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Author: Tan Youwen Zhenjiang Third Hospital Affiliated to Jiangsu University This article is published by Yimaitong authorized by the author, please do not reprint without authorization.
Guided reading space-occupying lesions is a special term in medical imaging diagnostics, usually appearing in X-ray, B-ultrasound, CT and other examination results.
It means that there is an "extra thing" in the inspected part, and this "extra thing" can cause pressure and displacement of the surrounding tissues.
Space-occupying lesions generally refer to tumors (benign or malignant), parasites, etc.
, and do not involve the cause of the disease.
Common clinical multiple lesions that are benign are more common in cysts, but malignant space-occupying lesions are on the rise in recent years, and they are often diagnosed and often lose the opportunity for radical treatment.
Today, we present a very interesting case.
Case sharing patient, male, 56 years old, with a history of chronic hepatitis B for more than 30 years, no standard antiviral treatment, upper abdominal discomfort and dull pain with no obvious cause more than 3 months ago, the degree is not severe, the pain does not radiate to other parts, more than half a year The weight loss was about 5 kg.
CT of the abdomen showed that the right lobe of the liver occupied space, and the posterior peritoneal cavity had multiple enlarged lymph nodes.
Liver and kidney function TBIL 17.
4 ALT 66 AST 53 ALP 141 GGT 290 BUN 4.
08 CRE 73.
Hepatitis B surface antigen is positive.
AFP 78.
53, CEA 3.
57, CA199 86.
26.
HBV DNA 2.
59*x10^5 IU/mL. MRI and chest CT after admission: 1.
Thick-walled mass near the vena cava of the posterior upper segment of the right posterior lobe, containing a cavity, nodules in the left lobe of the liver, a little rich in blood vessels, and no normal hepatocyte components in it.
Consider liver abscess; 2 .
Liver cirrhosis, splenomegaly; cyst of the left lobe; 3.
Multiple enlarged lymph nodes in the retroperitoneum; 4.
Mass on the right side of the anterior inferior mediastinum, with ring enhancement, considering the inflammatory lesions may be large; 5.
Thick-walled mass of the upper lobe of the right lung, Consider the possibility of lung abscess; 6.
A small amount of fluid in the right thoracic cavity.
The clinical diagnosis was liver abscess, lung abscess, mediastinal abscess, and pneumonia.
Treatment plan: recheck after 2 weeks of anti-infective treatment with imipenem.
It can be seen from chest CT that the lung abscess has been significantly improved, and the previously elevated WBC and C-reactive protein are also normal.
From the perspective of imaging and treatment effects, both support the diagnosis of lung abscess.
However, the space-occupying lesions of the liver showed no obvious changes on MRI.
The size of the posterior upper vena cava of the right hepatic lobe is about 34mm*36mm*33mm, and the lesion extends along the subcapsule of the liver.
T1WI shows low signal and T2WI shows slightly high signal.
DWI shows that the edge of the lesion is diffusely limited, and the edge of the lesion is light in the enhanced scan Degree enhancement, portal venous phase, secretory phase and delayed scan (3min, 6min) around the lesion showed progressive enhancement, and there was no obvious contrast agent uptake in the hepatobiliary phase.
A nodule with a diameter of about 20mm was seen in the left inner lobe of the liver.
T1WI showed low signal, T2WI showed slightly high signal, DWI showed limited diffusion, enhanced scan arterial phase, portal phase lesions showed mild enhancement, delayed scan (6min) angiography Part of the drug was withdrawn, and there was no significant uptake of contrast agent during hepatobiliary stage.
According to the opinion of the imaging department, "liver abscess" was reviewed after treatment, and it was still considered that the inflammatory infiltration might be large.
Diagnosis is at a deadlock.
From the analysis of clinical data, the patient’s post-hepatitis B liver cirrhosis, upper abdomen discomfort for 3 months, weight loss of 5Kg for half a year, elevated AFP and CA199 tumor indicators, support the possibility of malignant lesions, but the lung abscess is clear and the treatment is effective.
Imaging supports the inflammatory space-occupying lesions of the liver.
At this time, T-SPOT.
