CASE 137: APPENDIX TUMOR, Dr PHAN THANH HẢI , Dr LÝ VĂN PHÁI, Dr NGUYỄN THIỆN HÙNG, MEDIC MEDICAL CENTER, HCMC, VIETNAM.

Man 25 year-old was in pain at RLQ for 3 days. In abdominal ultrasound scans with curve probe 3.5 MHz (image 1), a cross-sectional view disclosed a big appendix in black border and its central part in white spot like bull-eye.

Image 2 in longitudinal section, the appendix was like a finger, noncompressible with white line in its center looks like an ascaris inside appendix.

Ultrasound with linear probe 12 MHz, (image 3: cross-sectional scanning) showed many rings in the center as intussusception.

Image 4, longitudinal section: the appendix with black content like mucocele.

But there was no raising of WBC in blood test. For verifying the appendiceal mucocele, a colonoscopy was done and detected this mass was like a finger covering by mucosa and protruding from appendiceal aperture (see photo).

It was hard, not content the mucus after many punctures, so it was thought to be a solid tumor according the report of endoscopist.

MDCT without CE also susgested a tumor of appendix (see CT image).

Via endoscopic laparoscopy, operation was done but surgeon could not detect any tumor of appendix. Open surgery detected the appendiceal tumor being an intracecal intussusception of appendix. And the surgeon removed the tumor after opening of cecum (see photo).

Microscopic histology and histoimmunostaining report is chronic inflammation and fibrosis of appendix.

 

Appendiceal intussusception into cecum is a rare condition so it could be detected in open surgery.

CASE 136: COLD ABSCESS, Dr PHAN THANH HẢI, Dr LÊ ĐÌNH VĨNH PHÚC, MEDIC MEDICAL CENTER, HCMC, VIETNAM

WOMAN 31 YO COMPLAINED OF PAIN AT LEFT LOWER LUMBAR REGION, DIFFICULT WALKING, FOR ONE MONTH BUT NO  FEVER.

ULTRASOUND  EXAMINATION DETECTED A BIG MASS IN THE LOWER POLE OF LEFT KIDNEY, COVERED PSOAS MUSCLE AND  STORED AT LATERAL WALL OF ILIAC CREST. ITS CONTENT WAS VISCOUS FLUID WITH  DEBRIS. 

BLOOD TEST WITH RAISING OF WBC OF 11K WITH 65 % NEUTROPHIL.

MDCT  WAS  DONE IN DISCLOSING OF MANY LESIONS OF SPINAL BONES AND ILIAC  BONE.

We think it an abscess around the destruction bone (spinal and iliac ). Puncture for aspiration is done, the withdrawed pus was in brownish color, smelless.

During aspiration, the tip of needle is made doppler color due to the flow out of the pus (see video). At the iliac crest erosive the bone made doppler artefact like twinkling.
The pus is analysis: no bacteria, no BK present in direct microscope view. But ADA test is strong positive: 126 UI/L. It make a diagnosis of COLD ABSCESS due to BONE TUBERCULOSIS. (ADA: 100% sensitive, 98% specific).

Ref on ADA: ijcri-00203201122-dikensoy.pdf

CASE 135: HUGE CYSTIC LYMPHANGIOMA of PANCREAS, Dr PHAN THANH HẢI, MEDIC MEDICAL CENTER, HCMC, VIETNAM.

MALE 26YO  PAIN AT RIGHT LUMBAR AREA  AND POLYURIA.
XRAY KUB FILM SHOWED A RIGHT URETERAL STONE AND ONE MASS ON THE LEFT  SITE OF HIS ABDOMEN.

ULTRASOUND  DISCLOSED RIGHT HYDRONEPHROSIS AND A BIG CYSTIC TUMOR AT THE LEFT RETROPERITONEAL AREA EXTENDING  FROM THE LEFT KIDNEY TO THE PELVIS.

AT FIRST, ONE SONOLOGIST'S SUGGESTION WAS PSEUDOCYST OF PANCREAS.
MDCT abdomen with CE showed this tumor being in retroperitoneum without contrast enhancement, and right hydronephrosis due to ureteral stone.

Blood test Amylasemia of 70.3 (normal= 35-115UI/mL).
Percutanous puncture withdrawed 3 liters of brown clear fluid. Analysis no abnormal cell, no inflamation cell, with biochemistry results.

Ultrasound guided puncture images and then 3 liters of fluid removed...

