Radiofrequency ablation is an inferior option to liver resection for solitary hepatocellular carcinoma≤5 cm without cirrhosis:A population-based study with stratification by tumor size

Background:About 10%-20%of all individuals who develop hepatocellular carcinoma(HCC)do not have cirrhosis.Comparisons are rarely reported regarding the effectiveness of radiofrequency ablation(RFA)and liver resection(LR)in survival of HCC without cirrhosis and stratification by tumor size≤5 cm.Methods:We used the Surveillance,Epidemiology,and End Results(SEER)database and identified 1505 patients with a solitary HCC tumor≤5 cm who underwent RFA or LR during 2004-2015.Patients were classified into non-cirrhosis and cirrhosis groups and each group was categorized into three subgroups,according to tumor size(≤30 mm,31-40 mm,41-50 mm).Results:In patients without cirrhosis,LR showed better 5-year HCC cancer-specific survival than RFA in all tumor size subgroups(≤30 mm:82.51%vs.56.42%;31-40 mm:71.31%vs.46.83%;41-50 mm:74.7%vs.37.5%;all P<0.05).Compared with RFA,LR was an independent protective factor for HCC cancer-specific survival in multivariate Cox analysis[≤30 mm:hazard ratio(HR)=0.533,95%confidence interval(CI):0.313-0.908;31-40 mm:HR=0.439,95%CI:0.201-0.957;41-50 mm:HR=0.382;95%CI:0.159-0.916;all P<0.05].In patients with cirrhosis,for both tumor size≤30 mm and 31-40 mm groups,there were no significant survival differences between RFA and LR in multivariate analysis(all P>0.05).However,in those with tumor size 41-50 mm,LR showed significantly better 5-year HCC cancer-specific survival than RFA in both univariate(54.72%vs.23.06%;P<0.001)and multivariate analyses(HR=0.297;95%CI:0.136-0.648;P=0.002).Conclusions:RFA is an inferior treatment option to LR for patients without cirrhosis who have a solitary HCC tumor≤5 cm.

Accessory renal arteries-a source of hypertension:A case report

BACKGROUND Secondary hypertension is a relatively rare condition most commonly caused by renovascular disease due to atherosclerotic vascular disease or fibromuscular dysplasia.Although accessory renal arteries are frequent,to date,only six cases of secondary hypertension determined by their existence have been reported.CASE SUMMARY We describe a case of a 39-year-old female who came to the emergency department with an urgent hypertensive crisis and hypertensive encephalopathy.Despite normal renal arteries,the computed tomography angiography revealed an inferior polar artery with 50%stenosis of its diameter.Conservative treatment with amlodipine,indapamide and perindopril was adopted,leading to blood pressure control within one month.CONCLUSION To the best of our knowledge,there are controversies regarding accessory renal arteries as a potential etiology for secondary hypertension,but the seven similar cases already described,along with the current case,could reinforce the necessity of more studies concerning this subject.

Lightweight Classification Network for Pulmonary Tuberculosis Based on CT Images

With the continuous development of medical informatics and digital diagnosis,the classification of tuberculosis(TB)cases from computed tomography(CT)images of the lung based on deep learning is an important guiding aid in clinical diagnosis and treatment.Due to its potential application in medical image classification,this task has received extensive research attention.Existing related neural network techniques are still challenging in terms of feature extraction of global contextual information of images and network complexity in achieving image classification.To address these issues,this paper proposes a lightweight medical image classification network based on a combination of Transformer and convolutional neural network(CNN)for the classification of TB cases from lung CT.The method mainly consists of a fusion of the CNN module and the Transformer module,exploiting the advantages of both in order to accomplish a more accurate classification task.On the one hand,the CNN branch supplements the Transformer branch with basic local feature information in the low level;on the other hand,in the middle and high levels of the model,the CNN branch can also provide the Transformer architecture with different local and global feature information to the Transformer architecture to enhance the ability of the model to obtain feature information and improve the accuracy of image classification.A shortcut is used in each module of the network to solve the problem of poor model results due to gradient divergence and to optimize the effectiveness of TB classification.The proposed lightweight model can well solve the problem of long training time in the process of TB classification of lung CT and improve the speed of classification.The proposed method was validated on a CT image data set provided by the First Hospital of Lanzhou University.The experimental results show that the proposed lightweight classification network for TB based on CT medical images of lungs can fully extract the feature information of the input images and obtain high-accuracy classification results.

