Multifocal hepatocellular carcinoma in a cirrhotic liver
A 65 year old male cirrhotic patient with cachexia, abdominal pain and weight loss. Multifocal hypervascular focal hepatic lesions were visible at triphasic CT and the patient is coming for further characterisation by multiphasic MRI. Alpha-fetoprotein (2316.3 ng/ ml).
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- liver cirrhosis, portal hypertension, splenomegaly and mild ascites.
- a right hepatic lobe segment VII 16 mm focal hepatic lesion is seen. The lesion appears hyperintense on GRE T1 in-phase images with evident signal drop in the out-of-phase GRE images (chemical shift artefact); denoting intralesional fat. The lesion is T2 hyperintense.
- post-contrast, the lesion is mildly hypervascular in the arterial phase, with immediate rapid wash out in the portal venous and delayed phases with evident capsular enhancement. This lesion is small fat-containing HCC with typical imaging criteria according to the American association of the study of Liver disease (AASLD).
- another right liver lobe hypervascular focal lesion is seen at segment VII with adjacent tumorous arterio-portal shunt. The lesion shows rapid wash out with capsular enhancement in the portal venous and delayed phases. Also noted is the focal signal drop out in the out-of-phase GRE images.
Diagnosis: Multifocal hepatocellular carcinomas (HCC). The rapid arterial enhancement with rapid wash-out in the portal venous phase for a lesion more than 1 cm in a SINGLE modality; either CT or MRI is virtually diagnostic of hepato-cellular carcinoma (HCC) according to the latest update of the American association of the study of Liver disease (AASLD). Hyperintensity on both T2- and diffusion-weighted images is helpful in the diagnosis of hypervascular HCC smaller than 2 cm. Fat-containing hypervascular liver lesions that are hypointense on in-phase with further signal drop out in the out-of-phase sequence (chemical shift artefact) are strongly associated with the diagnosis of HCC.
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