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TUMORS OF
THE LIVER
MARIA THERESA M. NAVARRO, MD
4th Year Radiology Resident
Department of Medical Imaging
Quirino Memorial Medical Center
Hepatic
Hemangioma
s
HEPATIC HEMANGIOMAS
CAVERNOUS HEMANGIOMA – most common
benign neoplasm of the liver
second most common hepatic tumor, exceeded
only by metastases
affects all age groups
women > men
within the right lobe of the liver
few millimeters to greater than 20 cm diameter
HEPATIC
HEMANGIOMAS
mesodermal in origin
histologically : blood-filled cavernous
vascular spaces of variable size and
shape lined single layer of flat endothelium
stable lesions, rarely increase or decrease
in size
IMAGING FEATURES OF
CAVERNOUS HEMANGIOMAS
PLAIN FILMS
mostly, too small to be identified on plain films of
the abdomen
very large lesions, nonspecific findings :
ULTRASOUND
well-circumscribed, homogenous, densely
echogenic masses with posterior acoustic
enhancement
differential diagnosis:
hepatocellular ca
metastatic disease
hepatic adenoma
ULTRASOUND
demonstrate varying internal complexity,
depending on the degree of thrombosis, fibrosis,
hemorrhagic necrosis, or calcification
sonographic heterogeneity – more common in
larger lesions.
hyperechoic pattern (67% to 70%) – presence of
multiple vascular interfaces between the walls of
the cavernous sinuses and the blood within
them
IMAGING FEATURES OF
CAVERNOUS HEMANGIOMAS
COMPUTED TOMOGRAPHY
CT diagnosis is based on the understanding of
the neoplasm’s vascular hemodynamics
blood typically circulates slowly within the the
after injection
or until lesion is isodense with normal hepatic
Surrounding peritumoral
edema
IMAGING FEATURES OF
CAVERNOUS HEMANGIOMAS
mass
Arterial-portal venous shunting
Identification of a persistent pool of
contrast puddling within such
lesions may be the only means of
diagnosing these complicated
hemangiomas short of performing
a biopsy or surgical resection
APPROACH TO IMAGING OF
SUSPECTED HEMANGIOMAS
(Modification scheme by Freeny)
GROUP I
Patients who have well-circumscribed, homogeneous,
hyperechoic lesions
No clinical symptoms referable to the liver
Normal liver function results
No known primary neoplasm
Patients who have lesions with atypical sonographic
patterns
Abnormal clinical findings
Known primary neoplasm
Group I Patients
Labeled-RBC scintigraphy with SPECT
tomographic imaging is the preferred procedure
of definitive lesion characterization due to its
relative low cost and near 100% specificity and
positive predictive value.
(1.5 cm to 2.0 cm lesions)
Group I Patients
Magnetic Resonance Imaging
reserved for lesions smaller than1.5 to 2.0 cm
lesions 2.5 cm or smaller located adjacent to the
heart or major intrahepatic vessels
Both modalities – useful in patients with multiple
suspected hemangiomas
Group I Patients
MRI is not advocated if the patient has
a known primary hypervascular
endocrine neoplasm
If these studies yield undeterminate
findings for hemangioma
angiography or
percutaneous needle
APPROACH TO IMAGING OF SUSPECTED
HEMANGIOMAS
(Modification scheme by Freeny)
GROUP II
Patients who have focal hepatic lesions detected on
routine dynamic-incremental bolus CT studies
HEMANGIOM
Peripheral A
Delayed
contrast Images
enhancemen Show
t Isodense Fill-
APPROACH TO IMAGING OF SUSPECTED
HEMANGIOMAS
GROUP II
MRI APPEARANCE IS
CLASSIC HEMANGIOM
A
NO
KNOWN
PRIMARY
NEOPLAS
APPROACH TO IMAGING OF
SUSPECTED HEMANGIOMAS
GROUP III
ATYPICAL MRI
APPEARANCE
KNOWN PRIMARY NEOPLASM
(hypervascular endocrine
tumor)
ADDITIONAL SPECT CTAngiography or
IMAGING WITH FINDINGS Percutaneous
LABELED-RBC NEGATIVENeedle Biopsy
SPECT
LESIONS TOO
SMALL
APPROACH TO IMAGING OF SUSPECTED
HEMANGIOMAS
Lesions less than 1 cm are
difficult to consistently
characterize using any
noninvasive modality
Follow-up
ultrasound
or MRI at 6
unchanged inmonthschanged in size
size and and morphology
morphology
no further percutaneous biopsy
evaluation
Hepatocellular
Adenoma,
Focal Nodular
Hyperplasia,
and Others
Hepatocellular
Adenoma,
Uncommon solid primary liver tumor
Related to the use of oral contraceptives in women
and anabolic steroids in men
Pathology : large (usually > 10 cm) solitary lesions
with a thin tumor capsule
maybe rich in fat or glycogen
Ultrasound : well-delineated heterogenous but
primarily echogenic hepatic mass
Hyperechogenicity – attributed to the presence of
intratumoral fat and glycogen
Hepatocellular
Adenoma,
Non-contrast-enhanced CT
Predominantly isodense with liver but may appear
either uniformly hypodense due to extensive
steatosis
Or heterogeneous with foci of hypodensity caused by
tumor necrosis and areas of hyperdensity secondary
to recent intratumoral hemorrhage
Hepatocellular
Adenoma,
Radionuclide Scintigraphy
Most HAs are devoid of Kupffer cells, they
appear cold on sulfur colloid scintigraphy
Show uptake of the tracer
Because of the lack of bile ductules, the tracer
is not excreted, and delayed scans therefore
depict HAs as areas of markedly increased
Hepatocellular
Adenoma,
Hepatocellular
Adenoma,
Magnetic Resonance Imaging
Mimic malignant liver tumors, with the non-necrotic,
nonhemorrhagic solid component showing
Hypointense appearance on T1 images and slight
hyperintense on T2 images
However, the high fat or glycogen content, or both, of these
tumors can render them isointense or even hyperintense on
T1 images
Hypointense tumor capsule best seen on T1 images
Intratumoral bleeding – hyperintense on T1 images and
hypointense on T2 images
(Left) Axial T1WI MR shows hypointense encapsulated mass
with hyperintense foci (hemorrhage or fat).
