Usefulness of follow-up after surgery for hepatocellular carcinoma (HCC): Adrenal metastasis from highly differentiated HCC
Nagasaki Harbor Medical Center
Dr. Kazunori Mitarai, Dept. of Radiology
DATE : 2021
Introduction
Patient’s background
Male; 80s; body weight: 54 kg; adrenal metastasis from highly differentiated HCC
Assessment objectives
EOB-MRI monitoring after surgery for highly differentiated HCC
Contrast agent used
Gadoxetate disodium(Gd-EOB-DTPA) injection, 0.1 mL/kg
Case explanation
The patient had undergone surgery for highly differentiated HCC 4 years previously. Although HCC recurrence in the liver was not found by EOB-MRI during postoperative monitoring, a mass showing a tendency to increase in size was found in the left adrenal gland. No endocrinological abnormalities were found.
Imaging findings
A mass 8 cm in diameter and with distinct margins was found in the caudate lobe, and it showed a mosaic-shaped and heterogeneously high signal in the hepatobiliary phase.
Surgery was performed, and a diagnosis of highly differentiated HCC was made.
Fig. 1. EOB-MRI 4 years previously
Periodic monitoring by EOB-MRI showed no recurrence in the liver
Fig. 2. EOB-MRI at the present time (1)
A mass found in the left adrenal gland was 2 cm in diameter, had distinct margins, and gave an intermediate signal with T2WI, and a slightly high signal with DWI.
No fat content was found by chemical-shift imaging (not shown).
In the dynamic study, dark staining was maintained from the arterial phase to the portal phase, and a markedly high signal was shown from the late phase to the hepatobiliary phase.
A metastasis from the HCC that had existed previously was suspected on the basis of the markedly high signal in the hepatobiliary phase, and the tendency to increase gradually in size.
Surgery was performed, and the diagnosis made was HCC metastasis.
Fig. 3. EOB-MRI at the present time (2)
Photography protocol
| Imaging type | Photography sequence | Photography duration (s) | TE （msec） | TR （msec） | FA （deg） | Fat sat (type) | ETL (number) | P-MRI (Reduction Factor) |
| T2WI cor | HASTE | 18 | 64 | 750 | 120 | ー | ー | 3 |
| T2WI | HASTE | 18 | 73 | 500 | 115 | ー | ー | 2 |
| Dual echo | 2D FLASH | 18 | 1.26 2.52 | 180 | 42 | ー | ー | 2 |
| Contrast agent administration | ||||||||
| Dynamic | VIBE | 15 | 1.16 | 3.13 | 10 | Q-fatsat | ー | 3 |
| DWI | EPI | ー | 59 | 1300 | 90 | SPAIR | ー | 2 |
| T2WI fs | TSE | 84 | 77 | 3000 | 120 | SPAIR | 23 | 2 |
| Heavy T2 | HASTE | 68 | 232 | 1600 | 158 | ー | ー | 2 |
| HBP | VIBE | 15 | 1.16 | 3.13 | 10 | Q-fatsat | ー | 3 |
| HBP cor | VIBE | 20 | 1.17 | 3.41 | 10 | Q-fatsat | ー | 3 |
| Imaging type | Holding breath (yes/no) | NEX (calculation number) | k-space | In-plane resolution (mm) | Slice thickness (mm) | FOV (mm) | Rectangular FOV(%) | Phase direction (step number) |
| T2WI Cor | Yes | 1 | ー | 0.96×0.96 | 7.0 | 370 | 100 | 250 |
| T2WI | Yes | 1 | ー | 1.19×1.19 | 5.0 | 380 | 81.3 | 156 |
| Dual echo | Yes | ー | Interleaved | 0.72×0.72 | 5.0 | 380 | 75 | 163 |
| Contrast agent administration | ||||||||
| Dynamic | Yes | 1 | Sequential | 1.16×1.16 | 3.0 | 380 | 75 | 180 |
| DWI | No | ー | ー | 1.32×1.32 | 5.0 | 380 | 77.1 | 81 |
| T2WI fs | Yes | 1 | Interleaved | 1.16×1.16 | 5.0 | 380 | 75 | 168 |
| Heavy T2 | Yes | 1 | ー | 1.16×1.16 | 5.0 | 380 | 78.1 | 198 |
| HBP | Yes | 1 | Sequential | 1.16×1.16 | 3.0 | 380 | 75 | 180 |
| HBP cor | Yes | 1 | Sequential | 1.12×1.12 | 3.0 | 360 | 100 | 240 |
| Imaging type | Read direction (matrix number) | Actual scan (%) | Slice Gap (mm) | Slice number | Three-dimensional partition number | Three-dimensional actual scan (%) | 3D over Sampling(%) |
| T2WI Cor | 384 | 65 | 1.0 | 22 | ー | ー | ー |
| T2WI | 320 | 60 | 1.0 | 32 | ー | ー | ー |
| Dual echo | 256 | 85 | 1.0 | 32 | ー | ー | ー |
| Contrast agent administration | |||||||
| Dynamic | 320 | 75 | 0 | 80 | 1 | 60 | 20 |
| DWI | 140 | 75 | 1.0 | 32 | ー | ー | ー |
| T2WI fs | 320 | 70 | 1.0 | 32 | ー | ー | ー |
| Heavy T2 | 320 | 79 | 1.0 | 32 | ー | ー | ー |
| HBP | 320 | 75 | 0 | 80 | 1 | 60 | 20 |
| HBP cor | 320 | 75 | 0 | 80 | 1 | 60 | 20 |
Devices used and contrast conditions
| MRI device | MAGNETOM Skyra / SIEMENS |
| Automatic injection device | Sonic Shot GX (Nemoto Kyorindo) |
| Workstation | ー |
| Contrast conditions | Dose (mL) | Administration rate (mL/s) | Photography timing | |
| Gadoxetate disodium(Gd-EOB-DTPA) | 0.1mL/kg | 1.5 | With bolus-tracking, 5, 60, 180 and 240 s after the contrast agent reached the abdominal aorta; and in the hepatobiliary phase (from 900 s) | |
| Physiological saline solution for flushing | 25 | 1.5 |
Usefulness of Gadoxetate disodium(Gd-EOB-DTPA) contrast MRI with this patient
After liver cancer treatment, patients are known to be at high risk for recurrence.
Periodic screening on the basis of tumor-markers and imaging, for early detection of recurrence, can increase the opportunities to undergo radical treatment, due to early detection of HCC, and thus contribute to improved prognosis.
At the author’s hospital, the presence or absence of recurrence was determined by follow-up by periodic diagnostic imaging (EOB-MRI), and adrenal metastasis was found during this monitoring.
Numerous types of lesion, both benign and malignant, occur in the adrenal gland, but benign adenoma is the most frequent.
Approximately 50% of adrenal masses in cancer patients are metastases, but it has been reported that 87% of lesions up to 3 cm in diameter are benign.
This patient had a mass 2 cm in diameter, and it is difficult to determine whether a lesion is benign or malignant by size alone, but a markedly high signal was shown in the EOB-MRI hepatobiliary phase, suggesting that the mass was of hepatocyte origin, enabling preoperative diagnosis as metastasis from previous HCC.
Precautions relating to administration
9. Precautions relating to patients with specific background factors (taken from the Package Insert)
9.8 Elderly patients
Administration must be performed with care, and with sufficient monitoring of the patient’s condition.
Elderly patients generally have depressed physiological function.
- *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.
