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LI-RADS M – Metastatic Urothelial Cancer

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0:01

This patient is a 62-year-old male and

0:04

has a history of hepatitis C, cirrhosis.

0:09

Had a new liver lesion seen on an

0:12

ultrasound exam, and an MR was requested to,

0:14

figure out what this lesion was.

0:18

Let's start looking at the MR images, and we'll

0:20

start off in this instance with a T2-weighted

0:22

image, and we'll just sort of scroll through it.

0:25

We can see a lesion up here at the liver dome.

0:28

But there are numerous liver lesions, and

0:29

all of them sort of look very similar.

0:32

We can see a bunch of them

0:32

here in the right hepatic lobe.

0:35

Another one here in the right hepatic lobe.

0:37

And for the purpose of this discussion, I'm

0:39

going to take one representative lesion and

0:40

sort of go through it and describe what we see.

0:43

So this is a lesion that I'm

0:44

going to focus on for the moment.

0:46

So this is our T2-weighted sequence.

0:48

There's no fat saturation on

0:50

this particular imaging sequence.

0:52

Um, and we see a lesion here, centered

0:54

in segment 7, maybe a bit of it in segment 8.

0:57

On the T2-weighted images,

0:59

it's really rather bright.

1:00

I mean, there's portions of it on the side that

1:03

have sort of intermediate signal, but if you

1:05

look at the central portion of it, it looks

1:07

quite, quite bright on the T2-weighted images.

1:11

The next set of images I want to look

1:12

at if, uh, you know, I were to evaluate

1:14

this in a very systematic fashion is to

1:16

look at the T1 in phase and T1 out of phase.

1:20

Out-of-phase images, just to look to see

1:22

if there's any lipid within these lesions.

1:24

So again, you can see the lesion

1:25

here centered in segment 7.

1:27

And the lesion looks identical in

1:29

the in and out-of-phase images.

1:30

That tells you if there's no lipid or

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other sort of content within this lesion.

1:35

That helps us sort of describe it a little bit

1:37

more and understand what it could represent.

1:40

The next image I'll look at for this patient

1:42

is the T1-weighted fat-saturated image.

1:46

Prior to giving contrast, so no contrast on

1:49

board, just to get a sense of what this lesion

1:51

looks like before we give the contrast agent.

1:53

Again, we see this lesion over here, and it

1:55

is hypointense on the T1-weighted images.

1:59

Remember, it was rather bright

2:00

on the T2-weighted images.

2:01

Contains no lipid content.

2:03

It's rather dark on the T1-weighted images.

2:05

Let's see what this does

2:06

with intravenous contrast.

2:08

So here we have our post-contrast images.

2:10

This is the T1 Fatsat post

2:12

contrast arterial phase.

2:14

Portal venous phase, equilibrium phase

2:17

image, and again we just picked one of the

2:19

lesions, but all the lesions look similar to

2:21

this, uh, lesion in the right hepatic lobe.

2:24

And there is rim enhancement surrounding this.

2:27

Right, so we've seen a bunch of liver lesions so

2:29

far in these patients with cirrhosis that have

2:32

had non-rim arterial phase hyperenhancement.

2:36

This one's a little bit different.

2:37

This has rim enhancement surrounding it.

2:39

And for the most part, the internal, uh, aspect

2:42

of this lesion really demonstrates no real

2:45

enhancement, maybe very low-level enhancement.

2:48

So what we're really left with is a

2:50

patient who certainly has cirrhosis, but

2:55

has multiple, multiple liver lesions.

2:58

They're very bright on the T2-weighted images.

3:00

At least portions of them are very bright.

3:02

They don't contain any lipid, fat, essentially.

3:06

It's dark on the T1-weighted images.

3:08

And there is rim enhancement.

3:11

So none of these imaging features are

3:14

really good for hepatocellular carcinoma.

3:17

Given the multiplicity of the lesions,

3:19

the presence of rim enhancement, the

3:20

possibility that these reflect metastatic

3:23

disease needs to be considered.

3:26

So in this instance, if we want to

3:28

classify this as a LI-RADS lesion, we

3:30

would classify it as a LI-RADS M lesion.

3:34

Remember, LI-RADS M lesions tell us that

3:37

whatever we're dealing with in the liver is

3:39

almost certainly going to be malignant.

3:41

But the likelihood of it being HCC is on

3:44

the lower end, maybe 30-37% approximately.

3:47

Therefore, this can be brought to a tumor

3:49

board setting, classified as a LI-RADS M.

3:53

In all likelihood, this would require biopsy.

3:55

This indeed was biopsied and

3:57

turned out to be metastatic urothelial

4:00

cancer in a patient who has cirrhosis.

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So unusual to see metastasis to a

4:06

cirrhotic liver, but it can happen.

4:08

And it should be on your radar, particularly

4:10

when you have lesions that are multiple and

4:12

have rim enhancement and really don't have

4:14

any other imaging features that support

4:16

the diagnosis of hepatocellular carcinoma.

Report

Faculty

Mahan Mathur, MD

Associate Professor, Division of Body Imaging; Vice Chair of Education, Dept of Radiology and Biomedical Imaging

Yale School of Medicine

Tags

Neoplastic

MRI

Liver

Gastrointestinal (GI)

Body

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