TheHepaticLesion:RadiologicAssessment

TheAffiliatredhospitalofNBUWangJIANHUAwoxingw@2014-12-29TheHepaticLesion:2014-12-29CASECASE肝臟解剖與常見病影像診斷課件肝臟解剖與常見病影像診斷課件肝臟解剖與常見病影像診斷課件ObjectivesNormalliveranatomyImagingtechniquesCommondiseasesimagingdiagnosisDiffusediseasesFocaldiseases

ObjectivesNormalliveranatomyAnatomyoftheliversegments

Twodifferentaspects:morphologicalanatomyandfunctionalanatomy.

C.Couinaud(1957)dividedtheliverintoeightfunctionallyindepedentsegments.

Thisclassificationwillbepresentedherewithseveralillustrations.Anatomyoftheliversegments

Couinaudclassification

Dividestheliverintoeightfunctionallyindepedentsegments.

Eachsegmenthasitsownvascularinflow,outflowandbiliarydrainage.

Inthecentreofeachsegmentthereisabranchoftheportalvein,hepaticarteryandbileduct.

Intheperipheryofeachsegmentthereisvascularoutflowthroughthehepaticveins.Couinaudclassification

DividePortahepatisSecondPortahepatisPortahepatisSecondPortahepa肝臟解剖與常見病影像診斷課件Righthepaticveindividestherightlobeintoanteriorandposteriorsegments.

CrosstransversePortalveindividestheliverintoupperandlowersegments.

Middlehepaticveindividestheliverintorightandleftlobes(orrightandlefthemiliver).ThisplanerunsfromtheinferiorvenacavatothegallbladderfossaLefthepaticveindividestheleftlobeintoamedialandlateralpart.RighthepaticveindividestheTheimageonthefarleftisattheleveloftherightportalvein.Atthisleveltherightportalveindividestherightlobeoftheliverintosuperiorsegments(7and8)andtheinferiorsegments(5and6).

Theleveloftherightportalveinisinferiortotheleveloftheleftportalvein.Atthelevelofthesplenicvein,whichisbelowtheleveloftherightportalvein,onlytheinferiorsegmentsareseen(rightimage).TheimageonthefarleftisaCounterclockwiseCounterclockwise1CaudatelobeSegment1Segment4aSegment8Segment72Leftlateraluppersagment8Rightanterioruppersagment4Leftmedialsagment7RightposterioruppersagmentSegment21CaudatelobeSegment1SegmentLeftlateraluppersagmentLeftlateraluppersagmentLeftlaterallowsegmentLeftlaterallowsegmentLeftmedialsegmentLeftmedialsegmentRightposterioruppersegmentRightposterioruppersegmentRightanteriorupperdegmentRightanteriorupperdegmentRightanteriorlowdegmentRightanteriorlowdegmentRightposteriorlowsegmentRightposteriorlowsegmentLiveranatomyLiveranatomyImagingtechniquesUS:firstchoice,screening,difficulttocharacterizethelesionsCT:importanttechniqueMRI:problemresolvingtechniqueGoodmethodsofdecidingpositionandpredictingthenatureofthemassImagingtechniquesUS:firstchCTtechniquesCTtechniques7090120CTenhancedtechniques7090120CTenhancedtechniquesTheliverhasadualbloodsupplyfromthehepaticarteryandportalvein.Hepaticartery:1/3Portalvein:2/3TheliverhasadualbloodsupPortalveinphase60-70secafterborustracking-Hepaticmetastatictumor3minutesPortalveinphase-HepaticmetWhydoweneedmultiple-phaseenhancdmentIncreasethecontrastbetweennormalparenchymaandthelesionsothatincreasethedetectionrateUnderstandingthecharacteristicsofbloodsupplyandspeculatingthepathologicalchangesforthequalitativediagnosisWhydoweneedmultiple-phaseCASECASEMultiple-phaseenhancementMultiple-phaseenhancementMRIadvantagesMRIisoftenusedasaproblem-solveingtechniquetogiveadditionalinformationtoUSandCTExcellenttechniquefoedemonstratingtumoursImagescanbeobtainedincoronalandsagittalplanesIntravenuouscontrastisusedtoimprovevisualizationandhelpcharccterizelesions.Newliver-specificagents:SometakenbythehepatocytessomebythereticuloendothelialcellMRIadvantagesMRIisoftenuseMRIMRIMRCPMRCPMultiple-phaseEnhancementMultiple-phaseEnhancementArterialphaseEquilibriumphaseDelayedphase90minMultihance

