Giant exophytic gastrointestinal stromal tumor (GIST) causing gastric outlet obstruction: case report and review of literature.

BACKGROUND: Gastrointestinal stromal tumors (GISTs) are rare mesenchymal tumors, mostly located within the stomach. About 30% of GISTs are incidentally diagnosed and as they become symptomatic may be associated with bleeding, bowel obstruction or spontaneous rupture. CASE PRESENTATION: We present the case of a middle-aged patient diagnosed with a giant gastric GIST, which presented for intermittent gastric outlet obstruction symptoms, and emphasize the major imagistic, histopathological, and therapeutic challenges that may be encountered. There are only several cases of gastric exophytic gastric GIST provoking intermittent gastric outlet obstruction. Tumor resection should be adapted to every patient's status, focused on en bloc extraction, with preservation of invaded organs as much as possible.

Perceived Stress in Hepatitis C Virus Infected Patients under the DAA-Based Therapy.

The Hepatitis C Virus (HCV) infection often associates medical and mental health conditions which lead to increased levels of distress. Our study aimed at assessing the level of perceived stress on a sample of 90 HCV infected patients treated with Direct-Acting Antiviral (DAA) agents for 12 weeks, and its possible correlations with clinical and evolutionary elements. The evaluation was conducted in three phases: before administration of the DAAs (BSL), at the End of the Treatment (EOT), and 24 weeks after the BSL (Sustained Viral Response­SVR). The perceived stress was measured using the Perceived Stress Scale (PSS). The efficiency of the DAA treatment reduced the levels of stress (98.99% moderate and high stress at BSL to 70.00% at SVR). It was observed, for the entire study period (BSL to SVR), that the decrease in the perceived stress severity was significantly associated with demographic items such as gender (p < 0.01), urban environment (p < 0.001), the age of the subjects (p < 0.05), and clinical data such as F4 degree of fibrosis (p = 0.001) and overweight or obesity class II (p < 0.01). The perceived stress is directly associated with the severity of the HCV infection, and it could be significantly lowered by an efficient therapeutic approach, as DAAs are nowadays.

Depressive and Anxious Symptoms in Hepatitis C Virus Infected Patients Receiving DAA-Based Therapy.

Hepatitis C virus (HCV) represents the most important etiologic factor for advanced fibrosis/cirrhosis and hepatocellular carcinoma associated with a psychological dimension. Our study aims to assess, on a sample comprising of 90 HCV-infected subjects (96.67% F3-F4 METAVIR), the relationship between Direct-Acting Antiviral (DAA) therapies and the psychological effects of the liver disease, focused on the anxious and depressive symptoms. The comprehensive evaluation was done before starting the DAA treatment (BSL), after 12 weeks (End of Treatment-EOT), respectively after another 12 weeks (Sustained Viral Response-SVR). Presumable depressive and/or anxious symptoms were evaluated by Hospital Anxiety and Depression Scale (HADS). The reported depressive symptoms decreased from 21.11% (BSL) to 1.11% (SVR) (p < 0.00001), while the anxious ones dropped from 43.34% (BSL) to 4.44% (SVR) (p < 0.00001), without a clear evolutionary pattern. We identified no statistically significant interaction between comorbidities (anemia, CKD, obesity) over HADS scores evolution (p > 0.05), while the DAAs side-effects (fatigue, headache, pruritus) significantly influenced the anxious and depressive symptoms (p < 0.05). During and after the DAA-based therapy, patients with HCV infection presented a significantly reduced rate of the associated depressive and anxious relevant symptoms.

Contrast-enhanced ultrasound for the assessment of focal nodular hyperplasia - results of a multicentre study.

