肝臟解剖與常見病影像診斷課件

TheHepaticLesion:RadiologicAssessment

TheAffiliatredhospitalofNBUWangJIANHUAwoxingw@2014-12-29TheHepaticLesion:2014-12-29CASECASE肝臟解剖與常見病影像診斷課件肝臟解剖與常見病影像診斷課件肝臟解剖與常見病影像診斷課件ObjectivesNormalliveranatomyImagingtechniquesCommondiseasesimagingdiagnosisDiffusediseasesFocaldiseases

ObjectivesNormalliveranatomyAnatomyoftheliversegments

Twodifferentaspects:morphologicalanatomyandfunctionalanatomy.

C.Couinaud(1957)dividedtheliverintoeightfunctionallyindepedentsegments.

Thisclassificationwillbepresentedherewithseveralillustrations.Anatomyoftheliversegments

Couinaudclassification

Dividestheliverintoeightfunctionallyindepedentsegments.

Eachsegmenthasitsownvascularinflow,outflowandbiliarydrainage.

Inthecentreofeachsegmentthereisabranchoftheportalvein,hepaticarteryandbileduct.

Intheperipheryofeachsegmentthereisvascularoutflowthroughthehepaticveins.Couinaudclassification

DividePortahepatisSecondPortahepatisPortahepatisSecondPortahepa肝臟解剖與常見病影像診斷課件Righthepaticveindividestherightlobeintoanteriorandposteriorsegments.

CrosstransversePortalveindividestheliverintoupperandlowersegments.

Middlehepaticveindividestheliverintorightandleftlobes(orrightandlefthemiliver).ThisplanerunsfromtheinferiorvenacavatothegallbladderfossaLefthepaticveindividestheleftlobeintoamedialandlateralpart.RighthepaticveindividestheTheimageonthefarleftisattheleveloftherightportalvein.Atthisleveltherightportalveindividestherightlobeoftheliverintosuperiorsegments(7and8)andtheinferiorsegments(5and6).

Theleveloftherightportalveinisinferiortotheleveloftheleftportalvein.Atthelevelofthesplenicvein,whichisbelowtheleveloftherightportalvein,onlytheinferiorsegmentsareseen(rightimage).TheimageonthefarleftisaCounterclockwiseCounterclockwise1CaudatelobeSegment1Segment4aSegment8Segment72Leftlateraluppersagment8Rightanterioruppersagment4Leftmedialsagment7RightposterioruppersagmentSegment21CaudatelobeSegment1SegmentLeftlateraluppersagmentLeftlateraluppersagmentLeftlaterallowsegmentLeftlaterallowsegmentLeftmedialsegmentLeftmedialsegmentRightposterioruppersegmentRightposterioruppersegmentRightanteriorupperdegmentRightanteriorupperdegmentRightanteriorlowdegmentRightanteriorlowdegmentRightposteriorlowsegmentRightposteriorlowsegmentLiveranatomyLiveranatomyImagingtechniquesUS:firstchoice,screening,difficulttocharacterizethelesionsCT:importanttechniqueMRI:problemresolvingtechniqueGoodmethodsofdecidingpositionandpredictingthenatureofthemassImagingtechniquesUS:firstchCTtechniquesCTtechniques7090120CTenhancedtechniques7090120CTenhancedtechniquesTheliverhasadualbloodsupplyfromthehepaticarteryandportalvein.Hepaticartery:1/3Portalvein:2/3TheliverhasadualbloodsupPortalveinphase60-70secafterborustracking-Hepaticmetastatictumor3minutesPortalveinphase-HepaticmetWhydoweneedmultiple-phaseenhancdmentIncreasethecontrastbetweennormalparenchymaandthelesionsothatincreasethedetectionrateUnderstandingthecharacteristicsofbloodsupplyandspeculatingthepathologicalchangesforthequalitativediagnosisWhydoweneedmultiple-phaseCASECASEMultiple-phaseenhancementMultiple-phaseenhancementMRIadvantagesMRIisoftenusedasaproblem-solveingtechniquetogiveadditionalinformationtoUSandCTExcellenttechniquefoedemonstratingtumoursImagescanbeobtainedincoronalandsagittalplanesIntravenuouscontrastisusedtoimprovevisualizationandhelpcharccterizelesions.Newliver-specificagents:SometakenbythehepatocytessomebythereticuloendothelialcellMRIadvantagesMRIisoftenuseMRIMRIMRCPMRCPMultiple-phaseEnhancementMultiple-phaseEnhancementArterialphaseEquilibriumphaseDelayedphase90minMultihance

