Hypodense Liver Lesions Research Articles

Incidental detection of endometriosis with 18F-fluorodeoxyglucose positron emission tomography-computed tomography in a patient with cervical intraepithelial neoplasia and adenomyosis

Endometriosis is commonly associated with chronic pelvic pain and its presentation varies between individuals. The only way to confirm the presence of endometriosis is via keyhole or open surgery. In the presence of hematuria, deep endometriotic infiltration needs to be considered. We share an interesting case highlighting the role of 18F-fluorodeoxyglucose positron emission tomography-computed tomography in evaluating a posterior urinary bladder wall lesion and hypodense liver lesions in a middle-aged woman with presenting with frank hematuria in the background of treated cervical intraepithelial neoplasia and adenomyosis.

Improved visualization of hypodense liver lesions in virtual monoenergetic images from spectral detector CT: Proof of concept in a 3D-printed phantom and evaluation in 74 patients

ObjectivesThe well-known boost of iodine associated-attenuation in low-keV virtual monoenergetic images (VMI_low) is frequently used to improve visualization of lesions and structures taking up contrast media. This study aimed to evaluate this concept in reverse. Hence to investigate if increased attenuation within the liver allows for improved visualization of little or not-enhancing lesions. MethodsA 3D-printed phantom mimicking the shape of a human liver exhibiting a lesion in its center was designed and printed. Both, parenchyma- and lesion-mimic were filled with different solutions exhibiting 80/100/120HU and 0/15/40/60HU, respectively. Further, a total of 74 contrast-enhanced studies performed on a spectral detector CT scanner (SDCT) were included in this retrospective study. Patients had MRI or follow-up proven cysts and/or hypodense metastases. VMI of 40–200 keV as well as conventional images (CI) were reconstructed. ROI were placed in lesion and parenchyma(-mimics) on CI and transferred to VMI. Signal- and contrast-to-noise ratio were calculated (S-/CNR). Further, two radiologists independently evaluated image quality. Data was statistically assessed using ANOVA or Wilcoxon-test. ResultsIn phantoms, S/CNR was significantly higher in VMI_low. The cyst-mimic in highly attenuating parenchyma-mimic on CI yielded a CNR of 6.4 ± 0.8; using VMI_40 keV, mildly hypodense lesion-mimic in poorly attenuating parenchyma-mimic exhibited a similar CNR (5.8 ± 0.9; p ≤ 0.05). The same tendency was observed in patients (cyst in CI/metastasis in VMI_40 keV: 4.4 ± 1.2/3.9 ± 1.8; p ≤ 0.05). Qualitative analysis indicated a benefit of VMI_40 keV (p ≤ 0.05). ConclusionsVMI_low from SDCT allow for an improved visualization of hypodense focal liver lesions exploiting the concept of contrast blooming in reverse.

Virtual Monoenergetic Images for Diagnostic Assessment of Hypodense Lesions Within the Liver: Semiautomatic Estimation of Window Settings Using Linear Models.

The aim of the study was to establish the reference window settings for display of virtual monoenergetic images (VMIs) from spectral detector computed tomography when assessing hypodense liver lesions. In patients with cysts (n = 24) or metastases (n = 26), objective (HU, signal-to-noise ratio [SNR]) and subjective (overall image quality, lesion conspicuity and noise) were assessed. Furthermore, 2 readers determined optimal window center/width (C/W) for conventional images (CIs) and VMIs of 40 to 120 keV. Center/width were modeled against HUliv with and without respect to the keV level (models A and B). Attenuation and SNR were significantly higher in low-keV VMIs and improved overall image quality and lesion conspicuity (P ≤ 0.05). Model B provided valid estimations of C/W, whereas model A was slightly less accurate. The increase in attenuation and SNR on low-keV VMIs requires adjustment of C/W, and they can be estimated in dependency of HUliv using linear models. Reference values for standard display of VMIs of 40 to 120 keV are reported.

