Vol 3 | Issue 1 | Jan - Apr 2015 | page:23-30 | Udit Chauhan, Ravi Shanker Solanki, Alok Kumar Udiya, Gurucharan S Shetty, M K Narula.

Author: Udit Chauhan[1], Ravi Shanker Solanki[1], Alok Kumar Udiya[1], Gurucharan S Shetty[1], M K Narula[1].

[1] Lady Hardinge Medical College, University of Delhi.
Institute at which research was conducted: Lady Hardinge Medical College,New Delhi.
University Affiliation of Thesis: University of Delhi.
Year of Acceptance: 2013.

Address of Correspondence
Dr. Udit Chauhan
31 B, Pusa Road ,Opposite Metro Pillar 121,
110005, Delhi.
Email: dr.udit.chauhan@gmail.com

 Abstract

The study was aimed to evaluate the features of various hepatic masses using triple phase multidetector computed tomography and to correlate features of triple phase multidetector computed tomography with clinical and cytohistopathology/operative findings. Technique of the triple phase was individualised as per the case with the application of empirical delay technique for timing the scan delay. Authors found the modality to be highly accurate for detection and characterisation of hepatic masses in addition to be able to provide significant information for the planning and management of the disease.

Introduction

Liver is a important constituent of the digestive tract and is involved in maintenance of the body's metabolic homeostasis. Because of its major function of detoxification of body and its rich blood supply by hepatic artery and portal vein, it becomes prone to various diseases including benign, malignant and metastases.

Material and Method

PLACE OF STUDY
The study is proposed to be conducted in the department of radiodiagnosis,Lady Hardinge Medical College and Associated Smt Sucheta Kriplani and Kalawati Saran Children Hospital ,New Delhi in close association with Department of Surgery .
STUDY PERIOD
The study period will be from November 2010 to March 2012.
STUDY POPULATION
The study will comprise of patients with hepatic masses on basis of cilinical findings or on ultrasonography.A minimum of 30 patients will be included in the study.

STUDY METHOD
Each patient included in the study after obtaining an informed consent ,will be subjected to a detailed history ,clinical examination and diagnostic work up plan. Plain X-ray abdomen ,routine Hb%,TLC DLC,ESR and liver function tests,renal function tests would be done in all patients.
PlainCT will be followed by triple phase contrast ct using iodinated water soluble contrast media. Technique of triple phase will be individualized as per the case.

