Hepatic metastases

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Hepatic metastases are 18-40 times more common than primary liver tumours ⁶. Ultrasound, CT, and MRI are helpful in detecting hepatic metastases and evaluation across multiple post-contrast CT series, or MRI pulse sequences are necessary.

Epidemiology

The demographics of patients with liver metastases will mirror that of the underlying primaries. Incidence, therefore, increases with age.

Clinical presentation

Liver metastases are usually asymptomatic and found during workup of a malignancy ~~which~~that has presented in other ways. If the hepatic metastatic burden is large, then the presentation or symptoms related to the liver disease may include:

localised pain and tenderness due to capsular stretching
disordered liver metabolic function
ascites
low-grade fever ²

Pathology

The most common sites of primary malignancy that metastasise to the liver are ²:

gastrointestinal tract (via portal circulation)
breast cancer
lung cancer
genitourinary system
melanoma
- uveal melanoma
sarcomas
adrenocortical carcinomas ¹³
essentially all metastatic solid malignancies
testicular cancer ¹⁵

Radiographic features

One of the main difficulties in liver imaging for metastatic disease is the high prevalence of benign liver lesions that can be misinterpreted as evidence of metastatic disease, thus dramatically changing a ~~patients~~patient's stage, and therefore treatment options. Liver haemangiomas, and to a lesser degree focal nodular hyperplasia (FNH), are the main sources of confusion ³. Additionally, pseudolesions (e.g. transient hepatic attenuation differences (THADs), focal fatty sparing / focal fatty change) may further muddy the waters. Therefore, an understanding of the various appearances of metastatic disease is crucial.

Ultrasound

Routine greyscale ultrasound, contrast-enhanced ultrasound, and intra-operative ultrasound all have roles to play.

Unfortunately, not only do metastases have a wide range of appearances, but background echogenicity changes of the liver due to fatty change make absolute statements difficult to make. In general, however, metastases may appear as ³:

rounded and well ~~defined.~~ -defined
positive mass effect with distortion of adjacent vessels.
hypoechoic: most common ~65% and is a concerning feature ⁸
hypoechoic halo due to compressed and fat ~~spared~~-spared liver.
cystic, calcified, infiltrative and echogenic appearances are all possible: see liver metastases ultrasound appearances

Contrast-enhanced ultrasound has similar characteristics to CT, able to distinguish between hypovascular liver lesions, and hypervascular liver lesions.

CT

Liver metastases are typically hypoattenuating on unenhanced CT, enhancing less than surrounding liver following contrast ¹. If there is concomitant hepatic steatosis, then the lesions may be iso- or even slightly hyperattenuating. Enhancement is typically peripheral, and although there may be central filling in, on portal venous phase, the delayed phase will show washout; helpful in distinguishing a metastasis from a haemangioma ¹.

Some primaries have a tendency to produce hyper-enhancing metastases, including renal cell carcinoma, thyroid carcinoma, neuroendocrine tumours, etc. (see hypervascular liver lesions).

MRI

The appearance of liver metastases on MRI is also variable, but MRI is more sensitive than CT for the detection of liver metastases ⁵. MRI examination of the liver may involve numerous sequences (see liver MRI protocol), and choice of the gadolinium contrast agent (extracellular contrast agent or Eovist) is an important consideration.

~~Most~~The most frequent appearances are ⁵:

T1: moderately hypointense
T2: mildly to moderately hyperintense
T1 C+ (Gd): enhancement may be lesional or perilesional ⁷ (enhancement outside the confines of the T1 delineated lesion)
- small lesions (<1.5 cm) tend to uniformly enhance.
- larger lesions (>1.5 cm) tend to show transient rim enhancement (i.e. with washout); helpful feature in distinguishing a metastasis from a liver haemangioma
- perilesional enhancement is most commonly seen in colorectal and pancreatic adenocarcinoma metastases ⁵
T1 C+ (Eovist):
- Eovist is often useful for detection and confirmation of metastatic disease
- on the delayed phase, metastatic ~~lesion~~lesions do not retain any Eovist and essentially appear as "holes" in the liver

Fluid-fluid levels are considered a specific finding for neuroendocrine tumour metastases ⁹.