DISCUSSION: IT WAS A BIG CYST OF RETROPERITONEUM. BASED ON THE WALL, NO SEPTATION, AND ANALYSIS OF THE FLUID, WE CAN RULE OUT URINOMA, OR PSEUDOCYST OF PANCREAS. IT IS LYMPHANGIOMA OF THE TAIL OF PANCREAS.

(REF. Abdominal Lymphangiomas: Imaging Findings with Pathologic Correlation.)

CASE 134: PAINFUL MASS at UMBILICAL REGION, Dr PHAN THANH HẢI, MEDIC MEDICAL CENTER, HCMC, VIETNAM

Man 32 yo, 4 days ago, suddenly got pain at left site of umbilicus, progressive, no fever nor GI trouble.
Emergency ultrasound of abdomen: no free fluid, no free air, at the umbilicus there is one mass near the abdominal wall, along from epigatric area to urinary bladder, hyperechoic, no air inside. Pressing over the mass is very painful (2 images of longitudinal and cros-sectional scan at the left umbilicus).

 

Blood test : elevated WBC of 16k.

Emergency doing abdomen MDCT:  in cross section, sagital views at umbilicus, and frontal view  this mass located from the transverse colon to nearby urinary bladder. It was great omentum.
Suspicion of  a great omentum infarction (see 3 CT pictures).

EMERGENCY OPERATION AT BD HOSPITAL DETECTED GREAT OMENTUM INFARCTION DUE TO VENOUS THROMBOSIS.

REF:1105-Federle-Omental_Infarction.pdf

CASE 133: SCAR of REMOVED BREAST TUMOR, Dr PHAN THANH HẢI, MEDIC MEDICAL CENTER, HCMC, VIETNAM

WOMAN 57 yo WENT THROUGH A LUMPECTOMY AT THE LEFT BREAST BY CANCER FOR 7 YEARS AND RADIOTHERAPY. NOW SHE NOTICES THE SCAR AT THIS SITE GETTING BIGGER AND HARDER.

ULTRASOUND OF LEFT BREAST AT 5h AREA : THE SCAR HAS STRONG SHADOWING NON COMPRESSIBLE, NO AXILLARY NODE (4 IMAGES).

MRI IS DONE WITH GADO CE DYNAMIC (2 IMAGES).

Resection biopsy of the scar was done, and pathological report was fibrosis and inflamation cell infiltration.
Microscopic result of  the biopsy showed that to be a KELOID.

DISCUSSION:  Caution of the scar on one breast post operation is always more difficult. With CDI ultrasound there is no vascular supply for this scar nor mass in the posterior black shadowing area. Biopsy of course is the choice for a clear diagnosis. 

Reference: POSTERIOR ACOUSTIC SHADOWING in BENIGN BREAST LESIONS

CASE 132:OVARIAN TUMORS and COLON TUMOR TOGETHER, Dr PHAN THANH HẢI, MEDIC MEDICAL CENTER, HCMC VIETNAM

Female patient 17yo, has been treated at a province hospital as PID for 3 months. Ultrasound at Medic detected 2 ovary tumors in pelvic region with ascites.

Reviewing of scanning, ultrasound disclosed a mass which belonged her R/colon with "umbrella" sign.

Blood test of CA 125=125 UI.
MDCT of abdomen was done with CE.

MDCT showed foreign bodies intralumen of right colon and ovarian tumors.
COLONOSCOPY  detected  multiple polyps of colon which obstructed at right angle of colon.

BIOPSY  made diagnosing of colon cancer.

And  the ovarian tumors maybe were  KRUKENBERG TUMORS  DUE TO COLON CANCER SEEDING.

CASE 131: LEFT SUPRACLAVICULAR NODES, PELVIC TUMOR AND MESENTERIC NODES, Dr PHAN THANH HẢI, MEDIC, MEDICAL CENTER, HCMC, VIETNAM

Woman 36 yo, one month after operation by pelvic abscess, she detected her neck swollen on the left site. Ultrasound the neck and abdomen.

Many lymph nodes were at the left supraclavicular area (Troisier's node), one big and many small hypoechoic around.

 

 
Doppler CDI can see the hilus of the lymph node, and thyroid gland was normal.

At left iliac fossa, ultrasound scan detected the elliptical structure, CDI showed  that the lymph node at mesenteria like sandwich sign.

 
DISCUSSION:
Sandwich sign  in ultrasound  is the same as finding  made by MDCT in  hypertrophy of the lymph node   with the vessel inside this mass.

Ultrasound is the best for diagnosis of  the scenario including very poor echostructure  like cyst  of  LYMPHOMA.

Biopsy of course  is the final  report with histo-chemistry staining.