Result and Discussion

Out of 60 patients referred from various clinical departments a total of 15 patients were excluded.8 patients were excluded as USG features suggested abscess, 4 patients had USG features suggestive of hydatid cyst, 2 patients had USG features suggestive of simple cyst of liver and 1 patient suspected of HCC was lost to follow up and FNAC could not be performed. Therefore a total of 45 cases were included in the study. Out of 45 cases there were a total of 4 benign and 41 malignant masses. Of the 4 benign cases there were 3 hemangioma and 1 infantile hemangioendothelioma. Of the malignant masses, 16 cases were of metastases, 14 cases were CA GB with hepatic infiltration, 5 cases were of HCC and 3 each were hepatoblastoma and cholangiocarcinoma.
Maximum number of cases were in the age group of 41-50yrs (24.44%) and 55.56% were females.
Metastases were seen in 16 of the total of 45 cases (35.56%) and was single largest group.Ca GB with hepatic infiltration was the second largest group (14 cases) comprising 31.11%. Most common symptom in the cases presenting with hepatic masses was pain abdomen (71.11%) with weight loss being the second most common symptom (68.88%). Most common sign was lump RHC /hepatomegaly (62.22%). Most common abnormality in LFT was elevated alkaline phosphatase (46.67%).
Out of the total of 4 benign lesions, 3(75%) were correctly diagnosed on US. All the lesions were correctly diagnosed on CT. Out of 41 malignant lesions, 39 (95.12%) were correctly diagnosed on USG and 2 cases (4.88%) were misdiagnosed. Triple phase CT was able to correctly diagnose 40 malignant lesions (97.56%) and misdiagnosed 1 lesion (2.44%).
HEMANGIOMA (n=3): All the 3 cases of haemangioma in our study were females. Two of the cases were in the age group of 51-60yr and one was 33yrs old. All the lesions were hyperechoic in echogenecity and were single in number (100%). 2 lesions (66.67%) had well defined margins and one had ill defined margins (33.34%). All the lesions (100%) were hypo dense on plain scan and showed early discontinuous peripheral enhancement in arterial phase with progressive centripetal filling in the delayed phase.
INFANTILE HEMANGIOENDOTHELIOMA (n=1): This was a case of 10mth old male child who was referred with clinical suspicion of hepatoblastoma. Case had pallor, lump and tenderness right hypochondrium, laboratory investigations were normal except for anaemia. On USG multiple well defined lesions were seen in both lobes and were heterogeneous with predominantly hyperechoic character. The lesions showed arterial flow pattern on Doppler examination.On triple phase CT the lesions were multiple, seen in both the lobes with largest lesion of app. 5cmx4.5cm size. The lesions were hyper dense on plain scan with early and discontinuous peripheral enhancement on arterial phase and progressive centripetal fill in on delayed phase. Additionally there was narrowing in calibre of infra celiac aorta.
HEPATOCELLULAR CARCINOMA (n=5): There were 5 cases of HCC in the study and all of them were correctly clinically suspected based on the clinical features and elevated levels of AFP in all the cases. 4 cases were in the age group of 40-70yrs and 1 case was 29yr old. All the cases were males. In our study all the cases had pain abdomen (100%) as the presenting feature, 4 cases had abdominal distension (80%). Lesions were multiple in all the cases (100%). There was bilateral lobe predominance (80%) with well defined margins of the lesions in 80% of cases. 60% cases had heterogeneous predominantly hyperechoic lesions, 20% of the cases had heterogeneous predominantly hypoechoic lesions and 20%had hyperechoic lesion with hypoechoic capsule. All the cases had cirrhosis and ascites (100%). All the lesions (100%) were hypodense on NCCT and showed early enhancement in arterial phase with persistent enhancement in portovenous inflow phase and washout in portovenous phase. Tumoral vessels were seen in 4 cases (80%) and 2 cases (20%) showed presence of arterioportal shunts. All the cases had portal vein thrombosis (100%). IVC thrombus and hepatic vein thrombus was seen in 2 (40%) cases each. 4 cases were in stage IIIa (80%), and one (20%) case was in stage IIIc.
HEPATOBLASTOMA (n=3): Of the 3 cases in the study 2 were males and one was female. One patient was 7yr old and the other two were 2yrs old each. AFP was elevated in all the cases (100%). Abdominal X-ray was done all the cases which revealed hepatomegaly. Lesions were seen in right lobe and were single in all the cases (100%). Lesions were well defined in two cases (66%) and ill defined in one case. In 2 cases the lesions were heteroechoic and hypoechoic in one of the cases. Calcification was seen in one case. One case had ascites (33%). Two lesions were hypodense on NCCT (33%) while one was heterogeneous. Only one of the lesions showed calcification. One of the lesions showed enhancement in arterial phase with evidence of washout in portovenous phase (early washout). The other two cases enhanced in portovenous inflow and portovenous phase with no evidence of early washout rather they showed persistent enhancement.
CHOLANGIOCARCINOMA (n=3): Of all the cases with cholangiocarcinoma 2 were females (66.67%) and were in the age group of 40-50yrs. One of the case was male (33.34%) of 71yr age. All the cases had jaundice and hyperbilirubinemia at presentation (100%). All the cases had single lesion (100%) in right lobe (100%), with well defined margins (100%). All the lesions were hypoechoic and were associated with IHBRD (100%). Gall bladder was distended in 2 cases (66.67%) and these 2 cases had calculus also (66.67%). In none of the cases primary confluence was patent. One (33.34%) case had lymph node enlargement and 2 cases (66.67%) had ascites. All the lesions were isodense on NCCT and showed no enhancement in arterial and porto venous inflow/late arterial phase but were enhanced in delayed phase (100%).
