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CI

Cancer Imaging (2004) 4, S42–S46
DOI: 10.1102/1470-7330.2004.0011

ARTICLE

Liver cancer imaging: role of CT, MRI, US and PET
Maria Raquel Oliva and Sanjay Saini

Department of Radiology, Massachusetts General Hospital and Harvard Medical School, White 270,
55 Fruit Street, Boston, MA 02114, USA
Corresponding address: Dr Sanjay Saini, Department of Radiology, Massachusetts General Hospital and Harvard
Medical School, White 270, 55 Fruit Street, Boston, MA 02114, USA. Tel.: +1-617-726-3937
E-mail: ssaini@partners.org

Date accepted for publication 6 February 2004

Abstract
Liver imaging in patients with a history of known or suspected malignancy is important because the liver is a common
site of metastatic spread, especially tumours from the colon, lung, pancreas and stomach, and in patients with chronic
liver disease who are at risk for developing hepatocellular carcinoma. Since benign liver lesions are common, liver-
imaging strategies should incorporate liver lesion detection and characterisation. Survey examination in patients with
a known extra-hepatic malignancy to exclude the presence of hepatic and extra-hepatic involvement is normally
undertaken with a contrast-enhanced computed tomography examination. When patients with hepatic metastases
are being considered for metastasesectomy, they undergo a staging examination with contrast-enhanced magnetic
resonance imaging (MRI) using tissue-specific contrast agents. Patients with chronic liver disease who are at risk
for hepatocellular carcinoma undergo periodic liver screening for focal liver detection, usually with ultrasonography
(US) with MRI being used when US is equivocal. Finally, contrast-enhanced MRI with extra-cellular gadolinium
chelates is preferred for characterisation of indeterminate hepatic masses with liver biopsy used when tissue diagnosis
is needed.
Keywords: Liver cancer imaging; computed tomography; magnetic resonance imaging; ultrasonography; positron emission
tomography.

Introduction disease remains crucial to patient management [4] .
However, since benign liver lesions are very com-
Liver imaging is commonly undertaken in patients with mon [5,6] , liver-imaging strategies should incorporate liver
cancer history because, after lymph nodes, the liver is the lesion characterisation as an equally important goal. Sev-
most frequently involved organ by metastases [1] . Liver eral imaging modalities are now available for detection
metastases most often arise from primary tumours in and characterisation of focal liver lesions. These include
colon, breast, lung, pancreas and stomach [2] . Although ultrasonography (US), computed tomography (CT), mag-
in Europe and the United States a malignant liver netic resonance imaging (MRI) and positron emission
mass is more likely to represent a metastatic deposit
tomography (PET). Since technological advances in these
than a primary hepatic malignancy [1] , hepatocellular
modalities and associated contrast media continue to
carcinoma (HCC) is the most common primary cancer
of the liver and its incidence has increased in occur, no broad consensus exists over which modality
Japan and portions of the developing world, arising should be used.
mainly in patients with chronic liver disease [3] . In In this paper we outline a practical approach for liver
both situations, accurate detection of malignant liver imaging in the oncologic population.

This paper is available online at http://www.cancerimaging.org. In the event of a change in the URL address, please use the DOI
provided to locate the paper.

