C a s e  
1.19 
Figure 1.19.1  Figure 1.19.2  Figure 1.19.3
A B
Figure 1.19.4 
Figure 1.19.5 
Hi sto ry: 30-year-old woman with a long-standing his-
tory of palpitations and lightheadedness; she recently was
hospitalized for severe hypertension with hypertensive
retinopathy
I m ag in g F in din gs : Coronal SSFSE (Figure  1.19.1),
axial fat-suppressed FSE T2-weighted (Figure  1.19.2), and
diffusion-weighted (b=600 s/mm2) (Figure  1.19.3) images
demonstrate a hyperintense mass in the posterior right hepatic
lobe with very high central signal intensity. No associated
signal dropout could be seen on IP and OP T1-weighted
SPGR images (images not shown). Note the signal loss ante-
riorly, which is likely secondary to 3-T shading artifact (see
Case 17.6). Axial postgadolinium (Multihance) portal venous
c h a p t e r 1. L i ve r :   F o c a l   M a s s e s   •   37
 
C
(Figure 1.19.4A) and delayed (Figure 1.19.4B) phase 3D SPGR
images demonstrate gradual hypoenhancement of the mass
relative to background liver. A 90-minute delayed hepatobili-
ary phase image (Figure 1.19.4C) shows only minimal hyper-
intensity in the center of the lesion. Fused image from PET
CT (Figure  1.19.5) demonstrates intense radiotracer activity
corresponding to the mass.
D i ag n o sis : Primary hepatic paraganglioma
C om m e n t: There are only a handful of case reports
describing primary hepatic paragangliomas; these lesions
are, of course, most commonly found in the adrenals, where
they are known as pheochromocytomas. Approximately 10% of
pheochromocytomas are extra-adrenal in location, and 75%
of these occur in the organ of Zuckerkandl, the retroperito-
neal chromaffin body adjacent to the abdominal sympathetic
plexus extending from above the inferior mesenteric artery
origin through the aortic bifurcation, with most remaining
lesions found in the neck, chest, and bladder.
Patients generally present with signs related to their exces-
sive catecholamine production, including paroxysmal hyper-
tension, flushing, tachycardia, headaches, diaphoresis, and chest
pain, although they may also be completely asymptomatic.
Paragangliomas are responsible for a very small percentage of
hypertension (0.1%-0.5%), and the diagnosis, when clinically
suspected, can be made by screening plasma metanephrine (99%
sensitivity) or urinary vanillylmandelic acid (95% sensitivity).
The appearance of this lesion is certainly not diagnostic
of hepatic paraganglioma. The 2 major differential diagnostic
considerations in a patient of this age are FNH and adenoma.
38  •   M ayo C l i n i c B o dy M R I C a s e   R e vi ew
The lesion is more hyperintense on the T2-weighted image
than the typical FNH, but it does appear to have a central scar.
However, the hepatobiliary phase image removes FNH from
the differential diagnosis because there is no contrast reten-
tion. Although the lesion had no signal dropout from IP to
OP images to suggest the presence of fat, there is no convinc-
ing evidence on MRI to exclude adenoma from the differential
diagnosis.
PET CT was performed after the MRI and following
documentation of elevated serum catecholamine levels, since
it was considered very unlikely that the hepatic mass repre-
sented the primary tumor. The endocrinologists thought it
represented either a metastasis or a benign red herring, but
PET CT also failed to detect any additional lesions. The
patient underwent subsegmental resection of the mass, with
pathology demonstrating a paraganglioma without evidence
of malignancy.