Case Report # 1

Submitted by: James Korf, MS4

Faculty reviewer: Sandra Oldham, MD

Date accepted: 27 August 2014

Radiological Category: Principal Modality (1):

Principal Modality (2):

Gastrointestinal

Angiography

CT abdomen w/ and w/out contrast

Case History

The patient is a 51 year old male with a past medical of HepC who presents for follow up imaging after a 2x 4 x4cm liver mass was noted on abdominal US evaluating previous abdominal distension.

Abdominal CT W/ and W/Out Contrast:Precontrast Phase

Arterial Phase

Arterial Phase

Venous Phase

Venous Phase

Venous Phase

Delayed Phase

• Vascular

• Infection

• Neoplastic

• Degenerative

• Idiopathic

• Congenital

• Autoimmune/ Allergic

• Traumatic

• Endocrine

Which one of the following is your choice for the appropriate diagnosis?

Test Your Diagnosis

• Vascular

• Infection

• Neoplastic

• Degenerative

• Idiopathic

• Congenital

• Autoimmune/ Allergic

• Traumatic

• Endocrine

Which one of the following is your choice for the appropriate diagnosis?

Test Your Diagnosis

Heterogeneous lesion found in segment 4 of the liver, diameter <20mm. Mass displays an area of low attenuation that does not enhance with contrast. Lesion exhibits Iso-density during pre-contrast phase, hyper-dense during arterial phase, iso-density with the venous phase, and hypo-density during delayed phase.

Patchy enhancement of liver parenchyma can be noted especially on venous phase. Live edges show mild scalloping. Some evidence of portal hypertension with portal vein measuring 16 mm, and some splenomegaly noted.

Right hepatic artery arises from superior mesenteric artery, and left hepatic artery arises from celiac axis.

• Cyst

• Hemangioma

• Metastasis

• Primary Malignancy

Findings:

Differentials:

Findings and Differentials

Algorithm for potentially cancerous liver lesions.

Discussion

American College of Radiology. Liver Imaging Reporting and Data System version 2013.1. Accessed August 2014, from http://www.acr.org/Quality-Safety/Resources/LIRADS/.

Cysts

•Believed to be congenital in origin•Benign avascular fluid filled lesion•Low attenuation relative to liver parenchyma•Does not enhance with contrast•Tend to be solitary and homogenous

Discussion

Liver Cysts

Mortelé, Koenraad J.  and Ros, Pablo R. Cystic Focal Liver Lesions in the Adult: Differential CT and MR Imaging Features. RadioGraphics 2001 21:4, 895-910

Our patient

Hemangiomas

• Benign vascular tumor• Low attenuation on unenhanced CT scans• Have a characteristic nodular enhancement beginning the periphery that progresses centrally•The contrast is retained, causing hemangiomas to be enhanced and hyper dense on delayed phase

Discussion

Liver Hemangioma

Precontrast

Arterial phase

Venous phase

Uptodate.com. Courtesy of Jonathan Kruskal, MD. Graphic 70560 Version 3.0

Our Patient

Metastasis

•Tend to be multiple, but can occasionally present as a solitary nodule.•Typical present as low attenuating masses.•Most commonly GI in origin, and spread via portal venous system•Therefore these metastases often enhance during venous contrast phase

Discussion

RCC Metastasis: Venous phase

Our Patient

Primary Malignancy

•Hepatocellular Carcinoma is the common primary malignancy of liver• Frequently seen in the setting of liver cirrhosis•Also must consider Colangiocarcinoma

•Defining features of HCC– Arterial hyper enhancement– Washout vs. Fading– Capsule or Corona enhancement– Threshold growth– Invasion of portal vein

•Other features that are often found– Central necrosis– Calcifications

Discussion

Algorithm for potentially cancerous liver lesions.

Discussion

American College of Radiology. Liver Imaging Reporting and Data System version 2013.1. Accessed August 2014, from http://www.acr.org/Quality-Safety/Resources/LIRADS/.

Capsule and Corona Enhancement in HCC

American College of Radiology. Liver Imaging Reporting and Data System version 2013.1. Accessed August 2014, from http://www.acr.org/Quality-Safety/Resources/LIRADS/.

Washout and Fading in HCC

American College of Radiology. Liver Imaging Reporting and Data System version 2013.1. Accessed August 2014, from http://www.acr.org/Quality-Safety/Resources/LIRADS/.

Our Patient

Hepatocellular Carcinoma mass with a LI-RAD 4B classification

Diagnosis: Hepatocellular Carcinoma

American College of Radiology. Liver Imaging Reporting and Data System version 2013.1. Accessed August 2014, from http://www.acr.org/Quality-Safety/Resources/LIRADS/.

LR1: Continued routine surveillance usually is appropriate. LR2: Continued routine surveillance usually is appropriate. LR3: Appropriate management is variable, depending mainly on size, stability, and clinical considerations. LR4: Close follow up, additional imaging, biopsy, or treatment (loco-regional treatment, sub-total hepatic resection) may be appropriate.

LR5: Treatment without biopsy is appropriate.

Management

•Case Followup

Case Follow Up : Attempted T.A.C.E

Case Follow Up : Attempted T.A.C.E

American College of Radiology. Liver Imaging Reporting and Data System version 2013.1. Accessed August 2014, from http://www.acr.org/Quality-Safety/Resources/LIRADS/

Herring, William. Learning Radiology: Recognizing the Basics, Second Edition. Pp 183-190. © 2012 Mosby, Inc.

Lise M, Da Pian PP, Nitti D. Colorectal metastases to the liver: present results and future strategies. J Surg Oncol Suppl. 1991;2:69-73.

Mortelé, Koenraad J.  and Ros, Pablo R. Cystic Focal Liver Lesions in the Adult: Differential CT and MR Imaging Features. RadioGraphics 2001 21:4, 895-910

Uptodate.com. Courtesy of Jonathan Kruskal, MD. Graphic 70560 Version 3.0

References