An incidental hepatic epithelioid hemangioendothelioma in a patient with chronic hepatitis: lost in the maze.

A 60-year-old woman with a 20-years history of hepatitis B presented with 2 weeks of dull pain in the right upper quadrant and intermittent nausea. Abdominal MRI showed a solitary lesion in Segment VIII of the liver. It demonstrated multi-layered target appearance resembling a "maze" on diffusion-weighted image (DWI) and T2 weighted images (T2WI), and appeared as a low signal target with a hypointense core on the hepatobiliary phase. Histopathology confirmed hepatic epithelioid hemangioendothelioma (HEHE). Our case showed a solitary hepatic lesion with as many as six layers and overall appearances are more like a "maze", which was a diagnostic challenge. However, this maze-like manifestation actually makes hepatocellular carcinoma as the main differentials being very unlikely. Other differential diagnosis such as metastasis,cholangiocarcinoma or atypical hemangioma are also unlikely to show more than three layers. Core pattern, regarded as a noval imaging feature of HEHE, is different from general features of hepatocellular carcinoma or cholangiocarcinoma. Our case highlights that HEHE needs to be taken into consideration when a multi-layer appearing hepatic lesion is found incidentally in the cirrhotic liver.