Approach to Focal Liver Lesions

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Approach to Focal Liver Lesions

1 Sep, 1:30 PM

[Music] good evening to all this is the 12th talk on turf expansion by kerala iria thanks for the vision of iri kerala leaders dr ncj prakash iri kerala president and dr rijo matthew iri kerala secretary now we have professor dr keshavadas associate dean of sri chitra tirunal institute for medical sciences at tiruvanthapuram for the opening remarks and welcome address over to you sir good evening uh dr judy and good evening ramesh for the invitation again for this turf expansion series which is the ira kerala chapter considers a very very important series because we want to reach to the radiologists and the radiology students for the newer techniques that are coming up and also how to analyze cases radiologically and as well as the role of interventional radiology and management of patients so in this regard today i just wanted to discuss two important things because we are taking the topic of liver lesions today two important thing that we have to understand is our course that is the md course of the dmrt course these are the dnb course these are very short courses three years or two years is too short to learn radiology and therefore it is essential that post md you have to develop some sort of skill enhancement as far as liver imaging is concerned there has been a lot of work which has happened in elastography both in using ultrasound then there are techniques using mr now this is a new technique unless we start using these we will not be able to learn and during your md or dmb days you might not learn these techniques because the hospital where you are working might not have these facilities but whenever we get a chance we should try to learn these newer methods similarly contrast enhanced ultrasound for differentiating various liver lesions these are all things which are coming up not only on the skill development part the second part that we have to look at is research because as you know that other clinicians especially hepatologists gastroenterologists and all are doing a lot of research in these areas uh even in areas related to imaging so we should also work along with them to see that our work is recognized the work of a radiologist is recognized so with those short words on research and skill development in radiology i uh i also want to invite omar mahesh or radio who will be formally uh introduced to you by dr judy uh i'm happy that dr omar mahesh already has joined this and we we know each other uh though we had not met before uh he i am happy to uh tell that uh both of us were taught under the same teacher professor vr kiram yes dr judy you can take over thank you thank you sir today speaker is dr umam maheshwar reddy associate professor in radio diagnosis narayana medical college nellur to enlighten us on the topic imaging of focal level lesions welcome sir over teaser thank you once again uh thank you very much uh now this is the fifth of august i've give i've been given to kerala like uh mi it's become second home after another place to me like i'm very overwhelmed and today i'm over excited because rejoicer and uh i've been associated with judy madame this is time i'm being associated with her and uh this is the first time i am associated with the associate dean of tirunal i'm very happy to be part of it and my interests are neuro imaging sir i've been to harvard and learned tips and tricks but definitely not even a foot match to work done by you and i practice pinnacle of neuroimaging at the same time my interests are in abdominal imaging also so i collect cases and i try to show it in the podiums in most of the talks in kerala i have given through abdominal imaging until now thank you very much for the opportunity sir ramesh sir vijay sir mgcj prakash judy madam thanks for introducing me let me go through the topic without wasting your time this is divided my talk into two parts the first part is predominantly so this is as sir said absolutely right liver imaging most of the advances are happening in contrast enhanced ultrasound liver elastography in ultrasound and also mr elastography and there are newer techniques called liver lab which can assess the hemocitrine and liver extent of fibrosis all these things are more towards a diffuse liver disease concept it is important all of the radiologists have to be there on the toes because recently i have a call from one of my residents he called me asking for can you he was he was a gastroenterologist resident from amrita and he was giving his dnb exam and he asked me sir can you elaborate about functional mri in liver and pancreas so i was shocked that the way they are getting trained in imaging and imaging has become part and parcel of their subject so even same with neuro imaging before we know about any sequence they are they are they are ready and asking uh about it uh so we should always update ourselves so that we have to expand our stuff this is a very good initiative by kerala chapter so straight away liver imaging is taking uh so many newer horizons like one of the most important thing is in mdct uh you can assess the volume of the liver and also with the 3d reconstructions we can give a beautiful anatomy for the surgeon for a resection because if there is a small lesion in right lobe of liver and a surgeon wants to resect it he needs to know a perfect anatomy of the photovenous and the hepatic artery circulation a radiologist who