Shahid M.Hussain • Michael F.Sorrell

Liver MRI

Shahid M. Hussain • Michael F.Sorrell

Liver MRI

Correlation with Other Imaging Modalities and Histopathology

Second Edition

Forewords by Willis C. Maddrey and Richard C. Semelka Shahid M. Hussain, M.D. Michael F. Sorrell, M.D. Herbert B. Saichek Professor of Radiology Robert L. Grissom Professor of Medicine University of Nebraska Medical Center University of Nebraska Medical Center Omaha, NE, USA Omaha, NE, USA

ISBN 978-3-319-06003-3 ISBN 978-3-319-06004-0 (eBook) DOI 10.1007/978-3-319-06004-0 Springer Cham Heidelberg New York Dordrecht London

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Foreword I

Liver MRI, now in its second edition, is a comprehensive well-written approach to the state of MRI art as regards the liver. Magnetic resonance imaging techniques and applications have rapidly and extensively evolved since the introduction of the technology in the early 1970s. Hepatologists have benefited greatly from the widespread availability and utilization of MRI which allows precise visualization of the liver and its surroundings in multiple planes and with extremely high resolution. Through MRI, we have relearned (or on occasion learned!) the precise anatomy of the liver and the environment in and around the liver. Through MRI we gain often valuable knowledge about blood flow to and from the liver. Furthermore, complications of cirrhosis have been carefully delineated including assessment of portal hypertension and demonstration of blockages in the portal vein, inferior vena cava, or hepatic veins. By going directly to MRI, clinicians save time, increase accuracy of diagnosis, and avoid ionizing radiation. In many aspects MRI is cost-efficient by decreasing the number of often used less precise imaging studies while adding considerably to the surety of a diagnosis. Advances in the formulation of contrast agents have made the procedure progressively safer and reactions to contrast agents have considerably diminished. Problems encountered earlier with nephrogenic fibrosis caused by gadolinium-based contrast media especially in patients with borderline renal function have largely been solved by new formulations. Even the issue of claustrophobia, which is a problem for many patients, has been minimized by the development of more open MRI. The differential diagnosis of a hepatic nodule is a superb example of the power of MRI in directing the clinician to the correct conclusion. A nodule (or suspected nodule) often initially identified on an ultrasono- graphic examination is evaluated by proceeding directly to MRI. The accurate diagnosis of hepatic nodules requires differentiation between hemangiomas, hepatic adenomas, focal nodular hyperplasia, regenerative nodules, and of course primary or metastatic tumors. Since many small malignant tumors are candidates for surgical removal, the information gleaned from the MRI provides a road map for designing resectional sur- gery. In addition MRI has well-recognized roles in the assessment of patients being considered for liver transplantation and in the post-transplantation follow-up. All these conditions are fully described in Liver MRI. The use of MRI in patients with a variety of chronic liver diseases may provide sufficient diagnostic information so that liver biopsy is less often needed. Within this volume many highly specific and rarely encountered disorders of the liver are well described. There are sections of the volume such as changes of the liver during pregnancy that I might never use but am comforted by knowing where I should go should the need arise. The section on hepatic vein thrombosis is of particular interest as is the section on iron in the liver and the changes found with progressive accumulation of iron up to and including the stage of cirrhosis. Liver MRI is a worthy companion to standard textbooks regarding the liver. As a non-radiologist, I approached the book cautiously only to be surprised by its accessibility in explaining the interpretation of hepatic disorders through the use of well-chosen images. The artistic drawings accompanying the radiographs are well done and informative. I found myself reading further and enjoying the learning experience. Armed with information from this volume, the clinician will be better prepared for productive consultations with radiologic colleagues. The volume is encyclopedic in scope yet designed so as to be approachable and understandable.

