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GI Radiology > Malignant tumors of the liver, Chapter 89 > Flashcards

Malignant tumors of the liver, Chapter 89 Flashcards

Review Gore Chapter 89, Malignant tumors of the liver Page 1625 -

1
Q

HCC, Atypical HCC, childhood HCC
Clear cell CA, Giant cell CA
Cacinosarcoma, Fibrolamellar carcinoma
Hepatoblastoma, sclerosing hepatic carcinoma

Cholangiocarcinoma, cystadenocarcinoma

Angiosarcoma, Epithelioid hemangioendothelioma
Leiomyosarcoma, Malignant fibrous histocytoma
Primary lymphoma, primary hepatic osteosarcoma

Which one are Mesenchymal origin, Cholangiocellular origin and Hepatocellular origin?

A

> Hepatocellular origin
- HCC, Atypical HCC, childhood HCC
- Clear cell CA, Giant cell CA
- Cacinosarcoma, Fibrolamellar carcinoma
- Hepatoblastoma, sclerosing hepatic carcinoma
Cholangiocellular origin
- Cholangiocarcinoma, cystadenocarcinoma
Mesenchymal origin
- Angiosarcoma, Epithelioid hemangioendothelioma
Leiomyosarcoma, Malignant fibrous histocytoma
Primary lymphoma, primary hepatic osteosarcoma

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2
Q

What is the 1st and 2nd most common malignancy in liver ?

What is the most common liver malignancy in childhood ?

A

1st - Hepatocellular carcinoma (HCC)
2nd - Intrahepatic Cholangiocarcinoma (ICAC)

Hepatoblastoma is the most common liver malignancy in childhood.

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3
Q

What are three major growth pattern of HCC?

A
  1. Single or massive HCC
    » มีลักษณะเป็นก้อนเดี่ยวๆ มักจะมีขนาดใหญ่
  2. Nodular or multifocal HCC
    » เป็นลักษณะที่มี multiple well-separated nodules
    คล้ายๆกับ metastasis
  3. Diffuse or cirrhotomimetic HCC
    » เป็นลักษณะที่มี multiple small foci ทั่วทั้งตับ ในลักษณะ diffuse

มี Variant หนึ่งของ HCC ที่มี Prognosis ดี คือ

Encapsulated HCC, because of its great resectability.

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4
Q

The HCC usually developed central necrosis or hemorrhage because of its lack of _____ .

A

Stroma

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5
Q

Between vascular invasion and biliary system invasion which are more common in HCC?

A

Vascular invasion

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6
Q

“In microscopic findings of HCC cells are resemble to normal hepatocytes..”

Does the following sentence is true ?

A

Yes, so in sometime it may difficult to distinguish HCC, normal hepatocyte, hepatic adenoma.

โดยเฉพาะ well-differentiate HCC
จะเหมือน normal hepatocyte จะเรียงตัวกันเปนเเบบ trabecular แต่ มีการเรียงตัวกันหนามากกว่า 3 ชั้น

โดยการวัดระหว่าง sinusoid ถึง sinusoid

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7
Q

Dose HCC able to produce bile ?

A

Yes, in a well-differentiated tumor.

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8
Q

Please give the example of substance produced by abnormal HCC ?
1._____ 2._____ 3._____ 4._____

A
  1. Mallory bodies
  2. Alpha-fetoprotein
  3. Alpha1-trypsin
  4. other serum protein, fat and glycogen.
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9
Q

If the HCC contain a large amount of fat, they will be called “____”

A

Clear cell carcinoma of liver.

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10
Q

What is the most frequent HCC histologic growth pattern ?

A

Trabecular, เป็นความพยายามของ HCC ที่จะเลียนแบบ cords ที่เห็นใน normal liver.

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11
Q

Trabecular is the growth pattern of HCC may appear solid or give appearance of acinar (pseudoglandular).
How can it give
1. acinar pattern
2. solid pattern

A

Acinar pattern เป็นลักษณะของ trabecular มาเรียงกัน แต่มีตรงกลาง ที่เก็บ tumor secretion

Solid pattern เป็นลักษณะของ trabecular มาเรียงกัน อย่างเดียว

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12
Q

Concerning about HCC, Important of “Acinar” (pseudoglandular) growth pattern มีผลต่อภาพทางรังสีอย่างไร ?

