PMC7599369_01
Clinical Images.. A. Pre-operative discharging necrotic material from a lower limb lesion of the patient.. B. Pre-operative peri-ankle erythematous lesions.
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She had lesions resembling erythema nodosum as well as a discharging lesion from her left heel (Fig. 1A, B). She was admitted to hospital early due to severe pain and worsening appearance of the lower limb lesions requiring analgesia, IV antibiotics for a possible superimposed cellulitis component and leg elevation (Fig. 1A, B).
Radiology.. A. Coronal CT showing irregular liver mass with approximate dimensions 8.7 x 11.0 x 8.8 cm.. B. Axial CT showing irregular liver mass with approximate dimensions 8.7 x 11.0 x 8.8 cm.. C. Axial T1 MRI Liver well circumscribed liver mass.. D. Axial T2 MRI demonstrating a lobulated well-circumscribed mass.
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The lesion involved the left hepatic vein, abutted the middle hepatic vein and did not definitely contact the inferior vena cava (See Fig. 2A, B). MRCP demonstrated a T1 hypointense well circumscribed hypervascular mass present within Segment 2 (See Fig. 2C). A lobulated well-circumscribed mass was demonstrated at the pancreatic tail which was also hypervascular (See Fig. 2D).
Histopathology (Liver Biopsy).. A. PAS stain, showing positive staining of fine cytoplasmic granules.. B. H&E stain, showing the typical acinar cell pattern.. C. Chymotrypsin: Immunohistochemical stain for chymotrypsin showing granular pattern of cytoplasmic staining.
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The initial diagnosis was made by needle core biopsy of segment 2/3 of the liver mass showing a carcinoma with distinctive features of polygonal cells with granular cytoplasm arranged in acinar structures (Fig. 3A, B). The tumour cell granules were PAS positive, and immunohistochemistry for chymotrypsin showed diffuse cytoplasmic staining (Fig. 3C).
Histopathology (Post-operative specimens).. A. Left hemihepatectomy specimen with tumour evident.. B. Distal pancreatectomy specimen showing primary ACC.. C. Large solitary liver metastasis.. D. Distal pancreatectomy specimen showing primary ACC.
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The surgeon performed a left hemihepatectomy (including resection of the middle hepatic vein) using the Erbe waterjet and staples for vascular structures (Fig. 4A). Pathological examination demonstrated the pancreas containing a 6 cm primary tumour which appeared to infiltrate the peripancreatic adipose tissue (Fig. 4B). The liver contained an 11 cm solid, fleshy tumour consistent with a metastasis (Fig. 4C). Histology from both tumours confirmed features of ACC with identical histological features to the original liver biopsy (Fig. 4D).