Willis C. Maddrey, M.D. Adelyn and Edmund M. Hoffman Distinguished Chair in Medical Science Arnold N. and Carol S. Ablon Professorship in Biomedical Science Department of Internal Medicine UT Southwestern Dallas, TX, USA Foreword II

In this second edition of this well-received book on MRI of the liver, Shahid Hussain has evolved all aspects of this work. The text is greatly expanded, including description of up-to-date sequences; many more figures are included; and he has incorporated as a coauthor Michael Sorrell who is a highly regarded hepatologist. In this regard Dr. Hussain has incorporated all elements necessary to generate a new textbook that keeps pace with the evolving nature of healthcare. Not only is it necessary to keep current and expand knowledge into imaging, which he has done, but by incorporating the efforts of a highly regarded clinician, he maintains the focus on what is essential for patients and for their care. In the current environment of superspecializa- tion, this attention to patient-centric care, by involvement of experts with differing areas of expertise, is mandatory to ensure optimal patient management and outcome. It is also imperative, as multiple imaging modalities evolve, to pay attention to correlation of findings from the modality under description (MRI) with the other modalities that are commonly used to investigate an organ system, in this case, CT, ultrasound, and nuclear medicine. This serves therefore to put into context all the varying information that may be generated on a particular patient with particular imaging findings in the liver. As individual radiologists with subspe- cialization focus on their own area of interest, it becomes mandatory that some reference or source ties all this disparate information together. This is what this book accomplishes. The major focus of this book remains the description of MR imaging as the premier imaging modality to investigate the liver. Dr. Hussain has expanded considerably the content of this book in this regard, especially into diffuse liver diseases. As MRI is also very technology driven, this book provides up-to-date information on these technical advances. MR imaging is complex, due to the variety and depth of information provided and to the technical nature of the modality. Drs. Hussain and Sorrell have been able to render MRI descriptions into readily comprehen- sible information. This is aided by the correlation with other imaging modalities, to contextualize the findings. This book solidifies Shahid Hussain’s standing as one of the world’s greatest authorities on imaging of diseases of the liver. Michael Sorrell brings to the table international expertise into clinical information on patients with a variety of hepatic disease processes. This book remains a must-read for individuals interested in imaging findings in patients with suspected liver disease, including radiologists, hepatologists, residents, radiology technicians, and medical students.

Richard C. Semelka, M.D. Professor and Vice-Chair of Quality and Safety, Director of MRI Services Department of Radiology University of North Carolina at Chapel Hill Chapel Hill, NC, USA Preface

MR imaging has become the major tool for the diagnosis of liver diseases. The cross-sectional imaging techniques in general and MRI in particular often generate bewildering amount of information to accurately assess various liver abnormalities. This textbook provides the in-depth background information of all aspects of liver MRI and its applications to improve the level of understanding of the experts as well as the students of this field. With the faster imaging sequences, safer contrast media, lack of ionizing radiation, superb intrinsic soft tissue contrast, dynamic contrast-enhanced imaging, diffusion-weighted imaging, Dixon-based imaging (liver fat and iron quantification), MRCP, 4D flow imaging, MR elastography, and the liver-specific contrast agents, liver MRI has become central to the assessment of a wide spectrum of benign and malignant liver disorders. A substantial body of literature has demonstrated the efficacy of liver MRI compared to ultrasound and triple-phase CT. The clinicians and radiologists should collaborate and apply the best possible modality to assess the liver disorders in their clinical setting.

How to Use This Book

Part I of the book provides the background information in regard to the MRI technique, contrast media, safety, and differential diagnosis. To diagnose most liver diseases, four sequences are most important to evaluate. These include: (1) a fat-suppressed T2-weighted sequence (or an equivalent sequence), (2) a T1 in-phase gradient- echo sequence, (3) arterial-phase dynamic gadolinium-enhanced images, and (4) delayed-phase gadolinium- enhanced images. This book provides computer-generated drawings of these or four similar MRI sequences to highlight and explain the most important diagnostic findings. The direct MRI drawing comparison facilitates the interpretation of the important imaging findings. In addition, background information and up-to-date avail- able literature are provided, with correlation to other imaging modalities (US, CT) and pathology. Liver abnormalities are divided into five major categories. Within each category, subcategories are provided and more specific diagnoses are listed alphabetically. Based on this book, liver MRI can be approached as follows: Step I: Categorize the liver abnormality into one of the five groups: 1. High fluid content liver lesions (high signal on T2 which persists on longer T2) 2. Solid liver lesions (moderately high signal on T2; similar to the spleen or lower) 3. Diffuse liver lesions (expressed by the diffuse or segmental abnormal signal or enhancement) 4. Vascular liver lesions (visible mainly in the arterial phase) 5. Biliary tree abnormalities (visible on T2-weighted and MRCP sequences) Step II: Evaluate the signal intensity on fat-suppressed T2- and T1-weighted sequences as well as gadolinium-enhanced images and attempt a more specific diagnosis. Step III: Compare your working diagnosis to the specific examples within each category systematically and confirm your finding into a more definitive (differential) diagnosis. This approach is consistently applied throughout the book, which shows that most liver lesions can be detected and characterized based on this method.