Radiology report

The following should be included in the radiology report ¹⁷:

number, size and location (using the Couinaud classification) of tumour(s)
relationship to the main portal pedicles and hepatic veins
portal vein patency
radiological signs of portal hypertension
extrahepatic metastatic disease

Treatment and prognosis

Hepatic metastases from colorectal adenocarcinoma can potentially be treated with hepatic metastasectomy, since they may be the only site of metastatic disease. Up to 20% of patients undergoing metastasectomy for this indication remain disease-free ¹⁰. Multiple staging systems for disease-free survival after metastasectomy have been proposed and are being refined. One of the more frequently used systems ~~(Clinical risk score (CRS),~~(e.g. "Fong" score) includes variables such as ¹¹:

node-negative primary
single hepatic metastasis
hepatic metastasis size <5 cm
CEA <200 ng/mL
disease-free interval >1 year

These variables suggest a better metastasectomy disease-free survival.

Transarterial chemotherapy and radioembolisation are other options for the treatment ~~for~~of hepatic metastases. MRI ~~guided~~-guided adaptive radiation therapy is a new and unique method of liver tumour treatment for both primary and metastatic disease ¹⁶.

Differential diagnosis

General differential imaging considerations include:

hepatic haemangioma: usually hyperechoic, geographic, no mass effect, discontinuous peripheral nodular enhancement and 'filling in' ¹
multiple hepatic cysts: no enhancement or mural nodules; can be hyper-dense/intense due to blood or infection
hepatocellular carcinoma (HCC): hypervascular, more often solitary, possible hypoechoic US halo, cirrhotic liver, vascular invasion
focal nodular hyperplasia (FNH)
- often younger patients
- central scar, with persistent delayed enhancement
hepatic adenoma
transient hepatic attenuation differences (THAD): often in cirrhosis
multifocal fatty infiltration/focal fatty sparing: periligamentous, perivascular distribution; MRI in-out phase signal changes, vessels course through "lesions"; no mass effect
multiple biliary hamartomas
cholangiocarcinoma: delayed enhancement, capsular retraction
multiple liver abscesses: possible CT cluster sign and right pleural effusion
hepatic peliosis
primary non-Hodgkin lymphoma ¹²

