Imaging characteristics of hypervascular focal nodular hyperplasialike lesions in patients with chronic alcoholic liver disease

BACKGROUND Focal nodular hyperplasia(FNH)-like lesions are hyperplastic formations in patients with micronodular cirrhosis and a history of alcohol abuse.Although pathologically similar to hepatocellular carcinoma(HCC)lesions,they are benign.As such,it is important to develop methods to distinguish between FNH-like lesions and HCC.AIM To evaluate diagnostically differential radiological findings between FNH-like lesions and HCC.METHODS We studied pathologically confirmed FNH-like lesions in 13 patients with alco-holic cirrhosis[10 men and 3 women;mean age:54.5±12.5(33-72)years]who were negative for hepatitis-B surface antigen and hepatitis-C virus antibody and underwent dynamic computed tomography(CT)and magnetic resonance imaging(MRI),including superparamagnetic iron oxide(SPIO)and/or gadoxetic acid-enhanced MRI.Seven patients also underwent angiography-assisted CT.RESULTS The evaluated lesion features included arterial enhancement pattern,washout appearance(low density compared with that of surrounding liver parenchyma),signal intensity on T1-weighted image(T1WI)and T2-weighted image(T2WI),central scar presence,chemical shift on in-and out-of-phase images,and uptake pattern on gadoxetic acid-enhanced MRI hepatobiliary phase and SPIO-enhanced MRI.Eleven patients had multiple small lesions(<1.5 cm).Radiological features of FNH-like lesions included hypervascularity despite small lesions,lack of“corona-like”enhancement in the late phase on CT during hepatic angiography(CTHA),high-intensity on T1WI,slightly high-or iso-intensity on T2WI,no signal decrease in out-of-phase images,and complete SPIO uptake or incomplete/partial uptake of gadoxetic acid.Pathologically,similar to HCC,FNH-like lesions showed many unpaired arteries and sinusoidal capillarization.CONCLUSION Overall,the present study showed that FNH-like lesions have unique radiological findings useful for differential diagnosis.Specifically,SPIO-and/or gadoxetic acid-enhanced MRI and CTHA features might facilitate differential diagnosis of FNH-like lesions and HCC.

Microstructure and properties of LZQT600-3 HCCDIBs for plunger pump cylinder

It is important to improve the comprehensive performance of the ductile iron bars(DIBs)for the cylinder block of the extra high pressure hydraulic plunger pump and accelerate the industrial application.In this work,the LZQT600-3 DIBs with the diameter of 145 mm were prepared by the horizontal continuous casting(HCC)process,that is,LZQT600-3 HCCDIBs.The microstructure and room temperature tensile properties of different sections[left-edge(surface layer),left-1/2R(left half of the radius),and the center of the HCCDIBs]were studied.The results show that the spheroidization of LZQT600-3 HCCDIBs matrix from the left-edge,left-1/2R to the center is at nodulizing grade II and above.As the cooling rate gradually decreases from surface to the center of the HCCIBs,the number of spheroidized graphite is gradually reduced,the size is gradually increased,the shape factor is decreased,and the pearlite content and lamellate spacing are increased.Along the horizontal direction of the section,the hardness of the material is distributed symmetrically around the center of the HCCDIBs.In the vertical direction,the hardness distribution in the center of the HCCDIBs is asymmetrical due to the gravity during the solidification process.Therefore,the microstructure in the lower part of the section solidifies relatively quickly.The left-edge has the best tensile mechanical properties,and the ultimate tensile strength,yield tensile strength and elongation are 597.3 MPa,418.5 MPa and 9.6%,respectively.The tensile fracture belongs to the ductile-brittle hybrid fracture.The comprehensive performances of LZQT600-3 HCCDIBs meet the actual application requirements of ultra-high pressure hydraulic plunger pump cylinder.

Primary pulmonary meningioma and minute pulmonary meningothelial-like nodules: Rare pulmonary nodular lesions requiring more awareness in clinical practice

In this editorial,we comment on an article by Ruan et al published in a recent issue of the World Journal of Clinical Case.Pulmonary meningothelial proliferative lesions,including primary pulmonary meningiomas,minute pulmonary meningothelial-like nodules,and metastatic pulmonary meningiomas are rare pulmonary lesions.These lesions are difficult to differentiate from lung cancers based on clinical and imaging manifestations.Herein,we briefly introduce the clinical,imaging,and pathological characteristics of these lesions and discuss their pathogenesis to strengthen the current understanding of pulmonary meningothelial proliferative lesions in clinical diagnosis and therapy.