Pancreatic Adenocarcinoma Disguised as Diabetic Ketoacidosis: A Case Review

BACKGROUND Diabetic ketoacidosis (DKA) as a presenting symptom for pancreatic exocrine tumors is well documented; however, it is rarely a presenting symptom of pancreatic adenocarcinoma.CASE DESCRIPTION A 48-year-old female presented with a 3-day history of generalized weakness and bilious vomiting. She appeared acutely ill, having mild epigastric tenderness on examination. The initial workup was consistent with DKA secondary to new-onset DM. She improved with intravenous fluids, insulin per DKA protocol, and electrolyte repletion. She was discharged home with a new insulin regimen. One week later, she returned to the emergency department with severe abdominal pain, nausea, and vomiting. Laboratory studies were significant for new transaminitis (ALT 79 U/L, AST 49 U/L), elevated alkaline phosphatase (527 U/L), and elevated lipase (241 U/L). A CT scan revealed an enlarged edematous pancreas with a hypodensity in the distal pancreatic body concerning for necrotizing pancreatitis and multiple hypodense liver lesions. Due to concern for pancreatic pseudocyst versus necrosis, an endoscopic ultrasound (EUS) with fine needle aspiration (FNA) was performed. EUS revealed three malignant-appearing lymph nodes in the celiac region, diffuse enlargement of the pancreatic body, and multiple lesions in the left lobe of the liver. Cytology obtained via celiac lymph node FNA was consistent with metastatic adenocarcinoma with signet ring cell features. Oncology and Palliative Medicine were consulted for stage IV adenocarcinoma, likely pancreatic in origin. Palliative chemotherapy was considered; however, patient's condition deteriorated. She transitioned to hospice care and expired shortly thereafter. DISCUSSION Patients with pancreatic cancer typically present with abdominal pain, weight loss, asthenia, anorexia and obstructive jaundice. DM is present in at least 50% of these patients and is an independent risk factor for pancreatic cancer-imparting a two-fold increased risk. In contrast, up to 80% of patients with pancreatic adenocarcinoma present with new-onset hyperglycemia at time of diagnosis. Furthermore, hyperglycemia presenting as DKA is exceedingly rare. Among adult patients presenting with DKA, 47% had known type 1 DM, 26% had known type 2 DM, and 27% had newly diagnosed DM. CONCLUSIONS Physicians should be aware of and consider pancreatic cancer in newly diagnosed type 2 DM presenting with DKA, especially when obvious precipitating factors are absent.1401.tif Figure 1: No Caption available.

Imaging characteristics of Fasciola gigantica, a report of 29 cases

ObjectiveTo analyze imaging findings of Fasciola (F.) gigantica infection on computed tomography (CT), magnetic resonance imaging (MRI), and ultrasonography (US). MethodTwenty-nine patients with F. gigantica were admitted to the Affiliated Hospital of Dali University (n = 18) and Dali Prefecture People's Hospital (n = 11) from November 2011 to April 2012. All patients were examined by routine CT scan and US, and 24 of them were detected by MRI and MR cholangiopancreatography (MRCP). Serologic methods using enzyme-linked immunosorbent assay (ELISA) in 27 patients, stool examination in all patients, and hepatic tissue biopsy in 3 patients were performed. CT and US as follow-up examination was carried out in most patients for 3 years. ResultsMultiple and scattered hypodense lesions in liver were seen in all patients on CT. Four types of hepatic lesions were observed on MRI as follows: tunnel-like lesions, abscesses, enhancement lesions, and iso- or slightly hypointense areas on T1-weighted images or T2-weighted images. These hepatic lesions were hypoechoic on US. Pathological images showed coagulation necrosis of liver lesions. Multiple calcifications were disclosed in 19 patients at follow-up. ConclusionThe imaging findings of CT, MRI, and US are helpful for the diagnosis of acute and chronic stages of Fasciola gigantica in liver.

Dysphagia Caused by Cervical Plate Erosion through the Hypopharynx

CASE REPORT A 53-year-old woman with a history of neurofibromatosis, Hodgkin's lymphoma, and C3-T2 fusion 4 years prior for swan-neck cervical deformity was admitted for evaluation of left frontal skull mass and progressively worsening dysphagia of solid foods and thick liquids over 6 weeks. Computed tomography (CT) of the abdomen, pelvis, and lumbothoracic spine showed multiple hypodense liver lesions and diffuse sclerotic bone lesions within the thoracic and lumbar spine, ribs, sacrum, and ischium suspicious for metastatic malignancy. Fine-needle aspiration of the liver lesions yielded immunochemistry positive for focal CA 19-9 staining suggestive of adenocarcinoma of upper gastrointestinal (GI) origin. Serum CEA and CA 19-9 were within normal limits. Esophagogastroduodenoscopy did not reveal an upper GI tumor; however, a metal object was seen in the hypopharynx just above the upper esophageal sphincter (Figure 1). It appeared to be fixed and could not be moved with grasping forceps. The adult gastroscope could not be advanced beyond the object; however, the ultraslim could. A sagittal CT view of the neck with contrast showed the offset of the anterior cervical internal fusion plate with direct communication to the hypopharyngeal airway and suggesting erosion through the posterior hypopharyngeal soft tissue (Figure 2). Given the patient's multiple comorbidities and presumably metastatic cholangiocarcinoma, neurosurgery service recommended medical management rather than surgical management. A 6-week course of intravenous ertapenem was initiated due to the high risk of abscess formation. The patient underwent gastric tube placement for feeding and was eventually discharged under hospice care.Figure 1.: Esophagogastroduodenoscopy showing a foreign metal object in the hypopharynx above the upper esophageal sphincter.Figure 2.: Sagittal view of the neck with contrast-enhanced computed tomography showing direct communication between the anterior cervical internal fusion plate and the hypopharyngeal airway.Dysphagia is an underrecognized but significant complication of cervical fusion surgeries.1 The incidence of esophageal perforation after anterior cervical spine surgery is estimated to be between 0.02% and 1.49% with a mortality rate of 6%.2 Most esophageal erosions occur in the intraoperative or immediate postoperative setting, although there has been an increase in cases with delayed presentation, which often lead to dramatic clinical deterioration with a higher mortality risk of 20-50%.3 Most esophageal injuries are due to iatrogenic injury intraoperatively from inappropriate placement or dislodgement of retractors or hardware migration. Delayed injuries are typically due to chronic compression, abscess formation, repetitive friction of the plating system, or hardware dislodgement and chronic migration.4 Diagnosis can be made with cervical radiographs; however negative imaging does not rule out esophageal injury. Operative intervention is recommended, but conservative medical treatment is appropriate depending on the patient and the clinical circumstances.5 Although cervical endplate erosion of the esophagus has been well documented in the literature, hypopharyngeal erosion has only been reported once previously.6 It is imperative that health care providers are vigilant and complete a thorough workup in patients with persistent or worsening dysphagia who have undergone a previous anterior cervical surgery. DISCLOSURES Author contributions: S. Kothari and T. Almouradi wrote the manuscript. T. Almouradi is the article guarantor.

