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
77
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