This document discusses malignant liver lesions. It describes the different types of primary and secondary malignant tumors that can occur in the liver. The most common are metastatic deposits from other primary cancers, and hepatocellular carcinoma (HCC). HCC is described in detail, including risk factors, pathogenesis, imaging appearance on ultrasound, CT and MRI, staging systems, treatment surveillance, and diagnostic criteria. Other liver cancers such as cholangiocarcinoma are also briefly mentioned.

1. MALIGNANT LIVER LESIONS
BY-DR.SAHIL CHAUDHRY
MODERATOR-DR.GANESH K.
AJIMS MANGALORE

2. Malignant focal lesions of the liver can broadly be
classified as under:
• Hepatocellular Tumors
• Cholangiocellular
Tumors
• Mesenchymal Tumors
• Metastatic deposits
• Lymphoma
Primary Secondary

3. • Metastasis to the liver from an extrahepatic
malignancy is by far the commonest cause of a
malignant hepatic neoplasm.
• Hepatic metastases are particularly common from
primary malignancies of the gastrointestinal tract,
breast and lung.

4. Hepatocellular Carcinoma (HCC)
• most common malignant neoplasm of the liver
worldwide.
• Etiology also varies among different population
groups and the risk factors include hepatitis B and C
infection, alcoholic cirrhosis, primary
hemochromatosis, and exposure to carcinogens like
aflatoxin.

5. • Majority of HCCs are thought to arise in a stepwise
fashion from a regenerating nodule which develops
into a dysplastic nodule which finally develops a
focus of HCC.
• HCC frequently invades the portal vein (in about
40% cases) and less often the inferior vena cava and
hepatic veins (15%).

6. REGENERATIVE NODULE
( MICRO OR MACRONODULAR)
DYSPLASTIC FOCI (<1mm)
LOW- GRADE DYSPLASTIC NODULE
(>/=1mm)
HIGH-GRADE DYSPLASTIC NODULE
DYSPLASTIC NODULE WITH FOCUS OF HCC
(NODULE WITHIN A NODULE)
LARGE HCC
HEPATOCARCINOGENESIS

7. HEPATOCARCINOGENESIS

8. HEPATOCARCINOGENESIS

9. Pathology
INTRANODULAR HEMODYNAMIC CHANGE DURING
HEPATOCARCINOGENESIS IN CIRRHOTIC LIVER

10. PATHOLOGICAL CLASSIFICATION:
- Solitary - bulk in one lobe with satellite nodules
- Multifocal- small foci of nodules <2cm (upto 5 cm) in
both lobes
- Diffuse infiltrating form- tiny indistinct nodules assoc.
with cirrhosis
Mosaic pattern- confluent small tumor nodules with
interspersed septa and necrosis
MORPHOLOGICAL CLASSIFICATION:
Small HCC = <2cm
Large HCC= >2cm

11. TX,NX,MX – NOT ASSESSED
T0,N0,M0 - NOT FOUND
T1 – ONE NODULE </= 1.9CM
T2 – ONE NODULE 2-5CM;TWO OR THREE NODULES ALL <3CM
T3 – ONE NODULE > 5CM;TWO OR THREE NODULES,AT LEAST ONE > 3 CM
T4A- FOUR OR MORE NODULES,ANY SIZE
T4B – T2,T3 OR T4A PLUS GROSS INTRAHEPATIC PORTAL OR HEPATIC VEIN
INVOLVEMENT
N1- REGIONAL(PORTA HEPATIS) NODE INVOLVEMENT
M1 – METASTASIS INCLUDING EXTRAHEPATIC PORTAL OR HEPATIC VEIN
INVOLVEMENT
STAGING :
I T1
II T2
III T3
IVA1 T4A
IVA2 T4B
IVB ANY N1,ANY M1
American Liver Tumor Study Group Modified TNM Classification
And Staging System

12. HCC SURVEILLANCE
- Includes Child-Pugh class A and B patients
- Combined US and AFP levels
- Normal serum level of AFP < 20ng/ml
- Diagnostic level of AFP for HCC in cirrhosis >400ng/ml
- USG for detection of tumor or nodule (6mthly)
Journal of Hepatology 35 (2001) 421–430

13. EUROPEAN ASSOCIATION FOR STUDY OF LIVER
(EASL) Diagnostic criteria for HCC in cirrhotic liver
Nodules >
2cm
Arterial hypervascularization with any two
imaging modalities
(CEUS, CECT, CEMR, Angiography)
OR
Arterial hypervascularization in any one modality
+
AFP level >400ng/ml
Nodules 1-2
cm
FNAC or Biopsy
Nodules <1
cm
Close monitoring by US every 3 mths until lesion
grows to >1cm
(Absence of growth does not rule out malignancy)
World J Gastroenterol. 2009 March 21; 15(11): 1301–1314.

