Case 4

This is an MRI liver study; the salient abnormality is a large mass occupying segments VII, VIII and IV of the liver, and showing heterogeneous signal intensity. The mass shows heterogeneous post contrast enhancement, mostly at the rim with some internal enhancement, which is most prominent in the portal venous phase. There is no retention of contrast media in the hepatobiliary delayed phase.

While there is hepatomegaly, there is no evidence of advanced liver parenchymal disease. There is some heterogeneous restricted diffusion, as some parts of the mass appear bright on the DWI images with corresponding low ADC values.

There is also a short segment of the transverse colon which shows circumferential mural thickening and luminal narrowing, with sharp transition and shouldering between this segment and the normal colon; this is the classic ‘apple core’ finding.

The mass in the liver shows frankly malignant features; while there normally would be a differential diagnosis which includes peripheral cholangiocarcinoma and fibrolamellar HCC, when found in conjunction with the apple core lesion in the colon- which represents an adenocarcinoma- the most likely diagnosis is a solitary giant hepatic metastasis.

I would notify the referring physician and recommend image guided tissue biopsy, as well as colonoscopy for diagnosis. The case should then be flagged for discussion at colorectal oncology MDT.