-<p><strong>Hepatic metastases</strong> are 18-40 times more common than <a href="/articles/liver-tumours">primary liver tumours</a> <sup>6</sup>. Ultrasound, CT, and MRI are helpful in detecting hepatic metastases and evaluation across multiple post-contrast CT series, or MRI pulse sequences are necessary. </p><h4>Epidemiology</h4><p>The demographics of patients with liver metastases will mirror that of the underlying primaries. Incidence, therefore, increases with age.</p><h4>Clinical presentation</h4><p>Liver metastases are usually asymptomatic and found during workup of a malignancy which has presented in other ways. If the hepatic metastatic burden is large, then the presentation or symptoms related to the liver disease may include:</p><ul>
+<p><strong>Hepatic metastases</strong> are 18-40 times more common than <a href="/articles/liver-tumours">primary liver tumours</a> <sup>6</sup>. Ultrasound, CT, and MRI are helpful in detecting hepatic metastases and evaluation across multiple post-contrast CT series, or MRI pulse sequences are necessary. </p><h4>Epidemiology</h4><p>The demographics of patients with liver metastases will mirror that of the underlying primaries. Incidence, therefore, increases with age.</p><h4>Clinical presentation</h4><p>Liver metastases are usually asymptomatic and found during workup of a malignancy that has presented in other ways. If the hepatic metastatic burden is large, then the presentation or symptoms related to the liver disease may include:</p><ul>
-</ul><h4>Radiographic features</h4><p>One of the main difficulties in liver imaging for metastatic disease is the high prevalence of benign liver lesions that can be misinterpreted as evidence of metastatic disease, thus dramatically changing a patients stage, and therefore treatment options. <a href="/articles/hepatic-haemangioma-3">Liver haemangiomas</a>, and to a lesser degree <a href="/articles/focal-nodular-hyperplasia">focal nodular hyperplasia (FNH)</a>, are the main sources of confusion <sup>3</sup>. Additionally, pseudolesions (e.g. <a href="/articles/transient-hepatic-attenuation-differences">transient hepatic attenuation differences (THADs)</a>, <a href="/articles/focal-fatty-sparing-of-the-liver">focal fatty sparing</a> / <a href="/articles/focal-hepatic-steatosis">focal fatty change</a>) may further muddy the waters. Therefore, an understanding of the various appearances of metastatic disease is crucial.</p><h5>Ultrasound</h5><p>Routine greyscale ultrasound, contrast-enhanced ultrasound, and intra-operative ultrasound all have roles to play.</p><p>Unfortunately, not only do metastases have a wide range of appearances, but background echogenicity changes of the liver due to fatty change make absolute statements difficult to make. In general, however, metastases may appear as <sup>3</sup>:</p><ul>
~~-<li>rounded and well defined. </li>~~
~~-<li>positive mass effect with distortion of adjacent vessels. </li>~~
+</ul><h4>Radiographic features</h4><p>One of the main difficulties in liver imaging for metastatic disease is the high prevalence of benign liver lesions that can be misinterpreted as evidence of metastatic disease, thus dramatically changing a patient's stage, and therefore treatment options. <a href="/articles/hepatic-haemangioma-3">Liver haemangiomas</a>, and to a lesser degree <a href="/articles/focal-nodular-hyperplasia">focal nodular hyperplasia (FNH)</a>, are the main sources of confusion <sup>3</sup>. Additionally, pseudolesions (e.g. <a href="/articles/transient-hepatic-attenuation-differences">transient hepatic attenuation differences (THADs)</a>, <a href="/articles/focal-fatty-sparing-of-the-liver">focal fatty sparing</a> / <a href="/articles/focal-hepatic-steatosis">focal fatty change</a>) may further muddy the waters. Therefore, an understanding of the various appearances of metastatic disease is crucial.</p><h5>Ultrasound</h5><p>Routine greyscale ultrasound, contrast-enhanced ultrasound, and intra-operative ultrasound all have roles to play.</p><p>Unfortunately, not only do metastases have a wide range of appearances, but background echogenicity changes of the liver due to fatty change make absolute statements difficult to make. In general, however, metastases may appear as <sup>3</sup>:</p><ul>