Interventional treatment for symptomatic acute-subacute portal and superior mesenteric vein thrombosis

AIM: To summarize our methods and experience with interventional treatment for symptomatic acute-sub-acute portal vein and superior mesenteric vein throm-bosis (PV-SMV) thrombosis. METHODS: Forty-six patients (30 males, 16 females, aged 17-68 years) with symptomatic acute-subacute portal and superior mesenteric vein thrombosis were ac-curately diagnosed with Doppler ultrasound scans, com-puted tomography and magnetic resonance imaging. They were treated with interventional therapy, including direct thrombolysis (26 cases through a transjugular intrahepatic portosystemic shunt; 6 through percutane-ous transhepatic portal vein cannulation) and indirect thrombolysis (10 through the femoral artery to superior mesenteric artery catheterization; 4 through the radial artery to superior mesenteric artery catheterization). RESULTS: The blood reperfusion of PV-SMV was achieved completely or partially in 34 patients 3-13 d after thrombolysis. In 11 patients there was no PV-SMV blood reperfusion but the number of collateral vessels increased signif icantly. Symptoms in these 45 patients were improved dramatically without severe operationalcomplications. In 1 patient, the thrombi did not respond to the interventional treatment and resulted in intestinal necrosis, which required surgical treatment. In 3 patients with interventional treatment, thrombi reformed 1, 3 and 4 mo after treatment. In these 3 patients, indirect PV-SMV thrombolysis was performed again and was successful. CONCLUSION: Interventional treatment, including direct or indirect PV-SMV thrombolysis, is a safe and effective method for patients with symptomatic acutesubacute PV-SMV thrombosis.

Different imaging techniques in the head and neck:Assets and drawbacks

In this review,the gold standard imaging techniques for the head and neck and the latest upcoming techniques are presented,by comparing computed tomography(CT),magnetic resonance imaging and positron emission tomography-CT,as well as ultrasound,depending on the examined area.The advantages and disadvantages of each examination protocol are presented.This article illustrates the connection between the imaging technique and the examined area.Therefore,the head and neck area is divided into different sections such as bony structures,nervous system,mucous membranes and squamous epithelium,glandular tissue,and lymphatic tissue and vessels.Finally,the latest techniques in the field of head and neck imaging such as multidetector CT,dual-energy CT,flash CT,magnetic resonance angiography,spectroscopy,and diffusion tensor tractography using 3 tesla magnetic resonance are discussed.

A geriatric patient with diffuse idiopathic skeletal hyperostosis

The most frequent health problems seen in senility are chronic and degenerative diseases. A 75-year-old male patient with the complaints of weight loss and difficulty in swallowing was admitted to our hospital from a nursing home. Upper system fiber-optic gastrointestinal endoscopy was performed and a mass at the junction of the hypopharynx and esophagus just below recessus piriformis obstructing almost the whole of the lumen and blocking the distal passage was detected. Computed tomography revealed marked narrowing secondary to osseous hypertrophy in the air column of the hypopharynx and proximal esophagus. Diffuse idiopathic skeletal hyperostosis or Forestier’s disease is an idiopathic disease characterized by the ossification of the anterior longitudinal ligament of vertebra and some of the extraspinal ligaments. In the present case we aim to discuss an elderly patient who suffered from dysphagia and weight loss and the diagnostic stages.

Imaging of hemorrhagic primary central nervous system lymphoma: A case report

BACKGROUND A primary central nervous system lymphoma(PCNSL)presenting with massive hemorrhage is a rare occurrence that is difficult to distinguish from a high-grade glioblastoma.Comprehensive descriptions of the imaging characteristics of such tumors have not yet been reported.Herein,we reported a case of a PCNSL with massive hemorrhage by presenting the imaging features of computed tomography(CT)imaging and structural and perfusion magnetic resonance imaging(MRI).CASE SUMMARY A 48-year-old man presented with headache lasting for 10 d.CT of the brain showed a round,heterogeneous,high-density lesion with surrounding edema in the right temporal lobe.For further diagnosis,a series of MRI examinations of the brain were subsequently performed,and a hemorrhagic lesion with ring-like enhancement was determined.The whole lesion was relatively hypoperfused on arterial spin labeling images.Surgical resection of the lesion and histopathological examination confirmed that the lesion was a diffuse large B-cell lymphoma with massive hemorrhage.CONCLUSION PCNSLs with hemorrhage occur very rarely,and structural and perfusion MRI examinations are requested exceedingly rarely.This case provided insight into some characteristics of a hemorrhagic lymphoma on CT and MRI examinations.Perfusion MRI examination may be useful for the differential diagnosis of PCNSLs and other brain tumors.

