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

April 10, 2014, 9:53 pm
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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.



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CASE 267:PELVIC MASS and MELENA, Dr PHAN THANH HẢI, Dr LÊ ĐÌNH TÍN, Dr LÊ ĐÌNH VĨNH PHÚC, MEDIC MEDICAL CENTER, HCMC, VIETNAM

July 23, 2014, 10:03 pm
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Man  37 yo in urgency by  melena and  hypotension.
Ultrasound of  abdomen first detected  one mass of 6cm at  the pelvis, well bordered  (US image 1: mass  near  the  urinary  bladder  wall, US 2: very hypoechoic with linear probe 12MHz, US 3 elasto: this mas soft and inhomogeneous, and video hypervascular mass).






MSCT with CE of this mass showed rapid  and high CE enhancement (see 3 CT images).





There were no relation between the mass with GI tract lumen.
 Blood test  Hct  20%  post blood transfusion.  And  gastroscopy and colonoscopy: NAD (nothing abnormal detected).
Today, laparotomy found out the mass in the small bowel wall, with vascular congestion. And there was one site eroding the mucosa layer of intestine. Maybe bleeding from this site (see operation images).









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CASE 268: HEMATURIA, Dr PHAN THANH HẢI, MEDIC MEDICAL CENTER, HCMC, VIETNAM

August 1, 2014, 6:56 am
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Male 18yo  pain at  right  renal fossa  and  hematuria.
Ultrasound first  detected  one mass at upper pole  right  renal, size of 4 cm  multilobulated,   ruptured  the  capsule and    structure  was  inhomogenous, cystic and solid  with calcification.
Doppler  showed  hypovascular supplying  to this tumor ( see  3 pictures -video).






One sonologist  suggested  TCC( transitional cell carcinoma ).
MSCT with  CE of  urography of the renal mass which composes  fatty tissue, calcification, expanding  outsite of  the renal capsule, look liked  AML (see 3 CT images-3D).









Do you thing  biopsy this mass is  necessary and risk ? This case  had been open operation for  partial nephrectomy.
See specimen and wait for  its microscopic report.
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CASE 269: IUD PENETRATION, Dr PHAN THANH HẢI, Dr JASMINE THANH XUÂN, MEDIC MEDICAL CENTER, HCMC, VIETNAM

August 13, 2014, 4:59 am
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WOMAN  53 YO WHO HAD  AN IUD INSERTED FOR 16 YEARS , IN ROUTINE CHECK- UP BY  ABDOMEN ULTRASOUND (US) DETECTED  ONE MASS  OF URINARY BLADDER WHICH WAS LIKE  T SHAPE IUD  IN  PENETRATION  FROM  UTERUS  LUMEN TO URINARY BLADDER  WALL(SEE 4 US IMAGES). 






FOR  MAKE SURE THIS IUD IN PENETRATION TO URINARY BLADDER, ABDOMINAL MSCT  WAS DONE.(SEE 3  CT PICTURES).




For evaluation intra urinary bladder tip of  IUD or not, cystoscopy  detected one mass edema  of mucosa near  right  ureteral meatus (see photo).



This patient refused   treatment, returning home.

REFERENCE:


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CASE 270: MASS nearby STOMACH, Dr PHAN THANH HẢI, MEDIC MEDICAL CENTER, HCMC, VIETNAM

August 18, 2014, 5:54 am
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Woman  44 yo,  epigastric pain for one  month. Ultrasound first  of abdomen detected one round hypechoic mass,  size of 2-3 cm at the border of antrum ( see 2 pictures of ultrasound) .and  sonologist suggested it a  GIST of stomach.





Gastroscopy  detected nothing.
MSCT with CE of this mass:  Mass was not far from the wall of antrum, enhancement with
contrast,  but  in position of  rotation,  so CT cannot  make sure that  from the wall of antrum (see CT pictures with CE) or not.





Radiologist suggested that a lymph node, size of  2,4 cm  near antrum.
Blood  test  nothing abnormal.