Nodular Pulmonary Amyloidosis with Interstitial Lung Disease—Case Report and Literature Review

Amyloidosis is a rare spectrum of disease which involves deposition of misfolded extracellular proteins (amyloids) in various body organs leading to progressive organ dysfunction. Clinical presentation can be variable depending on the organ involved and type of protein. Amyloidosis can be classified based on quantity, type, and location of these proteins. Amyloid light-chain amyloidosis develops in the bone marrow, producing abnormal forms of light-chain proteins, which cannot be broken down. These proteins transform into amyloid fibrils and form amyloid deposits in different organs. Pulmonary amyloidosis is uncommonly diagnosed since it is rarely symptomatic. Diagnosis of pulmonary amyloidosis is usually made in the setting of systemic amyloidosis;however, it may present as localised pulmonary disease. Localized pulmonary Amyloidosis can present as nodular, cystic, or tracheobronchial amyloidosis. Depending on the degree of the interstitial involvement, it may affect alveolar gas exchange and cause respiratory symptoms. This is a case of a 47-year-old female with background history of interstitial lung disease presenting with progressive shortness of breath. Computed tomography scan revealed bilateral pulmonary nodules. The patient was referred to our thoracic surgery team with the suspicion of bronchogenic malignancy with metastasis. Diagnostic video assisted wedge resection was performed for this patient, and histology confirmed pulmonary amyloidosis of nodular type. Amyloid deposition simulates both inflammatory and neoplastic conditions. Definitive diagnosis requires biopsy confirmation therefore early detection and commencing the patient on appropriate treatment pathway may help in symptomatic relief and better outcome.

结节性类弹性纤维病一例

结节性类弹性纤维病（nodular elastoidosis）是一种日光弹力组织变性,笔者曾收治1例,现报道如下。1临床资料患者,男,69岁,因面部起皮疹7年就诊。患者7年前发现面部出现大片皮色丘疹及黑头粉刺,无自觉症状,一直未曾就诊,后皮损逐渐增多,自行外用多种外用软膏,无明显效果。

Effects of Different Processes on Phases and Service Performance of FeSiMg8RE5 Alloy

The difference of nodularizer in phase morphology and service performance by three processes was introduced.The three processes include directly pressing magnesium into molten alloy stirring by nitrogen gas and no stirring from 5 t arc furnace and melting magnesium in the intermediate frequency furnace.The microstructure patterns were observed by scanning electron microscope, and composition of phases was measured by energy dispersive spectrometer method.X-ray diffraction method was used to determine the phase structure of the nodularizer.The results show that spheroidizing reaction time and violent degree of nodularizers are influenced by grain size and distribution uniformity of siliconizing magnesium phase; spheroidizing reaction degree can be mitigated and spheroidizing time be increased by using N2 stirring in pressing magnesium from arc furnace.

Characterization of focal liver masses using acoustic radiation force impulse elastography

