Multiple Hepatic Masses Research Articles

Rare hepatic malignant tumors: dynamic CT, MRI, and clinicopathologic features: with analysis of 54 cases and review of the literature

To evaluate the dynamic CT, MRI, and clinicopathologic characteristics of rare hepatic malignant tumors (HRMTs), improving the understanding and diagnosis of the tumors. A retrospective analysis of 54 cases of HRMTs diagnosed by pathology in our hospital during January 1, 2005 to September 1, 2011. The types of tumors included hepatic sarcoma (n=8), malignant lymphoma (n=4), malignant fibrous histiocytoma (MFH, n=7), malignant melanoma (MM, n=4), squamous cell carcinoma (SCC, n=5), primary clear cell carcinoma of the liver (PCCCL, n=7), stromal tumors (ST n=4), hepatoblastoma (HB, n=8), carcinoid (n=6), primary primitive neuroectodermal tumor (pPNET, n=1). Age of the patients ranged from 1 to 79years (mean=46.7years). There were more men in this group (34/54). Symptoms of HRMTs show no specificity. Except PCCCL and HB, the serum AFP of most HRMTs was negative. 43 patients had a single hepatic mass, and 11 patients had multiple hepatic masses. Diameters ranged from 2 to 15cm (mean=7.7cm). Precontrast CT revealed that most masses had uneven density (n=46) and ill-demarcated margin (n=37). Enhanced CT showed most lesions unevenly enhanced (n=49), of which PCCCL had a prompt enhancement in the arterial phase and rapid wash-out on the portal venous phase and delayed phase; malignant lymphoma and ST had slight enhancement, MFH and undifferentiated embryonal sarcoma had gradual delayed enhancement. Most masses had low-signal on T1WI and high-signal on T2WI, while MM had high-signal on T1WI and low-signal on T2WI. Although there is frequent overlap in the CT, MRI, and clinicopathologic appearances between the rare malignant tumors, some HRMTs have characteristic imaging features that can suggest a specific diagnosis.

Large cell neuroendocrine carcinoma of the colon: A rare and aggressive tumor.

A 74-year old female presented to the emergency room with right lower quadrant abdominal pain, nausea and vomiting for 3 days. Due to a contrast dye allergy, a non-contrast CT scan of the abdomen and pelvis was performed which showed a lesion in the right colon with a dilated cecum and small bowel (Figure 1). Plain X-ray of the chest showed no obvious pathology. An exploratory laparotomy revealed a large obstructing mass at the right colon proximal to the hepatic flexure, with massive lymphadenopathy and abdominal adhesions. Intra-operative palpation and inspection of the liver was unremarkable without evidence of a suspicious mass. The patient underwent right hemicolectomy with anastomosis. Figure 1 Serial non-contrast CT scans of abdomen. (A) CT performed at the time of initial evaluation at admission showed no visible liver lesions. (B) Subsequent CT taken 10 days later showed multiple large liver lesions. The surgical tissue was reviewed by pathology, and on gross specimen, while the ileocecal valve mucosa contained discontinuous deposits of tumor associated with lymphatic tumor emboli, there was no evidence of distant metastasis. On microscopic evaluation the tumor cells had diffuse architecture with necrosis, ample cytoplasm, and numerous mitotic figures (10-20 mitoses per single high power field). Immunohistochemistry showed diffuse cytoplasmic staining for synaptophysin, as well as positive staining for CD-56, CK-7, Ki-67 (in nearly 90% of the cells) and negative staining for CK-20 consistent with large cell neuroendocrine carcinoma (Figure 2). Of the total lymph nodes present in the surgical specimen 17 out of 24 showed metastatic disease. Thus the final pathology was felt to be most compatible with an aggressive high-grade large cell neuroendocrine carcinoma of the colon. Figure 2 Pathologic examination with H&E staining and immunohistochemical analysis. (A) H&E stain showing tumor ulcerating though normal surface epithelium. (B) H&E stain at high magnification showing cytological malignant features such ... On post-operative day number 10, the patient developed bilious drainage from the lower portion of the surgical incision. A non-contrast CT of the abdomen and pelvis showed interval development of approximately 5 hypodense lesions within the liver measuring 4-6 cm in size. Comparison of the post-operative scan to the pre-operative CT indicated that the hepatic lesions were new (Figure 1). Given the rapid development of these lesions and concern for potential liver abscesses the decision was made for a drainage procedure. An attempt at interventional radiology guided drainage was unsuccessful and subsequently the patient underwent a surgical exploration. Intra-operative findings were notable for multiple palpable hepatic masses through out both lobes of the liver. By gross inspection the hepatic lesions measured 4-6 cm in size, with complete replacement of the left hepatic lobe and a large firm mass at the surface of the right hepatic lobe. A wedge biopsy of one of the liver masses was performed and frozen section showed morphologic features similar to the previously resected tumor consistent with metastatic large cell neuroendocrine carcinoma. An additional intra-operative finding was a small bowel enterocutaneous fistula 10 cm proximal to the previous anastomotic site, which was resected and reanastomized. Two weeks later, the patients condition deteriorated with development of a second enterocutaneous small bowel fistula. At that time the family withdrew care and the patient subsequently expired.

