Enlarged solitary necrotic nodule of the liver misinterpreted as a metastatic liver cancer

Clinical Journal of Gastroenterology 10/2009; 2(5):355-360. DOI: 10.1007/s12328-009-0103-y


Solitary necrotic nodule of the liver is a rare nonmalignant lesion of unknown etiology. It is defined as a nodule with a
completely necrotic core enclosed by a hyalinized fibrotic capsule containing elastic fiber. We report a 74-year-old woman
with a solitary necrotic nodule of the liver that mimicked metastasis from a previous rectal adenocarcinoma. She was referred
to us for an asymptomatic liver nodule in segment 8 that had increased in diameter from 5 to 15mm over the past 8months.
Ultrasonography showed a well-defined, oval, hypoechoic mass, and computed tomography showed a hypodense area without contrast
enhancement except for a ring-like enhancement during hepatic arteriography. Magnetic resonance imaging revealed a mass that
was hypointense on T1-weighted imaging and slightly hyperintense on T2-weighted imaging. The patient underwent hepatectomy
of segment 8. The resected specimen contained an oval nonencapsulated nodule with firm and gritty consistency and a well-defined
margin. Histologic findings were compatible with those of solitary necrotic nodule. Clinicians should recognize the existence
of this lesion as one of the differential diagnoses of metastatic liver nodule. Solitary necrotic nodules can change size,
and when enlarged, differentiation from metastasis is extremely difficult.

KeywordsNecrotic nodule-Liver-Metastasis

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    ABSTRACT: Background: Solitary necrotic nodule of the liver (SNNL) is a rare benign lesion with an uncertain aetiology. There are no typical diagnostic clinical or radiological features, and this lesion is usually detected incidentally during imaging for other purposes. Methods: We describe the clinical and radiological findings in three patients with histologically confirmed SNNL. The pertinent presenting features were documented and subsequent serological testing for parasites was performed. Results: All three patients underwent resection because it was not possible to exclude a solitary malignancy on preoperative imaging. All three nodules had a serpiginous shape with areas of necrosis that showed marked staining for eosinophil granules. However, no viable parasites were seen in any specimen. There were no specific radiological features that were present in all three patients. Two patients had travelled to areas where parasitic infections are endemic and one patient had an eosinophilia on presentation. The histopathological findings in conjunction with the clinical presentation suggest that SNNL may be parasitic in origin. Conclusion: The diagnosis of SNNL is usually made after surgical excision. A preoperative diagnosis is difficult to make even with the use of multiple imaging modalities. The clinical and histopathological findings described in our three patients suggest that a transient parasitic infection is likely to be the cause in many cases. A history of potential exposure to parasites and serological testing for an eosinophilia or parasitic antibodies may help make the diagnosis of SNNL without the need for resection.
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    ABSTRACT: A 91-year-old Japanese female had been diagnosed to have liver cirrhosis caused by NASH approximately 10 years prior to this presentation, and had been treated with oral medication. She was admitted to our hospital for the purpose of controlling ascites. Liver cirrhosis associated with a large amount of ascites was observed on ultrasonography and computed tomography (CT) on admission, and the treatment with diuretics and paracentesis was initiated. On the 36th day after her admission, dyspnea and hypoxemia suddenly occurred, and an X-ray showed right hydrothorax. The serum levels of AST and ALT were elevated to 439 IU/l and 1196 IU/l, respectively, on the ninth day after the occurrence of hepatic hydrothorax. Ultrasonography and CT revealed multiple hypoechoic and low density nodules in the liver and a portal thrombus. On the 19th day after the occurrence of right hydrothorax, the patient died of liver and respiratory failure. On autopsy, liver cirrhosis, portal thrombus, right hydrothorax, right atelectasis and ascites were observed. The multiple hypoechoic and low density nodules in the liver proved to be completely necrotic tissue of pseudolobules, which were caused by an ischemic liver, which were suspected to have been caused by hypoxia due to the hydrothorax and decreased portal vein flow due to the portal thrombus.
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