Progressive Centripetal Enhancement Research Articles

FDG PET/CT in Papillary Intralymphatic Angioendothelioma of the Spleen.

Splenic papillary intralymphatic angioendothelioma is extremely rare. We describe FDG PET/CT and MRI findings of splenic papillary intralymphatic angioendothelioma in a young adult. The splenic tumor showed hypodensity and increased FDG uptake with SUVmax of 4 on PET/CT, heterogeneous signal intensity with internal hypointense stellate scars on T2-weighted image, and progressive centripetal enhancement on dynamic contrast-enhanced T1-weighted images. This case indicates that papillary intralymphatic angioendothelioma should be included in the differential diagnosis of FDG-avid splenic lesions.

CT and MRI features of sclerosing angiomatoid nodular transformation of the spleen: A report of 18 patients with pathologic correlation

PurposeThe purpose of this study was to describe the computed tomography (CT) and magnetic resonance imaging (MRI) features of sclerosing angiomatoid nodular transformation (SANT) of the spleen and correlate imaging features with those obtained at histopathologic analysis. Materials and methodsA total of 18 patients (9 men, 9 women; mean age, 42.2±10.7 [standard deviation (SD)] years; range, 23–59 years) with histopathologically confirmed SANT were retrospectively evaluated. The presenting symptoms, gross pathologic changes, and histopathologic and correlative immunohistochemical results were recorded. CT (n=8) and MRI (n=12) features were analyzed by two radiologists and included number, size, shape, boundary, attenuation, signal intensity, and enhancement patterns. ResultsSeventeen patients (17/18; 94%) had a single SANT without specific clinical symptoms and one patient (1/18; 6%) had multiple SANTs with left-upper-quadrant bloating and pain. The largest lesion diameter exceeded 3cm. On plain CT images, SANTs were slightly hypoattenuating in seven patients (7/8; 88%), isoattenuating in one patient (1/8; 13%), and contained calcification in two patients (2/8; 25%). On T2-weighted MR images, SANTs displayed hypointensity in ten patients (10/12; 83.3%), isointensity in one patient (1/12; 8%) and hyperintensity in one patient (1/12; 8%). On T2-weighted images, stellate or scattered fibrous scars were observed in all patients (12/12; 100%). On diffusion-weighted images, SANTs appeared as heterogenous or homogeneous hypointense in 12 patients (12/12; 100%). Compared to out-of-phase images, SANTs displayed decreased local signal intensity on in-phase images in 12 patients (12/12; 100%). On enhanced CT and MRI images, SANTs had clear boundaries (17/18; 94%), oval (7/18; 39%) or lobular (7/18; 39%) shape, displayed progressive centripetal enhancement (18/18; 100%), spoke-wheel pattern (14/18; 78%), nodular enhancement (11/18; 61%), or delayed enhancement of central fibrous scar (9/18; 50%). ConclusionsSANT of the spleen predominantly manifests as a solid, single, oval or lobular, and well-defined lesion with a fibrous scar and occasional calcification. Typical enhancement characteristics include progressive and centripetal enhancement, spoke-wheel pattern, nodular enhancement, and delayed enhancement of central fibrous scar. Hypointensity on T2- and diffusion-weighted images are due to hemosiderin deposition and fibrous tissue.

Evaluation of Skull Base Tumors with Dynamic TurboFLASH MRI during Gadolinium Injection.

Background and Purpose This study was aimed to investigate the role of dynamic TurboFLASH gadolinium (Gd) magnetic resonance (MR) imaging in improving the differential diagnosis of skull base tumors. Methods Eleven patients with skull base tumors underwent standard MR and ultrafast TurboFLASH sequence during gadolinium injection. Results The characterization of tumor vascularity was performed. Different patterns of gadolinium uptake for each tumor type were observed. This is particularly important to identify tumors at high risk of intraoperative bleeding. All glomus tumors, typically highly vascularized, showed an enhancement at the arterial phase, reflecting the arterialization of these tumors which is not detectable on conventional MR. No signal increase at the arterial phase was instead observed in other cases in which the ruling out of a glomus tumor was important because of the location of the lesion. Moreover TurboFLASH identified the pathognomonic "filling-in" profile of cavernous sinus cavernous hemangiomas (CSCH), that is, the progressive centripetal enhancement of the lesion at the beginning of the venous phase. Conclusion The dynamic analysis of tumor contrast enhancement with the TurboFLASH sequence provides useful additional information to that obtained with conventional MR, improving the differential diagnosis of skull base tumors, particularly in the distinction between glomus and nonglomus tumors and in diagnosing CSCH.

