Multimodality Imaging of Tumour Thrombus

Differentiation of solid and friable tumour thrombus in patients with renal cell carcinoma: The role of MRI apparent diffusion coefficient

PURPOSE

Inferior vena cava (IVC) involvement by renal cell carcinoma (RCC) is associated with a higher disease stage and is considered a risk factor for poor prognosis. This study aimed to investigate the role of the apparent diffusion coefficient (ADC) of MRI 3D texture analysis in the differentiation of solid and friable tumour thrombus in patients with RCC.

MATERIALS AND METHODS

The study involved 27 patients with RCC with tumour thrombus in the renal vein or IVC, surgically treated with nephrectomy and thrombectomy and in whom preoperatively abdominal MRI including the DWI sequence was conducted. For 3D texture analysis, the ADC map was used, and the first-order radiomic features were calculated from the whole volume of the thrombus. All tumour thrombi were histologically classified as solid or friable.

RESULTS

The solid and friable thrombus was detected in 51.9 ​% and 48.1 ​% of patients, respectively. No differences in mean values of range, 90th percentile, interquartile range, kurtosis, uniformity and variance were found between groups. Equal sensitivity and specificity (93 ​% and 69 ​%, respectively) of ADC mean, median and entropy in differentiation between solid and friable tumour thrombus, with the highest AUC for entropy (0.808), were observed. Applying the skewness threshold value of 0.09 allowed us to achieve a sensitivity of 86 ​% and a specificity of 92 ​%.

CONCLUSIONS

In patients with RCC and tumour thrombus in the renal vein or IVC, the 3D texture analysis based on ADC-map allows for precise differentiation of a solid from a friable thrombus.

Management and Outcomes of Wilms Tumor With Suprarenal Intravascular Extension: A Pediatric Surgical Oncology Research Collaborative Study

OBJECTIVE

The purpose of this study was to describe management and outcomes from a contemporary cohort of children with Wilms tumor complicated by inferior vena caval thrombus.

BACKGROUND

The largest series of these patients was published almost 2 decades ago. Since then, neoadjuvant chemotherapy has been commonly used to manage these patients, and outcomes have not been reported.

METHODS

Retrospective review of 19 North American centers between 2009 and 2019. Patient and disease characteristics, management, and outcomes were investigated and analyzed.

RESULTS

Of 124 patients, 81% had favorable histology (FH), and 52% were stage IV. IVC thrombus level was infrahepatic in 53 (43%), intrahepatic in 32 (26%), suprahepatic in 14 (11%), and cardiac in 24 (19%). Neoadjuvant chemotherapy using a 3-drug regimen was administered in 82% and postresection radiation in 90%. Thrombus level regression was 45% overall, with suprahepatic level showing the best response (62%). Cardiopulmonary bypass (CPB) was potentially avoided in 67%. The perioperative complication rate was significantly lower after neoadjuvant chemotherapy [(25%) vs upfront surgery (55%); P =0.005]. CPB was not associated with higher complications [CPB (50%) vs no CPB (27%); P =0.08]. Two-year event-free survival was 93% and overall survival was 96%, higher in FH cases (FH 98% vs unfavorable histology/anaplastic 82%; P =0.73). Neither incomplete resection nor viable thrombus cells affected event-free survival or overall survival.

CONCLUSIONS

Multimodal therapy resulted in excellent outcomes, even with advanced-stage disease and cardiac extension. Neoadjuvant chemotherapy decreased the need for CPB to facilitate resection. Complete thrombectomy may not always be necessary.

Imaging of abdominopelvic oncologic emergencies

With advancements in cancer treatment, the survival rates for many malignancies have increased. However, both the primary tumors and the treatments themselves can give rise to various complications. Acute symptoms in oncology patients require prompt attention. Abdominopelvic oncologic emergencies can be classified into four distinct categories: vascular, bowel, hepatopancreatobiliary, and bone-related complications. Radiologists need to be familiar with these complications to ensure timely diagnosis, which ultimately enhances patient outcomes.

Intravascular Tumor Extension and Pulmonary Tumor Embolism in Children With Solid Malignancies: Is There a Role for Inferior Vena Cava Filters?

