Volume 7 Issue 1 December 2024 ISSN 2635-4608

Vol 7

AIMS OF THE JOURNAL The scope of the ScholarGen Journal of Medical Imaging (SJMI) is all about medical imaging. The SJMI publishes medical imaging theories, methods, systems and data collection, image reconstruction and image analysis. Also, SJMI covers related research fields for cell and molecular level imaging for early detection and diagnosis of disease.

Radiography MRI Nuclear medicine Ultrasound Thermography Molecular Imaging NMR in Biomedicine Software, Tools Other studies on radiology

SCOPE OF THE JOURNAL JOURNAL HIGHLIGHT Radiography Magnetic Resonance Imaging Nuclear medicine Ultrasound Thermography Molecular Imaging NMR in Biomedicine Software, Tools Other studies on radiology

Indexing

Open Access Journals by scholargen publisher is licensed under a Creative Commons Attribution- NonCommercial 4.0 International License. 4-17-27 Tenjin-cho, Kodaira, Tokyo, Japan Email : info@scholargen.com Scholargen International Cooperation

Pirogov St., 630090, Novosibirsk, Russia 35B, Pocket B, Siddhartha Extn, New Delhi Private Bag X3, Rondebosch 7701, Cape Town 75, Nowon-ro, Nowon-gu, Seoul, Korea Sydney, New South Wales 2052, Australia Samarkand city, 18 Amir Temur str, Uzbekistan 2329 West Mall Vancouver, BC, Canada Spui 21, 1012 WX Amsterdam, Netherlands

Content ISSN 2635-4608 j. med. Imaging(ScholarGen) Volume 7, Issue 1, December 2024

1. A Case Study of Abdominal Wall Desmoid Tumor in a 33-Year-Old Woman ----------------------------------- ------------- Davronov Oybek M.D., Gippeum Park M.D., Uralboev Ikromjon Erkinovich M.D and Hwunjae Lee M.D.,Ph.D.

7. Dual Energy CT Imaging of Hepatocellular Carcinoma Using Lipiodol in Intermediate-Stage Chemotherapy Treatment ----------------------------------------------------------------------------------------------------- ----------------- Soe Lwin Aye M.D. , Sobirjon Mamarajabov M.D., Ph.D.

, V. R. Singh, Hwunjae Lee M.D., Ph.D.

13. Personal Data Protection Issues in the Era of Artificial Intelligence ------------------------ Giljae Lee, Ph.D.

19. The Role of Molecular Imaging in Predictive Medicine: A Review ---------------------------------------------- --------------------------------------- Gippem Park M.D., Muzaffar Annaev M.D. , Juyeon Kim Ph.D., Gyehwan Jin Ph.D.

29. A case study of pancreatic cystadenomas in an old woman -------------------------------------------------------- --- Guppeum Park M.D., Soe Lwin Aye M.D., Sobirjon Mamarajabov M.D., Ph.D., Hwunjae Lee M.D., Ph.D.

35. Diagnosis of Hepatic Hemangioma in a 35-Year-Old Female with an Incidental Liver Lesion Detected on Ultrasound Examination ------------------------------------------------------------------------------- Davronov Oybek M.D., Muzaffar Annaev M.D., Uralboev Ikromjon Erkinovich M.D., Byungju Ahn Ph.D., Hwunjae Lee M.D., Ph.D.

SJMI(2024) 01;1-5 ISSN : 2635-4608

DOI http://dx.doi.org/10.31916/sjmi2024-01-01

_________________________________________________________________________________________________________

A Case Study of Abdominal Wall Desmoid Tumor in a 33-Year-Old Woman

1+

2+

Davronov Oybek M.D. , Gippeum Park M.D.

Uralboev Ikromjon Erkinovich M.D. and Hwunjae Lee M.D.,Ph.D.

