case_images: PMC7556100_01
case_images: MRI with Eovist  (gadoxetate disodium contrast) shows the persistent portal vein thrombosis (dotted arrrow) and the segment 7 lesion (solid arrow). The lesion measures 2.6 cm and is faintly hypointense with hyperintense rim on precontrast T1W image (a), enhances centrally on arterial phase (b), central washout with a persistent hyperintense rim on portal venous phase (c), and no Eovist  uptake centrally with a persistent hyperintense rim on hepatocyte phase. This appearance is suspicious for HCC.
case_images: CRIT2020-8824099.001.jpg
case_images: PMC7556100_01_CRIT2020-8824099.001.jpg
case_images: fig1
case_images: MRI with Eovist  (gadoxetate disodium contrast) showed a 26-mm hepatic lesion with arterial hyperenhancement and associated washout, consistent with hepatocellular carcinoma (OPTN 5B) (Figure 1).
case_images: Contrast-enhanced ultrasound (US) demonstrates a 2.5 cm mass in segment 7 (arrow) that is echogenic on grayscale (a) and has early enhancement relative to the liver parenchyma (b). At 5 minutes postcontrast injection, there is a very subtle washout (c).
case_images: CRIT2020-8824099.002.jpg
case_images: PMC7556100_01_CRIT2020-8824099.002.jpg
case_images: fig2
case_images: Contrast-enhanced ultrasound also showed distinct arterial enhancement and delayed subtle washout:again consistent with hepatocellular carcinoma (Figure 2).
case_images: Retrospective review of a contrast-enhanced CT of the liver performed 8 months prior to contrast-enhanced MRI demonstrates portal vein thrombosis (dotted arrow) and a 2.3-cm lesion in segment 7 (arrow) that is faintly hypodense on precontrast (a), enhances centrally with a hypoenhancing rim on arterial phase (b), and subtly hypodense with a subtle rim of hyperenhancement on 3 min delay phase (c). In a patient with chronic liver disease, this appearance would be suspicious for HCC.
case_images: CRIT2020-8824099.003.jpg
case_images: PMC7556100_01_CRIT2020-8824099.003.jpg
case_images: fig3
case_images: The retrospective review of the contrast-enhanced CT scan revealed a 23 mm intrahepatic lesion with arterial enhancement and very subtle washout, suspicious for HCC (Figure 3).
case_images: (a) The boundary between normal liver tissue and the lesional tissue is difficult to appreciate on H&E stain on low power (H&E stain, 20x magnification). (b) However, immunohistochemical stain for glutamine synthetase highlights the lesional area with patchy brown staining. Nodular architectural typical for FNH is also more evident. Adjacent normal liver tissue (arrows) shows the characteristic perivenular staining only (glutamine synthetase immunohistochemical stain, 20x magnification). (c) Large abnormal muscular arteries (arrow) without associated bile ducts of similar size are seen, a characteristic feature of FNH (H&E stain, 100x magnification). (d) Large fibrous tracts with ductular proliferation, similar to that seen in cirrhotic livers, is seen within the lesion (H&E stain, 100x magnification). (e) On high power, the hepatocytes within the lesion appear similar in appearance to the background nonlesional hepatocytes. No significant cell plate architectural abnormality or cytologic atypia diagnostic of hepatocellular carcinoma is identified (H&E stain, 200x magnification). (f) Reticulin stain highlights fibrous tracts within the lesion (arrows). Also, significant thickening of the hepatocellular plates, a feature of hepatocellular carcinoma, is absent (reticulin stain, 100x magnification).
case_images: CRIT2020-8824099.004.jpg
case_images: PMC7556100_01_CRIT2020-8824099.004.jpg
case_images: fig4
case_images: Microscopic examination of the liver biopsy (Figure 4) revealed a lesion composed of cytologically normal-appearing hepatocytes arranged in incomplete nodules (panels (a) and (e)).