liver-specificagents:specificallytakenbythehepatocytesPortalveinphaseArterialphaseEquilibriumphasHepatocarcinomacan’ttaketheagentmultihanceHepatocarcinomamultihanceCommonliverdiseasesimagingDiffusediseases:

fattyliver,cirrhosisFocaldiseases:

Benign：Livercyst,absecess,hemangiomaFocalnodulehyperplasia(FNH)adenoma

Malignant:heptocellularcarcinomacholangiocarcinomametastasistumorsCommonliverdiseasesimagingDFattyliverRelativelyfrequentfindingHypercholesterolaemiaobesityordiabetes,alcoholaddictandpatientsonchemotherapyorhormonotherapyDiffuseorlocalFattyinfiltrationleadstoareductionintheattenuationoftheaffectedparenchymacausinglowdensityonCTscansFattyliverRelativelyfrequent肝臟解剖與常見病影像診斷課件局灶性脂肪肝局灶性脂肪肝FattyliverFattyliverCirrhosisPathology:Livercelldegenerationandnecrosis,extensivefibrosisnodularregeneration----liverstructureandbloodcirculationsystemreconstructionImagingFeatures:Xray：esophagus,thebottomofthestomachvaricesCirrhosisPathology:LivercellCT、MRI

findings1/Shapemorphology：hepatomegaly/atrophic,liverloberatiochange,outerconcavecontour，parenchymalnodularregeneration2/Density:Inhomogeneousattenuation3/ContrastEnhancement(CE):inhomogeneousdegreeofenhancement,intrahepaticarterioportalfistulas4/Extrahepaticfindings:varices，scites,splenomegaly.5/Thedifferentialdiagnosis：

HepatocellularcarcinomaCT、MRI

findings1/Shapemorphol肝臟解剖與常見病影像診斷課件肝臟解剖與常見病影像診斷課件肝臟解剖與常見病影像診斷課件肝臟解剖與常見病影像診斷課件肝臟解剖與常見病影像診斷課件HepaticCystHepaticCystCT、MRIFeaturesRoundandquasi-circularSharpdemarcatationNonenhancingUniformdensityorsignal

CT：lowdensity(waterdensity0-15HU）T1WI：verylowsignalintensityT2WI：veryhighsignalintensityHepaticCystCT、MRIFeaturesHepaticCystHepaticAbscessBacterialandamebicliverabscessPathology：Pus/Necrosis/Fibertissue，InflammatorycellsinfiltrationEdemaImagingFeaturesSingleormultiplelowdensitylesionRoundorovalCircumferential[s?,k?mf?'ren??l]wall/enhancementfluildorgas-fluidlevelMRI：T1WI:hypo-intensityT2WI:hyper-intensityHepaticAbscessBacterialanda肝臟解剖與常見病影像診斷課件肝臟解剖與常見病影像診斷課件InflammatorygranulationtissueEdemaareaNecrosisTargetsignInflammatorygranulationtissu肝臟解剖與常見病影像診斷課件TargetsignAftertreatmentInflammatorygranulationtissueNecrosisedemaareaTargetsignAftertreatmentInflHemangioma

Pathology：BenignlesionCavernoushemangioma(mostly)/capillary/hemangioendotheliomaAtypeofbloodvesselmalformation(hemangioma)thathasrelativelylargeblood-filledspaces(cavities)Nocontaintissueoftheorganinwhichtheyaresituated.ImagingFeatures:Singleormultiplelowdensitylesion(CTvalue:30-40HU)Roundoroval,Sharpmargin,no

capsule

Contrast:earlyperipheralnodularenhancement,graduallyfillinginovertimeMRI：T1WI:hypo-intensityT2WI:hyper-intensityHemangioma

