Hepatic angiomyolipoma associated with splenic hamartoma

A 52-year-old woman was admitted to our hospital with thrombophlebitis of the internal jugular vein. Abdominal ultrasonography demonstrated a high echogenic mass measuring 4.5 cm in diameter in the liver, and abdominal CT revealed another liver tumor and an isodensity mass in the spleen. Abdominal MRI and angiography were performed and we presumed the tumors to be two hepatic angiomyolipoma and a splenic hamartoma. As an abdominal CT 21 months later revealed that all tumors were growing, these tomors were surgically resected. The histological diagnoses were hepatic angiomyolipoma and splenic hamartoma.     

Ultrasonography and magnetic resonance imaging of heel fat pad inflammatory-oedematous lesions in rheumatoid arthritis

OBJECTIVE: To study heel fat pad (HFP) inflammatory-oedematous lesions in selected patients with rheumatoid arthritis (RA) using ultrasonography (US) and power Doppler US (PDUS), to describe and compare US features of these lesions with those obtained with magnetic resonance imaging (MRI), and to describe changes in the lesions after a short-term follow-up with conventional or anti-tumour necrosis factor-alpha (TNFalpha) therapy. METHODS: Twelve heels of eight RA outpatients with HFP inflammatory-oedematous lesions were studied by US, PDUS, and unenhanced MRI. All the patients were followed up and US was performed after 3 months. Five patients started on anti-TNFalpha therapy. RESULTS: HFP lesions appeared at US as a heterogeneous and hypoechoic subcalcaneal mass, with loss of normal lobular structure and increased thickness of HFP, because of focal rupture of fibrous septae with oedema and fluid. PDUS showed peripheral vascularization of HFP lesions in 9/12 heels. In 3/12 heels some vascular signals was also detectable inside the lesion, always along the residual echoic septa. No detectable flow was observed within the central fluid-filled spaces. MRI of the HFP lesions showed areas of mean intensity in T1-weighted sequences and high intensity in T2-weighted sequences, with poorly or well-defined margins. After 3 months, PDUS showed reduction in HFP lesion vascularity (associated with reduction in pain) in 10/12 heels, while poor regression of grey-scale US abnormalities was observed. CONCLUSIONS: Both US and MRI are capable of demonstrating structural abnormalities in the HFP. PDUS is useful to assess and monitor inflammatory vascularization of the HFP lesions.     

Power Doppler ultrasonography for assessment of synovitis in the metacarpophalangeal joints of patients with rheumatoid arthritis: a comparison with dynamic magnetic resonance imaging

OBJECTIVE: To evaluate the effectiveness of power Doppler ultrasonography (PDUS) for assessing inflammatory activity in the metacarpophalangeal (MCP) joints of patients with rheumatoid arthritis (RA), using dynamic magnetic resonance imaging (MRI) as a reference method. METHODS: PDUS and dynamic MRI were performed on 54 MCP joints of 15 patients with active RA and on 12 MCP joints of 3 healthy controls. PDUS was performed with a LOGIQ 500 unit by means of a 7-13-MHz linear array transducer. Later the same day, MRI was performed with a 1.0T MR unit. A series of 24 coronal T1-weighted images of the second through the fifth MCP joints was obtained, with intravenous injection of gadolinium diethylenetriaminepentaacetic acid after the fourth image (dynamic MRI). From the MR images, the rate of early synovial enhancement (RESE; defined as the relative enhancement per second during the first 55 seconds postinjection) was calculated and compared with the flow signal on PDUS, which was scored as present or absent. RESULTS: In RA patients, flow signal on PDUS was detected in 17 of 54 MCP joints examined. Postcontrast MR images revealed an RESE of > or = 1.0%/second in 18 of 54 RA MCP joints. PDUS showed no flow in 47 of 48 MCP joints with an RESE of <1.0%/second and revealed flow in 16 of 18 MCP joints with an RESE of > or = 1.0%/second. Using dynamic MRI as a reference, PDUS had a sensitivity of 88.8% and a specificity of 97.9%. CONCLUSION: PDUS was reliable for assessing inflammatory activity in the MCP joints of RA patients, using dynamic MRI as the standard. PDUS and clinical assessment of joint swelling/tenderness were only weakly correlated.     

