Sex: female
Age: 74 years
History
Cirrhosis HBV(+)
Laboratory data
Alphafetoprotein 24,1 ng/ml; albumin 3,14 g/dl; bilirubin O,9 mg/dl; SGOT 57 U/l; SGPT 47 U/l; platelets 83’000 / ccm.
Physical findings
None available.
Case text
Ultrasound showed a solid focal liver lesion of the VI hepatic segment , with bulging of the hepatic contour, 20 mm in diameter.
Image 1-2
Spiral CT of the liver.
Arterial phase CT scan (image 1); Portal venous phase CT scan (image 2).
Image 3-5
MRI of the liver, pre and post contrast injection.
T2-weighted fast spin-echo image (image 3).
Unenhanced Tl-weighted breath-hold gradient-echo image (image 4).
Contrast enhanced Tl-weighted breath-hold gradient-echo image (image 5).
Image 1-2
1. What is the abnormality present on the spiral CT scan?
The arterial phase and the portal venous phase show no abnormality (images 1,2). The lesion is not confirmed by spiral CT.
2. What is your diagnosis?
Focal liver lesion.
3.What is your differential diagnosis?
Macrodegenerative or dysplastic nodule or early HCC. False-positive nodular lesion at US is a possible differential diagnosis as well.
4. What is your next diagnostic step?
MRI of the liver.
Image 3-5
5. What are the abnormalites present on the MRI of the liver?
No lesion is seen on the T2-weighted image (image 1). The TESLASCAN-enhanced Tl-weighted gradient-echo shows a slightly hyperintense lesion of the VI hepatic segment (20 mm) (image 3).
6. Does MRI provide any additional information?
Yes, it suspects a focal liver lesion in the VI segment (20 mm).
7. What is your diagnosis?
Macroregenerative nodule in cirrhosis or early HCC.
8. What is the differential diagnosis?
None.
9. What is your next diagnostic step?
Biopsy of lesion.
Histology showed early hepatocellular carcinoma. The small hepatocellular carcinoma was subsequently treated by percutaneous ethanol injection.
Final diagnosis
Early hepatocellular carcinoma.
Differential diagnosis
Macroregenerative/dysplastic nodule.
Discussion
Hepatocellular carcinoma (HCC) is one of the most common neoplasms world wide. This malignancy occurs in association with cirrhosis in more than 90% of patients. Therefore, patients with cirrhosis undergo screening procedures, such as US, for early detection of HCC in a preclinical stage. When a small mass lesion is detected with US in a patient with cirrhosis, the most important differential diagnosis is between HCC and macroregenerative nodule. The demonstration of arterial hypervascular supply to the tumor by spiral CT may enable the diagnosis of HCC. However, some well-differentiated tumors, termed "early HCC" may fail to enhance as they did not yet develop an arterial neovascular supply ("immature" neovascularity). In our case, the lesion failed to enhance in the arterial phase. TESLASCAN-enhanced MRI showed uptake of contrast by the tumor (The lesion is only slightly hyperintense compared to the liver parenchma, since the normal parenchyma enhances after TESLASCAN injection as well.) Uptake of TESLASCAN indicates that the tumor has hepatobiliary function. This does fit with the diagnosis of early, well-differentiated HCC or a macroregenerative/dysplastic nodule. The diagnosis can not be further specified by TESLASCAN-enhanced MRI.