CLINICAL AND  RADIOLOGY CANNOT  MAKE SURE DIAGNOSIS FOR THE MASS.
IN LAPAROSCOPY FOR BIOPSY THIS MASS,  IT  IS NOT  FROM THE WALL OF ANTRUM.  (SEE OPERATION FOTO 1,2,3)  







REMOVING COMPLETLY THIS ROUND SOFT  MASS. 
SEE  MACRO  PHOTO. 
WAIT FOR PATHOLOGY REPORT.
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CASE 271: BOCHDALECK HERNIA, Dr PHAN THANH HẢI, Dr VÕ NGUYỄN THÀNH NHÂN, MEDIC MEDICAL CENTER, HCMC, VIETNAM

August 23, 2014, 9:18 pm
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Man 43 yo,  after a great meal, his comments were vomitting  and epigastric pain.
Emergency  abdomen ultrasound  was nothing abnormal detected (NAD).
Standing  chest abdomen X-rays showed that  left lung pneumonia in suspicion (see  chest X-ray film).


MSCT of chest-abdomen detected left  diaphragm in rupture and the  great omentum  going up to the  lung (see CT foto).



For  make sure  the colon was still  in abdomen,  Xray colon enema was done (see foto).


It was an emergency  case  with no  history of trauma.
Laparo and  thoracoendoscopy detected  a big defected wound  of posterior left  diaphragm;  great omentum  going up to the lung.
It is  BOCHDALEK HERNIA, need to suture for repairing left diaphragm (see foto).


REFERENCE:   anatomy of diaphragm.


History about Bochdalek.



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CASE 272: ASCITIS UNKNOWN ORIGINE, Dr PHAN THANH HẢI, MEDIC MEDICAL CENTER, HCMC, VIETNAM

September 1, 2014, 6:08 pm
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Patient 42 yo, labor of the load of bread, one  month ago  complaint by  periumbilical pain crisis.durring 1-2  minutes, no  fever  no  diarrhea,   more and  more frequent.
Ultrasound  abdomen  first time detected  free fluid ascitis in  large amount of volume  but unknown origine (see  ultrasound  images).




Gastroendoscopy showed gastritis with  negative HP test,



MSCT no CE also made sure this  liver  no cirrhosis and ascitis unknown origine.






Blood test report = WBC  rising.





What is your  diagnosis for the case and what do you do next ? 




Ultrasound guided punction of ascitis which was removed the yellowish  clear fluid  and biochemistry and cytology analysis.



RECENTLY LAB  REPORT of  BLOOD TEST from THIS PATIENT.

DISCUSSION:

 This case  was represented unknown  ascitis  at first  time by  ultrasound and CT scan, and blood test  report was  eosinophil  rising  too much,  43%, that many doctors were looking for a  parasite infected cause.
But, ascitis  analysis was  transudate fluid  and hypoalbumine,   while  CA125  was very high, of 1380 UI/mL  in the male patient. So it was  difficult to explain that.

Cytology of  ascitis fluid  showed  that  many  white blood cells  of eosinophil  in  one staining microscopic champ.
Second report  of blood test today  ruled out parasite infection, but IgE very high,  of  1168 UI/mL, that  suggested an  eosinophylic gastroenteritis.


For  review and  make sure  this  diagnosis, an other  ultrasound scanning of  abdomen perfomed  to  detect   thickening of  intestine wall.  And  cytology  smear of ascitis  fluid  was more eosinophil cells. 

A course of  corticotherapy was started today. Wait for  clinical response.
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CASE 273: FOREIGN BODY on HEAD, Dr LÊ THỐNG NHẤT- Dr PHAN THANH HẢI, MEDIC MEDICAL CENTER, HCMC, VIETNAM

September 4, 2014, 3:46 am
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Male patient 33 yo from Ca mau province.
For 20 days before Medic admission, patient had been hurt by a stabbing wound by bamboo chopstick at his right temporal region.
But after a first-aid bandage, the wound was getting swollen and infected, then he came up to Medic Center .
Ultrasound at Medic detected foreign body into the wound which was correlated to a part of bamboo chopstick.



MSCT of the head showed a tubular object  in the right temporal region.






Patient  underwent  a surgery to remove the foreign body at the same day. Specimen was a part of bamboo chopstick of 6cm length.


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CASE 274: PTA OR NOT, Dr PHAN THANH HẢI, MEDIC MEDICAL CENTER, HCMC, VIETNAM

September 11, 2014, 1:42 am
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WOMAN 50YO, AFTER 5 YEARS TREATED HYPERTHYROIDISM AS STABLE STAGE,  BUT  BLOOD TESTS DETECTED  PTH VALUE VERY HIGH  AND  HYPERCALCEMIA. IT  SUGGESTED HYPERTHYROIDISM (SEE BLOOD TEST RESULT).



ULTRASOUND DETECTED ONE MASS AT  RIGHT LOWER LOBE, HARD WITH
ELASTO, AND HYPOVASCULAR, SIZE OF 2 CM.




