PMC9636016_01
Abdominal contrast-enhanced computed tomography (CECT) (A-D) and contrast-enhanced ultrasonography (CEUS) with Sonazoid (E-G) for the initial diagnosis, and preoperative CECT (H-K). (A, H) Plain, (B) I arterial-dominant phase, (C) J portal venous phase, and (D) K late venous phase of CECT. (E) B-mode, (F) vascular phase, and (G) Kupffer phase of CEUS. Abdominal CECT on first admission showed a well-defined, approximately 2-cm round tumor (arrowheads) in segment 8 of the right hepatic lobe (A). A high-density region was noted inside the tumor during the arterial-dominant phase (B), while a low-density region was noted during the portal venous phase (C) and late venous phase (D). A B-mode scan showed a 2-cm hypoechoic nodule (E; arrowheads). CEUS showed hyperenhancement during the vascular phase (F) and a defect during the Kupffer phase (G). Abdominal CECT before surgery showed a lack of enhancement in the arterial-dominant phase (I) and low density during all phases (H-K).
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Multiphasic contrast-enhanced computed tomography (CECT) and CEUS with Sonazoid (GE Healthcare, Waukesha, WI, USA) were performed for the qualitative diagnosis (Fig. 1). The tumor was enhanced during the arterial-dominant phase (Fig. 1B) and washed out during the late venous phase (Fig. 1D). CEUS revealed hyperenhancement during the vascular phase (Fig. 1F) and a defect during the Kupffer phase (Fig. 1G). The tumor enhancement on CECT was lost in the arterial-dominant phase in July before the surgery (Fig. 1I) and spontaneous necrosis was suspected.
Macroscopic and histological images of the resected specimen. (A) Macroscopic findings, (B) microscopic findings of the red-bordered section in A (hematoxylin-eosin stain; magnification x40), and (C) microscopic finding of the green-bordered section in B (hematoxylin-eosin stain; magnification x100). The hepatically resected specimen contained a tumor measuring 2.5 x 1.9 x 1.7 cm (A). The tumor was encapsulated with a thick fibrous capsule, and the entire region within the tumor was necrotized. The histopathological findings revealed ghosts of tumor cells arranged in a trabecular pattern and some viable cancer cells remaining in the tumor (B, C).
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The hepatically resected specimen contained a tumor, the cut surface of which revealed a yellowish mass with a fibrous capsule (Fig. 2A). Viable cancer cells were observed in one region of the tumor (Fig. 2B, C).
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Abdominal CECT for the initial diagnosis. (A) Plain, (B) arterial-dominant phase, (C, E-G) portal venous phase, and (D) late venous phase. Abdominal CECT shows an approximately 4-cm round tumor in segment 8 of the right hepatic lobe (A; arrowheads). Heterogeneous enhancement was seen inside the tumor during the arterial-dominant phase (B), with insufficient washout during the portal venous phase (C) and late venous phase (D). Abdominal CECT also revealed gallstone cholecystitis (E; arrows), extrinsic compression of the common bile duct by the gallbladder stones (F; arrows) and intrahepatic bile duct dilation (G).
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A 4-cm low-density tumor was observed on an abdominal CT scan (Fig. 3A), and the tumor exhibited some internal nodules. The internal nodules were heterogeneously enhanced during the arterial-dominant phase (Fig. 3B) and washed out insufficiently during the late venous phase (Fig. 3D). CECT also revealed gallstone cholecystitis (Fig. 3E), extrinsic compression of the common bile duct by the gallbladder stones (Fig. 3F), and dilation of the intrahepatic bile duct (Fig. 3G).
Gd-EOB-DTPA-enhanced magnetic resonance imaging (MRI). (A) T1-weighted image (plain), (B) T2-weighted image, (C) diffusion-weighted image, (D) arterial-dominant phase, (E) late venous phase, and (F) hepatobiliary phase. MRI shows a hypointense mass on T1-weighted imaging (A; arrowheads), and a mainly hyperintense mass on T2-weighted imaging (B) and diffusion-weighted imaging (C). Gd-EOB-DTPA-enhanced MRI revealed heterogeneous enhancement in the internal nodules during the arterial-dominant phase (D), with insufficient washout seen during the late venous phase (E) and a defect during the hepatobiliary phase (F).
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T1-weighted imaging (Fig. 4A) and hyperintense on diffusion-weighted imaging (Fig. 4C). The enhanced pattern of Gd-EOB-DTPA was the same as that on CECT (Fig. 4D, E), and the tumor exhibited a defect during the hepatobiliary phase (Fig. 4F).
CEUS with sonazoid. (A) B-mode scan, (B) vascular phase at 25 s, (C) vascular phase at 29 s, and (D) the Kupffer phase. The B-mode scan showed a 4-cm mass containing mixed hypoechoic and hyperechoic areas (A; arrowheads). CEUS revealed a vascular spot in the hypovascular area during the vascular phase (B, C) and complete defect during the Kupffer phase (D).
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A B-mode scan showed that the mass that contained mixed hypoechoic and hyperechoic areas (Fig. 5A), and CEUS revealed internal blood flow during the vascular phase (Fig. 5B), followed shortly thereafter by a vascular spot in the hypovascular area (Fig. 5C). The mass appeared as a complete defective lesion of the inner and outer nodules during the Kupffer phase (Fig. 5D).
Macroscopic and histological images of the resected specimen and needle biopsy. (A, B) Microscopic findings of the needle biopsy (hematoxylin-eosin stain; magnification x100). (C) Macroscopic findings of the resected specimen. (D) Microscopic findings of the red-bordered section in C (hematoxylin-eosin stain; magnification x40). (E) Microscopic findings of the green-bordered section in D (hematoxylin-eosin stain; magnification x100). (F) Microscopic findings of the blue-bordered section in D (hematoxylin-eosin stain; magnification x100). The needle biopsy shows some normal hepatocytes without cytologic atypia (A) and necrotic tissue (B). The hepatically resected specimen contained a tumor measuring 3.9 x 3.0 x 2.2 cm (C). The cut surface of the tumor revealed several yellowish nodules and a grayish-white area replaced by fibrotic tissue. The yellowish nodules were mainly composed of necrotic tissue and surrounded by a fibrous capsule (D). Viable cancer cells remained in the nodules and were arranged in a thick trabecular pattern (E, F).
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The cut surface of the hepatically resected specimen revealed several yellowish nodules and a grayish white area replaced by fibrotic tissue (Fig. 6C). The yellowish nodules were mainly composed of necrotic tissue and a fibrous capsule surrounding the nodules (Fig. 6D). Viable cancer cells remained in the nodules and were arranged in a thick trabecular pattern (Fig. 6E, F).