Sandbox:Dildar

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Dildar Hussain, MBBS [2]

Small cell lung cancer X rays

Small cell carcinoma of Lung

Chest x-ray: Small cell carcinoma of the lung. Antero-posterior view, Case courtesy of A.Prof Frank Gaillard, via,Radiopaedia.org

[[Image: Left-hilar-mass-small-cell-lung-cancer-2.png.jpeg|thumb|Chest x-ray: Small cell carcinoma of the lung.Case courtesy of Dr Henry Knipe, via, Radiopaedia.org Lung cancer surgery Editor-In-Chief: C. Michael Gibson, M.S., M.D. [3]; Associate Editor(s)-in-Chief: If investigations confirm lung cancer, CT scan and often positron emission tomography (PET) are used to determine whether the disease is localised and amenable to surgery or whether it has spread to the point where it cannot be cured surgically. Blood tests and spirometry (lung function testing) are also necessary to assess whether the patient is well enough to be operated on. If spirometry reveals poor respiratory reserve (often due to chronic obstructive pulmonary disease), surgery may be contraindicated. Surgery itself has an operative death rate of about 4.4%, depending on the patient's lung function and other risk factors.[1] Surgery is usually only an option in non-small cell lung carcinoma limited to one lung, up to stage IIIA. This is assessed with medical imaging (computed tomography, positron emission tomography). A sufficient pre-operative respiratory reserve must be present to allow adequate lung function after the tissue is removed. Pulmonary Reserve The American College of Chest Physicians established clinical practice guidelines for the physiologic evaluation of patients with lung cancer being considered for resectional surgery.[2] The preoperative physiologic assessment should include a cardiac evaluation and spirometry to measure the FEV1 and carbon monoxide diffusion capacity (DLCO). Depending on these results the patients can be stratified into different risk groups and further testing may be required or surgery can be initiated. Pulmonary reserve is measured by spirometry. The minimum forced vital capacity (FVC) for pneumonectomy in men is 2 liters. The minimum for lobectomy is 1.5 liters. In women, the minimum FVC values for pneumonectomy and lobectomy are 1.75 liters and 1.25 liters respectively.[3] Surgery Procedures include wedge resection (removal of part of a lobe), lobectomy (one lobe), bilobectomy (two lobes) or pneumonectomy (whole lung). In patients with adequate respiratory reserve, lobectomy is the preferred option, as this minimizes the chance of local recurrence. If the patient does not have enough functional lung for this, wedge resection may be performed.[4] Radioactive iodine brachytherapy at the margins of wedge excision may reduce recurrence to that of lobectomy.[5] Also, many times during lung cancer surgery, the doctor will remove some of the lymph nodes to test for cancer. If the lymph nodes test positive for cancer then that is indicative of the disease spreading beyond the lung. There will most likely be subsequent treatments to help eliminate the remaining cancer. Patient Selection Not all patients are suitable for operation. The stage, location and cell type are important limiting factors. In addition, patients who are very ill with a poor performance status or who have inadequate pulmonary reserve would be unlikely to survive. Even with careful selection, the overall operative death rate is about 4.4%.[1] Stage "Stage" refers to the degree of spread of the cancer. See non-small cell lung cancer staging In non-small cell lung cancer, stages IA, IB, IIA, and IIB are suitable for surgical resection.[6] Stages IIIA, IIIB, and IV tend to involve the spreading out of the cancer. In that case chemotherapy or radiation is usually deemed the appropriate action to take because surgery will not adequately solve the diseased lungs. Types of Surgery Lobectomy (removal of a lobe of the lung) Pneumonectomy (removal of an entire lung) Wedge resection Sleeve resection Overview Surgery is the best treatment option of lung cancer for patients with resectable tumors. The feasibility of surgery depends on the stage of lung cancer at the time of diagnosis. Indications Surgical intervention is not recommended for the management of [disease name]. OR Surgery is not the first-line treatment option for patients with [disease name]. Surgery is usually reserved for patients with either: [Indication 1] [Indication 2] [Indication 3] The mainstay of treatment for [disease name] is medical therapy. Surgery is usually reserved for patients with either: [Indication 1] [Indication 2] [Indication 3] Surgery Surgery is the best treatment option of lung cancer for patients with resectable tumors. The feasibility of surgery depends on the stage of lung cancer at the time of diagnosis. The procedures for lung cancer imclude: Wedge resection (removal of part of a lobe) Wedge resection is performed in the patients who do not have adequate respiratory reserve. Radioactive iodine brachytherapy at the margins of wedge resection may reduce recurrence to that of lobectomy. Lobectomy (one lobe) Lobectomy is the preferred option for patients with adequate respiratory reserve because it reduces the chances of local recurrence. Bilobectomy (two lobes) Pneumonectomy (whole lung) Contraindications References Lung Cancer Differential Condition/disease Signs/symptoms Tests Pneumonia/bronchitis Typical symptoms include fever, cough, dyspnea, and chest pain; recurrent pneumonia or bronchitis in a smoker or former smoker should raise the suspicion of lung cancer CXR is the first test performed; CT imaging can be helpful to evaluate pulmonary masses that might not be well visualised with chest x-ray; bronchoscopy can also be used to assess for endobronchial lesions or to biopsy suspicious pulmonary masses Carcinoid tumor Often asymptomatic with normal physical examination; may cause cough, dyspnea, hemoptysis, unilateral wheezing, or post-obstructive pneumonia if the tumor is endobronchial or compressing the central bronchi CT chest: 80% of carcinoid tumors appear as an endobronchial nodule and 20% as a parenchymal nodule, with smooth, rounded borders and is highly vascularized; flexible bronchoscopy shows raised, pink, vascular, lobulated lesions; endobronchial forceps biopsy is usually required for pathology to be diagnostic; bronchial brushings, sputum specimens, and lavage fluid rarely provide sufficient tissue for a conclusive diagnosis Metastatic cancer from a non-thoracic primary site Signs and symptoms depend on the location of the primary tumor and distant disease and may include pain, weight loss, malaise, cough, dyspnea, clubbing, or focal wheezing; physical findings may be present depending on the location and extent of the disease CT chest shows one or multiple nodules of variable sizes from diffuse micronodular