PMC9170397_01
MRI T2-weighted coronal view, showing the huge heterogenous liver mass. The hepatic pedicle (arrows) and segment 6 pedicle (arrowheads) were not involved by the tumor.
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None of the three hepatic veins could be identified (PRETEXT classification type IVc), but an inferior right hepatic vein was present, with 9.3 mm in diameter, draining the spared segment 6 (Figures 1 and 2).
MRI Images. (a) Axial T1 weighted: tumor involvement of major hepatic veins (arrows) and liver segments 2, 4A, 7, and 8. (b) Axial T1 weighted: tumor involvement of segment 3 and caudate lobe; right posterior portal vein is free (arrow). (c) Axial T1 weighted: tumor involvement of segment 4B and the right anterior portal vein (arrow); IRHV entering segment 6 (arrowhead). (d) Coronal T1 weighted, 20-minute hepatobiliary phase: view of the IRHV in segment 6 (arrows) draining into the IVC (arrowheads).
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None of the three hepatic veins could be identified (PRETEXT classification type IVc), but an inferior right hepatic vein was present, with 9.3 mm in diameter, draining the spared segment 6 (Figures 1 and 2).
Intraoperative view of segment 6 remnant liver after resection (RHV: right hepatic vein; IRHV: inferior right hepatic vein; LHV: left hepatic vein; MHV: middle hepatic vein; S7 PV: segment 7 portal vein; RAPV: right anterior portal vein; S5: segment 5).
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Finally, hepatic veins were divided with a vascular stapler (Figures 3 and 4).
Surgery details:intraoperative view. (a) Inferior vena cava with RHV (arrows) and common trunk of MHV and LHV (arrowheads) divided by vascular stapler. (b) IRHV between forceps.
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Finally, hepatic veins were divided with a vascular stapler (Figures 3 and 4).
Intraoperative Doppler ultrasonography showing IRHV patency after resection, with hepatofugal flow (arrow).
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After hepatectomy, blood outflow through the IRHV was rechecked through Doppler ultrasonography (Figure 5).
Surgical specimen:analysis confirmed the lobulated, multilocular, cystic-solid, and heterogeneous hepatic tumor, with a fibrous pseudocapsule, measuring 23 cm x 12.5 cm.
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The histopathological and immunohistochemical analysis confirmed positive staining for vimentin, alfa-1-antitrypsin, alpha 1-antichymotrypsin, and Bcl-2 (Figures 6 and 7), which endorsed the diagnosis of UESL.
Histopathological exam demonstrating fusiform, oval, or stellate tumor cells distributed over myxoid or fibrous stroma. Nuclear pleomorphism and hyperchromasia are noted. Cell cytoplasm is granular and eosinophilic, with ill-defined cell borders. In the top left, the remnant bile duct is involved by neoplastic cells (H&E, 20x objective). Image insert: strong and diffuse immunostaining for alpha 1-antichymotrypsin (40x objective).
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The histopathological and immunohistochemical analysis confirmed positive staining for vimentin, alfa-1-antitrypsin, alpha 1-antichymotrypsin, and Bcl-2 (Figures 6 and 7), which endorsed the diagnosis of UESL.
Postoperatory PET scan images. (a) No evidence of disease in the liver (arrow is showing an encapsulated fluid collection). (b) Blastic bone lesion at the left humerus (arrow).
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Although there are no things of disease recurrence in the liver, a recent PET scan identified a blastic lesion at the left humerus, compatible with bone metastasis (Figure 8).