Presentation
History of alcoholism, weight loss, and elevated liver enzymes.
Patient Data
Multiple predominantly arterial enhancing masses throughout the liver, with a large conglomerate occupying the majority of the right hepatic lobe. This majority of this large conglomerate has arterial enhancement and washout on portal venous phase imaging. A few other satellite lesions have more heterogeneous enhancement, with areas of enhancement or hypoenhancement on both arterial and portal venous phase imaging. Example smaller lesion with homogeneous arterial enhancement and washout on portal venous phase images (classic for HCC) is noted along the anterior aspect of segment 2-3, with slight contour deformity of the liver capsule.
Mass effect on the hepatic and portal veins without definite tumor thrombus.
New rounded mass in the left adrenal gland. No abdominal adenopathy. No findings of metastases elsewhere.
Case Discussion
Three categories of macroscopic growth of hepatocellular carcinoma: Nodular, mass effect, and infiltrative. Infiltrative HCC as characterized by the spread of minute tumor nodules throughout the liver. It has an aggressive course and substantially worse prognosis than nodular HCC.
On imaging, it can have an ill-defined appearance spreading over multiple hepatic segments or occupying entire lobes of the liver. The classic findings of hepatocellular carcinoma (arterial enhancement and washout on delayed phase imaging) may not be present with infiltrative tumor, likely due to alterations in normal perfusion/frequent presence of portal vein thrombosis.
In this case, large portions of the lesion have arterial enhancement and washout, and others do not, perhaps due to the lack of portal vein thrombosis. Multiple satellite lesions are also common.
In some cases, it can be difficult to distinguish from cirrhosis due to the permeative appearance. In this case, the patient does not have gross morphologic changes of cirrhosis, although he has a history of alcohol abuse and is at risk for HCC. It is reasonable in the setting to confirm the diagnosis ultrasound-guided biopsy.
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