© Georg Thieme Verlag, Stuttgart Fortschr. Röntgenstr. 127, 1 (1977) 1-8
By O. H. Gutierrez and j. Rösch 7 Figures Department of Diagnostic Radiology, University of Oregon Health Sciences Center, Portland, Oregon 97201
Angiographic differential diagnosis of hepatic conditions can be difficult and it is not always possible to give clinician all the answers, even though major angiographic abnormalities are present. To gamble on a decisive diagnosis rather than admit uncertainty can harm the patient. In such circumstances, it is wisest to present the clinician with a list of the most likely possibilities and eventually define the need for further studies. In this way, he will not be misled, but he will be able to take the necessary steps to the correct final diagnosis.
Grenzen der angiographischen Differentialdiagnose der größeren hepatischen Prozesse Eine Differentialdiagnose des Leberzustands durch Angiographie ist oft schwierig und auch, wenn bedeutende angiographische Anomalitäten vorliegen, ist es nicht immer möglich, auf alle klinischen Fragen eine Antwort zu finden. Eine Verdachtsdiagnose anstelle von zugegebener Ungewißheit kann den Patienten gefährden. Hier ist angezeigt, dem Kliniker die Reihe der wahrscheinlichen Möglichkeiten zu nennen und ansonsten auf die Notwendigkeit weiterer Untersuchungen hinzuweisen. So wird er nicht irregeleitet, sondern kann die erforderlichen Maßnahmen zur Erstellung der Enddiagnose in die Wege leiten.
hepatogram as well as extrahepatic changes often permits an accurate differential diagnosis (10, 19, 21, 27). In 11 instances (6%) of 183 consecutive hepatic angiograms Of 183 consecutive proven pathologic hepatic angiograms done for subsequently proven pathologic hepatic processes, done during the last two years, we were able to establish a either the diagnosis was incorrect (4 patients) or a satis- satisfactory diagnosis in 172 (94%). This report is directed factory differential diagnosis was not established (7 patients), to our failures. These consisted of four incorrect diagnoses despite obvious angiographic abnormalities. Incorrect diag- and seven instances where, despite obvious angiographie noses were made in patients with suppurative hepato- abnormalities, we were unable to differentiate between carcinoma and liver cyst, macronodular regenerative cir- inflammatory or degenerative lesions and neoplasms. In rhosis, and multiple intrahepatic abscesses. Satisfactory some cases this distinction was equally impossible even in differential diagnoses could not be established in patients retrospect. A review of the foregoing experience has sugwith enlarged intrahepatic ducts, acute viral hepatitis, gested some means for further improvement in the diagrecurrent cirrhosis and acute liver necrosis. On analysis, nostic accuracy of hepatic angiography. means for minimizing diagnostic failure include the use of enhancement techniques such as infusion angiography and pharmacoangiography and an unbiased, detailed analy- Case material sis of the angiographic findings. Changes secondary to the Case 1: A 36 year old male with bacterial endocarditis and mitral pathologic process and the coexistence of multiple proc- valve replacement two years ago did well until two months prior esses, however, can occasionally prevent an accurate ro admission, when he developed mild fever and right shoulder
Abstract
diagnosis.
pain. A purulent pleural effusion and enlarged liver were found and
Introduction
Hepatic angiography (Figs. la and b) revealed a 15 x 15 cm
Since its introduction by Bierman et al. (1) and particularly after the work of Ödman (17), hepatic angiography has been widely used in the diagnosis of numerous hepatic processes.
Its diagnostic accuracy has been reported to range from 74 to 96% (6, 14, 20). The diagnostic limitations of hepatic angiography are related mainly to the lesion, especially its size, vascularity, multiplicity and location. A diameter of
liver scan showed a large defect in the right lobe which on ultrasonography had a cystic appearance with strong internal echoes.
avascular mass in the upper part of the enlarged right liver lobe which displaced surrounding vessels and exhibited a thin hypervascular rim, slightly irregular in outline. No tumor neovascularity was seen. The angiographie diagnosis was liver abscess. At surgery, a large irregular intrahepatic abscess was found which had thick walls and contained purulent material. External drainage was instituted. Histologic study of an excised portion of the abscess wall revealed anaplastie carcinoma, most likely hepatocarcinoma.
at least 5 mm is generally considered necessary for the Postoperatively, the patient had selective intraarterial chemodiagnosis of a solitary hypervascular lesion, and that of thetapy. Infusion hepatic angiography done at the time of cathe-
2 cm for an avascular lesion (2, 4, 10, 19, 23). Difficulties, ter placement (Figs. le and d) showed a slight increase in size of however, often arise in the diagnosis of lesions located in the mass and multifocal tumor neovascularity with dense areas the left lobe or close to the liver surface (2, 4, 19, 21, 23, 26). of blushing, particularly on the lateral portions of the mass. Although diagnosis by hepatic angiography is also limited Case2:A three week old infant had a palpable, slowly enlarging, by the nonspecificity of certain angiographic abnormalities, upper abdominal mass since birth. Liver scan showed a large a systemic evaluation of the findings in all phases of the defect and ultrasound demonstrated a massively enlarged liver * Supported in part by USPHS Grant HL 05828 and the George
Alfred Cook Memorial Fund through the Medical Research Foundation of Oregon.
with abnormal internal echoes. Hepatic angiography (Fig. 2) revealed diffuse hepatomegaly with a 7 X 8 cm mass in the upper part of the right and medial part of the left lobe. Surrounding vessels were displaced and crowded
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Limitations of angiographic differential diagnosis in major hepatic processes*
0. H. Gutierrez and J. Rösch
Fortschr. Röntgenstr. 127, 1
Fig. la Figs. la and b.