Multiple hepatocellular adenomas in a patient with glycogen storage disease type I: various enhancement patterns in MRI with Gd-EOB-DTPA

The patient is a 20-year-old man with glycogen storage disease type I (GSD-type I). In his teens, multiple focal hepatic masses were detected on abdominal ultrasonography (US), which were diagnosed as multiple hepatocellular adenomas from the imaging. During follow-up, these masses had shown intermittent growth in size. In the evaluation of Gd-EOB-DTPA (gadolinium-ethoxybenzyl-diethylenetriamine penta-acetic acid) MR imaging, these masses showed various signal intensities from hypo- to hyperintense during the hepatocyte-specific phase. Intermittent growth and elevation of serum PIVKA-II levels indicate the potential for malignant transformation, so the patient underwent partial hepatectomy. The resected masses were all consistent with benign hepatocellular adenomas histopathologically.

Pancreatoblastoma: Two Case Reports From a Medical Center in Taiwan

Although pancreatoblastoma (PB) is an extremely rare tumor, it is the most common pancreatic tumor in children. We reported 2 cases of PB treated at a medical center in Taiwan. One was a 3.5-year-old boy who presented with abdominal pain. Physical examination demonstrated abdominal masses. Multiple pancreatic and hepatic masses were noted by magnetic resonance imaging. He underwent surgical resection but tumor could not be removed completely, which was confirmed by the pathology. He received chemotherapy consisting of cisplatin and doxorubicin after the surgery but the tumor progressed rapidly. He died of progressive disease and sepsis. The other case was a 4-year-old boy presented with abdominal pain. Computed tomography showed pancreatic tumor. He underwent surgical resection and pathology showed PB. He received chemotherapy after complete tumor resection. He is disease free till now. Complete tumor resection is the major difference of these 2 patients and is the most important factor affecting the outcome.

Abdominal Fibrosarcoma Associated with a Retained Surgical Swab in a Dog

An abdominal fibrosarcoma surrounding a retained surgical swab was identified in a 3-year-old neutered female rottweiler dog presented with chronic inappetence and lethargy. Laparotomy revealed a mass within the omentum, multiple hepatic masses and enlarged mesenteric lymph nodes. The dog was humanely destroyed and submitted for necropsy examination. Microscopically, the omental mass was consistent with a sarcoma surrounding centrally located fibres of foreign material and was infiltrated by epithelioid macrophages containing intracytoplasmic fibre fragments. Sarcoma tissue was also present in mesenteric lymph nodes, liver, spleen and lungs, and some affected lymph nodes contained intralesional epithelioid macrophages with fibre fragments. Immunohistochemical and electron microscopical examinations were consistent with a diagnosis of fibrosarcoma. By fibre analysis and electron microscopy, the intratumoural fibres were identified as cotton fibres with features identical to those obtained from a surgical swab. To our knowledge this is the first description of an abdominal fibrosarcoma associated with a retained surgical swab in a dog. Other examples of foreign body-associated sarcomas in the veterinary literature are vaccine- and implant-induced sarcomas.