opacities (miliary) to well-defined masses, lesions are often irregular and in the periphery of the lower lung zones; CT/MRI head, CT abdomen and pelvis: extrapulmonary cancers that commonly metastasis to the lung include melanoma, thyroid carcinoma, esophageal cancer; ovarian cancer; sarcomas; and adenocarcinomas of the colon, breast, kidney, and testis; PET-FDG scan shows increased uptake in both primary and distant sites, certain metastatic lesions, such as renal cell carcinoma, have a lower probability of 18-fluorodeoxyglucose (FDG) uptake; CT-guided transthoracic needle aspiration (TTNA) can reveal characteristic malignant cells, pneumothorax complicates 20% to 30% of TTNA procedures, the choice between bronchoscopy and TTNA is based on lesion size, location, risks, and local expertise; biopsy during flexible bronchoscopy and biopsy may show characteristic malignant cells, bronchoscopy has a 100% yield for endobronchial lesions (which are extremely rare in metastatic deposits from other primary tumors) Infectious granuloma History may include travel to endemic areas, pet/animal exposures, and specific leisure activities (e.g., caving); may feature cough, dyspnea, hemoptysis, weight loss, fever, joint aches, skin lesions, and night sweats, or no symptoms; many possible causes: Histoplasma capsulatum, Mycobacterium tuberculosis, Coccidioides immitis, Cryptococcus neoformans, Aspergillus, Pseudallescheria boydii, Fusarium species, zygomycetes, and others; non-specific skin findings may be seen in atypical mycobacteria and cryptococcosis; lymphadenopathy may be present with active disease CT-guided TTNA can be used for diagnostic sampling, pneumothorax complicates 20% to 30% of TTNA procedures, the choice between bronchoscopy and TTNA is based on lesion size, location, risks, and local expertise; CT chest typically shows lesions <2 cm diameter and round with smooth borders, old granulomatous disease may feature central, laminated, or diffuse calcification pattern, mediastinal lymphadenopathy without calcifications is sometimes present, nodules from angioinvasive fungi (e.g., Aspergillus, Pseudallescheria boydii, Fusarium species, and zygomycetes) may demonstrate the "halo sign" (ground-glass opacity surrounding the nodule), occasionally, calcifications can be seen in the spleen or liver; fungal serologies: positive during active infection; flexible bronchoscopy and biopsy can sometimes provide sample for identification and culture and sensitivity of organism; PET: usually negative (<2.5 standardised uptake values), may be positive in active infectious processes Sarcoidosis Cough, dyspnea, fatigue weight loss, fever, night sweats, rash, eye pain, photophobia blurred vision, and red eye; pulmonary examination is usually unrevealing; can affect any organ, so physical findings depend on specific organs affected; skin lesions including maculopapular eruptions, subcutaneous nodular lesions, and red-purple skin lesions CT chest: mediastinal adenopathy often present with sarcoid. Sarcoid nodules have predilection for upper zones, although can be located throughout the lung; flexible bronchoscopy and biopsy can demonstrate presence of non-caseating granulomas; CT-guided TTNA can provide access to material from some lesions inaccessible to flexible bronchoscopy; laboratory markers: ACE elevation may be seen in sarcoidosis but is non-specific Rheumatoid arthritis Arthralgias, pain, skin nodules, pleural effusions, pleuritis, joint pain, and deformity CT chest typically shows lung nodule 3 mm to 7 cm, predominantly in peripheral upper and mid-lung zones, may show cavitation; flexible bronchoscopy and biopsy shows rheumatoid necrobiotic nodule, necrobiotic nodules demonstrate a central zone of eosinophilic fibrinoid necrosis surrounded by palisading fibroblasts, the nodule often centered on necrotic inflamed blood vessels; laboratory markers: patients with lung nodules due to rheumatoid arthritis frequently have high levels of rheumatoid factor, although seronegative cases have been reported Wegener's granulomatosis Cough, chest pain, dyspnea, hemoptysis, rhinorrhoea, epistaxis, ear/sinus pain, hoarseness, fever, fatigue, anorexia, weight loss, palpable purpura, painful ulcers, uveitis, upper airway inflammation, and sinus pain CT chest shows solitary or multiple lung nodules, airways are frequently affected; Flexible bronchoscopy or CT-guided TTNA may show necrotising granulomatous inflammation; laboratory markers: anti-neutrophil cytoplasmic antibody (ANCA), ANCA testing results depend on the extent and severity of the disease Arteriovenous malformation Dyspnea is uncommon, may cause hemoptysis, pulmonary bruit, arteriovenous communications, or hemorrhagic telangiectasia in the skin, mucous membranes, and other organs, cyanosis and finger clubbing may be present, eurological symptoms from cerebral aneurysms, cerebral emboli CT chest shows round or oval nodule(s) with feeding artery and draining vein often identified, most common in lower lobes, multiple lesions in 30% of cases, usually round or oval, ranging from 1 cm to several cm in diameter; pulmonary angiography confirms presence and location of AVMs, identifies feeding arterial and venous structures, in cases of significant hemoptysis, pulmonary angiogram is combined with bronchial artery embolisation; ABG analysis may show decreased pO2 and decreased oxygen saturation when AV flow is severe., in cases of severe systemic AVMs, chronic hypoxemia may cause polycythemia Amyloidosis Weight loss, paresthesias, dyspnea, and fatigue are the most common symptoms associated with amyloidosis and are common to all systemic forms; weight loss of >9 kg is common; small vessel involvement can cause jaw or limb claudication, and rarely angina; amyloid purpura is present in about 1 in 6 patients, typically peri-orbital; eyelid petechiae are common; hepatomegaly >5 cm below the right costal margin is seen in 10% of patients and splenomegaly is usually of modest degree CT chest shows lung involvement characterised by focal pulmonary nodules, tracheobronchial lesions, or diffuse alveolar deposits; serum immunofixation shows presence of monoclonal protein; urine immunofixation shows presence of monoclonal protein; immunoglobulin free light chain assay shows abnormal kappa to lambda ratio Bronchiolitis obliterans organizing pneumonia (BOOP) Normally presents as a flu-like illness followed by a second illness lasting 1 to 4 months, with low-grade fever, non-productive cough, malaise, dyspnea, and weight loss; sometimes features pleuritic chest pain and hemoptysis; in most patients, auscultation reveals fine, dry lung crackles; finger clubbing is unusual CT chest typical features include: patchy "ground-glass" opacities in a sub-pleural and/or peribronchovascular distribution; thickening of bronchial walls and cylindrical dilation; 3 to 