Presentation
Abdominal pain in an end-stage renal failure patient on dialysis.
Patient Data
Cirrhotic liver. Subcapsular slightly hypodense mass in segment 8 measuring 4.2 x 4.4 x 3.2 (TRV x AP x CC) cm, mildly hyperenhancing at the arterial phase and already hypoenhancing at the portal phase. Radiographic features and presence of cirrhosis favor hepatocellular carcinoma (HCC), with focal nodular hyperplasia (FNH) on the differential list.
Ascites, moderate amount. Extensive omental stranding, probably due to ascites alone.
The gallbladder contains small stones.
The spleen is enlarged, of normal density.
Atrophic kidneys.
Several diverticula in the distal descending and proximal sigmoid colon.
Status post prostatectomy. Few gold seeds for brachytherapy have remained in situ.
Chronic compression fracture of L3 vertebra, with moderate loss of height. Anterolisthesis, grade 1, of L4 on L5.
Healed fractures in several consecutive ribs on both sides. Old fractures with nonunion in superior and inferior right pubic rami
The hepatic mass was biopsied. Histopathology: hepatocellular carcinoma. Further imaging and cytology samples from several sessions of paracentesis showed no evidence of metastatic disease.
The patient received one round of transcatheter arterial chemoembolization (TACE).
Had a repeat CT abdomen for abdominal pain and vomiting one month after the previous exam shown above.
In comparison with the previous CT exam:
The subcapsular mass shows iodized oil (strikingly hyperdense material) accumulation almost in its entirety, except in a small area in its anterior aspect which, importantly, does not enhance. Additional subtle perilesional subcapsular accumulation of iodized oil.
Ascites, large amount.
Case Discussion
This case shows the changes in appearance of hepatocellular carcinoma after the accumulation of iodized oil in the mass from one round of transcatheter arterial chemoembolization (TACE). This treatment method has shown to be superior to others for selected cases. There are even studies showing comparable efficacy of arterial embolization alone, without a chemotherapeutic agent.
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