CASE 336:02 year Abscess in Leg Muscle due to Missed Foreign Body, Dr LÊ THANH LIÊM, Dr LÊ THÔNG LƯU, Dr PHAN THANH HẢI, MEDIC MEDICAL CENTER, HCMC, VIETNAM

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case-336-leg-abscess-for-2-years-due-to-missed-foreign-body-

CASE 335: HEMOPERITONEUM, Dr PHAN THANH HẢI, MEDIC MEDICAL CENTER, HCMC, VIETNAM.

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case-335-hemoperitoneum-

WOMAN 33 YO, ACUTE   LEFT PELVIC PAIN, ULTRASOUND  EMERGENCY  SHOWED NORMAL SIZE OF UTERUS, ENDOMETRIUM  IN MIDDLE OF MENSTRUAL CYCLE, AND HAVING A LOT OF FLUID AND  BLOOD ARROUND  UTERUS TO MORRISSON'S  SPACE  OF ABDOMEN.

IT WAS A CASE OF HEMOPERITONEUM.

ULTRASOUND  DETECTED  ONE ROUND  MASS  AT LEFT  PELVIS WHICH WAS  SUSPECTED AN  OVARY CYST WITH SIZE OF 4 CM.

PUNCTION OF ABDOMEN  AT  RIGHT ILIAC FOSSA  REMOVED OLD  BLOOD.

BLOOD TESTS  WERE NORMAL  BETA HCG,  Hct   21%, NORMAL AMYLASEMIA.

MSCT  WITH CE  DETECTED  2 MASSES  BOTH 2 SIDES RIGHT AND LEFT  UTERUS; THE LEFT ONE  WAS  VERY QUICK CE ENHANCED  IN COMPARISON TO THE RIGHT  ONE  NON-CE ENHANCE.

Patient was  in admission of emergency of  surgery hospital.
After receiving of  2 units of blood transfusion, the vital status was stable.
Follow- up by  ultrasound one week later  the  blood clot  in pelvis was not rising  but not dissolved. Laparoscopic surgery  for  washer  this blood  and  detected  right ovary was normal, while  left ovary  had  ruptured one cyst but  already  stop bleeding.

Report of surgeon was rupture  of luteinic corpus  with blood loss more than 2,000 ml-- a  severe case of internal bleeding.

CASE 334: MULTIPLE HEPATIC TUMORS: Dr PHAN THANH HẢI, MEDIC MEDICAL CENTER, HCMC, VIETNAM.

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case-334-multiple-hepatic-tumors-

WOMAN 43YO, CHRONIC INFECTED HBV, PAIN AT  LIVER.

ULTRASOUND   DETECTED  INTRA HEPATIC   MULTIPLE FOCAL LESIONS WITH SUGGESTION OF  LIVER HEMANGIOMA (US1, US 2).

REPORT OF MSCT WITH CE   WAS    MADE  DIAGNOSIS OF   MULTIPLE  FOCAL HCC (  CT 1, CT 2).

MRI WITH  PRIMOVIST ALSO   WAS   DIFFUSE   HCC.

BLOOD TEST OF   WAKO  WERE  NEGATIVE,  CEA AND CA 19-9   WERE  IN  NORMAL  LEVEL.

FIBROTEST  WAS  SCORED  F2.

DISCUSSION: History were chronic infected HBV and Wako triple test negative. Do you trust in reports of ultrasound, CT with CE, and MRI Primovist ?

Biopsy  report  is  adenocarcinoma  metastasis from GI tract.

It is a case of CUP (cancer unknown  primary).

CASE 333: LUNG MASS, Dr PHAN THANH HẢI, MEDIC MEDICAL CENTER, HCMC, VIETNAM

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case-333-lung-mass-

Man 52 yo, fever  unknown  origine  for 3 months, blood tests: nothing abnormal detected.

MSCT scan of full body detected  a small nodule on right lung,  size of 1 cm with some  pericarena lymph nodes  enhanced  with  CE and  one subcutaneous mass of 3 cm in the  back of  left  neck  (CT lung images).

Ultrasound of this mass  revealed round border, very hypoechoic, nonvascular filling intramass, no posterior enhancement, no sister mass together ( see 3 US  images and  video clip).

Biopsy was done for this mass and microscopy result was  adenocarcinoma metastasis from the lung.

