CASE 218: LEFT SUPRACLAVICULAR MASS, Dr PHAN THANH HẢI, MEDIC MEDICAL CENTER, HCMC, VIETNAM

MAN 55 YO, LUMBAGO FOR 3 MONTHS.  MRI  SPINAL  SHOWED SOME  DESTRUCTIVE  SPINES SUSPECTING  METASTASIS  AND  A BIG  MASS  ON  LEFT  SUPRACLAVICULAR AREA.

ON ULTRASOUND  B MODE,  IT WAS A BILOBED MASS WHICH HAS DIFFERENT  ECHOSTRUCTURE . 

COLOR DOPPLER PRESENTED THIS HYPOVASCULAR MASS  LIKED SANDWICH SIGN.

ON ELASTOSCAN  ONE  PART OF THIS MAS WAS  SOFT  AND  ANOTHER ONE  WAS  HARD MASS.

WHERE DO YOU GUIDE  FOR  FNAC (HARD MASS OR  SOFT  MASS)?

WE DID PERFORM FNAC OF THIS SOFT MASS, REMOVING EASILY THE FLUID LIKED MILK;

FLUID ANALYSIS  : GRAM STAINING= NEGATIVE BACTERIA, BK NEGATIVE, BUT CELL BLOCK WAS ADENOCARCINOMA [SEE REPORT].

CASE 217: THYROID TUMOR, Dr PHAN THANH HẢI, MEDIC MEDICAL CENTER, HCMC VIETNAM

WOMAN 41 YO, 5 YEARS AGO DETECTED SWOLLEN RIGHT SITE OF THE NECK.

ULTRASOUND DETECTED  A RIGHT LOBE OF THYROID, SOLID,  WELL- BORDERED, WITH SIZE OF 3 - 4 CM IN DIAMETER WHILE THE LEFT LOBE WAS ATROPHY. ON  COLOR DOPPLER  IT WAS NOT A  HYPERVASCULAR NODULE.

ELASTOSCAN WAS SOFT TUMOR.

NO CERVICAL LYMPH NODE DETECTABLE

BLOOD TESTS WERE NORMAL  VALUE OF TSH , T3, AND T4.

WHAT IS YOUR SUGGESTION,  FNAC OR NOT FOR THIS CASE.

Ultrasound guided for FNAC this mass and the result was colloidal goiter.

DISCUSSION:

B-mode ultrasound of thyroid is not full examination of the thyroid, only about the thyroid anatomy .Color Doppler explaines the vasculature, and ELASTOSCAN can guide for FNAC with high accuracy.

REFERENCE

 

CASE 216: MULTIPLE INTRAABDOMINAL NODULES, Dr PHAN THANH HẢI, MEDIC MEDICAL CENTER, HCMC, VIETNAM

Man 32 yo,abdominal pain, no fever. Emergency ultrasound of abdomen ruled out acute appendicitis, but there are ascites, and many small round nodules of  average of 2cm in diameter at great curvature of stomach, intra great epiploon, and at hilus of liver . All of them were  very poor echo like cyst (SEE 4 IMAGES= H.1: black nodule in hilus liver, H.2: cross section of abdomen and nodule intra great omentum, H.3:  echo poor nodule at great curvature of stomach, H4 : ascites at pelvis).

Blood test are normal. Punction of ascites fluid for analyse. PCR of tuberculosis is negative.

THIS CASE  UNDERWENT BIOPSY VIA LAPAROTOMY SHOWING  MULTIPLE WHITE SPOTS OVER PERITONEUM, LIKED CARCINOMATOSIS.

REMOVING ONE BIG MASS.AT GREAT CURVATURE OF STOMACH. CUTTING SURFACE SHOWED FLUID LIKED CASEUM.

SUGGESTION OF TUBERCULOSIS. WAIT FOR MICROSCOPY REPORT.

Microsopic  report  is  tuberculosis lymphadenitis (photo).

Discussions:

Why the result  of analysis of ascites fluid is negative  from TB PCR, ADA?
WHY TUBERCULOSIS LYMPH NODE  are VERY  BLACK in echogeneicity?
HOW to DIFFERENTIATE it WITH LYMPHOMA ?
 
