0:02

Hello and welcome to Noon Conference hosted by MRI Online.

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In response to the changes happening around

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the world right now and the shutting down of in

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person events, we have decided to provide free

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noon conferences to all radiologists worldwide.

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Today we are joined by Professor Menuh.

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Professor Menuh is the head of the Department of

0:21

Radiology at the Hospital Saint Antoine in Paris, and he

0:26

is also the editor-in-chief of the European Radiology.

0:30

A reminder that there will be a Q&A session

0:33

at the end of the lecture, so please use the

0:35

Q&A feature to ask your questions, and we will

0:37

get to as many as we can before our time is up.

0:40

Also, Professor Menuh will be asking some questions

0:43

during his presentation today, and he asked that

0:46

you please direct your answers to the chat window.

0:48

That being said, thank you all for joining us today.

0:51

Professor Menuh, I will let you take it from here.

0:54

Okay.

0:54

Thank you.

0:55

Thank you very much for the introduction.

0:57

Uh, and, uh, I'm very, I'm very glad to be

1:00

here and to share something with you, which

1:03

is, uh, very simple, but I think very useful.

1:06

Uh, the reason why I decided to give this

1:08

talk is that in my daily practice, I see

1:11

radiological reports that do not answer just.

1:15

Do not answer the question.

1:16

You know that one of the problems of radiologists

1:19

is that the radiologist commonly

1:21

answers the question he asks himself, but

1:24

not the question the clinician is asking him.

1:27

So this is very important for hepatocellular

1:32

carcinoma because, as you know, uh, imaging, uh, is,

1:34

uh, really a prominent method for the diagnosis,

1:37

for the follow-up, and for the decision strategy.

1:41

So, number one, uh, I would like you to

1:44

remember the four questions that the, uh,

1:47

clinician is asking the radiologist to answer.

1:51

Number one, obviously, can you find a tumor for me?

1:55

Um, anything, nodule, infiltration, anything,

1:58

is there a tumor, is there no tumor?

2:01

The second question is, if there is a tumor,

2:04

are you sure that it is hepatocellular

2:06

carcinoma or could it be anything else?

2:09

And if you're not sure, what is the strategy you

2:12

recommend in order to, uh, go to the final diagnosis?

2:18

And if it is hepatocellular carcinoma, what

2:21

is important for the staging and for the

2:24

discussion before we decide on a treatment?

2:27

These are the four questions you should answer.

2:31

Please remember them, and your report is not complete if

2:34

you have not answered these four different questions.

2:39

So, to try to guide you through the answers to these

2:43

different questions, I have prepared three cases for you.

2:46

Number one, number one, and please be attentive

2:50

because very soon there will be a question for you.

2:54

The question number one is, uh, it is a 72-year-old man.

3:00

Uh, on ultrasound screening, we found

3:02

a 15-millimeter hypoechoic nodule.

3:06

It was detected in segment six of the liver.

3:11

And we saw that one year ago, the ultrasound was normal.

3:15

Unfortunately, a normal ultrasound one year ago

3:19

doesn't mean much because unless you are absolutely

3:23

sure that the person who performed the ultrasound

3:26

one year ago was absolutely perfect and very well

3:29

trained, sometimes you just can miss a small nodule,

3:33

and this does not mean that the nodule appeared.

3:38

And then we did what we should do

3:40

after a nodule is found on ultrasound.

3:44

We decided to go for an MRI.

3:48

And I will show you the MRI in this patient.

3:52

These are the selected images for this patient.

3:55

So, you remember, this is a 72-year-old man.

3:59

At the arterial phase, we have enhancement.

4:03

This kind of enhancement.

4:05

At the portal phase, we have a washout.

4:09

I don't know if we have a capsule, yes or

4:11

no, maybe a partial capsule, I, I don't know.

4:14

If you're looking at the diffusion-weighted

4:17

imaging, you can see that maybe there is a very

4:21

small hyperintensity, a small restriction, but

4:25

this is not, this is not absolutely violent.

4:28

On T2, the lesion is hyperintense, obviously.

4:34

And this patient had a PET CT, and although the PET CT

4:38

with FDG was not positive, we were able to see that the

4:44

nodule was hypo, uh, that's hypoattenuating on plain CT.

4:50

And we had the same examination one year before,

4:53

and the examination with CT one year before showed

4:57

that there was absolutely nothing at this place.

5:01

So, you have most of the size, enhancement, washout, you

5:07

know the size, and what, how it appears on diffusion,

5:11

on T2, on plain CT, FDG, and how it was one year ago.

5:16

So now, here comes the first question I have for you.

5:20

So, please, uh, one of these statements is wrong.

5:24

Only one.

5:25

Only one.

5:26

So, would you agree to say that

5:29

this is a typical non-RIM wash-in?

5:34

Would you agree to say that this

5:36

is a typical non-RIM washout?

5:40

Would you say that the moderate absent diffusion

5:43

restriction is rather common in hepatocellular carcinoma?

5:49

Would you say that if FDG PET is normal, it may indicate

5:55

that it might be a poorly differentiated HCC, while in

5:59

this case, the coline PET would likely be very positive?

6:03

And do you finally think so that it is, this patient

6:08

is a good candidate due to the localization of

6:11

the tumor, is a good candidate for a laparoscopic

6:15

resection in case, obviously, we find no other

6:19

liver lesions and no extrahepatic lesions?

6:25

What do you think?

6:26

What do you think?

6:27

You can answer by the letter in the chat.

6:32

Which one of these statements do you think is wrong?

6:43

Well, sounds good.

6:45

Sounds good.