TB was positive and Mycobacterium tuberculosis was 38KD positive. Is it an abscess of liver tuberculosis? Is antibiotic treatment ineffective? Diagnosis of liver biopsy cannot be further accurately treated.
Pathological examination has become an indication.
It is more difficult to locate and puncture space-occupying lesions than ordinary liver biopsy.
For ordinary liver puncture, the most suitable puncture part can be selected, which is mostly at the outer edge of the liver.
Positional lesions are difficult to puncture and locate, and it is often difficult to place a needle in place.
Multiple positioning increases the occurrence of complications such as bleeding.
If the occupying lesion is a malignant tumor, there may be implantation and metastasis.
We chose CT-guided biopsy, using 17G puncture sheath and 18G puncture needle.
Before the operation, we plan to puncture two sites at two sites respectively.
First, the first needle will puncture the edge of the space-occupying lesion next to the vena cava, and take the dark red tissue 2CM.
Submitted for bacteriological examination including acid-fast staining.
For the second time, puncture the center of the space-occupying lesions adjacent to the vena cava, take the white tissue 2cm, and send it for pathology.
Before the complications of puncture, it was planned to puncture two space-occupying sites in the liver, but the patient had cirrhosis with hypersplenism, and the platelets were only 53*x10^9.
During the operation, it was found that the puncture point was difficult to stop bleeding, and hemorrhage was found in the pleural cavity during the puncture process.
The puncture of the second lesion was temporarily terminated.
After the bleeding did not continue to increase, he returned to the ward completely.
Pathological diagnosis: Pathological findings: the puncture tissue is gray, liver cirrhosis changes, tumor cells show obvious cell atypia, glandular changes, doxeroid structure, abundant fibrous septa, and more eosinophilic and neutrophil infiltration.
Pathological diagnosis: intrahepatic cholangiocarcinoma (medium-poorly differentiated adenocarcinoma).
There are still many doubts about the diagnosis of intrahepatic cholangiocarcinoma ICC (intrahepatic cholangiocarcinoma ICC), which seems to have a satisfactory result, which can also explain the clinical course.
It can also explain why the imaging department repeatedly diagnosed liver abscess.
But why is it ICC instead of hepatocellular carcinoma (HCC)? This patient has long-term hepatitis B cirrhosis! The well-known risk factors for the onset of ICC include: congenital choledochal cyst, chronic cholangitis, primary sclerosing cholangitis, biliary cirrhosis, cholelithiasis, intrahepatic bile duct stones and so on.
This patient did not, and both AFP and CA199 were elevated.
Are these two placeholders of the same nature? The lesions of the left liver show typical "fast forward and fast out" manifestations in imaging.
Is this HCC? The puncture is the ICC! Of course, there is no need for another liver biopsy.
It does not help the patient's prognosis very much, and the ethics is not supported.
HCC combined with ICC mixed liver cancer (cHCC-CC) refers to primary liver cancer in which the tumor tissue has both hepatocellular carcinoma and cholangiocarcinoma.
It is the least common type of primary liver cancer, accounting for 0.
4%-14.
2%.
In 1949, Allen classified according to pathology, type A (double tumor type): separate HCC and ICC released in different parts of the liver, and normal liver tissue between them; type B (connected type): contact mass, namely HCC and ICC grow in the same part of the liver and are mixed with each other, but the morphological characteristics of the two are different; Type C: HCC and ICC contain two components in the same tumor.
In 1985, Goodman was improved again, and it was divided into type I (collision type), type II (migrating type), and type III (fiberboard layer type).
In 2010, WHO classified cHCC-CC into typical type, intermediate cell type and thin bile duct cell type.
Conventional MRI sequence cHCC-CC mostly showed low signal on T1WI, medium or slightly high signal on T2WI.
The signal of tumor on T2WI image was affected by many factors, such as tumor blood supply, tumor parenchymal and interstitial component ratio and necrotic tissue How much wait.
The performance of cHCC-CC dynamic MRI scan can also be divided into several types.
The enhancement method is similar to the CT enhancement method, which is determined by the proportion and distribution of HCC and ICC in the tumor.
Tan Youwen, Chief Physician, Ph.
D.
