Student SYB

Chet Cunha MS IVJanuary 22, 2009

History•61 y/o M with known HCV x 5 yrs.

presenting with vague abdominal discomfort.

•Outside CT showed single suspicious lesion in liver.

•US guided bx shows mild chronic hepatitis with no evidence of malignancy or cirrhosis.

•PE and ROS unremarkable.

DDxHepatic mass lesions

• Malignancy - HCC, lymphoma, hemangiosarcoma, intrahepatic cholangiocarcinoma, mets (GI, GU, ovarian, pancreatic)

• Benign tumors - hemangioma, adenoma

• Cysts - hepatic cysts, hydatid cysts, polycystic liver disease

• Abscesses - pyogenic, amebic, fungal

• Focal fatty infiltration

• Caroli’s disease

Labs

•CBC/BMP unremarkable.

•No LFT abnormalities.

•Elevated Alpha-fetoprotein.

•HAV/HBV serologies negative.

W/U of hepatic lesion

•CT with contrast

•MRI

•US

•Tc-99m

•Lipiodol Angiography with CT f/u

•US, CT guided, or open bx for definitive dx

Imaging - Lipiodol Angiogram

Imaging - Lipiodol Angiogram

Imaging - Triphasic CT 2 weeks after

Angiography

Imaging - Triphasic CT 2 weeks after

Angiography

Imaging - Triphasic CT 2 weeks after

Angiography

Periportal lymphadenopathy

Imaging - Triphasic CT 2 weeks after

Angiography

Smaller middle lobebut no frank evidence of

cirrhosis

HCC•Most often seen in presence of

cirrhosis (EtOH, HBV, HCV, hemochromatosis, aflatoxin, alpha 1 antitrypsin)

•AFP often, but not always elevated

•3 growth patterns:• Solitary mass (often large)

• Multifocal/nodular

• Diffuse

HCC Radiographically

•US appearance variable

•MR - hypo in T1, hyper in T2

•Unenhanced CT - hypoattenuated lesions

•CT with contrast - hyper in arterial phase

•Often invades portal vasculature

HCC - Treatment Options

•Surgical resection

•Chemoembolization

•Radiofrequency ablation

•Chemotherapy

•Liver transplantation (If pt has 1 lesion <5cm or 3 lesions <3cm*)

*N.B. these measurements can be reevaluated following neoadjuvant therapy

Further Reading

• Gourtsoyiannis, N.C., Ros, P.R. Radiologic-Pathologic Correlations from Head to Toe. Springer Publishing, Berlin 2005.

• Grossman, Z.D., Katz, D. S., et al. Cost-Effective Diagnostic Imaging. Mosby Elsevier, Philadelphia, 2006.

• Weinstein, W.M., Hawkey, C.J., Bosch, J. Clinical Gastroenterology and Hepatology. Mosby Elsevier, Philadelphia, 2005.