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This patient is a 62-year-old male and

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has a history of hepatitis C, cirrhosis.

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Had a new liver lesion seen on an

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ultrasound exam, and an MR was requested to,

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figure out what this lesion was.

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Let's start looking at the MR images, and we'll

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start off in this instance with a T2-weighted

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image, and we'll just sort of scroll through it.

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We can see a lesion up here at the liver dome.

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But there are numerous liver lesions, and

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all of them sort of look very similar.

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We can see a bunch of them

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here in the right hepatic lobe.

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Another one here in the right hepatic lobe.

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And for the purpose of this discussion, I'm

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going to take one representative lesion and

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sort of go through it and describe what we see.

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So this is a lesion that I'm

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going to focus on for the moment.

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So this is our T2-weighted sequence.

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There's no fat saturation on

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this particular imaging sequence.

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Um, and we see a lesion here, centered

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in segment 7, maybe a bit of it in segment 8.

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On the T2-weighted images,

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it's really rather bright.

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I mean, there's portions of it on the side that

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have sort of intermediate signal, but if you

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look at the central portion of it, it looks

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quite, quite bright on the T2-weighted images.

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The next set of images I want to look

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at if, uh, you know, I were to evaluate

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this in a very systematic fashion is to

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look at the T1 in phase and T1 out of phase.

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Out-of-phase images, just to look to see

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if there's any lipid within these lesions.

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So again, you can see the lesion

1:25

here centered in segment 7.

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And the lesion looks identical in

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the in and out-of-phase images.

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That tells you if there's no lipid or

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other sort of content within this lesion.

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That helps us sort of describe it a little bit

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more and understand what it could represent.

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The next image I'll look at for this patient

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is the T1-weighted fat-saturated image.

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Prior to giving contrast, so no contrast on

1:49

board, just to get a sense of what this lesion

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looks like before we give the contrast agent.

1:53

Again, we see this lesion over here, and it

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is hypointense on the T1-weighted images.

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Remember, it was rather bright

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on the T2-weighted images.

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Contains no lipid content.

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It's rather dark on the T1-weighted images.

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Let's see what this does

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with intravenous contrast.

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So here we have our post-contrast images.

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This is the T1 Fatsat post

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contrast arterial phase.

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Portal venous phase, equilibrium phase

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image, and again we just picked one of the

2:19

lesions, but all the lesions look similar to

2:21

this, uh, lesion in the right hepatic lobe.

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And there is rim enhancement surrounding this.

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Right, so we've seen a bunch of liver lesions so

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far in these patients with cirrhosis that have

2:32

had non-rim arterial phase hyperenhancement.

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This one's a little bit different.

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This has rim enhancement surrounding it.

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And for the most part, the internal, uh, aspect

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of this lesion really demonstrates no real

2:45

enhancement, maybe very low-level enhancement.

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So what we're really left with is a

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patient who certainly has cirrhosis, but

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has multiple, multiple liver lesions.

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They're very bright on the T2-weighted images.

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At least portions of them are very bright.

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They don't contain any lipid, fat, essentially.

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It's dark on the T1-weighted images.

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And there is rim enhancement.

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So none of these imaging features are

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really good for hepatocellular carcinoma.

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Given the multiplicity of the lesions,

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the presence of rim enhancement, the

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possibility that these reflect metastatic

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disease needs to be considered.

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So in this instance, if we want to

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classify this as a LI-RADS lesion, we

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would classify it as a LI-RADS M lesion.

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Remember, LI-RADS M lesions tell us that

3:37

whatever we're dealing with in the liver is

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almost certainly going to be malignant.

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But the likelihood of it being HCC is on

3:44

the lower end, maybe 30-37% approximately.

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Therefore, this can be brought to a tumor

3:49

board setting, classified as a LI-RADS M.

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In all likelihood, this would require biopsy.

3:55

This indeed was biopsied and

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turned out to be metastatic urothelial

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cancer in a patient who has cirrhosis.

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So unusual to see metastasis to a

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cirrhotic liver, but it can happen.

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And it should be on your radar, particularly

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when you have lesions that are multiple and

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have rim enhancement and really don't have

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any other imaging features that support

4:16

the diagnosis of hepatocellular carcinoma.