Fig. lb Selective hepatic angiography (a: Arterial phase, b: Parenchymal phase).
Figs. lad. Case 1. Suppurative hepatocarcinoma together. The mass contained several areas of neovascularity consisting of irregular small vascular nets. In the capillary phase,
the mass was relatively translucent, surrounded by a slightly hypervascular rim, and contained several focal, irregular blushes. The angiographie diagnosis was hepatic tumor (hepatoblastoma
or hemangioendothelioma) with probable internal bleeding or
portal phase of the superior mesenteric pharmacoangiogram was normal, including the intraheparic branches in the lower portion of the liver (Fig. 3e).
In the differential, liver cirrhosis either exhibiting major
regenerative nodules or complicated by an infiltrative
necrosis. Surgery revealed a large cystic lesion protruding from the anterior
malignancy such as cholangiocarcinoma were considered. Because of the advanced deformity, disorganization and
surface of the liver and filled with malodorous debris; it was marsupialized. Histologic examination of the resected wall and debris revealed a liver cyst with inflammation and necrosis but
encased appearance of the arteries, a neoplasm was the preferred diagnosis.
no evidence of tumor. The patient recovered following antibiotic therapy and ten months later was asymptomatic. Case 3: A 47 year old female with known alcoholic hepatitis had progressive enlargement of the abdomen and 15 pound weight
larged right lobe with regenerative micro- and macro-
loss during the two months prior to hospitalization. Physical examination disclosed the liver to be grossly enlarged, hard and
Exploratory laparotomy revealed a hard, gigantically ennodules. Multiple biopsies showed micronodular cirrhosis
and acute alcoholic hepatitis. There was no tumor. On medical therapy for the past 1 /z years, the patient has done well; her liver has slightly decreased in size.
and atrophy of the left liver lobe. The arterial phase (Fig. 3 a) showed tortuosity and crowding of vessels in the upper part of the right lobe. Vessels in the lower two-thirds of the liver, in-
Case 4: A 50 year old male had a partial gastrectomy six months prior to angiography for gastric reticulum cell sarcoma extending into the porta hepatis. His postsurgical course was complicated by several bouts of E. coli septicemia. A week before admission, he developed jaundice and again became septic. Physical findings
cluding medium-sized branches, were irregular and disorganized. Many were stretched, narrowed, irregular in ca]iber and outline, and with an encased appearance. Neovascularity in the form of
included an enlarged, tender liver, jaundice (serum bilirubin 7 mg%) and a fever of 104°F. Liver scan showed multiple defects in both lobes.
small vascular nets and lakes was present in the lower part of
Hepatic angiography showed a diffusely enlarged liver. The arterial phase revealed increased hepatic vascularity with displaced and stretched branches centrally and in the left lobe. Peripheral branches in the right lobe were stretched, narrowed,
nodular. Liver function tests were slightly abnormal. Hepatic angiography showed extensive enlargement of the right
the liver. The hepatogram (Fig. 3h) showed a mottled appearance with multiple ill-defined, irregular densities, particularly in the upper part of the liver and translucencies in the lower part. The
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2
Fig.lc
Fortschr. Röntgenstr. 127, 1
Fig.id
Figs. ic and d. Selective infusion hepatie angiography (a: Arterial phase, b: Parenchymal phase).
Fig. 2. Case 2. Suppurative liver cyst. Hepatic angiography of a completely replaced hcpatïc artery originating from the superior mesenteric artery.
3
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Limitations of angiographic differential diagnosis in major hepatic processes
Fortschr. Röntgenstr. 127, 1
Fig. 3a
0. H. Gutierrez and J. Rösch
Fig. 3h
Figs. 3 ac. Case 3. Macronodular regenerative cirrhosis. - Figs. 3 a and b. Selective hepatic angiography of a replaced hepatic artery originating from the superior mesenteric artery (a: Arterial phase, b: Parenchymal phase).
irregular in outline and some were occluded. Neovascularity was present in a few peripheral areas of the liver and in the hilum. The hepatogram showed multiple ill-defined defects, which were scattered throughout the liver and surrounded by a slightly hypervascular rim, particularly in rhe central hepatic area. The central mass was thought to be a large multilocular abscess, while the changes of the peripheral hepatic branches and neovascularity in the liver periphery and porta hepatis were thought to reflect liver metastases and local recurrence of his malignancy.
Despite aggressive antibiotic treatment, the patient died 15 days after angiography. Autopsy revealed a large, multilocular abscess in the central part of the left lobe and numerous abscesses from 2 to 5 mm in diameter in other parts of the liver. Larger abscesses were also present in the subhepatic region and lesser omental bursa. No tumor was found. Case 5: A 76 year old male is representative of four patients with pancreatic carcinoma and obstructive jaundice where we could not exclude or differentiate between enlarged intrahepatic ducts and liver metastases. The patient was severely jaundiced (serum bilirubin 32 mg%) and had a large, hard, slightly nodular liver. Angiography and transjugular cholangiography were both performed.
