Case of the month May 2025: Primary or secondary liver lesion – the lifelong question
May 1, 2025
1 Raphael Hauser; raphael.hauser@regionh.dk
2 Chenxi Huang; chenxi.huang.01@regionh.dk
* Correspondence: raphael.hauser@hotmail.com
Clinical history
A 50-year-old male with a medical history of congenital chloride diarrhea, intrahepatic biliary stones, recurring cholangitis, cholecystectomy and splenomegaly underwent a routine follow-up MRCP (Magnetic Resonance Cholangio Pancreaticography) including diffusion weighted sequences. The patient was not known to have liver cirrhosis.
An MRCP 10 months earlier showed dilation of the bile ducts in liver segment 5 with multiple biliary stones. After three mild cases of cholangitis, and due to three months without symptoms, it was decided to start with a conservative approach instead of Percutaneous Transhepatic Biliary Drainage (PTBD).
The follow-up abdominal MRCP including diffusion weighted sequences identified a stenosis and a focal lesion of 20 mm with diffusion restriction in segment 5 of the liver. The bile ducts were dilated peripherally to the stenosis.
Images
Due to the stenosis and the suspicion of a focal lesion, an ultrasound (US) examination was requested. The following image was acquired during the examination.
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Question 1 of 4
1. Question
Question 1: Which of the following answers correspond best with what you see on the US image?
Correct
CORRECT ANSWER EXPLAINED BELOW Correct answer to Q1 is: Well defined process with heterogeneous echogenicity and dilation of the peripheral bile duct.
Incorrect
CORRECT ANSWER EXPLAINED BELOW Correct answer to Q1 is: Well defined process with heterogeneous echogenicity and dilation of the peripheral bile duct.
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Question 2 of 4
2. Question
Image 3: Ultrasound – Subcostal transverse view of the liver showing a well-defined process with heterogeneous echogenicity (marked with an arrow) and dilation og the peripheral bile duct.
Question 2: What would be your next step to get closer to the diagnosis?
Correct
CORRECT ANSWER EXPLAINED BELOW Correct answer to Q2 is: CEUS (contrast enhanced ultrasound) to characterize the focal liver lesion previously seen.
Incorrect
CORRECT ANSWER EXPLAINED BELOW Correct answer to Q2 is: CEUS (contrast enhanced ultrasound) to characterize the focal liver lesion previously seen.
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Question 3 of 4
3. Question
Additional Discussion:
Contrast enhanced ultrasound (CEUS) showed transient arterial enhancement and early wash-out after injection.
Question 3: Considering the findings, which diagnosis is then most likely?
Correct
CORRECT ANSWER EXPLAINED BELOW Correct answer to Q3 is: Malignant tumor – most likely cholangiocarcinoma.
Incorrect
CORRECT ANSWER EXPLAINED BELOW Correct answer to Q3 is: Malignant tumor – most likely cholangiocarcinoma.
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Question 4 of 4
4. Question
Discussion:
A malignant tumor is the most likely diagnosis. In the case of a malignant tumor, ultrasound will show an isolated lesion with heterogeneous echogenicity. When using CEUS, an early peripheral enhancement is seen and early washout. The non-enhancing center may represent necrosis.
In the case of a hemangioma, ultrasound will typically show a well-defined hyperechoic lesion on B-mode. When using CEUS a hemangioma shows peripheral nodular discontinuous enhancement in the arterial phase with continued “filling in” of the lesion in the delayed phase.
A cyst is typically visualized on ultrasound as a hypoechoic lesion with posterior acoustic enhancement. Lastly, a hepatic abscess will be shown as a lesion surrounded by a fibrotic capsule without enhancement.
Question 4: What would be your next step to make the final diagnosis?
Correct
CORRECT ANSWER EXPLAINED BELOW Correct answer to Q4 is: Core needle biopsy.
Discussion:
Core needle biopsy will be the next step to make the final diagnosis. Surgical resection is not performed without preoperative histological diagnosis. Fine needle biopsy cytology will rarely be sufficient for a final diagnosis. Chemotherapy can be initiated when the final diagnosis is known.
Image 4: Ultrasound – Subcostal transverse view showing biopsy needle in the lesion.
Additional Discussion
Needle biopsy showed adenocarcinoma (most likely from the bile ducts).
Conclusion
Early-stage cancers, that have not spread to other organs or tissues, can be surgically resected. However, only a small number of cholangiocarcinomas are resectable at the time of diagnosis. Hepatolithiasis is an established risk factor for cholangiocarcinoma 1.
In our case, needle biopsy showed adenocarcinoma (most likely from the bile ducts). A PET/CT revealed a metastasis in the vertebral spine. Consequently, the patient was not eligible for surgical resection and was treated with palliative chemotherapy. Systemic chemotherapy is generally used to treat unresectable metastatic, or recurrent cholangiocarcinoma.
CEUS is a valuable tool in determining the nature of liver lesions 2.Conflicts of interest
“The authors declare no conflict of interest.”
References
- Tyson GL, El-Serag HB. Risk Factors of Cholangiocarcinoma. Hepatology. 2011;54(1):173–184.
- D’Onofrio M, Crosara S, De Robertis R, Canestrini S, Mucelli RP. Contrast- enhanced ultrasound of focal liver lesions. AJR Am J Roentgenol. 2015;205:W56–W66.
Incorrect
CORRECT ANSWER EXPLAINED BELOW Correct answer to Q4 is: Core needle biopsy.
Discussion:
Core needle biopsy will be the next step to make the final diagnosis. Surgical resection is not performed without preoperative histological diagnosis. Fine needle biopsy cytology will rarely be sufficient for a final diagnosis. Chemotherapy can be initiated when the final diagnosis is known.
Image 4: Ultrasound – Subcostal transverse view showing biopsy needle in the lesion.
Additional Discussion
Needle biopsy showed adenocarcinoma (most likely from the bile ducts).
Conclusion
Early-stage cancers, that have not spread to other organs or tissues, can be surgically resected. However, only a small number of cholangiocarcinomas are resectable at the time of diagnosis. Hepatolithiasis is an established risk factor for cholangiocarcinoma 1.
In our case, needle biopsy showed adenocarcinoma (most likely from the bile ducts). A PET/CT revealed a metastasis in the vertebral spine. Consequently, the patient was not eligible for surgical resection and was treated with palliative chemotherapy. Systemic chemotherapy is generally used to treat unresectable metastatic, or recurrent cholangiocarcinoma.
CEUS is a valuable tool in determining the nature of liver lesions 2.Conflicts of interest
“The authors declare no conflict of interest.”
References
- Tyson GL, El-Serag HB. Risk Factors of Cholangiocarcinoma. Hepatology. 2011;54(1):173–184.
- D’Onofrio M, Crosara S, De Robertis R, Canestrini S, Mucelli RP. Contrast- enhanced ultrasound of focal liver lesions. AJR Am J Roentgenol. 2015;205:W56–W66.