Scirrhous hepatocellular carcinoma displaying atypical findings on imaging studies

We describe a 15-mm scirrhous hepatocellular carcinoma （HCC） in a 60-year-old man with B-type cirrhosis. Ultrasound disclosed a 15-mm hypoechoic nodule in segment 7. Contrast-enhanced US revealed heterogeneous, not diffuse, hypervascularity in the early phase and a defect in the Kupffer phase.Contrast-enhanced computed tomography （CT） revealed a heterogeneous hypervascular nodule in the early phase and a low-density area in the late phase.Magnetic resonance imaging （MRI） revealed iso- to hypointensity at T1 and high intensity at T2-weighted sequences. Contrast-enhanced MRI also revealed a heterogeneous hypervascular nodule in the early phase and washout in the late phase. Super-paramagnetic iron oxide-MRI revealed a hvoerintense nodule. CT during hepatic arteriography and CT during arterial portography revealed heterogeneous hyperattenuation and a perfusion defect, respectively. Based on these imaging findings the nodule was diagnosed as a mixed well-differentiated and moderately-differentiated HCC.Histologically, the nodule was moderately-differentiated HCC characterized by typical cytological and structural atypia with dense fibrosis. Immunohistochemically,the nodule was positive for heterochromatin protein 1 and alpha-smooth muscle actin, and negative for cytokeratin 19. From the above findings, the nodule was diagnosed as scirrhous HCC. Clinicians engaged in hepatology should exercise caution with suspected scirrhous HCC when imaging studies reveal atypical findings, as shown in our case on the basis of chronic liver disease.

Capillary refill time as a guide for operational decision-making process of autoimmune pancreatitis:Preliminary results

AIM: To investigate the efficacy of a novel intraoperative diagnostic technique for patients with preliminary diagnosis of autoimmune pancreatitis(AIP).METHODS: Patients with pancreatic surgery were reviewed to identify those who received a preliminary diagnosis of AIP between January 2010 and January 2014. The following data were collected prospectively for patients with a pathological diagnosis of AIP: clinical and demographic features, radiological and operative findings, treatment procedure, and intraoperative capillary refill time(CRT) in the pancreatic bed.RESULTS: Eight patients(six males, two females; mean age: 51.4 years) met the eligibility criteria of pathologically confirmed diagnosis. The most frequent presenting symptoms were epigastric pain and weight loss. The most commonly conducted preoperative imaging studies were computed tomography and endoscopic retrograde pancreaticodoudenography. The most common intraoperative macroscopic observations were mass formation in the pancreatic head and diffuse hypervascularization in the pancreatic bed. All patients showed decreased CRT(median value: 0.76 s, range: 0.58-1.35). One-half of the patients underwent surgical resection and the other half received medical treatment without any further surgical intervention. CONCLUSION: This preliminary study demonstrates a novel experience with measurement of CRT in the pancreatic bed during the intraoperative evaluation of patients with AIP.

Detection of hypervascular hepatocellular carcinoma: Comparison of multi-detector CT with digital subtraction angiography and Lipiodol CT

AIM: The purpose of this study was to compare the diagnostic accuracy of biphasic multi-detector row helical computed tomography (MDCT), digital subtraction angiography (DSA)and Lipiodol computed tomography (CT) in detection of hypervascular hepatocellular carcinoma (HCC).METHODS: Twenty-eight patients with nodular HCC underwent biphasic MDCT examination: hepatic arterial phase (HAP) 25 s and portal venous phase (PVP) 70 s after injection of the contrast medium (1.5 mL/kg). They also underwent hepatic angiography and intra-arterial infusion of iodized oil. Lipiodol CT was performed 3-4 wk after infusion. MDCT images were compared with DSA and Lipiodol CT images for detection of hepatic nodules.RESULTS: The three imaging techniques had the same sensitivity in detecting nodules ＞20 mm in diameter. There was no significant difference in the sensitivity among HAP-MDCT, Lipiodol CT and DSA for nodules of 10-20 mm in diameter. For the nodules ＜10 mm in diameter, HAP-MDCT identified 47, Lipiodol CT detected 27 (X2= 11.3, P= 0.005＜0.01, HAP-MDCT vs Lipiodol CT) and DSA detected 16(X2= 9.09, P= 0.005＜0.01 vs Lipiodol CT and X2= 29.03,P = 0.005＜0.01 vs HAP-MDCT). However, six nodules ＜10 mm in diameter were detected only by Lipiodol CT.CONCLUSION: MDCT and Lipiodol CT are two complementary modalities. At present, MDCT does not obviate the need for DSA and subsequent Lipiodol CT as a preoperative examination for HCC.

Application of Intraoperative Contrast-Enhanced Ultrasound in the Resection of Brain Tumors

Objective:To investigate the value of routine intraoperative ultrasound(IU)and intraoperative contrast-enhanced ultrasound(ICEUS)in the surgical treatment of brain tumors,and to explore the utilization of ICEUS for the removal of the remnants surrounding the resection cavity.Methods:In total,51 patients who underwent operations from 2012 to 2018 due to different tumors in the brain were included in this study.The clinical data were evaluated retrospectively.IU was performed in all patients,among which 28 patients underwent ICEUS.The effects of IU and ICEUS on tumor resection and recurrence were evaluated.

