Clinical Image

Is there any special imaging finding in a pedunculated focal nodular hyperplasia with suspected torsion?

Soultana Foutzitzi¹

Alexandra Giatromanolaki²

Ioannis Chrysafis³

Savas P Deftereos⁴

¹ MD, MSc Consultant of Radiology Department, University Hospital of Alexandroupolis, Alexandroupolis, Greece

² MD, PhD Professor of Pathology Department, University Hospital of Alexandroupolis, Alexandroupolis, Greece

³ MD, Director of Radiology Department, University Hospital of Alexandroupolis, Alexandroupolis, Greece

⁴ MD, PhD, Associate Professor of Radiology, University Hospital of Alexandroupolis, Alexandroupolis, Greece

Address correspondence to:

Soultana Foutzitzi

Dragana, Alexandroupolis,

Greece

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Article ID: 101370Z01SF2022

doi: 10.5348/101370Z01SF2022CI

How to cite this article

Foutzitzi S, Giatromanolaki A, Chrysafis I, Deftereos SP. Is there any special imaging finding in a pedunculated focal nodular hyperplasia with suspected torsion? Int J Case Rep Images 2022;13(2):243–245.

ABSTRACT

No Abstract

Keywords: CT, Pedunculated FNH, Torsion

Case Report

A 31-year-old woman with no significant medical history presented with epigastric pain in the emergency department of our hospital. Her laboratory tests revealed slightly elevated levels of serum glutamic-oxaloacetic transaminase with 97 U/L (normal <33 U/L) and serum glutamic pyruvic transaminase with 110 U/L (normal <31 U/L) and leukocytosis with 12.52 white blood cells (WBC)/μL (normal 3.50–10.80 WBC/μL). Severe tenderness was felt over the epigastrium, which extended to the right upper quadrant of the abdomen. Abdominal ultrasonography (US) revealed a well-defined, solid, oval structure with an approximate diameter of 4 cm and a heterogeneous, largely isoechoic to liver echogenicity. The mass was in contact with the lower surface of the liver and has an echogenic structure (scar) at its center. Abdominal computed tomography with a multiphase liver protocol (arterial, venous, and delayed phases) (CECT) revealed a mass-like lesion attached to the liver (segment II), measuring 4 cm at its widest dimension (Figure 1). The mass was hanging from the liver, with a vascular pedicle. On CT, the lesion was hypodense at the native time (Figure 1A), heterogeneously hyperdense at the arterial phase (Figure 1B), with a hypodense central scar that started capturing the intravenous contrast in the late phase (Figure 1C and Figure 1D). This heterogeneity on CT strengthened the possibility of a pedunculated Focal Nodular Hyperplasia (FNH) with torsion, which was in accordance with the erred abdominal pain. This possibility was reinforced by the “corkscrew-like” appearance of the peduncle on CT scan (Figure 1E and Figure 1F). This was considered an evidential finding (special imaging finding, otherwise key finding).

Surgically, a well-circumscribed, ovoid tumor mass, histopathologically confirmed as FNH (Figure 1G), originating from segment II of the liver, and a semi-twisted pedicle was identified and removed.

Figure 1: A multiphase CECT, revealing a mass-like lesion attached to the liver segment II: (A) hypodense in the native time and (B) heterogeneously hyperdense in the arterial time, with a hypodense central scar (B, C) that started contrast enhancement in the late phase (D). The mass (arrowhead) viewed in sagittal (E) and coronal plane (F), hanging from the liver, with a prominent vascular pedicle (arrows), considered as the key finding (G). Microscopically, liver sections revealed typical nodular appearance with prominent fibrosis, dilated arterial branches, and lymphocytic infiltration.

Discussion

Focal nodular hyperplasia [1],[2],[3] is a benign liver tumor that usually does not require surgery [4]. The diagnosis is challenging for rare pedunculated forms of FNH, which may require resection. Furthermore, torsion of the pedicle must be considered when heterogeneity is depicted by CT. While FNH is a common benign liver tumor, pedunculated FNH is a rare entity of a challenging diagnosis, since it may be mistaken for other benign or malignant liver tumors. The depiction of “corkscrew-like” appearance of the peduncle on CT scan was considered an evidential finding (special imaging finding, otherwise key finding).

Conclusion

The recognition of “corkscrew-like” appearance of the peduncle on CT scan improves patient care by avoiding potential complications such as torsion of the pedicle or compression of the surrounding organs.

REFERENCE

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Koolwal J, Birkemeier KL, Zreik RT, Mattix KD. Pedunculated focal nodular hyperplasia in a healthy toddler. Proc (Bayl Univ Med Cent) 2018;31(1):97–9. [CrossRef] [Pubmed] Back to citation no. 1

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SUPPORTING INFORMATION

Author Contributions

Soultana Foutzitzi - Conception of the work, Design of the work, Acquisition of data, Analysis of data, Drafting the work, Final approval of the version to be published, Agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Alexandra Giatromanolaki - Acquisition of data, Analysis of data, Revising the work critically for important intellectual content, Final approval of the version to be published, Agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Ioannis Chrysafis - Acquisition of data, Drafting the work, Final approval of the version to be published, Agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Savas P Deftereos - Conception of the work, Design of the work, Acquisition of data, Drafting the work, Revising the work critically for important intellectual content, Final approval of the version to be published, Agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Data Availability Statement

The corresponding author is the guarantor of submission.

Consent For Publication

Written informed consent was obtained from the patient for publication of this article.

Data Availability

All relevant data are within the paper and its Supporting Information files.

Competing Interests

Authors declare no conflict of interest.

Copyright

© 2022 Soultana Foutzitzi et al. This article is distributed under the terms of Creative Commons Attribution License which permits unrestricted use, distribution and reproduction in any medium provided the original author(s) and original publisher are properly credited. Please see the copyright policy on the journal website for more information.