EURORAD ESR

Case 14447

Infiltrative-type hepatocellular carcinoma with neoplastic portal thrombosis: value of diffusion-weighted and hepatocyte-specific contrast MRI

Author(s)
Tonolini Massimo, MD.

"Luigi Sacco" University Hospital, Radiology Department; Via G.B. Grassi 74 20157 Milan, Italy; Email:mtonolini@sirm.org
 
Patient
female, 55 year(s)
 
 
  • Figure 1
    Ultrasound
     

    Sonography showed massive echogenic thrombosis (arrowheads) causing dilatation of main portal vein (calipers in b) and lobar branches, without focal liver masses. Note minimal ascites (+).

     
    Area of Interest: Portal system / Hepatic veins; Imaging Technique: Ultrasound; Procedure: Diagnostic procedure; Special Focus: Neoplasia;

    Sonography showed massive echogenic thrombosis (arrowheads) causing dilatation of main portal vein (calipers in b) and lobar branches, without focal liver masses. Note minimal ascites (+).

     
    Area of Interest: Portal system / Hepatic veins; Imaging Technique: Ultrasound; Procedure: Diagnostic procedure; Special Focus: Neoplasia;

    Associated mild splenomegalgy with patent splenic hilar vessels at color Doppler ultrasound.

     
    Area of Interest: Portal system / Hepatic veins; Imaging Technique: Ultrasound; Procedure: Diagnostic procedure; Special Focus: Neoplasia;
     
     
  • Figure 2
    Quadriphasic liver CT (precontrast and arterial-dominant phases)
     

    Precontrast acquisition (a...c) showed increased ascites (+) compared to Fig.1, subtle inhomogeneous hypoattenuation involving the 7th segment (*), and confirmed massive solid portal thrombosis (arrowheads).

     
    Area of Interest: Portal system / Hepatic veins; Imaging Technique: CT; Procedure: Diagnostic procedure; Special Focus: Neoplasia;

    Precontrast acquisition (a...c) showed increased ascites (+) compared to Fig.1, subtle inhomogeneous hypoattenuation involving the 7th segment (*), and confirmed massive solid portal thrombosis (arrowheads).

     
    Area of Interest: Portal system / Hepatic veins; Imaging Technique: CT; Procedure: Diagnostic procedure; Special Focus: Neoplasia;

    Precontrast acquisition (a...c) showed increased ascites (+) compared to Fig.1, subtle inhomogeneous hypoattenuation involving the 7th segment (*), and confirmed massive solid portal thrombosis (arrowheads).

     
    Area of Interest: Portal system / Hepatic veins; Imaging Technique: CT; Procedure: Diagnostic procedure; Special Focus: Neoplasia;

    The massive portal thrombosis (arrowheads) appeared hypervascularised on arterial-dominant phase images (d,e) with a "thread-and-streaks" appearance.

     
    Area of Interest: Portal system / Hepatic veins; Imaging Technique: CT; Procedure: Diagnostic procedure; Special Focus: Neoplasia;

    The massive portal thrombosis (arrowheads) appeared hypervascularised on arterial-dominant phase images (d,e) with a "thread-and-streaks" appearance.

     
    Area of Interest: Portal system / Hepatic veins; Imaging Technique: CT; Procedure: Diagnostic procedure; Special Focus: Neoplasia;

    At the 7th liver segment an ill-defined region (*) showed inhomogeneously increased perfusion in the arterial-dominant acquisition phase (f). Note ascites (+).

     
    Area of Interest: Portal system / Hepatic veins; Imaging Technique: CT; Procedure: Diagnostic procedure; Special Focus: Neoplasia;
     
     
  • Figure 3
    Quadriphasic liver CT - portal venous and equilibrium phase images
     

    In the portal venous phase (a...e) the intra- and extrahepatic portal thrombosis (arrowheads) showed contrast washout. Note ascites (+).

     
    Area of Interest: Portal system / Hepatic veins; Imaging Technique: CT; Procedure: Diagnostic procedure; Special Focus: Neoplasia;

    In the portal venous phase (a...de the intra- and extrahepatic portal thrombosis (arrowheads) showed contrast washout. Note ascites (+).

