Hepatocellular carcinoma developing in a cirrhotic liver

Case contributed by Dr Andrew Lawson


Hep C, for liver surveillance.

Patient Data

Age: 40
Gender: Male

Coarsely echogenic liver. ARFI value of 3.4.

Focal lesion in the left lobe.

Acoustic Radiation Force Impulse (ARFI):

ARFI reference values: <1.35 - absent or mild fibrosis (F0 or F1) 1.35-1.55 - significant fibrosis (F2) 1.55- 1.80 - severe fibrosis (F3) >1.80 - cirrhosis (F4) These thresholds are not absolute. Based on metanalysis of pooled data which included a predominance of HCV patients - Friedrich-Rust et al J Viral hepatitis 2012, 19 e212-1219 Results should be interpreted in clinical context. Such things as inflammatory activity & venous congestion can elevate the ARFI value.

In segment 2, there is a reasonably well defined hypodense lesion measuring approximately 1.9 cm in size immediately adjacent to the diaphragmatic surface. Adjacent there is some prominent arterial vessels. These vessels are similar to the previous study. There is heterogenous arterial enhancement of the left lobe of the liver. A more focal nodular region of arterial enhancement measuring 8x16mm In segment 4a/2 appears hypodense on the portal venous imaging. The portal vein is still patent. Spleen is not enlarged. In the portal venous imaging, there is some irregular enhancement particularly under the dome near the lesion, with some suggestion on washout on the portal venous imaging.

An irregular segment 2 lesion measuring 39 x 71 x 25 mm demonstrates T2 hyperintensity, arterial phase enhancement portal and portal phase washout. The lesion invades and expands the left hepatic vein and origin of the middle hepatic vein. It extends into the IVC upto the right atrium. The middle hepatic vein poorly enhances. Differential liver parenchymal enhancement of segments 6/7 likely secondary to hepatic vein occlusion. There is a more well defined peripherally septated peripherally enhancing component more anteriorly measures 27 x 35 mm. The appearances are consistent with hepatocellular carcinoma. Multiple enlarged porta hepatis, gastroepiploic and celiac lymph nodes identified. New left 22mm heterogeneously enhancing left adrenal lesion is consistent with metastasis. The biliary system is within normal limits. The common bile duct measures 2.8mm in diameter. No choledocholithiasis. Small volume free perihepatic fluid.

Conclusion: Segment II lesion as described with features consistent with aggressive, rapidly progressive HCC. There is extension of tumor into the left hepatic vein and common channel with the middle hepatic vein, IVC up to the junction with the right atrium. There is bland thrombosis of the distal portion of the middle hepatic vein. Multiple involved locoregional lymph nodes and new left adrenal lesion consistent with metastasis. Probable second HCC within segment 7 as described.

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Case information

rID: 26464
Published: 23rd Dec 2013
Last edited: 14th Aug 2019
Inclusion in quiz mode: Included

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