Chandler Yap, MS4July 19, 2021

RADY 401 Case Presentation

Chief Concern: Hyperglycemia

• Patient is 64 year old male.

• Chief concern: • Symptomatic hyperglycemia: woke up with BS >400 at home. Recently diagnosed with DM 3

months ago.

• ROS: +15lb weight loss x3 months; +polyuria, +polydipsia x3mo; +DOE after 15-20ft, +chronic cough x3mo; + BLE neuropathy

• Medical/Surgical Hx: Newly diagnosed DM 3 months prior, untreated HCV, compensated cirrhosis, known Li-RADs 3 lesions last evaluated 11/2019, COPD

• Social: 50 pack year hx, +marijuana, +cocaine, denies EtOH, homelessness, transportation limitations

• Medications: metformin, glipizide, atorvastatin

• Vitals: T: 98F HR: 71 BP: 143/90 RR 18 SpO2: 100%; +orthostatics

• Exam: Nontoxic, dry mucous membranes, RRR, no m/r/g, Lungs CTAB, abdomen soft, non-tender, no masses appreciated, no peripheral edema, neurologically intact

Work-up and Inpatient Course

• CBC: WBC 4400, Hb 9.1, Plt 70,

• CMP: Na 130, Cl 98, K 3.9, Bicarb 25, BS 630, Cr 1.18, ALT 42, AST 60, Tbili 1.2, Albumin 2.9, TP 6.2, INR 1.2, AFP 17.7

• We have a couple problems to evaluate and treat:

• Hyperglycemia

• Chronic cough in setting 50pack year hx, +WL 15lb in 3 mo.

• Cirrhosis in setting of chronic HCV with known liver lesion, lost to follow-up.

• What imaging studies would you want to obtain?

ACR Appropriateness Criteria

• CT Chest with IV contrast• ED obtained as concerned for

pulmonary malignancy

• Multiphase CT abdomen • Obtained by in-patient team

following review of pertinent past medical history

CT Chest with Contrast

CT chest coronal - lung window CT chest axial - abdominal window

Severe, diffuse

emphysematous changes

throughout, no

pulmonary nodules,

masses, lesions noted.

On axial window of CT

chest, we can

appreciate known prior

lesion, further

evaluated on subsequent

study

CT Abdomen and Pelvis, Multiphase

CT Abdomen - axial. Arterial phase CT Abdomen - axial. Portal venous phase

Hepatic surface nodularity.

1.7 x 1.2 cm enhancing

lesion in hepatic segment

5. Washout on the portal

venous phase. LI-RADS 5. No

new focal hepatic lesions. HCC is arterially fed

CT Abdomen and Pelvis, Coronal

Moderate

splenomegaly, 13.5

cm in craniocaudal

dimension. No focal

splenic lesions.

Patient Outcome

• Patient was started on insulin for management of his DM. Multi-phase CT imaging demonstrated LI-RADS 5 lesion. Hepatology and hepatobiliary surgery were consulted for additional management. Patient was considered a good candidate and underwent microwave ablation with cholecystectomy, with intraoperative pathology confirming HCC. Patient was referred to outpatient hepatology for treatment of his Hepatitis C and established with hospital clinic for ongoing management of his DM, where he was diagnosed with latent autoimmune diabetes in adults (LADA).

Discussion: HCC Overview

• HCC is the 5th most common cancer in the world.• Pre-existing cirrhosis is present in >80% of individuals diagnosed• Major causes of cirrhosis world wide: HBV, HCV, EtOH, NAFLD• HCV is the most common cause in western countries; annual risk incidence of 2%-8%

per year when evidence of cirrhosis. • Risk for HCC, age, overall health, functional status, ability to comply with surveillance

requirements all play into who should be screened.

• Surveillance with either US alone or US+AFP with optimal interval of four to eight months.

• Either multiphase CT or MRI with contrast is recommended for initial diagnostic testing.

• CT scan: ~74-100% sensitive, 81-100% specific; MRI: Sensitivity ~88%, specificity ~94%

Note: Histologic confirmation

is not needed if LI-RADS 5 in

setting of cirrhosis

US is ~60% sensitive,

90% Specific

Discussion: Differential Diagnosis of Liver Lesions in Cirrhosis

Reminder: Keep other things in mind- Not all lesions are HCC!

(a) Unenhanced- hypoechoic lesion (b) Arterial phase- Contrast enhancement of

lesion(c) Portal venous phase- Contrast washout (d) Delayed phase- Pseudocapsule (black

arrow) is best demonstrated in the delayed phase.

