Obstructive jaundice and right hypochondrial discomfort.
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Right lobe of liver shows an infiltrating retractile mass lesion with heterogeneous enhancement. The lateral, superior and inferior margins of the lesion show enhancement in delayed phase whereas the medial aspect of the lesion close to the left lobe shows arterial phase enhancement with washout in subsequent phases.
Lesion measures approximately 10 x 6 cm and is seen to infiltrate and obliterate the right hepatic duct and extend into the porta hepatis where it infiltrates the proximal common bile duct with resultant IHBR dilatation in the left lobe of the liver. CBD stent seen in situ.
Right portal vein, right hepatic artery are seen passing through the tumour without significant luminal narrowing. Right and middle hepatic veins are infiltrated and obliterated by the tumour. Main portal vein, common hepatic artery and their branches supplying the left lobe are free of tumour.
Multiple other ring enhancing lesion are scattered in both lobes of liver suggestive of metastasis
The following findings were discussed with hepatobiliary surgeons in favor of cholangiohepatoma:
- Capsular retraction, delayed central enhancement, absence of capsule and infiltration of CBD at porta were in favor of cholangiocarcinoma. Also, the ring enhancing metastasis also favors cholangiocarcinoma.
- Arterial enhancement and washout in subsequent phases in some areas of the tumour favours hepatocellular carcinoma.
- Ca19-9 and AFP were both elevated.
US guided Tru-cut biopsy from the deposit in the left lobe of the liver was performed and showed:
Liver biopsy showing mixed hepatocellular and cholangiocarcinoma. Sections show liver tissue with multiple foci of tumor composed of pleomorphic cells arranged in glandular pattern and intervened by desmoplastic stroma. The adjacent liver tissue also shows multiple foci of dysplastic / neoplastic hepatocytes arranged in trabeculae and pseudoacinar pattern.
Patient was started on chemotherapy thereafter.