Liver Fx 1 Large Hypervascular Arterial Fed Mass 2 Exophytic Dx DDX HCC Angio 65M presents with RUQ pain Weight loss

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Liver


65M presents with
right upper quadrant (RUQ) pain and
weight loss

 

  • Large Hypervascular Arterial Fed Liver Mass – Suspected HCC

  • This angiographic image reveals a large, exophytic, hypervascular liver mass, primarily fed by branches of the hepatic artery. The prominent arterial enhancement and the mass’s size and protruding contour raise suspicion for hepatocellular carcinoma (HCC), although other arterial-phase-enhancing liver lesions must also be considered.

  • Ashley Davidoff MD – TheCommonVein.com (03552)

  • Table 1 – Clinical Context

    Element Detail
    History 65M with RUQ pain and weight loss
    Physical Exam May show hepatomegaly, palpable mass, signs of chronic liver disease
    Epidemiology Common in patients with cirrhosis, hepatitis B/C, or chronic liver disease
    Relevant Clues Arterial phase hypervascularity + exophytic growth → raises concern for HCC

    Table 2 – Observation

    Observation Description
    Fx 1 Large, hypervascular, arterial-phase-enhancing liver mass
    Fx 2 Exophytic growth pattern (protruding beyond normal hepatic contour)

    Table 3 – Classification of the Finding: Arterial-Phase Enhancing Liver Masses

    Category Examples
    Malignant HCC, hypervascular metastases (e.g., RCC, NETs)
    Benign Neoplasms Focal nodular hyperplasia (FNH), hepatic adenoma
    Vascular Lesions Hemangioma (atypical), arterioportal shunts
    Inflammatory Abscess with rim-enhancement (less likely here)

    Table 4 Hypervascular Liver Mass

    Unit Liver parenchyma, hepatic arterial branches
    Size Large (>5 cm)
    Shape Lobulated or spherical; exophytic projection
    Structure Solid mass; no central necrosis on angiography noted
    Pattern Intense enhancement during arterial phase; washout not visible here
    Contour Exophytic contour distorts liver margin
    Transition Zone Abrupt margin between mass and normal liver
    Context Occurs in cirrhotic liver (suspected); arterial supply prominent

    Table 5 – Differential Diagnosis of Arterial-Phase Hypervascular Liver Mass

    Diagnosis Distinguishing Features
    Hepatocellular carcinoma Arterial enhancement, washout on venous/delayed phases, risk factors (cirrhosis, hepatitis)
    Focal nodular hyperplasia Central scar, homogeneous enhancement, no washout
    Hepatic adenoma Variable enhancement, no central scar, risk with OCP/anabolic steroids
    Hypervascular metastases History of known primary (e.g., RCC, thyroid, NETs), multiple lesions
    Hemangioma (atypical) Peripheral nodular enhancement with centripetal fill-in

2. Findings and Diagnosis


65M presents with
right upper quadrant (RUQ) pain and
weight loss

03552 liver fx hypervascular mass HCC hepatocellular carcinoma hepatoma angiogram amgiography Courtesy Ashley Davidoff MD

Page 2 – Radiologic Findings and Differential Diagnosis

Title: Liver – Large Hypervascular Arterial Fed Mass

Table 1 – Clinical Context

Element Detail
History 65M with right upper quadrant (RUQ) pain and weight loss
Physical Exam Hepatomegaly may be present; signs of chronic liver disease (e.g., jaundice, ascites)
Epidemiology Common in cirrhotic or hepatitis B/C patients; typically >60 years, male predominance
Relevant Clues Hypervascular arterial phase enhancement in at-risk liver raises suspicion for HCC

Table 2 – Observation

Observation Description
Primary Finding Large arterial-fed mass in the liver with intense arterial-phase enhancement
Secondary Finding Exophytic growth pattern distorting hepatic contour
Special Signs None specifically named; but pattern resembles “arterial dominance” of HCC

