CASE CHALLENGES: Liver

Complex Mass in the Liver

Patient comes in with palpable epigastric mass
and a recent onset of discomfort.

What do we got? If you had only the enhanced scan,
I think there are a number of bad things
that could look like that,
that could be mural nodularity, but what is it really?
Hemorrhage? This is clotted blood.
And if you put an ROI on that, it didn't enhance.

Now I know because this was resected,
because it was symptomatic,
that this is a benign cyst with hemorrhage.
Would we be justified in saying, look,
I'm a little worried about this lesion.
I'm pretty sure this is
spontaneous hemorrhage into a large cyst.
Absolutely, and that's probably what we said to them.

So, hemorrhage into a cyst, whether it is in the ovary
or the kidney or the adrenal
or the liver, can be difficult to distinguish
from a complex cystic mass.
Why didn't that layer? I think
because it's stuck to the wall for some reason.
I don't really know for sure. Most often it does.

Innumerable Tiny Lesions in the Liver

Diagnosis innumerable,
tiny lesions in the liver, you say, well,
I guess it could be the world's most numerous little cysts
or the world's,
smallest cyst in polycystic liver disease.

Now notice here, by the way, that there are eclipse here.
This patient has underlying
or had resection of renal cell carcinoma.
So are we concerned about those being metastases?
Well, yeah, I guess,
but are metastatic renal cell carcinomas going to be
that low density on a contrast enhanced scan?
No. And that's really not a common pattern
for metastases from renal cell carcinoma.

So what did we really do? We called the physician.
She's in our outpatient,
oncology imaging center,
wheeled her across the hall.
These le some of the lesions are sonocent.
Most of them, because they're so small, are quite echogenic.
This is absolutely a characteristic appearance
of biliary hamartomas.

So what we said to the referring physician is,
we're almost positive that these are not metastases.
These are characteristic of biliary hamartomas.
We'll keep an eye on it when she gets her subsequent,
scans, but we don't wanna send her away
with innumerable two small to characterize lesions.
Metastases are not excluded.
That would be a really bad way to phrase the dictation.

So we've just reviewed that. Here's another one.
Just comes across the desk.
Lots and lots and lots of little lesions.
The small ones,
are too small
to characterize the larger ones.
Can you see by the way, that they're,
they're a little less spherical
and a little less simple also than simple cyst.
There is mural nodularity there.
The,
the fibrous stuff in the wall
and on mr.
They're usually very,
very bright if you do an MRCP on these lesions.
By the way, these do not communicate with the biliary tree,
and that's one of the ways you, that's a ineffective way
of distinguishing this from coli's disease.
The cystic dilation of intrahepatic bile ducts,
which might bear a very passing similarity.

Tough Case: Adjacent to the Gallbladder

Here's a real tough case. This is a scary case.
So this,
case came through.
This is the gallbladder.
I have to tell you on multiple sequential pictures.
This soft tissue was adjacent to the gallbladder,
but really seemed like it belonged to this lesion,
which is separate from the gallbladder
and has this clump of irregular calcification in the wall.
Any ideas there? So this was dictated,
and I'm not highly critical of this as saying,
well, I don't know what that is.
It's maybe an old collapsed hemorrhagic cyst
or something else.
It really didn't conjure up any,
confident diagnosis
and no recommendation was made for further evaluation.

I actually didn't read that scan.
I read this one five years later.
I read it when this patient came into the ED
with sudden onset of hypotension
and right upper quadrant pain.
And this is now a ruptured biliary cyst
adenocarcinoma bleeding into the peritoneal cavity.

So biliary cyst adenomas are pre-malignant lesions.
Is that a real tough diagnosis to make here? Absolutely.
But if I see irregular calcification in the wall
of a complex cystic mass,
I'm at least going to consider that.
And it would've been nice if this was resected back here.
But I fully admit that's a tough,
tough diagnosis to make.

Typical Appearance of Biliary Cystadenoma

Here is a more typical appearance.
Oh, interesting that I misspoke there.
Okay, this case comes through here is a complex
cystic mass in the liver.
I read this in one of our other outpatient imaging centers.
I didn't read the ultrasound. The ultrasound was read
as complex cystic mass in the liver.
Could be a complicated simple cyst
or it could be a biliary cyst adenoma slash carcinoma.
And here's the CT scan. Here's that lesion.
But what else do you see in this liver?
Better on coronal imaging.
By the way, this is a 72-year-old man.

Do we like biliary cystadenoma? We do not.
It'd be fine for that. But biliary cyst adenomas are always
solitary and occur almost exclusively in women.
This is a 72-year-old man.
What he really has is a whole bunch of hepatic cysts
and the ones that are next to each other,
or this could be just a septated cyst,
but these are just multiple
simple hepatic cysts, but a challenge.