gives such detail will always be appreciated you need to tell what is what exactly to be done and uh and if you can characterize a lesion better and if you can tell what are the relations at the same time how much is the volume of the resection which you are going to perform if you give such detail they will develop a confident oreo so these are the beautiful md mdct data set images which is giving attenuation of the liver volume of the liver and everything and we are getting a detailed photovenous anatomy and uh hepatic venous anatomy so these are also important for planning interventions like tips whenever you want to perform a tips procedure you want to know the variant anatomy all these things are important and you can diagnose them by this so this is the minimum minimum intensity maximum intensity projection images of photovenous circulation these are important to assess the collaterals whenever there is a cirrhosis you can definitely identify the collateral pathways and you so that if this patient has bleeding you can assess where exactly is happening and all so mdct reconstructions are very important they play a vital private role in liver imaging so this is an interesting case this is a minimum and test projection this is shown to show the importance of minimum intensity production on a black lesion which you are seeing the segment six of liver is nothing but a fat containing lesion that is a hepatic angiomyol lipoma which is again the same the case is of tuberous sclerosis you can see a large kidney and large kidney right side it is post nephrectomy status again there is a ruptured angioma lipoma on left left side you can see a enlarged kidney showing a lot of ams so this was a tuberous pleurosis case with a hepatic angiomyolipoma so if you decrease the attenuation you will be able to appreciate the in the minimum intensity projection you can appreciate the fat containing lesions better so otherwise you would have got it confused with a normal sister something like that next is again a volume rendered image here to assess the segment of stenosis this is a case of butchery syndrome where your caudately lobe is enlarged and you are you are seeing a clear stenosis of the ivc joining the uh supra hepatic portion of ivc so this was a case of virtually syndrome here volume rendered images are depicting the photovenous collaterals and you are able to see the enlarged cardiac and you are able to exactly assess the stenosis percentage axial and coronal images may not give you the exact detail first image you can see the stenosis pinpoint which is very important again some signs in mdct for example photovenous thrombosis is where one of the important sign which you can think about a malignancy whenever is the tumor thrombus enhancing like in the second image is in central area you can see a tumor thrombus enhancing within the portal vein so this is one of the clear indication that you are dealing with a malignant lesion again whenever there is a thrombosis you can see lot of collateral surrounding it this is because of altered circulation capsular retraction see this is one sign assessing which is very important capsular retraction if you are seeing a case of capsular retraction most of the time you are seeing a case of a malignancy uh it can be seen rarely in a sclerosis or something like that most of the time are in case of a congenital abnormality or a serotic abnormality called focal convenient fibrosis otherwise most of the conditions in a non-enhancing lesion causing capsular retraction unless otherwise proven is a cholangiocarcinoma rarely it can be called metastasis from adenocarcinoma or a hepatocellular carcinoma so you can see the capsule being retracted here whenever you see a lesion in the liver and there is some amount of heterogeneity around it so if this was a presumed cyst in the segment six of liver however if you see surrounding the this there is some amount of third leg enhancement that is transient hepatic attenuation different like enhancement that means it is not definitely not a simple cyst it is complexist there may be a metastasis associated so you should always look at subtle certain if if it was a simple cyst you wouldn't have seen some third next to it so in such information signs you should always think about some a collingenic abscess or a metastasis if you see such signs this is a case of class skin's tumor where you can see ihbrd intra-hepatic biliary radical dilatation and also a metastasis in segment 8 of liver so ihbrd was a clear sign of a malignant disease so whenever you see a ihbrd unless until if it is extrinsic compression you should always think about a malignant disease like hylar cholangiocarcinoma so this is a simple system you can see the surrounding what i am trying to emphasize is i have organized the images in such a way that first image is the plain image followed by a plain image it is an artillery image then a photo in this image and a delayed image so this is a classical simple system hardly there is any enhancement and you can if you have any doubt don't hesitate to perform a usg so usg will differentiate hemangiomas from small cystic lesions very easily sometimes usg is very useful in diagnosing simple cysts from metastasis also so this is a rare case which i encountered isolated polycystic liver disease so when normally smalls is whenever you see these are one main complexes or a biliary system when whenever using a cis in liver associated with polycystic kidney disease it is again