EURORAD ESR

Case 14451

Beware of hepatocellular carcinoma in HIV-infected patients !

Author(s)
Tonolini Massimo, MD.

"Luigi Sacco" University Hospital, Radiology Department; Via G.B. Grassi 74 20157 Milan, Italy; Email:mtonolini@sirm.org
 
Patient
male, 54 year(s)
 
 
  • Figure 1
    Unenhanced and post-contrast CT (quadriphasic technique)
     

    Precontrast images (a,b) showed multicompartmental ascites (+), advanced-stage cirrhotic liver with caudate and left lobe hypertrophy, solid-attenuation thrombosis (*) of portal bifurcation and left branch.

     
    Area of Interest: Liver; Imaging Technique: CT; Procedure: Diagnostic procedure; Special Focus: Neoplasia;

    Precontrast images (a,b) showed multicompartmental ascites (+), advanced-stage cirrhotic liver with caudate and left lobe hypertrophy, solid-attenuation thrombosis (*) of portal bifurcation and left branch.

     
    Area of Interest: Liver; Imaging Technique: CT; Procedure: Diagnostic procedure; Special Focus: Neoplasia;

    Arterial-phase acquisition (c,d) showed expansile, enhancing thrombosis (*) of portal bifurcation and left branch, ascites (+), faint patchy hyperenhancement along ventromedial and dorsal aspect of left liver lobe...

     
    Area of Interest: Liver; Imaging Technique: CT; Procedure: Diagnostic procedure; Special Focus: Neoplasia;

    Arterial-phase acquisition (c,d) showed expansile, enhancing thrombosis (*) of portal bifurcation and left branch, ascites (+), faint patchy hyperenhancement along ventromedial and dorsal aspect of left liver lobe...

     
    Area of Interest: Liver; Imaging Technique: CT; Procedure: Diagnostic procedure; Special Focus: Neoplasia;

    Portal venous phase (e,f) confirmed solid thrombosis (*) of portal bifurcation and left branch, hypoattenuating nonenhancing partial bland thrombosis of portal trunk (arrows), and multicompartmental ascites (+).

     
    Area of Interest: Liver; Imaging Technique: CT; Procedure: Diagnostic procedure; Special Focus: Neoplasia;

    Portal venous phase (e,f) confirmed solid thrombosis (*) of portal bifurcation and left branch, inhomogeneous washout (arrowheads) involving most of left liver lobe, and multicompartmental ascites (+).

     
    Area of Interest: Liver; Imaging Technique: CT; Procedure: Diagnostic procedure; Special Focus: Neoplasia;

    Equilibrium phase images (g,h) showed contrast washout of intrahepatic portal thrombosis (*), inhomogeneous washout (arrowheads) involving most of the left liver lobe, including a roundish mass in the dorsal 3rd...

     
    Area of Interest: Liver; Imaging Technique: CT; Procedure: Diagnostic procedure; Special Focus: Neoplasia;

    Equilibrium phase images (g,h) showed contrast washout of intrahepatic portal thrombosis (*), inhomogeneous washout (arrowheads) involving most of the left liver lobe, including a roundish mass in the dorsal 3rd...

     
    Area of Interest: Liver; Imaging Technique: CT; Procedure: Diagnostic procedure; Special Focus: Neoplasia;
     
     
  • Figure 2
    Liver MRI - precontrast T2- and diffusion-weighted images
     

    Coronal (a) and axial (b,c) T2-weighted images showed increased ascites (+), faint hyperintensities along ventromedial and dorsal aspects of left liver lobe (arrowheads), moderately high signal of intrahepatic portal...

     
    Area of Interest: Liver; Imaging Technique: CT; Procedure: Diagnostic procedure; Special Focus: Neoplasia;

    T2-weighted images showed faint hyperintensities along ventromedial and dorsal aspects of left liver lobe (arrowheads) plus a centimetric nodule (thin arrow), moderately high signal of intrahepatic portal thrombus (*).

     
    Area of Interest: Liver; Imaging Technique: CT; Procedure: Diagnostic procedure; Special Focus: Neoplasia;

    T2-weighted images showed increased ascites (+), faint hyperintensities along ventromedial and dorsal aspects of left liver lobe (arrowheads), moderately high signal of intrahepatic portal thrombus (*) compared to...