Emotion processing in Parkinson's disease: a blood oxygenation level-dependent functional magnetic resonance imaging study

Parkinson's disease is a neurodegenerative disorder caused by loss of dopamine neurons in the substantia nigra pars compacta. Tremor, rigidity, and bradykinesia are the major symptoms of the disease. These motor impairments are often accompanied by affective and emotional dysfunctions which have been largely studied over the last decade. The aim of this study was to investigate emotional processing organization in the brain of patients with Parkinson's disease and to explore whether there are differences between recognition of different types of emotions in Parkinson's disease. We examined 18 patients with Parkinson's disease(8 men, 10 women) with no history of neurological or psychiatric comorbidities. All these patients underwent identical brain blood oxygenation level-dependent functional magnetic resonance imaging for emotion evaluation. Blood oxygenation level-dependent functional magnetic resonance imaging results revealed that the occipito-temporal cortices, insula, orbitofrontal cortex, basal ganglia, and parietal cortex which are involved in emotion processing, were activated during the functional control. Additionally, positive emotions activate larger volumes of the same anatomical entities than neutral and negative emotions. Results also revealed that Parkinson's disease associated with emotional disorders are increasingly recognized as disabling as classic motor symptoms. These findings help clinical physicians to recognize the emotional dysfunction of patients with Parkinson's disease.

Pearls and pitfalls in magnetic resonance imaging of hepatocellular carcinoma

Hepatocellular carcinoma(HCC)is the most common primary hepatic malignancy,which usually arises in cirrhotic liver.When the typical enhancement pattern,consisting of late arterial hyperenhancement followed by washout,is present in nodules larger than 1 cm,HCC can be confidently diagnosed without the need for tissue biopsy.Nevertheless,HCC can display an atypical enhancement pattern,either as iso or hypovascular lesion,or hypervascular lesion without washout.Not only the enhancement pattern of HCC could be atypical,but also a variety of histological types of HCC,such as steatotic,scirrhous,fibrolamellar,or combined hepatocellular-cholangiocellular carcinoma could raise diagnostic dilemmas.In addition,distinct morphological types of HCC or different growth pattern can occur.Awareness of these atypical and rare HCC presentations on magnetic resonance imaging is important for accurate differentiation from other focal liver lesions and timely diagnosis,which allows optimal treatment of patients.

Comparison of Endoscopic Retrograde Cholangiopancreatography(ERCP)and Magnetic Resonance Cholangiopancreatography(MRCP)in Bile Duct Imaging

Purpose: The aim of this study was to compare magnetic resonance cholangiopancreatography (MRCP) with endoscopic retrograde cholangiopancreatography (ERCP) in diagnosing bile duct pathologies. Materials and Methods: We documented the data of 171 patients with both ERCP and MRCP between January 2009 and December 2010 at the Konya Education and Research Hospital. Results: Of the 171 patients, 100 (58.5%) were female and 71 (41.5%) were male. The median age was 63 (55 to 89). ERCP was used to diagnose bile duct stones in 102 (59%) patients, bile duct tumour in 14 (8%) patients, hydatic cysts opening up to the bile duct in 4 (2%) patients and bile duct stenosis in 3 (1.8%) patients. For the detection of bile duct stones, MRCP had a sensitivity of 92%, a specificity of 74% and a diagnostic accuracy of 83%. For bile duct tumours, MRCP had a sensitivity of 85%, a specificity of 98% and a diagnostic accuracy rate of 92%. Conclusion: In our centre, the results of MRCP and ERCP were similar for the last two years. However, MRCP was superior with respect to diagnosis as it was cheaper and non-invasive. Thus, ERCP should be preferred for therapeutic processes.