Multiple Lesions: Hemangiomas

All right, how about this one? This case was
actually sent to me from outside
and the person who sent it said, this guy's got a number
of lesions in his liver.
I gave him contrast. They didn't fill in completely.
And I'm worried that,
some of them look like him angios,
but you know, because they didn't fill in completely.
I'm worried that these are really metastatic disease
or something horrible like angiosarcoma.

But look at it. Each of the lesions
independently fulfills the criteria for hemangioma.
The large lesions have a central scar that won't fill in.
Most of the lesion is blood density.
On non-contrast, the enhanced portions
of the lesions are isod dense to blood on every phase
of imaging, they're nodular discontinuous.
And these are typical hemangiomas
just happens to be multiple.
And I frequently see eight 10 hemangiomas in a liver,
and that's no concern.

So once again, we can really diagnose hemangiomas
confidently by CT alone.
In the great majority of cases, though,
MR provides even additional comfort in some cases.
We've just talked about that. So we won't.

Single Phase CT: Confirmation with Ultrasound

Here's,
another patient.
Patient had a single phase ct
nodular peripheral enhancement.
There were eight lesions.
All that looked like this
because it was a single phase of imaging,
we weren't a hundred percent confident
that those were hemangiomas wheeled the
patient across the hall.
Every one of these lesions was uniformly hyper coic.

So we didn't dictate out the CT scan saying multiple
hypodense liver lesions complex,
Concern for metastases.
We said the patient has multiple cavernous angiomas.

Not a Cavernous Hemangioma: Metastasis

All right, here's a case.
Do we like cavernous angioma here?
No, we don't
because cavernous angiomas do not have continuous ring
enhancement that is very worrisome for malignancy.
Lots of lesions, bad lesions have progressive fill in.
That is the least useful criterion.
And many portions of this lesion
that are not scarred are not iso dense to blood.

So this could be a cholangiocarcinoma
or it could be metastasis proved to be metastasis,
but this is not cavernous hemangioma.

Hypervascular Lesion: Focal Nodular Hyperplasia (FNH)

What's this lesion? Uniformly
hypervascular on arterial phase
fades into background liver on portal venous.
The central portion of this
shows delayed persistent enhancement on one of the usual
gadolinium based contrast, medium media, FNH.
And we looked it down.

Adenoma in an 18-Year-Old Girl

Alright, here's a good one.
18-year-old girl comes into the ED
after a motor vehicle crash.
She has this lesion. Really didn't look like,
any sort
of acute hepatic injury.
Well-defined hepatic mass,
probably has some hemorrhage within it
or some heterogeneous enhancement,
not really a specific finding.
And a young girl, we're gonna think about an adenoma.
She was on birth control pills definitely is not an FNH,
definitely not an acute traumatic injury.

So, then it's partially encapsulated.
So very suggestive of adenoma, but not definitive.
Once the dust had settled,
got a CT scan, I'm sorry,
an MR scan in phase out of phase imaging,
signal dropout tells us this contains what FAT
or lipid T two weighted imaging.
Not very different than underlying liver vus enhanced scan,
absolutely no uptake or retention.
This is a
n adenoma.

We're gonna stop with that. We have a little time
for some questions.

Questions and Answers

Sir, you
Showed an image of a, of a,
a low density lesion with a neuro nodule,
which you said was thyroid cancer and cystic meth.
Yes. What about the CY psychosis?
How would you tell the difference between the para
with the cus that didn't calcify versus a meth?

Wow, the question is how would I
distinguish cystic metastasis metastasis from
sister psychosis?
Well, for start, I have never diagnosed
cystic psychosis in the liver.
So,
that's probably how I would start.
It probably happens, but I have never seen that.
A lot I work in California, you'll
See a lot.

All right, well, when they come,
hopefully I will keep that in mind.
For widespread liver abscesses,
particularly opportunistic infections, then
that is generally a sick patient and sick by me.
Meaning,
you know, like,
the
opportunistic infections, it's a bone marrow transplant
patient or a leukemic patient or whatever. Yes, sir.

When you talk about the, the heman to the phase,
how you compare it to the dec phase?
Yeah, I get that question a lot.
So,
when you're talking about,
the enhanced portions
of the hemangioma,
looking is against the blood vessels, what blood vessels
and I, I was deliberately non-specific about that
because it varies in some patients,
and it varies depending in part on the rate
and timing of the bolus.

So look at vessels around the liver.
So on the arterial phase imaging, the enhanced portions
of the lesion tend to look more
like larger arteries like the hepatic artery on venous phase
imaging, they tend to look more like the veins
and on delayed phase imaging,
and I showed you at least one example of that, the, the,
the contrast leaves the hemangioma slower than it
does the blood vessels.
So it can actually be slightly
more dense than a portal veins
and more close to a paddock vein.
So I would approach it that way, way in the back.
Thanks. What is your role for
how long do you follow,
adenomas?

