focal liver mass powerpoint presentation .ppt

Focal liver mass me be tumor or other type of masses and can be diagnosed originaaly by ultrasono graphy and confirmed by pathophysiological diagnosis .

2. HCCHCC

4. Hepatic VenousPortal Venous
Tripple Phase Helical CTTripple Phase Helical CT
Foley, WD. Multiphase Hepatic CT with a Multirow Detector CT Scanner. 2000 (175): 679-685.
Axial C+ CT
Arterial Phase

Axial C+ CT
Portal Venous
Phase
Axial C+ CT
Hepatic Venous
Phase
Contrast Injection
Arterial
0 15 30 45 60 75
Time (sec)

5. 11--HemangiomaHemangioma
22--Focal nodular Focal nodular
hyperplasiahyperplasia
33--AdenomaAdenoma
44--Liver cystsLiver cysts… …
11--Primary liver cancersPrimary liver cancers
Hepatocellular carcinomaHepatocellular carcinoma
2-Fibrolamellar 2-Fibrolamellar
carcinomacarcinoma
33--CholangiocarcinomaCholangiocarcinoma
44--MetastasesMetastases
Benign Malignant
Classification:

7. •Symptomatic or Incidentally detected
•History of Hepatitis or extra hepatic malignant
tumor
•Liver function tests
•Cirrhotic or Non cirrhotic
Things to consider usually.....

8. Fortuitous
Non cirrhotic
Symptomatic
Non cirrhotic
Chronic disease
Cirrhosis
Benign Malignant
Hémangioma
FNH
Adénoma
Metastasis
FLC
HCC
DN
RN
Circumstances of discovery

13. Detection of liver massesDetection of liver masses
* arterial phase imaging* arterial phase imaging
* portal venous phase* portal venous phase
* equilibrium phase* equilibrium phase

14. 
Minority of tumors contain calcifications , cystic components, fat Minority of tumors contain calcifications , cystic components, fat
or hemorrhage and will be detected on NECT.or hemorrhage and will be detected on NECT.

When we give IV contrast, it is important to When we give IV contrast, it is important to
understand that there is a dual blood supply to the understand that there is a dual blood supply to the
liverliver. .

Normal parenchyma is supplied for 80% by PV & only for 20% Normal parenchyma is supplied for 80% by PV & only for 20%
by hepatic artery, so it will enhance in the portal venous phase.by hepatic artery, so it will enhance in the portal venous phase.

All liver tumors however get 100% of their blood All liver tumors however get 100% of their blood
supply from hepatic artery , so when they supply from hepatic artery , so when they
enhance it will be in arterial phaseenhance it will be in arterial phase

15. Small HCC in Small HCC in
cirrhotic liver , cirrhotic liver ,
not visible on not visible on
NECT , clearly NECT , clearly
visible in visible in
arterial phase, arterial phase,
and not visible and not visible
in portal in portal
venous phasevenous phase . .

16. 
In the In the arterial phasearterial phase hypervascular tumors hypervascular tumors
will enhance via the hepatic artery , when normal will enhance via the hepatic artery , when normal
liver parenchyma does not yet enhances , liver parenchyma does not yet enhances ,
because contrast is not yet in the portal venous because contrast is not yet in the portal venous
system.system.

These hypervascular tumors will be visible as These hypervascular tumors will be visible as
hyperdense lesions in a relatively hypodense hyperdense lesions in a relatively hypodense
liver liver

However when the surrounding liver However when the surrounding liver
parenchyma starts to enhance in the portal parenchyma starts to enhance in the portal
venous phase , these hypervascular lesions may venous phase , these hypervascular lesions may
become obscured.become obscured.

17. 
In the In the portal venous phaseportal venous phase
hypovascular tumors are detected when hypovascular tumors are detected when
the normal liver parenchyma enhances the normal liver parenchyma enhances
maximally.maximally.

These hypovascular tumors will be visible These hypovascular tumors will be visible
as hypodense lesions in a relatively as hypodense lesions in a relatively
hyperdense liver.hyperdense liver.