14. AMERICAN ASSOCIATION FOR STUDY OF LIVER DISEASES
(AALD)
Diagnostic criteria for HCC in Cirrhotic Liver
LESION > 2cm
Typical imaging features on
one modality
(CECT or CEMR)
LESION 1-2 cm
Typical imaging features on
two modalities
Radiology May 2008 247:311-330

15. Clinical Presentation
• Upper abdominal pain, malaise, fever, weight loss,
palpable mass and rapid deterioration of liver
function in patients with chronic cirrhosis are
possible indicators.
• Alfa-fetoprotein (AFP) is a useful serum marker
and is elevated in 50-70% cases, and levels above
1000 ng/mL are strongly suggestive of HCC.

16. IMAGING MODALITIES
ULTRASONOGRAPHY
- B Mode
- Duplex and color flow Doppler
- Microbubble-enhanced sonography
COMPUTED TOMOGRAPHY
- Biphasic/ Triphasic CT
- Angiography assisted CT (CTHA,CTAP)
- CT after injection of Iodized oil
MAGNETIC RESONANCE IMAGING
- MRI
- CEMRI
- Nonspecific Extracellular Gadolinium –chelates
- Reticuloendothelial agents– SPIO
- Hepatocellular – Mangafodipir trisodium (Mn-DPDP)
- Mixed – Gd-BOPTA, Gd-EOB- DTPA
- Double CEMRI
ANGIOGRAPHY

17. USG
• Solid tumors without necrosis are hypoechoic whereas
hyperechoic appearance is attributable to fatty
metamorphosis, fibrosis, or sinusoidal dilatation.
• The majority of small HCCs (< 2 cm) are hypoechoic,
whereas the larger HCCs are hyperechoic or of
heterogeneous echo texture.
• Color Doppler may also demonstrate intra-lesional
vascularity in the form of a tangle of vessels within the
tumor indicating hypervascularity and arterio-venous
shunting

18. • HCC has a propensity to invade the portal vein,
hepatic vein or both, and this is depicted as echoes
either partially or completely filling the lumen.
• Color Doppler flow imaging is a useful adjunct for
detection of vascular invasion.
• The presence of arterial waveform within the
thrombus indicates that it is neoplastic rather than
bland thrombus.
• This distinction is vital because it has been shown
that the presence of malignant portal vein
thrombosis is the worst prognostic factor in
predicting recurrence of HCC following surgical
resection or liver transplantation.

22. HYPOECHOIC NODULES ECHOGENIC NODULE
ECHOGENIC NODULE IN CIRRHOSIS EXOPHYTIC MAS IN CIRRHOSIS

23. PV TUMOR THROMBUS

27. BASELINE AP
150s
HCC

29. MICROBUBBLE CONTRAST– ENHANCED US
Lesion Vascular imaging AP Enhancement PVP Enhancement
HCC
Hypervascular
Diffuse
Heterogenous
Greater than liver Less than liver
Washout over time
METASTASES
Hypovascular
Marginal
enhancement
Hypervascular
Less than liver
Marginal
enhancement
Greater than liver
Greater/Equal/Less
than liver
HEMANGIOMA
Marginal
Puddles and pools
Greater than liver
Peripheral nodular
Centripetal
progression
Equal/Greater
Sustained
enhancement
FNH
Hypervascular
Stellate vessels
Tortuous feeding
artery
Greater than liver
Diffuse
Homogenous
Equal/Greater
Nonenhancing scar
Sustained
enhancement
Diagnostic Ultrasound;Rumack:3rd Edition

30. Limitations-
• Less spacial resolution
• Limited late phase information
• Hemodynamic changes in cirrhotic patients
with hyperdynamic circulation and shunting,
the parenchymal enhancement in the late
phase is heterogeneous
• inability to evaluate the extrahepatic
extension

31. CT
• The liver receives 75-80% of its blood supply from
the portal vein and 20-25% from the hepatic artery.
• On the other hand most liver tumors receive the
majority of their blood supply from the hepatic
artery.
• HCCs have a rich arterial supply and are better
visualized on the arterial phase.

