​​歐放精選(010):肝臟血管瘤及其它血管瘤性腫瘤及腫瘤樣病變:常見及少見的影像學表現、磁共振診斷誤區及對策

ECR 2011 / C-1900

Hepatic hemangiomas, and other hemangiomatous tumors and tumor-like lesions: usual, unusual imaging manifestations, pitfalls and problem-solving MR techniques

Congress:

ECR 2011

Poster Number:

C-1900

Type:

Educational Exhibit

Keywords:

MR, CT, MR-Diffusion/Perfusion, Haemangioma, Liver

Authors:

K. Matsuzaki, M. Takeuchi; Tokushima/JP

DOI:

10.1594/ecr2011/C-1900

DOI-Link:

https://dx.doi.org/10.1594/ecr2011/C-1900

Learning objectives

- To review the various imaging manifestations of hepatic hemangiomas, and other hemangiomatous tumors and tumor-like lesions. 

- To describe clinical and imaging features of hemangiomatous lesions for the differential diagnosis, pitfalls, and problem-solving MR techniques. 

Background

Hepatic hemangiomas and other hemangiomatous tumors and tumor-like lesions may show characteristic clinical and imaging manifestations reflecting their pathologic features. Various degeneration in hemangiomas, and surrounding parenchymal changes may influence the imaging manifestations of hemangiomas. 

In this exhibit we demonstrate usual, unusual imaging manifestations of hepatic hemangiomas and other hemangiomatous lesions, pitfalls and problem-solving MR techniques.

Imaging findings OR Procedure details

Various hemangiomas and other hemangiomatous lesions such as cavernous and sclerosed hemangiomas, solitary necrotic nodule as the end-stage of sclerosed hemangiomas, giant hemangiomas, hemangiomatosis, angiomyolipomas, and angiosarcomas may show characteristic clinical and imaging manifestations reflecting their pathologic features.  

Various degeneration such as hyalinization, cystic formation, fibrosis, calcification and thrombosis, and surrounding parenchymal changes such as co-existing fatty infiltration of the liver with peri-tumoral focal spared areas, peripheral parenchymal retraction, and arterial-portal venous shunts may influence the imaging manifestations. Problem-solving MR techniques such as chemical shift imaging, diffusion-weighted imaging (DWI), SPIO-MRI and Gd-EOB-MRI for the diagnosis of problematic cases are reviewed.

 

[Cavernous hemangioma]

- Most common benign neoplasm of the liver.

- Frequently affects middle-aged - postmenopausal women.

- Occurs sporadically.

- Usually asymptomatic.

- Composed of numerous vascular channels lined by a single layer of benign endothelial cells, which are supported by a thin fibrous stroma.

- Usually solitary; 10% multiple.

- Calcification: less common (< 10%)

 

Imaging manifestations:

- Well demarcated, round or lobular mass.

- Low on plain CT (isodense to blood)

- Water-like signal intensity on T1/T2WI (low on T1WI/very high on T2WI)

- High on DWI.

- Characteristic dynamic CT/MR findings:

Early (arterial) phase: peripheral nodular enhancement.

Portal -Venous phase: progressive, centripetal filling.

Delayed phase: prolonged enhancement.

Fig. 1: Internal structure

Fig. 2: CE patterns on Dynamic study

Fig. 3: Dynamic CT (typical)

Fig. 4: Dynamic MRI (typical)

Fig. 5: Diffusion-weighted imaging (DWI)

Fig. 6: Cyst vs Hemangioma

 

- Superparamagnetic iron oxide (SPIO) MRI

Characteristic signal increase on SPIO-T1WI due to the pooling of SPIO particles with paramagnetic T1-shortening effect.

Slight signal decrease on SPIO-T2WI due to T2*-shortening effect of SPIO particles. 

Fig. 7: SPIO pattern

Fig. 8: SPIO (typical)

 

- Gd-EOB-MRI (Gadoxetic acid disodium)

May show "pseudo washout" (no persisting enhancement during the equilibrium - delayed phase) due to contrast uptake in the surrounding normal liver parenchyma.

Low intensity on hepatobiliary phase of Gd-EOB-MRI (No uptake)

Fig. 9: EOB MRI (typical)

 

Small, high-flow hemangioma:

- Flash filling: Rapid, intense homogeneous or dominant portion enhancement on the arterial phase mimicking hypervascular metastasis or hepatocellular carcinoma. 

- SPIO-MRI is useful for the diagnosis.

 

Fig. 10: Dynamic CT

Fig. 11 Dynamic MRI

 

Giant hemangioma:

- Diameter > 10cm

- May cause abdominal discomfort and/or pain.

- May be associated with Kasabach-Merritt syndrome (thrombocytopenia)

 

- Usually without bulging of liver contour.

- May be heterogeneous low density on plain CT due to degeneration - fibrous scar.

- May show heteogeneous, incomplete centripetal filling with unenhanced central scar on the delayed phase.

- May contain marked high intense central scar or cystic degeneration on T2WI.

 

Fig. 12: Giant hemangioma

 

Other atypical manifestations

- Arterial-portal venous shunt (A-P shunt)

- A-P shunt is usually associated with malignant tumors but can also be seen in hemangiomas. 

- Not rare.

 

- Pedunculated hemangioma

- Exophytic growth from the liver surface.

- Very rare. 

- May be complicated by subacute torsion and infarction.