     
    Area of Interest: Portal system / Hepatic veins; Imaging Technique: CT; Procedure: Diagnostic procedure; Special Focus: Neoplasia;

    In the portal venous phase (a...de the intra- and extrahepatic portal thrombosis (arrowheads) showed contrast washout. Note ascites (+).

     
    Area of Interest: Portal system / Hepatic veins; Imaging Technique: CT; Procedure: Diagnostic procedure; Special Focus: Neoplasia;

    In the portal venous phase (a...e) the intra- and extrahepatic portal thrombosis (arrowheads) showed contrast washout. Also the 7th liver segment (*) showed large, ill-defined hypoattenuation from contrast washout....

     
    Area of Interest: Portal system / Hepatic veins; Imaging Technique: CT; Procedure: Diagnostic procedure; Special Focus: Neoplasia;

    In the portal venous phase (a...e) the intra- and extrahepatic portal thrombosis (arrowheads) showed contrast washout. Also the 7th liver segment (*) showed large, ill-defined hypoattenuation from contrast washout....

     
    Area of Interest: Portal system / Hepatic veins; Imaging Technique: CT; Procedure: Diagnostic procedure; Special Focus: Neoplasia;

    Focused reconstructions (f, g) showed portosystemic venous collaterals (thin arrows) consistent with portal hypertension. Note ascites (+).

     
    Area of Interest: Portal system / Hepatic veins; Imaging Technique: CT; Procedure: Diagnostic procedure; Special Focus: Neoplasia;

    Focused reconstructions (f, g) showed portosystemic venous collaterals (thin arrows) consistent with portal hypertension. Note ascites (+).

     
    Area of Interest: Portal system / Hepatic veins; Imaging Technique: CT; Procedure: Diagnostic procedure; Special Focus: Neoplasia;

    Equilibrium phase images (h..k) confirmed contrast washout of the intra- and extrahepatic portal thrombosis (arrowheads). Note ascites (+).

     
    Area of Interest: Portal system / Hepatic veins; Imaging Technique: CT; Procedure: Diagnostic procedure; Special Focus: Neoplasia;

    Equilibrium phase images (h..k) confirmed contrast washout of the intra- and extrahepatic portal thrombosis (arrowheads). Note ascites (+).

     
    Area of Interest: Portal system / Hepatic veins; Imaging Technique: CT; Procedure: Diagnostic procedure; Special Focus: Neoplasia;

    Equilibrium phase images (h..k) confirmed contrast washout of the intra- and extrahepatic portal thrombosis (arrowheads). Note ascites (+).

     
    Area of Interest: Portal system / Hepatic veins; Imaging Technique: CT; Procedure: Diagnostic procedure; Special Focus: Neoplasia;

    In the equilibrium phase subtle "mosaic" hypoattenuation corresponding contrast washout was seen at the large, ill-defined region at the 7th liver segment (*). Note ascites (+).

     
    Area of Interest: Portal system / Hepatic veins; Imaging Technique: CT; Procedure: Diagnostic procedure; Special Focus: Neoplasia;
     
     
  • Figure 4
    Multiparametric liver-specific contrast (Gd-EOB-DTPA) MRI - T2 and diffusion-weighted images
     

    On T2-weighted images (a...c) he massive portal thrombosis (arrowheads) showed solid-type, inhomogeneous signal intensity with internal vascular flow voids; regressed ascites; extensive "geographic" mildly...

     
    Area of Interest: Liver; Imaging Technique: MR; Procedure: Diagnostic procedure; Special Focus: Neoplasia;

    On T2-weighted images (a...c) he massive portal thrombosis (arrowheads) showed solid-type, inhomogeneous signal intensity with internal vascular flow voids. Extensive "geographic" mildly hyperintense "geographic"...

     
    Area of Interest: Liver; Imaging Technique: MR; Procedure: Diagnostic procedure; Special Focus: Neoplasia;

    On T2-weighted images (a...c) he massive portal thrombosis (arrowheads) showed solid-type, inhomogeneous signal intensity with internal vascular flow voids. Extensive "geographic" mildly hyperintense "geographic"...

     
    Area of Interest: Liver; Imaging Technique: MR; Procedure: Diagnostic procedure; Special Focus: Neoplasia;

    Both portal thrombosis (arrowhead in e) and extensive "geographic" abnormal regions (*) of right liver lobe appeared hyperintense on high (800) b-value diffusion-weighted images.