Shahid M. Hussain, M.D. Herbert B. Saichek Professor of Radiology University of Nebraska Medical Center Omaha, NE, USA

Michael F. Sorrell, M.D. Robert L. Grissom Professor of Medicine University of Nebraska Medical Center Omaha, NE, USA XII X PartI MRI Technique, Contrast, Safety, Anatomy, and DifferentialXI Part I MRI Technique, Contrast, Safety, Anatomy, and Differential

Contents

Foreword I ...... IX Foreword II ...... X Preface ...... XI

Part I MRI Technique, Contrast, Safety, Anatomy, and Differential 1 Liver MRI: Comparison of the Two Main Approaches ...... 2 2 Gadolinium-Based Contrast Agents: An Overview ...... 4 3 Gadolinium-Based Contrast Agents: Uptake and Excretion Pathways ...... 6 4 Liver-Specific Contrast Agents: Uptake in the Liver and Lesions ...... 8 5 MR Imaging Technique and Protocol ...... 10 6 Liver MRI: Pulse Sequence Diagram of T1- and T2-Weighted Sequences ...... 12 7 Magnetic Resonance Cholangiopancreatography (MRCP) Technique ...... 14 8 Liver MRI: Diffusion-Weighted Imaging and Apparent Diffusion Coefficient ...... 16 9 DWI: Liver Lesion Characterization ...... 18 10 Dixon-Based Sequence: Technique and Applications ...... 20 11 Liver MRI: Simple Steps to Change a Nondiagnostic into Diagnostic Exam ...... 22 12 Liver Segmental and Vascular Anatomy at MR Imaging ...... 24 13 Portal and Hepatic Venous Anatomy with the New Liver Anatomy Concepts ...... 26 14 Hepatic Arterial Anatomy and Variants ...... 28 15 Biliary Tree Anatomy and Variants ...... 30 16 Liver Lesions: Appearance with the Enhancement Patterns (Drawings) ...... 32 17 Liver Lesions: Appearance with the Enhancement Patterns (MR Images) ...... 34 18 T2 Bright Liver Lesions: Differential Diagnosis ...... 36 19 T1 Bright Liver Lesions: Differential Diagnosis ...... 38 20 T2 Bright Central Scar: Differential Diagnosis ...... 40 21 Lesions in Fatty Liver: Differential Diagnosis ...... 42

Part II Fluid-Filled Liver Lesions 22 Abscess I: Pyogenic Type with US and CT Correlation ...... 46 23 Abscess II: Pyogenic Type with DWI and MinIP Patterns ...... 48 24 Biliary Hamartomas (Von Meyenburg Complexes) ...... 50 25 Cyst I: Typical Small ...... 52 26 Cyst II: Typical Large with MR-CT Correlation ...... 54 27 Cyst III: Multiple Small Lesions with MR-CT-US Comparison ...... 56 28 Cyst IV: Adult Polycystic Liver and Kidney Disease ...... 58 29 Cystadenocarcinoma: Cystic and Solid Components ...... 60 30 Hemangioma I: Typical Small ...... 62 31 Hemangioma II: Typical Medium Sized with Pathology Description ...... 64 32 Hemangioma III: Role of Diffusion-Weighted Imaging ...... 66 33 Hemangioma IV: Typical Giant ...... 68 34 Hemangioma V: Typical Giant Type with a Large Central Scar ...... 70 35 Hemangioma VI: Flash-Filling with US and CT Correlation ...... 72 36 Hemangioma VII: Multiple Lesions, Comparison with US and CT Findings ...... 74 37 Hemorrhage ...... 76 XIV Contents

