Shiny liver
Dr. Ahmed Refaey F R C R
Consultant RadiologistPrince Sultan Military Medical
City
Format of the lecture
• Detection of liver masses by CT• Hypervascular tumors of the liver• Case of the day
Detection of liver masses by CT
* Triphasic study * arterial phase * portal venous phase * equilibrium phase ( delayed phase )
• When we give IV contrast, it is important to understand that there is a dual blood supply to the liver.
• Normal parenchyma is supplied for 80% by PV & only for 20% by hepatic artery, so it will enhance in the portal venous phase.
• All liver tumors however get 100% of their blood supply from hepatic artery , so when they enhance it will be in arterial phase
• In the arterial phase hypervascular tumors will enhance via the hepatic artery , when normal liver parenchyma does not yet enhances , because contrast is not yet in the portal venous system.
• These hypervascular tumors will be visible as hyperdense lesions in a relatively hypodense liver
• In the portal venous phase hypovascular tumors are detected when the normal liver parenchyma enhances maximally.
• These hypovascular tumors will be visible as hypodense lesions in a relatively hyperdense liver.
• In the equilibrium phase at about 10 minutes after contrast injection , tumors become visible, that either :
- retain their contrast ( become relatively hyperdense to the normal liver )
- wash out their contrast faster than normal liver parenchyma ( become relatively hypodense to the normal liver ).
Hemangiomahcc
• Above: arterial phase showing hypervascular FNH
• Middle: portal venous phase showing hypovascular metastases
• Down: equilibrium phase showing relatively dense cholangiocarcinoma
Arterial phase imaging
Optimal timing
Hypervascular tumors will enhance optimally at 35 seconds after contrast injection (late arterial phase)
• A patient who underwent two phases of arterial imaging at 18 and 35 seconds .
• In the early arterial phase we nicely see the arteries , but we only see some irregular enhancement within the liver .
• In the late arterial phase, we can clearly identify multiple tumor masses.
Portal venous phase
• Portal venous phase imaging work on the opposite idea . We image the liver when it is loaded with contrast through the portal vein to detect hypovascular tumors.
• The best moment to start scanning is at about 75 sec.
• Hypovascular metastases seen as hypodense lesions in late portal venous phase
Liver metastases cancer colon
Equilibrium phase
• Starts when contrast is moving away from the liver and the liver starts to decrease in density .
• This phase begins at about 3-4 minutes after contrast injection and imaging is best done at 10 minutes after contrast injection.
• This phase can be valuable if you are looking for:
1- fast tumor washout in hypervascular tumors2- retention of contrast in blood pool like in
hemangioma3- retention of contrast in fibrous tissue in capsule
( HCC )or scar tissue ( cholangiocarcinoma or FNH )
• 1- fast tumor washout in hypervascular tumors like HCC
• 2- retention of contrast in the blood pool as in hemangioma
• 3- retention of contrast in fibrous tissue in capsule ( HCC ) or scar tissue (cholangiocarcinoma , FNH)
Hypervascular hepatic tumors
• 1ry• Benign• Hemangioma• Focal nodular hyperplasia• adenoma• Malignant • HCC• Fibrolamellar HCC
• 2ry• Hypervascular
metastasis• Primary hypervasculr tumours• Thyroid carcinoma• Choriocarcinoma• Renal cell carcinoma• Iselet cell tumors of pancreas• Malignant
pheochromocytoma• Malignant melanoma• Carcinoid tumor• 15% of cancer breast
Case of the day
• History :
A 40 year old male came with abdominal pain
• Technique
Triphasic contrast enhanced CT was performed for the chest, abdomen and pelvis.
Arterial phase
PV phase
Hypervascular hepatic tumors
• 1ry• Benign• Hemangioma• Focal nodular
hyperplasia• adenoma• Malignant • HCC
• 2ry• Hypervascular
metastasis
• Primary hypervasculr tumours
• Thyroid carcinoma• Choriocarcinoma• Renal cell carcinoma• Iselet cell tumors of pancreas• Malignant
pheochromocytoma• Malignant melanoma• Carcinoid tumor• 15% of cancer breast
• Primary hypervasculr tumours• Thyroid carcinoma• Choriocarcinoma• Renal cell carcinoma• Iselet cell tumors of pancreas• Malignant pheochromocytoma• Malignant melanoma• Carcinoid tumor• 15% of cancer breast
• Primary hypervasculr tumours
• Thyroid carcinoma• Choriocarcinoma• Renal cell carcinoma• Iselet cell tumors of
pancreas• Malignant
pheochromocytoma• Malignant melanoma• Carcinoid tumor• 15% of cancer breast
• Primary hypervasculr tumours• Thyroid carcinoma• Choriocarcinoma• Renal cell carcinoma• Iselet cell tumors of pancreas• Malignant pheochromocytoma• Malignant melanoma• Carcinoid tumor• 15% of cancer breast
• Primary hypervasculr tumours• Thyroid carcinoma• Choriocarcinoma• Renal cell carcinoma• Iselet cell tumors of pancreas• Malignant pheochromocytoma• Malignant melanoma• Carcinoid tumor• 15% of cancer breast
• Location of carcinoid tumor:
• Appendix …………………………. 45%• Small bowel ……………………… 35% - ilium ( 91%) .. Jejenum (7%)..
Duodenum ( 2%)• Rectum …………………………….. 10%• Colon ……………………………….. 5%• Stomach ………………………….. < 3%
• Diagnosis
Carcinoid tumor of the stomach with hypervascular metastasis to the liver
Carcinoid tumor
Carcinoid tumor
• Low-grade malignancy, resemble adenocarcinoma, but do not have their aggressive behaviour
• Clinical presentation:• Asyptomatic ( 66%)• Abdominal pain/intestinal obstruction ( 19%)• Nausea, weight loss (16%)• Palpable mass ( 14%)• Carcinoid syndrome ( 7%)
• Carcinoid syndrome:• Cause: excess serotonin level when the metabolic
pathway to 5-HIAA is bypassed (a) with extensive liver metastasis (b) with 1ry pulmonary/ovarian carcinoids• Recurrent diarrhea (70%)• Right sided endocardial fibroelastosis (35%), resulting
in tricuspid regurgitation and right heart failure• Desquamative skin lesions / pellagra /nausea
/vomiting /fever/cutaneous flushing ….. (5%)• Prognosis: carcinoid syndrome has a higher morbidity
and mortality than does the tumor itself
Thank you