Professional Documents
Culture Documents
DEPARTMENT OF ONCOLOGY
AND RADIOLOGY
PREPARED BY I.M.LESKIV
Imaging techniques.
c
MRI scan of a haemangioma. (a) Low intensity area (arrows) on a Tl-weighted
image, (b) High intensity area (arrows) on a T2-weighted image. This
haemangioma was an incidental finding.
a b
Liver
neoplasms
Metastases, notably from carcinoma of the stomach, colon, pancreas, lung and
breast are much more common than primary tumours (hepatoma and
malignant lymphoma, both of which can be multifocal).
Metastases are often multiple, situated peripherally and of variable size. At
ultrasound, they may show increased echogenicity or, more usually, decreased
echogenicity compared with the surrounding parenchyma. At times, they show
a complex echo pattern and when they undergo central necrosis they may even
resemble cysts. A metastasis may have an echogenic centre giving an
appearance described as a target lesion. Some metastases have an echo pattern
virtually identical to that of the surrounding parenchyma, which means they
cannot be identified at sonography. At CT, metastases are seen as rounded
areas, usually lower in density than the contrast enhanced surrounding
parenchyma. Most are well demarcated from the adjacent parenchyma.
Intense contrast enhancement is sometimes seen within the tumour, or
immediately surrounding it - a useful differentiating feature, which is not seen
with cysts. MRI is an excellent method of demonstrating metastases that have
a signal lower than normal liver on a Tl-weighted scan and a high signal on a
T2-weighted scan.
Primary carcinomas of the liver, which include hepatocellular carcinoma and
cholangiocarcinoma, are often large and usually solitary but they may be
multifocal. Their CT, ultrasound and MRI features are similar to metastatic
neoplasms
Hepatoma. The CT scan shows a large, well-defined mass of variable density
(arrows).
Longitudinal scan. The cursors indicate an echogenic mass which
proved to be a metastasis. D, diaphragm; IVC, inferior vena cava.
CT scan of metastasis. This large low
density mass is situated deeply in the
right lobe of the liver
a b c
Liver cysts
Simple cysts of the liver, both single and multiple, are usually congenital in origin;
some are due to infection. Multiple hepatic cysts occur in adult polycystic disease,
which not only affects the kidneys but may also involve the liver and other organs.
These cysts are variable in size and are scattered through Ihe liver.
At ultrasound, liver cysts show the typical features of cysts elsewhere in the body,
namely sharp margin, no echoes within the lesion, and intense echoes from the front
and back walls with acoustic enhancement deep to the larger cysts.
At CT, cysts show very well-defined margins and have attenuation values similar to
that of water. Lesions below 2 cm in diameter may be difficult to distinguish from
solid neoplasms because portions of the normal liver may be present on a particular
CT section, and partial volume averaging may then result in a CT number close to
that of soft tissues. Below 1 cm in diameter it is almost never possible to distinguish
cyst from neoplasm.
At MRI, the features are similar to those found at CT. Cysts have the expected
signal intensity of water, namely Cysts due to echinococcus (hydatid) disease may be
single or multiple; a few show calcified walls. Daughter cysts may be seen within a
main cyst at both ultrasound and CT. Unless these features are present, hydatid
cysts may prove indistinguishable from simple cysts at both ultrasound and CT.
Liver cysts, (a) Simple cyst of liver. CT scan shows a well-defined
lesion of water density. (b) CT scan showing a multilocular hydatid
cyst in the right lobe of the liver (arrows).
Liver abscess
The abdominal plain film is of value in finding gas or calcium in the biliary tract.
Approximately 10% to 15% of gallstones are calcified and readily identifiable as
gallstones on plain films. At times there may be an accumulation of calcium in the
gallbladder that simulates contrast material (milk of calcium bile) Occasionally the
gallbladder wall is calcified (porcelain gallbladder), which is important because of
the association of this abnormality with gallbladder carcinoma
Gas may be seen in the center of gallstones in a triangular pattern (Mercedes-Benz
sign) Gas in the biliary ducts implies an abnormal connection between the gut and
the gallbladder or common bile duct This may be caused by penetration of a
duodenal ulcer into the biliary tract or gallstone erosion into the stomach,
duodenum, or colon. It is more often a consequence of surgical anastomosis of the
gut to the biliary tract or to sphincteroplasty of the sphincter of Oddi.
Gas is occasionally seen in the ducts as a manifestation of cholangitis caused by a
gas-forming organism. Gas in the gallbladder and its wall (emphysematous
cholecystitis) is the manifestation of a. similar infection and usually occurs in
diabetics, secondary to occlusion of the cystic artery caused by diabetic
angiopathy. Gas in the portal vein, seen peripherally in the liver, implies necrotic
bowel, but it may occur with severe cholecystitis-cholangitis.
Oral cholecystography
Oral cholecystography was first accomplished
seven decades ago and was revolutionary. The
ingestion of a nontoxic iodinated organic
compound that is absorbed in the small bowel,
excreted by the liver, and concentrated in the bile
provides the opportunity to discover noncalcified
gallstones preoperatively. In addition to
gallstones, other intraluminal abnormalities of
the gallbladder can be detected.
