Dr. Pepe’s Diploma Casebook: Case 21 – SOLVED!


Dear Friends,

This week, we have an oncologic patient with liver nodule detected on US examination. Below are the images from an MRI examination.

Possible diagnoses:

1. Liver hemangioma
2. Hepatocellular carcinoma (HCC)
3. Liver metastasis
4. Focal nodular hyperplasia (FNH)


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    23 Responses to : Dr. Pepe’s Diploma Casebook: Case 21 – SOLVED!

    1. Juan says:

      Would Contrast Enhanced Ultrasound provide an answer? And prevent the need for an MRI?

      • Dr. Pepe says:

        Actually US with contrast was done earlier and metastases suspected. MRI was performed to confirm diagnosis and evaluate the whole liver

    2. yelpe says:

      hepatic adenoma

    3. Dr Hesham says:

      the way of contrast is not of hcc

    4. mike says:

      Liver haemangioma, blodd-pool on postcontrast images…

    5. Beenish says:

      tis differential always confuses me…cud tis be a haemangioma??? lukin forward for explanation n discussion

    6. Dr Petrov says:

      I think this may be sloitary metastasis or HCC !

    7. Genchi Bari italia says:

      A me sembra che i noduli, visibili dopo m.d.c., siano 3 : il piu’ grosso , uno piu’ piccolo dietro di esso ed uno periferico, sotto-glissoniano, sulla superficie anteriore.Essi si impregnano intensamente dopo CE e diventano piu’ tenui in fase venosa.Regola KISS: metastasi ipervascolarizzate.NB. attendo replica alla mia osservazione sulla risoluzione del caso 20.

    8. ovidiu says:

      liver hemangioma

    9. Dr. T says:

      My answer is liver metastatsis…………..

    10. Alice says:

      There are two liver nodules with similar characteristics:
      Hypointens on T1
      Hyperintens on T2
      Homogenous arterial enhancement
      Still hyperintens on the venous images
      HCC and FNH can be ruled out
      Mets are a possibility if we are dealing with a tumour known to cause hypervascular mets, especially if the patient underwent chemotherapy.
      Without more clinical information I would choose hemangiomas as most likely.

    11. BASEEL says:


    12. Charles says:

      I wouldn’t choose 1, because of the mild hyperintensity on T2 image.
      I wouldn’t choose 2, because of the slow wash out on postgadolinium images
      Although FNH could show such behaviour, I’ll go with hypervascularized metastases, because lesions are multiple and it is an oncologic patient.

    13. Naxia says:

      Similar to Blood pool. Hemangioma

    14. Badr says:

      in taking with consideration patient history of oncology, lesion is likely chemotherapy treated or mucinous mets … also hepatic hemangioma can be included,

    15. genchi bari italia says:

      cosa ho vinto questa volta?

      • Dr. Pepe says:

        Sorry, Sara made the diagnosis 9 hours and 6 minutes earlier than you.
        Your discussion was excellent, though.

    16. genchi bari italia says:

      ancora una volta non sono d’accordo: la diagnosi non deve essere di metastasi , ma deve stabilire anche il tipo di metastasi: ipervascolarizzata! e’ questo appunto il motivo della DD con la HFN!!!

    17. NOVIAN says:

      What is in that pictures?