Discussion: Clinical onset is fever unknown origine, CT lung detected small spicular nodule , pericarena nodes and the patient himself detected one subcutaneous mass at posterior of his left neck; biopsy of this mass made diagnosis of metastasis from lung cancer  which is small cell lung cancer.

Conclusion = Small  lung cancer  metastasis to skin  and  paraneoplasic  fever.

Reference: Case in NEJM.

CASE 332 : PERITONEAL CARCINOMATOSIS, Dr PHAN THANH HẢI, MEDIC MEDICAL CENTER, HCMC, VIETNAM.

case-332-peritoneal-carcinomatosis-

Woman 68 yo with abdomen distension and pain.

Ultrasound  scan detected  ascites  with   pelvic mass ( US images) suspected  peritoneal carcinomatosis.

CT  scan of abdomen with CE with  radiologist  report  was   peritoneal carcinomatosis,

unknown  primary cancer (CUP).

Blood tests:   raised CEA and  CA-125 markers.

Abdomen tap removed gelatineous fluid that analysis of  this fluid no cancer cell revealed.

Laparoscopy biopsy of  peritoneal  vegetation reported  mucinous carcinoma.

Discussion:  In this case  of  68 yo female ascites  like  jelly, CT and ultrasound  cannot detected ovary tumor. Blood tests  pointed  CEA  very high in comparison to CA-125.  The most common cause is  from rupture of appendiceal.carcinoma and  spreading  intraperitoneum.

CASE 331: MASS INSIDE STOMACH, Dr PHAN THANH HẢI, MEDIC MEDICAL CENTER, HCMC, VIETNAM.

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case-331-mass-inside-stomach

Child 5 yo long history of epigastric pain and anorexia treated  as  HP  infected gastritis.

Ultrasound detected intragastric mass  with  large UMBRELLA SIGN  [showdown  like the  sunshine over the umbrella] which  covered  more  50%  of  lumen of stomach ( see US pictures 1, 2, 3).

MSCT of  abdomen revealed this mass  inside  stomach,  multilayer  structure, not  developmental from the wall of  stomach.

Based on ultrasound  and abdomen CT, suggestion  of radiologist  is  gastric trichobezoar.

What is your  suggestion, endoscopy  or  operation for removing the mass inside stomach?
Operation of gastrostomy removed the hair mass.

Reference:
Umbrella's sign of ultrasound.
https://www.google.com/?gfe_rd=cr&ei=g5_tU8msNeuJ8Qfjl4HADg&gws_rd=ssl#q=umbrella%27sign+ultrasound&imgrc=iff-XjzsO-ZxoM%3A

CASE 330 : SMALL HCC, Dr PHAN THANH HẢI, MEDIC MEDICAL CENTER, HCMC, VIETNAM

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case-330-small-hcc-

Man  66 yo with history  no infected  HBV, HCV but  high values of liver enzymes for a long time.

Ultrasound of liver showed fatty infiltrating in liver.

Blood test of HCC RISK  positive  with AFP: 33.6 ng/ml; AFP-L3%: 62,4% and DCP: 21mAU/mL.

MRI of liver  with PRIMOVIST and DWI detected a  small focal lesion, size  of 0.8cm at the liver border in  segment 6,  very  bright  in DWI  and captured  and washed out  Primovist like a HCC.

Diagnosis  was made for a small HCC,  wait for operation.

DISCUSSION:

Biopsy or not for  the case:  hepatologist and  radiologist said no because worrying of sedding cancer cells.

RFA or  SURGERY? RFA  could  perform if ultrasound  can see the tumor. Yes,  WE CAN SEE  THIS  HCC ( see  2 US  pictures).

This case is  planning to do RFA in  next week and test HCC Risk (WAKO)  24 hours after this procedure.

After 48 hrs RFA [ 27-08-2015] 2nd Wako test repeated (AFP: 21.7 ng/ml, AFP-L3 : 60.5%, DCP: 21mAU/mL
Wako test  again  10 days after RFA [ 6-09-2015] 3rd Wako test ( AFP: 7.6ng/ml, AFP-L3: 42.1%,DCP: 20 mAU/mL)
Wako test  will be performed one month after RFA.

REFERENCE:
MayoClinics Report HCC_AFP_L3