Liver Lesions - HD

Disclosures and Approach

I have no disclosures except that this no financial disclosures,
but it's not really basic gray scale
because I don't think you can do gray scale
without using color.
There'll be a little color snuck in there.
You'll see that.

The other thing I tell my residents is
that I don't think you can make a diagnosis
in a vacuum.
The other disclosure is this is not just an atlas of
birdwatching and features of liver lesions.
Really, I tailor my diagnosis based on the history as well.
We will look at imaging features,
but absolutely whether it's a screening ultrasound
and a patient at risk or it's an incidental finding when
you're looking at a kidney for something else
or the patient is symptomatic,
that is gonna tailor your diagnosis based on
the imaging features.

Screening Patients

I'm gonna start a little bit with screening.
I know IA is gonna talk about this as well,
but it's important for us to remember that the patients
who are screened, I'll give you a hint,
this is gonna be a Sam's question.
Are the patients with cirrhosis?

I'm seeing a lot of these folks coming through
and the screening patient is different from the patient
who comes in with elevated LFTs,
maybe has a fatty liver, et cetera.
These patients actually have an underlying liver disease
that puts them at risk for cancer.
We are obligated
to be thinking about do they have a primary
liver malignancy.

These are screening,
these patients are currently screened every six months
'cause that's been the most cost effective way
to find significant cancer.
Basically any new lesion in these folks
with cirrhosis has to be evaluated for potential HCC.
It doesn't matter what the cause of the cirrhosis is,
it's the cirrhosis that sets up the goal for the screening.

What do they look like?
Any new lesion, non-specific ultrasound features,
Stephanie's gonna be talking about this.
Basically I need contrast
to tell whether it's gonna be an HCC
and I'm gonna show you right now.
Here's one with an mr, which enhances,
washes out, et cetera.
That's an HCC in this patient.

Here's another patient.
Do I know whether this is HCC or not by ultrasound?
I can't tell it's heterogeneous.
It may or may not be vascular.
It needs contrast.
In this case it was a CT that was done.
It enhances arterial phase.
It grows actually over a couple of months.
You can see here in December, it's growing
and it's enhancing so lot.
We're going to hear about that from IA later with rads.

Limitations and Pitfalls in Screening

What are the limitations?
I'm seeing several of these people a day
and where are the pitfalls?
What do I need to watch out for?

The biggest thing I think
of is we are limited at the dome
and limited with lesions on the ribs.
My sonographers often don't scan up high
enough and they miss it.
As anybody see the lesion here, okay,
ISO coic lesions, yeah, they're gonna be hard.
Diffuse infiltrating disease.
That's hard.

Anybody see a lesion?
Not yet.
Here's another one.
Anybody see a lesion?
Not yet.
Here's the tips.
There it is.
Two weeks later there's the lesion, okay?
It's vascular and it's a little HCC.
Make sure you get up there under the dome
and make sure you pan out wide by the ribs.

Here's another patient, a hep C cirrhosis, right?
Upper quadrant pain.
There's obviously a portal vein
thrombosis that has an hepatic artery waveform in it.
This is tumor.
Where's the primary?
Sometimes this is all you see.
Here it is on ct.
There's certainly an area here.
I don't see the tumor here,
but I do see it in the portal vein.

Elevated LFTs and Cholangiocarcinoma

The next category of patients,
this patient has elevated liver function tests
and didn't have a history of cirrhosis.
The initial ultrasound diagnosis on this was
intrahepatic biliary duct dilatation.
This was of course all these are done at an
outside hospital, right?

At least you make the diagnosis
of isolated biliary duct dilatation
that should make you think that something's wrong.
Does this patient have sclerosis
cholangitis or is there a tumor?
If you look carefully at this, what's the lesion
or what's the abnormality?
There's a contour deformity here, right?
This is deep, but is it really just deep
and not well penetrated
or is there really a lesion there?

This patient actually, sorry, came in
and you can see there is actually a discreet lesion there
when you set up your parameters well
to look all the way through the liver.
This was an int hepatic cholangiocarcinoma,
which is the second most common primary hepatic malignancy.
The reason I'm including it here is
because these patients with cirrhosis, again,
who we're seeing on our screening ultrasounds,
are also at risk for cholangios.

In addition to being at risk for HCCs, we know
that ductal disease puts people at risk for cholangios
as well as viral disease.
Cirrhosis, certainly should make you think.
It may not be an HCC, but if you see dilated ducts
and somebody who's at risk, think about cholangio two.

These things are all on your handouts.
I'm not gonna read you the slides
'cause we're running a little bit behind.
Cholangiocarcinoma, how do you pick it up?
The gray scale again, variable, it may be invisible.
Remember it's a stricturing lesion,
so you may not actually see much of a mass.