Table 3 – Evaluation: Large Hypervascular Arterial Fed Mass

Component Description
Units (U) Liver parenchyma, hepatic artery branches
Size (S) Large (>5 cm)
Shape (S) Lobulated, roughly spherical
Position (P) Arising from right lobe; exophytic (partially projecting outside liver margin)
Character (C) Solid, homogeneous, strongly enhancing in arterial phase
Time (T) Presumed chronic process in this clinical setting
Connections and Associations May compress adjacent bowel/stomach; often coexists with background liver disease (e.g., cirrhosis)

Table 4 – Classification of the Primary Finding: Large Hypervascular Arterial Fed Liver Mass

Subtype Description / Key Features
Type A – HCC Common in cirrhotic liver, arterial enhancement with venous/delayed washout
Type B – FNH Homogeneous enhancement, often with central scar, stable in young women
Type C – Adenoma Hypervascular, often in young women on OCPs; risk of hemorrhage

Table 5a – Differential Diagnosis: Most Likely

Rank Category Examples / Notes
1 Neoplastic – Malignant Hepatocellular carcinoma (HCC) – fits clinical + imaging criteria
2 Neoplastic – Benign Focal nodular hyperplasia (FNH) – less likely, no central scar
3 Neoplastic – Benign Hepatic adenoma – less likely in older male; but possible depending on Hx

Table 5b – Differential Diagnosis: Other Possibilities

Category Examples / Notes
Neoplastic – Malignant Hypervascular metastases (e.g., neuroendocrine, renal cell carcinoma)
Neoplastic – Benign Atypical hemangioma (peripheral enhancement with delayed fill-in not seen here)
Vascular Arterioportal shunts or aneurysms – may mimic mass; look for feeding/draining vessels
Infectious Pyogenic abscess with arterial rim enhancement – usually associated with systemic signs
Inflammatory Inflammatory pseudotumor – rare; mimics HCC
Iatrogenic Post-embolization mass effect or scar tissue
Inherited / Congenital Vascular malformations (rare, e.g., hereditary hemorrhagic telangiectasia)

Table 6 – Radiologic Strategy & Guidelines

Modality / Tool Use Case Guideline / Reference
CT – Triphasic Detection and characterization of HCC ACR Appropriateness Criteria – Jaundice (https://www.acr.org/-/media/ACR/Files/Appropriateness-Criteria/Jaundice.pdf)
MRI with contrast Better for small lesions; characterizes washout, capsule, fat, etc. LI-RADS v2018 Guidelines (https://www.acr.org/Clinical-Resources/Reporting-and-Data-Systems/LI-RADS)
Angiography Evaluates arterial supply; may guide embolization Radiopaedia – Hepatic Arteriography (https://radiopaedia.org/articles/hepatic-arteriography)

Table 7 – Pearls (Imaging & Pattern Recognition)

Pearl Explanation
Arterial enhancement is key for HCC suspicion Classic for HCC; evaluate for washout in venous or delayed phases
Exophytic liver lesions may mimic extrahepatic tumors Always trace lesion origin to the liver and look for hepatic arterial feeders
LI-RADS aids structured interpretation Use in known cirrhosis or risk patients; helps guide next steps
Angiography helpful in embolization planning Identifies vascularity and feeder arteries for therapeutic targeting
Always assess liver background Look for signs of cirrhosis, portal hypertension, or satellite lesions

3. Clinical


Page 3 – Known Diagnosis and Clinical Context

Dx Focus: In this patient, the diagnosis was suspected to be hepatocellular carcinoma (HCC) based on the presence of a large, exophytic, hypervascular arterial-fed liver mass in a high-risk clinical setting (older male with RUQ pain and weight loss).