a adult polycystic level this is associated with adpd but you can also get really a dreadful condition called polycystic liver disease which is isolated and it progresses so rapidly patient may require a liver transplant if diagnosed with this condition so this is an isolated adult polycystic liver disease not associated with kidney disease so this is a snippet from a diagnostic imaging you can see this is how the liver appears in a adult polycystic kidney disease and again coming about some more cystic lesions this is a classical necklace pattern hydrates this normally hydrated cysts will not show enhancement but however if i did the etiology is from echinococcus multilocularis you can definitely see some amount of enhancement so this is a classified calcified hydrated system you can seriously see how beautiful the renderings are you can appreciate the images the shell of the hydrated so this gives a confidence to the surgeon who is operating because i highlighted is a simple diagnosis for radiologists but uh surgeon will be really worried whether i'll destroy any biliary radicals or maybe porto in a system whenever you are operating it so if you can tell him and assure himself this is a calcified hydrated system these are the relations with the this is the venous anatomy and this is how it is uh appearing once you open it you see a capsular projection so you'll be really happy to know the information from you and he'll go to the surgical theater with lot of confidence that what he is going to deal reporting simply that the side edited scene in so-and-so segment will not help the radiology has to go beyond what we are seeing now we need to take an active part and we need to think about as sajin who's operating it so whenever the in cect system enhancement and septations announcement can be seen in case of econo caucus granulosus however if this hydrated cyst is from multi-locularis echinococcus multilocularis you will see a minimal enhancement of any non-calcified portion so these are the differential diagnosis for multihepad along with the whatever cystic cleanse i've seen you should always think about carolyn disease where you can also see a dot sign which is and sometimes very commonly recently one of my colleague has aspirated cystic metastasis thinking that it's an abscess that is a very common mistake necrotic metastasis look like abscess so you should have a thorough checkup you need to see all the patterns in such cases mr will help we will get a typical halo sign in the liver whenever there is a hepatic metastasis so this i already described these are the treated metastasis which exactly mimic like cystic lesions so coming to a commoner lesion which is liver abscess liver abscess it's no enhancement will be seen an arterial phase at all except there will be peripheral transient hepatic attenuation difference and the capsule may show an enhancement that is nothing but a compressed parent time of the liver however you may see a satellite-like appearance whenever it is a case of pyogenic abscess you will not see even in amoebic capsules you will not you will not be appreciating such things however if it is a case of amoebic qualities you should always look for the ascending colon descending colon cecum and look for the fat standing associated with it and uh you should take an active part in putting pigtails and draining by yourself so this is again a beautiful volume rendered image of the hepatic abscess to see the volume destruction so that such images may you may think they are like not very useful but if you can convey images through color to the consultant you always appreciate the radiology better than the 2d ampere images so this is a typical sign described for a biogenic abscess you get a satellite like pockets which ultimately coils to become a bigger abscess a very rare case i encountered like uh in my practice and i've saved it like you can see a small lesion in the segment four of liver which is not showing any enhancement hepatic tuberculosis is an extremely rare diagnosis unless until it is associated with a miliary tv in our case it was not an uh malaria tb lungs were clear and the liver spleen was not showing any lesions and we have biopsied this lesion and it turned out to be hepatic tuberculosis we always think one twice before giving such a rare diagnosis what i take home from you is it is a non-enhancing lesion it mimics a metastasis be careful okay and the common very very common day in and day out some lesions in bone are do not touch some lesions in liver are do not touch if you see such a classical enhancement pattern you should give an assurance even in a case of carcinoma saying that i am 100 sure about what i am dealing with do not biopsy it or do not fna it so whenever you see a centripetal puddling enhancement so this is nothing but a giant uh this is a hemangioma with a large blood filled caverns so when so automatically the immediately the artery delivers the blood blood to the periphery followed by it the caverns individually and gradually fill so that is why you get a classical centripetal enhancement in case of hemangiomas so beautifully the maximum intensity projection image showing the arterial supply to the hemangioma and a beautiful understanding of the puddling enhancement sometimes a giant hemangioma will be confusing you rs cleros hemangioma or a flash hemangioma there are four types as early there are many types but degenerations occur calcified imaging and all most important are flash