4,5,6*

Received: 25 May 2024 / Accepted: 16 August 2024 / Published online: 30 December 2024 The Author(s) 2024 ⓒ

The patient presented with a progressively enlarging, Desmoid tumors, also known as aggressive painful mass in the left abdominal region, which had been

fibromatosis, are rare, benign soft tissue neoplasms developing over the past few months. Imaging studies, characterized by locally invasive growth. These tumors including contrast-enhanced CT and MRI, were performed originate from fibroblasts and commonly occur in the to evaluate the mass. CT revealed a soft tissue mass with a abdominal wall, particularly in females of reproductive age. density of 35 Hounsfield units, while MRI demonstrated Although desmoid tumors are non-metastatic, they can heterogeneous signal characteristics, with hypointensity on infiltrate surrounding tissues, leading to significant T1-weighted images, hyperintensity on T2-weighted morbidity and a high recurrence rate following incomplete images, and progressive enhancement following gadolinium contrast. A biopsy confirmed the diagnosis of surgical excision. The exact etiology of desmoid tumors remains unclear; however, genetic mutations, hormonal desmoid tumor. Treatment options were discussed, and influences, and trauma are considered contributing factors. surgical resection was recommended for the symptomatic In this case study, we present the clinical features, imaging mass. Desmoid tumors, though benign, pose significant characteristics, diagnosis, and treatment of a desmoid management challenges due to their locally aggressive nature and high recurrence rate. This case emphasizes the tumor in the abdominal wall of a 35-year-old woman. importance of early diagnosis through imaging and biopsy, ------------------------------------------------------------------- and highlights the need for careful management, including the potential use of adjuvant therapies in recurrent or Department of Urology, Samarkand State Medical inoperable cases. University, 18 Amir Temur St, Samarkand, Uzbekistan

Department of Internal Medicine, Samarkand State Medical University, 18 Amir Temur St, Samarkand, Uzbekistan

Department of Orthopedic-Thoracic, Children multibranch medical center of Samarkand, Uzebekistan

1. Introduction

Keywords: Abdominal wall, Desmoid tumor, CT, MRI, Biopsy, Differential diagnosis

Desmoid tumors, also known as aggressive fibromatosis, are benign but locally invasive soft tissue neoplasms. Although non-metastatic, these Interdisciplinary Program of Biomedical Engineering, tumors are characterized by aggressive growth, Yonsei University College of Medicine, Seoul 03722, infiltrating surrounding tissues, and a high rate of Republic of Korea recurrence following incomplete excision[1]. *Corresponding author ( ) + first author

2 SJMI(2024) 01;1-5

Desmoid tumors most commonly occur in females of reproductive age, typically affecting the abdominal wall, but can also arise in other soft tissues, including the chest, limbs, and pelvis[2]. While the exact etiology remains unclear, several factors including genetic mutations (particularly in the familial adenomatous polyposis gene), hormonal influences (such as pregnancy or oral contraceptives), and trauma have been implicated in the pathogenesis of desmoid tumors[2]. This case study presents the clinical, imaging, and pathological characteristics of a desmoid tumor in a 35-year-old woman, discussing the differential diagnosis, diagnostic workup, treatment options, and prognosis.

2. Cause and Etiology

3. Pathophysiology

4. Epidemiology

Desmoid tumors originate from fibroblasts in the fascial and musculoskeletal structures. Histologically, they are characterized by dense collagen and fibroblastic tissue. The tumor cells proliferate in a disorganized manner, infiltrating surrounding tissues and forming a firm, fibrous mass. These tumors exhibit aggressive local behavior, often encasing blood vessels and nerves, but do not metastasize to distant organs. The high collagen content in desmoid tumors contributes to their firm consistency and characteristic imaging features[6].