5 mm diameter centrilobular nodules or other ill-defined nodules, mediastinal lymphadenopathy, pleural effusions; pulmonary function tests typically show a restrictive pattern; bronchoalveolar lavage (BAL shows a mixed cell pattern, with an increase in lymphocytes, neutrophils, eosinophils, mast cells, foamy macrophages, and occasional plasma cells, CD4+/CD8+ cell ratio is decreased, the ratio of lymphocytes to CD8+ cells is significantly increased; transbronchial lung biopsy in combination with BAL can be a useful approach, prior to possible open biopsy; open lung biopsy is often required for a definitive diagnosis Pulmonary tuberculosis Cough longer than 2 to 3 weeks, discolored or bloody sputum, night sweats, weight loss, loss of appetite, and/or pleuritic chest pain Chest x-ray: primary disease commonly presents as middle and lower lung zone infiltrates, ipsilateral adenopathy, atelectasis from airway compression, and pleural effusion can be seen, reactivation-type (post-primary) pulmonary TB usually involves apical and/or posterior segment of right upper lobe, apicoposterior segment of left upper lobe, or superior segment of either lower lobe, with or without cavitation, as disease progresses it spreads to other segments/lobes; sputum smear: positive for acid-fast bacilli (AFB), sputum may be spontaneously expectorated or induced, and at least 3 specimens should be collected (minimum 8 hours apart, including an early morning specimen, which is the best way to detect Mycobacterium tuberculosis), organisms other than M. tuberculosis, especially on-tuberculous mycobacteria (e.g., M. kansasii and M. avium , may be positive for AFB stain; nucleic acid amplification tests (NAAT): positive for M. tuberculosis DNA or RNA amplification tests for rapid diagnosis, may be used on sputum or any sterile body fluid Non-Hodgkin's lymphoma (NHL) Aggressive NHL may present with fever, drenching night sweats, malaise, weight loss, cough, shortness of breath, abdominal discomfort, headache, change in mental status, dizziness, ataxia, pleural effusion, lymphadenopathy, pallor, purpura, jaundice, hepatomegaly, splenomegaly, skin nodules, and abnormal neurological examination, low-grade NHL patients often minimally symptomatic or asymptomatic CT chest: frequently anterior mediastinum, can determine if mass is cystic or solid and whether it contains calcium or fat, contrast enhancement provides information concerning vascularisation of the mass and relationship to adjacent structures; FBC with differential: shows thrombocytopenia, pancytopenia; Blood smear: shows nucleated red blood cells, giant platelets; lymph node biopsy with immunohistochemistry: shows characteristic cells, preferably obtain excisional or core biopsy to provide information on lymph node architecture; mediastinoscopy: used to sample mediastinal nodes Hodgkin's lymphoma Predominantly a disease of young adults; most patients present with a several-month history of persistent adenopathy, most commonly of the cervical chain Plain chest x-ray: typically shows mediastinal mass/large mediastinal adenopathy; PET scan: involved sites appear fluorodeoxyglucose (FDG)-avid (bright) with PET imaging; lymph node biopsy with immunohistochemistry: the Hodgkin's cell can be a characteristic Reed-Sternberg cell, or one of its variants, such as the lacunar cell in the nodular sclerosis subtype; in nodular lymphocyte-predominant Hodgkin's lymphoma, the characteristic cell is the lymphocytic and histiocytic (L&H) cell, also referred to as a popcorn cell Thymoma/thymic carcinoma Approximately 30% of patients with thymoma are asymptomatic at the time of diagnosis; may also present with cough, chest pain, signs of upper airway congestion, superior vena cava syndrome, dysphagia, or hoarseness; may have features of paraneoplastic syndromes associated with thymoma including myasthenia gravis, polymyositis, lupus erythematosus, rheumatoid arthritis, thyroiditis, and Sjogren's syndrome; about 30% of patients have symptoms suggestive of myasthenia gravis (e.g., ptosis, double vision) Plain chest x-ray: in 50% of the patients, thymomas are detected by chance with plain-film chest radiography; CT chest: 90% occur in anterior mediastinum; Positron emission tomography (PET): may be of value in determining malignancy and extramediastinal involvement; pre-operative biopsy: indicated if there are atypical features or if imaging suggests invasive tumor and patient is under consideration for induction therapy Bronchogenic cyst Usually diagnosed in infancy and childhood, although 50% are diagnosed after 15 years of age; Approximately 50% of patients are asymptomatic; in adults, chest pain (often pleuritic) and dysphagia (due to esophageal compression) are the most common symptoms; may also feature recurrent cough and chest infection/pneumonia, superior vena cava syndrome, tracheal compression, and pneumothorax Two-view chest radiography: typically shows a sharply demarcated spherical mass of variable size, most commonly located in the middle mediastinum around the carina, can appear as a solid tumor or show air-fluid level if cyst is infected or contains secretions; CT chest: frequently middle mediastinum, typically at level of the mediastinum, calcifications may also be seen; MRI: frequently middle mediastinum, typically at level of the mediastinum, T2-weighted images show a homogeneous mass of moderate-to-bright intensity, on T1-weighted images, lesions may vary in intensity depending on protein content of the cyst Tracheal tumors Common symptoms include dyspnea, cough, hemoptysis, wheeze, and stridor; less commonly, hoarseness and dysphagia may be present Plain chest radiographs are generally insensitive for detection of tracheal tumors, clues that may indicate the presence of a tracheal tumour include abnormal calcification, tracheal narrowing, post-obstructive pneumonia, and/or atelectasis; helical CT enables accurate calculation of tumor volumes and can help differentiate mucosal lesions from submucosal lesions; MRI can be useful in assessing extension into surrounding tissue and vascular anatomy; bronchoscopy allows direct visualisation, opportunity for biopsy, and potential for laser treatment Thyroid mass Symptoms and signs depend on size of mass; may be visible/palpable as lump on anterior aspect of neck; may present with dysphagia, hoarseness, difficulty breathing, and pain in neck or throat; may also be signs and symptoms of hyper- or hypothyroidism depending on the nature of the mass Laboratory testing should include thyroid function panel, with TSH, free T4, free T3; I-123 thyroid scan is ordered for patients with overt or subclinical hyperthyroidism a hyperfunctioning (hot) nodule is almost always benign, most nodules are hypofunctioning (cold) (most of these are benign, but malignant nodules are also cold); ultrasound and doppler