Pathological Complete Remission of Advanced Hepatocellular Carcinoma with Main Portal Vein Tumor Thrombosis by Hepatic Arterial Infusion Chemotherapy

Cures for advanced hepatocellular carcinoma (HCC) with portal vein tumor thrombosis (PVTT) are rare and difficult. We report a case of pathologically confirmed complete remission of HCC induced by hepatic arterial infusion chemotherapy (HAIC). A 45-year-old male patient had a massive HCC in the right lobe of the liver and tumor thrombus in the right and main portal veins. He achieved a partial response after two cycles of HAIC with 5-fluorouracil (750 mg/m2) and cisplatin (25 mg/m2). After the completion of six cycles he received a curative partial hepatectomy, and histopathology revealed complete necrosis without any viable tumor cell. He was in good health at a 4-month follow-up. These results suggest that this regimen is a promising therapeutic modality for the treatment of advanced HCC with PVTT.

Saccular Aneurysm of Intraheparic Portal Vein Mimicking Hypervascular Hepatic Mass: A Case Report

A portal vein aneurysm is divided into two groups; an extrahepatic portal vein aneurysm and an intrahepatic portal vein aneurysm. The morphology of an aneurysm can be divided into types such as fusiform, bilobulated and saccular. A saccular aneurysm that arises from the intrahepatic portal branch is extremely rare. We report here a case of a saccular aneurysm of the intrahepatic portal branch mimicking an intrahepatic hypervascular mass, as seen on a dynamic CT scan, with the radiological findings.

The Efficacy of an Ultrasound-guided Core Needle Biopsy with an 18G Cutting Needle for the Diagnosis of Pancreatic Diseases

PURPOSE: The objective of this study is to evaluate the efficacy and safety of an ultrasound-guided core needle biopsy with an 18G cutting needle in patients suspected of having a pancreatic disease by analyzing the diagnostic performance and complication rate. MATERIALS AND METHODS: The study population comprised 35 consecutive patients who underwent an ultrasound-guided core needle biopsy using a high-speed biopsy gun accompanied with an 18G cutting-type needle between May of 2001 and October of 2005. The diagnostic performance (i.e., the acquisition rate and diagnostic accuracy) and complications associated with core needle biopsies were evaluated for its efficacy and safety. RESULTS: Thirty-six sessions of ultrasound-guided core needle biopsies were performed in 35 consecutive patients. All patients, except two (serous cystadenoma and autoimmune pancreatitis) were diagnosed with various subtypes of pancreatic cancer. The acquisition rate and diagnostic accuracy were 97% (35/36) and 94% (34/36), respectively. A complication occurred only in one patient (3%), which further proved to be a delayed complicaton (i.e., needle tract implantation). CONCLUSION: According to our findings, the ultrasound-guided core needle biopsy is a viable and safe method for the dignosis of pancreatic diseases. Moreover, it enables the diagnosis of the pancreatic cancer subtype.

The Pathologic Splenic Rupture of a Patient with Scrub Typhus: A Case Report

A pathologic splenic rupture is rare, occurring primarily in a spleen affected by infective, hematological, and neoplastic disease. To the best of our knowledge, no prior reports of a pathologic splenic rupture due to scrub typhus exist. Intrasplenic pseudoaneurysms and focal infarctions are visible on an initial CT scan. Moreover, the spontaneous splenic rupture occurred a week later. We report a case of nontraumatic-splenic rupture in a patient with scrub typhus.

Hypotensive Splenic Infarction: A Case Report

Splenic infarction occurs when parenchymal ischemia of the spleen is evoked by an occlusion of the arterial or venous circulation. The most common causes include infiltrative hematological disease and thromboembolic conditions, but a hypotensive splenic infarction may be a rare cause of splenic infarction. A 62-year-old female patient presented with a hypotensive splenic infarction after massive bleeding. CT showed geographic low-density lesions in the central part of the spleen on the tissue equilibrium phase of dynamic CT. Usually, a depressed scar occurs in the course of healing of a splenic infarction. However, in this case recovery of blood flow and regeneration of the infarcted spleen was seen during the follow-up CT scans. We report a case of hypotensive splenic infarction with a review of the literature.