32. TECHNIQUES
Rate of contrast injection: 3ml/s v/s 5ml/s
Concentration of contrast :300mgI/ml v/s 400mgI/ml
Quadruple-Phase MDCT of the Liver in Patients with
Suspected Hepatocellular Carcinoma: Effect of Contrast
Material Flow Rate AJR 2006; 186:1571-1579

33. SOLITARY HCC .The arterial phase image (A) shows a large mass in the
right lobe with arterial enhancement. The venous phase (B) shows
washout of contrast and a subtle capsule (arrow heads) is seen in the
delayed phase (C)

34. Multifocal HCC. The arterial phase (A) image shows multiple
hypervascular focal lesions with evidence of cirrhosis.
These lesions show wash out in the portal venous phase (B) and are
seen as hypodense lesions in the delayed phase (C)

35. AP
PVP
Multicentric HCC
C-3

36. Poorly diff HCC
with satellite nodules
C-4

37. Diffusely infiltrating HCC
With satellite nodule
C-5

38. Well diff HCC

39. In addition, arterial phase imaging is useful in
demonstrating
• arterioportal shunting (early enhancement of intra-
hepatic portal venous branches) and
• enhancement of portal venous thrombus
confirming it to be tumor thrombus.

40. • Arterio-portal shunt:
The arterial phase CT
image shows a large
enhancing lesion (m)
in the segments 3 and
4 of liver with contrast
in the left hepatic
artery (arrow) and left
branch of portal vein
(arrow head)
suggesting arterio-
portal shunting

41. • Vascular invasion is common with HCC.
• Portal vein invasion is due to portal venous drainage
of HCC.
• A tumor thrombus in portal vein is diagnosed if the
main portal vein has a diameter of > 23 mm (bland
thrombus rarely causes portal vein dilatation) and
the thrombus shows enhancement in arterial phase

42. Portal vein thrombus: The arterial phase CT image (A) shows two enhancing lesions
(arrow) in segments 3 and 4 of liver with arterio-portal shunting. The portal vein in
the venous phase image (B) shows a large filling defect (star) with ‘thread and
streak’ pattern of enhancement suggestive of tumor thrombus.

43. • IVC invasion: The axial
CT image shows an
exophytic mass (m)
arising from left lobe of
liver extending into the
IVC (arrow)

44. HCC VARIANTS
 Predominantly Clear cell type – intracytoplasmic fat
signal drop on opposed phase T1W
 Fibrolamellar HCC – central calcification, scar and
pseudocapsule (good prognosis)
 Sarcomatoid HCC – Central necrosis/hemorrhage (poor prog.)
 Combined HCC-Cholangiocarcinoma
 Sclerosing HCC – intense fibrosis ;progressive and prolonged
enhancement
AJR 2009; 193:W7–W13

45. Lesions Simulating HCC
• Focal confluent fibrosis
• Infarcted regenerative nodule
• Small hemangioma
• Arterioportal shunt
• Enhancing dysplastic and
regenerative nodule
• Nodular hyperplasia in the Budd-
Chiarri syndrome

47. • HCCs may occasionally rupture and may lead to
hemoperitoneum.
• A ruptured HCC is hypodense on arterial phase images
showing only peripheral rim enhancement with focal
discontinuity (‘enucleation sign’).
• Since the imaging appearance of HCC can be variable it
is said that any mass in a cirrhotic liver that does not
fulfill criteria for a cyst or hemangioma should be
considered as HCC until proved otherwise.