Intra-operative color Doppler ultrasonography for assessing splenic blood supply during spleen-preserving distal pancreatectomy: a case report

A 67 year-old Japanese woman presented with a cystic tumorous lesion, measuring 5 cm in diameter, in the tail of the pancreas. She underwent a spleen-preserving distal pancreatectomy (SPDP), in which the splenic artery and vein were divided because they were involved in scar formation around the lesion. Intra-operative color Doppler ultrasonography (CDUS) confirmed that splenic circulation via collaterals (short gastric and left gastroepiploic vessels) was preserved throughout the salvaged spleen. Histology of the resected specimen showed localized pancreatitis with a pseudocyst without neoplastic tissue. The patient's post-operative course was uneventful with no evidence of splenic failure and she was discharged 20 days after the operation. A literature review suggests that SPDP without preserving the splenic artery and vein may result in failure of the preserved spleen due to inadvertent injury to the remaining collaterals. Based on the experience of our case, we think that intra-operative CDUS is useful for assessing splenic circulation after SPDP with division of the splenic artery and vein.     

Epidermoid splenic cyst a in child. Report of a case

The authors present a case of epidermoid splenic cyst in masculine patient of 13 years, that presented decrease of appetite, fever and alimentary vomits and tangible abdominal mass in the physical exam. Abdominal ultrasonography demonstrated expansible lesion in the topography of the spleen, and computerized tomography revealed intrinsic homogeneous lesion of the spleen, without communication with pancreas. To the laparotomy, cystic mass of great extension was observed, submitted total esplenectomy, being diagnosed in the histopatological exam epidermoid splenic cystic. In the follow-up patient developed with disappearance of the symptoms. The epidermoid splenic cyst are rare, they can be seen mainly in children and young adults, what proposes a congenital origin for this disease.     

Gastric varices with splenic vein occlusion treated by splenic arterial embolization

A 53-year-old man was admitted to our hospital in August 1997 with enlarged gastric varices. Computed tomography (CT) showed splenic vein occlu-sion, gastric varices, and extra-gastric wall collateral veins. Color flow images of gastric varices were clearly visualized, and the velocity in the gastric varices was 19.6 cm/s via endoscopic color Doppler ultrasonography (ECDUS). The patient was diagnosed with gastric varices according to angiographic findings of splenic vein occlusion, and splenic arterial embolization was performed. Two weeks after the splenic arterial embolization, CT showed peripheral areas of low attenuation in the spleen, due to splenic infarction, with 70% of the spleen volume showing low attenuation. Eight months after the splenic arterial embolization, ECDUS revealed a decrease in gastric variceal color flow images, with the velocity in the gastric varices being 10.3 cm/s. Received: April 26, 1999 / Accepted: August 27, 1999     

Imaging findings of splenic hamartoma

AIM: To assess CT and MR manifestations and their diagnostic value in splenic hamartoma with review of literatures. METHODS: We described a woman who was accidentally found to have a splenic tumor by ultrasound of the abdomen. CT and MR findings of this splenic hamartoma were proved by pathology retrospectively. RESULTS: The CT and MR findings in this case included a ball-like mass with homogeneous mild-hypodensity lesions on non-enhanced CT scans or isointensity on T1-weighted images and mild hypointensity on T2-weighted images, progressive homogeneous enhancement on multiple-phase spiral CT and MR enhanced scans, and isodense enhancement on delayed post-contrast CT scans and obvious hyperintensity relative to the spleen on delayed MR images. CONCLUSION: Splenic hamartoma has some specific radiological features. However, the diagnosis of this disease must be based on clinical features and confirmed by pathology.     