Dysphagia Caused by Cervical Plate Erosion through the Hypopharynx

CASE REPORT A 53-year-old woman with a history of neurofibromatosis, Hodgkin's lymphoma, and C3-T2 fusion 4 years prior for swan-neck cervical deformity was admitted for evaluation of left frontal skull mass and progressively worsening dysphagia of solid foods and thick liquids over 6 weeks. Computed tomography (CT) of the abdomen, pelvis, and lumbothoracic spine showed multiple hypodense liver lesions and diffuse sclerotic bone lesions within the thoracic and lumbar spine, ribs, sacrum, and ischium suspicious for metastatic malignancy. Fine-needle aspiration of the liver lesions yielded immunochemistry positive for focal CA 19-9 staining suggestive of adenocarcinoma of upper gastrointestinal (GI) origin. Serum CEA and CA 19-9 were within normal limits. Esophagogastroduodenoscopy did not reveal an upper GI tumor; however, a metal object was seen in the hypopharynx just above the upper esophageal sphincter (Figure 1). It appeared to be fixed and could not be moved with grasping forceps. The adult gastroscope could not be advanced beyond the object; however, the ultraslim could. A sagittal CT view of the neck with contrast showed the offset of the anterior cervical internal fusion plate with direct communication to the hypopharyngeal airway and suggesting erosion through the posterior hypopharyngeal soft tissue (Figure 2). Given the patient's multiple comorbidities and presumably metastatic cholangiocarcinoma, neurosurgery service recommended medical management rather than surgical management. A 6-week course of intravenous ertapenem was initiated due to the high risk of abscess formation. The patient underwent gastric tube placement for feeding and was eventually discharged under hospice care.Figure 1.: Esophagogastroduodenoscopy showing a foreign metal object in the hypopharynx above the upper esophageal sphincter.Figure 2.: Sagittal view of the neck with contrast-enhanced computed tomography showing direct communication between the anterior cervical internal fusion plate and the hypopharyngeal airway.Dysphagia is an underrecognized but significant complication of cervical fusion surgeries.1 The incidence of esophageal perforation after anterior cervical spine surgery is estimated to be between 0.02% and 1.49% with a mortality rate of 6%.2 Most esophageal erosions occur in the intraoperative or immediate postoperative setting, although there has been an increase in cases with delayed presentation, which often lead to dramatic clinical deterioration with a higher mortality risk of 20-50%.3 Most esophageal injuries are due to iatrogenic injury intraoperatively from inappropriate placement or dislodgement of retractors or hardware migration. Delayed injuries are typically due to chronic compression, abscess formation, repetitive friction of the plating system, or hardware dislodgement and chronic migration.4 Diagnosis can be made with cervical radiographs; however negative imaging does not rule out esophageal injury. Operative intervention is recommended, but conservative medical treatment is appropriate depending on the patient and the clinical circumstances.5 Although cervical endplate erosion of the esophagus has been well documented in the literature, hypopharyngeal erosion has only been reported once previously.6 It is imperative that health care providers are vigilant and complete a thorough workup in patients with persistent or worsening dysphagia who have undergone a previous anterior cervical surgery. DISCLOSURES Author contributions: S. Kothari and T. Almouradi wrote the manuscript. T. Almouradi is the article guarantor.

