Hepatocellular carcinoma presenting as a huge intra-abdominal mass: a case report.

Hepatocellular carcinoma (HCC) is the most common primary malignant tumor of the liver and is generally associated with hepatitis B or C virus-related cirrhosis. A giant intra-abdominal HCC mass that fills nearly the whole abdomen is not often reported in the literature. In this report, we present a case in which a patient with hepatitis B developed a giant intra-abdominal mass that originated from segment three of the liver and infiltrated the stomach and transverse colon. We were able to resect the tumor without leaving any tumor tissue behind. Although HCC presenting as a huge mass with invasion of the gastrointestinal tract is uncommon, this pathology should be considered in the differential diagnosis of giant intra-abdominal masses. The case presented here also indicates that surgical resection is possible in selected patients.

Comparison of the diagnostic performances of diffusion parameters in diffusion weighted imaging and diffusion tensor imaging of breast lesions.

PURPOSE: To evaluate the diagnostic efficiency of the diffusion parameters measured by conventional diffusion-weighted imaging (DWI) and diffusion tensor imaging (DTI) for discrimination of malignant breast lesions from benign lesions and the normal breast. MATERIALS AND METHODS: The study included 52 women with 55 breast lesions (30 malignant, 25 benign). DTI and DWI were performed complementary to dynamic contrast MRI at 3T. Apparent diffusion coefficient (ADC) of DWI, mean diffusivity (MD) and fractional anisotropy (FA) values of DTI were measured for lesions and contralateral breast parenchyma in each patient. We used b factors of 0, 50, 850, 1000 and 1500 s/mm(2) for DWI and b 0 and 1000 s/mm(2) for DTI. ADC, MD and FA values were compared between malignant and benign lesions, and the normal parenchyma by univariate and multivariate analyses. RESULTS: Diffusion parameters showed no difference according to menopausal status in the normal breast. ADC and MD values of the malignant lesions were significantly lower than benign lesions and normal parenchyma (p=0.001). The FA showed no statistical significance. With the cut-off values of ≤ 1.23 × 10(-3)mm(2)/s (b 0-1000 s/mm(2)) and ≤ 1.12 × 10(-3)mm(2)/s (b 0-1500 s/mm(2)), ADC showed 92.85% and 96.15% sensitivity; 72.22% and 73.52% PPV, respectively. With a cut-off value of ≤ 1.27 × 10(-3)mm(2)/s (b 1000 s/mm(2)), MD was 100% sensitive with a PPV of 65.90%. Comparing the diagnostic performance of the parameters in DTI with DWI, we obtained similar efficiency of ADC with b values of 0,1000 and 0,1500 s/mm(2) and MD with a b value of 0, 1000 s/mm(2) (AUC = 0.82 ± 0.07). CONCLUSION: ADC of DWI and MD of DTI values provide significant discriminative factors for benign and malignant breast lesions. FA measurement was not discriminative. Supported with clinical and dynamic contrast MRI findings, DWI and DTI findings provide significant contribution to the final radiologic decision.

The role of preoperative radiological assessment of vascular injury on surgical decision making in mutilating injuries of the upper extremity.

Preoperative assessment of the extent of vascular injury is important in patients with mutilating injuries of the upper extremity. The aim of this report was to discuss the influence of computed tomography angiography (CTA) and digital subtraction angiography (DSA) on the operating room decision-making in mutilating injuries and limb-salvage procedures of the traumatic upper extremity. Four DSA and 3 CTA were performed in 7 patients with a mean age of 28.3 (range, 4-48) years. The results of the DSA and CTA altered the preoperative planning. In 5 patients, the reconstructive decision of the type of flap was altered, whereas in all 7 patients, either the level or type of anastomosis was changed after radiologic investigations. The mean follow-up period was 37.8 months. During the follow-up period, all patients underwent subsequent procedures such as sensory restoration, tendon reconstruction, or capsulotomy. The effects of radiologic results in which flap selection, target donor vessel, and level and type of anastomosis have changed are discussed in correlation with intraoperative findings.

Diffusion weighted MR imaging in the differential diagnosis of haemangiomas and metastases of the liver.

