HOW TO HANDLE HEPATIC HOW TO HANDLE HEPATIC INCIDENTALOMASINCIDENTALOMAS

Richard M. Gore, MD

North Shore University Health SystemUniversity of Chicago

Evanston, IL

SCBT/MR 2010San Diego, California

March 7, 201016:20-16:30

DEFINITIONSDEFINITIONS

•• UDOs= SMALL HYPOATTENUATING HEPATIC UDOs= SMALL HYPOATTENUATING HEPATIC LESIONSLESIONS

•• TSTC= TOO SMALL TO CHARACTERIZETSTC= TOO SMALL TO CHARACTERIZE•• THADS= TRANSIENT HEPATIC ATTENUATION THADS= TRANSIENT HEPATIC ATTENUATION

DIFFERENCESDIFFERENCES•• THIDS=TRANSIENT HEPATIC INTENSITY THIDS=TRANSIENT HEPATIC INTENSITY

DIFFERENCESDIFFERENCES•• FLASH FILLERS= ROBUSTLY ENHANCING FLASH FILLERS= ROBUSTLY ENHANCING

HEPATIC LESIONS (UBOs)HEPATIC LESIONS (UBOs)

HEPATIC CYSTSHEPATIC CYSTS

BILE DUCT HAMARTOMASBILE DUCT HAMARTOMAS

•• FOCAL FOCAL DISORDERLY DISORDERLY COLLECTION OF COLLECTION OF BILE DUCTS BILE DUCTS

•• WITH EXTREME WITH EXTREME DILATION THE DILATION THE CYSTS ARE CYSTS ARE VISIBLE ON VISIBLE ON IMAGINGIMAGING

•• 5% INCIDENCE AT 5% INCIDENCE AT AUTOPSYAUTOPSY

BILE DUCT HAMARTOMASBILE DUCT HAMARTOMAS

CLINICALLY RELEVANT BECAUSE MUSTCLINICALLY RELEVANT BECAUSE MUSTBE DIFFERENTIATED FROM:BE DIFFERENTIATED FROM:

DIFFUSE METASTASESDIFFUSE METASTASESMICROABSCESSESMICROABSCESSESPRIMARY SCLEROSING CHOLANGITISPRIMARY SCLEROSING CHOLANGITISPERIBILIARY CYSTS IN CIRRHOSISPERIBILIARY CYSTS IN CIRRHOSISCAROLICAROLI’’S DISEASES DISEASEAPCLDAPCLD

EXTRINSIC COMPRESSION: RIB, DIAPHRAGM,EXTRINSIC COMPRESSION: RIB, DIAPHRAGM,HEMANGIOMA OR OTHER MASS: THADS, THIDSHEMANGIOMA OR OTHER MASS: THADS, THIDS

THIRD INFLOW: PARABILIARY VEINS, EPIGASTRICTHIRD INFLOW: PARABILIARY VEINS, EPIGASTRIC--PARAUMBILICAL VEINS, ABHERRANT VEINSPARAUMBILICAL VEINS, ABHERRANT VEINS

FOCAL FATFOCAL FAT

•• SUBCAPSULAR SUBCAPSULAR LOCATIONLOCATION

•• POLYGONAL, POLYGONAL, WEDGE SHAPED, WEDGE SHAPED, GEOGRAPHIC ZIGGEOGRAPHIC ZIG--ZAG APPEARANCEZAG APPEARANCE

•• NORMAL VESSELS NORMAL VESSELS TRAVERSE TRAVERSE ““MASSMASS””

•• NO CAPSULE, NO NO CAPSULE, NO MASS EFFECTMASS EFFECT

UBOs IN CIRRHOTIC UBOs IN CIRRHOTIC PATIENTSPATIENTS

•• 38% PTS WITH CIRRHOSIS OR CHRONIC 38% PTS WITH CIRRHOSIS OR CHRONIC HEPATITIS HAD UBOsHEPATITIS HAD UBOs

•• 72% 72% ↓↓ IN SIZE OR NO IN SIZE OR NO ΔΔ•• GEOGRAPHIC, WEDGE SHAPE, TRIANGULAR GEOGRAPHIC, WEDGE SHAPE, TRIANGULAR

SHAPE MOST LIKELY BENIGNSHAPE MOST LIKELY BENIGN•• OCCLUSION OF SMALL HEPATIC AND PORTAL OCCLUSION OF SMALL HEPATIC AND PORTAL