6:46

Um, sounds good.

6:48

Sounds very good.

6:50

Actually, this is absolutely true that normal FDG

6:54

does not indicate a poorly differentiated HCC.

6:58

This is the opposite.

7:00

The more differentiated it is, the more colline

7:03

will be positive, and the less differentiated it

7:07

is, the more colline FDG PET will be positive.

7:12

Okay, very good.

7:15

And some of you have answered, uh, B.

7:17

Well, this is a typical non-RIM washout.

7:20

Typical, absolutely typical.

7:23

Some have answered that maybe the last one

7:26

is not true, but this is very true because

7:29

this is a very easy location for resection.

7:33

of a tumor.

7:35

When you're asking a surgeon, he likes the left lobe,

7:38

he likes the segment four, he likes the segment six,

7:42

and he also likes the lower part of the segment six,

7:45

but he doesn't like the segment eight, he doesn't

7:48

like the segment seven, he doesn't like the two.

7:52

top part of the segment four.

7:54

So this is a quite easy position for, uh, resection.

8:00

Good, very good.

8:03

So the good answer was the wrong one,

8:06

but the good answer was this one.

8:10

PET is not today, uh, a part of the workup of HCC.

8:15

Therefore, if you are making the workup of a

8:18

patient with HCC, PET is not necessarily,

8:22

uh, in the list of the examinations to put.

8:24

perform.

8:25

We have, uh, a couple of, uh, in progress, uh,

8:29

protocols to define if PET is indicative, yes or no.

8:34

But the fact that, uh, you don't know if the

8:37

choline or FDG will be positive, you would have to

8:41

perform both examinations and it would be a little

8:44

bit, uh, costly, uh, time consuming and maybe not

8:47

so much advantage for the, uh, for the patient.

8:51

So.

8:52

It's work in progress, but it's not

8:54

exactly a necessary examination for today.

8:59

Good.

8:59

So, in your report, from the appearance of the lesion,

9:04

you should describe the presence of a non-rim washing and

9:09

washout, which are typical of hepatocellular carcinoma.

9:14

You should report on the presence or absence of a capsule.

9:18

In this case, I consider that it's indeterminate.

9:21

I'm not sure that there is a capsule.

9:24

Obviously, you should, uh, register the number, the size,

9:28

the location, the localization of the nodules, because

9:32

we will have a discussion between ablation, resection.

9:37

And, uh, uh, obviously transplantation

9:40

or some palliative, uh, care.

9:42

And you should also make every attempt to, uh,

9:46

compare to previous examinations to assess if

9:49

there is a significant growth over time.

9:54

At this point, I think that LiARADS may be very helpful.

9:58

So my recommendation is that you keep somewhere in

10:03

your pocket because it's pretty not so easy to remember.

10:08

Keep this slide in your pocket and refer to it

10:12

anytime you have to, you have to classify your tumor.

10:16

So how should we classify this tumor?

10:20

We have two main columns: no enhancement, enhancement.

10:25

Non-rim arterial phase hepatic enhancement.

10:31

So if we don't have enhancement, the classification

10:35

will differ between less than two

10:37

centimeters and more than two centimeters.

10:41

If we have enhancement, we have three columns.

10:44

One is less than 10.

10:47

The third one is equal or more than 20.

10:50

And obviously, there is a middle column, which is 10 to 19.

10:54

In our case, we will go to this column because we have

10:59

a non-rim enhancement and it measures 15 millimeters.

11:03

So this is the correct column.

11:06

In order to know in which case we are going to stop,

11:10

we need to determine how many signs we have.

11:16

Do we have any?

11:17

Yes.

11:18

We have a washout, non-rim washout, so it's one.

11:23

And we also have growth, because we determined

11:27

that the lesion was absent one year before.

11:30

So, we have two out of the three signs.

11:34

Once again, I'm not sure about the capsule.

11:37

If you are not sure, say no.

11:39

So, we have two.

11:42

Column, middle, line.

11:44

So the final case is LR5, which is

11:51

hepatocellular carcinoma is absolutely certain.

11:56

You remember that the LI-RADS classification,

11:59

uh, classifies the tumor in five categories.

12:03

LR1 is certainly benign.

12:05

LR2 is not.

12:07

Probably benign.

12:08

LR3 is, you don't know, you need additional examination.

12:13

LR4 is very likely hepatocellular carcinoma.

12:18

However, you cannot be 100 percent sure.

12:21

And LR5, you are absolutely sure

12:24

that it is hepatocellular carcinoma.

12:27

There is some kind of a weird case

12:29

here, which is half orange, half red.

12:33

In this case, this is a case when a middle-sized tumor

12:37

has only one out of these, uh, of these findings.

12:42

So it's a little bit complicated, but if the

12:46

single, uh, sign you have is the threshold growth,

12:51

it means that you are red.

12:54

If it's any of the other ones, you will stay orange.

12:59

So please copy this slide, keep it in your pocket,

13:02

and anytime you have a tumor, refer to it to

13:05

see which column, which line, which case you

13:09

are finally, finally allocating to this tumor.

13:14

Okay.

13:14

So what do you think the multidisciplinary

13:19

team meeting will recommend for this patient?

13:22

So this is a question for you.

13:24

Do you think we will recommend liver transplantation,

13:28

laparoscopic surgery, ablation, transarterial

13:32

chemoembolization, or systemic chemotherapy?

13:37

So this is your turn.

13:47

Interesting.

13:48

Interesting.

13:51

So, um, I would say that there is a balance

13:54

between, uh, surgery, ablation, and ablation.

