case_images: PMC9170397_01
case_images: MRI T2-weighted coronal view, showing the huge heterogenous liver mass. The hepatic pedicle (arrows) and segment 6 pedicle (arrowheads) were not involved by the tumor.
case_images: CRIS2022-9673901.001.jpg
case_images: PMC9170397_01_CRIS2022-9673901.001.jpg
case_images: fig1
case_images: None of the three hepatic veins could be identified (PRETEXT classification type IVc), but an inferior right hepatic vein was present, with 9.3 mm in diameter, draining the spared segment 6 (Figures 1 and 2).
case_images: MRI Images. (a) Axial T1 weighted: tumor involvement of major hepatic veins (arrows) and liver segments 2, 4A, 7, and 8. (b) Axial T1 weighted: tumor involvement of segment 3 and caudate lobe; right posterior portal vein is free (arrow). (c) Axial T1 weighted: tumor involvement of segment 4B and the right anterior portal vein (arrow); IRHV entering segment 6 (arrowhead). (d) Coronal T1 weighted, 20-minute hepatobiliary phase: view of the IRHV in segment 6 (arrows) draining into the IVC (arrowheads).
case_images: CRIS2022-9673901.002.jpg
case_images: PMC9170397_01_CRIS2022-9673901.002.jpg
case_images: fig2
case_images: None of the three hepatic veins could be identified (PRETEXT classification type IVc), but an inferior right hepatic vein was present, with 9.3 mm in diameter, draining the spared segment 6 (Figures 1 and 2).
case_images: Intraoperative view of segment 6 remnant liver after resection (RHV: right hepatic vein; IRHV: inferior right hepatic vein; LHV: left hepatic vein; MHV: middle hepatic vein; S7 PV: segment 7 portal vein; RAPV: right anterior portal vein; S5: segment 5).
case_images: CRIS2022-9673901.003.jpg
case_images: PMC9170397_01_CRIS2022-9673901.003.jpg
case_images: fig3
case_images: Finally, hepatic veins were divided with a vascular stapler (Figures 3 and 4).
case_images: Surgery details:intraoperative view. (a) Inferior vena cava with RHV (arrows) and common trunk of MHV and LHV (arrowheads) divided by vascular stapler. (b) IRHV between forceps.
case_images: CRIS2022-9673901.004.jpg
case_images: PMC9170397_01_CRIS2022-9673901.004.jpg
case_images: fig4
case_images: Finally, hepatic veins were divided with a vascular stapler (Figures 3 and 4).
case_images: Intraoperative Doppler ultrasonography showing IRHV patency after resection, with hepatofugal flow (arrow).
case_images: CRIS2022-9673901.005.jpg
case_images: PMC9170397_01_CRIS2022-9673901.005.jpg
case_images: fig5
case_images: After hepatectomy, blood outflow through the IRHV was rechecked through Doppler ultrasonography (Figure 5).
case_images: Surgical specimen:analysis confirmed the lobulated, multilocular, cystic-solid, and heterogeneous hepatic tumor, with a fibrous pseudocapsule, measuring 23 cm x 12.5 cm.
case_images: CRIS2022-9673901.006.jpg
case_images: PMC9170397_01_CRIS2022-9673901.006.jpg
case_images: fig6
case_images: The histopathological and immunohistochemical analysis confirmed positive staining for vimentin, alfa-1-antitrypsin, alpha 1-antichymotrypsin, and Bcl-2 (Figures 6 and 7), which endorsed the diagnosis of UESL.
case_images: Histopathological exam demonstrating fusiform, oval, or stellate tumor cells distributed over myxoid or fibrous stroma. Nuclear pleomorphism and hyperchromasia are noted. Cell cytoplasm is granular and eosinophilic, with ill-defined cell borders. In the top left, the remnant bile duct is involved by neoplastic cells (H&E, 20x objective). Image insert: strong and diffuse immunostaining for alpha 1-antichymotrypsin (40x objective).
case_images: CRIS2022-9673901.007.jpg
case_images: PMC9170397_01_CRIS2022-9673901.007.jpg
case_images: fig7
case_images: The histopathological and immunohistochemical analysis confirmed positive staining for vimentin, alfa-1-antitrypsin, alpha 1-antichymotrypsin, and Bcl-2 (Figures 6 and 7), which endorsed the diagnosis of UESL.
case_images: Postoperatory PET scan images. (a) No evidence of disease in the liver (arrow is showing an encapsulated fluid collection). (b) Blastic bone lesion at the left humerus (arrow).
case_images: CRIS2022-9673901.008.jpg
case_images: PMC9170397_01_CRIS2022-9673901.008.jpg
case_images: fig8
case_images: Although there are no things of disease recurrence in the liver, a recent PET scan identified a blastic lesion at the left humerus, compatible with bone metastasis (Figure 8).