18. 
In the In the equilibrium phaseequilibrium phase at about at about
10 minutes after contrast injection , tumors 10 minutes after contrast injection , tumors
become visible, that either loose their become visible, that either loose their
contrast slower than the normal liver , or contrast slower than the normal liver , or
wash out their contrast faster than normal wash out their contrast faster than normal
liver parenchyma. These lesions will liver parenchyma. These lesions will
become either relatively hyperdense or become either relatively hyperdense or
hypodense to the normal liverhypodense to the normal liver

19. 
AboveAbove: arterial : arterial
phase showing phase showing
hypervascular FNHhypervascular FNH

MiddleMiddle: portal : portal
venous phase venous phase
showing showing
hypovascular hypovascular
metastasesmetastases

DownDown: equilibrium : equilibrium
phase showing phase showing
relatively dense relatively dense
cholangiocarcinomacholangiocarcinoma

20. Arterial phase imagingArterial phase imaging

21. 
Optimal timingOptimal timing andand speed of contrastspeed of contrast
injection injection andand type of CT scanner type of CT scanner are very are very
important for good arterial phase imaging.important for good arterial phase imaging.
Arterial phase imagingArterial phase imaging

22. Optimal timingOptimal timing
Arterial phase imagingArterial phase imaging

23. 
Hypervascular tumors will enhance optimally at Hypervascular tumors will enhance optimally at
35 seconds35 seconds after contrast injection (late after contrast injection (late
arterial phase)arterial phase)
Arterial phase imagingArterial phase imaging

24. 
A patient who underwent A patient who underwent
two phases of arterial two phases of arterial
imaging at 18 and 35 imaging at 18 and 35
seconds . seconds .

In the In the early arterial phaseearly arterial phase
we nicely see the arteries we nicely see the arteries
, but we only see some , but we only see some
irregular enhancement irregular enhancement
within the liver .within the liver .

In the In the late arterial phaselate arterial phase, ,
we can clearly identify we can clearly identify
multiple tumor masses.multiple tumor masses.

25. 
Notice that in the late arterial phase, there has to Notice that in the late arterial phase, there has to
be some enhancement of the portal vein .be some enhancement of the portal vein .

The only time that an arterial phase is needed is The only time that an arterial phase is needed is
when you need an arteriogram , for instance as a when you need an arteriogram , for instance as a
roadmap for chemoembolization of a liver tumor.roadmap for chemoembolization of a liver tumor.
Arterial phase imagingArterial phase imaging

26. Speed of contrast Speed of contrast
injectioninjection
Arterial phase imagingArterial phase imaging

27. For arterial phase the best results are with an For arterial phase the best results are with an
injection of injection of 5 ml/sec5 ml/sec
Arterial phase imagingArterial phase imaging

28. 
Patient with liver Patient with liver
cirrhosis and cirrhosis and
multifocal HCC multifocal HCC
injected at 2.5 injected at 2.5
ml/sec and at 5 ml/sec and at 5
ml/sec. ml/sec.

At 5 ml/sec. there At 5 ml/sec. there
is far better is far better
contrast contrast
enhancement and enhancement and
better tumor better tumor
detection.detection.

29. Portal venous phasePortal venous phase

30. Portal venous phase imaging work on the opposite idea . We Portal venous phase imaging work on the opposite idea . We
image the liver when it is loaded with contrast through the portal image the liver when it is loaded with contrast through the portal
vein to detect vein to detect hypovascularhypovascular tumors. tumors.

The best moment to start scanning is at about The best moment to start scanning is at about 75 sec75 sec.,so this .,so this
is a late portal phase , because enhancement of portal vein is a late portal phase , because enhancement of portal vein
already starts at 35 sec in the late arterial phase.already starts at 35 sec in the late arterial phase.

Late portal venous phase is also known as hepatic phase Late portal venous phase is also known as hepatic phase
because there already must be enhancement of hepatic veins . because there already must be enhancement of hepatic veins .
If you don’t see enhancement of hepatic veins , you are too If you don’t see enhancement of hepatic veins , you are too
early. early.
Portal venous phasePortal venous phase

31. 
Hypovascular Hypovascular
metastases metastases
seen as seen as
hypodense hypodense
lesions in late lesions in late
portal venous portal venous
phase phase

32. Liver metastases Liver metastases cancer coloncancer colon

33. Equilibrium phaseEquilibrium phase

34. 
Starts when contrast is moving away from the Starts when contrast is moving away from the
liver and the liver starts to decrease in density .liver and the liver starts to decrease in density .