Desmoid tumors are rare, with an estimated incidence of 2 to 4 cases per million people per year. They most commonly occur in individuals aged 20 to 40 years, with a slight predilection for females, particularly during reproductive years. The majority of cases occur sporadically, but desmoid tumors are Genetic Factors : Most desmoid tumors are more frequent in individuals with familial associated with mutations in the APC gene, adenomatous polyposis (FAP). The abdominal wall especially in individuals with familial adenomatous is the most common location, but these tumors can polyposis (FAP), a genetic disorder that predisposes also arise in the extremities, chest, and pelvis[7]. to multiple colon polyps and an increased risk of desmoid tumors. In sporadic cases, somatic mutations affecting the β -catenin gene (CTNNB1) Patients with desmoid tumors typically present with a have been observed[3]. progressively enlarging, painless or mildly painful mass in the affected region. In this case, the 35-year- Hormonal Factors : Desmoid tumors are more old woman presented with a growing, painful mass in commonly found in women, especially during the left abdominal wall, which had been developing pregnancy or with the use of oral contraceptives, over the past few months. The mass was firm and suggesting that estrogen and progesterone may play a non-mobile on physical examination. Although role in tumor development[4]. desmoid tumors are usually asymptomatic, larger Trauma : Physical trauma or surgical incisions have tumors can cause pain, discomfort, and pressure on been linked to the development of desmoid tumors, adjacent structures, potentially leading to functional particularly in the context of surgical wounds or impairment. The clinical presentation often prompts scars[5]. investigation with imaging studies, as seen in this

The exact cause of desmoid tumors remains largely unknown. However, several factors have been identified as potential contributors to their development

5. Clinical Presentation

SJMI(2024) 01;1-5 3

case.

6. Imaging Features

Imaging plays a crucial role in the diagnosis and management of desmoid tumors. Common imaging modalities include: Non-Contrast CT : Desmoid tumors appear as soft tissue masses with heterogeneous density. They typically demonstrate areas of both high and low attenuation, reflecting the variable collagen and myxoid content[8].

Fig. 2 Abdomen MRI. A: Axial T1 weighted image fat suppressed, B: Sagittal T1 weighted image fat suppressed, C: Enhanced T1 weighted image fat suppressed arterial phase, D: Axial T2 weighted image, E: Sagittal T2 weighted image, F: T2 weighted image fat suppressed, G: Enhanced T1 weighted image suppressed arterial phase, H: Enhanced T1 weighted image fat suppressed portal venous phase, I: Enhanced T1 weighted image suppressed delayed phase. Ultrasound : On ultrasound, desmoid tumors often appear as hypoechoic masses, though echogenicity

Fig. 1 Non-Contrast CT scan of aAbdomen. A: Axial plane, can vary depending on the collagen content[10]. B: Sagittal plane MRI : MRI is particularly useful in evaluating desmoid tumors. On T1-weighted images, the mass appears hypointense due to the dense collagen content, while T2-weighted images show hyperintensity. After the administration of gadolinium contrast, progressive enhancement is often seen. MRI helps delineate the extent of local invasion and is essential for surgical planning[9].

Fig. 3 Ultrasound image in desmoid tumors In this case, the imaging findings included a mass in the left rectus abdominis muscle with a density of 35 HU on CT, and heterogeneous signal characteristics on MRI with hypointensity on T1 and hyperintensity on T2, along with progressive enhancement following contrast administration.

4 SJMI(2024) 01;1-5

cases where the tumor is symptomatic or growing, surgical resection is the primary treatment. However, The differential diagnosis of a solid abdominal wall complete excision can be challenging due to the mass includes[11]: infiltrative nature of desmoid tumors, and recurrence is common after incomplete removal[6]. Lipoma : A benign fatty tumor that typically appears as a well-circumscribed, hyperechoic mass on For tumors that are difficult to remove surgically or ultrasound and low attenuation on CT. in cases of recurrence, alternative therapies may be considered, including: Endometrioma : A mass that can occur in the abdominal wall, especially in women with a history Nonsteroidal Anti-Inflammatory Drugs (NSAIDS) : of endometriosis, usually appearing as a cystic lesion. Drugs like sulindac may be used to reduce tumor size

7. Differential Diagnosis

Desmoid Tumor : A firm, infiltrative mass with a characteristic imaging pattern. Sarcoma : A malignant tumor that may present as a large, aggressive mass, usually with more heterogeneous and irregular features on imaging.