Metastatic Angiosarcoma: A Rare Cause of Chylothorax

SESSION TITLE: Pulmonary Manifestations of Systemic Disease 3 SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Metastatic angiosarcoma (MA) is a rare malignancy originating from soft tissue, and chylothorax is an even rarer manifestation of this disease. We present a unique case of MA with pulmonary and pleural involvement which presented with unilateral chylothorax and ascites. CASE PRESENTATION: A 49 year old female with a history of latent tuberculosis infection (LTBI) presented with a 2 week history of abdominal pain and dyspnea. Physical examination was significant for an ill appearance with decreased right sided breath sounds and moderate ascities. Laboratory analysis was significant for hypoalbuminemia, hyponatremia, and elevated CA 125. CT imaging revealed a large right sided pleural effusion, moderate ascities with peritoneal enhancement, and hypodense liver lesions. Paracentesis was significant for a serum ascites albumin gradient of 1.3 with negative cytology. Thoracentesis was consistent with a chylous effusion with lymphocytic predominance and a pleural adenosine deaminase of 23.7. A chest tube was placed and drained 3 liters of fluid daily. All Infectious work up was negative. Repeat CT imaging revealed right lung interstitial opacities and a wedge biopsy was consistent with angiosarcoma with pleural infiltration. The patient passed away shortly after diagnosis. DISCUSSION: Angiosarcomas are rare neoplasms originating from soft tissues, commonly heart, breast, and skin. Pulmonary involvement indicates metastatic disease, usally presenting with pulmonary nodules or diffuse alveolar hemorrhage. In these cases, the disease is aggressive with 5 year survival rates less than 20%. Only 1 case of MA presenting as a chylothorax has been reported. The rarity of these tumors makes diagnosis exceptionally difficult and requires a multidisciplinary approach. CONCLUSIONS: While this patient had risk factors for other process which can cause ascities and chylothorax (LTBI), ultimately her symptoms were related to a more rare disease process - MA. Angiosarcoma should be included in the differential of chylothorax, especially when other more common diagnoses have been excluded. Reference #1: Abraham, V. A Rare Find-Primary Pulmonary Angiosarcoma. CHEST Journal. October 2011; 140(4). Reference #2: Pan, Z et al. Diffuse alveolar hemorrhage due to metastatic angiosarcoma of the lung: a case report. Oncology Letters. December 2015; 10(6). 3853-3855. Reference #3: Vavilis, D et al. Primary ovarian angiosarcoma—review of the literature and report of a case with coexisting chylothorax. European Journal of Gynaecologic Oncology. 2007; 28(4): 287-9. DISCLOSURE: The following authors have nothing to disclose: Rishi Mehta, Jessica Johnson, Katherine Young No Product/Research Disclosure Information

Hepatocellular Carcinoma in Non-Cirrhotic Liver Patients: Is it Possible?

Cirrhosis is a major risk factor for developing HCC (hepatocellular carcinoma), therefore cirrhotic patients should still be included in surveillance HCC programs even after sustained virological response (SVR). To date, there are few studies on non-cirrhotic patients and development of HCC. A 64-year-old man with history of end-stage renal disease, diabetes mellitus type 2 and hepatitis C, treated unsuccessfully with interferon and DAA (direct acting antiviral) agent, was being evaluated for kidney transplant, and found to have new liver lesions. Laboratory work up was significant for alpha-fetoprotein (AFP) 6.2, hepatitis C ribonucleic acid (HCV RNA) 475,514 IU/mL with normal transaminases, bilirubin, albumin and INR. Computed tomography (CT) of the abdomen showed two hypodense liver lesions, more apparent on delayed imaging. First one was an ill-defined 2.4 x 1.7 cm lesion at the segment VIII, with irregular nodular enhancement. Second one was a 1.7 x 1.7cm lesion on segment IV/VII. These radiological findings were suspicious for hepatocellular carcinoma. Positron Emission Tomography (PET) CT scan showed increased uptake in the liver lesion on segment VIII. Of note, an ultrasonography of the abdomen done 6 months prior to the CT as part of surveillance for HCC was negative for hepatic lesions. Fibroscan (Transient Elastography) showed mild disease, with a reading of 6.1 kPa. Liver biopsy was consistent with mild portal inflammation/mild fibrosis and moderately differentiated hepatocellular carcinoma. Patient was referred to Interventional Radiology for Y90 radio embolization. This case illustrates that even patients with no bridging fibrosis or cirrhosis can develop HCC. This stands out from our current understanding of HCC development and its relationship with final stages of liver fibrosis. The risk of recurrent HCC after being cured is 0.33 percent per year. Therefore, patients with SVR and established cirrhosis are included in the screening HCC program. Age 65 or more, and presence of cirrhosis at the time of SVR were associated with annual HCC risk of 0.9% and 1.55%, respectively. With our case report, we raise the question that non-cirrhotic patients with chronic hepatitis C infection who were treated with DAA should be part of the screening program of HCC. Their inclusion in the program warrants prospective future trials and detailed information regarding timing and imaging studies.Figure

First Reported Case of Endoscopic Ultrasound-Guided Core Biopsy Yielding Diagnosis of Primary Adrenal Leiomyosarcoma