Low-grade fibromyxoid sarcoma of the liver: A case report

BACKGROUND Low grade fibromyxoid sarcoma(LGFMS)is a rare and benign mesenchymal tumor with indolent course,most commonly found in young or middle-aged men.The majority of the LGFMSs are located in the trunk and deep soft tissue of the lower extremities.They appear as well circumscribed,although not encapsulated,which often leads to incomplete surgical resection.Despite their seemingly benign appearance,these tumors have aggressive behavior with high metastatic and recurrence rates.Accurate histopathologic examination of the specimen and its immunohistochemical analysis are mandatory for a precise diagnosis.CASE SUMMARY We report a case of a 38 year-old-man who presented with jaundice and upper abdominal discomfort.Multi-detector computed tomography and magnetic resonance imaging showed a large left liver tumor mass,extending to the hepatoduodenal ligament.Left hepatectomy was performed with resection and reconstruction of hepatic artery and preservation of middle hepatic vein.Histopathologic examination confirmed the tumor being a low-grade fibromyxoid sarcoma.Three and a half years after surgery,the patient died after being diagnosed with spine metastasis.CONCLUSION Due to poor response to all modalities of adjuvant treatment,we consider that the focus of treatment should be on surgery as the only option for curing the disease.

Radiographic and magnetic resonances contrast agents:Essentials and tips for safe practices

With extended and continued expansion of medical imaging utilization in modern medical practice over last decade, radiologists as well as other faculty staff dealing with radiographic and magnetic resonances contrast media(CM) have to be well oriented with their potential hypersensitivity reactions and recognize high-risk groups liable to develop it so as to enable early recognition. Radiologists and other medical staff involved in administration and dealing with CM have to be ready to implement prompt, practical and effective management plan to deal with these scenarios should they emerge. Strategies to prevent potential contrastinduced acute and delayed renal injuries have to be routinely exercised. Paying attention to the pregnant and nursing women, pediatrics, diabetics, as well as other fragile populations is of utmost importance for patient safety during contrast administrations. Radiologists should play a pivotal role in orienting patients about necessity to use CM for their imaging studies, in case it is needed, and assure them about its safety. Moreover, they have to be oriented with the medico-legal issues related to use of CM. These will pay as improved patient safety as well as safe daily working environmentat different levels of radiology practices.

Prevalence and Factors Associated with Depression, Anxiety and Stress in IBD Patients Undergoing Intravenous Biological Therapy during the COVID-19 Pandemic-Montenegro Experience

Throughout its duration,the coronavirus disease 2019(COVID-19)pandemic has been affecting lives worldwide and has had a sizeable impact on mental health,particularly for those who already suffer from a chronic illnesses.Depression,Anxiety and Stress(DAS)are common psychiatric comorbidities in inflammatory bowel disease(IBD)patients.This study aims to determine the prevalence and risk factors for moderate and severe symptoms of DAS in IBD patients have been undergoing intravenous biological therapy(IvBTh)during the COVID-19 pan-demic.The study was conducted between September 1st and November 30th,2020 at the Clinical Center of Mon-tenegro-IBD unit,where all patients from Montenegro received the registered IvBTh.This case control study consists of 94 IBD patients that completed a validated questionnaire Depression,Anxiety and Stress Score-21(DASS-21).A total of 59 patients received tumor necrosis factor alpha inhibitors(anti-TNF therapy),while 35 received anti-integrin therapy.After we calculated the DASS-21 score,we divided the patients into two groups:those who had moderate and severe symptoms(if they had any of the mentioned DASS-21 subscale score above limit for moderate or more severe symptoms:DASS-21 Depression,higher than 14;DASS-21 Anxiety,higher than 10 and DASS-21 Stress,higher than 19)and those who did not have significant symptoms(DASS-21 subscale score did not exceed the limit).We also examined demographic data,data on IBD characteristics and COVID-19 data and their impact on mental disorders.Standard statistical processing tests were used to identify risk factors for examined mental disorders.Following the DASS-21 criteria,we diagnosed the least moderate depression in 19.1%,anxiety in 14.9%and stress in 20.2%patients.The multivariate analysis indicated there to be a statistically significant relation of being higher at risk of developing depression,anxiety and stress when suffering from an active form of IBD(OR 6.487;95%Cl 1.220–34.500,P=0.028).Almost one third(30.9%)of patients have at least one of the examined mental disorders during the COVID-19 pandemic.Particular attention and efforts must be better focused on patients who suffer from an active form of IBD during the ongoing COVID-19 pandemic.

