carcinoma mimicking hydatid disease . Rim calcification in primary liver cell

The case described is of a primary liver cell carcinoma (PLCC), which was initially misdiagnosed as hepatic hydatid disease. The computed tomographic appearances ofhepatic hydatid disease are often characteristic although not specific. When supported by the clinical findings, however, they will probably not be confused with other liver masses. In this case the presence of peripheral rim calcification, commonly seen in hydatid disease but which has not been previously noted in PLCC, lead to an erroneous diagnosis. (Gut 1994; 35: 567-568) The Departments of Radiodiagnosis and Hepatobiliary Surgery, The Royal Free Hampstead NHS Trust, London A W Mitchell J N P Higgins J Tate R Dick Correspondence to: Dr A W Mitchell, Department in Radiodiagnosis, The Royal Free Hampstead NHS Trust, Pond Street, London NW3 2QG. Accepted for publication 26 July 1993 Hydatid disease remains a common disease especially in central Europe and even today 'it is unwise to dismiss it as a curiosity'.'2 Primary liver cell carcinoma is a comparatively rare tumour in western Europe (1-2/100000), although its incidence is greatly increased in patients with cirrhosis. This case shows the only recorded case ofrim calcification in a patient with untreated primary liver cell carcinoma (PLCC). He was referred from abroad where clinical and computed tomographic findings seemed strongly suggestive of hydatid disease and treatment was planned on this basis. Case report A 56 year old Greek plumber presented with a two month history of upper abdominal discomfort, intermittent fever, mild obstructive jaundice, and tenderness in the right upper quadrant. As part of the investigations computed tomography was performed, which showed a multicystic lesion in the liver with peripheral curvilinear calcification (Figure). A diagnosis of hydatid disease was made. Jaundice was thought to be secondary to external compression of the major bile ducts by the mass. At laparotomy a solid tumour was found in the liver and a diagnostic biopsy performed. Histological review of the lesion showed PLCC and cirrhosis with no special features. Hepatitis B serology was positive but there was no rise in the serum a feto protein concentration. After his recovery he was referred to the Royal Free Hospital for further management. Investigations for metastases were negative. A second laparotomy was performed but intraperitoneal deposits were found and a planned resection was abandoned. Biopsy of a diaphragmatic lesion also seen on computed tomography confirmed PLCC. After a period of recovery the patient had a systemic course of epirubicin and returned home. Discussion Many causes of hepatic calcification have been described.3 The presence of calcification, however, is not usually helpful in the differential diagnosis of hepatic masses. Relating specifically to malignancy it occurs with almost equal frequency in PLCC and colonic carcinoma secondaries.34 The computed tomographic morphology of the calcification, is only comparatively specific when it is peripheral, dense, and curvilinear as seen in the walls of hydatid cysts and amoebic abscesses. Otherwise the pattern is unhelpful.3 In the case described it was the combination of rim calcification and the demographic frequency of hydatid disease that lead to an erroneous diagnosis. Involvement of the liver by Escherichia granulosus is suggested by computed tomography by the presence of well defined oval or spherical lesions of near water density but these signs are not specific and may be seen in abscesses, cystic (A) Computed tomography through the right lobe ofthe liver. Curvilinear calcification is arrowed in the wall ofthe complex lesion; (B) Enhanced computed tomography 1 5 cm below (A). Arrows point to wall calcification. Within the large cystic space enhancing material is present, while three smaller cystic lesions are seen 3 cm beyond the main mass. group.bmj.com on January 14, 2018 Published by http://gut.bmj.com/ Downloaded from