13:59

So this is absolutely correct.

13:01

This would be the, the correct balance.

14:05

Uh, why shouldn't we do liver transplantation?

14:09

Uh, a basic reason is that 70

14:12

years old is a little bit too old.

14:14

Too old for considering a liver transplantation.

14:19

Uh, TACE, no, no TACE because we don't,

14:24

we don't do TACE for a localized tumor.

14:26

If it's only one tumor, we will hesitate

14:28

between laparoscopic surgery and ablation.

14:33

But unfortunately, let me show you what we decided.

14:37

We decided to go through systemic chemotherapy.

14:40

So this looks very stupid.

14:44

But I will tell you why this is not so stupid.

14:48

And the reason why it's not so stupid is

14:51

one small detail was missed on the images.

14:57

I just let you 10 seconds to try to detect

15:01

which detail was missed in this case.

15:06

I guess it's not so easy, but look.

15:10

Let's concentrate on the portal

15:12

phase and forget about the liver.

15:15

What is this?

15:17

This is a pancreas.

15:19

What is the reason why the pancreas is in this position

15:25

close to the spine? There is only one reason for that,

15:29

and it is because the patient had previous nephrectomy.

15:35

If he had previous nephrectomy,

15:37

it is because he had a kidney cancer.

15:41

And this liver lesion is not hepatocellular carcinoma.

15:45

It is a secondary deposit.

15:49

So don't forget, please, and this is important.

15:52

So any consideration of the signs, wash in,

15:56

wash out, Ly rate, is only valid in patients

16:01

which are at risk for hepatocellular carcinoma,

16:06

which means patients with chronic liver disease.

16:10

I did not tell you that this

16:11

patient had a chronic liver disease.

16:14

And the reason why I did not tell you that

16:16

this patient had a chronic liver disease

16:18

is because he had no chronic liver disease.

16:21

So please remember that washing, non-rim washing, washout

16:27

is absolutely not specific to hepatocellular carcinoma.

16:32

You will find it in many tumors, starting with the

16:36

liver metastasis from kidney cancer, also in the

16:40

neurocranial tumors, and globally in the spleen.

16:43

Very common tumors like some metastasis from breast cancer.

16:49

Okay.

16:50

So in my report, I do not forget to mention

16:54

that there are signs of chronic liver disease.

16:57

And I look at the history of the patient and I check that

17:02

we have absolutely no information about any primary tumor.

17:08

And once again, LYRADS is valid only

17:11

in patients at risk, chronic hepatitis,

17:15

or cirrhosis.

17:18

Good.

17:19

Now let's go to the case, uh, the case number two.

17:25

Um, this is, uh, a patient.

17:30

It's a male, 63 years old with cirrhosis.

17:34

And this cirrhosis is related to viral C hepatitis.

17:38

We found the liver nodule at ultrasound in the left

17:42

lobe, and the diameter on ultrasound is 16 millimeters.

17:47

Once again, we perform MRI.

17:50

And we don't have, unfortunately, any previous imaging.

17:56

Let's have a look at the images.

17:59

Top left, we have T2.

18:02

And the T2 shows that the liver

18:05

lesion is moderately hyperintense.

18:09

Look at the portal vein.

18:10

There is no thrombosis, but the portal vein

18:13

shows very small, but multiple peribiliary.

18:17

And this is a very typical appearance

18:19

of what we see in many patients.

18:21

You should not confuse it with biliary

18:24

ductal dilatation or with portal thrombosis.

18:28

On T1 with the FATSAT, the lesion is, uh, slightly hypo

18:37

intense, and if you compare the, uh, lesion in-phase

18:43

and out-of-phase, you can see that there is some fat.

18:47

There is some kind of a difference between

18:49

the two lesions, and this is indicative of the

18:53

presence of some fat in the lesion, which is

18:56

important, but which is not a major finding.

19:01

This is diffusion.

19:02

We can see that there is hyper

19:04

restriction on this, uh, on this mass.

19:08

Uh, I don't, I'm not a great fan of the ADC.

19:12

And once again, the ADC doesn't show anything.

19:15

At least it's not white when it's

19:17

white, completely white in ADC.

19:20

Sometimes you can guess that this is a benign tumor,

19:23

but if it's not white, we can't say really much.

19:26

After injection at the arterial phase, we have enhancement.

19:31

Arterial phase enhancement, which is

19:33

central, which is not rim enhancement.

19:37

At the portal phase and the delayed

19:40

phase, we, we don't find really anything.

19:44

No clear washout either at the, uh, at

19:49

the portal or at the, um, late phase.

19:53

So finally, let's summarize it.

19:59

Number one, don't forget to check that the

20:03

nodule you see on CT or MRI is the same then

20:07

seen on ultrasound.

20:08

Sometimes ultrasound sees something

20:10

and MR sees something else.

20:12

We just do not assume, we just assume that

20:16

it is the same, but it's not always the same.

20:19

So this question now is, uh, which is the

20:22

classification, the LIRADS classification

20:25

you are going to provide to this patient?

20:27

So once again, 16 millimeters, uh, we have non-rim washout.

20:33

We have no washout, we have no capsule, and

20:38

we have absolutely no idea about the history.

20:42

So,

20:49

uh, interesting, because all the, all the answers go

20:55

absolutely all directions, absolutely all directions, okay?

21:01

So, um, so let's go back to the, to our table, LIRADS.

21:10

We know that it is, uh, this patient has

21:13

a cirrhosis, so we can use the LIRADS.

21:16

This is a preliminary question.

21:19

There is a non-rim, arterial phase, hepatic

21:22

enhancement, and it is 16 millimeters.

