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DOI: 10.1148/rg.255045180
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Focal Hepatic Lesions: Diagnostic Value of Enhancement Pattern Approach with Contrast-enhanced 3D Gradient-Echo MR Imaging1

Khaled M. Elsayes, MD2, Vamsidhar R. Narra, MD, Yuming Yin, MD, Govind Mukundan, MD, Markus Lammle, MD and Jeffrey J. Brown, MD

1 From the Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 S Kingshighway Blvd, St Louis, MO 63110. Presented as an education exhibit at the 2003 RSNA Annual Meeting. Received September 8, 2004; revision requested September 30; final revision received February 22, 2005; accepted March 1. J.J.B. is a consultant to GE Healthcare and Tyco/Mallinckrodt; all remaining authors have no financial relationships to disclose.


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  		Figure 1a.  Hepatocellular carcinoma (HCC) in a 63-year-old man with liver cirrhosis. Axial (a) and coronal (b) arterial phase 3D GRE VIBE MR images show an enhancing focus of HCC (arrow). Note the accurate depiction of the vascular relationship on the coronal image.

 


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  		Figure 1b.  Hepatocellular carcinoma (HCC) in a 63-year-old man with liver cirrhosis. Axial (a) and coronal (b) arterial phase 3D GRE VIBE MR images show an enhancing focus of HCC (arrow). Note the accurate depiction of the vascular relationship on the coronal image.

 


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  		Figure 2.  Simple hepatic cyst. Axial contrast-enhanced 3D GRE T1-weighted VIBE MR image shows a simple cyst (arrow) with the typical features of nonenhancement and low signal intensity. The diagnosis was confirmed at 18-month follow-up in combination with these typical imaging features.

 


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  		Figure 3.  Hepatic cysts in a patient with Caroli disease. Axial contrast-enhanced 3D VIBE MR image shows cystic dilatation of the biliary ducts manifesting as multiple small, nonenhancing cysts. Note the presence of the "central dot sign" (arrow).

 


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  		Figure 4.  Hepatic cysts in a patient with adult polycystic kidney disease. Axial contrast-enhanced 3D GRE T1-weighted VIBE MR image shows multiple cysts involving the liver and both kidneys. Note that some of the cysts are hemorrhagic.

 


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  		Figure 5a.  Regenerating nodules. Axial IR T2-weighted (a) and contrast-enhanced 3D GRE T1-weighted VIBE (b) MR images show multiple small (<5-mm) focal lesions representing regenerating nodules. The lesions exhibit low signal intensity on both images and no enhancement after contrast material injection.

 


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  		Figure 5b.  Regenerating nodules. Axial IR T2-weighted (a) and contrast-enhanced 3D GRE T1-weighted VIBE (b) MR images show multiple small (<5-mm) focal lesions representing regenerating nodules. The lesions exhibit low signal intensity on both images and no enhancement after contrast material injection.

 


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  		Figure 6a.  Dysplastic nodules. Axial unenhanced (a) and contrast-enhanced (b) 3D GRE T1-weighted VIBE MR images show multiple small focal lesions representing dysplastic nodules. The lesions exhibit high signal intensity on both images and no enhancement after contrast material administration. On axial T2-weighted images (not shown), the lesions demonstrated low signal intensity.

 


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  		Figure 6b.  Dysplastic nodules. Axial unenhanced (a) and contrast-enhanced (b) 3D GRE T1-weighted VIBE MR images show multiple small focal lesions representing dysplastic nodules. The lesions exhibit high signal intensity on both images and no enhancement after contrast material administration. On axial T2-weighted images (not shown), the lesions demonstrated low signal intensity.

 


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  		Figure 7a.  Lipoma. Axial in-phase T1-weighted (a) and contrast-enhanced 3D GRE T1-weighted VIBE (b) MR images show lipoma with the typical features of high signal intensity on the non-fat-suppressed image (arrow in a) and low signal intensity with no enhancement on the fat-suppressed (VIBE sequence) image (arrow in b).

 


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  		Figure 7b.  Lipoma. Axial in-phase T1-weighted (a) and contrast-enhanced 3D GRE T1-weighted VIBE (b) MR images show lipoma with the typical features of high signal intensity on the non-fat-suppressed image (arrow in a) and low signal intensity with no enhancement on the fat-suppressed (VIBE sequence) image (arrow in b).

 


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  		Figure 8a.  Biliary hamartoma. Coronal MR cholangiopancreaticogram (a) and axial contrast-enhanced VIBE MR image (b) show multiple lesions (arrows in b) representing biliary hamartomas. The lesions demonstrate low T1 and high T2 signal intensity and a thin rim of enhancement.