AIM:To investigate the diagnostic performance of acoustic radiation force impulse(ARFI) elastography for characterizing focal liver mass by quantifying their stiffness.METHODS:This prospective study included 62 patients with a focal liver mass that was well visualized on conventional ultrasonography performed in our institution from February 2011 to November 2011.Among them,12 patients were excluded for ARFI measurement failure due to a lesion that was smaller than the region of the interest and at an inaccessible location(deeper than 8 cm)(n = 7) or poor compliance to hold their breath as required(n = 5).Finally,50 patients with valid ARFI measurements were enrolled.If a patient had multiple liver masses,only one mass of interest was chosen.The masses were diagnosed by histological examination or clinical diagnostic criteria.During ultrasonographic evaluation,stiffness,expressed as velocity,was checked 10 times per focal liver mass and the surrounding liver parenchyma.RESULTS:After further excluding three masses that were non-diagnostic on biopsy,a total of 47 focal mass lesions were tested,including 39(83.0%) malignant masses [24 hepatocellular carcinomas(HCC),seven cholangiocellular carcinomas(CCC),and eight liver metastases] and eight(17.0%) benign masses(five hemangiomas and three focal nodular hyperplasias,FNH).Thirty-seven(74.0%) masses were confirmed by histological examination.The mean velocity was 2.48 m/s in HCCs,1.65 m/s in CCCs,2.35 m/s in metastases,1.83 m/s in hemangiomas,and 0.97 m/s in FNHs.Although considerable overlap was still noted between malignant and benign masses,significant differences in ARFI values were observed between malignant and benign masses(mean 2.31 m/s vs 1.51 m/s,P = 0.047),as well as between HCCs and benign masses(mean 2.48 m/s vs 1.51 m/s,P = 0.006).The areas under the receiver operating characteristics curves(AUROC) for discriminating the malignant masses from benign masses was 0.724(95%CI,0.566-0.883,P = 0.048),and the AUROC for discriminating HCCs from benign masses was 0.813(95%CI,0.649-0.976,P = 0.008).To maximize the sum of sensitivity and specificity,an ARFI value of 1.82 m/s was selected as the cutoff value to differentiate malignant from benign liver masses.Furthermore,the cutoff value for distinguishing HCCs from benign masses was also determined to be 1.82 m/s.The diagnostic performance of the sum of the ARFI values for focal liver masses and the surrounding liver parenchyma to differentiate liver masses improved(AUROC = 0.853;95%CI,0.745-0.960;P = 0.002 in malignant liver masses vs benign ones and AUROC = 0.948;95%CI,0.896-0.992,P < 0.001 in HCCs vs benign masses).CONCLUSION:ARFI elastography provides additional information for the differential diagnosis of liver masses.However,our results should be interpreted in clinical context,because considerable overlap in ARFI values existed among liver masses.

Endoscopic Kyoto classification of Helicobacter pylori infection and gastric cancer risk diagnosis

Recent advances in endoscopic technology allow detailed observation of the gastric mucosa.Today,endoscopy is used in the diagnosis of gastritis to determine the presence/absence of Helicobacter pylori(H.pylori)infection and evaluate gastric cancer risk.In 2013,the Japan Gastroenterological Endoscopy Society advocated the Kyoto classification,a new grading system for endoscopic gastritis.The Kyoto classification organized endoscopic findings related to H.pylori infection.The Kyoto classification score is the sum of scores for five endoscopic findings(atrophy,intestinal metaplasia,enlarged folds,nodularity,and diffuse redness with or without regular arrangement of collecting venules)and ranges from 0 to 8.Atrophy,intestinal metaplasia,enlarged folds,and nodularity contribute to gastric cancer risk.Diffuse redness and regular arrangement of collecting venules are related to H.pylori infection status.In subjects without a history of H.pylori eradication,the infection rates in those with Kyoto scores of 0,1,and≥2 were 1.5%,45%,and 82%,respectively.A Kyoto classification score of 0 indicates no H.pylori infection.A Kyoto classification score of 2 or more indicates H.pylori infection.Kyoto classification scores of patients with and without gastric cancer were 4.8 and 3.8,respectively.A Kyoto classification score of 4 or more might indicate gastric cancer risk.

Nodular regenerative hyperplasia:Evolving concepts on underdiagnosed cause of portal hypertension

Nodular regenerative hyperplasia(NRH)is a rare liver condition characterized by a widespread benign transformation of the hepatic parenchyma into small regenerative nodules.NRH may lead to the development of non-cirrhotic portal hypertension.There are no published systematic population studies on NRH and our current knowledge is limited to case reports and case series.NRH may develop via autoimmune,hematological,infectious,neoplastic,or drug-related causes.The disease is usually asymptomatic,slowly or nonprogressive unless complications of portal hypertension develop.Accurate diagnosis is made by histopathology,which demonstrates diffuse micronodular transformation without fibrous septa.Lack of perinuclear collagen tissue distinguishes NRH from typical regenerative nodules in the cirrhotic liver.While the initial treatment is to address the underlying disease,ultimately the therapy is directed to the management of portal hypertension.The prognosis of NRH depends on both the severity of the underlying illness and the prevention of secondary complications of portal hypertension.In this review we detail the epidemiology,pathogenesis,diagnosis,management,and prognosis of NRH.

