This is a pictorial essay aimed at illustrating the features of primary malignant hepatic lesions seen in adults. When racing through journal articles, I find myself concentrating on the images and captions and referring to the text last (if at all). The outline below is a guide and is ordered according to the frequency in which these lesions present clinically. I encourage you to click through the images and captions and enhance your understanding of the pathological substrates that account for the imaging features seen in these malignancies.

MALIGNANT HEPATIC NEOPLASMS in ADULTS [Link to Images]

• Hepatocellular Carcinoma (HCC)
• Fibrolamellar Carcinoma (FLC)
• Intrahepatic Cholangiocarcinoma (I-CAC)
• Biliary Cystadenocarcinoma
• Sarcomas (Angiosarcoma, MFH, Fibrosarcoma, Leiomyosarcoma)
• Epitheloid Hemangioendothelioma
• Lymphoma

HEPATOCELLULAR CARCINOMA (HCC) [Link to Images]

Clinical

• Most common primary visceral malignancy worldwide
• AFP — elevated in 90% but poor screen
• High incidence areas — Asia; aggressive; Hepatitis B,C
• Low incidence areas — Western hemisphere; insidious, ETOH, hemochromatosis
• Growth Patterns

- replacing, sinusoidal, pseudo-capsular

• Forms

- infiltrative, expansile, diffuse

• Prognostic Factors

- capsule, cirrhosis, PV invasion, necrosis/hemorrhage

Radiology [Link to Images]

• US

- <3 cm=hypoechoic; >3 cm=mixed echotexture; fat=hyperechoic; hemorrhage/necrosis=mixed/cystic; vascular invasion

• CT [Link to Images]

- hypodense; arterial enhancement (>1 cm); no calcification; hemochromatosis; vascular invasion

• MR [Link to Images]

- T1=variable signal intensity, 20% increased;T2=hyperintense; capsule

Treatment/Prognosis

• Surgery (10–20%)
• Percutaneous ablation (RF, ETOH)
• Arterial embolization
• Transplantation
• Survival = < 6 months

FIBROLAMELLAR CARCINOMA (FLC) [Link to Images]

Clinical

• 5-35 yo; M=F; no cirrhosis; AFP normal

Pathology

• Neoplastic hepatocytes with eosinophilic cytoplasm
• Lamellar fibrosis
• Well circumscribed, lobulated with radiating septa
• Calcification up to 40%

Radiology

• Hypervascular
• Central scar
• Calcification

Treatment/Prognosis

• Survival = 32 to 68 months (mean)

INTRAHEPATIC CHOLANGIOCARCINOMA (I-CAC) [Link to Images]

Clinical

• Second most common primary liver malignancy
  
• 10-20% of all malignancies

Pathology

• Adenocarcinoma
• Abundant fibrous stroma; calcification; large and unencapsulated
• Satellite nodules; usually solid
• No cirrhosis
• Associated with Thototrast, hepatolithiasis, Clonorchis senensis, PSC, Caroli’s Disease

Radiology

• Hypovascular with delayed enhancement
• Calcification
• Extrahepatic extension; irregular borders; satellite nodules

Treatment/Prognosis

• Surgery; XRT; poor success with ablation
• Mean survival <1 year

BILIARY CYSTADENOCARCINOMA [Link to Images]

• Females
• Mucinous cystic neoplasms
• Multiloculated cystic mass +/- with septa
• Excellent prognosis with surgical removal

SARCOMAS

• Angiosarcoma [Link to Images]

- Thorotrast

- Malignant vascular cells

- Multifocal or solitary; hypervascular

• Other sarcomas

- Necrosis, cystic degeneration

- Heterogeneous density/signal intensity

EPITHELIOID HEMANGIOENDOTHELIOMA [Link to Images]

• Female > Males
• Variable survival independent of treatment or stage of disease
• Peripheral masses which coalesce over time; do not deform liver capsule

LYMPHOMA [Link to Images]

• AIDS
• Multifocal or isolated mass(es)