Isolated duct dilatation.
That should make you think, Hmm,
is there a cholangio somewhere in there?
Here's a nice case from the A RP.
You can see the ducts are dilated
and when you look closely here you can see vessel.
Here's the duct and there it is.
It's iso, basically ISO coic to the adjacent liver.
But there is a little mass here in the duct.
I call it a stealth lesion.

Here you can see on CT dilated ducts
and here is a little bit of the mass centrally.
When you look at the path, again,
a stricturing lesion sort of crawling along,
sometimes crawling in the ducts as well.
I didn't bring you more ductal pictures,
but just remember if there's a mid ductal lesion
that's a soft tissue mass,
that's almost always cholangio as well.

Incidental Findings

I'm gonna move on from our high risk patients into
people who just show up at your doorstep without symptoms
really, but they're sent in maybe for something else.
Elevated LFTs, I'd call these incidentals as well
as somebody who's coming in for renal stones
or maybe for gallbladder.

Here's somebody who has a big mass,
about four centimeter mass in the liver.
44-year-old guy incidental ultrasound finding.
Can I tell what it is?
I can't.
This patient needs to go on to other imaging
or needs contrast, right?

In this case, is it a primary H CCC or a met?
I don't know.
Is it benign?
The odds are it's gonna be benign, right?
The patient doesn't have any other symptoms
but you sort of have to prove it.
This patient in my practice will go on at this point,
to an MRI.
This is an obviously TTU bright lesion hemangioma.

These are our most common,
incidental benign hepatic lesions.
They're considered a hamartoma.
Anywhere from one to 20%, rarely are symptomatic.
Occasionally they will enlarge during pregnancy
and very, very, very rarely will bleed management.
Basically this is another Sam's issue
and I'd be welcoming questions
and comments on this as to what people do with them
and I will tell you it's variable in my practice.

Some partners ask for a follow-up ultrasound on these.
Some people ask for an MR on these
and some people do nothing.
The literature though tells us that in a patient
with no risk factors for malignancy,
if you see a classic looking heman
and we'll go through the features,
they do not require a follow-up.
Some people do do a single three to six month follow-up.

What's classic And about half of them turn out
to be classic and homogeneous hyper coic
and some posterior acoustic
enhancement that you can see here.

What are the other features
that you've seen about the other half?
You can see a hypoechoic margin
or an echogenic margin with a hypoechoic center
or sometimes these hypoechoic little nodules in it.
You can see scalloped borders.
It may not be nice and smooth
and as with our index case, it can be heterogeneous
and even hypo coic.

I will say that now that everybody seems
to have a fatty liver, unfortunately many
of our he angios have become hypoechoic.
Ultrasound isn't as good as we used to be
'cause our background has changed.

The other thing about hemangiomas to remember,
I learned this from Bill Middleton,
I found this really helpful,
is it can be a variable appearance in a single patient.
This patient has a lesion here that's vascular,
that's a little bit scary.
Hyper coic over here.

This patient, because this was atypical went on
to an mr this one classic hemangioma enhancing nicely.
This one same thing.
Atypical appearance does need to be corroborated.
We're using mr but you can use ultrasound contrast as well.
It can have a variable appearance in the same exam.
I looked around to find an example
and one came in last week which was great.

Here we are, eight in the morning hypoechoic maybe
through transmission, I don't know.
Here we are, eight 20 this now it's getting hypoechoic
but a little bit hypo coic in the center,
different position.
This one's sagittal, this is transverse.
Now I've got the through transmission.
It's more hyper coic
and I actually knew this was he angio the patient had had
a prior MRI.
Here it is proven he angio different appearance within
the same exam depending on positioning
and just timing and blood flow.

What do I do with them?
When should I confirm them If they have any
atypical features?
Vascularity, even though this can be normal in he angios,
you still wanna be sure it's not something else.
Is there shadowing or risk factors for malignancies?

I'll show you some examples here.
Here's a patient with Hep C
who we were doing a screening for cirrhosis.
This looks fairly classic here
but it's a high risk patient.
He goes on and he gets his mr,

how about this patient, right?
Upper quadrant pain, is this a giant hemangioma?
What's wrong with it?
Through transmission,
no shadowing vascularity.
Yep, lots of it.
Irregular margins.
Large ECU echogenic,
lobulated vascular attenuating needs confirmation.

Here's the ct,
this is not peripheral discontinuous
interrupted globular enhancement.
It's basically hypo attenuating.
What else do you see?
Free air and colon mass obstructing mass.
This patient actually had a large colon
cancer with a perforation.
That's why he came in with right upper quadrant pain.
Giant echogenic mass on ultrasound.

