Metastatic colon carcinoma

Case contributed by Dr Jan Frank Gerstenmaier

Presentation

History of colon cancer. Liver lesions were found on ultrasound performed for abdominal pain.

Patient Data

Age: 72
Gender: Female

Ultrasound

Modality: Ultrasound

Liver was of normal size and echogenicity. A 2 cm low echogenicity lesion with irregular margins is seen in segment 6 of the liver. Appearance is non-specific but a metastatic deposit is in the differential diagnosis.

Abdominal CT is not available for direct correlation. It is not seen on the arterial phase liver images of the chest CT.

Intrahepatic biliary ducts are of normal calibre. However there was ring down artefact from a number of ducts. This is not due to gas. Small calculi are another possibility but appearance is otherwise non-specific for biliary pathology. Extrahepatic biliary ducts are of normal calibre with the common hepatic duct measuring 4 mm in diameter.

Gallbladder was mildly thickwalled consistent with chronic cholecystitis. It contained a single large calculus measuring 3.5 cm in diameter. The gallbladder wall was not calcified and there was no focal gallbladder mass although a small mass could be obscured by the large calculus.

Main portal vein that measured 8 mm in diameter.

Flow direction the main portal vein was normal.

No collateral vessels identified and no free intraperitoneal fluid.

Biliary ducts were of normal calibre with the common hepatic duct measuring gap 2 in diameter.

Pancreas was normal in appearance.

Right kidney measured approximately 9 cm and left kidney 10.5 cm in length. No focal renal lesion or hydronephrosis. Spleen measured 4.5 cm in coronal length.

Abdominal aorta measured up to 1.5 centimetres in transverse diameter.

Conclusion: Large gallstone within the gallbladder. Single 2 cm low echogenicity lesion in segment 6 of the liver. Suggest correlation with the recent abdominal CT.

 

CT LIVER

Modality: CT

Two hypodense segment VI liver lesions are identified. Inferiorly a well-circumscribed 12mm lesion correlates with the lesion seen on US. More superiorly, in close proximity to the caudate lobe, is a smaller 10mm lesion. Both lesion are hypodense on all phases with no arterial enhancement and are highly suspicious of metastases in the known context of malignancy. Appearances are not typical of cysts or haemangiomas.A tiny 3mm focal hypodensity within segment VII peripherally is too small to characterise.A 13mm focus of para-falciform low attenuation is characteristic of focal fatty infiltration.Portal vein and hepatic veins appear unremarkable.Large 3cm gallstone again noted.The other imaged abdominal viscera are unremarkable.

Conclusion:

Two hypodense, non/minimally enhancing segment VI liver lesions measuring 12mm and 10mm are of uncertain nature (no ring enhancement) but remain suspicious for metastatic disease in the context of known colorectal cancer. Correlation with contrast enhanced US is suggested.

PET/CT

Modality: Nuclear medicine

Focal increased radio-tracer uptake in segment VI/I consistent with a metastasis.

The patient underwent right hemihepatectomy

Pathology findings:

Right hemihepatectomy 1. Half of caudate lobe 2. Gallbladder 3. Right liver MACROSCOPIC DESCRIPTION: 1. "Half of caudate lobe, right hepatectomy": Three specimens received: Specimen 1 is a discoid subcapsular semicircular fragment of liver 30x20x12mm. Sectioning shows non cirrhotic slightly fatty liver parenchyma. No focal lesions are seen. Specimen 2 is a right hepatectomy with a surgical resection face 140x60mm. The liver is 95mm from medial to lateral. Most of the liver is covered by capsule. Sectioning shows non cirrhotic liver with two nodules. One is in the posterior mid liver and is 17x14x14mm. The nodule extends to within 1mm of the capsular surface of the liver and 9mm from the resection face. Second nodule is in the inferior mid portion of the liver and is 20x15x15mm. This is 10mm from the capsular surface and 15mm from the closest resection margin. Specimen 3 is a detached gallbladder is received 95mm x 40 x 30mm. Gallbladder wall is 2-3mm in thickness. A single pigment cholesterol stone is present measuring 40mm in maximal dimension. BLOCK DESIGNATION: A - Caudate lobe B-C - Superior nodule and closest margin D - Inferior nodule E - Gallbladder neck, body and fundus 2. "Abdominal lymph node": Specimen is a nodule 17x12x7mm. Multiple TS. (SD) MICROSCOPIC DESCRIPTION: 1. Liver parenchyma with two deposits of focally necrotic moderately differentiated adenocarcinoma maximum dimensions 17mm and 20mm. The resection margins are clear. The remaining liver parenchyma including the caudate lobe specimen show normal lobular architecture, normal portal tracts and focal macrovesicular fatty change. The gallbladder specimen has almost completely denuded mucosa, Rokitansky-aschoff sinuses, mild mural fibrosis and minimal inflammation. 2. Necrotic focally calcified adipose tissue surrounded by fibrous tissue with adjacent normal adipose tissue. No lymph node identified. DIAGNOSIS: 1. Half of caudate lobe, right hepatectomy and gallbladder: * Metastatic moderately differentiated adenocarcinoma consistent with a colorectal primary tumour. - 17mm and 20mm in maximum dimension. - Clear of resection margins. - Mild macrovesicular fatty change. * Chronic cholecystitis and cholelithiasis. 2. Abdominal lymph node: Encysted fat necrosis.

Case Discussion

CT, US and EPT/CT appearaances of a colon carcinoma metastasis

PlayAdd to Share

Case Information

rID: 30998
Case created: 15th Sep 2014
Last edited: 10th Feb 2016
Inclusion in quiz mode: Included

Updating… Please wait.
Loadinganimation

Alert accept

Error Unable to process the form. Check for errors and try again.

Alert accept Thank you for updating your details.