CASE 925: HEPATIC HILUM LESION, Dr PHAN THANH HẢI, Dr PHAN THANH HẢI PHƯỢNG, MEDIC MEDICAL CENTER, HCMC, VIETNAM.

 A 52 year-old woman with dull pain around the epigastrium and mild fever at night. No other symptoms.

MSCT scan at ITO Hospital, on May 12th, suspected liver abscess , but patient not be treated, referred to Binh Dan Hospital. On May 20th, examined at Binh Dan Hospital and had an MRI scan and biopsy recommended.

Contrast-enhanced abdominal CT scan from ITO Hospital results:

 Image 02 shows adjacent lesion in segment IV of the right liver lobe, measuring 45x30mm, d2 = 40x28mm, with partial protrusion of the liver border, relatively well-defined boundaries, heterogeneous mixed density, contrast enhancement in both rim and central areas; mainly in a granular form. 

- Right kidney cyst measuring 11x10mm. 

- No abnormalities in shape or density of the pancreatic and adrenal parenchyma on both sides were observed. 

- Intrahepatic and extrahepatic ducts are not dilated.

- Gallbladder is not enlarged, with a few gallstones with a maximum diameter of 11mm; currently, there is no wall thickening or infiltration of the surrounding tissue.

22-5

Patient was still painful slightly in epigastrium, no fever.

Murphy sign negative.

hs CRP : 25.7H. Normal bilirubines and liver enzymes. Negative AFP, Toxo, and HBV tests.

Liver lesion is near the gallbladder wall, with thickened gallbladder wall, that are not ruled out a hepatic tumor (image and size unchanged from previous ultrasound) .

Ultrasound Diagnosis: Liver abscess - Gallstones - Right renal cyst.

MRI from Medic Center results:

These are images of the liver taken with a 1.5 MRI machine, with GADOLINIUM contrast agent injected. 

 Right hepatic lobe lesion adjacent to the gallbladder in subsegments V-VI, measuring 68x51mm, well-defined, with a polygonal border, showing higher signal intensity than the liver parenchyma on T2WI and lower signal intensity than the liver parenchyma on TIGER. After GADO contrast injection, the lesion showed heterogeneous peripheral contrast enhancement in the arterial phase, increased centripetal conduction in the portal venous and late phases, and restricted diffusion. Irregular thickening of the gallbladder wall and several gallstones with a maximum size of 7mm were noted.

No portal vein thrombosis was observed. The common bile duct was clear and free of stones.

Spleen signal intensity is within normal limits. Pancreas signal intensity is normal. Right renal cyst is 10mm.

No ascites was observed. Hilar and pancreatic head lymph nodes measured a maximum of 17x12mm.

** MRI conclusions

SUGGESTED GALLBLADDER CANCER METASTASIS  to the LIVER (Differential Diagnosis: INTRAHEPATIC BILE DUCT TUMOR INVASION of the GALLBLADDER) + GALLBLADDER STONES, max. SIZE # 7mm. HEPATIC HILAR and PANCREATIC HEAD LYMPH NODES, max SIZE #17X12mm + RIGHT KIDNEY CYST 10mm.

Lab data and liver biopsy results from Medico Pharmaceutical University Hospital:

Lab data:

Liver biopsy:

Liver biopsy result: 

The sample was liver tissue, showing metastatic cells, atypical nuclei, and hyperchromatic nuclei. These cells formed indistinct, infiltrating ducts. The stroma showed an inflammatory reaction. Conclusion: MODERATELY DIFFERENTIATED CARCINOMA, METASTASIS UNDETECTED. 

It is recommended to combine clinical and other paraclinical findings (gastrointestinal endoscopy, etc.) to help determine the origin.

So our case is not a liver abscess with gallbladder stones. Because the patient denied a surgical intervention, we should accept the biopsy conclusions for a case of liver cancer with hepatic hilar lymph nodes and gallstones.