METASTASES (n=16): Metastases were seen in 16 of the total of 45 cases (35.56%) and was the largest number among the group, majority of these cases were in the age group of 61-70y (25%). Weight loss was most common symptom (87.5%). The lesions were multiple (87.5%), distributed in both the lobes (81.25%) and had well defined margins (93.75%) in most of the cases. Most common character was hyperechoic (37.5%) followed by target appearing (31.25%). 1 case had anechoic cystic character. Lymphnodes were enlarged in 7 cases (43.75%). In 87.5% of the cases lesions were multiple and were well defined in 100% of the cases. 93.75% of the cases showed hypodense lesions on NCCT. 7 cases (43.75%) showed enhancement in the arterial phase while 3 cases each (18.75%) showed enhancement in portovenous inflow and portovenous phase.3 cases did not enhance in any of the phases(18.75%). 2 cases showed washout (12.5%) while 7 cases (43.75%) showed persistent enhancement. There were 2 cases of Ca larynx in the age group of 50-60yrs .Both were males. One case had single lesion in right lobe with ill-defined margins and hyperechoic character. This lesion was hyperdense on NCCT and showed early enhancement in arterial phase with persistent enhancement in portovenous phase and did not show early washout. Second case had multiple lesions in both the lobes target type in character. The lesions in this case were hypodense on NCCT and showed early enhancement in arterial phase with no evidence of early washout. One case had CA rectum (35Y/F) with bilateral ovarian metastases, ascites and rectovaginal fistula. The lesions were multiple in both the lobes with target appearance on USG and hypodense on NCCT. The lesions showed no enhancement throughout the arterial and portovenous inflow/ late arterial phase with only peripheral enhancement in portovenous phase. There were two cases of adenocarcinoma lung and both had multiple well defined target like lesions in both the lobes on USG. Neither of the case showed enhancement in arterial phase but showed enhancement in portovenous inflow/late arterial and portovenous phase. There were two cases of RCC with metastases to liver. Lesions were single in one case and multiple in another with hyperechoic character. Both the cases had hypodense lesions on NCCT with one case showing early arterial enhancement and early washout while other showed enhancement in portovenous inflow phase. There was a case of 59Y/M that had Ca oesophagus. Lesions were multiple, bilateral and well defined with hyperechoic character on USG. The lesions were hypodense on NCCT with early arterial enhancement and no early washout. There were 2 cases of malignancy of anal canal. One was 65Y/F who had multiple hyperechoic lesions on USG. The lesions were hypodense on NCCT with early peripheral enhancement on arterial phase and persistent enhancement through the portovenous inflow and portovenous phase. Other was a 30Y/M diagnosed with malignant melanoma of anal canal. This patient had multiple anechoic lesions which were hypodense on NCCT showing no enhancement on any phase. A case of 65Y/F that had CA breast with multiple hypoechoic lesions on USG. The lesions were hypodense on NCCT with no enhancement on any of the phases. A case of 35Y/F with bulky ovaries and elevated CA-125 levels was diagnosed CA ovary. There were multiple metastases to spleen, liver and omentum. There were multiple well defined hypoechoic lesions on USG. The lesions were hypodense on NCCT and did not show enhancement on any of the phases. A case of 42Y/M who had illeal thickening and multiple target like lesions on USG was diagnosed as small bowel malignancy on USG. On NCCT the lesions were hypodense and enhanced only on portovenous phase. A 25Y/F with periampullary carcinoma had multiple hypoechoic lesions in both the lobes of liver which were hypodense on NCCT and showed early peripheral enhancement on arterial phase with persistent enhancement on portovenous inflow and portovenous phase with no early washout
CARCINOMA GALL BLADDER WITH HEPATIC INFILTRATION (n=14): There were total 14 cases of Ca gall bladder with hepatic infiltration. Majority of the cases (57.14%) were in the age group of 41-50yrs. All the cases were females except for 3 males (21.42%). Most common abnormality in the gall bladder was irregular asymmetric thickening of the wall predominantly in the region of neck and body (35.71%). Mass replacing the GB fossa was seen in 4 cases out of 14(28.57%). Lesions in liver were single and in right lobe in 13 cases (92.85%). These lesions were predominantly hyperechoic (78.57%). 5 cases had involvement of porta hepatis(35.71%). Non contiguous involvement of liver was seen in 1 case (7.14%). On triple phase CT most of the lesions show early enhancement in arterial phase (57.14%). 1 case did not show any enhancement in any of the phases. Only one case showed early washout while 12 cases showed persistent enhancement (87.71%). 11 cases showed lymphnode enlargement in the peripancreatic and periportal region on CT and 4 had pyloroduodenal involvement (28.57%).
Overall the diagnostic accuracy of USG was 93.33% and that of triple phase CT was 97.78%.