This phase begins at about 3-4 minutes after This phase begins at about 3-4 minutes after
contrast injection and imaging is best done at contrast injection and imaging is best done at
10 minutes after contrast injection.10 minutes after contrast injection.

Equilibrium phaseEquilibrium phase

35. 
This phase can be valuable if you are This phase can be valuable if you are
looking for:looking for:
1- fast tumor washout in hypervascular tumors1- fast tumor washout in hypervascular tumors
2- retention of contrast in blood pool like in 2- retention of contrast in blood pool like in
hemangiomahemangioma
3- retention of contrast in fibrous tissue in capsule 3- retention of contrast in fibrous tissue in capsule
( HCC )or scar tissue ( cholangiocarcinoma or ( HCC )or scar tissue ( cholangiocarcinoma or
FNH )FNH )
Equilibrium phaseEquilibrium phase

36. 
1- fast tumor washout 1- fast tumor washout
in hypervascular in hypervascular
tumors like HCCtumors like HCC

37. 
2- retention of 2- retention of
contrast in the blood contrast in the blood
pool as in pool as in
hemangiomahemangioma

38. 
3- retention of 3- retention of
contrast in fibrous contrast in fibrous
tissue in capsule tissue in capsule
( HCC ) or scar ( HCC ) or scar
tissue tissue
(cholangiocarcinoma (cholangiocarcinoma
, FNH), FNH)

39. Equilibrium phaseEquilibrium phase

40. Relative hyperdense lesions in Relative hyperdense lesions in
the delayed phasethe delayed phase

Fibrous tissue that’s well organized and dense is very Fibrous tissue that’s well organized and dense is very
slow to let iodine or gadolinium in.slow to let iodine or gadolinium in.

Once contrast gets in however, it is equally slow to get Once contrast gets in however, it is equally slow to get
back out in the equilibrium phase.back out in the equilibrium phase.

So when the normal liver parenchyma washes out, the So when the normal liver parenchyma washes out, the
fibrous component of the tumor will look brighter than the fibrous component of the tumor will look brighter than the
background liver tissue.background liver tissue.

41. 
Small Small
cholangiocarcinoma cholangiocarcinoma
not visible in portal not visible in portal
venous phase , but venous phase , but
seen as relative seen as relative
hyperdense lesion hyperdense lesion
in the equilibrium in the equilibrium
phase.phase.

42. 
HCC in a HCC in a
cirrhotic cirrhotic
liver. Notice liver. Notice
fast wash fast wash
out in out in
equilibrium equilibrium
phase phase
compared to compared to
surrounding surrounding
liver liver
parenchymaparenchyma
..

44. Characterization of liver massesCharacterization of liver masses

Hypervascular lesionsHypervascular lesions
Hypovascular lesionsHypovascular lesions

ScarScar

Capsule Capsule

CalcificationCalcification

Fat Fat

HemorrhageHemorrhage

Cystic componentsCystic components
Retraction of liver capsuleRetraction of liver capsule

Peripheral enhancement & progressive fill inPeripheral enhancement & progressive fill in

47. Hepatic Hemangiomas
-Benign vascular lesions of liver .
-The commonest liver tumor
-Autopsy studies : 0.4-20 percent
-3-5 decades
•-Thought to arise from congenital hamartomas
(abnormal growth of normal tissue), it can also
develop from dilatation of blood vessels in a normal
tissue
-Usually asymptomatic
•-Incidental discovry: US++

48. Hepatic Hemangiomas
US: well-defined, uniformly hyperechoic liver mass with
peripheral feeder vessels that are characteristic of a
hemangioma .
Cavernous
angiomas

49. Hepatic Hemangiomas
US Diagnosis
In practice:
.Us characteristic feature
.No context of neoplastic diesease
.Normal liver function tests
Hemangioma
NO
CT or MRI
YES

50. Hepatic Hemangiomas
CT: The pathognomonic features of caverneous hemangioma:
peripheral nodular and discontinuous enhancement and
progressive centripetal fill-in
IV -
HAP
PVP
DP

51. HemangiomaHemangioma

Blood pool and hemangiomaBlood pool and hemangioma
Normally when we look at lesions filling with Normally when we look at lesions filling with
contrast, the density of these lesions is always contrast, the density of these lesions is always
compared to the density of the liver compared to the density of the liver
parenchyma.parenchyma.