Diagnostic Accuracy of Percutaneous Cytodiagnosis of Hepatic Masses, by Ultrasound Guided Fine Needle Aspiration Cytology

Objective: To evaluate the diagnostic accuracy, usefulness and limitations of ultrasound guided FNAC of hepatic masses. Design: Cross – sectional analytical (comparative study). Place and Duration: Department of histopathology, Sheikh Zayed Hospital, Lahore. Study period 1 year. Material and Methods: A total of 32 patients with solitary or multiple hepatic masses underwent FNAC from March 1999 to March 2000. Adequate aspirates were obtained in all these cases. Smears were stained with May-Grunwald Giemsa, Hae-matoxylin and Eosin and Papanicolaou stain. Needle biopsies from the same cases were also obtained and processed. These were stained with routine Haematoxylin and Eosin staining. The blood clots obtained during FNAC were fixed in 10% neu-tral buffered formalin. The histopathology of these blood clots was used for cases whose needle core biopsy was not avai-lable. The screened FNAC smears were divided into 3 categories i.e., benign (group – I), malignant (group – II), non-neoplastic / inflammatory lesions (including cysts and abscesses) (group – III). Results: Out of 32 cases, 6 were categorized as benign, 18 as malignant, and 8 as non-neoplastic inflammatory lesions. Three false negative diagnoses, including 1 for malignant tumour and 2 for benign tumours was obtained. There was 1 false positive diagnosis for malignancy. FNAC – histological correlation showed a 94.2% sensitivity and 92.3% diagnostic accu-racy for malignant tumours, while benign tumours posed maximum diagnostic problems, giving a 66.67% sensitivity and 85.7% diagnostic accuracy. FNAC picked up correctly all the non-neoplastic lesions giving a 100% sensitivity and diagnostic accuracy. Conclusion: Majority of the malignant tumours can be categorized on FNAC, with a high degree of accuracy, while benign tumours should be subjected to biopsy, as there is a relatively greater possibility of false negative diagnosis. Key words: FNAC, benign, malignant, non-neoplastic.

Radiological findings of isolated hepatic tuberculosis in a child with tubulointerstitial nephritis-uveitis syndrome

Isolated hepatic tuberculosis is a rare manifestation of tuberculosis in children although its incidence has been increasing, especially in immunosuppressed patients. Imaging studies frequently present a diagnostic challenge, especially for the nodular form. Thus a high index of suspicion is required for diagnosis. On US, hepatic tuberculosis may rarely present as a macronodular form (also called pseudotumour or tuberculoma). We report a 15-year-old girl with multiple hepatic macronodular masses due to isolated hepatic tuberculosis.

Hepatic epithelioid hemangioendothelioma: A diagnostic pitfall in aspiration cytology

Hepatic epithelioid hemangioendothelioma (EH) is a rare vascular neoplasm. An accurate radiologic diagnosis is usually difficult due to the presence of multiple nodules, simulating metastatic carcinoma. Though histologic features of this tumor are well described, cytologic reports of hepatic EH are very few in the available literature. We describe a case of a young healthy adult male who was found to have multiple hepatic masses on radiologic investigations. A guided fine needle aspiration demonstrated a poorly differentiated neoplasm. The diagnosis was made on core biopsy assisted by immunohistochemistry, which showed characteristic features of EH. He is doing well 14 months after diagnosis, without surgical excision or chemotherapy. An accurate diagnosis of hepatic EH on aspiration cytology requires an adequate specimen and awareness of its cytologic features, including discohesive atypical cells with intracytoplasmic lumina and intranuclear inclusions. Since this tumor is usually unresectable but has a favorable prognosis as compared to hepatocellular carcinoma, a correct diagnosis is essential for appropriate management and prognostication.

Hepatocellular Carcinoma with Direct Invasion to the Stomach

A 71-year-old man was admitted to our hospital with abdominal pain. Hepatocellular carcinoma (HCC) had been diagnosed 2 years earlier and he had undergone 7 courses of intra-hepato-arterial chemotherapy (IHAC). We performed gastrointestinal fiberscopy and identified a massive protrusion on the lesser curvature. Abdominal contrast-enhanced computed tomography revealed multiple hepatic masses and an extrahepatic enlarged mass with invasion to the pancreas and stomach. A specimen for endoscopic biopsy revealed adenocarcinoma that stained positive for alpha-fetoprotein. Gastrointestinal bleeding resulting from direct invasion of HCC is unusual.