AIM: Contrast-enhanced ultrasound (CEUS) has become a relevant imaging method for the evaluation of focal liver le-sions (FLL). The aim of this study was to evaluate the performance of CEUS for the assessment of focal nodular hyperplasia (FNH) in a large study group. MATERIAL AND METHODS: We performed a multicentre prospective observational study, which included successive CEUS examinations from fourteen Romanian centres. CEUS examinations were performed in de novo FLL, using low mechanical index ultrasound, following an intravenous bolus of 2.4 ml SonoVue. CEUS was considered conclusive for FNH if a typical pattern was present following contrast (rapid "spoke-wheel" enhancement during the arterial phase, hyperenhanced lesion during venous phase, hyper- or isoenhanced in the late phase). In all cases a reference method was available (contrast enhanced CT or MRI or biopsy). The trial was registered in clinicaltrials.gov (Identifier NCT01329458). RESULTS: During the 6 years study, 2062 "de novo" FLL were evaluated by CEUS. From this cohort, 94/2062 (4.5%) had a typical enhancing pattern for FNH as described in the EFSUMB guidelines. Contrast enhanced CT/MRI and biopsy diagnosed additional 15 FNH. From the 94 cases diagnosed as FNH by CEUS, in nine the final diagnosis was different (five of them adenomas). CEUS had 85% sensitivity, 99.5% specificity, 90.4% positive predictive value, 99.2% negative predictive value and 98.8% diagnostic accuracy for the diagnosis of FNH. CONCLUSIONS: CEUS is a sensitive and very specific method for the diagnosis of FNH.

Contrast-Enhanced Ultrasound for the Characterization of Malignant versus Benign Focal Liver Lesions in a Prospective Multicenter Experience - The SRUMB Study.

AIM: This study evaluated the accuracy of contrast-enhanced ultrasound (CEUS) for the differential diagnosis of benign vs. malignant focal liver lesions (FLL) in a real-life, multicenter experience. METHODS: This prospective study, including 14 Romanian centers, was performed over a 6 year period (February 2011- April 2017) and included 2062 FLLs assessed by CEUS. Inclusion criteria were: newly diagnosed FLL on B-mode ultrasound, less than three lesions/patient, all FLLs evaluated by CEUS and by a second-line imaging technique (contrast enhanced CT or contrast enhanced MRI) or histology, considered as reference. The trial was registered in clinicaltrials.gov (Identifier NCT01329458). RESULTS: From the 2062 FLLs included in the study, 57.2% (1179) were malignant and 42.8% (883) were benign. CEUS had 83.9% sensitivity (Se), 97.8% specificity (Sp), 98.1% positive predictive value (PPV), 82.2% negative predictive value (NPV) and a diagnostic accuracy (Ac) of 89.9% for the positive diagnosis of malignant lesions. For the benign lesions, CEUS had 97.8% Se, 83.9% Sp, 82.2% PPV, 98.1% NPV 89.9% Ac. The diagnostic performance of CEUS for hepatocellular carcinoma was 76.6% Se, 98.4% Sp, and 91.2% Ac; for hemangioma: 89.2% Se, 99% Sp, and 96.9% Ac and for metastases: 90.9% Se, 98.4% Sp, and 96.9% Ac. CONCLUSIONS: CEUS proved a high accuracy in differentiating the malignant vs. benign character of a FLL. It can be confidently used as a first line imaging method in daily practice.

Left gluteal metastasis from a hepatocellular carcinoma - an unusual finding.

Hepatocellular carcinoma (HCC) is the primary malignant tumor of the liver that is directly derived from parenchymal cells. It is usually encountered in patients already suffering from a long-established liver disease that has evolved past the stage of liver cirrhosis. It is usually associated with viral liver infections, alcohol consumption or other dietary habits that lead to liver damage. Metastases are not rare and are usually found incidentally after a period of monitoring the main liver disease. We present here a rare case of HCC metastasis found in the right gluteal region, in a hepatitis C virus-infected patient also displaying lung tumor lesions. Diagnosis of both the metastasis and of the primary tumor were found during the same hospital visit, employing contrast-enhanced computed tomography, magnetic resonance imaging and ultrasound (US), with positive biopsy of the metastatic lesion, performed under US guidance. The patient received oncological treatment, with good prognosis and stable evolution during the next eight months since diagnosis.

A rare case of ovarian splenosis.

Splenosis is a very rare entity that often appears following a traumatic rupture of the spleen or after splenectomy and represents heterotopic transplantation of splenic tissue. The ovary is reported as an atypical and rare localization. We report a case of a middle-aged woman, which presented with a left adnexal mass. Transvaginal ultrasonography, computed tomography (CT) and high-field 3T magnetic resonance imaging (MRI) revealed the left adnexal mass. Laparoscopy was performed, and histological and immunohistochemical examination revealed that resected mass was splenic tissue.

