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Hepatocellular carcinoma with portal vein tumour thromus

Case contributed by Azza Elgendy
Diagnosis almost certain

Presentation

14 year history of hepatitis C virus.

Patient Data

Gender: Male

The liver shows established liver cirrhosis, extensive nodularity, and parenchymal dysmorphism. Large ill-defined infiltrative mass involving the caudate lobe with tumour thrombus extending into the left branch of the portal vein as well as the main portal vein. Early arterial enhancement and washout are seen consistent with HCC. Multiple smaller subcentimetric hypervascular lesions are seen elsewhere in the liver that could be dysplastic nodules rather than multicentric HCC.

Portal hypertension with splenomegaly, opened portosystemic collaterals and ascites. 

Incidentally noted is a small gall bladder stone. 

Case Discussion

Established cirrhotic changes are seen. Ill-defined infiltrative mass involving the caudate lobe with tumour thrombus involving the left branch of portal vein as well as the main portal vein. Satellites are seen elsewhere suggestive of regenerative or dysplastic nodules rather than small multicentric HCC with tumour thrombus. Portal hypertension, splenomegaly and a small volume of ascites.

The differential diagnosis of small hypervascular liver lesions in a cirrhotic liver includes arterioportal shunts or pseudolesions (for very small lesions), dysplastic nodules, and small HCCs. Occasionally, a cirrhotic liver may have preexisting flash-filling haemangiomas that may mimic malignant lesions.    

Multiphasic magnetic resonance imaging (MRI) including DWI is extremely useful in the detection and characterisation of regenerating and dysplastic nodules and small HCCs. 

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