In hemangiomas, however you should not In hemangiomas, however you should not
compare the density of the lesion to the liver but compare the density of the lesion to the liver but
to the bloodpool to the bloodpool

52. 
This means that the areas of enhancement in a This means that the areas of enhancement in a
hemangioma should match the attenuation of the hemangioma should match the attenuation of the
appropriate vessels { appropriate vessels { blood poolblood pool } at all times. } at all times.

So, in the arterial phase the enhancing parts of the So, in the arterial phase the enhancing parts of the
lesion must have almost the same attenuation value lesion must have almost the same attenuation value
as the enhancing aorta.as the enhancing aorta.

While in the portal phase, it must match the While in the portal phase, it must match the
attenuation value of the portal vein . And so in venous attenuation value of the portal vein . And so in venous
or delayed phase.or delayed phase.

53. 
So, if it does not match the bloodpool in So, if it does not match the bloodpool in
every single phase of contrast every single phase of contrast
enhancement , enhancement , foregetforeget the diagnosis of a the diagnosis of a
hemangioma.hemangioma.

54. 
Hemangiomas less than 1 cm frequently Hemangiomas less than 1 cm frequently
demonstrate immediate homogenous demonstrate immediate homogenous
enhancement , isodense to aorta.enhancement , isodense to aorta.

Hemangiomas larger than 1 cm generally Hemangiomas larger than 1 cm generally
show slow centripetal spread of nodular show slow centripetal spread of nodular
enhancement enhancement

55. 
Hemangioma in Hemangioma in
non-enhanced non-enhanced
CT, late arterial, CT, late arterial,
late portal late portal
venous, and venous, and
equilibrium equilibrium
phase. Notice phase. Notice
that the that the
attenuation of attenuation of
the the
hemangioma hemangioma
matches the matches the
bloodpool in bloodpool in
every single every single
phasephase..

56. Hemangioma

57. Hemangioma

58. Hemangioma

59. 
Flash filling Flash filling
hemangioma hemangioma
in in
unenhanced, unenhanced,
arterial & arterial &
portal venous portal venous
phase . phase .
Notice it Notice it
matches the matches the
bloodpool.bloodpool.

60. 
Giant Giant
hemangioma hemangioma
with scar tissue. with scar tissue.
Notice that the Notice that the
enhancement enhancement
matches the matches the
bloodpool in all bloodpool in all
phases, central phases, central
scar is scar is
hypodense on hypodense on
NECT & stays NECT & stays
hypodense.hypodense.

61. Progressive fill inProgressive fill in

The lesion definitely has some The lesion definitely has some
features of hemangioma like features of hemangioma like
nodular enhancement in the nodular enhancement in the
arterial phase & progressive fill in arterial phase & progressive fill in
portal venous & equilibrium portal venous & equilibrium
phase.phase.

In portal venous phase however In portal venous phase however
the enhancement is not as bright the enhancement is not as bright
as the enhancement of portal as the enhancement of portal
vein . The conclusion must be vein . The conclusion must be
that this lesion doesn’t match that this lesion doesn’t match
blood pool in all phases , so it blood pool in all phases , so it
can’t be hemangioma.can’t be hemangioma.

So progressive fill in is a non-So progressive fill in is a non-
specific feature of that can be specific feature of that can be
seen in many other tumors like seen in many other tumors like
metastases or metastases or
cholangiocarcinoma.cholangiocarcinoma.