+<li>rounded and well-defined</li>
+<li>positive mass effect with distortion of adjacent vessels</li>
~~-<a href="/articles/sonographic-halo-sign">hypoechoic halo</a> due to compressed and fat spared liver. </li>~~
~~-<li>cystic, calcified, infiltrative and echogenic appearances are all possible: see <a href="/articles/ultrasound-appearances-of-liver-metastases">liver metastases ultrasound appearances</a>~~
+<a href="/articles/sonographic-halo-sign">hypoechoic halo</a> due to compressed and fat-spared liver</li>
+<li>cystic, calcified, infiltrative and echogenic appearances are all possible: see <a href="/articles/ultrasound-appearances-of-hepatic-metastases">liver metastases ultrasound appearances</a>
-</ul><p>Contrast-enhanced ultrasound has similar characteristics to CT, able to distinguish between <a href="/articles/hypovascular-liver-lesions">hypovascular liver lesions</a>, and <a href="/articles/hypervascular-liver-lesions">hypervascular liver lesions</a>.</p><p>See also: <a href="/articles/ultrasound-appearances-of-liver-metastases">ultrasound appearance of hepatic metastases</a>.</p><h5>CT</h5><p>Liver metastases are typically hypoattenuating on unenhanced CT, enhancing less than surrounding liver following contrast <sup>1</sup>. If there is concomitant hepatic steatosis, then the lesions may be iso- or even slightly hyperattenuating. Enhancement is typically peripheral, and although there may be central filling in, on portal venous phase, the delayed phase will show washout; helpful in distinguishing a metastasis from a <a href="/articles/hepatic-haemangioma-3">haemangioma</a> <sup>1</sup>.</p><p>Some primaries have a tendency to produce hyper-enhancing metastases, including <a href="/articles/renal-cell-carcinoma-1">renal cell carcinoma</a>, <a href="/articles/follicular-thyroid-cancer">thyroid carcinoma</a>, <a href="/articles/neuroendocrine-tumours">neuroendocrine tumours</a>, etc. (see <a href="/articles/hypervascular-liver-lesions">hypervascular liver lesions</a>).</p><h5>MRI</h5><p>The appearance of liver metastases on MRI is also variable, but MRI is more sensitive than CT for the detection of liver metastases <sup>5</sup>. MRI examination of the liver may involve numerous sequences (see <a href="/articles/liver-protocol-mri">liver MRI protocol</a>), and choice of the gadolinium contrast agent (extracellular contrast agent or Eovist) is an important consideration.</p><p>Most frequent appearances are <sup>5</sup>:</p><ul>
+</ul><p>Contrast-enhanced ultrasound has similar characteristics to CT, able to distinguish between <a href="/articles/hypovascular-liver-lesions">hypovascular liver lesions</a>, and <a href="/articles/hypervascular-liver-lesions">hypervascular liver lesions</a>.</p><p>See also: <a href="/articles/ultrasound-appearances-of-liver-metastases">ultrasound appearance of hepatic metastases</a>.</p><h5>CT</h5><p>Liver metastases are typically hypoattenuating on unenhanced CT, enhancing less than surrounding liver following contrast <sup>1</sup>. If there is concomitant hepatic steatosis, then the lesions may be iso- or even slightly hyperattenuating. Enhancement is typically peripheral, and although there may be central filling in, on portal venous phase, the delayed phase will show washout; helpful in distinguishing a metastasis from a <a href="/articles/hepatic-haemangioma-3">haemangioma</a> <sup>1</sup>.