slowed patency of the right branch of portal vein
Patency of main trunk of portal vein
normal perfusion of the left liver lobe, synchronous however with the portal advanced phase.
Progressive but slow perfusion of the right hepatic lobe.
Abdomen Ultrasound in Emergency (fig. 1):Large (over 15 cm.) expansive hypervascular middle lesion (epi-meso-gastric) of doubtful origin (liver, gut, mesentery, pancreas?).Another inhomogeneous vascularised focal lesion in the right hepatic lobe (about 5 cm.).Other inhomogeneous vascularized mass (about 4 cm.) in the left hypochondrium of doubtful origin (spleen, left kidney?).Moderate amount of ascites over/under mesocolic.
ANGIO MDCT (arterial perfusion phase, fig. 2):Large neoplastic lesion of the left hepatic lobe (over 16 cm.) fed from left hepatic arterydiffusely hypertrophic.Focal neoplastic lesion (approximately 5 cm.) on the right hepatic lobe (S6/S7) fed by slightly hypertrophic branches of the right hepatic artery (anterior and segmental).Slight arterial-venous shunts (portal) in both liver lesions.Focal neoplastic lesion (about 4 cm.) in the upper pole of left kidney fed by a network of smallperipheral arteries.
VENOUS MDCT (venous perfusion phase and focused portal perfusion: fig. 3):Progressive enhancement of the solid portions of all lesions (hepatic and left kidney). Persistent contrast exclusion both necrotic areas and thin stromal and vascular scaffold.Discrete increase in throughput/perfusion time of the mesenteric and portal venous axes. Normal patency of splenic, mesenteric and portal vein that appears to be slightly larger (hemodynamic overload drainage due to arterial/venous shunt ).
MDCT (late perfusion focused phase, fig. 4):Wide inhomogeneous (solid and necrotic) lesion in the left hepatic lobe.Inhomogeneous hypodense solid lesion in the right hepatic lobe.Inhomogeneous hypodense solid lesion in the upper pole of left kidney.Moderate amount of ascites over/under mesocolic.MDCT Diagnosis:Probable bilobar liver hemangiosarcoma and left renal metastasis.
SURGERY (fig. 5):- Resection of the entire left hepatic lobe.- Resection of hepatic nodule in the right lobe.- Left nephrectomy.Macroscopic Pathological Anatomy and Histology (fig. 5):Entire Left Liver Lobe: large vascular tumor composed of irregular vascular channels, large stromal compound and large areas of necrosis (angiosarcoma).Right Liver Lobe Nodule: well-differentiated angiosarcoma, grade 2. Left Kidney: upper pole lesion composed of irregular vascular channels, large stromal compound, areas of necrosis, referable to metastasis of vascular tumor (angiosarcoma).

Liver Hemangiosarcoma

By Giuseppe Francesco Davì


History: Female patient 46 y, born in Morocco, arrived to the Emergency Room for an atypical abdominal pain crisis. Patient was unresponsive to painkillers and antispasmodics and showed a visible anemic context, confirmed by laboratory.


Findings:

CT 1: slowed patency of the right branch of portal vein :: CT 1 ::
slowed patency of the right branch of portal vein







CT 2: Patency of  main trunk  of portal vein :: CT 2 ::
Patency of main trunk of portal vein







CT 3: normal perfusion of the left liver lobe, synchronous however  with the portal advanced phase. Progressive but slow perfusion of the right hepatic lobe. :: CT 3 ::
normal perfusion of the left liver lobe, synchronous however with the portal advanced phase.
Progressive but slow perfusion of the right hepatic lobe.







Ultrasound 1: Abdomen Ultrasound in Emergency (fig. 1):Large (over 15 cm.) expansive hypervascular middle lesion (epi-meso-gastric)  of doubtful origin (liver, gut, mesentery, pancreas?).Another inhomogeneous vascularised focal lesion  in the right hepatic lobe (about 5 cm.).Other inhomogeneous vascularized mass (about 4 cm.) in the left hypochondrium of doubtful origin (spleen, left kidney?).Moderate amount of ascites over/under mesocolic. :: Ultrasound 1 ::
Abdomen Ultrasound in Emergency (fig. 1):Large (over 15 cm.) expansive hypervascular middle lesion (epi-meso-gastric) of doubtful origin (liver, gut, mesentery, pancreas?).Another inhomogeneous vascularised focal lesion in the right hepatic lobe (about 5 cm.).Other inhomogeneous vascularized mass (about 4 cm.) in the left hypochondrium of doubtful origin (spleen, left kidney?).Moderate amount of ascites over/under mesocolic.