Hepatie angiography showed the enlarged liver. The arterial phase (Fig. 4a) revealed stretching and focal displacement of intrahepatic branches with areas of poor filling, irregu-
larity and cutoff of some peripheral branches. Irregular encasement and cutoff vessels were also seen in the panere-
atic head. The parenchymal hepatogram (Fig. 4b) was unhomogenous and contained multiple, well-defined, relative radiolucencies with interposed areas of increased density. Some of the lucencies had a stripe-like appearance. The gall bladder showed increased mural blush but was normal in size. Transjugular cholangiography demonstrated marked dilatation of the intrahepatie biliary system and the common bile duct, which was occluded distally. The cystic duct and gall bladder were not filled. The diagnosis of pancreatic carcinoma with occlusion of
the common bile duct was obvious; however, we were unable to tell anything about liver metastases. In this and another similar patient, no metastases were found at surgery.
Two other patients with identical angiographic findings did prove to have metastases at surgery, one about 1 cm and the other about 2-3 cm in diameter. In cases 9, 10, and 11, we were unable to differentiate between three acute non-neoplastie processes, namely viral hepatitis, recurrent regenerating cirrhosis, liver necrosis and tumor metastases. In all three patients, we favored a nonneoplastic diagnosis; however, our confidence was low. Two of the three patients had rapidly enlarging livers and gave histories of known or suspected prior malignancies.
Their liver function tests were either normal or slightly positive; liver scans showed hepatomegaly with mottling and filling defects.
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4
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In the patient with acute viral hepatitis, hepatic angiography in the arterial phase (Fig. Sa) revealed an enlarged, hypervascular liver with straightened mediumsized branches and poorly filled, irregular small peripheral branches. Some of these were displaced and many had irregular outlines. The parenchymal hepatogram was unhomogeneous with multiple, mostly ill-defined small areas of either radiolucency or increased nodular density (Fig. Sb). The patient with recurrent cirrhosis and major regenerative nodules had a markedly enlarged liver on hepatic angiography. Its arterial phase (Fig. 6a) revealed stretching of medium-sized branches with narrowing and irregularity of small peripheral branches. These were displaced in some areas; tortuous, corkscrewed or seemingly encased in other places; some had indistinct outlines. The parenchymal phase of the study (Fig. 6b) disclosed an unhomogeneous hepatogram with multiple irregular, ill-defined large defects and interposed areas of irregular density.
The patient with acute liver necrosis who died in acute liver failure five days after the study had a history of rapidly
increasing jaundice for two weeks and decreasing consciousness two days prior to examination. Angiography was done to exclude hepatic vascular occlusion, since the prior liver scan had shown no hepatic uptake. The celiac angiogram (Fig. 7) showed a small liver; displacement,
Portal phase of the superior mesenteric pharmacoangiogram after preinjection of priscoline. Fig. 3 c.
Figs. 4a and b.
Case 5. Pancreatic carcinoma with obstructive jaundice and enlarged intrahepatic biliary ducts. Selective hepatic angiography (a: Arterial phase, b: Parenchymal phase).
Fig. 4a
Fig. 4b
Fortschr. Rönrgenstr. 127, 1
Fig. Sa
Figs. Sa and b.
0. H. Gutierrez and J. Rösch
Fig. Sb
Case 9. Acute viral hepatitis. Selective hepatic angiography.(a: Arterial phase, b: Parenchymal phase.)
narrowing and stretching of some medium-sized hepatic branches; and marked irregularity and disorganization of peripheral branches. These were incompletely filled and had blurred outlines. Some were interrupted, some displaced and their filling persisted into the early capillary phase. The hepatogram revealed several large, poorly outlined defects. The gall bladder was distended. The venous phase showed patent portal trunks with minor collaterals.
Discussion The angiographic di erential diagnosis of liver diseases has been discussed and the characteristic appearances of individual lesions described in detail in several prior reports (2, 4, 8, 10, 12, 19, 21, 27). Diagnostic limitations, however,
exist, and it is sometimes difficult and occasionally impossible to differentiate even between major inflammatory, degenerative and neoplastic processes. Diagnostic accuracy is influenced by several factors, some of them of an external nature such as the technique used, examination quality and observer experience. Others include internal features of the
process itself, such as its size, vascularity, location and particularly its secondary changes. The coincidence of two or more processes can provide an even greater problem.
Top quality studies, including superselective hepatic injections and enhancement techniques such as infusion hepatography and pharmacoangiography are often essential for maximum diagnostic accuracy in liver disease (3, 5, 7,
9, 11, 13). In our patient whose necrotic hepatoma was mistaken for an abscess (Case 1), we were satisfied with the superselective study, partially because of the patient's seemingly straightforward history. Had we done infusion
hepatography prior to surgery, we would probably have shown sufficient neovascularity to indicate the presence of a necrotic tumor. Both infusion hepatography and pharmacoangiography with priscoline are known to increase hepatic filling, particularly in the demonstration of tumors (7, 9, 13). The use of vasoconstrictors (epinephrine, angiotensin) can also aid in the differential diagnosis (3, 5, 11). Experienced assessment of angiograms, unbiased by clinical
findings with detailed analysis of abnormal findings in
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6
Limitations of angiographic differential diagnosis in major hepatic processes
Fortschr. Röntgenstr. 127, 1
7
Figs. 6a and b. Case 10. Recurrent cirrhosis with major regenerative nodules. Selective hepa-
tic angiography (a: Arterial phase, b: Paren-
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chymal phase).