Yeah, the, the question is,
at what intervals
and for how long do I follow adenomas based on some stuff
that I have learned recently about the genetics
and,
three different subtypes of adenoma,
which is a little too complicated to get into here.
It's going to be very different.

So we are going to classify these
depending on the exact type of adenoma it is,
because some of these have no malignant potential at all
and others have quite high malignant potential.
But that's a very sophisticated sort of analysis
that frankly is going to be possible only in places
that take care of a lot of these lesions
and a place where the pathologist is very familiar
with the immunohistochemical features of these lesions
and the genetic markers for them.

So that's a unfortunately, maybe a little vague.
I, I understand you can't walk away saying, oh,
I got this good pearl for this.
You, we need to know that there are three different
distinct subtypes of adenomas that
smart surgeons and pathologists
and clinicians know about hepatologists.
And that's going to drastically,
should drastically influence the method
of following these patients
because it influences the prognosis, the likelihood
of hemorrhage and the likelihood of malignant degeneration.
So I have to leave it at that for now. Yes, sir.

The images of the biliary hamartomas,
would you also consider sarcoid?
Good question. Images
of biliary hamartomas would I consider sarcoid?
They do have a, a vague, or they do have some similarity.
Usually if you have that much sarcoid in the liver,
and I showed one case yesterday
and Elliot Fishman showed,
several,
there's usually more surface nodularity of the liver.
The liver looks more scarred.
Usually there is, if you've got extensive hepatic sarcoid,
you have similar lesions in the spleen.
Usually if you have extensive hepatosplenic sarcoid,
there is abdominal lymphadenopathy.
And,
Elliot alluded to this,
and I definitely follow this, look at those sections
through the lung bases
and look to see if you can't see characteristics scarring
and other changes in the lungs
that support the diagnosis of sarcoid.

Having said all that, the patients with biliary hamartomas,
the lesions in the liver are the only lesions
unless they are part of a bigger syndrome of,
hepa orreal, fibro polycystic disease.
So I've seen patients who have biliary hamartomas
and congenital hepatic fibrosis or biliary hamartomas
and polycystic disease, biliary hamartomas
and autosomal recessive,
renal disease.

So, but in most cases, not to make it overly complex,
in most cases, they just look like lots
of little cysts,
in the liver.
So I,
hope that answers it.
And, and again, I don't really think about
opportunistic infections because these patients are
invariably asymptomatic relative
to the liver lesions. Yes, sir.

On the images of the biliary hamartomas, your non,
your unenhanced images
where you had multiple low density areas, if
that patient comes across your board for rule out, you know,
renal calculus and it's a 20-year-old versus a 40-year-old
versus 70-year-old, they all fit their criteria
for pearls for any or all of those.

Are you gonna just say, these are benign, do nothing?
Or in which cases, if any,
are you gonna say we need to do more?
'cause they all meet your criteria. They're all small,
they're less than 2.50 cent
or whatever it was, 2.5 centimeters, but they're multiple
and, and it's totally irrelevant, you know, history.

How aggressive are you, if at all?
I'm not very aggressive at all.
I would say I might very well do one other
type of imaging study.
In fact, I showed you a couple with ultrasound, right?
We, we did the CT scan
and we said, look, almost surely these are
biliary hamartomas.
And in those two cases, I literally
wheeled the patient across the hall, did the ultrasound,
talked to the patient, found
that this is a healthy asymptomatic,
patient,
and the combination of the innumerable
very echogenic lesions on ultrasound mixed with the
slightly complex cyst,
appearance on ct,
was further reassuring that these are biliary hamartomas.

I have a couple of,
questions submitted here.
If you see an incidental electrogenic,
small hepatic mass on routine ultrasound,
do you recommend any,
follow up for presumed heman?

Um, and I would say
that if this is a non-oncology patient,
we're doing a routine,
upper abdominal ultrasound
and it's uniformly echogenic, preferably even
with a little bit of a through transmission,
I would say I would be comfortable saying
that's a hemangioma.

Other people would say, well, come on.
Yeah, okay, you can be 90% sure.
Let's go for a hundred percent. Okay.
Nobody would fault you for that.
But I think what you should say is, Hey, look,
this is almost surely in Aman
on a slight chance it might be something more worrisome.
Let's get,
and I would do an mr.
Like I say,
I showed you one case, in fact
where we did a ct.
I dunno why we chose CT in that case instead of mr. But Mr.
Overall it's gonna have a slight edge,
over CT
and definitive identification of, of,
human gmas.

Okay. Another question about Billy ear hamartomas.
Actually, we just answered that. So if,
if we see,
uh, he, what it looks like, human GMAS on ct, is
that characteristic enough to,
just call it versus other evaluation?

Okay, I don't wanna run over my time, so we'll move on
to the next lecture.
Thanks for your attention.