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Enhancement Patterns of Focal Liver Masses: Discordance Between Contrast-Enhanced Sonography and Contrast-Enhanced CT and MRI

Stephanie R. Wilson1, Tae Kyoung Kim1, Hyun-Jung Jang1 and Peter N. Burns2,3

1 Department of Medical Imaging, Toronto General Hospital, 585 University Ave., Toronto, ON, Canada, M5G 2N2.
2 Department of Medical Biophysics, University of Toronto, ON, Canada.
3 Department of Imaging Research, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.


Figure 1
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  		Fig. 1A —29-year-old man with lipase deficiency exhibiting portal venous phase discordance due to diffusion of contrast agent. Axial phase sonography (A), CT (B), and MRI (C) images all show heterogeneous enhancement.

 

Figure 2
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  		Fig. 1B —29-year-old man with lipase deficiency exhibiting portal venous phase discordance due to diffusion of contrast agent. Axial phase sonography (A), CT (B), and MRI (C) images all show heterogeneous enhancement.

 

Figure 3
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  		Fig. 1C —29-year-old man with lipase deficiency exhibiting portal venous phase discordance due to diffusion of contrast agent. Axial phase sonography (A), CT (B), and MRI (C) images all show heterogeneous enhancement.

 

Figure 4
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  		Fig. 1D —29-year-old man with lipase deficiency exhibiting portal venous phase discordance due to diffusion of contrast agent. Portal venous phase imaging is discordant, with sonography (D) showing washout but CT (E) and MRI (F) both showing increased lesional enhancement. Biopsy confirmed malignant cholangiohepatoma. It is hypothesized that portal phase enhancement in CT (E) and MRI (F) indicates contrast material in tumor interstitium.

 

Figure 5
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  		Fig. 1E —29-year-old man with lipase deficiency exhibiting portal venous phase discordance due to diffusion of contrast agent. Portal venous phase imaging is discordant, with sonography (D) showing washout but CT (E) and MRI (F) both showing increased lesional enhancement. Biopsy confirmed malignant cholangiohepatoma. It is hypothesized that portal phase enhancement in CT (E) and MRI (F) indicates contrast material in tumor interstitium.

 

Figure 6
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  		Fig. 1F —29-year-old man with lipase deficiency exhibiting portal venous phase discordance due to diffusion of contrast agent. Portal venous phase imaging is discordant, with sonography (D) showing washout but CT (E) and MRI (F) both showing increased lesional enhancement. Biopsy confirmed malignant cholangiohepatoma. It is hypothesized that portal phase enhancement in CT (E) and MRI (F) indicates contrast material in tumor interstitium.

 

Figure 7
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  		Fig. 2A —46-year-old woman with metastatic colon cancer exhibiting discordance due to timing of imaging. Axial contrast-enhanced sonograms obtained 10 (A) and 18 (B) seconds after initiation of contrast injection show initial hypervascularity (A) followed by rapid washout as contrast enhancement of liver parenchyma progressively increases.

 

Figure 8
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  		Fig. 2B —46-year-old woman with metastatic colon cancer exhibiting discordance due to timing of imaging. Axial contrast-enhanced sonograms obtained 10 (A) and 18 (B) seconds after initiation of contrast injection show initial hypervascularity (A) followed by rapid washout as contrast enhancement of liver parenchyma progressively increases.

 

Figure 9
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  		Fig. 2C —46-year-old woman with metastatic colon cancer exhibiting discordance due to timing of imaging. Arterial phase axial CT scan shows same metastasis as hypovascular mass. CT scan is timed to miss transient hypervascularity in early arterial phase.

 

Figure 10
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  		Fig. 2D —46-year-old woman with metastatic colon cancer exhibiting discordance due to timing of imaging. Graph shows quantitative measurement of enhancement from contrast-enhanced sonogram. Metastatic lesion fills rapidly to peak and washes out within 5 seconds of initiation of arterial enhancement in hepatic parenchyma. Lesion becomes enhanced at lower level than liver for rest of arterial phase. Typical timing for arterial phase contrast-enhanced CT image is indicated.

