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Essential in oncologic imaging what radiologistes need to know

Essentials in Oncologic Imaging
What Radiologists Need to Know
Liver: Primary, Metastases

Richard Baron, M.D.
University of Chicago


Liver Malignancies

• Primary

– Hepatocellular Carcinoma (~85 – 90%)
– Cholangiocarcinoma (~5 – 10%)
– Rare tumors (Angiosarcoma, Lymphoma, Epithelioid
Hemangioendothelioma, others)

• Metastases


HCC without cirrhosis


Mosaic and capsule


HCC in Cirrhosis

• 10 – 14% of advanced cirrhosis harbors HCC
• 25% of Hepatitis B/C patients develop HCC within


10 years
Compare to risk of colon cancer in 50 y.o.:
< 1% prevalence, 7% lifetime incidence


Screening Cirrhosis: 1329 patients
Peterson et al, Radiology, 2000

Patients
Alcohol
B Hepatitis
C Hepatitis
B/C Hepatitis
C Hep/Alcohol
PBC
PSC
Other

%HCC

86
22
99
22
22
47
31
99

10%

27%
22%
18%
18%
2%
0%
8%

430

14% 59 pts


Screening Cirrhosis: 1329 patients
Peterson et al, Radiology, 2000

Patients
Alcohol
B Hepatitis
C Hepatitis
B/C Hepatitis
C Hep/Alcohol
PBC
PSC
Other

%HCC

86
22
99
22
22
47
31
99

10%
27%
22%
18%
18%
2%
0%
8%

430

14% 59 pts


Pathogenesis of HCC:
Key Role of Dysplastic Nodules

• Regenerative Nodule
• Large Regenerative Nodule
• Dysplastic Nodule
• HCC (nodule-in-nodule)
• HCC


Dysplastic Nodules: MR

CT: ~ 10% Lim et al, BJR 2004
MR: 10 – 15% Krinsky, Radiology 2001


Dysplastic Nodules:
Low Grade
- Nuclear atypia is minimal
- Portal tracts present
High Grade
- High nuclear cytoplasmic ratio
- Rare mitotic figures
- Resistance to iron accumulation
-New vessels (nontriadal arteries) increase
-Portal flow to nodules decreases



HCC
AP
PV


HCC: Detection
Patient
Detection

Lesion
Detection

Study

CT

67 – 73%

35%

Peterson, 2000

MR

77%

37%

Krinsky, 2001

91%

Bhartia, 2003

MR
Dual Contrast
US

~ 50%

~ 35%

multiple


48 y.o. male, chronic hepatitis C
Solitary 2.5 cm lesion

AP

PV

EQ


What would be next best step
To plan appropriate treatment?
A. Biopsy Lesion
B. Confirm with MR exam
C. Make Rx plans as HCC
D. F/U imaging in 3 - 6 mos.


HCC Dx: 2005 AASLD CRITERIA
> 20 mm Liver Lesion, chronic liver disease
One imaging technique with typical HCC

AP

(AP hypervascularity & EQ washout)
One imaging technique showing a mass with
AFP levels > 200 ng/ml

10-20 mm

Two imaging techniques with
typical HCC (AP hypervascularity & washout

< 10 mm

PV

Repeat US every 3-6 months for 2 yrs

American Association for the Study of Liver Diseases
(AASLD) Practice Guideline. Hepatology 2005;42:1208

EQ


HCC Dx: 2010 AASLD CRITERIA
> 10 mm Liver Lesion, chronic liver disease
One imaging technique with typical HCC

AP

(AP hypervascularity & EQ washout)

< 10 mm
Repeat US every 3-6 months for 2 years

American Association for the Study of Liver Diseases (AASLD)
Practice Guideline. Bruix and Sherman. Hepatology 2010

PV

EQ


Why is non biopsy Dx important?
2009

2011


01/22/2008

Pre

10/30/2007

Value of Equilibrium Phase CT

Early arterial

Late arterial

Portal

Equilibrium

Courtesy of M. Hori , Osaka


‘Peliotic HCC’

T1

AP

AP

PV

T2

PV

EQ

2 hr


AP

PV

EQ


Small (10-20 mm) Enhancing CT/MR Nodules
• O’Malley et al (Am J. Gastro 2005): 28% HCC
– Doubling time – 6 mos.
• Jeong et al (AJR, 2002):

13% HCC

• Most small enhancing nodules are not HCC
• Delay, washout characteristics helpful in characterizing
• Multimodality imaging & Follow-up imaging essential


HCC: MRI signal intensities
AP

EQ

Delay

T1

T2

DWI


Enhancing Nodule: Value of T2 characteristics

AP

EQ


OP T1

F/U OP T1
2007 f/u 2007

IP T1

OP T1
2008

“Nodule
in
Nodule”
Evolution


Evolution Dysplastic Nodule to HCC
2005

T2
2006

2007

T1


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