VEINS IN CLDVEINS IN CLD•• WEDGE SHAPED OR TRIANGULAR PSEUDOWEDGE SHAPED OR TRIANGULAR PSEUDO--

LESIONS DUE TO FOCAL ARTERIALLESIONS DUE TO FOCAL ARTERIAL-- PORTAL PORTAL VENOUS SHUNTS WHICH ALSO OCCURS IN VENOUS SHUNTS WHICH ALSO OCCURS IN CIRRHOSISCIRRHOSIS

NYU Radiology 235: 938NYU Radiology 235: 938--944, 2005944, 2005

UBOs SEEN ON ARTERIAL UBOs SEEN ON ARTERIAL PHASE IN CIRRHOSISPHASE IN CIRRHOSIS

•• 169 lesions in 28 patients169 lesions in 28 patients•• All wedge shaped, subcapsular lesions All wedge shaped, subcapsular lesions

were benignwere benign•• Nodular or irregular lesions: subcapsular Nodular or irregular lesions: subcapsular

59= benign; 11= HCC59= benign; 11= HCC•• Nodular or irregular lesions: central Nodular or irregular lesions: central

39= benign; 17= HCC39= benign; 17= HCC

Hwang JCAT 32: 39Hwang JCAT 32: 39--45, 200845, 2008

EXTRAHEPATIC MALIGNANCIES EXTRAHEPATIC MALIGNANCIES AND THE CIRRHOTIC LIVERAND THE CIRRHOTIC LIVER

•• METS DO NOT GO TO A CIRRHOTIC METS DO NOT GO TO A CIRRHOTIC LIVERLIVER-- TOO INHOSPITABLETOO INHOSPITABLE

•• MR: LESIONS THAT FOLLOW SPLEEN IN MR: LESIONS THAT FOLLOW SPLEEN IN CANCER PATIENTS ARE METSCANCER PATIENTS ARE METS

•• MR: LESIONS THAT FOLLOW SPLEEN IN MR: LESIONS THAT FOLLOW SPLEEN IN CIRRHOTIC PATIENTS ARE HCCCIRRHOTIC PATIENTS ARE HCC

METS vs INCIDENTALOMAMETS vs INCIDENTALOMA

•• AT POST MORTEM LIVER MOST AT POST MORTEM LIVER MOST COMMON SITE OF METS COMMON SITE OF METS ≤≤ 36%36%

•• AT POST MORTEM, AT POST MORTEM, ≤≤ 52% OF NON52% OF NON--CANCER PATIENTS HAVE BENIGN CANCER PATIENTS HAVE BENIGN HEPATIC LESIONSHEPATIC LESIONS

HEPATIC INCIDENTALOMAS:HEPATIC INCIDENTALOMAS:UDOs WHICH ARE TSTCUDOs WHICH ARE TSTC

•• CONVENTIONAL CT LESIONS < 1.5CONVENTIONAL CT LESIONS < 1.5--2 cm2 cm•• UDOs <15mm IN 17% OP, 82% HAD CA UDOs <15mm IN 17% OP, 82% HAD CA

51% LESIONS DEEMED BENIGN51% LESIONS DEEMED BENIGN

Jones AJR 158: 535Jones AJR 158: 535--539, 1992539, 1992

HEPATIC INCIDENTALOMASHEPATIC INCIDENTALOMAS

•• TSTC LESIONS, <1cm FOUND IN 12.7% TSTC LESIONS, <1cm FOUND IN 12.7% ONCOLOGY PATIENTSONCOLOGY PATIENTS

•• 11.6% WERE MALIGNANT11.6% WERE MALIGNANT

Schwartz Radiology 210: 71Schwartz Radiology 210: 71--74, 199974, 1999

HEPATIC INCIDENTALOMASHEPATIC INCIDENTALOMAS

•• 25% OF PTS WITH GASTRIC AND 25% OF PTS WITH GASTRIC AND COLORECTAL LESIONS HAD UDOsCOLORECTAL LESIONS HAD UDOs

•• METS PRESENTING ONLY AS UDOs METS PRESENTING ONLY AS UDOs SEEN IN ONLY 2.2%SEEN IN ONLY 2.2%

Jang JCAT 26: 718Jang JCAT 26: 718--724, 2002724, 2002

UDOs IN BREAST CANCER UDOs IN BREAST CANCER PATIENTSPATIENTS

•• IN PATIENTS WITH BREAST CANCER IN PATIENTS WITH BREAST CANCER WHO HAVE UDOs BUT NO DEFINITE WHO HAVE UDOs BUT NO DEFINITE METS AT THE TIME OF Dx DO NOT METS AT THE TIME OF Dx DO NOT HAVE AN INCREASED RISK OF HAVE AN INCREASED RISK OF DEVELOPING METS LATER ONDEVELOPING METS LATER ON

