Presentation
Hepatic hilar mass encountered at cholecystectomy done due to recurring right upper quadrant pain.
Patient Data
The gallbladder has been removed. Mild bile duct dilatation in right hepatic lobe. Fat infiltration and minute amount of fluid in gallbladder fossa, as expected (POD1). Thickened right prerenal fascia.
Solid mass or merged cluster of several enlarged lymph nodes in the hepatic hilum measuring 3.4 x 5.0 x 9.4 (TRV x AP x CC) cm, mildly heterogeneous, isodense to the pancreas, with subtle calcifications, appearing to involve hepatic segment 1 and visually inseparable from the pancreas. The mass surrounds and narrows the portal vein and surrounds the common hepatic artery.
Numerous lymph nodes in different mediastinal stations up to 12 mm in thickness (small axis diameter), including bilateral supraclavicular lymph nodes. Retrocrural lymph nodes up to 8 mm thick; hepatogastric ligament lymph nodes up to 8 mm thick; root of mesentery lymph nodes up to 17 mm thick; numerous bilateral para-aortic lymph nodes up to 16 mm thick, some confluent; right external iliac lymph nodes up to 10 mm thick.
Slightly hypodense focus in hepatic segment 5 measuring 9 mm in diameter, probable metastasis.
1.4 x 1.8 cm node in left adrenal gland, possible metastasis.
Subsegmental atelectasis in lung bases. Minimal pleural effusions.
Tiny enhancing hypodense focus in right kidney, probably benign. Duplex left renal collecting system, with ureters uniting distally.
Enlarged uterus, probably due to fibroids.
Synostosis between T11-T12 vertebral bodies.
Summary:
Large hepatic hilar mass or cluster of enlarged lymph nodes. Metastatic spread to abdominal, mediastinal, and probably right external iliac nodes. Probable solitary liver metastasis and possible left adrenal metastasis.
Increased uptake in bilateral supra- and infraclavicular lymph nodes; in small mediastinal lymph nodes.
Uptake in known hepatic hilar mass that involves the pancreatic head and the duodenum, and in many retroperitoneal nodes.
1.5 cm left adrenal mass.
1.7 lesion in hepatic segment 5.
Focal uptake in right acetabulum, without CT finding.
Case Discussion
A healthy young woman underwent elective laparoscopic cholecystectomy due to right upper quadrant pain that had been recurring for some time. Ultrasonography done elsewhere (not available) had demonstrated a large calculus within the gallbladder but non-dilated intra- and extrahepatic bile ducts. During the operation, a firm mass was noticed in the hepatic hilum. A 3 cm lymph node was removed along with the gallbladder for histopathology evaluation.
The day after the operation, CT chest-abdomen-pelvis showed massive hilar lymphadenopathy and metastatic spread to many other abdominal and mediastinal lymph node stations, and presumably to the liver and left adrenal as well.
Histopathology:
Gallbladder:
Neuroendocrine carcinoma, metastatic, high grade in multiple foci, the largest one 2 cm in greatest diameter with areas of large cell type, scattered foci of squamous differentiation seen. Immunostains: Positive: Pankeratin, CK7, synaptophysin, chromogranin, CD56, CK20. Negative: TTF.
The tumor invades the entire gallbladder wall, mucosal ulceration. Lymphatic, blood vessel and neural invasion seen. One periserosal lymph node with metastatic carcinoma seen. Cholelithiasis.
Lymph node: (biopsy): Metastatic carcinoma.
PET-CT done 2 weeks after the initial CT and after having received the histopathology report, verified all of the presumed metastases.
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