Fig. 6a
Fig. 6h
relation to uninvolved structures is a crucial part of the differential diagnosis. In our opinion, a knowledge of the patient's clinical situation is essential for planning the angio-
graphic study. In its evaluation, however, only the angiographic findings should be considered. This is not always easy to achieve; influential clinical findings contributed to a faulty diagnosis in two of our patients (necrotic hepatoma, Case 1, and multiple liver abscesses, Case 4). Unwarranted emphasis on one or two dominant, seemingly straight-
forward abnormalities can also easily lead to diagnostic errors, as happened in our patients with suppurative cysts (Case 2), macronodular cirrhotic liver regeneration (Case 3),
and multiple hepatic and subhepatic abscesses (Case 4). Many angiographie changes are nonspecific; changes of natural organ vessels, just as neovascularity and blood flow abnormalities, can appear in malignant or benign tumors as well as inflammatory lesions (24). Irregular hepatic arterial encasement, considered by some others as a
8
Fortschr. Röntgenstr. 127, 1
0. H. Gutierrez and J. Rösch: Limitations of angiographic differential diagnosis
the hepatogram due to enlarged intrahepatic ducts here prevent a detailed evaluation. Liter at u r Bierman, H. R., E. R. Miller, R. L. Byron, Jr., K. S. Dod, K. H. Kelly,
D. H. Black: Intra-arterial catherization of viscera in man. Amer. J. Roenrgenol. 66 (1951) 555 Boijsen, E.: Selective hepatic anglography in primary and secondary
tumors of liver. Rev, in
Hépat. 15
(1965) 385
Boijsen, E., H. Rednian: Effect of epinephrinc on celiac and superior mescnter:c angiography. Invest. Radiol. 2 (1967) 184
Büchelrr, E., J. Boldt, H. Fromm-
hold: Leistungsfähigkeit und Grenzen der Leberarteriographie. Fortschr. Röntgenstr. 119 (1973) 5311
Fig. 7. Case 11. Acute liver necrosis. Selective celiac angiography.
Ekelund, L., A. Lunderquist: Pharmacoangiography wïth angiotensin. Radiology 110 (1974) 533
Du Priest, R. W., Jr., J. E. Haines, J. Rösch, W. W. Krippaehne: A comparison of scintiscans and arteriograms for identifying metastatic ultra-
reliable criterion for malignancy (15), can also appear in benign lesions such as macroregenerative nodules (18, 28). Similarly, the cystic wall in the newborn can show isolated areas of newly formed vessels resembling tumor neovascularity (Case 2). Experienced, deliberate analysis of the entire angiogram can minimize errors and uncertainty. In our patient with macroregenerative nodules (Case 3), the normal appearance of portal branches in the area of major arterial involvement might have led us away from the erroneous diagnosis of cholangiocarcinoma (18), since an infiltrative tumor could be expected to affect not only arteries but also the neighboring veins (12, 25). Differential diagnosis, however, is difficult in acute nonneoplastic diseases such as hepatitis or liver necrosis, recurrent alcoholic hepatitis or cirrhosis and in secondary intraneoplastic changes such as bleeding and necrosis (2, 4, 6, 19, 21, 22, 23). In our experience, a finding of indistinctly outlined, deformed peripheral and sometimes even mediumsized vessels is indicative of a fresh process with massive perivascular infiltration. Similarly, defects in the parenchymal hepatogram caused by inflammatory infiltrates or
necrosis usually have irregular, poorly demarcated, fuzzy outlines. With bleeding inside a pathologic process (usually a tumor), or with its inflammation or necrosis, the original angiographic appearance substantially changes and can even mimic primary hematoma or abscess. The discovery of localized areas of residual tumor neovascularity, however,
hepatic tumors. Surg. Gyner. Obstet. 136 (1973) 705
Freeny, P. C., R. Antonovic, O. H. Gutierrez, J. Rösch: Diagnostic effectiveness of infusion hepatic angiography: A comparison with the conventional technique. Fortschr. Röntgenstr. 124 (1976) 534 Frommhold, H.,
malignant disease of the liver. Radiology 86 (1966) 284 Ney, F. G., J. H. Feist, L. R. Altemus, V. R. Ordinario: The characof
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Biicheler,
1. Boldt: Das arterielle Leberbild bei portaler Hypertension. Fortschr. Röntgenstr. 121 (1974) 728
Goldstein, H. M., A. Thaggard, S. Wallace, H. L. Neiman: Priscolineaugmented hepatic angiography. Radiology 119 (1976) 275
Hepp, J., C. Hermandez, J. Moreaux, H. Bismuth: L'arteriographie dans les affections chirurgicales du foie, du pancreas et de la rate. Masson and Cie, Paris 1968 Kaplan, J. H., J. J. Bookstein: Abdominal visceral pharmacoangio-
