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Patient Data :

Age : 37 - Gender : Female

Diagnosis :

Primary hepatic neuroendocrine tumor

Findings :

T2 axial image shows a huge heterogeneous mass in the left lobe. There is also mild biliary dilatation. Arterial phase image shows a prominent enhancement. Delayed image demonstrate washout, and there is no contrast uptake on hepaotobiliary phase.

History :

A patient presents with history of abdominal pain . No laboratory abnormality was revealed (AFP, CEA, and CA 19-9 are in between normal ranges) and the patient did not described any weight loss.
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ibrahim ;
9/19/2014 6:17:20 PM
My favoritie diagnosis is HCC because of enhancing pattern. Cholangiocarcinoma is my second ddx, becuase there is no cirrhosis nor hepatitis B history, AFP is in normal range and adjacent intrahepatic bile ducts seem dilated. Hypervascular metastasis is also possible.
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suna ;
9/19/2014 8:51:51 PM
I think,the lesion in liver enhances on early arterial phase and wash-out on delayed phase. Also it does not enhance on hepatobiliary phase and has high signal intensity on diffusion MRI so the lesion is most likely malign and HCC is possible diagnosis but other malign hypervascular lesions can be considered in differential diagnosis , like NET's or metastasis.
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Ruslan ;
9/22/2014 11:55:00 AM
Absence of cirrhosis and presence of the expanded distal bile ducts mimic cholangiocarsinoma...But enhancing pattern resembles HCC.
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manal hamisa ;
9/22/2014 5:21:49 PM
the first diagnosis is central cholangiocarcinoma with dilated biliary radicles left lobe
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Miguel, Mamdoh and Kiran ;
9/22/2014 8:20:05 PM
Fibrolamellar HCC would be the first diagnosis.
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hakan from Hadrianopolis ;
9/23/2014 7:09:43 PM
There are a few similar lesions in the liver ( left and right lobes). 1. Hyper vascular metastasis from NETm, melanoma, thyroid Ca, RCCa or others. 2. Fibrolamellar HCCa (metastatic liver).
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Fikret ;
9/23/2014 11:46:39 PM
Hipervascular NET metasthasis I think Cholangiocellular carcinom does not have avid enhancement in early arteryel phases, and does not wash out, it enhances better in delayed phases
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Murat eses ;
9/23/2014 11:48:15 PM
first of all thanks for brain teaser cases. Wash out pattern of lesion, hypointensity on hepatobiliary phase, diffusion restriction, dark signal on ADC, all of them suggest that lesion has malignant nature. But we don't see cirrhotic liver and tumor markers are all normal. I don't see any retraction of liver capsule adjacent to lesion. This findings make HCC and cholangiocarcinoma less likely but still possible. Young age of patient and mailgnant nature of lesion suggest fibrolamellar HCC but I think all hypervascular malignant lesions must be considered.
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