     
    Area of Interest: Liver; Imaging Technique: MR; Procedure: Diagnostic procedure; Special Focus: Neoplasia;

    Both portal thrombosis (arrowhead in e) and extensive "geographic" abnormal regions (*) of right liver lobe appeared hyperintense on high (800) b-value diffusion-weighted images.

     
    Area of Interest: Liver; Imaging Technique: MR; Procedure: Diagnostic procedure; Special Focus: Neoplasia;

    On apparent diffusion coefficient (ADC) maps the portal thrombosis (arrowhead) showed corresponding low signal intensity with measured ADC values in the range 0.92-1.09x10-3 mm2/s.

     
    Area of Interest: Liver; Imaging Technique: MR; Procedure: Diagnostic procedure; Special Focus: Neoplasia;
     
     
  • Figure 5
    Multiparametric liver-specific contrast (Gd-EOB-DTPA) MRI - Precontrast T1, dynamic acquisitions
     

    Precontrast T1-weighted images demonstrated extensive "geographic" hypointense regions (*) involving the right liver lobe, and massive portal thrombosis with similar moderately low signal intensity (arrowhead in b).

     
    Area of Interest: Liver; Imaging Technique: MR; Procedure: Diagnostic procedure; Special Focus: Neoplasia;

    Precontrast T1-weighted images demonstrated extensive "geographic" hypointense regions (*) involving the right liver lobe, and massive portal thrombosis with similar moderately low signal intensity (arrowhead in b).

     
    Area of Interest: Liver; Imaging Technique: MR; Procedure: Diagnostic procedure; Special Focus: Neoplasia;

    Most of the right liver lobe was involved by "geographic" hyperperfused regions (*9 in arterial-dominant images (c), with subsequent contrast washout in the portal venous phase (d).

     
    Area of Interest: Liver; Imaging Technique: MR; Procedure: Diagnostic procedure; Special Focus: Neoplasia;

    Most of the right liver lobe was involved by "geographic" hyperperfused regions (*9 in arterial-dominant images (c), with subsequent contrast washout in the portal venous phase (d).

     
    Area of Interest: Liver; Imaging Technique: MR; Procedure: Diagnostic procedure; Special Focus: Neoplasia;

    The massive intra- and extrahepatic portal thrombosis (arrowheads) showed prominent hypointensity corresponding to contrast washout in portal venous phase (e,f) images.

     
    Area of Interest: Liver; Imaging Technique: MR; Procedure: Diagnostic procedure; Special Focus: Neoplasia;

    The massive intra- and extrahepatic portal thrombosis (arrowheads) showed prominent hypointensity corresponding to contrast washout in portal venous phase (e,f) images.

     
    Area of Interest: Liver; Imaging Technique: MR; Procedure: Diagnostic procedure; Special Focus: Neoplasia;

    Delayed hepatobiliary-specific phase (g,h) showed frank hypointensity of extensive "geographic" abnormal regions (*) of right liver lobe, consistent with lost hepatocyte function compared to spared, enhanced areas...

     
    Area of Interest: Liver; Imaging Technique: MR; Procedure: Diagnostic procedure; Special Focus: Neoplasia;

    Delayed hepatobiliary-specific phase (g,h) showed frank hypointensity of extensive "geographic" abnormal regions (*) of right liver lobe, consistent with lost hepatocyte function compared to spared, enhanced areas...

     
    Area of Interest: Liver; Imaging Technique: MR; Procedure: Diagnostic procedure; Special Focus: Neoplasia;
     
     
  • Figure 6
    Follow-up unenhanced MRI (10 weeks after Figs.4&5)
     

    Repeated MRI including T2-(a,b) and T1-weighted (c) showed reappearance of abundant ascites (+), increased diameter of solid, malignant portal thrombosis (arrowheads).

     
    Area of Interest: Liver; Imaging Technique: MR; Procedure: Diagnostic procedure; Special Focus: Neoplasia;

    Repeated MRI including T2-(a,b) and T1-weighted (c) showed reappearance of abundant ascites (+), increased diameter of solid, malignant portal thrombosis (arrowheads).

     
    Area of Interest: Liver; Imaging Technique: MR; Procedure: Diagnostic procedure; Special Focus: Neoplasia;

    Repeated MRI including T2-(a,b) and T1-weighted (c) showed reappearance of abundant ascites (+), increased diameter of solid, malignant portal thrombosis (arrowheads).

