Online Images in the Medical Sciences| Volume 364, ISSUE 2, e23-e24, August 2022

A rare hepatic epithelioid hemangioendothelioma mimicking hepatocellular carcinoma in a patient with hepatitis

      A previously healthy 60-year-old woman presented to the hospital with 2 weeks of dull pain in the right upper quadrant and intermittent nausea. On admission her hepatitis B surface antigen was positive, serum alpha-foetoprotein (8 ng/ml), carbohydrate antigen 125 (10.3 U/ml), carbohydrate antigen 199 (9.9 U/ml) and liver function were within the normal range. Magnetic resonance imaging (MRI) showed a solitary lesion measuring 39 mm × 40 mm × 54 mm in Segment VIII of the liver. It demonstrated an unusual multi-layered target appearance resembling a “maze”. On diffusion-weighted image (DWI) the mass surprisingly showed six layers with alternate high and low signals (Fig. 1a), while on T2-weighted image (T2WI) five layers can be seen (Fig. 1b). The lesion didn't demonstrate as many layers on T1WI, however a target appearance was still recognizable (Fig. 1c). On Gd-EOB-DTPA enhanced MRI, the lesion showed progressive rim enhancement on the arterial and portal venous phase (Fig. 1d, e), and appeared as a low signal target with a distinct hypointense core on the hepatobiliary phase (Fig. 1f). Initial diagnosis included hepatocellular carcinoma, cholangiocarcinoma, or metastasis. The patient underwent biopsy and histopathology confirmed hepatic epithelioid hemangioendothelioma (HEHE). Immunohistochemical staining showed positive for CD34 and CD31 (Fig. 1g, h).
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