Dose Efficiency in Dual Source High-Pitch Computed Tomography of the Chest

Objectives: Evaluation of radiation efficiency of dual source high-pitch (DSHP) chest CT in comparison to single source technique with special regards to individual patient anatomy. Methods: 150 consecutive patients who underwent chest CT with automated tube current modulation were evaluated retrospectively and divided into three study groups, each with an equal quantity of 50 patients (DSHP vs. single source 128 slices vs. single source 16 slices). By using a dedicated workstation, volumetric analyses of each of the scanned anatomic area were performed and correlated to the individual dose length product (DLP). The calculated result was defined as dose efficiency. Results: DLP was 203 mGycm (DSHP), vs. 269 mGycm (single source) vs. 273 mGycm (16 slice CT). The total patient volume was lowest in the dual source group with 18956.3 cm3 (vs. 22481.2 cm3 vs. 22133.8 cm3). With regards to the DLP, the calculated dose efficiency of dual source CT was better than the 128 slice CT (p = 0.045) and the 16 slice CT (p < 0.01). Conclusions: DSHP CT has considerably better dose efficiency compared to 16 slice CT. Compared to 128 slice single source technique, the high-pitch mode does not cause any dose penalty when performing chest CT.

Frontiers of COVID-19-related myocarditis as assessed by cardiovascular magnetic resonance

Coronavirus disease 2019(COVID-19)is caused by severe acute respiratory syndrome coronavirus 2(SARS-CoV-2)infection.In some patients,COVID-19 is complicated with myocarditis.Early detection of myocardial injury and timely intervention can significantly improve the clinical outcomes of COVID-19 patients.Although endomyocardial biopsy(EMB)is currently recognized as the‘gold standard’for the diagnosis of myocarditis,there are large sampling errors,many complications and a lack of unified diagnostic criteria.In addition,the clinical methods of treating acute and chronic COVID-19-related myocarditis are different.Cardiac magnetic resonance(CMR)can evaluate the morphology of the heart,left and right ventricular functions,myocardial perfusion,capillary leakage and myocardial interstitial fibrosis to provide a noninvasive and radiation-free diagnostic basis for the clinical detection,efficacy and risk assessment,and followup observation of COVID-19-related myocarditis.However,for the diagnosis of COVID-19-related myocarditis,the Lake Louise Consensus Criteria may not be fully applicable.COVID-19-related myocarditis is different from myocarditis related to other viral infections in terms of signal intensity and lesion location as assessed by CMR,which is used to visualize myocardial damage,locate lesions and quantify pathological changes based on various sequences.Therefore,the standardized application of CMR to timely and accurately evaluate heart injury in COVID-19-related myocarditis and develop rational treatment strategies could be quite effective in improving the prognosis of patients and preventing potential late-onset effects in convalescent patients with COVID-19.

Metastatic hepatocellular carcinoma of the external auditory canal

This report describes a rare case of metastatic hepatocellular carcinoma (HCC) presenting a huge mass in the left external auditory canal (EAC). The patient was a 55-year-old man with hepatitis B virus-related HCC. He presented to our department with a three-month history of increasing left otalgia,and hearing loss with recent fresh aural bleeding. Histopathologic examination indicated that the tumor was secondary to HCC. Although external irradiation was not effective,the tumor was treated with surgical debulking and high dose rate 192 Ir remote afterloading system (RALS) for postoperative intracavitary irradiation. A review of the literature revealed only five other cases of HCC metastasis to the temporal bone,all of which mainly metastasized in the internal acoustic meatus. The present case is the first report of HCC metastasis to the EAC.

Disease modifying treatment of spinal cord injury with directly reprogrammed neural precursor cells in non-human primates

BACKGROUND The development of regenerative therapy for human spinal cord injury(SCI)is dramatically restricted by two main challenges:the need for a safe source of functionally active and reproducible neural stem cells and the need of adequate animal models for preclinical testing.Direct reprogramming of somatic cells into neuronal and glial precursors might be a promising solution to the first challenge.The use of non-human primates for preclinical studies exploring new treatment paradigms in SCI results in data with more translational relevance to human SCI.AIM To investigate the safety and efficacy of intraspinal transplantation of directly reprogrammed neural precursor cells(drNPCs).METHODS Seven non-human primates with verified complete thoracic SCI were divided into two groups:drNPC group(n=4)was subjected to intraspinal transplantation of 5 million drNPCs rostral and caudal to the lesion site 2 wk post injury,and lesion control(n=3)was injected identically with the equivalent volume of vehicle.RESULTS Follow-up for 12 wk revealed that animals in the drNPC group demonstrated a significant recovery of the paralyzed hindlimb as well as recovery of somatosensory evoked potential and motor evoked potential of injured pathways.Magnetic resonance diffusion tensor imaging data confirmed the intraspinal transplantation of drNPCs did not adversely affect the morphology of the central nervous system or cerebrospinal fluid circulation.Subsequent immunohistochemical analysis showed that drNPCs maintained SOX2 expression characteristic of multipotency in the transplanted spinal cord for at least 12 wk,migrating to areas of axon growth cones.CONCLUSION Our data demonstrated that drNPC transplantation was safe and contributed to improvement of spinal cord function after acute SCI,based on neurological status assessment and neurophysiological recovery within 12 wk after transplantation.The functional improvement described was not associated with neuronal differentiation of the allogeneic drNPCs.Instead,directed drNPCs migration to the areas of active growth cone formation may provide exosome and paracrine trophic support,thereby further supporting the regeneration processes.