Pathology：BenignlHemangiomaHemangioma肝臟解剖與常見病影像診斷課件HemangiomaHemangioma肝臟解剖與常見病影像診斷課件肝臟解剖與常見病影像診斷課件肝臟解剖與常見病影像診斷課件FNH影像特征平掃密度信號(hào)與肝實(shí)質(zhì)接近強(qiáng)化明顯內(nèi)部瘢痕假包膜少見FNH影像特征平掃密度信號(hào)與肝實(shí)質(zhì)接近肝腺瘤Hepatocelluaradenoma女,18歲增強(qiáng)：強(qiáng)化明顯肝腺瘤Hepatocelluaradenoma女,1男,22歲易出血男,22歲易出血女性、23歲，MRI掃描征象：包膜、脂肪女性、23歲，MRI掃描征象：包膜、脂肪肝臟解剖與常見病影像診斷課件肝細(xì)胞癌我國最常見的惡性腫瘤之一發(fā)病率居惡性腫瘤的第2或第3位惡性程度高，5年生存率低于5%肝細(xì)胞癌我國最常見的惡性腫瘤之一肝細(xì)胞癌中國85%左右的HCC與病毒性肝炎肝硬化有關(guān)10％的中國人感染乙型肝炎病毒日本70％左右的HCC與丙型肝炎有關(guān)美國30-50％左右的HCC與丙型肝炎有關(guān)肝細(xì)胞癌中國肝細(xì)胞癌大體病理分型塊狀型直徑大于5厘米，大于10厘米為巨塊型結(jié)節(jié)型癌結(jié)節(jié)直徑小于5厘米，單發(fā)或多發(fā)彌漫型癌結(jié)節(jié)小，彌漫分布小肝癌單發(fā)結(jié)節(jié)小于3厘米，或2個(gè)病灶直徑之和小于3厘米肝細(xì)胞癌大體病理分型肝細(xì)胞癌臨床表現(xiàn)右上腹痛消瘦乏力，進(jìn)行性加重腹脹、腹瀉、惡性、納差黃疸發(fā)熱AFP升高>400ug/L，持續(xù)4周以上，除外妊娠、活動(dòng)性肝炎或生殖細(xì)胞腫瘤。肝細(xì)胞癌臨床表現(xiàn)肝臟解剖與常見病影像診斷課件肝臟解剖與常見病影像診斷課件肝細(xì)胞癌肝細(xì)胞癌肝細(xì)胞癌肝細(xì)胞癌肝細(xì)胞癌肝細(xì)胞癌小肝細(xì)胞癌的定義國際胃腸病學(xué)會(huì)（1994年）單個(gè)病灶直徑小于等于2厘米兩個(gè)病灶，其直徑之和小于等于2厘米日本Okuda單個(gè)病灶直徑小于等于4.5厘米四個(gè)以內(nèi)病灶，直徑之和小于等于3.5厘米中國肝癌病理協(xié)作組？？單個(gè)病灶直徑小于等于2厘米兩個(gè)病灶，其直徑之和小于等于2厘米小肝細(xì)胞癌的定義國際胃腸病學(xué)會(huì)（1994年）小肝細(xì)胞癌CT-CCT+C動(dòng)脈期CT+C門脈期小肝細(xì)胞癌CT-CCT+C動(dòng)脈期CT+C門脈期丙型肝炎合并小肝癌丙型肝炎合并小肝癌膽管癌伴肝內(nèi)子灶膽管癌伴肝內(nèi)子灶肝臟解剖與常見病影像診斷課件BulleyesignBulleyesign肝臟解剖與常見病影像診斷課件intrahepaticmetastasis