Intravascular tumor extension is an uncommon complication of solid malignancies that, when present in the inferior vena cava (IVC), can result in fatal pulmonary tumor embolism. Currently, neoadjuvant chemotherapy and surgery are the mainstays of treatment; however, there are no consensus guidelines for management. We describe three cases of pediatric solid malignancies with associated IVC extension and pulmonary tumor embolism. We hypothesize that there is scope for IVC filter placement in such cases to mitigate the risk of fatal pulmonary tumor embolism.

Breaking down tumor thrombus: Current strategies for medical management

Tumor thrombus, the intravascular extension of tumor into adjacent blood vessels, is frequently encountered in patients with renal cell carcinoma and hepatocellular carcinoma, and often involves the abdominal vasculature including the renal vein, portal vein, and the inferior vena cava. While a bland thrombus is composed of platelets and fibrin, in contrast, a tumor thrombus refers to an organized collection of tumor cells. Though oftentimes detected incidentally on imaging, tumor thrombus may have significant clinical implications and can be challenging to differentiate from bland thrombus. Additionally, the optimal management of tumor thrombus, including the use of anticoagulation, remains poorly described. This review summarizes common causes of tumor thrombus, as well as its impact on staging, prognosis, and treatment.

Primary extraskeletal osteosarcoma of the post-hepatic caudal vena cava in a dog-Case report

Extraskeletal osteosarcoma (EOSA) in dogs is a rare malignant mesenchymal tumor of somatic soft tissues or more commonly visceral organs with a poor prognosis. In dogs, EOSAs have been described as arising from multiple locations, but differently from humans, never from a main vessel. In this report, we describe the first case of an EOSA arising from the post-hepatic caudal vena cava in a 7-year-old male neutered mix breed dog. This report focuses on the description of the diagnostic challenges to obtain a preoperative diagnosis, highlights the importance of histopathology for a correct diagnosis, and introduces a new differential diagnosis for an animal presenting with a suspected thrombus of the vena cava.

Robotic Partial vs Radical Nephrectomy for Clinical T3a Tumors: A Narrative Review

Introduction: T3a renal masses include a diverse group of tumors that invade the perirenal and/or sinus fat, pelvicaliceal system, or renal vein. The majority of cT3a renal masses represent renal cell carcinoma (RCC) and have historically been treated with radical nephrectomy (RN) given their aggressive nature. With the adoption of minimally invasive approaches to renal surgery, the combination of improved observation, pneumoperitoneum, and robotic articulation has allowed urologists to consider partial nephrectomy (PN) for more complex tumors. Herein, we review the existing literature regarding robot-assisted PN (RAPN) and robot-assisted RN (RARN) in the management of T3a renal masses. Methods: A literature search was performed using PubMed for articles evaluating the role of RARN and RAPN for T3a renal masses. Search parameters were limited to English language studies. Applicable studies were abstracted and included in this narrative review. Results: T3a RCC caused by renal sinus fat or venous involvement is associated with ∼50% lower cancer-specific survival than those with perinephric fat invasion alone. CT and MRI can both be used to stage cT3a tumors, however, MRI is more accurate when assessing venous involvement. Upstaging to pT3a RCC during RAPN does not confer a worse prognosis than pT3a tumors treated with RARN; however, patients who undergo RAPN for T3a RCC with venous involvement have relatively higher rates of recurrence and metastasis. Intraoperative tools including drop-in ultrasound, near-infrared fluorescence, and 3D virtual models improve the ability to perform RAPN for T3a tumors. In well-selected cases, warm ischemia times remain reasonable. Conclusions: cT3a renal masses represent a diverse group of tumors. Depending on substratification of cT3a, RARN or RAPN can be employed for treatment of such masses.

Vascular Malformations and Tumors: A Review of Classification and Imaging Features for Cardiothoracic Radiologists

The International Society for the Study of Vascular Anomalies (ISSVA) classification is a comprehensive histology-based scheme that was updated in 2018. It is important for cardiothoracic imagers to understand this classification to ensure that accurate terminology is used and that archaic terms are avoided when vascular lesions are described. Knowledge of the various malformations (including common conditions, such as venous malformation, arteriovenous fistula, and arteriovenous malformation) and vascular tumors allows for timely diagnosis and appropriate management. This review describes various vascular anomalies, in accordance with ISSVA classification and terminology; highlights key imaging features associated with each; and discusses the role of different imaging modalities. Keywords: Pulmonary, Soft Tissues/Skin, Vascular, Arteriovenous Malformation © RSNA, 2023.