Supervisor of Master's Candidates of Jiangsu University, Director of the Department of Hepatology, Zhenjiang Third Hospital Affiliated to Jiangsu University, columnist of Yimaitong
Guided reading space-occupying lesions is a special term in medical imaging diagnostics, usually appearing in X-ray, B-ultrasound, CT and other examination results.
It means that there is an "extra thing" in the inspected part, and this "extra thing" can cause pressure and displacement of the surrounding tissues.
Space-occupying lesions generally refer to tumors (benign or malignant), parasites, etc.
, and do not involve the cause of the disease.
Common clinical multiple lesions that are benign are more common in cysts, but malignant space-occupying lesions are on the rise in recent years, and they are often diagnosed and often lose the opportunity for radical treatment.
Today, we present a very interesting case.
Case sharing patient, male, 56 years old, with a history of chronic hepatitis B for more than 30 years, no standard antiviral treatment, upper abdominal discomfort and dull pain with no obvious cause more than 3 months ago, the degree is not severe, the pain does not radiate to other parts, more than half a year The weight loss was about 5 kg.
CT of the abdomen showed that the right lobe of the liver occupied space, and the posterior peritoneal cavity had multiple enlarged lymph nodes.
Liver and kidney function TBIL 17.
4 ALT 66 AST 53 ALP 141 GGT 290 BUN 4.
08 CRE 73.
Hepatitis B surface antigen is positive.
AFP 78.
53, CEA 3.
57, CA199 86.
26.
HBV DNA 2.
59*x10^5 IU/mL. MRI and chest CT after admission: 1.
Thick-walled mass near the vena cava of the posterior upper segment of the right posterior lobe, containing a cavity, nodules in the left lobe of the liver, a little rich in blood vessels, and no normal hepatocyte components in it.
Consider liver abscess; 2 .
Liver cirrhosis, splenomegaly; cyst of the left lobe; 3.
Multiple enlarged lymph nodes in the retroperitoneum; 4.
Mass on the right side of the anterior inferior mediastinum, with ring enhancement, considering the inflammatory lesions may be large; 5.
Thick-walled mass of the upper lobe of the right lung, Consider the possibility of lung abscess; 6.
A small amount of fluid in the right thoracic cavity.
The clinical diagnosis was liver abscess, lung abscess, mediastinal abscess, and pneumonia.
Treatment plan: recheck after 2 weeks of anti-infective treatment with imipenem.
It can be seen from chest CT that the lung abscess has been significantly improved, and the previously elevated WBC and C-reactive protein are also normal.
From the perspective of imaging and treatment effects, both support the diagnosis of lung abscess.
However, the space-occupying lesions of the liver showed no obvious changes on MRI.
The size of the posterior upper vena cava of the right hepatic lobe is about 34mm*36mm*33mm, and the lesion extends along the subcapsule of the liver.
T1WI shows low signal and T2WI shows slightly high signal.
DWI shows that the edge of the lesion is diffusely limited, and the edge of the lesion is light in the enhanced scan Degree enhancement, portal venous phase, secretory phase and delayed scan (3min, 6min) around the lesion showed progressive enhancement, and there was no obvious contrast agent uptake in the hepatobiliary phase.
A nodule with a diameter of about 20mm was seen in the left inner lobe of the liver.
T1WI showed low signal, T2WI showed slightly high signal, DWI showed limited diffusion, enhanced scan arterial phase, portal phase lesions showed mild enhancement, delayed scan (6min) angiography Part of the drug was withdrawn, and there was no significant uptake of contrast agent during hepatobiliary stage.
According to the opinion of the imaging department, "liver abscess" was reviewed after treatment, and it was still considered that the inflammatory infiltration might be large.
Diagnosis is at a deadlock.
From the analysis of clinical data, the patient’s post-hepatitis B liver cirrhosis, upper abdomen discomfort for 3 months, weight loss of 5Kg for half a year, elevated AFP and CA199 tumor indicators, support the possibility of malignant lesions, but the lung abscess is clear and the treatment is effective.
Imaging supports the inflammatory space-occupying lesions of the liver.
At this time, T-SPOT.
TB was positive and Mycobacterium tuberculosis was 38KD positive. Is it an abscess of liver tuberculosis? Is antibiotic treatment ineffective? Diagnosis of liver biopsy cannot be further accurately treated.