</p><p>Some primaries have a tendency to produce hyper-enhancing metastases, including <a href="/articles/renal-cell-carcinoma-1">renal cell carcinoma</a>, <a href="/articles/follicular-thyroid-cancer">thyroid carcinoma</a>, <a href="/articles/neuroendocrine-tumours">neuroendocrine tumours</a>, etc. (see <a href="/articles/hypervascular-liver-lesions">hypervascular liver lesions</a>).</p><h5>MRI</h5><p>The appearance of liver metastases on MRI is also variable, but MRI is more sensitive than CT for the detection of liver metastases <sup>5</sup>. MRI examination of the liver may involve numerous sequences (see <a href="/articles/liver-protocol-mri">liver MRI protocol</a>), and choice of the gadolinium contrast agent (extracellular contrast agent or Eovist) is an important consideration.</p><p>The most frequent appearances are <sup>5</sup>:</p><ul>
~~-<li>on the delayed phase, metastatic lesion do not retain any Eovist and essentially appear as "holes" in the liver</li>~~
+<li>on the delayed phase, metastatic lesions do not retain any Eovist and essentially appear as "holes" in the liver</li>
-</ul><p>Fluid-fluid levels are considered a specific finding for neuroendocrine tumour metastases <sup>9</sup>.</p><h4>Treatment and prognosis</h4><p>Hepatic metastases from colorectal adenocarcinoma can potentially be treated with hepatic <a href="/articles/metastatectomy">metastasectomy</a>, since they may be the only site of metastatic disease. Up to 20% of patients undergoing metastasectomy for this indication remain disease-free <sup>10</sup>. Multiple staging systems for disease-free survival after metastasectomy have been proposed and are being refined. One of the more frequently used systems (Clinical risk score (CRS), "Fong" score) includes variables such as <sup>11</sup>:</p><ul>
+</ul><p>Fluid-fluid levels are considered a specific finding for neuroendocrine tumour metastases <sup>9</sup>.</p><h4>Radiology report</h4><p>The following should be included in the radiology report <sup>17</sup>:</p><ul>
+<li>number, size and location (using the <a title="Couinaud classification of hepatic segments" href="/articles/couinaud-classification-of-hepatic-segments">Couinaud classification</a>) of tumour(s)</li>
+<li>relationship to the main portal pedicles and hepatic veins</li>
+<li>portal vein patency</li>
+<li>radiological signs of <a title="Portal hypertension" href="/articles/portal-hypertension">portal hypertension</a>
+</li>
+<li>extrahepatic metastatic disease</li>
+</ul><h4>Treatment and prognosis</h4><p>Hepatic metastases from colorectal adenocarcinoma can potentially be treated with hepatic <a href="/articles/metastatectomy">metastasectomy</a>, since they may be the only site of metastatic disease. Up to 20% of patients undergoing metastasectomy for this indication remain disease-free <sup>10</sup>. Multiple staging systems for disease-free survival after metastasectomy have been proposed and are being refined. One of the more frequently used systems (e.g. "Fong" score) includes variables such as <sup>11</sup>:</p><ul>
-</ul><p>These variables suggest a better metastasectomy disease-free survival.</p><p>Transarterial chemotherapy and radioembolisation are other options for treatment for hepatic metastases. MRI guided adaptive radiation therapy is a new and unique method of liver tumour treatment for both primary and metastatic disease <sup>16</sup>.</p><h4>Differential diagnosis</h4><p>General differential imaging considerations include:</p><ul>
+</ul><p>These variables suggest a better metastasectomy disease-free survival.</p><p>Transarterial chemotherapy and radioembolisation are other options for the treatment of hepatic metastases. MRI-guided adaptive radiation therapy is a new and unique method of liver tumour treatment for both primary and metastatic disease <sup>16</sup>.</p><h4>Differential diagnosis</h4><p>General differential imaging considerations include:</p><ul>

