Rachel Jimenez

Gillian Lieberman, MD
March 2008
Imaging Hepatocellular Carcinoma:
The Role of Radiology in Diagnosis & Treatment
Clinical Presentation
50 year old man with chronic Hepatitis C &
cirrhosis, awaiting transplant
What is the role of imaging in the pre-transplant patient?
Monitoring of a liver transplant candidate includes:
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Blood tests to determine liver & kidney function
EKG, Echocardiogram, & Cardiac stress test to assess heart function
Chest X-ray (CXR) and pulmonary function test to assess lung health
Abdominal ultrasound (US) to view the liver & evaluate vessel patency
Computed Tomography (CT) to assess liver size and anatomy
Magnetic Resonance Imaging (MRI) to evaluate for lesions
Ultrasound (US)
Best FIRST test in pre-transplant surveillance
High availability
Low cost
Non-invasive
High Specificity
Operator experience
Obese patients
Low sensitivity)
Limited differentiation of soft tissue
Advantages: Limitations:
Performed every 3-6 months to look for new lesions or
changes to vessel patency
Bialecki, E. & Di Bisceglie, HPB , 2005.
Our Patient: Screening Liver Ultrasound
Sagittal View
Isoechoic mass in Segment VIII
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Our Patient: Screening Liver Ultrasound
Transverse View
A hypoechoic rim is visible around the mass
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Our Patient: Screening Liver Ultrasound
Doppler
Portal vein & major vessels are patent
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Anatomy: Couinaud Classification
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Differential diagnosis:
M. M. Reeder and B Felson, Gamuts in Radiology, Springer-Verlag Telos, 3
rd
edition, 1993.
Benign:
Adenoma
Hemangioma
Hamartoma
Fatty Infiltration
Focal Nodular Hyperplasia
Regenerative nodular hyperplasia
Malignant:
Hepatocellular carcinoma
Hepatoblastoma
Hemangiosarcoma
Cholangiocarcinoma
Leiomyosarcoma
Hemangiopericytoma
Metastases
Solitary liver mass in US
Differential diagnosis:
M. M. Reeder and B Felson, Gamuts in Radiology, Springer-Verlag Telos, 3
rd
edition, 1993.
Benign:
Adenoma
Hemangioma
Hamartoma
Fatty Infiltration
Focal Nodular Hyperplasia
Regenerative nodular hyperplasia
Malignant:
Hepatocellular carcinoma
Hepatoblastoma
Hemangiosarcoma
Cholangiocarcinoma
Leiomyosarcoma
Hemangiopericytoma
Metastases
Solitary liver mass in US
Isoechoic
Differential diagnosis:
M. M. Reeder and B Felson, Gamuts in Radiology, Springer-Verlag Telos, 3
rd
edition, 1993.
Benign:
Adenoma
Hemangioma
Hamartoma
Fatty Infiltration
Focal Nodular Hyperplasia
Regenerative nodular hyperplasia
Malignant:
Hepatocellular carcinoma
Hepatoblastoma
Hemangiosarcoma
Cholangiocarcinoma
Leiomyosarcoma
Hemangiopericytoma
Metastases
Solitary liver mass in US
Isoechoic
Hypoechoic rim
Herbay, A., Frieling, T., Niederau, C., & Hussinger, D. (1997) AJR, 169(9): 1539.
Magnetic Resonance Imaging (MRI)
BEST test for evaluating abnormal ultrasound in patients
with known liver disease
Advantages: Limitations:
Useful in distinguishing benign from malignant masses
using T2 non-contrast & T1 phase-contrast sequences
High sensitivity (82-96)%
High resolution
Bialecki, E. & Di Bisceglie, HPB , 2005.
Expensive
Time Intensive
Patient Dependent
Our Patient: Liver Mass on T1 Abdominal MRI
A cirrhotic liver, enlarged spleen, and ascites
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Non-contrast T1
Our Patient: Liver Mass on T2 Abdominal MRI
Ill-defined round 5cm lesion with increased signal
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Non-contrast T2
Our Patient: 3 Phase Contrast Enhanced T1 MRI
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Portal Venous Phase Arterial Phase Delayed Phase
Lesion demonstrates enhancement during the arterial phase
and washout during the venous phase
Comparison Patient: Focal Nodular Hyperplasia on MRI
Non-contrast T2 Delayed phase T1
Contrast our patients MRI with this patients. MRI demonstrating
the typical appearance of FNH on C+ MRI
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Hyperintense Hypointense
Enhancement of stellate scar Enhancement of stellate scar
MRI Summary
* Pathology confirmed diagnosis of HCC
5 cm mass in segment VIII of liver
No lymphadenopathy or vessel involvement
Increased signal intensity during arterial phase
Decreased signal intensity during venous phase
No evidence of stellate scar
Patient history
Diagnosis: Hepatocellular Carcinoma*
Hepatocellular Carcinoma
Hepatocellular carcinoma (HCC) is a primary tumor of
hepatocytes that develops in the setting of chronic liver disease.
Hagop et al., MD Anderson Manual of Medical Oncology, 2006.
