28100235 Visualization

A 61 Age - year Age - old Age male Sex was referred Clinical_event to the emergency Nonbiological_location department Nonbiological_location by his general practitioner in April Date 2010 Date for investigation of loose Sign_symptom bowel Sign_symptom motions Sign_symptom and an episode of black Sign_symptom stool Sign_symptom .
The patient had a history of insulin History - dependent History type History II History diabetes History mellitus History , hypertension History , ischaemic History heart History disease History with History two History previous History ischaemic History events History , obstructive History sleep History apnoea History , depression History , schizophrenia History and a previous History incisional History hernia History repair History .
On examination, he was morbidly Disease_disorder obese Disease_disorder ( BMI Diagnostic_procedure 45 Lab_value ) and was noted to have marked hepatomegaly Disease_disorder .
This was not associated with any recent weight Sign_symptom loss Sign_symptom , haematemesis Sign_symptom , jaundice Sign_symptom or abdominal Biological_structure pain Sign_symptom .
The patient denied History previous History blood History transfusions, History usage History of History intravenous History drugs History and History did History not History drink History alcohol History .
A faecal Diagnostic_procedure occult Diagnostic_procedure blood Diagnostic_procedure test Diagnostic_procedure was negative Lab_value , and the patient’s last colonoscopy Diagnostic_procedure 2 Date years Date prior Date was unremarkable Lab_value .
He was referred Clinical_event to our tertiary Nonbiological_location centre Nonbiological_location for further management after an ultrasound Diagnostic_procedure scan Diagnostic_procedure ( USS Diagnostic_procedure ) displayed an ovoid Shape mass Sign_symptom of mixed Detailed_description echogenicity Detailed_description arising from the liver Biological_structure , measuring 12 Area   × Area   9 Area cm Area .
A computed Diagnostic_procedure tomography Diagnostic_procedure ( CT Diagnostic_procedure ) scan confirmed a malignant Detailed_description appearing Detailed_description , pedunculated Detailed_description lesion Sign_symptom attached to segment Biological_structure IV Biological_structure (Fig.1).
A subsequent magnetic Diagnostic_procedure resonance Diagnostic_procedure imaging Diagnostic_procedure ( MRI Diagnostic_procedure ) confirmed that on T2 Detailed_description weighted Diagnostic_procedure imaging Diagnostic_procedure ( WI Diagnostic_procedure ), the lesion Sign_symptom was isointense Detailed_description to the liver Biological_structure peripherally with central Detailed_description branching Detailed_description hyperintensities Detailed_description (Fig.2a) which corresponded to the hypointensities Sign_symptom seen on T1WI Diagnostic_procedure (Fig.2b).
Enhancement Detailed_description of the lesion Sign_symptom was noted in arterial Detailed_description phase Detailed_description (Fig.3a), during portal Detailed_description venous Detailed_description phase Detailed_description (Fig.3b) and at Detailed_description 2 Detailed_description min Detailed_description (Fig.3c), with some central Detailed_description areas Detailed_description of Detailed_description non Detailed_description - enhancement Detailed_description .
The lesion Sign_symptom becomes slightly Detailed_description hypointense Detailed_description on delayed Detailed_description images Detailed_description at 10 Detailed_description (Fig.3d) and 20 Detailed_description min Detailed_description compared to the surrounding liver Biological_structure .
Laboratory Diagnostic_procedure investigations Diagnostic_procedure revealed a mildly Lab_value elevated Lab_value gamma Diagnostic_procedure - glutamyl Diagnostic_procedure transpeptidase Diagnostic_procedure of 137 Lab_value IU/L Lab_value (normal 5–50 IU/L).
Hepatitis Diagnostic_procedure screen Diagnostic_procedure , alpha Diagnostic_procedure - fetoprotein Diagnostic_procedure , carcinoembryonic Diagnostic_procedure antigen Diagnostic_procedure and cancer Diagnostic_procedure antigen Diagnostic_procedure 19–9 were all unremarkable Lab_value .
The patient underwent a subsegmental Detailed_description resection Therapeutic_procedure of the 15 Distance cm Distance segment Biological_structure IVb Biological_structure mass Sign_symptom in June Date 2010 Date .
There was severe Severity hepatic Disease_disorder steatosis Disease_disorder , but no cirrhosis Disease_disorder .
The patient was discharged Clinical_event postoperative day Date seven Date without complications Sign_symptom .
Pathology Diagnostic_procedure of the resection Biological_structure specimen Biological_structure confirmed SFTL Disease_disorder .
