Sex: female
Age: 64 years
History
Cirrhosis HCV(+).
Laboratory data
Alphafetoprotein 31 ng/ml; albumin 3,2 g/dl; bilirubin 1.9 mg/dl; SGOT 54 U/l SGPT 33 U/l; platelets 67’000 / ccm.
Physical findings
None available.
Case text
Ultrasound showed a solid hypoechoic lesions (IV hepatic segment, 15 mm).
Image 1-2
Spiral CT of the liver.
Arterial phase CT scan (images 1 and 2).
Image 3-6
MRI of the liver.
Unenhanced T2-weighted spin-echo sequence (images 3 and 4).
Contrast enhanced T1-weighted breath-hold gradient-echo sequence (images 5 and 6).
Image 1-2
1. What is the abnormality present on the spiral CT scan?
The arterial phase scans shows a hypervascular lesion (IV hepatic segment) in image 1; no lesion can be visualized in image 2.
2. What is your diagnosis?
Hepatocellular carcinoma.
3. What is the differential diagnosis?
Hepatic hemangioma or hypervascular metastasis.
4. What is your next diagnostic step?
MRI of the liver.
Image 3-6
5. What are the abnormalites present on the MRI of the liver?
TESLASCAN-enhanced Tl-weighted gradient-echo images show 2 hyperintenses lesions, both in the IV hepatic segment (15 mm and 25 mm).
6. Does MRI provide any additional information?
MRI reveals an additional focal liver lesion in the segment IV (25 mm).
7. What is your diagnosis?
Multinodular hepatocellular carcinoma.
8. What is the differential diagnosis?
None. Hemangiomas and metastases show no enhancement after administration of TESLASCAN.
9. What is your next diagnostic step?
Biopsy of lesions.
Final diagnosis
Multinodular hepatocellular carcinoma.
Differential diagnosis
None. Hemangiomas and metastases show no enhancement after administration of TESLASCAN.
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 or dysplastic nodules. Less frequent focal lesions that may be detected in a cirrhotic liver include hemangiomas and metastases. Focal nodular hyperplasia and hepatocellular adenoma do not develop on a cirrhotic background.
The demonstration of arterial hypervascular supply to the tumor by spiral CT may enable one to exclude the diagnosis of macroregenerative or dysplastic nodules, since these lesions do not have arterial neovascularity. However, some small hemangiomas and hypervascular metastases may enhance in arterial-phase spiral CT images, such as HCC. The uptake of TESLASCAN by the lesions definitely indicate that the tumor are or primary hepatocellular origin, since they mantain an hepatobiliary function. This allows to exclude the diagnoses of hemangiomas and metastases and undoubtedly indicate a well-differentiated multinodular HCC.The diagnosis was confirmed at histology.