3.0T MR Coronary Angiography after Arterial Switch Operation for Transposition of The Great Arteries-Gd-FLASH Versus Non-Enhanced SSFP.A Feasibility Study

Background:Patency of the coronary arteries is an issue after reports of sudden cardiac death in patients with transposition of the great arteries(TGA)operated with arterial switch(ASO).Recent studies give rise to concern regarding the use of ionising radiation in congenital heart disease,and assessment of the coronary arteries with coronary MR angiography(CMRA)might be an attractive non-invasive,non-ionising imaging alternative in these patients.Theoretically,the use of 3.0T CMRA should improve the visualisation of the coronary arteries.The objective of this study was to assess feasibility of 3.0T CMRA at the coronary artery origins by comparing image quality with non-contrast CMRA in ASO TGA patients to healthy age-matched controls,and by comparing image quality with non-contrast CMRA to contrast enhanced CMRA in the patient group.Material and methods:Twelve patients,9-15 years(mean 11.9 years,standard deviation 1.5 years),and 12 age-matched controls(mean 12.7 years,standard deviation 1.7 years)were examined with 3D balanced steady-state free precession(SSFP).Nine of twelve patients had Gadolinium-enhanced fast low-angle shot(Gd-FLASH)performed after SSFP.Image quality at the coronary artery origins was evaluated subjectively with a 10 cm figurative visual analogue scale(fVAS)and objectively by signal-to-noise and contrast-to-noise ratio(SNR,CNR).Results:All,but one,coronary artery origins were identified.No significant difference in image quality scores was found between patients and controls with SSFP(mean values 6.5 cm—9.1 cm in patients and 7.0 cm—8.0 cm in controls,p-values>0.1).With SSFP,intra-observer fVAS mean score was 6.7 cm—8.6 cm and with Gd-FLASH 7.7 cm—8.7 cm.CNR was higher with Gd-FLASH(p<0.03).Intra-observer agreement index(AI)with SSFP was moderate-to-good(0.43–0.71)and with Gd-FLASH good(0.64–0.79)in all origins.Inter-observer AI was good in the left main stem(LMS)with SSFP(0.65).With Gd-FLASH inter-observer AI was good in LMS(0.78)and moderate(0.5)in the left anterior descending artery,but lacking in the other origins though with a good agreement on Bland-Altman plots.Conclusions:Our findings indicate a better,more reproducible image quality with Gd-FLASH than with non-contrast SSFP CMRA on 3.0T for evaluation of the coronary artery origins in ASO TGA children and adolescents.

Giant androgen-producing adrenocortical carcinoma with atrial flutter: A case report and review of the literature

BACKGROUND Adrenocortical carcinoma(ACC),the second most aggressive malignant tumor,lacks epidemiological data worldwide;therefore,every new case can improve the understanding of the pathology and treatment of this malignancy.CASE SUMMARY We present the case of a 66-year-old Caucasian woman with a giant androgenproducing ACC(21 cm×17 cm×12 cm;2100 g),without metastases,which unusually presented with an acute onset of atrial flutter and congestive heart failure.The cardiac complications observed in our case support the hypothesis that androgen excess in women is a cardiovascular risk factor.Androgen excess in women can be a rare cause of reversible dilated cardiomyopathy,therefore a comprehensive approach to the patient is essential to improve the recognition of androgen-secreting ACC.The atrial flutter was remitted after initiation of drug treatment during admission.The severe heart failure was totally remitted at 6 mo after radical open surgery to remove the giant ACC.CONCLUSION Radical open surgery to remove a giant androgen-producing ACC was the firstline treatment to cure the excess of androgen,which determined the total remission of cardiac complications at 6 mo after surgery in the women of this case report.