21:25

So once again, this is the column.

21:29

Do we have the washout?

21:31

No.

21:32

Do we have an enhancing capsule?

21:34

No.

21:35

Do we have a threshold growth?

21:37

Well, actually, we don't know.

21:39

So the correct line is no, and the correct case, so we have

21:46

to classify this lesion as LR3, which is indeterminate.

21:53

We don't know if it is benign, we don't know if it is

21:56

malignant, but because there is enhancement at least, we

22:00

need to go a little bit further to characterize this lesion.

22:06

What do you need now?

22:07

What would you do?

22:08

What would you do personally?

22:10

Would you see, would you say that I would

22:13

like to perform a four-phase or three-phase,

22:16

multiphase CT to see better the washout?

22:20

Would you like to perform a new MRI

22:23

with liver-specific contrast media?

22:25

Because the first one was performed

22:27

with extracellular contrast media.

22:30

Would you go to a guided biopsy?

22:34

Would you be the interventional radiologist

22:37

who would say, well, I would do nothing.

22:40

I will go to ablation in any case.

22:43

Or the surgeon who says, what do

22:45

you want to bother with anything?

22:47

It's so easy to resect it, uh, with laparoscopic surgery.

22:52

So I will do surgery anyway, whatever it is.

22:55

So.

23:03

So interesting.

23:04

Another proposal would be to make a follow-up.

23:08

Yes.

23:14

Okay.

23:15

So guided biopsy, uh, and MRI.

23:18

Uh, this would be, this would be your favorite.

23:25

Um,

23:28

Well, there is no bad answer, really, because

23:31

you, you could say, uh, one examination fails,

23:36

uh, maybe the other one would be better.

23:39

Maybe CT would be better.

23:41

It happens.

23:42

However, in my experience, it's very rare that it happens.

23:45

That CT brings more information

23:47

about the washout than MR.

23:50

But well, if you want to do, to do that, uh, no problem.

23:54

And in any case, you know, that you will need to perform CT,

23:58

uh, just for the staging, looking for potential metastasis.

24:03

So making a CT is not necessarily a bad idea.

24:07

However, personally, I'm not expecting

24:09

too much information from CT.

24:13

Would you like an MRI with liver-specific contrast media?

24:17

Yes, and I will show you, this is what we did.

24:20

Would you perform a guided biopsy?

24:22

We, we did not do it, uh, for two reasons.

24:26

Uh, one reason is that the, the nodule is really on the,

24:30

anterior face of the, the anterior aspect of the liver.

24:34

So it will be very difficult to make a biopsy without, uh,

24:39

without, uh, going, without going through the normal liver.

24:44

So, well, this is the situation where we are

24:47

exposed to tumor seeding after the biopsy.

24:50

So yeah, the biopsy can be discussed, but I

24:53

would not do it immediately for seeding reason.

24:56

And the second reason is that this patient could

24:59

potentially be eligible for a transplantation.

25:03

And as you know, the tumor seeding is

25:05

something that people don't like very much

25:08

when they are aiming at the transplantation.

25:12

Nothing, I will do ablation anyway.

25:15

Why not?

25:15

Because this is a small and very simple lesion.

25:20

As long as the interventional radiologist

25:24

does a biopsy at the same time, because we

25:26

need to have the final diagnosis and surgery.

25:30

Well, maybe sometimes you can do

25:32

surgery because it's so simple.

25:34

Once again, it's so simple because

25:36

it's just very minimal surgery.

25:39

So there is no really bad answer, but this is what we do.

25:43

We did, uh, an examination with liver-specific contrast

25:50

media and we used the multi-hance, which is gadobenate,

25:54

and performed the examination 90 minutes after injection.

25:59

As compared with the gadoxetic acid, the Primavist,

26:03

the gadobenate has one drawback and one advantage.

26:07

The advantage is that it behaves

26:10

exactly like an extracellular contrast

26:13

media for the first part of the examination.

26:16

So you don't have to worry about what we call

26:18

the transition zone with the, with the Primavist.

26:22

But obviously, the drawback is that MultiHance

26:26

goes to the hepatocytes and the

26:30

biliary system with a very small proportion,

26:32

which is only 5%, while conversely the

26:37

Primavist goes 50 percent to the liver.

26:41

So the enhancement is much better with, uh,

26:44

with Primavist, but the advantage of the

26:48

MultiHance is that we can use it

26:51

as an extracellular contrast media during the first

26:56

part of the examination and as a liver-specific

27:00

contrast media, 90 minutes after injection.

27:03

So in this case, the MultiHance

27:06

showed two interesting images.

27:09

One is that the center of the lesion,

27:12

the nodule in itself, is black, is

27:15

not enhancing, is not normal liver.

27:19

So it is a small, it is an ancillary finding

27:23

that favors hepatocellular carcinoma.

27:26

And the second interesting finding is that there is

27:29

a rim enhancement, peripheral enhancement.

27:33

I will show you in a minute what that means.

27:38

So this is, uh, magnification.

27:40

You can see the tumor in itself that

27:43

does not enhance and the peripheral enhancement.

27:49

Good.

27:50

I should say that I like very much this paper that was

27:53

published from a Korean team, uh, six years ago now.

27:58

And it shows you how managing with, uh, liver-specific

28:04

contrast media, you may gain and you may lose.

28:09

Look, if you are considering only arterial phase and

28:14

portal phase and then wash in, wash out, the sensitivity

28:20

of the association of these two signs is 71 percent and

28:25

the specificity is extremely high, it is 98 percent.

