PMC6066153_01
Upper abdomen magnetic resonance, T1-weighted with fat saturation after contrast, in portal phase, axial section, showing secondary hepatic lesions in (A) segments II and IVa (white arrows), (B) segment VII (white arrow) and (C) segment VI (white arrows). Upper abdomen magnetic resonance, T1-weighted with fat saturation after contrast, in portal phase, axial section, showing secondary hepatic lesions in (D) segments II and IVa (white arrows), (E) segment VII (white arrow) and (F) segment VI (white arrows). There are necrotic areas, which showed no lesions in a previous study: images D and E (dotted white arrows) and image E, area of hyperenhancement in segment VII (white arrow)
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II, IVa ( Figure 1 A), VII ( Figure 1 B) and VI ( Figure 1 C), despite the chemotherapeutic management. In an Oncology multidisciplinary meeting, it was decided to perform SIRT. MRI ( Figure 1 D to 1 F). Moreover, there were necrotic areas not showing the previous lesions ( Figure 1 D to 1 E). A wedge-shaped hyperenhancement area stands out around the lesion in segment VII ( Figure 1 E).
PMC6066153_02
(A) Magnetic resonance imaging of upper abdomen in T2, with no fat saturation, in coronal section, showing bulky hepatic tumor (metastases) located preferably in the right hepatic lobe (white line). Diffuse heterogeneity of coalescent lesions, with high signal central areas (white arrows). (B-E) Magnetic resonance imaging of upper abdomen in T1, with fat saturation, after contrast, in the axial and coronal sections: in B and C, before SIRT, note the bulky hepatic tumor (metastases) located, preferably in the right lobe. In D and E, 2 months after SIRT, there are extensive necrotic areas of infiltrating lesions in the right hepatic lobe (white arrows). Complete necrosis of the tumor lesion in the gallbladder bed stand out (dotted white arrow)
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An abdominal MRI showed a bulky hepatic tumor occupying preferably the right hepatic lobe (white line), not involving the portal vein, but it was unresectable ( Figure 2 A). There was diffuse heterogeneity of the coalescent lesions, with central areas suggesting necrosis ( Figure 2 A).
PMC6066153_03
Upper abdomen magnetic resonance, T1-weighted with fat saturation after contrast, in portal phase, coronal section. (A) Two viable nodules in segment VI of the right hepatic lobe (arrows). (B) Complete necrosis of tumor lesions in segment VI (arrows). Larger lesions (inflammation) were observed, but some exuberant necrotic areas appeared (C and D). Upper abdomen image, axial section, diffusion sequence, shows, (C) before SIRT, a hepatic lesion in segment VI with diffusion restriction (arrow), confirmed in the apparent diffusion coefficient map (not represented here), indicating a high-cellularity neoplastic lesion (viable tumor). In D, after SIRT, the diffusion restriction image disappeared in the same position previously described (white arrow)
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In December 2015, in a control MRI, multinodular liver metastases were observed ( Figure 3 A), besides involvement of retroperitoneal lymph nodes. Two months after SIRT, the MRI showed larger tumor lesions and exuberant necrotic areas ( Figure 3 B). The magnetic resonance images in diffusion sequence are excellent to assess tumor viability (displaying restriction to pretreatment diffusion "viable tumor"- ( Figure 3 C). In this case, diffusion restriction was absent (absence of tumor) in the post-treatment with SIRT ( Figure 3 D).
PMC6066153_04
Upper abdomen magnetic resonance, T1-weighted with fat saturation after contrast, in arterial phase, axial section. (A) Expansive formation compatible with infiltrative hepatocellular carcinoma involving most of the right lobe, associated to several satellite lesions (white arrows). B) Observe thrombosis in the portal vein trunk and right branch (dotted white arrow). (C) Upper abdomen magnetic resonance T1-weighted with fat saturation after contrast, in arterial phase, axial section, shows involution of the infiltrative tumor lesion in the right lobe (black arrow) and necrosis of the infiltrative tumor of the portal vein right branch (white arrow). Moreover, observe atrophy of the right lobe (black arrow) and mild paradoxical hypertrophy of the left hepatic lobe (wide white arrow)
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Magnetic resonance imaging showed an expansive formation compatible with infiltrative hepatocellular carcinoma involving nearly all right lobe, several satellite lesions ( Figure 4 A) and thrombosis in the portal vein right branch and trunk ( Figure 4 B). In this case, two side effects of SIRT were observed: atrophy of the right lobe and mild hypertrophy of the left hepatic lobe (paradoxical hypertrophy) ( Figure 4 C).