The other typical imaging features include:1) Internal mosaic pattern2) Presence of fat3) Vascular invasion4) Interval growth of >50% on serial

imaging in less than 6 months

CT Abdomen with contrast - axial. Multiple phases

Classic HCC Findings on Imaging

Large HCC with heterogeneous enhancement in the arterial phase (a). Washout with mosaic appearance in the portal venous phase (b)

Large HCC with portal vein tumor thrombus. The PV is enlarged and filled with thrombus (black arrow).

Primary lesion (curved arrow) does not enhance but appears hypodense.

Classic HCC Findings on Imaging, cont

Discussion: LI-RADS Criteria

Discussion: LI-RADS cont

What do these

numbers mean for

our patients??

Many radiologic

findings contribute

to LI-RADS category

- The Barcelona Clinic Liver Cancer (BCLC) system helps dictate therapeutic strategies for HCC:- Based on clinical status, Childs-Pugh score, and radiographic findings of tumor: size, number, vascular invasion, metastasis.

- Stage 0: Very early stage; Asymptomatic early tumor. Management: resection, radiofrequency ablation(RFA), microwave ablation(MVA)

- Stage A: Early stage; asymptomatic tumor(s). Orthotopic liver transplant(OLT) if multiple lesions. Multiple additional treatment modalities.

- Stage B: Asymptomatic multifocal disease. Transcatheter arterial chemoembolization (TACE) is recommended management.

- Stage C: Symptomatic and invasive and/or metastatic disease. Management typically palliative, slow tumor growth.

- Stage D: End Stage Disease. Terminal stage. Best supportive care (BSC), symptomatic treatment.

Discussion: Management of HCC

UNC Top Three

• HCC is the 5th most common cancer worldwide and is associated with significant morbidity and mortality. HCV is the leading cause in the western world.

• Ultrasound with or without AFP is the preferred modality of HCC surveillance for patients with cirrhosis. Further work-up with multi-phase CT or MRI.

• Classic findings on CT/MRI shows arterial phase enhancement followed by a washout in the portal and/or delayed phase with a pseudocapsulearound the nodule. Characteristic findings of liver lesions are summarized by LI-RADS criteria.

References• American College of Radiology. (2018). CT/MRI LI-RADS® v2018 CORE.

https://www.acr.org//media/ACR/Files/RADS/LI-RADS/LI-RADS-2018-Core.pdf.

• American College of Radiology. (2020). American College of Radiology ACR Appropriateness Criteria® Liver Lesion-Initial Characterization. ACR Appropriateness Criteria. https://acsearch.acr.org/docs/69472/Narrative/.

• Choi, J.-Y., Author Affiliations From the Department of Radiology, H, van M., HB, E.-S., KA, M. G., M, K., RP, B., ND, T., Al, E., G, B., GL, T., F, T., J, B., European Association For The Study Of The Liver; European Organization For Research And Treatment Of Cancer, M, O., KT, P., JA, M., N, N., L, L., … Lewin, M. (2014, August 25). CT and MR Imaging Diagnosis and Staging of Hepatocellular Carcinoma: Part I. Development, Growth, and Spread: Key Pathologic and Imaging Aspects. Radiology. https://pubs.rsna.org/doi/10.1148/radiol.14132361.

• Hennedige T, Venkatesh SK. Imaging of hepatocellular carcinoma: diagnosis, staging and treatment monitoring. Cancer Imaging. 2013;12(3):530-547. Published 2013 Feb 8. doi:10.1102/1470-7330.2012.0044

• Lee, Y. J., Author Affiliations from the Department of Radiology, J, F., EV, G., Et Al, M, S., G, F., JM, L., A, F., J, B., EA,P., M, D. M., K, K., A, C., JA, B., PF, W., RM, H., BA, D., R, H., … McInnes, M. (2015, January 5). Hepatocellular Carcinoma: Diagnostic Performance of Multidetector CT and MR Imaging-A Systematic Review and Meta-Analysis. Radiology. https://pubs.rsna.org/doi/10.1148/radiol.14140690.

• Marrero, J. A., & Kulik, L. M. (2018). Diagnosis, Staging, and Management of Hepatocellular Carcinoma: 2018 Practice Guidance by the American Association for the Study of Liver Diseases. AASLD practice guidelines. https://www.aasld.org/sites/default/files/2019-06/AASLD_2018_HCC_Guidance_on_Diagnosis%2C_Staging_and_Management_hep_29913%20%281%29.pdf.