Introduction Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) or core biopsy (EUS-CB) is a safe, effective modality for sampling adrenal lesions [1]. We present the first case of primary adrenal leiomyosarcoma diagnosed by EUS-CB. Case Description 50 year old male presented with abdominal pain and weight loss for a year. Physical exam and labs were normal. Computed Tomography (CT) abdomen showed an 8.1 cm heterogeneous left adrenal mass and several hypodense liver lesions concerning for metastatic disease. Positron Emission Tomography (PET) scan showed FDG avid left adrenal mass and mildly avid lung and liver lesions suggestive of metastatic disease. Pheochromocytoma was ruled out with negative urine metanephrines and catecholamines. There was no clinical evidence of Cushing's Syndrome. Adrenal cortical carcinoma was considered but as there was no evidence of precursor steroids being produced, EUS-CB of the left adrenal mass was performed. This revealed a spindle cell neoplasm with extensive necrosis. Tumor cells stained positive for desmin, cytokeratin Mak6, and S-100, and negative for CD34 and chromogranin. Based on these findings, a diagnosis of primary leiomyosarcoma of the left adrenal gland was made. Adriamycin and olaratumab with palliative radiation for pain was then initiated as metastatic disease precluded surgery. Discussion Primary adrenal leiomyosarcomas are extremely rare, with less than 35 cases reported [2]. They grow rapidly, do not produce any adrenal hormonal derangements, and lack characteristic tumor markers or imaging findings, making preoperative diagnosis difficult. Diagnosis is usually made on surgical resection or autopsy [2]. To our knowledge, this is the first case of primary adrenal leiomyosarcoma diagnosed by EUS. In our case, in which metastatic disease was noted, this diagnosis affected clinical management and prevented further invasive procedures.Figure: CT abdomen showing 8.1 cm heterogeneous left adrenal mass.Figure: EUS showing irregular, hypoechoic left adrenal mass measuring 63 x 44 mm.Figure: Spindle cell neoplasm with extensive tumor necrosis (A). High power view showing fascicular growth pattern and cytological pleomorphism (B).

Noise Texture Deviation: A Measure for Quantifying Artifacts in Computed Tomography Images With Iterative Reconstructions.

The aims of this study were to introduce the measure noise texture deviation as quantitative parameter for evaluating iterative reconstruction (IR)-specific artifacts in computed tomography (CT) images and to test whether IR-specific artifacts, quantified through this measure, are reduced in advanced modeled IR (ADMIRE) as compared with sinogram-affirmed IR (SAFIRE) images of the liver ex vivo and in patients with hypodense liver lesions. In the ex vivo study part, an abdominal phantom was used. In the institutional review board-approved in vivo study part, 40 consecutive patients (mean age, 63 years) with hypodense liver lesions undergoing abdominal CT in the portal-venous phase were included. Images were reconstructed with filtered back projection, with the second-generation IR algorithm SAFIRE and with the third-generation IR algorithm ADMIRE. Noise power spectra and noise texture deviation were calculated in the phantom; image noise was measured in the phantom and in patients. Two blinded readers evaluated all image data regarding IR-specific artifacts (plastic-like, blotchy appearance); patient data were evaluated regarding conspicuity and confidence for detecting hypodense liver lesions. Image noise was significantly reduced at increasing IR levels (P < 0.001) with both algorithms, with no significant differences between corresponding strength levels of SAFIRE and ADMIRE (all, P > 0.05). Noise power spectra were similar at corresponding strength levels of SAFIRE and ADMIRE (all, P > 0.05). Noise texture deviation in ADMIRE was reduced compared with corresponding strength levels of SAFIRE (all, P < 0.001) and strongly correlated with subjective IR-specific artifacts (r = 0.88, P < 0.001). Iterative reconstruction-specific artifacts were significantly reduced in ADMIRE compared with that in SAFIRE images at strength levels 3 or greater, both ex vivo and in vivo (all, P < 0.001). There were no significant differences in the readers' ratings of lesion conspicuity and lesion confidence in detecting hypodense liver lesions between SAFIRE and ADMIRE (P > 0.05). Only lesion conspicuity was superior with SAFIRE and ADMIRE compared with filtered back projection (all, P < 0.001). Noise texture deviation is a quantitative measure reflecting IR-specific artifacts and is reduced in CT images with ADMIRE compared with SAFIRE.

Epstein–Barr virus associated multi-organ smooth muscle tumours following renal transplantation

A 19-year-old girl underwent renal transplantation for endtage renal disease. She had been Epstein–Barr virus (EBV)-naive re-transplant and seroconverted 15 months later but had been ell. Persistent epigastric pain despite treatment of Helicobacter ylori-associated gastritis necessitated a CT scan, which revealed ultiple hypodense liver lesions (segments 4a, 4b, 5) with the argest one measuring 5.1 cm by 5.8 cm with multiple nodular esions up to 11 mm in the spleen. F-18 FDG PET/CT scans conrmed these (Fig. 1A). EBV viral load measured by quantitative PCR as persistently high. Subsequent PET/CT scan revealed nodular esions in the lungs suggestive of pulmonary involvement (Fig. 1B). Targeted biopsy of the largest of the hepatic lesions revealed itotically inactive spindle-shaped cells, atypical hyperchromatic uclei and eosinophilic cytoplasm with strong diffuse positive taining with H & E (Fig. 2A) and EBER-ISH (Fig. 2B). This confirmed he diagnosis of EBV-associated smooth muscle tumour.

Hypodense liver lesions in patients with hepatic steatosis: do we profit from dual-energy computed tomography?

