GI Section III: Liver Masses Flashcards
The most common benign liver neoplasm
Hemangioma
Hemangioma facts
Favors women 5:!
Enlarge with pregnancy.
Hemangioma
Hyperechoic (dark in fatty liver)
Vessels adjacent to the lesion, NOT in the lesion
Hemangioma
tends to match the aorta in signal and have
“peripheral nodular discontinuous enhancement”.
can be used to diagnose hemangiomas - bigger than 2 cms
Tc-99m-labeled RBCs
Typical Hemangioma
- Classically Hyperechoic (bright) on ultrasound
- Enhanced thru transmission is common
- NO Doppler flow inside the lesion itself
- Calcifications are extremely rare
Giant Hemangioma
> 5 cm
Similar CT findings to regular hemangioma
Potential complication complication of Hemangioma
Kasabach-Merritt syndrome - consumptive coagulopathy
Flasii Filling
Hemagioma
< 2 cm
Technically not a hemangioma, but historically referred to as one. - Rapid flash filling
They otherwise retain contrast and remain isodense to blood pool. They do not washout the way an HCC would.
The second most common benign liver neoplasm.
Focal nodule hyperplasia
FNH start in utero as an?
AVM
FNH composistion
Normal hepatocytes abdnomally arranged ducts and Kupffer cells (reticuloendothelial cells)
FNH
“spoke wheel” US Doppler
FNH
“Homogeneous” on arterial phase - Same to the IVC (not aorta)
FNH
Can be a “Stealth” lesion on MRI - T1 and T2 isointense. Can have acentralscar.
Scar will demonstrate delayed enhancement (like scars do).
FNH biopsy rule
You have to hit the scar, otherwise path results will say normal hepatocytes.
Can develop after chemotherapy treatment with oxaliplatin (chemo for bowel cancer)
FNH
What other test is used to confirm FNH
Sulfur Colloid - Hot
Usually a solitary lesion seen in a female on OCPs
Adenomas
Alternatively could be seen in a man on anabolic steroids.
Adenomas
Associated with glycogen storage disease (von Gierke) or liver adenomatosis
Adenomas
Big fat diabetic girl named Von Gierke + hepatic mass?
Adenomas
What imaging methods can reliably differentiate hepatic adenoma from hepatocellular carcinoma?
NONE
Adenomas
Chemical-shift imaging showing loss of signal on out-of-phase images can confirm the presence of fat.
Most common location for hepatic adenoma (75%)
Right Lobe liver
Adenoma Managment
- Stop the OCPs and re-image, they should get smaller.
- Smaller than 5cm, watch them.
- Larger than 5cm they often resect because
(1) they can bleed and
(2) they can rarely turn into cancer.
What are teh adenoma subtypes?
Inflammatory
* Most common
* Highest bleed rate
HNF-1 alpha mutated
* Second most common
* Multiple masses
Beta catenin mutated
* Least common
* Anabolic steroids
* Glycogen storage disease
* Familial adenomatous polyposis
HCC occurs typically in what setting?
Cirrhosis and chronic liver disease; Hep B, Hep C, hemachomatosis, glycogen storage disease, Alpha 1 antitrypsisn
What is elevated in HCC
AFP (80-95%)
HCC invades what vessles?
Portal vein
Hepatic vein invation - more specific finding
What is the average doubling time of HCC?
3 - 4.5 months
Early HCC
You will only see them in the arterial phase
Sometimes there is rim enhancement - mistaken for hemangioma
RIM enhancement is NEVER hemangioma
Large HCC with mozaic pattern in a non cirrhotic patient. - LATE appearance
PVP: Hypodense - due to fast washout
Delayed: Prolonge capsule and septal enhancement
very large with a mozaic pattern, a capsule, hemorrhage, necrosis and fat evolution.
HCC is a silent tumor, so if patients do not have cirrhosis or hepatitis C, you will discover them in a late stage.
LEFT: Diffusely enhancing tumor thrombus in HCC with portal vein invasion.
RIGHT: Tumor thrombus with vessels within the thrombus.