A new approach to studying angiogenesis in rheumatoid arthritis by means of power Doppler ultrasonography and measurement of serum vascular endothelial growth factor

OBJECTIVE: To evaluate angiogenesis as an essential component of pannus formation and cartilage destruction in rheumatoid arthritis (RA) using power Doppler ultrasonography (PDUS) and serum vascular endothelial growth factor (VEGF) measurement. METHODS: Twenty-one RA patients with a painful and swollen wrist and 12 healthy controls were examined with ultrasound. By means of standard scans, vascularity near and inside the joint capsule was visualized with PDUS. Two trained investigators performed sonography. Representative video clips were stored and read by two independent investigators, under blinded conditions, with regard to the microvascular Doppler flow being either inside or outside the joint capsule and with respect to a qualitative estimate of the intensity of blood flow, according to a grading from 1 to 3. Serum levels of VEGF were measured with a standard quantitative sandwich ELISA. RESULTS: The power Doppler mode identified increased synovial microvascular blood flow inside the joint capsule in 17 of 21 RA patients (81%) vs one of the healthy controls. We found large variation in serum VEGF levels in RA patients and in healthy controls. The degree of synovial vascularity determined by PDUS showed no correlation with the immediate serum VEGF level in the same patient. CONCLUSION: The high correlation between intra-articular microvascular power Doppler flow and clinical synovitis in RA patients (P<0.0001) indicates that PDUS may be helpful in studying the role of synovial blood vessels in rheumatoid inflammation.     

Ultrasound7 versus ultrasound12 in monitoring the response to infliximab in patients with rheumatoid arthritis

This study aimed to assess the responsiveness of ultrasonography (US)-7 in patients with rheumatoid arthritis (RA). Eighty-two RA patients were recruited and followed up for 22 weeks. The clinical, laboratory, and X-ray assessments, along with grayscale US (GSUS) and power Doppler US (PDUS) examinations were performed at baseline, 6, 14, and 22 weeks after infliximab treatment. GSUS for synovitis and PDUS for synovitis and paratendinitis/tenosynovitis were assessed by a semi-quantitative (0 to 3) score, while GSUS for paratendinitis/tenosynovitis and bone erosion was qualitatively assessed as absent or present (0 or 1). US scores in both 7-joint (US7) and 12-joint (US12) systems were evaluated. After 6, 14, and 22 weeks of treatment with infliximab, indices such as US scores, 28-joint disease activity (DAS28) score, and tender and swelling joint count were all significantly improved compared to baseline. US7 scores were significantly correlated with that of US12. Strong correlations were identified between most US7 scores with DAS28, health assessment questionnaire (HAQ), and C-reactive protein (CRP) levels. When DAS28 was used as a reference, the US7 cutoff for disease remission was less than 35 for GS?+?PD and also less than 29 for GS and 1 for PD, respectively. Additionally, the positive percent agreement, negative percent agreement, and overall percent agreement for GS?+?PD were 77.78, 76.19, and 76.67 %, respectively, which were all higher than that of GS or PD. US7 may be a feasible tool to assess the therapeutic response in RA patients.     

Lymphoepithelial cyst of the pancreas

A case of lymphoepithelial cyst (LEC) of the pancreas is presented. A 48-year-old man complaining of general fatigue was found to have a heterogeneous water-dense mass protruding from the surface of the pancreas on plain computed tomography (CT). Dynamic CT disclosed septa within the mass. Magnetic resonance imaging (MRI) showed a hypoiintense mass on T1-weighted imaging, and a hyperintense mass on T2-weighted imaging. MRI with gadolinium enhancement revealed septa within the mass. Endoscopic ultrasonography showed septa and fine echogenic structures within the cystic echoic lesion. Endoscopic retrograde pancreatecraphy showed a normal duct system. Distal pancreatectomy with splenectomy was performed, with a suspected diagnosis of cystic neoplasms of the pancreas. Histopathologic examination disclosed LEC of the pancreas. Our case suggests that LEC should be considered in the differential diagnosis of cystic neoplasms of the pancreas.     