Focal nodular hyperplasia of the liver in 86 patients

BACKGROUND: Focal nodular hyperplasia (FNH), the second most common benign hepatic tumor after hemangioma, is characterized by a stellate central scar and hyperplastic nodules. Although some large FNH may be associated with significant symptoms, more frequently they are discovered incidentally on physical examination or the work-up of unrelated symptoms. Since its nature and pathogenesis are still controversial, accurate diagnosis of FNH based on clinical presentation and radiographic studies is difficult. The purpose of this study was to explore the diagnosis and treatment of FNH. METHODS: Eighty-six FNH patients confirmed pathologically were treated at the Liver Cancer Institute in our hospital from 1996 to 2006. Their clinical manifestions, imaging presentation, pathological findings, and surgical results were analyzed retrospectively. RESULTS: Of the 86 patients with 99 foci, 54 were male and 32 female, with a mean age of 37 years. Eighty patients had a single solitary focus and 6 had multiple foci. Tumor diameter was less than 5 cm in 69 patients, 5-10 cm in 15, and more than 10 cm in 2. The overall rate of correct preoperative diagnosis was 59.3% (51/86) including 32.9% (26/79) by color Doppler flow imaging (CDFI), 60.3% (35/58) by CT, and 77.4% (24/31) by MRI. All the 86 patients underwent resection with good curative effect. CONCLUSIONS: CT and MRI are important diagnostic methods for FNH but it is difficult to make a definite preoperative diagnosis for partial classical and all non-classical FNH patients. We suggest that patients with clinical symptoms or with indefinite diagnosis should accept surgical removal.

Differential diagnosis and management of liver tumors in infants

During the first year of life, most of the liver neoplasms are benign in origin, but some of these histologically benign lesions may be challenging in their management. Although most hepatic hemangiomas can be safely observed until involution is documented, some patients will need treatment due to progressive hepatomegaly, hypothyroidism and/or cardiac failure. Large mesenchymal hamartomas may require extensive hepatic resection and an appropriate surgical plan is critical to obtain good results. For malignant neoplasms such as hepatoblastoma, complete surgical resection is the mainstay of curative therapy. The decision about whether to perform an upfront or delayed resection of a primary liver malignant tumor is based on many considerations, including the ease of resection, surgical expertise, tumor histology and stage, and the likely chemosensitivity of the tumor. This article reviews the initial management of the more common hepatic tumors of infancy, focusing on the differential diagnosis and treatment options.

Hepatic focal nodular hyperplasia in children:Imaging features on multi-slice computed tomography

AIM:To retrospectively analyze the imaging features of hepatic focal nodular hyperplasia(FNH) in children on dynamic contrast-enhanced multi-slice computed tomography(MSCT) and computed tomography angiography(CTA) images.METHODS:From September 1999 to April 2012,a total of 218 cases of hepatic FNH were confirmed by either surgical resection or biopsy in the Sun Yat-sen Memorial Hospital of Sun Yat-sen University and the Cancer center of Sun Yat-sen University,including 12 cases(5.5%) of FNH in children(age ≤ 18 years old).All the 12 pediatric patients underwent MSCT.We retrospectively analyzed the imaging features of FNH lesions,including the number,location,size,margin,density of FNH demonstrated on pre-contrast and contrastenhanced computed tomography(CT) scanning,central scar,fibrous septa,pseudocapsule,the morphology of the feeding arteries and the presence of draining vessels(portal vein or hepatic vein).RESULTS:All the 12 pediatric cases of FNH had solitary lesion.The maximum diameter of the lesions was 4.0-12.9 cm,with an average diameter of 5.5 ± 2.5 cm.The majority of the FNH lesions(10/12,83.3%) had well-defined margins.Central scar(10/12,83.3%) and fibrous septa(11/12,91.7%) were commonly found in children with FNH.Central scar was either isodense(n = 7) or hypodense(n = 3) on pre-contrast CT images and showed progressive enhancement in 8 cases in the equilibrium phase.Fibrous septa were linear hypodense areas in the arterial phase and isodense in the portal and equilibrium phases.Pseudocapsule was very rare(1/12,8.3%) in pediatric FNH.With the exception of central scars and fibrous septa within the lesions,all 12 cases of pediatric FNH were homogenously enhanced on the contrast-enhanced CT images,significantly hyperdense in the arterial phase(12/12,100.0%),and isodense in the portal venous phase(7/12,58.3%) and equilibrium phase(11/12,91.7%).Central feeding arteries inside the tumors were observed on CTA images for all 12 cases of FNH,whereas no neovascularization of malignant tumors was noted.In 9 cases(75.0%),there was a spoke-wheel shaped centrifugal blood supply inside the tumors.The draining hepatic vein was detected in 8 cases of pediatric FNH.However,the draining vessels in the other 4 cases could not be detected.No associated hepatic adenoma or hemangioma was observed in the livers of the 12 pediatric cases.CONCLUSION:The characteristic imaging appearances of MSCT and CTA may reflect the pathological and hemodynamic features of pediatric FNH.Dynamic multi-phase MSCT and CTA imaging is an effective method for diagnosing FNH in children.