Successful mechanical thrombectomy and stent exclusion of sacral chordoma tumor thrombus

A 77-year-old man with history of sacral chordoma and pulmonary embolism presented to the emergency room with a 1-day history of diffuse left flank and lower extremity swelling. The patient was found to have thrombus in the left common and external iliac veins. The patient was brought to Interventional Radiology for mechanical thrombectomy using the Inari ClotTriever and a sample of extracted thrombus was sent to pathology. Analysis on the sample was positive for sacral chordoma, consistent with tumor thrombus. The patient returned after 6 weeks with similar symptoms and repeat mechanical thrombectomy was performed with the Inari ClotTriever and stent placement through the left common and external iliac vein with an Ovation iX stent graft. The patient remained asymptomatic following the second procedure at repeat follow-up at 6 weeks.

Ultrasonographic findings of abdominal thrombosis in dogs

ABSTRACT This retrospective case series study describes the clinical and vascular ultrasound findings of 26 dogs diagnosed with abdominal thrombosis. Images were selected based on the detection of intravascular echogenic thrombus or the absence of vascular flow on color Doppler, confirmed by surgery or necropsy. Images were acquired using the Mylab 40 model, with linear and microconvex multifrequency probes. All the reports were evaluated along with the corresponding images by a veterinary diagnostic imaging radiologist. The ultrasonographic aspects evaluated were echogenicity (92.3%), anechogenicity (7.7%), vascularization (11.5%), mineralization (15.4%), and recanalization (7.7%) of the thrombosis. The vascular and hemodynamic findings were dilation of the affected vein (57.7%), total occlusion of blood flow (30.8%), presence of turbulent flow (65.38%), and visualization of smoke signal (blood flow detected as moving echogenic points in dynamic bidimensional mode) (11.5%). Neoplasms (19 cases) and nephropathies (13 cases) were the most common clinical conditions in the affected dogs. Eleven cases of vascular invasion due to adrenal neoplasms were identified. The results indicate that the vascular ultrasound examination is an important method for diagnosis, as 23 of the 26 cases did not show any clinical signs of thrombosis.

Renal cell carcinoma with inferior vena cava tumor thrombus initially misdiagnosed as bland thrombus due to hypercoagulable state

Renal cell carcinoma with inferior vena cava tumor thrombus can be misdiagnosed as an inferior vena cava thrombosis if not evaluated carefully with imaging. We describe a case of renal cell carcinoma with inferior vena cava tumor thrombus that was initially misdiagnosed as an inferior vena cava thrombosis due to a possible hypercoagulable state. After 7 months of anticoagulation therapy with no improvement, a right radical nephrectomy and thrombectomy was performed without cardiopulmonary bypass, and a diagnosis of papillary renal cell carcinoma with a level-IIId tumor thrombus was confirmed with no presence of a bland thrombus. We demonstrate the complexity of identifying and treating renal cell carcinoma with venous tumor thrombus and the importance of differentiating between a malignant thrombus and a bland thrombus.

Solitary Fibrous Tumor of Internal Jugular Vein: An Extremely Rare Entity with Review of Literature

Solitary fibrous tumor (SFT) is an unusual spindle cell neoplasm that commonly arises from pleura. In the last decade, multiple case reports have described its diverse occurrence in extrapleural locations involving almost every anatomic site. Intravascular SFT is extremely rare and has been reported in inferior vena cava and renal vein only, to the best of our knowledge. SFT of the internal jugular vein has never been reported. We present a case of a SFT arising from internal jugular vein with extraluminal exophytic component extending into supraclavicular fossa. It should also be considered as a differential diagnosis for neoplasm arising from the internal jugular vein.

Role of anticoagulation in the management of tumor thrombus: A 10-year single-center experience

BACKGROUND

Children with cancer diagnosis are overall at a higher risk of thrombosis. For a newly diagnosed blood clot, patients are commonly started on anticoagulants to prevent further extension and embolization of the clot. In the rare instance that a pediatric patient has a tumor thrombus, role of anticoagulation is less clear.

PROCEDURE/METHODS

Patients under 21 years of age with a finding of tumor thrombus on imaging from 2010 to 2020 at Texas Children's Hospital were identified and their medical records were reviewed.