The delayed enhancement in this The delayed enhancement in this
lesion is due to fibrotic tissue in a lesion is due to fibrotic tissue in a
cholangiocarcinoma & is a cholangiocarcinoma & is a
specific feature of this tumorspecific feature of this tumor

62. Rim enhancementRim enhancement
The enhancement of a The enhancement of a
hemangioma starts peripheral. It hemangioma starts peripheral. It
is nodular or globular & is nodular or globular &
discontinuous.discontinuous.
Rim enhancement is continuous Rim enhancement is continuous
peripheral enhancement is peripheral enhancement is
never hemangioma.never hemangioma.
Rim enhancement is a feature Rim enhancement is a feature
of malignant lesions , especially of malignant lesions , especially
metastases.metastases.
Left: rim enhancement in breast Left: rim enhancement in breast
carcinomacarcinoma
Right: nodular discontinuous Right: nodular discontinuous
enhancement in hemangiomaenhancement in hemangioma

63. 
Hemangioma on dynamic MRI will show Hemangioma on dynamic MRI will show
the same enhancement characteristics as the same enhancement characteristics as
on contrast enhanced CTon contrast enhanced CT

64. Hepatic Hemangiomas
Diagnosis
MRI :
.Hypointense and well defined in T1
.Marked hyperintensity that increases with echo time
on T2
.The same caracteristic pattern of enhacement as is
seen at CT

65. Hemangioma

66. Focal nodular hyperplasiaFocal nodular hyperplasia
FNHFNH

67. Focal Nodular Hyperplasia (FNH)
.Benign nodule formation of normal liver tissue
.2nd most common benign hepatic lesion
.More common in young and middle age women
.Male to female :5-17
.Usually asymptomatic
.May cause minimal pain
.Response of parenchyma to a vascular malformation or portal
duct injury.

68. Focal Nodular Hyperplasia (FNH)
Diagnosis:
US: Nodule with varying echogenicity
Color Doppler imaging may show central
vessels

70. Focal Nodular Hyperplasia (FNH)
Diagnosis: CT
HAP
PVP
DP
IV-

71. Focal Nodular Hyperplasia (FNH)
Diagnosis: CT

72. Focal Nodular Hyperplasia (FNH)
Diagnosis:MRI typical finding
.Isointense to hypointense on T1-weighted images
.Slightly hyperintense to isointense on T2-weighted images
.Brisk homogeneous enhancement
.Delayed enhancement of the central scar

73. Focal Nodular Hyperplasia (FNH)
Diagnosis:MRI typical finding

74. Focal Nodular Hyperplasia (FNH)
20% of FNH cases are classified as nonclassic
Biopsy
Attal P et al. Radiology 2003;228:465-472

75. FNH

78. FNH

80. Hemangioma & FNHHemangioma & FNH

81. FNH

82. 
FNH seen as FNH seen as
hypervascular hypervascular
lesion in the late lesion in the late
arterial phase & arterial phase &
isodense in the isodense in the
portal venous portal venous
phase . No scar phase . No scar
was seen.was seen.

83. 
T2W, T1W T2W, T1W
without without
gadolinium gadolinium
and a and a
delayed delayed
phase after phase after
gadoliniumgadolinium..

84. 
Best diagnostic clue: brightly and homogeneously enhancing Best diagnostic clue: brightly and homogeneously enhancing
mass in arterial phase on CT or MRI with delayed enhancement mass in arterial phase on CT or MRI with delayed enhancement
of the central scar.of the central scar.

Central scar containing AVMCentral scar containing AVM

Central scar seen in 2/3 of large and 1/3 of smal FNH.Central scar seen in 2/3 of large and 1/3 of smal FNH.

No malignant transformationNo malignant transformation

No association with oral contraceptives.No association with oral contraceptives.

Nuclear study: normal or increase uptake {only FNH contains Nuclear study: normal or increase uptake {only FNH contains
kuffer cells that cause increase uptake in 9% of cases }kuffer cells that cause increase uptake in 9% of cases }
…….pathognomonic…….pathognomonic

Classic FNH looks like a cross section of an orange ( central Classic FNH looks like a cross section of an orange ( central
scar, radiating septa )scar, radiating septa )

85. AdenomaAdenoma

88. 
Adenoma showing Adenoma showing
capsule in delayed capsule in delayed
phasephase

FNH seen as FNH seen as
hypervascular lesion in hypervascular lesion in
the late arterial phase the late arterial phase
& isodense in the & isodense in the
portal venous phase . portal venous phase .
No scar was seen.No scar was seen.