38 Hemorrhage: Within a Solid Tumor ...... 78 39 Hydatid Disease (Echinococcosis): MRI and CT Findings with the Cyst Anatomy ...... 80 40 Mucinous Metastasis I: Mimicking a Hemangioma ...... 82 41 Mucinous Metastasis II: Role of DWI, PET, and Liver Segmentation ...... 84

Part III Solid Liver Lesions III A: Metastases: colorectal 42 Colorectal Metastases I: Typical Lesion ...... 90 43 Colorectal Metastases II: MRI Findings in a Fatty Liver ...... 92 44 Colorectal Metastases III: With Liver-Specific Gadolinium-Based Contrast Agent ...... 94 45 Colorectal Metastases IV: Typical Multiple Lesions ...... 96 46 Colorectal Metastases V: Metastases Versus Cyst ...... 98 47 Colorectal Metastases VI: Metastases Versus Hemangiomas ...... 100 48 Colorectal Metastases VII: Large, Mucinous, Mimicking a Primary Liver Tumor ...... 102 49 Colorectal Metastases VIII: With Portal Vein and Bile Duct Encasement ...... 104 50 Colorectal Metastases IX: Recurrent Disease Versus RFA Defect ...... 106 51 Colorectal Metastases X: MR Imaging Findings Post-chemotherapy ...... 108

III B: Metastases: non-colorectal 52 Breast Carcinoma Liver Metastases ...... 112 53 Melanoma Liver Metastases I: Focal Type ...... 114 54 Melanoma Liver Metastases II: Diffuse Type ...... 116 55 Neuroendocrine Tumor I: Typical Liver Metastases ...... 118 56 Neuroendocrine Tumor II: Pancreatic Tumor Metastases ...... 120 57 Neuroendocrine Tumor III: Gastrinoma Liver Metastases ...... 122 58 Neuroendocrine Tumor IV: Carcinoid Tumor Liver Metastases ...... 124 59 Neuroendocrine Tumor V: Peritoneal Spread ...... 126 60 Neuroendocrine Tumor VI: Role of Diffusion-Weighted Imaging ...... 128 61 Ovarian Tumor Liver Metastases: Mimicking Giant Hemangioma ...... 130 62 Renal Cell Carcinoma Liver Metastasis ...... 132

III C: Primary solid liver lesions in cirrhotic liver 63 Cirrhosis I: Liver Morphology ...... 136 64 Cirrhosis II: Regenerative Nodules and Confluent Fibrosis ...... 138 65 Cirrhosis III: Dysplastic Nodules ...... 140 66 Cirrhosis IV: Cyst in a Cirrhotic Liver ...... 142 67 Cirrhosis V: Multiple Cysts in a Cirrhotic Liver ...... 144 68 Cirrhosis VI: Hemangioma in a Cirrhotic Liver ...... 146 69 Hepatocellular Carcinoma: UNOS/OPTN Reporting ...... 148 70 HCC in Cirrhosis I: Gadoxetate (Liver-Specific) Versus Nonspecific GBCA ...... 150 71 HCC in Cirrhosis II: Stepwise Carcinogenesis ...... 152 72 HCC in Cirrhosis III: Nodule-in-Nodule in the Arterial Phase and DWI ...... 154 73 HCC in Cirrhosis IV: Small Classic Lesion with EASL/AASLD Diagnostic Criteria . . . . . 156 74 HCC in Cirrhosis V: With History of Nonalcoholic Steatohepatitis (NASH) ...... 158 75 HCC in Cirrhosis VI: Typical Small with Pathologic Correlation ...... 160 76 HCC in Cirrhosis VII: Small with and Without a Tumor Capsule ...... 162 77 HCC in Cirrhosis VIII: Nodule-in-Nodule on the T2-Weighted Sequence ...... 164 78 HCC in Cirrhosis IX: Mosaic Pattern with Pathologic Correlation ...... 166 79 HCC in Cirrhosis X: Typical Large with Mosaic and Capsule ...... 168 80 HCC in Cirrhosis XI: Mosaic Pattern with Fatty Infiltration ...... 170 81 HCC in Cirrhosis XII: Large Growing Lesion with Portal Invasion ...... 172 82 HCC in Cirrhosis XIII: Segmental Diffuse with Portal Vein Thrombosis ...... 174 Contents XV