Schwannoma : A benign nerve sheath tumor, often seen as a well-defined mass with a characteristic "target sign" on imaging. Lymphoma : A malignancy that can present as a soft tissue mass, often with more extensive nodal involvement.

and symptoms.

9. Prognosis

: A selective estrogen receptor modulator Tamoxifen that has shown efficacy in treating desmoid tumors, especially in hormone-sensitive cases. Chemotherapy : Although not routinely used, chemotherapy can be considered for large or inoperable tumors.

Molecular-targeted Therapies : Agents like sorafenib, an oral multikinase inhibitor, may be considered in refractory cases.

Neurofibroma : A benign peripheral nerve tumor that The prognosis of desmoid tumors is variable. While may present similarly but typically shows nerve they are benign and non-metastatic, their locally fascicles on imaging. aggressive behavior and high recurrence rate can lead to significant morbidity. The recurrence rate Metastasis : Although rare, metastatic lesions can following surgical excision ranges from 20% to 68%. present as abdominal wall masses, often with Tumors that are completely excised have a better associated primary malignancy. prognosis, while those with incomplete excision or those located in challenging anatomical areas may require additional treatments, such as radiation or Management of desmoid tumors is tailored to the systemic therapy. In some cases, desmoid tumors tumor’s size, location, symptoms, and patient factors. may stabilize or regress without intervention[5]. In this case, the tumor was diagnosed by biopsy, and treatment options were considered. For asymptomatic or small tumors, observation may be appropriate. In Desmoid tumors of the abdominal wall are rare

8. Treatment

10. Conclusion

SJMI(2024) 01;1-5 5

benign, but locally aggressive lesions that present a [5] Mishra DP, Rout SS. “Desmoid Tumors: A Clear Perspective or a Persisting Enigma? A Case Report unique challenge in diagnosis and treatment. This and Review of Literature”, World J Oncol. 2016 case highlights the importance of imaging studies Feb;7(1):21-27. doi: 10.14740/wjon961w. and biopsy for accurate diagnosis and underscores [6] Kasper B, Ströbel P, Hohenberger P. Desmoid the potential difficulty in managing these tumors due tumors: clinical features and treatment options for to their tendency for local recurrence. Surgical advanced disease. Oncologist. 2011;16(5):682-93. doi: 10.1634/theoncologist.2010-0281. resection remains the treatment of choice, though systemic therapies may be necessary for recurrent or [7] Peng PD, Hyder O, Mavros MN, Turley R, inoperable tumors. Groeschl R, Firoozmand A, Lidsky M, Herman JM, Choti M, Ahuja N, Anders R, Blazer DG 3rd, Gamblin TC, Pawlik TM. Management and Acknowledgments recurrence patterns of desmoids tumors: a multi- institutional analysis of 211 patients. Ann Surg Oncol. We would like to thank the clinical and radiology 2012 Dec;19(13):4036-42. doi: 10.1245/s10434-012- staff for their assistance in this case report, and the 2634-6. patient for providing informed consent for the use of her data in this study. [8] Walker EA, Petscavage JM, Brian PL, Logie CI, Montini KM, Murphey MD. Imaging features of Conflict of Interest superficial and deep fibromatoses in the adult The authors declare that they have no conflicts of population. Sarcoma. 2012;2012:215810. doi: 10.1155/2012/215810. interest.