---------

Case Summary:

 1. A 52-year-old woman presented with dull epigastric pain and low-grade nocturnal fever. Initial assessment at a referring facility suggested a liver abscess based on computed tomography (CT) findings. However, following further evaluation at Binh Dan Hospital and MRI at Medic, imaging characteristics shifted the diagnostic suspicion from a benign lesion to a malignancy. A subsequent liver biopsy at the University MedicoPharmaceutical Hospital confirmed the diagnosis of metastatic, moderately differentiated carcinoma. This case illustrates the pivotal role of integrating imaging and pathology in revising a diagnosis from liver abscess to a complex malignancy.

2. Clinical Progression and Medical History Diagnosis and Treatment Timeline:

 May 12th: Abdominal MSCT scan at ITO Hospital; preliminary diagnosis suspected liver abscess, but the patient did not receive treatment. 

May 20th: Examination at Binh Dan Hospital; doctors determined that the CT scan was insufficient for a conclusion and recommended further MRI and biopsy to determine the nature of the tumor. 

May 22nd: MRI and other paraclinical tests performed at Medic Center. The patient still experienced mild epigastric pain, but the fever had subsided, and Murphy's sign was negative.

Clinical data:

Inflammatory Markers: hs CRP is elevated (25.7 mg/L). Tumor markers and Serology: AFP, Toxoplasmosis, and HBV are all negative. Liver function: Bilirubin and liver enzymes are within normal limits.

3. Results of Advanced Clinical and Pathological Examinations: 

The shift in imaging modality from CT (without full contrast enhancement) to 1.5-Tesla MRI (using Gadolinium-based contrast agents) represented an "imaging turning point," revealing the malignant characteristics of the tumor.

Note: MRI findings of "centripetal enhancement" and "restricted diffusion" are the most significant objective indicators for ruling out a diagnosis of liver abscess and pointing towards a malignant solid tissue nature.

Liver biopsy at the University MedicoPharmaceutical Hospital considered the gold standard for determining the histological nature of this lesion. Microscopic description: "The tissue sample is liver tissue, showing the presence of metastatic cells with atypical and intensely colored nuclei. These cells are arranged to form indistinct, invasive duct-like structures. The stroma shows accompanying inflammation." Pathological conclusion: MODERATELY DIFFERENTIATED CARCINOMA, METASTASIS UNDETECTED (Moderately differentiated carcinoma, primary focus undetermined). 

4. Summary of Conclusions and Differential Diagnosis analysis: 

Based on imaging (MRI), the preferred diagnosis is: Gallbladder cancer with hepatic metastasis. Differential diagnosis to note: Intrahepatic cholangiocarcinoma directly invading the gallbladder. 

Reason for ruling out "Liver abscess": Although there were symptoms of fever and elevated hs CRP, the contrast enhancement on MRI and histological biopsy results (atypical nuclei, invasive ductal structure) confirmed the undeniable malignancy.

Co-morbidities identified: 

Gallstones (7-11mm).

Right kidney cyst.

Enlarged lymph nodes in the hepatic hilum and pancreatic head (typical locations of metastatic lymph nodes). 

Management and Clinical Outcome: 

Due to the histopathological findings confirming metastatic cancer but with an unclear primary site, specialists recommended further gastrointestinal endoscopy and other systemic investigations to determine the tumor origin. However, the patient refused surgical intervention. In this context, the liver biopsy results combined with imaging of the hepatic hilum lymph nodes were accepted as the final diagnosis to guide care and prognosis for the patient.

CASE 924: OVARIAN TUMOR and Increased CA-125, Dr PHAN THANH HẢI, Dr JASMINE THANH XUÂN, MEDICMEDICALCENTER, HCMC VIETNAM,

 A  42 year-old single woman,  reported regular monthly menstruation with no abdominal pain during periods. But in this month's period, the patient experienced dull pain in the lower abdomen. The pain subsided after menstruation ended. 

Past medical history: The patient has had annual general blood tests at Medic since 2024, with no abnormalities recorded. 

