Essential in oncologic imaging what radiologistes need to know

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 ... 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