[9] Simonetti I, Bruno F, Fusco R, Cutolo C, Setola SV, Patrone R, Masciocchi C, Palumbo P, Arrigoni F, Picone C, Belli A, Grassi R, Grassi F, Barile A, Izzo [1] Jiming Zhao, Fajuan Cheng, Zhigang Yao, Bin F, Petrillo A, Granata V. Multimodality Imaging Zheng, Zhihong Niu, Wei He, “Surgical Assessment of Desmoid Tumors: The Great Mime in Management of a Giant Desmoid Fibromatosis of the Era of Multidisciplinary Teams. J Pers Med. 2022 Abdominal Wall with Vessels Invasion in a Young Jul 16;12(7):1153. doi: 10.3390/jpm12071153. Man: A Case Report and Review of the Literature”, Frontiers in Surgery, 11 April 2022, Sec. [10] Li Lou, Jianbo Teng, Hengtao Qi, Yongguang Genitourinary Surgery, Volume 9 – 2022 Ban, “Sonographic Appearances of Desmoid https://doi.org/10.3389/fsurg.2022.851164 Tumors”, Journal of Ultrasound in Medicine, Volume33, Issue8, August 2014, Pages 1519-1525, [2] George H. Sakorafas, Christos Nissotakis, et al, https://doi.org/10.7863/ultra.33.8.1519. “Abdominal desmoid tumors”, Surgical Oncology, Volume 16, Issue 2, August 2007, Pages 131-142, [11] Ballard DH, Mazaheri P, Oppenheimer DC, https://doi.org/10.1016/j.suronc.2007.07.009 Lubner MG, Menias CO, Pickhardt PJ, Middleton WD, Mellnick VM. Imaging of Abdominal Wall [3] Latchford A, Volikos E, Johnson V, Rogers P, Masses, Masslike Lesions, and Diffuse Processes. Suraweera N, Tomlinson I, Phillips R, Silver A. Radiographics. 2020 May-Jun;40(3):684-706. doi: “APC mutations in FAP-associated desmoid tumours 10.1148/rg.2020190170. are non-random but not 'just right'”. Hum Mol Genet. 2007 Jan 1;16(1):78-82. doi: 10.1093/hmg/ddl442.

References

[4] Joglekar SB, Rose PS, Sim F, Okuno S, Petersen I. “Current perspectives on desmoid tumors: the mayo clinic approach”, Cancers (Basel). 2011 Aug 8;3(3):3143-55. doi: 10.3390/cancers3033143.

SJMI(2024) 01;7-11 ISSN : 2635-4608

DOI http://dx.doi.org/10.31916/sjmi2024-01-02 _______________________________________________________________________________________________________

Dual Energy CT Imaging of Hepatocellular Carcinoma Using Lipiodol in Intermediate-Stage Chemotherapy Treatment

Soe Lwin Aye M.D ., Sobirjon Mamarajabov

, V. R. Singh , Hwunjae Lee

M.D., Ph.D.

4,5,6*

M.D., Ph.D

Received: 12 August 2024 / Accepted: 14 October 2024 / Published online: 30 December 2024 The Author(s) 2024 ⓒ

Abstract

This study investigates the role of dual-energy computed tomography (DECT) in differentiating between Lipiodol-induced artifacts and true tumor enhancement during post-TACE surveillance of HCC. We present a case of a 62-year-old female patient with HCC who underwent TACE, followed by DECT imaging for monitoring. DECT imaging revealed a lesion in the liver that appeared to enhance in the arterial phase, raising concerns for tumor recurrence. However, virtual non-contrast (VNC) imaging showed no enhancement, and the iodine map confirmed the presence of residual Lipiodol, rather than active malignancy. This case illustrates the diagnostic challenge of distinguishing between Lipiodol and tumor lesions, particularly when Samarkand State Medical University, 18 Amir Temur residual Lipiodol mimics tumor enhancement. DECT Street, Samarkand, Uzbekistan was critical in identifying residual Lipiodol and distinguishing it from true tumor recurrence. This Director, PDM University, India study highlights the utility of DECT in enhancing Department of Radiology, Yonsei University College of diagnostic accuracy for patients undergoing TACE, Medicine, Seoul 03722, Republic of Korea minimizing unnecessary interventions, and ensuring appropriate follow-up care. By providing detailed YUHS-KRIBB Medical Convergence Research Institute, tissue characterization and iodine mapping, DECT Yonsei University College of Medicine, Seoul 03722, improves differentiation between artifacts and Republic of Korea pathological findings in post-treatment liver imaging, Interdisciplinary Program of Biomedical Engineering, ultimately contributing to better patient management Yonsei University College of Medicine, Seoul 03722, and outcomes. Republic of Korea