Table – Disease-Specific Analysis: Hepatocellular Carcinoma (HCC)

Element Detail
Definition A primary malignant tumor of hepatocytes, typically arising in cirrhotic or chronically diseased livers
Etiology Most commonly due to chronic hepatitis B or C, alcohol-related cirrhosis, NAFLD, and exposure to aflatoxins
Structural Changes Formation of solid liver masses, often hypervascular, with potential for capsular invasion, vascular spread (e.g., portal vein), and exophytic growth
Functional Changes Can impair hepatic function, reduce synthetic capacity (albumin, clotting factors), lead to portal hypertension, and result in hepatic insufficiency
Labs Elevated AFP (alpha-fetoprotein), liver enzymes (AST, ALT), bilirubin, INR; may include hepatitis B/C serologies
Treatment Depends on staging: options include surgical resection, liver transplant (Milan criteria), transarterial chemoembolization (TACE), radiofrequency ablation (RFA), systemic therapy (sorafenib, atezolizumab/bevacizumab)

Table – Pearls (Clinical and Diagnostic Reasoning)

Pearl
Arterial-phase hyperenhancement is a key imaging feature of HCC, but must be accompanied by washout and capsule appearance for definitive non-invasive diagnosis
HCC is one of the few malignancies that can be diagnosed without biopsy when LI-RADS 5 criteria are met
Exophytic liver masses may mimic gastrointestinal or adrenal tumors; always trace their vascular supply back to the liver
Elevated AFP supports diagnosis but is neither specific nor sensitive alone—normal AFP does not exclude HCC
TACE is preferred for intermediate-stage HCC when not amenable to surgery; transplant is curative but requires strict selection criteria
Always evaluate for underlying liver disease (cirrhosis) as this guides both prognosis and treatment eligibility (e.g., Child-Pugh, MELD)

4. Historical and Cultural


Table – History, Culture, and Art of HCC and the Liver

Each section is labeled once, and each concept within the section is its own unit.

Section Content
Historical Notes Ebers Papyrus (~1500 BCE) – Early descriptions of liver disease in ancient Egypt.
  Autopsy Observations (18th–19th c.) – Liver tumors first recognized via pathology.
  Cirrhosis-HCC Link (20th c.) – Chronic liver disease identified as precursor to HCC.
  Imaging Advances – Angiography, CT, and MRI revolutionized HCC diagnosis.
Cultural Insights Mesopotamian Hepatoscopy – Priests read livers as divine signs of fate.
  Traditional Chinese Medicine – Liver seen as regulator of Qi and emotions.
  Symbol of Vitality – The liver metaphorically linked to blood and life-force across cultures.
Artistic References Prometheus Myth – Regenerating liver symbolized healing and punishment.
  Shakespeare – Liver as emotional center: “liver of blaspheming Jew” (Merchant of Venice).
  Vesalius’ Drawings – Renaissance anatomical art depicted detailed liver structure.
Notable Figures Dr. Thomas Starzl – Father of liver transplantation; transformed survival in HCC.
  Dr. Hans Popper – Pioneered hepatology; foundational work on cirrhosis and HCC.
  Mickey Mantle – Public figure with liver cancer, raised awareness on transplantation.

5. MCQs


Q1: Which of the following imaging features is most characteristic of hepatocellular carcinoma (HCC) on contrast-enhanced CT or MRI?

Option Answer Choice
A Peripheral nodular enhancement
B Hypovascularity in the arterial phase
C Central scar with homogeneous enhancement
D Arterial-phase hyperenhancement with venous washout

Correct Answer and Explanation

Correct Answer Explanation
D Hallmark imaging pattern of HCC; used in non-invasive diagnosis per LI-RADS 5.

Incorrect Answer Explanations

Choice Why Incorrect
A Suggests hemangioma with centripetal fill-in pattern, not typical of HCC.
B Metastases are usually hypovascular; HCC is typically hypervascular.
C FNH has central scar and homogeneous enhancement, not typical for HCC.

Q2: Which of the following is the most common global risk factor for hepatocellular carcinoma?

Option Answer Choice
A Hepatitis C virus (HCV)
B Hepatitis B virus (HBV)
C Non-alcoholic fatty liver disease (NAFLD)
D Hemochromatosis

Correct Answer and Explanation

Correct Answer Explanation
B HBV is endemic in Asia/Africa and is the leading global cause of HCC.