Cadaveric Liver Transplantation for a Giant Mass

Question: A 44-year-old woman was admitted to our institution complaining of abdominal fullness, evident shortness of breath, weight loss, anorexia, petechial hemorrhages, ecchymosis, and swelling of feet and ankles that have been present for 3 years. There was no significant property at her medical history besides the absence of family history for hemangioma, and she was not taking any medications. At physical examination, increased abdominal circumference was noticed, and the edge of the liver was palpated well at right lower quadrant. Laboratory tests revealed abnormal hepatic functions, albumin (3.3 g/dL; control, 3.5–5.2), prolonged prothrombin time (20 s; control, 10–15.8), prolonged International Normalized Ratio (1.92; control, 0.9–1.3), and borderline low platelet count (119/mm3), which were compatible with Kasabach–Merritt syndrome. On coronal abdominal computed tomography and 3-dimensional volume-rendered imaging, a 22 × 18 × 23-cm mass in the right hepatic lobe which nearly replaced the right hepatic lobe was showed. The right diaphragm was elevated, and there was a mass effect on right atrium, and right ventricle. The inferior vena cava, main and left portal veins, and gastric outlet were compressed by the lesion, and then truncus coliacus was deviated to the left. Right kidney displaced inferomedially, and rotated 90° around its long axis (Figure A, B). What is the most likely diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. The dynamic hepatic computed tomography of the patient revealed that the mass had peripheral nodular centripetal enhancement with persistent nonenhancement areas in the central part of the mass might be secondary to fibrous scar (Figure C). She was considered to have cadaveric liver transplantation because of respiratory distress, risk of bleeding owing to trauma, and the presence of Kasabach–Merritt syndrome. The patient underwent transplantation, and the removed liver weighed 4.8 kg (dry weight). Pathologic examination of the surgical specimen affirmed the diagnosis of cavernous hemangioma with peripheral sponge-like matrix full of blood products, and central fibrous scar tissue (Figure D). Her clinical status gradually improved posttransplantation and platelet count (193/mm3), prothrombin time (13 s), International Normalized Ratio (1.2), and albumin (3.8 g/dL) levels all returned to normal the 1-month follow-up. Giant cavernous hemangiomas are a minor atypical subgroup of hepatic hemangiomas, which are defined as ≥1 diameter >5 cm.1Vilgrain V. Boulos L. Vullierme M.P. et al.Imaging of atypical hemangiomas of the liver with pathologic correlation.RadioGraphics. 2000; 20: 379-397Crossref PubMed Scopus (331) Google Scholar Giant cavernous hemangiomas are symptomatic with their complications, which are Kasabach–Merritt syndrome (consumptive coagulopathy with intravascular coagulation, clotting, and fibrinolysis within the hemangioma), compression of adjacent organs, inflammatory changes, and potential volvulus of a pedunculated lesion.2Prasanna P.M. Fredericks S.E. Winn S.S. et al.Best cases from the AFIP: giant cavernous hemangioma.RadioGraphics. 2010; 30: 1139-1144Crossref PubMed Scopus (14) Google Scholar The pathognomonic imaging characteristics of hemangioma are peripheral nodular puddling with progressive centripetal enhancement on dynamic studies.1Vilgrain V. Boulos L. Vullierme M.P. et al.Imaging of atypical hemangiomas of the liver with pathologic correlation.RadioGraphics. 2000; 20: 379-397Crossref PubMed Scopus (331) Google Scholar When hemangiomas are >3 cm, central scarring is typically seen in lesions, owing to intralesional ischemia or hemorrhage.2Prasanna P.M. Fredericks S.E. Winn S.S. et al.Best cases from the AFIP: giant cavernous hemangioma.RadioGraphics. 2010; 30: 1139-1144Crossref PubMed Scopus (14) Google Scholar Management of very large (>10 cm) hepatic hemangiomas include surgical resection, enucleation, arterial embolization, hepatic irradiation, and liver transplantation.3Sood D. Mohan N. Singh A. et al.Living donor liver transplantation for giant cavernous hemangioma of liver in a child.Pediatr Transplant. 2011; 15: E135-138Crossref PubMed Scopus (4) Google Scholar

