Differential Diagnosis of Non Segmental Consolidations 2161 105X.S8 001

Hypervascular Hepatic Lesions: Spectrum of Clinico-
Radiological Features and Differential Diagnosis
Poster No.: C-0874

Congress: ECR 2013
Type: Educational Exhibit
Authors: R. Taiji, N. Marugami, J. Takahama, A. Marugami, T. Akashi, T.
Taoka, K. Kichikawa; Kashihara/JP
Keywords: Neoplasia, Education, Ultrasound, MR, CT, Liver, Abdomen
DOI: 10.1594/ecr2013/C-0874
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Learning objectives
1. To review the current imaging techniques of contrast enhanced-US/CT/MRI

and mechanisms of liver specific contrast agents
2. To illustrate the spectrum of clinic-radiological features of hypervascular
hepatic lesions
3. To discuss the clinico-radiological key findings in differential diagnosis
Background
Hypervasular hepatic lesions include both benign and malignant etiologies. In spite
of development of multimodality imaging or liver specific contrast agents, the
characterization of hepatic lesions often presents a diagnostic challenge to diagnostic
radiologists.
Imaging findings OR Procedure details
1 Multimodality Imaging
Current multimodality techniques of contrast enhanced-imagings using US, CT and MRI.

Mechanism of action of liver specific contrast agents ( Sonazoid, Gd-EOB-DTPA and
SPIO ) compared with extracellular contrast agent.
• Contrast enhanced Ultrasound (US)
Contrast media: Sonazoid
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Fig. 1: Ultrasound contrast media; Sonazoid
References: - Kashihara/JP
Page 3 of 36
Fig. 2: Sonazoid-enhanced US
• Contrast enhanced CT (DCE-CT)
Contrast media: Iodine
• Dynamic contrast enhance MR (DCE-MRI)
Contrast media: Gadolinium (Gd), SPIO, Gd-EOB DTPA (EOB)
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Fig. 3: Gd-DTPA vs. SPIO vs. Gd-EOB-DTPA
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Fig. 4: Distribution of contrast media
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Fig. 5
Page 7 of 36
Fig. 6: SPIO-enhanced MR imaging
Page 8 of 36
Fig. 7: EOB-enhanced MR imaging
2, Hypervascular hepatic lesions
Common
• Hepatocellular carcinoma (HCC), Hemangioma, Focal nodular hyperplasia

(FNH), hepatic adenoma, hepatic metastasis, pseudo lesion (A-P shunt)
Uncommon
• Hepatic angiomyolipoma (HAML), Intrahepatic cholangiocellular carcinoma

(ICC), dysplastic nodule, Inflammatory pseudotumor (IPT), Pseudolymphoma
3, Case presentations
Hepatocellular carcinoma
Page 9 of 36
• Clinical Features
• • Cirrhotic liver (Alcoholism, Viral infection, NASH)
• Increased tumor marker (AFP, PIVKA-II)
• Radiological clues
• • Mosaic pattern
• Hyper- on arterial phase and hypo- on late phase (washout)
• Capsule rim
• EOB uptake (2.5-8.5%)
Fig. 8: Hepatocellular carcinoma

Page 10 of 36
Fig. 9: Hepatocellular carcinoma: Sonazoid-enhanced US
Page 11 of 36
Fig. 10: Hepatocellular carcinoma: Dynamic CT
Page 12 of 36
Fig. 11: Hepatocellular carcinoma: EOB-MRI
Page 13 of 36
Fig. 12: Hepatocellular carcinoma: EOB-MRI
Hepatic cavernous hemangioma
• Clinical features
• • Normal liver
• • Wax and wane sign (chameleon sign)
• Centripetal filling , Flash filling
• Isodence (isointense) to blood vessels
• Hiperintense on T2WI similar to CSF
• Positive enahncement on SPIO-T1WI
Page 14 of 36
Fig. 13: Hepatic hemangioma: US
Page 15 of 36
Fig. 14: Hepatic hemangigoma: Dynamic CT
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Fig. 15: Hepatic hemangioma: Dynamic CT
Page 17 of 36
Fig. 16: Hepatic hemangioma: SPIO-MRI
Focal Nodular Hyperplasia
• Clinical Features
• • Normal liver
• rd th
3 -4 decades
• • Central scar
• Homogenous enhancement at arterial phase
• lack of corona enhancement
• SPIO. EOB uptake
• Draining to hepatic vein
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Fig. 17: Focal nodular hyperplasia: Dynamic CT
Page 19 of 36
Fig. 18: Focal nodular hyperplasia: SPIO-MRI
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Fig. 19: Focal nodular hyperplasia: SPIO-MRI
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Fig. 20: Focal nodular hyperplasia: Dynamic CT
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Fig. 21: Focal nodular hyperplasia: Angiography
Page 23 of 36
Fig. 22: Focal nodular hyperplasia: Single lebel CT hepatic angiography
Page 24 of 36
Fig. 23: Focal nodular hyperplasia: EOB-MRI
Hepatic metastases
Past history of malignancy
Elevated tumor marker
Difficulty in differentiation between mets and HCC
• Hyper vascular metastases from
Renal cell carcinoma
Page 25 of 36
Breast cancer
Pancreatic neuroendocrine tumor
Thyroid cancer
Malignant melanoma
Sarcoma
Carcinoid
Gastric cancer et al
Fig. 24: Hepatic metastases from RCC: Dynamic CT

