CASE 630: PHYLLODES TUMOR in COVID19, Dr PHAN THANH HẢI, Dr HỒ CHÍ TRUNG, Dr JASMINE THANH XUÂN, Dr TRÂN THỊ HỒNG VÂN, MEDIC MEDICAL CENTER, HCMC, VIETNAM

 Female patient 41 yo from Baclieu province with left breast mass getting bigger for months, now after COVID 19 lockdown stop, she came to Medic to solve her big left breast.

Breast US revealed the huge left breast many structural  types solid, cystic, fatty and calcifications, but the skin and nipple were intact that was diagnosed as phyllodes tumor.

On mammography, the tumoral mass infltrated totally the left breast with calcifications. It existed benign hypersensitivity, BI-RADS 3.

MRI confirmed the huge left breast tumor.

Operation for enucleation of the left breast tumor # 1.2 kilogram from the left breast was done and, later in 3 months, will perform a cosmetic recreation of her breast.

Anapathological result was phyllodes tumor.

REFERENCE:

Cystosarcoma Phyllodes

 

Mary Ann Kosir

, MD, Wayne State University School of Medicine

https://www.msdmanuals.com/vi/chuy%C3%AAn-gia/ph%E1%BB%A5-khoa-v%C3%A0-s%E1%BA%A3n-khoa/nh%E1%BB%AFng-r%E1%BB%91i-lo%E1%BA%A1n-tuy%E1%BA%BFn-v%C3%BA/kh%E1%BB%91i-u-phyllodes

CASE 629:Huge focal nodular hyperplasia presenting in a 7-year-old child: Dr Phan Thanh Hai, Dr Nguyen Duc Duy Linh, Dr Nguyen Ngoc Xuan Giang , MEDIC BÌNH AN, MEDIC MEDICAL CENTER, HCMC, VIETNAM

A healthy 7-year-old boy on imaging examinations, including abdominal ultrasound and computed tomography (CT):

 

An abdominal ultrasound scan revealed a 5.3 × 5.2 cm lesion which was homogeneous  hypoechoic solid mass and its central scar in the right lobe of the liver. It existed Doppler signals of central feeding artery in the mass on a fatty infiltrated  of parenchyma of liver.

On CT  of abdomen, NECT showed a 5.7 × 5.4 cm hyperdense  mass in comparison to normal liver in the right hepatic lobe, which displayed a central star-like scar in the low-density area. On the contrast CT scan (CECT) transient, intense, and homogeneous enhancement in the hepatic arterial phase and hyperdense to normal liver in the venous phase. In the delayed phase, mass was  in hyperdense to liver while central scar was in hypodense density.

Laboratory testing revealed the following: alanine aminotransferase (ALT) and aspartate aminotransferase (AST) were 30.1 U/L (normal, 3–30 U/L) and 32.3 U/L (normal, 6–25 U/L), respectively; viral serologic tests for hepatitis B and C were negative; the alpha-fetoprotein (AFP) level was 1.6 ng/mL; and the carbohydrate antigen 19-9 (CA 19-9) level was 7.03 U/mL.

DISCUSSIONS and CONCLUSIONS

Primary tumors of the liver, including malignant and benign tumors, constitute 1%–2% of all pediatric tumors. Focal nodular hyperplasia (FNH) is a benign lesion of the liver which is usually found in healthy adults. However, FNH is rare in children, and comprises only 2% of all pediatric liver tumors. It is occasional for children suffering from FNH without symptoms. We usually use some imaging modalities (ultrasound and CT scan) to ensure the diagnosis and follow-up the FNH of liver.

 

References:

1. https://www.ultrasoundmedicvn.com/2017/06/case-437-liver-tumor-dr-phan-thanh-hai.html

2. https://www.ultrasoundmedicvn.com/2020/07/case-592-focal-nodular-hyperplasia-of.html

CASE 628: HYDROCELE VAGINALIS, Dr PHAN THANH HẢI, Dr NGUYỄN MINH THIỀN, MEDIC MEDICAL CENTER, HCMC, VIETNAM

 Male patient was born in 1937, with diabetis and arterial hypertension for 10 years. Getting big scrotum for 30 years and had been withdrawed 3 times but he still has feeling discomfort at scrotum since 6 years.

