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Atypical Focal Nodular Hyperplasia of the Liver: Imaging Features of Nonspecific and Liver-Specific MR Contrast Agents

¹ Department of Radiology, University of Vienna, Waehringer Gürtel 18-20, A-1090 Vienna, Austria.
² Department of Radiology, University of Washington, Harborview Medical Center, Box 359728, Seattle, WA 98104-2499.
³ Department of Radiology, Klinikum Karlsruhe, Moltkestr. 90, D-76133 Karlsruhe, Germany.
⁴ Department of Surgery, University of Vienna, A-1090 Vienna, Austria.
⁵ Department of Pathology, University of Vienna, A-1090 Vienna, Austria.
⁶ Department of Nuclear Medicine, University of Vienna, A-1090 Vienna, Austria.
⁷ Department of Radiology, Duke University Medical Center, Durham, NC 27710.

View larger version (132K): [in a new window]   Fig. 1A. —Focal nodular hyperplasia in 27-year-old woman with typical contrast enhancement after administration of gadolinium chelates and mangafodipir trisodium. Unenhanced T1-weighted gradient-recalled MR image shows barely visible lesion in right lobe of liver beneath capsule. Lesion is isointense to surrounding liver parenchyma with ill-defined hypointense central scar (arrow).

View larger version (143K): [in a new window]   Fig. 1B. —Focal nodular hyperplasia in 27-year-old woman with typical contrast enhancement after administration of gadolinium chelates and mangafodipir trisodium. T2-weighted turbo spin-echo MR image shows lesion as isointense to surrounding liver parenchyma with hyperintense central scar (arrow).

View larger version (131K): [in a new window]   Fig. 1C. —Focal nodular hyperplasia in 27-year-old woman with typical contrast enhancement after administration of gadolinium chelates and mangafodipir trisodium. Gadolinium-enhanced dynamic T1-weighted gradient-recalled echo MR image obtained during arterial dominant phase shows lesion as markedly hyperintense to liver parenchyma. Note that central scar and pseudocapsule (arrow) are better depicted on this image than on A.

View larger version (127K): [in a new window]   Fig. 1D. —Focal nodular hyperplasia in 27-year-old woman with typical contrast enhancement after administration of gadolinium chelates and mangafodipir trisodium. Gadolinium-enhanced T1-weighted gradient-recalled echo MR image obtained during delayed phase also reveals lesion and central scar (arrow) are isointense and invisible.

View larger version (130K): [in a new window]   Fig. 1E. —Focal nodular hyperplasia in 27-year-old woman with typical contrast enhancement after administration of gadolinium chelates and mangafodipir trisodium. Mangafodipir trisodium—enhanced T1-weighted gradient-recalled echo MR image shows lesion enhancement equal to that of surrounding liver parenchyma. Note that central scar and pseudocapsule (arrow) are more conspicuous on this image than on A.

View larger version (115K): [in a new window]   Fig. 2A. —Focal nodular hyperplasia in 40-year-old woman with typical contrast agent uptake after administration of ferumoxides. Unenhanced T1-weighted gradient-recalled echo MR image shows lesion to be slightly hypointense to liver parenchyma with markedly hypointense central scar (arrow).

View larger version (124K): [in a new window]   Fig. 2B. —Focal nodular hyperplasia in 40-year-old woman with typical contrast agent uptake after administration of ferumoxides. Unenhanced T2-weighted turbo spin-echo MR image shows lesion as isointense to liver parenchyma with hyperintense central scar (arrow).

View larger version (123K): [in a new window]   Fig. 2C. —Focal nodular hyperplasia in 40-year-old woman with typical contrast agent uptake after administration of ferumoxides. Gadolinium-enhanced T1-weighted gradient-recalled echo MR image obtained during arterial dominant phase shows lesion (arrow) to be isointense to liver parenchyma. This finding is atypical.

View larger version (109K): [in a new window]   Fig. 2D. —Focal nodular hyperplasia in 40-year-old woman with typical contrast agent uptake after administration of ferumoxides. Gadolinium-enhanced T1-weighted gradient-recalled echo MR image obtained during delayed phase also shows lesion as isointense to liver parenchyma without uptake of contrast agent in central scar (arrow), which remains hypointense. This finding is atypical.

View larger version (111K): [in a new window]   Fig. 2E. —Focal nodular hyperplasia in 40-year-old woman with typical contrast agent uptake after administration of ferumoxides. Ferumoxides-enhanced T2-weighted turbo spin-echo MR image reveals lesion with marked signal intensity loss that is slightly less than that of surrounding liver parenchyma (arrow).

View larger version (108K): [in a new window]   Fig. 3A. —Focal nodular hyperplasia in 38-year-old woman with atypical features on unenhanced T1-weighted image and typical enhancement after administration of mangafodipir trisodium. Note usefulness of gadolinium chelates to reveal additional lesions. Unenhanced T1-weighted gradient-recalled echo MR image shows lesion (2 cm in diameter) in left lobe of liver to be slightly hyperintense to surrounding liver parenchyma with hypointense central scar and hypointense pseudocapsule (arrow).