Incorrect Answer Explanations

Choice Why Incorrect
A HCV is a major cause in the West, but less prevalent globally.
C NAFLD is rising but not yet the top global cause.
D Hemochromatosis is rare and hereditary.

Q3: What is the best next step when a 3 cm liver lesion in a cirrhotic patient shows arterial enhancement and venous washout on CT?

Option Answer Choice
A Liver biopsy
B Repeat ultrasound
C Diagnose HCC and initiate staging
D PET scan

Correct Answer and Explanation

Correct Answer Explanation
C Meets LI-RADS 5 criteria → definitive diagnosis without biopsy in cirrhosis.

Incorrect Answer Explanations

Choice Why Incorrect
A Biopsy not needed; risk of tumor seeding.
B Ultrasound lacks specificity and does not guide next steps.
D PET scan is not routinely used for diagnosing or staging HCC.

Q4: Which of the following best describes an exophytic liver mass?

Option Answer Choice
A Protrudes beyond liver contour
B Infiltrates within liver tissue
C Surrounded by satellite nodules
D Hypodense with central necrosis

Correct Answer and Explanation

Correct Answer Explanation
A Exophytic = outward growth beyond the natural contour of the liver.

Incorrect Answer Explanations

Choice Why Incorrect
B Infiltrative growth stays within liver and spreads irregularly.
C Satellite nodules refer to nearby secondary lesions, not contour distortion.
D Hypodense necrosis describes internal makeup, not shape or contour.

Q5: Which imaging modality is best for identifying arterial feeders and guiding embolization in liver tumors?

Option Answer Choice
A MRI
B Ultrasound
C Angiography
D PET scan

Correct Answer and Explanation

Correct Answer Explanation
C Angiography visualizes arterial anatomy → essential for embolization (e.g., TACE).

Incorrect Answer Explanations

Choice Why Incorrect
A MRI is for tissue detail, not interventional planning.
B Ultrasound lacks resolution for hepatic arterial branches.
D PET is not a primary tool for HCC therapy planning.

Q6: Which laboratory marker is most commonly elevated in hepatocellular carcinoma?

Option Answer Choice
A CA 19-9
B Alpha-fetoprotein (AFP)
C CEA
D PSA

Correct Answer and Explanation

Correct Answer Explanation
B AFP is elevated in 50–70% of HCC cases.

Incorrect Answer Explanations

Choice Why Incorrect
A CA 19-9 is for pancreaticobiliary tumors.
C CEA is used for colorectal and GI cancers.
D PSA is specific for prostate cancer.

Q7: Which of the following is considered a curative treatment for early-stage hepatocellular carcinoma?

Option Answer Choice
A Surgical resection or transplant
B Transarterial chemoembolization (TACE)
C Sorafenib
D Radiation therapy

Correct Answer and Explanation

Correct Answer Explanation
A Resection or transplant are curative for early-stage HCC (BCLC 0–A).

Incorrect Answer Explanations

Choice Why Incorrect
B TACE is palliative, used in intermediate-stage disease.
C Sorafenib is systemic therapy for advanced-stage HCC.
D Radiation is limited due to liver sensitivity; not standard therapy.

6. Memory Image


Page 6 – Memory Image (No Auto Image Generation)

Dx: DDx Hepatocellular Carcinoma (HCC)

Table – Visual Metaphor (Textual Only)

Component Description
Visual Metaphor “Crimson Volcano” – a bright, erupting mass rising from the liver surface, symbolizing a hypervascular, exophytic tumor fed by arterial fire
Anatomy Targeted Liver parenchyma, hepatic arterial supply
Physiology Angle Arterial hyperperfusion, vascular dominance, parenchymal invasion
Diagnostic Link Imaging shows intense arterial enhancement with outward protrusion
Memory Hook Bright eruption from liver = hypervascular exophytic HCC; volcanic = aggressive, eruptive nature of tumor
Artistic Style Surreal anatomical overlay with bold red-yellow arterial flares
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Challenge

2. Findings and Diagnosis

3. Clinical

4. Historical and Cultural

5. MCQs

6. Memory Image

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