Here's another one.
Echogenic lesion is their through transmission
or a enhancement?
No, they're shadowing.
It's a little bit vascular.
You need to see what it is.
Here it is.
It's got fat A ML right?

These are uncommon but you can see them.
Usually you'll see renal lesions as well.

How about this patient?
Slightly genic
no through transmission.
Incidental except that the patient has
right upper quadrant pain.
Atypical hemangioma needs confirmation.
Here we are.
It's not bright on T two it does enhance.
It does not wash out.
Has a nice little central car scar on gavis.
This is FNH which is our second most
common benign tumor.

We are gonna find a bunch of these.
They are associated with vascular abnormalities
and hemangiomas in about 20%.
I will show you the one
feature this was supposed to be.
How you can diagnose these on gray scale.
They're often ISO coic.
We see them by contour.
Anybody have an idea of what might be useful
to tell if it's an FNH something
that Stephanie's gonna talk about
the spoke wheel vascular pattern And we can actually see
this by turning on the color doppler.
Remember this for the Sam's questions.

Third lesion, right upper quadrant pain.
Notice we're moving now into the people who have symptoms.
It's indetermined by ultrasound.
Avascular needs confirmation.
What do we see on a ct?
Hyper attenuating,
no contrast has been given, doesn't enhance.
That means that this is blood, right?

When you're thinking of bleeding lesions,
not thinking about he angios.
Really not thinking about FNH,
you're thinking about adenomas.
These are our third most common benign lesions,
but they are relatively rare
and they're at risk for hemorrhage if they're big.
Usually the patients we try to get them off whatever,
drug or enabling feature is making them grow
and sometimes they shrink on their own.

Other things that can bleed.
This is another adenoma.
This patient is pregnant, right?
Upper quadrant pain you can see a lot, a lot,
a lot of hemorrhage here.
Subcapsular hemorrhage and this is a lesion.
When you see it on MRI, it
has obvious hemorrhage within it.
Another adenoma.

Symptomatic Solid Lesions

I'm gonna move now into symptomatic solid lesions
and then we'll move into the cysts
and the avascular lesions.

We talked about bleeding.
The other thing, the most common thing that I see
that's symptomatic is actually metastasis.
How do I figure out that these are mets?
'cause their imaging appearance is quite variable.
I look for history.
I look for nodal disease in the,
in the adjacent images.
If I can see a primary somewhere else in the abdomen.

The appearance we all know can be hypoechoic,
hypoechoic, these are OID ones.
This patient happens to have a partially necrotic
one from an endocrine.
This part of this patient has a hypoechoic lesion.
Here's a patient with some nodal disease.
This was not very, very evident on CT
'cause we hadn't have contrast.
We do need contrast
to see more conspicuity of these liver lesions.
Nicely seen as hypo coic lesions by ultrasound.

Here's another lesion.
Calcified lesions you can see here on
ultrasound as well as on ct.
For those you think about am mucinous lesion
like colon cancer.

Difficult Metastases

I wanna spend a little time on the difficult metastases.
It's easy when you have a discreet lesion,
you know you gotta characterize it, right?
What about the ones that we can't see?

Does anybody see the lesions here?
Stephanie of course does.
Look
for architectural distortion.
Look for the portal triads.
If you don't see the portal triads, that might be your clue.
All bets are off in the cirrhotics
because they don't have portal triads either.
But in your regular patients they should.

Infiltrative architectural distortion as well
as contour abnormality.
Loss of the portal triads.
I'm just gonna show you a bunch of examples.
Here's the lesion back here
by the IVC here it is easily seen once you've got contrast
on board in ct.

Here's another one.
See the lesions Heart to see.
You can see some little vessels
but we should see more portal triads right
here it is on Mr Innumerable metastases and they're small
and they're bright on the mr.

They're in here as well.
Here's another one.
This patient had polycystic liver
and kidney disease transplant patient.
See the lesions really hard
'cause the cysts give you some through transmission.

Give you another image.
Start looking back here again.
There should be portal triads here.
They're not here.
Here is the MR here, the cysts
and again innumerable lesions.
This was the metastatic Merkel cell carcinoma.
Just enormous number of mets interspersed
and these cysts made it very difficult.

Brief mention, I think you probably will
all recognize this.
A young patient, vague abdominal pain symptomatic has a mass
with a central calcification.
Anybody fibro lamella carcinoma.
You got it.
It's a subtype of HCC.
We can see the central scar, on all modalities.
But just for ultrasound, look for the calcium in the center
'cause we can see that quite well.