48. WITH SUBCAPSULAR BLEED

49. MAGNETIC RESONANCE IMAGING

50. MRI PROTOCOL
Precontrast:
T1W in-and opposed-phase GRE
T2W Fat-suppressed fast SE
Dynamic Imaging:
T1W fat-suppressed GRE
Hepatobiliary phase imaging:
T1W fat-suppressed spoiled GRE

53. MAGNETIC RESONANCE IMAGING
T1 – Iso to hyperintense - (Fat/Glycogen/Cu /Fe) - 47-62%
T2- Moderately hyperintense - (70-90%)
Ring sign = Hypointense capsule on T1 (24-78%)
Double layer of inner hypo and outer hyperintensity on T2
Central scar/calcification – Hypo on T1 and T2
Dynamic CEMR– Criteria favoring malignancy are size larger than 2
cm,“washout,” hyperintensity at T2-weighted imaging, delayed
enhancing tumor capsule, and rapid interval growth
Radiology: Volume 247: Number 2—May 2008

54. T1
T2
CASE-1

55. AP
PVP

56. Solitary HCC: The T1W axial image (A) shows a large hypointense mass lesion in segment 8
of liver, with foci of hemorrhage (arrow heads). The lesion Is heterogeneously
hyperintense on T2W image (B) On contrast enhanced arterial phase image (C) the lesion
is hypervascular and shows washout in the venous phase (D) and a capsule (arrow heads)
in the delayed phase (E)

57. APPEARANCE OF NODULES WITH HEPATOBILIARY
SPECIFIC CONTRAST AGENTS
Type of
Cirrhotic
Nodule
T1W T2W Dynamic Imaging Delayed phase
REGENERATIVE
NODULE Iso to Hyper Iso to Hypo
Enhances in PVP
Iso or Hyper
Iso to Hyper
Dysplastic
Nodule
Well Diff.
Variable,often
Hyper Iso to Hypo ” Enhances
Dysplastic
Nodule
Poorly Diff.
Variable Mildly Hyper May enhance in AP
May or may not
Enhance
HCC
Well Diff. Variable Hyper
May enhance in AP
Washout in PVP
May or may not
Enhance
HCC
Modeately to
Poorly Diff.
Heterogenous Hyper
Enhances in AP
Washout in PVP
No
Enhancement

58. T2WFS
T1GRE T2GRE
T2FST1GRE
RN
SIDEROTIC RN

59. T1GRE
T2FSTSE
HAP T1GRE
DN

60. HCC with dysplastic nodules

61. T2 illdefined hyperinteense mass
Rt lobe
Multiple hyperintense nodules
Lt lobe not seen on T1

62. PC T1 heterogenous enhancement
Of mass in rt lobe

63. • Liver specific MR contrast agents such as
superparamagnetic iron oxide (SPIO) and
Mangafodipir have also been tried for detection and
characterization of HCC.
• SPIO increases the sensitivity of MRI in HCC
detection and is useful in detection of small HCCs in
cirrhotic liverand is the current gold standard.
• Gadobenate dimeglumine (Gd-BOPTA) has the
advantage of being both intravascular and
hepatobiliary contrast agent.

64. • The most sensitive sequence for detecting small HCC is
the immediate post-gadolinium arterial phase on which
small tumors enhance intensely.
• However, this feature is not specific as severely
dysplastic nodules will also enhance.
• A more specific feature is washout of tumor below the
signal of liver at 2 minutes post-contrast with late
enhancement of the pseudocapsule.
• The arterial phase also allows distinction from
metastatic disease because HCCs typically demonstrate
enhancing stroma through the entire tumor whereas
metastases have peripheral enhancement.

65. HEPATOBILIARY SPECIFIC CONTRAST AGENT
RadioGraphics2009: 29, 1725-1748.

66. ANGIOGRAPHY
• Main role in the management
• Most HCC - hypervascular
• Arterial feeders - dilated, tortuous,
distorted and displaced
• Tumor stain / lakes or venous pools
• Arterioportal shunting

68. MANAGEMENT
• Surgical
– Liver
transplantation
– Partial resection
• Non – surgical
Intraarterial techniques
• TACE/TAE/TART
Percutaneoous ablation
techniques
 Chemical
 Thermal
 Freezing
• Preop PVE

69. Intraarterial techniques
TACE / TAE
• Intraarterial delivery of chemotherapeutic agents,
emulsified in an oily medium, combined with embolic
material
• Aim: achieve cytoreduction
• Advantage
– greater concentrations
– prolonged periods of contact time
– minimizes systemic toxicity
– preserve as much functional liver tissue as possible

