Case Author(s): John R. Leahy, M.D. and Jerold Wallis, M.D. , 7/29/98 . Rating: #D2, #Q3

Diagnosis: Focal Nodular Hyperplasia

Brief history:

A 33 year old woman was noted to have an epigastric mass during a routine postpartum physical exam.

Images:

Anterior and posterior images are shown

View main image(ls) in a separate image viewer

View second image(ls). Transaxial SPECT images

View third image(ct). Contrast CT with liver windowing

Full history/Diagnosis is available below

Diagnosis: Focal Nodular Hyperplasia

Full history:

33 year old woman was found to have an epigastric mass on routine physical exam six months after the birth of her first child. The woman denied any symptoms. Initial CT evaluation of this mass was conducted at an outside institution. The patient was then referred for liver-spleen scintigraphy to further evaluate the mass.

Radiopharmaceutical:

5.3 mCi Tc-99m sulfur colloid i.v.

Findings:

Mildly increased colloid uptake is seen in a large lesion involving the left lobe of the liver. This corresponds to a well circumscribed 7 cm mass at this location on the CT.

Note that these are non-attenuation-corrected images, so there should be apparently decreased activity in deeper structures. The lesion is more intense that the immediately adjacent liver.

Discussion:

Focal nodular hyperplasia is a benign tumor seen more commonly in women (80-90 % of documented cases) than men. The origin is unknown, but a vascular malformation is suspected. The lesion frequently contains a central scar, and is characterized by the presence of Kupffer cells.

The Kupffer cells in focal nodular hyperplasia allow accumulation of sulphur colloid, which produces activity in the lesion which is equal to or greater than surrounding liver activity on liver-spleen scintigraphy. Most other liver lesions do not have Kupffer cells, and therefore show decreased activity. A subset of hepatic adenomas do accumulate sulphur colloid, and will also show activity on a liver-spleen scan. These lesions, however can usually be distinguished from focal nodular hyperplasia, because adenomas are prone to hemorrhage and necrosis, which appear as heterogeneous areas of decreased activity on the scan. SPECT imaging has been shown to increase the diagnostic accuracy in evaluating hepatic lesions.

References:

Sandler MP et al: Diagnostic Nuclear Medicine. 3rd ed. Baltimore, Williams and Wilkins. 1996. p753

Zeman RK, Pauschter DM, Schiebler ML, et al. Hepatic Imaging:current status. Radiologic Clinics of N. Am. 23(3):473-87, 1985.

DeLand FH, Shis WJ: The status of SPECT in tumor diagnosis. JNM 25(12): 1375-9, 1984

Followup:

No further evaluation or treatment was taken with this patient.

Major teaching point(s):

Though no longer used much as a primary imaging tool, liver-spleen scintigraphy can be used for problem solving in the evaluation of hepatic lesions.

Differential Diagnosis List

Hepatic adenoma

ACR Codes and Keywords:

References and General Discussion of Liver-Spleen Scintigraphy (Anatomic field:Gasterointestinal System, Category:Neoplasm, Neoplastic-like condition)

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Case number: ls004

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