   

Ultrasound revealed amount of fluid into scrotum that was more in left side.

CT scan comfirmed hydrocele vaginalis more  on left side than right one.

Under guiding ultrasound,  an amount of 350 mL yellowish fluid was withdrawed from left scrotum.

CONCLUSIONS

Choosing the fluid withdrawal technique under controlled  ultrasound for this case is reasonable as hypertension and diabetic status of the patient.

REFERENCE

CASE 627: PROSTATE CANCER with SHARING SHEAR WAVE ELASTOGRAPHY, Dr PHAN THANH HẢI, NGUYỄN MINH THIỀN, MEDIC MEDICAL CENTER, HCMC, VIETNAM

 Male patient was born in 1940,  with difficult urine discharge and high level of PSA > 100 ng/mL.

His prostatic hypertrophy with  10-30 mm lesions were in 2 lobes, in clasifying PI-RADs 5.

Seminal vesicules were invaded. Pelvic nodes 10-12 mm. Renal cysts of 2 kidneys. Right kidney  hydronephrosis degree I.  Bone metastasis vertebral column [thoracic, sacrolumbar], pelvic and femoral bones.

Enlarged prostate, structure change, not clear limited between transitional and peripheral zones. Hypervascular Doppler signals. Irregular prostatic capsule infiltrating around.

STRAIN ELASTOGRAPHY

DISCUSSIONS

CONCLUSION

CASE 626: T-SHAPE IUD PENETRATING UTERUS TO URINARY BLADDER, Dr PHAN THANH HẢI, LÊ THỐNG NHẤT, JASMINE THANH XUÂN, VÕ NGUYỄN THÀNH NHÂN, MEDIC MEDICAL CENTER, HCMC, VIETNAM.

 Female patient 46 yo  with trouble of urine discharge for 1 month.

She wore her IUD for 8 years but could not find  it out 4 years before in giving up this contraception measure.

Transabdominal ultrasound and TVS revealed a metallic foreign body in her bladder with strong color comet tail artifact.

And later MSCT confirmed the T- shape IUD which penetrated to urinary bladder and was coated outside surface of it in formation of stone.

Endoscopic surgery successfully performed on March 15 to remove the stone made T- shape IUD in TD hospital.

Through anterior face of uterus, the  body and one branch of T-shape IUD migrated inside the urinary bladder that a part of it was covered by stone.  Another branch of the IUD has been in the muscular layer of the urinary bladder that  adhered the urinary bladder wall to the uterus.

Endoscopy in surgery showed stone in urinary bladder. 

 

Specimen of  the T-shape IUD with stone covered on part, and another broken branch was in uterine muscle that adhered urinary bladder.

CONCLUSIONS:

Migration of T-shape IUD has highly risk of penetration the  hollow organes like rectum, urinary bladder. Ultrasound may help to detect the ectopic T-shape IUD but it needs obviously using other diagnostic imaging modalities,  endoscopic tools to confirm the status and location of it for appropriate management to the patient. 

REFERENCE

CASE 514 VUD

CASE 625: HEPATIC PREGNANCY, Dr PHAN THANH HẢI, Dr PHẠM VIỆT THANH, TỪ DỤ HOSPITAL , MEDIC MEDICAL CENTER, HCMC, VIETNAM

An intrahepatic pregnancy case in over 4 months could not diagnose by transvaginal ultrasound [TVS] for a 27yo patient, PARA 1001, beta HCG elevated in Kien giang province.

2 months before, on June 13, 2007, suspected an ectopic pregnancy, the patient had been removed her right ovarian tube although not finding out the gestational sac in Kien giang.