Clinical value of gadoxetic acid-enhanced magnetic resonance imaging in surgery for hepatocellular carcinoma- with a special emphasis on early hepatocellular carcinoma

Gadoxetic acid- or gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid-enhanced magnetic resonance imaging(EOB-MRI) achieves excellent lesion detection and characterization for both hypervascular hepatocellular carcinoma(HCC) in arterial phase imagingand hypovascular early HCC(small well-differentiated HCC of the vaguely nodular type) in hepatobiliary phase imaging, and has become an indispensable imaging modality in the treatment of HCC. Early HCCs have been detected more frequently since the introduction of EOB-MRI into daily clinical practice. Early HCC is known to progress to conventional hypervascular HCC, and many risk factors have been identified for the hypervascularization of early HCC including the diameter of the tumor, presence of fat, and imaging findings of EOB-MRI. The rate of the development of hypervascular HCC was previously reported to be high in patients with chronic liver disease and early HCC. The presence of early HCC is regarded as a predictor for the recurrence of HCC following hepatic resection. On the other hand, although early HCC itself is currently not regarded as a target lesion for hepatic resection, early HCC at high risk of hypervascularity needs to be treated by local ablation therapy. If concomitant early HCC with progressed HCC is at high risk of hypervascularization and the functional liver reserve of a patient is sufficient, its simultaneous treatment at the time of hepatic resection for progressed HCC is recommended. Further studies on larger numbers of patients are needed before this strategy is adopted.

Hypervascular aoustic tumor

objective: To explore the surgical treatment of hypervascular acoustic tumor (HAT). Methods: In past ten years (1975–1985) there were 90 patients with unilateral acoustic tumors were treated by surgery. Among them (4 cases of HAT and 86 cases of nonhypervascular acoustic tumors, NHATs) were retrospectively reviewed and clinical characteristics, radiological and surgical finding were compared. Results: HATs presented at a younger age than NHATs (28±10 vs. 54±17 years old) (P<0.01). MRI showed that HATs was solid, without tumor cyst, and larger than NHATs significantly (P<0.05). The surface of HATs consistently showed multiple flow voids representing large draining veins. The characteristic angiographical findings of HATs were extensive tumor vessels, tumor stains and early filling of draining veins; Vertebrobasilar arteries supplied HATs. The authors preferred the control hypotension anaesthesia to remove HATs and got total resection of 4 cases of HATs successfully. No patients has needed transfusion or suffered any other complications after operation. Conclusion: HATs was a solid tumor presented at young. Angiographical findings may provide characteristic manifestation, and could be managed by control hyper- tension in one-stage surgical approach.

Direct intratumoral embolization of hypervascular tumors of the head and neck

To evaluate a devascularization technique for hypervascular tumors of the head and neck by direct intratumoral puncture Methods Six cases of hypervascular tumor of the head and neck were reviewed, focusing on findings from digital subtraction angiography and preoperative direct intratumoral embolization and their effects after the operation Results Total devascularization by complete embolization was achieved in 2 cases: 1 nasopharyngeal angiofibroma and 1 spongiform tumor, both of which were completely excised endoscopically with blood loss of 60 ml Incomplete devascularization through 80%-90% embolization was achieved in the other 4 cases: 1 paraganglioma was totally removed with 800 ml of blood loss, 1 hemangioblastoma was not completely excised with 400 ml of blood loss and 2 nasopharyngeal angiofibromas involving the intracranial region were partially eliminated with a total blood loss of 1600 ml Conclusion The new technique of preoperative embolization of hypervascular tumors of the head and neck by direct intratumoral puncture, which can decrease blood loss during the accompanying tumor resection and increase the possibility of complete tumor removal, is feasible, convenient, safe, and effective

Clinical significance of interventional therapeutic bronchoscopy combined with bronchial arterial embolization in the treatment of hypervascular primary airway tumors in children

Importance Pediatric hypervascular primary airway tumors are progressive,fatal lesions with a low incidence,and the disease is often more serious than that in adults.Objective To evaluate the clinical efficacy and safety of interventional therapeutic bronchoscopy combined with conservative treatment and bronchial arterial embolization in children with primary airway tumors.Methods We retrospectively analyzed the clinical data of four pediatric patients with hypervascular primary airway tumor between 2017 and 2019 at Beijing Children’s Hospital.Results Two patients were low-grade bronchial mucoepidermoid carcinoma,one patient was pleomorphic adenoma,and one was bronchial leiomyoma.Interventional therapeutic bronchoscopy combined with bronchial arterial embolization was used for treatment(all four patients received general anesthesia).The tumors were safely resected in all patients via interventional bronchoscopy.There were no severe complications related to the procedures.All patients were followed up for 5–12 months,and one low-grade bronchial mucoepidermoid carcinoma recurred.Interpretation Interventional therapeutic bronchoscopy combined with bronchial arterial embolization appears to be a safe and efficient therapeutic method associated with less trauma and fewer complications,including no serious adverse events,in children with hypervascular primary airway tumors without bronchus wall infiltration.