Conclusion and Recommendation

Ultrasonography is a useful screening modality for hepatic masses with a diagnostic accuracy of 93.33%. So all the patients with the clinical suspicion of hepatic masses should be subjected to ultrasonography for initial detection and localisation of lesion.
·Triple phase MDCT is excellent for the characterisation of hepatic masses with a diagnostic accuracy of 97.78%.
·Metastases are the most common hepatic malignancy (35.56%) and are far more common than primary causes like HCC (11.11%).
·Amongst the benign lesions the most common is hemangioma (6.67%).
·MDCT with its short scanning times (single breath hold) is ideal for imaging in sick patients and pediatric age group.
·Triple phase MDCT is ideal for diagnosis of benign conditions like hemangioma and infantile hemangioendothelioma.
·Triple phase MDCT with its arterial, portovenous inflow (late arterial) and portovenous phases is an ideal modality for diagnosis and characterisation of HCC. It is helpful to provide additional information like vascular invasion, capsular delineation, arterioportal shunts and also provide a vascular road map for surgery and image guided interventions. Thereby having a promising role in management also.
·Pediatric malignant tumors like hepatoblastoma are diagnosed and managed with help of important information provided by triple phase MDCT. Vascular and tumor anatomical details are helpful to plan for neoadjuvant chemotherapy and surgical or image guided interventions.
·Cholangiocarcinoma is diagnosed in delayed phase images acquired during triple phase MDCT protocol. Vascular and biliary tract anatomical details provided by MIP and MinIP images are helpful in planning management.
·Metastases could be differentiated as hyper or hypovascular type based on triple phase CT characteristics. This further helps to define primary lesion. Information derived by various phases can help in planning image guided interventions.
Carcinoma gall bladder is usually detected at advanced stage. In these cases vascular and biliary anatomy and involvement of adjacent structure help in planning the management. These details are enhanced by the use of MPR, MIP and MinIP images..

Future Direction

To find out the beneficial effects on sports persons performance, lumbar core stability exercises could be given for a longer duration.

