Why Liver Tumors Appear As They Do?: Imaging-Pathologic Correlation

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1 Why Liver Tumors Appear As They Do?: Imaging-Pathologic Correlation Pablo R. Ros, MD, MPH University Hospitals of Cleveland Case Western Reserve University Cleveland, Ohio USA XLIV Curso Anual Sociedad Mexicana de Radiologia e Imagen Mexico, DF

2 El Por Que de la Correlacion Anatomo-Radiologica: Por que los Tumores Hepaticos se Ven como Ven Pablo R. Ros, MD, MPH University Hospitals of Cleveland Case Western Reserve University Cleveland, Ohio USA XLIV Curso Anual Sociedad Mexicana de Radiologia e Imagen Mexico, DF

3

4 Imaging-Pathologic Correlation Closes years of service 64 years of Rad-Path

5 Imaging-Pathologic Correlation Fundamental educational tool for Radiology Underlying microscopic basis of disease Resulting gross features Learn imaging characteristics regardless of technique Applicable to novel imaging: Optical and molecular Essential to increase imaging s accuracy

6 Imaging-Pathologic correlation Initiated in 1947 at AFIP Establishment of Radiologic Pathology Branch Founded as Army Medical Museum (1862)

7 Imaging-Pathologic correlation Radiologic-Pathologic correlation Limited to plain films: Chest and Bone (Elias Theros, MD) Imaging US, CT, MRI) expansion to solid viscera (Brain, Liver, Heart, Kidney, ) Resident courses (Standard worldwide)

8 Imaging Pathologic Correlation

9

10 Imaging Pathologic Correlation: Liver Tumors Liver: key organ for imaging correlation large size homogeneous parenchyma variety of focal lesions (benign, malignant, nonsurgical) multiple imaging modalities imaging diagnosis possible impact in management Basic pathological features CT and MRI / Adult / Primary Neoplasms Narrow differential diagnosis Imaging Characterization

11 Imaging Pathologic Correlation

12 Imaging Pathologic Correlation Focal Nodular Hyperplasia Fibrolamellar Carcinoma Intrahepatic Cholangiocarcinoma Hemangioma Hepatocellular carcinoma

13 Imaging Pathologic Correlation Scar (fibrosis) Blood (hemorrhage) Contour (capsule) Fat Bubble (cystic nature) Rock (calcification)

14 Scar: Focal Nodular Hyperplasia - Central scar - Vessels (result of AVM) - Radiating fibrous septa, nodules

15 Scar: Focal Nodular Hyperplasia - Central arteries - Large size - Edema

16 Scar: Focal Nodular Hyperplasia - Edema, vessels - Homogeneous, except for scar - Red orange color, no bile stain - Lobulated contour

17 Scar: Focal Nodular Hyperplasia - CT: Low density - T1 : Hypointense scar, septa - T2 : Hyperintense scar

18 Scar: Focal Nodular Hyperplasia - Very early enhancement - Arteries in scar - Enhancement in late phases

19 Scar: Focal Nodular Hyperplasia - Isointense in Portal Phase

20 Scar: Focal Nodular Hyperplasia - Early: rapid fill-in, homogeneous enhancement, vessels in scar - Late: rapid wash-out, enhancement of scar

21 Scar: Focal Nodular Hyperplasia - Large scar, mimics necrosis

22 Scar: Focal Nodular Hyperplasia - GRE, Doppler : high signal in scar - Central scar with large arterial branches

23 Scar: Fibrolamellar Carcinoma - Lamellar fibrosis - Confluent centrally - No vessels - No edema

24 Scar: Fibrolamellar Carcinoma - Central scar, Radiating Septa - No vessels - Calcification

25 Scar: Fibrolamellar Carcinoma - Low signal in T2 - No enhancement - Calcification

26 Scar: Fibrolamellar Carcinoma - Ill defined scar

27 Scar: Intrahepatic Cholangiocarcinoma - Mucin producing neoplasm: marked fibrosis - Fibrotic predominance (large central scars)

28 Scar: Intrahepatic Cholangiocarcinoma - Minimal arterial and portal enhancement - Vascular encasement

29 Scar: Intrahepatic Cholangiocarcinoma - T1: Hypointense scar - Early: No scar enhancement - Late: Scar enhancement

30 Imaging-Pathologic correlation in the Liver: Basic Pathologic Features Scar (fibrosis) Blood (hemorrhage) Contour (capsule) Fat Bubble (cystic nature) Rock (calcification)

31 - Large size, poor vascularity - Necrosis and hemorrhage - Contained bleeding or hemoperitoneum Blood: Hepatocellular Adenoma