A

Acinar (pseudoglandular) pattern หรือ fat deposition ใน:
US จะมีลักษณะ hyperechoic
CT จะมีลักษณะ hypodense
MR จะมีลักษณะ hyperintense

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13
Q

Please described the following terms..

  • Cirrhotic nodule
  • Dysplastic nodule
A
  • Cirrhotic nodule
    > a regenerative nodule, composed of hepatocyte and completely surround by fibrous septa
  • Dysplastic nodule
    > เป็นระยะที่อยู่ระหว่าง cirrhotic nodule (regenerating nodule) และ HCC
    > nodule that contain only dysplasia, no HCC
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14
Q

จงบอก synonym of “dysplastic nodule” ?

A

Adenomatous hyperplasia

Macroregenerative nodule

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15
Q

Dysplastic nodule is able to sub-divided into low-grade and high-grade types, depend on findings of ____.

A

Light microscopy

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16
Q

According to incidence of HCC เราสามารถแบ่งได้เป็น
low-incidence area and high-incidence area ซึ่งมีความแตกต่างของอาการ predisposing factors และ onset of presentation อย่างไร

A

Low-incidence areas
> S&S - insidious onset; malaise, fever and abdominal pain
> onset - 70-80 yr.
> Risks - Alcoholic cirrhosis, hemochromatosis, or steriod uses.

High-incidence areas
> S&S - may presented with hepatic rupture
> onset - 30-45 yr.
> Risks - HBV, HCV and exposures of aflatoxins

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17
Q

Do Ca++ is common in HCC ?

If not what variant or other hepatocellular origin neoplasm common in having calcification?

A

No, Fibrolamellar carcinoma

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18
Q

What pharmaceutical agent use in detect HCC ?

A

Sulfur colloid.

> > Give filling defect in HCC for detection in cirrhotic liver.

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19
Q

Between FDG-18 and C-11 acetate in detection of HCC in PET which one appear more reliable ?

A

C-11 is more promising.

30-50% of HCC not uptake FDG-18 or mildly uptake.
owing to mechanism “leak back” by G-6-phosphatase enzyme ย่อย FDG-18 แล้วปล่อย FDG กลับสู่กระแสเลือด

แต่อย่างไรก็ดี ในสถานการณ์ปัจจุบันการใช้ PET ใน HCC ยังไม่มี role

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20
Q 
What is the most sonographic findings of HCC ?
A) Hyperechoic
B) Hypoechoic
C) Mixed echoic
D) Isoechoic
A

Hyperechoic is the most frequent, esp. there is fatty change or marked sinusoid dilatation.

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21
Q

Based on size of HCCs and appearance in US what are these correlation?

A

< 3 cm : often hypoechoic with posterior acoustic enhancement.

> 3 cm : often have mosaic pattern or mixed pattern

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22
Q

If there is capsule in HCCs what is it appearance in US ?

A) ขาว
B) ดำ
C) แดง
D) เขียว

A

Answer : A) Thin hypoechoic band

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23
Q

What is the typical pattern enhancement of HCC in CECT ?

A

Arterial phase:
» Early arterial enhancement

Delayed phase:
» Early washout in delayed images

Portovenous phase:
» Variable enhancement on portovenous phase

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24
Q

What is the reason that HCC has early arterial enhancement and relatively hypodense on delayed phase images ?

A

Most of its blood supply are derived from hepatic artery.
» The cause of early enhancement and early washout by arterial blood.

Note: Tumor can have variable appearance on portal phase image.

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25
Q

ถ้าหากมองในแง่ของขนาด
Small HCC may appear as a lesion of different attenuation.
Large HCC almost always has central necrosis

ประโยคข้างต้นถูก หรือ ผิด

A

ถถถถถถถถ ถูกต้อง

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26
Q

If HCC has capsule what is the pattern of enhancement after contrast administration.

