A 27-year-old, healthy-appearing woman presented with vague abdominal discomfort. Her medical history included only oral contraception. Physical examination results were remarkable for a palpable mass of mild tenderness in the upper right quadrant. Serum levels of tumor markers (carcinoembryonic antigen, carbohydrate antigen 19-9, and α-fetoprotein) and serology results for echinococcosis were negative. Abdominal computed tomography and hepatic magnetic resonance imaging showed a 9-cm-diameter, solid, heterogeneous, capsulated mass with scattered calcifications that had developed from the inferior part of segment VI of the liver (Figure 1). Gastroscopy and colonoscopy results were normal. The patient underwent liver resection by bisegmentectomy of segments V and VI, including hepatic pedicle lymphadenectomy.
A contrast-enhanced abdominal computed tomographic scan (A) and a hepatic magnetic resonance image (B) showing a large, heterogeneous, solid, capsulated mass. A, Black arrows indicate intratumoral and peritumoral calcifications.
Gross examination of the surgical specimen revealed a solid, nodular, well-circumscribed, white mass. The cut surface was firm and had a homogeneous appearance without any evidence of necrosis or hemorrhage. Histologically, the lesion was characterized by a thin fibrous capsule and was composed of a proliferation of spindle cells with small nuclei and a collagen-rich stroma. Within the fibrocollagenous tissue, there were several dystrophic calcifications, psammoma bodies, lymphoid aggregates, and a few foamy macrophages (Figure 2). Immunohistochemical staining showed negative results for antibodies against S-100 protein, caldesmon, smooth muscle actin, desmin, CD34, CD117 (c-kit), anaplastic lymphoma kinase protein, and keratin. Stains were focally positive for β-catenin. Proliferation index Ki67 was inferior to 1%. No lymph node metastasis was observed.
The surgical specimen on gross examination (A) and a high-power photomicrograph showing dense collagen bundles, dystrophic calcifications (white arrows), and psammoma bodies (black arrows) (hematoxylin-eosin, original magnification ×100) (B).
A. Calcifying liver metastasis
B. Intrahepatic cholangiocarcinoma
C. Hepatic calcifying fibrous pseudotumor
D. Focal nodular hyperplasia
Nobili C, Rosso E, Oussoultzoglou E, Casnedi S, Jaeck D, Bachellier P. Image of the Month—Quiz Case. Arch Surg. 2011;146(2):237. doi:10.1001/archsurg.2010.339-a