CASE 599: TESTICULAR CANCER MIMICKING TESTIS TORSION , Dr PHAN THANH HẢI, Dr NGUYỄN MINH THIỀN, Dr MAI BÁ TIẾN DŨNG, MEDIC MEDICAL CENTER, HCMC VIETNAM

Male patient 31 yo, with sudden pain at left scrotum for 2 months had been treated as epidydimitis but treatment failed. He came to Medic for reexamination because swollen scrotum and testicular pain.

Ultrasound at Medic Center detected swollen left testis  with edema of epidydimis and hypervacularization. Testicular axis turned horizontally and left testis was inhomogenous with cystic necrosis and no vascular signal mimicking a left testicular torsion.

MRI of left testis #  60x85mm, inhomogenous signals that existed fluid and blood inside but captured a few of contrast. Edema of epidydimis and spermatic cord. No spermatocele.

Lab results showed no sign of inflammation, beta HCG, AFP, LDH raising that lead to think about a testicular  tumor non seminoma.

Operation removed left testis. It looks like tumor on macroscopic view. Histopathologic result is testicular embryonic carcinoma.

Post surgery one day,  blood tests dropped=  AFP, Beta HCG and LDH   ( AFP= 62, beta HCG= 8.9, LDH= 419). Normal. Chest XRray .  

DISCUSSION= Diagnosis of left testicular tumor based on patient history, age, beta HCG, LDH and AFP raising. No hypervascularizing of left testicular tumor maybe due to thrombosis of vessels in spermatic cord that could make mistake for ultrasound and MRI.

CASE 598: COLONOGASTRIC FISTULA DUE TO LEFT COLON TUMOR, Dr PHAN THANH HẢI- Dr VÕ THỊ THANH THẢO, MEDIC MEDICAL CENTER, HCMC, VIETNAM

 

Female patient 39yo, thin, pale, anemia with crises of epigastric and left flank pain without fever and lost weight for 2 weeks.

Ultrasound detected one mass in LUQ nearby gastric greater curvature that made thought about stomach tumor. But in swallowing water to examine, ultrasound revealed gas in the mass which adhered stomach so it may exist a fistula that connected gas in the mass and stomach.

Gastric endoscopy confirmed stool inside stomach and a fistula, d#10mm on gastric wall. Then a colonoscopy showed left colon tumor at splenic angle.

MSCT proved left colon tumor invaded stomach with fistula that adhered to gastric corpus. Lesion of thickening colon wall #25mm, degraded surrounding fatty tissue and captured mildly contrast.

Surgery was done to remove left colon tumor that seeding peritoneum, posterior uterus and lymph nodes. Tumor invaded stomach, tail of pancreas and lower pole of spleen.

Histopathological result post op is a colon adenocarcinoma grade 2 invasing serosa and metastasing nodes and peritoneum.

CASE 597: RECTUM CANCER, Dr PHAN THANH HẢI, Dr PHAN ANH TUẤN, MEDIC MEDICAL CENTER, HCMC, VIETNAM.

Male patient 60yo with lower GI tract hemorrhagia for months. At local hospital rectal endoscopy noted rectal wall rigid invasion. Biopsy results showed rectal ulcerative inflammation with anaplastic inversion. 

At Medic Center, colon enema with barium revealed contrast lacunae and rigid wall of rectal   tumor.        

Abdominal MSCT= Rectal wall lesion thickening #18mm captured contrast in medium intensity and degraded fatty tissue around . Some mesenteric  nodes 5-10mm. Being thought about rectal tumor invading tissue around and metastasing to nodes.

-                    

-                   Pelvic MRI= Invaded pattern tumor  is inside rectum # 82mm  which made narrowing rectal  lumen that is far from anus #46mm and invaded muscular layer toward posterior wall of rectum and presacral area from S2 to coccyx and adhered  posterior prostatic urethra wall. Gado captured non similarly with high signal intensity on T2W1, medium signal intensity on T1W1. Some 10-16mm nodes existed around rectum.

-                   Intraluminal rectal ultrasound with probe ASU-67, 7.5-10MHz,  views 360 degree detects rectal tumor far from anus 30-40mm. Tumor takes place entirely rectum and outside = invaded anterior sacrum posteriorly and adhered prostate and prostatic urethra anteriorly. Existing some 5-7mm nodes nearby tumor.

-                   Endoscopy of rectum revealed rectal ulcerative invasive lesions that made narrowing rectal lumen. Biopsy results is poor differentiated adenocarcinoma, type ring cell of rectum.

Chemotherapy is on going for patient at Binh dan hospital.                     

 CONCLUSION=

Intraluminal rectal ultrasound by probe view 360 degree is useful to assess rectal wall lesion and around rectum tissue,  taking part to detect rectum and rectal canal disorders.