Classic HCC vs FL HCC
Fibrolamellar HCC
Classic HCC vs FL HCC
Classic HCC
Central Scars of FNH and Fibrolamellar HCC
Focal Nodular Hyperplasia
Central Scars of FNH and Fibrolamellar HCC
FL HCC
NECT, arterial and portal venous phase in a patient with Hepatitis C with two lesions in the liver (arrows).
Hypervascular lesions in the right and left lobe
Upper images
NECT: isodense
AP: enhancement (not as dense as the bloodpool)
PVP: Isodense
Lower Images
NECT/AP/PVP: as dense as the blood pool
UPPER: Right lobe HCC
LOWER: Hemangioma
cancer of the bile duct
Cholangiocarcinoma
Cholangiocarcinoma believes in nothing Lebowski. It flicks you up, it takes the money (prognosis is poor).
Cholangiocarcinoma.
Who gets it?
Classic:
80 y.o. man + Primary sclerosis cholangitis (PSC, main risk factor in the west) + recurrent pyogenic “oriental” cholangitis (main risk factor in the east)
+ Caroli disease (Type V)
+ Hepatitis
+ HIV
+ Hx of cholangitis
+ Liver worms (clonorchis)
Non enhanced, arterial, portal venous and equilibrium phase.
Cholangiocarcinoma.
AP: Hypodense
PVP: Hypodense + peripheral enhancement
Equilibirum phase: Hyperdense
+ Liver capsule retraction
infiltrating mass with capsular retraction and delayed persistent enhancement is very typical for
What does cholangiocarcinoma look like?
Scar generating cancer
+ Delayed enhancement
+ desmoplastic pulling of the scar (capsular retration and ductal dilatation)
Cholangiocarcinoma
Only on the delayed images at 8-10 minutes after contrast injection a relative hyperdense lesion is seen. This is the fibrous component of the tumor.
“Painless jaundice”
CholangioCA (Just like pancreatic head CA)
Invades the Portal Vein
HCC
Encases the Portal Vein
CholangioCA
Cholangiocarcinoma that occurs at the bifurcation of the right and left hepatic ducts
Klatskin tumor
Klatskin tumor
Mass at the bifurcation fo the right and left hepatic ducts
Klatskin Tumor
small mass causing biliary obstruction
“Shoulder/abrupt tapering”
Delayed Enhancement
Peripheral Biliary Dilation
Liver
Capsular Retraction
NO tumor capsule
Cholangiocarcinoma
key factor for surgical candidacy for cholangioCA
Proximal extent of involvement
Implies biliary +/- vascular involvment of the hepatic lobe in Cholangiocarcinoma?
Atrophy of a lobe
Tumor markers:
A. Increased CEA and CA19-9
B. Normal CEA INC CA19-9
C. INC CEA Normal CA19-9
A. CholangioCA
B. Pancreatic CA
C. Colon CA
the most common primary sarcoma o f the liver
Angiosarcoma
Very rare
Associated with Toxic exposure -
Aresnic
Plyvinyl Cl
Radiation
Thorotrast
Hepatic Angiosarcoma
Assoc with Hemochomatosis and NF1 patients
Hepatic Angiosarcoma
Uncommon benign cystic neoplasm of the liver
+ middle aged women + Pain + jaundice
Solid + Nodular enhancing + capsule
Biliary Cystadenoma
This is way more common than a primary liver cancer
Hepatic metastasis (20-40x)
If you see mets in the liver, first think:
Colon
Calcified mets are usually the result of what mucinous neoplasms?
Colon
Ovary
Pancreas
Hepatic metastasis
Calcified metastasis in a patient with colon cancer.
Hyperechoic + hypervascular (renal, melanoma, carcinoid, choriocarcinoma, thyroid, islet cell)
Hypoechoic mets on usd =
Hypoechoic mets are often hypovascular -> more common look
Colon
Lung
Pancrease
Hepatic metastasis
Hypoechoic halo (target) - classic description
Mass on CT scan
low density masses with a continuous rim of enhancement
discontinueous = hemangioma
A background fatty liver may result in the lesions looking bright (higher density).
What type of lymphoma involves the liver 60% of the time
HL
Kaposi sarcoma
Causes diffuse periportal hypoechoic infiltration.
Similar to biliary duct dilatation