Page 26 of 36
Fig. 25: Hepatic metastases from PNET: Dynamic CT
Page 27 of 36
Fig. 26: Hepatic metastases from gastric cancer: Dynamic CT
Hepatic pseudolesion
• Hypervascular peudolesion
A-P shunt
Third flow
Gall bladder vein
Aberrant right gastric vein
Aberrant left gastric vein
Para umbilical vein / sappey's vein
Inflammation
Page 28 of 36
Portal vein occlusion
Liver cirrhosisCompression from rib bone
Asymptomatic
Isodence / isointense
Wedge shape enhancement
Specific lesions
EOB/SPIO uptake
Fig. 27: A-P shunt: EOB-MRI
Page 29 of 36
Cholangiocellular carcinoma
Abdominal pain
Elevated tumor marker#CEA, CA19-9#
Lobulated margin
Substantial delayed enhancement at CT/ Gd-MRI
(mimicking metastases)
Bile duct dilatation
Early wash out at SPIO-MRI / Sonazoid-US
Page 30 of 36
Fig. 28: Cholangiocellular carcinoma: Dynamic CT
Hepatic angiomyolipoma (HAML)
Asymptomatic
Fat tissue
Homogenous enhancement (minimal fat)
Draining to hepatic vein
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Fig. 29: Hepatic angiomyolipoma; EOB-MRI
Page 32 of 36
Fig. 30: Hepatic angiomyolipoma: Dynamic CT
Miscellaneous
Page 33 of 36
Fig. 31: Inflammatory pseudotumor: Dynamic CT
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Fig. 32: Pseudolymphoma: EOB-MRI
Conclusion
Radiologists should be familiar with current multimodality and liver specific contrast agent.
Some clinico-radiological key findings may allow diagnostic radiologists to lead to correct
diagnosis.
References
• Michael P. Federle, et al: Diagnostic imaging Abdomen
Page 35 of 36
• Chung YE, et al: Hepatocellular carcinoma variants: radiologic-pathologic
correlation. AJR Am J Roentgenol. 2009 Jul;193(1):W7-13.
• Jeong YY, et al: Hepatocellular carcinoma in the cirrhotic liver with helical
CT and MRI: imaging spectrum and pitfalls of cirrhosis-related nodules. AJR
Am J Roentgenol. 2005 Oct;185(4):1024-32.
• Kudo M: Diagnostic imaging of hepatocellular carcinoma: recent progress.
Oncology. 2011;81 Suppl 1:73-85. doi: 10.1159/000333265. Epub 2011 Dec
22.
• Chanyaputhipong J, et al: Gadoxetate Acid-Enhanced MR Imaging for HCC:
A Review for Clinicians. Int J Hepatol. 2011
• Arita J, et al: Usefulness of contrast-enhanced intraoperative ultrasound
using Sonazoid in patients with hepatocellular carcinoma. Ann Surg. 2011
Dec;254(6):992-9
• Lee JM, et al: Characterization of focal liver lesions with superparamagnetic
iron oxide-enhanced MR imaging: value of distributional phase T1-weighted
imaging. Korean J Radiol. 2003 Jan-Mar;4(1):9-18.
• Fowler KJ, et al: Magnetic resonance imaging of focal liver lesions:
approach to imaging diagnosis. Hepatology. 2011 Dec;54(6):2227-37.
• Silva AC, et al: MR imaging of hypervascular liver masses: a review of
current techniques. Radiographics. 2009 Mar-Apr;29(2):385-402.
• Kamura T, et al: Small hypervascular hepatocellular carcinoma versus
hypervascular pseudolesions: differential diagnosis on MRI. Abdom Imaging.
2002 May-Jun;27(3):315-24.
• Yoshimitsu K, et al: Unusual hemodynamics and pseudolesions of the
noncirrhotic liver at CT. Radiographics. 2001 Oct;21 Spec No:S81-96.
• Cai PQ, et al: Hepatic angiomyolipoma: CT and MR imaging findings with
clinical-pathologic comparison. Abdom Imaging. 2012 Sep 21.
• Högemann D, et al: Correlation of MRI and CT findings with histopathology
in hepatic angiomyolipoma. Eur Radiol. 2001;11(8):1389-95.
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Hypervascular Hepatic Lesions: Spectrum of Clinico-

Radiological Features and Differential Diagnosis

Poster No.: C-0874

1. To review the current imaging techniques of contrast enhanced-US/CT/MRI

Imaging findings OR Procedure details

Current multimodality techniques of contrast enhanced-imagings using US, CT and MRI.

• Contrast enhanced Ultrasound (US)

Contrast media: Sonazoid

• Contrast enhanced CT (DCE-CT)

Contrast media: Iodine

• Dynamic contrast enhance MR (DCE-MRI)

Contrast media: Gadolinium (Gd), SPIO, Gd-EOB DTPA (EOB)

2, Hypervascular hepatic lesions

• Hepatocellular carcinoma (HCC), Hemangioma, Focal nodular hyperplasia

• Hepatic angiomyolipoma (HAML), Intrahepatic cholangiocellular carcinoma

Fig. 8: Hepatocellular carcinoma

Hepatic cavernous hemangioma

Focal Nodular Hyperplasia

Past history of malignancy

Elevated tumor marker

Difficulty in differentiation between mets and HCC

• Hyper vascular metastases from

Renal cell carcinoma

Pancreatic neuroendocrine tumor

Fig. 24: Hepatic metastases from RCC: Dynamic CT

Gall bladder vein

Aberrant right gastric vein

Aberrant left gastric vein

Para umbilical vein / sappey's vein

Liver cirrhosisCompression from rib bone

Wedge shape enhancement

Fig. 27: A-P shunt: EOB-MRI

Elevated tumor marker#CEA, CA19-9#

Substantial delayed enhancement at CT/ Gd-MRI

Bile duct dilatation

Early wash out at SPIO-MRI / Sonazoid-US

Hepatic angiomyolipoma (HAML)

Homogenous enhancement (minimal fat)

Draining to hepatic vein

• Michael P. Federle, et al: Diagnostic imaging Abdomen

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