CT 4: ANGIO MDCT (arterial perfusion phase, fig. 2):Large neoplastic lesion of the left hepatic lobe (over 16 cm.) fed from left hepatic arterydiffusely hypertrophic.Focal neoplastic lesion (approximately 5 cm.) on the right hepatic lobe (S6/S7) fed by slightly hypertrophic branches of the right hepatic artery (anterior and segmental).Slight arterial-venous shunts (portal) in both liver lesions.Focal neoplastic lesion (about 4 cm.) in the upper pole of left kidney fed by a network of smallperipheral arteries. :: CT 4 ::
ANGIO MDCT (arterial perfusion phase, fig. 2):Large neoplastic lesion of the left hepatic lobe (over 16 cm.) fed from left hepatic arterydiffusely hypertrophic.Focal neoplastic lesion (approximately 5 cm.) on the right hepatic lobe (S6/S7) fed by slightly hypertrophic branches of the right hepatic artery (anterior and segmental).Slight arterial-venous shunts (portal) in both liver lesions.Focal neoplastic lesion (about 4 cm.) in the upper pole of left kidney fed by a network of smallperipheral arteries.







CT 5: VENOUS MDCT (venous perfusion phase and focused portal perfusion: fig. 3):Progressive enhancement of the solid portions of all lesions (hepatic and left kidney). Persistent contrast exclusion both necrotic areas and thin stromal and vascular scaffold.Discrete increase in throughput/perfusion time of the  mesenteric and portal venous  axes. Normal patency of splenic, mesenteric and portal vein that  appears to be slightly larger (hemodynamic overload drainage due to arterial/venous shunt ). :: CT 5 ::
VENOUS MDCT (venous perfusion phase and focused portal perfusion: fig. 3):Progressive enhancement of the solid portions of all lesions (hepatic and left kidney). Persistent contrast exclusion both necrotic areas and thin stromal and vascular scaffold.Discrete increase in throughput/perfusion time of the mesenteric and portal venous axes. Normal patency of splenic, mesenteric and portal vein that appears to be slightly larger (hemodynamic overload drainage due to arterial/venous shunt ).







CT 6: MDCT (late perfusion focused phase, fig. 4):Wide inhomogeneous (solid and necrotic) lesion in the left hepatic lobe.Inhomogeneous hypodense solid lesion in the right hepatic lobe.Inhomogeneous hypodense solid lesion in the upper pole of left kidney.Moderate amount of ascites over/under mesocolic.MDCT Diagnosis:Probable bilobar liver hemangiosarcoma and left renal metastasis. :: CT 6 ::
MDCT (late perfusion focused phase, fig. 4):Wide inhomogeneous (solid and necrotic) lesion in the left hepatic lobe.Inhomogeneous hypodense solid lesion in the right hepatic lobe.Inhomogeneous hypodense solid lesion in the upper pole of left kidney.Moderate amount of ascites over/under mesocolic.MDCT Diagnosis:Probable bilobar liver hemangiosarcoma and left renal metastasis.







Histology 1: SURGERY (fig. 5):- Resection of the entire left hepatic lobe.- Resection of hepatic nodule in the right lobe.- Left nephrectomy.Macroscopic Pathological Anatomy and Histology (fig. 5):Entire Left Liver  Lobe: large vascular tumor  composed of irregular vascular channels, large stromal compound and large areas of necrosis (angiosarcoma).Right Liver Lobe Nodule: well-differentiated angiosarcoma, grade 2. Left Kidney: upper pole lesion composed of irregular vascular channels, large stromal compound, areas of necrosis, referable to metastasis of vascular tumor (angiosarcoma). :: Histology 1 ::
SURGERY (fig. 5):- Resection of the entire left hepatic lobe.- Resection of hepatic nodule in the right lobe.- Left nephrectomy.Macroscopic Pathological Anatomy and Histology (fig. 5):Entire Left Liver Lobe: large vascular tumor composed of irregular vascular channels, large stromal compound and large areas of necrosis (angiosarcoma).Right Liver Lobe Nodule: well-differentiated angiosarcoma, grade 2. Left Kidney: upper pole lesion composed of irregular vascular channels, large stromal compound, areas of necrosis, referable to metastasis of vascular tumor (angiosarcoma).









Discussion:
MDCT with jodine contrast i.v.(perfusion and focused perfusion) [1,2,3,4] probably are the most complete easy problem-solving tool in patients with irrepressible abdominal pain.
The exciting speed of this method combines also optimal features of differential diagnosis probability and in any case allows, after a few minutes, the natural admittance of patient in the operating room for immediate correction of clinical and pathological causes, otherwise fatal.



Differential diagnosis: Liver hemangioma, Liver Hepatocellular carcinoma (HCC)

Diagnosis confirmation: Surgery / Histo



Category: Other

Region / Organ: Abdomen-Liver

Etiology: neoplastic

References:
1) Eric Barnes: ROI changes colorectal tumor perfusion measurements, AuntMinnie.com, August 26, 2008
2) Ernst Klotz, Siemens Medical Solutions: “Functional Imaging of Tumors Using Dynamic Multislice Computed Tomography (MSCT)”, Medical Solutions, October 2005
3) LI Zhiyong, WU Jianlin, NING Dianxiu and LIU Xiaofeng: Preliminary Application of Perfusion Imaging in Neoplasm in the Brain and Body with Multi-slice Helical CT. The Chinese-German Journal of Clinical Oncology. Springer Berlin / Heidelberg, Volume 4, Number 5 / October, 2005
4) Blomley MJ, Coulden R, Dawson P, et al.: Liver perfusion studied with ultrafast CT. J Comput Assist Tomogr1995; 19:424 -433




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