1470-7330/04/000042 + 05 c 2004 International Cancer Imaging Society

In this setting accurate detection phase imaging should be added to the portal venous phase of individual liver metastases is important because their acquisition [10] . During liver evaluation. gadobenate. there is an important role for contrast-enhanced CT study since CT has high sensibility PET at the time of initial diagnosis for cancer staging. demonstrated that combined pre. in our experience quently undergo abdominal survey examinations to look the major drawback of PET is that the heterogeneous for liver metastases. 93. our experience has demonstrated a higher and provide a gross estimate of liver tumour burden. in inations are performed in patients with known hepatic patients with vascular tumours such as neuroendocrine malignancy (primary or secondary) when liver resection tumours. Other lymph nodes [15] . MRI. as a result. the primary goal is it difficult to exclude small liver metastases (Fig. such as metastases in non-enlarged MRI for evaluating the extra-hepatic abdomen [8] . enhanced CT or a non-contrast MRI examination [18] . In to the pancreas. our approach is to perform an MRI examination performed to fully evaluate the liver. (93%) and specificity (100%) for detecting hepatic primarily due to its higher sensitivity for detecting extra- metastases [7] . However. melanoma and renal cell cancer (Fig. liver staging exam- for examination of the abdomen and pelvis. US and PET S43 Imaging hepatic metastases characterisation [15] .and post-contrast gadoxetate MRI had improved sensitivity for liver lesion detection compared to pre- contrast MRI. 1). iron oxide particles are Figure 1 Arterial phase contrast-enhanced com. Indeed. a suitable candidate for surgical therapy [17] . In Staging examinations most patients portal-venous phase imaging is sufficient In contrast to survey examinations. However. liver metastases without reticuloendothelial function show an unchanged signal [20] . ferucarbotran) [18] . and similar sensitivity to dual-phase CT and fewer false-positive lesions identified with pre. given the relatively higher cost of PET and its limited availability [15] . gadoxetate) and reticuloendothe- lial system compounds (ferumoxide.7%) [16] . Sahani et al. 2(a. computed tomography during arterial portography is no longer needed for accurate staging studies. a for the hepatocyte-specific T1 contrast agents which combined PET–CT examination is the preferred approach selectively affect the signal intensity of normal liver. ovarian cancer and other hepatic metastases [21–25] . comparison. Their primary puted tomography in a patient with renal cell effect on MR images is to decrease signal intensity of carcinoma demonstrating hypervascular metastases normal areas of liver on T2-weighted images [20] .9] . Several studies have should be performed in the presence of fatty infiltration consistently shown the superiority of a liver-specific of the liver since liver metastases can be obscured when contrast agent-enhanced MRI examination over contrast- hepatic steatosis is present [11] . However. After intravenous administration. since it allows anatomic localisation of ‘hot-spots’ for providing images of excellent signal-to-noise ratio by . accuracy for contrast-enhanced MRI over PET (100 Such survey examinations are best undertaken with a vs. several liver-specific compounds are avail- able for liver MRI. Indeed. resulting in improved detection of with colon rectal cancer. lymph node involvement and local hepatic uptake of the FDG radiopharmaceutical makes involvement. at present Survey examinations the use of PET or PET–CT for routine abdominal survey examination is not a practical consideration. Patients with a known extra-hepatic malignancy fre- regarding liver metastases detection. MRI using liver-specific contrast media. arterial is being considered. taken up by the reticuloendothelial system. These agents include water-soluble paramagnetic chelates with hepatocyte uptake (man- gafodipir. Liver cancer imaging: role of CT. Similarly. to determine the presence/absence of hepatic metastases b)) [15] . While US and MRI also have similar hepatic foci of metastases in areas in which CT has sub- accuracy. Furthermore. our preference is cancers is still under evaluation [12–14] . In this the accuracy of CT is poor and an MRI should be setting. Currently. However.and post-contrast gadoxetate MRI compared to dual-phase helical CT [19] . CT is preferred because it out-performs US and optimal sensitivity. If radiographic contrast media cannot be number and location determine whether the patient is administered due to iodine allergy or renal insufficiency. This increases The role of fluorine-18-labelled fluorodeoxyglucose the difference in signal between normal liver and (FDG)–PET imaging for abdominal evaluation in patients liver metastases. For example. If available. benefits of CT are easy access due to wide availability and patient-friendly protocols allowing even a chest– abdomen–pelvis CT examination in a less then 20-s breath hold using multidetector CT technology [8.

due to the high prevalence of For patients undergoing staging studies using liver- benign hepatic tumours such as cysts. (a) (b) Figure 3 T1-weighted MRI of the liver demonstrates higher metastases–liver contrast on hepatocyte-specific contrast agent (mangafodipir) enhanced images (a) compared to the pre-contrast images (b). Note that an additional lesion is seen on post-contrast image in segment IV. Furthermore. Optimal imaging technique for lesion characterisation requires imaging in arterial. haemangiomas and specific contrast agent-enhanced MRI. when a lesion is indeter- loss on T2-weighted images [20] . iron oxide-enhanced MRI depends on or equilibrium-phase scans. portal Liver lesion characterisation and equilibrium phases [33] . means of fast imaging sequences (Fig. and makes images minate on contrast-enhanced CT a dynamic contrast- particularly susceptible to motion artifacts. With delayed- In comparison. . Other benefits of liver-specific most commonly used contrast agents are the non- contrast-enhanced MRI are that dynamic images are not specific extra-cellular gadolinium chelates because they necessary nor does the whole liver need to be covered in are inexpensive. and they can enable characterisation of a wide range of hepatic diseases [32] . a dynamic scan focal nodular hyperplasia. 3(a. b)) [18] . cysts can be readily char- susceptibility effects [26] and produces signal intensity acterised as well.S44 M R Oliva and S Saini (a) (b) Figure 2 PET (a) demonstrates a focus of uptake in the right liver lobe in a patient with colon carcinoma who had undergone a metastasectomy. No tumour recurrence was present on follow-up scans. and well tolerated by patients. A portal phase. As mentioned before. the then the iron oxides [27] . liver lesion characterisation with gadolinium chelates can be done immediately is as important as lesion detection. resulting in a dual only contrast-enhanced CT is able to characterise the contrast study [34] . as seen on the CT (b). vast majority of haemangiomas [28–30] . afterwards with a second injection. enhanced MRI with gadolinium chelates is appropriate the hepatocyte-targeted compounds are better tolerated for lesion characterisation [31] . a single breath hold [27] . In clinical practice. However. safe.