Insight into congenital absence of the portal vein:Is it rare?

Congenital absence of portal vein （CAPV） was a rare event in the past. However, the number of detected CAPV cases has increased in recent years because of advances in imaging techniques. Patients with CAPV present with portal hypertension （PH） or portosystemic encephalopathy （PSE）, but these conditions rarely occur until the patients grow up or become old. The patients usually visit doctors for the complications of venous shunts, hepatic or cardiac abnormalities detected by ultrasonography （US）, computed tomography （CT） and magnetic resonance imaging （MR1）. The etiology of this disease is not clear, but most investigators consider that it is associated with abnormal embryologic development of the portal vein. Usually, surgical intervention can relieve the symptoms and prevent occurrence of complications in CAPV patients. Moreover, its management should be stressed on a case-by-case basis, depending on the type or anatomy of the disease, as well as the symptoms and clinical conditions of the patient.

肝脏局灶性结节增生的MSCT诊断

目的分析肝脏局灶性结节增生(FNH)的CT特征,以提高本病CT诊断水平。方法回顾性分析23例经病理证实的肝脏局灶性结节增生(FNH)的临床资料和CT表现。23例全部行CT平扫及三期增强扫描。结果 23例FNH均为单发肿块,位于肝脏包膜下16例,突出肝脏表面呈外生性生长7例。大小11mm×13mm^45mm×50mm;圆形或卵圆形21例,不规则形2例。23例FNH平扫均呈低密度影,15例密度均匀;8例密度不均匀。增强扫描:23例FNH动脉期明显强化,2例动脉期CT值接近同层面腹主动脉CT值,门静脉期和延迟期呈相对高和等密度22例,呈"快进慢出"的强化特点。14例肿块中央见裂隙状疤痕,疤痕呈缓慢渐进性强化。9例FNH肝门侧见增粗迂曲血管影,2例肿块中央见增粗迂曲血管影。结论 FNH的CT表现较具特征性,CT表现对本病的诊断和鉴别诊断具有重要价值。

Pseudolymphoma (reactive lymphoid hyperplasia) of the liver:A clinical challenge

Reactive lymphoid hyperplasia(RLH), also known as pseudolymphoma or nodular lymphoid lesion of the liver is an extremely rare condition, and only 51 hepatic RLH cases have been described in the literature since the first case was described in 1981. The majority of these cases were asymptomatic and incidentally found through radiological imaging. The precise etiology of hepatic RLH is still unknown, but relative high prevalence of autoimmune disorder in these cases suggests an immune-based liver disorder. Imaging features of hepatic RLH often suggest malignant lesions such as hepatocellular carcinoma and cholangiocarcinoma. In this report, we discuss two cases of hepatic RLH in patients with autoimmune hepatitis. We also present pathologic and magnetic resonance imaging findings, including one case utilizing a hepatocellular contrast agent, Eovist. Definitive diagnosis of hepatic RLH often requires surgical excision.

A case of hepatocellular carcinoma arising within large focal nodular hyperplasia with review of the literature

Focal nodular hyperplasia （FNH） is a relatively rare benign hepatic tumor, usually presenting as a solitary lesion; however, multiple Iocalizations have also been described. The association of FNH with other hepatic lesions, such as adenomas and haemangiomas has been reported by various authors. We herein report a case of a hepatocellular carcinoma arising within a large focal nodular hyperplasia, in a young female patient.

