CT Case 075
A 35-year-old women presents 4 weeks postpartum with a day of RUQ pain and fevers. She has mildly elevated LFTs.
She has a CT scan for further evaluation.
Describe and interpret the CT images
There is a large subcapsular haematoma seen scalloping the lateral aspect of right hepatic lobe measuring approximately 110 x 45 x 100 mm.
There are several additional arterial enhancing nodules seen throughout the liver.
The uterus appears very hypervascular.
Extensive work-up, including liver biopsy, determined this to be a diagnosis of choriocarcinoma.
Two weeks later, soon after commencing chemotherapy she presents with symptomatic anaemia.
A second CT scan is performed.
Describe and interpret the CT images
There is evidence of extensive disease progression involving the liver, pancreas, right kidney and lungs.
The hepatic lesions have undergone a significant interval increase in size and number and change in appearance with many of these lesions demonstrating puddles of contrast (blood within them). This appearance represents pseudo-aneurysms.
A small amount of free fluid is noted within the pelvis.
There is also significant interval increase in size and number of the pulmonary metastasis, a few demonstrating hyperdense contrast, and several demonstrating surrounding ground glass opacification concerning for perilesional haemorrhage.
Clinical Pearls
Choriocarcinoma is a very rare and a highly malignant epithelial tumour, it belongs to the malignant end of the spectrum in gestational trophoblastic disease (GTD).
It arises from trophoblastic tissue (the outer layer of cells of the blastocyst – the first few cells of the embryo). It can originate from any type of trophoblastic tissue (molar pregnancy, abortion, ectopic, preterm/term intrauterine pregnancy).
Most lesions begin in the uterus, although ectopic pregnancies can cause extra-uterine sites of origin. When choriocarcinoma metastasises, the most common sites are lung, brain, liver, pelvis, vagina, spleen, intestine, and kidney.
There is high risk of hypervascular metastasis with the associated risk of necrosis and haemorrhage. This is seen in this case with the subcapsular haematoma resulting from rupture of one of the hypervascular liver metastases.
References
- Veron Sanchez A, Bennouna I, Coquelet N, Cabo Bolado J, Pinilla Fernandez I, Mullor Delgado LA, Pezzullo M, Liberale G, Gomez Galdon M, Bali MA. Unravelling Peritoneal Carcinomatosis Using Cross-Sectional Imaging Modalities. Diagnostics (Basel). 2023 Jul 3;13(13):2253.
TOP 100 CT SERIES
Emergency Medicine Education Fellow at Liverpool Hospital NSW. MBBS (Hons) Monash University. Interests in indigenous health and medical education. When not in the emergency department, can most likely be found running up some mountain training for the next ultramarathon.
Dr Leon Lam FRANZCR MBBS BSci(Med). Clinical Radiologist and Senior Staff Specialist at Liverpool Hospital, Sydney
Sydney-based Emergency Physician (MBBS, FACEM) working at Liverpool Hospital. Passionate about education, trainees and travel. Special interests include radiology, orthopaedics and trauma. Creator of the Sydney Emergency XRay interpretation day (SEXI).
Provisional fellow in emergency radiology, Liverpool hospital, Sydney. Other areas of interest include paediatric and cardiac imaging.