The specimen displayed a pale Color tan Color nodular Shape appearance Shape with a firm Texture and Texture rubbery Texture cut Texture surface Texture .
Histological Diagnostic_procedure examination Diagnostic_procedure revealed fascicles Lab_value of Lab_value spindle Lab_value cells Lab_value in storiform Detailed_description arrangement Detailed_description with a pushing Detailed_description margin Detailed_description .
There was evidence Lab_value of Lab_value extracellular Lab_value collagen Lab_value deposition Lab_value , areas Lab_value of Lab_value myxoid Lab_value stroma Lab_value and branching Lab_value vessels Lab_value with Lab_value hyalinisation Lab_value .
The specimen Biological_structure displayed a high Lab_value mitotic Diagnostic_procedure rate Diagnostic_procedure of up to 9 Lab_value per Lab_value 10 Lab_value high Lab_value - power Lab_value fields Lab_value (HPF) with no Lab_value necrotic Lab_value or Lab_value haemorrhagic Lab_value features Lab_value .
Immunohistochemistry Diagnostic_procedure showed positive Lab_value staining for CD34 Diagnostic_procedure , CD99 Diagnostic_procedure and BCL-2.
The tumour was negative Lab_value for c Diagnostic_procedure - Kit Diagnostic_procedure , CD31 Diagnostic_procedure , SMA Diagnostic_procedure , desmin Diagnostic_procedure , cytokeratins Diagnostic_procedure ( AE1/AE3, Detailed_description MNF116 Detailed_description and Detailed_description Cam Detailed_description 5.2 Detailed_description ), EMA Diagnostic_procedure and S100 Diagnostic_procedure .
The margins Diagnostic_procedure were clear Lab_value .
The non-neoplastic remainder Biological_structure of Biological_structure the Biological_structure liver Biological_structure displayed pericellular Detailed_description fibrosis Sign_symptom indicative of steatohepatitis Disease_disorder .
The patient was followed Clinical_event - up Clinical_event regularly every Frequency 4 Frequency to Frequency 6 Frequency months Frequency with CT Diagnostic_procedure scans by the local Nonbiological_location general Nonbiological_location practitioner Nonbiological_location who liaised with the consultant Nonbiological_location surgeon Nonbiological_location .
There were two Lab_value episodes of re Clinical_event - admissions Clinical_event for further investigation of recurrent Detailed_description right Biological_structure upper Biological_structure quadrant Biological_structure pain Sign_symptom between Date 2011 Date and Date 2013 Date .
Multiple Detailed_description MRI Diagnostic_procedure scans performed during this period revealed expected Sign_symptom postsurgical Sign_symptom changes Sign_symptom with no tumour Sign_symptom recurrence Sign_symptom .
However, in May Date 2016 Date , the patient presented Clinical_event to his local Nonbiological_location emergency Nonbiological_location department Nonbiological_location with progressively worsening right Biological_structure upper Biological_structure quadrant Biological_structure pain Sign_symptom and increasing dyspnoea Sign_symptom with an oxygen Therapeutic_procedure demand Therapeutic_procedure .
CT Diagnostic_procedure of his chest Biological_structure , abdomen Biological_structure and pelvis Biological_structure revealed extensive Detailed_description tumour Sign_symptom recurrence Sign_symptom adjacent Biological_structure to Biological_structure the Biological_structure previous Biological_structure resection Biological_structure site Biological_structure (Fig.4).
In addition, there was a clinically significant right Detailed_description - sided Detailed_description pleural Disease_disorder effusion Disease_disorder and a pleural Biological_structure mass Sign_symptom at the right Biological_structure lung Biological_structure base Biological_structure measuring 3.8 Date cm Date (Fig.5).
Pleurocentesis Therapeutic_procedure was performed, draining 1400 Volume ml Volume of serosanguineous Biological_structure fluid Biological_structure .
Cytology Diagnostic_procedure was negative Lab_value for malignant Diagnostic_procedure cells Diagnostic_procedure .
The case was discussed Clinical_event extensively in a multi Nonbiological_location - disciplinary Nonbiological_location setting Nonbiological_location , and it was decided given the patient’s two sites of disease and significant perioperative risk that he was not a candidate for radical reoperation Therapeutic_procedure .
There were also no suitable chemo- or radiotherapeutic Therapeutic_procedure therapies Therapeutic_procedure available.
The patient was subsequently referred Clinical_event to the palliative Nonbiological_location team Nonbiological_location for management of his symptoms and discharged Clinical_event back to the community Nonbiological_location .
He was still alive Sign_symptom 1 Date month Date after Date discharge.