0:01

This patient is, uh, 50 years old, female,

0:04

with known cirrhosis, and this is being done

0:06

to evaluate for, uh, hepatocellular carcinoma.

0:10

So we'll start looking at the images.

0:12

In this instance, I'm also going to start

0:13

off with the T2-weighted images, and I want

0:16

to focus on this particular cut over here.

0:19

And so this is a T2-weighted image with

0:21

fat saturation, and we can see that

0:25

almost the entire left hepatic lobe

0:27

has a very, very abnormal signal in it.

0:30

And we see the nodularity of the

0:31

liver; that's the known cirrhosis.

0:34

This sort of liver signal is relatively normal

0:36

over here, but this is way too hyperintense on

0:40

the T2-weighted images, so it's quite abnormal.

0:43

We see foci of that sort of abnormal

0:46

signal within areas in the right

0:47

hepatic lobe, but most of the right

0:49

hepatic lobe looks relatively spared.

0:52

So we're going to have to

0:52

investigate that further.

0:54

The other thing that we see on this image

0:55

is we see a portion of the right portal

0:57

vein over here with an expected flow void.

1:01

Don't see the left portal vein.

1:03

We would expect it to be in this location,

1:05

but inside of it we don't see that flow void.

1:07

And in fact, what we do see is signal

1:10

that is equivalent to what we see spread

1:13

throughout this left hepatic lobe.

1:14

So we'll investigate that further by

1:16

looking at the post-contrast images.

1:19

Here we have our post-contrast images,

1:21

T1, Fatsat, post-contrast, arterial

1:25

phase; this is the portal venous phase.

1:28

Very difficult to sort of confidently assess

1:31

what's going on in this left hepatic lobe.

1:33

We can see over here, abnormal signals spread

1:36

throughout, maybe patchy areas of enhancement.

1:40

Difficult to say if there's any discrete

1:41

non-RIM arterial phase hyperenhancement.

1:44

Very difficult to know if those same areas are

1:46

definitely washing out of their pseudocapsule.

1:48

It's just a very, very infiltrative

1:50

tumor that's spreading throughout

1:52

all aspects of the left hepatic lobe.

1:54

Within the left portal vein,

1:56

we can see that it's expanded.

1:58

It has that gray signal within it in both

2:00

the arterial and portal venous phase images.

2:02

And so whenever we see that sort of gray

2:04

signal, be worried about tumor thrombus.

2:07

Compare this to the right portal vein,

2:08

which is patent and filling with contrast

2:10

over here, so it looks nice and white.

2:12

And so we're really left with

2:14

findings of, uh, tumor thrombus.

2:17

On this cut, the tumor thrombus is

2:19

in the left portal vein, and the

2:21

entire left hepatic lobe is abnormal.

2:24

But it's very difficult to qualify what

2:26

that abnormality is, you know, in terms

2:28

of its arterial enhancement and washout.

2:30

So based on the LI-RADS lexicon,

2:32

the presence of tumor thrombus

2:33

qualifies this lesion as LI-RADS category TIV.

2:38

Unlike our prior case where we had more

2:40

discrete mass with arterial hyperenhancement

2:42

and washout, that's not as present in this case.

2:45

And so this would potentially go to a tumor

2:47

board with this designation of tumor in

2:49

vein, and in order to make sure we knew we

2:52

were treating a hepatocellular carcinoma, we'd

2:54

probably have to biopsy something here for

2:56

confirmation before we initiated or made

2:59

any recommendations of the sort of treatment

3:01

algorithm that this patient had to follow.