89. 
Fat in Fat in
adenomaadenoma

90. 
Hemorrhage Hemorrhage
in adenomain adenoma

91. 
Best diagnostic clueBest diagnostic clue: spherical well defined : spherical well defined
hypervascular and heterogenous mass due to fat & hypervascular and heterogenous mass due to fat &
hemorrhage .hemorrhage .

Symptomatic in 80%-abdominal pain- ( FNH Symptomatic in 80%-abdominal pain- ( FNH
asymptomatic in 80%)asymptomatic in 80%)
98% in young females taking oral contraceptives98% in young females taking oral contraceptives

Not seen in males unless on anabolic steroids or with Not seen in males unless on anabolic steroids or with
glycogen storage disease.glycogen storage disease.

93. Malignant hypervascular Malignant hypervascular
lesionslesions

94. Hepatocellular Hepatocellular
carcinomacarcinoma
HCCHCC

95. Several morphological forms
Massive(>3cms)
Nodular (<3cms)
Diffuse
Hepatocellular Carcinoma
(HCC)
AFP (Alfa feto protein)
Is an HCC tumor marker
Values more than 100ng/ml are highly suggestive of HCC
Elevation seen in more than 70%

103. 
Any hypervascular lesion in a cirrhotic liver Any hypervascular lesion in a cirrhotic liver
is hepatocellular carcinoma untill proven is hepatocellular carcinoma untill proven
otherwise.otherwise.

HCC may be HCC may be solitary,solitary, multifocal multifocal or or diffusely diffusely
infiltratinginfiltrating..

Large HCC typically have a mosaic appearance Large HCC typically have a mosaic appearance
due to hemorrhage & fibrosis.due to hemorrhage & fibrosis.

104. 
HCC is a silent tumor, so if patients don’t have HCC is a silent tumor, so if patients don’t have
cirrhosis or hepatitis C , you will discover them in cirrhosis or hepatitis C , you will discover them in
a late stage. a late stage.

They tend to be large with mozaic pattern , a They tend to be large with mozaic pattern , a
capsule , hemorrhage and necrosis.capsule , hemorrhage and necrosis.

HCC become isodense or hypodense to liver in HCC become isodense or hypodense to liver in
the portal venous phase due to fast wash-outthe portal venous phase due to fast wash-out

On delayed images, the capsule and sometimes On delayed images, the capsule and sometimes
septa demonstrate prolonged enhancement. septa demonstrate prolonged enhancement.

105. 
Large Large
HCC with HCC with
mozaic mozaic
pattern in pattern in
a non a non
cirrhotic cirrhotic
liverliver

107. 
Cirrhotic liver with Cirrhotic liver with
hypervascular , hypervascular ,
inhomogenous inhomogenous
lesion.lesion.

The The
inhomogenous inhomogenous
enhancement and enhancement and
partial capsule are partial capsule are
helpful for the helpful for the
diagnosis of HCCdiagnosis of HCC

108. 
Small HCC in cirrhotic Small HCC in cirrhotic
liver not visible on liver not visible on
NECT , clearly visible NECT , clearly visible
on arterial phase, and on arterial phase, and
not visible in portal not visible in portal
venous phase venous phase

109. 
HCC in cirrhotic HCC in cirrhotic
liver , notice liver , notice
fast wash out in fast wash out in
equilibrium equilibrium
phase phase
compared to compared to
surrounding surrounding
liver liver
parenchymaparenchyma

110. PS: Triple Phase CTPS: Triple Phase CT
Axial C- CT Axial C+ CT: Arterial Phase
 Nodular liver
 No discrete lesions
Film Findings:  EarlyEarly hyperenhancinghyperenhancing lesionlesion

111. PS: Triple Phase CTPS: Triple Phase CT
Axial C+ CT: Portal Venous PhaseAxial C+ CT: Delayed Phase
 Quick washout of
enhancing lesion
Film Findings:  Hypoenhancing lesion with Hypoenhancing lesion with
peripheral rim of enhancementperipheral rim of enhancement

112. ????

