CASE 174: HCC or NOT ? Dr PHAN THANH HẢI, MEDIC MEDICAL CENTER, HCMC, VIETNAM

Male patient 56 yo strickly followed up by HCV, 2 weeks ago fever, chill, pain at liver region. Ultrasound of liver detected one mass at right lobe, size of 10cm with hypoechoic mixed structure inside. Doppler showed hypervascular. 2 fellows in sonology said that to be HCC.

DO YOU THING IT IS HCC WITH 5 ULTRASOUND IMAGES?.

Blood test report:

MDCT of liver without CE and with CE were in suggestion of liver tumor by radiologist report.

Do you thing ultrasound and CT can make diagnosis for this case, or clinical and blood test are the main reasons for diagnosis?.

What could you do next for this patient?.

This patient had been admitted in infectious tropical hospital. Blood test negative for amebiasis, and fasciola hepatica; antibiotic was in perfusion. After 2 days, patient was not in fever. Wait for result of blood culture and ultrasound reviewing the liver mass.

CASE 173: THORACIC OUTLET SYNDROME, Dr NGUYỄN PHƯỚC BẢO QUÂN, MEDIC CENTER in HUẾ

Female  33 years old complains pain in right arm when she has her arm in abduction and elevated position.

Ultrasound findings:

Fig 1: Right side of the image indicates normal dimension on transversal section of the R subclavian artery (arrow) before the test by which the patient elevates her arm in external rotation; left side of the image indicates small dimension on transversal section of the R subclavian artery during the test due to compression between the anterior scalene muscle anteriorly (white arrow head) and exostosis of the first rib posteriorly (black arrow).

Figure 2:The spectrum waveform of the radial artery before and during the test. 

Fig 3: Longitudinal section of the R subclavian artery indicates the stenosed segment with high flow velocity displayed by aliasing phenomenon and  post-stenotic dilatation segment as well. Note that focal thickening of the wall of the R subclavian artery at stenotic region (white arrow).

Fig 4: CT Angio images of the R subclavian artery demonstrate the stenosed segment due to exostosis of the first rib (red arrow) and poststenotic dilatation segment.

Diagnosis: Thoracic outlet syndrome in the first space.

Discussion: Thoracic outlet syndrome (TOS) is the name of a variety of conditions attributed to compression of the neurovascular structures as they traverse the thoracic outlet. (TOS) can occur at 3 spaces: 1/ The first space is the interscalene triangle. It is bordered by the anterior scalene muscle, the middle scalene muscle, and the upper border of the first rib. The interscalene triangle is the most common site for neural compression, vascular compression. 2/ The second space is the costoclavicular triangle, which is bordered by the clavicle, first rib, and scapula and contains the  subclavian artery and vein and the brachial nerves; 3/ The third and final space is beneath the coracoid process just deep to the pectoralis minor tendon; it is referred to as the subcoracoid space.

Reference: 

 1.Daryl A Rosenbaum, MD; Chief Editor: Sherwin SW Ho, MD. Thoracic Outlet Syndrome . http://emedicine.medscape.com.

2/ Paul B. Kreienberg, Dhiraj M.Shah et al. Thoracic outlet syndrome. Vascular diagnosis. Elsevier Saunders. 2005. P.512-522



CASE 172: HEPATIC ECTOPIC PREGNANCY, Dr PHAN THANH HẢI, MEDIC MEDICAL CENTER, HCMC, VIETNAM

Woman 24 yo, amenorrhea for 2 weeks, was suspected  in pregnancy, but ultrasound at pelvis showed uterus without gestational sac or mass beside uterus.

Ultrasound scan at liver detected one hyperechoic focal, hypovascular, round shape, size of 1.86 cm with fluid in central mass.

Blood test beta HCG is of 34k unit. Do you thing it is an ectopic pregnancy in liver and how to make sure the diagnosis for this case?.

MDCT with CE  was done  for  detection  the intrahepatic focal which was  near  the gall-bladder, size of  2cm, hypodense  cystic central and  blood supply by  hepatic artery (see 3 CT images).

ULTRASOUND AND MSCT LIVER SUGGESTED PRIMARY LIVER PREGNANCY WITH high value of beta HCG 32 k unit/ml. Methotrexate is drug of choice for treatment, after 2 weeks of injection of methotrexate the blood test beta HCG will be dropped to normal, the liver focal will get smaller as a cyst. This is a case of PLP (PRIMARY LIVER PREGNANCY) succesfully treated with METHOTREXATE. NO NEED of OPERATION. IT IS RESULT OF EARLY DIAGNOSTIC of PLP.

