MRI of Lesions in the Non-Cirrhotic Liver
Valerie Vilgrain

Synopsis

Liver lesions in the non cirrhotic liver may be observed on healthy liver or in patients with extrahepatic cancer. On healthy liver, most liver lesions are found incidentally consequent to the widespread use of imaging tests and the vast majority is benign. These benign liver tumours are a heterogeneous group of lesions with different cellular origins. However, some malignant tumors may also be found incidentally. MRI is indicated because MRI is the best imaging technique for tissue characterization. Interestingly, the most common benign liver lesions are hemangiomas and focal nodular hyperplasia, both diagnosed with high sensitivity and very high specificity on MRI. MRI is the key imaging modality in liver hemangiomas by showing typical findings on pre-contrast imaging (hypointense on T1-weighted sequences and strongly hyperintense on heavily T2-weighted sequences) and on contrast-enhanced sequences with a peripheral and globular enhancement of the lesion followed by a central enhancement on delayed phases. On diffusion-weighted MR sequences, the signal of an hemangioma drops with increasing b-values. Consequently the Apparent Diffusion Coefficient (ADC) value is high. The two most common imaging atypias are giant hemangiomas and rapidly filling hemangiomas. Both are easily diagnosed on MRI. On MRI, FNH usually associates several findings: i) lesion homogeneity except the central scar, ii) slightly different from the adjacent liver on precontrast US, CT or MRI [48, 49], iii) strong and homogeneous enhancement on arterial phase CEUS, CT or MR with a central vascular supply, which becomes similar to adjacent liver on portal and delayed phases [32, 50, 51] iv) central scar best seen on MRI (hypointense on precontrast T1-weighted images, strongly hyperintense on T2-weighted images, and becoming hyperintense on delayed phase using extracellular MR contrast agents because of the accumulation of contrast material in the fibrous tissue [52, 53] ), and v) lack of capsule with often lobulated contours. The diagnosis of FNH is based on a combination of these imaging features but none of them is completely specific of FNH. On diffusion-weighted MRI, FNH may appear hyperintense on high b values corresponding to mild diffusion restriction. Nevertheless, ADC values are usually close to that of the liver FNH usually associates several findings: i) lesion homogeneity except the central scar, ii) slightly different from the adjacent liver on precontrast T1- and T2-weighted MRI, iii) strong and homogeneous enhancement on arterial phase with a central vascular supply, which becomes similar to adjacent liver on portal and delayed phases iv) central scar that is hypointense on precontrast T1-weighted images, strongly hyperintense on T2-weighted images, and becoming hyperintense on delayed phase using extracellular MR contrast agents because of the accumulation of contrast material in the fibrous tissue, and v) lack of capsule with often lobulated contours. The diagnosis of FNH is based on a combination of these imaging features but none of them is completely specific of FNH. On diffusion-weighted MRI, FNH may appear hyperintense on high b values corresponding to mild diffusion restriction. Nevertheless, ADC values are usually close to that of the liver. Hepatobiliary MR contrast agents can be used to highlight the hepatocellular origin of the FNH. Most FNHs are iso or hyperintense on hepatobiliary phase, some having rim-accentuated enhancement. With hepatobiliary MR contrast agents, the sensitivity for diagnosing FNH has increased up to 90%. Hepatocellular adenomas (HCA) are less common than hemangioma or FNH but their prevalence is increasing likely due to the increase of the metabolic syndrome. Based on genomic analysis, three main molecular subtypes of HCA have been clearly identified so far, with a fourth class presently uncharacterised. Interestingly the two common, which represent 80% of all HCAs are well recognized on MRI. As the most striking pathologic features are the presence of fat or telangiectatic component, MRI is the most accurate technique. HNF-1α inactivated HCAs are characterized by the presence of marked steatosis on pathology. They appear homogeneous on MRI and have a variable signal on T2-sequences.The striking finding is a diffuse and homogeneous signal dropout on chemical shift T1-weighted sequences. They are usually moderately hypervascular and often show wash-out on portal and/or delayed phase using extracellular MR contrast agents. On high-b values diffusion-weighted MRI, they are iso-or moderately hyperintense. Using the diffuse and homogeneous signal dropout on chemical shift T1-weighted sequences, the sensitivity of MRI ranges from 87% to 91% and the specificity ranges from 89% to 100% for diagnosing HNF-1α inactivated HCA. Inflammatory HCAs are characterized on MRI by their telangiectatic features. They show a strong hyperintense signal on T2-weighted images (as strong as the signal of the spleen), which may be either diffuse or as a rimlike band in the periphery of the lesion and defines the atoll sign. On T1-weighted sequences, lesion signal intensity is variably iso- to hyperintense. When present, hyperintensity persists on fat suppressed and opposed-phase sequences. They are markedly hypervascular and show persistent enhancement on delayed phase using extracellular MR contrast agents. Using the two striking imaging findings (strong hypersignal on T2-weighted MR images and the persistent enhancement on delayed phase), the sensitivity of MRI ranges from 85% to 88% and the specificity ranges from 88% to 100% for diagnosing inflammatory HCA with extracellular contrast agents. Most HCAs are hypointense on hepatobiliary MR phase and this feature is helpful for differentiating HCA from FNH. However, recent studies have shown that nearly half of the inflammatory HCAs are iso-or hyperintense on hepatobiliary MR phase. In patients with extrahepatic cancer, liver lesions may be attributed to liver metastases or may be unrelated and are mostly benign. In these patients, it is estimated that approximately half of the liver lesions smaller than 2cm are benign. Therefore the goals of imaging are twofold: first lesion characterization and second intrahepatic staging if some lesions are liver metastases. MRI is also helpful for differentiating benign liver lesions from liver metastases. MRI findings of the latter are not unique and may vary with the primary cancer. However most liver metasases are hypovascular surrounded by a peripheral halo on contrast-enhanced sequences. For intrahepatic tumor staging, many original works and three meta-analyses have shown that MR imaging is significantly more sensitive for detecting liver metastases on a per-lesion basis than helical CT and FDG-PET. More recently, the sensitivity of MR imaging in liver metastases has increased compared to conventional sequences as a result of two improvements: diffusion-weighted MR sequences and the hepatospecific phase using gadoxetic acid (Gd-EOB-DTPA). Combined DW-MR and gadoxetic acid-enhanced MR imaging has the highest sensitivity for detecting liver metastases on a per-lesion basis.