To evaluate dual-energy CT (DECT) imaging of hypodense liver lesions in patients with hepatic steatosis, having a high incidence in the general population and among cancer patients receiving chemotherapy. One hundred and five patients with hepatic steatosis (liver parenchyma <40 HU) underwent contrast-enhanced DECT with reconstruction of pure iodine (PI), optimum contrast (OC), 80 kVp, and 120 kVp-equivalent data sets. Image noise (IN), lesion to liver signal to noise (SNR) and contrast to noise (CNR) ratios were quantitatively analysed; image quality was rated on a 5-point scale (1, excellent; 2, good; 3, fair; 4, poor; 5, non-diagnostic) by two independent reviewers. In 21 patients with hypodense liver lesions, IN was lowest in PI followed by 120 kVp-equivalent and OC, and highest in 80 kVp. SNR was highest in PI (1.30), followed by 120 kVp-equivalent (0.72) and 80 kVp (0.63), and lowest in OC (0.55). CNR was highest in 120 kVp-equivalent (4.95), followed by OC (4.55) and 80 kVp (4.14), and lowest in PI (3.63). The 120 kVp-equivalent series exhibited best overall qualitative image score (1.88), followed by OC (1.98), 80 kVp (3.00) and PI (3.67). In our study, the 120 kVp-equivalent series was best suited for visualization of hypodense lesions within steatotic liver parenchyma, while using DECT currently seems to offer no additional diagnostic advantage. • Hepatic steatosis has high incidence in the general population and following chemotherapy. • Hypodense liver lesions can be obscured by steatotic liver parenchyma in CT. • Low kV p -CT shows no advantage in detecting hypodense lesions in steatotic livers. • Additional DECT image information does not improve visualization of hypodense lesions in steatosis. • 120 kV p -equivalent imaging yields best quantitative and qualitative image analysis results.

Impact of Incremental Increase in CT Image Noise on Detection of Low-contrast Hypodense Liver Lesions

To determine the impact of incremental increases in computed tomography (CT) image noise on detection of low-contrast hypodense liver lesions. We studied 50 CT examinations acquired at image noise index (NI) of 15 and hypodense liver lesions and 50 examinations with no lesions. Validation of a noise addition tool to be used in the evaluation of the CT examinations was performed with a liver phantom. Using this tool, three 100-image sets were assembled: an NI of 17.4 (simulating 75% of the original patient radiation dose), 21.2 (simulating 50% dose), and 29.7 (simulating 25%). Three readers scored certainty of lesion presence using a five-point Likert scale. For original images (NI 15) plus images with NI of 17.4 and 21.2, sensitivity was >90% threshold (range, 95%-98%). For images with NI of 29.7, sensitivity was just below the threshold (89%). Reader Az values for receiver operating characteristic curves were good for original, NI 17.4, and NI 21.2 images (0.976, 0.973, and 0.96, respectively). For NI of 29.7, the Az decreased to 0.913. Detection sensitivity was <90% for both lesion size < 10 mm (85%) and lesion-to-liver contrast <60 Hounsfield units (85%) only at NI 29.7. For low-contrast lesion detection in liver CT, image noise can be increased up to NI 21.2 (a 50% patient radiation dose reduction) without substantial reduction in sensitivity.

Multiple Liver Lesions in a Patient With Positive Hepatitis C Serology and Elevated AFP: Is It HCC?

Question: A 41-year-old Tongan man presented with acute-onset right upper quadrant pain, worse with inspiration, and radiating to the right shoulder tip. He reported intermittent diarrhea over the past few months and small amounts of bright red rectal bleeding over the preceding 3 years. He had no fevers and no loss of weight. He had no significant past medical history except for pneumonia several years previously and was not taking any regular medications. He was a former smoker and drank alcohol once per month but consumed large amounts of kava (Piper methysticum). Clinical examination revealed right upper quadrant tenderness without guarding and normal chest auscultation. Laboratory analysis revealed deranged liver tests with alanine aminotransferase of 45 IU/L (normal, <40), alkaline phosphatase of 157 IU/L (normal, <120), γ-glutamyltransferase of 559 IU/L (normal, <71), and positive hepatitis C antibody enzyme immunoassay. Computed tomographic pulmonary angiography showed no evidence of pulmonary embolism, but incidentally noted multiple hypodense liver lesions, the largest lying posteriorly in the subdiaphragmatic region of liver segment VII measuring 6 cm in maximal diameter on axial sequences (Figure A). Tumor marker analysis found a significantly elevated alpha-fetoprotein (AFP) of 135,070 IU/mL (normal, <7). Subsequent multiphase computed tomography of the abdomen and pelvis confirmed multiple hypodense, nonarterially enhancing lesions within the liver. The liver did not seem to be cirrhotic and there were no signs of portal hypertension. In addition, several enlarged left mesorectal lymph nodes were noted with adjacent irregular rectal wall thickening (Figure B). What is the most likely diagnosis? What further investigations are required to confirm the diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. Liver lesions in patients with positive hepatitis C antibody tests should raise suspicion for hepatocellular carcinoma (HCC). However, the hepatic lesions did not fulfil imaging criteria for this diagnosis. In addition, the patient had only been tested for hepatitis C virus (HCV) antibodies and confirmation of HCV infection with hepatitis C polymerase chain reaction (PCR) testing was still awaited. The reported sensitivity and specificity of AFP for detecting HCC are 60% and 90%, respectively, at an AFP of 20 IU/mL in patients with cirrhosis.1Trevisani F. D'Intino P.E. Morselli-Labate A.M. et al.Serum alpha-fetoprotein for diagnosis of hepatocellular carcinoma in patients with chronic liver disease: influence of HBsAg and anti-HCV status.J Hepatol. 2001; 34: 570-575Abstract Full Text Full Text PDF PubMed Scopus (569) Google Scholar AFP may also be elevated in extrahepatic malignancies, including gonadal germ cell tumors and rarely in tumors of the pancreas, gallbladder, stomach, and colon. There are few case reports of AFP-producing colon carcinomas with most occurring in adult males, located in the rectum, with AFP levels of several thousand IU/mL.2Yachida S. Fukushima N. Nakanishi Y. et al.Alpha-fetoprotein-producing carcinoma of the colon: report of a case and review of the literature.Dis Colon Rectum. 2003; 46: 826-831Crossref PubMed Scopus (29) Google Scholar In view of the computed tomography findings of rectal thickening, colonoscopy was performed and revealed a polypoid, ulcerated rectal mass (Figure C). Histology confirmed poorly differentiated adenocarcinoma with positive immunostaining for AFP (Figure D). Ultrasound-guided biopsy of one of the echogenic liver lesions showed similar tumor and again was strongly positive for AFP (Figure E). The normal liver biopsy showed normal liver architecture with no evidence of fibrosis (Figure F). Confirmatory HCV recombinant immunoblot assay (RIBA) was negative and serum HCV RNA was not detected. The patient was referred for chemotherapy. This case highlights the need to confirm positive HCV enzyme immunoassays with RIBA or HCV-RNA PCR because EIAs can yield low positive predictive values among populations with a low prevalence of HCV infection.3Kamili S. Drobeniuc J. Araujo A.C. et al.Laboratory diagnostics for hepatitis C virus infection.Clin Infect Dis. 2012; 55: S43-S48Crossref PubMed Scopus (131) Google Scholar Furthermore, AFP can arise from malignancies other than HCC and histologic confirmation is recommended in patients with liver lesions that are atypical for HCC on imaging.