RESULTS

A total of 50 patients were identified. Most thrombi were incidental findings at diagnosis; however, two patients presented with pulmonary embolism (PE). Inferior vena cava extension was noted in 36% of the patients, and 24% patients had an intracardiac tumor thrombus. Anticoagulation was initiated in 10 patients (20%). There was no difference in the rate of bland thrombus formation and/or embolization in patients who did or did not receive anticoagulation. However, three of the six patients with asymptomatic tumor thrombus who were started on anticoagulation had bleeding complications compared to only two patients in the no anticoagulation cohort (p < .05).

CONCLUSION

Children with intravascular extension of solid tumors were not commonly started on anticoagulation at the time of diagnosis, irrespective of the extent of tumor thrombus. Furthermore, we observed a significant trend toward higher incidence of bleeding complications after initiation of anticoagulation for asymptomatic tumor thrombus. There is inadequate evidence at this time to support routine initiation of anticoagulation in pediatric patients with intravascular extension of solid tumors.

Case 290: Intravascular Cystic Synovial Sarcoma

History A 26-year-old man presented with a 1-month history of chest pain, a palpable and painful right inguinal mass, and edema in the right lower extremity. One month earlier, he started to experience left chest pain with no cough. Pulmonary CT angiography (CTA) revealed a left lower lobe segmental pulmonary embolus. The local hospital made a diagnosis of pulmonary embolism. He received anticoagulants, and his chest pain was gradually relieved. At the time of current presentation, the patient was experiencing right lower extremity swelling and pain. Physical examination revealed a 4 × 3 cm palpable right inguinal mass with no redness. His medical history and family history were negative. The results of laboratory work-up were normal, with a d-dimer level of 0.16 mg/L fibrinogen equivalent units (reference range, <0.46 mg/L) and an international normalized ratio of 2.45 (therapeutic range, 2.0-3.0 for a patient taking warfarin), except the prothrombin time was 28.2 seconds (reference range, 9.6-12.8 seconds) and the activated partial thromboplastin time was 52.2 seconds (reference range, 24.8-33.8 seconds). Echocardiography, chest radiography, chest CT, and contrast-enhanced (CE) CT revealed no abnormalities. The patient underwent right lower extremity vascular conventional US (Philips IU22; Philips) with an L9-3 probe (3-9 MHz, venous condition) and contrast-enhanced US (1.5-2.0 mL, SonoVue; Bracco) with an intravenous bolus injection at the initial evaluation. Two days later, noncontrast and contrast-enhanced CT images of the lower abdomen (1.5 mL per kilogram of body weight, 300 mg/mL iomeprol, Iomeron; Bracco) were acquired for further evaluation.

Dural venous sinus tumour thrombus from metastatic thymoma

Thymomas are the most common primary tumours of the anterior mediastinum. While intrathoracic disease progression through local invasion is well described in the literature, extrathoracic extension of disease is uncommon and intracranial metastases have seldom been reported. We present a case of extensive dural venous sinus tumour thrombus in a patient with metastatic invasive thymoma.

Occlusion of the internal jugular vein in differentiated thyroid carcinoma: Causes and diagnosis

Occlusion of the internal jugular vein (IJV) can be observed in thyroid cancer either on preoperative imaging with ultrasound or cross-sectional imaging, particularly contrast-enhanced CT-scan, and can be detected during follow-up when using these same imaging modalities. For thyroid cancer, four different causes of occlusion of the IJV can be identified: venous thrombosis associated with a hypercoagulable state, tumor thrombus in the vein, compression or invasion of the IJV by thyroid disease or lymph node metastases, and fibrotic collapse of the IJV following lateral neck dissection. Clinicians managing patients with thyroid cancer need to be aware of and able to diagnose each of these conditions. The overall patient impact and appropriate management of each will be discussed.