Primary liver AIDS-related lympoma

Non-Hodgkin's lymphomas (NHL) are the second most frequent malignancies in AIDS patients. The majority of NHL associated with AIDS involves extranodal sites, especially the digestive tract and the central nervous system. Primary liver lymphoma (PLL) is an uncommon neoplasm among these patients. Ultrasonography and computed tomography scans may be helpful in the diagnosis of focal hepatic lymphoma. Image-guided fine-needle biopsy with histopathology of the liver lesions is the gold standard for the diagnosis of hepatic lymphoma. We report a case of PLL as the initial manifestation of AIDS in a patient without any previous infection by hepatitis C or B virus, presented as multiple and large hepatic masses.

Case 13-2006

A 50-year-old man was referred because of a painful lytic bone lesion of the right ulna and multiple hepatic masses that had been identified on computed tomography. Biopsy of the bone lesion disclosed adenocarcinoma. Fanconi's anemia had been diagnosed 10 years earlier, and squamous-cell carcinoma of the esophagus 4 years earlier. A diagnostic procedure was performed.

Multiple hepatic masses in a 38-year-old male 10 years after renal transplantation

The patient is a 38-year-old male, diagnosed with IgA nephropathy at age 24, who underwent renal allograft transplantation 10 years ago. He presented with complaints of fever and non-productive cough. Clinical examination was notable for a low grade temperature (99.5 F), bibasilar crackles and a distended abdomen with overlying varices. Laboratory studies showed anaemia of chronic disease and normal liver function tests, except for a mildly depressed serum albumin level. Serum creatinine was elevated from his baseline of 2.5mg/dl to 4.2mg/dl. Additional past medical history includes former heavy use of alcohol, with none following his transplant. A right sided pulmonary infiltrate was detected on chest X-ray. Following antibiotic therapy for presumed pneumonia, his clinical symptoms resolved and his creatinine reverted to baseline level. An out-patient computed tomography (CT) scan was performed to evaluate the abdominal findings. Massive liver nodules in the lobes were present, replacing the hepatic parenchyma. The largest measured 13.5 cm in the left lobe, with a separate 12.5 cm mass in the right lobe (Figure 1). Radiologically, the lesions were perplexing, with a broad differential diagnosis including abscesses, haemangiomas, benign cystic lesions, metastases or hepatocellular carcinoma. Percutaneous core needle biopsy yielded a moderately cellular spindle cell neoplasm with minimal cellular pleomorphism and no mitotic activity (Figure 2). The spindle cells contained elongated, blunt-ended nuclei with finely stippled chromatin. Immunohistochemistry by the standard avidin–biotin–peroxidase complex method demonstrated myogenic differentiation of the tumour cells, which were immunoreactive to smooth muscle actin. In situ hybridization for EBV virus was strongly positive in >90% of the spindle cell nuclei (Figure 3). These findings are indicative of an EBV-associated myogenic tumour. A reduction of the immunosuppressive agents was recommended to the patient, who declined for fear of impending rejection. Currently he is being followed, with slow expansion in the size of the liver nodules. Six months following diagnosis of the liver lesions, a palpable 4 cm nodule in the right gluteal region developed. Additional smaller nodules in the same region were noted by imaging studies. Percutaneous needle core biopsy illustrated a histologically identical EBV-associated myogenic tumour.

Concurrent Male Gynecomastia and Testicular Hydrocele after Imatinib Mesylate Treatment of a Gastrointestinal Stromal Tumor

We report a gastrointestinal stromal tumor (GIST) patient with male gynecomastia and testicular hydrocele after treatment with imatinib mesylate. A 42 yr-old male patient presented for management of hepatic masses. Two years earlier, he had undergone a small bowel resection to remove an intraabdominal mass later shown to be a GIST, followed by adjuvant radiation therapy. At presentation, CT scan revealed multiple hepatic masses, which were compatible with metastatic GIST, and he was prescribed imatinib 400 mg/day. During treatment, he experienced painful enlargement of the left breast and scrotal swelling. Three months after cessation of imatinib treatment, the tumors recurred, and, upon recommencing imatinib, he experienced painful enlargement of the right breast and scrotal swelling. He was diagnosed with male gynecomastia caused by decreased testosterone and non-communicative testicular hydrocele. He was given androgen support and a hydrocelectomy, which improved his gynecomastia. The mechanism by which imatinib induces gynecomastia and hydrocele is thought to be associated with an inhibition of c-KIT and platelet-derive growth factor. This is the first report, to our knowledge, describing concurrent male gynecomastia and testicular hydrocele after imatinib treatment of a patient with GIST.