Systemic lupus erythematosus with hepatosplenic granuloma: a rare case.

Background. Systemic lupus erythematosus (SLE) is an autoimmune disease which is known to present with a wide variety of clinical manifestations. Case Report. A 15-year-old male presented with complaints of moderate grade fever and generalized body swelling. There was no history of cough, weight loss, joint pain, oral ulcerations, skin rash, photosensitivity, loss of hair, pain abdomen, jaundice, or any significant illness in the past. Contrast enhanced computerized tomography of the abdomen revealed hypodense lesions in both liver and spleen (without contrast enhancement), suggestive of granulomas along with few retroperitoneal and mesenteric lymph nodes. On the basis of immunological tests and renal biopsy report, SLE with hepatosplenic granulomatosis diagnosis was made. He was given pulse methylprednisolone 500 mg, for 3 days and he showed dramatic improvement clinically. Conclusion. Hepatic and splenic granulomas are not common in SLE, but this should be kept in differential diagnosis.

Combining automated attenuation-based tube voltage selection and iterative reconstruction: a liver phantom study

To determine the value of combined automated attenuation-based tube-potential selection and iterative reconstructions (IRs) for optimising computed tomography (CT) imaging of hypodense liver lesions. A liver phantom containing hypodense lesions was imaged by CT with and without automated attenuation-based tube-potential selection (80, 100 and 120 kVp). Acquisitions were reconstructed with filtered back projection (FBP) and sinogram-affirmed IR. Image noise and contrast-to-noise ratio (CNR) were measured. Two readers marked lesion localisation and rated confidence, sharpness, noise and image quality on a five-point scale (1 = worst, 5 = best). Image noise was lower (31-52%) and CNR higher (43-102%) on IR than on FBP images at all tube voltages. On 100-kVp and 80-kVp IR images, confidence and sharpness were higher than on 120-kVp FBP images. Scores for image quality score and noise as well as sensitivity for 100-kVp IR were similar or higher than for 120-kVp FBP and lower for 80-kVp IR. Radiation dose was reduced by 26% at 100 kVp and 56% at 80 kVp. Compared with 120-kVp FBP images, the combination of automated attenuation-based tube-potential selection at 100 kVp and IR provides higher image quality and improved sensitivity for detecting hypodense liver lesions in vitro at a dose reduced by 26%. • Combining automated tube voltage selection/iterative CT reconstruction improves image quality. • Attenuation values remain stable on IR compared with FBP images. • Lesion detection was highest on 100-kVp IR images.