32 Blood: Hepatocellular Adenoma

33 Blood: Hepatocellular Adenoma

34 Blood: Hepatocellular Adenoma - Heterogeneous - Hemosiderin rings

35 Blood: Hepatocellular Carcinoma

36 Blood: Angiosarcoma - Most vascular malignant tumor - Internal hemorrhage - Blood-fluid levels

37 Blood: Angiosarcoma

38 Blood: Hemangioma - Occasionally - Necrosis

39 Blood: Hemangioma

40 Imaging-Pathologic correlation in the Liver: Basic Pathologic Features Scar (fibrosis) Blood (hemorrhage) Contour (capsule) Fat Bubble (cystic nature) Rock (calcification)

41 Basic Pathologic Features: Contour (capsule) Hepatocellular Adenoma Hepatocellular Carcinoma Cystadenoma/Cystadeno carcinoma

42 Capsule: Hepatocellular Adenoma - Thin fibrous capsule - Well defined contour - Subcapsular vessels

43 Capsule: Hepatocellular Adenoma

44 Capsule: Hepatocellular Carcinoma

45 Capsule: Hepatocellular Carcinoma

46 Imaging-Pathologic correlation in the Liver: Basic Pathologic Features Scar (fibrosis) Blood (hemorrhage) Contour (capsule) Fat Bubble (cystic nature) Rock (calcification)

47 Fat: Hepatocellular Adenoma - Predominantly fatty - Also blood, capsule

48 Fat: Hepatocellular Adenoma - Predominantly fatty by CT

49 Fat: Hepatocellular Adenoma - Central fat

50 Fat: Hepatocellular Carcinoma

51 Fat: Hepatocellular Carcinoma - Fat, Capsule - Non-cirrhotic liver

52 Fat: Angiomyolipoma - Fat attenuation - Septa - Multiple

53 Fat: Angiomyolipoma Post gad - aneurysms

54 Fat: Focal Nodular Hyperplasia

55 Imaging-Pathologic correlation in the Liver: Basic Pathologic Features Scar (fibrosis) Blood (hemorrhage) Contour (capsule) Fat Bubble (cystic nature) Rock (calcification)

56 Bubble: Cystadenoma/Cystadenocarcinom a

57 Bubble: Cystadenoma/Cystadenocarcinom a

58 Bubble: Microbiliary Hamartoma - Small size - Multiple - Diffuse

59 Bubble: Abscess

60 Bubble: Abscess Clustering Rim enhancement

61 Bubble: Echinoccocal cyst

62 Bubble: Echinoccocal cyst

63 Imaging-Pathologic correlation in the Liver: Basic Pathologic Features Scar (fibrosis) Blood (hemorrhage) Contour (capsule) Fat Bubble (cystic nature) Rock (calcification)

64 Rock: Fibrolamellar Carcinoma

65 Rock: Hemangioma - Up to 20 % of cases - Large fibrotic areas

66

67 Imaging-Pathologic correlation in the Liver: Basic Pathologic Features Scar (fibrosis) Blood (hemorrhage) Contour (capsule) Fat Bubble (cystic nature) Rock (calcification)

68 Imaging-Tissue Correlation:Micro MRI

69 Imaging-Tissue Correlation BT20 Protease imaging DU4475 Bremer et al. Radiology, 2002

70 Fluorescence mediated tomography Ntziachristos, NatMed 2002

71 Radiolabeled monoclonal antibody targeting Prostate Specific Membrane Antigen (PSMA) Prostate (green) Tumor (red)

72 Correlation/Validation

73 Proof of Concept in BCS: Preliminary Trial Results a Tumor Associated Proteases 1 cm b Path. Neg. margin 5x Mag. Path. Pos. margin 1 cm c d e Anterior Posterior 1.25x Mag. 1.25x Mag.

74 Future: Missed Tumor Tissue After Resection a cavity b cavity cavity Nuclei GB119 Nuclei Vimentin c normal brain normal brain Tumor Tumor Nuclei GB119 resection cavity Nuclei Vimentin resection cavity

75 Imaging-Pathologic Correlation Fundamental educational tool for Radiology Underlying microscopic basis of disease Resulting gross features Learn imaging characteristics regardless of technique Applicable to novel imaging: Optical and molecular Essential to increase imaging s accuracy

76 Imaging-Tissue Correlation Essential to increase imaging s accuracy Payors not able to sustain current reimbursement at low specificity Value proposition: Characterization (diagnosis) Resectability Staging Response to therapy (Angiogenesis, DWI, ) Prognosis Tissular, Cellular and Molecular correlation

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