TO RESEARCH MORPHOLOGIC FEATURES, SIGNAL CHARACTERISTICS ON SONOGRAPHY AND DYNAMIC COMPUTED TOMOGRAPHY OF HEPATIC HEMANGIOMAS

Objectives: To assess morphologic features, signal characteristics on sonography and dynamic computed tomography of hepatic hemangiomas. To compare the agreement degree of diagnosis of hepatic hemangiomas between sonography and computed tomography. Material and methods: We researched the sonography and computed tomography findings in 50 patients including 82 lesions hepatic hemangiomas at Hue university hospital and Hue central hospital from march 2012 to june 2013, 21 men and 29 women, mean age 51.7 ± 13.9 (range 30 – 89). Results: Mean mass diameter was 3.7 ± 1.9 cm. Sonography revealed hyperechonic pattern in 97.6% and hypoechonic pattern in 2.4%. On nonenhanced computed tomography, almost tumors (70.8%) showed hypodense, 26.8% had cleftlike areas of lower density than the main mass and 2.4% showed hyperdense lesions in a hypodense fatty liver. Almost tumors were periperally hyperdense on early contrast - enhanced computed tomography, progressive centripetal enhancement and in the delayed phase 85.4% displayed isodense and 14.6% displayed hyperdense fill-in. Conclusions: Triphasic helical computed tomography has additional values for sonography in diagnosis of hepatic hemangioma with typical characteristics: hypodense lesion on nonenhanced computed tomography, periperally hyperdense on early contrast - enhanced computed tomography, progressive centripetal enhancement and complete isodense fill-in of the lesion in the delayed phase. For tiny lesion smaller than 15mm (especially smaller than 10 mm), computed tomography plays a less important role. Key words: Hepatic hemangiomas, signal characteristics, sonography, computed tomography, research.

Typical and Atypical Imaging Findings of Intrahepatic Cholangiocarcinoma Using Gadolinium Ethoxybenzyl Diethylenetriamine Pentaacetic Acid–Enhanced Magnetic Resonance Imaging

The objective of this study was to examine the imaging features of classic mass-forming intrahepatic cholangiocarcinoma (MICC) and nonclassic hypervascular MICC on gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid-enhanced magnetic resonance imaging. Twenty pathologically confirmed MICCs were included. Two radiologists retrospectively reviewed the imaging characteristics on T2-weighted imaging, diffusion-weighted imaging, dynamic contrast-enhanced images, and hepatobiliary phase (HBP) of each MICC. For the morphologic feature of defect, HBP signal intensity (SI) ratio was calculated by dividing the SI of the MICC by nearby normal liver parenchyma SI. Classic MICCs (n = 14) showed classic rim or peripheral enhancement at arterial dominant phase with centripetal enhance in the delayed phases. Hypervascular MICCs (n = 6) showed complete (n = 4) or near-complete (n = 2) arterial enhancement and washout (n = 6) on delayed phases. On HBP, 13 classic MICCs (93%) and 2 hypervascular MICCs (33%) showed cloud-like SI in the center ("EOB cloud") with peripheral defect. Mean SI ratio was 0.77 in classic MICCs and 0.59 in hypervascular MICC (P = 0.057). Classic MICCs (70%) frequently showed progressive centripetal enhancement on dynamic phase, and central EOB-cloud appearance with distinct peripheral defect on HBP. Nonclassic hypervascular MICCs comprised 30% of the MICCs in this study. Compared with classic MICCs, hypervascular MICCs showed wash-in on arterial dominant phase and washout on delayed phase.

Giant Cavernous Hemangioma

Figure 1. (a, b) Portal venous phase CT images (a obtained at a higher level than b) show a large mass in the right hepatic lobe. There is peripheral nodular puddling of contrast material as it fills in the lesion through the interstices. (c, d) Delayed phase CT images (c obtained at a higher level than d) show progressive centripetal enhancement of the mass with a central area of low attenuation (*), a finding compatible with a fibrous scar. Giant Cavernous Hemangioma1

Emergency presentation of a giant pedunculated liver haemangioma

A 45-year-old man with no past medical history presented with lower right abdominal pain of 1 day's duration associated with mild nausea and low-grade fever (37.5°C). At physical examination rebound tenderness was observed in the right lower abdomen. White blood cell count was slightly elevated (10,500/mm3). CT scan showed a 13cm wide hypodense mass, with peripheral nodular enhancement followed by progressive centripetal enhancement, that occupied most of the right peritoneal cavity and was connected to the liver by a vascularized peduncule (Fig.

