Radio Meet in dept of surgery at ohio.pptx

radiology

1. Pediatric Surgery-Radiodiagnosis Meet 4-04-2024

2. Baby Of Ashreen

3. CRNO: 20231054552 5 mth / M Wt – 6.4 kgs Antenatal History : FT/NVD/CIAB/ 3.4 Kg/ h/o jaundice +, h/o cyanosis +, NICU stay + Immunised . No developmental delay. Presentation- mass abdomen in epigastric region yellowish discoloration of eyes and skin since birth pale color stools. h/o phototherapy in local hospital.

4. On Examination- child active, playful, pallor +, icterus +. P/A – mass arising from epigastrium and left hypochondrium approx. size 6 x 4 cm, firm to hard, non tender, non pulsatile, smooth surface, upper margin not delineated. Rest S/E - Normal

5. USG Abdomen 22/11/2023 - a large solid-cystic lesion of size 6.8 cm x 6.5 cm is seen in left lobe of liver showing peripheral vascularity. HA- prominent , HVs/IVC- patent. PV 5.9 mm, hepatopetal flow , PSV – 13.5 cm/sec. RK and LK – WNL, spleen 6 cm. Triple phase CT Abdomen- 24/11/2023 - There is a large peripherally enhancing heterogenous mass (~6.1x6.2x6.9 cm) is seen in the left lobe of liver pronominally involving the segement II and III of liver. Few coarse calcifications also noted within. Progressive filling in port-venous phase is seen in the periphery of the mass. Hepatic artery is hypertrophied with suspicious focal flow related aneurysm in the periphery of the mass. Also seen arterio-venous fistula draining in to MHV. Posteriorly mass effect seen on the pancreatic head displacing it posteriorly. Mass effect also seen on the stomach displacing it towards left side. Liver is normal in size (~6.5 cm in CC span) and outline. IHBR are not dilated. Portal vein and splenoportal axis, hepatic veins and IVC are normal. Gall bladder is contracted. CBD is not dilated. Pancreas and spleen are normal. Both kidneys are normal in outline with normal cortical enhancement pattern. No obvious hydronephrosis/calculi/mass noted on either side. Bilateral adrenal glands are normal. No obvious abdominal / pelvic lymphadenopathy or ascites seen. Pelvic region reveal normal urinary bladder. Abdominal aorta, bilateral iliac, CA, SMA and bilateral main renal arteries appear normal. Impression- large peripherally enhancing heterogenous mass in left lobe of liver showing progressive filling in the periphery with focal flow related aneurysm and AV fistualization ? giant hemangioma.

6. MRI 14/12/23 - LIVER- Liver is enlarged in size (8.8 cm), with normal outline. There is large exophtyic relatively well define heterogenous T2 lesion (~6.0x5.0 cm in size)noted in the left lobe of liver .It shows patchy diffusion restriction on DWI/ADC. It also shows thick irregular peripheral enhancement with central non enhancing areas. Bilobar intrahepatic biliary radicals are not dilated with a normal C.B.D.PV, HV, IVC - Normally seenGB well distended with no e/o stones in the lumen.SPLEEN & PANCREAS Normal in anatomy and intensity. Spleen is normal.KIDNEYS - Bilateral kidneys are normal in size, shape, signal intensity and post contrast enhancement. Bowel loops appears normal.• No free fluid or collection seen.No evidence of any lymphadenopathy seen.Impression:Large relatively well defined thick nodular peripheral enhancing mass lesion in the left lobe of liver with areas of patchy diffusion restriction ...dd 1. Hemangioendothelioma

7. 26/12/23 HGB 9.8 TLC 7.1 x1000/ ul PLT 284x1000/ cumm S. Bilirubin, Total 10.47 mg/dl S. Bilirubin, Conjugated 8.24 mg/dl S. AST (SGOT) 92 u/L S. ALT (SGPT) 73 u/L S. Alkaline Phosphatase 500

8. Transarterial Chemo-Embolization by IVR done on 27/12/23. Under strict aseptic precautions, Right Femoral Artery cannulated and feeder vessels - Left Hepatic Artery & Branch of Left Gastric Artery were embolised using PUA 150-250 microns. Post embolization flush showed no enhancement in lesion

9. 30/12/23 HGB 10.1 TLC 7.3 x1000/ ul PLT 276x1000/ cumm S. Bilirubin, Total 9.5 mg/dl S. Bilirubin, Conjugated 7.97 mg/dl S. AST (SGOT) 90 u/L S. ALT (SGPT) 68 u/L S. Alkaline Phosphatase 427

10. Readmitted on 18/3/24 c/o abdominal lump and cough

11. 18/3/24 HGB 8.3 TLC 9.7 x1000/ ul PLT 196x1000/ cumm S. Bilirubin, Total 7.2 mg/dl S. Bilirubin, Conjugated 5.8 mg/dl S. AST (SGOT) 196 u/L S. ALT (SGPT) 94 u/L S. Alkaline Phosphatase 885