Bibliography

1. Rustgi AK, Saini S, Schapiro RH. Hepatic imaging and advanced endoscopic techniques. MCNA 1989;73(4):895-910.
2. Rubin GD, Dake MD. Current status of three dimensional spiral CT scanning for imaging the vasculature. RCNA 1995;33:863-86.
3. Hoon Ji, Jeffrey D, McTavish, Koenraad J, Walter Wiesner, Pablo R. Ros. Hepatic imaging with multidetector CT. RadioGraphics 2001;21:71–80.
4. Atasoy and Akyar. Multidetector CT contribution in liver imaging. EJR 2004;52:2-17.
5. Coffin CM, Diche T, Mahfouz A. Benign and malignant hepatocellular tumors: Evaluation of tumoral enhancement after mangafodipir trisodium injection on MR imaging. Eur Radiol 1999; 9:444-49.
6. Kirti Kulkarni, Robert Nishikawa, Richard L Baron. Contrast enhancement of hepatic hemangiomas on multiphase MDCT:Can We Diagnose hepatic hemangiomas by comparing enhancement with blood pool?. AJR 2010; 195:381–6.
7. Chen TS, Chen PS. The myth of Prometheus and the liver. J R Soc Med 1994; 87:754-55.
8. Berland LL, Smith JK. Multidetector array CT:once again, technology creates new opportunities. Radiology 1998; 209:327–29.
9. Rydberg J, Buckwalter KA, Caldemeyer KS. Multisection CT: scanning techniques and clinical applications. RadioGraphics 2000;20:1787–1806.
10. Klingenbeck-Regn K, Schaller S, Flohr T, Ohnesorge B, Kopp AF, Baum U. Subsecond multislice computed tomography: basics and applications. Eur J Radiol 1999; 31:110–24.
11. Hoon Ji, Jeffrey, McTavish, Koenraad J, Mortele, Walter Wiesner, Pablo R Ros. Hepatic Imaging with multidetector CT. RadioGraphics 2001;21:71–80.
12. Daniel T Boll, Elmar M Merkle. Liver :Normal anatomy ,imaging techniques,and diffuse diseases. In Haaga, JR, Dogra Vikram, Forsting Michael, Gilkeson RC,HA KH, Sundaram M, CT and MRI of whole body(5th ed) Mosby 2009.
13. Dodd GD. An American's guide to Couinaud's numbering system. AJR Am J Roentgenol 1993;161:574-75.
14. Ros PR .focal liver masses other than metastasis. In :Categorical course on gastrointestinal radiology .Oak book III.RSNA publications 1999.
15. Aytekin Oto, Kirti Kulkarni, Robert Nishikawa, Richard L. Baron. Contrast enhancement of hepatic hemangiomas on multiphase MDCT:Can We Diagnose hepatic hemangiomas by comparing enhancement with blood pool?. AJR 2010; 195:381–6.
16. Bartolotta TV, Midiri M, Galia M. Characterization of benign hepatic tumors arising in fatty liver with SonoVue and pulse inversion US. AbdomImaging 2007;32(1):84–91.
17. Blachar A, Federle MP, Ferris JV. Radiologists' performance in the diagnosis of liver tumors with central scars by using specific CT criteria. Radiology 2002;223(2):532-39.
18. Ros PR, Taylor H. Benign tumors of the liver. In: Gore RM, Levine MS, eds.Textbook of gastrointestinal radiology, 2nd ed. Philadelphia, PA: Saunders Company, 2000:1487–97.
19. Itai Y, Ohtomo K, Araki T, Furui S, Iio M, Atomi Y. CT and sonography of cavernous hemangioma of the liver. AJR 1983; 141:315–20.
20. Freeny PC, Marks WM. Patterns of contrast enhancement of benign and malignant hepatic neoplasms during bolus dynamic and delayed CT. Radiology 1986;174: 350-59.
21.Gaa J, Saini S, Ferrucci JT. Perfusion characteristics of hepatic cavernous hemangioma using IV CT angiography. Eur J Radiol 1991;88:113-15.
22. Bruneti JC, Van Hurtam. Spect in the diagnosis of hepatic hemangioma. j.nucl med 1985;26:89.
23. Luigi Grazioli, Michael P. Federle, Giuseppe Brancatelli, Tomoaki Ichikawa, Lucio Olivetti, Arye Blachar. Hepatic adenomas:imaging and pathologic findings. RadioGraphics 2001; 21:877–94.
24. Edmondson HA. Atlas of tumor pathology: tumors of the liver and intrahepatic bile ducts, fascWashington, DC: Armed Forces Institute of Pathology, 1958.
25. Reddy KR, Schiff E. Approach to a liver lesion. Semin Liver Dis 1993; 13:423–35.
26. Nakasaki H, Tanaka Y, Ohta M. Congenital absence of the portal vein. Ann Surg 1989; 210: 190–93.
27. Kawakatsu M, Vilgrain V, Belghiti J, Flejou JF, Nahum H. Association of multiple liver cell adenomas with spontaneous intrahepatic portohepatic shunt. Abdom Imaging 1994; 19:438–40.
28. Leese T, Farges O, Bismuth H. Liver cell adenomas. Ann Surg 1998; 208:558–64.
29. Golli M, Van Nhieu JT, Mathieu D. Hepatocellular adenoma: color Doppler US and pathologic correlations. Radiology 1994; 190:741–44.
30. Bartolozzi C, Lencioni R, Paolicchi A, Moretti M, Armillotta N, Pinto F. Differentiation of hepatocellular adenoma and focal nodular hyperplasia of the liver: comparison of power Doppler imaging and conventional color Doppler sonography. EurRadiol 1997; 7:1410–15.
31. Chung KY, Mayo-Smith WW, Saini S, Rahmouni A, Golli M, Mathieu D. Hepatocellular adenoma:MR imaging features with pathologic correlation. AJR Am J Roentgenol 1995; 165:303–8.
32. Boulahdour H, Cherqui D, Charlotte F. The hot spot hepatobiliary scan in focal nodular hyperplasia. J Nucl Med 1993; 34:2105–10.
33. Wanless IR, Mawdsley C, Adams R. On the pathogenesis of focal nodular hyperplasia of the liver. Hepatology 1985;5(6):1194–2000.