 

- Peripheral parenchymal retraction

- Peripheral parenchymal retraction is usually associated with malignant tumors with desmoplastic changes such as cholangiocellular carcinomas or metastatic adenocarcinomas.

- Hemangioma with fibrous degeneration may also cause peripheral parenchymal retraction. 

- Not common.

 

- Co-existing fatty infiltration of the liver with peri-tumoral focal spared areas

- On plain CT, hemangioma in fatty liver may not be seen, or may be hyperdense relative to the liver.

- Focal spared areas in fatty liver are common along the hepatic hilum or around the gallbladder due to non-portal venous supply.  Focal spared areas may also occur around the tumors such as hemangiomas due to the lack of portal venous supply.

- Chemical shift imaging is useful for the correct diagnosis of focal spared areas. 

- Hepatobiliary phase of Gd-EOB-MRI can demonstrate the correct tumor contour. 

- Nodular hyperplastic changes associated with hemangioma

- Increased arterial supply may cause nodular hyperplastic changes in surrounding hepatic parenchyma. 

- Very rare.

 

Fig. 13: Hemangioma with A-P shunt

Fig. 14: Pedunculated hemangioma

Fig. 15: Peri-tumoral focal spared area in fatty liver

 

[Hemangiomatosis]

- Extensive hemangioma throughout the liver.

- May be associated with some medications such as estrogen and metoclopramide.

- Liver transplantation should be considered for patients with congestive heart failure or progressive liver dysfunction.

- On imaging numerous hemangiomas are observed throughout the liver.

 

Fig. 16: Hemangiomatosis

 

[Sclerosed hemangioma]

- Cavernous hemangiomas that undergo degeneration, hyalinization and fibrous replacement.

- Extremely rare.

- A.K.A. thrombosed, or hyalinized hemangiomas.

- Definite preoperative diagnosis is difficult. 

- Geographic pattern.

- Volume loss manifested by capsular retraction due to fibrosis.

- Transient hepatic attenuation difference in the arterial phase (Segmental CE)

- Admixture of T2-low/delayed CE: sclerosis (fibrosis) and T2-high/CE(-): hyalinization.

 

Fig. 17: Sclerosed hemangioma

 

[Solitary necrotic nodule]

- Rare, nonmalignant lesion of the liver.

- Usually affects middle to high-aged men.

- Usually asymptomatic, occasionally abdominal pain or discomfort, rarely fever.

- Pathogenesis remains unclear, but may be multifactorial such as parasitic infection, trauma, and sclerosed hemangiomas (as the end-stage of sclerosed hemangiomas) 

- Hypoechoic, heterogeneous mass on US.

- Low dense mass on plain CT.

- Unenhanced in most lesions due to coagulative necrosis. 

- May show slight peripheral enhancement on the early phase of dynamic study due to granulation tissue with infiltration of inflammatory cells surrounding the necrotic area. CTA can clearly demonstrate peripheral enhancement (ring enhancement)

- Low on T1WI, iso - slight high on T2WI reflecting coagulative necrosis.

- Low - slight high on DWI.

- No SPIO uptake, No Gd-EOB uptake.

 

Fig. 18: Solitary necrotic nodule 1

Fig. 19: Solitary necrotic nodule 2

 

[Angiomyolipoma]

- Benign mesenchymal tumor (hamartoma) 

- Usually affect the kidneys, and rarely the liver.

- Composed of variable amounts of smooth muscle, adipose tissue, and vessels.

- May be associated with tuberous sclerosis.

- Usually asymptomatic, spontaneous rupture may occur in large masses. 

- Admixture of mature fat and soft tissue components is a characteristic imaging finding of this tumor.

- Hypervascularity and prolonged enhancement on dynamic study are the diagnostic clues.

 

Fig. 20: Angiomyolipoma

 

[Angiosarcoma]

- Malignant tumor of endothelial cells, and may form poorly organized vessels.

- Sinusoidal, papillary, and cavernous growth patterns may be observed.

- Drugs (Cyclophosphamide and anabolic steroids), Irradiation, and Environmental carcinogens (Polyvinyl chloride, Thorotrast, and Arsenicals) may cause angiosarcoma.

- Affects usually 60-70 years of age, male predominant.

- Symptoms: Weakness, pain, anemia.

- Rapid and early spread (intrahepatic, spleen, lungs, bone, lymphnodes, and peritoneum), Poor prognosis (Median survival time: 6 months) 

- Single or multiple hypodense masses on Plain CT, hemorrhagic area may show hyperdense.

- Usually shows heterogeneous CE pattern with the admixture of nodular, bizarre, or ring enhancement.

- May show similar CE pattern to hemangioma on dynamic study

- Heterogeneous intensity on MRI due to the admixture of tumor cells, flesh and old hemorrhage, fibrous tissue, necrosis, and dilated vascular spaces.

 

Fig. 21: Angiosarcoma: CT

Fig. 22: Angiosarcoma: MRI

Fig. 23: Angiosarcoma: Metastases

Conclusion

To recognize various imaging manifestations of hemangiomas and other hemangiomatous lesions, and making accurate diagnosis by using problem-solving MR techniques are important for appropriate management of the patients.

Personal Information

Kenji Matsuzaki, MD, PhD

Department of Radiology, University of Tokushima

3-18-15, Kuramoto-cho

Tokushima, 7708503, JAPAN 

tel: [phone]

fax: [phone] 

e-mail: [e-mail]

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FROM：https://epos.myesr.org/poster/esr/ecr2011/C-1900

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