A

Capsule มีลักษณะ
» isodense or hypodense ในช่วง hepatic arterial phase เทียบกับตับ
» Capsular enhancement ในช่วง delayed phase

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27
Q

Owing to HCC has tendency to invade portal vein and hepatic vein. Differential Diagnosis of tumor thrombus can be made through demonstration of ______ and _________ on arterial phase.

Please fill in the blank…

A

expansion of main portal vein >/= 23 mm
and
intravascular neovascularity

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28
Q

Please described “Enucleation sign” in HCC ..

A

Sign of rupture HCC
- On arterial phase, a rupture tumor appears as a nonenhancing hypodense lesion with focal discontinuity and peripheral rim enhancement
» Similar to enucleation orbital globe with the remaining intact sclera

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29
Q

How much the incidence of Hepatic venous tumor thrombus ?

A

6%

30
Q

What is sign “threads and streaks” ?

A

Sign ที่เป็น characteristic of intravascular tumor thrombus.

31
Q

Does HCC common to invade biliary system ?

A

No

32
Q

What are the appearance of HCC in T1W ?

if it has variable appearance what determine the appearance of HCC ?

A

In T1W image HCC มี variable appearance ขึ้นกับ ปริมาณ fatty change, internal fibrosis และ dominant histologic pattern.

33
Q

Please described signs or image findings of ruptured HCC ?

A

T-T

34
Q

จงบอก typical* findings ใน MRI ของ Cirrhotic nodule และ HCC ที่ใช้แยกกัน

A

Cirrhotic (regenerating) nodule
» T1W - High SI
» T2W - iso to hypo SI
(Fe สะสมใน nodule > เนื้อตับรอบๆ ร่วมกับ การมี inflammatory fibrous septa เนื้อตับรอบๆ)

HCCs
» T2W - High SI
!! แต่ well-differentiated HCC สามารถมี SI เหมือน nodule
» “nodule within a nodule” เป็นการเกิด HCC ใน low SI nodule

35
Q

Please described typical pattern enhancement in MRI of hepatocellular carcinoma …

If not typical please described the pattern enhancement and possible mechanism ?

A

คล้ายๆ CECT…

  • Early arterial enhancement.
  • Isointense in Venous phase
  • Hypo SI from early washout in Delayed phase

!!! แต่ บางครั้ง tumor เหล่านี้แสดง progressive enhancement ใน dynamic imaging คือ ไม่ washout
» จากที่ พบว่าเมื่อ tumor >1.5 cm มักจะมี fibrous capsule ที่เห็นเป็น hypointense band ใน delayed phase.

36
Q

MR สามารถ แสดง vascular invasion ของ HCC โดยมีลักษณะอย่างไรบ้าง ??

A

30-50% of cases แสดง
> Lack of flow void in multislice T1W GRE
> flow-compensated T2W FSE

อ่านแล้วไม่ get ไปอ่าน reference 55
Hytiroglu P, Theise ND : Differential diagnosis of hepatocellular nodular lesions. Semin Diagn Pathol 15:285-299, 1998.

37
Q

For tumor thrombus what is enhancemnet appearance in arterial phase ?

A

Early arterial enhancement.

38
Q

What is SPIO ?

A

SPIO
» ย่อมาจาก Superparamagnetic iron oxide
» หลักการ HCC จับ SPIO น้อย (เหล็ก ทำให้ decreased signal intensity) เลยถูกกด SI น้อย HCC เลยขาว ในพื้นดำ
» ใช้เพื่อช่วย detected small HCC lesions ใน cirrhotic liver. โดยใน study หนึ่งสามารถ detect small HCC มากขึ้น โดยใช้ SPIO-enhanced FLASH and long TR sequence (2000/70 and 2000/28)
!!! แต่ข้อจำกัดของ technique นี้คือ ใน early HCC อาจสะสม iron ได้ จากที่ยังมี reticuloendothelial cells อยู่ ซึ่งทำตัวเหมือน ตับปกติ … สำหรับข้อจำกัดนี้เค้าบอกให้ดูลักษณะ ใน unenhanced MR จะสามารถช่วยแยกได้

39
Q

Please give example naming of the hepatobiliary contrast agents…

A

Gd-EOB-DTPA, gadoxetate

40
Q

Please described the typical MR appearance of regenerating nodule and dysplastic nodule ….