     
    Area of Interest: Liver; Imaging Technique: CT; Procedure: Diagnostic procedure; Special Focus: Neoplasia;

    High b-value (800) diffusion-weighted images showed hyperintensities at the expansile intrahepatic thrombus (*) and extensive part of the left liver lobe (arrowheads).

     
    Area of Interest: Liver; Imaging Technique: CT; Procedure: Diagnostic procedure; Special Focus: Neoplasia;

    High b-value (800) diffusion-weighted images showed hyperintensities at the expansile intrahepatic thrombus (*) and extensive part of the left liver lobe (arrowheads). Note satellite tumour nodule (thin arrow).

     
    Area of Interest: Liver; Imaging Technique: CT; Procedure: Diagnostic procedure; Special Focus: Neoplasia;

    On corresponding apparent diffusion coefficient (ADC) map image, the intrahepatic thrombus (*) showed low signal with ADC values 1.1 ×10−3 mm2/s.

     
    Area of Interest: Liver; Imaging Technique: CT; Procedure: Diagnostic procedure; Special Focus: Neoplasia;
     
     
  • Figure 3
    Liver MRI - Dynamic study (1 molar Gadobutrol 1ml/kg)
     

    Hampered by limited breath-hold due to increased ascites (+), arterial-phase MRI showed mottled hyperenhancement at dorsal 3rd segment (arrowhead) and ventral nodule (thin arrow). Note intrahepatic portal thrombus (*).

     
    Area of Interest: Liver; Imaging Technique: MR; Procedure: Diagnostic procedure; Special Focus: Neoplasia;

    Portal venous (b) and equilibrium (c,d) phase images showed progressive contrast washout at involved areas of left liver lobe (arrowheads) and satellite nodule (thin arrow). Note ascites (+), intrahepatic portal...

     
    Area of Interest: Liver; Imaging Technique: MR; Procedure: Diagnostic procedure; Special Focus: Neoplasia;

    Portal venous (b) and equilibrium (c,d) phase images showed progressive contrast washout at involved areas of left liver lobe (arrowheads) and satellite nodule (thin arrow). Note ascites (+), intrahepatic portal...

     
    Area of Interest: Liver; Imaging Technique: MR; Procedure: Diagnostic procedure; Special Focus: Neoplasia;

    Portal venous (b) and equilibrium (c,d) phase images showed progressive contrast washout at involved areas of left liver lobe (arrowheads) and satellite nodule (thin arrow). Note ascites (+), intrahepatic portal...

     
    Area of Interest: Liver; Imaging Technique: MR; Procedure: Diagnostic procedure; Special Focus: Neoplasia;

    Nonenhancing partial bland thrombosis of the main portal trunk (arrows) persisted despite anticoagulation. Note increased ascites (+).

     
    Area of Interest: Liver; Imaging Technique: MR; Procedure: Diagnostic procedure; Special Focus: Neoplasia;

    Nonenhancing partial bland thrombosis of the main portal trunk (arrows) persisted despite anticoagulation. Note increased ascites (+).

     
    Area of Interest: Liver; Imaging Technique: MR; Procedure: Diagnostic procedure; Special Focus: Neoplasia;
     
     
  • Figure 4
    Follow-up thoracic CT
     

    Two months later, focused CT confirmed the development of a large (10x4.5 cm) solid mass at the dorsal right thoracic wall (thick arrows) causing aggressive costal osteolysis.

     
    Area of Interest: Liver; Imaging Technique: CT; Procedure: Diagnostic procedure; Special Focus: Metastases;

    Two months later, focused CT confirmed the development of a large (10x4.5 cm) solid mass at the dorsal right thoracic wall (thick arrows) causing aggressive costal osteolysis.

     
    Area of Interest: Liver; Imaging Technique: CT; Procedure: Diagnostic procedure; Special Focus: Metastases;
     
     
Precontrast images (a,b) showed multicompartmental ascites (+), advanced-stage cirrhotic liver with caudate and left lobe hypertrophy, solid-attenuation thrombosis (*) of portal bifurcation and left branch.
 
Precontrast images (a,b) showed multicompartmental ascites (+), advanced-stage cirrhotic liver with caudate and left lobe hypertrophy, solid-attenuation thrombosis (*) of portal bifurcation and left branch.
 
