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Patient with known HCC. Anyone guess the diagnosis and the potential causes ?

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Comment by Dr. Mohamed Refaey on May 26, 2008 at 5:00am
great case as usual Michele, thank you..
Comment by Vijay Sadasivam on April 2, 2008 at 3:12am
Interesting case Michele. My guess is a primary diaphragmatic mass, may be a hemangioma. But the history of tuberculosis and the presence of pleural calcifications also raise the possibility of a tubercular granuloma. What is the answer? This has remained undiagnosed for too long.
Comment by Michele Anzidei on February 6, 2008 at 6:09pm
I can't see the comments on the second page, so I will give out the diagnosis anyway.

It is an aneurysm of the right phrenic artery (or hypophrenic artery). It is commonly related to post-surgical or post-traumatic traction phenomena on the diaphragm and its vessels.

You can see the artery going up to the diaphragm and then dilatate. No venous structure can be seen (is an arterial phase !). I must say that Alessandro got very very close to the right answer !!

If you are interested you can have a look at this free online resource (Pubmed)...but my images are better ;-)

Shirai T, Amano J, Fujii N, Hirabayashi S, Suzuki A.
Rupture of inferior phrenic artery aneurysm. An unusual complication of mesenteric arteritis due to postcoarctectomy syndrome. Chest. 1994 Oct;106(4):1290-1.
Comment by Michele Anzidei on February 4, 2008 at 10:49am
You are coming close !! You have found the artery (right ipophrenic artery). But it's not a MAV...it's similar and its post-traumatic or post-stress.
Comment by Alessandro Lemos,MD on February 4, 2008 at 7:53am
Its an intrahepatic MAV
Comment by Michele Anzidei on February 4, 2008 at 6:16am
Well done for the phrenic branch !
But it's not mesothelioma. He was operated for a tubercoloma of the right lung.
Comment by Frank Gaillard on February 3, 2008 at 11:31pm
Well, it is hypervascular, looks to be either subcapsular or between liver and diaphragm and has a branch feeding it directly from the aorta (phrenic branch??)

I note lots of pleural plaques... can it be a mesothelioma (either peritoneal or pleural) secondary to asbestos exposure??

Well that is my 2 cents worth
Comment by Michele Anzidei on February 3, 2008 at 5:47pm
Argh ! Come on guys...I need a diagnosis. Just look at the images, especially at the last one (bottom right) !!!!
Comment by Michele Anzidei on January 25, 2008 at 8:58am
Hi CoolRad and welcome to the contest !

It has been there for long, but it is not an infra-diaphragmatic sequestration. It is correlated with the appearence of the right chest wall that presents some alteration of the ribs due to surgery.

If you look with attention at the MIP images, and in particular at the coronal one, you will pick an arterial vessel coming out from the aorta and going directly into the lesion. An analogue vessel is present on the opposite side.

Is it enough to change your diagnosis (obviusoly with the right one !!) ?
Comment by CoolRad on January 24, 2008 at 11:07pm
How long has it been there? I will take a wild wild guess! Here is a zebra: Is it a congenital vascular finding like a infra-diaphragmatic sequestration?

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