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HEPATOCELLULAR CARCINOMA RADIOLOGY
This document discusses imaging techniques for detecting and characterizing liver lesions. It focuses on multiphase CT and MRI protocols for hepatocellular carcinoma (HCC). CT involves non-contrast, arterial, portal, and delayed phase imaging. Arterial phase highlights hypervascular tumors fed by the hepatic artery. Portal phase detects hypovascular lesions. MRI features of HCC include hypointensity on T1-weighted imaging and hyperintensity on T2-weighted imaging. The Barcelona Clinic Liver Cancer staging system is also referenced.
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HEPATOCELLULAR CARCINOMA RADIOLOGY
- 1. -DR. BHANUPRIYA SINGH HCC-Malignant Liver lesion
- 3. IMAGING TECHNIQUES plainradiography : gross hepatomegaly calcification USG / CE-USG CT MRI Angiography Scintigraphy: Sulfur colloid , Tc99m labelled RBC’s PET
- 4. CT SCAN Noncontrast study: Contrast study: arterial phase: 20-40secs Portal phase : 60-80secs Early delayed: > 180 sec , best at 4 mins Late delayed : 4-6hrs 100ml contrast @3ml/sec
- 5. Understanding the phases Liver -dual blood supply Normal parenchyma - 80% portal vein 20% -hepatic artery All liver tumors blood supply from hepatic artery
- 6. Arterial phase 20-40 sec Hypervascular tumors enhance via the hepatic artery Normal liver parenchyma not yet enhanced Hypervascular tumors enhance optimally at 35 sec
- 7. Portal venous phase 60- 80 sec To detect hypovascular tumors
- 8. Delayed Phase Beginsat about > 180 sec Best done at 4 minutes
- 9. Pre contrast ArterialPhase 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 Hypervascular Mets Low attenuation Homogenous enhancement Hypodense Metastasis Low attenuation Hypodense Hypodense Cyst Low attenuation No enhancement Abscess Low attenuation may have irregular margins Transient regional enhancement Ring enhancement Multiphasic CT of Liver
- 10. T1W T2W Gadolinium HepatocellularCa ,iso or (fat degeneration) Metastasis Haemanigioma ++ (like CT) Adenoma often FNH + delayed FLC + delayed MRI of Liver
- 11. FOCAL FAT SPARING Diagnostic confusion with tumors Common sites Periportal region of the medial segment of left lobe (segment IV) Either side of falciform ligament Cranial aspect of GB fossa Characteristic features: Geographic appearance Lack of mass effect Vessels through the lesion
- 12. FOCAL NODULAR LIVER LESIONS: •Regenerative nodule • Cirrhotic nodule • Low grade dysplastic nodule (adenomatous hyperplasia) • High grade dysplastic nodule (adenomatous hyperplasia with atypia) • Dysplastic nodule with subfoci of HCC (early HCC) • HCC (overt HCC)
- 13. Hepatocellular Carcinoma Mostcommon primary malignancy of the liver Rising incidence, attributed to a rise in hepatitis B and C infection Typically diagnosed in adults(late middle age/elderly) Pt with cirrhosis present earlier
- 14. Risk factors: hepatitisB (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 Hepatocellular Carcinoma
- 16. USG USG -vary Small HCC’s (<3cms) -> hypoechoic with posterior acoustic enhancement ( fatty change/ marked sinusoidal dilatation) >3cms- mosaic or mixed pattern May invade poratl vein CD:central vascularity
- 22. CT SCAN 3patterns: Solitary Multicentric Diffuse Large hypodense mass Central low attenuation due to necrosis
- 23. CT Focal calcification- 7.5% Majority - hypervascular arterial phase Heterogenous enhancement due to central necrosis Isodense on delayed images Angioinvasive: portal vein /IVC Central Necrosis- Hetrogeneous +C
- 24. Arterial phase Demonstrationof arterial branches tumour Arterio portal shunts 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
- 26. Portal venous invasionby hepatocellular carcinoma. portal phase-expanded low attenuation focus in right portal vein.
- 29. IVC invasion: Theaxial CT image shows an exophytic mass (m) arising from left lobe of liver extending into the IVC (arrow)
- 30. MRI Small HCC’sv/s regenerative Cirrhotic nodule: hyper on T1 , hypo on T2 HCC : hypo on T1, hyperintense on T2 HCC arising in a siderotic nodule: “nodule within a nodule” appearance HCC - a small focus of high signal intensity within the low signal intensity nodule(T2).
- 33. Hepatocellular carcinoma andregenerative nodule. T1w MRI (A) and T2w MRI (B) demonstrating a hepatocellular carcinoma (white arrowhead) and an adjacent atypical regenerative nodule (black arrowhead). Majority of hepatomas have decreased signal intensity on T1WI -increased signal -fat or glycogen content
- 36. MRI IN DETECTINGEARLY HEPATO-CARCINOGENESIS
- 43. BARCELONA CLINIC LIVERCANCER STAGING SYSTEM
- 44.
Editor's Notes
- #7 Tumors enhance in arterial phase. Liver will enhance in the portal venous phase
- #8 Will be visible as hyperdense lesions in a relatively hypodense liver
- #9 also called the hepatic phase because there already must be enhancement of the hepatic veins
- #12 Metastasis
- #17 after lung and stomach cancer
- #18 HCC are typically diagnosed in adults in late middle age or elderly
- #29 Small HCC seen only in arterial phase in a patient with cirrhosis