0:01

Another chilling case here.

0:02

As we start from the top of T2-weighted images,

0:04

we see some of the lesions inside the liver.

0:07

And these lesions are showing

0:08

intensity similar to the spleen.

0:10

So these are intermediate lesions.

0:12

And whenever I see a lesion in the liver,

0:14

which has intensity similar to the spleen,

0:16

that is concerning lesion always.

0:20

And there are multiple.

0:21

So given the multiplicity and the appearance

0:23

on T2, I am favoring metastasis already.

0:26

And as we go downwards, we see the right kidney

0:30

is atrophic and the left kidney is missing.

0:34

That has already been operated by

0:36

somebody; it is missing postoperatively.

0:39

As we go downwards, we see a transplant in the

0:42

right lower quadrant, which is partially evaluated

0:44

on these images; it has a cyst as well.

0:48

So overall what I am seeing is one

0:50

kidney missing, and we are

0:52

seeing some metastasis in the liver.

0:54

But what is going on in

0:56

the left upper quadrant here?

0:58

There is a lesion which is lobulated in outline.

1:02

It shows similar characteristics

1:04

of the data intensity, which we

1:06

have seen in the top left quadrant.

1:07

Lesions in the liver, which are intermediate.

1:11

It is well defined in the outline,

1:13

confined to the tail of the pancreas,

1:15

and we can see some of the pancreatic tissue

1:17

along with the periphery of this lesion.

1:20

There are few deposits outside the pancreas

1:22

in the retroperitoneum, but if you look

1:24

carefully along with the periphery of

1:26

this lesion, it is not aggressively

1:29

involving any other vessel or other organs.

1:32

And let's go to the T1-weighted

1:33

images pre-contrast, and we see

1:37

T1 hypointense lesion in the liver.

1:39

And whenever we see a T1 hypodense lesions,

1:42

the diagnostic consideration

1:43

will remain metastasis for sure.

1:46

And then, as we go downwards to the same

1:49

area, the entire lesion appears hypointense,

1:53

but there are some areas of hemorrhage inside.

1:58

And as we thought earlier, the vessels are

2:00

well-preserved along with the periphery,

2:03

and that we can confirm in post-contrast images.

2:07

And that lesion is behaving like a

2:09

hyperenhancing lesion in the liver.

2:12

Other lesions are doing the same thing.

2:14

So whatever we have, it is

2:16

a hyperenhancing lesion.

2:18

Hyperenhancing metastasis, those come from

2:21

kidney, choriocarcinoma, thyroid, or melanoma.

2:26

So whenever you have this kind of hyperenhancing

2:28

lesion in the liver, you think about 4 primaries.

2:32

In this particular case, we have a known kidney

2:34

which has been removed due to some unknown reason,

2:37

which we don't know, but maybe likely RCC.

2:40

Then we have this hyperenhancing lesion in

2:43

the pancreatic tail, which is lobulated,

2:47

not locally aggressive, but causing deposit in the

2:49

mesentery, not involving overlying vessels,

2:53

but behaving slightly malignant given the appearance.

2:57

And if we see the same lesion here on the delayed

2:59

venous phase, it shows washout, central necrosis.

3:04

So a lesion which was hyperenhancing in the

3:06

arterial phase and washing out compared to the

3:09

rest of the parenchyma is suspicious for RCC.

3:12

So this patient possibly had

3:14

a history of RCC; that's why the right

3:15

kidney, left kidney was removed.

3:17

And now we have metastatic lesions

3:18

involving the pancreatic tail and hyper

3:21

enhancing metastasis in the liver.