hymenoma which will become arterial immediate enhancement not showing any because it's too small the cavern is too small it won't show puddling enhancement immediately it feels fla in a flash ah that may lead to some diagnostic confusion however what is important is in subsequent photovenous phase you will not show any it will not show any washout it will retain its contrast and it becomes maybe isotension liver or it will retain some contrast so that is a clinching point so yeah and not to worry if it is an arterial enhancing lesion we should be worried when it is a porto venous washout lesion take home please take home this point we should always worry for a lesion which is washing out on photovenous face rather than a lesion which is enhancing an article phase why all these things we exploit the dual liver blood supply means the liver has dual blood supply a hepatic arterial enhancement and a photo venous enhancement the first thing to lose in a malignancy case is a photo in a supply and uh art so whenever there is photovenous lack of a washout you should always think about a malignant lesion so this is a case of joint hemangioma it will look so heterogeneous and it looks so uh confusing so only only thing is you need to approach arterial photo winners and delayed phases so what will happen it will generally fill slowly a giant hemangioma sometimes take more than 30 minutes to fill normally a delayed phase is taken at 180 seconds uh so but in case when you are dealing with a centripetal feeling lesion you always think of doing a scan which is very very delayed so always these are the differential diagonals for multiple hypervascular lesions you can get hypervascular hcc then you can get rd reporter venus shunts in cirrhosis coming to a spectrum in serotonin lesions in serotic liver you get following lesions the first lesion i would like to emphasize is nodular regenerative hyperplasia nodular 2 hyperplasia is hyper dense and plane these are the sum of the lesions other than a calcified lesion it is suppose that iron deposition will give a hypertension no the first image is the plain image you can see the hyperdense lesions scattered in a shrunken liver and you can also see raw societies so this is a classical case of nodular regenerative hyperplasia it will not show any washout on photovenous it will show enhancement it may show or may not show article enhancement however it will definitely not show wash out so classical mr will help further in a mr it is t2 hypo intense because of metal deposition and it is t1 hyperintense and it will may or may not show article enhancement however it will definitely not show washout so if you see certain pattern it is like math you have to write it down article enhancement you have to write put awareness announcement you have to write it down how it appears on plate definitely you you will see the difference in diagnosing the liver lesions and again this is a case of macro regenerative hyperplasia where you are seeing and enhancing lesions which are which are retaining their contrast even in photovenous phase they are not washing out so not it is not gone into the phase of malignancy so it is still uh no need to ovulate or treat such patients you have to conservatively manage them and another important lesion in a cerotic liver which which mimics a ah you get a lot of fibrosis and you get a focal confluent fibrosis in case of serotic levels so this is another case of regenerative hyperplasia coming to another benign lesion which is very fascinating it is an almost hamartoma so in plane you can see a iso dense lesion which is showing a central scar enhancement so scar containing lesions commonly are three focal modular hyperplasia fibromyal or carcinoma and also you will see hcc sometimes with necrosis in central area you can see a scar how will you differentiate any scar only scar which confidently enhances in arterial phase is f scar so that is what will happen is the central scar in fnh is a pedicle through which the blood goes out so doppler image i am trying to show you the central scar is the stem of the fnh from which the entire raffinate gets the blood supply uh yeah this is that is called spoke wheel pattern of enhancement uh you can see you can appreciate in the third image you can see natural phase the central enhancement of the arteries in a case of fnh so it is isotope hypoechoic and usg and showing spoke will pattern of enhancement [Music] so this i already have discussed this hepatic angiomyelocoma this is an interesting case of focal confluent fibrosis because there is a lot of fibrosis happening in cirrhosis there will be volume loss and that volume loss will mimic a cholangiocarcinoma so you have to be careful and assess the enhancement patterns so that you can this is again a do not touch lesion so if it is seen in the capsular surface and if you are not seeing any heterogeneous enhancement in the rest of the liver parenchyma you can leave it alone and you can follow it up so this is a rare case of focal confluent fibrosis so classically we uh liver lesions one image as hemangioma is very common after metastasis the most common neoplasm is hepatocellular carcinoma especially in cases of hbv in patients with background cirrhosis we should always suspect hepatocellular carcinoma and you all have to read about lyrics in detail uh so you can classify further and help uh clinicians uh so lyrics is about this topic level so i'm not going into lyrics so here what i'm trying to tell you is in