Presentation
Double lung transplant 6 months prior for cystic fibrosis. Persistently raised CRP. Currently anemic, lymphopaenic, and thrombocytopaenic. Epstein-Barr virus DNA is positive.
Patient Data
Moderate left and small right pleural effusions.
Patchy consolidation in the right upper lobe is adjacent to the oblique fissure, with smaller ground-glass foci in the right upper lobe more superiorly. Bilateral lower lobe atelectasis, more so on the left than the right. Fluid tracking in the oblique fissure is bilateral. No cavitation. No airway dilatation, significant wall thickening, or frank airway plugging.
Mildly enlarged mediastinal nodes are likely reactive. Trace pericardial fluid.
Impression of 3.2 cm diameter area of hypoattenuation in the right lobe of the liver on this unenhanced exam, indeterminate appearance. Apparently, there is an irregular liver contour.
Opinion:
Bilateral pleural effusions and bilateral lower lobe compressive atelectasis with areas of consolidation in the right upper lobe, the appearances are altogether nonspecific. No cavitation.
Incidental indeterminate hypoattenuating area in the right lobe of the liver. The background liver contour appears irregular; is there a history of cirrhosis?
At least seven hypodense liver lesions were demonstrated, mainly in the right lobe of the liver. Nodular background liver, as noted previously, suggests cirrhosis. Patent hepatic vasculature.
At least three similar-appearing hypodense splenic lesions were seen. The spleen is enlarged, but there are no significant-sized portosystemic collaterals.
Tiny bilateral non-obstructing renal calculi were noted. The rest of the solid abdominal organs are unremarkable. Small-volume upper abdominal lymph nodes are nonspecific in the setting of chronic liver disease. No significant retroperitoneal lymphadenopathy. Small amount of ascites is present. The bowels are unremarkable.
There are moderately sized bilateral pleural effusions with some enhancement and complexity. Foci of enhancement are seen in the right pleural cavity with septa. Further posterior mediastinal-enhancing nodules are seen on the left.
Unremarkable bone review.
Conclusion:
Appearances are most likely to represent a post-transplant lymphoproliferative disorder. Appearances would be unusual for HCC.
Case Discussion
The patient proceeded with a US-guided liver biopsy. The pathology report stated that the tumor cells were poorly differentiated and showed sheet-like growth between liver cells. On immunohistochemistry, the cells were positive for CD45 and negative for AE1/3, confirming hematopoietic malignancy and giving a diagnosis of post-transplant lymphoproliferative disorder.
This case demonstrates the importance of reviewing the upper abdomen on CT chest imaging, even on unenhanced studies; in this case, assessing the liver on liver window settings made the very subtly hypoattenuating lesion on the CT chest more conspicuous.
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