28:31

Now if you use Primavist and not, and if you

28:36

associate in addition the transitional washout

28:42

and the wash in, you increase the sensitivity,

28:47

but you decrease slightly the specificity.

28:52

And if you consider the washing and only the

28:57

hepatobiliary phase washout, then the sensitivity for

29:02

the detection of hepatocellular carcinoma increases

29:05

very much, but the specificity is getting down.

29:10

So when using liver-specific contrast media, you

29:13

should be aware of the fact that you may have

29:17

to choose between sensitivity and specificity,

29:22

but you cannot have really both of them.

29:25

Nevertheless, the hepatobiliary phase is helpful.

29:31

It is an ancillary finding and in difficult

29:34

cases like this one where we decided to classify

29:37

it LR3, it may bring the LR3 to LR

29:44

4, which is likely hepatocellular carcinoma.

29:48

So what about the hyperintense rim?

29:52

The hyperintense rim has been

29:56

reported as being one of the signs

29:59

of microscopic hepatic venous invasion.

30:03

You know that this is a prognostic

30:06

factor and it is important.

30:08

So at this point, what is your recommendation?

30:11

Biopsy?

30:13

Wait and watch?

30:15

Ablation, laparoscopic surgery?

30:20

When I say wait and watch, it would be something

30:23

like four months or three months or four months.

30:30

Okay.

30:31

You like, uh, you like ablation.

30:33

Yes, of course.

30:35

And, uh, well, we, we did not say wait and watch because we

30:40

were about sure that it was, uh, hepatocellular carcinoma.

30:44

We thought it was very likely hepatocellular

30:47

carcinoma, even if we did not have the possibility.

30:51

So we decided to go to ablation because,

30:54

uh, we asked the interventional radiologist

30:57

to perform a biopsy at the same time.

31:00

But the reason why we did not go to

31:03

laparoscopic surgery is on the images.

31:06

Look at that.

31:07

What is this?

31:09

These are portosystemic collateral.

31:12

What does it mean?

31:13

It means that the patient has portal hypertension.

31:17

There is some ascites.

31:20

And if you say to a surgeon that the patient has portal

31:25

hypertension and potentially ascites, suddenly, the surgeon

31:32

will become a great, great fan of percutaneous ablation.

31:37

So in this case, we did not perform laparoscopic

31:41

surgery and we went for ablation and biopsy, and

31:46

the biopsy showed the poorly differentiated SCC

31:49

and at one year, there is still no recurrence.

31:54

For your report, don't forget, because it

31:56

is very important, the existence and the

31:59

severity of portal hypertension and ascites.

32:03

And this will be one of the first questions

32:06

that will be asked by the surgeon.

32:10

Please try to collect also signs for microvascular invasion.

32:15

There are not really good signs, but there are signs that

32:19

may let you think that there is microvascular invasion.

32:23

The number one is the rim enhancement at the arterial phase.

32:28

The number two is the small satellite nodules.

32:31

I will show you these images.

32:33

The third one is the existence of the

32:36

peritumoral perfusion abnormalities.

32:40

And the fourth one is the peritumoral enhancement

32:42

at the hepatobiliary phase as we have seen.

32:45

Let's have a look at this side.

32:48

This is a case of a small enhancement nodule.

32:52

But look, if you look carefully in this area, you can

32:56

see that there is a suspicion of peripheral nodule.

33:00

This patient has a capsule, and there is

33:03

probably no capsule at this place, which is

33:07

probably where there is microvascular invasion.

33:10

In this case, look at the peripheral rim enhancement,

33:15

which is another indication of microvascular invasion,

33:19

and pay also attention to these kind of lines here.

33:24

And here, that translate the

33:26

existence of perfusion, uh, defects.

33:31

And this is, this is usually

33:33

related to microvascular invasion.

33:35

So, these signs are not absolutely

33:38

pathognomonic, but they are interesting.

33:41

Look at the pathology of the

33:43

surgical, uh, specimen in this case.

33:46

This is the tumor, and these are

33:48

the small peripheral nodules.

33:50

Why is it important?

33:52

Can you imagine that we have

33:53

performed ablation for this tumor?

33:56

We will probably have missed this,

33:59

this small nodule, peripheral nodule.

34:05

Okay, number three, case number three,

34:09

this is a young woman, she is from Africa.

34:13

And as you can see, this is the T2,

34:16

this is the diffusion weighted imaging.

34:19

We have a rather large tumor with restriction

34:23

and mildly hyperintense on T2 weighting.

34:27

These are the T1 Ceres.

34:30

Uh, we have the in-phase.

34:34

Out-phase, it doesn't show any, any fat in the lesion.

34:38

The lesion is very homogeneous.

34:40

Fat saturation, again.

34:43

This is the arterial phase, and you can see that

34:46

there is a diffuse enhancement, which is central.

34:51

But at the portal phase, and at the

34:53

late phase, we don't have washout.

34:57

So, this is simple, this is a big tumor, arterial

35:00

enhancement, we don't see a capsule, we don't see a washout.

35:08

What is your Lyra classification?

35:12

3, 4, 5, 6.

35:18

What do you think?

35:26

Okay.

35:27

Okay.

35:27

Very good.

35:29

Um, let's go back to Lyra.

35:31

So it is, you will agree with me

35:34

that, uh, this is larger than 20.

35:38

At this point, we did not have yet the,

35:41

uh, the biopsy, but we knew that there were

35:44

some, uh, symptoms related to hepatitis.

35:49

More than 20.

35:50

We have, uh, no washout.

35:53

We have no enhanced seal capsule.