Multimodality Imaging of Abdominopelvic Tumors with Venous Invasion

A broad range of abdominal and pelvic tumors can manifest with or develop intraluminal venous invasion. Imaging features at cross-sectional modalities and contrast-enhanced US that allow differentiation of tumor extension within veins from bland thrombus include the expansile nature of tumor thrombus and attenuation and enhancement similar to those of the primary tumor. Venous invasion is a distinctive feature of hepatocellular carcinoma and renal cell carcinoma with known prognostic and treatment implications; however, this finding remains an underrecognized characteristic of multiple other malignancies-including cholangiocarcinoma, adrenocortical carcinoma, pancreatic neuroendocrine tumor, and primary venous leiomyosarcoma-and can be a feature of benign tumors such as renal angiomyolipoma and uterine leiomyomatosis. Recognition of tumor venous invasion at imaging has clinical significance and management implications for a range of abdominal and pelvic tumors. For example, portal vein invasion is a strong negative prognostic indicator in patients with hepatocellular carcinoma. In patients with rectal cancer, diagnosis of extramural venous invasion helps predict local and distant recurrence and is associated with worse survival. The authors present venous invasion by vascular distribution and organ of primary tumor origin with review of typical imaging features. Common pitfalls and mimics of neoplastic thrombus, including artifacts and anatomic variants, are described to help differentiate these findings from tumor in vein. By accurately diagnosing tumor venous invasion, especially in tumors where its presence may not be a typical feature, radiologists can help referring clinicians develop the best treatment strategies for their patients. ^©RSNA, 2020.

"Renal emergencies: a comprehensive pictorial review with MR imaging"

Superior soft-tissue contrast and high sensitivity of magnetic resonance imaging (MRI) for detecting and characterizing disease may provide an expanded role in acute abdominal and pelvic imaging. Although MRI has traditionally not been exploited in acute care settings, commonly used in biliary obstruction and during pregnancy, there are several conditions in which MRI can go above and beyond other modalities in diagnosis, characterization, and providing functional and prognostic information. In this manuscript, we highlight how MRI can help in further assessment and characterization of acute renal emergencies. Currently, renal emergencies are predominantly evaluated with ultrasound (US) or computed tomography (CT) scanning. US may be limited by various patient factors and technologist experience while CT imaging with intravenous contrast administration can further compromise renal function. With the advent of rapid, robust non-contrast MRI, and magnetic resonance angiography (MRA) imaging studies with short scan times, free-breathing techniques, and lack of ionization radiation, the utility of MRI for renal evaluation might be superior to CT not only in diagnosing an emergent renal process but also by providing functional and prognostic information. This review outlines the clinical manifestations and the key imaging findings for acute renal processes including acute renal infarction, hemorrhage, and renal obstruction, among other entities, to highlight the added value of MRI in evaluating the finer nuances in acute renal emergencies.

Primary synovial sarcoma of parotid gland with intravenous extension into the heart

We are reporting a case of a 47-year-old male with primary synovial sarcoma of the right parotid gland with tumor thrombus extension in the right internal jugular vein and right atrium. The rarity of this occurrence as documented in the review of the literature provides for uncertainty about proper management. Our case represents a rare occurrence with the unique radiological finding that has implications for management.

Tumor in the veins: an abdominal perspective with an emphasis on CT and MR imaging

Endovenous tumor thrombus in abdomen should be accurately diagnosed as it is a significant finding that may change medical and surgical treatment approaches. As some underlying reasons for endovenous tumor thrombi are relatively rare and imaging findings may be quite subtle, they can be easily overlooked which may have important clinical consequences. In this paper, we described the various imaging aspects of endovenous tumor thrombi originating from various tumor types in different venous structures of the abdomen.

Use of CEUS LI-RADS for the Accurate Diagnosis of Nodules in Patients at Risk for Hepatocellular Carcinoma: A Validation Study

Purpose

To validate the contrast agent-enhanced US Liver Imaging Reporting and Data System (CEUS LI-RADS) algorithm for accurate diagnosis of hepatocellular carcinoma (HCC) and categorization of all nodules encountered in patients at risk for HCC.

Materials and Methods

A single-center retrospective review of 196 nodules in 184 patients at risk for HCC (consisting of 139 HCCs, 18 non-HCC malignancies, and 39 benign nodules) was performed in a three-reader blinded read format, with the use of the CEUS LI-RADS algorithm. Pathologic confirmation was available for 143 nodules (122 HCCs, 18 non-HCC malignancies, and three benign nodules). Nodule sizes ranged between 1.0 and 16.2 cm. Nodules assessed with contrast-enhanced US were assigned various CEUS LI-RADS categories by three blinded readers. CEUS LI-RADS categorization was then compared against histopathologic findings, concurrent CT, and/or MR images or follow-up imaging to assess diagnostic accuracy of CEUS LI-RADS. In addition, the proportion of HCC in all LI-RADS (LR) categories, univariable and multivariable feature analysis, and interrater agreement using Light κ were determined.