occurrence of benign liver lesions in patients with newly . facility.htm. Hence patients with an before surgery in patients with hepatic malignancy [45.com/radio/topic394. Semelka RC. 39: 183–8. neither modality has adequate sensitivity. and extra- and cost-effective way to examine the liver parenchyma cellular gadolinium chelate contrast-enhanced MRI is and can be done as frequently as needed. distinction of HCC being considered for metastasectomy undergo a staging from other solid lesions such as regenerating nodules. However. Liver. nodules which typically are greater than 1 cm. 4(a–c)). Detection of focal masses within a cirrhotic liver is or with a fatty liver. US-based screening for HCC Finally. and effect on patient management: lesions generally do not show arterial phase enhancement comparison of single-phase spiral CT and current MR tech- although exceptions do occur [44] . 66: 1067–72. http:// Nevertheless. T2-weighted (b) and arterial phase extracellular Gd-chelate-enhanced MRI (c) demonstrating a T1 and T2 hyperintense mass which is enhanced in the arterial phase. Liver lesion hypointense and T1 hyperintense [35] . November 21. 7: 1040–7. Distribution of because it has superior diagnostic accuracy to CT [38] . MRI. Lien WM. Patients with hepatic metastases and to evaluate the extent of local chronic liver disease such as hepatitis C are at risk for involvement. This metastasis survey should be done developing HCC and undergo periodic liver screening for with contrast-enhanced CT. N Engl J Med 1999. MR can also characterise regenerative nodules which Surgery 1969. [5] Karhunen PJ. contrast-enhanced CT may be undertaken with a [6] Noone TC. [2] Ackerman NB.40] . Amin Z. Balci NC.46] . Graham ML. Since malignant lesions are of experimental liver metastases. J Magn Reson Imaging 1997. 340: 745–50. preoperative mapping of the hepatic artery. T1-weighted pre-contrast injection (a). portal has a sub-optimal sensitivity and specificity. in which case biopsy niques. abnormal liver US showing cirrhosis or focal mass often Vascular anatomy imaging can be done with CT undergo a contrast-enhanced CT or MRI examination [38] . MRI being reserved for focal liver detection. hepatic artery and portal vein blood to ‘small’ and ‘large’ tumors. [1] Khan AN. Screening with α-fetoprotein and those patients unable to receive intravenous contrast US is a useful tool for early diagnosis of HCC [36] .emedicine. angiography or MR angiography. Patients with chronic liver equally important and difficult task [35] . typically every used for evaluating patients with an abnormal US. In recent years References the value of dual arterial phase imaging has also been evaluated and is under investigation [42.43] . Distribution of hepatic artery typically T2 hyperintense. examination usually with contrast-enhanced MRI using dysplastic nodules and confluent hepatic fibrosis is an tissue-specific contrast agents. Mason AC. especially vein and the hepatic vein anatomy is often undertaken when liver cirrhosis is present [38] . Benign hepatic tumours and tumour like conditions may be needed. with extra-hepatic malignancy undergo survey exami- An accurate diagnosis of HCC with cirrhosis is important nations to exclude the presence of hepatic and extra- for patient care and treatment decision [35] . Kelekis NL et al. metastasis. Kondi ES et al. and usually occurs in liver tumour detection and characterisation. Imaging hepatocellular carcinoma Summary Hepatocellular carcinoma is the most common primary The goal of liver imaging in oncologic patients includes malignant hepatic neoplasm. indicative of an HCC. Rising incidence of hepatocellular are under 1 cm and T2 hypointense and dysplastic carcinoma in the United States. typically being 40–70% for early HCC detection [39. T2 [4] Semelka RC. 2003. Patients patients with chronic hepatic parenchymal disease [35] . characterization. these detection. 1 cm are likely to be malignant but should be distin. J Clin Pathol 1986. our preference is to use MRI and portal vein blood to ‘small’ liver metastases. and generally requires Unfortunately. If there is no access to a high-quality MRI in men. arterially enhancing lesions greater than www. Macdonald S. US and PET S45 (a) (b) (c) Figure 4 MRI of the liver in a patient with chronic liver disease. a separate examination. Common hepatic arterial phase and portal phase scans. [3] El-Serag HB. Patients with hepatic metastases a daunting challenge. Ultrasonography disease at risk for developing hepatocellular carcinoma is the primary screening test since it allows for a quick undergo periodic liver screening with US. In addition. With both modalities arterial phase imaging is critical for early detection of HCC [41] (Fig. Liver cancer imaging: role of CT. Worawattanakul S. The blood supply guished from arterial shunts. 3–6 months [37] . In addition.

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