graphy with angiotensin. Radiology 103 (1972) 79
Kaude, J., R. Rian: Cholangiocarcinoma. Radiology 100 (1971) 573 Kaude, J., R. Jensen, G. W. Wirtanen: Slow in(ection hepatic angin-
graphy. Acta radiol. 14 (1973) 700 Nebesar, R. A., J. J. Pollard,
D. L. Stone: Angiographic diagnosis
teristic angiographie criteria of malignancy. Radiology 104 (1972) 567
Novy, S. B., S. Wallace, A. M. Goldman, Y. Ben-Menachem: Pyogenic liver abscess. Amer. J. Roentgenol. 121 (1974) 388 Odman, P.: Percutaneous selective
angiography of the celiac artery. Acta Radiol. (Stockh.( 159 (1958) Rabinowitz, J. G., M. Kinkabwala, S. Ulreich: Macro-regenerative nodules in the cirrhotic liver. Amer. J. Ruentgenol. 121 (1974) 401
Reuter, 5. R., H. C. Redman: Gastrointestinal angiography. W. B. Saunders Co., Philadelphia 1972 Rossi, P., H. R. Gould: Anglography and scanning in liver disease. Radiology 96 (1970) 553
Rösch,'J., R. J. Steckel: Selective angiography of the abdominal viscera. In Selective Angiography, Golden's Diagnostic Radiology, Section 18. W. N. Hanafee, cd. The Williams and Wilkins Co., Baltimore 1972
Rourke, J. A., M. A. Bosniak, E. J. Ferris: Hepatic angiography in 'alcoholic hepatitis". Radiology 91 (1968) 290
Steckenmesser, R., S. Bayindir,
N. Heger, W. Ristig, H. Schirmer: Die Leistungsfähigkeit der selektiven Artenographie bei raumfordernden Prozessen der Leber. Fortschr. Röntgenstr. 114 (1971) 58
Viamonte, M., Jr., S. Roen, J. Le Page: Nonspecifity of abnormal vascularity in the angiographie diagnosis of malignant neoplasms. Radiology 106 (1973) 59 Walter, J. F., J. J. Bookstein,
E. V. Bouffard: Newer angiographie observations in cholangiocarcinoma. Radiology 118 11976) 19
Watson, R. C., H. A. Baltaxe: The angiographie appearance of pri-
mary and secondary tumors of the liver. Radiology 101 (1971) 539
Went, W., G. van Kaick, D.
Beduhn, F. J. Roth: Abdominal Angiography. Springer, New York 1974 Zurbriggen, S., U. Tylén: Angiographische Befunde bei fokaler nodulIter Hyperplasje der Leber. Fortschr. Röntgensrr. 122 (1975) 404
J. Rösch, M. D., Professor of Diagnostic Radiology, University of Oregon Health Sciences Center, 3181 SW Sam Jackson Park Road, Portland, Oregon 97201
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can help in distinguishing between necrotic tumor and abscess. The latter also has a more or less regular, circumferential hypervascular rim (10, 16, 19, 21). Despite the foregoing, we are skeptical about an accurate differential diagnosis in the coincidence of two or more processes. In cirrhotic liver, the angiographer has little, if any, chance to diagnose hypovascular tumorous nodules (6). Similarly difficult or nearly impossible is the diagnosis of metastases in patients with obstructive jaundice and enlarged intrahepatic ducts (19). This situation is relatively common, and unless the metastases are hypervascular (rarely so with tumors leading to obstruction of the extrahepatic biliary system) the angiographer can say little about the presence or absence of liver metastases. Deformed hepatic branches and particularly parenchymal defects in
By O. H. Gutierrez and j. Rösch 7 Figures Department of Diagnostic Radiology, University of Oregon Health Sciences Center, Portland, Oregon 97201
Angiographic differential diagnosis of hepatic conditions can be difficult and it is not always possible to give clinician all the answers, even though major angiographic abnormalities are present. To gamble on a decisive diagnosis rather than admit uncertainty can harm the patient. In such circumstances, it is wisest to present the clinician with a list of the most likely possibilities and eventually define the need for further studies. In this way, he will not be misled, but he will be able to take the necessary steps to the correct final diagnosis.
Grenzen der angiographischen Differentialdiagnose der größeren hepatischen Prozesse Eine Differentialdiagnose des Leberzustands durch Angiographie ist oft schwierig und auch, wenn bedeutende angiographische Anomalitäten vorliegen, ist es nicht immer möglich, auf alle klinischen Fragen eine Antwort zu finden. Eine Verdachtsdiagnose anstelle von zugegebener Ungewißheit kann den Patienten gefährden. Hier ist angezeigt, dem Kliniker die Reihe der wahrscheinlichen Möglichkeiten zu nennen und ansonsten auf die Notwendigkeit weiterer Untersuchungen hinzuweisen. So wird er nicht irregeleitet, sondern kann die erforderlichen Maßnahmen zur Erstellung der Enddiagnose in die Wege leiten.