On August 10, 2026, she had an annual blood test, and an additional CA- 125 test which showed elevated levels, leading to an abdominal and pelvic MRI and ultrasound.

Pelvic MRI:

Left ovarian cystic lesion, 65x50mm in diameter, with clear, smooth borders, no septa, no solid tissue, homogeneous high signal on T1W1, heterogeneous high signal on T2W2, and heterogeneous diffusion restriction.

• Dilation at the left fallopian tube.

• The uterus has several fibroids within the muscle, measuring 14mm, 20mm, and 50mm in diameter, not compressing the endometrium or surrounding areas.

Mucinous cyst in the left ovary, size 65x50mm (O-RADS 2). Dilated at the left fallopian tube. Multiple uterine fibroids within the muscle.

Pelvic ultrasound:

Multiple uterine fibroids (L4, L5/Figo)

Bilateral ovaries: homogeneous hypoechoic ground-glass opacities, measuring 52x69mm (left) and 17x20mm (right), with no protrusions or septa in the cyst wall, a clear capsule, and no increased vascularity → : Bilateral ovary endometriosis cysts.

Pelvic ultrasound suspected bilateral endometrioma, left greater than right tumor and tubal drainage due to fluid accumulationwhixh was not ruling out as endometrial hyperplasia in the fallopian tube. 

Conclusions 

Ultrasound findings of ovarian tumors (benign/malignant). O-RADS classification. Blood tests: CA- 125 and ROMA Test (CA-125 and HE 4) 

Note: CA- 125/blood levels are elevated; patient's age should be taken into account.

• ≥ 50 years old, menopause + ovarian tumor + increased CA- 125 test: suspected ovarian cancer 

• < 50 years old, still menstruating + ovarian tumor +  increased CA -125: look for other benign causes

CASE 923: POSITIVE CA 72-4 and COLLAGEN MILK, Dr PHAN THANH HẢI, Dr TRƯƠNG CÔNG THÀNH , MEDIC MEDICAL CENTER, HCMC, VIETNAM

 A 68 year-old physician with positive  CA 72-4 in taking hydrolyzed collagen milk  without biotin daily for one year. He denied using colchicine anytime in history.

Ultrasound detected a small stone in the right kidney.

and whole body CT noted a node of the left lung,  and a small cyst  and a stone of the kidney. A diverticule of the colon was noted.

Gastrointestinal endoscopy normal

Colonoscopy  and result of biopsy: TUBULAR ADENOMA WITH MILD INTESTINAL DYSPLASIA.

It consists of densely packed hyperplastic glandular ducts, separated by loose fibrous stroma. The glandular epithelial cells are poorly differentiated, atypical, interspersed with differentiated goblet-like cells, with some areas showing low-grade dysplasia. The polyp barrier could not be identified on this specimen.

CONCLUSION: TUBULAR ADENOMA WITH MILD INTESTINAL DYSPLASIA) (D12).

Lab data in the third time while not using hydrolyzed collagen milk for three days :

CYFRA 21-1<3.3 ng/mL

CA 72-4 (Cancer antigen 72-4) <8.20 U/mL

DiSCUSSSIONS:

May collagen milk involving in CA 72-4 levels?

Conditions that increase CA 72-4 are not related to cancer(*)

 •5% gastrointestinal or heart disease

• 4% of liver diseases

•  3-7% of cases involve pancreatitis.

• 6% lung diseases, 9% pneumonia. 

The majority are rheumatic diseases and arthritis.

Take PPIs and colchicine.

•10% of gynecological diseases, 25% of ovarian cysts

•5% of pregnant women have CA 72-4 levels that are double the normal limit.

(*) Trapé (2024). Factors influencing blood tumor marker concentrations in the absence of neoplasia. Tumor Biology. https://doi.org/10.3233_TUB-220023

In vitro studies suggest that collagen may be a potential anticancer agent (*). 

