Case 2

This is an MRI abdomen study showing a large, irregular, lobulated mass in the left upper quadrant of the abdomen, which appears inseparable from the lateral border of the left lateral segments of the liver – the mass is heterogeneously T2 hyperintense with a T2 hypo-intense central scar. It is iso-intense on the T1 sequence, with a hyperintense focus which likely represents a focus of haemorrhage. The central scar remains hypointense on T1.

The mass is displacing both the stomach and spleen posteriorly, with no frank invasion of these organs. It shows avid heterogeneous post-contrast enhancement on the arterial phase with enhancement equal to normal liver on the portal venous phase, except for the central scar which does not enhance. There is no contrast retention on the hepato-biliary phase.

There are scattered lesions in the right lobe of the liver, which are hyper-intense on T2 imaging, and show avid post-contrast enhancement on the arterial phase, with no retention of contrast on the hepato-biliary phase.

I note that the background liver parenchyma is normal. There is no liver cirrhosis.

The findings represent a large malignant mass arising from the liver, with hematogeneous metastatic spread to multiple other sites within the liver. This is most in keeping with a fibrolamellar hepatocellular carcinoma.

The differential diagnosis includes conventional HCC, however this is typically associated with a different demographic and underlying parenchymal liver disease.

Focal nodular hyperplasia may have a similar appearance, yet this is effectively ruled out by the lack of contrast retention on the hepatobiliary phase images. This entity tends to be much smaller and more well defined, the scar is T2 hyperintense, and is less heterogeneous.