Upper quadrant pain and abnormal liver function tests.

 

HISTORY: 28-year-old female with left upper quadrant pain and abnormal liver function tests.

 

FINDINGS: Images 1 and 2 are transverse and sagittal sonograms of the right upper quadrant demonstrating a large predominantly echogenic mass with a peripheral halo.  Of note is the fact that the intrahepatic cava

can not be visualized.  Images 3 and 4 are contrast-enhanced CT's

demonstrating a large heterogeneous mass occupying much of the right

lobe and the medial segment of the left lobe.  Note extensive tumor thrombus within the IVC.  The thrombus extends to the level of the left hepatic vein.

DIAGNOSIS: Cholangiocarcinoma with invasion of the inferior vena cava.

DISCUSSION: This case demonstrates the non specificity of many imaging features of hepatic neoplasms.  Given the relatively young age of the patient, a primary diagnostic consideration might be fibrolamellar

hepatocellular carcinoma, which is known to have an increased incidence in young females.  However, biopsy and special stains confirmed that

this was a cholangiocarcinoma probably arising from a peripheral bile duct.  This is an unusual form of cholangiocarcinoma.  The typical form arises from ductal epithelial at the bifurcation of the common hepatic duct (the so-called Klatzkin tumor).

Similarly, a hepatocellular carcinoma would be considered in the

differential diagnosis in light of the extensive venous invasion of this

lesion.  The extensive low density central within the tumor is typical

of tumor necrosis.  Therefore when the lesion is biopsied, it is

important to obtain a sample along the peripheral margin where more viable tumor cells may be obtained.  The patient rapidly succumbed to widespread metastasis.