Hepatic Echinococcus alveolaris

A 48-year-old woman was admitted with a blunt right-upper abdominal pain. An abdominal CT revealed multiple hepatic masses. Gastrointestinal and gynecological studies and tumor markers remained negative. A tru-cut liver biopsy revealed small cystic structures surrounded by eosinophils. Peripheral blood smear also disclosed eosinophilia (10% of 8500mm−3 leukocytes). Echinococcal indirect hemagglutination test was positive in dilutions up to 1/640. An MRI revealed hepatic hypodense lesions (left panel).

Atypical Hepatic Hemangiomas with Multiple Calcifications Mimicking Hepatic Metastases: Case Report

Although hepatic hemangioma is the most common benign tumor of the liver, it is rarely associated with calcifications. We report on the case of an asymptomatic 58-year-old man in whom multiple hepatic masses containing calcifications were discovered incidentally at ultrasonography. The radiologic features mimicked those of multiple hepatic metastases.

Natural Killer–like T-Cell Lymphoma of the Parotid in a Patient Infected With Human Immunodeficiency Virus

Abstract A 42-year-old man with acquired immunodeficiency syndrome developed a mass of the right parotid gland and multiple hepatic masses. Hematoxylin-eosin–stained sections of the parotid lesion showed a diffuse infiltrate of large mononuclear cells with vesicular nuclei and prominent nucleoli, consistent with a non-Hodgkin lymphoma. Immunohistochemical stains demonstrated expression of the T-cell markers CD3 and UCHL-1, as well as latent membrane protein 1 and T-cell intracellular antigen 1. Flow cytometry showed surface expression of CD2, CD3, CD7 (dim), CD8, and CD56. CD5 was not expressed. Molecular evaluation by polymerase chain reaction demonstrated monoclonal rearrangement of the T-cell receptor γ gene. Epstein-Barr virus early RNA and human immunodeficiency virus RNA were demonstrated by in situ hybridization. To our knowledge, this is the first reported case of T-cell lymphoma of the parotid in a patient infected with human immunodeficiency virus. After 2 separate chemotherapy regimens, the pat...

Spectrum of imaging findings of the liver in end-stage cirrhosis: Part II, focal abnormalities.

Cirrhosis, through the process of necrosis, fibrosis, regeneration, and malignant transformation, creates multiple focal benign and malignant hepatic masses. The detection and appearance of these masses varies with the severity of the cirrhotic process and the imaging technique used. Although some overlap exists in the imaging appearance of the benign and malignant masses, in most instances recognition of a few characteristic features will yield the correct diagnosis.

Inflammatory pseudotumor of the liver

We present a case of inflammatory pseudotumor of the liver (IPL), a rare benign hepatic lesion. A 66-year-old woman with fever, and right abdominal pain and mass underwent abdominal sonography and computed tomography. Both showed multiple hepatic masses. Ultrasound guided needle liver biopsy showed a dense chronic inflammatory lesion with innumerable foamy histiocytes and spindle fibroblasts consistent with IPL. She improved with conservative treatment. Clinical, pathologic, and imaging findings at IPL are reviewed.

Application of post-embedding immunogold technique in the diagnostic evaluation of fine-needle aspirates of neuroendocrine tumors

The diagnostic feature of a neuroendocrine tumor by transmission electron microscopy (TEM) is the presence of neurosecretory granules (NSG). However, other electron dense inclusions like lipid droplets and primary lysosomes may mimic NSC. In this study, post-embedding immunogold (PEI) technique using chromogranin A antibody has been used to confirm the ultrastructural impression of neuroendocrine tumor. This technique is contrasted with immunohistochemical results.Material for this study was obtained from 5 transabdominal fine needle aspirates of multiple hepatic masses of unknown nature, processed for light and electron microscopic examinations and immunohistochemistry. Thin gold sections were cut (Reichart) with a Diatome diamond knife and mounted on 200 mesh nickel grids. A nickel grid with section side down was placed on drops of 11% aqueous sodium metaperiodate for 30 minutes, and was then washed with distilled water. Grids were incubated in 1% albumin for 15 minutes and transferred directly to chromogranin A and incubated for 60 minutes at room temperature.