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 his study.

- 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.

CASE 926: PELVIC GIST MIMICKING OVARIAN TUMOR, Dr PHAN THANH HẢI, Dr VÕ THỊ PHƯƠNG TRINH, MEDIC MEDICAL CENTER, HCMC, VIETNAM.

 A 59 year-old HTA menopause woman with epigastric pain and lumbago.

Ultrasound detected an right ovarian  tumor 72x45mm, solid, mixed pattern,  hypervascular.

MRI confirmed a solid ovarian tumor.

At Từ Dū hospital the tumor was a right pelvic tumor maybe a GIST.

Surgery at Binh Dan Hospital and immunohistochemistry (IHC) result was an GIST.

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.

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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.