Slide 1

Report
Radiological Category: Abdominal
Principal Modality (1): MRI
Principal Modality (2): CT
Case Report Patient PP
Submitted by:
Matthew Clower, MSIV
Faculty:
Sandra Oldham, MD
Date:
29 August 2007
Presented during Radiology 4001.
Case History
80 year-old Caucasian woman presents to gastroenterologist complaining of
burning epigastric pain, dysphagia, weight loss, and RLQ pain.
PMH of hemicolectomy secondary to diverticulitis, cholecystectomy, and “lowgrade hepatitis.”
Denies EtOH/Tob/Drugs.
Family history of pancreatic and colon cancers.
Physical exam was unremarkable and laboratory studies were within normal limits.
Endoscopic Gastro-Duodenoscopy (EGD) and abdominal CT were ordered.
Case History
On EGD, the patient was found to have a small hiatal hernia. Biopsy of a gastric
polyp showed benign histology.
The following was found on the abdominal CT:
Radiological Presentations
Radiological Presentations
Radiological Presentations
Radiological Presentations
Radiological Presentations
Radiological Presentations
Radiological Presentations
Test Your Diagnosis
Which one of the following is your choice for the appropriate diagnosis? After
your selection, go to next page.
•Hepatocellular Carcinoma
•Cholangiocarcinoma
•Hemangioma
•Lipoma
•Arteriovenous Malformation
•Simple Cyst
•Focal Nodular Hyperplasia
•Adenoma
•Transient Hepatic Intensity Difference
Findings and Differentials
Findings:
5.4 x 4.7 x 4.6 cm mass in the right lobe adjacent to the gallbladder fossa.
Associated satellite lesions.
Nodular liver with capsular retraction.
No involvement of portal venous system or dilation of the bile ducts.
Arterial phase enhancement and marked delayed enhancement on CT and MRI.
Biopsy showed poorly differentiated carcinoma with occasional gland formation.
Differentials:
•Hepatocellular Carcinoma
•Cholangiocarcinoma
•Hemangioma
•Adenoma
•Focal Nodular Hyperplasia
Discussion
Hepatocellular Carcinoma
Associated with hepatitis, alcoholism, cirrhosis, and hemochromatosis.
Elevated LFTs and decreased synthetic function.
MRI: T1 hypointense, T2 hyperintense, intense arterial enhancement.
Histology: hepatocyte-like with pseudogland formation. May stain for
bile or AFP
Cholangiocarcinoma
Associated with PSC, liver fluke infection, hepatitis C, cirrhosis,
Thorotrast exposure.
May present with jaundice or may be asymptomatic.
MRI: Homogenous, T1 hypointense, T2 hyperintense, remains enhanced
on delayed images.
Histology: Typically glandular and well-differentiated, may resemble
biliary epithelium
Discussion
Hemangioma
Asymptomatic and found incidentally.
MRI: Nodular enhancement, T1 hypointense, T2 hyperintense.
Histology: Reveals vascular structures.
Adenoma
May rarely cause hepatomegaly and RUQ pain but typically incidentally
found. Associated with OCP use.
MRI: T1 hyperintense, T2 hyperintense due to fat content.
Histology: Uniform hepatocytes.
Focal Nodular Hyperplasia
Clinically silent.
Usually an incidental finding during imaging or autopsy.
MRI: Iso/hypointense on T1, iso/hyperintense on T2, central vessels
visible, uniform arterial enhancement with delayed
Histology: Resembles adenoma.
Diagnosis
Findings most consistent with intrahepatic mass-forming cholangiocarcinoma.
Next step: staging to determine resectability, usually with ERCP to evaluate biliary
structures and further body imaging to evaluate for metastasis.
Diagnosis
Cholangiocarcinoma is a cancer arising from the biliary duct system.
Incidence is 1 in 100,000 persons per year in the US (approx 2500 cases/yr).
Associated with PSC, liver fluke infection, hepatitis C, cirrhosis, Thorotrast exposure.
Tumors are classified by location: intrahepatic (25%), hilar (AKA Klatskin tumor), or
extrahepatic.
Further classified by morphology: mass-forming, periductal-infiltrating, or intraductalgrowing.
90% are adenomatous.
Treatment consists of surgical removal or palliative biliary decompression.
5-year survival is 9-18% overall and up to 22-36% for intrahepatic tumors.
Diagnosis
Nature Clinical Practice
Gastroenterology & Hepatology 2006
AJR 2003
References
Choi B, Lee J, Han J. Imaging of intrahepatic and hilar cholangiocarcinoma.
Abdominal Imaging 2004; 29:548-557.
Elsayes K, Narra V, et al. Focal Hepatic Lesions: Diagnostic Value of Enhancement
Pattern Approach with Contrast-enhanced 3D Gradient-Echo MR Imaging.
RadioGraphics 2005;25:1299-1320.
Leong T, Leong A. Prognostication in Intrahepatic Cholangiocarcinoma. Adv Anat
Pathol 2006;2:99-100.
Lim J. Cholangiocarcinoma: Morphologic Classification According to Growth Pattern
and Imaging Findings. AJR 2003;181:819-827.
Patel T. Cholangiocarcinoma. Nature Clinical Practice Gastroenterology & Hepatology
2005;1:33-42.
Emedicine.com.

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