 


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  		Figure 8b.  Biliary hamartoma. Coronal MR cholangiopancreaticogram (a) and axial contrast-enhanced VIBE MR image (b) show multiple lesions (arrows in b) representing biliary hamartomas. The lesions demonstrate low T1 and high T2 signal intensity and a thin rim of enhancement.

 


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  		Figure 9.  Hypovascular metastases in a 59-year-old patient with colon cancer. Early phase contrast-enhanced 3D GRE T1-weighted VIBE MR image shows hypovascular metastases with low signal intensity and no enhancement (arrow). Progressive enhancement was seen on delayed phase images (not shown).

 


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  		Figure 10.  Lymphoma. Axial contrast-enhanced 3D GRE T1-weighted VIBE MR image demonstrates two small, well-defined hepatic lymphomatous deposits with faint marginal enhancement (arrows). Marked central biliary dilatation is also noted.

 


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  		Figure 11.  Sarcoidosis. Axial contrast-enhanced 3D GRE T1-weighted VIBE MR image shows multiple nonenhancing, hypointense sarcoid lesions.

 


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  		Figure 12.  Histoplasmosis. Axial contrast-enhanced 3D GRE T1-weighted VIBE MR image shows non-enhancing hypointense lesions secondary to histoplasmosis. Note the enhancing areas surrounding these nonenhancing foci. Splenic involvement is also seen.

 


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  		Figure 13a.  Focal fat deposition. Axial in-phase (a), out-of-phase (b), and contrast-enhanced 3D GRE VIBE (c) T1-weighted MR images show multiple lesions, with typical signal dropout on the out-of-phase image compared with the in-phase image. Note also the presence of normally enhancing liver parenchyma within areas of altered fat deposition.

 


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  		Figure 13b.  Focal fat deposition. Axial in-phase (a), out-of-phase (b), and contrast-enhanced 3D GRE VIBE (c) T1-weighted MR images show multiple lesions, with typical signal dropout on the out-of-phase image compared with the in-phase image. Note also the presence of normally enhancing liver parenchyma within areas of altered fat deposition.

 


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  		Figure 13c.  Focal fat deposition. Axial in-phase (a), out-of-phase (b), and contrast-enhanced 3D GRE VIBE (c) T1-weighted MR images show multiple lesions, with typical signal dropout on the out-of-phase image compared with the in-phase image. Note also the presence of normally enhancing liver parenchyma within areas of altered fat deposition.

 


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  		Figure 14a.  Confluent hepatic fibrosis. Axial IR T2-weighted (a), non-fat-suppressed T1-weighted (b), and contrast-enhanced 3D GRE T1-weighted VIBE (c) MR images show a large, heterogeneous area of confluent hepatic fibrosis. The lesion exhibits low T1 signal intensity and high T2 signal intensity, with no significant early contrast enhancement. Retraction of the capsular surface is also noted (arrow in b).

 


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  		Figure 14b.  Confluent hepatic fibrosis. Axial IR T2-weighted (a), non-fat-suppressed T1-weighted (b), and contrast-enhanced 3D GRE T1-weighted VIBE (c) MR images show a large, heterogeneous area of confluent hepatic fibrosis. The lesion exhibits low T1 signal intensity and high T2 signal intensity, with no significant early contrast enhancement. Retraction of the capsular surface is also noted (arrow in b).

 


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  		Figure 14c.  Confluent hepatic fibrosis. Axial IR T2-weighted (a), non-fat-suppressed T1-weighted (b), and contrast-enhanced 3D GRE T1-weighted VIBE (c) MR images show a large, heterogeneous area of confluent hepatic fibrosis. The lesion exhibits low T1 signal intensity and high T2 signal intensity, with no significant early contrast enhancement. Retraction of the capsular surface is also noted (arrow in b).

 


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  		Figure 15.  Hepatic adenoma. Axial arterial phase contrast-enhanced VIBE MR image demonstrates an adenoma (white arrow) with typical immediate enhancement. Note also the focal area of hemorrhage (black arrow). Fading of the enhancement was seen on subsequent images (not shown).

 


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  		Figure 16.  Hypervascular metastases in a 55-year-old man with a carcinoid tumor. Axial early phase contrast-enhanced 3D GRE T1-weighted VIBE MR image shows multiple hypervascular metastases with marked enhancement (arrows). Delayed washout was seen on subsequent images (not shown).

 


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  		Figure 17.  THID. Axial contrast-enhanced 3D GRE T1-weighted VIBE MR image shows a hypoenhancing focal liver lesion involving the porta hepatis (arrow), with THID involving the left hepatic lobe as a result of invasion of the left portal vein branch. Biliary dilatation is also noted.