35:55

We have no threshold growth formal.

35:58

So it should be a Lyra L R four.

36:03

Uh, however, however,

36:06

we believed that it was very unlikely that this

36:09

tumor was similar two or three years later.

36:13

So, we thought that even if we did not have the

36:16

images, we thought that it was very likely that

36:20

there was tumor growth and we classified it LR5,

36:25

but I agree that it was absolutely disputable.

36:29

So we did a biopsy nevertheless and, uh,

36:33

this confirmed HCC and chronic B hepatitis.

36:39

So what do you think we should do as a treatment?

36:45

Immediate surgery?

36:47

Surgery after right portal vein embolization, surgery

36:50

after downstaging with a TACE, also refenib, TACE

36:55

alone, radioembolization, systemic chemotherapy.

36:59

What would you like?

37:07

I should say it was a difficult discussion.

37:12

Okay, so many of you would like to do surgery after

37:15

downstaging, and yes, this is something we discussed.

37:21

Um, uh, the reason why we did not choose the portal

37:26

vein embolization was because there was a self

37:30

portal embolization because there was no more right

37:33

portal vein, so there was nothing to be embolized,

37:38

uh, and the left liver, the remaining liver

37:41

was, uh, considered, uh, sufficient because the.

37:47

Removal of the tumor had removed

37:50

only tumor and not much of the liver.

37:52

This is why we did not go to downstaging with anything.

37:58

And we did not at this point perform radioembolization

38:02

because we had a surgical possibility.

38:05

And this is what we do.

38:07

We did immediate surgery and it was uneventful.

38:10

However, one year after surgery, one year.

38:14

Just one year.

38:16

Look what we found in the liver.

38:18

As you can see, the patient had right hepatectomy.

38:21

This is the Segment four remaining.

38:23

This is the remaining left lobe.

38:26

You can see this tumor, which is, uh, high intensity

38:30

on T2, high restriction, uh, some kind of, uh, hypo

38:37

intensity in a DC, uh, obviously hypo intense on T1.

38:43

With a rim enhancement, something which

38:46

is quite complex because there is a rim

38:48

enhancement and something like a capsule around.

38:52

I don't know what it is, but this rim

38:55

enhancement does not wash out, not at all.

39:00

And there is some kind of a tendency to wash

39:05

in the center of the lesion at the late phase.

39:09

So this was a recurrence of the tumor.

39:12

So what do you think here?

39:15

I think you would agree to say that it does

39:18

not look like a typical HCC and this is

39:22

the reason why we decided to classify it LRM.

39:28

So I would like to remind you that M does not

39:32

mean that it is not hepatocellular carcinoma.

39:36

It means that what you see is a malignant tumor but you

39:41

are unable to say if it is hepatocellular carcinoma,

39:46

cholangiocarcinoma metastasis, or a combined tumor in

39:51

the LRM classification, the majority are hepatocellular

39:57

carcinoma cases, but with a very atypical appearance.

40:02

So LRM some...

40:04

Some people think that LRM means

40:07

it's not a hepatocellular carcinoma.

40:09

This is not the case, and this means

40:12

that we cannot classify the tumor.

40:15

It's malignant, and we need a biopsy

40:20

to determine which kind of tumor it is.

40:24

So we were a little bit, uh, astonished

40:26

at this point, uh, to see this tumor.

40:29

And then we asked for a re-examination of the initial tumor.

40:34

And in fact, the initial tumor was

40:36

not a hepatocellular carcinoma.

40:39

It was a combined hepatocellular

40:41

carcinoma and cholangiocellular carcinoma.

40:44

The combination of both is, uh, rather common.

40:48

It's commonly overlooked because

40:50

of the heterogeneity of the tumor.

40:54

Do we have signs for that?

40:56

There are signs in the literature that are reported,

40:59

like the presence of satellite nodule, not very specific.

41:03

Hyperintense signal on T2, this is

41:06

true here, this is absolutely true.

41:09

It's true that hepatocellular carcinoma

41:11

is quite rarely so hyperintense.

41:15

Restricted diffusion, highly restricted diffusion, this

41:19

is true here also, this is very unusual to have such

41:23

a hepatocellular carcinoma with such a restriction.

41:27

Absence of capsule and peripheral

41:30

and progressive contrast enhancement.

41:32

This is very unusual.

41:33

Is the case in this, in this patient.

41:36

So this patient has a combined

41:39

hepatocellular and cholangiocarcinoma.

41:41

Why is it important?

41:42

Because the treatment is completely different.

41:45

So sorafenib is completely inefficient in this patient and

41:49

we need to give another treatment, which is systemic chemo,

41:54

systemic chemotherapy, although in this patient, because

41:57

it was a young lady, we tried to perform ablation, but we

42:02

also performed systemic chemotherapy with gemcitabine.

42:06

So please don't miss a very important sign,

42:10

suggesting a combined tumor, only suggesting,

42:13

not necessarily specific.

42:16

The biopsy might be very misleading because really the

42:21

tumor is very heterogeneous and there are compartments which

42:25

look like typical hepatocellular carcinoma and compartments

42:30

where it looks like cholangiocellular carcinoma.

42:34

And once again, the systemic treatment is different with

42:37

the family of sorafenib for HCC, gemcitabine, and

42:42

sometimes combined with oxaliplatin in the combined tumor.

42:48

At the end of this presentation, I think we've been through

42:51

most of the elements that should be in your report.

42:55

And I would like to remind you of the main key

42:58

words that are related to this presentation.