     
    Area of Interest: Liver; Imaging Technique: MR; Procedure: Diagnostic procedure; Special Focus: Neoplasia;

    High (800) b-value diffusion-weighted images (d..f in craniocaudal order) showed progression of the extensive signal changes from parenchymal infiltration (*) to the entire right liver and most of the enlarged caudate...

     
    Area of Interest: Liver; Imaging Technique: MR; Procedure: Diagnostic procedure; Special Focus: Neoplasia;

    High (800) b-value diffusion-weighted images (d..f in craniocaudal order) showed progression of the extensive signal changes from parenchymal infiltration (*) to the entire right liver and most of the enlarged caudate...

     
    Area of Interest: Liver; Imaging Technique: MR; Procedure: Diagnostic procedure; Special Focus: Neoplasia;

    High (800) b-value diffusion-weighted images (d..f in craniocaudal order) showed progression of the extensive signal changes from parenchymal infiltration (*) to the entire right liver and most of the enlarged caudate...

     
    Area of Interest: Liver; Imaging Technique: MR; Procedure: Diagnostic procedure; Special Focus: Neoplasia;
     
     
Sonography showed massive echogenic thrombosis (arrowheads) causing dilatation of main portal vein (calipers in b) and lobar branches, without focal liver masses. Note minimal ascites (+).
 
Sonography showed massive echogenic thrombosis (arrowheads) causing dilatation of main portal vein (calipers in b) and lobar branches, without focal liver masses. Note minimal ascites (+).
 
Associated mild splenomegalgy with patent splenic hilar vessels at color Doppler ultrasound.
 
Precontrast acquisition (a...c) showed increased ascites (+) compared to Fig.1, subtle inhomogeneous hypoattenuation involving the 7th segment (*), and confirmed massive solid portal thrombosis (arrowheads).
 
Precontrast acquisition (a...c) showed increased ascites (+) compared to Fig.1, subtle inhomogeneous hypoattenuation involving the 7th segment (*), and confirmed massive solid portal thrombosis (arrowheads).
 
Precontrast acquisition (a...c) showed increased ascites (+) compared to Fig.1, subtle inhomogeneous hypoattenuation involving the 7th segment (*), and confirmed massive solid portal thrombosis (arrowheads).
 
The massive portal thrombosis (arrowheads) appeared hypervascularised on arterial-dominant phase images (d,e) with a "thread-and-streaks" appearance.
 
The massive portal thrombosis (arrowheads) appeared hypervascularised on arterial-dominant phase images (d,e) with a "thread-and-streaks" appearance.
 
At the 7th liver segment an ill-defined region (*) showed inhomogeneously increased perfusion in the arterial-dominant acquisition phase (f). Note ascites (+).
 
In the portal venous phase (a...e) the intra- and extrahepatic portal thrombosis (arrowheads) showed contrast washout. Note ascites (+).
 
In the portal venous phase (a...de the intra- and extrahepatic portal thrombosis (arrowheads) showed contrast washout. Note ascites (+).
 
In the portal venous phase (a...de the intra- and extrahepatic portal thrombosis (arrowheads) showed contrast washout. Note ascites (+).
 
In the portal venous phase (a...e) the intra- and extrahepatic portal thrombosis (arrowheads) showed contrast washout. Also the 7th liver segment (*) showed large, ill-defined hypoattenuation from contrast washout. Note ascites (+).
 
In the portal venous phase (a...e) the intra- and extrahepatic portal thrombosis (arrowheads) showed contrast washout. Also the 7th liver segment (*) showed large, ill-defined hypoattenuation from contrast washout. Note ascites (+).
 
Focused reconstructions (f, g) showed portosystemic venous collaterals (thin arrows) consistent with portal hypertension. Note ascites (+).
 
Focused reconstructions (f, g) showed portosystemic venous collaterals (thin arrows) consistent with portal hypertension. Note ascites (+).
 
Equilibrium phase images (h..k) confirmed contrast washout of the intra- and extrahepatic portal thrombosis (arrowheads). Note ascites (+).
 
Equilibrium phase images (h..k) confirmed contrast washout of the intra- and extrahepatic portal thrombosis (arrowheads). Note ascites (+).
 
