CASE 935: RETROPERITONEAL SARCOMA, Dr PHAN THANH HẢI, Dr TRẦN MỘC HIỆP, MEDIC MEDICAL CENTER, HCMC, VIETNAM.

 A 17-year-old female patient  with lower back pain, which is  radiating down the thigh for three months prior to admission. She had no fever and normal bowel and bladder function. Echocardiogram, blood tests, X-rays, and electrocardiogram showed no abnormalities. Abdominal ultrasound revealed a large lesion in the anterior region of the right psoas muscle and adjacent to the right spine. MRI showed degeneration and central disc protrusion at the L5-S1 level, with no bilateral nerve root compression. The lesion was located in the right pelvic region, anterior to the pelvis and lateral to the psoas muscle.

In the pelvic region (P), anterior to the psoas muscle, extending from the iliac crest to close to the spine, there is a mixed echogenic mass, measuring 98x85x67mm, with increased vascularity.

Café au lait spots on the skin, ranging in color from light brown to dark brown, may indicate neurofibromatosis.

Based on the ultrasound findings, along with the observation of the patient's skin with numerous small brown nodules, the diagnosis suggests a retroperitoneal neurofibroma. However, because this structure is close to the spine, a tuberculous abscess is also a possible diagnosis (though less likely).

MRI RESULT

- Degeneration and central disc protrusion at the L5-S1 level, without bilateral nerve root compression. 

- Right pelvic lesion, anterior superior pelvis and lateral edge of the psoas muscle, measuring 95x85x78mm, possibly neurofibroma.

Result

Malignant spindle cell tumors may include:

 - Malignant peripheral neuroma

- Tumors of other origin: GIST, Smooth Muscle Sarcoma. Recommendation: Immunohistochemical staining: S100, CD117, Desmin, Vimentin, KI67

Immunohistochemistry Results

S100 (-)

CD117 (-)

DESMIN (-)

VIMENTIN (+) - KI67: (+) 80%

Suitable for Undifferentiated Pleomorphic Sarcoma (UPS)

CASE 934: SOFT TISSUE SEEDING MASSES in SUBCLAVIAN and PARASTERNAL, Dr PHAN THANH HẢI, Dr PHẠM THI THANH XUÂN, MEDIC MEDICAL CENTER, HCMC, VIETNAM.

 A 41-year-old female with palpable masses in the right subclavian and right parasternal regions 

 Medical history: 11 years ago, she underwent endoscopic right thyroidectomy via axillary approach due to a benign thyroid tumor.

For about a year now, the patient has noticed two lumps in the right subclavian and right parasternal regions. The lump are painless, and the patient is unsure whether it has increased in size.

Biopsy result of subclavian mass is benign thyroid tissue.

 Result of parasternal mass is thyroid tissue.

DISCUSSIONS 

Always thoroughly investigate the surgical history: when detecting nodular or mass-like lesions in the soft tissue of the neck, chest wall, or armpit, the first question to ask is: Does the patient have a history of endoscopic or robotic thyroidectomy? And compare the location of these subcutaneous masses with the location of the endoscopic port and the dissection tunnel. Disseminated nodules may have images and different sizes.

The common characteristic is that it lies along the surgical incision and the resulting cuts.

The lesions are isolated masses with relatively well-defined or irregular borders, hypoechoic or mixed cystic in appearance, located entirely within the subcutaneous soft tissue or muscle tissue along the surgical incision, with microvascularity similar to thyroid tissue signaling. BENIGN THYROID ARE STILL CONTAINS CELL DELETIONS.

Ultrasound characteristics of seeding mass:

Nodules along the endoscopic port or surgical incision may appear as hypoechoic or heterogeneous areas. Increased vascularity within the nodules increases suggestive of malignancy. Careful evaluation of size, shape, borders, echogenicity (hypoechoic is more concerning than isochoric or hyperechoic), and the presence of calcification is necessary to differentiate benign from malignant lesions. Nodules vary in size, but those larger than 6 mm should be considered cautiously, especially when they exhibit features suggestive of malignancy.

CASE 933 : PANCREATIC TUMOR in a Young Man, Dr PHAN THANH HẢI, Dr PHẠM THI THANH XUÂN, MEDIC MEDICAL CENTER, HCMC, VIETNAM

An 18-year-old male patient, Ho Chi Minh City - Date of examination: June 2, 2025 Reason for examination: Epigastric pain Medical history: Gastritis H. PYLORI (+)

 Patient history: For the past year, the patient has experienced persistent epigastric pain, treated with multiple courses of gastritis which only provided temporary relief but did not cure the condition. Approximately 3 weeks prior to the examination, the patient experienced severe epigastric pain, worsening in the afternoon, and shortness of breath.

Result of abdominal ultrasound was a pancreatic body tumor.

Lab data:

MSCT confirmed a pancreatic body tumor.

Surgery was performed one year after because the patient has to pass the exam of high school.

- Surgical indications for DP surgery: Pancreatic caudate body tumor 

- Surgical method: Scheduled, Laparoscopic

- DP surgical method: Pancreatic caudate resection with splenic preservation (Warshaw style, non-preserving)

- Abdominal examination: Location and size of the tumor.

