Liver SOL with long history may confuse with adenoma and FNH as both may have hypodense center. we approach such a case and solve what is it actually?

1. A case of hepatic adenoma
Presented By
Dr MD ABDUL QUIYUM
Resident phase B,HBS,BSMMU
DR. Shahanara Khanam
Resident, Phase-A ,Obstetrics and Gynaecology (ICMH)

2. Particulars of Patient
Name : Mrs. Halima
Age : 45 years
Sex : Female
Religion : Islam
Occupation : Housewife
Marital Status : Married
Address : Faridpur
Date of Admission : 19.12.2020
Date of Examination: 20.12.2020

3. Particulars of Hospital
Bed : FP 1
Unit : Yellow-1
Level : 5th
Block : C block
Hospital : BSMMU

4. Presenting Complaints:
 soft tissue mass in liver during USG evaluation of amenorrhea for
6 month.

5. History of Present Illness
According to the statement of the patient, she was
reasonably well 6 months ago. Then she developed
amenorrhea. Her amenorrhea persists for 6 months associated
with menopausal symptoms (hot flush) and during evaluation by
local physician, the USG report shows space occupying lesion in
the right lobe of liver and FNAC revealed no definitive
diagnosis.

6. History of Present Illness contd…
On query, patient has no history of pain, fever, anorexia and weight
loss. she has no history of blood mixed vomiting, passage of black
tarry stool during this period. Her bladder and bowel habit is
normal. She has no history of cough, chest pain or bone pain,
jaundice or any transfusion history.

7. History
Past history : History of cesarean section for 3 times.
Treatment history : Has a history of taking BISOPROLOL + AMLODIPIN for 1
year
Allergic history : Not known to allergy to any food or drug.
Immunization history : Immunized as per EPI schedule.
Personal history : Non smoker, not habituated to betel nut
Family history :No history of jaundice or cancer in her family.
Socio-economic history :Belongs to lower middle socio-economic status.

8. MENSTRUAL HISTORY
LMP – 3/4/2020
MP/MC-AMENORRHOEIC
AGE OF MENERCHE-13YEARS
CONTRACEPTION- OCP taking irregularly for years ,last 10 years.
OBSTETRIC HISTORY
PERIOD OF MARRIED LIFE:30year
PARA: 3+1
AGE OF LAST CHILD:14years

9. General Examination
Appearance :normal
Body built : average
Nutritional status : average
Anaemia : absent
Jaundice : absent
Cyanosis : absent
Clubbing : absent
Koilonychia : absent
Leuconychia : absent
Oedema : absent
Dehydration : absent

10. General Examination Contd…
Neck Vein : not engorged
Lymph Node :not palpable
Thyroid Gland :normal
Skin Condition and Hair Distribution :normal
Pulse :82 b/min
Blood Pressure :110/80 mm Hg
Temperature :98^F
Respiratory Rate :18 breaths/min

11. Systemic Examination
Gastrointestinal examination:
Mouth and oral cavity examination:
Lips, gums, teeth, tongue and oral cavity- normal.

12. Abdominal Examination
Inspection:
Shape : normal
Umbilicus : Centrally placed, inverted with vertical slit
Flanks : not full
Visible healthy scar mark was present at lower abdomen of previous of C/S.Surrounding
skin condition was normal. No visible engorged vein, peristalsis or visible lump.

13. Palpation:
Local temperature is normal, Abdomen is soft,non tender,
On deep palpation,a spherical mass at RHR ,firm in
consistency,mildly tender,moves with respiration continuous with
Liver,other movement and fixity cant be assessed.
GB couldnot be identified separately.
No other organomegaly or lump

14. Percussion:
Tympanatic. Upper border of liver dullness is in 5th intercostal space on right mid-
clavicular line.
Shifting dullness: absent
Auscultation: Bowel sound present. No hepatic bruits, renal bruits and Splenic rub.
Hernial orifices are intact.
Groin and external genitalia - normal.
Digital Rectal Examination not done.
Other Systemic examination
Examination of other systems reveals no abnormality.

