Cirrhosis, Hepatocellular Carcinoma and Portal Vein Thrombosis

Fig: Abnormal contour and size of liver consistant with cirrhosis.  Ascites.  Hepatocellular Carcinoma (red arrow) in segments 2, 3. Thrombus in the main Portal Vein extending into the Superior Mesenteric and Splenic Veins (white arrowhead) CLICK IMAGE FOR LARGER VIEW

Hepatocellular carcinoma (HCC) is a primary malignancy of the liver. Most cases of HCC are secondary to either a viral  infection (hepatitis B or C) or cirrhosis (alcoholism is the most common cause of hepatic cirrhosis).

On CT, HCC can have three distinct patterns of growth:

1. A single large tumor
2. Multiple tumors
3. Poorly defined tumor with an infiltrative growth pattern

The usual outcome is poor, because only 10 - 20% of hepatocellular carcinomas can be removed completely using surgery. 

A new tyrosine kinase receptor inhibitor, sorafenib has been shown in a Spanish phase III clinical trial to add two months to the lifespan of late stage HCC patients with well preserved liver function.  Sorafenib is a small molecular inhibitor of several Tyrosine protein kinases. A protein kinase is a kinase enzyme that modifies other proteins by chemically adding phosphate groups to them (phosphorylation). Phosphorylation usually results in a functional change of the target protein (substrate) by changing enzyme activity, cellular location, or association with other proteins. Tyrosine-specific protein kinases phosphorylate tyrosine amino acid residues, and like serine/threonine-specific kinases used in signal transduction. They act primarily as growth factor receptors and in downstream signaling from growth factors.  Sorafenib is unique in targeting the Raf/Mek/Erk pathway (MAP Kinase pathway). The MAPK/ERK pathway is a signal transduction pathway that couples intracellular responses to the binding of growth factors to cell surface receptors. This pathway is very complex and includes many protein component.

HCC presents radiographically as a spectrum, from large dominant hypervascular masses to diffuse, infiltrative, poorly visualized lesions.  Because of this imaging  for assessing treatment response in HCC with current modalities is challenging.  New imaging modalities for following HCC responses, especially to the new biologic therapies, must be developed.  Routine use of liver biopsy to conduct correlative studies is too risky . Diffusion weighted MR imaging may serve as an early biomarker of HCC response. Perfusion MRI is also being evaluated.

Thomas M, Zhu A (2005). "Hepatocellular carcinoma: the need for progress". J Clin Oncol 23 (13): 2892–9.

Diffusion-weighted MR imaging for determination of hepatocellular carcinoma response to yttrium-90 radioembolization. Deng J, Miller FH, Rhee TK, Sato KT, Mulcahy MF, Kulik LM, Salem R, Omary RA, Larson AC.  J Vasc Interv Radiol. 2006 Jul;17(7):1195-200.

CSF-OMA / CSF Pseudocyst

Sag CT and Oblique Sag VRCT show a ventriculoperitoneal shunt tube in the middle of a multilocular fluid collection in the lower abdomin and pelvis

CSF-oma ia s loculation of cerebrospinal fluid (CSF) at the distal end of the a ventriculoperitoneal shunt tube. It may occur secondary to adhesions. This results in an enlarging abdominal and/or pelvic mass at catheter tip, as CSF from the tip is no longer absorbed by peritoneum They can resolve spontaneously or after shunt revision and repositioning . Complications include infection and obstruction, the infection rate is 30% and can be higher in younger children.

Radiology of the Postoperative GI Tract, Bruce R. Javors, Ellen L. Wolf, Springer, 2003

Flexion Teardrop Fracture of C5

The flexion tear drop fracture is one of the most severe injuries of  the cervical spine. It is caused by extreme flexion of the cervical spine and often presents with loss of anterior column sensation and quadriplegia. The involved vertebral body is often displaced posteriorly  relative to the teardrop fragment which remains attached to the anterior longitudinal ligament. The facets may be subluxed, resulting in compression of  the spinal cord.


Kim KS, Chen HH, Russell EJ, Rogers LF: Flexion teardrop fracture of the cervical spine: radiographic characteristics AJR Am J Roentgenol. 1989 Feb;152(2):319-26.

Testicular Carcinoid

Figure 1: Large heterogeneous mass in the LT testicle

Figure 2: LT testicular mass has extensive vascularity on color doppler images.  Also has a cystic area.  This was a carcinoid tumor of the LT testicle mixed with teratoma.

