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OpenAthens Shibboleth
Special Feature
Feb 2013

Image of the Month—Quiz Case

Author Affiliations


Author Affiliations: Departments of Transplant Surgery (Drs Chavez, Danniel, Jarrar, Khanmoradi, and Ortiz) and Pathology (Dr Miick), Albert Einstein Healthcare Network, Philadelphia, Pennsylvania.

JAMA Surg. 2013;148(2):203-203. doi:10.1001/jamasurgery.2013.417a

A 68-year-old woman with hepatocellular carcinoma (HCC) underwent a liver transplant (LT). On preoperative evaluation, she had an α1-fetoprotein level of 43.7 ng/mL (normal range, <8 ng/mL [to convert to micrograms per liter, multiply by 1.0]), and a computed tomographic (CT) scan of her chest and a bone scan both had negative results. Her tumor was within the Milan criteria. Her native liver explant revealed a T2 lesion without vascular invasion or lymph nodes positive for tumor. One month later, she underwent a retransplant owing to hepatic artery disruption. The liver pathology only showed ischemia. The patient had a satisfactory recovery.

She presented to the emergency department a year later complaining of nausea, vomiting, and weight loss (6.3 kg [14 lb]). On physical examination, she was anicteric, afebrile, and normotensive with no hepatomegaly. Her workup included a white blood cell count of 3800 cells/μL (normal range, 4-11 cells/μL [to convert to ×109/L, multiply by 0.001]), a hemoglobin level of 7.6 g/dL (normal range, 12-16 g/dL [to convert to grams per liter, multiply by 10.0]), a creatinine level of 1.3 mg/dL (normal range, 0.7-1.5 mg/dL [to convert to micromoles per liter, multiply by 88.4]), normal albumin and liver enzyme levels, and a normal coagulation profile. Imaging studies included magnetic resonance imaging of the abdomen, CT angiography, a chest CT scan, a bone scan, and ultrasonography, all of which had negative results. She subsequently underwent a positron emission tomographic/CT scan (Figure 1).

Image not available

Figure 1. A and B, Fludeoxyglucose F18–positron emission tomographic/computed tomographic scans showing increased uptake in the upper half of the sternal body. L indicates left; and R, right.

What Is the Diagnosis?

A.  Osteomyelitis

B.  Chondrosarcoma

C.  Multiple myeloma

D.  Bone metastases from HCC