 


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  		Figure 18.  Drawings illustrate the change from a normal vascular supply (left) to THID (right). Normal flow in the portal vein (PV) becomes markedly lighter in THID, whereas normal flow in the hepatic artery (HA) becomes markedly heavier.

 


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  		Figure 19a.  FNH. Axial IR T2-weighted MR image (a) and contrast-enhanced 3D T1-weighted VIBE MR images obtained during the arterial (b) and equilibrium (c) phases show the typical features of FNH: high T2 signal intensity with immediate lesion enhancement (arrow in a), poor enhancement of the central scar on the early phase image (arrow in b), and increased enhancement of the scar on the delayed phase image (arrow in c).

 


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  		Figure 19b.  FNH. Axial IR T2-weighted MR image (a) and contrast-enhanced 3D T1-weighted VIBE MR images obtained during the arterial (b) and equilibrium (c) phases show the typical features of FNH: high T2 signal intensity with immediate lesion enhancement (arrow in a), poor enhancement of the central scar on the early phase image (arrow in b), and increased enhancement of the scar on the delayed phase image (arrow in c).

 


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  		Figure 19c.  FNH. Axial IR T2-weighted MR image (a) and contrast-enhanced 3D T1-weighted VIBE MR images obtained during the arterial (b) and equilibrium (c) phases show the typical features of FNH: high T2 signal intensity with immediate lesion enhancement (arrow in a), poor enhancement of the central scar on the early phase image (arrow in b), and increased enhancement of the scar on the delayed phase image (arrow in c).

 


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  		Figure 20a.  Fibrolamellar HCC. (a) Axial IR T2-weighted MR image demonstrates a lesion containing a low-signal-intensity central scar (arrow). (b, c) On contrast-enhanced 3D GRE T1-weighted VIBE MR images, the lesion demonstrates immediate contrast enhancement during the arterial phase (b) that fades during the portal venous phase (c), with a nonenhancing central scar. The findings on all three images are typical of fibrolamellar HCC.

 


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  		Figure 20b.  Fibrolamellar HCC. (a) Axial IR T2-weighted MR image demonstrates a lesion containing a low-signal-intensity central scar (arrow). (b, c) On contrast-enhanced 3D GRE T1-weighted VIBE MR images, the lesion demonstrates immediate contrast enhancement during the arterial phase (b) that fades during the portal venous phase (c), with a nonenhancing central scar. The findings on all three images are typical of fibrolamellar HCC.

 


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  		Figure 20c.  Fibrolamellar HCC. (a) Axial IR T2-weighted MR image demonstrates a lesion containing a low-signal-intensity central scar (arrow). (b, c) On contrast-enhanced 3D GRE T1-weighted VIBE MR images, the lesion demonstrates immediate contrast enhancement during the arterial phase (b) that fades during the portal venous phase (c), with a nonenhancing central scar. The findings on all three images are typical of fibrolamellar HCC.

 


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  		Figure 21a.  Pyogenic abscess. Axial IR T2-weighted (a) and contrast-enhanced 3D GRE T1-weighted VIBE (b) MR images show a pyogenic abscess with characteristic ring enhancement (arrow). Note the high T2 signal intensity of the lesion in a; this hyperintensity is exaggerated by iron deposition resulting from hemosiderosis.

 


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  		Figure 21b.  Pyogenic abscess. Axial IR T2-weighted (a) and contrast-enhanced 3D GRE T1-weighted VIBE (b) MR images show a pyogenic abscess with characteristic ring enhancement (arrow). Note the high T2 signal intensity of the lesion in a; this hyperintensity is exaggerated by iron deposition resulting from hemosiderosis.

 


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  		Figure 22.  Pyogenic abscesses. Axial contrast-enhanced 3D T1-weighted VIBE MR image shows multiple small, ring-enhancing pyogenic abscesses caused by Streptococcus viridans.

 


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  		Figure 23a.  Candidal abscesses. Axial IR T2-weighted (a) and contrast-enhanced VIBE (b) MR images show multiple small (<5-mm), ring-enhancing candidal abscesses (arrows).

 


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  		Figure 23b.  Candidal abscesses. Axial IR T2-weighted (a) and contrast-enhanced VIBE (b) MR images show multiple small (<5-mm), ring-enhancing candidal abscesses (arrows).

 


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  		Figure 24.  Pseudocapsule. Axial delayed phase contrast-enhanced 3D GRE T1-weighted MR image shows a tumor pseudocapsule (arrows) with the characteristic features of low signal intensity and conspicuous enhancement.