plane you're seeing an iso2 hypodense lesion there is literally an imaging it's very difficult to appreciate serotonin background however there is a clinch point here you can see corkscrew vessel pattern here in the second image so whenever you see a torch with corkscrew pattern of vessels you are most probably dealing with a early serotic lever don't hesitate to do an usb there will be capsular enhancement there will be capsular enhancement in case of cirrhosis and in photovenous there will be washout so these are the classical features an arterial enhancement in a background serotic lever with a photovenous washout photovenous washout is described in relation to the adjacent parenchyma whenever the adjacent parenchyma is brightly enhancing and the lesion is not showing or showing decreased enhancement it is called porto venus washout so you can also see capsular enhancement in delayed phase so this is a classical hcc so this is a classical hcc receiving article supply from hepatic artery giving a hepatic artery uh detailed anatomy is useful our variant anatomy is useful for hepatic artery and embolization so this is how you do volume rendered images to help the embolization so this is the post embolization this patient has developed a carcinoma next to the uh the amboloist portion and post embolization the lipidal is accumulated in the liver so the first image you are able to see the layered pattern and accumulation of lipidal solution so this is the embolizing agent which has been given and the lesion got treated however the patient developed a recurrence next to it so sometimes a smaller hccs will not follow the pattern of enhancement sometimes they may confuse in such cases afp levels will help you and in a rare and doubtful cases you have to do a biopsy here in this case there are hardly any arterial enhancement however there is washout however there is capsular enhancement so still in a serotic background a lesion showing washout if afp levels are elevated you should always think about a hepatocellular carcinoma again one more atypical enhancement because of uh photovenous uh thrombosis photovenous thrombosis you're you're seeing a classical uh with photovenous thrombosis again coming to another malignant disease what in the left lobe you are able to see near the hilum uh there is a lesion which is showing a capsular retraction and there is decreased enhancement compared to hcc which is an arterial enhancing lesion collagen carcinoma has serious deposition so that is why the lesions are hypodense the lesions which are they show decreased enhancement so this is a classical cholangiocarcinoma in the center of the lesion in the at the hilum this is a class skins tumor you are able to see an enhancing lesion at the high lump and which is causing ihvrd you can also appreciate the metastasis so this is a hypervascular metastasis from a duodenal carcinoma the carcinoid the fourth image you can see a duodenal carcinoid and a hypervascular enhancement so this is a hypervascular metastasis from a duodenal carcinoid so intense enhancement and retention of the contrast multiplicity of the lesion and a tumor so are the clinching points in diagnosing a hypervascular metastasis so this is a case of hemangioendothelioma rare case where you can see arterial enhancement and in podium venus there is centripetal washout sometimes rare diagnosis is called hepatocellular angiosarcoma you can diagnose such conditions commonly commonest pediatric neoplasm is hepatoblastoma so you have to always see for in children you can also see hepatic and hemangio endothelium where you can see decreased caliber of the iota whenever you see a habitoblastoma you have to see for decrease because the blood supply is so much to the liver it will consume all the blood supply and leading to quantization like phenomenon and below the renal arteries the iota will be of decreased caliber so this is again a rare case of hepatic lymphoma it was hypotense in all the sequences you may think it is a necrosis however you can see in a ultrasound correlated image it was showing a solid appearance and there was some amount of central vascularity such diagnosis only happen with post biopsy so we have we have given a solid lesion which is enhancing and we have concluded it and it turned out to be hepatic lymphoma so again one more take home point what i would like to see don't hesitate to do it i have an ac this was a small lesion which was appearing like a cyst on a liver imaging however whenever in the last image ultrasound image i am showing you the typical target pattern you could appreciate only an usd and we have biopsied this small uh fna we have done an fnac of a 7mm lesion and it turned out to be a metastasis so again focal fat sparing is one real difficulty we will be challenged facing in cases of a malignancy focal fat spearing can be easily diagnosed on usg it's a hyperechoic lesion however in cases when you have doubt we can do performing in phase out of phase imaging to confidently diagnose that again using a tissue harmonic imaging whenever you are performing a sonography will help for characterizing a simple cyst from a complexes so the right side image the left side image is tissue harmonics tha where you can see a septa and you can hardly appreciate the septa whenever you are using this normal performing a normal usg so the crispierness of the septa can be seen better with the tissue harmonic imaging these are helpful in diagnosing liver lesions okay then uh by understanding