 But, in 2 months later, with her RUQ pain from August 20, 2007, abdominal ultrasound at Medic Center and Tu Du hospital HCMC detected a 23 weeks fetus living in liver with positive heartbeats.

Placenta adhered largely to liver

On August 28, 2007, CT confirmed hepatic pregnancy aged 23 weeks that was entirely inside right lobe of liver. MSCT Angio with CE revealed vessels of fetal bag which was from hepatic artery and placenta largely adhered to liver.

. 

Ultrasound and abdominal CT in Medic Center detected a fetus # 23 weeks in the abdomen below the right diaphragm and inside right lobe of liver. The dimensions of fetal mass were 12x15x17cm. The placenta was 47mm thick, invaded the right liver and having a vascular supply from the right hepatic artery.

Diagnosis: great subhepatic pregnancy, indication for surgery and poor prognosis of critical case.

It would be a difficult case with high risk so Tu Du Hospital  invited a surgeon from Cho Ray Hospital to perform together a surgery for the patient.

The operation removed hepatic pregnancy but placenta suddenly detached itself from liver and profuse bleeding that could not be controlled.

 

Surgical report:

Laparotomy on August 30, 2007, there was about 200mL of blood flowing in the abdomen. The liver surface was smooth, but there was a lumpy mass in segments VI, VII, and VIII which was covered by anterior surface of the liver.

Dissecting the anterior and inferior border of the liver, a hepatic pregnancy mass was detected inside liver. The chorionic ridges of placenta penetrated deeply into the hepatic parenchyma, attaching to 2/3 surface of the liver. 

Opened the fetus bag, aspirated amniotic fluid, a dead girl fetus about 600g of weight was taken out.

Cut the umbilical cord to get the fetus and left the placenta in situ,  but the placenta detached itself from the liver, causing bleeding profusely. The surgeons had to decide to take  a part of the placenta and cut off the part of the liver that was attached to it.

This was a very complex technique and extremely difficult to stop bleeding. Tying the blood vessels from the liver stalk, the surgeons inserted gauzes to stop the bleeding. There were transfusing 8 units of blood  but it was still not controllable. About 15 minutes later, there was more bleeding from cut hepatic surface, then cardiac arrest occurred  and the patient died on surgical table.

Surgical diagnosis: Subhepatic pregnancy and death due to unstoppable bleeding.

DISCUSSIONS and  CONCLUSIONS

Hepatic pregnancy mass has grown (about 5 months # 20 - 23 weeks) in the diaphragmatic position and  had had bleeding 2 months ago, possibly from the gestational sac.

Using only the transvaginal probe,  doctors of Kien giang Province did not reveal the hepatic ectopic pregnancy and the surgeon did not find the fetus in the removed ovarian tube. Since then the fetus grew continously more 2 months and patient died due to a late ectopic pregnancy bleeding with grown fetus and placenta.

Right liver resection will be a safe solution? Currently, the technique of hemostasis of broken liver through the endovascular way is very easy to perform. 

But in this case, surgeons had controlled the main hepatic artery while  the blood loss from liver tissue and venous system continued bleeding due to the adhesion of placenta.

Recommendations: When diagnosing an ectopic pregnancy (GEU), an abdominal ultrasound examination should be using 2 probes together, vaginal probe and  abdominal probe. 

Medical treatment with MTX is safer than surgical management for early detecting ectopic pregnancy [in the abdomen, in the liver, in the spleen, ...]. 

The case was published in SIEU AM NGAY NAY 46, vol 2, 2007.

REFERENCES. 

 - PUBMED MEDLINE . Key word : hepatic ectopic pregnancy 

 - Williams Obstetrics..22nd Ed.. section III. Antepartum.. 

 - Stuart H Shippey et all Diagnosis and management of Hepatic Ectopic                    Pregnancy,   Obstet Gynecol. 2007,109 :544-6

  -Prasat K.V.S. et al.. Case report Primary hepatic pregnancy, Obgyn.net/pregnancy-birth/page=/pb/articles/hepatic-pregnancy