hepatogram as well as extrahepatic changes often permits an accurate differential diagnosis (10, 19, 21, 27). In 11 instances (6%) of 183 consecutive hepatic angiograms Of 183 consecutive proven pathologic hepatic angiograms done for subsequently proven pathologic hepatic processes, done during the last two years, we were able to establish a either the diagnosis was incorrect (4 patients) or a satis- satisfactory diagnosis in 172 (94%). This report is directed factory differential diagnosis was not established (7 patients), to our failures. These consisted of four incorrect diagnoses despite obvious angiographic abnormalities. Incorrect diag- and seven instances where, despite obvious angiographie noses were made in patients with suppurative hepato- abnormalities, we were unable to differentiate between carcinoma and liver cyst, macronodular regenerative cir- inflammatory or degenerative lesions and neoplasms. In rhosis, and multiple intrahepatic abscesses. Satisfactory some cases this distinction was equally impossible even in differential diagnoses could not be established in patients retrospect. A review of the foregoing experience has sugwith enlarged intrahepatic ducts, acute viral hepatitis, gested some means for further improvement in the diagrecurrent cirrhosis and acute liver necrosis. On analysis, nostic accuracy of hepatic angiography. means for minimizing diagnostic failure include the use of enhancement techniques such as infusion angiography and pharmacoangiography and an unbiased, detailed analy- Case material sis of the angiographic findings. Changes secondary to the Case 1: A 36 year old male with bacterial endocarditis and mitral pathologic process and the coexistence of multiple proc- valve replacement two years ago did well until two months prior esses, however, can occasionally prevent an accurate ro admission, when he developed mild fever and right shoulder
Abstract
diagnosis.
pain. A purulent pleural effusion and enlarged liver were found and
Introduction
Hepatic angiography (Figs. la and b) revealed a 15 x 15 cm
Since its introduction by Bierman et al. (1) and particularly after the work of Ödman (17), hepatic angiography has been widely used in the diagnosis of numerous hepatic processes.
Its diagnostic accuracy has been reported to range from 74 to 96% (6, 14, 20). The diagnostic limitations of hepatic angiography are related mainly to the lesion, especially its size, vascularity, multiplicity and location. A diameter of
liver scan showed a large defect in the right lobe which on ultrasonography had a cystic appearance with strong internal echoes.
avascular mass in the upper part of the enlarged right liver lobe which displaced surrounding vessels and exhibited a thin hypervascular rim, slightly irregular in outline. No tumor neovascularity was seen. The angiographie diagnosis was liver abscess. At surgery, a large irregular intrahepatic abscess was found which had thick walls and contained purulent material. External drainage was instituted. Histologic study of an excised portion of the abscess wall revealed anaplastie carcinoma, most likely hepatocarcinoma.
at least 5 mm is generally considered necessary for the Postoperatively, the patient had selective intraarterial chemodiagnosis of a solitary hypervascular lesion, and that of thetapy. Infusion hepatic angiography done at the time of cathe-
2 cm for an avascular lesion (2, 4, 10, 19, 23). Difficulties, ter placement (Figs. le and d) showed a slight increase in size of however, often arise in the diagnosis of lesions located in the mass and multifocal tumor neovascularity with dense areas the left lobe or close to the liver surface (2, 4, 19, 21, 23, 26). of blushing, particularly on the lateral portions of the mass. Although diagnosis by hepatic angiography is also limited Case2:A three week old infant had a palpable, slowly enlarging, by the nonspecificity of certain angiographic abnormalities, upper abdominal mass since birth. Liver scan showed a large a systemic evaluation of the findings in all phases of the defect and ultrasound demonstrated a massively enlarged liver * Supported in part by USPHS Grant HL 05828 and the George
Alfred Cook Memorial Fund through the Medical Research Foundation of Oregon.
with abnormal internal echoes. Hepatic angiography (Fig. 2) revealed diffuse hepatomegaly with a 7 X 8 cm mass in the upper part of the right and medial part of the left lobe. Surrounding vessels were displaced and crowded
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Limitations of angiographic differential diagnosis in major hepatic processes*
0. H. Gutierrez and J. Rösch
Fortschr. Röntgenstr. 127, 1
Fig. la Figs. la and b.
Fig. lb Selective hepatic angiography (a: Arterial phase, b: Parenchymal phase).
Figs. lad. Case 1. Suppurative hepatocarcinoma together. The mass contained several areas of neovascularity consisting of irregular small vascular nets. In the capillary phase,
the mass was relatively translucent, surrounded by a slightly hypervascular rim, and contained several focal, irregular blushes. The angiographie diagnosis was hepatic tumor (hepatoblastoma
or hemangioendothelioma) with probable internal bleeding or
portal phase of the superior mesenteric pharmacoangiogram was normal, including the intraheparic branches in the lower portion of the liver (Fig. 3e).
In the differential, liver cirrhosis either exhibiting major
regenerative nodules or complicated by an infiltrative
necrosis. Surgery revealed a large cystic lesion protruding from the anterior
malignancy such as cholangiocarcinoma were considered. Because of the advanced deformity, disorganization and
surface of the liver and filled with malodorous debris; it was marsupialized. Histologic examination of the resected wall and debris revealed a liver cyst with inflammation and necrosis but
encased appearance of the arteries, a neoplasm was the preferred diagnosis.
no evidence of tumor. The patient recovered following antibiotic therapy and ten months later was asymptomatic. Case 3: A 47 year old female with known alcoholic hepatitis had progressive enlargement of the abdomen and 15 pound weight
larged right lobe with regenerative micro- and macro-
loss during the two months prior to hospitalization. Physical examination disclosed the liver to be grossly enlarged, hard and
Exploratory laparotomy revealed a hard, gigantically ennodules. Multiple biopsies showed micronodular cirrhosis
and acute alcoholic hepatitis. There was no tumor. On medical therapy for the past 1 /z years, the patient has done well; her liver has slightly decreased in size.