12. CT ANGIO ABDOMEN 22/3/24 There is a large peripherally enhancing heterogenous mass (-5 x 4.6 x 4 cm) with central non- enhancing necrotic area is seen in the left lobe of liver involving the segement II and III. Multiple internal hyperdense foci are noted likely coarse calcifications. Progressive filling in porto -venous phase is seen in the periphery of the mass. Hepatic artery is hypertrophied The lesion is getting its blood supply from left hepatic artery, accessory left hepatic artery arising from left gastric artery, bilateral internal mammary arteries and right inferior epigastric artery. Venous drainage of the lesion is seen in to MHV and LHV. Liver is enlarged in size (-9.9cm in CC span) and outline. IHBR are not dilated. Portal vein and splenoportal axis, hepatic veins and IVC are normal. MRI 28/3/24 – reports pending

13. Labiya Nishad

14. CRNO: 2024173938 1 yr / F Wt – 8 kgs Antenatal History : FT/LSCS/CIAB/ normal milestone as per age No history of jaundice/cyanosis / NICU stay/ immunized Presentation- Antenatally detected Asymptomatic O/E – vitals WNL, Spo2 – 100% RS : B/L Equal air entry +, with conducted sounds in left lower zone Per abdomen – soft, non-tender

15. HRCT Thorax (17/02/2024) OUTSIDE : Ill-defined multiloculated cystic lesion is seen in the left lung lower lobe measuring 4.6 x 4.0 x 2.7 cm with definite communication with the pleural cavity, associated with mild pleural collection with pleural thickening and air foci in apical region of left lung. Ill-defined patchy area of collapsed/consolidation is seen in the left upper and lower lobe with multiple pleuro parenchymal bands. ? CCAM with active infective etiology Thoracic Angio (13/03/2024) – A large air filled irregular thin walled cystic lesion with few internal septations (4.6x4.8x2.6cm) is seen in left lower lobe. Few fibrotic bands in bilateral lower lobes and left lobe. Patchy basal atelectasis in bilateral lower lobes. Impression – Air filled larg thin walled cystic lesion with few internal sepatations in left lower lobe as described---CCAM

16. SURGERY - Lt posterolateral thoracotomy+ Enucleation of Cyst done on 18/03/2024 OPERATIVE FINDINGS -Position - Rt Lateral Position. Incision - Posterolateral in Left 5th intercostal space. Findings- Thickened adhered pleura, Hepatization of left lower lobe and thin walled air filled cyst. Steps- Lt Posterolateral thoracotomy incision. Thick fibrinous pleural layer present over lower lobe. Cyst wall identified and separated from lung parenchyma. Cyst wall punctured during dissection. Cyst separated completely from parenchyma and specimen delivered. Air leak test done and areas of leak closed in figure of 8 fashion using Prolene 5/0. Minor leaks managed with compression by pledgets . 16Fr ICD placed under vision from 7th intercostal space. Hemostasis ensured and layered closure done. Sterile dressings applied. Post operative course : Post-op X-ray chest on 21/03/2024 showed collection in the left side of chest for which IVR consultation was obtained : Single time aspiration was tried from10 ml needle in left pleural cavity, however nothing aspirated. ~ 15 - 20 ml organised collection in left pleural cavity, likely organised hemothorax. Repeat X-ray chest on 25/03/2024 showed resolving collection

17. Afiya Parveen

18. CRNO: 20221007024 11 yr / F Wt – 39 kgs Antenatal History : FT/CIAB/ normal milestone as per age No history of jaundice/cyanosis / NICU stay/ immunized Presentation- lower abdominal pain on & off since 2 years increased frequency of micturition constipation. No h/o fever or weight loss. O/E – vitals WNL, Spo2 – 100% Per abdomen – soft, non-tender, bowel and bladder habits normal

19. USG Abdomen 6/9/21 - Urinary tract – normal, UB – mildly thickened, 17.8x13mm hypoechoic lesion in pelvis in pararectal region on right side. Mildly thickened median umbilical folds in apex of UB. ? Enlarged pararectal LN. CECT Abdomen 7/9/21 - Urinary tract – normal, UB – mildly thickened 0.3cm, 3.2x1.8cm well defined non enhancing hypodense lesion in Rt retrorectal region involving Rt presacral space. ? tail gut duplication cyst. MRI Pelvis 18/5/23- 24x23 mm well defined thick walled hyperintense unilocular cystic lesion in precoccygeal space on Rt side. Abutting Rt ischio -coccygeus inferiorly and bulging into ischio -rectal fossa on the rt side. ? Epidermoid cyst

20. Operative Procedure - Posterior mid- saggital approach- excision of retrorectal cyst on 29/12/2023 Operative Finding - Prone position. Posterior midsaggital incision. Tip of coccyx excised. Mass visualized posterior to rectum in right paramedian location. En-masse excision done. Rectal wall intact. Saline wash given . Hemostasis ensured. Procedure uneventful

21. Kittu Yadav

22. CRNO: 2024081296 7 mth / M Wt – 8 kgs Antenatal History : FT/NVD/CIAB/ 3.5 Kg/ No NICU stay Immunised . No developmental delay. Presentation- High coloured urine yellowish discoloration of eyes and skin 5.5 yr age pale color stools.