Treatment with 1 ug/mL of collagen significantly reduced cell viability (p = 0.0045) and cell migration (56.86 ± 6.89% vs. 81.31 ± 2.65%, p < 0.0001) in HCT116 cancer cells, while promoting fibroblast proliferation (p = 0.0143) without causing cytotoxicity. 

Regarding tumor markers, CA19-9 levels after collagen treatment were significantly reduced (1.04 ± 0.21 vs. 4.61 ± 0.69, p = 0.013) in HCT116 cells, while CEA, CA72-4, and CYFRA 21-1 levels remained unchanged.

(*) Karcioglu Batur, Lutfiye et al. "Kiperin Double-Hydrolyzed Collagen as a Potential Anti-Tumor Agent: Effects on HCT116 Colon Carcinoma Cells and Oxidative Stress Modulation." Current issues in molecular biology vol. 47,5 364. 15 May. 2025, doi:10.3390/cimb47050364 

CONCLUSIONS:

Many benign conditions can increase CA 72-4 levels.

• Inform patients before ordering tests and rule out malignancy if results are abnormal.

• Clinical case: CA 72-4 levels increased while consuming collagen milk; CA 72-4 levels returned to normal after consumption stopped.

 No evidence has been found in the literature regarding the effect of collagen consumption on blood CA 72-4 levels. 

• Further attention be paid to detecting similar cases.

CASE 919, 920, 921, 922: BREAST PAPILLARY LESIONS: Dr PHAN THANH HẢI, Dr TRẦN THÙY TRANG, MEDIC MEDICAL CENTER, VIETNAM.

 Four cases of papillary lesions of the breast were detected by breast ultrasound.

CASE 1

32 yo multiple papillary lesions in 2 breasts, BI-RADS 4A,B.

Bilateral breasts show multiple hypoechoic structures; duct-associated, lobulated margins, horizontal orientation, non-calcified, measuring 5x4mm to 14x6mm, with increased vascularity. Right breast mass at the 11 o'clock position (3cm from the nipple) shows micro-lobulated margins and orientation perpendicular to the skin surface, measuring 11x7mm.
➔ Conclusion: Bilateral multiple papillomas, BI-RADS 4A–4B.

Breast MRI

Core biopsy and IHCS

Intraductal papillary lesions

CASE 2: 47 yo L breast plaque like lesion,  BI-RADS 4B 

Left breast: Located at the 5–6 o'clock position, 3 cm from the nipple, there is a hypoechoic plaque-like lesion; it is unencapsulated with spiculated and micro-lobulated margins, measuring 31 x 37 x 10 mm, and shows marked hypervascularity.
Conclusion: Plaque-like lesion in the left breast (BI-RADS 4B).
➔ Core biopsy of the left breast

Intraductal Papillary Carcinoma .

CASE 3: 43 yo R papillary tumor.

Right breast: 8 o'clock position,

1 cm from the nipple; hypoechoic nodule,

lobulated margins, horizontal orientation,

dimensions 4x5 mm and 4x6 mm;

associated with a duct, showing increased vascularity.

➔ Suggestive of right breast papilloma (BI-RADS 4a).

➔ Recommendation: FNA of the right breast nodule.

Papillary lesions of the right breast.

Intraductal papillary Carcinoma. 

Histopathology: Composed of hyperplastic mammary ductal epithelial cells arranged in clusters, exhibiting nuclear atypia, hyperchromasia, and atypical mitoses. The cells remain confined within the ducts; there is no evidence of stromal invasion.
➔ Suspicion of an intraductal breast lesion. Immunohistochemical staining recommended to assist in confirming the diagnosis: p63, CK5/6, ER, Ki-67 (Block 1).
Immunohistochemistry results (April 2, 2025): p63 negative (with focal p63 positivity at the periphery of epithelial cell clusters), CK5/6 positive, ER positive (30% of tumor cells), Ki-67 positive (20%).
➔ Post-immunohistochemistry conclusion: Intraductal carcinoma of the breast.

CASE 4: 46 yo L breast adenocarcinoma. 

