Hepatocellular carcinoma with metastatic porta-hepatis lymphadenopathy and IHBR dilatation
Presentation
Cirrhotic patient with jaundice and abdominal distension.
Patient Data
Ultrasongraphy revealed:
- Liver cirrhosis, portal hypertension and ascites.
- A right liver lobe segment V well-defined hypoechoic lesion.
- Enlarged porta-hepatis and peri-pancreatic lymphadenopathy with dilated intrahepatic biliary radicles.
- Cirrhotic configuration of the liver with irregular outline, heterogeneous parenchyma and hypertrophied left and caudate lobes.
- A right lobe segment V mild arterially enhancing hypervascular lesion is seen measuring 4 X 3.5 cm. The lesion shows washout in the portal and delayed venous phases with capsular enhancement. The lesion shows heterogenous predominantly hypointense T1 signal with foci of hyperintensity that show signal drop-out in the axial GRE out of phase images indicative of fatty metamorphic changes. It shows T2 mild hyperintensity with a small central T2 bright focus within (nodule within nodule appearance).
- Enlarged porta-hepatis and peri-operative lymph nodes are seen with the largest is 5 X 4 cm seen abutting the pancreatic head. The enlarged porta hepatis lymph nodes show evident restricted diffusion.
- Moderate dilatation of the intra-hepatic biliary radicles.
- Normal pancreas and both kidneys.
- The spleen is surgically removed.
- Mild ascites.
- Umbilical hernia containing small bowel loops and mesenteric fat.
Case Discussion
This case shows typical hepatocellular carcinoma (HCC) on top of cirrhotic liver with porta-hepatis and peri-pancreatic lymphadenopathy as well as dilatation of the intra-hepatic biliary radicles and ascites.
Hyperintensity on both T2- and diffusion-weighted images is helpful in the diagnosis of hypervascular HCC. Fat-containing hypervascular liver lesions that are hypointense on in-phase with further signal drop out in the out-of-phase sequence (chemical shift artefact) are strongly associated with the diagnosis of HCC.
Delayed hypointensity and enhancing rim improve the specificity of diagnosis of small HCC.