascular tumors
• Scanning is at about 75 seconds
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Delayed Phase
• Begins at about 3-4 minutes after contrast
injection and imaging is best done...
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Pre contrast Arterial Phase Portal venous
phase
Delayed
Hepatocelluar Ca Low attenuation Homo...
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T1W T2W Gadolinium
Hepatocellular Ca
,iso or (fat degeneration)
Metastasis
Haemanigioma
++ (l...
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Hepatocellular Carcinoma
• Most common primary malignancy of the
liver
• Third most common ca...
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Risk factors:
• hepatitis B (HBV) infection
• hepatitis C (HCV) infection
• alcoholism
• bili...
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Clinical presentation
Presentation is variable may include:
• constitutional symptoms
• jaund...
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• Majority of patient have cirrhosis
• More than 80% of patients with HCC have
cirrhosis
• Ma...
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Investigation
• alpha-fetoprotein (AFP) levels are
elevated in 50-75 % of cases
• Radiologica...
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Ultrasound
• Variable appearance
• Small <3cm usually hypoechoic
• Larger tumors often are he...
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CT
• Focal HCC
large usually hypodense mass
may have necrosis / fat / calcification
• Multifo...
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Enhancement pattern
• Transient early arterial enhancement and
then washes out
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MRI
T1(variable)
T1 C+ (Gd)
Enhancement similar to CT
Rim enhancement may persist
T2 –Hyperin...
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Fibrolamellar hepatocellular carcinoma
• Variant of HCC
• Younger age group(20-40years)
• Not...
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Ultrasound
• Usually large heterogeneous
predominantly hyperechoic lesion,
calcification may ...
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CT
• Large solitary well circumscribed
• Heterogeneous arterial enhancement
• 30-40% have cen...
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Hepatic metastasis
• More common than primary
• May be solitary but usually multiple
• Majori...
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Hypervascular metastases
• Carcinoids
• Leiomyosarcomas
• Neuroendocrine tumors
• Renal carci...
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Ultrasound
Hypoechoic metastasis
• Lymphoma
• Sarcoma
• Most adenocarcinoma(breast, lung, pan...
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Hyperechoic
• Colorectal carcinoma and other GIT
• Carcinoid, Renal cell carcinoma, islet cel...
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Cystic metastasis
• Ovarian carcinoma
• Cystadenocarcinoma of pancreas
• squamous cell carcin...
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CT
• On unenhanced CT -> Hypodense
• On Enhanced CT -> non enhancing
hypodense
• The margin o...
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MRI
• Most metastase are hypointense on T1
• Hyperintense on T2
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Interactive cases
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Liver calcification causes??
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Liver lesions