Krakora Radiology 233: 667Krakora Radiology 233: 667--673, 2004673, 2004

HEPATIC LESIONS DEEMED TO SMALL TO HEPATIC LESIONS DEEMED TO SMALL TO CHARACTERIZE AT CT: PREVALANCE ANDCHARACTERIZE AT CT: PREVALANCE AND

IMPORTANCE IN WOMEN WITH BREAST CANCERIMPORTANCE IN WOMEN WITH BREAST CANCER

•• 277/941 (29.4%) 277/941 (29.4%) ≥≥ 1 UDO1 UDO•• 1 YEAR FOLLOW UP: NO 1 YEAR FOLLOW UP: NO ΔΔ 92.7%, 92.7%,

DISAPPEAR 4.2%, LARGER IN 3.1%DISAPPEAR 4.2%, LARGER IN 3.1%•• IF YOU SEE AN UDO IN A PT WITH IF YOU SEE AN UDO IN A PT WITH

BREAST CA BUT NOT DEFINITE METS, BREAST CA BUT NOT DEFINITE METS, THIS IS A BENIGN FINDINGTHIS IS A BENIGN FINDING

H I Khalil 235: 872H I Khalil 235: 872--878, 2005 Radiology 878, 2005 Radiology

UDOs: LEAVE ME ALONE!UDOs: LEAVE ME ALONE!

•• UNDEREMPHASIZE THE REPORTING OF UNDEREMPHASIZE THE REPORTING OF UDOs <5mm IN SIZEUDOs <5mm IN SIZE

•• UDOs 5UDOs 5--10mm TSTC (<1% SIGNIFICANT 10mm TSTC (<1% SIGNIFICANT LESION IF NO Hx OF CANCER)LESION IF NO Hx OF CANCER)

•• UDOs 5UDOs 5--15 mm IN ONCOLOGY PT 15 mm IN ONCOLOGY PT REPORT AS STATISTICALLY MOST REPORT AS STATISTICALLY MOST LIKELY BENIGN BUT RECOMMEND F/ULIKELY BENIGN BUT RECOMMEND F/U

FLASH FILLERS: UBOsFLASH FILLERS: UBOs

•• HEMANGIOMAHEMANGIOMA•• FNH FNH •• ADENOMAADENOMA•• HYPERVASCULAR HYPERVASCULAR

METASTASESMETASTASES•• HEPATOMAHEPATOMA•• AVMSAVMS•• NOD REGEN NOD REGEN

HYPERPLASIAHYPERPLASIA•• THADS, THIDSTHADS, THIDS

FLASH FILLERS: UBOsFLASH FILLERS: UBOs

•• AVM, HCC, HYPERVASC METS, NRH, THADS, AVM, HCC, HYPERVASC METS, NRH, THADS, THIDS WASH OUT RAPIDLYTHIDS WASH OUT RAPIDLY

•• ADENOMAS WASH OUT MORE SLOWLYADENOMAS WASH OUT MORE SLOWLY•• HEMANGIOMAS RETAIN THEIR CONTRASTHEMANGIOMAS RETAIN THEIR CONTRAST

TRANSIENT HEPATICTRANSIENT HEPATICATTENUATION (INTENSITY)ATTENUATION (INTENSITY)

DIFFERENCESDIFFERENCES

THADSTHADSTHIDSTHIDS

NORMALNORMAL PORTAL VEIN THROMBOSISPORTAL VEIN THROMBOSISINCREASED PARENCHYMAL PRESSUREINCREASED PARENCHYMAL PRESSURE

PORTAL VEIN 10 mm HgPORTAL VEIN 10 mm HgHEPATIC ARTERY 120/70 mm HgHEPATIC ARTERY 120/70 mm HgMICROCIRCULATION 3MICROCIRCULATION 3--5 mm Hg5 mm Hg

HEPATIC VEIN 1HEPATIC VEIN 1--5 mm Hg5 mm Hg

THIDS AND THADSTHIDS AND THADS

•• PORTAL VEIN THROMBOSISPORTAL VEIN THROMBOSIS•• ADJACENT BENIGN OR MALIGNANT ADJACENT BENIGN OR MALIGNANT

HEPATIC MASS CAUSING HEPATIC MASS CAUSING ↑↑ PRESSUREPRESSURE•• SVC, IVC OBSTRUCTIONSVC, IVC OBSTRUCTION•• HEPATIC ARTERIAL HYPERTROPHYHEPATIC ARTERIAL HYPERTROPHY--