Median age group is 50-70 & predominates in men
HBV & HCV cause > 90% of HCC's worldwide
Patients with HCC usually have no physical symptoms
Common sites of metastasis include lung & bone
Median survival is 5% at 5 years
Staging of HCC
American Joint Committee on Cancer-TNM System
Stage TNM Scheme
I T1N0M0 Single tumor <2cm
II T2N0M0 >2cm or single tumor <2cm + vascular invasion
IIIA T3N0M0 Single tumor >5cm or >2cm + vascular invasion
IIIB T1-3N1M0 Positive Regional Lymph Node
IVA T4N0-1M0 Multiple tumors involving major vessels/multiple lobes
IVB T1-4N0-1M1 Remote Metastasis
Vauthey et al., J Clin Oncol, 2002.
Our Patient: Normal CXR
AP view of the thorax Left lateral view of the thorax
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The lungs are clear.
Our Patient: Normal RN Bone Scan
No evidence of MDP avid osseous metastases.
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Anterior
Posterior
Bone Scintigraphy: Technetium,
99
Tc
m
Staging of HCC
American Joint Committee on Cancer-TNM System
Stage TNM Scheme
I T1N0M0 Single tumor <2cm
II T2N0M0 >2cm or single tumor <2cm + vascular invasion
IIIA T3N0M0 Single tumor >5cm or >2cm + vascular invasion
IIIB T1-3N1M0 Positive Regional Lymph Node
IVA T4N0-1M0 Multiple tumors involving major vessels/multiple lobes
IVB T1-4N0-1M1 Remote Metastasis
Vauthey et al., J Clin Oncol, 2002.
Treatment
Liver transplantation 5 year survival 60-70%, limited to Stage I & II
HCC
Surgical resection 5 year survival 40-50%, limited to single, well-
demarcated, and anatomically accessible
lesions
Percutaneous destruction
e.g. Radiofrequency ablation
5 year survival ~40%, limited to lesions
measuring <3cm
Transcatheter Arterial
Chemoembolization (TACE)
OUR PATIENT
Modest survival benefit, Treatment of choice for
single intrahepatic lesions >5cm
Hagop et al., MD Anderson Manual of Medical Oncology, 2006.
Our Patient: Transcatheter Arterial Chemoembolization
A catheter is inserted into the hepatic artery via the femoral artery
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Our Patient: Transcatheter Arterial Chemoembolization
Contrast is injected to confirm proper placement of catheter
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Our Patient: Transcatheter Arterial Chemoembolization
Chemotherapy & embolic agents are mixed & injected together.
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Our Patient: CT Post-procedure Imaging
Used within 24 hours of procedure to assess for effective
delivery of chemotherapy to mass
successful chemoembolization of thehypervascular mass
Bialecki, E. & Di Bisceglie, HPB , 2005.
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Our Patient: CT at 3 Month Follow-up
BEST test for evaluation of known hepatic malignancy &
for detecting extra- hepatic metastases
Oliva & Saini, Cancer Imaging, 2004.
Interval decrease in mass sizeno new liver lesions.
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Summary
Ultrasound - Assessing for lesion & vessel patency
Magnetic resonance imaging - Characterizing known
lesion
Nuclear Scintigraphy/Plain Film - Tumor staging
Hepatic Angiography - Visualization for interventional
therapy
Computed tomography (CT) - Evaluation of tumor
progression post-therapy
Radiology vital in the medical management, diagnosis, &
therapy of Hepatocellular Carcinoma
Acknowledgments
Gillian Lieberman, MD
Maria Levantakis
Andrew Hines-Peralta, MD
Diana Ferris, MD
Alice Lee, MD
References
M. M. Reeder and B Felson, Gamuts in Radiology, 3
rd
edition, Springer-Verlag Telos, 1993.
Bialecki, E. & Di Bisceglie, A. Diagnosis of hepatocellular carcinoma. HPB (Oxford). 2005; 7(1): 2634.
Bruix J, Sherman M, Lloret JM, Beaugrand M, Lencioni R, Burroughs AK, et al. Clinical management of
hepatocellular carcinoma. Conclusions of the Barcelona-2000 EASL conference. European
Association for the Study of the Liver. J Hepatol. 2001;35:421
Hagop M. Kantarjian, Robert A. Wolff, Charles A. Koller (Eds.) The MD Anderson Manual of Medical
Oncology. Chapter 15, Pancreatic Cancer and Hepatobiliary Malignancies. New York, McGraw-
Hill, 2006.
Herbay, A., Frieling, T., Niederau, C., & Hussinger, D. (1997) Solitary Hepatic Lesions with a
Hypoechoic Rim: Value of Color Doppler Sonography. AJR, 169(9): 1539.
Maria Raquel Oliva, M. & Saini, S. Liver cancer imaging: role of CT, MRI, US and PET. Cancer Imaging.
2004; 4. S42-S46.
M. M. Reeder and B Felson, Gamuts in Radiology, 3
rd
edition, Springer-Verlag Telos, 1993.
Vauthey JN, Lauwers GY, Esnaola NF. Simplified staging for hepatocellular carcinoma. J Clin Oncol
2002;20:15271536.
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