(Right) Axial T2WI MR shows mass nearly isointense to liver
with
central focus of hyperintensity (hemorrhage).
Hepatocellular
Adenoma,
Angiograms
Hypervascular tumors with large peripheral vessels
Centripetal flow
Usually there is no arteriovenous shunting or vascular
invasion, as is often seen in hepatocellular carcinoma
No specific diagnostic specificity can be gained
Hepatocellular
Adenoma,
CONCLUSION
Hypervascular tumors with large peripheral vessels
Centripetal flow
Usually there is no arteriovenous shunting or
vascular invasion, as is often seen in hepatocellular
carcinoma
No specific diagnostic specificity can be gained
FOCAL NODULAR
HYPERPLASIA
Clinical Background
most common solid benign tumor of the liver
usually found incidentally
etiology unknown, but postulated that a congenital
vascular malformation may trigger the development
of hepatocyte hyperplasia
hormonal influence more common in women on
their 3rd to 5th decades
controversy regarding its association with the use of
oral contraceptives
FOCAL NODULAR HYPERPLASIA
Pathology
well-circumscribed, usually solitary mass, no capsule
with centrally located scar tissue surrounded by nodules of
hyperplastic hepatocytes
nodules divided by thin septae that radiate from the central
scar, when there is one
no normal portal venous structures
usually located at the liver surface bulge in the liver contour
or pedunculated mass
1 cm to > 15 cm
hemorrhage, necrosis, and calcification are rare
FOCAL NODULAR HYPERPLASIA
Radiology
Angiography
seldom performed for the tissue
characterization of focal liver tumors
hypervascular mass possessing a centrifugal
or “spoke wheel” pattern of vascular supply
MACROREGENERATIVE NODULE AND
NODULE REGENERATIVE
HYPERPLASIA
Clinical Background
MACROREGENERATIVE NODULE (MRN)
10%-14% of the patients with chronic liver
disease, such as advanced cirrhosis
Severe hepatic injury such as aftermath of
massive hepatic necrosis
MACROREGENERATIVE NODULE AND
NODULE REGENERATIVE
HYPERPLASIA
Clinical Background
NODULAR REGENERATIVE HYPERPLASIA
(NRH)
much rarer condition
arises without any hepatic injury or fibrosis
but is associated with a variety of systemic
diseases such as rheumatoid arthritis and
polyarteritis nodosa.
MACROREGENERATIVE NODULE (MRNs)
Pathology
Well-circumscribed nodules composed of
hepatocytes that are arranged in normal cords
and contain portal areas
Fibrosis is absent or slight
Multiple
1 to 6 cm in diameter
Necrosis and hemorrhage (rare)
NODULAR REGENERATIVE HYPERPLASIA
(NRH)
Pathology
Not known
May stem from occlusion of the intrahepatic
branches of the portal vein
Few millimeter to 1 cm
Scattered diffusely throughout the liver
MACROREGENERATIVE NODULE AND
NODULE REGENERATIVE HYPERPLASIA
Cross sectional imaging – difficult because
of the small size of NRH
altered gross hepatic morphology that accompanies
cirrhosis and MRNs
alteration in the echogenicity and MR signal intensity
of uninvolved hepatic tissue can interfere with lesion
detection
No specific features on UTZ and CT, except for
round liver lesions up to several centimeters in
diameter in the setting of MRNs
MACROREGENERATIVE NODULE AND
NODULE REGENERATIVE HYPERPLASIA
Infectious
Traumatic