15. Salient Feature
Mrs. Halima khatun 45 years old patient presented with space occupying
lesion at right lobe of liver during ultrasonic evaluation for amenorrhoea for 6
month.She has no history of pain,fever,weight loss,haematemesis or any
symptoms suggestive of metastasis.She had taken OCP irregularly for 20 years
and underwent 3 times caesarean section and not positive for HBsAg.
On general examination, not anaemic not icteric ,vital parameter within
normal limit, liver is palpable. Other systemic examinations reveal no
abnormality.

16. Provisional Diagnosis
Heamangioma involving right lobe of liver
Points in favour:
Most common benign tomor
1.Sol in liver
2.Long history
3.H/O OCP intake
4.No pain, anorexia, weight loss

17. Differential Diagnosis
1.Hepatic adenoma
2. Ca GB
2. HCC
1.Sol in liver
2.H/o taking OCP
3.Long history
1.No history of pain
2.No tenderness
1.Sol in lIver
2.Age of
1.No weight loss
2.No
heamatemesis/malaena
Spherical mass at RHR
Firm in
consistency,moved with
respiration
No pain
No weight loss
No anorexia

18. Approach to manage..
1. review of USG report
2.further investigation for evaluating SOl

19. USG of whole
abdomen
Liver : Normal in size.
Hepatic parenchymal
echotexture is bright all over.
Hypoechoic mass lesion
(8.3cm x 7.6cm) is noted in
sub-hepatic region could not
separated from liver.
GB: partially contracted.wall
thickness normal
Impression : Hypoechoic
mass lesion (8.3cm x 7.6cm)
in sub-hepatic region.
Hypoechoic
mass
GB

20. USG of Whole Abdomen

21. FNAC from mass lesion
-----necrotic material

22. 1st line investigation
CBC
LIVER function test
Tumor marker
Viral marker
CE-CT of HBS

23. Investigation Profile
Complete Blood Count :
Hb% -12.2 gm/dl,
ESR-15 mm in 1ST hour
WBC- 10000/cumm, (N-69% )
LFT
 S. Bilirubin : 0.7 mg/dl,
 S. ALP : 268 U/L,
 S. Albumin : 3.8 gm/dl,
 PT : 12.0 s & INR : 1.00
S.ALT :20 U/L

24. Investigation Profile Contd…
Tumour Markers:
CA 19-9 : 36 U/ml
CEA : 3.42 ng/ml
AFP : 2.10 ng/ml
Viral marker :
HBsAg : Negative
AntiHBcAb : Negative
Anti HCV : Negative
Other GA investigation
S. Electrolytes : Na: 136
mmol/l, K: 4.7 mmol/l, Cl: 99 mmol/l
 Creatinine : 0.86 mg/dl
RBS : 4.7 mmol/L
Chest X-ray P/A view : Normal
ECG : Normal
Echocardiography : No RWMA. EF
– 66%.

25. CE-CT of Whole Abdomen
Plain
contrast

27. CT Scan of Whole Abdomen

28. CT SCAN REPORT

29. Diagnostic confusion
1. exophytic lesion with central hypodense area (adenoma / FNH)
2.relatively long history ( 6 month)
3.AFP normal.
Then we proceed for 2nd line investigation
MRI of Liver
Sulphar colloid scan

30. MRI ABDOMEN
Axial
view

32. coronal
mrcp

33. MRI REPOT

34. Liver Scan

36. Confirmatory Diagnosis
Exophytic Adenoma /HCC arising from segment V of liver :

37. Exophytic liver tumor
When tumor arising from liver but center of tumor lies outside of liver surface.
Exophytic tumor from rt lobe : confusion with origin
Then consider : some sign
1. beak sign
2.prominent feeding artery sign
3.phantom organ sign
4.embaded organ sign

38. Adenoma
CT scan
FNH
HCC
Characterization of
lesion

40. F
N
H
HCC
adenoma
patient

41. Tc 99 Sn Scan
Tc 99 BrIDA scan

42. Size 8*11 cm
Find : HCC after excision

43. Initially as HCC ,after resection
showed haemangioma

45. Iinitially as HCC later embryonal sarcoma in adult

46. Plan of Management
CTP –A
MELD
PS 0
BCLC stage c
8*9 cm
Preoperative bowel preparation and =+-consent of stoma
Reverse L incision
Nonantomic liver resection +- ligation of feeding vessel
Post operative surveillance +-chemotherapy

47. THANK YOU