References changed:

1. Carlo Bartolozzi. Magnetic Resonance Imaging in Liver Disease. (2003) ISBN: 9781588902368 - <a href="http://books.google.com/books?vid=ISBN9781588902368">Google Books</a>
2. Gerard M. Doherty, Lawrence W. Way. Current Surgical Diagnosis & Treatment. (2006) ISBN: 007142315X - <a href="http://books.google.com/books?vid=ISBN007142315X">Google Books</a>
3. Riccardo Lencioni, Dania Cioni, Carlo Bartolozzi. Focal Liver Lesions. (2004) ISBN: 9783540644644 - <a href="http://books.google.com/books?vid=ISBN9783540644644">Google Books</a>
4. Eugene Lin, Edward Escott, Kavita Garg et al. Practical Differential Diagnosis for CT and MRI. (2008) ISBN: 9781588906557 - <a href="http://books.google.com/books?vid=ISBN9781588906557">Google Books</a>
5. Richard C. Semelka. Abdominal-Pelvic MRI. (2006) ISBN: 0471692735 - <a href="http://books.google.com/books?vid=ISBN0471692735">Google Books</a>
6. Namasivayam S. Imaging of Liver Metastases: MRI. Cancer Imaging. 2007;7(1):2-9. <a href="https://doi.org/10.1102/1470-7330.2007.0002">doi:10.1102/1470-7330.2007.0002</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/17293303">Pubmed</a>
7. Danet I, Semelka R, Leonardou P et al. Spectrum of MRI Appearances of Untreated Metastases of the Liver. AJR Am J Roentgenol. 2003;181(3):809-17. <a href="https://doi.org/10.2214/ajr.181.3.1810809">doi:10.2214/ajr.181.3.1810809</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/12933487">Pubmed</a>
8. Wernecke K, Vassallo P, Bick U, Diederich S, Peters P. The Distinction Between Benign and Malignant Liver Tumors on Sonography: Value of a Hypoechoic Halo. AJR Am J Roentgenol. 1992;159(5):1005-9. <a href="https://doi.org/10.2214/ajr.159.5.1329454">doi:10.2214/ajr.159.5.1329454</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/1329454">Pubmed</a>
9. Sommer W, Zech C, Bamberg F et al. Fluid–fluid Level in Hepatic Metastases: A Characteristic Sign of Metastases of Neuroendocrine Origin. Eur J Radiol. 2012;81(9):2127-32. <a href="https://doi.org/10.1016/j.ejrad.2011.09.012">doi:10.1016/j.ejrad.2011.09.012</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/21978774">Pubmed</a>
10. Pulitanò C, Castillo F, Aldrighetti L et al. What Defines ‘cure’ After Liver Resection for Colorectal Metastases? Results After 10 Years of Follow-Up. HPB (Oxford). 2010;12(4):244-9. <a href="https://doi.org/10.1111/j.1477-2574.2010.00155.x">doi:10.1111/j.1477-2574.2010.00155.x</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/20590894">Pubmed</a>
11. Fong Y, Fortner J, Sun R, Brennan M, Blumgart L. Clinical Score for Predicting Recurrence After Hepatic Resection for Metastatic Colorectal Cancer. Ann Surg. 1999;230(3):309. <a href="https://doi.org/10.1097/00000658-199909000-00004">doi:10.1097/00000658-199909000-00004</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/10493478">Pubmed</a>
17. Shin D, Ingraham C, Dighe M et al. Surgical Resection of a Malignant Liver Lesion: What the Surgeon Wants the Radiologist to Know. AJR Am J Roentgenol. 2014;203(1):W21-33. <a href="https://doi.org/10.2214/ajr.13.11701">doi:10.2214/ajr.13.11701</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/24951226">Pubmed</a>
1. Carlo Bartolozzi. Magnetic Resonance Imaging in Liver Disease: Technical Approach, Diagnostic Imaging of Liver Neoplasms, Focus on a New Superparamagnetic Contrast Agent. (2003) ISBN: 1588902366
2. Gerard M. Doherty, Lawrence W. Way. Current Surgical Diagnosis & Treatment (Current Surgical Diagnosis and Treatment). (2005) ISBN: 007142315X
3. A.L. Baert (Foreword), R. Lencioni (Editor), D. Cioni (Editor) et al. Focal Liver Lesions: Detection, Characterization, Ablation (Medical Radiology / Diagnostic Imaging). (2005) ISBN: 3540644644
4. Lin, Eugene.. Practical Differential Diagnosis for CT and MRI. (2008) ISBN: 9781588906557
5. Richard C. Semelka. Abdominal-Pelvic MRI. (2005) ISBN: 0471692735
6. Namasivayam S. Imaging of Liver Metastases: MRI. Cancer Imaging. 2007;7(1):2-9. <a href="https://doi.org/10.1102/1470-7330.2007.0002">doi:10.1102/1470-7330.2007.0002</a>
7. Danet I, Semelka R, Leonardou P et al. Spectrum of MRI Appearances of Untreated Metastases of the Liver. AJR Am J Roentgenol. 2003;181(3):809-17. <a href="https://doi.org/10.2214/ajr.181.3.1810809">doi:10.2214/ajr.181.3.1810809</a>
8. Wernecke K, Vassallo P, Bick U, Diederich S, Peters P. The Distinction Between Benign and Malignant Liver Tumors on Sonography: Value of a Hypoechoic Halo. AJR Am J Roentgenol. 1992;159(5):1005-9. <a href="https://doi.org/10.2214/ajr.159.5.1329454">doi:10.2214/ajr.159.5.1329454</a>
9. Sommer W, Zech C, Bamberg F et al. Fluid–fluid Level in Hepatic Metastases: A Characteristic Sign of Metastases of Neuroendocrine Origin. Eur J Radiol. 2012;81(9):2127-32. <a href="https://doi.org/10.1016/j.ejrad.2011.09.012">doi:10.1016/j.ejrad.2011.09.012</a>
10. Pulitanò C, Castillo F, Aldrighetti L et al. What Defines ‘cure’ After Liver Resection for Colorectal Metastases? Results After 10 Years of Follow-Up. HPB (Oxford). 2010;12(4):244-9. <a href="https://doi.org/10.1111/j.1477-2574.2010.00155.x">doi:10.1111/j.1477-2574.2010.00155.x</a>
11. Fong Y, Fortner J, Sun R, Brennan M, Blumgart L. Clinical Score for Predicting Recurrence After Hepatic Resection for Metastatic Colorectal Cancer. Ann Surg. 1999;230(3):309. <a href="https://doi.org/10.1097/00000658-199909000-00004">doi:10.1097/00000658-199909000-00004</a>

