CASE 474: LEFT LIVER LOBE TUMOR, Dr PHAN THANH HẢI, MEDIC MEDICAL CENTER, HCMC, VIETNAM

Man  52 yo  with HBV chronic hepatitis ,    follow up  every 6 months  and negative AFP, HBV -DNA . But  ultrasound   detected  a big tumor # 6 cm in diameter in left lobe of liver.

US  1:  transverse scanning of  this tumor is well bordered,   hypoechoic pattern.

US 2:  longitudinal scanning  at tumor site.

US 3:  color Doppler=  vascular supply to tumor is from left  liver.

MRI  with Primovist  uptaked  and washed out  as a HCC in liver ( MRI 1, 2, 3, 4).

Blood test  Wako=  only DCP  raised =91 UI.

Summary:  in case of  HBV chronic hepatitis,, ultrasound detected  a big tumor in liver, Wako test only raised DCP.

OPERATION   PER OP  VIEW BY ENDOSCOPY THE TUMOR AT LEFT LOBE of LIVER ANTERIOR AND POSTERIOR and MACRO SPECIMEN of  TUMOR.

MICROSCOPIC IS WELL DIFFERENTIATED HCC.

DISCUSSION: WHY IN THIS CASE   WAKO TEST IS  NOT SUITABLE ?  WHICH VALOUR of WAKO TEST COULD BE  PPV FOR HCC ?

 Wako test post op  4 days after operation  = AFP:1.3 ng/mL;  L3: 0.5%;  DCP: 55 mAU/mL.

This 52 yo male  patient with chronic HBV but  AFP is lower than cut of value screening and no  ultrasound  screening  before  operation.   Wako test is  only DCP  rising  to 92 mAU/mL. Reference  ( publication April 12,2016 http:// doi.org/10.1371/journal.pone.0153227  : Diagnostic evaluation of DCP versus AFP  for Hepatitis Bvirus related  HCC   in China):

1-  30-40%  HCC in CLD with  AFP normal serum level.
2-  non HCC patients  have  15-58%  AFP  rise  over  cutt of value  20ng/mL.
3-  in CLD having cirrhosis  AFP rises  11-47%  but non HCC.
4-  DCP  rises level that correlated with size tumor and advanced progress.
5 - DCP drops very fast after surgery, and  rises  early in recurrent HCC.

Conclusion : AFP only not sensitive for screening  HCC. So DCP in Wako test is the choice for routine screening  HCC and monitoring after treatment.

BLOOD TEST  WAKO  AGAIN    RESULT IS  AFP: 1,5;   L3 : 0,5;   DCP DROP TO 38mUI/mL

CONCLUSION  2:

DCP IS VERY SENSITIVE FOR DETECTION of HCC AND FOLLOW UP POST OP.

CASE 473: SCIATIC NERVE TUMOR, Dr PHAN THANH HẢI, MEDIC MEDICAL CENTER, HCMC, VIETNAM.

Woman 59yo  detected  one mass  at right buttock that is in slow growth and no painfull.

Ultrasound scan

US 1= longitudinal scan of  this mass with size 6.7 cm,  ovoid, hypoechoic  in gluteus maximus muscle   near sciatic nerve  like a size of a mango.

US 2 = crossed section of this tumor is well bordered and hypovascular pattern. 

US 3 = elasoscanning of  this mass is inhomogeneous  structure.

MRI scan

MRI 1   crossed section   this mass is   well bordered  in a muscle   

MRI 2   frontal view this mas is  bordered of right sciatic nerve.

MRI 3   relation of this mass and right sciatic nerve.

Core  biopsy is done and histology report is   neuroma.

CASE 472: INCIDENTAL BREAST TUMOR , Dr PHAN THANH HẢI, MEDIC MEDICAL CENTER, HCMC, VIETNAM

WOMAN 58YO   FOR SCREENING  TO DO WHOLE BODY MSCT. 