A 
Regenerating nodule 
T1W and T2W >> Iso intense
\+ Siderotic nodule
(น่าจะเป็น regen nodule ที่มี Fe)
May low SI on T2W from Fe accumulation
>> Supply by portal venous system
Dysplastic nodule 
T1W >> hyperintense
T2W >> hypointense
!! Hyperintense in hypointense nodule
(nodule within a nodule) indicated HCC foci in dysplastic nodule.
41
Q

Fibrolamellar carcinoma (FLC) is the slow-growing tumor that majority arise in cirrhotic liver.

Does the above sentence in true?

A

Wrong.

80% FLC arise in normal liver.
20% arise in cirrhotic liver.
[80/20 normal/cirrhotic]

42
Q

Does the following sentence is true ?

Fibrolamellar carcinoma (FLC) is composed of neoplastic hepatocyte seperate into cords by lamellar fibrous strands.

A

Yes

43
Q

Do the following sentences are corrected ?
» Fibrolamellar carcinoma (FLC) also has Alpha-fetoprotein as the same as HCC.
» The large FLC has no necrotic core.
» ~1/2 FLC has single three of fibrous strands.

A

All are wrong…
» FLC not produce alpha-fetoprotein
» FLC as the same as HCC, if large it will have centreal necrotic core.
» FLC ~1/2 developed multilamellated fibrous strands.

44
Q

Does satellite nodules and multifocality are not often presented in Fibrolamellar carcinoma (FLC)

A

Wrong.

Fibrolamellar carcinoma (FLC) often has satellite nodules and able to have multifocality.

45
Q

For the Fibrolamellar carcinoma (FLC) usually has central scar and multiple fibrous septa…
» Make this tumor resemble to ____.

A

Focal nodular hyperplasia (FNH)

46
Q

Concerning about Fibrolamellar carcinoma, please described age incidences, risk factors, clinical S&S and prognosis.

A

> > Age incidence:
Adolescent and young adult < 40 years of age

> > Risk factor
No known, no gender predilection

>> S&S
pain, malaise, Wgt loss
Occasional jaundice (invade biliary tree)
2/3 palpable mass
Alpha-fetoprotein is normal.

> > Prognosis
Considerably better > HCC
[45-60 mo. vs 6mo]
High likelihood to cure in Sx 40%

47
Q 
Fibrolamellar carcinoma (FLC) has not produce alpha-fetoprotein.
So the serum alpha-fetoprotein will ?
A) Arise high
B) Abnormal low
C) Normal
D) Variably
A

Normal อะดิ อย่าคิดมากกก

48
Q

Concerning about Fibrolamellar carcinoma (FLC), please described image findings:
» Plain radiograph findings..
» Nuclear Scintigraphy
» Ultrasonography

A

> > Plain radiograph:
ตอบไรก้อได้ แต่ขอให้ตอบ
Partially calcified upper abdominal mass.

> > Nuclear Scintigraphy:
[Currently no longer use!!]
In the past, Sulfur colloid agent ถูกใช้เพื่อ detected filling defect.

> > Ultrasound:
A large, well-defined, lobulated mass with variable echotexture**..
** 60% has mixed echotexture with predominate hyper and isoecho content
++ If central scar exist, จะเห็นเป็น central hyperechogenicity.

49
Q

Fibrolamellar carcinoma (FLC) in US usually has mixed echotexture what echo are/is predominate ?
A) Black (hypo) and White (hyper)
B) Black and Gray (iso)
C) Gray and White

A

Answer is C

60% has mixed echotexture with predominate hyper and isoecho content.