and atrophy of the left liver lobe. The arterial phase (Fig. 3 a) showed tortuosity and crowding of vessels in the upper part of the right lobe. Vessels in the lower two-thirds of the liver, in-
Case 4: A 50 year old male had a partial gastrectomy six months prior to angiography for gastric reticulum cell sarcoma extending into the porta hepatis. His postsurgical course was complicated by several bouts of E. coli septicemia. A week before admission, he developed jaundice and again became septic. Physical findings
cluding medium-sized branches, were irregular and disorganized. Many were stretched, narrowed, irregular in ca]iber and outline, and with an encased appearance. Neovascularity in the form of
included an enlarged, tender liver, jaundice (serum bilirubin 7 mg%) and a fever of 104°F. Liver scan showed multiple defects in both lobes.
small vascular nets and lakes was present in the lower part of
Hepatic angiography showed a diffusely enlarged liver. The arterial phase revealed increased hepatic vascularity with displaced and stretched branches centrally and in the left lobe. Peripheral branches in the right lobe were stretched, narrowed,
nodular. Liver function tests were slightly abnormal. Hepatic angiography showed extensive enlargement of the right
the liver. The hepatogram (Fig. 3h) showed a mottled appearance with multiple ill-defined, irregular densities, particularly in the upper part of the liver and translucencies in the lower part. The
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Fig.lc
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Fig.id
Figs. ic and d. Selective infusion hepatie angiography (a: Arterial phase, b: Parenchymal phase).
Fig. 2. Case 2. Suppurative liver cyst. Hepatic angiography of a completely replaced hcpatïc artery originating from the superior mesenteric artery.
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Limitations of angiographic differential diagnosis in major hepatic processes
Fortschr. Röntgenstr. 127, 1
Fig. 3a
0. H. Gutierrez and J. Rösch
Fig. 3h
Figs. 3 ac. Case 3. Macronodular regenerative cirrhosis. - Figs. 3 a and b. Selective hepatic angiography of a replaced hepatic artery originating from the superior mesenteric artery (a: Arterial phase, b: Parenchymal phase).
irregular in outline and some were occluded. Neovascularity was present in a few peripheral areas of the liver and in the hilum. The hepatogram showed multiple ill-defined defects, which were scattered throughout the liver and surrounded by a slightly hypervascular rim, particularly in rhe central hepatic area. The central mass was thought to be a large multilocular abscess, while the changes of the peripheral hepatic branches and neovascularity in the liver periphery and porta hepatis were thought to reflect liver metastases and local recurrence of his malignancy.
Despite aggressive antibiotic treatment, the patient died 15 days after angiography. Autopsy revealed a large, multilocular abscess in the central part of the left lobe and numerous abscesses from 2 to 5 mm in diameter in other parts of the liver. Larger abscesses were also present in the subhepatic region and lesser omental bursa. No tumor was found. Case 5: A 76 year old male is representative of four patients with pancreatic carcinoma and obstructive jaundice where we could not exclude or differentiate between enlarged intrahepatic ducts and liver metastases. The patient was severely jaundiced (serum bilirubin 32 mg%) and had a large, hard, slightly nodular liver. Angiography and transjugular cholangiography were both performed.
Hepatie angiography showed the enlarged liver. The arterial phase (Fig. 4a) revealed stretching and focal displacement of intrahepatic branches with areas of poor filling, irregu-
larity and cutoff of some peripheral branches. Irregular encasement and cutoff vessels were also seen in the panere-
atic head. The parenchymal hepatogram (Fig. 4b) was unhomogenous and contained multiple, well-defined, relative radiolucencies with interposed areas of increased density. Some of the lucencies had a stripe-like appearance. The gall bladder showed increased mural blush but was normal in size. Transjugular cholangiography demonstrated marked dilatation of the intrahepatie biliary system and the common bile duct, which was occluded distally. The cystic duct and gall bladder were not filled. The diagnosis of pancreatic carcinoma with occlusion of
the common bile duct was obvious; however, we were unable to tell anything about liver metastases. In this and another similar patient, no metastases were found at surgery.
Two other patients with identical angiographic findings did prove to have metastases at surgery, one about 1 cm and the other about 2-3 cm in diameter. In cases 9, 10, and 11, we were unable to differentiate between three acute non-neoplastie processes, namely viral hepatitis, recurrent regenerating cirrhosis, liver necrosis and tumor metastases. In all three patients, we favored a nonneoplastic diagnosis; however, our confidence was low. Two of the three patients had rapidly enlarging livers and gave histories of known or suspected prior malignancies.
Their liver function tests were either normal or slightly positive; liver scans showed hepatomegaly with mottling and filling defects.
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In the patient with acute viral hepatitis, hepatic angiography in the arterial phase (Fig. Sa) revealed an enlarged, hypervascular liver with straightened mediumsized branches and poorly filled, irregular small peripheral branches. Some of these were displaced and many had irregular outlines. The parenchymal hepatogram was unhomogeneous with multiple, mostly ill-defined small areas of either radiolucency or increased nodular density (Fig. Sb). The patient with recurrent cirrhosis and major regenerative nodules had a markedly enlarged liver on hepatic angiography. Its arterial phase (Fig. 6a) revealed stretching of medium-sized branches with narrowing and irregularity of small peripheral branches. These were displaced in some areas; tortuous, corkscrewed or seemingly encased in other places; some had indistinct outlines. The parenchymal phase of the study (Fig. 6b) disclosed an unhomogeneous hepatogram with multiple irregular, ill-defined large defects and interposed areas of irregular density.