REFERENCE: Case in MEDIC of DATE 2008: Subhepatic Ectopic Pregnancy 

CASE 171: THICKENING OF ANTRUM WALL, Dr PHAN THANH HẢI, MEDIC MEDICAL CENTER, HCMC, VIETNAM

Woman 39yo, anorexia, vomitting and loss weight rapidly.

Ultrasound abdomen first detected  dilated stomach too big, and the antrum wall thickening  like the uterus cervix (pseudocervix sign). At the pelvis,  uterus was covered around by ascites (see 3 ultrasound pictures).

MDCT ABDOMEN WAS DONE, some FRONTAL, AND SAGITAL SECTIONS SHOWED THE ANTRUM THISKENING OF THE WALL.

GASTRO-ENDOSCOPY SAW THE ANTRUM STENOSIS.

BIOPSY WAS PERFORMED. WAIT FOR MICROSCOPY REPORT.

ALL OF THE DIAGNOSTIC PROCEDURES SPENT FOR 2 HOURS.

Biopsy report  was  gastric  cancer.

Reference: gastric pyloris stenosis..pdf

CASE 170: A BREAST TUMOR, Dr PHAN THANH HẢI, MEDIC, MEDICAL CENTER, HCMC, VIETNAM

Woman 77 yo, by herself detected one lump at her left breast.

Ultrasound  examination: this mass was at  section  of 10 hr  of left breast, size  arround 2 cm ( B mode US picture). 

It was  hypoechoic and  irregular  border, with very strong shadowing (image 2 and 3), and on CDI, hypervascular and  very high PI.

 

On PDI again, this tumor was hypervascular; axillary scan no detected nodes.

Ultrasound first  suggests breast cancer, next step is mammography or  MRI.
 

THIS PATIENT  REFUSED  TO DO MAMMOGRAPHY AND MRI BECAUSE  THE FIRST TECHNIQUE  WAS PAINFUL  AND THE SECOND ONE MADE  CLAUSTROPHOBIA FOR  HER LONG TIME AGO.

MSCT  IS CHOSEN FOR STAGING  THIS CASE. (SEE  3 CT SLICES )

 

MSCT non CE  showed that tumor  was small size of  1.8 cm, spiculate hypercalcification and detected no  lymphatic nodes of axillary or retrosternum, it was staging I.

Biopsy was done and report was breast cancer type NOS.

 

 

Ref.  MSCT staging of breast cancer

 

 

CASE 169: CBD MASS, Dr PHAN THANH HẢI, MEDIC MEDICAL CENTER, HCMC, VIETNAM

MAN 50 YO, ONE MONTH AGO, PAIN AT RUQ AREA,  FEVER AND JAUNDICE PROGRESSING. ULTRASOUND AT FIRST DETECTED THE GALL BLADDER TOO BIG, NO STONE AND DILATED CBD with DIAMETER OF  2.6 CM,  WITH  PENCIL SIGN  AT ODDI AMPULA. [SEE 3 ULTRASOUND  IMAGES].

MDCT  OF ABDOMEN WITH CE  SHOWED  ODDI AMPULA  HAVING  A MASS  WITH CE  (SEE  2  CT IMAGES).

ERCP was done and  detected  ampular  tumor. Biopsy was performed  and  left a stent for biliary decompression.

Microscopic  report  from  biopsy is adenocarcimoma of Vater ampulla tumor.

Reference:  January 1993 Buck and Elsayed, RadioGraphics.

 

CASE 168: NOT HAVING GALLBLADDER, Dr PHAN THANH HẢI, MEDIC MEDICAL CENTER, HCMC, VIETNAM

Man 48 yo in hospital admission by fever and jaundice progressing. Physical examination: pain at right subcostal area, past history was known diabetes and gallbladder stone. Plain abdominal XRay film standing showed ilius status.

Ultrasound of abdomen revealed small fluid collection at the border of liver, and CANNOT FIND OUT THE GALL BLADDER BUT DETECTED ONE  HYPERECHOIC MASS ADHERED TO LOWER BORDER OF LIVER. THE CBD WAS NOT IN DILATATION.

Blood tests with elevated WBC of 16K (90% neutrophil).

MDCT non CE found that the gallbladder without stone nor fluid into gallbladder.

What is your explanation of the ultrasound images for this gallbladder?

Based on clinical  status:  fever, jaundice, pain at right subcostal area, and imaging modalities (abdomen plain film, ultrasound  and MDCT) with  blood tests, the  diagnosis was acute cholecystitis lead to gallbladder empyema. The IV antibiotic resulted clinically good response in medical treatment.

Reference: 

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