70. TACE / TAE contd..
• Agents –doxorubicin / cisplatin, doxorubicin
and mitomycin C combination
• Lipiodol – carrying agent, tumor seeking
• Avoid injecting into gastroduodenal artery

71. TACE / TAE contd..
• Cx
– Postembolization syndrome ( transient abdominal
pain, ileus and fever)
– Ischemic cholecystitis, hepatic abscess, biliary
strictures and rarely death.
• C/I
– Invasion of main PV
– Child-Pugh class C pt.
– Portosystemic shunt, hepatofugal blood flow
– Any C/I for arterial procedure
– End-stage tumoral disease

72. TACE

73. Transarterial Radionuclide Therapy (TART)
• Therapeutic dose of irradiation can be
delivered to the tumour while the rest of the
liver and the patient's body receive minimal
irradiation
• 90Y microspheres, Rhenium188

74. Transarterial radioembolization
• 90Y microspheres are delivered via a catheter
placed into HA
• Unable to traverse tumor vasculature
• Embolized within the tumor
• Exert local radiation effect
• Relatively limited concurrent injury to
surrounding normal tissue

75. Preoperative portal vein embolization
(POPVE)
• Improve the prognosis after extended
hepatectomy
• FLR ≤ 25% total liver volume
≤ 40% (compromised LFT)
• Approach :
– percutaneous approach
– direct ileocolic vein catheterization (requiring
laparotomy)

76. PVE

77. Ablative techniques
• Chemical desiccation
– ethanol ablation / acetic acid
• Heating (radiofrequency ablation, laser,
microwave )
• Freezing (cryoablation)

78. Chemical Ablation contd…
Eligibility
• Those with small (3 cm) HCC
• No extrahepatic disease or vascular
invasion
• Who are poor surgical candidates

79. Thermal Ablation Therapy
• Heat used to kill malignant cell
• Energy sources
– Electromagnetic energy (RF, microwave)
– Laser
– Sound energy (HIFU)

80. Radiofrequency ablation (RFA)
• Induce thermal injury through
electromagnetic energy deposition
• Tissue temp achieved & duration of heating
determines tissue damage
• Cooled-tip electrode needles
expandable electrode needles
• Reduced efficacy of RF ablation in larger
tumors
• Perfusion-mediated vascular cooling

81. Nano Knife (Irreversible Electroporation)

82. HEPATOBLASTOMA
• most common primary liver tumor of childhood.
• occurs in the first 3 years of life, whereas hepatocellular
malignancies in children older than five years tend to be
morphologically similar to those found in adults.
• The most common presentation is a painless abdominal mass,
however anorexia, weight loss, pain and jaundice can occur.
• Serum AFP levels are elevated in over 90% of patients.

83. • Large, inhomogeneous
echogenic mass
sometimes with
calcification.
• Anechoic foci due to
necrosis and a lobular
pattern caused by
septation may be seen.

84. • CT scan most
commonly
demonstrates a well-
defined hypodense
mass with mild
enhancement.
• Involvement of portal
vein and IVC can be
demonstrated.

85. • If portal vein invasion is present, initial
preoperative chemotherapy is given to shrink
the tumor away from portal vein and then
surgical excision is done.
• Lung metastasis is common at presentation
and CT scan of the chest is routinely
performed before treatment.

86. MRI
• lobulated mass that is hypointense on T1W and
hyperintense on T2W scans.
• Internal septa are seen as bands of low signal
intensity.
• On CEMR, immediate diffuse enhancement
followed by washout is noted.

87. FIBROLAMELLAR HEPATOCELLULAR
CARCINOMA (FLC)
• found in young adults with a mean age of 23 years without
cirrhosis or raised afp.
• Usually present as a solitary large circumscribed mass that is
partly or completely encapsulated.
• Satellite nodules are often seen.
• The major radiological clue to the diagnosis is the presence of
central fibrous scar and central stellate calcification.

88. • On sonography, usually
seen as a lobulated
predominantly
hyperechoic mass,
although hypo and
isoechoic forms have also
been described.
• Central hyperechoic areas
with foci of shadowing
correlate with the central
scar and calcification
within the scar.