Intracystic hemorrhage of a simple liver cyst mimicking a biliary cystadenocarcinoma

Simple liver cysts are rarely complicated by intracystic hemorrhage. We encountered a case of simple liver cyst that was morphologically similar to biliary cystadenocarcinoma, which was complicated by asymptomatic intracystic hemorrhage and successfully treated by right lobectomy. A large cystic lesion of the liver was detected in a 57-year-old woman during a mass screening health check. Abdominal ultrasonography (US) revealed that the cystic lesion, containing many hyperechoic papillary structures, occupied almost the entire region of the right hepatic lobe. In addition, a round mural nodule, measuring approximately 5 cm in diameter, was detected in the cystic wall. Abdominal computed tomography (CT) revealed that the inner part of the cystic lesion showed homogeneous low density, but CT did not show the round nodule detected by US. On T1-weighted sequence of magnetic resonance imaging (MRI), the lesion showed homogeneous high signals, together with a low-signal tumorous lesion in the cystic wall. T2-weighted sequence of MRI showed unhomogeneous high signals, together with high signals in the tumorous part. These findings did not exclude the possibility of a malignant cystic tumor, such as biliary cystadenocarcinoma. Therefore, right lobectomy was performed. Histological examinations of resected tissue specimens revealed that the lesion was a liver cyst containing a large amount of blood clot, and that the tumorous lesion detected by US and MRI was a large mass of blood clot which was partly liquefied. This case indicates the diagnostic importance of the morphological discordance between CT and US or MRI findings for liver cyst containing a large amount of blood clot. Received: May 7, 2001 / Accepted: December 27, 2001 Reprint requests to: Y. Kitajima     

Multiple Nodular lesions In Spleen Associated With Visceral Leishmaniasis: A Case Report of MRI-Findings

The spleen is one of the most commonly involved organs of visceral leishmaniasis (VL). However, there were few reports about imaging findings of splenic leishmaniasis, especially regarding MRI findings.This case report describes a 45 years old male patient from Zhejiang province of southeastern China, who was admitted for persistent fever of unknown origin, with splenomegaly and multiple hypodense/low echo nodules on CT/ultrasonography (USG) studies. MRI showed multiple nodules with concentric rings in the spleen on T2-weighted imaging (T2WI), with no obvious diffusion restriction on diffusion weighted imaging (DWI), and gradual ring-like enhancement after intravenous administration of contrast medium. So MRI suggested necrotic granulomatous lesion. By reviewing the clinical history and following positive serological leishmania antibody test, the patient was finally confirmed a recent infection with VL.The patient received antimony gluconate therapy intravenously.At 4 months follow-up, the contrast-enhanced abdominal MRI showed that the size of the spleen was returned to normal and the splenic lesions were completely resolved except for reduced infarction compared with the previous MRI.This is the first case which was performed MRI examination completely. Meanwhile, it is the second case which MRI findings were reported. As for the characteristics of MRI in this case, there are several features, which are helpful for giving the diagnosis and differential diagnosis of VL.     

Hormone-producing serous cystadenoma of the pancreas

The clinical and histochemical examination of hormone-producing serous cystadenomas of the pancreas are presented. The study material was obtained from five female patients. The patients underwent diagnostic examinations, including ultrasonography, computer tomography (CT), magnetic resonance imaging (MRI) and Doppler ultrasonography examination of abdomen. In all cases the presence of serous cystadenoma of pancreas was detected in the histopathologically verified sections. The test applied to immunohistochemically localize paraffin-embedded sections of neoplastic tissues of the pancreas was the LSAB2-HRP test using monoclonal antibodies against epithelial membrane antigen (EMA), carcinoembryonic antigen (CEA), synaptophysin, p53 and polyclonal antibodies against insulin, glucagon, somatostatin and pancreatic polypeptide. In one patient, ultrasonography revealed an irregular space filled with fluid resembling a multicellular cystic lesion. The Doppler ultrasonography examination showed a pathologically vascularized focus in the pancreatic head. In the adenoma sections of this patient, the immunohistochemical techniques revealed a strong positive somatostatin, pancreatic polypeptide and synaptophysin expression in the lining epithelium of neoplastic cysts.     