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11","thumbnail":"https://prod-images-static.radiopaedia.org/images/2717429/84da0c382a569bcbabc962cfe7fa79f1b4959f43ac926f55ef65b2e180108b55_big_gallery.jpeg","isStack":true,"diagnosticCertainty":"probable"},{"imageId":4281894,"studyId":24245,"caseSlug":"malignant-gastrointenstinal-stromal-tumour-stomach","caption":"Case 12: from GIST tumour","thumbnail":"https://prod-images-static.radiopaedia.org/images/4281894/e6f0e878aa420f1d1977b1ea5b9268_big_gallery.jpg","isStack":true,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":5454317,"studyId":26789,"caseSlug":"rectosigmoid-carcinoma-with-hepatic-metastases","caption":"Case 13: from rectosigmoid carcinoma","thumbnail":"https://prod-images-static.radiopaedia.org/images/5454317/28f5de25ac408e931685521d4d090b_big_gallery.jpg","isStack":true,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":7457480,"studyId":30401,"caseSlug":"hepatic-metastases-2","caption":"Case 14: from colon cancer PET-CT ","thumbnail":"https://prod-images-static.radiopaedia.org/images/7457480/e4f10295b05c4bf5c8303ac0194123_big_gallery.jpeg","isStack":false,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":8039513,"studyId":31387,"caseSlug":"testicular-seminoma-with-metastases","caption":"Case 15: from seminoma of testis","thumbnail":"https://prod-images-static.radiopaedia.org/images/8039513/4c972b546defc7b2c116b311bc3b0a_big_gallery.jpg","isStack":true,"diagnosticCertainty":"confirmed_unsubstantiated"},{"imageId":53769170,"studyId":98812,"caseSlug":"spontaneous-rupture-of-hepatic-metastases","caption":"Case 17 : spontaneous rupture","thumbnail":"https://prod-images-static.radiopaedia.org/images/53769170/VENAS-030_big_gallery.jpeg","isStack":true,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":55683047,"studyId":110051,"caseSlug":"metastatic-breast-cancer-8","caption":"Case 18: metastatic breast cancer","thumbnail":"https://prod-images-static.radiopaedia.org/images/55683047/330105_big_gallery.jpeg","isStack":true,"diagnosticCertainty":"confirmed_unsubstantiated"},{"imageId":57277772,"studyId":117959,"caseSlug":"metastatic-sigmoid-colon-adenocarcinoma-1","caption":"Case 19: metastatic sigmoid colon adenocarcinoma","thumbnail":"https://prod-images-static.radiopaedia.org/images/57277772/17._big_gallery.jpeg","isStack":true,"diagnosticCertainty":"confirmed_unsubstantiated"},{"imageId":59128008,"studyId":119695,"caseSlug":"breast-carcinoma-with-liver-metastasis","caption":"Case 20: from breast with calcification ","thumbnail":"https://prod-images-static.radiopaedia.org/images/59128008/6ea5775f1457299161aa82decbad550c60bff7a66b1ea6f580010a2945aa49c7_big_gallery.jpeg","isStack":true,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":58362212,"studyId":120739,"caseSlug":"metastatic-pancreatic-ductal-adenocarcinoma-2","caption":"Case 21: from pancreatic ductal