Unusual presentation of hepatocellular carcinoma and assisted diagnosis by liver scan

A 66-year-old woman reported intermittent right epigastric pain of 2 years' duration. Sonography showed a hyperechoic nodule in the lower portion of her right hepatic lobe (segment 6). Computed tomography (CT) showed features of focal nodular hyperplasia (FNH). Magnetic resonance imaging (MRI) could not distinguish between hepatocellular carcinoma (HCC) and FNH. Serum alpha-fetoprotein and carcinoembryonic antigen levels were unremarkable (3.9 ng/dl and 1.1 ng/dl, respectively). Liver scintigraphy showed a photopenic area in the corresponding site seen on the radiologic examinations. Histologic analysis indicated HCC with cirrhosis. FNH is a benign condition, but HCC is a fatal malignant disease. A correct differential diagnosis between FNH and HCC is critical.