Usefulness of EOB-MRI for treating intrahepatic cholangiocellular carcinoma
Tokyo Medical University Hospital
Dr. Kazuhiro Saito, Dept. of Radiology
DATE : 2021
Introduction
Patient’s background
Male; 60s; body weight: 79 kg; intrahepatic cholangiocellular carcinoma
Assessment objectives
Primary complaint: None in particular
History of current illness: Approximately 4 years previously, a high DUPAN-2 level was found at a medical examination, and tests including computed tomography (CT) were performed. At that time, a hepatic mass was found. The hepatic mass was then monitored as a hemangioma. After 2 years, as the mass had shown a tendency to increase in size, an ultrasound-guided biopsy was performed. The diagnosis made by biopsy was hamartomatous lesion of the portal vein region, and the subsequent approach taken was therefore monitoring at 6-month intervals.
Previous medical history: Severe acute pancreatitis 3 years previously.
Contrast agent used
Gadoxetate disodium(Gd-EOB-DTPA) injection, 0.1 mL/kg
Case explanation
Although malignant lesions such as cholangiocellular carcinoma and metastatic tumor were suspected on the basis of the imaging, no malignant signs were confirmed by biopsy, so the patient was just monitored. However, the tendency toward size increase subsequently became clear, so surgery was performed. Partial resection of S7 of the liver was performed, and a diagnosis of intrahepatic cholangiocellular carcinoma was made.
Various degrees of differentiation were shown in the lesion interior, and in the highly differentiated region signs of cholangiolocellular carcinoma with little dysplasia were found. During the 3 years since surgery no recurrence has been seen. The background liver showed hepatic cirrhosis.
Imaging findings
A low-signal lesion 30 mm in diameter was found in the margin of S7 of the liver.
Fig. 1. Simple MRI
The lesion shows ring-shaped dark staining.
Fig. 2. EOB-MRI arterial phase
A region toward the interior of the mass showed contrast enhancement.
Fig. 3. EOB-MRI portal phase
Most of the mass showed a high signal, but fainter than the hepatic parenchyma.
Fig. 4. EOB-MRI transition phase
The marginal region of the mass showed a distinct low signal, and the central region showed a faint low signal.
Fig. 5. EOB-MRI hepatobiliary phase
A high signal was shown in the circumference, and a low signal was shown in the central region.
Fig. 6. T2-weighted image
Photography protocol
| Imaging type | Photography sequence | Photography duration (min:s) | TE (msec) | TR (msec) | FA (deg) | Flipback (yes/no) | Fat sat (type) | ETL (number) |
| Dual echo | 2DFLASH | 2 × 13 s | 2.38/ 4.76 | 125 | 75 | No | DIXON | － |
| Contrast agent administration | ||||||||
| Dynamic | 3D-VIBE | 10s | 1.2 | 3.3 | 15 | No | Q-fat sat | － |
| DWI | SS-EPI | 1:31 | 66 | 5644 | 90 | No | CHESS | － |
| T2WI | 3D-TSE | 5:21 | 149 | 3913 | 120 | No | CHESS | 45 |
| HBP | 3D-VIBE | 20s | 1.2 | 3.3 | 15 | No | Q-fat sat | － |
| Imaging type | P-MRI (Reduction Factor) | Holding breath (yes/no) | NEX (calculation number) | k-space | In-plane resolution (mm) | Slice thickness (mm) | FOV (mm) | Rectangular FOV(%) |
| Dual echo | 2 | Yes | 1 | Linear | 1.3mm×1.3mm | 5 | 400×275 | 68.8% |
| Contrast agent administration | ||||||||
| Dynamic | 2 | Yes | 1 | Linear | 1.3mm×1.3mm | 2 | 400×250 | 62.5% |
| DWI | 2 | No | 4 | Linear | 1.3mm×1.3mm | 5 | 400×320 | 80% |
| T2WI | 2 | No | 1.4 | Linear | 1.3mm×1.3mm | 3 | 400×275 | 68.8% |
| HBP | 2 | No | 1 | Linear | 1.3mm×1.3mm | 2 | 400×250 | 62.5% |
| Imaging type | Phase direction (step number) | Read direction (matrix number) | Actual scan (%) | Slice Gap (mm) | Slice number | 3D partition number | 3D actual scan (%) | 3D over sampling(%) |
| Dual echo | 154 | 320 | 70% | 1mm | 30 | ー | ー | ー |
| Contrast agent administration | ||||||||
| Dynamic | 144 | 320 | 72% | 0mm | 96 | 1 | 45% | 0 |
| DWI | 120 | 150 | 62.5% | 1mm | 30 | ー | ー | ー |
| T2WI | 156 | 320 | 71% | 0mm | 64 | 1 | 69% | 12.5% |
| HBP | 150 | 320 | 75% | 0mm | 96 | 1 | 59% | 8.3% |
Devices used and contrast conditions
| MRI device | Avanto 1.5T (Siemens) |
| Automatic injection device | Sonic Shot 50 (Nemoto Kyorindo Co., Ltd.) |
| Workstation | ー |
| Contrast conditions | Dose (mL) | Administration rate (mL/s) | Photography timing | |
| Gadoxetate disodium(Gd-EOB-DTPA) | 7.9 | 2 | Arterial phase: Determined by monitoring scan Portal phase: 70 s after con-trast agent administration Transition phase: After 240 s Hepatobiliary phase: After 20 min | |
| Physiological saline solution for flushing | 40 | 2 |
Usefulness of Gadoxetate disodium(Gd-EOB-DTPA) contrast MRI with this patient
This patient had intrahepatic cholangiocellular carcinoma caused by alcoholic hepatic cirrhosis. The patient was monitored for a prolonged time, and the malignancy was not diagnosed even with a biopsy. However, ring-shaped dark staining was found in the arterial phase, and in the hepatobiliary phase a ring-shaped, low-signal region with a targetoid appearance was found in the margin. These findings strongly suggested a malignant tumor other than hepatocellular carcinoma, such as intrahepatic cholangiocellular carcinoma or mixed-type hepatic tumor, equivalent to LR-M as shown by LI-RADS (version 2018). EOB-MRI was found to be useful for qualitative diagnosis of the lesion, enabling appropriate treatment to be provided.
- *The case introduced is just one clinical case, so the results are not the same as for all cases.
- *Please refer to the Package Insert for the effects and indications, dosage and administration method, and warnings, contraindications, and other precautions with use.