83 HCC in Cirrhosis XIV: With History of Nonalcoholic Fatty Liver Disease (NAFLD) . . . . 176 84 HCC in Cirrhosis XV: Multiple Lesions Growing on Follow-Up ...... 178 85 HCC in Cirrhosis XVI: Multiple T1 Hyperintense Lesions with Subtraction Imaging . . . . 180 86 HCC in Cirrhosis XVII: Capsular Retraction and Suspected Diaphragm Invasion ...... 182 87 HCC in Cirrhosis XVIII: Diffuse Within the Entire Liver with Portal Vein Thrombosis ...... 184 88 HCC in Cirrhosis XIX: With Intrahepatic Bile Duct Dilatation ...... 186

III D: Primary solid liver lesions in non-cirrhotic liver 89 Focal Nodular Hyperplasia I: Typical with Large Central Scar and Septa ...... 190 90 Focal Nodular Hyperplasia II: Typical with Pathologic Correlation ...... 192 91 Focal Nodular Hyperplasia III: Mimicking Metastasis; Role of Liver-Specific Contrast Agents ...... 194 92 Focal Nodular Hyperplasia IV: Typical with Follow-Up Exam ...... 196 93 Focal Nodular Hyperplasia V: Multiple FNH Syndrome ...... 198 94 FNH VI: Findings on the Dynamic Contrast-Enhanced and Hepatobiliary Phases ...... 200 95 Focal Nodular Hyperplasia VII: Gadoxetate Versus Gadobenate ...... 202 96 Focal Nodular Hyperplasia VIII: Fatty Lesion with Concurrent Fatty Adenoma ...... 204 97 Focal Nodular Hyperplasia IX: Atypical with T2 Dark Central Scar ...... 206 98 Hepatic Adrenal Rest Tumor (HART): Fat-Containing with a Left Adrenal Mass ...... 208 99 Hepatic Angiomyolipoma: MR-CT Comparison ...... 210 100 Hepatic Lipoma I: MR-CT-US Comparison ...... 212 101 Hepatic Lipoma II: Findings on Dixon Imaging ...... 214 102 Hepatocellular Adenoma I: Typical with Pathologic Correlation ...... 216 103 Hepatocellular Adenoma II: New Genotypes and Phenotypes ...... 218 104 Hepatocellular Adenoma III: Role of Liver-Specific Contrast and HBP ...... 220 105 Hepatocellular Adenoma IV: Large Exophytic with Pathologic Correlation ...... 222 106 Hepatocellular Adenoma V: Typical Fat-Containing ...... 224 107 Hepatocellular Adenoma VI: With Large Hemorrhage ...... 226 108 Hepatocellular Adenoma VII: Multiple in Fatty Liver (Non-OC-Dependent) ...... 228 109 Hepatocellular Adenoma VIII: Multiple in Fatty Liver (OC-Dependent) ...... 230 110 Hepatocellular Adenoma IX: Changes During Pregnancy ...... 232 111 HCC in Non-cirrhotic Liver I: Small with MR-Pathology Correlation ...... 234 112 HCC in Non-cirrhotic Liver II: Large with MR-Pathology Correlation ...... 236 113 HCC in Non-cirrhotic Liver III: Large Lesion with Inconclusive CT ...... 238 114 HCC in Non-cirrhotic Liver IV: Cholangiocellular or Combined Type ...... 240 115 HCC in Non-cirrhotic Liver V: Central Scar and Capsule Rupture ...... 242 116 HCC in Non-cirrhotic Liver VI: Capsule with Pathologic Correlation ...... 244 117 HCC in Non-cirrhotic Liver VII: Very Large with Pathologic Correlation ...... 246 118 HCC in Non-cirrhotic Liver VIII: Vascular Invasion and Satellite Nodules ...... 248 119 HCC in Non-cirrhotic Liver IX: Adenoma-Like HCC with Pathologic Correlation . . . . . 250 120 Intrahepatic Cholangiocarcinoma I: With Pathologic Correlation ...... 252 121 Intrahepatic Cholangiocarcinoma II: With DWI, PET, and DSA Correlation ...... 254