34. Stephan W. Anderson, Jonathan B. Kruskal, Robert A. Kane. Benign Hepatic Tumors and Iatrogenic Pseudotumors.
35. Semelka RC, Martin DR, Balci C, Lance T. Focal liver lesions: comparison of dual-phase CT and multisequence multiplanar MR imaging including dynamic gadolinium enhancement. J Magn Reson Imaging 2001;13(3):397–401.
36. Ellen M Chung, Regino Cube, Rachel B Lewis, Richard M Conran. Pediatric liver masses: radiologic-pathologic correlation part 1- benign tumors. RadioGraphics 2010; 30:801–26.
37. Boon LM, Burrows PE, Paltiel HJ. Hepatic vascular anomalies in infancy: a twenty-seven-year experience. J Pediatr 1996;129(3):346–54.
38. Ishak KG, Goodman ZD, Stocker JT. Benign mes­enchymal tumors and pseudotumors. In: Rosai J, Sobin L, eds. Atlas of tumor pathology: tumors of the liver and intrahepatic bile ducts. Washington, DC: Armed Forces Institute of Pathology, 2001; 71–157.
39. Keslar PJ, Buck JL, Selby DM. Infantile hemangio­endothelioma of the liver revisited. RadioGraphics 1993;13(3):657–70.
40. Kassarjian A, Zurakowski D, Dubois J, Paltiel HJ, Fishman SJ, Burrows PE. Infantile hepatic heman­giomas: clinical and imaging findings and their cor­relation with therapy. AJR Am J Roentgenol 2004; 182(3):785–95.
41. Paltiel HJ, Patriquin HB, Keller MS, Babcock DS, Leithiser RE Jr. Infantile hepatic hemangioma: Dop­pler US. Radiology 1992;182(3):735–42.
42. Zurakowski D, Dubois J, Paltiel HJ, Fishman SJ, Burrows PE. Infantile hepatic heman­giomas: clinical and imaging findings and their cor­relation with therapy. AJR Am J Roentgenol 2004; 182(3):785–795.
43. Buck JL, Selby DM. Infantile hemangio­endothelioma of the liver revisited. RadioGraphics 1993;13(3):657–70.
44. Lucaya J, Enriquez G, Amat L, Gonzalez-Rivero MA. Computed tomography of infantile hepatic heman-gioendothelioma. AJR Am J Roentgenol 1985;144 (4):821-26.
45. Goodman ZD, Stocker JT. Benign mes­enchymal tumors and pseudotumors. In: Rosai J, Sobin L, eds. Atlas of tumor pathology: tumors of the liver and intrahepatic bile ducts. Washington, DC: Armed Forces Institute of Pathology, 2001; 71–157.
46. Stocker JT, Ishak KG. Mesenchymal hamartoma of the liver: report of 30 cases and review of the litera­ture. Pediatr Pathol 1983;1(3):245–67.
47. Kamata S, Nose K, Sawai T. Fetal mesenchymal hamartoma of the liver: report of a case. J Pediatr Surg 2003;38(4):639–41.
48. Koumanidou C, Vakaki M, Papadaki M, Pitsoulakis G, Savvidou D, Kakavakis K. New sonographic ap­pearance of hepatic mesenchymal hamartoma in childhood. J Clin Ultrasound 1999;27(3):164–67.
49. Mortele KJ, Ros PR. Benign liver neoplasms. Clin Liver Dis 2002;6(1):119–45.
50. Ros PR, Goodman ZD, Ishak KG. Mesenchy­mal hamartoma of the liver: radiologic-pathologic correlation. Radiology 1986;158(3):619–24.
51. Horton KM, Bluemke DA, Hruban RH, Soyer P, Fishman EK. CT and MR imaging of be­nign hepatic and biliary tumors. RadioGraphics 1999;19(2):431–51.
52. Edmondson HA. Differential diagnosis of tumors and tumor-like lesions of the liver in infancy and childhood. AMA J Dis Child 1956;91(2):168–86.
53. Torbenson M. Review of the clinicopathological features of fibrolamellar carcinoma. Adv Anat Pathol 2007;14(3):217–23.
54. El-Serag HB, Davila JA. Is fibrolamellar carcinoma different from hepatocellular carcinoma? A US population-based study. Hepatology 2004;39(3):798–803.
55. Saab S,Yao F. Fibrolamellar HCC:case reports and review of literature. Dig Dis Sci 1996 ;41:1981-85.
56. McLarney JK, Rucker PT, Bender GN, Goodman ZD, Kashitani N, Ros PR. Fibrolamellar carcinoma of the liver: radiologic-pathologic correlation. RadioGraphics 1999;19(2):453–71.
57. Matsui O,Kobayashi S,Gabata T,Ueda K.Liver;focal hepatic mass lesion .In:Haaga JR ,Dogra VS, Forsting M,Gilkeson RC , Ha KH ,Sundaram M,editors.CT &MRI of whole body .5th ed. Mosby, Inc;2009.p.1526.
58. Rucker PT, Bender GN, Goodman ZD, Kashitani N, Ros PR. Fibrolamellar carcinoma of the liver: radiologic-pathologic correlation.RadioGraphics 1999;19(2):453–471.
59. Liver Cancer study group of JAPAN :General rules for the clinical and pathological study of primary liver cancer .Tokyo , Kanchara;2003.
60. Tanaka S, Kitamura T, Imaroka S. Hepatocellular carcinomas : Sonographic and histological correlation .AJR 1983;140:701-07
61. Tanaka S, Kitamura Colour Doppler imaging of liver tumors .AJR 1990;154:504-14.
62. Lee K H Y, O'Malley M E, Haider M A, Hanbidge A, Triple phase MDCT of hepatocellular carcinoma :AJR 2004; 182:643 -49.
63. Asayama Y, Yoshimitsu K, Nishihara Y. Arterial blood supply of HCC and histologic grading :Radiologic –Pathologic correlation .AJR 2008 ;190:W28-34.
64. Gazelle SG, Saini S, Mueller P. Hepatobiliary and pancreatic Radiology imaging and intervention. Thieme 1998.
65. Shahid M Hussain, Caroline Reinhold, Donald G Mitchell. Cirrhosis and Lesion Characterization at MR Imaging. RSNA, 2009. radiographics.rsna.org