23. On Examination- child active, playful, pallor +, icterus +. P/A – mass arising from epigastrium and left hypochondrium approx. size 6 x 4 cm, firm to hard, non tender, non pulsatile, smooth surface, upper margin not delineated. Rest S/E - Normal

24. On Admission 29/2/24 HGB 11.1 TLC 19.3 x1000/ ul PLT 482x1000/ cumm S. Bilirubin, Total 7.8 mg/dl S. Bilirubin, Conjugated 3.14 mg/dl S. AST (SGOT) 291 u/L S. ALT (SGPT) 287 u/L S. Alkaline Phosphatase 1611

25. Alpha-fetoprotein (AFP) 4.68 ml (0.6-6.65) S. LDH 667 u/L (207.0-414.0) CA 19.9 252.00 u/ml 0.0-37.0

26. HPE Microscopic Section from liver biopsy shows distorted lobular architecture and islanda of benign hepatocytes in loose myxomatous stroma with scattered bland stellate shaped mesenchymal cells, branching bile ducts. The hepatocytes showing focal macrosteatosis at places . No necrosis or mitotic figures identified .On IHC biliary epithelium shows Ck7 positive. Mesenchymal cells are Vimentin and SMA positive CD 34 negative Remarks Features are s/o mesenchymal hemartoma however clinico -radiological and serological correlationn is advised.

27. USG Abdomen 19/2 /2024 - Liver 7.5cm, a large ill defined mostly hypoechoic lesion 4.2x4x3.5cm with lobulated margins with coarse chunky calcifications seen in GB fossa and involving adjacent liver parenchyma (Seg 4 & 5 ) extending into porta causing moderate bilobar IHBRD. ? Hepatoblatoma

28. MRCP 22/2/24 - Diffuse circumferential 12 hyperintense wall thickening is seen in the GB measuring 17mm in maximum thickening. On DWI the thickening shows restricted diffusion. The thickening is involving the porta and the floor of primary confluence. Primary confluence is just formed. There is bilobar upstream IHBRD (RHD-6mm: LHD-4.5mm.) Right and left secondary confluences are formed. Laterally the lesion shows loss of fat planes with segment V and VIII of liver with areas of infiltration. The lesion is also encasing the portal vein 180 degrees. Rest of the Liver(8cm in ce span) is normal in size, outline and signal intensity.CBD is not dilated. No intraluminal filling defects noted.Pancreas - Normal in signal intensity. MPD is normal. No peripancreatic collection.Spleen -Normal in size and signal intensity(5.7cm)There is mild ascites. IMPRESSION:Neoplastic GB mass with type II hilar block. CT Abdo 19/2/24 - large ill defined infiltrative heterogeneously mass lesion (-4.6 x 3.6 x 4.9 cm) is seen arising From segment IV/V and encasing the GB. The lesion is extending into the porta and encasing the CHD with resultant upstream mild IHBRD. At porta it is also abutting main portal vein and hepatic artery proper without any luminal compromise. The lesion shows internal linear nyperdensity likely calcification. Enhancing thrombus is seen within left portal vein with itsmild distension. Right portal vein is normalLever is normal in size and outline. No obvious focal lesion seen. Mild bilobar IHBRD seen.Hepatic artery, main portal vein and splenoportal axis, hepatic veins and IVC are normalPancreas and spleen are normal.Both kidneys are normal in outline with normal cortical enhancement pattern. No obvious hydronephrosis/calculi mass noted on either sidesteneral adrenal glands are normal. IMPRESSION - A large ill defined infiltrative heterogeneously mass lesion arising from segment IV/V of liver and encasing the gall bladder with extension and infiltration as described-likely neoplastic etiology ( hepatoblastoma).

29. PTBD 5/3/24 – 8Fr in left ductal system. Biopsy taken PTBD 21/3 – catheter changed PTBD 23/3/24 – 10 Fr Malecot’s placed at hilum

30. 3/4/24 HGB 11 TLC 29.8 x1000/ ul PLT 335x1000/ cumm S. Bilirubin, Total 1.1 mg/dl S. Bilirubin, Conjugated 0.49 mg/dl S. AST (SGOT) 74 u/L S. ALT (SGPT) 69 u/L S. Alkaline Phosphatase 658

31. THANK YOU