adenocarcinoma","thumbnail":"https://prod-images-static.radiopaedia.org/images/58362212/26._big_gallery.jpeg","isStack":true,"diagnosticCertainty":"confirmed_unsubstantiated"},{"imageId":60418223,"studyId":129556,"caseSlug":"metastatic-esophagogastric-adenocarcinoma","caption":"Case 22: from oesophagogastric adenocarcinoma","thumbnail":"https://prod-images-static.radiopaedia.org/images/60418223/b35b430b38fc58ff4d3cd506e5df34b6c5041a8a9a107102007a09bbe9cdcb34_big_gallery.jpeg","isStack":true,"diagnosticCertainty":"confirmed_unsubstantiated"},{"imageId":60308868,"studyId":129246,"caseSlug":"metastatic-pancreatic-ductal-adenocarcinoma-4","caption":"Case 23: from pancreatic ductal adenocarcinoma","thumbnail":"https://prod-images-static.radiopaedia.org/images/60308868/ebc131cd31a2cb47c6cc387eef027e701a01980049b93cbc16c4b5ad35b9c1d5_big_gallery.jpeg","isStack":true,"diagnosticCertainty":"confirmed_unsubstantiated"},{"imageId":60549232,"studyId":130099,"caseSlug":"metastatic-rectosigmoid-cancer-with-polycystic-kidney-and-liver-disease","caption":"Case 24: Metastatic rectosigmoid cancer with polycystic kidney and liver disease","thumbnail":"https://prod-images-static.radiopaedia.org/images/60549232/09cbaafb4661ab876d95dc3a1b4b2b8d2ab22701bd75c48055ed450b8c6fae6e_big_gallery.jpeg","isStack":true,"diagnosticCertainty":"confirmed_unsubstantiated"},{"imageId":63284343,"studyId":140625,"caseSlug":"atypical-hepatic-metastases","caption":"Case 25: atypical metastases","thumbnail":"https://prod-images-static.radiopaedia.org/images/63284343/00f95141b9122315fdaf34178cf3f63b13d9d5c867b3a19ee590e21f9003a411_big_gallery.jpeg","isStack":true,"diagnosticCertainty":"confirmed_unsubstantiated"}],"ddx_inclusions":[{"imageId":16381,"studyId":6853,"caseSlug":"hydatid-cyst-of-the-liver","caption":"Hepatic hydatid disease","thumbnail":"https://prod-images-static.radiopaedia.org/images/16381/e65c3858e22d194105df665cb56e1b_big_gallery.jpeg","isStack":false,"diagnosticCertainty":"confirmed_unsubstantiated"},{"imageId":29094,"studyId":8022,"caseSlug":"cholangiocarcinoma-1","caption":"Cholangiocarcinoma","thumbnail":"https://prod-images-static.radiopaedia.org/images/29094/0f104209b8d6186fd8112296848fd7_big_gallery.jpg","isStack":true,"diagnosticCertainty":"confirmed_unsubstantiated"},{"imageId":24846,"studyId":7649,"caseSlug":"polycystic-liver","caption":"Polycystic liver","thumbnail":"https://prod-images-static.radiopaedia.org/images/24846/e8c409e71292fa2b1c719320f17811_big_gallery.jpeg","isStack":true,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":61340979,"studyId":132931,"caseSlug":"amoebic-liver-abscess-2","caption":"Amoebic liver abscess","thumbnail":"https://prod-images-static.radiopaedia.org/images/61340979/d5473c4ebfbe3a816dfdd00fde198cf33cb4744d39cacaa8cc8d0bc5cadbcb7e_big_gallery.jpeg","isStack":false,"diagnosticCertainty":"confirmed_unsubstantiated"}],"lang":"gb"}