Desmoplastic Small Round Cell Tumor: A Case Report / 영남의대학술지

Desmoplastic small round cell tumor (DSRCT) is a rare and highly malignant mesenchymal tumor found in the abdominal cavity. It mainly affects young male patients. We report a case of DSRCT that occurred in the abdominal cavity of a 50-year-old man. The tumor was characterized by small round tumor cells with irregular nests in the prominent desmoplastic stroma. The tumor cells showed immunoreactivity for epithelial membrane antigen, desmin, vimentin, and neuron specific enolase.

Microvascular Injury of the Peribiliary Plexus Associated with Transarterial Chemoembolization: A Study of Surgical Specimens

PURPOSE: We attempted to evaluate the relationship between transarteiral chemoembolization (TACE) and injury to the peribiliary plexus by evaluating the number of microvessels in the peribiliary plexus of surgical specimen. MATERIALS AND METHODS: Surgical specimens were obtained from 78 hepatocellular carcinoma patients and 22 patients with liver metastases. They were divided into 4 groups (Group 1; hepatocellular carcinoma without TACE [n=30], Group 2; hepatocellular carcinoma receiving preoperative TACE once [n=37], Group 3; hepatocellular carcinoma receiving preoperative TACE more than two times [n=11] and Group 4; metastatic carcinoma of the liver patients without a history of liver disease [n=22]). Immunohistochemical staining for factor VIII-related antigen was performed in all the specimens and the number of microvessels in the inner capillary layer and the outer venous layer of the bile duct (> 200 micrometer in diameter) was counted. RESULTS: The mean numbers of microvessels in the inner capillary layer were 4.50, 4.08, 1.64 and 2.05, and those in the outer venous layer were 25.23, 20.00, 18.36 and 12.32 for the 4 groups, respectively. The number of microvessels in group 4 was statistically fewer than that of group 1 (p<0.01). In the hepatocellular carcinoma patients, the number of microvessels was decreased as the number of TACE sessions was increased. CONCLUSION: The number of microvessels in the peribiliary plexus is increased in chronic liver disease patients. It may be from the increased portal pressure and flow stagnation in the sinusoidal and portal venules. TACE can have an effect on microvascular injury of the peibiliary plexus, and this can be a cause of bile duct necrosis and biloma.

The Usefulness of MDCT in Acute Intestinal Bleeding

PURPOSE: We wanted to evaluate the usefulness of MDCT for localizing a bleeding site and for helping make a decision on further management for acute intestinal bleeding. MATERIALS AND METHODS: We conducted a retrospective review of 17 consecutive patients who presented with acute intestinal bleeding and who also underwent MDCT before angiography or surgery. The sensitivity of MDCT for detecting acute intestinal bleeding was assessed and compared with that of conventional angiography. RESULTS: The sensitivity of MDCT for the detection of acute intestinal bleeding was 77% (13 of 17), whereas that of angiography was 46% (6 of 13). All the bleeding points that were subsequently detected on angiography were visualized on MDCT. In three cases, the bleeding focus was detected on MDCT and not on angiography. In four cases, both MDCT and angiogphy did not detect the bleeding focus; for one of these cases, CT during SMA angiography was performed and this detected the active bleeding site. CONCLUSION: In patients with acute intestinal bleeding, MDCT is a useful image modality to detect the bleeding site and to help decide on further management before performing angiography or surgery. When tumorous lesions are detected, invasive angiography can be omitted.

