Case reports

1991, The British Journal of Radiology, 64, 64-66

angiomatous elements are particularly rare. We could only find three previously reported cases of lymphangiohaemangioma of the mediastinum. Balbaa and Chesterman (1957) reported the clinical findings and appearances on chest radiography in two cases of lymphangiohaemangioma of the mediastinum, both in very young children (18 months and 7 weeks, respectively)'. The third reported case described the CT appearances of a lymphangiohaemangioma in a 10year-old girl (Angtuaco et al, 1983) which showed a near-water density component and contrast enhancement following intravenous contrast medium administration. It is convenient to divide tumour-like vascular malformations into haemangiomas and lymphangiomas, with a separate sub-division for lymphangiohaemangioma, but recognizing that lymphangiohaemangiomas behave like lymphangiomas (Bruce Williams, 1981; Mulliken & Glowacki, 1982). Lymphangiomas may produce focal masses or they may take a diffuse form. The focal masses are seen in capillary, cavernous and cystic forms. They often contain clear fluid and, therefore, on CT show a density close to that of water (Brown et al, 1986; Pilla et al, 1982). Although lymphangiomas are benign tumours, they may infiltrate along tissue planes and invest vital structures, often making it impossible to remove them completely at surgery with resulting high recurrence rates (Brown et al, 1986). Malignant change has not been reported with lymphangioma or with lymphangiohaemangioma of the mediastinum. In the only previous report of CT in a case of mediastinal lymphangiohaemangioma, Angtuaco et al (1983) suggested that CT scanning was diagnostically helpful because enhancement of the vascular spaces within the lesion was demonstrated on the post-contrast images. In our case there was no significant difference in attenuation before and after the administration of intravenous contrast medium, despite good opacification of

the major intrathoracic arteries and veins. Nor was there any recognizable near-water density component to the lesion. This case illustrates, therefore, that even a large lymphangiohaemangioma may show indeterminate CT attenuation characteristics which do not allow distinction from other soft tissue masses. The lack of contrast enhancement is, however, in keeping with the observation that blood does not always circulate through the vascular elements of a haemangioma, since these structures may be incompletely differentiated (Seybold et al, 1949). In our case, histological examination revealed that the vascular elements were not formed into vessels and it is, therefore, not surprising that neither the CT scan nor the aortogram showed vascularity within the tumour mass. References ANGTUACO, E. J. C , JIMENEZ, J. F., BURROWS, P. & FERRIS, E.,

1983. Lymphatic-venous malformation haemangioma) of mediastinum. Journal Assisted Tomography, 7, 895-897.

(lymphangioof Computer

BALBAA, A. & CHESTERMAN, J. T., 1957. Neoplasms of vascular

origin in the mediastinum. British Journal of Surgery, 188, 545-555. BROWN, L. R., REIMAN, H. M., ROSENOW, E. C , GLOVICZKI,

P. M. & DIVERTIE, M. B., 1986. Intrathoracic lymphangioma. Mayo Clinic Proceedings, 61, 882-892. BRUCE

WILLIAMS,

H.,

1981.

Hemangiomas

and

lymphangiomas. Advances in Surgery, 15, 317-349. MULLIKEN, J. B. & GLOWACKI, J., 1982. Hemangiomas and

vascular malformations in infants and children: a classification based on endothelial characteristics. Plastic and Reconstructive Surgery, 69, 412-420. PILLA, T. J., WOLVERSON, M. K., SUNDARAM, M. & HEIBERG,

E., 1982. CT evaluation of cystic lymphangiomas of the mediastinum. Radiology, 144, 841-842. SEYBOLD, W. D., MCDONALD, J.

R.,

CLAGETT, O. T. &

HARRINGTON, S. W., 1949. Mediastinal tumors of blood vascular origin. Journal of Thoracic Surgery, 18, 503-519.