APatientwithcoloncarcinomahistoryintrahepaticmetastasisAPatie食管靜脈曲張臍血管再通食管靜脈曲張臍血管再通肝臟解剖與常見病影像診斷課件肝臟解剖與常見病影像診斷課件肝臟解剖與常見病影像診斷課件肝臟解剖與常見病影像診斷課件肝臟解剖與常見病影像診斷課件肝臟解剖與常見病影像診斷課件肝臟解剖與常見病影像診斷課件77%95%77%95%ThankyouThankyouTheHepaticLesion:RadiologicAssessment

TheAffiliatredhospitalofNBUWangJIANHUAwoxingw@2014-12-29TheHepaticLesion:2014-12-29CASECASE肝臟解剖與常見病影像診斷課件肝臟解剖與常見病影像診斷課件肝臟解剖與常見病影像診斷課件ObjectivesNormalliveranatomyImagingtechniquesCommondiseasesimagingdiagnosisDiffusediseasesFocaldiseases

ObjectivesNormalliveranatomyAnatomyoftheliversegments

Twodifferentaspects:morphologicalanatomyandfunctionalanatomy.

C.Couinaud(1957)dividedtheliverintoeightfunctionallyindepedentsegments.

Thisclassificationwillbepresentedherewithseveralillustrations.Anatomyoftheliversegments

Couinaudclassification

Dividestheliverintoeightfunctionallyindepedentsegments.

Eachsegmenthasitsownvascularinflow,outflowandbiliarydrainage.

Inthecentreofeachsegmentthereisabranchoftheportalvein,hepaticarteryandbileduct.

Intheperipheryofeachsegmentthereisvascularoutflowthroughthehepaticveins.Couinaudclassification

DividePortahepatisSecondPortahepatisPortahepatisSecondPortahepa肝臟解剖與常見病影像診斷課件Righthepaticveindividestherightlobeintoanteriorandposteriorsegments.

CrosstransversePortalveindividestheliverintoupperandlowersegments.

Middlehepaticveindividestheliverintorightandleftlobes(orrightandlefthemiliver).ThisplanerunsfromtheinferiorvenacavatothegallbladderfossaLefthepaticveindividestheleftlobeintoamedialandlateralpart.RighthepaticveindividestheTheimageonthefarleftisattheleveloftherightportalvein.Atthisleveltherightportalveindividestherightlobeoftheliverintosuperiorsegments(7and8)andtheinferiorsegments(5and6).

Theleveloftherightportalveinisinferiortotheleveloftheleftportalvein.Atthelevelofthesplenicvein,whichisbelowtheleveloftherightportalvein,onlytheinferiorsegmentsareseen(rightimage).TheimageonthefarleftisaCounterclockwiseCounterclockwise1CaudatelobeSegment1Segment4aSegment8Segment72Leftlateraluppersagment8Rightanterioruppersagment4Leftmedialsagment7RightposterioruppersagmentSegment21CaudatelobeSegment1SegmentLeftlateraluppersagmentLeftlateraluppersagmentLeftlaterallowsegmentLeftlaterallowsegmentLeftmedialsegmentLeftmedialsegmentRightposterioruppersegmentRightposterioruppersegmentRightanteriorupperdegmentRightanteriorupperdegmentRightanteriorlowdegmentRightanteriorlowdegmentRightposteriorlowsegmentRightposteriorlowsegmentLiveranatomyLiveranatomyImagingtechniquesUS:firstchoice,screening,difficulttocharacterizethelesionsCT:importanttechniqueMRI:problemresolvingtechniqueGoodmethodsofdecidingpositionandpredictingthenatureofthemassImagingtechniquesUS:firstchCTtechniquesCTtechniques7090120CTenhancedtechniques7090120CTenhancedtechniquesTheliverhasadualbloodsupplyfromthehepaticarteryandportalvein.Hepaticartery:1/3Portalvein:2/3TheliverhasadualbloodsupPortalveinphase60-70secafterborustracking-Hepaticmetastatictumor3minutesPortalveinphase-HepaticmetWhydoweneedmultiple-phaseenhancdmentIncreasethecontrastbetweennormalparenchymaandthelesionsothatincreasethedetectionrateUnderstandingthecharacteristicsofbloodsupplyandspeculatingthepathologicalchangesforthequalitativediagnosisWhydoweneedmultiple-phaseCASECASEMultiple-phaseenhancementMultiple-phaseenhancementMRIadvantagesMRIisoftenusedasaproblem-solveingtechniquetogiveadditionalinformationtoUSandCTExcellenttechniquefoedemonstratingtumoursImagescanbeobtainedincoronalandsagittalplanesIntravenuouscontrastisusedtoimprovevisualizationandhelpcharccterizelesions.Newliver-specificagents:SometakenbythehepatocytessomebythereticuloendothelialcellMRIadvantagesMRIisoftenuseMRIMRIMRCPMRCPMultiple-phaseEnhancementMultiple-phaseEnhancementArterialphaseEquilibriumphaseDelayedphase90minMultihance