Equilibrium phase images (h..k) confirmed contrast washout of the intra- and extrahepatic portal thrombosis (arrowheads). Note ascites (+).
 
In the equilibrium phase subtle "mosaic" hypoattenuation corresponding contrast washout was seen at the large, ill-defined region at the 7th liver segment (*). Note ascites (+).
 
On T2-weighted images (a...c) he massive portal thrombosis (arrowheads) showed solid-type, inhomogeneous signal intensity with internal vascular flow voids; regressed ascites; extensive "geographic" mildly hyperintense "geographic" regions (*) in the right liver lobe.
 
On T2-weighted images (a...c) he massive portal thrombosis (arrowheads) showed solid-type, inhomogeneous signal intensity with internal vascular flow voids. Extensive "geographic" mildly hyperintense "geographic" regions (*) involved the right liver lobe.
 
On T2-weighted images (a...c) he massive portal thrombosis (arrowheads) showed solid-type, inhomogeneous signal intensity with internal vascular flow voids. Extensive "geographic" mildly hyperintense "geographic" regions (*) involved the right liver lobe.
 
Both portal thrombosis (arrowhead in e) and extensive "geographic" abnormal regions (*) of right liver lobe appeared hyperintense on high (800) b-value diffusion-weighted images.
 
Both portal thrombosis (arrowhead in e) and extensive "geographic" abnormal regions (*) of right liver lobe appeared hyperintense on high (800) b-value diffusion-weighted images.
 
On apparent diffusion coefficient (ADC) maps the portal thrombosis (arrowhead) showed corresponding low signal intensity with measured ADC values in the range 0.92-1.09x10-3 mm2/s.
 
Precontrast T1-weighted images demonstrated extensive "geographic" hypointense regions (*) involving the right liver lobe, and massive portal thrombosis with similar moderately low signal intensity (arrowhead in b).
 
Precontrast T1-weighted images demonstrated extensive "geographic" hypointense regions (*) involving the right liver lobe, and massive portal thrombosis with similar moderately low signal intensity (arrowhead in b).
 
Most of the right liver lobe was involved by "geographic" hyperperfused regions (*9 in arterial-dominant images (c), with subsequent contrast washout in the portal venous phase (d).
 
Most of the right liver lobe was involved by "geographic" hyperperfused regions (*9 in arterial-dominant images (c), with subsequent contrast washout in the portal venous phase (d).
 
The massive intra- and extrahepatic portal thrombosis (arrowheads) showed prominent hypointensity corresponding to contrast washout in portal venous phase (e,f) images.
 
The massive intra- and extrahepatic portal thrombosis (arrowheads) showed prominent hypointensity corresponding to contrast washout in portal venous phase (e,f) images.
 
Delayed hepatobiliary-specific phase (g,h) showed frank hypointensity of extensive "geographic" abnormal regions (*) of right liver lobe, consistent with lost hepatocyte function compared to spared, enhanced areas such as in caudate and left lobe.
 
Delayed hepatobiliary-specific phase (g,h) showed frank hypointensity of extensive "geographic" abnormal regions (*) of right liver lobe, consistent with lost hepatocyte function compared to spared, enhanced areas such as in caudate and left lobe.
 
Repeated MRI including T2-(a,b) and T1-weighted (c) showed reappearance of abundant ascites (+), increased diameter of solid, malignant portal thrombosis (arrowheads).
 
Repeated MRI including T2-(a,b) and T1-weighted (c) showed reappearance of abundant ascites (+), increased diameter of solid, malignant portal thrombosis (arrowheads).
 
Repeated MRI including T2-(a,b) and T1-weighted (c) showed reappearance of abundant ascites (+), increased diameter of solid, malignant portal thrombosis (arrowheads).
 
High (800) b-value diffusion-weighted images (d..f in craniocaudal order) showed progression of the extensive signal changes from parenchymal infiltration (*) to the entire right liver and most of the enlarged caudate lobe.
 
High (800) b-value diffusion-weighted images (d..f in craniocaudal order) showed progression of the extensive signal changes from parenchymal infiltration (*) to the entire right liver and most of the enlarged caudate lobe.
 
High (800) b-value diffusion-weighted images (d..f in craniocaudal order) showed progression of the extensive signal changes from parenchymal infiltration (*) to the entire right liver and most of the enlarged caudate lobe.
 
 
 
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