0:01

So the following patient is a 65-year-old

0:03

gentleman with cirrhosis, and they're looking

0:06

for hepatocellular carcinoma by doing an MRI.

0:10

So let's go ahead and look

0:10

at some of the images.

0:12

We'll jump right to the post-contrast images.

0:15

Now I want you to focus on this

0:16

lesion over here in segment 7.

0:20

Here we have the T1 Fatsat.

0:23

That post-contrast image in the arterial

0:26

phase, this is the portal venous phase.

0:28

And this lesion, as I said, in the

0:29

segment 7, if we were just to evaluate

0:31

it quickly, we'll notice that there's

0:33

non-RIM arterial phase hyperenhancement.

0:37

If you were to measure it, you get it just

0:39

at around 2 centimeters, so we'll mark

0:41

it as greater or equal to 20 millimeters.

0:43

And remember, when you have a lesion

0:45

of this size demonstrating non-RIM

0:47

arterial phase hyperenhancement,

0:49

you just need one more feature.

0:51

Either washout, pseudocapsule,

0:53

or growth to call it a LI-RADS V.

0:55

If you look at the portal venous

0:56

phase, you can see a very, very thin

0:58

rim of enhancement surrounding this.

1:00

No real internal washout, but the

1:02

rim is present, so the presence of

1:05

that pseudocapsule will then allow

1:07

us to call this a LI-RADS V lesion.

1:11

And given the relatively small size and

1:14

location, this was deemed to be amenable for

1:17

percutaneous ablation, which was performed.

1:20

And this is what the lesion looks

1:22

like after the ablation, done a few

1:24

months after the treatment itself.

1:26

So this is a T1-weighted

1:28

image with fat saturation.

1:30

We've given contrast.

1:32

We have the arterial phase over here.

1:34

We have the portal venous phase over here.

1:36

And these also are subtracted images.

1:38

I really do like looking at the subtracted

1:40

images when we have post-ablative HCCs in order

1:44

to sort of take away all that potential fat.

1:46

hyperintense T1 content that can be

1:49

seen with these ablation cavities.

1:51

But you can see the ablation cavity over here

1:53

in segment 7 appearing completely avascular.

1:56

It's important to kind of

1:57

scroll through it up or down.

1:59

You don't see any nodules of arterial

2:01

hyperenhancement, no nodules that

2:03

wash out, nothing that tells us

2:05

that there's any viable

2:07

tumor left in this lesion.

2:09

So this is a successful

2:10

treatment of a LI-RADS V lesion.

2:12

And so, this is something that requires, uh,

2:15

routine follow-up every couple of months to

2:17

make sure that no disease develops within this.

2:20

And of course, you do need the follow

2:21

up to make sure no disease develops

2:22

in other portions of the liver.

2:24

And so, let's relook at this lesion

2:25

in a couple more months to see

2:27

how it's developed in the interim.

2:29

So now, if you look at this lesion, it looks

2:30

a little bit different than it did previously.

2:32

So, the same sort of sequences we're going

2:34

to put up, T1-weighted, Fatsat, post-

2:37

contrast, arterial phase, portal venous phase.

2:40

As I said, I like using subtraction images when

2:42

I look at these ablation cavities to make sure

2:44

all the hyperintense T1 content is removed.

2:46

And over time, the cavity itself will

2:48

typically diminish in size, so this cavity

2:50

is smaller than what it was previously.

2:52

But what's more concerning is that, in

2:54

the interim, this nodule here, arterial

2:57

hyperenhancement has developed.

2:58

This nodule is right at the periphery

3:00

of this cavity, inseparable from it.

3:03

Hard to argue that there's a washout

3:04

within this nodule because the internal

3:06

content of this nodule looks very

3:07

similar to the liver parenchyma.

3:09

Maybe there's a rim of enhancement surrounding

3:11

it, but those findings are sort of irrelevant.

3:14

The key finding is that you have an

3:16

arterially enhancing nodule that is now

3:20

new and it's associated with this cavity.

3:23

And this means that there is recurrent disease.

3:27

Multidisciplinary tumor board

3:30

to assess what the best next step is in

3:33

order to treat that area of recurrence.