Carcinoid tumor of the testis can occur as a primary neoplasm or as metastases. This tumor accounts for less than 1% of all testicular neoplasms, with 1.1%–3.1% of cases associated with carcinoid syndrome. They are most common in individuals ranging in age from 40 to 60 years. 25% of primary testicular carcinoid tumors are mixed with teratoma, these have a better prognosis. Orchiectomy is generally curative. Long-term follow-up is recommended.


Primary Carcinoid Tumor of the Testis Found at the Time of Elective Sterilization.  JOHN C. THOMAS AND J. STEPHEN JONES. Journal of Andrology, Vol. 25, No. 3, May/June 2004

St Lukes Update

The Radiology Residency at St Lukes is progressing nicely.  The reading room renovations are nearly complete and new ergonomic workstation tables have been delivered and are being set up.  Thanks to everyone involved in this transition it has gone very well.  I will post images of the new reading area when it is set up.

Constrictive pericarditis (CP) is a reduction in the elasticity, or stiffening, of the pericardium. This results in impaired filling of the heart with blood. Symptoms include, exercise intolerance, liver failure, dyspnea, and renal failure, Causes include: Viral infection, Tuberculosis (15% of cases). Surgery. Irradiation. Hemodialysis, Neoplasia with pericardial infiltration,. Bacterial, fungal, or parasitic infections. Inflammation after myocardial infarction (Dressler syndrome). Asbestosis . Autoimmune diseases. Imaging findings, such as calcifications and thickening of the pericardium, may be present, but the most reliable and most important findings are related to the filling pattern of the heart. Patients respond to a complete surgical pericardiectomy.

Metachromatic Leukodystrophy

SEPTEMBER IS LEUKODYSTROPHY MONTH

Metachromatic leukodystrophy is an autosomal recessive disorder caused by a deficiency of the lysosomal enzyme arylsulfatase A,  necessary for the normal hydrolysis of sulfatides (cerebroside 3-sulfate). Sulfatides are a component of the myelin. With metachromatic leukodystrophy, sulfatides accumulate within glial cells and neurons in the white matter of the brain, destroying normal myelin. It is diagnosed biochemically on the basis of an abnormally low level of arylsulfatase A in peripheral blood leukocytes and in the urine.   

There are three types of metachromatic leukodystrophy based on patient age at presentation: late infantile, juvenile, and adult. The most common type is late infantile metachromatic leukodystrophy.  Our patient presented as an adult. Adult metachromatic leukodystrophy can appear in adults of any age. The first symptoms are often changes in personality. Adult metachromatic leukodystrophy  is often misdiagnosed as other disorders such as schizophrenia or depression. As the disease progresses,  memory impairment, speech, and movement control slowly get worse . People with adult metachromatic leukodystrophy may sometimes live 10 to 30 years or more after onset.

MRI findings are symmetric, confluent high signal intensity on FLAIR / T2-weighted images in the periventricular white matter and centrum semiovale. A posterior predominance of white matter abnormalities has been noted.  Subcortical U fibers can be involved later in demyelination. Other sites of involvement were the genu and splenium of the corpus callosum, the posterior limbs of the internal capsule, the descending pyramidal tracts, the claustrum, and the cerebral white matter. Diffuse brain atrophy may result. No enhancement  is seen.

The only treatment that may affect the progression of metachromatic leukodystrophy  is a bone marrow or cord blood transplant. Transplant cells can make the arylsulfatase A . Recombinant human arylsulfatase A is being evaluated in Europe for enzyme replaement.

CheonJE, Kim IO, Hwang YS, et al. Leukodystrophy in children: a pictorial review of MR imaging features. RadioGraphics 2002; 22: 461–476.

Case Conference For 8.27.09

Case Conference for 8.27.09

This is a learning experience. Blogger has a limited window size. Let the video load and then pause and drag the slider bar to sucessive slides.

MR Ductography at 3T

This is an MR ductogram done at 3T with a fluid sensitive heavy T2 sequence. The patient had extensive bilateral ductal ectasia / dilatation due to long term antipsychotic meds.

Great News

In addition to St Lukes as a new teaching site for our residency program, the largest hospital in town and the largest group in Toledo are now teaching affiliates of UT's radiology residency progrm. TRA and The Toledo Hospital are going to host rotations in IR and Nucs. This adds tremendous experties and a large voulme of interesting cases to the training program. Dr Tom Win will be the site director for TTH/TRA.

As you can see from the title, Mercy Healthcare is no longer affiliated with the University of Toledo Radiology Residency Program. Our new partner is St Luke's Hospital, and we are moving to support imaging education at St Luke. Toledo Hospital and Toledo Radiologic Associates have also expressed interest in helping with our residency program.