Essentials in Oncologic Imaging What Radiologists Need to Know Liver: Primary, Metastases Richard Baron, M.D University of Chicago Liver Malignancies • Primary – Hepatocellular Carcinoma (~85 – 90%) – Cholangiocarcinoma (~5 – 10%) – Rare tumors (Angiosarcoma, Lymphoma, Epithelioid Hemangioendothelioma, others) • Metastases HCC without cirrhosis Mosaic and capsule HCC in Cirrhosis • 10 – 14% of advanced cirrhosis harbors HCC • 25% of Hepatitis B/C patients develop HCC within • 10 years Compare to risk of colon cancer in 50 y.o.: < 1% prevalence, 7% lifetime incidence Screening Cirrhosis: 1329 patients Peterson et al, Radiology, 2000 Patients Alcohol B Hepatitis C Hepatitis B/C Hepatitis C Hep/Alcohol PBC PSC Other %HCC 86 22 99 22 22 47 31 99 10% 27% 22% 18% 18% 2% 0% 8% 430 14% 59 pts Screening Cirrhosis: 1329 patients Peterson et al, Radiology, 2000 Patients Alcohol B Hepatitis C Hepatitis B/C Hepatitis C Hep/Alcohol PBC PSC Other %HCC 86 22 99 22 22 47 31 99 10% 27% 22% 18% 18% 2% 0% 8% 430 14% 59 pts Pathogenesis of HCC: Key Role of Dysplastic Nodules • Regenerative Nodule • Large Regenerative Nodule • Dysplastic Nodule • HCC (nodule-in-nodule) • HCC Dysplastic Nodules: MR CT: ~ 10% Lim et al, BJR 2004 MR: 10 – 15% Krinsky, Radiology 2001 Dysplastic Nodules: Low Grade - Nuclear atypia is minimal - Portal tracts present High Grade - High nuclear cytoplasmic ratio - Rare mitotic figures - Resistance to iron accumulation -New vessels (nontriadal arteries) increase -Portal flow to nodules decreases Liver Metastases • • Most common liver malignancy Generally variable, noncharacteristic features Does not meet classic benign dx (cyst, hemangioma, or FNH) with known primary tumor • Site of origin can occasionally be suggested Liver Metastases • • • • Hypovascular (colon, lung, pancreas, many others) Hypervascular (renal, islet cell, breast, thyroid, sarcomas) Ca++ in mucinous tumors (colon, ovary) Change over time in appropriate setting Significance of Small ( 15% on CT Stable Disease Size of < 30% or of < 20% Progressive Disease > 20% increase in sum of target lesions diameters Liver Tumors: Practical Summary • Understanding the clinical setting is essential – Chronic Liver Disease – Presence of other primary tumor and type • Optimizing imaging and contrast techniques – Vary with underlying type of tumor suspected • Regular communications and interactions with oncologists/hepatologists/surgeons is essential [...]... 2002): 13% HCC • Most small enhancing nodules are not HCC • Delay, washout characteristics helpful in characterizing • Multimodality imaging & Follow-up imaging essential HCC: MRI signal intensities AP EQ Delay T1 T2 DWI Enhancing Nodule: Value of T2 characteristics AP EQ OP T1 F/U OP T1 2007 f/u 2007 IP T1 OP T1 2008 “Nodule in Nodule” Evolution Evolution Dysplastic Nodule to HCC 2005 T2 2006 2007 T1 Hypovascular... washout) One imaging technique showing a mass with AFP levels > 200 ng/ml 10-20 mm Two imaging techniques with typical HCC (AP hypervascularity & washout < 10 mm PV Repeat US every 3-6 months for 2 yrs American Association for the Study of Liver Diseases (AASLD) Practice Guideline Hepatology 2005;42:1208 EQ HCC Dx: 2010 AASLD CRITERIA > 10 mm Liver Lesion, chronic liver disease One imaging technique... 2000 MR 77% 37% Krinsky, 2001 91% Bhartia, 2003 MR Dual Contrast US ~ 50% ~ 35% multiple 48 y.o male, chronic hepatitis C Solitary 2.5 cm lesion AP PV EQ What would be next best step To plan appropriate treatment? A Biopsy Lesion B Confirm with MR exam C Make Rx plans as HCC D F/U imaging in 3 - 6 mos HCC Dx: 2005 AASLD CRITERIA > 20 mm Liver Lesion, chronic liver disease One imaging technique with... hypoattenuating nodules transformed to enhancing vascular lesions (Takayasu et al, AJR, 2006) AP PV 2008 AP EQ 2009 Diagnosis of Small Nodules Forner et al, Hepatology, 2007 Serially followed cirrhotic patients for 3 yrs 89 patients developed NEW nodule 60 HCC, 1 cholangiocarcinoma 28 benign nodules (regenerative/dysplastic predominate) 24/89 nodules = hypovascular (only 2/24 = HCC) STAGING HCC: TNM... Lungs Lymph Nodes Regional Distant Bone Adrenal Peritoneum Brain All other sites 55% 53% 41% 12% 28% 11% 11% 2% 7% Ferris et al, Radiology, 2000 48 y.o male, chronic hepatitis C 3 lesions; Largest = 3 cm AP PV EQ To evaluate for possible liver transplantation, which is next best step ? A Biopsy largest lesion B F/U in 3 mos to show stability C Proceed to transplantation list without further steps D Patient... MELD score upgrade to 22 (15% mortality in 3 mos) Milan criteria: – Single tumor 2 – 5.0 cm – Multifocal tumor (3 nodules, 3cm, OR tumor involving a major venous branch Tumor(s) with direct invasion of adjacent organs other than gallbladder Regional lymph node metastasis Distant Metastasis STAGING HCC: TNM based I II IIIA IIIB IIIC IV Tumor T1 Solitary N0 M0 T2 Multiple N0tumor ( ... washout characteristics helpful in characterizing • Multimodality imaging & Follow-up imaging essential HCC: MRI signal intensities AP EQ Delay T1 T2 DWI Enhancing Nodule: Value of T2 characteristics... HCC D F/U imaging in - mos HCC Dx: 2005 AASLD CRITERIA > 20 mm Liver Lesion, chronic liver disease One imaging technique with typical HCC AP (AP hypervascularity & EQ washout) One imaging technique... present High Grade - High nuclear cytoplasmic ratio - Rare mitotic figures - Resistance to iron accumulation -New vessels (nontriadal arteries) increase -Portal flow to nodules decreases HCC AP PV