MRI WITH GADO CE, ALSO CONFIRMED  ONE MASS AT  LOWER  POLE OF
THYROID GLAND, SUSPECTING  PTA, SIZE ARROUND 2 CM.





IN PREOPERATION  ENDOCRINOLOGIST  REQUESTED GAMMA SPECT  MIBI.
BUT THE REPORT WAS  NOT ABNORMAL ISOTOPE, MEANING  NOT  PTA.
(SEE  SCAN MIBI UPTAKE) . 


 DO YOU HAVE DISCUSSION FOR THIS CASE, OPERATION OR NOT ?.
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CASE 275: LUNG MASS, Dr PHAN THANH HẢI, MEDIC MEDICAL CENTER, HCMC, VIETNAM

September 13, 2014, 2:27 am
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BOY 5 YO   3 DAYS AGO   FEVER AND COUGH.

PEDIATRIC DOCTOR  REQUESTED  BOOD TESTS  FOR  RULE OUT  DENGUE FEVER AND  CHEST  XRAY.
RESULT   RETURNED  QUICKLY (SEE   BLOOD TESTS  AND CHEST XRAY).




DISCUSSION:
FEVER AND RISING OF WBC  WITH  MORE NEUTRO CELLS  ARE  ACUTE
INFECTION, WE CAN RULE OUT  DENGUE FEVER.
BUT THE CHEST X-RAY WAS ABNORMAL, ONE RADIOLOGIST  SUGGESTED  LUNG TUMOR. AND HE  REQUESTED THORAX CT SCAN.



ULTRASOUND  OF  THE CHEST  BY TRANSTHORACIC  DETECTED THIS MASS AT THE LEFT LUNG  WHICH WAS  SOLID  ECHOTRUCTURE  LIKE HEPATIC TISSUE.
IT HAD AIR IN THE MASS AND  VESSELS  WERE NOT BENDING ( SEE ULTRASOUND  IMAGES  WITH  CDI AND VIDEO)
  




Sonologist suggested consolidation pneumonia.
For make sure diagnosis we performed low dose CT Scan  without CE (see CT pictures).





Radiologist reported that a lobular pneumonia in  consolidation phase of the left lung.
Antiobiotic treatment is in urgency.
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CASE 276: PTC, Dr LÊ THANH LIÊM, MEDIC MEDICAL CENTER, HCMC, VIETNAM

September 25, 2014, 11:41 pm
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Female 29 yo,  getting big neck  faster.





 Last  year she got some  small colloidal  cyst on right lobe. But at this time ultrasound detected hypoechoic mass on right lobe,  #34x60x24mm with many small cysts inside, calcified and hyperechoic nodules and  vascular network between cysts which was thought to be colloidal cysts.  







With elastoultrasound ARFI, lesion was harder than the surrounding, black color on VTI and blue code on Esie Touch. Elastographic velocity was higher , V=2.7à3.14 m/s than the surrounding, v=1.28m/s. It suggested a malignant lesion on elastographic US.




Microscopic result of FNAC was PTC.


Discussion: An interesting  case of PTC with appearance of many small cysts which make confusion to colloidal cysts. Clinical findings which helped to diagnose are tumor getting bigger faster on one lobe of thyroid. And ARFI elastoUS  keeps the predictive role in diagnosing exactly for this case.

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CASE 277: CLOSE BY KNEE JOINT TUMOR, Dr PHAN THANH HẢI, MEDIC MEDICAL CENTER, HCMC, VIETNAM

October 2, 2014, 1:06 am
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MAN 21 YO   PAIN  NEAR  THE  LEFT   KNEE  AFTER  PLAYING  FOOTBALL.
 X-RAY FIRST OF LEFT KNEE AREA D ETECTED ONE MASS  INTRA
MUSCLE WITH  CALCIFICATION  AND ADHERENT TO FEMUR BONE  WITH SIGN OF PERIOSTEAL  EROSION.





ULTRASOUND OF THIS MASS  REVEALED  HYPOECHOIC PATTERN WITH CALCIFICATION INTRA MASS,
HYPOVASCULAR,  SIZE  ARROUND 4 CM.






ELASTOGRAM  SHOWED THAT MASS WAS HARD AND CENTRAL NECROSIS.







MRI  OF THIS MAS PROVED COMING FROM THE FEMUR BONE AND IN   EXTENSION OUT  TO
MUSCLE, LOOKED LIKE  BONE TUMOR (SEE  MRI 1, 2, 3 ).