Cysts and Complex Cystic Masses

Let's move on to CYS and complex cystic masses.
I'm gonna divide it into the symptomatic
and the asymptomatic asymptomatic simple cyst.
Nobody needs review.
Just remember even thin septations are probably okay,
don't worry too much about 'em.
Polycystic liver disease, same thing.
We'll talk about these at the end if we have time.

Symptomatic Cystic Lesions

Symptomatic though, liver abscesses, the big problem
for us and for me it's a differential.
Is it a liver abscess that I'm dealing with
or is it necrotic met?
That comes up sometimes in
your clinical settings.

Here it's really the history.
Is there pain, fever, moles, et cetera.
Half of them don't have a source
and only about half of them will have through transmission.
But I do look for the gray scale findings, if you will,
through transmission behind something means to me
that it is not solid,
it is fluid even if it's got a bunch of junk in it.

If I see a lot of through transmission behind it
and I don't see any vascularity
or it's just all around the edge,
I think about could it be an abscess If you see gas,
that's very helpful but they aren't that common to find gas.
Gas is in a very small minority.

This is a problem because you have some central liver
tissue, that's okay.
The cystic spaces around it,
which are the areas basically
that are coalescing little abscesses.
The sort of classic rosette appear appearance you might see
on CT or MRI.

Solid appearance, acoustic enhancement.
I'll turn on the color
and hopefully get a little bit better flow than this.
If it's avascular, I would be thinking about an abscess.
Some of these this person went on to mr I'm not sure why.
You can see the halo of edema sort of around this
and a fluid and debris level within it.

Thick rimmed cavity through transmission.
Avascular is an abscess or a tumor
and I can't tell I need the clinics clinical symptoms.
These people really do need to be sampled because
unless you know that they're, they're febrile and septic
and so forth, you're gonna be talking about this
as this could be a tumor.

As it turned out, this patient did have acute cholecystitis
and this was an adjacent liver abscess.
But it needed further verification.

This is an ant mini for you guys probably cyst
with daughter cysts and another cyst
behind it looks the same on ultrasound
as it does on any other imaging modality
and OC cocal cyst, right?
We know that these can be drained percutaneously in
sclerosis and we're just gonna look for the imaging pattern.

How about this one?
These are more
cysts, polycystic liver.
Excellent.
Usually seen with polycystic kidneys as well.
Here are the kidneys for you.
These do not require anything.
These do not actually lead to liver failure,
in most cases.

How about this one?
What's wrong with this
for just a polycystic liver disease?
Look at the margins.
These are not, these are not tiny, tiny thin walled cysts.
These have thick walls.
Once you see thick walls, is it infection or is it tumor?
Even if you don't see
vascularity, think about tumor.
This was metastatic carcinoid.

The last thing is a cyst lookalike.
This patient had an SBO has aplastic anemia.
These look like they could be cyst,
but they really don't have a wall
and they do have a little bit of
vascularity in them, some of them.
They don't have a rim as I said.
Cyst, lookalike always turn on the color
lymphoma, right?

Hypoechoic very, very uniform.
They do transmit sound.
They can create masses, they're aggressive
and they can be nearly koic.
Think about that as well.

Cystic Tumors

I think in the instance of, for the instance of time,
I'll skip this if you
or just mention that there are a couple of cystic tumors.
I wasn't sure how much biliary stuff to put in here.
These have been renamed, they used to be cyst adenomas.
They are now called intraductal papillary
neoplasms of the bile duct.
They have septations which can enhance.

If they are simple,
thin septations, don't worry about them.
But once they start forming thicker septations,
nodular septations, then you have
to think about malignancy.

Mural nodules are rare in the mu cystic neoplasm.
They are, this used to be your papillary cyst adenoma.
Once they have introductional papillary neoplasm
with this sort of, this cauliflower like appendage in it,
sticking in with vascularity with enhancement,
think about this could be malignant
and the more solid components you have,
the more likely it is to be malignant.

Here's another one with a big, big mass in it.
Enhancing, as you can see.
This comes out, looks as you would expect it to.
This was an again, introduct papillary neoplasm.
These are sort of like the IPNs and the pancreas.
That's how I remember them.

They can be relatively benign.
Once they start getting solid growing enhancing components,
malignant need to come out.

Conclusion

All right, so in conclusion,
we are the first imaging for liver lesions.
I think if we wanna make a diagnosis
and not just give a differential, we need the indication
and the history to be able to narrow things down.
The significant imaging features
for me are still echogenicity.
Remember, you're dealing against a background liver
and hopefully that's normal.
The flow is important.
Architectural distortion and margins.

Thank you so much.
It's been a pleasure.