Detection of focal nodular hyperplasia with liver colloid single photon emission computed tomography: a case report and review of the literature By Cumali Aktolun, MD and Hikmet Bayhan, MD Giilhane Military Medical Academy Hospital, Department of Nuclear Medicine, 06010-Etlik-Ankara, Turkey (Received April 1990 and in revised form June 1990) Keywords: Focal nodular hyperplasia, Liver scan, Liver colloid scintigraphy, Liver colloid SPECT, "Tc m -albumin colloid

Focal nodular hyperplasia (FNH) is a benign hamartomatous liver mass (Robbins et al, 1984). It is usually Address correspondence to Cumali Aktolun, MD, Giilhane Military Medical Academy Hospital, Department of Nuclear Medicine, 06010-Etlik-Ankara, Turkey.

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identified incidentally during ultrasonographic examination, other diagnostic procedures or autopsy. The patients are often asymptomatic (Drum, 1982). Physical examination is found to be normal in most of the cases. Jaundice, hepatomegaly, palpable mass, and chronic intermittent vague abdominal pain, especially in the The British Journal of Radiology, January 1991

Case reports

Figure 1. Ultrasonographic examination showing a hyperechoic and well defined space-occupying lesion in the liver (left), and a polyp in the gallbladder (right).

right upper quadrant, may be present in some patients. Eighty-eight per cent of the cases are female, of whom 80% give a history of oral contraceptive or supplemental oestrogen use (Kerlin et al, 1983). The lesion may be solitary (55%) or multiple, and it is usually located in the right lobe of the liver (Rogers et al, 1981), varying in size between 1 and 20 cm, and containing hepatocytes, bile ducts and Kuppfer cells (Rogers et al, 1981; Robbins et al, 1984). Colloid scintigraphic appearance may be hyperactive (40%), hypoactive (30-60%) or normoactive (30-55%) (Diament et al, 1982; Kerlin etal, 1983; Rogers et al, 1981; Welch et al, 1985). A central, stellate-shaped collageneous scar with peripherally radiating septa is the typical histopathologic feature of FNH (Kerlin et al, 1983; Rogers et al, 1981). We present a case of FNH with planar colloid scintigraphy demonstrating slightly increased uptake in the ultrasonographically detected lesion. Single photon emission computed tomography (SPECT) showed a hyperactive region at the lesion site. Case report The patient was a 29-year-old woman, and had a history of oral contraceptive use, pulmonary tuberculosis and jaundice. An ultrasonographic examination was performed to follow up

ANTERIOR

(a)

RIGHT LATERAL

POSTERIOR (C)

Vol. 64, No. 757

Figure 2. Focal, slightly increased radiocolloid uptake (arrow) in the liver which could be seen only in the anterior projection (a) of the liver-spleen scintigraphy. Right lateral (b) and posterior (c) projection images appeared normal.

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Discussion

CORONAL SLICES

Incidental discovery of an asymptomatic focal hepatic lesion creates a significant diagnostic problem. An integrated approach (ultrasonography, colloid scintigraphy, transmission CT and, in most of the cases, biopsy) is usually necessary for diagnosis; this is especially so for FNH. Hepatic imaging is a popular application of abdominal SPECT, allowing evaluation of the cross-sectional and three-dimensional distribution of radiocolloid in the liver. It also enhances the contrast resolution. Colloid SPECT has a higher sensitivity and specificity than planar scintigraphy in the detection of hepatic masses (Brendel et al, 1984; Carrasquillo et al, 1983; Strauss etal, 1982). In conclusion, an ultrasonographically solid hepatic lesion larger than 2 cm in diameter with a scintigraphic finding of high colloid uptake is highly suggestive of FNH, and SPECT can provide further information on the nature of the lesion in addition to a positive contribution to image contrast.