BACKGROUND: The purpose of the study was to evaluate the value of diffusion-weighted imaging in the differential diagnosis of haemangiomas from metastases of the liver. PATIENTS AND METHODS.: We analyzed 69 lesions in 38 patients (33 haemangiomas; 36 metastases) in the retrospective study. Diffusion-weighted imaging was performed using a breath-hold single-shot echo-planar spin echo sequence with three b factors (0, 500 and 1000 sec/mm(2)), and apparent diffusion coefficients (ADCs) were calculated. For the quantitative evaluation, signal intensity of the lesions, lesion-to-liver signal intensity ratios, ADC of the lesions, and lesion-to-liver ADC ratios were compared between the groups. The statistical significance was determined by student's-t test. RESULTS: With the b factor 500 sec/mm(2), no statistical significance was achieved (p>0.05). With the b factor of 1000 sec/mm(2), both the signal intensity and lesion-to-liver signal intensity ratio of the metastases were significantly higher than those for haemangiomas (p<0.001). The cut-off value at 2.6 yielded a sensitivity of 86% and a specificity of 82% for the lesion-to-liver signal intensity ratio. The ADC, and lesion-to-liver ADC ratio of the metastases were significantly lower than those of haemangiomas (p<0.001). With cut-off value of 1.7, ADC ratio had a sensitivity of 88% and a specificity of 72% for ADC lesion/liver. CONCLUSIONS: Diffusion-weighted imaging with high b value may help in the differential diagnosis of metastases from haemangiomas of the liver.

Color Doppler ultrasonographic flow parameters in the differentiation of benign and malignant causes of omental thickening.

OBJECTIVE: The purpose of the study was to determine if color Doppler ultrasonographic (US) quantitative flow parameters are valuable to differentiate malignant peritoneal or omental involvement from benign causes. MATERIALS AND METHODS: Twenty-six consecutive patients with peritoneal or omental thickening detected by gray scale US, computed tomography, and magnetic resonance underwent color Doppler US examinations. All the Doppler signal waveforms were recorded, and resistive (RI) and pulsatility indices (PI) were calculated automatically by the US machine. In the statistical analysis of RI and PI, unpaired t test was used. A P < 0.05 was considered significant. RESULTS: Nineteen of 20 malignant and 5 of 6 benign lesions had detectable color Doppler US pulsatile flow signals. The mean RI and PI values were 0.6260 and 1.36, respectively, for the benign group and 0.5384 and 1.4147, respectively, for the malignant group. For malignant lesions, mean RI was lower (P = 0.0796), and mean PI was higher (P = 0.9183) than benign lesions. However, these differences were not statistically significant. CONCLUSIONS: Overlapping RI and PI values in benign and malignant omental lesions limit the clinical value of flow parameters in the differentiation of benign and malignant involvement of the omentum.

Driven equilibrium (drive) MR imaging of the cranial nerves V-VIII: comparison with the T2-weighted 3D TSE sequence.

PURPOSE: The aim of this study is to evaluate the efficacy of the driven equilibrium radio frequency reset pulse (DRIVE) on image quality and nerve detection when used in adjunction with T2-weighted 3D turbo spin-echo (TSE) sequence. MATERIALS AND METHODS: Forty-five patients with cranial nerve symptoms referable to the cerebellopontine angle (CPA) were examined using a T2-weighted 3D TSE pulse sequence with and without DRIVE. MR imaging was performed on a 1.5-T MRI scanner. In addition to the axial resource images, reformatted oblique sagittal, oblique coronal and maximum intensity projection (MIP) images of the inner ear were evaluated. The nerve identification and image quality were graded for the cranial nerves V-VIII as well as inner ear structures. These structures were chosen because fluid-solid interfaces existed due to the CSF around (the cranial nerves V-VIII) or the endolymph within (the inner ear structures). Statistical analysis was performed using the Wilcoxon test. P < 0.05 was considered significant. RESULTS: The addition of the DRIVE pulse shortens the scan time by 25%. T2-weighted 3D TSE sequence with DRIVE performed slightly better than the T2-weighted 3D TSE sequence without DRIVE in identifying the individual nerves. The image quality was also slightly better with DRIVE. CONCLUSION: The addition of the DRIVE pulse to the T2-weighted 3D TSE sequence is preferable when imaging the cranial nerves surrounded by the CSF, or fluid-filled structures because of shorter scan time and better image quality due to reduced flow artifacts.

Conservative treatment of giant abdominal wall hematoma.

A fifty-seven-year-old male patient on warfarin therapy presented to the emergency department with severe abdominal pain that had started after a cough episode and persisted for four days. Ultrasonography showed an extensive hematoma, 17x14x7 cm in size, but failed to determine whether it was located intra-abdominally or in the abdominal wall. Computed tomography confirmed the diagnosis of abdominal wall hematoma (25x21x10 cm). The patient was treated conservatively, and abdominal findings resolved progressively in three days. This case report illustrates that ultrasonography findings may sometimes be inconclusive and, in the early period, computed tomography may be required to confirm the diagnosis of abdominal wall hematomas. Giant abdominal wall hematomas can be successfully treated with conservative methods even physical findings of acute abdomen accompany the clinical picture. To our knowledge, this is the largest abdominal wall hematoma hitherto reported in the literature.