Pelioid-type hepatocellular carcinoma masquerading as a hepatic hemangioma on technetium-99m red blood cell scintigraphy

Malignant Tumors Misdiagnosed as Liver Hemangiomas

Background and Aim: To derive lessons from the data of patients who were followed for various periods with the misdiagnosis of liver hemangioma and eventually found to have a malignancy.

Material and Methods: The records of 23 patients treated between 2003 and 2018 were analyzed retrospectively.

Results: Twelve patients were men and 11 were women; median (range) age was 55 (35–80). The principal diagnostic modality for the initial diagnosis was ultrasonography (n:8), magnetic resonance imaging (MRI) (n:13), and computed tomography (CT) (n:2). At our institution, MRI was performed in 16 patients; the diagnosis was made with the available MRI and CT studies in five and two patients, respectively. In other words, the ultrasonography interpretations were not confirmed on MRI; in others, the MRI or CT examinations were of low quality or they had not been interpreted properly. Fifteen patients underwent surgery; the other patients received chemotherapy (n:6) or chemoembolization (n:2). The misdiagnosis caused a median (range) 10 (0–96) months delay in treatment. The final diagnoses were hepatocellular carcinoma in 12 patients, cholangiocarcinoma in four patients, metastatic mesenchymal tumor, metastasis of colon cancer, metastatic neuroendocrine carcinoma, sarcomatoid hepatocellular carcinoma, angiosarcoma, thoracic wall tumor, and metastatic tumor of unknown primary in one patient each.

Conclusions: High-quality MRI with proper interpretation and judicious follow up are vital for the accurate differential diagnosis of liver lesions.

Hepatoblastoma Mimicking Hemangioma in Labeled Red Blood Cell Scintigraphy

Although Tc red blood cell (RBC) scintigraphy is a very specific method to differentiate a hemangioma from other hepatic masses, several cases of false-positive Tc RBC scintigraphy have been previously reported throughout the literature. We report an additional case that presented in a 15-month-old boy with hepatoblastoma showing increased labeled RBC activity mimicking hemangioma.

99mTc-red blood cells SPECT and planar scintigraphy in the diagnosis of hepatic hemangiomas

The aim of the study is the assessment of the value of SPECT (single photon emission computerized tomography) using 99mTc-labeled red blood cells in the detection of liver hemangioma, in comparison to planar imaging. With planar red blood cell scintigraphy, sensitivity of the method was 76%, specificity 98%, positive predictive value 98% and negative predictive value 79%. With SPECT, sensitivity of the method was 95%, specificity 98%, positive predictive value 98% and negative predictive value 94%. The smallest lesion detected by planar red blood cell scintigraphy was 1.2 cm, and with SPECT red blood cell scintigraphy 0.8 cm. The use of 99mTc-labeled red blood cells SPECT improved the sensitivity much more in smaller lesions (0.8 to 2 cm), than in bigger ones (2-5 cm). SPECT with radiolabeled red blood cells significantlyy improves the results of scintigraphic findings, especially in the small lesions.

Hepatocellular carcinoma with extensive peliotic change

Peliosis hepatis is a rare lesion histologically characterized by multiple cavities representing dilated sinusoids filled with blood in the liver. Although it has been observed in the liver parenchyma in association with several diseases and medications, there are few reports of nodules of hepatocellular carcinoma (HCC) showing extensive peliotic change. We describe a case of HCC showing extensive peliotic change in the cancer nodule. A 73-year-old man with a liver tumor was referred to our hospital for further investigation. Abdominal ultrasonography revealed an 8-cm hyperechoic lesion with a halo and mosaic pattern in segment 8 (S8) of the liver. Dynamic magnetic resonance imaging of the liver showed early irregular enhancement of the peripheral part of the lesion, and the effect persisted into the late phase, spreading into the central part of the nodule. Hepatic arteriography showed the "cotton-wool" sign, usually observed in cavernous hemangiomas. Fine-needle aspiration biopsy revealed the diagnosis of HCC. Anterior sectionectomy of the liver was conducted. Histological examination of the resected specimen showed that the tumor was a well-differentiated HCC with extensive dilated sinusoid-like structures in the main portion of the nodule, suggestive of peliotic change.

Pelioid-type hepatocellular carcinoma with numerous eosinophilic infiltrations in a patient with primary biliary cirrhosis

A 65-year-old woman with liver injury was referred to our hospital in 1992. She was diagnosed with primary biliary cirrhosis (PBC) of Scheuer's histological classification stage IV. She was treated with 600 mg/day of ursodeoxycholic acid. A 1-cm mass in S7 was detected in August 1995. The serum alpha-fetoprotein (AFP) level increased to 1288 ng/mL in January 1996. Angiography showed a cotton wool-like appearance in the delayed phase. Because the size of the tumor appeared to be increasing and the serum AFP levels increased with high levels of L3 fraction, a pelioid-type hepatocellular carcinoma (HCC) was strongly suspected. Hepatic artery infusion with SMANCS and partial resection of S7 and S8 of the liver were performed in March 1996. The pathological diagnosis for theresected liver tumor was pelioid-type HCC. The serum AFP level decreased to 50 ng/mL after the operation, but relapsed HCC was detected in S6 and S7. Angiography in September 1996 revealed multiple hypervascular lesions, and hepatic artery infusion with SMANCS was again performed; however, we were unable to suppress the progression of the relapsed HCC. The patient died due to an intra-abdominal rupture of relapsed HCC and subsequent liver failure in December 1996. We report a rare case of pelioid-type HCC with numerous eosinophilic infiltrations arising from PBC.

99mTc-labelled red blood cell single-photon emission computed tomography for the diagnosis and follow-up of juvenile nasopharyngeal angiofibroma

AIM

To confirm the usefulness of blood pool scintigraphy with Tc-labelled red blood cells ((99m)Tc-RBCs) in the diagnosis and follow-up of juvenile nasopharyngeal angiofibroma.

METHODS

A prospective study design was used. (99m)Tc-RBCs were prepared by a modified in-vivo method. After the rapid intravenous injection of 370-740 MBq of (99m)Tc-RBCs, dynamic imaging of 1-min duration was performed. After dynamic imaging, static acquisitions at 5 min (second phase: blood pool phase) and 2 h (third phase: static image) were obtained. In addition, single-photon emission computed tomography (SPECT) imaging was performed at 2 h. SPECT images were obtained using a rotating gamma camera (GE-Starcam 4000 XR/T).

RESULTS

All patients showed no activity in the first phase and mild activity in the second phase (blood pool phase). All patients with juvenile nasopharyngeal angiofibroma showed a prominent increased activity in the third phase and in SPECT images.

CONCLUSIONS

This study shows that blood pool scintigraphy with (99m)Tc-RBC SPECT is very accurate, easy to perform and a suitable alternative to pre-operative and post-operative imaging techniques, including computed tomography scan, magnetic resonance imaging (MRI) and MRI angiography, for the detection of juvenile nasopharyngeal angiofibroma.