LEFT BREAST: At the 3 o'clock position, 4 cm from the nipple, there is a hypoechoic nodule with regular margins and a horizontal orientation (D = 5x5 mm); it appears associated with a duct and shows no increased vascularity. + At the 2 o'clock position, 1 cm from the nipple, there is a hypoechoic area with irregular margins (D = 9x7 mm) and no increased vascularity.

➔ Left breast lesions at 2 o'clock (BI-RADS 4a) and 3 o'clock (BI-RADS 3).

Recommendation: FNA.

Intraductal papillary Carcinoma (C50).

DISCUSSION 

Papillary lesions in the breast are a heterogeneous group of lesions that may include benign tumors (such as papillomas, papillomas with atypical epithelial hyperplasia (ADH)) or cancerous tumors (DCIS, papillary carcinoma in situ or invasive, encapsulated papillary carcinoma, papillary carcinoma of the body, papillary carcinoma of the breast).

• Benign papillomas also present with diverse imaging findings: 

Mass-like form: a tumor within the duct lumen or cyst, possibly accompanied by duct dilation. 

Plaque form: a flattened tumor that spreads along the duct wall, not forming a distinct round mass;.it may thicken the duct wall or create a dense area adhering to the duct wall, forming an ill-defined plaque with increased vascularity.

Intraductal branching form: spreading along the duct lumen, developing into multiple branching papillae within the duct lumen, occupying many branches of the duct system. 

---->Overlapping appearance, indistinguishable from types of cancer within the ducts.

On SWE ultrasound:

• Papillomas are the most common histological type causing false positives on elastography.

Diagnostic traps:

• Fibrovascular core: Papilloma has a connective tissue and blood vessel axis > Increased central stiffness > False positive

• Stromal fibrosis: Increased collagen around the lesion → increased stiffness > False positive

• Hyalinization: Common in long-standing papillomas > increased stiffness > False positive.  

. Hemorrhage within the tumor > decreased stiffness > False negative. 

. Lesions that are too small: ROI includes surrounding tissue → Inaccurate assessment of lesion stiffness.

• Encapsulated papillary carcinoma: Minimal stromal reaction, may not be excessively firm → False negative

For avoiding mistakes please keep in mind:

1. Risk factors:

  Age: >55 years-old 

  Large lesion: > 1cm. Peripheral papillary lesions (> 3cm) or multiple lesions.

  History of breast cancer or high-risk lesions: ADH (Atypical ductal hyperplasia), LCIS, DCIS, history of contralateral breast cancer.

  Family history and gene mutations. 

2. High BI-RADS classification lesion. 

3. Lesions with ADH pathology.

CASE 918: MADELUNG DISEASE in a Young Asian Woman, Dr PHAN THANH HẢI, Dr JASMINE THANH XUÂN, Dr VÕ NGUYỄN THÀNH NHÂN, MEDIC MEDICAL CENTER and Dr NGUYỄN PHAN TÚ DUNG, VIETNAM.

A 24 year-old nurse with height 1600cm, weight 90kg is suffering from her big size of butt circumference # 136cm.

 Symmetrical hypertrophy of the butt, firmly palpable and painless. 

She would like to reduce her butt size by cosmetic management.

Ultrasound notes hypertrophy of fatty tissue which was hypoechoic homogeneous pattern without capsule of her butt, no tumor inside.

MSCT confirmed symmetric fatty tissue of the subcutanous layer of the butt and nothing abnormal detected in the abdomen and bone or vessels.

Surgery with ultrasound knife removed the fatty tissue masses # 2.5kg each side.

Right mass # 18x16mm. Left mass 22x16cm

Post-op removing two masses of the butt using vacuum-assisted closure.

Specimen were benign lipoma. 

Madelung disease, also known as Madelung-Launois-Bensaude syndrome or neck lipomatosis or multiple symmetric lipomatosis. That is a rare benign entity clinically characterized by the presence of multiple and symmetric, non-encapsulated masses of fatty tissue. The extra fatty tissues are usually involving the neck and the upper region of the trunk, mainly in the posterior aspect. Limb involvement is usually proximal and around the shoulder and hip girdles.

