Multifocal hepatocellular carcinoma

Case contributed by Dr Safwat Mohammad Almoghazy

Presentation

A case of suspected liver nodule and elevated AFT for MRI liver to rule out HCC.

Patient Data

Age: 60 years
Gender: Male

The liver is mildly enlarged size, showing cirrhotic features in the form of a serrated outline with multiple small dysplastic nodules scattered in the liver parenchyma. Multiple focal lesions seen in multiple segments mainly at IV, V, and VI,  the largest is seen at segment IVb/V measuring about 6.0 x 5.0 cm. these masses display intermediate signal intensity in T2WI,  hypointense signal in  T1WI and show early enhancement followed by washout. There is evidence of restricted diffusion.

One of the lesions is seen inseparable from the anterior branch of the right portal vein which shows marginal enhancement and central wash out with a lack of normal enhancement pattern, denoting malignant thrombosis.

The portal vein is dilated measuring about 1.8 cm. the spleen is enlarged with dilated portosystemic collaterals suggestive of portal hypertension.

No ascites or peritoneal deposits. No pathologically significantly enlarged periaortic lymphadenopathy seen.

Impression:    

 

  1. Findings mentioned above impressive of multifocal hepatocellular carcinoma with malignant thrombus at the anterior branch of the right portal vein.
  2. Features of portal hypertension.

The liver is enlarged and showed mild irregularity along its surface suggestive of cirrhotic features. 4.6 x 3.4 cm lesion is seen in liver segment 6 reaching to the capsule that showed early arterial enhancement and washout in the portal venous and delayed phase, the lesion just abutting the colon, this lesion is highly suspicious of HCC.

There is evidence of large heterogeneously enhancing predominantly hyperdense in the arterial phase and showed early wash out in the portal venous and delayed phase is seen at segment 5 and 8 reaching to the capsule measuring approximately 6.0 x 6.2 cm in maximum AP and transverse diameter also it is seen abutting the gall bladder at a certain region. Along the superior medial aspect of this lesion, there is evidence of tubular hypodense structure showed mild enhancement, likely representing a thrombosed segment of the anterior right portal vein branch. The portal vein, main right, and left portal veins are normally opacified with no evidence of thrombus, yet the portal vein calibre measuring 13.5 mm

At segment 6 there is evidence of 2.7 x 2.6 cm lesion that showed faint hypodensity in the arterial phase that showed mild enhancement in the portal venous phases and decreases enhancement in the delayed phase. This lesion due to its size likely representing HCC versus being regenerating module.

Evidence of small subcapsular lesion seen at left lobe segment 3 measuring approximately
12 x 11 mm that showed arterial enhancement and washout in the portal venous and
delayed phase mostly representing HCC.

Small stone is seen at the neck of the gallbladder.

Conclusion:

  1. Cirrhotic liver (nodular) with multiple hypervascular masses in the right hepatic lobe.
  2. Filling defect in portal vein branches suggestive of malignant thrombus.

Case Discussion

This male patient with elevated AFT and suspected of hepatocellular carcinoma (HCC), which was confirmed on both MRI and CT with typical features of multifocal HCC. Subsequently, the patient underwent management of HCC. 

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Case information

rID: 54908
Case created: 5th Aug 2017
Last edited: 10th Sep 2017
Inclusion in quiz mode: Included

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