TOPIC OUTLINES
• What is it?
• Where is it?
• How I do it?
II
IVa
VIII
VII III
IVb
VI
IVa
II
VIII
VII
P IV P II
P III
Umbilical fissure
GB
IVb III
PV
V
Bifurcation
VI
Umbilical fissure
GB IVb
III
P VI VI
TOPIC OUTLINES
• History
• Symptom
• Cirrhosis
• Malignancy
• Pill, hormone
• Fever
• BW change
• Solid , Cystic , Complex
• Enhancing pattern
IMAGING TECHNIQUES
• Ultrasound
• CT
• Multiple phases
• Non contrast • Venous
• Early arterial • Delayed (equilibrium)
• Late arterial
IMAGING TECHNIQUES
• MRI
• Gadolinium
• Hepatobiliary specific
contrast (Primovist®)
• Non contrast
• Early arterial
• Late arterial
• Venous
• Delayed (equilibrium)
• Hepatobiliary phase
(Primovist®)
• T1, T2 , DWI, In phase,
out of phase (opposed)
Arterial Venous
Delayed HB
T1 น ด T2 น ข ว
Two = White
Solid Liver Tumor
Hypervascular Hypovascular
Hemangioma ICC
HA CRLM
FNH Other liver mets
HCC DN
Liver mets NET
Renal cell CA
HCC
• US
• Mosaic pattern
• Contrast enhancement Cirrhotic
• Early arterial (mosaic) enhancement Liver
background
• Washout on portal phase
• Enhancing capsule in delayed phase
• Non uptake HSA
MOSAIC PATTERN FROM US
Hypoechoic halo
Hyperechoic
Post.
hyperechoic
Lateral shadowing
Non-contrast Arterial
Venous Delayed
Arterial Venous
Delayed HB
HEMANGIOMA
Most common benign tumors
• US
• Well-defined, homogenous hyperechoic
• Contrast enhancement
• Peripheral nodular enhancement on arterial phase
Small lesion :
• Progressive centripetal fill in on later phase homogenous
enhance in arterial
• Enhance persists into delayed phase
• MR Flash-filled hemang.
• Hyperintense on T2, Hypointense on T1
HEMANGIOMA
• Interrupted nodular enhancement
HEMANGIOMA
• Interrupted nodular enhancement
• centripetal filling-in
HEMANGIOMA
• Interrupted nodular enhancement
• Centripetal filling-in
• Progressive enhanced
HEMANGIOMA
Arterial Venous Delayed
HEMANGIOMA
T1 T2
FOCAL NODULAR HYPERPLASIA (FNH)
• Contrast enhancement
• Early enhancement in arterial phase
• Iso-attenuating to liver in venous and delayed phase
• Enhance central scar in delayed phase
Arterial Venous
Delayed
HEPATIC ADENOMA (HA)
• Contrast enhancement
• Similar to FNH but usually has fat or hemorrhage
in HA
• Non uptake HSA
Pill, HRT
Non contrast Arterial
Venous Hepatocyte
INTRAHEPATIC CHOLANGIOCARCINOMA(ICC)
• Contrast enhancement
• Rim enhancement in arterial phase
• Slow progressive enhancement on subsequent phase
Ddx : CRLM
Growth into or along bile duct
Dilated proximal bile duct
Subcapsular retraction
Non- contrast Arterial
Venous
Non-contrast Arterial
Venous Delayed
Non-contrast Arterial
Venous Delayed
Cystic Liver Tumor
Simple cyst Neoplastic cyst Infection Solid tumor with
necrosis
Solitary IPNB Abscess
Multiple MCN
APLKD
SIMPLE CYST
• US
• Unilocular, anechoic
• Posterior enhancement
• Smooth wall (no mural or papillary projection)
• Contrast enhancement
• Non-enhancement
• MR
• Homogenous and hypointense on T1
• Hyperintense on T2
Arterial
T1 T2
NEOPLASTIC CYST
• US
• Multiloculated
• Septate, papillary projection
• Invasion
• Contrast enhancement
• Wall enhancement
ABSCESS
• US
• Multiloculated, septate, air
• Contrast enhancement
• Peripheral rim enhancement
• Double target sign (Multi layer enhancement)
• THAD (Transient hepatic attenuation difference)
Abscess VS solid tumor necrosis
Non-contrast Arterial
Venous Delayed
Double target sign
Fibrous
Granulation
Necrotic
ABSCESS VS SOLID TUMOR NECROSIS
• Abscess • Solid tumor necrosis
• Gas + • Gas -
• Double target sign + • Double target sign -
• THAD + • THAD -
• Prox. IHD dilate - • Prox. IHD dilate +
• Capsular retraction - • Capsular retraction +
• Delayed enhancement +
Arterial Venous
Delayed HB
Arterial
Non contrast
Venous Delayed
CONCLUSIONS
• Arterial enhancing lesion
• HCC, HA, FNH, Hypervascular metas.
• FNH VS HA
• Central scar
• Fat, bleeding component
• MRI with hepatocyte specific contrast
• Central scar
• F-HCC, FNH
CONCLUSIONS
• Hepatobiliary specific contrast
• All tumor never uptake HSC , except FNH and dysplastic nodule
• ICC VS CRLM
• HX + PE (PR)
• Anemia
• Tumor marker (CEA, CA19-9) also rising
• Peripheral bile duct dilataion
• EGD + colonoscope
CONCLUSIONS
• Liver abscess VS ICCA necrosis
• Gas +
• Double target sign +
• THAD +
CONCLUSIONS
Arterial Venous Delayed Special features
HCC Enhancement Rapid wash out Wash out -
FNH Enhancement Isodensity -Isodensity Uptake Primovist
-Enhancing central
scar
HA Enhancement Isodensity Possible fat
or intra-tumoral bleeding
Hemangioma -Peripheral Progressive centripetal filled-in Hyposignal in T1
interrupted nodular Hypersignal in T2
Liver abscess Rim enhancement Double target sign
IHC Slow progressive enhancement from arterial to delayed phase -Peripheral dilated bile duct
-Capsular retraction
