CASE 247: INTRAHEPATIC AVM, Dr PHAN THANH HAI, Dr NGUYEN CAO CUONG, Dr TRAN NGAN CHAU, MEDIC MEDICAL CENTER, HCMC, VIETNAM

A 31-year-old male patient complained about 3-day mild fever, right subcostal abdominal pain. He did not have any other symtomps such as voimiting, diarrhea and no history of abdominal surgery, trauma, liver biopsy or alcohol abuse. On physical examination, no mass in the right subcostal. B-mode ultrasound (US) findings showed a cystic structure (21x21mm) in the sixth segment, it communicated with 2 parallel –dilated - tubular - structure (d = 8 and 9mm) originated from the right portal vein and right hepatic vein.

Doppler US showed yin-yang sign, right portal vein flow and right portal vein flow in the cystic structure.

MSCT Angio comfirmed the AVM in right lobe of liver.

The patient underwent an abdominal laparoscopic surgery for resection the AVM.  In the course of operation, surgeon saw the sac pulsating.

The patient remains well post-op.

Microscopic result is concordant with hepatic AVM.

CASE 246: PANCREAS TUMOR, Dr PHAN THANH HẢI, MEDIC MEDICAL CENTER, HCMC, VIETNAM

14yo girl  for  a long time epigastric pain  like gastric syndrome.

But ultrasound detected one round mass of 4 cm at the head of pancreas, without dilated CBD or Wirsung duct. CDI no detection vascular intratumor and echostructure was inhomogeneous (see 3 US pictures).

MSCT with CE showed  this mass well bordered at the head of pancreas, slow enhancement of contrast.

Blood tests no abnormal.

Based on clinical status and  ultrasound and MSCT imaging,  what is your suggestion of diagnosis and what is your plan for treatment ?

Discussion: young girl with chronic pain.

US and MSCT cannot make sure diagnosis.

Operation for biopsy this tumor; the tumor is fixed to deep structure, thickening of the wall.After opening  the wall, the black fluid came out and red blood following. Biopsy the wall of this tumor and one lymph node nearby.

Microscopic report is  pseudocyst of  pancreas and  lymphadenitis.

Plan to treat  is waiting  and seeing  the evolution  of  this cyst.

REFERENCE
 pdf..  Management  cystic structure of pancreas.

 

CASE 245: CERVICAL VAGUS NERVE SCHWANNOMA, Dr PHAN THANH HAI - Dr LAM CAM TU, MEDIC MEDICAL CENTER, HCMC, VIETNAM

Woman 51yo detected lateral left neck mass, no pain (see foto ).

ENT doctor did endoscopy for rule out a cavum cancer, and FNAC did not detect cancer cell metastasis to this mass.

Ultrasound report was an ellipse mass of 3 x 5 cm,  well-bordered,  hypoechoic, hypovascular with small cystic formation which deplaced the CCA and internal jugular vein (IJV) that well confirmed by 3D vascular CT angio (see 4 CT pictures).

Discussion:  This 51 yo woman with the mass in upper portion of left lateral neck, painless for a long time suggesting malignancy.
Ultrasound is the fist choice for diagnosis after consultation of ENT doctor. Ultrasound picture is like a cystic mass, hypovascular supplied which situated  between CCA and  internal jugular vein. The tumor developed in the sheath of carotid artery and expansion. MSCT 3D angio shows very well  the  displacement of  CCA and IJV,  that is the key for  diagnosis;  this tumor developed from carotid sheath like schwannoma (neurilemnoma).  

Operation for  removing  this  tumor easily;  macroscopic view shows capsule thickening  tissue that is  soft,  like brain tissue.

Microscopic report is a schwannoma of vagus nerve.

REFERENCE:

Case report pdf

CASE 244: AVM and MESENTERIC PANNICULATIS, Dr PHAN THANH HAI, Dr LY VAN PHAI, MEDIC MEDICAL CENTER, HCMC, VIETNAM

Man 31 yo, one week ago complained  of epigastric pain and vomiting.

Clinical examination he had red skin on the right thorax and atrophied muscles of right arm.

Emergent abdominal ultrasound scan showed  one mass of 4cm located near the head of pancreas, at processus uncinatus which  compressed duodenum..
(see 3 ultrasound pictures.. P1.color doppler at right subclavicule suspected A-V-M) , P4 .P5..crossed scan and longitudinal scan of this mass at the head of pancreas.)

Gastroendoscopy went down just to duodenum but nothing detected.

MSCT with CE: this mass was in retroperitoneum compressing duodenum D2,

contrast injection was slowly enhancement , but it had air in the  mass ( see 4 CT  with CE pictures CT1, is angiogram of right axillary artery, CT2. this mass with air inside, CT3, relation with right kidney and aorta, CT4 vascular SMA and mass).

Blood tests were no abnormal.

What is your suggestion for diagnosis ?.

Operation laparotomy for  biopsy this tumor  and  bypass anatomosis ; this tumor was  covered SMA then  cannot remove.
Microscopy is  fibrosis, no  cancer cell detection.

It is a fibrosis mesenteric case.
 

Discussion: this 31 yo patient, vomitting at the clinical onset,     due to  obstruction  of upper  GI tract . Ultrasound and  CT showed  the mass  near  the processus uncinatus of  pancreas  and   SMA encasement .

Operation cannot  remove  this tumor   because  it  fixed  to superior  mesenteric artery, biopsy  this mass  with report   no cancer cell,only  fibrosis  tissue suggesting a  pseudotumor like  mesenteric  panniculatis. It is  rare case   response with  corticoid  treatment   or  with  colchicine.

REFERENCE

case  of mesenteric panniculatis.

 

CASE 243: GALLBLADDER TUMOR, Dr PHAN THANH HAI, MEDIC MEDICAL CENTER, HCMC, VIETNAM

Man 69 yo,  pain  at  epigastric area, no  fever,  no GI tract trouble.

Abdominal  ultrasound  detected  abnormal  gallbladder: thickening of the wall with one  mass  at gall bladder  fundus  invasion to liver, suggestion of gallbladder abscess ( see 4 ultrasound pictures).

Blood test  are normal:   WBC  not rising, CA 19-9  normal

MRI with CE gado  showed this mass  in  high  enhancement  invasion in to  liver and  transverse colon, the  biliary system was  normal.

With  this clinical situation and blood tests, US first and  MRI,  what is your diagnosis ?

DISCUSSION: this case  had no  clinical signs of acute  cholecystisis, no stone  in gallbladder; ultrasound  showed  the  wall of  the gallbladder   perforated and  adherent , invading  liver  tissue, this mass was  hypovascular  in protruding  into lumen of gallbladder as a tumor and  going to extra wall of gallbladder.

Open operation  with  diagnosis  of  tumor of gall bladder (surgeon  removed  gallbladder  and  resection one part of liver  and  great omentum).  Specimen was  hard and necrosis.

Microscopic with imunohistostaining is leiomyosarcoma of the gallbladder..it is very rare  case in the word  had been published.

REFERENCE: