DECLARATION HEPATOBILIARY IMAGING CASE PRESENTATIONS

11/1/2016

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Dr. Chirag Patel Sunnybrook Health Sciences Centre

University of Toronto

HEPATOBILIARY IMAGING

CASE PRESENTATIONS

ORGAN IMAGING – 2016

DECLARATION

• No financial disclosures or affiliations with commercial organisations

• No discussion of investigational or “off-label” use of medical devices, products or pharmaceuticals

CASE 1 33yr old lady

Hx of renal stones & resected pituitary adenoma (non-

functional) – 2004

Total thyroidectomy

2014 – Abdominal Pain

CT Abdo/Pelvis requested

CT - PV CT - PV

CT - PV

CT - U

CT - A

CT - PV

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T2FS

T2FS T2w

T2w T1-IP T1-OP

T1-OP T1-IP

T1FS – Pre Gad T1FS+Gad - Art PV

Equilibrium 5min

Q1

A. Metastases

B. Adenomas

C. Hepatocellular carcinoma

D. Multifocal Angiomyolipomas

E. Multi-Nodular hepatic steatosis

What is the likely hepatic diagnosis?

A. Metastases

B. Adenomas

C. Hepatocellular carcinoma

D. Multifocal Angiomyolipomas

E. Multi-Nodular hepatic steatosis

What is the likely hepatic diagnosis?

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Repeat Biopsy:

- Metastatic, well-differentiated Neuroendocrine Tumour

- Moderate surrounding hepatic steatosis

FAT??

• Normal chromogranin A, C-peptides, gastrin & glucagonoma

• Asymptomaic TUMOUR

FATTY CHANGE IN LIVER

GLUCAGON

INSULIN

Metastatic PNET - Insulinoma

• Pancreatic Neuroendocrine Tumour

• Pituitary Adenoma

• Renal stones Parathyroid adenoma

MEN1 CT

FOCAL FAT

CT

Insulinoma Subcapsular Hepatic Steatosis Wanless IR et al. Mod Pathol 1989. Khalili K et al. AJR 2002

CT

67yr old man. Abdo Pain

post colonoscopy. CT

COMPANION 1 CECT - Art CECT - PV CECT - Del

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T2w

T2w-FS

T2w-FS

T1w-OP

T1w-IP

T1w-FS + C

Dynamic contrast

T1w-OP

T1w-IP

*

*

MULTIFOCAL NODULAR FATTY INFILTRATION (MNFI)

CECT

MNFI

• Multiple

• Rounded/spherical

• Lack of Mass effect

• Lack of Vascular distortion

• Central hepatic signal/density

Kronke TJ. Eur Radiol 2000.

CASE 2 59yr old lady.

Struck in abdomen with shopping cart

FAST +ve

Haemodynamically stable Trauma CT

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CT -PV

CT -PV

CT -PV

10 H.U.

CT -PV 4 days later. Increased abdominal pain

Day 1 Day 4

Q2

A. Pancreatic injury

B. Acute haemorrhage from hepatic injury

C. Duodenal injury

D. Bile duct injury

E. IVC injury

What is the most likely diagnosis?

A. Pancreatic injury

B. Acute haemorrhage from hepatic injury

C. Duodenal injury

D. Bile duct injury

E. IVC injury

What is the most likely diagnosis?

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What test would you do next?

A. MRI Liver

B. Ultrasound +/- aspiration

C. HIDA

D. ERCP

E. Multiphasic CT

What test would you do next?

A. MRI Liver

B. Ultrasound +/- aspiration

C. HIDA

D. ERCP

E. Multiphasic CT

MRCP

T1FS + Primovist

T1FS + Primovist

Laparotomy & exploration

• Severed CBD with length of contused CBD

• Pancreatic head contusion

• Hepaticojejunostomy created (just below the bifurcation)

Common bile duct injury

COMPANION 2

54yr old gentleman.

RUQ pain and fever

PMH – APLS (DVT/PE), HTN,

CKD

Urgent US

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CT (Triphasic)

CT

CT

Cholangiogram

Biliary Anatomic

Variance

Cystic duct

Rt Anterior Sector

Lt Main

CHD

Rt Posterior Sector • Anomalous insertion of the cystic

duct Rt posterior sector duct

• Low insertion of the Rt posterior

sector duct into the CHD

Biliary Variance – 30%

(risk factor of bile duct injury)

Mortele KJ et al. AJR 2001

MRI + Primovist

Post-Primo 20min

60min

60min

60min

• Bile leak from three separated ducts (left main, right posterior and

right anterior)

• Three separate hepaticojejunal anastomoses

• Roux-en-Y reconstruction.

Surgical Exploration

• Re-admitted with cholangitis (4 months post-op)

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MRCP Primo – 20min Primo – 5min

Primo – 5min Primo – 10min

Primo – 10min

Primo – 20min

Lee NK et al. Radiographics 2009

55yr old man

SOB – Right hilar mass with RLL collapse

Bronchoscopy confirmed malignant lesion

Staging CTs

CASE 3

CECT - Art

CECT - PV

CECT - Del

T2w

T2w-FS

DWI b0

T1w-OP T1w-IP

b750 ADC

T1w-FS T1w-FS + C

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Q3 A. Focal Nodular Hyperplasia

B. Adenoma

C. HCC

D. Haemangioma

E. Metastasis

What is the hepatic lesion?

A. Focal Nodular Hyperplasia

B. Adenoma

C. HCC

D. Haemangioma

E. Metastasis

What is the hepatic lesion?

METASTASIS – LUNG PRIMARY

T2w T2w-FS

T1w-FS

COMPANION CASE 3

METASTASIS – COLONIC PRIMARY Semelka RC et al. Abdom Imaging 1999

SUMMARY

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Benign hepatic lesions may mimic

malignancy or vice-versa

Differentiating features can be subtle

Important to recognize atypical features,

particularly in relation to apparently benign

lesions.

Hepatobiliary anatomical variance is

relatively common

Pay attention to biliary and vascular

variance

Further Reading

1. Fatty Liver: Imaging Patterns and Pitfalls – Hamer OW et al, Radiographics

2006.

2. Fat-containing Lesions of the Liver: Radiologic-Pathologic Correlation –

Prasad SR et al, Radiographics 2005.

3. Biliary Imaging: Multi-modality approach to imaging biliary injuries and their

complications – Melamud K et al, Radiographics 2014.

4. Biliary MR imaging with Primovist and its clinical applications - Lee NK,

Radiographics 2009.

5. Chemotherapy-treated ;iver metastases mimicking haemangiomas on MR –

Semelka RC, Abdominal Imaging 1999.