liver-specificagents:specificallytakenbythehepatocytesPortalveinphaseArterialphaseEquilibriumphasHepatocarcinomacan’ttaketheagentmultihanceHepatocarcinomamultihanceCommonliverdiseasesimagingDiffusediseases:

fattyliver,cirrhosisFocaldiseases:

Benign：Livercyst,absecess,hemangiomaFocalnodulehyperplasia(FNH)adenoma

Malignant:heptocellularcarcinomacholangiocarcinomametastasistumorsCommonliverdiseasesimagingDFattyliverRelativelyfrequentfindingHypercholesterolaemiaobesityordiabetes,alcoholaddictandpatientsonchemotherapyorhormonotherapyDiffuseorlocalFattyinfiltrationleadstoareductionintheattenuationoftheaffectedparenchymacausinglowdensityonCTscansFattyliverRelativelyfrequent肝臟解剖與常見病影像診斷課件局灶性脂肪肝局灶性脂肪肝FattyliverFattyliverCirrhosisPathology:Livercelldegenerationandnecrosis,extensivefibrosisnodularregeneration----liverstructureandbloodcirculationsystemreconstructionImagingFeatures:Xray：esophagus,thebottomofthestomachvaricesCirrhosisPathology:LivercellCT、MRI

findings1/Shapemorphology：hepatomegaly/atrophic,liverloberatiochange,outerconcavecontour，parenchymalnodularregeneration2/Density:Inhomogeneousattenuation3/ContrastEnhancement(CE):inhomogeneousdegreeofenhancement,intrahepaticarterioportalfistulas4/Extrahepaticfindings:varices，scites,splenomegaly.5/Thedifferentialdiagnosis：

HepatocellularcarcinomaCT、MRI

findings1/Shapemorphol肝臟解剖與常見病影像診斷課件肝臟解剖與常見病影像診斷課件肝臟解剖與常見病影像診斷課件肝臟解剖與常見病影像診斷課件肝臟解剖與常見病影像診斷課件HepaticCystHepaticCystCT、MRIFeaturesRoundandquasi-circularSharpdemarcatationNonenhancingUniformdensityorsignal

CT：lowdensity(waterdensity0-15HU）T1WI：verylowsignalintensityT2WI：veryhighsignalintensityHepaticCystCT、MRIFeaturesHepaticCystHepaticAbscessBacterialandamebicliverabscessPathology：Pus/Necrosis/Fibertissue，InflammatorycellsinfiltrationEdemaImagingFeaturesSingleormultiplelowdensitylesionRoundorovalCircumferential[s?,k?mf?'ren??l]wall/enhancementfluildorgas-fluidlevelMRI：T1WI:hypo-intensityT2WI:hyper-intensityHepaticAbscessBacterialanda肝臟解剖與常見病影像診斷課件肝臟解剖與常見病影像診斷課件InflammatorygranulationtissueEdemaareaNecrosisTargetsignInflammatorygranulationtissu肝臟解剖與常見病影像診斷課件TargetsignAftertreatmentInflammatorygranulationtissueNecrosisedemaareaTargetsignAftertreatmentInflHemangioma