REF

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CASE 215: PELVIS TUMOR, Dr PHAN THANH HẢI, MEDIC MEDICAL CENTER, HCMC, VIETNAM

Woman 50 yo amenorrhea 3 years ago, and hypogastric area distention like being of pregnancy for 6 months.

Ultrasound at the pelvis had a masss of 20 cm in diameter, cystic septation structure which cannot separate with cervis uterus by TVS ultrasound.

MRI of pelvis showed  that mass was cystic septation with very thick border (see MRI images).

DIFFICULTY FOR DIAGNOSING THIS CASE AS THIS MASS WAS TOO BIG, ULTRASOUND WAS LIMITED OF ANGLE OF FIELD OF VIEW.

MRI CANNOT STUDY THE MOTION OF THIS MASS, STRUCTURE WAS LOOKED LIKE OVARIAN CYSTIC TUMOR, BUT MRI  SHOWED  THE BORDER VERY THICK.

OPEN OPERATION FOR REMOVING THE UTERUS AS A SAME MASS.

SECTION OF THIS MASS WAS UTERINE FIBROMA IN NECROSIS, AND MICROSCOPY CONFIRMED.

IT IS A HUGE UTERINE FIBROMA NECROSIS LOOKED LIKE OVARIAN CYST.

Reference

DEGENERATED UTERINE FIBROID MIMICKING HYDROMETRA

CASE 214: ADRENAL TUMOR, Dr PHAN THANH HẢI, MEDIC MEDICAL CENTER, HCMC, VIETNAM

Woman 50 yo, hypertension on medical treatment, well controlled, one week ago she was getting very weak and  falling down to brain trauma. CT scan the head has nothing, but  blood test  showed hypokalemia  K = 1.7 mEq /ml, abnormal EKG  with  wave T= U deformation. Ultrasound scan of abdomen detected one  2cm small tumor at right adrenal area (2 pictures).

MSCT with CE showed  this tumor in high enhancement (HU= 8.2  rising to 59.9) (see 2 CT pictures).

Blood tests from adrenal gland hormones were normal, aldosterone dynamic test was=84 pg/mL, after test 115pg/mL.

This case was operated by endoscopy for removing this tumor. See macro and microscopic specimen and report is adenoma of cortical adrenal (photo).

CASE 213: BILOBED GALLBLADDER, Dr PHAN THANH HẢI, MEDIC MEDICAL CENTER, HCMC, VIETNAM

Woman 29 yo,  recurrent pain at subhepatic area.

Ultrasound detected stone in gallblader with thickening wall and one cystic mass with size of 2 cm  nearby. Sonologist reported that was CBD cyst and chronic cholecystitis due to stone [3 images].

MSCT  also had same report as ultrasound report (see  image CT).

Surgeon ordered  MRCP. The MRI report was different which thought about  bilobar gallbladder that had 2 parts: one part had stone and  thickening of the wall, and another part was connected to the neck of gall bladder which had  normal wall and normal CBD.

Endoscopic surgery for removing gall bladder with stone in its fundus.

Macroscopic specimen of this gallbladder was correlated with 3 modalities of  imaging: ultrasound, CT and MRI.

 

 REFERENCE

 



CASE 212: APPENDICEAL ABSCESS, Dr NGUYỄN ĐỨC DUY LINH, Dr NGUYỄN NGỌC XUÂN GIANG, Dr PHÙ VĂN TUỐT, BÌNH AN HOSPITAL, VIETNAM

Man 38 yo with chief complaints: fever and lower abdominal pain for 10 days. Pain not releasing but getting worse with colicky pain and having dysenteric syndrome. Endoscopy  ruled out a  colonic tumor and noted  that sigmoid colon may pushed by an uncertain mass from outside.

Ultrasound of abdomen detected an abcess  in  minor pelvis which was thought to be an appendiceal abscess. 

Later  abdominal CT confirmed a right pelvic abscess with fecolith and a diagnosis of appendiceal  abscess was made.\

WBC= 14.76 K with 78.3% of neutrophile and CRP=87.24mg/L.

 Endoscopic surgery was performed. 

A wall-off abscess at pelvic region was detected which was due to perforated inflammed appendix at liberal tip . The pelvic abscess was removed and patient getting well.