0:00

So this next patient is a 36-year-old gentleman.

0:03

History provided is liver mass, and CT scan was

0:06

performed with or without contrast to evaluate it.

0:09

As we scroll down on the CT images on the non-

0:11

contrast phase, you can see a very large mass

0:14

that really replaces almost the entire liver.

0:19

On the post-contrast sequences, you can see

0:21

that there is very heterogeneous enhancement.

0:24

Um, and it's really a bizarre-looking lesion with lots of

0:27

enhancements seen in all sorts of portions of this mass.

0:30

They did do another portal venous phase image, and on that

0:33

image, we can see that some of the lesion looks isodense

0:38

to the liver parenchyma, some of it looks hyperdense.

0:40

So it's just a very bizarre-looking lesion that's

0:43

replacing much of the liver, and for this reason,

0:46

an MRI was ordered to further evaluate this.

0:50

So we'll start our evaluation of this lesion on, uh, on

0:53

these MR sequences by looking at our T2-weighted sequences.

0:57

On the T2-weighted sequence performed without

0:59

FATSAT, we really see a very, very large lesion.

1:03

Quite bright, hyperintense T2 signal seen throughout it.

1:07

On the T2-weighted sequence performed

1:09

with FATSATuration, show similar findings.

1:12

A very large liver lesion replacing much of the liver, in

1:15

fact, and has quite bright signal on the T2-weighted images.

1:19

Next up, we're going to look at

1:20

the T1 in and out of phase images.

1:23

In the out-of-phase image, we can see a very,

1:25

very large lesion, T1 hypointense with respect

1:28

to the liver parenchyma on the in-phase image.

1:30

Again, very large lesion, T1 hypointense.

1:34

Looks pretty similar whether it's on

1:35

the in-phase or out-of-phase images.

1:37

There's no signal loss in the out-

1:38

of-phase image to suggest fat.

1:40

There's no signal loss in the in-phase image to suggest,

1:43

uh, content that causes, uh, susceptibility artifact.

1:46

Next up, we're going to look at the, uh,

1:47

imaging evaluation of this on the T1 fat-

1:50

saturated pre-contrast imaging sequence.

1:53

And so we're on T1 fat-sat pre-contrast image.

2:00

It has pretty homogeneous signal that is T1 hypointense

2:04

with respect to the liver parenchyma.

2:07

There's no areas of hyperintense T1 signal to suggest

2:11

blood contents, melanin, or proteinaceous debris.

2:14

And finally, on the post-contrast images, we

2:16

can see that this lesion definitely enhances.

2:20

On the arterial phase image, very tough to sort of figure

2:24

out where this lesion starts, where this lesion ends,

2:27

but what we can say with perhaps more certainty is that

2:31

wherever there's contrast enhancement on the arterial phase,

2:34

that progressively fills in on the portal venous phase.

2:38

And, and on our equilibrium phase.

2:41

So while this lesion is sort of bizarre in the sense that

2:44

it's hard to sort of define its borders, its enhancement

2:47

characteristics are quite compatible with a hemangioma.

2:51

And this turns out to be a very

2:53

rare entity called hemangiomatosis.

2:57

And this really refers to this entity where you

3:00

have almost innumerable hepatic hemangiomas which

3:04

replace the majority of the liver parenchyma.

3:08

Now, this patient happened to have a prior MRI a few

3:10

years back, so I'll show you what that looks like just to

3:13

give you a sense of how progressive this entity can be.

3:16

And so here I've pulled up the study from, uh, about five

3:20

years ago compared to the study done more recently in

3:23

this patient, and here we have the T2-weighted sequences.

3:26

And just focusing on, uh, on this particular slide,

3:29

so here we have a T2 FAT SAT sequence seen in both.

3:32

This is the old exam from about five years

3:35

prior, this is the more recent new study.

3:37

If we just look at the T2 signal in the interim, here we can

3:40

see that, uh, there's bright T2 signal here, there's bright

3:43

T2 signal here, with relatively normal liver parenchymal

3:46

signal in between, and now that has all been replaced.

3:50

by this bright T2 signal seen throughout

3:52

the majority of the right hepatic lobe.

3:54

So this, uh, is, uh, how hemangiomatosis can progress.

3:58

You have these very ill-defined hemangiomas

4:00

that really replace the entire liver.

4:03

And particularly when this entity occurs in infants,

4:06

it can be associated with high-output cardiac failure.

4:10

So, that's something to look out for in

4:11

pediatric patient populations.