الموقع الرسمي للدكتور أحمد رفاعي

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Case No; 7

1/24/2013

10 Comments

 
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Differential diagnosis

 ·        Hypervascular hepatic  metastasis from renal cell carcinoma
·        Hepatocellualr carcinoma (HCC)
·        Hypervascular benign lesion

 Clue for the diagnosis:
·        Because renal cell carcinoma is a hypervascular tumor and its metastasis is following its nature, i.e.  hypervascular,  therefore, the 1st  diagnosis is metastasis , but we have to differentiate between the behavior of hypervascular malignant lesions in the liver ( metastasis and HCC )  and the other  hypervascular benign lesions that can coexist incidantely   ( like hemangioma, focal nodular hyperplasia and adenoma). 
·        The hypervascular malignant tumors in the liver are washing out the contrast in the portovenous and delayed phase more than the normal liver parenchyma  (become more hypodense than the adjacent normal enhancing liver parenchyma)
·      In this case, the tumour is markedly enhancing in the arterial phase, but  becomes isodense to the liver parenchyma in portovenous and delayed phases, suggests a benign hypervascular tumor rather than malignant metastatic deposit.
·        The tumor also has a central hypodense scar (blue arrow) which does not enhance in the arterial, or the port venous phase, but enhances in the delayed phase. The enhancement pattern of the scar is pathognomonic for focal nodular hyperplasia (FNH).  The scar of FNH is formed histologically of fibrous tissue and AVM ( arteriovenous malformation) which explains its enhancement in the delayed phase ( fibrosis and AVM usually show delayed enhancement).
 ·        The diagnosis  was confirmed by sulphur colloid scanwhich showed increase uptake by the tumor which is  also another pathognomonic feature of  focal nodular hyperplasia as it is the only tumor that contains Kupffer cells which cause increase uptake.
 
·      N.B.:
Multiphase contrast CT is crucial for diagnosis of any focal liver lesion (s). It is of note that this lesion was missed in a previous CT exam as it was performed as single phase contrast study.  

Diagnosis :
Focal nodular hyperplasia in a patient with a history of renal cell carcinoma.

 Teaching points
 Focal nodular hyperplasia : 
·       The 2nd mostcommon benign tumor of liver after hemangioma
·        Usually solitary (95%)
·        Frequently has central fibrous scar contains  arteriovenous malformation
·        M:F= 1:4
·        Highly vascular tumor
 ·        On US: iso to hypoechoic , with displacement of hepatic vessels
 ·        On CT :
       -        Transient intense hyperdensity on arterial phase, followed rapidly by  isodensity on portovenous phase
       -         Hypodense central scar in arterial and portovenous phases , shows enhancement on the delayed phase
     -         
  ·        On MRI:
-     Dynamic MRI has widely replaced CT for diagnosis of focal liver lesions in many institutions.
-    Iso to hypointense on T1W,  slightly hyperintense on T2W
-    Dense enhancement on arterial phase, iso intense on portovenous phase
 -    Central scar: hypointense   on T1W, hyperintense on T2W, and showed enhancement   on delayed phase.

·      On nuclear study :
* Sulphur colloid scan : normal uptake in 50-70%. Increase uptake in about 10% of cases but in such cases of increase uptake, it is pathognomonic, as the focal nodular hyperplasia is the only hepatic tumor that contains sufficient Kupffer cells to cause increase uptake.

10 Comments
Khaled abd el baky
1/24/2013 05:35:02 am

thanks

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Ahmed Refaey
1/24/2013 03:00:59 pm

welcome Dr Khaled

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mohamed
1/24/2013 12:30:36 pm

what a marvelous case .. superb explanation .. thanks dr

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Ahmed Refaey
1/24/2013 03:01:44 pm

thanks Dr Mohamed

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Moustafa Adel
1/24/2013 01:19:40 pm

nice case and discussion, thank u sir

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Ahmed Refaey
1/24/2013 03:02:38 pm

thanks Dr Mustafa

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Dr.momen
1/30/2013 07:06:15 pm

Nice teaching case dr. Ahmed .

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ayat
2/6/2013 04:47:22 pm

thanks ....an interesting case ,,,,,JAZAK ALLAH 5AYRAN

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dr Sameh Baghagho
2/7/2013 03:45:48 pm

nice case dr Ahmed

Reply
Ahmed Mossa
2/19/2013 03:37:51 am

شكرا جزيلا علي المجهود الرائع والمعلومات القيمه جزاك الله خير

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