1

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

2

Jessica Y. Leung, HMS 2004

Gillian Lieberman, MD

Mr. B.HPI:•

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

3

Jessica Y. Leung, HMS 2004

Gillian Lieberman, MD

Mr. B. –

RUQ ultrasound

Large lesion in R hepatic lobe, solid with heterogeneous echotexture

BIDMC PACS

4

Jessica Y. Leung, HMS 2004

Gillian Lieberman, MD

DDx

of Solid Liver MassWhat types of cells are in the liver?

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

collection_display.asp, HMS #61

•

Invading cells•

Metastases•

Lymphoma•

Carcinoid

•

Hepatocytes•

Adenoma, hepatoblastoma•

Focal nodular hyperplasia•

Hepatocellular

carcinoma•

Bile ducts •

Cholangioma•

Cholangiocarcinoma•

Blood vessels•

Hemangioma, hemangioendothelioma

•

Angiosarcoma

Normal liver histology

5

Jessica Y. Leung, HMS 2004

Gillian Lieberman, MD

DDx

of Liver Mass in Adult

> 50 yo

(Mr. B.)•

Common•

Hemangioma•

Metastases

•

Uncommon•

Angiosarcoma•

Hepatocellular

carcinoma•

Intrahepatic

cholangiocarcinoma

< 50 yo•

Common•

Focal nodular hyperplasia

•

Uncommon•

Fibrolamellar

carcinoma•

Hepatocellular

carcinoma

Reeder MMM. Reeder and Felson’s

Gamuts

in Radiology. 1993.

6

Jessica Y. Leung, HMS 2004

Gillian Lieberman, MD

Mr. B.’s

diagnosis

•

Ultrasound-guided biopsy demonstrated hepatocellular

carcinoma

http://www.kumc.edu/instruction/medicine/pathology/ed/ch_14/c14_s35a.html

Example of HCC on liver biopsy

7

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 presentationSchwartz JM, Carithers

RL. UpToDate

Online 10.3

Kamel

IR, Bluemke

DA. J Vasc

Interv

Radiol

2002; 13:S173

8

Jessica Y. Leung, HMS 2004

Gillian Lieberman, MD

Imaging modalities for HCC

•

Ultrasound•

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

9

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

10

Jessica Y. Leung, HMS 2004

Gillian Lieberman, MD

Mr. B. –

Abdominal CT1. Multiple hypoattenuating

lesions pre-contrast

3. Hypodense

in portal venous and equilibrium phases

2. Early arterial enhancementBIDMC PACS

11

Jessica Y. Leung, HMS 2004

Gillian Lieberman, MD

•

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

Imaging modalities for HCC (cont’d)

Schwartz JM, Carithers

RL. UpToDate

Online 10.3

Kamel

IR, Bluemke

DA. J Vasc

Interv

Radiol

2002; 13:S173

12

Jessica Y. Leung, HMS 2004

Gillian Lieberman, MD

Patient 2 -

HCC on MRI

BIDMC PACSCentral area of T2 hyperintensity

suggestive of necrosis

13

Jessica Y. Leung, HMS 2004

Gillian Lieberman, MD

Mr. B. -

Angiography

BIDMC PACS

R hepatic artery angiogram –

Hypervascularity

of HCC

14

Jessica Y. Leung, HMS 2004

Gillian Lieberman, MD

Mr. B. –

Post-chemoembolization

BIDMC PACS

1.

1% lidocaine

2.

Chemotherapeutic (doxorubicin, lipiodol) + contrast

15

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

16

Jessica Y. Leung, HMS 2004

Gillian Lieberman, MD

Findings associated with HCC

•

Mass effect or local invasion •

Often secondary to underlying cirrhosis

17

Jessica Y. Leung, HMS 2004

Gillian Lieberman, MD

Patient 2 -

Mass effect

BIDMC PACS

Compression of portal vein

18

Jessica Y. Leung, HMS 2004

Gillian Lieberman, MD

Patient 3 -

Vascular invasion

BIDMC PACS

Ascites

Portal vein invasion

19

Jessica Y. Leung, HMS 2004

Gillian Lieberman, MD

Patient 2 -

Portal hypertension

BIDMC PACS

Caput Medusae

seen on CT reconstruction

20

Jessica Y. Leung, HMS 2004

Gillian Lieberman, MD

Patient 3 -

Portal hypertension (cont’d)

BIDMC PACS

Varices

21

Jessica Y. Leung, HMS 2004

Gillian Lieberman, MD

Non-HCC liver masses

DO NOT BE FOOLED!

•

Metastases •

Spectrum of appearances, usually low attenuation on CT, contrast may or may not enhance

•

Hemangioma•

Focal nodular hyperplasia

22

Jessica Y. Leung, HMS 2004

Gillian Lieberman, MD

Patient 4 -

Hemangioma

Hypodense

on pre-

contrast scan

Peripheral enhancement during bolus phase of IV contrast

BIDMC PACS

23

Jessica Y. Leung, HMS 2004

Gillian Lieberman, MD

Patient 5 -

Focal Nodular Hyperplasia

BIDMC PACS

Hyperdense

lesion in setting of fatty liver

Enhances in arterial phase, accentuates central fibrous scar

Scar enhances during late arterial phase… enhancement washes out during portal venous and equilibrium phase

24

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

25

Jessica Y. Leung, HMS 2004

Gillian Lieberman, MD

References1.

Schwartz JM, Carithers

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

carcinoma. UpToDate

Online 10.3.

2.

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 (<1.5 cm) malignant hepatic neoplasms. AJR Am J Roentgenol

1995; 164:879.

3.

Sherman M, Peltekian

KM, Lee C. Screening for hepatocellular carcinoma in chronic carriers of hepatitis B virus: Incidence and prevalence of hepatocellular carcinoma in a North American urban population. Hepatology

1995; 22:432.

4.

Kim TK, Kim AY, Choi

BI. Hepatocellular carcinoma: harmonic ultrasound and contrast agent. Abd

Imaging 2002; 27:129.

5.

Murakami T, Kim T, Takahashi S, Nakamura H. Hepatocellular carcinoma: multidetector row helical CT. Abd

Imaging 2002; 27:139.

6.

Kamel

IR, Bluemke

DA. Imaging evaluation of hepatocellular carcinoma. J Vasc

Interv

Radiol

2002; 13(9 Pt 2):S173.

7.

Reeder MMM. Reeder and Felson's

Gamuts

in Radiology: Comprehensive Lists of Roentgen Differential Diagnosis.

New York: Springer-Verlag New York Inc, 1993.

26

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