 

Figure 11
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  		Fig. 3A —34-year-old man with asymptomatic rapidly enhancing hemangioma exhibiting discordance due to differences in timing. Contrast-enhanced sonography was performed after outside CT, which suggested focal nodular hyperplasia. Sequential contrast-enhanced sonographic frames at 6 seconds (A), 9 seconds (B), and 17 seconds (C) in arterial phase show marginal enhancement, peripheral nodular enhancement, and centripetal progression of enhancement sustained for remainder of period of observation to 300 seconds.

 

Figure 12
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  		Fig. 3B —34-year-old man with asymptomatic rapidly enhancing hemangioma exhibiting discordance due to differences in timing. Contrast-enhanced sonography was performed after outside CT, which suggested focal nodular hyperplasia. Sequential contrast-enhanced sonographic frames at 6 seconds (A), 9 seconds (B), and 17 seconds (C) in arterial phase show marginal enhancement, peripheral nodular enhancement, and centripetal progression of enhancement sustained for remainder of period of observation to 300 seconds.

 

Figure 13
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  		Fig. 3C —34-year-old man with asymptomatic rapidly enhancing hemangioma exhibiting discordance due to differences in timing. Contrast-enhanced sonography was performed after outside CT, which suggested focal nodular hyperplasia. Sequential contrast-enhanced sonographic frames at 6 seconds (A), 9 seconds (B), and 17 seconds (C) in arterial phase show marginal enhancement, peripheral nodular enhancement, and centripetal progression of enhancement sustained for remainder of period of observation to 300 seconds.

 

Figure 14
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  		Fig. 3D —34-year-old man with asymptomatic rapidly enhancing hemangioma exhibiting discordance due to differences in timing. Contrast-enhanced sonography was performed after outside CT, which suggested focal nodular hyperplasia. Axial arterial phase CT image obtained 35 seconds after contrast administration shows uniformly enhanced mass. Diagnostic considerations include hemangioma and focal nodular hyperplasia. Mass exhibited sustained enhancement in portal venous phase on both sonogram and CT scan.

 

Figure 15
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  		Fig. 4A —68-year-old woman with asymptomatic biopsy-proven hepatic angiomyolipoma exhibiting discordance due to lesional fat. Baseline sonogram shows highly echogenic mass in posterior aspect of right lobe of liver. Profound echogenicity and disruption of diaphragmatic echo distal to mass raise possibility of fat-containing mass.

 

Figure 16
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  		Fig. 4B —68-year-old woman with asymptomatic biopsy-proven hepatic angiomyolipoma exhibiting discordance due to lesional fat. Arterial phase sonogram at peak of enhancement shows hypervascularity in lesion.

 

Figure 17
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  		Fig. 4C —68-year-old woman with asymptomatic biopsy-proven hepatic angiomyolipoma exhibiting discordance due to lesional fat. Portal venous phase image shows echogenic mass. Liver has become enhanced. Without quantification, it is impossible to determine whether mass has washed out.

 

Figure 18
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  		Fig. 4D —68-year-old woman with asymptomatic biopsy-proven hepatic angiomyolipoma exhibiting discordance due to lesional fat. Unenhanced axial CT image corresponding to A shows low-attenuation (–41 H) mass consistent with presence of fat.

 

Figure 19
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  		Fig. 4E —68-year-old woman with asymptomatic biopsy-proven hepatic angiomyolipoma exhibiting discordance due to lesional fat. Arterial phase CT image shows vascularity related to mass. Degree of hypervascularity was more evident on contrast-enhanced sonogram.

 

Figure 20
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  		Fig. 4F —68-year-old woman with asymptomatic biopsy-proven hepatic angiomyolipoma exhibiting discordance due to lesional fat. Portal venous phase CT image shows similar difficulty to contrast-enhanced sonogram in determining washout.

 

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