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The Role Of Cinematic Rendering In The Detection And Evaluation Of Suspected Hepatic Tumors: How We Do It



The Role Of Cinematic Rendering In The Detection And Evaluation Of Suspected Hepatic Tumors: How We Do It

Elliot K. Fishman MD
Linda Chu MD
Satomi Kawamoto MD
Johns Hopkins Hospital


The role of 3D imaging in the liver has classically focused on a combination of classic volume rendering (VRT) and maximum intensity projection (MPR) techniques. While the literature has shown a range of clinical applications for 3D imaging ranging from pre-operative planning for hepatic resection, to vascular mapping for lesion definition and pattern recognition, to detection of vascular complications (arterial and venous) the introduction of cinematic rendering has to date not seen universal adoption as a valuable adjunct especially for liver tumors. In this exhibit we will try to define our experience with cinematic rendering (CR) in the evaluation of the liver focusing on the evaluation of hepatic masses. Discussion into the realm of vascular evaluation in cirrhosis (i.e. vascular malformation or shunting) or the patient post trauma (i.e. bleeding from the hepatic artery)or post liver transplant (i.e. hepatic artery patency) is beyond the scope of this exhibit.


Cinematic Rendering of Liver: Protocol and Technical Notes

  • Protocol is typically Dual phase acquisition (35/70 sec) with .75 mm thick sections at .5 mm intervals
  • Create 3D Cinematic Renderings using select custom designed presets for liver pathology followed by adjusting parameters for the current case. Study time is under 5 minutes
  • Analyze the texture maps of the tumor and adjacent normal liver for enhancement patterns and flow changes
  • Vascular mapping of the liver from dual phase datasets with arterial and venous maps performed in all cases
  • 3D Cinematic Rendering is routinely supplemented with MIP and classic VRT
  • Additional report often created from the 3D CRT study


Our experience with Cinematic Rendering of the Liver is also Referring Physician Driven

  • Understanding the needs of your referring physicians in critical with any post –processing technique just as it is for designing the basic CT acquisition study protocol. What information the oncologist or surgeon want may be different
  • The use of MIP, VRT and CR together is often ideal as one tries to bridge the gap with new technology. Two case studies using all 3 technique are documented on the next two slides and give you a flavor of what we believe may work in your practice


Hepatoma: MIP vs Cinematic Rendering with CR Texture Mapping



Hepatoma in Cirrhotic Liver Comparing VRT, MIP and CR



Cinematic Rendering of the Liver: Applications

  • Lesion detection
  • Lesion extent and vascular involvement
  • Vascular mapping
  • Differential diagnosis o the lesion
  • Surgical planning based on 3D mapping
  • Improved radiologist understanding of the characteristic of the hepatic lesion


Benign Hepatic Tumors

Cinematic Rendering helps define many of the classic signs of various benign tumors including hemangioma, focal nodular hyperplasia (FNH), and hepatic adenoma (HA). The CR images nicely define the vascular map and the cases show the pattern of lesions with CR and compare it to dual phase imaging and classic VRT and MIP reconstruction.


Vascular mapping of the liver mass in a pattern classic for hemangioma



Range of CR images using a number of presets of a hepatic hemangioma.

Hepatic Hemangioma


Incidental FNH with classic enhancement similar to the IVC on arterial images and the lesion becomes isodense on venous phase imaging.

Incidental FNH



Hepatic Tumors


Vascular enhancement on arterial phase imaging which becomes isodense on venous phase imaging classic for Hepatic Adenoma.

Hepatic Adenoma



Hepatic Tumors


Multiple lesions under 1cm are multifocal hepatic adenomas.

Hepatic Adenomas


Multiple hepatic adenomas under 5 mm in size seen in the liver on CR.

Hepatic Adenomas


CTA in arterial and venous phase imaging with the lesion seen best on on venous phase imaging. This is one of the patterns for Hepatoma.



Range of Cinematic Rendering Appearances of the Hepatoma.



CTA of Hepatoma which is hypovascular in the left lobe of the liver. The CR images nicely define the mass for pre-op planning.




Hepatic Tumors


Fibrolamellar HCC in a young female

Fibrolamellar HCC in a young female


CR demonstrates the large mass with neovascularity. Bulky adenopathy is also seen.

Large mass


Intrahepatic Cholangiocarcinoma shows rim enhancement with no significant vascularity

Intrahepatic Cholangiocarcinoma


The CR nicely defines the pseudocapsule of the tumor with enhancement of the tumor wall.



Cholangiocarcinoma with neovascularity looks similar to HCC with portal vein extension. MIP best defines the neovascularity




Hepatic Tumors


Adenocarcinoma Body of the Pancreas with liver metastases that are hypovascular metastases.




Hepatic Tumors


Duodenal Carcinoid Tumor with liver metastases that are hypervascular.

Duodenal Carcinoid Tumor


Vascular metastases best seen on select CR images.

Vascular metastases


Neuroendocrine Tumor with liver metastases shown on both arterial and venous phase imaging.

Neuroendocrine Tumor


CR nicely defines the extent of liver metastases on a range of CR presets

Liver Metastases


Pitfall: Adenosquammous Carcinoma of the Pancreas with Liver Abscess Post Op (Klebsiella and Enterococcus) simulating tumor recurrence. Perfusions changes well defined.

Adenosquammous Carcinoma


CR images nicely define the perfusion changes around the abscesses.

Perfusion changes


Conclusion and Next Steps

The future of cinematic rendering for applications like liver tumor imaging include;
  • Role of AI to define the optimal presets for a range of cinematic renderings
  • Ability to combine CT with additional studies like PET CT
  • Advanced visualization techniques including using HoloLens for Augmented Reality


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