43:02

First, you should remember the non-RIM enhancement,

43:06

the non-RIM washout, the existence of the

43:09

capsule, and the growth over previous examination.

43:14

You remember also that LYRADS is a very

43:17

good tool but applies only to patients

43:20

with a risk for hepatocellular carcinoma.

43:24

So to use LYRADS, you need to know that

43:26

the patient has chronic liver disease.

43:29

Hepatobiliary phase and liver contrast may

43:33

help if you have the possibility to use them.

43:36

However, they are ancillary findings.

43:38

They are not, for the moment, major findings.

43:42

Try to find signs for microvascular invasion, because they

43:46

will not change the indication, but they will lead you to

43:52

maybe warn somebody who would perform ablation, that maybe

43:57

if he performs ablation, he needs to have very good margins.

44:01

And same for the, for the surgeon.

44:05

Beware of portal hypertension because

44:07

this is very important for the surgeon.

44:10

And if the surgeon finds portal hypertension

44:13

and you did not warn him before surgery,

44:16

you will have another enemy with you.

44:20

And finally,

44:21

combined tumors are quite common and obviously

44:26

they are difficult to diagnose, but they may lead

44:29

to very different treatment strategies.

44:33

So that's the end of this presentation.

44:35

I would like to thank everybody for attending and, uh,

44:39

also for playing the game of the questions with me.

44:43

And, uh, now obviously we, we have time

44:46

to answer some questions.

44:49

I saw I was not able to answer

44:52

the question during the presentation but maybe

44:58

if those who had the question in the chat can

45:03

transfer them in the Q&A, I will be more than happy to try

45:07

to give not answers, but my vision of these problems.

45:15

Excuse me, Professor Menu.

45:16

I think it was after, it was for your second

45:19

question. One of our attendees asked, "If this is

45:24

a solitary MET and with surgical risks, could

45:27

ablation of this solitary MET be an option?"

45:32

Well, obviously, the evaluation of the

45:36

surgical risk is absolutely mandatory.

45:40

And I'm really in favor of ablation as long

45:44

as it is feasible and as long as we have

45:47

the possibility to make a biopsy.

45:50

But I think it's interesting from your answers,

45:52

Anytime I ask the audience if you would go for

45:56

ablation or for surgery, approximately 50%

45:01

want to ablation and 50% want to surgery.

46:04

And when I give this, uh, such a presentation in

46:08

the surgical audience, it's interesting

46:11

to say that the results are absolutely the same.

46:14

So, uh, surgeons finally like ablation also mainly

46:18

because they consider that ablation is

46:21

very good for the patient at risk for surgery.

46:25

And, uh, both of them,

46:27

both of them are valid

46:31

and may be discussed.

46:35

And another interesting issue that, uh, just like

46:38

last year, we made a very small study, uh,

46:43

comparing the answers of the multidisciplinary, of

46:47

several multidisciplinary teams to the same question.

46:51

So we asked in three different hospitals, "What would you do?"

46:55

And we had the same question six months later.

46:58

And, uh, in the three cases, we always had

47:02

different answers from surgery or ablation between

47:06

the different hospitals, but also within the

47:09

same hospital, at the two different periods.

47:12

And this means that the multidisciplinary team is sometimes

47:16

reacting to what happens the week before, and there is no

47:19

absolutely formal discussion or advantage of ablation.

47:25

So there is another question, which is

47:27

"Does fat content indicate benign nature?"

47:30

Not at all.

47:31

Fat is one sign associated with hepatocellular carcinoma.

47:37

And in the case I showed you, the small nodule without,

47:42

without washout, the presence of fat was something

47:47

that pushed us to do something really, you know, that fat

47:52

in a liver lesion is associated with mainly liver adenoma,

47:57

sometimes hyperplasia, focal nodular hyperplasia.

48:02

Sometimes we have, uh, obviously, fats

48:06

bearing or fatty heterogeneous fat content.

48:09

But in this case, this was an enhancing nodule.

48:13

An enhancing nodule in a cirrhotic patient with

48:15

that, I would not wait to do something.

48:19

And this was one of the reasons why we went there.

48:23

Another question is, in the case of HCC with a vascular

48:26

invasion, what would be the therapeutic option?

48:32

Well, I partially answered.

48:35

If there is invasion of the portal vein,

48:39

it depends where the invasion is. If it is peripheral,

48:43

surgery is not disqualified yet, although the results

48:47

are really disappointing. But the more there is a

48:51

portal vein embolization, the more we use to go to

48:54

radioembolization, which is probably the

48:58

safest method to treat this kind of patient.

49:03

Some people do TACE, uh, usually

49:06

with beads, in this patient.

49:09

It really depends on the general status of the patient,

49:13

the localization, the importance of the portal

49:17

vein thrombosis, and also about the remaining liver.

49:22

But our first choice now for patients

49:26

with large portal vein invasion

49:29

is to go to radioembolization.

49:34

So, is microwave and RFA

49:38

better with signs of microinvasion?

49:41

I’m not sure I can answer this question.

49:46

Because the difference between the two, I'm not sure

49:49

that there is such a difference in the long-term

49:51

results, and the difference between the two depends

49:54

mainly on the localization of the tumor.

49:58

This is another reason why you have to

50:02

detail if the lesion is close to the pole or

50:05

hepatic vein, which is not very good for RFA,

50:09

or is close to the biliary tract,

50:12

which is not good for anything.

50:15

And, but saying that one is better than the other

50:21

in case of microinvasion, I'm not sure that it

50:24

has been demonstrated or even largely studied.

50:28

I would say that what is important, if you suspect

50:31

microvascular invasion, please be sure that you.