can be used to define dimensions of thyroid nodules and solid/cystic component(s), features suspicious of malignancy include microcalcifications, a more tall-than-wide shape, hypervascularity, marked hypoechogenicity, or irregular margins, it can also guide fine-needle aspiration, which can reveal malignant cells or cyst fluid; CT neck can evaluate cervical lymph nodes in cases of medullary thyroid cancer, and extension of the scan into the chest can help evaluate a retrosternal thyroid mass Other conditions that can be mistaken for lung cancer including the following: Pneumomediastinum Empyema Abscess Pneumothorax (tension and traumatic) Pleural effusion Pneumothorax Superior Vena Cava Syndrome Differential Diagnosis Lung cancer must be differentiated from other cavitary lung lesions. Causes of lung cavities Differentiating Features Differentiating radiological findings Diagnosis confirmation Malignancy (Primary lung cancer) Elderly male or female Chronic smokers Presents with a low-grade fever, absence of leukocytosis, systemic complaints weight loss, fatigue Absence of factors that predispose to gastric content aspiration, no response to antibiotics within 10 days Hemoptysis is commonly associated with bronchogenic carcinoma A coin-shaped lesion with thick wall(>15mm) is seen on CXR with less ground glass opacities Bronchoalveolar lavage cytology shows malignant cells Biopsy of lung Pulmonary Tuberculosis Mostly in endemic areas Symptoms include productive cough, night sweats, fever, and weight loss CXR and CT demonstrates cavities in the upper lobe of the lung Sputum smear positive for acid-fast bacilli and nucleic acid amplification tests (NAAT) is used on sputum or any sterile fluid for rapid diagnosis and is positive for mycobacteria. Necrotizing Pneumonia Any age group Acute, fulminant life threating complication of prior infection >100.4 °F fever, with hemodynamic instability Worsening pneumonia-like symptoms CXR demonstrates multiple cavitary lesions Pleural effusion and empyema are common findings CBC is positive for causative organism Loculated empyema Children and elderly are at risk Pleuritic chest pain, dry cough, fever with chills Dullness to percussion decreased breath sounds, and reduced vocal resonance on examination Empyema appears lenticular in shape and has a thin wall with smooth luminal margins Thoracocentesis Granulomatosis with polyangiitis (Wegener's) Women are more commonly effected than man Kidneys are also involved Upper respiratory tract symptoms, perforation of nasal septum, chronic sinusitis, otitis media, mastoiditis. Lower respiratory tract symptoms (e.g. hemoptysis, cough, dyspnea) Renal symptoms, hematuria, red cell casts Pulmonary nodules with cavities and infiltrates are a frequent manifestation on CXR Positive for P-ANCA Biopsy of the tissue involved shows necrotizing granulomas Rheumatoid nodule Elderly females of 40-50 age group Manifestation of rheumatoid arthritis Presents with other systemic symptoms including symmetric arthritis of the small joints of the hands and feet with morning stiffness are common manifestations Pulmonary nodules with cavitation are located in the upper lobe (Caplan syndrome) on X-ray Positive for both rheumatoid factor and anticyclic citrullinated peptide antibody. Sarcoidosis More common in African-American females Often asymptomatic except for enlarged lymph nodes Associated with restrictive lung disease Erythema nodosum Lupus pernio (skin lesions on face resembling lupus) Bell palsy Epithelioid granulomas containing microscopic Schaumann and asteroid bodies On CXR bilateral adenopathy and coarse reticular opacities are seen CT of the chest demonstrates extensive hilar and mediastinal adenopathy Additional findings on CT include fibrosis (honeycomb, linear, or associated with bronchial distortion), pleural thickening, and ground-glass opacities. Biopsy of lung shows non-caseating granuloma Bronchiolitis obliterans (Cryptogenic organizing pneumonia) Rare condition and mimics asthma, pneumonia and emphysema It is caused by drug or toxin exposure, autoimmune diseases, viral infections, or radiation injury People working in industries are at high risk Presents with fever, cough, wheezing, and shortness of breath over weeks to months Common appearance on CT is patchy consolidation,often accompanied by ground-glass opacities and nodules. Biopsy of the lung Pulmonary function tests demonstrate low fev1/fvc Langerhans cell Histiocytosis Exclusively afflicts smokers, with a peak age of onset of between 20 and 40 years Clinical presentation varies, but symptoms generally include months of dry cough, fever, night sweats, and weight loss Skin is involved in 80% of the cases, scaly erythematous rash is typical Thin-walled cystic cavities are the usual radiographic manifestation, observed in over 50% of patients by either CXR or CT scans. Biopsy of the lung PBC USG There are no ultrasound findings associated with primary biliary cirrhosis. However, the ultrasound is mandatory for liver and biliary tree for all cholestatic patients for the differentiation of intrahepatic from extrahepatic cholestasis. The ultrasound findings may include: Cholestasis Abdominal lymphadenopathy Ultrasound examination of the liver and biliary tree is obligatory in all cholestatic patients in order to differentiate intrahepatic from extrahepatic . When the biliary system appears normal and serum AMA are present, no further radiologic workup is necessary. , particularly in the hilar region of the liver, is seen in 80% of patients with PBC PBC CT Findings on CT scan suggestive of advanced primary biliary cirrhosis include: Small heterogeneously attenuating liver Varices Splenomegaly Lymphadenopathy Findings on CT scan suggestive of less advanced disease include: Enlarged or normal size liver Smooth contour liver Little atrophy Lacelike fibrosis Regenerative nodules Varices Ascites Lymphadenopathy Synonoms Solitary hyperplastic nodule Hepatic hamartoma Focal cirrhosis Hamartomatous cholangiohepatoma Hepatic pseudotumor Historical Perspective In early 1900s,Focal nodular hyperplasia was first described. Between 1918-1982,96.625 autopsy studies were conducted out of which 8 percent of nonhemangiomatous lesions were focal nodular hyperplasia. In 1994,Working party of the world congresses of gastroenterology suggested a standardized terminology of nodular hepatic lesions that placed Focal noduldar carcinoma in the group of regenerative nodules, as opposed to dysplastic or neoplastic nodules. Differentiating Focal nodular hyperplasia from Other diseases Focal nodular hyperplasia must be differentiated from: Hepatocellular carcinoma Cholangiocarcinoma Pancreatic carcinoma Liver hemangioma Liver abscess Cirrhosis Inflammatory lesions Abbreviations: RUQ= Right upper quadrant of the abdomen, LUQ= Left upper quadrant, LLQ= Left lower