113. 
In the arterial phase we see two hypervascular lesions. Now do In the arterial phase we see two hypervascular lesions. Now do
not just concentrate on the images, where you see the lesions not just concentrate on the images, where you see the lesions
best. You have to look at all the other images, because they best. You have to look at all the other images, because they
give you the clue to the diagnosis. give you the clue to the diagnosis.
The upper images show a lesion that is isodens to the liver on The upper images show a lesion that is isodens to the liver on
the NECT. In the arterial phase there is enhancement, the NECT. In the arterial phase there is enhancement, but not but not
as dense as the bloodpoolas dense as the bloodpool..

In the portal venous phase the lesion is again isodense to the In the portal venous phase the lesion is again isodense to the
surrounding liver parenchyma and you can't see it. If you only surrounding liver parenchyma and you can't see it. If you only
had the portal venous phase you surely would miss this lesion. had the portal venous phase you surely would miss this lesion.
The lower images show a lesion that is visible on all images. The lower images show a lesion that is visible on all images.
You see it on the NECT and you could say it is hypodens You see it on the NECT and you could say it is hypodens
compared to the liver. Does this help you? No, not in the least. compared to the liver. Does this help you? No, not in the least.
However if you look at the bloodpool, you will notice that on all However if you look at the bloodpool, you will notice that on all
phases it is as dense as the bloodpool. phases it is as dense as the bloodpool.
So we have a HCC in the right lobe on the upper images and a So we have a HCC in the right lobe on the upper images and a
hemangioma in the left lobe on the lower images. The key is to hemangioma in the left lobe on the lower images. The key is to
look at all the phases.look at all the phases.

114. Adenoma Adenoma
showing showing
capsule in capsule in
delayed delayed
phasephase

FNH seen as FNH seen as
hypervascular hypervascular
lesion in the late lesion in the late
arterial phase & arterial phase &
isodense in the isodense in the
portal venous portal venous
phasephase
The inhomogenous
enhancement and partial
capsule are helpful for the
diagnosis of HCC

115. HCC & PV thrombosisHCC & PV thrombosis
Many patients with cirrhosis have portal venous Many patients with cirrhosis have portal venous
thrombosis and many patients with HCC have thrombosis and many patients with HCC have
thrombosis. thrombosis.
These are two common findings and they can be These are two common findings and they can be
coincidental. coincidental.
It is very important to make the distinction between It is very important to make the distinction between
just thrombus and tumor thrombus. just thrombus and tumor thrombus.
First, if you have a malignant thrombus in the portal First, if you have a malignant thrombus in the portal
vein, it will always enhance and you'll see it best in vein, it will always enhance and you'll see it best in
arterial phase. arterial phase.
Secondly, if you have a malignant thrombus in the Secondly, if you have a malignant thrombus in the
portal vein, it will increase the diameter of the vessel. portal vein, it will increase the diameter of the vessel.
Sometimes a tumor thrombus may present with Sometimes a tumor thrombus may present with
neovascularity within the thrombus .neovascularity within the thrombus .

116. 
Above Above : diffusely : diffusely
enhancing tumor enhancing tumor
thrombus in HCC thrombus in HCC
with portal venous with portal venous
thrombosis.thrombosis.

DownDown: tumor : tumor
thrombus with thrombus with
vessels within the vessels within the
thrombusthrombus

119. Fibrolamellar HCCFibrolamellar HCC

123. 
Non Non
enhanced enhanced
image , a image , a
fibrolamaellar fibrolamaellar
HCC usually HCC usually
presents as a presents as a
big mass with big mass with
central central
calcificationcalcification..

124. 
FLC in late FLC in late
arterial arterial
phase , phase ,
central central
calcification & calcification &
heterogenous heterogenous
enhancementenhancement
..