Pathology：BenignlesionCavernoushemangioma(mostly)/capillary/hemangioendotheliomaAtypeofbloodvesselmalformation(hemangioma)thathasrelativelylargeblood-filledspaces(cavities)Nocontaintissueoftheorganinwhichtheyaresituated.ImagingFeatures:Singleormultiplelowdensitylesion(CTvalue:30-40HU)Roundoroval,Sharpmargin,no

capsule

Contrast:earlyperipheralnodularenhancement,graduallyfillinginovertimeMRI：T1WI:hypo-intensityT2WI:hyper-intensityHemangioma

Pathology：BenignlHemangiomaHemangioma肝臟解剖與常見病影像診斷課件HemangiomaHemangioma肝臟解剖與常見病影像診斷課件肝臟解剖與常見病影像診斷課件肝臟解剖與常見病影像診斷課件FNH影像特征平掃密度信號與肝實質接近強化明顯內部瘢痕假包膜少見FNH影像特征平掃密度信號與肝實質接近肝腺瘤Hepatocelluaradenoma女,18歲增強：強化明顯肝腺瘤Hepatocelluaradenoma女,1男,22歲易出血男,22歲易出血女性、23歲，MRI掃描征象：包膜、脂肪女性、23歲，MRI掃描征象：包膜、脂肪肝臟解剖與常見病影像診斷課件肝細胞癌我國最常見的惡性腫瘤之一發病率居惡性腫瘤的第2或第3位惡性程度高，5年生存率低于5%肝細胞癌我國最常見的惡性腫瘤之一肝細胞癌中國85%左右的HCC與病毒性肝炎肝硬化有關10％的中國人感染乙型肝炎病毒日本70％左右的HCC與丙型肝炎有關美國30-50％左右的HCC與丙型肝炎有關肝細胞癌中國肝細胞癌大體病理分型塊狀型直徑大于5厘米，大于10厘米為巨塊型結節型癌結節直徑小于5厘米，單發或多發彌漫型癌結節小，彌漫分布小肝癌單發結節小于3厘米，或2個病灶直徑之和小于3厘米肝細胞癌大體病理分型肝細胞癌臨床表現右上腹痛消瘦乏力，進行性加重腹脹、腹瀉、惡性、納差黃疸發熱AFP升高>400ug/L，持續4周以上，除外妊娠、活動性肝炎或生殖細胞腫瘤。肝細胞癌臨床表現肝臟解剖與常見病影像診斷課件肝臟解剖與常見病影像診斷課件肝細胞癌肝細胞癌肝細胞癌肝細胞癌肝細胞癌肝細胞癌小肝細胞癌的定義國際胃腸病學會（1994年）單個病灶直徑小于等于2厘米兩個病灶，其直徑之和小于等于2厘米日本Okuda單個病灶直徑小于等于4.5厘米四個以內病灶，直徑之和小于等于3.5厘米中國肝癌病理協作組？？單個病灶直徑小于等于2厘米兩個病灶，其直徑之和小于等于2厘米小肝細胞癌的定義國際胃腸病學會（1994年）小肝細胞癌CT-CCT+C動脈期CT+C門脈期小肝細胞癌CT-CCT+C動脈期CT+C門脈期丙型肝炎合并小肝癌丙型肝炎合并小肝癌膽管癌伴肝內子灶膽管癌伴肝內子灶肝臟解剖與常見病影像診斷課件BulleyesignBulleyesign肝臟解剖與常見病影像診斷課件intrahepaticmetastasis

APatientwithcoloncarcinomahistoryintrahepaticmetastasisAPatie食管靜脈曲張臍血管再通食管靜脈曲張臍血管再通肝臟解剖與常見病影像診斷課件肝臟解剖與常見病影像診斷課件肝臟解剖與常見病影像診斷課件肝臟解剖與常見病影像診斷課件肝臟解剖與常見病影像診斷課件肝臟解剖與常見病影像診斷課件肝臟解剖與常見病影像診斷課件77%95%77%95%ThankyouThankyouTheHepaticLesion:RadiologicAssessment

TheAffiliatredhospitalofNBUWangJIANHUAwoxingw@2014-12-29TheHepaticLesion:2014-12-29CASECASE肝臟解剖與常見病影像診斷課件肝臟解剖與常見病影像診斷課件肝臟解剖與常見病影像診斷課件ObjectivesNormalliveranatomyImagingtechniquesCommondiseasesimagingdiagnosisDiffusediseasesFocaldiseases

ObjectivesNormalliveranatomyAnatomyoftheliversegments

Twodifferentaspects:morphologicalanatomyandfunctionalanatomy.