quadrant, RLQ= Right lower quadrant, LFT= Liver function test, SIRS= Systemic inflammatory response syndrome, ERCP= Endoscopic retrograde cholangiopancreatography, IV= Intravenous, N= Normal, AMA= Anti mitochondrial antibodies, LDH= Lactate dehydrogenase, GI= Gastrointestinal, CXR= Chest X ray, IgA= Immunoglobulin A, IgG= Immunoglobulin G, IgM= Immunoglobulin M, CT= Computed tomography, PMN= Polymorphonuclear cells, ESR= Erythrocyte sedimentation rate, CRP= C-reactive protein, TS= Transferrin saturation, SF= Serum Ferritin, SMA= Superior mesenteric artery, SMV= Superior mesenteric vein, ECG= Electrocardiogram Disease Clinical manifestations Diagnosis Comments Symptoms Signs Abdominal Pain Fever Rigors and chills Nausea or vomiting Jaundice Constipation Diarrhea Weight loss GI bleeding Hypo- tension Guarding Rebound Tenderness Bowel sounds Lab Findings Imaging Focal nodular hyperplasia Diffuse ± − − ± − − + + − − − Normal Normal Liver function tests Normal AFP Minor elevations of Aspartate Alanine aminotransferase Alkaline phosphatase Gamma glutamyl transpeptidase Us Multiphasic helical CT scan Open biopsy if diagnosis can not be established Hepatocellular carcinoma/Metastasis RUQ + − + + + + + + + − + Normal Hyperactive if obstruction present High levels of AFP in serum Abnormal liver function tests Thrombocytopenia US CT MRI Liver biopsy Other symptoms: Splenomegaly Variceal bleeding Ascites Spider nevi Asterixis Cholangiocarcinoma RUQ + − + + − − + − − − + Normal Elevated CA 19-9 Increased amylase / lipase Increased stool fat content Contrast-enhanced ultrasound CT scan Calcification Pseudocyst Dilation of main pancreatic duct MRI Predisposes to pancreatic cancer Pancreatic carcinoma MidEpigastric − − + + + − + − − − + Normal ↑ Alkaline phosphatase ↑ serum bilirubin ↑ gamma-glutamyl transpeptidase ↑ CA 19-9 MDCT with PET/CT MRI EUS Skin manifestations may include: Bullous pemphigoid Cicatricial pemphigoid Migratory superficial thrombophlebitis (classic Trousseau's syndrome) Pancreatic panniculitis Disease Abdominal Pain Fever Rigors and chills Nausea or vomiting Jaundice Constipation Diarrhea Weight loss GI bleeding Hypo- tension Guarding Rebound Tenderness Bowel sounds Lab Findings Imaging Comments Gallbladder cancer Midepigastric − − + + − + + − − − − Normal ↑ Alkaline phosphatase ↑ CA 19-9 US CT MRI Liver hemangioma Intermittent RUQ − − + + − − − − − − − Normal Abnormal LFTs US Single-photon emission computerized tomography(SPECT) MRI US will reveal hypoechoic lesions Liver abscess RUQ + − + + − − + − − − − Normal Hypoalbuminemia Abnormal liver function tests US CT Cirrhosis RUQ+Bloating + − + + − − + − − − − Normal Hypoalbuminemia Prolonged PT Abnormal LFTs Hyponatremia Thrombocytopenia US Nodular, shrunken liver Ascites Stigmata of liver disease Cruveilhier- Baumgarten murmur Inflammatory lesions RUQ ± − + + − − − − − − − Normal Hypoalbuminemia Prolonged PT Abnormal LFTs Hyponatremia Thrombocytopenia US Nodular,shrunken or coarse liver Stigmata of liver disease Focal Nodular Hyperplasia FNH is typically benign, and usually no treatment is needed. Hemangiomas are the most common and are entirely benign. Treatment is unnecessary unless their expansion causes symptoms Focal nodular hyperplasia (FNH) is a non-malignant hepatic tumor that is not of vascular origin. In one autopsy series of 96,625 patients, 8 percent of non-hemangiomatous lesions were FNH, representing 66 percent of all benign non-hemangiomatous lesions seen between 1918 and 1982 [1]. In large retrospective studies of patients referred for ultrasound and multidetector computed tomography, the prevalence of focal nodular hyperplasia was 0.2 percent and 1.6 percent, respectively [2,3]. FNH is seen in both sexes and throughout the age spectrum, although it is found predominantly in women (in a ratio of 8 or 9:1) between the ages of 20 and 50 years [4]. FNH comprises up to 2 percent of liver tumors in children [5]. This topic review will focus on the pathogenesis, clinical manifestations and management of FNH. An approach to patients presenting with a focal liver lesion is discussed separately. (See "Solid liver lesions: Differential diagnosis and evaluation".) PATHOGENESIS — FNH has various labels: solitary hyperplastic nodule, hepatic hamartoma, focal cirrhosis, hamartomatous cholangiohepatoma, and hepatic pseudotumor. This profusion of terms epitomizes the confusion surrounding our understanding of the pathogenesis of the many conditions in which nodules of benign appearing hepatocytes are found. The International Working Party of the World Congresses of Gastroenterology proposed a standardized nomenclature in 1994, which placed FNH in the group of regenerative nodules, as opposed to dysplastic or neoplastic nodules [6]. This fits well with our current understanding of the pathogenesis of FNH. The contention that this lesion is non-neoplastic has been bolstered by the reported polyclonal origin of the hepatocytes [7], although this is disputed by others [8]. Previously considered to be a hamartoma, a neoplasm, a response to ischemia or other injury, or a focal area of regeneration, FNH is now generally accepted to be a hyperplastic (regenerative) response to hyperperfusion by the characteristic anomalous arteries found in the center of these nodules [4,9,10]. Whether vascular injury is also involved is less clear, but FNH is occasionally supplied primarily by portal venous blood due to thrombosis of the anomalous central artery [11]. The association of FNH with hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu disease [12]) and hepatic hemangiomas strengthens the hypothesis that FNH is a congenital vascular anomaly. Two pathology studies found cavernous hemangiomas in 6.5 and 2.3 percent of patients with FNH [13,14] and an imaging study, using ultrasound and dynamic CT, found that 23 percent of FNH patients had associated hemangiomas [15]. Multiple FNH lesions have also been noted in association with hemihypertrophy and vascular malformations (Klippel-Trénaunay-Weber syndrome) [16]. FNH with similar clinical and radiographic features has been documented in identical twins supporting a role of congenital vascular anomalies in its pathogenesis and a possible genetic predisposition to the disease [17]. PATHOLOGY — FNH is most often solitary (80 to 95 percent), and usually less than 5 cm in diameter. Only 3 percent are larger than 10 cm, although FNH as large as 19 cm have been reported [1,13,18]. It has a sharp margin with no capsule and may be pedunculated. The characteristic finding is the presence of a central stellate scar (picture 1) containing an inappropriately large artery with multiple branches radiating through the fibrous septa to the periphery. These branches divide the mass into multiple small nodules or cords of normal appearing hepatocytes (picture 2). The scar-like tissues within