Presentation
Abdominal pain for past week.
Patient Data
Liver has serrated border.
Numerous, small, rounded masses, both hyperdense and hypodense, dispersed throughout both hepatic lobes. Large conglomerate of masses in and around segment 8. The masses show hyperenhancement on arterial phase with substantial washout on portal phase. A minority of them have hypodense center. No appreciable mass effect on portal or hepatic veins.
Very few hepatic hilar lymph nodes up to 10 mm in small axis diameter and non-enlarged hepatogastric lymph nodes. Said nodes are elongated but are also hyperenhancing.
Common origin of right hepatic artery (RHA) and left gastric artery (LGA), right of celiac trunk origin. Origin of right inferior phrenic artery (IPA) from common RHA-LGA trunk.
Disc bulge at L4-L5 level, exerting mild pressure on the thecal sac and narrowing the neural foramina.
Case Discussion
Complained of colicky abdominal pain radiating to the right shoulder and nausea for the past week. Vital signs normal. On examination, impression of tenderness with guarding; hard to tell if peritoneal irritation. CRP 41, liver function tests: AST 91 U/L, ALT 77 U/L, GGT 319 U/L, Alkaline phosphatase 149. History of hepatitis B virus (HBV). Currently not on any medication.
A triple-phase liver CT protocol was done, which showed innumerable small round masses scattered in a cirrhotic liver, suggestive of infiltrative HCC, possibly with regional lymph node spread. A CT chest was done (not shown here), which showed no metastatic spread to the chest.
A biopsy was obtained from a liver mass.
Histopathology:
Carcinoma probably of liver origin.
Immunostains:
Pankeratin, hepatocyte positive. CK19 negative. Glypican-3 inconclusive.
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