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Essential Radiology for Oncologist: Abdominal Imaging

Piyaporn Apisarnthanarak, M.D. Department of Radiology, Faculty of Medicine Siriraj Hospital Objectives

• Pro and cons of each imaging modality • Basic CT protocol • Basic CT anatomy • Know keywords for diagnosis of common intraabdominal tumors Imaging Modalities

• Ultrasound • CT • MRI Imaging Modalities

• Ultrasound – Cheap and available – For screening (need further investigation) – Poor penetration of fat and air • CT: investigation of choice – Main imaging study for tumor evaluation – Radiation and iodine contrast Imaging Modalities

• MRI – High contrast resolution – Good for tissue characterization – No radiation – Limitations: • Cost • Not available • Claustrophobia • High magnetic fields • Motion artifacts • Difficult to interpret CT vs MRI

• CT is preferred – Available, easy to understand – Thin slice, less artifact

• MRI is suggested for – Ped or pregnant – Allergic to iodine contrast – Impaired renal function ?? – Prostatic CA, breast CA – CT can not give the diagnosis – DDx post-op fibrosis or recurrent tumor Abdominal CT Protocols

• Noncontrast • Postcontrast – Arterial phase – Portal phase – Delayed phases Hepatic CT Protocols

Noncontrast Arterial

Portal Delayed Noncontrast CT

• Liver density – Fatty liver

• Mass – Internal fat, calcification or bleeding – Enhancement by compare with postcon CT – May give more accurate size measurement Normal

Fatty Liver

Moderate Severe Noncontrast CT

• Liver density – Fatty liver

• Mass – Internal fat, calcification or bleeding – Enhancement by compare with postcon CT – May give more accurate size measurement Fatty Mass

Noncontrast Postcontrast Calcified Mass

Noncontrast Postcontrast Bleeding Mass

Noncontrast Postcontrast Noncontrast CT

• Liver density – Fatty liver

• Mass – Internal fat, calcification or bleeding – Enhancement by compare with postcon CT – May give more accurate size measurement More Accurate Size Measurement

Noncon Postcon

Radiology 1999;213:825-30 Arterial Phase

• Detection of hypervascular mass – Primary hepatic CA - HCC - CholangioCA – Hypervascular liver metastases - Neuroendocrine tumors - RCC - GIST - ChorioCA - Melanoma - Some breast CA - Some sarcoma – Other benign liver mass - Heman - FNH - Hepatic Portovenous Phase

• Routine for abdominal CT – Homogeneous organ enhancement – Vascular evaluation • Detection: hypovascular liver mass Liver Liver Liver

Noncontrast Arterial Portal Noncontrast Arterial Portal

Hypervascular Liver mass Noncontrast Arterial Portal

Hypervascular Liver mass Hypervascular Liver Mass

Arterial phase

Portal phase Pseudolesions (Perfusion Alteration) Noncontrast Arterial Portal

Hypovascular Liver mass Noncontrast Arterial Portal

Hypovascular Liver mass Hypovascular Liver Mass Portal Vein Invasion

Portal phase Varices

Arterial phase

Portal phase Delayed Phase

• Contrast washout from organs • Good for – Hemangioma – CholangioCA – Fibrosis Hemangioma CholangioCA

Noncontrast Postcontrast

Radiology 2006;238:150-5 ABDOMINAL LYMPHADENOPATHY

CASES Case 1

• A 56-year-old woman with history abdominal fullness, weakness and weight loss

Case 1

• What is the most likely diagnosis?

A. Hemangiomatosis B. Hepatic adenomatosis C. Hepatocellular D. E. Liver metastasis Case 1

• What is the most likely diagnosis?

A. Hemangiomatosis B. Hepatic adenomatosis C. D. Cholangiocarcinoma E. Liver metastasis HCC

• Underlying liver cirrhosis • Hypervascular lesion (arterial enhancing mass) • Washout with capsular enhancement on portal phase • Vascular invasion esp. portal vein – DDx: cholangioCA (less common) • +/- Biliary dilatation (less common than cholangioCA) • Ruptured in subcapsular or pedunculated lesion HCC

• Underlying liver cirrhosis • Hypervascular lesion (arterial enhancing mass) • Washout with capsular enhancement on portal phase • Vascular invasion esp. portal vein – DDx: cholangioCA (less common) • +/- Biliary dilatation (less than cholangioCA) • Ruptured in subcapsular or pedunculated lesion Arterial

Portal Underlying Cirrhosis HCC with PV Thrombosis HCC with PV Thrombosis Portal Vein Invasion

Portal phase HCC with Invasion Ruptured HCC Metastatic HCC DDx: Hypervascular Lesion

• HCC • Hypervascular metastases • Other benign hepatic lesions – FNH – Hepatic adenoma – Hemangioma • Pseudolesions Case 2

• A 64-year-old man with history of RUQ pain, and weight loss Case 2 Case 2

• What is the most likely diagnosis?

A. Hepatocellular carcinoma B. Cholangiocarcinoma C. Biliary D. Liver metastasis E. Liver abscess Case 2

• What is the most likely diagnosis?