Rare case of an abdominal mass: Reactive nodular fibrous pseudotumor of the stomach encroaching on multiple abdominal organs

Reactive nodular fibrous pseudotumor(RNFP), which presents abdominal clinical manifestations and malignant radiographic results, usually requires radical resection as the treatment. However, RNFP has been recently described as an extremely rare benign postinflammatory lesion of a reactive nature, which typically arises from the sub-serosal layer of the digestive tract or within the surrounding mesentery in association with local injury or inflammation. In addition, a postoperative diagnosis is necessary to differentiate it from the other reactive processes of the abdomen. Furthermore, RNFP shows a good prognosis without signs of recurrence or metastasis. A 16-year-old girl presented with a 3-mo history of epigastric discomfort, and auxiliary examinations suggested a malignant tumor originating from the stomach; postoperative pathology confirmed RNFP, and after a 2-year follow-up period, the patient did not display any signs of recurrence. This case highlights the importance of preoperative pathology for surgeons who may encounter similar cases.

Complete spontaneous regression of giant focal nodular hyperplasia of the liver: Magnetic resonance imaging evaluation with hepatobiliary contrast media

Focal nodular hyperplasia(FNH) of the liver is a benign lesion occurring in 0.6%-3% of the general population that probably reflects a local hyperplastic response of hepatocytes to a vascular abnormality. Most lesions are diagnosed incidentally and the natural history of the disease remains largely unknown. It has been shown that most FNH remain stable, or even regress, over a long follow-up period. We present a patient with FNH of the liver who was followed up for 7 years. A 26-yearold woman with a 5-year history of oral contraceptive use was referred to our hospital in February 2005 for further examination of a liver tumour. The diagnosis of FNH was made using magnetic resonance(MR) imaging with hepatospecific contrast media; this technique allows a correct diagnosis, in particular distinguishing FNH from hepatic adenoma, avoiding an invasive procedure such as the lesion biopsy. After 7-year from the diagnosis, we observed the complete spontaneous regression of the lesion by enhanced MR scanning. In this patient, discontinuation of oral contraceptive use and two childbirths may have influenced the natural history of FNH. To our knowledge, in the English literature there is no report illustrating a complete regression of giant FNH but only studies of decreasing in size. The present case suggests that a young patient with giant FNH should be managed conservatively rather than by resection, because FNH has the potential for spontaneous regression.

Clinical characteristics of a group of adults with nodular lymphoid hyperplasia:A single center experience

AIM： To describe the clinical and histological characteristics of a group of adults with small-bowel nodular lymphoid hyperplasia （NLH）. METHODS： Patients were searched for five years in pathology records of our institution. The biopsy material was reassessed using strict histopathological criteria. Clinical data were obtained from medical records. RESULTS： Small-bowel NLH was diagnosed in 18 cases. The female： male ratio was 2 ： 1. The most frequent symptoms were diarrhea （72%）, involuntary weight loss （72%） and abdominal pain （61%）. Nine patients （50%） had immunodeficiency. Small-bowel bacterial overgrowth was found in three （17%） cases. At small-bowel NLH diagnosis, three （17%） had associated lymphoma： two intestinal and one extra-intestinal lymphomas. In two patients with villous atrophy and anti-endomysial antibodies the diagnosis of celiac disease was established. Giardia larnblia infection was found in only one patient with hypogammaglobulinemia （Herman＇s syndrome）. CONCLUSIONS： NLH is uncommon in adult patients. Associated diseases are immunodeficiency and lymphoid tissue malignancies.

Ultrasonography of sclerosing angiomatoid nodular transformation in the spleen

We report three rare cases of sclerosing angiomatoid nodular transformation(SANT) in the spleen.We compared the conventional and contrast-enhanced ultrasonographic appearance.The conventional sonographic examinations exhibited solitary lesions without common respects,while contrast-enhanced ultrasonography(CEUS) revealed nodular appearance mimicking its pathologic characteristics.It suggests that CEUS can provide morphologic information for diagnosing SANT.