50
Q

Concerning about Fibrolamellar carcinoma (FLC), please described image findings in Computed tomography
» Unenhanced CT
» A&V phase
» Delayed phase

A

> > NCCT : Well-defined hypodense mass with area of low density (necrosis, scar or hemorrhage) and satellite calicificatrion in central scar

> > A & V phase:
Non scaring area shows heterogeneous enhancement pattern ซึ่งเกิดจากเป็นบริเวณที่มี hypervascularity และเซลล์ ปนอยู่กับ fibrous (lamellae and scar) ร่วมกับ necrotic area

> > Delayed phase: [มีสามสิ่งให้จำ]
1. Relatively homogeneous enhancement; probably contrast washout in vascular component with delayed enhancement of fibrous septa..
[เข้าใจว่าดู washout ทั่วๆ, จากส่วนที่เป็นเส้นเลือด ส่วนที่เป็น fibrous ก็ยังไม่ enhance]
2. [Some case !] Delayed enhancement of central scar, resemble to FNH
3. ถึงแม้ว่า FLC เป็น uncapsulated แต่สามารถแสดงลักษณะ delayed peripheral rim enhancement ได้ จากเนื้อ liver ที่ถูกกดที่อยู่ขอบๆ [เนื้อถูกกดเลือดเลยเข้าไปเลี้ยงยากม้าง]

51
Q

Concerning about Fibrolamellar carcinoma (FLC), please described image findings:
» MRI

A 
ส่วนที่ไม่มี scar
>> T1W
- Iso to hypo SI with normal liver
>> T2W
- Iso to slightly hyper SI with normal liver

ส่วนที่มี scar
» T1W and T2W
- hypointense
[ !! ใน Gore เขียนว่ามี case FLC ที่ T2W ขาว ซึ่งตอนแรก case นี้ Dx เป็น FNH ]

Post-gadolinium
» เหมือนใน CT:
A & V phases - heterogeneous enhanced
Delayed phases - 1. Homo enhanced
2. Delayed scar enh.
3. Delayed periph enh.
“Hetero enhancement in A&V phase and progressive homogeneous enhancement in delayed phase with +/- delayed scar enhancement”

52
Q

In atypical cases of FNH, เมื่อ MR แสดงลักษณะของ FNH แต่ไม่มีการ uptake ของ sulfur colloid ใน scinitigraphy what recommendation should be addressed ?

A

Biopsy should be established to confirm / excluded FNH..

53
Q

FNH มักจะเป็น differential diagnosis of fibrolamellar carcinoma (FLC) จงบอก ลักษณะที่ใช้แยกโรคมา 4 ข้อ

A
  1. Central Scar
    - Mostly FLC is low T2, FNH high T2
  2. Calcification
    - FNH not (rare) calcification
    [<1.5% vs 55% in FNH : FLC]
  3. Symptoms
    - Asymptomatic - FNH
    - FLC มักมี Symptoms
  4. Histology
    - Malignant features + Eosinophilic hepatocyte in FLC
    - Normal hepatocyte and bile ductule in FNH
54
Q 
Hepatoblastoma is a malignant tumor mainly originate from ?
A) Mesenchymal origin
B) Cholangiocellular origin
C) Hepatocellular origin
D) None of above
A

Answer C

Hepatocyte origin but often contained mesenchymal elements

55
Q

What are the cells that may be the component of hepatoblastoma ?

A
  1. Fetal Hepatocyte (epithelial)
  2. Embryonal Hepatocyte (epithelial)
  3. Mesenchymal cells*
    &raquo_space; primitive mesenchymal tissue
    &raquo_space; Osteoid material and /or cartilage
56
Q

Does Mixed Hepatoblastoma microscopically composed of ?

A

All of cells types.

Fetal and Embryonal hepatocyte
+ Mesenchymal cells

57
Q

Does following sentence is corrected.

The histologic subtype of hepatoma has prognostic implication to hepatoblastoma.

A

Corrected.

58
Q

Between

  1. Fetal hepatocyte predominate
  2. Embryonal hepatocyte predominate
  3. Anaplastic hepatoblastoma

Please ranking the poorest prognosis to best prognosis.

A
  1. > >
    1. > > 1.
59
Q

How much percentage of hepatoblastoma have multifocality ?

A

20%

60
Q

What is the most common liver tumor in childhood ?

What is the peak age incidence ?

What gender did tumor predilect ?

A
  • Hepatoblastoma
  • Between 18 and 24 month
    [May present in adolescent or young adult]
  • More frequent in Male than Female
61
Q

What are the clinical manifestation of hepatoblastoma ?

Does Alpha-fetoprotein usually low in pateint with hepatoblastoma ?

