Evaluation of a Focal Lesion in the Liver

Abstract

Question: A 64-year-old, moderately obese female who underwent a computed tomography of her chest, including upper abdomen, for evaluation of persistent cough and sinus congestion showed an irregular, heterogenous mass in the liver involving the left lobe medial segment down to the gallbladder fossa and perhaps involving and possibly arising from the gallbladder wall. There was also some extension of the mass over the anterior aspect of the medial segment and also inferiorly anterior to the anterior segment of the right lobe. The main mass was approximately 5 cm in size (Figure A). The patient reported no symptoms related to the liver mass. She denied fevers, chills, and weight loss, and had no abdominal pain. Her past medical history was significant only for hyperlipidemia. Laboratory tests performed showed an elevated aspartate aminotransferase (AST) and alanine aminotransferase (ALT) of 39 and 70, respectively, and also revealed a new diagnosis of diabetes, with a glycosylated hemoglobin level of 10.1. The alpha-fetoprotein, CEA, and CA19-9 were all within normal range. What is the diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. Ultrasonography of the liver (Figure B) and magnetic resonance imaging (MRI) with in- and out-of-phase images (Figure C) was performed and revealed that the mass-like lesion in the liver was due to focal fatty change.1Zezos P. Tatsi P. Nakos A. et al.Focal fatty liver sparing lesion presenting as a ”pseudotumor”: case report.Acta Gastroenterol Belg. 2006; 69: 323-326PubMed Google Scholar, 2Marin D. Iannaccone R. Catalano C. et al.Multinodular focal fatty infiltration of the liver: atypical imaging findings on delayed T1-weighted Gd-BOPTA-enhanced liver-specific MR images.J Magn Reson Imaging. 2006; 24: 690-694Crossref PubMed Scopus (15) Google Scholar, 3Alobaidi M. Shirkhoda A. Benign focal liver lesions: discrimination from malignant mimickers.Curr Probl Diagn Radiol. 2004; 33: 239-253Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar Focal fatty infiltration can often look like a cholangiocarcinoma, gallbladder carcinoma, or metastases within the liver. The most common causes are obesity, diabetes mellitus, high alcohol consumption, and altered metabolism owing to chemotherapy. An exercise and weight loss program was recommended and she was started on metformin for her diabetes. At her follow-up visit after 3 months, the patient had lost 4.2 kg. Laboratory tests showed a normal AST of 20, a minimally elevated ALT of 32 (normal, 9–29), and a drop of the glycosylated hemoglobin from 10.1 to 6.5. A repeat MRI (Figure D) showed almost complete resolution of the area of geographic focal fat in her liver as well as the small areas in the periphery of the liver. This was probably related to her weight loss and improved glycemic control.