Usefulness of novel imaging modalities in diagnosis of focal nodular hyperplasia of the liver

A 17-year-old woman was admitted because of a liver tumor found incidentally by ultrasonography. Liver function was normal and there were no markers of hepatitis viruses or malignancy. Abdominal ultrasonography, computed tomography (CT), and magnetic resonance imaging revealed a mass (2cm in diameter) in the lateral segment of the left lobe of the liver. The lesion was not detected by hepatic arteriography. However, dynamic CT with fast scanning and dynamic CO₂-enhanced ultrasonography demonstrated initial central enhancement of the mass followed by centrifugal spread of enhancement to the periphery. Color Doppler flow imaging detected a central color spot, shown to be an artery by a pulsed Doppler spectrum analysis. Fine-needle biopsy confirmed a diagnosis of focal nodular hyperplasia. Dynamic CT with fast scanning, dynamic CO₂-enhanced ultrasonography, and color Doppler flow imaging were useful in detecting the vascular pattern specific to focal nodular hyperplasia. Investigation of further cases with these novel imaging modalities should help to establish a comprehensive diagnostic procedure and thus avoid unnecessary surgery for focal nodular hyperplasia, which is a completely benign lesion.     

Usefulness of color Doppler ultrasonography (CDUS) and three-dimensional spiral computed tomographic angiography (3D-CT) for diagnosis of unruptured abdominal visceral aneurysm

A 52-year-old Japanese man was transferred to our center where screening by means of ordinal ultrasonography and color Doppler ultrasonography revealed an abdominal visceral aneurysm. Although we were unable to confirm the site of this aneurysm by means of ultrasonographic examination, thin-sliced contrast enhanced computed tomography and three-dimensional spiral computed tomographic angiography showed that the aneurysm was situated at the root of the splenic artery. Transcatheter arterial embolization of the aneurysm was performed by metallic coil with occlusion of the main route of the splenic artery because it was technically difficult to embolize the aneurysm alone while preserving the main splenic arterial flow. Angiography of the celiac trunk after transcatheter arterial embolization showed no enhancement of the aneurysm or splenic artery, and superior mesenteric arteriography after transcatheter arterial embolization showed enhancement of the spleen by collateral circulation from the superior mesenteric artery. One year after transcatheter arterial embolization, repeated contrast enhanced computed tomography revealed the enhancement of the spleen, and color Doppler ultrasonography revealed no blood flow in the aneurysm. Color Doppler ultrasonography and 3D-spiral computed tomographic angiography are both useful for diagnosis of a visceral aneurysm, for confirmation of its exact site and form, and for deciding upon a treatment procedure.     

Pancreatic hamartoma.

Pancreatic hamartoma is a rare benign lesion and may be mistaken for a malignancy, as demonstrated by two cases. The first case was a 29-year-old man who presented with a 7-month history of intermittent upper abdominal pain, nausea and vomiting and a 15-kg weight loss. CT and MRI revealed a mass in the head of the pancreas. The second case was a 62-year-old man who presented with a 2-year history of intermittent abdominal pain, vomiting and a 25-kg weight loss. Although positron emission tomography was normal, CT revealed thickening of the duodenal wall and endoluminal ultrasonography revealed a tumour in the head of the pancreas. Both patients recovered from uneventful Kausch-Whipple pancreatoduodenectomy (in the first patient, it was pylorus-preserving), and in each case the histological diagnosis was hamartoma. Pancreatic hamartoma can present with vague, non-specific symptoms which, despite modern diagnostic tools, can be difficult to diagnose. Surgical resection with histopathological examination is required to confirm the diagnosis.     