Results

The LR-5 category, determined through radiologist categorization of nodules using the CEUS LI-RADS criteria, showed sensitivity, specificity, positive predictive value, and negative predictive value of 86% (119 of 139), 96% (55 of 57), 98% (119 of 121), and 73% (55 of 75), respectively, for the diagnosis of HCC. Two false-positive cases of LR-5 included a cholangiocarcinoma and a combined hepatocellular and cholangiocarcinoma. The remainder of the cholangiocarcinomas in the sample (n = 8) were appropriately categorized as LR-M. Multivariable logistic regression analysis showed that washout of greater than 60 seconds was the contrast-enhanced US feature most predictive of HCC diagnosis, whereas washout of less than 60 seconds was the feature most predictive of nonhepatocellular malignancy. The proportion of HCC nodules categorized in the LR-M and LR-4 categories was 35% and 20%, respectively. Light κ agreement between readers for LI-RADS categorization was 90%.

Conclusion

This study showed excellent specificity for the CEUS LI-RADS LR-5 category, allowing for confident imaging diagnosis of HCC, without necessity for pathologic confirmation. In addition, there was accurate differentiation of HCC from non-HCC malignancies and benign nodules. Only a single cholangiocarcinoma was misdiagnosed as category LR-5, with the remainder of the cholangiocarcinomas in the sample appropriately characterized as category LR-M.Keywords: Abdomen/GI, Evidence Based Medicine, Liver, Neoplasms-Primary, Ultrasound-Contrast© RSNA, 2020.

Myeloproliferative Neoplasms: A Primer for Radiologists

The myeloproliferative neoplasms (MPNs) are a heterogeneous group of diseases including polycythemia vera, essential thrombocythemia, and primary myelofibrosis. Knowledge of the radiological and clinical features of MPNs and their associated complications is critical for interpreting radiologists. The purpose of this article is to provide a primer to radiologists summarizing the modern understanding of MPNs from an imaging-based perspective, including common disease-related findings and complications related to hematopoietic cell transplant.

Tumor thrombus in the venous drainage pathways of primary, recurrent and metastatic disease on routine oncologic imaging studies: beyond hepatocellular and renal cell carcinomas

Radiologists routinely evaluate for tumor thrombus in the portal and hepatic veins in patients with hepatocellular carcinoma and in the renal vein and inferior vena cava in patients with renal cell carcinoma. However, tumor thrombus occurs in association with numerous other tumor types, e.g. colorectal carcinoma and pancreatic neuroendocrine tumor. Furthermore tumor thrombi are not limited to the primary tumor but also seen with local recurrence and metastatic disease. While less recognized, these thrombi nevertheless affect patterns of recurrence and prognosis. Their detection is critical for accurate local staging and early detection of local recurrence and metastatic disease. The purpose of this pictorial review is to draw the attention of radiologists to the less familiar manifestations of tumor thrombus, review the imaging findings and illustrate the clinical significance of these thrombi.

Imaging of hepatic toxicity of systemic therapy in a tertiary cancer centre: chemotherapy, haematopoietic stem cell transplantation, molecular targeted therapies, and immune checkpoint inhibitors

The purpose of this review is to familiarise radiologists with the spectrum of hepatic toxicity seen in the oncology setting, in view of the different systemic therapies used in cancer patients. Drug-induced liver injury can manifest in various forms, and anti-neoplastic agents are associated with different types of hepatotoxicity. Although chemotherapy-induced liver injury can present as hepatitis, steatosis, sinusoidal obstruction syndrome, and chronic parenchymal damages, molecular targeted therapy-associated liver toxicity ranges from mild liver function test elevation to fulminant life-threatening acute liver failure. The recent arrival of immune checkpoint inhibitors in oncology has introduced a new range of immune-related adverse events, with differing mechanisms of liver toxicity and varied imaging presentation of liver injury. High-dose chemotherapy regimens for haematopoietic stem cell transplantation are associated with sinusoidal obstruction syndrome. Management of hepatic toxicity depends on the clinical scenario, the drug in use, and the severity of the findings. In this article, we will (1) present the most common types of oncological drugs associated with hepatic toxicity and associated liver injuries; (2) illustrate imaging findings of hepatic toxicities and the possible differential diagnosis; and (3) provide a guide for management of these conditions.