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The following patient is a 52-year-old gentleman

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with liver masses, otherwise healthy.

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No past medical history that we know of, and we're

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performing an MRI to evaluate these lesions.

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So let's start looking at

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some of these images here.

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We'll start off with our T2-weighted images,

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and as we scroll through it, we can see that there

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are numerous liver lesions seen in this patient.

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You can see one over here, one over

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here, one over here, one over here.

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And so, certainly, numerous lesions.

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Predominantly in the right hepatic lobe,

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there's some in the left hepatic lobe.

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And if I just give you a representative

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lesion here, on our T2-weighted sequence,

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we can see that they're fairly hyper-

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intense in their imaging appearance.

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In and out of phase, I won't show, but

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I'll tell you that the liver is steatotic,

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but the lesions themselves are not.

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Remember, again, that the liver itself

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does not particularly have any features

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to suggest that there is cirrhosis, and

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we have no past medical history to suggest

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the patient has chronic liver disease.

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So I'll move on to the post-contrast

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images to see what these lesions look like.

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So here we have the post-contrast images,

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and I'll just start scrolling through some

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of these lesions, and all of them essentially

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have a very, very similar imaging appearance.

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I'm just going to focus on this

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lesion here on the right hepatic lobe.

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So here we have a T1, FATSAT, post-contrast

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arterial phase, this is the portal venous phase.

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And if we look at this lesion, a little

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bit of motion on this exam, but we can

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still see that there's a lesion over here.

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It demonstrates non-RIM arterial

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phase hyperenhancement.

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So, we've heard that sort of phrase many

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times before with respect to describing

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HCCs or hepatocellular carcinomas.

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I would imagine this is probably

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around two centimeters in size or so.

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When we look at the characteristics on the

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portal venous phase, this has washout, this has

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a pseudocapsule, and we see multiple lesions.

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And so, when you see something like this,

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there may be the temptation to call this

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multifocal hepatocellular carcinoma.

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And I've certainly made

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that mistake in the past.

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But what's important to understand is

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that, again, the patient has no history

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of cirrhosis, no risk factors of chronic

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liver disease, and the likelihood of this

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being multifocal HCC in a patient without

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those risk factors is pretty small.

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More likely, this is going to be

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something that is spread to the liver, i.e.

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metastatic disease, and certainly there's some

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metastatic disease that give you hypervascular

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metastases that can look quite similar to

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what a hepatocellular carcinoma can look like.

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But they're not gonna be HCCs.

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They're gonna be hypervascular metastases.

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And the common tumors that do that, they

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need to think about are neuroendocrine

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tumors, renal cell carcinomas, melanoma,

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thyroid carcinomas, and there's a whole

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laundry list of them, but these are some

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of the more common ones that can do it.

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So again, the teaching point here

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is that hypervascular METs can look

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like hepatocellular carcinomas.

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You're going to see multiple lesions in

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patients who do not have cirrhosis or

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don't have any history of chronic liver

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disease or any risk factors to place

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them at risk for chronic liver disease.

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So if you see lesions like this, you've

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got to think of hypervascular METs.

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You've got to look around the

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body to see if there's anything

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primary relating from some

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of these primary tumors.

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And ultimately, you'd have to

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biopsy it to make the diagnosis.