Presentation
Chronic liver cirrhosis with recent treatment with SOVALDI® recently developed abdominal pain
Patient Data
The liver is moderately enlarged measuring 21.5 cm in craniocaudal span with irregular outline, enlarged lateral segment of the left lobe and deepened interlobar fissure. No CT evidence of intrahepatic biliary radicle dilatation.
Multiple ill-defined hypodense infiltrative lesions are seen at both hepatic lobes, the largest one is at the lateral segment of the left lobe, measuring 13.7 x 11.3 cm along maximum dimensions with exophytic components infiltrating the left diaphragmatic copula. They display faint heterogeneous arterial enhancement with wash out of the contrast in the porto-venous and delayed phases.
Total occlusion of the left portal vein with heterogeneously enhancing thrombus. Patent portal vein trunk and the right portal vein.
The spleen is moderately enlarged measuring 18.3 cm with multiple ill-defined hypodense and hypoenhancing focal splenic lesions.
A large left para-aortic soft tissue mass is seen encasing the left renal vessels, measuring 8.3 x 8.1cm along maximum cross-sectional dimensions. It shows heterogeneous enhancement with hypodense areas of breaking down. Other smaller similar aortocaval and peripancreatic soft tissue masses are also seen measuring 3.2 x 2.6 cm and 2.2 x 1.9 cm.
Multiple peritoneal masses are seen at the perihepatic and perisplenic regions are also seen, the largest one measures 4.4 x 3 cm.
Mild ascites.
Nodular thickening of both adrenal glands is noted with the left adrenal gland is seen inseparable from the large left para-aortic soft tissue mass.
Multiple subcutaneous soft tissue masses are seen the largest one is at the right side of the umbilical region measuring 4 cm in diameter.
Multiple bilateral pulmonary nodules are noted with a large left cradio-phrenic mass measuring 6.7 x 3.6 cm.
Case Discussion
Cirrhotic hepatomegaly with multiple bilobar hypovascular infiltrative lesions, consistent with multifocal hepatocellular carcinomas (HCCs) seen invading the left portal vein with probably tumoral/malignant thrombosis (T4).
Multiple para-aortic, aortocaval, peripancreatic and cradio-phrenic masses as described, likely metastatic lymphadenopathy. Mild ascites.
Multiple peritoneal and subcutaneous masses and bilateral basal pulmonary nodules, likely metastatic. Moderate splenomegaly with splenic hypoenhancing and hypovascular soft tissue mass lesions.
The differential diagnosis is less likely malignant lymphoproliferative disorder in a cirrhotic liver with extensive parenchymal deposits and enlarged abdominal lymphadenopathy.
According to the American Joint Commission on Cancer (AJCC) 8th edition staging system for patients with Hepatocellular Carcinoma (HCC), this case is considered T4N1M1 (stage IVB) 1.
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