Hypervascular Hyperplastic Nodules Appearing in Chronic Alcoholic Liver Disease: Benign Intrahepatic Nodules Mimicking Hepatocellular Carcinoma

PURPOSE: Hypervascular hyperplastic nodules in those patients with chronic alcoholic liver disease and who are hepatitis B and C negative have recently been reported on. The purpose of this study was to correlate the radiologic and pathologic findings with the clinical significance of these hypervascular hyperplastic nodules in chronic alcoholic liver disease. MATERIALS AND METHODS: The study included eight hypervascular nodules of seven patients with chronic alcoholic liver disease, and these patients had abused alcohol for more than 20 years. Eight hypervascular nodules were seen on the arterial phase of dynamic CT scans, but the possibility of HCC was excluded pathologically (n=4) or clinically. The radiologic and pathologic findings, and the changes of these nodules on follow up CT scans were retrospectively analyzed. RESULTS: All nodules showed good enhancement on the arterial phase. The tissue equilibrium phase of the dynamic CT scans showed isodensity in seven patients and low density in one patient. Ultrasound scans revealed hypoechoic findings for three nodules, isoechoic findings for two nodules, hyperechoic findings for one nodule, and two nodules were not detected. Angiograms (n=6) showed late incremental tumor staining, and all the nodules were well seen on the sinusoidal phase. CT during hepatic angiography (n=4) showed well stained tumor. CT during arterial portography (n=4) showed no defect in three nodules and nodular defect in one nodule. The MR images (n=3) showed low signal intensity in two nodules and iso-signal intensity in one nodule on T2WI. Five of six cases for which follow up CT scans were performed showed decrease in size and one was disappeared. CONCLUSION: Radiologically, it is often difficult to differentiate the hypervascular hyperplastic nodules seen in the chronic alcoholic liver disease from hepatocellular carcinoma, and histological confirmation is needed for excluded hepatocellular carcinoma. However, late tumor staining during the sinusoidal phase without any blood supply by feeding vessels or any arterioportal shunt on the angiogram, isodensity during the tissue equilibrium phase of dynamic CT and low signal intensity on T2WI may suggest the presence of hypervascular hyperplastic nodule.

Schwannoma of the Appendix: A Case Report

Schwannoma is a benign neurogenic tumor arising from the nerve sheath, and it presents as a well defined mass. Isolated gastrointestinal schwannoma is a relatively rare finding and schwannoma of the appendix is extremely rare. We report here on a case of schwannoma that arose from the appendix, and this lesion was pathologically confirmed.

Undiffentiated Carcinoma with Osteoclast-like Giant Cells of the Pancreas / 대한소화기학회지

Undifferentiated carcinoma with osteoclast-like giant cells is a rare neoplasm of exocrine pancreas. Till recently, some cases have been reported, however histogenesis of the tumors are controversial and their characteristic findings have not been described yet. Thirty five-year-old men and 75-year-old men were presented with upper abdominal pain and a palpable mass. On computed tomography, one case showed a well enhancing solid tumor with low density and the other was showed a mainly cystic tumor with peripheral enhancement in the body and tail of the pancreas. One case accompanied multiple metastatic liver masses with subhepatic lymph node enlargement. Tumor staining was seen on angiography. Biopsy and pancreatectomy were performed. Pathological findings revealed tumors composed of neoplastic spindle shaped or pleomorphic large cells with scattered non-neoplastic osteoclast-like giant cells. In one case, there were small foci of adenocarcinoma components in the periphery of the tumor. On immunohistochemical stain, neoplastic cells showed focal positivity for epithelial membrane antigen and vimentin. Tumors were diagnosed as undifferented carcinoma with osteoclast-like giant cells. We report these rare cases with a review of literature.

Prepancreatic Postduodenal Portal Vein: A Case Report

Prepancreatic postduodenal portal vein (PPPV) is a rare anomaly in which the portal vein runs between the pancreatic head and the duodenum. Understanding of this portal vein anomaly is important to avoid devastating complications, including portal vein ligation, resection or intraoperative hemorrhage. A 28-year-old female patient presented with right upper quadrant pain that she had suffered with for 2 days. Before performing laparoscopic cholecystectomy, we detected an abnormal shaped portal vein that ran in front of the pancreatic head and posterior to the duodenum on the CT scan. We report here on a rare case of prepancreatic postduodenal portal vein that was incidentally discovered on the CT axial images and coronally reformated images, in addition to observing it on the conventional portography.