Percutaneous
transhepatic
cholangiography
Percutaneous transhepatic cholangiography is accomplished by
injecting contrast material under fluoroscopic vision through a
narrow gauge needle placed in the parenchyma of the liver. It is
valuable for the same reasons as ERG and has the advantage of
allowing the operator to institute biliary drainage if necessary. It is
increasingly reserved for patients with biliary obstruction who need
permanent or temporary biliary drainage. Needle biopsy of masses,
drainage of fluid collections, and placement of external and internal
drainage (choledochoduodenal) stents all can be accomplished
percutaneously.
In acute cholecystitis, sonography will usually detect gall stones, inflammatory debris
and gall bladder wall thickening, but unless there is visible oedema adjacent to the wall of
the gall bladder, ultrasound cannot distinguish acute from chronic cholecystitis. In
patients with abdominal pain and tenderness, ultrasound is sometimes used primarily to
locate the gall bladder to determine whether it is truly the gall bladder that is tender.
A hepatobiliary radionuclide scan actually answers the question 'Is the cystic duct
patent'? No available test is very good at diagnosing the gall bladder inflammation itself,
but since the cystic duct is always obstructed in acute cholecystitis, a normal
hepatobiliary scan excludes the diagnosis. Conversely, a diagnosis of cystic duct
obstruction in the correct clinical setting strongly indicates acute cholecystitis Jaundice.
Clinical examination and biochemical tests often permit the cause of jaundice to be
diagnosed. Imaging tests may, however, be required when there is doubt as to the nature
of the jaundice. The basis of this distinction is that dilated biliary ducts are a feature of
jaundice from biliary obstruction. More often, imaging is used to determine the site and,
if possible, the cause of obstruction in those patients with known large duct obstruction,
the common causes of which are: impacted stone in the common bile duct; carcinoma of
the head of the pancreas; carcinoma of the ampulla of Vater.
acute cholecystitis
Ultrasound is the more sensitive test and is usually the first test to be performed.
Dilated intrahepatic biliary ducts are seen at ultrasound as serpentine structures
paralleling the portal veins, a finding known as 'the double-channel sign'. The
common bile duct lies just in front of the portal vein and is dilated when more than 7
mm in diameter. If there is large duct obstruction, the biliary tree will be dilated
down to the level of obstruction. Ultrasound is good for demonstrating the level of
obstruction and sometimes the specific cause for biliary obstruction can be seen, e.g.
a stone impacted within the common bile duct or a mass in the pancreatic head.
More often, the cause cannot be seen, mainly because associated inflammation
causes localized ileus of the duodenum and bowel gas then obscures the common
bile duct. Computed tomography may provide useful information about the cause of
obstruction. Two points should be appreciated: substantial dilatation of the common
hepatic and common bile ducts may be present with only minimal dilatation of the
intrahepatic ducts; and secondly, the intrahepatic biliary tree may not dilate at all
within the first 48 hours following obstruction. An ERCP or percutaneous
cholangiogram may be needed both to differentiate jaundice from large duct
obstruction from other causes of jaundice, and to establish the site and determine the
cause of any obstruction that may be present and, if possible, to treat the condition.
Some centres use a radionuclide hepatobiliary agent to confirm or exclude biliary
obstruction. The problem with this approach is that with severe jaundice there may
be insufficient excretion of the radionuclide to distinguish bile duct obstruction from
hepatocellular disease.
Dilated intrahepatic ducts, (a) Longitudinal scan through the liver showing dilatation of
the biliary system. Dilated intrahepatic ducts are arrowed. GB, gall bladder, (b) Double-
channel sign. A dilated biliary duct lies in front of a portal vein. Normally the duct is
much smaller than the accompanying portal vein, (c) CT scan showing dilated
intrahepatic ducts (arrows) in the liver.
b
Stones in the common bile duct (CBD). Percutaneous cholangiogram.
The common bile duct is dilated measuring Carcinoma of the pancreas. There is
2 cm in diameter and a large stone (arrow) complete obstruction of the common
is seen in its lower portion. PV, section bile duct (arrow). Note the dilated
through portal vein. intrahepatic ducts.
ADENOMYOMATOSIS
In adenomyomatosis the gall bladder wall
is thickened and may show altered
echogenicity due to small projections of
the lumen into the wall, known as
Rokitansky-Aschoff sinuses. There is
dispute as to whether this condition causes
symptoms.
Polyps. These tiny polyps (arrows) in the gall bladder are aggregations
of cholesterol and do not cause acoustic shadowing.
PANCREAS
CT and ultrasound have now become the mainstays for imaging the pancreas. A major
advantage of CT over ultrasound is that it can image the pancreas regardless of the amount of
bowel adjacent to it, whereas the ultrasound beam is absorbed by gas in the gastrointestinal
tract. Arteriography, ERCP and MRI are used in selected cases.