Mucinous cystic neoplasm in a young male patient

A 25-year-old Japanese man was admitted to our hospital with a history of recurrent pancreatitis and a pseudocyst of the pancreas. Abdominal computed tomography (CT) and magnetic resonance imaging (MRI) revealed an encapsulated multilocular cystic mass 5 cm in diameter in the pancreatic tail. Endoscopic ultrasonography demonstrated a mural nodule, and endoscopic retrograde pancreatography showed a communication of the lesion with the main pancreatic duct. A neoplastic cystic tumor was suspected, and a resection of the body tail of the pancreas was performed. The lesion was a multilocular cyst having a common fibrous capsule and viscous content. Histologically, the cystic lesion was lined with a single layer of columnar cells with low-grade atypia. Ovarian-type stroma (OS) was confirmed, and it showed positive for antiestrogen receptor and antiprogesteron receptor staining. Based on these findings, the lesion was diagnosed as mucinous cystic neoplasm (MCN), an adenoma that shows extraordinarily high prevalence in women. Further study on the pathogenesis of MCN in male patients should be undertaken to elucidate the process of development.     

Splenic hamartoma associated with thrombocytopenia

A case of splenic hamartoma associated with thrombocytopenia is reported. A 70-year-old man was referred to our hospital because of carcinoma of the body of the pancreas. Hematological examination disclosed thrombocytopenia and elevated serum CA19-9 and Span-1 levels. In addition to typical findings of pancreatic carcinoma, a solid mass was observed in the spleen by imaging procedures. On ultrasonography, the splenic mass was well demarcated and slightly hypoechoic. Computed tomography demonstrated a homogeneous low-density mass 5 cm in diameter. On T1- and T2-weighted magnetic resonance images, the splenic mass was demonstrated as low intensity and high intensity, respectively. On selective angiography, the tumor was hypervascular. Distal pancreatectomy plus splenectomy was performed. Microscopically, the splenic tumor consisted of red pulp tissue and was diagnosed as splenic hamartoma.     

肝脏上皮样血管平滑肌脂肪瘤实时超声造影征象研究

目的 分析总结肝脏上皮样血管平滑肌脂肪瘤(EAML)的灰阶超声、多普勒超声(CDFI)和超声造影(CEUS)表现。方法 回顾性分析我院经手术后组织病理学检查证实的20个EAML患者的临床、灰阶超声、CDFI和CEUS资料。结果 20例病灶均为单发,最大径为(49.23±10.3)mm;病灶内部回声为低回声14例(70.0%),高回声3例(15.0%),高低混合不均匀回声3例(15.0%);CDFI显示0级4例(20.0%),I级3例(15.0%),II级10例(50.0%),III级3例(15.0%);阻力指数(RI)为0.46±0.34;CEUS显示所有病灶动脉期都表现为快速高增强,其中13例(86.6%)为整体均匀增强,门静脉期高增强12例(80.0%),等增强2例(13.3%),低增强1例(6.6%),延迟期仍表现为高增强10例(66.6%),等增强4例(26.6%),低增强1例(6.6%)。结论 EAML灰阶超声主要表现为低回声,CDFI显示为富血供、低阻力型血流,CEUS主要表现为快进慢退/不退,三者结合或有助于提高诊断的准确性。     

Asymptomatic lymphangioma involving the spleen and retroperitoneum in adults

Lymphangioma, a benign neoplasm of the lymphatic system, is common in children but rare in adults. Its clinical manifestations include abdominal pain, nausea,vomiting and a palpable mass. However, abdominal sonography or abdominal computed tomography (CT) scan can also incidentally reveal lymphangioma. A larger or symptomatic lymphangioma is treated with total resection to prevent recurrence, infection, torsionand enlargement. Although lymphangioma rarely becomes malignant, its prognosis is generally good.We report a cystic lymphangioma of the spleen and retroperitoneum, which was incidentally found in a 56-year-old man who was hospitalized due to a colon mass. Physical examination showed no specific findings.Abdominal CT revealed a 5.7 cm, non-enhanced multilobulated cystic mass with multiple septa in the spleen and a 10 cm lobulated cystic mass in the paraaorticarea. Splenectomy and retroperitoneal resectionof the cystic mass were conducted. The endothelium of splenic and retroperitoneal cyst was immunohistochemically stained with D2-40 antibody. The patient was finally diagnosed with splenic cystic and retroperitoneal cavernous lymphangioma.