Case 45

Presentation

A 40-year-old man with no past medical history is admitted for long-standing pain in the left upper quadrant. He is not a smoker or a drinker. Physical examination is unremarkable; the patient was in a good condition with normal blood pressure and stools. There is no sign of portal hypertension. Abdominal ultrasound shows hepatomegaly with several hypoechoic nodules.

▪ CT Scans

Figure 45.1A

Figure 45.1B

CT Scan Report

Abdominal computed tomography (CT) scan shows four hypervascularized nodules during the arterial phase, favoring intrahepatic benign tumors. The lesions are hypodense in portal phase.

Differential Diagnosis

Differential diagnoses for intrahepatic tumors include hemangiomas, hepatocarcinomas, metastases of thyroid and kidney cancers, multiple nodular hyperplasias, and polyadenomas, even when there is no washout.

Case Continued

Esophagogastric endoscopy and colonoscopy are normal. Similarly, plasma levels of gastric vasoactive intestinal peptide (VIP) and calcitonin are normal. Levels of plasma serotonin and urinary 5-hydroxyindoleacetic acid (5-HIAA) are one and a half and two times normal, respectively, on two successive
assays. Levels of carcinoembryonic antigen (CEA) and cancer antigen (CA) 19-9 are normal.

At this stage, we suspect the diagnosis of liver metastases of a carcinoid tumor located in the appendicular region (suspicion of a positive lymph node in the right inferior quadrant).

A CT-scan-guided biopsy leads to the diagnosis of well-differentiated endocrine (carcinoid) tumor.

▪ MRI

Figure 45.2

MRI Report

Magnetic resonance imaging (MRI) of the liver did not show the classic bulb sign, which would favor hemangioma, but disclosed more intrahepatic lesions in the right lobe.

▪ Octreotide Scintigram

Figure 45.3

Octreotide Scintigraphy Report

There is increased uptake of radionucleotide by the terminal ileum in the location of the primary tumor, and uptake is revealed in other areas. There are several ileal and lymphatic foci in the right iliac region; multiple foci are identified in the liver.

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