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Liver lesions

  1. 1. Powerpoint Templates Page 1 Liver lesions Dr. Aftab Qadir
  2. 2. Powerpoint Templates Page 2 Benign Liver lesions • Hemangioma • Focal nodular hyperplasia • Hepatic adenoma • Liver cyst • Liver abscess
  3. 3. Powerpoint Templates Page 3 Malignant • Hepatocellular carcinoma • Heptoblastoma Rare malignant: • Fibrosarcoma • Angiosarcoma • Leiomyosarcoma • Lymphoma
  4. 4. Powerpoint Templates Page 4 Hypervascular lesions Benign • Heamangioma • Adenoma • FNH Malignant • HCC • Hypervascular metastasis
  5. 5. Powerpoint Templates Page 5 Hypovascular lesions • Hypovascular liver tumors are more common. • Most hypovascular lesions are metastases.
  6. 6. Powerpoint Templates Page 6 Multiphasic CT For detection of liver lesions • Non enhance CT • Arterial phase • Portal venous phase • Delayed
  7. 7. Powerpoint Templates Page 7 Understanding the phases • Liver has dual blood supply • Normal parenchyma is supplied for 80% by the portal vein and only for 20% by the hepatic artery • All liver tumors get 100% of their blood supply from the hepatic artery
  8. 8. Powerpoint Templates Page 8 Arterial phase • In the arterial phase hypervascular tumors will enhance via the hepatic artery, when normal liver parenchyma does not yet enhances, because contrast is not yet in the portal venous system. • Hypervascular tumors will enhance optimally at 35 sec after contrast injection
  9. 9. Powerpoint Templates Page 9 Portal venous phase • To detect hypovascular tumors • Scanning is at about 75 seconds
  10. 10. Powerpoint Templates Page 10
  11. 11. Powerpoint Templates Page 11 Delayed Phase • Begins at about 3-4 minutes after contrast injection and imaging is best done at 10 minutes • Valuable for washout of contrast(HCC),retention of contrast(heamangioma),retention of contrast in fibrous tissue (capsule of HCC, central scar of FNH)
  12. 12. Powerpoint Templates Page 12
  13. 13. Powerpoint Templates Page 13 Pre contrast Arterial Phase Portal venous phase Delayed Hepatocelluar Ca Low attenuation Homogenous enhancement Washout of lesion Isodense Adenoma Low attenuation Homogenous enhancement 85% Iso or hypodense Iso or hypodense Haemangioma Low attenuation Peripheral puddles Partial Fill in Complete fill in FNH Iso/Low attenuation Homogenous enhancement Hypodense Isodense Metastasis(hypervascular) Low attenuation Homogenous enhancement Hypodense Metastasis Low attenuation Hypodense Hypodense Cyst Low attenuation No enhancement Abscess Low attenuation may have irregular margins Transient regional increase enhancement Ring enhancement Multiphasic CT of Liver
  14. 14. Powerpoint Templates Page 14 T1W T2W Gadolinium Hepatocellular Ca ,iso or (fat degeneration) Metastasis Haemanigioma ++ (like CT) Adenoma often FNH + delayed MRI of Liver
  15. 15. Powerpoint Templates Page 15 Hepatocellular Carcinoma • Most common primary malignancy of the liver • Third most common cause of cancer- related death • The incidence of HCC is rising, largely attributed to a rise in hepatitis C infection
  16. 16. Powerpoint Templates Page 16 Risk factors: • hepatitis B (HBV) infection • hepatitis C (HCV) infection • alcoholism • biliary cirrhosis • food toxins e.g. aflatoxins • congenital biliary atresia • inborn errors of metabolism haemochromatosis alpha-1 antitrypsin deficiency type 1 glycogen storage disease Wilson disease
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  18. 18. Powerpoint Templates Page 18 Clinical presentation Presentation is variable may include: • constitutional symptoms • jaundice • portal hypertension from invasion of the portal vein • hepatomegally / mass
  19. 19. Powerpoint Templates Page 19 • Majority of patient have cirrhosis • More than 80% of patients with HCC have cirrhosis • May be Focal, multiple or diffusely infiltrative
  20. 20. Powerpoint Templates Page 20 Investigation • alpha-fetoprotein (AFP) levels are elevated in 50-75 % of cases • Radiological investigation including ultrasound, CT and MRI • Biopsy
  21. 21. Powerpoint Templates Page 21 Ultrasound • Variable appearance • Small <3cm usually hypoechoic • Larger tumors often are heterogeneous • May invade the portal vein • Most tumors will show central vascularity on Doppler study Larger tumors often are heterogeneous
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  25. 25. Powerpoint Templates Page 25 CT • Focal HCC large usually hypodense mass may have necrosis / fat / calcification • Multifocal HCC multiple masses of variable attenuation may also have central hypodense necrotic portions • Diffuse HCC may be difficult to distinguish from associated cirrhosis
  26. 26. Powerpoint Templates Page 26 Enhancement pattern • Transient early arterial enhancement and then washes out
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  30. 30. Powerpoint Templates Page 30 MRI T1(variable) T1 C+ (Gd) Enhancement similar to CT Rim enhancement may persist T2 –Hyperintense Post SPIO (Iron oxide) - increases sensitivity in diagnosing small HCC’s Enhancement similar to CT
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  33. 33. Powerpoint Templates Page 33 Fibrolamellar hepatocellular carcinoma • Variant of HCC • Younger age group(20-40years) • Not associated with cirrhosis • No association with HCC risk factors • Usually present with constitutional symptoms • Fibrolamellar carcinomas typically are single large tumours Not associated with cirrhosis Fibrolamellar carcinomas typically are single large tumours
  34. 34. Powerpoint Templates Page 34 Ultrasound • Usually large heterogeneous predominantly hyperechoic lesion, calcification may be seen(40%)
  35. 35. Powerpoint Templates Page 35 CT • Large solitary well circumscribed • Heterogeneous arterial enhancement • 30-40% have central scar • Calcification can be seen on non enhanced CT
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  39. 39. Powerpoint Templates Page 39 Hepatic metastasis • More common than primary • May be solitary but usually multiple • Majority are hypovascular • Extremely variable appearance on ultrasound
  40. 40. Powerpoint Templates Page 40 Hypervascular metastases • Carcinoids • Leiomyosarcomas • Neuroendocrine tumors • Renal carcinomas • Thyroid carcinomas • Choriocarcinomas • Occasionally pancreas, ovary, or breast
  41. 41. Powerpoint Templates Page 41 Ultrasound Hypoechoic metastasis • Lymphoma • Sarcoma • Most adenocarcinoma(breast, lung, pancreas)
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  43. 43. Powerpoint Templates Page 43 Hyperechoic • Colorectal carcinoma and other GIT • Carcinoid, Renal cell carcinoma, islet cell tumor
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  45. 45. Powerpoint Templates Page 45 Cystic metastasis • Ovarian carcinoma • Cystadenocarcinoma of pancreas • squamous cell carcinoma Calcified metastasis • Mucinous adenocarcinoma of colon
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  48. 48. Powerpoint Templates Page 48 CT • On unenhanced CT -> Hypodense • On Enhanced CT -> non enhancing hypodense • The margin of the lesions can vary from well defined to ill defined • Hyperattenuating lesions are uncommon
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  50. 50. Powerpoint Templates Page 50 MRI • Most metastase are hypointense on T1 • Hyperintense on T2
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  52. 52. Powerpoint Templates Page 52 Interactive cases
  53. 53. Powerpoint Templates Page 53 Liver calcification causes??
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  61. 61. Powerpoint Templates Page 61 Thank you

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