Presentation
Patient was known case of hemorrhoids. Patient has history of chronic constipation since last 1 year. Now patient presented with the pain in right hypochondrium.
Patient Data
18 x 18 mm sized well defined hyperenhancing lesion noted in anterior rectal wall at 12 o’clock position, approx. 8 cm from anal verge. The lesion bulges anteriorly in perirectal fat. (The lesion is more clearly delineated in rectal contrast study).
Few small heterogeneously enhancing lymph nodes noted in right perirectal fat space.
More laterally in right perirectal fat space, approx. 35 x 25 mm sized irregular marginated heterogeneously enhancing soft tissue density lesion is noted. The lesion invades right internal iliac vein. The lesion also abuts lateral aspect of right seminal vesicle with loss of fat plane – possibility of invasion.
29 x 20 mm sized heterogeneously enhancing enlarged lymph node is noted along right external iliac vessels, antero-lateral to above mentioned lesion.
Contrast filling defect is seen in right internal iliac vein and right common iliac vein – suggestive of thrombosis.
Inferior vena cava shows heterogeneously enhancing lesion completely obliterating its lumen from the level of confluence of bilateral common iliac veins upto the level of joining of left renal vein – suggestive of tumoral thrombosis.
Intraperitoneal dilated collateral vein is noted in right side of abdomen originating from right external iliac vein and draining into inferior vena cava at the joining of right renal vein.
29 x 22 x 17 mm sized well defined hypodense lesion is noted in segment V of liver reaching upto its antero-lateral surface. The lesion shows peripheral enhancement on post-contrast study with internal hypoenhancement as compared to normal liver parenchyma.
Rest of the organs appear normal.
Case Discussion
Small hyperenhancing rectal lesion appears to be primary malignant lesion with metastatic lymph nodes in right perirectal space.
Another irregular marginated lesion in right perirectal space which appears to invade the surrounding structures is likely to be metastatic lymph nodal mass.
Tumor thrombosis in inferior vena cava.
Lesion in liver appears to be metastasis which was the cause for the present complaint of patient.
Biopsy of the rectal lesion was done: Histopathology report with Immunohistochemistry shows Neuroendocrine Tumor, Well Differentiated, WHO grade I with KI 67 index: 2%
As it happens in most of the cases of neuroendocrine tumor, the lesion in rectum was detected incidentally with presenting complaint being the pain in right hypochondrium due to hepatic metastasis.
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