CASE 596: SEVERE STENOSIS of ILIAC ARTERY, Dr PHAN THANH HẢI, Dr NGUYỄN NGHIỆP VĂN, Dr VÕ NGUYỄN THÀNH NHÂN, Dr VÕ HIẾU THÀNH, Dr HỒ KHÁNH ĐỨC, MEDIC MEDICAL CENTER, HCMC, VIETNAM.

Male patient, 51yo, from Kien giang province,  with asthenia of right leg in walking about a distance of 100 meter.

At Medic Center, vascular ultrasound revealed aliasing spectrum of  right common iliac artery in stenosis # 80% due to atherosclerosis.

Right common femoral artery shows Doppler spectral biphasic pattern.

Right pedial artery with tardus parvus pattern and decreasing severely of arterial flow.

CT Angio later comfimed diagnostic.

Transferred to Binh Dan hospital, by via DSA, patient went to arterial dilatation and stenting to recover flow of root of right common iliac artery.

DSA before arterial dilatation= Confirmed diagnostic of 80% stenosis of right iliac artery root.

After arterial dilatation and stenting= Well recovered arterial flow, and no more arterial stenosis on controlled film.

Patient remains well and discharged in healthy status one day later.

CONCLUSION: Atherosclerosis causes severe stenosis #80% of right common iliac artery which had been rapidly diagnosed, and safety of management by arterial dilatation and stenting. Only one day lasting for treatment in hospital, patient finely discharged without intermittent claudication symptom.

CASE 595: HCC WITH NEGATIVE WAKO TEST, Dr PHAN THANH HẢI, MEDIC MEDICAL CENTER,HCMC,VIETNAM

Male patient 58yo, with HCV infection that had been treated by interferon for several months.

In check-up, ultrasound detected one round mass # 3cm look like a cyst.

WAKO tests= AFP=5.7, L3= 0.5, DCP=16.

MSCT with CE detected non tumor.

Gado MRI of  liver reported HCC.

MR image shows a lesion in hepatic segment V; with the size 24mm, well-defined. The lesion demonstrates high signal intensity on T2WI and low signal intensity on T1WI.

The lesion had restricted on Diffusion Dynamic MRI: On arterial phase image demonstrates unequivocal arterial enhancement relative to the surrounding liver; On the portal venous phase has decreased in enhancement relative to the surrounding liver (washout); On the delay phase has decreased in enhancement relative to the surrounding liver and enhance capsule is found which helps further solidify the imaging diagnosis of HCC.

-This patient has negative Wako test. Volk et al (2007) and Hann et al (2013) demonstrate of  Wako test with sensitivity (83%) and specificity (>90%) for detecting HCC.

Operation removed the liver tumor.

 Histopathologic report= HCC well-differentiated.

CASE 594: LUNG TUMOR ON PATIENT WITH CORONARY STENTS, Dr PHAN THANH HẢI, Dr DƯƠNG PHI SƠN, MEDIC MEDICAL CENTER,HCMC VIETNAM

Male patient 66yo with 6 year stenting 2 coronary branches  now left chest pain and dypsnea.

Chest CT for check-up. Coronary stents in good condition, but detected left lung tumor while expands FOV

Ultrasound of liver detected hypoechoic solid mass # 46x30mm at subsegment VII, well-bordered, basket shape vascularized that was  thought a metastasis lesion maybe from left lung tumor.

Lung biopsy and  histopathological result= adenocarcinoma poor differentialized invasive in lung [C34].

CONCLUSION=Coronary CTA helps revealing exactly coronary lesions, but detecting other lesions nearby heart if enlarging FOV.  In this case, coronary CT detected left lung tumor that confirmed later by lung biospy with histopathological result.

CASE 593: HYPERTHYROIDISM and DIARRHEA, Dr PHAN THANH HẢI, Dr TRƯƠNG CÔNG THÀNH, MEDIC MEDICAL CENTER, HCMC, VIETNAM

Female patient 36yo with diarrhea and loss of weight # 9 kg for 11 months. After being failed of treatment as diarrhea in 4 other hospitals she came to Medic Center.

In clinical examination, P=101 bpm, BP =126/79mmHg, she got diarrhea, tachycardia, slight goiter,  hand tremor, hyperpigmentation and humid skin­.

Hyperthyroidism proved on color Doppler ultrasound, rapid sinusoid heart rate on EKG, low TSH and raised free T4 on lab results.

With Grave's disease management [methimazole 5mg] for one month, free T4 downs from 3.61 to 1.9, patient remains well and stop diarrhea.

Diarrhea for a long time due to many items of etiology including a thyroid mass.

According to Robbin's Pathology, hyperthyroidism leads to an overactivity of the sympathetic system. It also goes on to mention that this sympathetic hyperstimulation in the gut leads to increased motility leading to diarrhea and malabsorption.