A. Hepatocellular carcinoma B. Cholangiocarcinoma C. Biliary cystadenocarcinoma D. Liver metastasis E. Liver abscess CholangioCA

• Endemic area • Biliary dilatation with or without mass • Low density mass with progressive enhancement – DDx: hepatic hemangioma • +/- PV invasion • Associated capsular retraction CholangioCA

• Endemic area • Biliary dilatation with or without mass • Low density mass with progressive enhancement – DDx: hepatic hemangioma • +/- PV invasion • Associated capsular retraction Case 2 CholangioCA with Hilar Mass CholangioCA without Detectable Mass Progressive Enhancement CholangioCA

• Progressive enhancement in delayed phases >> fibrous component >> poor prognostic factor.

Radiology 2006;238(1):150-5 Hemangioma

- Peripheral puddle (nodular) enhancement - Incontinuous fashion - Progressive filling in - Dense as vessels CholangioCA

- Peripheral enhancement - Continuous fashion - Progressive filling in - Less dense Type • Location – Peripheral (IHD) type – Hilar type (Klatskin tumor) – Extrahepatic (CBD) type • Pattern – Mass forming type – Infiltrative type – Intraluminal polypoid mass Mass Forming Type

Peripheral cholan Mass Forming Type

Hilar cholan Infiltrative Type

Hilar cholan Intraluminal Polypoid Mass

Extrahepatic cholan Metastatic CholangioCA Case 3

• A 72-year-old woman with chronic constipation, fatique and weight loss Case 3 Case 3

• What is the most likely diagnosis?

A. Multiple liver abscesses B. Multifocal HCC C. Multifocal cholangioCA D. Multiple liver metastases E. Hepatic lymphoma Case 3

• What is the most likely diagnosis?

A. Multiple liver abscesses B. Multifocal HCC C. Multifocal cholangioCA D. Multiple liver metastases E. Hepatic lymphoma Hepatic Metastases

• Underlying CA elsewhere • Normal liver • Target lesion • Calcified liver lesion (mucin-producing adenoCA) – DDx: granuloma • Multiple, diffuse • +/- biliary dilatation • Rare vascular invasion Hepatic Metastases

• Underlying CA elsewhere • Normal liver • Target lesion • Calcified liver lesion (mucin-producing adenoCA) – DDx: granuloma • Multiple, diffuse • +/- biliary dilatation • Rare vascular invasion Target Lesions Target Lesions Calcified Liver Met

CA colon met CA breast met Calcified Liver Met Liver Metas with Bile Duct Dilatation Evaluation

• Liver metastases – Hypervascular – Hypovascular – Calcified lesion • Primary CA with route of spreading • Other distant metastases – Splenic met – LN met – Carcinomatosis peritonei – Lung met • Response after Rx Hypervascular Met Hypervascular Liver Met

• (, ) • GIST • RCC • Thyroid • Some breast CA • Melanoma • ChorioCA • Sarcoma CA Sigmoid Colon with LN and Liver Metastases CA Sigmoid Colon with LN and Liver Metastases Pancreatic CA with Peritoneal Metastases CA Cervix with Liver, LN and Lung Metastases Responsed Lesions

Before chemo

After chemo Pseudocirrhosis

Before chemo

After chemo Before Rx

GIST with 1 mo FU Liver Met

5 yr FU Case 4 Case 4

• What is the most likely diagnosis?

A. B. Gastric adenoCA C. Gastric GIST D. Hypertrophic gastritis E. Intussusception Case 4

• What is the most likely diagnosis?

A. Gastric lymphoma B. Gastric adenoCA C. Gastric GIST D. Hypertrophic gastritis E. Intussusception Gastric Lymphoma vs by CT

Perigastric adenopathy is seen in 50%–60% of cases of both lymphoma and adenocarcinoma GIST AdenoCA Lymphoma

-M/C mesenchymal tumor of -M/C gastric -M/C GI lymphoma GI tract stomach (70%), NHD>HD, small intestine (20-30%) Secondary>primary

-Solitary, large, round -Most endophytic mass -Thicker, more diffuse tumor of gastric wall or irregular focal wall circumferential -Exophytic (common)/ thickening involvement Intramural/endophytic -Ulcer common -HD can be scirrhous or - Necrosis, ulcer, cavitate thickened fold common (heterogeneous -MALT lymphoma>multiple enhancement) round, confluent nodule -25% calcification Obstruction rare -Scirrhous CA (linitis -Remain distensible, gastric plastica)> outlet obstruction (rare) nondistensible -Gastric outlet obstruction Metas to liver, peritoneum Regional LN, ascites, LN (over than gastric but LN rare metastasis drainage) is clue Gastric Lymphoma Gastric CA

Gastric lymphoma

AJR 2010;195:1124–30 Gastric GIST Abdominal Lymphoma

• Lymphadenopathy – Soft: sandwich sign • Hepatosplenomegaly • Masses – Liver, spleen, renal, etc. – Bowel: stomach, terminal ileum – Peritoneal Lymphoma: Sandwich Sign

ISRN Radiology 2013 Lymphoma

AJR 2008;191:198-206 ISRN Radiology 2013 Renal Lymphoma

AJR 2008;191:198-206 ISRN Radiology 2013 Lymphoma: Bowel

AJR 2008;191:198-206 ISRN Radiology 2013 Peritoneal Lymphomatosis

ISRN Radiology 2013 Peritoneal Lesions

• Carcinomatosis peritonei • • Peritoneal lymphomatosis • • TB peritoneum CA Ovary with Liver, Spleen and Peritoneal Metastases CA Ovary with Pseudomyxoma Peritonei Peritoneal Lymphomatosis

ISRN Radiology 2013 TB Peritoneum

Indian J Radiol Imaging 2010;20:58-62