Primary Adenosquamous Carcinoma of the Liver: A Case Report / 대한간학회지

Primary adenosquamous cell carcinoma of the liver, a variant of cholangiocarcinoma is very rare disease and its prognosis is known to be very poor. We describe here a case of primary adenosquamous carcinoma of the liver. The patient was a 60-year-old woman who complained of an eight-month history of intermittent upper abdominal pain. Abdominal computed tomography scan revealed a low density mass and intrahepatic duct stones within the dilated left intrahepatic duct in the left lateral segment. Needle biopsy of the mass was done and the histologic diagnosis was cholangiocarcinoma. Left lobectomy was then performed. Upon gross examination, there was a well defined solid mass and intrahepatic duct stone in the dilated bile duct. Microscopically, the tumor was composed of both adenocarcinoma and squamous cell carcinoma.

Intrahepatic Biloma after Transcatheter Arterial Chemoembolization: Evaluation of Imaging Findings, Clinical Course and Treatment

PURPOSE: We evaluated the imaging findings, clinical course and treatment of biloma after transcatheter arterial chemoemolization (TACE) of hepatocelluar carcinoma (HCC). MATERIALS AND METHODS: After TACE of HCC in 11 patients with intrahepatic biloma, the findings of dynamic CT and angiography were retrospectively analysed. Hemodynamic change occurring in the hepatic artery and portal vein, the presence of intrahepatic bile duct dilatation, and serum bilirubin levels were analyzed. Changes in the size of the biloma at follow-up study, the extent of additional management, and the overall clinical course were also analyzaed. RESULTS: Hepatic artery obliteration was observed in all cases; this involved the right hepatic artery in eight, and the segmental artery in three. There was decreased portal venous flow in seven cases and portal thrombosis in one. The intrahepatic duct was dilated in all cases but significantly elevated serum bilirubin levels were not noted. Follow-up study showed that in five cases the size of the biloma had increased; in four of these there was infection, and drainage was performed. In the remaining six cases the size of the biloma did not change, even where a segment or lobe had atrophied. CONCLUSION: Angiography showed that after TACE hepatic arterial obliteration occurred in all patients with intrahepatic biloma after TACE. During infection or where a biloma has increased in size, intervention is required.

Postoperative Recurrent Inflammatory Myofibroblastic Tumor of the Retroperitoneum: Case Report

Inflammatory myofibroblastic tumor is a rare benign condition of unknown etiology, and may simulate malignancy. Histologically, it is composed of myofibroblasts, plasma cells and histiocytes, and is found in the lung, liver, orbit, skin, mesentery, retroperitoneum and maxillary sinus. We report a case of postoperative recurrent inflammatory myofibroblastic tumor of the retroperitoneum, occurring in a 45-year old man who complained of a palpable abdominal mass.

Radiologic Differentiation Between Homogeneously Solid Renal Cell Carcinoma and Muscle-Predominant Renal Angiomyolipoma

PURPOSE: To compare the differential radiologic findings of renal cell carcinoma presenting as a homogeneous solid mass (HS-RCC) and muscle-predominant angiomyolipoma (MP-AML). MATERIALS AND METHODS: Nine of 76 surgically and pathologically proven RCCs presenting at CT or magnetic resonance (MR) imaging as a homogeneous solid mass, and four cases of MP-AML were included in this study. Echogenicity at sonography, attenuation at non-enhanced CT (NECT), the contour of the mass, signal intensities at T1- and T2-weighted MR imaging, the existence of a capsule, and the pattern and degree of enhancement at CT and MR imaging were retrospectively analyzed. RESULTS: Two of five HS-RCCs were isoechoic and three were hyperechoic. Two of three MP-AMLs, however, were isoechoic, and one was mixed echoic. All nine HS-RCCs were round or oval in shape, but three MPAMLs were lobulated and one was round. At NECT, seven of eight HS-RCCs were isodense and one was hypodense compared to surrounding normal renal parenchyme, but three MP-AMLs were hyperdense masses and one was isodense. At enhanced CT, HS-RCCs showed various degrees of homogeneous enhancement, but all MP-AMLs showed moderate homogeneous enhancement. All three MP-AMLs demonstrated heterogeneous hypointensity at T2-weighted MRI and homogeneous hypointensity at T1-weighted MRI. HS-RCCs showed various signal intensities at both T1- and T2-weighted MRI, and in five cases, heterogeneous high signal intensity at T2-weighted MRI. Capsules were observed in seven of nine HS-RCCs but not in any of the three MP-AMLs. At enhanced T1-weighted MRI, MP-AMLs showed mild to moderate enhancement, but HSRCCs showed mild, moderate, and strong enhancement in two, two, and five cases, respectively. CONCLUSION: Echogenicity, density at NECT, signal intensity at MR T2-WI, the contour of the mass, and the existence of a capsule are features which are useful in the differential diagnosis of HS-RCC and MP-AML.