89. • On unenhanced CT,
FLC is a well defined,
lobulated and
hypodense lesion.
• The central stellate
calcification has been
reported as a
distinctive radiological
feature and occurs in
a high proportion (up
to 55%) of these
lesions.

90. • After intravenous
contrast, FLC shows
heterogeneous
enhancement in arterial
and venous phases
• The scar does not show
early enhancement but
may enhance on delayed
images.

91. • On MRI, FLC is hypo- to iso-intense on T1W
images and hyperintense on T2W images.
• The scar because of its fibrous nature, remains
hypointense on T1- and T2-weighted images.
• The enhancement pattern on CEMR is similar
to that seen on CT scans.

92. D/D
• The central scar is
hyperintense on T2W scans
in FNH.
• < 1.5% of cases of FNH
show calcification.
• FNH is managed
conservatively.
• hypointense in FLC
• the scar of FLC shows
calcification.
• FLC is surgically treated.
FNH FLC

93. Treatment
• These include hepatic arterial infusion
chemotherapy and embolization and
percutaneous techniques like ethanol
ablation, and radiofrequency ablation.

94. INTRAHEPATIC CHOLANGIOCARCINOMA
(ICCA)
• second most common primary malignant hepatic
tumor.
• It has an increased incidence in patients with
Caroli’s disease, sclerosing cholangitis, intrahepatic
calculi and inflammatory bowel disease.

95. Presentation
• Patients present clinically with abdominal pain,
anorexia and weight loss.
• Jaundice occurs only if major ducts are
obstructed.
• A normal serum AFP may be helpful in suggesting
ICCA rather than HCC.

96. USG
• Sonographically, one or more hyperechoic, iso- or
hypoechoic masses may be seen.
• Homogeneous hypoechoic pattern is more common.
• On Doppler USG most of them show internal
vascularity.
• Dilated intrahepatic bile ducts distal to the mass may
also be seen.

97. Intrahepatic cholangiocarcinoma.
A: Gray-scale sonogram shows
hypo-echoic nodule (arrows);
B: At CEUS during the arterial
phase the lesion shows
markedly inhomogeneous
enhancement (arrows);
C: The lesion appears as
hypoenhancing
mass in comparison with
adjacent parenchyma in late
phase (arrows).

98. • On unenhanced CT it is seen as a well-defined round to
oval, hypodense mass and on contrast enhanced CT
scan it typically shows early peripheral enhancement.
• A delayed central enhancement is often seen which
may take 5-15 minutes.
• Capsule retraction and biliary dilatation adjacent to the
mass are highly suggestive of ICCA (as these are rarely
seen with HCC)

99. • these lesions are
hypointense on T1W
and hyperintense on
T2W images

100. • On CEMR, smaller lesions (2-4
cm) enhance homogeneously
but those > 4 cm show thick
peripheral enhancement with
centripetal progression.
• In addition, DWI shows
restriction of diffusion unlike
hemangioma.

101. Metastatic Disease
• The liver is second only to regional lymph
nodes as a site for metastatic disease.
• It is far more common than primary liver
cancer.
• The colon, stomach, pancreas, and breast are
the common primary sites.
• Metastases are more common in the right
lobe of the liver.

102. • Hepatic metastases may
be hypoechoic,
hyperechoic, cystic or
mixed echogenicity.

103. • The most common pattern is hypoechoic with
no distal shadowing or enhancement.
• This is produced by highly cellular and
hypovascular lesions.
• Hyperechoic metastases are often seen with
colonic and gastrointestinal malignancies and
with vascular metastases from islet cell
tumors, carcinoid, choriocarcinoma and renal
cell carcinoma.

104. • They may be surrounded by a
hypoechoic halo producing the
bull’s eye or target appearance.
• Presence of halo indicates an
aggressive tumor and is
commonly seen with
bronchogenic carcinoma.
• Calcification may be seen in
mucinous metastases from
colon and ovary.

105. • Cystic metastases are seen with adenocarcinoma
of pancreas, ovary and colon.
• Since most metastases are hypovascular the usual
protocol is to scan in the portal venous phase of
enhancement.

106. • On unenhanced CT most metastases are
hypodense to the liver parenchyma, whereas
some are indistinguishable from normal liver.
• Small lesions are nodular and homogeneous,
while larger lesions are more irregular,
heterogeneous and with ill-defined margins.