- Tumor size (length x width x height) cm: 3x3x3

 - Intrusion into the retroperitoneal space: Yes

 - Exposure of the portal vein behind the pancreas: Yes

 - Vascular abnormalities: None

 - Pancreatic resection site: Pancreatic neck

 - Pancreatic resection instrument: Stapler

 - Lymph node dissection: None 

- Pancreatic resection margin: None 

- Splenic preservation: Warshaw-style splenic preservation 

- Post-operative check: Thorough hemostasis, sufficient gauze and instruments

 - Drainage placement: Number of drains, location

 - Drainage location: Adjacent to the pancreatic resection margin 

- Number of drains: 1

 - Intraoperative complications: None 

- Blood loss: 50ml.

 

On July 23, 2025, the results of immunohistochemical staining were: Synaptophysin (+), Chromogranin (-), CD56 (+). 

Beta-Catenin (+), CD10 (+). CONCLUSION AFTER IMMUNOCHEMICAL STAINING: SOLID PANCREATIC PARAPANCREATIC TUMOR (SOLID)

PSEUDOPAPILLARY TUMOR).

This is a rare clinical case of a solid pseudopapillary neoplasm (SPN) of the pancreas. While SPNs typically occur in young women in their 20s and 30s, their presentation in an 18-year-old male is highly unusual. Studies suggest that SPNs in males can pose specific diagnostic challenges and may carry a slightly higher risk of invasive progression or malignant potential compared to those in females.

CASE 931-932:UPPER UROTHELIAL CANCER, Dr PHAN THANH HẢI, Dr PHẠM THÊ ANH, MEDIC MEDICAL CENTER, HCMC VIETNAM

 Two cases of upper urothelial cancer in man.

CASE 1:

A 66 year-old man with right flank pain.

Ultrasound detected right ureter tumor in the middle part.

MSCT confirmed right ureter tumor.

Surgical specimen

CASE 2:

Male  55-year-old, with right flank pain.

Ultrasound detected right hydronephrosis.

MSCT confirmed a right upper urothelial cancer and metastasized lung and brain.

The renal tissue sample showed neoplastic cells in the ureteropelvic layer, with large neoplastic cells, hyperchromatic and abnormal nuclei, cells arranged in clusters and cells, and invading the cervical layer.

- Surgical margins, no malignant cells present.

CONCLUSION: HIGHLY MALIGNANT URETERAL CARCINOMA OF THE RENAL PIT, INVASION TO THE

FASCIA.

Chemotherapy was performed and cessation after 8 months.

Upper urothelial cancer is a rare entity with poor prognosis.

REFERENCE:

CASES 929-930: AVF ULTRASOUND ASSESSMENTS, Dr PHAN THANH HẢI, Dr PHAN THANH HẢI PHƯỢNG, MEDIC MEDICAL CENTER, HCMC VIETNAM.

 By the two cases of vessel obstacles of AVF for renal hemodialysis.

Indications for AVI Doppler Ultrasound Examination

Pre-operative vascular examination of the arm to create arteriovenous anastomosis. Assess good shunt/graft maturity after 4-6 weeks. Assess complications when AVF function is abnormal: (1)

• Difficulty inserting the cannula

 • Blood clot detected during aspiration

Venous pressure greater than 200 mmHg or 300 cc/minute/pump

Increased RT >15 %

• Decreased blood urea rate <60% Suggestions for abnormal functional AVF: (2) 

• Collapsed inlet suggested by low arterial flow

• Poorly mature AVF

 • Loss of palpation 

• Distal extremity ischemia 

• Skin/soft tissue infection

• Aneurysm/pseudoaneurysm around the graft/needle insertion site

CASE 1  

• Female patient, 39 year-old

• Ultrasound examination of left arm AVF suspected

suspected blockage

• The patient is painless and has no unusual symptoms.

Ultrasound examination of left arm AVF:

AVF of the brachial artery and cephalic vein: AVF: Calcified plaques causing 30-40% stenosis, inner diameter = 4.5 mm, biphasic spectrum, flow velocity = 99 ml/min. Several stenotic segments of the vein are calcified, causing a significant reduction in flow after stenosis. From the middle half of the arm to the shoulder, 90% stenosis and near occlusion are present. Fibrosis and collapse of the short confluence segment.

Case 2:

• Male patient, 62 year-old

•Ultrasound examination of AVF 2025. Patient

with cephalic vein stenosis causing venous thrombosis has undergone angioplasty and thrombectomy.

Post repaired 

.

 

Lessons learned

• Discuss with the Clinical Physician: PTV/Interventional Vascular Surgeon to address the root cause of the problem.

• When there is widespread thrombosis: locate the highest possible stenosis and combine with contrast-enhanced CT to assess blind spots. 

• For calcified blood vessels, SMI assists in accurately assessing the thrombus and differentiating from atherosclerotic stenosis from collapse after thrombosis.

• Always review previous results.

Reference:

 

CASE 928: CA 72-4 elevated due to using Colchicine, Dr PHAN THANH HẢI, Dr TRƯƠNG CÔNG THÀNH, MEDIC MEDICAL CENTER, HCMC, VIETNAM

CASE 927: INTESTINAL MALT, Dr PHAN THANH HẢI, Dr NGUYỄN PHƯỚC TOÀN, MEDIC MEDICAL CENTER, HCMC, VIETNAM.

 A 46 year-old woman without abdominal pain.

Ultrasound detected right bowel wall thickening and lymph nodes maybe due to lymphoma infiltrating.

MSCT confirmed  lymphoma infiltrating a bowel tumor and lymph nodes.

A RCHOP management was performed in 6 treatments and for three years the patient has been remained well without relapse.