A Case of Resection of Biloma with Hepatocellular Carcinoma after Embolization / 대한간학회지

Intrahepatic biloma is one of the rare complications occurring after transcatheter arterial chemoembolization (TACE). Biloma after TACE may result from the development of peripheral bile duct necrosis caused by microvascular damage of the peribiliary capillary plexus, and intrahepatic ductal stenosis. We report a case of resection of intrahepatic biloma with hepatocellular carcinoma after TACE.

MR Imaging of Normal Ovary in Menstruating Women: Detection Rate and Size of the Ovary and the Number and Size of the Follicle According to the Age

PURPOSE: To determine the rates at which normal ovaries in women of reproductive age were observed at MRI, as well as differences in the size of a normal ovary and follicles, and the number of follicles, according to age. MATERIALS AND METHODS: The MRI findings in 46 patients with normal ovaries were retrospectively analysed and proven grossly at surgery and/or pathologically. The detection rate and size of the ovaries, and the number of follicles and size of the largest were determined, and differences were analyzed according to age: under 30, 30-39, and 40 years or over. RESULTS: Among 46 patients, bilateral ovaries were detected in 39 and unilateral ovary in seven. The overall detection rate was 92.4% (85/92), varying according to age. It was 100% (18/18) in those aged under 30, 95% (38/40) in the 30-40 age group, and 85.3% (29/34) among those aged 40 or over. Ovary size ranged between 15 and 50 (average, 24.3) mm and was most commonly 20-30 mm, regardless of age (60%). The average size was 28.8 mm under 30 years of age, 25.3 mm between 30 and 39, and 20.3 mm at age 40 or over (p<0.01). The number of follicles was recorded as 2, 3, 4, or 5 or more, with 10.6%, 23.5%, 18.8% and 47.1% of patients, respectively, assigned to these categories. Among those aged 30-39, ovaries containing five or more follicles were most common, with 83.3% of those under 30 and 47.4% of those aged 30-39 falling into this category. Among patients aged 40 or over, only 24.1% of ovaries contained five or more follicles; most (37.9%) contained three (p<0.05). The size of the largest follicle ranged from 2 to 30 mm and, regardless of age, 5-10-mm follicles were most common (43.5%). There were no significant differences according to age. CONCLUSION: MRI is a useful tool for detecting normal ovaries in women of reproductive age. We found that most normal ovaries were 20-30 mm in size and contained five follicles or more, the largest follicle being 5-10 mm. The size of an ovary and the number of follicles decreased significantly with age.

A Case of Nodular Hepatic Involvement of Multiple Myeloma Mimicking Hypervascular Hepatocellular Carcinoma / 대한간학회지

Nodular hepatic involvement of multiple myeloma is very rare. We report a case of nodular hepatic involvement of multiple myeloma, mimicking hypervascular hepatocellular carcinoma.

Primitive Neuroectodermal Tumor of the Kidney: A Case Report

Primitive neuroectodermal tumor (PNET) is relatively uncommon, arising outside the central nervous system. Very rarely, it occurs within the urinary system. A 55-year-old woman presented with gross hematuria and right flank pain which had begun two months earlier. A well-marginated, low-density mass containing high-density portions representing hemorrhage was seen in the right kidney at pre-enhanced CT; contrast enhancement was not prominent. At both T1- and T2- weighted MR imaging, a multilocular cystic mass with high signal intensity portions representing hemorrhage was observed. Contrast enhancement was absent. We report the radiologic findings in this case of renal PNET.