Contrast enhanced ultrasound for the diagnosis of liver hemangiomas - results of a Romanian multicentre study.

BACKGROUND AND AIM: Contrast enhanced ultrasound (CEUS) has been proven to be a reliable method for the characterization of focal liver lesions (FLL). The aim of this paper was to evaluate the performance of CEUS for the diagnosis of liver hemangiomas in a large cohort of patients. MATERIAL AND METHOD: We performed a multicentre prospective study which included successive CEUS examinations from fourteen centers from Romania. CEUS examinations were performed in de novo FLL, using low mechanical index ultrasound, following an intravenous bolus of 2.4 ml SonoVue. CEUS was considered conclusive for hemangioma if a typical pattern was present following contrast (centripetal fill in during the arterial phase, hyperenhanced lesion during venous and late phases). In all cases a reference method was available (contrast CT or MRI or biopsy). The trial was registered in clinicaltrials.gov (Identifier NCT01329458). RESULTS: During February 2011 - May 2015, 1153 CEUS examinations were performed for the evaluation of de novo FLL. Out of the 1153 de novo FLL, 238 cases were diagnosed as hemangiomas by CEUS (typical enhancing pattern). Contrast CT/MRI and biopsy diagnosed additional 24 hemangiomas. From the 238 cases diagnosed as hemangiomas by CEUS, in 11 the final diagnosis was different. Considering contrast CT/MRI and biopsy as reference methods, CEUS had 90.4% sensitivity, 98.8% specificity, 95.4% positive predictive value, 97.4% negative predictive value, resulting in 96.9% diagnostic accuracy for the diagnosis of hemangiomas. CONCLUSION: CEUS is a sensitive and very specific method for the diagnosis of hemangiomas.

Hybrid ultrasound imaging techniques (fusion imaging).

Visualization of tumor angiogenesis can facilitate non-invasive evaluation of tumor vascular characteristics to supplement the conventional diagnostic imaging goals of depicting tumor location, size, and morphology. Hybrid imaging techniques combine anatomic [ultrasound, computed tomography (CT), and/or magnetic resonance imaging (MRI)] and molecular (single photon emission CT and positron emission tomography) imaging modalities. One example is real-time virtual sonography, which combines ultrasound (grayscale, colour Doppler, or dynamic contrast harmonic imaging) with contrast-enhanced CT/MRI. The benefits of fusion imaging include an increased diagnostic confidence, direct comparison of the lesions using different imaging modalities, more precise monitoring of interventional procedures, and reduced radiation exposure.

Molecular bases of hepatic fibrogenesis - genetic and therapeutical implications in chronic viral C hepatitis.

Hepatitis C virus represents one of the major health problems of actual world, as almost 170 million of world population and 1 million persons in Romania are infected with HCV. Considering the increasing importance of HCV, it is imposed that we elucidate the molecular mechanisms, which are the base of hepatic fibrogenesis and potential targets for therapy, for diminishing progression to cirrhosis and avoid the appearance of complications. Activation of stellate cells is the main event in hepatic fibrosis. They also express almost all key components needed for the pathological degradation of matrix and that is why they play an important role not only in the production, but also in the degradation of the matrix. Recently, the worldwide research has also been oriented towards another type of cells with possible function in fibrogenesis and response to antiviral therapy: hepatic progenitor cells. The presence of hepatic progenitor cells in chronic C viral hepatitis is associated with severity of the disease, grade of fibrosis and the risk of hepatocarcinoma. Traditionally perceived as irreversible, reversibility of advanced fibrosis has been described recently in antiviral therapy trials for chronic C viral hepatitis. The favorable effect of interferon therapy on hepatic histology, including fibrosis, has been shown even in patients without sustained virusological response. During the last years, the advantages of the so-called support therapy using interferon have been demonstrated in patients with an increased rate in progression of fibrosis. Further research of the factors associated with progression of fibrosis will allow optimization of criteria for patient's antiviral therapy.