Arterial-phase acquisition (c,d) showed expansile, enhancing thrombosis (*) of portal bifurcation and left branch, ascites (+), faint patchy hyperenhancement along ventromedial and dorsal aspect of left liver lobe (arrowheads in d).
 
Arterial-phase acquisition (c,d) showed expansile, enhancing thrombosis (*) of portal bifurcation and left branch, ascites (+), faint patchy hyperenhancement along ventromedial and dorsal aspect of left liver lobe (arrowheads in d).
 
Portal venous phase (e,f) confirmed solid thrombosis (*) of portal bifurcation and left branch, hypoattenuating nonenhancing partial bland thrombosis of portal trunk (arrows), and multicompartmental ascites (+).
 
Portal venous phase (e,f) confirmed solid thrombosis (*) of portal bifurcation and left branch, inhomogeneous washout (arrowheads) involving most of left liver lobe, and multicompartmental ascites (+).
 
Equilibrium phase images (g,h) showed contrast washout of intrahepatic portal thrombosis (*), inhomogeneous washout (arrowheads) involving most of the left liver lobe, including a roundish mass in the dorsal 3rd segment (h). Note ascites (+).
 
Equilibrium phase images (g,h) showed contrast washout of intrahepatic portal thrombosis (*), inhomogeneous washout (arrowheads) involving most of the left liver lobe, including a roundish mass in the dorsal 3rd segment (h). Note ascites (+).
 
Coronal (a) and axial (b,c) T2-weighted images showed increased ascites (+), faint hyperintensities along ventromedial and dorsal aspects of left liver lobe (arrowheads), moderately high signal of intrahepatic portal thrombus (*).
 
T2-weighted images showed faint hyperintensities along ventromedial and dorsal aspects of left liver lobe (arrowheads) plus a centimetric nodule (thin arrow), moderately high signal of intrahepatic portal thrombus (*).
 
T2-weighted images showed increased ascites (+), faint hyperintensities along ventromedial and dorsal aspects of left liver lobe (arrowheads), moderately high signal of intrahepatic portal thrombus (*) compared to hypointense bland extrahepatic thrombus (arrow).
 
High b-value (800) diffusion-weighted images showed hyperintensities at the expansile intrahepatic thrombus (*) and extensive part of the left liver lobe (arrowheads).
 
High b-value (800) diffusion-weighted images showed hyperintensities at the expansile intrahepatic thrombus (*) and extensive part of the left liver lobe (arrowheads). Note satellite tumour nodule (thin arrow).
 
On corresponding apparent diffusion coefficient (ADC) map image, the intrahepatic thrombus (*) showed low signal with ADC values 1.1 ×10−3 mm2/s.
 
Hampered by limited breath-hold due to increased ascites (+), arterial-phase MRI showed mottled hyperenhancement at dorsal 3rd segment (arrowhead) and ventral nodule (thin arrow). Note intrahepatic portal thrombus (*).
 
Portal venous (b) and equilibrium (c,d) phase images showed progressive contrast washout at involved areas of left liver lobe (arrowheads) and satellite nodule (thin arrow). Note ascites (+), intrahepatic portal thrombosis (*).
 
Portal venous (b) and equilibrium (c,d) phase images showed progressive contrast washout at involved areas of left liver lobe (arrowheads) and satellite nodule (thin arrow). Note ascites (+), intrahepatic portal thrombosis (*).
 
Portal venous (b) and equilibrium (c,d) phase images showed progressive contrast washout at involved areas of left liver lobe (arrowheads) and satellite nodule (thin arrow). Note ascites (+), intrahepatic portal thrombosis (*).
 
Nonenhancing partial bland thrombosis of the main portal trunk (arrows) persisted despite anticoagulation. Note increased ascites (+).
 
Nonenhancing partial bland thrombosis of the main portal trunk (arrows) persisted despite anticoagulation. Note increased ascites (+).
 
Two months later, focused CT confirmed the development of a large (10x4.5 cm) solid mass at the dorsal right thoracic wall (thick arrows) causing aggressive costal osteolysis.
 
Two months later, focused CT confirmed the development of a large (10x4.5 cm) solid mass at the dorsal right thoracic wall (thick arrows) causing aggressive costal osteolysis.
 
 
 
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