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Case 357

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83 year-old male patient, admitted at the Emergency Room with right hypochondrium intense pain. Physical examination reveals painless hepatomegaly, without further alterations. Murphy and Courvoisier signs were both negative. Personal history of chronic kidney disease stage 4, hypertension and abdominal aorta prothesis. Social drinker, former smoker, denies liver diseases or family history of those. Liver enzymes altered, anaemia and alpha-fetoprotein within normal range. Imaging exams are shown as requested.

Considering the clinical data and the images, the most adequate conduct to better elucidate the diagnosis is:

a) Percutaneous core needle biopsy

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b) Laparotomy with right lobectomy

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c) Contrast enhanced magnetic resonance imaging

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d) Contrast enhanced ultrasound

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Image analysis

 

Image 1 - Analysis: Upper abdomen ultrasound. Liver, cross sectional (A) and gallbladder, longitudinal sectional (B). (A): Small accumulation of homogeneous liquid, without septum, compatible with mild ascites. 

 

Image 2 - Analysis: Upper abdomen ultrasound. Liver, right lobe, B-mode study (1a, 2a, 3a) and Power Doppler (1b, 2b, 3b). (1a): heterogeneous mass, mainly echogenic with halo and central barely defined hypoechogenic areas, with well-established limits, measuring 4.1 x 4.1 x 4.2 cm (red circle). Power Doppler study (1b): small flux in the hepatic capsule, next to the lesion periphery (white arrow). (2a): round hypoechogenic mass, well delimitated, heterogeneous, without posterior acoustic shadowing, measuring 4.1 x 4.2 x 5.2 cm (yellow circle). Doppler study (2b):peripheric lesion flux capitation, possibly related to it (blue arrow). (3a): round, well defined and heterogeneous hypoechogenic mass, without posterior acoustic shadowing, measuring 5.1 x 7.1 x 5.3 (green circle). Doppler study (3b): central and peripheric vascularization in the lesion (yellow arrows).

 

Image 3 - Analysis: Abdominopelvic magnetic resonance imaging (MRI), T2-weighted, no contrast. Axial view of the upper abdomen (A) and abdominopelvic coronal view (B). Liver with usual dimensions, partially lobed contours secondary to multiple round heterogeneous and confluent lesions in the right lobe (red circle), compromising segments V and VI, with multiple permeation haemorrhagic focus measuring, altogether, 10.5 x 7.8 cm at its larger axial dimensions. Magnetic susceptibility artefacts (blue circle) related to the presence of aortic endoprosthesis limiting the visualization of the left lobe. In the kidneys, presence of multiple cortical cysts (yellow arrows), some with fine permeation septum, the largest measuring 5.7 cm on the right and 7.1 cm on the left.

 

Image 4 - Analysis: Abdominopelvic multislice computed tomography (CT), no contrast. Axial view of upper abdomen (A) and abdominopelvic coronal view (B). Liver with increased dimensions, partially lobed contours presenting hypodense lesion with amorphous calcification on the right lobe (circled in red), compromising segments V and VI. Presence of aortic and bi-iliac endoprosthesis (yellow arrows) as treatment for aortic aneurysmatic dilatation.

Highlights

-   Focal lesions of the liver are usually incidental findings and most of them correspond to benign nodules in asymptomatic patients;

-   Metastatic tumours are the most common cancers in the liver, in which the original site must be evaluated;

-   Hepatocellular carcinoma is the main primary liver cancer and has in cirrhosis an important cause;

-   Liver nodules propaedeutics is wide and must assess clinical data, laboratorial tests, imaging findings and, in some cases histology;

-  Contrast enhanced ultrasound is, when available, an alternative to the usual imaging methods in patients in whom iodine and gadolinium based contrast are contraindicated and Doppler evaluation is inconclusive.

References

-Forones N, Santos N. Hepatocarcinoma. In: Miszputen S, ed. by. Gastroenterologia. 2nd ed. São Paulo: Manole; 2007. p. 199-203.

- Souza e Silva I, Matos C, Szejnfeld D, Carvalho S. Lesões focais do fígado. In: Ferraz M, Silva A, Schiavon J, ed. by. Manual de Hepatologia para Clínicos e Residentes. 1st ed. Rio de Janeiro: Atheneu; 2018. p. 643-654.

- Schwartz J, Kruskal J. Solid liver lesions: Differential diagnosis and evaluation [Internet]. Uptodate.com. 2018 [cited 28 June 2018]. Available from: http://bit.ly/2lFFFRG.

- Marrero J, Ahn J, Rajender Reddy K. ACG Clinical Guideline: The Diagnosis and Management of Focal Liver Lesions. The American Journal of Gastroenterology. 2014;109(9):1328-1347.

- Friedrich-Rust M, Klopffleisch T, Nierhoff J, Herrmann E, Vermehren J, Schneider M et al. Contrast-Enhanced Ultrasound for the differentiation of benign and malignant focal liver lesions: a meta-analysis. Liver International. 2013;33(5):739-755.

- D’Ippolito, Giuseppe; Caldana, Rogério Pedreschi. Gastrointestinal. Rio de Janeiro: Elsevier, 2011. (Colégio Brasileiro de Radiologia e Diagnóstico por Imagem).

Author

Bruno Campos Santos, 6thyear medical student at Universidade Federal de Minas Gerais.

Email: bruno_campos[at]outlook.com

 

Paula Meyer de Lima Silveira,6thyear medical student at Universidade Federal de Minas Gerais.

Email:paula-meyer[at]hotmail.com

Supervisor

Guilherme Grossi Lopes Cançado, MD, M.Sc., Gastroenterologist at the Hospital das Clínicas da Universidade Federal de Minas Gerais and the Military Police Hospital.

Email: guilhermegrossi[at]terra.com.br

 

Tulio Bernardino, MD, Assistant Professor at the Anatomy and Imaging Department of the Medical School of UFMG.

Email:ituliob[at]gmail.com

Reviewers

Mateus Nardelli, Izabella Costa, Eduardo Paolinelli, Fernando Amorim, Ariádna Andrade, Viviane Santuari Parisotto Marino, MD, Ph.D.

Translated by

Bruno Campos Santos, 5thyear medical student at Universidade Federal de Minas Gerais.

E-mail: bruno_campos[at]outlook.com

Test question

a)

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b)

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c)

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d)

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e)

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Commentics

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