Acknowledgements

No acknowledgement found.

References

Stark DD, Felder RC, Wittenberg J, Saini S, Butch RJ, White ME, et al. Magnetic resonance imaging of cavernous hemangioma of the liver: tissue-specific characterization. AJR Am J Roentgenol 1985;145:213-222. Semelka RC, Brown ED, Ascher SM, Patt RH, Bagley AS, Li W, et al. Hepatic hemangiomas: a multi-institutional study of appearance on T2-weighted and serial gadolinium-enhanced gradient-echo MR images. Radiology 1994;192:401-406. Doo KW, Lee CH, Choi JW, Lee J, Kim KA, Park CM. "Pseudo washout" sign in high-flow hepatic hemangioma on gadoxetic acid contrast-enhanced MRI mimicking hypervascular tumor. AJR Am J Roentgenol 2009;193:W490-496. Danet IM, Semelka RC, Braga L, Armao D, Woosley JT. Giant hemangioma of the liver: MR imaging characteristics in 24 patients. Magn Reson Imaging 2003;21:95-101 Mortele KJ, Praet M, Van Vlierberghe H, Kunnen M, Ros PR. CT and MR imaging findings in focal nodular hyperplasia of the liver: radiologic-pathologic correlation. AJR Am J Roentgenol 2000;175:687-692. Kehagias D, Moulopoulos L, Antoniou A, Hatziioannou A, Smyrniotis V, Trakadas S, et al. Focal nodular hyperplasia: imaging findings. Eur Radiol 2001;11:202-212. Agnello F, Ronot M, Valla DC, Sinkus R, Van Beers BE, Vilgrain V. High-b-value diffusion-weighted MR imaging of benign hepatocellular lesions: quantitative and qualitative analysis. Radiology 2012;262:511-519. Laumonier H, Bioulac-Sage P, Laurent C, Zucman-Rossi J, Balabaud C, Trillaud H. Hepatocellular adenomas: magnetic resonance imaging features as a function of molecular pathological classification. Hepatology 2008;48:808-818. Ronot M, Bahrami S, Calderaro J, Valla DC, Bedossa P, Belghiti J, et al. Hepatocellular adenomas: accuracy of magnetic resonance imaging and liver biopsy in subtype classification. Hepatology 2011;53:1182-1191. van Aalten SM, Thomeer MG, Terkivatan T, Dwarkasing RS, Verheij J, de Man RA, et al. Hepatocellular adenomas: correlation of MR imaging findings with pathologic subtype classification. Radiology 2011;261:172-181. Niekel MC, Bipat S, Stoker J. Diagnostic imaging of colorectal liver metastases with CT, MR imaging, FDG PET, and/or FDG PET/CT: a meta-analysis of prospective studies including patients who have not previously undergone treatment. Radiology 2010; 257:674-684. Wu LM, Hu J, Gu HY, Hua J, Xu JR. Can diffusion-weighted magnetic resonance imaging (DW-MRI) alone be used as a reliable sequence for the preoperative detection and characterisation of hepatic metastases? A meta-analysis. Eur J Cancer 2013; 49:572-584. Chen L, Zhang J, Zhang L, et al. Meta-analysis of gadoxetic acid disodium (Gd-EOB-DTPA)-enhanced magnetic resonance imaging for the detection of liver metastases. PLoS One 2012; 7:e48681


Proc. Intl. Soc. Mag. Reson. Med. 24 (2016)
0000