A 
Clinical Manifestation:
- Abdominal swelling
- Anorexia and Wieght Loss
- Rare case: precoccious puberty
  owing to secretion of 
   >>> gonadotrophin or testosterone
- Pulmonary metastasis, common @ Dx.

Wrong,
Alpha-fetoprotein usually high in hepatoblastoma.

62
Q

Please described the pathologic findings of hepatoblastoma…

A

Generally, a large well-circumscribed solitary mass with nodular or lobulated surface.

For epithelial hepatoblastoma - Cut surface are homogeneous > mixed hepatoblastoma
[usually contained osteiod and cartilage - large Ca++, fibrotic bands]

63
Q

Please tells the associated condition with hepatoblastoma ?

A
  1. Wilm’s tumor
  2. Familial polyposis coli
  3. Hemihypertrophy
  4. Beckwith-Wiedemann syndrome
64
Q

Please describe image findings of hepatoblastoma….
» Radiographs
» Nuclear medicine
» Ultrasound

A

> > Radiographs
- A large RUQ mass with extensive coarse, dense calcification from osteiod formation.

> > Nuclear Scintigraphy

  • Large filling defect in Sulfur Colloid scan
  • May uptake Gallium & FDG & Excrete iminodiacetic acid derivative agents ??

> > Ultrasound

  • Echogenic mass with shadowing echogenic foci from intra-tumoral calcification.
  • Hyperechoic and/or cystic areas from hemorrhagic foci and/or necrotic area.
  • CDUS shows hypervascularity
65
Q

Please describe image findings of hepatoblastoma in computed tomography
» Plain CT
» Post-contrast CT

A

> > Plain CT

  • A solid hypodense mass with or without calcification.
  • When lobulated - fibrous band can be seen.
  • When marked heterogeneous and calcification, mixed hepatoblastoma is considered.

> > Post-contrast CT

  • Early arterial thick peripheral rim enhancement, – viable hypervascular tumor
  • Invasion of adjacent organ or perihepatic vessels
66
Q

Please describe image findings of hepatoblastoma in Angiography..

A
  • Hypervascular mass with “spoke-wheel” pattern, คล้าย FNH
  • hypovascular or avascular zone could be hemorrhage area in tumor
  • AV shunting is uncommon
  • Vascular invasion is rare
67
Q

Please describe image findings of hepatoblastoma in MRI

A

T1W

  • Hypo SI
  • Hyper SI foci from hemorrhage

T2W

  • High SI
  • Internal fibrous septa, low SI bands

[ For mixed type hepatoblastoma ]
Heterogenous SI in T1W and T2W owing to calcification, hemorrhage, fibrosis, necrosis and fibrous septa component.

Post-Gd
- immediate diffuse (homogeneous or heterogeneous) enhancement followed by rapid washout

68
Q

What is the cell origin of Intrahepatic cholangiocarcinoma (ICAC) or adenocarcinoma of bile duct origin ?

A

Cholangiocellular origin

69
Q

How much Intrahepatic cholangiocarcinoma (ICAC) account for all cholangiocarcinoma ?

A

10%,
the remainders are Klaskin’s (Hilar) and bile duct cholangiocarcinoma

(Gore คงหมายถึง Extrahepatic ม้างงง)

70
Q

Please described pathologic findings of Intrahepatic cholangiocarcinoma (ICAC) or adenocarcinoma of bile duct origin.

A

> > Gross appearance:

  • Large, firm mass with cut-section appearance of whitish fibrous tissue.
  • Rare to have internal necrosis or hemorrhage.

> > Microscopic appearance:

  • Adenocarcinoma with glandular appearance and cells resembling the biliary epithelium
  • Mucin and calcification often seen.
  • Large amount of desmoplastic reaction.
71
Q

Please described….
the Pathologic-Radiologic correlates of intrahepatic cholangiocarcinoma in CT, US and MR.

  • Fibrosis
  • Necrosis and hemorrhage (ค่อนข้าง rare)
A
  • Fibrosis
    > US - hyperechoic
    > CT & MR - hypo dense / SI
  • Necrosis and hemorrhage
    > Heterogeneous appearance

GI Radiology (5 decks)

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