FNH nodules are composed of abnormally large portal tracts including large feeding arteries, portal veins, and bile ducts [10]. The arteries drain into adjacent hepatic veins. This radiating, branching pattern produces the spoke and wheel image typically seen on angiography. Although normal bile ducts are absent, bile ductules derived from hepatocyte metaplasia are usually prominent, traveling along the fibrous septa (picture 3). Sinusoids and Kupffer cells are typically present, distinguishing it from hepatocellular adenoma (HA), which usually lacks bile ducts and Kupffer cells [1,13,14,18,19]. The minimal microscopic criteria for the diagnosis of classical FNH are nodular architecture, abnormal vessels, and proliferation of bile ductules [13]. Lymphocyte infiltration, canalicular bile plugs, copper deposition, and feathery degeneration of hepatocytes may suggest cholestasis and/or inactive cirrhosis. Irregular intimal fibrosis or hypertrophy of the media may be seen in large arteries and veins, at times even occluding the lumen [13,14,19]. When present, portal veins are dilated and/or stenotic [10]. Non-classical variants — Non-classical forms of FNH lack either the typical nodular architecture or vascular malformations, but always contain bile ductular proliferation. They almost always lack the characteristic central scar [13]. Three variants have been recognized: ●The most common of these, the telangiectatic type, often presents with multiple FNH. In addition to the lack of a central scar, the mass is characterized by the absence of nodular architecture and the presence of single, quite regular plates of hepatocytes separated by sinusoids fed directly by anomalous arteries [13,20]. The risk of bleeding appears to be similar to the risk observed in patients with a hepatic adenoma [21]. ●A mixed hyperplastic and adenomatous form may be difficult to distinguish from HA due to its subtle vascular and bile ductular findings [13,20]. ●A third histologic variant consisting of FNH with cytologic atypia resembling dysplasia of large cell type has been proposed [13]. A comprehensive pathological study of 305 lesions failed to identify a macroscopic central stellate scar in 50 percent and noted non-classical histology in 20 percent of the lesions, most showing a telangiectatic variant [13]. The surprisingly high number of lesions without a central scar was almost exclusively due to the large number of masses that had non-classical histology. Ninety-five percent of those with non-classical histology did not have a scar, whereas only 18 percent of those with classical histology lacked a scar [13]. The overall prevalence and clinical significance of these variants remains to be determined. DIAGNOSIS — The diagnosis of FNH is usually made by demonstrating its characteristic features on imaging tests and excluding other lesions. The latter can typically be accomplished by assessment of the context in which FNH is detected and by obtaining specific radiologic and laboratory testing (table 1). The differential diagnosis includes hepatic adenoma, hepatocellular carcinoma, fibrolamellar carcinoma, cirrhosis, large regenerative nodules, hemangioma, and hypervascular metastases. (See "Solid liver lesions: Differential diagnosis and evaluation".) Symptoms — The majority of reports have found that symptoms or signs directly attributable to FNH are infrequent. Two-thirds to three-fourths of patients are identified incidentally [18], with the mass noted at the time of surgery, on an abdominal imaging study, or at autopsy. Unlike hepatic adenomas, FNH rarely presents with acute onset of hemorrhage, necrosis, or infarction [22,23]. However, symptomatic presentations have been described. In one series, for example, abdominal discomfort or a palpable liver mass was observed in 25 percent of 41 patients [24]. Another series that included 168 patients found that 60 percent had abdominal pain and 4 percent had an abdominal mass [13]. The high number of symptomatic patients in the second report probably reflects selection bias since all of the patients were identified from pathology specimens obtained at the time of surgical resection [13]. Laboratory tests — Liver tests are most often normal although minor elevations in aspartate and alanine aminotransferase, alkaline phosphatase and gamma glutamyl transpeptidase levels may be seen [13,14,24]. The alpha-fetoprotein is normal. Imaging tests — A confident diagnosis can usually be made through a combination of imaging modalities; tissue diagnosis is usually not required. Ultrasonography — Although often first identified on ultrasound examination, FNH is variably hyper, hypo, or isoechoic [24] and US is able to identify the central scar in only 20 percent of cases [25]. The ultrasound characteristics are difficult to distinguish from an adenoma or malignant lesions. Power Doppler ultrasound may help differentiate the arterial flow in FNH from the venous flow in HA [24,26,27]. Contrast-enhanced ultrasonography — Several reports have described improved characterization of focal liver lesions using contrast-enhanced ultrasonography compared with standard ultrasonography [28-30]. While the approach is not approved in the United States, it is available in other countries. Test characteristics compared with other imaging modalities remain incompletely defined, although emerging data suggest its ability for differentiation among solid liver lesions is comparable with MRI [31]. (See "Contrast-enhanced ultrasound for the evaluation of liver lesions".) CT scan — A properly timed dynamic, triphasic, helical CT scan performed without contrast, and with contrast during the hepatic arterial and portal venous phases, will often be highly suggestive of the diagnosis [32,33]. The lesion may be hypo or isodense on non-contrast imaging with the central scar identified in one-third of patients. The lesion becomes hyperdense during the hepatic arterial phase due to the arterial origin of its blood supply (image 1). FNH is generally isodense during the portal venous phase, although the central scar may become hyperdense as contrast diffuses into the scar. While characteristic of FNH, a central scar may be present in the fibrolamellar variant of HCC. (See "Epidemiology, clinical manifestations, diagnosis, and treatment of fibrolamellar carcinoma", section on 'Imaging'.) MRI — There may be little to distinguish FNH from normal liver on standard MRI, since it is composed of the same elements as normal liver. An isointense lesion is noted on T1-weighted images, while an isointense to slightly hyperintense mass appears on T2-weighted images (image 2 and image 3) [34]. The scar typically shows high signal intensity on T2-weighted images due to vessels or edema in the scar (image 3) [35]. Gadolinium infusion produces rapid enhancement of the FNH mass due to its arterial