Transcript Shiny liver - الموقع الرسمي للدكتور

Shiny liver
Dr. Ahmed Refaey
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 ).
Hemangioma
hcc
• 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 tumors
2- retention of contrast in blood pool like in
hemangioma
3- 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
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• 2ry
Benign
• Hypervascular
Hemangioma
metastasis
Focal nodular hyperplasia • Primary hypervasculr
tumours
adenoma
• Thyroid carcinoma
• Choriocarcinoma
Malignant
• Renal cell carcinoma
• Iselet cell tumors of pancreas
HCC
• Malignant
pheochromocytoma
Fibrolamellar HCC
• 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
• 2ry
• Benign
• Hypervascular
• Hemangioma
metastasis
• Focal nodular
hyperplasia
• Primary hypervasculr
tumours
• adenoma
• Thyroid carcinoma
• Choriocarcinoma
• Malignant
• Renal cell carcinoma
• Iselet cell tumors of
• HCC
pancreas
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•
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•
Malignant
pheochromocytoma
Malignant melanoma
Carcinoid tumor
15% of cancer breast
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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
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•
•
•
•
•
•
•
•
Primary hypervasculr tumours
Thyroid carcinoma
Choriocarcinoma
Renal cell carcinoma
Iselet cell tumors of pancreas
Malignant pheochromocytoma
Malignant melanoma
Carcinoid tumor
15% of cancer breast
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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