Single breath‐hold multiarterial dynamic MRI of the liver at 3T using a 3D fat‐suppressed keyhole technique

To evaluate the feasibility of single breath-hold, multiarterial MRI of the liver using the THRIVE-CENTRA-keyhole technique. Twenty-eight patients with 63 focal hepatic lesions underwent liver MR examinations that included the three-dimensional THRIVE-CENTRA-keyhole sequence. Three or six phases were obtained for arterial phase scanning during a single breath-hold. Central k-space data were collected for each phase but the remaining peripheral k-space data were collected only once. The enhancement pattern of each hepatic lesion was analyzed according to the specific diagnosis. Hepatocellular carcinomas (n = 24) enhancement patterns included: rim enhancing (n = 9), homogeneous (n = 7), nodule-in-nodule (n = 5), or heterogeneous (n = 3). A late peritumoral rim was observed in four (17%) of the hepatocellular carcinomas. Most metastases (17 of 18; 94%) demonstrated peripheral rim enhancement. The progressive centripetal enhancement of hemangiomas (n = 6) was clearly depicted. Focal nodular hyperplasia (n = 4) showed early homogeneous enhancement and one lesion demonstrated a central scar. The THRIVE-CENTRA-keyhole technique can be used to acquire single breath-hold, multiarterial images depicting improved enhancement characteristics of focal hepatic lesions. This technique will allow accurate timing of arterial scanning with 3D acquisition and high temporal resolution.

Hepatic Mesenchymal Hamartoma Mimicking Hemangioma on Multiple-phase Gadolinium-enhanced MRI

Mesenchymal Hamartoma [MH] is a cystic benign liver mass occurring in children. Diagnostic confusion with hepatoblastoma may arise when alpha-feto-protein is elevated, and with hemangioendothelioma when imaging shows centripetal filling. We demonstrate one such case with progressive centripetal enhancement of a liver mass with Gadolinium enhanced multiple phase gradient-echo MRI, in a child with raised alpha-feto protein.

Characterization of focal liver lesions using contrast-enhanced sonography with a low mechanical index mode and a sulfur hexafluoride-filled microbubble contrast agent

To characterize focal liver lesions (FLLs) using real-time contrast-enhancedsonography (CEUS) with a low mechanical index mode and a sulfur hexafluoride-filled microbubble contrast agent. CEUS was performed in 190 patients with FLLs, including hepatocellular carcinoma (HCC) (n = 107), liver metastasis (n = 21), intrahepatic cholangiocarcinoma (ICC) (n = 7), liver hemangioma (n = 37), focal nodular hyperplasia (FNH) (n = 11), regenerative nodule (n = 6) and liver lipoma (n = 1). The cadence contrast pulse sequencing technique and the contrast agent SonoVue(R) were used for CEUS examination. The enhancement patterns during the arterial, portal, and late phases were evaluated. HCC showed hyperenhancement in 100 (93.5%) of 107 nodules during the arterial phase and hypoenhancement in 102 (95.3%) during the late phase. Liver metastases showed homogeneous enhancement in 8 of 21 (38.1%) nodules and a peripheral regular rim-like enhancement in 11 of 21 (52.4%) nodules during the arterial phase and marked hypoenhancement in 16 of 21 (76.2%) nodules during the late phase. ICC exhibited irregular rim-like enhancement in 4 of 7 (57.1%) nodules during the arterial phase and hypo-enhancement in 7 of 7 (100%) nodules during the late phase. Hemangioma showed peripheral nodular hyperenhancement, and progressive centripetal enhancement was seen in 35 of 37 (94.6%) lesions during the arterial phase. All 11 cases of FNH exhibited homogeneous hyperenhancement during the arterial phase and hyperenhancement (n = 1) or isoenhancement (n = 9) during the late phase. The sensitivity, specificity, and positive predictive value, respectively, were 88.8%, 89.2%, and 91.3% for HCC; 81%, 100%, and 100% for liver metastasis; 57.1%, 100%, and 100% for ICC; 94.6%, 100%, and 100% for liver hemangioma; and 90.9%, 97.8%, and 71.4% for FNH. Low-mechanical index CEUS permits real-time, complete assessment of vascularity in FLLs, which in turn facilitates their characterization.