PET CT   MADE STAGING  THIS TUMOR WAS  LOCAL  INVASION   HIGH
UPTAKED  18 FDG, SUSPECTED OSTEOSARCOMA.






OPEN  SURGERY  BIOPSY FOR  MAKING SURE  DIAGNOSIS.

WAIT FOR MICROSCOPY REPORT.


MICROSCOPIC REPORT WAS  PERIOSTEAL SARCOMA.
WHAT IS  PLAN of TREATING FOR 21 YO YOUNG PATIENT?  
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CASE 278: UNKNOWN ASCITES, Dr PHAN THANH HẢI-Dr LÊ TỰ PHÚC, MEDIC MEDICAL CENTER, HCMC, VIETNAM

October 8, 2014, 6:28 am
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MAN 30 YO   ABDOMINAL PAIN  SOME MONTHS AGO,   ABDOMEN WAS DISTENTION AND  CANNOT EATING, NO FEVER  NO TRAUMA OR TUBERCULOSIS IN  HISTORY.
ABDOMEN ULTRASOUND  DETECTED ASCITES  WITH  BOWEL  ADHERENCE IN MASS, LIKE COCOON  SIGN ( 2 VIDEO).
















MSCT of ABDOMEN WITH  CE REVEALED  NORMAL LIVER  WITHOUT TUMOR ( SEE  CT  3 PICTURES).





PUNCTURE of ASCITES SHOWED OLD  BLOODY  FLUID. ANALYSIS RESULTED NORMAL AMYLASE,  ADA, AND  CA 125.

WHAT IS  YOUR  SUGGESTION of  DIAGNOSIS..AND  HOW TO MAKE SURE DIAGNOSIS FOR THE CASE.
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CASE 279: RETROPERITONEAL PELVIC TUMOR, Dr PHAN THANH HẢI- Dr LÊ TUẤN KHUÊ. MEDIC MEDICAL CENTER, HCMC, VIETNAM

October 26, 2014, 11:47 pm
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MALE PATIENT 42 yo, from CA MAU PROVINCE, GETTING  HIS LOWER ABDOMEN BIGGER  AS 3 MONTH WITHOUT ANY SYMPTOM.

HE WAS TRANSMITTED TO CANCER HOSPITAL AND BINH DAN HOSPITAL.

ON CYSTOSCOPY HIS URINARY BLADDER WAS PRESSED FROM OUTSIDE.

ULTRASOUND AT MEDIC DETECTED A HUGE MASS IN PELVIS, CENTRAL NECROSIS.



AT BINH DAN HOSPITAL, COLONOSCOPY WAS PERFORMED AND THE RESULT WAS SIGMOID COLITIS.



AND CT of BINH DAN HOSPITAL REVEALED A HUGE RETROPERITONEAL MASS IN PELVIC REGION.



OPERATION  WAS DONE TO REMOVE THE TUMOR WHICH WAS of 15X20cm IN SIZE FROM ANTERIOR OF URINARY BLADDER TO PROMONTORY of SACRUM.




THE RESULT of HISTOPATHOLOGY AND HISTOIMMUNOLOGIC STAINING WAS A SCHWANNOMA.


REFERENCE:


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CASE 280: FETUS ONE KIDNEY in HYDRONEPHROSIS, Dr PHAN THANH HẢI, MEDIC MEDICAL CENTER, HCMC, VIETNAM

November 3, 2014, 10:52 pm
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Woman in pregnancy  31 yo  PARA 2002. First time cesarian delivery, but  now  check for the second delivery. Prenatal ultrasound that  detected  oligoamniotic  and  but fetus having only one right hydronephrosis [see image US 1, US 2 ].




Urinary bladder was  normal and cannot find out the left fetal kidney (US 3 video  showed the facial fetus and  his nose and mouth  in normal respiration).


Fetal MRI  made sure that  only one abnormal  right fetal kidney, small and cannot find out the left fetal kidney [see MRI 1, frontal section  MRI 2  section, MRI 3, sagital section, MRI 4.)




Prenatal 36 weeks  detected  renal  malformation  with agenesis of kidney.