C.Couinaud(1957)dividedtheliverintoeightfunctionallyindepedentsegments.

Thisclassificationwillbepresentedherewithseveralillustrations.Anatomyoftheliversegments

Couinaudclassification

Dividestheliverintoeightfunctionallyindepedentsegments.

Eachsegmenthasitsownvascularinflow,outflowandbiliarydrainage.

Inthecentreofeachsegmentthereisabranchoftheportalvein,hepaticarteryandbileduct.

Intheperipheryofeachsegmentthereisvascularoutflowthroughthehepaticveins.Couinaudclassification

DividePortahepatisSecondPortahepatisPortahepatisSecondPortahepa肝臟解剖與常見病影像診斷課件Righthepaticveindividestherightlobeintoanteriorandposteriorsegments.

CrosstransversePortalveindividestheliverintoupperandlowersegments.

Middlehepaticveindividestheliverintorightandleftlobes(orrightandlefthemiliver).ThisplanerunsfromtheinferiorvenacavatothegallbladderfossaLefthepaticveindividestheleftlobeintoamedialandlateralpart.RighthepaticveindividestheTheimageonthefarleftisattheleveloftherightportalvein.Atthisleveltherightportalveindividestherightlobeoftheliverintosuperiorsegments(7and8)andtheinferiorsegments(5and6).

Theleveloftherightportalveinisinferiortotheleveloftheleftportalvein.Atthelevelofthesplenicvein,whichisbelowtheleveloftherightportalvein,onlytheinferiorsegmentsareseen(rightimage).TheimageonthefarleftisaCounterclockwiseCounterclockwise1CaudatelobeSegment1Segment4aSegment8Segment72Leftlateraluppersagment8Rightanterioruppersagment4Leftmedialsagment7RightposterioruppersagmentSegment21CaudatelobeSegment1SegmentLeftlateraluppersagmentLeftlateraluppersagmentLeftlaterallowsegmentLeftlaterallowsegmentLeftmedialsegmentLeftmedialsegmentRightposterioruppersegmentRightposterioruppersegmentRightanteriorupperdegmentRightanteriorupperdegmentRightanteriorlowdegmentRightanteriorlowdegmentRightposteriorlowsegmentRightposteriorlowsegmentLiveranatomyLiveranatomyImagingtechniquesUS:firstchoice,screening,difficulttocharacterizethelesionsCT:importanttechniqueMRI:problemresolvingtechniqueGoodmethodsofdecidingpositionandpredictingthenatureofthemassImagingtechniquesUS:firstchCTtechniquesCTtechniques7090120CTenhancedtechniques7090120CTenhancedtechniquesTheliverhasadualbloodsupplyfromthehepaticarteryandportalvein.Hepaticartery:1/3Portalvein:2/3TheliverhasadualbloodsupPortalveinphase60-70secafterborustracking-Hepaticmetastatictumor3minutesPortalveinphase-HepaticmetWhydoweneedmultiple-phaseenhancdmentIncreasethecontrastbetweennormalparenchymaandthelesionsothatincreasethedetectionrateUnderstandingthecharacteristicsofbloodsupplyandspeculatingthepathologicalchangesforthequalitativediagnosisWhydoweneedmultiple-phaseCASECASEMultiple-phaseenhancementMultiple-phaseenhancementMRIadvantagesMRIisoftenusedasaproblem-solveingtechniquetogiveadditionalinformationtoUSandCTExcellenttechniquefoedemonstratingtumoursImagescanbeobtainedincoronalandsagittalplanesIntravenuouscontrastisusedtoimprovevisualizationandhelpcharccterizelesions.Newliver-specificagents:SometakenbythehepatocytessomebythereticuloendothelialcellMRIadvantagesMRIisoftenuseMRIMRIMRCPMRCPMultiple-phaseEnhancementMultiple-phaseEnhancementArterialphaseEquilibriumphaseDelayedphase90minMultihance