50:36

are able to have very thick margins,

50:41

uh, around the, uh, the ablated area.

50:44

This is, this is very, very important.

50:48

Uh, can you explain how to detect the peri

50:51

biliary cysts in portal hypertension?

50:52

Peri-biliary cysts are related to

50:55

cirrhosis, not really to portal hypertension.

50:59

Oh, it's, it's very simple.

51:01

I don't know if I can come back to this case.

51:03

I can probably come back to this case.

51:05

And if I scroll back,

51:14

Yeah, here it is.

51:16

This is top left, uh, how it appears.

51:22

In some cases, these are big cysts.

51:25

So these are big cysts that you should

51:27

not confuse, and they are coalescent.

51:30

And sometimes they really look like

51:32

dilatation of the biliary tract.

51:34

But this is very unusual because you,

51:37

you would have dilatation of the biliary tract

51:39

without cholestasis, biological cholestasis.

51:43

In case you have a small biliary cyst, you can

51:46

see that the portal environment is very large.

51:51

Uh, it's much thicker than it is usually.

51:54

And the reason is that there are

51:57

millions of peribiliary cysts.

52:00

And what you can see here are only really the

52:03

smallest biliary cysts, peribiliary cysts.

52:07

As long as you know that it exists, it's not anymore a

52:11

problem to make the diagnosis, and please, please, please

52:14

don't say that there is a dilatation of the, of the bile duct.

52:17

This is an appearance that you will

52:20

very commonly find in cirrhosis.

52:22

Enlargement of the portal area and the presence

52:28

of small or sometimes large fluid cystic lesions.

52:33

Thank you.

52:33

Not related.

52:34

We, we call them peri-biliary cysts, but they have

52:37

absolutely no relationship with, with the bile ducts.

52:43

So when should we read about seeding to UHCC?

52:48

Uh, it depends on your level of anxiety.

52:51

I am personally rather anxious and I do

52:55

not perform a biopsy, uh, when I don't

52:59

completely, completely, absolutely need it.

53:03

Uh, number one, I.

53:05

Try not to perform a biopsy for patients

53:08

that are potentially candidates for liver

53:10

transplantation, unless, unless we have no other

53:15

option to find out the final diagnosis.

53:18

Second, I'm not in favor of doing a percutaneous

53:22

biopsy when you need to put the needle directly in

53:26

the tumor without any part of normal liver, uh, to

53:31

make the hemostasis or the cytologic hemostasis.

53:35

I don't worry about the biopsy during ablation because the

53:39

ablation will do the job and they will not be seeding, uh,

53:45

after I've seen once seeding after ablation, but only once.

53:50

So these are the two cases where I would be a little bit

53:53

reluctant to do a biopsy if the patient is a potential

53:57

candidate for surgery or if the tumor is really anterior

54:02

and if I cannot guarantee that I cannot go through

54:06

the, through a normal liver before I do the biopsy.

54:10

But once again, sometimes it is absolutely of

54:14

dramatic importance to know about the tumor.

54:17

And in that case, well, we do a biopsy knowing the risk.

54:24

So is there a difference in ablation versus surgery?

54:28

Yes, uh, there is a big difference.

54:33

The difference in surgery is that the margin

54:35

you see it and if the resection is R1,

54:40

you see it from the pathological report.

54:43

Uh, while on, uh, ablation, you never know.

54:48

If there is a very small nodule that was in the limit

54:51

of the ablation, you didn't see it during the

54:54

examination and you don't see it during the ablation.

54:59

This explains the long-term difference between

55:04

uh, resection and ablation, this is the margin.

55:09

Obviously, if the surgeon performs a resection

55:12

which is small, which is, for instance,

55:14

less than one centimeter, uh, there is exposure

55:18

to local recurrence.

55:22

That's it.

55:23

Otherwise, if the lesion is clear-cut, especially if

55:27

there is a capsule, especially if there is a complete

55:30

capsule, I feel really safe with, uh, with ablation.

55:36

Any specific technique of ablation

55:38

for doing surface lesions?

55:41

I'm not myself a specialist in, uh, in ablation.

55:47

And what I see is that my colleagues who perform ablation,

55:51

when they have very, very powerful lesions, they, uh, they,

55:56

they try to use, uh, cryotherapy, uh, more and more.

56:02

Uh, not all centers, uh, have the possibility

56:05

to use cryotherapy, but some, some do.

56:09

And some other centers, uh, they would

56:11

perform, uh, ablation with, uh, the two

56:15

needles and, uh, with the two-point needles.

56:19

And they say that it's a no-touch, no-touch ablation,

56:23

which is supposed to be a good, uh, a good method.

56:27

However, I'm not sure that we have absolutely

56:30

large series to, uh, to be aware of that.

56:35

So this is more or less a recipe.

56:38

And what I tell you is what I heard

56:40

from my interventional colleagues.

56:43

Okay.

56:44

Well, that seems to be it for the questions.

56:46

Um, as we bring this to a close, I want to thank

56:48

Professor Menu for this lecture and thanks to all

56:51

of you for participating in our noon conference.

56:54

A reminder that this conference will

56:55

be available on demand on MRI Online.com

57:00

In addition to all previous noon conferences.

57:02

Be sure to join us again on Wednesday for a lecture from

57:06

Dr. Lacey McIntosh on evaluation of

57:08

pulmonary nodules by CT and PET/CT.

57:12

You can register for that at MRIOnline.

57:14

com and follow us on social media at The MRI Online

57:19

for updates and reminders on upcoming noon conferences.

57:22

Thanks again and have a great day.