 


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  		Figure 25.  Axial contrast-enhanced VIBE MR image obtained after treatment of a focus of HCC shows a radiofrequency-ablated area with typical ring enhancement (arrowhead).

 


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  		Figure 26a.  Nodule-within-a-nodule enhancement pattern. Axial unenhanced (a) and arterial phase contrast-enhanced (b) 3D GRE T1-weighted VIBE MR images show an area of HCC (arrowhead) arising within a dysplastic nodule (arrow).

 


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  		Figure 26b.  Nodule-within-a-nodule enhancement pattern. Axial unenhanced (a) and arterial phase contrast-enhanced (b) 3D GRE T1-weighted VIBE MR images show an area of HCC (arrowhead) arising within a dysplastic nodule (arrow).

 


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  		Figure 27a.  Peripheral washout sign. Axial arterial phase (a) and delayed phase (b) contrast-enhanced 3D GRE T1-weighted VIBE MR images show a metastatic deposit from colon cancer. The lesion is hypoenhancing on the arterial phase image. On the delayed phase image, it has a peripheral rim (arrows) that is hypointense relative to the center of the lesion.

 


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  		Figure 27b.  Peripheral washout sign. Axial arterial phase (a) and delayed phase (b) contrast-enhanced 3D GRE T1-weighted VIBE MR images show a metastatic deposit from colon cancer. The lesion is hypoenhancing on the arterial phase image. On the delayed phase image, it has a peripheral rim (arrows) that is hypointense relative to the center of the lesion.

 


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  		Figure 28.  Cystadenoma. Axial contrast-enhanced 3D GRE T1-weighted MR image shows a multilocular cystic lesion (arrow) with an enhancing rim and septa, findings that represent a biliary cystadenoma.

 


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  		Figure 29a.  Hematoma in a 49-year-old woman who had sustained trauma. (a) Axial IR T2-weighted MR image shows a septated hematoma with high signal intensity. (b) On an axial contrast-enhanced 3D GRE T1-weighted MR image, the hematoma demonstrates rim enhancement (arrow).

 


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  		Figure 29b.  Hematoma in a 49-year-old woman who had sustained trauma. (a) Axial IR T2-weighted MR image shows a septated hematoma with high signal intensity. (b) On an axial contrast-enhanced 3D GRE T1-weighted MR image, the hematoma demonstrates rim enhancement (arrow).

 


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  		Figure 30a.  Hemangioma. Axial portal venous phase (a) and delayed phase (b) contrast-enhanced 3D GRE T1-weighted MR images show a hepatic hemangioma with the typical findings of early peripheral nodular enhancement (arrow in a) and progressive centripetal filling (arrow in b). These findings helped confirm the diagnosis.

 


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  		Figure 30b.  Hemangioma. Axial portal venous phase (a) and delayed phase (b) contrast-enhanced 3D GRE T1-weighted MR images show a hepatic hemangioma with the typical findings of early peripheral nodular enhancement (arrow in a) and progressive centripetal filling (arrow in b). These findings helped confirm the diagnosis.

 


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  		Figure 31a.  Intrahepatic cholangiocarcinoma in a 69-year-old man. (a) Axial arterial phase contrast-enhanced 3D GRE T1-weighted VIBE MR image shows a low-signal-intensity tumor area with faint peripheral enhancement. (b) On an axial delayed phase contrast-enhanced 3D GRE T1-weighted VIBE MR image, the tumor area demonstrates progressive filling (arrow).

 


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  		Figure 31b.  Intrahepatic cholangiocarcinoma in a 69-year-old man. (a) Axial arterial phase contrast-enhanced 3D GRE T1-weighted VIBE MR image shows a low-signal-intensity tumor area with faint peripheral enhancement. (b) On an axial delayed phase contrast-enhanced 3D GRE T1-weighted VIBE MR image, the tumor area demonstrates progressive filling (arrow).

 


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  		Figure 32a.  Peliosis hepatis. Axial IR T2-weighted (a) and portal venous phase contrast-enhanced 3D GRE T1-weighted VIBE (b) MR images show multiple small, confluent cystic lesions. The lesions demonstrate enhancement on the portal venous phase image, a finding that represents peliosis hepatis.

 


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  		Figure 32b.  Peliosis hepatis. Axial IR T2-weighted (a) and portal venous phase contrast-enhanced 3D GRE T1-weighted VIBE (b) MR images show multiple small, confluent cystic lesions. The lesions demonstrate enhancement on the portal venous phase image, a finding that represents peliosis hepatis.

 




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