References Figure 3. Transaxial, sagittal and coronal slices of SPECT BRENDEL, A. L., LECCIA, F., DRUILLARD, J., GALLI, F. S., showing a hyperactive region in the liver, most evident in the ERSUE, J., WYNCHANK, S., BARAT, J. L. & DUCASSOU, D., coronal slices (arrow). 1984. SPECT, planar scintigraphy, and transmission computed tomography: a comparison of accuracy in the diagnosing focal hepatic disease. Radiology, 153, 527-532. a polyp in the gallbladder diagnosed one year before. A hyper- CARRASQUILLO, J. A., ROGERS, J. V., WILLIAMS, D. Y., OLSON, echoic and well defined lesion with an area 55 x 35 mm was D. O. & LARSON, S. M., 1983. Single-photon emission detected in the liver in close relation to the gallbladder and computed tomography of the liver. American Journal of porta hepatis (Fig. 1). The differential diagnosis included Roentgenology, 141, 937-941. haemangioma, hepatic cell adenoma, FNH, focal degeneration DIAMENT, M. J., PARVEY, L. S., TONKIN, I. L. D., JOHNSON, K. in the cirrhotic liver and hepatoma. D., BERNSTEIN, R. & WEBER, B., 1982. Hepatoblastoma; technetium sulfur colloid uptake simulating focal nodular Hepatic blood pool imaging was carried out with in vivo labelled "Tc m red blood cells to assess the nature of the lesion. hyperplasia. American Journal of Roentgenology, 139, The evaluation of dynamic, planar static and SPECT images 168-171. did not suggest a hepatic haemangioma. DRUM, D. E., 1982. Current status of radiocolloid hepatic Three days later, the patient was adminstered 222 MBq scintigraphy for space-occupying disease. Seminars in (6 mCi) "Tc m -albumin colloid intravenously to evaluate the Nuclear Medicine, XII, 64-74. uptake in the lesion. Seven hundred thousand counts were KERLIN, P., DAVIS, G. L., M C G I L L , D. B., WEILAND, L. H., collected for each of the standard anterior, right lateral and ADSON, M. A. & SHEEDY II, P. F., 1983. Hepatic adenoma posterior views with a matrix size of 256 x 256. No defect was and focal nodular hyperplasia: clinical, pathologic and detected in the planar colloid scintigraphy, but a slightly radiologic features. Gastroenterology, 84, 994-1002. increased uptake was seen at the site of the ultrasonographi- ROBBINS, S. L., COTRAN, R. S. & KUMAR, V., 1984. Pathologic cally demonstrated lesion in the liver (Fig. 2). A 64 x 64 matrix basis of disease, 3rd edn. (lgaku-Shoin/Saunders, circular SPECT with 30-second duration 64 frames per 360° Philadelphia), p. 934. was performed just after planar colloid scintigraphy. A hyper- ROGERS, J. V., MACK, L. A., FREENY, P. C , JOHNSON, M. L. & active region (hot spot) was evident in the transaxial, coronal SONES, P. J., 1981. Hepatic focal hyperplasia; angiography, and sagittal slices of SPECT. The lesion was seen most clearly CT, sonography and scintigraphy. American Journal of in the coronal slices (Fig. 3). The location of the hyperactive Roentgenology, 137, 983-990. region was coincident with the ultrasonographic appearances. STRAUSS, L., BOSTEL, F., CLORIUS, J. H., RAPTOU, E., Of the entities listed in the differential diagnosis, only FNH WELLMAN, H. & GEORGI, P., 1982. Single photon emission contains reticulo-endothelial cells; other entities would all have computed tomography (SPECT) for assessment of hepatic been expected to show a defect of uptake at the site of the lesions. Journal of Nuclear Medicine, 23, 1059-1065. lesion. Blood pool and colloid imaging were carried out with a WELCH, T. J., SHEEDY II, P. F. & M C G I L L , D. B., 1985. Focal GE-400-ACT Starcam gamma camera and computer system. nodular hyperplasia and hepatic adenoma: comparison of angiography, CT, US, and scintigraphy. Radiology, 156, Coeliac angiography was performed to evaluate the blood 593-595. supply of the lesion, and no separate artery supply was seen. Histopathologic examination of a sample obtained from ultrasonography-guided needle biopsy revealed the typical structure of FNH.

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The British Journal of Radiology, January 1991

Detection of focal nodular hyperplasia with liver colloid single photon emission computed tomography: a case report and review of the literature.

Case reports 1991, The British Journal of Radiology, 64, 64-66 angiomatous elements are particularly rare. We could only find three previously repor...
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