RADIOLOGIST REPORTED ONE MASS AT  RIGHT  BREAST  SIZE# 1.3 CM.(  CT1  FRONTAL VIEW, CT2  AXILLARY AREA).

ULTRASOUND POST CT VERIFIED THIS MASS  WITH  SIZE  # 2 CM   VERY STRONG  SHADOWING, AND HYPERVASCULAR.

US1,  US2  ELASTO  IS  31.9 kPa .

US3 , AXILLARY NODE    SIZE 1.5CM WITH HILUS 

US4 ,  CDI  = VASCULAR  HILUS DEFORMATION.

CORE BIOPSY  RESULT IS  BREAST CANCER, STAGE T2 N2.

OPERATION  for MASTECTOMY AND   AXILLARY   LYMPHADENECTOMY. SPECIMEN  TUMOR IS SMALL SCLEROSIS   MANY LYMPH NODES.

POST OP  HISTOLOGY REPORTED   THIS CANCER  METASTATIZES TO AXILLARY LYMPH NODES.

REFERENCE:

CASE 471: MESENTERIC LYMPHOMA, Dr PHAN THANH HẢI, MEDIC MEDICAL CENTER, HCMC, VIETNAM.

Man 70yo  with  epigastric pain. Ultrasound of abdomen detected  one hypoechoic mass like a cyst # 4.9cm near SMA.

US 1=   longitudinal scan at epigastric area.

US 2 = CDI:   this mass  is near SMA.

US  3 = crossed scanning= this mass  is placed over the head of pancreas in relation  with  celiac artery and vein.

US 4=  some  small lymph nodes near the big anesthetic mass.

MSCT CE=

CT  1 : crossed section  this mass  over the artery and vein.

CT 2:  the pancreas is normal.

   

CT 3:  frontal section of this intramesenteric mass near  SMA and vein   with some  lymph nodes in mesentery.

Endoscopy gastric and colon are normal, blood test and all cancer markers are normal 

Laparotomy for  biopsy= many nodes in mesentery.

Microscopic with histobiochemistry  is  follicular B CELL LYMPHOMA.

SUMMARY :  MANY LYMPH NODES IN MESENTERY  WITH TYPICAL APPEARANCE HYPOECHOIC PATTERN LOOKED LIKE A CYST,THE MOST COMMON IS LYMPHOMA.

Reference :    MEDIC ULTRASOUND case 452 : Castleman disease.

CASE 470: TROISIER-VIRCHOW NODES, Dr PHAN THANH HAI, MEDIC MEDICAL CENTER, HCMC, VIETNAM.

MAN 70 YO  COUGH . NO FEVER. CHEST CT   DETECTION  IS LEFT LUNG  LESION  WITH WIDERING OF MEDIASTINUM.
(CT1/ CT2:   SUPRA LEFT CLAVICULAR  MASS SUSPECTED LYMPH NODES.

ULTRASOUND  of SUPRA LEFT CLAVICULAR  AREA IS  MULTIPLE LYMPH NODES.

US1=LYMPH NODES ROUND 2CM, LOSS HILUS, HYPOECHOIC,  HYPOVASCULAR.

US 2 =THE VASCULAR SUPPLY IS  INTER-NODES  LIKE A RING.

US 3= ELASTOSCAN of THIS NODES WITH CENTRAL 23 kPa.

ULTRASOUND EXAMINATION REPORT IS METASTASIS  LYMPH NODES   THAT WERE TROISIER-VIRCHOW NODES.

WAIT FOR  BIOPSY.
MICROPATHOLOGY REPORT WITH  IMMUNOHISTOCHEMISTRY  IS   NEURO ENDOCRINO-

CARCINOMA METASTASIS TO  TROISIER -VIRCHOW NODE.

REFERENCE :  ANATOMY TROISIER NODE

                         PICTURE OF  DR TROISIER --PROF VIRCHOW.