66. Vauthey JN. Staging systems for HCC. In: Innovations in cancer therapies: the future of cross-specialty cancer treatment—program book of the 1st International Symposium on Image-Guided Therapy for Cancer, London, England, May 1–4, 2005. Beverly, Mass: Innovations in Cancer Therapies, 2005; 22–31.
67. American Joint Committee on Cancer. Liver (including intrahepatic bile ducts). In: Green FL, Page DL, Fleming ID, et al, eds. AJCC cancer staging handbook. 6th ed. New York, NY: Springer, 2002; 121–144.
68. Rivard & lowe. Radiological resoning:Multiple hepatic masses in an infant:AJR 2008;190:June 2008; 50.
69. Christophoros stoupis. The Rocky Liver: Radiologic- pathologic correlation of calcified hepatic masses : Radiographics 1998 ;18:675-85.
70. Lu M, Green MC. Hypervascular multifocal hepatoblastoma:Dynamic gadolinium-enhanced MRI findings indistinguishable from infantile hemangioendothelioma. Paed Rad 2007;37:587-91.
71. Furui S, ItaiY, Ohtomo K. Hepatic epitheloid hemangioendothelioma:report of five cases. Radiology 1989;171:63-68.
72. Silvermann PM, Ram PL, Korobkin M. CT appearance of induced angiosarcoma of the liver. J Comp Ass Tom 1983;4:655-58.
73. Fazelle GS, Lee MJ, Hahn PF. US, CT & MRI of Primary and secondary liver lymphoma. J Comp Ass Tom 1994;18:412-15.
74. Shirkhoda A, Ros PR. Lymphoma of the solid abdominal viscera. RCNA 1990;28:785-99.
75. Zornoza J, Ginaldi S. Computed tomography in hepatic lymphoma. Radiology 1981; 138:405-10.
76. Bechtold RE, Karstaedlt N, Glass TA. Prolonged hepatic enhancement on computed tomography in a case of hepatic lymphoma. J Comp Asst Tomo 1985;9:186-9.
77. Bloom CM, Langer B, Wilson SR. Role of US in the detection, characterization, and staging ofcholangiocarcinoma. RadioGraphics 1999;19:1199–1218.
78. Nisha I. Sainani, Onofrio A, Catalano, Nagaraj Setty , Holalkere, Andrew X. Zhu, Peter F. Hahn, Dushyant V. Sahani. Cholangiocarcinoma: Current and Novel Imaging Techniques. RadioGraphics 2008; 28:1263–87.
79. Yoshiki Asayama, Kengo Yoshimitsu, Hiroyuki Irie, Tsuyoshi Tajima, Akihiro Nishie. Delayed-phase dynamic CT enhancement as a prognostic factor for mass-forming intrahepatic cholangiocarcinoma. Radiology 2006;238: 208-15.
80. Lewis KH, Chezmar JL. Hepatic metastases. Magn Reson Imaging Clin N Am 1997; 5:319–30.
81. Sugawara Y, Yamamoto J, Yamasaki S, Shimada K, Kosuge T, Sakamoto M. Cystic liver metastases from colorectal cancer. J Surg Oncol 2000;74:148–52.
82. Withers. The liver. In:Rumack CM, Wilson SR,Charboneau JW,editors. Diagnostic ultrasound.1st ed. St Louis. Mosby Year Book Inc;1991.p.45-86.
83. W. Dennis Foley, Ulku Kerimoglu. Abdominal MDCT: Liver, Pancreas, and Biliary Tract Seminars in Ultrasound, CT, and MRI 2004;25:122-44.
84. Philippe Soyer. Detection of Hypovascular Hepatic Metastases at Triple-Phase Helical CT: Sensitivity of Phases and Comparison with Surgical and Histopathologic Findings. Radiology 2004; 231:413–20.
85. Terayama N, Matsui O, Veda K. Peritumoral rim enhancement of liver metastasis : Haemodynamics observed on single level dynamic CT during hepatic arteriography and histopathological correalation . J Comp Asst Tomo 2002;26:975-80.
86. Gregory T. Sica, Hoon Ji, Pablo R Ros. CT and MR Imaging of Hepatic Metastases. AJR 2000;174:691-98.
87. Roberts KW, Daugherty SF. Primary carcinoma of the gallbladder. Surg Clin North Am 1986; 66:743–49.
88. Naveen Kalra, Sudha Suri, Rajesh Gupta, S K Natarajan, Niranjan Khandelwal, J D Wig, Kusum Joshi. MDCT in the Staging of Gallbladder Carcinoma. AJR 2006; 186:758–62.
89. Alessandro Furlan, James V Ferris, Keyanoosh Hosseinzade, Amir Borhani. Gallbladder Carcinoma Update:Multimodality Imaging Evaluation, Staging, and Treatment Options. AJR 2008; 191:1440–47.
90. Angela D Levy, Linda A Murakata, MC Charles A, Rohrmann Jr. Gallbladder Carcinoma: Radiologic-Pathologic Correlation. RadioGraphics 2001; 21:295–314.
91. Kim JH, Kim TK, Kim BS. Preoperative evaluation of gallbladder carcinoma: efficacy of combined use of MR imaging, MR cholangiography, and contrast-enhanced dual-phase three-dimensional MR angiography. J Magn Reson Imaging 2002; 16:676–84.
92. Murakami M, Kim T, Takahashi S. Evaluation of optimal timing of the arterial phase imaging for the detection of hypervascular hepatocellular carcinoma by using triple arterial phase imaging of multidetector-row helical CT. Radiology 2000; 217:367
93. Foley WD, Mallisee TA, Hohenwalter MD. Multiphase hepatic CT with a multirow detector CT scanner. Am J Roentgenol 2000; 175:679–85.
94. Chen IY, Katz DS, Jeffrey RBJ Do arterial phase helical CT images improve detection or characterization of colorectal liver metastases. J Comput Assist Tomogr 1997;21:391–97.
95. John P Harris, Rendon C Nelson. Abdominal Imaging with Multidetector Computed Tomography. J Comput Assist Tomogr 2004;28:17–19.