blood supply, producing a hyperintense lesion on early films (image 2). On delayed images it becomes more isointense with respect to normal liver. The central scar enhances on delayed imaging as contrast gradually diffuses into the fibrous center of the mass [36-39]. In one study, gadolinium enhanced MRI had a sensitivity and specificity of 70 and 98 percent, respectively [24]. A relatively new MR contrast agent has been introduced into clinical use. Unlike currently used gadolinium-based contrast agents for MRI, this agent, a Gd-BOPTA chelate of Gadobenate Dimeglumine, has a dual route of elimination, through both renal and hepatobiliary excretion (image 4). Thus, it can be useful for distinguishing hepatic adenomas from focal nodular hyperplasia. (See "Solid liver lesions: Differential diagnosis and evaluation".) Angiography — Although angiography may reveal the diagnostic "spoked wheel" appearance of FNH, its use is rarely indicated [32,40,41]. ROLE OF ORAL CONTRACEPTIVES — FNH was first described in the early 1900s, long before the advent of oral contraceptives (OCPs). It is seen in men and children who do not use OCPs and its incidence remained steady after the introduction of OCPs in 1960, in sharp contrast to the dramatic rise in the incidence of HA with the widespread use of OCPs. Thus use of OCPs is not required for the development of FNH [42-44]. On the other hand, FNH may be responsive to estrogens [11]. Patients taking OCPs tend to have larger, more vascular tumors, have more symptoms, and reports of hemorrhage or rupture in patients with FNH have all occurred in patients taking OCPs [45-48]. However, the magnitude of the risk associated with OCPs is uncertain. In a study of 216 women with FNH, use of OCPs did not appear to influence the size or number of FNH lesions or size changes (which were rare) during follow-up for an average of two years [49]. A case control trial comparing 23 women with histologically confirmed FNH to 94 controls estimated the odds ratio of OCP use to be 2.8 (95% CI, 0.8 to 9.4) for those who had ever used OCPs and 4.5 (95% CI, 1.2 to 16.9) for those who had ≥3 years of use [50]. We generally do not insist that oral contraceptives and other estrogen containing preparations should be discontinued. However, it is reasonable to obtain a follow-up imaging study in 6 to 12 months in women who continue taking these drugs. MANAGEMENT — The natural history of FNH is one of stability and lack of complications. Lesions generally do not change over time, although they occasionally become smaller [49,51-54]. However, as mentioned above, enlargement of FNH in the setting of OCPs and during pregnancy have been reported [55]. There is no evidence for malignant transformation of FNH [13,24,56,57]. Patients who are suspected of having FNH based upon the evaluation described above should be managed conservatively [24,35,49,51,52,54,58,59]. If a diagnosis remains unclear, a liver biopsy may be helpful, but may also be misleading since only resection will be definitive [60]. Follow-up studies at three and six months will often be sufficient to confirm the stability of the lesion and its benign nature, after which no long-term follow-up is required routinely. Surgery should be reserved for the rare, very symptomatic FNH lesion, and the highly suspicious lesion, which has eluded diagnosis by all other modalities. We generally do not insist that oral contraceptives and other estrogen containing preparations should be discontinued. However, it is reasonable to obtain a follow-up imaging study in 6 to 12 months in women who continue taking these drugs. Small FNH do not appear to pose a significant risk to a successful pregnancy [49,61], although close observation is strongly recommended and resection may be prudent for large (>8 cm) FNH. SUMMARY AND RECOMMENDATIONS ●Focal nodular hyperplasia (FNH) is a non-malignant hepatic tumor that is not of vascular origin. It is now generally accepted to be a hyperplastic (regenerative) response to hyperperfusion by the characteristic anomalous arteries found in the center of these nodules. (See 'Pathogenesis' above.) ●FNH is most often solitary (80 to 95 percent) and usually less than 5 cm in diameter. Only 3 percent are larger than 10 cm. (See 'Pathology' above.) ●The majority of reports have found that symptoms or signs directly attributable to FNH are infrequent. (See 'Symptoms' above.) ●The diagnosis of FNH is usually made by demonstrating its characteristic features on imaging tests and excluding other lesions. The latter can typically be accomplished by assessing the context in which FNH is detected and by obtaining specific radiologic and laboratory testing (table 1). (See 'Diagnosis' above and "Solid liver lesions: Differential diagnosis and evaluation".) ●The natural history of FNH is one of stability and a lack of complications. Thus, we suggest that patients who are suspected of having FNH based upon the evaluation described above be managed conservatively (Grade 2B). (See 'Management' above.) ●FNH may be responsive to exogenous estrogens. We generally do not insist that oral contraceptives and other estrogen-containing preparations should be discontinued. However, it is reasonable to obtain a follow-up imaging study in 6 to 12 months in women who continue taking these drugs. (See 'Role of oral contraceptives' above.) Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1.Craig J, Peters R, Edmundson H. 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HCC Differnetial Table Abbreviations: RUQ= Right upper quadrant of the abdomen, LUQ= Left upper quadrant, LLQ= Left lower quadrant, RLQ= Right lower quadrant, LFT= Liver function test, SIRS= Systemic inflammatory response syndrome, ERCP= Endoscopic retrograde cholangiopancreatography, IV= Intravenous, N= Normal, AMA= Anti mitochondrial antibodies, LDH= Lactate dehydrogenase, GI= Gastrointestinal, CXR= Chest X ray, IgA= Immunoglobulin A, IgG= Immunoglobulin G, IgM= Immunoglobulin M, CT= Computed tomography, PMN= Polymorphonuclear cells, ESR= Erythrocyte sedimentation rate, CRP= C-reactive protein, TS= Transferrin saturation, SF= Serum Ferritin, SMA= Superior mesenteric artery, SMV= Superior mesenteric vein, ECG= Electrocardiogram Disease Clinical manifestations Diagnosis Comments Symptoms Signs Abdominal Pain Fever Rigors and chills Nausea or vomiting Jaundice Constipation Diarrhea Weight loss GI bleeding Hypo- tension Guarding Rebound Tenderness Bowel sounds Lab Findings Imaging Hepatocellular carcinoma/Metastasis RUQ + − + + + + + + + − + Normal Hyperactive if obstruction present High levels of AFP in serum Abnormal liver function tests Thrombocytopenia US CT MRI Liver biopsy Other symptoms: Splenomegaly Variceal bleeding Ascites Spider nevi Asterixis Cholangiocarcinoma RUQ + − + + − − + − − − + Normal Elevated CA 19-9 Increased amylase / lipase