SUMPSUMP•• PERIPHERAL ARTEROPORTAL SHUNTPERIPHERAL ARTEROPORTAL SHUNT•• ABERRANT VENOUS DRAINAGEABERRANT VENOUS DRAINAGE

FLASH FILLERFLASH FILLER

•• KNOWN PRIMARY KNOWN PRIMARY HYPERVASCULAR HYPERVASCULAR MALIGNANCYMALIGNANCY

•• HEMANGIOMAHEMANGIOMA•• FNH FNH •• ADENOMAADENOMA•• HYPERVASCULAR HYPERVASCULAR

METASTASESMETASTASES•• HEPATOMAHEPATOMA•• AVMSAVMS•• NOD REGEN NOD REGEN

HYPERPLASIAHYPERPLASIA•• THADS, THIDSTHADS, THIDS

FLASH FILLERFLASH FILLER

•• KNOWN CIRRHOSISKNOWN CIRRHOSIS

•• HEMANGIOMAHEMANGIOMA•• FNH FNH •• ADENOMAADENOMA•• HEPATOMAHEPATOMA•• AVMSAVMS•• NOD REGEN NOD REGEN

HYPERPLASIAHYPERPLASIA•• THADS, THIDSTHADS, THIDS

FLASH FILLERFLASH FILLER

•• BUDD CHIARIBUDD CHIARI

•• HEMANGIOMAHEMANGIOMA•• FNH FNH •• ADENOMAADENOMA•• AVMSAVMS•• NOD REGEN NOD REGEN

HYPERPLASIAHYPERPLASIA•• THADS, THIDSTHADS, THIDS

FLASH FILLERFLASH FILLER

•• FEEDING VESSELSFEEDING VESSELS

•• HEMANGIOMAHEMANGIOMA•• FNH FNH •• ADENOMAADENOMA•• AVMSAVMS•• THADS, THIDSTHADS, THIDS

FLASH FILLERFLASH FILLER

•• ORAL ORAL CONTRACEPTIVESCONTRACEPTIVES

•• HEMANGIOMAHEMANGIOMA•• FNH FNH •• ADENOMAADENOMA•• THADS, THIDSTHADS, THIDS

FLASH FILLERFLASH FILLER

•• SO NOW WHAT?SO NOW WHAT?•• HEMANGIOMAHEMANGIOMA•• FNH FNH •• THADS, THIDSTHADS, THIDS

FLASH FILLERFLASH FILLER

•• OLDOLD•• HEMANGIOMAHEMANGIOMA•• FNH FNH •• THADS, THIDSTHADS, THIDS

FLASH FILLERFLASH FILLER

•• YOUNGYOUNG•• HEMANGIOMAHEMANGIOMA•• FNHFNH•• THADS, THIDSTHADS, THIDS

INCIDENTALOMA INCIDENTALOMA

•• IdentifyIdentify•• CharacterizeCharacterize•• Gonadal FortitudeGonadal Fortitude

–– StopStop–– Work up (how?)Work up (how?)–– Follow (when?)Follow (when?)–– BiopsyBiopsy–– Remove Remove

INCIDENTALOMA INCIDENTALOMA

•• Early incidentaloma detection may not lead to Early incidentaloma detection may not lead to longer survivallonger survival

•• Detecting and following incidentalomas provides Detecting and following incidentalomas provides no benefit for many conditionsno benefit for many conditions

•• Incidental findings, false positives and Incidental findings, false positives and overdiagnosis lead to healthy people getting extra overdiagnosis lead to healthy people getting extra teststests

•• Aggressively pursuing findings probably does more Aggressively pursuing findings probably does more harm than goodharm than good

INCIDENTALOMA INCIDENTALOMA

•• Appreciate the insignificance of the overwhelming Appreciate the insignificance of the overwhelming majority of majority of incidentalomasincidentalomas

•• Limit reporting to those that could herald disease in Limit reporting to those that could herald disease in which the course of the disease may be alteredwhich the course of the disease may be altered

•• Try to characterize the lesion, but balance risk and Try to characterize the lesion, but balance risk and cost of additional studiescost of additional studies

•• Quantify the probability of importanceQuantify the probability of importance•• Direct referring clinicians to the most costDirect referring clinicians to the most cost--

effective approach to managing the few effective approach to managing the few incidentalomasincidentalomas that must be pursuedthat must be pursued