An Unusual Presentation of Metastatic Hypopharyngeal Squamous Cell Carcinoma

Purpose: Squamous cell neoplasms of the head and neck commonly metastasize to the lungs, mediastinal lymph nodes, liver, and bone- gastrointestinal metastases (especially small bowel) are extremely rare. We report a case of hypopharyngeal squamous cell carcinoma with metastasis to the duodenum presenting with anemia. A 53-year-old male with a known history of Stage IV-hypopharngeal squamous cell cancer status post chemoradiation therapy, presented with a 3-day history of dark stools and fatigue. The patient was afebrile, and his physical examination revealed scleral pallor. Laboratory data revealed a WBC of 4.4 k/cm2, a hemoglobin of 7.1 g/dL, platelets of 207 k/cm2, an albumin of 2.4g/dL and normal electrolytes. Carcinoembryonic Antigen (CEA) was 41.1ng/mL, and CA 19-9 Antigen was 2,932 U/mL. Contrast-enhanced CT scan of the chest, abdomen, and pelvis revealed a 4-cm mediastinal mass with extensive hilar adenopathy, numerous hypodense liver lesions and extensive duodenal wall thickening. Our patient underwent upper endoscopy (EGD), which revealed a large fungating ulcerated mass with stigmata of recent bleeding in the second portion of the duodenum- this was biopsied with cold forceps and revealed a poorly differentiated squamous cell carcinoma. Immunohistochemical staining (IHC) was performed and was positive for p63 and CK5/6- supporting the diagnosis of recurrent disease. Subsequently, radial endoscopic ultrasound (EUS) demonstrated a 50 x 28 mm poorly defined mediastinal mass, numerous malignant appearing subcarinal lymph nodes, and an irregular hypoechoic 33 x 65 mm left lobe liver lesion. Examination of the duodenum revealed a 12 x 35 mm heterogeneous mass with poorly defined borders in the second portion, a 16 x 11 mm peripancreatic lymph node and a large amount of abdominal ascites. EUS-FNA was performed on the mediastinal, hepatic and duodenal masses. Immediate cytologic evaluation (ICE) revealed malignant cells and cell block subsequently demonstrated metastatic squamous cell carcinoma with extensive necrosis from all three sites. Squamous cell carcinomas of the head and neck develop distant metastases in 11-23% of patients. There are several reports of metastasis to the small bowel (most frequently the ileum) and patients usually present with abdominal pain and/or obstructive symptoms. We report a rare presentation of a 53-year-old male with recurrent squamous cell carcinoma with metastasis to the duodenum presenting with anemia. This case demonstrates how patients with squamous cell carcinoma can present atypically when distant metastases develop.

Pathology Quiz Case 1

A 57-YEAR-OLD WOMAN PRESENTED WITH A 2-year history of chronic cough. Onset was associated with flulike symptoms. Her cough worsened, and she started to have difficulty in airway functioning and dysphagia. She denied any hoarseness. A physical examination showed that she was in no apparent distress. Her voice was normal. Flexible fiber-optic laryngoscopy showed a large, posterior, broadly based interarytenoid mass significantly obstructing the posterior glottis, splaying open the arytenoids (Figure 1). The vocal cords were mobile. Computed tomographic imaging of the neck showed a soft-tissue lesion in the larynx obstructing the airway and bilateral level II and III lymphadenopathy. Computed tomographic imaging of the abdomen and pelvis showed hypodense liver lesions. A biopsy of the mass was performed under local anesthesia. Hematoxylin-eosin staining at low (original magnification 40) (Figure 2) and higher (original magnification 200) (Figure 3) magnifications is shown. Immunohistochemical staining was positive for c-Kit (CD117) and DOG1 (discovered on GIST), and negative for pancytokeratin, CD34, CD45, melan-A, S100, and CD68. Gomori methenamine silver stain demonstrated focal fungal organisms, and the acid-fast bacilli stain was negative for organisms. The patient then underwent an awake tracheotomy, endoscopic transoral laser partial laryngectomy, and bilateral selective neck dissections. A rubbery mass originating from the right arytenoids, growing over the interarytenoid area and extending to the left arytenoid, was discovered. The left arytenoid itself was free of tumor. Infiltrating portions of the tumor were not completely removed. The postcricoid area, esophageal inlet, and bilateral true cords were free of tumor. The final pathologic findings showed a spindle cell tumor measuring 2.7 1.2 1.7 cm in size with 5 mitoses per 50 high-power fields (HPFs). Twenty of 30 lymph nodes were positive for metastatic disease. What is your diagnosis?

Development and Evaluation of a Software Tool for the Generation of Virtual Liver Lesions in Multidetector-Row CT Datasets

Development and evaluation of a software tool for the insertion of simulated hypodense liver lesions in multidetector-row computed tomography (CT) datasets. Forty software-generated hypodense liver lesions were inserted at random locations in 20 CT datasets by using the "alpha blending" technique and compared with 40 real metastatic lesions. The location, diameter (5-20 mm) and density of the simulated lesions were individually adjusted to closely resemble real lesions in each patient. Three blinded readers evaluated all 80 lesions twice in a 2-week interval using a five-point Likert confidence scale under standardized conditions. Nonparametric tests were used to statistically evaluate possible differences in scoring between real and simulated lesions. The correctness of the observer rating for real and simulated lesions was compared to chance distribution using the chi-squared statistics. The inter- and intraobserver variability was determined using Kendall's coefficient of concordance. The observer study did not reveal significant differences between the scoring for real versus simulated lesions for any of the readers (P > .05). The distribution of correct and false scoring of the lesions was not significantly different from chance distribution (P > .05). Inter- and intraobserver agreement was poor (Kendall W coefficient = 0.12/0.13). The proposed algorithm is suitable for creating realistic virtual liver lesions in CT datasets.