Delayed Delayed
phase with phase with
hypodense hypodense
central scarcentral scar

133. 
Hypervascular Hypervascular
metastases metastases
with typical with typical
peripheral peripheral
enhancementenhancement

134. 
Peripheral Peripheral
enhancement enhancement
in metastases in metastases
from breast from breast
carcinoma carcinoma

135. Hypervascular metastasesHypervascular metastases

136. Hypervascular metastases Hypervascular metastases cancercancer
breastbreast

141. CholangiocarcinomaCholangiocarcinoma

157. Characterization of Characterization of
liver massesliver masses

158. 
ScarScar

CalcificationCalcification

CapsuleCapsule

FatFat

BloodBlood

Retraction of liver capsuleRetraction of liver capsule

159. Focal nodular hyperplasiaFocal nodular hyperplasia

160. Fibrolamellar HCCFibrolamellar HCC

161. HemangiomaHemangioma

162. CalcificationCalcification

MetastasesMetastases

Fibrolamellar HCCFibrolamellar HCC

CholangiocarcinomaCholangiocarcinoma

hemangiomahemangioma

163. Calcified mestastases Calcified mestastases ca ovaryca ovary

164. Calcified metastasesCalcified metastases

165. Fibrolamellar HCCFibrolamellar HCC

166. CapsuleCapsule

Hepatocellular carcinoma “ HCCHepatocellular carcinoma “ HCC “ “

Adenoma Adenoma

Biliary cystadenomaBiliary cystadenoma

167. HCCHCC

168. AdenomaAdenoma

169. FatFat

AdenomaAdenoma

HCCHCC

Metastatic liposarcomaMetastatic liposarcoma

AngiomyolipomaAngiomyolipoma

170. AdenomaAdenoma

171. BloodBlood

HCCHCC

Adenoma Adenoma

172. HCCHCC

173. AdenomaAdenoma

174. Retraction of liver capsuleRetraction of liver capsule

Cholangiocarcinoma Cholangiocarcinoma

Breast cancer metastasesBreast cancer metastases

175. CholangiocarcinomaCholangiocarcinoma

177. Cancer breast metastasesCancer breast metastases

178. Hepatic CystHepatic Cyst
http://bb.westernu.edu/web/Pathology/webpath60/webpath/
radiol/heparad/
Axial C+ CT
Film Findings:
 Sharply demarcated,
non enhancing, water-dense
cyst.

179. Focal Nodular HyperplasiaFocal Nodular Hyperplasia
Axial C+ CT
Film Findings:
 Enhancing lesion with
central filling defect (central
scar)
http://uuhsc.utah.edu/rad/medstud/BodyCaseStudies/
BodyCase6a.htm

180. HCC: MR ImagingHCC: MR Imaging
Axial T1 Weighted MR
Precontrast
Axial T1 Weighted MR
Arterial Phase
Axial T1 Weighted
MR Portal-phase

Variable intensity on T1 and T2 weighted imagingVariable intensity on T1 and T2 weighted imaging

Early Early arterial phase enhancementarterial phase enhancement

Quick washoutQuick washout

Rim enhancementRim enhancement of fibrous capsule in portal/delayed of fibrous capsule in portal/delayed
phasesphases

181. Liver Metastasis (Colonic Liver Metastasis (Colonic
Adenocarcinoma)Adenocarcinoma)
Axial C+ CT
Film Findings:
 Multiple hypoenhancing
heterogenous lesions
http://www.mypacs.net/repos/mpv3_repo/viz/full/
11724/586248.jpg

182. Liver AbscessLiver Abscess
Axial C+ CT
Film Findings:
 Well demaracated
hypoenhancing lesion
 Rim of increased Rim of increased
enhancement relative to enhancement relative to
central regioncentral region
http://www.e-radiography.net/ibase5/Hepatic/index.htm

183. Early arterial enhancement, fast washout,
delayed fibrous capsule enhancement
Hepatocellular
Carcinoma (HCC)
Mostly multiple low attenuation lesions, rim
enhancement without “filling in”
Metastasis
Variable, central changes due to
hemorrhage often seen
Hepatocellular
Adenoma
Early filling in arterial phase with central
filling defect (scar)
Focal Nodular
Hyperplasia (FNH)
Peripheral filling in of contrast over time
“Light Bulb Sign” on T2 MRI
Hemangioma
Sharply demarcated wall, water density,
non-enhancing
Hepatic Cyst
PSClassical CT FindingsLesions
Abscess
Well demarcated hypodense areas with
peripheral enhancement, may see gas

A Walk Through The Differential DiagnosesA Walk Through The Differential Diagnoses::