The normal pancreas is an elongated retroperitoneal organ surrounded by a variable amount
of fat. The head nestles in the duodenal loop (for CT scanning the duodenum is opacified by an
oral contrast agent) and the uncinate process folds behind the superior mesenteric artery and
vein; these vessels form a useful landmark to help identify the head of the pancreas. The body
of the pancreas lies in front of the superior mesenteric artery and vein, and passes behind the
stomach, with the tail situated near the hilum of the spleen. The splenic vein, which can be a sur
prisingly large structure, is another very useful landmark. Lying behind the pancreas, it joins
the superior mesenteric vein posterior to the neck of the pancreas to form the portal vein.
In most people the pancreas runs obliquely across the retroperitoneum, being higher at the
splenic end. Because of this oblique orientation, CT shows different portions of the pancreas on
the various sections. The normal pancreas shows a feathery texture, corresponding to
pancreatic lobules interspersed with fat. At ultrasound, the pancreas gives reasonably uniform
echoes of medium to high level compared to the adjacent liver. The pancreatic duct may be seen
over short segments as a linear echo in the centre of the pancreas, the normal lumen being no
more than 2 mm in diameter. The normal pancreatic duct is not visible on CT.
The shape and size of the pancreas is so variable that normal measurements have not proved
very useful. Atrophy is a common feature with ageing.
CT of normal pancreas. Note that several sections are needed to display the
pancreas, (a) The head (arrows) nestling between the second part of the
opacified duodenum (D) and the superior mesenteric vessels (SMA and
SMV). (b) CT taken 3 cm higher, showing the body and part of the tail
(arrows). Note the feathery texture of the pancreas.
Endoscopic retrograde pancreatography. The pancreatic duct has been
cannulated from the endoscope in the duodenum. Contrast has been injected to
demonstrate a normal duct system.
Ultrasound of normal pancreas (transverse scan). Ao,
aorta; CBD, common bile duct; GB, gall bladder; IVC,
inferior vena cava; PV, portal vein; SMA, superior
mesenteric artery; SV, splenic vein.
Pancreatic masses
The usual causes of masses in, or immediately adjacent to, the pancreas are: carcinoma of the
pancreas, neoplasm of the adjacent lymph nodes, focal pancreatitis, pancreatic abscess and
pseudocyst formation. Occasionally, congenital cysts may be seen.
Most neoplasms of the pancreas are adenocarcinomas, two-thirds of which occur in the head of the
pancreas. Tumours arising in the head may obstruct the common bile duct giving rise to
jaundice and are therefore sometimes diagnosed when relatively small. Tumours arising in the
body and tail have to be fairly large to give rise to signs or symptoms, pain being the cardinal
symptom. Since the pancreas is so variable, measurements have not proved useful in diagnosing
masses. The important sign of carcinoma of the pancreas at both CT and ultrasound is
therefore a focal mass deforming the outline of the gland. These neoplasms have frequently
already invaded the retro-peritoneum at the time of presentation, causing irregular obliteration
of the fat around the pancreas, a feature which is readily recognized at CT. If CT is used with
intravenous contrast enhancement, it is sometimes possible to differentiate the relatively lower
density of the tumour from the enhancing normal pancreatic tissue.
Obstructive dilatation of the pancreatic duct can be seen at CT but is more readily apparent at
sonography. With obstruction of the common bile duct, it is often possible to recognize
dilatation of the duct down to the level of the tumour. The liver, which should always be
included in any examination of the pancreas, should routinely be examined carefully for signs
of spread of tumour.
The presence of endocrine secreting tumours, of which insulinoma is the commonest example, is
suggested by biochemical investigations. These tumours are difficult to detect as they are
usually small and do not deform the pancreatic contour. They may be seen on ultrasound, CT
or MRI as small round masses within the pancreas. Sometimes selective angiography is
required, where they stand out from the rest of the pancreas by virtue of their hypervascularity.
Carcinoma of pancreas, (a) CT scan showing focal mass in head of
pancreas (arrows). Ao, aorta; IVC, inferior vena cava, (b) Ultrasound,
transverse scan (different patient), showing a similarly situated mass
(arrows). Ao, aorta; Spl v., splenic vein.
a b
Acute pancreatitis
c
PSEUDOCYSTS
Pseudocysts are a complication of acute pancreatitis in which tissue
necrosis leads to a leak of pancreatic secretions, which are then
contained in a cyst-like manner within and adjacent to the pancreas.
They can be well demonstrated by either CT or ultrasound as thin or
thick walled cysts containing fluid, arising within or adjacent to the
pancreas. They vary in size from very small to many centimetres in
diameter and may even be seen on a barium meal causing anterior
displacement and compression of the stomach and/or duodenum.
Many pseudocysts resolve in the weeks following an attack of acute
pancreatitis. Some persist and may need surgical or percutaneous
drainage. Both CT and ultrasound are excellent methods of
following such cysts and determining the best approach to treatment.
Pancreatic pseudocyst, (a) CT scan showing
large cyst arising within the pancreas
(arrows), (b) Ultrasound (transverse scan).
The arrows indicate a pseudocyst arising
from the body of the pancreas. P, pancreas.
Same patient as 6 weeks later.
Chronic pancreatitis
b
Pancreatic trauma