108. • After contrast
administration,
metastases from
hypovascular tumors
may have an enhancing
rim that can be seen
during arterial phase
and occasionally during
portal phase.

109. • Dual phase scanning
may be useful for
detection of metastases
from hypervascular
primaries such as renal
cell carcinoma and islet
cell tumors

110. • Liver metastases like most
other liver lesions are
hypointense to normal liver on
T1W images and hyperintense
on T2W images

111. • Six appearances of liver metastasis have been
described on MRI.
• Doughnut shape is usually seen with larger
lesions, where the lesion is of low signal
intensity on T1W images with central necrosis
which has even lower signal.
• These lesions have target appearance on T2W
image.

112. • Amorphous appearance is seen with heterogenous
masses with ill-defined margins.
• Peripheral halo is seen with some metastasis and
represents either tumor infiltration or surrounding
edema.
• Light bulb morphology, where the lesion is
hyperintense on T2W images, is seen with cystic and
hypervascular metastasis.
• Cauliflower appearance is typically seen with colorectal
metastasis. Here the lesion has scalloped margins with
enhancing periphery and internal septae.

113. FROM GIST

114. FROM OVARY

115. CA RECTOSIGMOID

117. LYMPHOMA
• Primary hepatic lymphoma is rare and most
often of Non-Hodgkin’s (diffuse histiocytic)
type.
• Primary hepatic lymphoma is much more
common in organ transplant recipients treated
with cyclosporine and patients with AIDS.

118. • The most common appearance is that of a
solitary large mass, which is hypodense on
unenhanced CT and does not enhance
significantly after intravenous contrast.
• Tumors are moderately low in signal intensity on
T1W scans and mild to moderately hyperintense
on T2W scans and show mild heterogeneous
enhancement on immediate postgadolinium
images.

119. • Secondary liver involvement in
lymphoma is more common
than primary lymphoma and
occurs both in Hodgkin’s
disease and in Non-Hodgkin’s
lymphoma.
• Diffuse infiltration is more
common in Hodgkin’s disease,
whereas diffuse and nodular
hepatic involvement is equally
frequent in Non-Hodgkin’s
lymphoma.

120. Infantile haemangioendothelioma
• composed of large endothelial-lined vascular
channels seen in fetuses and neonates.
• substantial arteriovenous shunting which may
lead to fetal cardiovascular compromise and
hydrops fetalis.
• fetuses may also develop haemolytic anaemia,
thrombocytopenia, and consumptive
coagulopathy (Kasabach-Merritt sequence)
and unexplained congestive heart failure.

121. • Ultrasound
• variable sonographic appearance with prominent vascular
channels. Colour Doppler sonographic evaluation will show
increased flow.
• CT
There is typical peripheral enhancement with gradual filling in.
Another characteristic finding is reduction in the aortic caliber
mid-aortic syndrome) below the level of coeliac branch because of
the important vascular distribution toward the liver. The same
process will cause celiac trunk and hepatic artery hypertrophy.
• MRI
• Large flow voids are usually present. Typical signal
characteristics include
• T1: hypointense
• T2: hyperintense

123. DW MRI in focal liver lesions
• With advances in hardware and coil systems, DW MRI –
now be applied to liver imaging with improved image quality.
• Enables qualitative & quantitative assessment of tissue
diffusivity (ADC) without Gd chelates, which makes it a
highly attractive technique, particularly in patients with
severe RF at risk for NSF.
• detection and characterization with better results
compared with T2-WI.
• should be interpreted in conjunction with conventional
sequences.
Taouli and Koh , Radiology 2010.

124. Taouli and Koh , Radiology 2010.

125. b0
b100
b500 b1000
HCC
ADC

126. Treatment assessment Taouli and Koh , Radiology 2010.

127. SNIPPETS-
• Cirrhotic liver adenoma /fnh/metastasis bad diagnosis ,consider
regenerative/dysplastic/Hcc
• HCC variegated ehnhancement with intra tumoral neovascualrity
• Metastasis circumferential enhancing ring
• Peripheral puddles in hemangioma,follows blood pool
• TSTC for <5mm
• Neuro endocrine liver metastasis
• Centripetal filling is non specific