View larger version (112K): [in a new window]   Fig. 3B. —Focal nodular hyperplasia in 38-year-old woman with atypical features on unenhanced T1-weighted image and typical enhancement after administration of mangafodipir trisodium. Note usefulness of gadolinium chelates to reveal additional lesions. Unenhanced T2-weighted turbo spin-echo MR image shows lesion to be slightly hyperintense to surrounding liver parenchyma. Note that central scar and pseudocapsule (arrow) are hyperintense.

View larger version (106K): [in a new window]   Fig. 3C. —Focal nodular hyperplasia in 38-year-old woman with atypical features on unenhanced T1-weighted image and typical enhancement after administration of mangafodipir trisodium. Note usefulness of gadolinium chelates to reveal additional lesions. Gadolinium-enhanced dynamic T1-weighted gradient-recalled echo MR image obtained during arterial dominant phase shows lesion to be markedly hyperintense to liver parenchyma (black arrow). In addition, second lesion (white arrow) can now be seen in segment IV and appears hyperintense as well. Second lesion appeared unchanged at follow-up, so diagnosis of focal nodular hyperplasia is likely.

View larger version (106K): [in a new window]   Fig. 3D. —Focal nodular hyperplasia in 38-year-old woman with atypical features on unenhanced T1-weighted image and typical enhancement after administration of mangafodipir trisodium. Note usefulness of gadolinium chelates to reveal additional lesions. Gadolinium-enhanced dynamic T1-weighted gradient-recalled echo MR images obtained during delayed phase. Note that strong enhancement seen during arterial dominant phase has faded and that lesion located in segment IV is no longer visible. Note delayed accumulation of gadolinium chelate in scar of lesion in left lobe (arrow).

View larger version (107K): [in a new window]   Fig. 3E. —Focal nodular hyperplasia in 38-year-old woman with atypical features on unenhanced T1-weighted image and typical enhancement after administration of mangafodipir trisodium. Note usefulness of gadolinium chelates to reveal additional lesions. Mangafodipir trisodium—enhanced T1-weighted gradient-recalled echo MR image reveals lesion with contrast agent uptake equal to that of surrounding parenchyma. Note that central scar and pseudocapsule (arrow) do not show uptake of contrast agent and are more conspicuous on this image. Second lesion is isointense to surrounding parenchyma and therefore is not visible.

View larger version (124K): [in a new window]   Fig. 4A. —Focal nodular hyperplasia in 32-year-old woman with weak enhancement after administration of gadolinium chelates and typical enhancement after administration of ferumoxides and mangafodipir trisodium. Unenhanced T1-weighted gradient-recalled echo MR image reveals lesion (arrow) to be isointense to surrounding liver parenchyma with impression on gallbladder.

View larger version (122K): [in a new window]   Fig. 4B. —Focal nodular hyperplasia in 32-year-old woman with weak enhancement after administration of gadolinium chelates and typical enhancement after administration of ferumoxides and mangafodipir trisodium. Unenhanced T2-weighted turbo spin-echo MR image shows lesion (arrow) to be slightly hyperintense to surrounding liver parenchyma with impression of gallbladder.

View larger version (124K): [in a new window]   Fig. 4C. —Focal nodular hyperplasia in 32-year-old woman with weak enhancement after administration of gadolinium chelates and typical enhancement after administration of ferumoxides and mangafodipir trisodium. Gadolinium chelates—enhanced dynamic T1-weighted gradient-recalled echo MR image obtained during arterial dominant phase reveals lesion (arrow) to be isointense to liver parenchyma. This finding is atypical.

View larger version (124K): [in a new window]   Fig. 4D. —Focal nodular hyperplasia in 32-year-old woman with weak enhancement after administration of gadolinium chelates and typical enhancement after administration of ferumoxides and mangafodipir trisodium. Mangafodipir trisodium—enhanced T1-weighted gradient-recalled echo MR image shows lesion with more contrast agent uptake than that of surrounding parenchyma. Note that central scar (arrow) is more conspicuous on this image.

View larger version (115K): [in a new window]   Fig. 4E. —Focal nodular hyperplasia in 32-year-old woman with weak enhancement after administration of gadolinium chelates and typical enhancement after administration of ferumoxides and mangafodipir trisodium. Ferumoxides-enhanced T2-weighted turbo spin-echo MR image reveals lesion with uptake of contrast agent and marked signal intensity loss. However, signal intensity loss is less than that of surrounding parenchyma (arrow).

View larger version (32K): [in a new window]   Fig. 5. —Diagram illustrates workup algorithm for diagnosis of focal nodular hyperplasia.

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