Presentation
Cirrhotic patient, 6 months US screening.
Patient Data
Features of cirrhosis with a mass lesion in segment VI abutting the liver capsule and measuring 3.1 cm. No other focal lesions. Portal vein is patent and has anterograde flow, no recanalization of the paraumbilical vein. Normal spleen.
Segment VI well-defined mass lesion measuring 4 cm with a marked central arterial enhancement that washes out partially on the portal venous phase, with persistent rim enhancement. On delayed hepatobiliary phase there is some retained uptake. Central patchy restricted diffusion. No other lesions.
LI-RADS 5
Macroscopy: Labeled "Segment 6 liver tumor". A liver wedge 57 x 55 x 37 mm with a capsular surface on 2 sides. Distorting the capsule on one side is a nodule 40 x 35 mm. At the top of the nodule is an area of the disrupted capsule 23 x 13 mm (inked green). The cut surface underlying the nodule shows an ovoid mass 45 x 36 x 30 mm. The mass is present 2 mm from the resection margin (inked black). The surrounding parenchyma composed of tan nodues to 3 mm.
Microscopy: Sections show a solitary, rounded hepatocellular tumor deep to the capsule. The tumor is composed of atypical hepatocytes forming thick trabeculae, solid nests and microacinar arrangements with luminal bile. Tumor cells have moderately pleomorphic nuclei with prominent nucleoli. Tumor is 2 mm clear of the parenchymal resection margin. There is a disruption of the overlying fibrous capsule at least 10 mm in diameter (A3). No lymphovascular or perineural invasion is identified. The surrounding liver tissue is composed of hepatocellular nodules separated by thick fibrous septa. There is macrovesicular steatosis involving approximately 5% of hepatocytes.
Conclusion: Segment 6 liver tumor, excision:
Moderately differentiated hepatocellular carcinoma, 45 mm in size.
- Resection margin clear (2 mm).
- Disruption of the overlying hepatic capsule (see comment).
- Surrounding liver shows cirrhosis with mild steatosis.
- AJCC 8th edition: pT1b
Case Discussion
Screening ultrasound in a cirrhotic patient has flagged a new lesion - this was further worked out with MRI which confirmed the lesion to be consistent with HCC (LI-RADS 5).
A note is made that the use of hepatobiliary agent (Primovist), as in this case, only plays with ancillary features on the application of the LI-RADS.
This patient was offered surgery over percutaneous ablation given the size of the lesion.
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