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