Teaching Case

History of cirrhosis and obstructive jaundice. Ultrasonography showed dilated bile ducts and an inhomogeneous liver parenchyma. An ampulloma was diagnosed endoscopically and an intracanalicular stent was introduced. In the follow-up, laboratory results showed a raising alphafetoprotein level.

Patient admitted with a history of cirrhosis and obstructive jaundice. Ultrasonography showed dilated bile ducts and an inhomogeneous liver parenchyma. An ampulloma was diagnosed endoscopically and an intracanalicular stent was introduced. Cholestasis progressively subsided but laboratory results showed a raising alphafetoprotein level. CT scan and MRI were requested to rule out a hepatoma.

Hepatocellular carcinoma (HCC) is a primary malignant neoplasm of the liver most common in Africa and Asia frequently associated with cirrhosis. Patients present with aspecific symptoms. An abdominal mass is sometimes palpable in later stages. Laboratory results often show a markedly elevated alphafetoprotein level. More than 75% of patients with HCC have extrahepatic spread at the time of diagnosis. CT shows a solitary mass or possibly satellite lesions. MRI is superior to CT in demonstrating the fibrous capsule seen in 50% of the hepatomas and in delineating the tumor margin and venous invasion. Intravenous administration of super-paramagnetic iron oxide (SPIO) considerably enhances contrast between hepatoma and normal liver tissue due to T2 shortening. SPIO particles are phagocytised by cells of the macrophage-monocytic system which results in a marked signal loss of normal liver tissue. Most malignant tumors lack reticuloendothelial cells and do not loose signal after SPIO infusion and thus show a higher signal compared to the normal liver tissue. The iron oxide contrast not only improves diagnostic confidence but also allows better delineation of the tumor margins compared to the precontrast images.