background liver is also important sometimes you may say uh lesions we on the background lemur liver so this is a case of amidon tax toxicity where the generalized hyperintensity in hemocitrosis with multiple transfusions you get spleen will be hypertense and also the liver will be hyperdense so so this is the end of the first part let me go to the second part okay that was an amino toxicity and as i said lesions containing scar are fnh fibular lamellar carcinoma you get in sometimes in hcc atypical hcc you can get in was a case of sclerosis with a refibular lamellar carcinoma with a central scar okay so always is hypodense lesion causing in the center causing ihbrd think about a cholangiocarcinoma so this was a case of cholangiocarcinoma so you can appreciate the hbr you can appreciate the lesion which is hypodense not enhancing in this case there was capsular retraction not was not there so this is a case of liver lesion with the amoebic qualities so so hypotenuse lesion you can appreciate here so this is a case of liver liver lesion uh just few more slides about liver mri are like few cases i would like to discuss and we can stop the because i've shown so many cases so this is a case of amoebic labor uh absence and qualities so this is again an interesting case from my collection uh so here you can see it looks like a lesions multiple lesions in the liver however this is a classical case of hepatic cystosomiasis which is a typical tuttle back sign so it looks like a turtle back and it is called hepatic cystosomiasis uh coming to liver mri so mdct does the most of the job like you can definitely diagnose liver lesions confidently with mdct but an advantage is speed speed of performing the study uh if you're uh diagnosing a liver lesion in a morbid patient who has ascites cirrhosis and all today till date again i suggest you to go and to diagnose through the mdct however if you're dealing with a lesion the patient is very very cooperative you you have an advantages you have certain advantages to diagnose certain lesions confidently and liver mri the first thing is what i would like to emphasize is that you can you have additional tools like diffusion mri in phase out of phase mri you have heptos specific contrast agents uh so such things will add and it becomes easy to diagnose liver lesions confidently and mri here let us see this case this is a borrowed case of uh i do have so many hypothetic status cases but this was more a classical example so that is why i picked it so what will happen is you you may sometimes have difficulty in diagnosing a hepatic steatosis in ct because it mimics like any other lesion [Music] hepatic steatosis is a lesion in in phase imaging hepatic sterosis will be hypo uh hyperintense followed in a out of phase imaging the hepatic steroids will disappear completely again the usefulness of liver diffusion so whenever you are dealing with a case of metastasis you are a lesion like hemangioma you can definitely look for a classical diffusion mri diffusion mris are performed with three b values and you can confidently [Music] you can confidently diagnose liver metastasis through diffusion mri last interesting concept and i have to i do have some cases to show you but interesting concept is heptocellular contrast agents until now in mdct what i have shown you is uh the enhancement patterns are all similar to the enhancement given through the regular gadolinium it's like omniscan or whatever regular uh mri contrast agents you use the typical mdct patterns and mr enhancement patterns will be the same however we do have these are the extracellular contrast agents whatever you do even ct will exploit the same principle so we do have other contrast specific agents like we have a magnum fourier trisodium which has to be given as a deep infusion which will be excreted through the real radicals and you will have delayed biliary radical dependent enhancement uh but that is cumbersome so that is gone now nobody is using magnetophobia trisodium so what do we have is like right now gudolinium bopta and we do have a eos so uh so which is again called as multi-hands so uh both so in in india we don't have eos we are not able to use because it's extremely costly so but in western world they are obsessed with eovis when i did my fellowship i was seeing for every case of suspected metapstasis in a liver they used to give a used contrast and they used to perform a 30 minute blade scan so i have some examples i will be showing it so what will happen is when a 30 minute scan if the background liver enhances the lesions which are not native to the liver will definitely show decreased enhancement so that is uh that is one phenomenon and the second thing is the lesions which don't have hepatocytes for example because of dysplasia heptacellular carcinoma will not have hepatocytes so that will show decreased enhancement so that is again a interesting phenomenon which is very exploited in people so let us see this interesting case here it is it is basically done with an extracellular agent uh in t2 the c2 fatsat image due to fat site lesion the lesion is hypo intense and in diffusion it is hardly showing any restriction and it is hyper intense on t1 coming to the arterial phase the lesion is showing enhancement and in photovenous and delayed phases the lesion is retaining its contrast so in a cirrhotic bank there is a cerosis there is shrunken in size and there is a splenomegaly so this is a classical case of nodular regenerative hyperplasia