Essential in oncologic imaging what radiologistes need to know

HCC Dx: 2005 AASLD CRITERIA> 20 mm Liver Lesion, chronic liver disease One imaging technique with typical HCC AP hypervascularity & EQ washout One imaging technique showing a mass with

Essentials in Oncologic Imaging What Radiologists Need to Know

Liver: Primary, Metastases

Richard Baron, M.D

University of Chicago

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

Screening Cirrhosis: 1329 patients

Peterson et al, Radiology, 2000

Dysplastic Nodules: MR

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

AP

PV

HCC: Detection

Patient Detection

Lesion Detection Study

48 y.o male, chronic hepatitis C

Solitary 2.5 cm lesion

A Biopsy Lesion

B Confirm with MR exam

D F/U imaging in 3 - 6 mos

What would be next best step

To plan appropriate treatment?

HCC Dx: 2005 AASLD CRITERIA

> 20 mm Liver Lesion, chronic liver disease

One imaging technique with typical HCC

(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 Repeat US every 3-6 months for 2 yrs

American Association for the Study of Liver Diseases

(AASLD) Practice Guideline Hepatology 2005 ;42:1208

AP

PV

EQ

> 10 mm Liver Lesion, chronic liver disease

One imaging technique with typical HCC

(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

AP

PV

EQ

Why is non biopsy Dx important?

2009

2011

01/22/2008 Value of Equilibrium Phase CT

10/30/2007

Pre Early arterial Late arterial Portal Equilibrium

Courtesy of M Hori , Osaka

AP PV EQ

• 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

Small (10-20 mm) Enhancing CT/MR Nodules

HCC: MRI signal intensities

Enhancing Nodule: Value of T2 characteristics

“Nodule

in Nodule” Evolution

2007 f/u 2007

2008

Evolution Dysplastic Nodule to HCC

2005

Hypovascular Nod ules

10 – 15% of small HCC are hypovascular

60% of small hypoattenuating nodules

transformed to enhancing vascular lesions

(Takayasu et al, AJR, 2006)

Diagnosis of Small Nodules

Forner et al, Hepatology, 2007Serially followed cirrhotic patients for 3 yrs

89 patients developed NEW nodule

OR tumor involving a major venous branch

T4 Tumor(s) with direct invasion of

adjacent organs other than gallbladder

Ferris et al, Radiology, 2000

48 y.o male, chronic hepatitis C

3 lesions; Largest = 3 cm

A Biopsy largest lesion

B F/U in 3 mos to show stability

C Proceed to transplantation list

without further steps

D Patient is not candidate for

transplantation

To evaluate for possible liver transplantation,

which is next best step ?

Mazzaferro et al N Engl J Med 1996;334:693-699

False Positive CT Diagnosis

False Positive CT Diagnosis

Summary of key issues in HCC

• Very common in chronic liver

disease

• Detection difficult despite claims

in literature

• US/CT/MRI can all be used as

screening tools, but require

optimizing techniques

• Liver transplantation often only real cure option

• Radiology assessment/reports are critical to determining patient treatment options

• Wording, number and exact size

of lesions (to decimal point) in radiology reports have dramatic impact on care

A Contrast washout key to diagnosis

B Most lesions show homogeneous

retention of contrast material

C Usually vascular lesions with

marked arterial enhancement

D Can range from near water density

to densely solid lesions

In imaging Hepatic Cholangiocarcinoma, which of

the following is true?

• Underlying histologic stroma

– Fibrous versus glandular stroma

• Locations

– Intrahepatic, Proximal CBD, Distal

• Associations: PSC, Choledochal cysts; infections, chemical toxins

~ 10% Intrahepatic

Spectrum of Cholangiocarcinoma Pathology

Mixed Stroma

Cholangiocarcinoma: Fibrous Stroma

+C EQ

+C EQ

Cholangiocarcinoma: Glandular Stroma

Cholangiocarcinoma: Contrast Enhancement

STAGING Chol CA: TNM based

T2 Solitary Tumor with microvascular invasion,

OR multiple tumor (< 5 cm);

T3 Multiple tumors > 5cm,

OR tumor involving a major venous branch

T4 Tumor(s) with direct invasion of

adjacent organs other than gallbladder

Treatment and Staging Impact

Surgery is only cure possibility

Imaging role preparing for resection:

Exclude AdenoCa metastasis from unknown primary

Poor prognosis: Multiple nodules; bi-lobar disease;

vascular invasion; positive lymph nodes

Difficult surgery: Central lesions; chronic liver disease

Surgery offered to potentially resectable patients regardless of stage

Value of Delay Equilibrium Phase

Liver Metastases

• Most common liver malignancy

• Generally variable, noncharacteristic features

Does not meet classic benign dx (cyst, hemangioma, or FNH) with known primary tumor

• Site of origin can occasionally be suggested

Liver Metastases

• Hypovascular (colon, lung, pancreas, many others)

• Hypervascular (renal, islet cell, breast, thyroid, sarcomas)

• Ca++ in mucinous tumors (colon, ovary)

• Change over time in appropriate setting

Significance of Small (<1.0 – 1.5 cm) Hepatic Lesions

44 Considered Metastases on Follow-Up

Schwartz et al., Radiology, 1999

Recon thickness 10 mm 7.5 mm 5.0 mm 2.5 mm

No Lesions 90 112 137 167

Weg, et al., Radiology, 1998

58 year old breast cancer patient

T2

Biliary Hamartomas

Colon Ca Islet Cell Ca

DWIAP

AP

Liver Specific Contrast Agents

Carcinoid Metastasis

Sarcomas (and GIST)

Mucin Producing Tumors

Ovarian, colon, mucinous pancreas

Post Treatment Necrosis

GIST Mets

6 month follow-up

Choi Criteria: GIST

Liver Tumors: Practical Summary

• Understanding the clinical setting is essential

– Chronic Liver Disease

– Presence of other primary tumor and type

• Optimizing imaging and contrast techniques

– Vary with underlying type of tumor suspected

• Regular communications and interactions with

oncologists/hepatologists/surgeons is essential