Student Image Challenge 112
March 16, 2026
SUBMIT YOUR CASE
EFSUMB invites submission of interesting cases for the website section 'Case of the Month'. All CoM submissions are eligible for selection for free registration at the next Euroson congress. The EFSUMB Publications Committee will review all Best Case of the Month submissions at the end of March 2026. Two cases that receive the most 'likes' over a period from the last congress to March 2026 and judged on a range of factors, including scientific value, will receive free registration for the next EUROSON congress and the third case will receive a cash prize of 100 EUR.
Atypical CEUS Pattern as a Diagnostic Clue in a Focal Liver Lesion
Authors:
Paula Mauloni, Daniela Agostinelli, Silvia Vecchio, Carla SerraDiagnostic and Therapeutic Interventional Ultrasound Unit
IRCCS Azienda Ospedaliero-Universitaria di Bologna
VIDEO 1: On CEUS (Video 1), the lesion exhibited early peripheral rim-like enhancement in the arterial phase, followed by centripetal filling with persistent non-enhancing central areas, likely representing necrotic foci. Washout occurred within one minute, suggesting a cholangiocarcinoma component, either alone or in combination with a hepatocellular component.
1Clinical History
A 69-year-old female with chronic HBV-related liver disease was referred to our Unit in 2025 for contrast-enhanced ultrasound (CEUS) following the detection of a focal hepatic lesion during routine follow-up with ultrasound. She had a history of hepatic resection and adjuvant chemotherapy for hepato-cholangiocarcinoma in 2009.
2Image Findings
On B-mode ultrasound, a focal hepatic lesion with irregular margins was observed, characterized by a hypoechoic peripheral rim and a centrally hyperechoic component (Fig. 1). Color Doppler imaging demonstrated vascular signals at the periphery of the lesion (Fig. 2).
On CEUS (Video 1), the lesion exhibited early peripheral rim-like enhancement in the arterial phase, followed by centripetal filling with persistent non-enhancing central areas, likely representing necrotic foci. Washout occurred within one minute, suggesting a cholangiocarcinoma component, either alone or in combination with a hepatocellular component.
Panoramic imaging was subsequently performed: a CT scan followed by MRI confirmed the suspicion of malignancy, without evidence of biliary dilatation or vascular invasion (Figs. 3 and 4); however, a definitive diagnosis could not be established.
Prostate-specific membrane antigen (PSMA) PET was also performed, and findings were more consistent with hepatocellular carcinoma (HCC).
On CEUS (Video 1), the lesion exhibited early peripheral rim-like enhancement in the arterial phase, followed by centripetal filling with persistent non-enhancing central areas, likely representing necrotic foci. Washout occurred within one minute, suggesting a cholangiocarcinoma component, either alone or in combination with a hepatocellular component.
Panoramic imaging was subsequently performed: a CT scan followed by MRI confirmed the suspicion of malignancy, without evidence of biliary dilatation or vascular invasion (Figs. 3 and 4); however, a definitive diagnosis could not be established.
Prostate-specific membrane antigen (PSMA) PET was also performed, and findings were more consistent with hepatocellular carcinoma (HCC).
3Diagnosis
Surgical resection was performed, and histopathological examination revealed a combined hepatocellular–cholangiocarcinoma (cHCC-CCA), representing a late intrahepatic recurrence
4Discussion
cHCC-CCA is a rare primary liver malignancy characterized by mixed hepatocellular and biliary differentiation. Its prognosis is worse than that of HCC and comparable to intrahepatic CCA. Preoperative diagnosis is challenging due to heterogeneous and overlapping imaging features, often leading to misclassification as either HCC or CCA.
In our case, CEUS demonstrated a mixed pattern from the outset. A single panoramic imaging modality might have been sufficient for staging prior to surgery. This case highlights the value of CEUS in the characterization of focal liver lesions and its potential to reduce the need for multiple imaging techniques.
In our case, CEUS demonstrated a mixed pattern from the outset. A single panoramic imaging modality might have been sufficient for staging prior to surgery. This case highlights the value of CEUS in the characterization of focal liver lesions and its potential to reduce the need for multiple imaging techniques.
5Teaching Points
• cHCC-CCA is a rare and aggressive primary liver tumor with a challenging diagnostic workup
• Atypical CEUS findings should raise suspicion for mixed tumors
• Histopathological examination remains essential for a definitive diagnosis
• Long-term surveillance is required due to the high risk of recurrence
• Atypical CEUS findings should raise suspicion for mixed tumors
• Histopathological examination remains essential for a definitive diagnosis
• Long-term surveillance is required due to the high risk of recurrence
6References
1. Amory B, Goumard C, Laurent A, Langella S, Cherqui D, Salame E, Barbier L, Soubrane O, Farges O, Hobeika C, Kawai T, Regimbeau JM, Faitot F, Pessaux P, Truant S, Boleslawski E, Herrero A, Mabrut JY, Chiche L, Di Martino M, Rhaiem R, Schwarz L, Resende V, Calderaro J, Augustin J, Caruso S, Sommacale D, Hofmeyr S, Ferrero A, Fuks D, Vibert E, Torzilli G, Scatton O, Brustia R; AFC‑ICC‑2009, AFC‑LLR‑2018, and PRS‑2019 Study Group. Combined hepatocellular‑cholangiocarcinoma compared to hepatocellular carcinoma and intrahepatic cholangiocarcinoma: different survival, similar recurrence: report of a large study on repurposed databases with propensity score matching. Surgery. 2024;175(2):413‑423. doi:10.1016/j.surg.2023.09.040
2. Gera S, Ettel M, Acosta‑Gonzalez G, Xu R. Clinical features, histology, and histogenesis of combined hepatocellular‑cholangiocarcinoma. World J Hepatol. 2017;9(6):300–309. doi:10.4254/wjh.v9.i6.300. PMID: 28293379; PMCID: PMC7785105.
2. Gera S, Ettel M, Acosta‑Gonzalez G, Xu R. Clinical features, histology, and histogenesis of combined hepatocellular‑cholangiocarcinoma. World J Hepatol. 2017;9(6):300–309. doi:10.4254/wjh.v9.i6.300. PMID: 28293379; PMCID: PMC7785105.
