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Case 217

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Male patient, 61 years-old, diagnosed with hepatitis C 23 years ago. Currently has cirrhosis with mild portal hypertension and small-caliber esophageal varices, but remains well adjusted (Child-Pugh score A5). In the ultrassound screening, a solid hyperechoid nodule between segments VIII and IV of the liver was identified. A magnetic resonance imaging of the abdomen with the injection of paramagnetic contrast was requested to better identify the lesion (Images attached).

Taking into consideration the images and the patient data, what is the most likely diagnosis of the lesion?

a) Hepatocellular carcinoma

25%

b) Metastatic tumor

25%

c) Hepatic hemangioma

25%

d) Cholangiocarcinoma

25%
   

Image analysis

Image 1: Magnetic Resonance Imaging of the abdomen, weighted in T1, after contrast injection, arterial phase. We can observe the aorta (red circle) enhanced by th contrast, while the vena cava and the portal vein, as well as the liver parenchyma, present their usual signal intensities, demonstrating that the sequence is in the arterial phase. One can obsere a nodule of approximately 3cm between liver segments VIII and IV (green circle), with well-defined limits and important gadolinium enhancement. It is noteworthy that the liver's dimensions are slightly reduced. 

 

 

Image 2: Magnetic Resonance Imaging of the abdomen, weighted in T1, after contrast injection, portal phase. In this image the portal vein (blue arrow) and the liver parenchyma are highlighted, while the vena cava (red circle) is not fully highlighted by contrast, characterizing the portal phase of the study. Note that, in this image, the nodule's signal (green circle) is smaller than the parenchymal, due to the washout phenomenon (rapid clearance of the contrast). This behavior is tipical (96%) of the hepatocellular carcinoma (HCC), since its blood supply is primarily arterial, while the liver's is mainly portal. Finally, there is a thin peripheral enhanced layer around the lesion, the pseudocapsule, a little less specific, but frequent feature, in HCC.

Highlights 

  • - HCC is the most prevalent primary liver tumor (70 to 85% of cases);

  • - HCC's peak of incidence is at age 70 and it is 2 to 4 times more prevalent in males;

  • - It occurs most often associated with liver cirrhosis;

  • - Imaging for diagnosis: CT and contrasted MRI. It tipically occurs as a well-defined nodule, hypervascular with the washout phenomenon;

  • - Alpha fetoprotein can be used to assist in the diagnosis, but presents too many false positives and negatives;

  • - The main curative treatment currently are radiofrequency ablation, nodule resection and liver transplantation. 

References

  • - Gomes MA, Priolli DG, Tralhão JG, Botelho MF. Carcinoma hepatocelular: epidemiologia, biologia, diagnóstico e terapias. Rev Assoc Med Bras.2013;59(5):514–524.

  • - Kulik LM, Chokechanachaisakul A. Evaluation and Management of Hepatocellular Carcinoma. Clin liver dis. 2015; 19: 23-43.

  • - Paranagua-Vezozzo DC, Ono SK, Alvarado-Mora MV, Farias AQ, Cunha-Silva M, França JID, Alves VAF, Sherman M, Carrilho FJ. Epidemiology of HCC in Brazil: incidence and risk factors in a ten-year cohort. Ann hepatol. 2014; 13 (4): 386-393.

Authors

  • Felipe Gonçalves Martins, 4th year medical student at UFMG.

  • E-mail: felipemartins.md[at]gmail.com

  • Fernanda Alves Morais Ferreira, 4th year medical student at UFMG.

  • E-mail: falvesmferreira[at]gmail.com

  • Thamires Marx da Silva Santos, 4th year medical student at UFMG.

  • E-mail: tatamarx[at]gmail.com

  • André Ribeiro Guimarães, 6th year medical student at UFMG.

  • E-mail: guimaraesandrer[at]hotmail.com

Supervisor

Rodrigo Dias Cambraia, hepatologist at the Alpha Institute of Gastroenterology of HC-UFMG.

E-mail: rdcambraia[at]gmail.com 

Reviewers

Bárbara Queiroz, Fellype Borges, Cairo Mendes, Daniela Braga and prof Viviane Parisotto. 

Translated by

Bárbara de Queiroz e Bragaglia, 6th year medical student at UFMG.

E-mail: barbara.bragaglia[at]gmail.com

 

Test question

a)

25%

b)

25%

c)

25%

d)

25%

e)

25%
   

Commentics

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