liver-specificagents:specificallytakenbythehepatocytesPortalveinphaseArterialphaseEquilibriumphasHepatocarcinomacan’ttaketheagentmultihanceHepatocarcinomamultihanceCommonliverdiseasesimagingDiffusediseases:

fattyliver,cirrhosisFocaldiseases:

Benign：Livercyst,absecess,hemangiomaFocalnodulehyperplasia(FNH)adenoma

Malignant:heptocellularcarcinomacholangiocarcinomametastasistumorsCommonliverdiseasesimagingDFattyliverRelativelyfrequentfindingHypercholesterolaemiaobesityordiabetes,alcoholaddictandpatientsonchemotherapyorhormonotherapyDiffuseorlocalFattyinfiltrationleadstoareductionintheattenuationoftheaffectedparenchymacausinglowdensityonCTscansFattyliverRelativelyfrequent肝臟解剖與常見病影像診斷課件局灶性脂肪肝局灶性脂肪肝FattyliverFattyliverCirrhosisPathology:Livercelldegenerationandnecrosis,extensivefibrosisnodularregeneration----liverstructureandbloodcirculationsystemreconstructionImagingFeatures:Xray：esophagus,thebottomofthestomachvaricesCirrhosisPathology:LivercellCT、MRI

findings1/Shapemorphology：hepatomegaly/atrophic,liverloberatiochange,outerconcavecontour，parenchymalnodularregeneration2/Density:Inhomogeneousattenuation3/ContrastEnhancement(CE):inhomogeneousdegreeofenhancement,intrahepaticarterioportalfistulas4/Extrahepaticfindings:varices，scites,splenomegaly.5/Thedifferentialdiagnosis：

HepatocellularcarcinomaCT、MRI

findings1/Shapemorphol肝臟解剖與常見病影像診斷課件肝臟解剖與常見病影像診斷課件肝臟解剖與常見病影像診斷課件肝臟解剖與常見病影像診斷課件肝臟解剖與常見病影像診斷課件HepaticCystHepaticCystCT、MRIFeaturesRoundandquasi-circularSharpdemarcatationNonenhancingUniformdensityorsignal

CT：lowdensity(waterdensity0-15HU）T1WI：verylowsignalintensityT2WI：veryhighsignalintensityHepaticCystCT、MRIFeaturesHepaticCystHepaticAbscessBacterialandamebicliverabscessPathology：Pus/Necrosis/Fibertissue，InflammatorycellsinfiltrationEdemaImagingFeaturesSingleormultiplelowdensitylesionRoundorovalCircumferential[s?,k?mf?'ren??l]wall/enhancementfluildorgas-fluidlevelMRI：T1WI:hypo-intensityT2WI:hyper-intensityHepaticAbscessBacterialanda肝臟解剖與常見病影像診斷課件肝臟解剖與常見病影像診斷課件InflammatorygranulationtissueEdemaareaNecrosisTargetsignInflammatorygranulationtissu肝臟解剖與常見病影像診斷課件TargetsignAftertreatmentInflammatorygranulationtissueNecrosisedemaareaTargetsignAftertreatmentInflHemangioma

Pathology：BenignlesionCavernoushemangioma(mostly)/capillary/hemangioendotheliomaAtypeofbloodvesselmalformation(hemangioma)thathasrelativelylargebloo