Madelung’s disease causes fatty tissue to grow on neck, upper back and shoulders. It can cause symptoms like difficulty swallowing, talking or moving the head.

Madelung’s disease is a rare condition where extra fatty tissue builds up in places it normally wouldn’t, like around the neck and shoulders. It causes painless, fatty masses that grow over time. If the lumps get too big, they can affect nearby body functions. 

Less commonly, fatty deposits appear on Abdomen, Chest, Hips, Thighs.

This fatty tissue is different than a fatty lump (lipoma) or typical body fat. It spreads and mixes under the skin — looking like jelly spread on a piece of bread. It also grows evenly. For example, it will be on both the left and right sides of the shoulders.

Risk factors

Alcohol use disorder is one of the biggest risk factors. Between 60% and 90% of people with this disease also have cirrhosis of the liver from heavy alcohol use.

Other risk factors include:

Being male and between the ages of 30 and 70

Having a biological family history of the disease

Having a metabolic disorder, like diabetes or hyperlipidemia

May classify the type of Madelung’s disease based on where the fat has built up:

Type 1 (classic type): This type is most common in men. Fat builds up in only the neck, shoulders and upper body. It can sometimes give someone athletic-looking appearance. It’s strongly associated with alcohol use disorder.

Type 2: This type is more common in women, but rarer overall. Fat builds up in the upper body, like Type 1. It also builds up in the abdomen, thighs and hips. It doesn’t have a strong connection to alcohol use disorder.

So our case may be classified in type 2 of Madelung disease based on: no alcohol intake,  symmetric lipomatosis  at the butt.

REFERENCES:

1/ https://rarediseases.org/rare-diseases/madelungs-diseases

2/

3/ Việt Đức Hospital: A 45 yo woman with a lipoma at her posterior neck and two fatty masses at her back. A published Madelung disease case of female patient.

4/ Some 24 other cases in drunken men in Vietnam from northern hospitals were published on Internet.

https://tapchiyhocvietnam.vn/index.php/vmj/article/view/7064

CASE 917: ABSCESSES post FILLING of BREAST AUGMENTATION for 24 years, Dr PHAN THANH HẢI, Dr JASMINE THANH XUÂN, Dr VÕ THỊ PHƯƠNG TRINH, Dr LÊ HỮU LINH, MEDIC MEDICAL CENTER and Dr NGUYỄN PHAN TÚ DUNG, VIETNAM.

A 48 year-old with two huge breasts due to filling breast augmentation by artificial fat liquid for 24 year in oversea. She got painful breast for one month.

X-ray saw no breast abscess.

Ultrasound detected  intricate fluid into breasts which were not like abscess fluid.

Because MRI with breast coil could not fit with the huge breast, MSCT was done in note the  filling fluid was not silicone.

WBC: 16,3×10^9/L

Emergency surgery was done in the same day to remove the breast complex contents which were amount # 2.5 liters each breast.

In surgery, many granulomata inside the breast fields were many amorphous nodules into breast fluid on ultrasound. 

Specimen was the inflamed tissue with reaction  of foreign body phagocytosis of macrophages.

The female patient remains well and discharges after two days in hospital. 

Major medical regulators like the FDA strongly warn against using any liquid injectable fillers (including silicone, hydrogels, or facial dermal fillers) for breast augmentation due to severe safety risks:  

• Product Migration: Free liquid fillers can travel into other parts of the body, causing chronic pain, hard lumps (granulomas), and severe inflammation.  

• Vascular Occlusion: Injected fluid can enter blood vessels, leading to tissue death (necrosis) or life-threatening embolisms.  

• Mammogram Interference: Foreign liquid materials obscure breast tissue, making early detection of breast cancer extremely difficult.

• Removal Difficulty: Unlike solid breast implants, free fluid cannot simply be "taken out" if something goes wrong; it bonds with natural tissue and often requires destructive surgery to excise.