Presentation
Previously operated renal cell cancer and colorectal cancer, subsequent curative hepatic metastasectomy (path proven RCC mets). Follow-up.
Patient Data
In the right lobe of the liver (segments 5/6) postoperative scarring is visible. Adjacent to the scar confluous ill-defined lesions can be discerned, these are hypoattenuating in the noncontrast scan, moderately hyperenhancing in the arterial phase, and wash out partially by the portal venous phase. Altogether the findings are concerning for recurrence. Also note how using liver window facilitates lesion conspicuity in any phase.
Other findings: prior left nephrectomy and adrenalectomy, status post cholecystectomy and sigmoid resection, known small adrenal adenoma on the right.
CEUS (two weeks later)
- On B-mode multiple hypo/isoechogenic ill-defined lesions are visible in the right lobe of the previously operated liver.
- After administration of contrast (SonoVue) the lesions show early and bright hyperenhancement compared to the normal liver tissue.
- In the portal venous phase pronounced washout corroborates the malignant imaging features.
Case Discussion
Renal cell cancer metastases tend to be hypervascular, which is well illustrated by the dynamic CEUS imaging.
I would like to stress two main points: firstly, liver window (W:150 L:75) is a must, and can facilitate the assessment of the liver in any phase of any CT study where this organ or part of it is depicted. Secondly, picking up true lesion hypervascularity in CT can be challenging, as the lesions blend in soon into the sea of normal hepatic enhancement. Dynamic imaging such as CEUS stands a better chance in this respect.