Worsening abdominal pain. History of carcinoma with unknown primary site, concerned for cholangiocarcinoma. History of HCV.3/10/2016 liver biopsy demonstrated poorly differentiated carcinoma with overall impression not favoring metastatic disease from gynecological primary, rather intrahepatic cholangiocarcinoma or metastases from pancreatic biliary or upper GI tract primary. ABDOMEN:LIVER, BILIARY TRACT: Diffuse fatty infiltration. Hepatomegaly measuring 20.5 cm in length.There are numerous mildly T2 hyperintense masses in the liver, some of which appear targetoid, with a dominant mass in the lateral segment of the left hepatic lobe measuring approximately 8.2 x 5.8 cm (series 501/14). For future reference a right hepatic dome segment 7 lesion measures 2.1 x 2.2 cm (series 501/31).The masses demonstrate peripheral nodular thick-walled enhancement and internal heterogeneous enhancement which appears to subtly progressively fill-in on delayed imaging. There is no obvious capsular retraction. There is a serosal implant anterior to the left hepatic lobe (series 501/13).There is moderate intra and extrahepatic biliary ductal dilatation to the level of the porta hepatis, likely related to bulky lymphadenopathy.The gallbladder is distended with gallbladder wall thickening/pericholecystic fluid.SPLEEN: Small amount of perisplenic ascites. Normal splenic size without a focal lesion.PANCREAS: Small amount of peripancreatic fluid. There are numerous enlarged peripancreatic lymph nodes. No pancreatic atrophy or pancreatic ductal dilatation. A bulky lymph node at the level of the pancreatic head appears to invade and/or displace (series 5 and 1/12) the pancreatic parenchyma.ADRENAL GLANDS: No significant abnormality noted. Retroperitoneal metastatic lymphadenopathy near the adrenal fossa bilaterally.KIDNEYS, URETERS: Simple appearing right renal cyst. No hydronephrosis or suspicious lesion.RETROPERITONEUM, LYMPH NODES: Extensive retroperitoneal, gastrohepatic, mesenteric and portal caval heterogeneously enhancing necrotic lymphadenopathy. The lymphadenopathy results in regional mass effect including narrowing of the portal vein at the hepatic hilum/porta hepatis and narrowing of the left renal vein.For future reference, an inferior aortocaval lymph node measures 1.9 x 1.3 cm (series 601/10).BOWEL, MESENTERY: No significant abnormality noted.BONES, SOFT TISSUES: Discoid atelectasis, similar to that seen on recent CT. Cardiophrenic lymphadenopathy.OTHER: No significant abnormality noted.
Constellation of findings favoring a mass forming intrahepatic cholangiocarcinoma with dominant lesion in the left hepatic lobe with numerous satellite/metastases in the right liver lobe. Bulky heterogeneously enhancing lymphadenopathy in the upper abdomen with associated mass effect as described above. Most significantly the porta hepatis lymphadenopathy results in moderate central and extrahepatic biliary ductal dilatation and attenuation of the portal vein.Perihepatic serosal implant. Bibasilar discoid atelectasis better seen on recent CT.