The patient with acute liver necrosis who died in acute liver failure five days after the study had a history of rapidly
increasing jaundice for two weeks and decreasing consciousness two days prior to examination. Angiography was done to exclude hepatic vascular occlusion, since the prior liver scan had shown no hepatic uptake. The celiac angiogram (Fig. 7) showed a small liver; displacement,
Portal phase of the superior mesenteric pharmacoangiogram after preinjection of priscoline. Fig. 3 c.
Figs. 4a and b.
Case 5. Pancreatic carcinoma with obstructive jaundice and enlarged intrahepatic biliary ducts. Selective hepatic angiography (a: Arterial phase, b: Parenchymal phase).
Fig. 4a
Fig. 4b
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Fig. Sa
Figs. Sa and b.
0. H. Gutierrez and J. Rösch
Fig. Sb
Case 9. Acute viral hepatitis. Selective hepatic angiography.(a: Arterial phase, b: Parenchymal phase.)
narrowing and stretching of some medium-sized hepatic branches; and marked irregularity and disorganization of peripheral branches. These were incompletely filled and had blurred outlines. Some were interrupted, some displaced and their filling persisted into the early capillary phase. The hepatogram revealed several large, poorly outlined defects. The gall bladder was distended. The venous phase showed patent portal trunks with minor collaterals.
Discussion The angiographic di erential diagnosis of liver diseases has been discussed and the characteristic appearances of individual lesions described in detail in several prior reports (2, 4, 8, 10, 12, 19, 21, 27). Diagnostic limitations, however,
exist, and it is sometimes difficult and occasionally impossible to differentiate even between major inflammatory, degenerative and neoplastic processes. Diagnostic accuracy is influenced by several factors, some of them of an external nature such as the technique used, examination quality and observer experience. Others include internal features of the
process itself, such as its size, vascularity, location and particularly its secondary changes. The coincidence of two or more processes can provide an even greater problem.
Top quality studies, including superselective hepatic injections and enhancement techniques such as infusion hepatography and pharmacoangiography are often essential for maximum diagnostic accuracy in liver disease (3, 5, 7,
9, 11, 13). In our patient whose necrotic hepatoma was mistaken for an abscess (Case 1), we were satisfied with the superselective study, partially because of the patient's seemingly straightforward history. Had we done infusion
hepatography prior to surgery, we would probably have shown sufficient neovascularity to indicate the presence of a necrotic tumor. Both infusion hepatography and pharmacoangiography with priscoline are known to increase hepatic filling, particularly in the demonstration of tumors (7, 9, 13). The use of vasoconstrictors (epinephrine, angiotensin) can also aid in the differential diagnosis (3, 5, 11). Experienced assessment of angiograms, unbiased by clinical
findings with detailed analysis of abnormal findings in
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Limitations of angiographic differential diagnosis in major hepatic processes
Fortschr. Röntgenstr. 127, 1
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Figs. 6a and b. Case 10. Recurrent cirrhosis with major regenerative nodules. Selective hepa-
tic angiography (a: Arterial phase, b: Paren-
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chymal phase).
Fig. 6a
Fig. 6h
relation to uninvolved structures is a crucial part of the differential diagnosis. In our opinion, a knowledge of the patient's clinical situation is essential for planning the angio-
graphic study. In its evaluation, however, only the angiographic findings should be considered. This is not always easy to achieve; influential clinical findings contributed to a faulty diagnosis in two of our patients (necrotic hepatoma, Case 1, and multiple liver abscesses, Case 4). Unwarranted emphasis on one or two dominant, seemingly straight-
forward abnormalities can also easily lead to diagnostic errors, as happened in our patients with suppurative cysts (Case 2), macronodular cirrhotic liver regeneration (Case 3),
and multiple hepatic and subhepatic abscesses (Case 4). Many angiographie changes are nonspecific; changes of natural organ vessels, just as neovascularity and blood flow abnormalities, can appear in malignant or benign tumors as well as inflammatory lesions (24). Irregular hepatic arterial encasement, considered by some others as a
8
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J. Rösch, M. D., Professor of Diagnostic Radiology, University of Oregon Health Sciences Center, 3181 SW Sam Jackson Park Road, Portland, Oregon 97201
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can help in distinguishing between necrotic tumor and abscess. The latter also has a more or less regular, circumferential hypervascular rim (10, 16, 19, 21). Despite the foregoing, we are skeptical about an accurate differential diagnosis in the coincidence of two or more processes. In cirrhotic liver, the angiographer has little, if any, chance to diagnose hypovascular tumorous nodules (6). Similarly difficult or nearly impossible is the diagnosis of metastases in patients with obstructive jaundice and enlarged intrahepatic ducts (19). This situation is relatively common, and unless the metastases are hypervascular (rarely so with tumors leading to obstruction of the extrahepatic biliary system) the angiographer can say little about the presence or absence of liver metastases. Deformed hepatic branches and particularly parenchymal defects in