liver-specificagents:specificallytakenbythehepatocytesPortalveinphaseArterialphaseEquilibriumphasHepatocarcinomacan’ttaketheagentmultihanceHepatocarcinomamultihanceCommonliverdiseasesimagingDiffusediseases:

fattyliver,cirrhosisFocaldiseases:

Benign：Livercyst,absecess,hemangiomaFocalnodulehyperplasia(FNH)adenoma

Malignant:heptocellularcarcinomacholangiocarcinomametastasistumorsCommonliverdiseasesimagingDFattyliverRelativelyfrequentfindingHypercholesterolaemiaobesityordiabetes,alcoholaddictandpatientsonchemotherapyorhormonotherapyDiffuseorlocalFattyinfiltrationleadstoareductionintheattenuationoftheaffectedparenchymacausinglowdensityonCTscansFattyliverRelativelyfrequent肝臟解剖與常見病影像診斷課件局灶性脂肪肝局灶性脂肪肝FattyliverFattyliverCirrhosisPathology:Livercelldegenerationandnecrosis,extensivefibrosisnodularregeneration----liverstructureandbloodcirculationsystemreconstructionImagingFeatures:Xray：esophagus,thebottomofthestomachvaricesCirrhosisPathology:LivercellCT、MRI

findings1/Shapemorphology：hepatomegaly/atrophic,liverloberatiochange,outerconcavecontour，parenchymalnodularregeneration2/Density:Inhomogeneousattenuation3/ContrastEnhancement(CE):inhomogeneousdegreeofenhancement,intrahepaticarterioportalfistulas4/Extrahepaticfindings:varices，scites,splenomegaly.5/Thedifferentialdiagnosis：

HepatocellularcarcinomaCT、MRI

findings1/Shapemorphol肝臟解剖與常見病影像診斷課件肝臟解剖與常見病影像診斷課件肝臟解剖與常見病影像診斷課件肝臟解剖與常見病影像診斷課件肝臟解剖與常見病影像診斷課件HepaticCystHepaticCystCT、MRIFeaturesRoundandquasi-circularSharpdemarcatationNonenhancingUniformdensityorsignal

CT：lowdensity(waterdensity0-15HU）T1WI：verylowsignalintensityT2WI：veryhighsignalintensityHepaticCystCT、MRIFeaturesHepaticCystHepaticAbscessBacterialandamebicliverabscessPathology：Pus/Necrosis/Fibertissue，InflammatorycellsinfiltrationEdemaImagingFeaturesSingleormultiplelowdensitylesionRoundorovalCircumferential[s?,k?mf?'ren??l]wall/enhancementfluildorgas-fluidlevelMRI：T1WI:hypo-intensityT2WI:hyper-intensityHepaticAbscessBacterialanda肝臟解剖與常見病影像診斷課件肝臟解剖與常見病影像診斷課件InflammatorygranulationtissueEdemaareaNecrosisTargetsignInflammatorygranulationtissu肝臟解剖與常見病影像診斷課件TargetsignAftertreatmentInflammatorygranulationtissueNecrosisedemaareaTargetsignAftertreatmentInflHemangioma

Pathology：BenignlesionCavernoushemangioma(mostly)/capillary/hemangioendotheliomaAtypeofbloodvesselmalformation(hemangioma)thathasrelativelylargebloo