Workshop esgar zech 1 pdf

June 2009 in Lisbon Workshop LIVER IMAGING Meet the Expert WS15THURSDAY,JUNE15th,2007C.J.Zech,Munich/DE R.Hammerstingl,Frankfurt/DE Christoph J Zech, M.D.. 50-60 sec portalvenous / venou

ESGAR Annual Meeting 12 – 15 June 2009 in Lisbon

Workshop LIVER IMAGING

Meet the Expert

WS15THURSDAY,JUNE15th,2007C.J.Zech,Munich/DE

R.Hammerstingl,Frankfurt/DE

Christoph J Zech, M.D.

Institute of Clinical Radiology (Chair: Prof Dr Dr M Reiser)

Munich University Hospitals - Grosshadern

CJZech

automatic

ca 50-60 sec portalvenous /

venous phase

15 sec Late-arterial –

Early-Arterial

Report MRI:

„benign lesion in marked steatosis hepatis, most likely an adenoma“

CJZech

PerilesionalEnhancement≠Tumor

Thesizeofthelunglesionappearsdifferent….Thesamewindowsshouldbeusedonsubsequentexaminationstomeasureanylesions

Asaruleofthumb,theminimumsizeofthelesionshouldbenolessthandoubletheslicethickness.Lesionssmallerthanthisaresubject…

From: Therasse et al (2000) New Guidelines to Evaluate the Response to Treatment in Solid Tumors J Natl Cancer Inst;92:205.

pragmaticallyadequatetools

thatsatisfyanoncriticalrole

relativetoclinicaloutcome

widelyacceptedandknown

wellevaluatedandvalidated

highinterobservervariability

changesoftumor/tissuequality(necrosis,calcification,decreasedCM-uptake…)arenotaddressed

Effortstodevelopreproduciblemethodsformeasuringvolumesofinfiltrativetumorsthatlackclearmargins,alreadyrecognizedasaseriousproblemforlinearandtwo-dimensionalarea

CJZech measurement,lieattheheartofthechallenge

tolowcontrastsituationintheliver

manuallyverytimeconsuming

definitionofstabledisease,progressionorresponseaccording

toWHO/RECISTnopossible

• I don’t want to use 5 different agents for

shelf?

CJZech

Hepatocyte - selective agents

Kupffer-Cell

Multihance® (Gd-BOPTA )Teslascan® (Mn-DPDP)Primovist® (Gd-EOB-DTPA)

Hepatocyte

Hepatocyte - selective agents

imagingsequencesnotthesame

aswithGd-chelates…e.g.T2*)

• additionalECMexamination(CT,

rateofadverseeventsisaslow

aswithGd-chelates

imagingsequencesnotthesame

aswithGd-chelates…e.g.T2*)

provideextracellularandspecificinformation

~ 5-10min

bolus injection

recommended dose: 0.025 mmol /kg

arterial, portal-venous

Hirohashi S et al., ISMRM 2003

t

~ 10 min

T1wpre

liver-specific phase

dynamicstudiesMRCP

bolus injection

recommended dose: 0.05-0.1mmol /kg

arterial, portal-venous equilibrium

T2w+

schedule patient

•

•

CJZech

Very Small Liver Nodule (1cm)

Hypervascular nodule < 2cm (with 2 modalities)

& no SPIO uptake

Biopsy if not typical in one modality

Treat as HCC

CJZech

Matsui O Imaging of multistep human hepatocarcinogenesis by

CTAP Intervirology 2004;47(3-5):271-6

T1 Gd art T2

CJZech

T1 arterial Gd

CT arterial

T2* Resovist

Follow up recommended Imaging techniques are not sufficient to differentiate between dysplastic nodules or HCC in lesions < 1cm

typical vascular pattern in 2 modalities = HCC atypical vascular pattern = biopsy according to EASL guidelines (but biopsy of small lesions also difficult) MRI with recent scanners and SPIO / Gd – enhanced MRI can be helpful for differentiation

Consider TACE and Lipiodol-CT