96. Atasoy C, Akyar S. Multidetector CT: contributions in liver imaging. Eur J Radiol. 2004;52(1):2-17.
97. Ji H, Mc Tarish JD. Hepatic imaging with multidetector CT. Radiographics 2001;21:71-75.
98. Boll and Merkel. Liver:Imaging Techniques, and Diffuse Diseases. In:Haaga JR, Dogra VS, Forsting M, Gilkeson RC, Ha KH, Sundaram M, editors. CT &MRI of whole body .5th ed.Mosby,Inc;2009.
99. Saini S. Imaging of the hepatobiliary tract. NEJM 1997;336(26):1889-94.
100. Mayo Foundation for Medical Education and Research (MFMER) [Online]. 2011 [cited 2011 Jan 12]; Available from: URL: http://www.mayoclinic.com/health/liver-hemangioma/DS01125">Liver hemangioma.
101. Justus E. Roos, Roger Pfiffner, Thomas Stallmach, Gerd Stuckmann, Borut Marincek, Ulrich Willi. Infantile Hemangioendothelioma. RadioGraphics 2003; 23:1649–55.
102. Sharma R, Madhusudan KS:Malignant focal lesions of Liver. In:Gupta AK, Chowdhury V, Khandelwal N, editors. Diagnostic Radiology.3rd ed. New Delhi. Jaypee Brothers Medical Publishers;2009.p.245-249.
103. Jeong Hwan Kim, Moon Seok Choi, Hyuk Lee, Do Young Kim, Joon Hyeok Lee, Kwang Cheol Koh, Byung Chul Yoo, Seung Woon Paik And Jong Chul Rhee. Clinical features and prognosis of hepatocellular carcinoma in young patients from a hepatitis B-endemic area. Journal of Gastroenterology and Hepatology 2006 ;21:588–594
104. Hussain SM, Semelka RC, Mitchell DG. MR imaging of hepatocellular carcinoma. Magn Reson Imaging Clin N Am 2002;10:31–52.
105. Kamel IR, Liapi E, Fishman EK. Liver and Biliary System:Evaluation by multidetector CT.RCNA 2005;43:977-97.
106. Jae Ho Byun, Tae Kyoung Kim, Choong Wook Lee, Jeong Kyong Lee, Ah Young Kim, Pyo Nyun Kim. Arterioportal Shunt:Prevalence in Small Hemangiomas versus That in Hepatocellular Carcinomas 3 cm or Smaller at Two-Phase Helical CT. Radiology 2004; 232:354–60.
107. Ishak KG, Goodman ZD, Stocker JT. Tumors of the liver and intrahepatic bile ducts. Washington, DC: Armed Forces Institute of Pathology 2001;222-25.
108. Ellen M Chung, Grant E Lattin, Maj, MC Regino Cube, Rachel B. Lewis, Carlos Marichal Hernández, Robert Shawhan, Richard M. Conran. Pediatric liver masses: radiologic- pathologic correlation part 2. malignant tumors. RadioGraphics 2011; 31:483–507.
109. Siegel, Marilyn J. Liver and Biliary Tract. In Marilyn J Siegel, Pediatric Body CT( 2nd ed) Lippincott Williams & Wilkins 2008.
110. Yuichi Kitagawa, Masato Nagino, Junichi Kamiya, Katsuhiko Uesaka, Tsuyoshi Sano, Hideo Yamamoto, Naokazu Hayakawa, Yuji Nimura. Lymph Node Metastasis from Hilar Cholangiocarcinoma: Audit of 110 Patients Who Underwent Regional and Paraaortic Node Dissection. Annals Of Surgery 2001;233:385-92.
111. Liu WW, Zeng ZY, Guo ZM, Xu GP, Yang AK, Zhang Q, Zhonghua Er, Bi Yan Hou, Ke Za Zhi. Distant metastases and their significant indicators in laryngeal cancer. Chinese journal of oncology 2003;38(3):221-4.
112. Vassilios Raptopolous , Simon Blake , Karen Weisinger, Michael Atkins. Multiphase contrast enhanced helical CT of liver metastases from RCC. Eur radiol 2001;11:2504-9.
113. Marx MV, Balfe DM: Computed tomography of the esophagus. Semin Ultrasound CT MR 1987; 8:316-48.
114. Blake, Weisinger, Atkins, Raptopoulos. Liver metastases from melanoma:detection with multiphasic contrast enhanced CT. Radiology 1999;213:92-96.
115. H Roach, Whipp, J Virjee, M P Callaway. A pictorial review of the varied appearance of atypical liver metastasis from carcinoma of the breast.BJR 2005;78 :1098-1103.
116. Jin Wei Kwek, Revathy B Iyer. Recurrent Ovarian Cancer:Spectrum of Imaging Findings. AJR 2006; 187:99–104.
117. Fergus V Coakley, Patricia H Choi, Christina A Gougoutas, Bhavana Pothuri, Ennapadam Venkatraman, Dennis Chi. Peritoneal metastases: detection with spiral CT in patients with ovarian cancer. Radiology 2002; 223:495–99.
118. Johannes Sailer, Johannes Zacherl, Wolfgang Schima. MDCT of small bowel tumours. Cancer Imaging 2007; 7(1): 224–33.
119. Stella S. Cancers of unknown primary origin: current perspectives and future therapeutic strategies. Journal of Translational Medicine 2012;10:12.
120. G Jerusalem, A Rorive, G Ancion, R Hustinx , G Fillet. Diagnostic and therapeutic management of carcinoma of unknown primary: radio-imaging investigations. Annals of Oncology 2006;17(10):168–176.
121. Hamrick RE Jr, Liner FJ, Hastings PR, Cohn I Jr. Primary carcinoma of the gallbladder. Ann Surg 1982; 195:270- 73.
122. Sons HU, Borchard F, Joel BS. Carcinoma of the gallbladder: autopsy findings in 287 cases and review of the literature. J Surg Oncol 1985; 28:199– 206.
123. Wang, Larry L, Filippi, Renee Zon, Zurakowski, David et al. Effects of Neoadjuvant Chemotherapy on Hepatoblastoma: A Morphologic and Immunohistochemical Study. American Journal of Surgical Pathology: March 2010 ; 34 :287-99.
124. K Ito, A Govindarajin, Y Fong. Surgical treatment of hepatic colorectal metastasis, The Cancer Journal 2010; 16(2):80-86.

Download Full Text PDF |  Download Full Thesis