so these are the various phases it is not showing washout coming to this plastic nodules here this is a uh yeah let me show you the plane first so the background lever is slightly hyper dense and you are seeing lot of nodular echo texture and the spleen is definitely hypo intense and uh so one or two lesions again are hyperintense on plane itself now t1 based image the lesion is hyperintense so that means there is some associated nodular regeneration also in arterial phase you can see there are lesions enhancing in second image and the first image you are seeing there are enhancing lesions in photo venus again there most of them are most of them are showing washout so but what is important what i would like to emphasize is the lesions which are enhancing or not showing washout so whenever you see arterial enhancement auto venous washout delayed capsular enhancement in a two centimeter size lesion are greater than 1.5 side lesion you are dealing with a hepatocellular carcinoma but if you have something minus when you have no arterial enhancement are you when you have no put awareness wash out and when you when the lysine is too small and if it show its hyperintense on plane study definitely it is either a nodular lesion nodular regenerative hyperplasia or it is plastic nodule rather than a early hepatocellular customer this is one take home point i would like to emphasize so in background cirrhosis you should be able to confidently diagnose this plastic nodules and what i was telling about this fascinating thing is the eo is for metastasis uh look at this case in in the last image is t2 where the the mass is hyperintense and the first two coronals are t1 based where the lesion is hypotenuse in contrast the lesion was not showing enhancement so now whether the lesion contains biliary lesion or not whether is it a case of collagen carcinoma so a collagen carcinoma can have some residual biliary lesion so some subtle enhancement you can have it but however and the lesion is also showing capsular retraction now you are stuck whether it's a collingo carcinoma or is it a metastasis so when you perform an eovist scan that means when you are looking at the biliary radical excretion the lesion [Music] the lesion is showing no enhancement at all in a delayed most can see the arteries are literally gone however you are seeing the background level is enhancing like anything and the lesion is very dark it is not showing enhancement enhancement at all so this is a case of collagen carcinoma again and another interesting case in haste sequence you are seeing the uh lesion in segment six so see this case uh interesting test and diffusion weighted there is hardly any there is subtle diffusion restriction uh you are seeing an arterial phase the lesion is enhancing in this case the afp levels were very low eff levels were not high in photovenus the lesion is showing washout so article enhancing lesion showing photovenous washout one thing is for sure we are dealing with a malignant lesion so let us characterize af levels are low low so here you are seeing a lesion definitely not showing any scar enhancement in delayed scans so this is a and the eos scan you can see the kidney excreting the contrast so in delete most scans the lesion is hypotense that means it doesn't contain any biliary radicals so that means it is definitely a malignant lesion because of lower fp levels because of classical enhancement pattern so this is a case of fibrolamellar carcinoma so another case of fibrolamellar carcinoma but this doesn't have an eos scan so it is so confusing uh it is showing so much of heterogeneity and scar wasn't present in this case so it is showing article enhancement and retaining contrast so the sensitivity of mdct in diagnosing labor legions is approximately somewhere between 84 percent and if it goes like you can reach up to 92 percent in by uh sensitivity specificity reaches up to 92 percent by doing a liver mri with all the associated contrast agents uh maybe exploiting the diffusion weighted imaging exploiting the in phase out of imaging uh exploiting uh specific contrast regions it will all help sometimes you can also perform cover cells imaging by injecting the super paramagnetic contrast agents so such things are yet to come we have to explore and uh it is important to train all of uh the people so that we can confidently uh diagnose it so again an mri you can see this arterial phase the lesion huge lesion which is showing centripetal enhancement in arterial phase so this is a classical uh gene hemangioma you can appreciate is hypo why because it is fibrous tissue here it is a vascular particle that is the difference and you can also appreciate delayed scar enhancement in focal modular hyperplasia but not in fiber lamellar carcinoma so and a last image this is a textbook image picked up and you can see there will be uh in because fnh has some amount of live alive biliary radicals and hepatocytes it will show enhancement or retention of contrast you remember the previous case in fibromyalgia there were no uh proper hepatocytes that is why it was not retaining any contrast however in here you are able to see uh uh so that is how you differentiate benign versus malignant so fnh if you can conveniently diagnose this again it do not touch lesion so looking at enhancement patterns is very important and this is again a rare like very uh interesting case with their doneness like hardly you can't appreciate the lesions in the plane at all so it's impossible