0:00

So this next case is a 29-year-old female,

0:03

uh, who presents with an indeterminate

0:05

liver mass in another imaging modality.

0:08

There was some suspicion that this could reflect

0:10

vocal nodule hyperplasia or potentially an adenoma.

0:13

So we did this study, uh, with our routine sequences

0:17

in addition to giving intravenous contrast with

0:20

EOVIST that has partial hepatobiliary excretion.

0:23

However, we're going to go about looking at this

0:25

systematically, looking at our T2-weighted sequences.

0:29

As we scroll through our T2-weighted sequences

0:31

right at the hepatic dome, we'll see that there

0:33

is a liver lesion that we need to evaluate.

0:35

On the T2-weighted images performed without fat

0:38

saturation, you can see the lesion over here.

0:40

It is, uh, slightly T2 hyperintense on this sequence.

0:46

On the T2-weighted images, turbo spin-echo

0:49

sequence performed with fat saturation.

0:52

Because there's a little bit more, it's more susceptible

0:54

to motion, it's a little bit more difficult to delineate

0:56

the lesion, though, we're just looking at the T2

0:59

characteristics Is slightly T2 hyperintense, so we'll

1:06

need to evaluate this further on our remaining sequences.

1:09

Next up, we need to look at our T

1:11

one in and out-of-phase sequence.

1:13

So you scroll down, we can see this liver lesion of

1:15

the hepatic dome once again, and we'll start off by

1:18

looking at it on the endphase sequence over here.

1:21

Very, very tough to delineate.

1:22

I would argue that it's probably ISO intense with

1:25

respect to the liver parenchyma in this sequence.

1:27

It's very difficult to delineate now the aase sequence.

1:31

It's still quite difficult to see however.

1:34

It is slightly better seen, and

1:37

it is slightly T1 hypointense.

1:41

So the fact that this lesion becomes slightly darker in the

1:47

out-of-phase images compared to the in-phase images tells us

1:50

that, on some level, this lesion contains microscopic lipid.

1:58

That becomes an important, uh, aspect of this

2:01

case as we'll look at, uh, the next slide.

2:03

As we further evaluate this lesion with the other sequences.

2:07

T1 fat-saturated pre-contrast image.

2:11

And on this sequence, the T1 pre-contrast fat

2:15

saturated image, again, it's tough to see this lesion.

2:18

It may be slightly, slightly T1 hypointent

2:22

with respect to the liver parenchyma.

2:24

The final set of sequences that we need to

2:26

look at are the T1 post-contrast sequences.

2:29

So we can see what this lesion does

2:32

on the post-contrast sequences.

2:33

Notice that there is enhancement.

2:35

On the arterial phase, very homogeneous, quite

2:38

hypervascular on the arterial phase images.

2:41

And on the portal venous phase, remains

2:43

hypervascular, but again, it becomes more iso

2:45

intense with respect to the liver parenchyma.

2:49

Finally, we're going to look at the EOVIST image at

2:51

20 minutes to see, uh, what this lesion looks like.

2:53

As we scroll through here on the, uh, 20-minute image,

2:57

you can see the lesion once again in the hepatic dome.

3:01

And it demonstrates that there is overall

3:04

T1 hyperintensity within this lesion.

3:07

Areas of it look a little bit heterogeneous, so there are

3:09

portions out here that look more hyperintense than portions

3:12

centrally, but overall, there is hyperintense T1 signal.

3:16

So the reason I wanted to show this case is that it has some

3:20

imaging features of focal nodule or hyperplasia, however,

3:23

there are other imaging features that are slightly atypical.

3:26

So this was, turned out to be a biopsy-proven,

3:29

uh, case of focal nodule or hyperplasia.

3:31

The features that are suggestive of it.

3:34

Or that.

3:35

It is relatively iso intense to the liver parenchyma

3:37

on the T2 and T1-weighted imaging sequences.

3:40

Now, the T2-weighted imaging sequences, in fact,

3:43

it was slightly hyperintense, but it wasn't

3:45

very, very bright on the T2-weighted sequences.

3:49

On the post-contrast images, there

3:51

was arterial hyperenhancement.

3:52

On the portal venous phase images, it looked like it was iso

3:55

intense or becoming iso intense with respect to the liver.

4:01

it was hyperintense as well.

4:04

So these imaging features are all

4:06

compatible with focal nodular hyperplasia.

4:09

However, when we did the T1 in and out-of-phase

4:12

image, this lesion demonstrated signal loss on the

4:16

out-of-phase image, there was decreased signal.

4:19

And that tells us that there is some

4:21

degree of microscopic lipid in this lesion.

4:24

So microscopic lipid is not a feature that we

4:26

typically see in focal nodular hyperplasia.

4:29

And so one of the reasons I wanted to show this case is

4:31

that, um, there are times when we can diagnose things

4:34

as focal nodular hyperplasia fairly confidently based

4:37

on imaging features, but if there's anything that's off,

4:40

such as the presence of lipid, you do need to biopsy to

4:43

make sure that that indeed is what you're dealing with.