SURGERY II
Lecture Title
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X. RADIOLOGIC EVALUATION OF THE LIVER
ULTRASOUND
 Useful, initial imaging test of the liver: inexpensive, widely available
and no radiation exposure
 Additionally, intraoperative UTZ can provide real-time accurate
information useful for surgical planning
 Excellent for diagnosing biliary pathology, focal liver lesions and for
trauma
 Limitations:
o Incomplete imaging of the liver
o Incomplete visualization of lesion boundaries
o If px is obese or px is with overlying bowel gas:  image
quality
o Low sensitivity and specificity for mass
 If a mass is observed using UTZ  proceed to CT or MRI
 However, contrast-enhanced UTZ (i.e.injection of gas microbubble
agents) increases the sensitivity and specificity of ultrasound in
detecting and diagnosing liver lesions (whether benign or malignant).
 Contrast-enhanced ultrasound imaging of the liver improves
delineation of liver lesions through identification of dynamic
enhancement patterns and the vascular morphology of the lesion
INTRAOPERATIVE ULTRASOUND
 Intraoperative ultrasound is considered the gold standard for
detecting liver lesions, and studies have shown that it can identify
20% to 30% more lesions than other preoperative imaging modalities.
o For tumor staging
o Visualization of intrahepatic vascular structures
o Guidance of resection plane by assessment of the
relationship of the mass to the vessels
o UTZ-guided biopsy and ablation of tumors
ULTRASOUND ELASTOGRAPHY
 Transient elastography
 used to assess the degree of fibrosis or cirrhosis in the liver
 have a sensitivity of 87% and a specificity of 91% for the diagnosis of
cirrhosis when compared with liver biopsy
 Advantage:
o Unlike liver biopsy, ultrasound elastography is non-
invasive and can be repeated often without additional
risk to the patient
o can acquire information from a larger area of the tissue
relative to needle biopsy, provid- ing a better
understanding of the entire hepatic parenchyma and
reducing sampling error.
COMPUTED TOMOGRAPHY
 modern-day CT scans provide detailed morphologic information on
the number, size, distribution, and vascularity of liver lesions
 Contrast medium is routinely used in CT evaluation and a CT scan
with a dual or triple phase bolus of IV contrast can achieve the
greatest enhancement of contrast between normal and pathologic
tissues.
 After injection of the contrast agent, the rapid scan time of helical CT
allows for CT sections through the liver in both the arterial dominant
phase (20 to 30 seconds after the beginning of contrast delivery) and
venous or portal dominant phase (60 to 70 seconds after contrast
injection)
o ARTERIAL PHASE: many hepatic tumors that derive
the majority of their blood supply from the hepatic artery
as well as other hypervascular lesions are well
delineated during this phase
o PORTAL PHASE: provides optimal enhancement of the
normal liver parenchyma because the majority of its
blood supply is derived from the portal vein. This allows
for detec- tion of hypovascular lesions because they will
appear hypoattenuated in relation to the brighter normal
liver parenchyma
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CT CHOLANGIOGRAPHY
 involves the use of contrast agents, which are excreted by
hepatocytes into the bile ducts
 Used for biliary disease: provides information on hepatocyte function
and bile flow, in addition to high-resolution depiction of the biliary tree
 compared well to endoscopic retrograde cholangiopancreatography
(ERCP) in identifying obstructive biliary disease
 Advantages: ability to depict small nondilated peripheral biliary
radicals
o useful in the context of live liver donation or complex
biliary surgery to aid in the preoperative depiction of
biliary anatomy
 Can be used in post-op setting for the detection of biliary leakage or
obstruction.
 Limitation: biliary tree may not be well visualized in patients with
excessively dilated bile ducts or in those with hyperbilirubinemia, as
bilirubin excretion is impaired in these cases.
MAGNETIC RESONANCE IMAGING
 As with the iodinated contrast media use in CT scanning, multiple
contrast agents have been developed for MRI to increase the
difference in signal intensity between normal liver and pathologic
lesions.
 Usually gadolinium-based compounds
MR ELASTOGRAPHY
 Can also detect fibrosis or cirrhosis
 However, because of its high cost, the clinical utility of this modality
remains to be determined.
MAGNETIC RESONANCE CHOLAGIOPANCREATOGRAPHY
(MRCP)
 enables rapid, noninvasive depiction of both the biliary tree and the
pancreatic duct without the use of ionizing radiation or intravenous
contrast media
 Indication: biliary obstruction
 provides visualization of dilated bile ducts, and the high spatial and
contrast resolution often enables accurate assessment of the level of
occlusion in the biliary tree
 can be enhanced with liver-specific MRI contrast agents that are
actively secreted into the bile, but the clinical indications for such
studies are still a matter of intensive investigation
POSITRON EMISSION TOPOGRAPHY
 nuclear medicine test that produces images of metabolic activity in
tissues by detect- ing gamma rays emitted by a radioisotope
incorporated into a metabolically active molecule
 Fluorodeoxyglucose (FDG) is the most common metabolic molecule
used in PET imaging
 Integrated PET/CT improves diagnostic accuracy over standard PET
or CT alone and has been shown to be sensitive in the detection of
liver metastases derived from a wide range of cancers, including
colorectal, breast or lung primaries
 The role of FDG-PET/CT in colorectal cancers lies predominantly in
tumor staging and follow-up, particularly in the detection of occult
intrahepatic metastases or extrahepatic disease
 PET/CT has also been shown to be more accurate than contrast-
enhanced CT in tumor surveillance after radio- frequency ablation
 HOWEVER, it has a low sensitivity in the detection of HCC (50-60%)
because high-grade HCC lesions have increased FDG uptake
compared to low-grade HCCs
o Another modality is being studied which combines the
use of FDG with C-acetate, a tracer preferentialy
accumulated by well-differentiated HCC lesions.
 In cholangiocarcinoma tumors, FDG avidity depends on the
morphologic characteristics and location of the lesion
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