Increased stool fat content Contrast-enhanced ultrasound CT scan Calcification Pseudocyst Dilation of main pancreatic duct MRI Predisposes to pancreatic cancer Pancreatic carcinoma MidEpigastric − − + + + − + − − − + Normal ↑ Alkaline phosphatase ↑ serum bilirubin ↑ gamma-glutamyl transpeptidase ↑ CA 19-9 MDCT with PET/CT MRI EUS Skin manifestations may include: Bullous pemphigoid Cicatricial pemphigoid Migratory superficial thrombophlebitis (classic Trousseau's syndrome) Pancreatic panniculitis Focal nodular hyperplasia Diffuse ± − − ± − − + + − − − Normal Normal Liver function tests Normal AFP Minor elevations of Aspartate Alanine aminotransferase Alkaline phosphatase Gamma glutamyl transpeptidase Us Multiphasic helical CT scan Open biopsy if diagnosis can not be established Disease Abdominal Pain Fever Rigors and chills Nausea or vomiting Jaundice Constipation Diarrhea Weight loss GI bleeding Hypo- tension Guarding Rebound Tenderness Bowel sounds Lab Findings Imaging Comments Gallbladder cancer Midepigastric − − + + − + + − − − − Normal ↑ Alkaline phosphatase ↑ CA 19-9 US CT MRI Liver hemangioma Intermittent RUQ − − + + − − − − − − − Normal Abnormal LFTs US Single-photon emission computerized tomography(SPECT) MRI US will reveal hypoechoic lesions Liver abscess RUQ + − + + − − + − − − − Normal Hypoalbuminemia Abnormal liver function tests US CT Cirrhosis RUQ+Bloating + − + + − − + − − − − Normal Hypoalbuminemia Prolonged PT Abnormal LFTs Hyponatremia Thrombocytopenia US Nodular, shrunken liver Ascites Stigmata of liver disease Cruveilhier- Baumgarten murmur Inflammatory lesions RUQ ± − + + − − − − − − − Normal Hypoalbuminemia Prolonged PT Abnormal LFTs Hyponatremia Thrombocytopenia US Nodular,shrunken or coarse liver Stigmata of liver disease Classification Historical Perspective Pathophysiology Causes Differentiating Splenic Rupture from Other Diseases Epidemiology and Demographics Risk Factors Screening Natural History, Complications and Prognosis Diagnosis Diagnostic Study of Choice History and Symptoms Physical Examination Laboratory Findings Electrocardiogram X-Ray MRI Other Imaging Findings Other Diagnostic Studies Algorithms                                             Major molecular events in the pathogenesis of HCC                                                                                                                                                                                   Genomic alterations                                 Epigenetic modifications                             Growthfactor pathway alterations                                                                                                                                                       Gene Mutations   Gene Amplification               DNA methylation micro RNA         Micro RNA           LNC RNA             Major Signaling pathways                                                                                                   •TERT promoter •TP53 •CTNNB1 •AXIN1 •AXIN2 •ATM •RPS6KA3 •JAK1 •IL6R •IL6ST •ARID1 •ARID2   •CCND1 •FGF19 •CDKNA2A •CDKNA2B •AXIN1 •IRF2 •MET               GSTP1 •E-Cadherin •CDKNA2 •RASSF1A •SOCS-3 •MIGMT         •MiR-155 •Mir-122 •Mir-224 •Mir-21           •HULC •HEIH •Dreh •MVIH •HOTAIR •MDIG •LINE1             •Wnt/β –catenin •Tyrosine kinase pathways EGF HGF/c-MET FGF VEGF •IGF •HIF •TGF β •Hedgehog Elderly Male with jaundice from pancreatic cancer, By James Heilman, MD (Own work) [CC BY 3.0 (http://creativecommons.org/licenses/by/3.0)], via Wikimedia Commons The incidence of HCC has almost tripled since the early 1980s in the United States where it is the fastest rising cause of cancer-related deaths1. According to population based Surveillance Epidemiology and End Results registry data, the overall HCC age adjusted incidence rates for liver and intrahepatic ducts cancer is as high as 8 per 100,000 underling population in 2010 (Fig. 1) of which at least 6 per 100,000 related to HCC. Men are at approximately three times higher risk than women. Asian men (i.e., Chinese, Korean, Filipino, and Japanese) have the highest age-adjusted incidence rates. However, the largest proportional increases have occurred among Hispanics followed by blacks and non-Hispanic whites, whereas the lowest proportional increases have occurred among Asians. In contrast to Asians/Pacific Islanders, HCC incidence rates are reported to be higher among Hispanics born in the United States than among foreign-born Hispanics2. HCC incidence rates have increased in each successive birth cohort born between 1900 and 19593 (Fig. 2). In addition, the age distribution of HCC patients has shifted to younger ages, with the greatest proportional increases among individuals 45–60 years old (Fig. 2). There is a south to north gradient in the incidence and mortality of HCC; Southern states including Texas, Louisiana, and Mississippi have some of the highest HCC incidence rates in the nation (Fig. 3). In one study, Texas Latino and especially South Texas Latinos had the highest age-adjusted HCC incidence rates (as high as 10.6/100,000)4. Video codes Normal video {{#ev:youtube|dU26cGlmkRg}} {{#ev:youtube|4uSSvD1BAHg}} {{#ev:youtube|PQXb5D-5UZw}} {{#ev:youtube|UVJYQlUm2A8}} Video in table {{#ev:youtube|5ucSlgqGAno}} Floating video Title https://https://www.youtube.com/watch?v=o1VTHP_oYD8}} Redirect REDIRECTEsophageal web synonym website https://mq.b2i.sg/snow-owl/#!terminology/snomed/10743008 Image Normal versus Abnormal Barium study of esophagus with varices Image to the right C. burnetii, the Q fever causing agent Image and text to the right <figure-inline><figure-inline><figure-inline><figure-inline><figure-inline><figure-inline><figure-inline><figure-inline><figure-inline><figure-inline><figure-inline><figure-inline><figure-inline><figure-inline><figure-inline><figure-inline><figure-inline><figure-inline><figure-inline><figure-inline><figure-inline></figure-inline></figure-inline></figure-inline></figure-inline></figure-inline></figure-inline></figure-inline></figure-inline></figure-inline></figure-inline></figure-inline></figure-inline></figure-inline></figure-inline></figure-inline></figure-inline></figure-inline></figure-inline></figure-inline></figure-inline></figure-inline> Recent out break of leptospirosis is reported in Bronx, New York and found 3 cases in the months January and February, 2017. Gallery Histopathology of a pancreatic endocrine tumor (insulinoma). Source:https://librepathology.org/wiki/Neuroendocrine_tumour_of_the_pancreas Histopathology of a pancreatic endocrine tumor (insulinoma). Chromogranin A immunostain. Source:https://librepathology.org/wiki/Neuroendocrine_tumour_of_the_pancreas Histopathology of a pancreatic endocrine tumor (insulinoma). Insulin immunostain. Source:https://librepathology.org/wiki/Neuroendocrine_tumour_of_the_pancreas References