Part IV Diffuse Liver Parenchymal Disorders 122 Autoimmune Hepatitis I: Serial MRI Changes with Laboratory Correlation ...... 258 123 Autoimmune Hepatitis II: Overlap Syndromes ...... 260 124 HIV/HCV Hepatitis Developing into Cirrhosis with Laboratory Correlation ...... 262 125 Congestive Hepatopathy (Nutmeg Liver) ...... 264 126 Dixon-Based Sequence: Assessment of Liver Fat and Iron Deposition ...... 266 127 Focal Fatty Infiltration Mimicking Metastases ...... 268 128 Focal Fatty Sparing Mimicking Liver Lesions ...... 270 129 Hemosiderosis: Iron Deposition, Acquired Type ...... 272 XVI Contents

130 Hemochromatosis: Severe Type ...... 274 131 Liver Iron Concentration: Assessment Based on a T2* Map ...... 276 132 Hemochromatosis with Solitary HCC ...... 278 133 Hemochromatosis with Multiple HCCs ...... 280 134 Thalassemia with Iron Deposition ...... 282

Part V Vascular Liver Lesions 135 Arterioportal Shunt I: Early Enhancing Lesion in a Cirrhotic Liver ...... 286 136 Arterioportal Shunt II: Early Enhancing Lesion in a Non-cirrhotic Liver ...... 288 137 Budd-Chiari Syndrome I: Abnormal Enhancement and Intrahepatic Collaterals ...... 290 138 Budd-Chiari Syndrome II: Gradual Deformation of the Liver ...... 292 139 Budd-Chiari Syndrome III: Nodules Mimicking Malignancy ...... 294 140 Hereditary Hemorrhagic Telangiectasia (HHT) ...... 296 141 Hepatic Epithelioid Hemangioendothelioma (HEHE) ...... 298

Part VI Biliary Tree Abnormalities 142 Bile Leakage: Liver-Specific MR Contrast and Correlation with US, CT, and HIDA . . . . . 302 143 Caroli’s Disease I: Intrahepatic with Segmental Changes ...... 304 144 Caroli’s Disease II: Involvement of the Liver and Kidneys ...... 306 145 Cholelithiasis (Gallstones) ...... 308 146 Choledocholithiasis (Bile Duct Stones) ...... 310 147 Gallbladder Carcinoma I Versus Gallbladder Wall Edema ...... 312 148 Gallbladder Carcinoma II: Hepatoid Type of Adenocarcinoma ...... 314 149 Hilar Cholangiocarcinoma I: Typical ...... 316 150 Hilar Cholangiocarcinoma II: Bismuth-Corlette Classification ...... 318 151 Hilar Cholangiocarcinoma III: Intrahepatic Mass ...... 320 152 Hilar Cholangiocarcinoma IV: Partially Extrahepatic Tumor ...... 322 153 Hilar Cholangiocarcinoma V: Metal Stent with Interval Growth ...... 324 154 Hilar Cholangiocarcinoma VI: Biliary Dilatation Mimicking Klatskin at CT ...... 326 155 Primary Sclerosing Cholangitis I: Cholangitis and Segmental Atrophy ...... 328 156 Primary Sclerosing Cholangitis II: With Intrahepatic Cholestasis ...... 330 157 Primary Sclerosing Cholangitis III: With Intrahepatic Stones ...... 332 158 Primary Sclerosing Cholangitis IV: With Biliary Cirrhosis ...... 334 159 Primary Sclerosing Cholangitis V: With Intrahepatic Cholangiocarcinoma ...... 336 160 Primary Sclerosing Cholangitis VI: With Hilar Cholangiocarcinoma ...... 338

Part VII Pediatric Liver Lesions 161 Hepatoblastoma I: With Age-Dependent Differential Diagnosis ...... 342 162 Hepatoblastoma II: With Vascular Invasion ...... 344 163 Undifferentiated Embryonal Sarcoma of the Liver (UESL): MRI and CT Findings . . . . . 346

Index ...... 349