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A 35-Year-Old Woman with Progesterone Implant Contraception and Multiple Liver Masses
01. Oktober 2001 (online)
A 35-year-old woman presented to an outside hospital in January 2000 with epigastric and right upper quadrant abdominal pain that radiated to the right shoulder. There was no history of antecedent trauma. By physical examination, the abdomen was tender but nondistended. There were no stigmata of chronic liver disease. Past medical history was significant for occasional use of alcohol and estrogen-based oral contraception from 1978 to 1981. The patient had four children, ages 7 to 15 years. No medical contraceptive was used from 1981 until 1998, when a subcutaneous levonorgestrel implant (Norplant) was placed in her arm.
Laboratory values were as follows: hemoglobin 13.7 g/dL, alanine aminotransferase (ALT) 114 U/L, aspartate aminotransferase (AST) 107 U/L, and albumin 4.4 g/dL. Computed tomography (CT) of the liver with intravenous contrast was significant for a 16-cm subcapsular hematoma in the right lobe of the liver, and multiple focal lesions in both lobes ranging from a few millimeters to 5 cm. These latter lesions did not demonstrate increased blood pool activity on delayed images and were interpreted as most consistent with metastases. CT of the thoracic cavity showed a large right pleural effusion and compressive atelectasis of the right lung. There was no clinical intervention at this time.
Three months later, the patient was referred to St. Louis University Hospital for further evaluation. Results of the physical examination were unchanged. Pertinent laboratory values at this time were as follows: hemoglobin 14.2 g/dL, albumin 3.2 g/dL, prothrombin time 15 seconds (12.6-15), ALT 21 U/L, AST 19 U/L, alkaline phosphatase 84 U/L, and total bilirubin 0.6 mg/dL. Serum tumor markers were negative, including carcinoembryonic antigen 1.3 ng/mL (0-3), CA-125 23 U/mL (0-35), α-fetoprotein 1 ng/mL (0-5), and CA 19-9 11 U/mL (0-37).
A repeat CT of the liver with oral and intravenous contrast confirmed multiple hyperdense lesions with rapid washout of the contrast material (Fig. ). These findings were interpreted as unlikely to represent metastatic disease and more consistent with hepatic adenomas. Because of the concern of rebleeding and possible capsular rupture, the patient underwent resection of the hematoma and two of the larger subcapsular lesions. During surgery, gross observations of lesions in segments V-VIII resulted in a partial resection of the right lobe of the liver.
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