These five contrast-enhanced CT images were obtained in the portal venous phase showing a large lesion in the right hepatic lobe, extending over multiple segments, involving V, VI, VII and VIII — so all four segments of the right lobe appear to be involved. The lesion probably measures up to 10 centimeters or so. It may represent several confluent lesions, but independent of that, there is clearly multisegment involvement of the right lobe. I do not see any disease in the left lobe, so the patient may be a candidate for a right hepatectomy, either with or without preoperative chemotherapy to attempt to shrink this disease down.
Conceivably, if the image from the preoperative scan was performed too early in the contrast bolus, it could have made the lesion hard to see. In fairness, it is possible that it grew during the six-week period, but I doubt that nothing was there on the preoperative scan, so the scan may have been technically suboptimal — that would be the primary consideration.
Postchemotherapy:
Six contrast-enhanced CT images, obtained in the portal venous phase after chemotherapy, show little to no change in the size of the large volume of disease occupying all segments of the right lobe. If anything, the disease may have progressed slightly. Upon examination, I think disease is present on the top-left image, extending to the left side of the middle hepatic vein, and I see more convincing involvement of segment IV.
He has an extra hepatic vein — four hepatic veins are present on that top left image, a relatively common occurrence. I use the plane of the gallbladder to decide which one is the middle hepatic vein. In this case, one of the difficulties is determining which vein is indeed the middle hepatic vein that distinguishes the left and right lobes. The procedure that I use in these cases is to find the gallbladder and work upwards from the gallbladder, and the vein that I find in that plane, I call the middle hepatic vein, which on this top left image is probably most closely approximated by the vein that is most to the left side of the patient. Calling that vein the middle hepatic vein would then place all of his disease in the right hepatic lobe.
