Presented during Radiology 4001.

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Presented during Radiology 4001.
Radiological Category
Principal Modality (1) Principal Modality (2)
Abdominal
MRI
CT
Case Report Patient PP
Submitted by
Matthew Clower, MSIV
Faculty
Sandra Oldham, MD
Date
29 August 2007
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Case History

• 80 year-old Caucasian woman presents to
  gastroenterologist complaining of burning
  epigastric pain, dysphagia, weight loss, and RLQ
  pain.
• PMH of hemicolectomy secondary to diverticulitis,
  cholecystectomy, and low-grade hepatitis.
• Denies EtOH/Tob/Drugs.
• Family history of pancreatic and colon cancers.
• Physical exam was unremarkable and laboratory
  studies were within normal limits.
• Endoscopic Gastro-Duodenoscopy (EGD) and
  abdominal CT were ordered.

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Case History

• On EGD, the patient was found to have a small
  hiatal hernia. Biopsy of a gastric polyp showed
  benign histology.
• The following was found on the abdominal CT

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Radiological Presentations
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Radiological Presentations
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Radiological Presentations
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Radiological Presentations
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Radiological Presentations
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Radiological Presentations
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Radiological Presentations
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Test Your Diagnosis
Which one of the following is your choice for the
appropriate diagnosis? After your selection, go
to next page.

• Hepatocellular Carcinoma
• Cholangiocarcinoma
• Hemangioma
• Lipoma
• Arteriovenous Malformation
• Simple Cyst
• Focal Nodular Hyperplasia
• Adenoma
• Transient Hepatic Intensity Difference

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5.4 x 4.7 x 4.6 cm mass in the right lobe
adjacent to the gallbladder fossa.Associated
satellite lesions.Nodular liver with capsular
retraction. No involvement of portal venous
system or dilation of the bile ducts.Arterial
phase enhancement and marked delayed enhancement
on CT and MRI.Biopsy showed poorly
differentiated carcinoma with occasional gland
formation.
Findings and Differentials
Findings
Differentials

• Hepatocellular Carcinoma
• Cholangiocarcinoma
• Hemangioma
• Adenoma
• Focal Nodular Hyperplasia

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Discussion

• Hepatocellular Carcinoma
• Associated with hepatitis, alcoholism,
  cirrhosis, and hemochromatosis.
• Elevated LFTs and decreased synthetic function.
• MRI T1 hypointense, T2 hyperintense, intense
  arterial enhancement.
• Histology hepatocyte-like with pseudogland
  formation. May stain for bile or AFP
• Cholangiocarcinoma
• Associated with PSC, liver fluke infection,
  hepatitis C, cirrhosis, Thorotrast exposure.
• May present with jaundice or may be
  asymptomatic.
• MRI Homogenous, T1 hypointense, T2
  hyperintense, remains enhanced on delayed
  images.
• Histology Typically glandular and
  well-differentiated, may resemble biliary
  epithelium

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Discussion

• Hemangioma
• Asymptomatic and found incidentally.
• MRI Nodular enhancement, T1 hypointense, T2
  hyperintense.
• Histology Reveals vascular structures.
• Adenoma
• May rarely cause hepatomegaly and RUQ pain but
  typically incidentally found. Associated with
  OCP use.
• MRI T1 hyperintense, T2 hyperintense due to fat
  content.
• Histology Uniform hepatocytes.
• Focal Nodular Hyperplasia
• Clinically silent.
• Usually an incidental finding during imaging or
  autopsy.
• MRI Iso/hypointense on T1, iso/hyperintense on
  T2, central vessels visible, uniform arterial
  enhancement with delayed
• Histology Resembles adenoma.

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Findings most consistent with intrahepatic
mass-forming cholangiocarcinoma.Next step
staging to determine resectability, usually with
ERCP to evaluate biliary structures and further
body imaging to evaluate for metastasis.
Diagnosis
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Cholangiocarcinoma is a cancer arising from the
biliary duct system.Incidence is 1 in 100,000
persons per year in the US (approx 2500
cases/yr).Associated with PSC, liver fluke
infection, hepatitis C, cirrhosis, Thorotrast
exposure.Tumors are classified by location
intrahepatic (25), hilar (AKA Klatskin tumor),
or extrahepatic.Further classified by
morphology mass-forming, periductal-infiltrating,
or intraductal- growing.90 are
adenomatous.Treatment consists of surgical
removal or palliative biliary decompression.5-ye
ar survival is 9-18 overall and up to 22-36 for
intrahepatic tumors.
Diagnosis
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Diagnosis
Nature Clinical Practice Gastroenterology
Hepatology 2006
AJR 2003
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Choi B, Lee J, Han J. Imaging of intrahepatic
and hilar cholangiocarcinoma. Abdominal Imaging
2004 29548-557.Elsayes K, Narra V, et al.
Focal Hepatic Lesions Diagnostic Value of
Enhancement Pattern Approach with
Contrast-enhanced 3D Gradient-Echo MR Imaging.
RadioGraphics 2005251299-1320.Leong T, Leong
A. Prognostication in Intrahepatic
Cholangiocarcinoma. Adv Anat Pathol
2006299-100. Lim J. Cholangiocarcinoma
Morphologic Classification According to Growth
Pattern and Imaging Findings. AJR
2003181819-827.Patel T. Cholangiocarcinoma.
Nature Clinical Practice Gastroenterology
Hepatology 2005133-42.Emedicine.com.
References