DISCUSSION:
In this case,  fetus has only one  kidney  in  hydronephrosis.
The mother  has to undergo a cesarian deliverying  and  strict  survey the neonate, and if  the  hydronephrosis is  still progressing, an emergency  endostent by JJ is method for  reduction of intrarenal pressure.
It is  look like  POTT SYNDROME, this  baby needs   DNA gene examination.
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CASE 281: INSULINOMA, Dr PHAN THANH HẢI-Dr NGUYỄN THÀNH ĐĂNG, MEDIC MEDICAL CENTER, HCMC, VIETNAM

November 5, 2014, 7:52 pm
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Woman 39yo  after  delivering her  second  baby, she  had  hypoglycemia  repeatedly  and  more  frequently.  But ultrasound  of pancreas  many time with many sonologists  cannot detect  abnormal in pancreas (see 3  ultrasound pictures  at Medic).







MRI  with gado detected  a small mass  of 1 cm in diameter  at the  head  of  pancreas ( see 3 MRI pictures)




Operation was done  for removing  this mass  and for  microscopic report.




After  removing  the mass of  pancreas,  the  sugar blood was getting  stable and returning to norma value.



Microscopic report was an insulinoma. 

TODAY PATIENT  DISCHARGED FROM HOSPITAL.

IN FASTING  INSULIN WAS  8.1 UI/ML  IN COMPARISON TO PRE-OP VALUE OF 50.9UI/ML.

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CASE 282: SUPRAPUBIC MASS, Dr PHAN THANH HẢI-Dr LÊ THỐNG NHẤT, MEDIC MEDICAL CENTER, HCMC, VIETNAM

November 19, 2014, 10:48 pm
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Man 45 yo, 3 months after operation  for repairing left  inguinal  hernia,  pain in micturition and  polykiuria; clinical palpation  detected one mass  at suprapubic area.
Ultrasound  detected  this mass being a cyst, size of 10cm with many  bodies hyperechoic  intra cystic, which were looked like  foreign  bodies  ( see 4  US pictures). This  mass was  intra  abdominal  wall in  compression to urinary bladder.







MRI  of pelvis with gado reported  a  mass which was liked an abscess with  viscous fluid content  and cannot see  intracystic structure.






What is your suggestion for diagnosis of the suprapubic mass?

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CASE 283: SCARPA TRIANGLE MASS, Dr PHAN THANH HẢI, MEDIC MEDICAL CENTER, HCMC, VIETNAM

November 25, 2014, 6:13 am
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WOMAN 28YO  DETECTED HERSEFT  AT THE  RIGHT GROIN (SCARPA'S TRIANGLE)  ONE MASS  GROWING BIGGER  FOR 3 MONTHS WITHOUT PAIN  NOR TRAUMA.

ULTRASOUND  FOUND IT OUT  FIRST  BEING  A MASS WHICH WAS MULTILOBULATED, INTRAMUSCULAR, HYPOVASCULAR AND  HARD  IN ELASTOGRAPHY ULTRASOUND ( SEE  4 IMAGES).







MRI WAS DONE  FOR MAKE  SURE DIAGNOSING OF  MUSCLE TUMOR THAT WAS EXTENDING  INTO  MEDIAN COMPARTMENT  OF THE RIGHT THIGH (see 2 MRI images).



MSCT  DETECTED THE  HEAD OF  FEMUR BONE AND ILIAC BONE IN  EROSION.



PET- CT  MADE POSITIVE  FDG  CAPTURE OF THIS TUMOR.


WHAT IS YOUR SUGGESTION OF DIAGNOSING FOR THE CASE BY MANY DIAGNOSTIC MODALITIES?

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CASE 284: DIFFUSE LYMPHOMA, Dr LÊ THANH LIÊM, MEDIC MEDICAL CENTER, HCMC, VIETNAM

November 26, 2014, 7:01 am
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CASE 285: SKIN TUMOR, Dr PHAN THANH HẢI - Dr LÊ THÔNG LƯU, MEDIC MEDICAL CENTER, HCMC, VIETNAM

December 5, 2014, 6:49 am
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Man  31 yo,  past  history 3 years  before went through an operation for removing one small  tumor at the neck. which was suspected a  sebaceous cyst. But now it was in recurrence with size of 2cm. Clinical palpation was not  painful, hard, subcutaneous tumor ( see  foto) due to  scar  by later operation.




Ultrasound found out a subcutaneous tumor, cystic formation, inhomogeneous structure, hypovascular in Doppler ultrasound scanning.





Elastoscan of this tumor is soft in central part, well-bordered, and the covered skin is in intact.



Preoperation  diagnosis  was  not  looked like  sebaceous cyst recurrence. 

Surgery  removed this tumor..


Surgeon reported  macroscopy of the  tumor being like  caverneous  hemangioma.
Microscopic result  confirmed  the  diagnosis for the case.


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