Pathological examination has become an indication.
It is more difficult to locate and puncture space-occupying lesions than ordinary liver biopsy.
For ordinary liver puncture, the most suitable puncture part can be selected, which is mostly at the outer edge of the liver.
Positional lesions are difficult to puncture and locate, and it is often difficult to place a needle in place.
Multiple positioning increases the occurrence of complications such as bleeding.
If the occupying lesion is a malignant tumor, there may be implantation and metastasis.
We chose CT-guided biopsy, using 17G puncture sheath and 18G puncture needle.
Before the operation, we plan to puncture two sites at two sites respectively.
First, the first needle will puncture the edge of the space-occupying lesion next to the vena cava, and take the dark red tissue 2CM.
Submitted for bacteriological examination including acid-fast staining.
For the second time, puncture the center of the space-occupying lesions adjacent to the vena cava, take the white tissue 2cm, and send it for pathology.
Before the complications of puncture, it was planned to puncture two space-occupying sites in the liver, but the patient had cirrhosis with hypersplenism, and the platelets were only 53*x10^9.
During the operation, it was found that the puncture point was difficult to stop bleeding, and hemorrhage was found in the pleural cavity during the puncture process.
The puncture of the second lesion was temporarily terminated.
After the bleeding did not continue to increase, he returned to the ward completely.
Pathological diagnosis: Pathological findings: the puncture tissue is gray, liver cirrhosis changes, tumor cells show obvious cell atypia, glandular changes, doxeroid structure, abundant fibrous septa, and more eosinophilic and neutrophil infiltration.
Pathological diagnosis: intrahepatic cholangiocarcinoma (medium-poorly differentiated adenocarcinoma).
There are still many doubts about the diagnosis of intrahepatic cholangiocarcinoma ICC (intrahepatic cholangiocarcinoma ICC), which seems to have a satisfactory result, which can also explain the clinical course.
It can also explain why the imaging department repeatedly diagnosed liver abscess.
But why is it ICC instead of hepatocellular carcinoma (HCC)? This patient has long-term hepatitis B cirrhosis! The well-known risk factors for the onset of ICC include: congenital choledochal cyst, chronic cholangitis, primary sclerosing cholangitis, biliary cirrhosis, cholelithiasis, intrahepatic bile duct stones and so on.
This patient did not, and both AFP and CA199 were elevated.
Are these two placeholders of the same nature? The lesions of the left liver show typical "fast forward and fast out" manifestations in imaging.
Is this HCC? The puncture is the ICC! Of course, there is no need for another liver biopsy.
It does not help the patient's prognosis very much, and the ethics is not supported.
HCC combined with ICC mixed liver cancer (cHCC-CC) refers to primary liver cancer in which the tumor tissue has both hepatocellular carcinoma and cholangiocarcinoma.
It is the least common type of primary liver cancer, accounting for 0.
4%-14.
2%.
In 1949, Allen classified according to pathology, type A (double tumor type): separate HCC and ICC released in different parts of the liver, and normal liver tissue between them; type B (connected type): contact mass, namely HCC and ICC grow in the same part of the liver and are mixed with each other, but the morphological characteristics of the two are different; Type C: HCC and ICC contain two components in the same tumor.
In 1985, Goodman was improved again, and it was divided into type I (collision type), type II (migrating type), and type III (fiberboard layer type).
In 2010, WHO classified cHCC-CC into typical type, intermediate cell type and thin bile duct cell type.
Conventional MRI sequence cHCC-CC mostly showed low signal on T1WI, medium or slightly high signal on T2WI.
The signal of tumor on T2WI image was affected by many factors, such as tumor blood supply, tumor parenchymal and interstitial component ratio and necrotic tissue How much wait.
The performance of cHCC-CC dynamic MRI scan can also be divided into several types.
The enhancement method is similar to the CT enhancement method, which is determined by the proportion and distribution of HCC and ICC in the tumor.
Tan Youwen, Chief Physician, Ph.
D.
Supervisor of Master's Candidates of Jiangsu University, Director of the Department of Hepatology, Zhenjiang Third Hospital Affiliated to Jiangsu University, columnist of Yimaitong
