ACG Regional Course- Indianapolis Copyright ACG 2012
Liver Mass Work Up Jorge A. Marrero, MD, MS Keith S. Henley, MD Collegiate Professor of Gastroenterology Director Multidisciplinary Liver Tumor Program Director,
Work-up of a Liver Mass • History and Physical • Radiology – MRI vs CT
• Histology
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ACG Regional Course- Indianapolis Copyright ACG 2012
Age-Adjusted Incidence Rates in USA: 1975-2008 Cholangiocarcinoma
Rate pre 100,0000
Hepatocellular Carcinoma
www.seer.gov
Evaluation • Detailed history – age, age gender gender, history of cancer cancer, history of liver disease, steroid use, exposure (vinyl choride)
• Physical Examination – palpable mass, fever, ascites, stigmata of liver disease, bruit in RUQ
• Laboratory data – evidence of chronic liver disease, evidence of hematologic disease, tumor markers (CEA, AFP, CA 19-9)
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ACG Regional Course- Indianapolis Copyright ACG 2012
Arterial-dominant phase
Portal-venous phase 60-90 s
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Washout of an Arterially Enhancing Mass in Cirrhosis Variables
Odds Ratio (95%CI)
All patients (n=124) AFP > 20 ng/ml 11.7 (2.3-30.7) Washout 61 (3.8-73)
Washout
< 2 cm only (n=35) 6.3 (1.8-13)
Marrero JA, et al Liver Transplant 2004
Contrast Washout in HCC
Arterial Phase
August 2012
Portal Venous Phase
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MR vs CT • Comparable • MR slight superior to CT for focal lesion detection and characterization *
* Sica AJR 2000, Kondo AJR 2000, Semelka JMRI 1997 Yamashita Radiology 1996, de Lange Radiology 1996
MRI versus CT in Diagnosis of HCC in Cirrhosis Gold Std
No Pts No.
No No. Nodules
HCC (n)
Explant
34
88
Explant Explant Explant E l t
43 50 49
69 127 136
Burrel M, et al. Hepatology 2003;38:1034 Rode A, et al. J Comput Assist Tomogr 2001;25:327
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CT (%) Sens Sp
MRI (%) Sens Sp
54
51
84
61
93
13 76 77
53 61 50
92 66 79
77 76 70
58 75 82
de Ledinghem V, et al. Eur J Gastro Hep 2002;14:159 Libbrecht L, et al. Liver Transpl. 2002 Sep;8(9):749
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Eovist: Distribution and Elimination Intravenous administration ~50% Plasma, extracellular extravascular space
liver/hepatocyte OATP1 cMOAT
~50% kidneys
• Biphasic distribution –Dynamic phase –Hepatocyte phase • Dual elimination
bile/feces
urine OATP1 = organic anion transporting polypeptide 1 (active, ATP dependent) cMOAT = canalicular multi-organic anion transporter
Small HCC characterized on Eovist-enhanced MRI
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ACG Regional Course- Indianapolis Copyright ACG 2012
Other Liver Masses
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ACG Regional Course- Indianapolis Copyright ACG 2012
Hemangioma • Well circumscribed circumscribed, lobulated • Peripheral location • Filling of contrast from early through late phases • 3 types based on size • Treatment: conservative
McFarland EG et al. Radiology 1994;193(1): 43-7 Bennett GL et al. AJR 2000; 174(2): 477-85
art
5 min delayed
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ACG Regional Course- Indianapolis Copyright ACG 2012
Focal Nodular Hyperplasia (FNH) • T2: iso or mildly hyperintense • Arterial phase: homogeneous blush • Delayed phase: iso or hypointense • Central scar: 10-49% ((vessels,, ducts,, fibrosis inflammation, edema) • Treatment: conservative
FNH T2
Central scar
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ACG Regional Course- Indianapolis Copyright ACG 2012
art
PV
5 min delayed
Hepatic Adenoma • T1: hypo, iso or hyperintense (fat, hge) • T2: mildly hyperintense, heterogenous • Arterial: hypervascular (heterogeneous) • Delayed: iso or hypointense • Thin pseudocapsule (DD: HCC) • Treatment: resection
Chung KY et al. AJR 1995; 165(2):303-308
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art
5 min delayed
Contrast Washout in HCC
Arterial Phase
August 2012
Portal Venous Phase
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Atypical Hepatocellular Carcinoma • 85% of HCC > 2cm have “washout”(1) • Some lesions are atypical • Biopsy is important for these lesions
HCC Art
Del
Art
Del
HCC
Bolondi L, et al, Hepatology 2002; 42 (1):27-34
Metastasis from colon ca
art
PV
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Cholangiocarcinoma
Proper hepatic artery (possibly involved in tumor)
Common hepatic artery Splenic artery T2 Celiac artery
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ACG Regional Course- Indianapolis Copyright ACG 2012
Intrahepatic Cholangiocarcinoma • Hypodense yp in the arterial and portal venous phase with some peripheral enhancement. • Hyperdense in the equilibrium phase indicating dens fibrous tissue. • The lesion causes retraction of the liver capsule p The finding of an infiltrating mass with capsular retraction and delayed persistent enhancement is very typical for a cholangiocarcinoma.
Biopsy of Liver Mass
• 1012 biopsies using sheath • 3% bleeding • No seeding reported – 128 HCC Maturen K, et al. AJR 2006; 187:1184–1187
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ACG Regional Course- Indianapolis Copyright ACG 2012
International Consensus on Small Nodular Lesions in The Liver IWP classification Pathological features
Clinical (imaging)
Clinico-pathological
L-DN
H-DN
WD-HCC
MD-HCC
Gross appearance distinctly-nodular Stromal invasion
vaguely-nodule (–)
(–)
+/ –
+/ –
Arterial supply
iso/hypo
iso/hypo rarely hyper + Early HCC
iso/hypo
hyper
Portal vein supply + Premalignant
+ – Progressed HCC
H-DN: High grade dysplastic nodule, L-DN: Low-grade dysplastic nodule, WD: Well-differentiated, MD: Moderately differentiated, iso: isovascular, hypo: hypovascular, hyper: hypervascular
portal tract
Unpaired artery
International Consensus Group for Hepatocellular Neoplasia. Hepatology. 2009;49:658-664.
Conclusions • History and physical exam is important to determine the p presence of liver disease, history of cancer and medications • Imaging is critical. MRI better for characterizing lesions – 3 phase examination is essential – MRI iimportant t t in i Cholangiocarcinoma Ch l i i (extrahepatic > intrahepatic)
• Biopsy is important if imaging equivocal
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