A 52 year-old woman with dull pain around the epigastrium and mild fever at night. No other symptoms.
MSCT scan at ITO Hospital, on May 12th, suspected liver abscess , but patient not be treated, referred to Binh Dan Hospital. On May 20th, examined at Binh Dan Hospital and had an MRI scan and biopsy recommended.
Contrast-enhanced abdominal CT scan from ITO Hospital results:
Image 02 shows adjacent lesion in segment IV of the right liver lobe, measuring 45x30mm, d2 = 40x28mm, with partial protrusion of the liver border, relatively well-defined boundaries, heterogeneous mixed density, contrast enhancement in both rim and central areas; mainly in a granular form.
- Right kidney cyst measuring 11x10mm.
- No abnormalities in shape or density of the pancreatic and adrenal parenchyma on both sides were observed.
- Intrahepatic and extrahepatic ducts are not dilated.
- Gallbladder is not enlarged, with a few gallstones with a maximum diameter of 11mm; currently, there is no wall thickening or infiltration of the surrounding tissue.
Liver lesion is near the gallbladder wall, with thickened gallbladder wall, that are not ruled out a hepatic tumor (image and size unchanged from previous ultrasound) .
Ultrasound Diagnosis: Liver abscess - Gallstones - Right renal cyst.
These are images of the liver taken with a 1.5 MRI machine, with GADOLINIUM contrast agent injected.
Right hepatic lobe lesion adjacent to the gallbladder in subsegments V-VI, measuring 68x51mm, well-defined, with a polygonal border, showing higher signal intensity than the liver parenchyma on T2WI and lower signal intensity than the liver parenchyma on TIGER. After GADO contrast injection, the lesion showed heterogeneous peripheral contrast enhancement in the arterial phase, increased centripetal conduction in the portal venous and late phases, and restricted diffusion. Irregular thickening of the gallbladder wall and several gallstones with a maximum size of 7mm were noted.
No portal vein thrombosis was observed. The common bile duct was clear and free of stones.
Spleen signal intensity is within normal limits. Pancreas signal intensity is normal. Right renal cyst is 10mm.
No ascites was observed. Hilar and pancreatic head lymph nodes measured a maximum of 17x12mm.
** MRI conclusions
SUGGESTED GALLBLADDER CANCER METASTASIS to the LIVER (Differential Diagnosis: INTRAHEPATIC BILE DUCT TUMOR INVASION of the GALLBLADDER) + GALLBLADDER STONES, max. SIZE # 7mm. HEPATIC HILAR and PANCREATIC HEAD LYMPH NODES, max SIZE #17X12mm + RIGHT KIDNEY CYST 10mm.
Lab data and liver biopsy results from Medico Pharmaceutical University Hospital:
Liver biopsy:
Liver biopsy result:
The sample was liver tissue, showing metastatic cells, atypical nuclei, and hyperchromatic nuclei. These cells formed indistinct, infiltrating ducts. The stroma showed an inflammatory reaction. Conclusion: MODERATELY DIFFERENTIATED CARCINOMA, METASTASIS UNDETECTED.
It is recommended to combine clinical and other paraclinical findings (gastrointestinal endoscopy, etc.) to help determine the origin.
So our case is not a liver abscess with gallbladder stones. Because the patient denied a surgical intervention, we should accept the biopsy conclusions for a case of liver cancer with hepatic hilar lymph nodes and gallstones.
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Case Summary:
1. A 52-year-old woman presented with dull epigastric pain and low-grade nocturnal fever. Initial assessment at a referring facility suggested a liver abscess based on computed tomography (CT) findings. However, following further evaluation at Binh Dan Hospital and MRI at Medic, imaging characteristics shifted the diagnostic suspicion from a benign lesion to a malignancy. A subsequent liver biopsy at the University MedicoPharmaceutical Hospital confirmed the diagnosis of metastatic, moderately differentiated carcinoma. This case illustrates the pivotal role of integrating imaging and pathology in revising a diagnosis from liver abscess to a complex malignancy.
2. Clinical Progression and Medical History Diagnosis and Treatment Timeline:
May 12th: Abdominal MSCT scan at ITO Hospital; preliminary diagnosis suspected liver abscess, but the patient did not receive treatment.
May 20th: Examination at Binh Dan Hospital; doctors determined that the CT scan was insufficient for a conclusion and recommended further MRI and biopsy to determine the nature of the tumor.
May 22nd: MRI and other paraclinical tests performed at Medic Center. The patient still experienced mild epigastric pain, but the fever had subsided, and Murphy's sign was negative.
Clinical data:
Inflammatory Markers: hs CRP is elevated (25.7 mg/L). Tumor markers and Serology: AFP, Toxoplasmosis, and HBV are all negative. Liver function: Bilirubin and liver enzymes are within normal limits.
3. Results of Advanced Clinical and Pathological Examinations:
The shift in imaging modality from CT (without full contrast enhancement) to 1.5-Tesla MRI (using Gadolinium-based contrast agents) represented an "imaging turning point," revealing the malignant characteristics of the tumor.
Note: MRI findings of "centripetal enhancement" and "restricted diffusion" are the most significant objective indicators for ruling out a diagnosis of liver abscess and pointing towards a malignant solid tissue nature.
Liver biopsy at the University MedicoPharmaceutical Hospital considered the gold standard for determining the histological nature of this lesion. Microscopic description: "The tissue sample is liver tissue, showing the presence of metastatic cells with atypical and intensely colored nuclei. These cells are arranged to form indistinct, invasive duct-like structures. The stroma shows accompanying inflammation." Pathological conclusion: MODERATELY DIFFERENTIATED CARCINOMA, METASTASIS UNDETECTED (Moderately differentiated carcinoma, primary focus undetermined).
4. Summary of Conclusions and Differential Diagnosis analysis:
Based on imaging (MRI), the preferred diagnosis is: Gallbladder cancer with hepatic metastasis. Differential diagnosis to note: Intrahepatic cholangiocarcinoma directly invading the gallbladder.
Reason for ruling out "Liver abscess": Although there were symptoms of fever and elevated hs CRP, the contrast enhancement on MRI and histological biopsy results (atypical nuclei, invasive ductal structure) confirmed the undeniable malignancy.
Co-morbidities identified:
Gallstones (7-11mm).
Right kidney cyst.
Enlarged lymph nodes in the hepatic hilum and pancreatic head (typical locations of metastatic lymph nodes).
Management and Clinical Outcome:
Due to the histopathological findings confirming metastatic cancer but with an unclear primary site, specialists recommended further gastrointestinal endoscopy and other systemic investigations to determine the tumor origin. However, the patient refused surgical intervention. In this context, the liver biopsy results combined with imaging of the hepatic hilum lymph nodes were accepted as the final diagnosis to guide care and prognosis for the patient.
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