to diagnose but they have given a uv scan and they have scanned the liver entire level to a wipe 3d sequence or like anything so you can pick up a subtle metastasis uh by giving the eos scans so that is uh one fascinating thing maybe it will come up cheaper in india and we'll also be exploiting that sooner so this is uh uh again a textbook image showing a subtle small metastasis in a case of colorectal carcinoma thank you very much uh so i overview i need i touched so many lesions and i tried to emphasize on the typical enhancement patterns for each of you so that you can get in get those cases directly and follow it in your routine practice thank you dr judy thank you thank you sir no no that was okay [Music] thank you sir that was an excellent uh talk and uh i'm sure our consultants and our radio uh radio gpgs have got much out of fetzer so just a few questions uh just one of them is uh is ct diagnostic for hepatocellular carcinoma and non-serotic liver yes what they say is now the criteria is so important if you see a typical enhancement pattern like if you see arterial enhancement if you see photo venous wash out and if you have capsular enhancement and if you have raised afp levels no need to biopsy the lesion no need to biopsy the lesion at all you can directly treat it as hcc uh so whether it is cirrhotic or non-serotic it's okay if you have the typical enhancement pattern and raise the afp levels you can treat it as hcc however if you don't have raised icp levels and if it is a non-periodic liver then definitely you have to biopsy the lesion so very very very confidently we can diagnose hcc by uh by imaging our city however we need some markers like afp to confirm our diagnosis thank you sir uh do you have one of the images for biliary lesion other than collagen you know i don't don't have any collection you could have picked up from any uh sister dinomas or one mayor but complexes i don't have any collection so i tried to show maximum from my own collection so the lesions again follow the pattern they say that uh you can differentiate biliary system from a typical complex system but it really is very difficult from practical point of view we have to we we will give it as a complexes unless until when we biopsy it and the epithelium shows some other epithelium rather than the regular issue then we have today okay there's one more uh uh focal facts pairing i'm sure you've mentioned it before sir but uh just for the sake of our viewer a focal fat sparing and fatty liver how to defer it so again uh it may look a simple question but it is such a challenging question when you have a case carcinoma stomach and you have a liver lesion next to the false form ligament and the lesion is plane in plane if it is showing some attenuation lower than the rest of the liver parenchyma have a tick you do multimodality imaging whenever you are in doubt with a focal fat sparing first you have to start with ultrasound the lesion is hyper aquatic or not if the lesion is hyperequating thick it is going towards focal level fat is very next whether in plain city the lesion is high potential or not thick it is going through its focal fat spearing next is in phase out of phase imaging you have to do in phase out of phasemen in phase it will be hyper and in outer phase again it in phase out of his sparing in in sparing you'll look it as hyper hyper so that that is how you have to differentiate both one last question also i'll take uh best face in triple phase ct to see hepatic veins in a suspected case of butchery syndrome hepatic means i would like to suggest a venous phase somewhere between 120 seconds so it takes time from portal veins [Music] in between delayed for a focal lesions you take it around 180 seconds so hepatic venus should be timed in between uh delayed and the photovenous so that you get a beautiful hepatic vein somewhere between 80 to 10 seconds will be ideal from my practical point of view so and one last question hcc versus hepatic adenoma uh how would you how would you it's it's differentiate impossible i have i have i have given another two cases i has hcc and they turned out to be hepatic adenomas uh it is because they follow the similar pattern however if a patient is young with oc pills if the patient has the lesion has uh some fat again hcc can show fat but more frequently hepatic adenomas show and again hemorrhage uh hepatic anomalies are more frequently hemorrhage than his thesis you can write it down here and there but ultimately i will put a hcc as a diagnosis rather than hepatic adenoma given it is really challenging and difficult to diagnose both i understand sir thank you sir i think that's about it uh yeah thank you very much sir um so whenever there is [Music] there will be hyperinflation out of phase opposed phase they will be deep so that is how you have to differentiate so that that is how you have to differentiate so it is interesting you need to approach everybody uh it's good that i have ignited so many questions and people have understood what i've told most of it again thank you very much for the opportunity i'm happy to take more questions if any other no i think that's about it sir thank you so much uh sir for your extensive knowledge


Join Dr. Umamaheswara Reddy V. for an insightful session organized by 'IRIA, Kerala' on 'Approach to Focal Liver Lesions' where he will guide us on some really interesting concepts and hacks to capture some focal lesions.


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