Hepatocellular carcinoma (HCC) is the most prevalent form of primary liver cancer, with transarterial chemoembolization (TACE) being a standard treatment for intermediate-stage disease. During TACE, Lipiodol, an iodine-based contrast agent, serves as both a drug carrier and an imaging agent. However, residual Lipiodol can create artifacts on follow-up imaging, potentially mimicking tumor enhancement and complicating diagnostic interpretations. ___________________________________________

Mohawk Valley Health System, 111 Hospital drive, Utica, New York 13502, United States

*Corresponding author ( )

Keywords: Hepatocellular carcinoma, Transarterial chemoembolization, Residual Lipiodol., Dual-energy CT

8 SJMI(2024) 01;7-11

technology, providing enhanced tissue differentiation by using two different X-ray energy levels. DECT allows for the generation of iodine maps and virtual Hepatocellular carcinoma (HCC) is the most non-contrast (VNC) images, which are especially common primary malignancy of the liver, responsible useful for distinguishing between residual Lipiodol for approximately 75-85% of all primary liver and tumor lesions[6]. This study explores the role of cancers worldwide[1]. It is a leading cause of cancer- DECT in improving diagnostic accuracy in post- related morbidity and mortality, particularly in TACE surveillance for HCC. regions with high rates of chronic liver disease, such as Asia and sub-Saharan Africa[2]. Among various treatment options, transarterial chemoembolization A 62-year-old female with a history of HCC in the (TACE) is widely used for patients with right liver lobe was treated with TACE. She had been intermediate-stage HCC, offering a minimally diagnosed with intermediate-stage HCC and invasive approach to control tumor growth by underwent a successful TACE procedure several delivering chemotherapeutic agents directly to the months prior, during which Lipiodol was used as a tumor while simultaneously embolizing its blood contrast agent to embolize the tumor’s vasculature. supply[3]. Following treatment, routine follow-up imaging, Lipiodol, an iodine-based contrast agent, plays a including DECT, was performed to assess the status pivotal role in TACE by providing excellent contrast of the liver lesions and evaluate for potential for tumor visualization during and after the recurrence. procedure, acting as both a drug carrier and an DECT imaging revealed a suspicious lesion in imaging agent[4]. However, a significant challenge segment 4 of the liver that exhibited significant in post-TACE surveillance is differentiating between enhancement in the arterial phase, raising concerns residual Lipiodol and true disease recurrence on about tumor recurrence. This lesion demonstrated the follow-up imaging[4]. Due to its high iodine content, typical imaging features of an HCC lesion, known Lipiodol enhances tumor lesions during TACE, but it for its hypervascularity. However, virtual non- also remains in the liver for extended periods, contrast (VNC) images showed no enhancement, potentially creating imaging artifacts[5]. These suggesting that the apparent enhancement was not artifacts can mimic enhancing lesions on follow-up related to active disease. scans, making it difficult to distinguish between viable tumor tissue and residual Lipiodol[5]. Conventional imaging methods, such as computed tomography (CT) and magnetic resonance imaging (MRI), may lack the sensitivity to differentiate between Lipiodol-induced artifacts and true tumor recurrence, resulting in potential misdiagnoses[5].

1. Introduction

2. Case Report

Fig. 1 Dual Energy CT image. A: A suspected lesion in the liver 4th area was shown to be enhanced in the arterial

Dual-energy computed tomography (DECT) represents a significant advancement in imaging phase, raising concerns about tumor recurrence. B: No enhancement of the lesion was confirmed in the virtual

SJMI(2024)01;7-11 9

non-contrast (VNC) image.

These findings suggested that the enhancement observed in the arterial phase was due to residual Lipiodol and not to tumor recurrence. The lesion remained stable on follow-up imaging, and the patient did not exhibit any clinical signs of recurrence. The DECT analysis effectively identified residual Lipiodol and prevented unnecessary intervention, ensuring accurate management.

3. Imaging Findings

In the arterial phase, the lesion in segment 4 of the liver showed significant enhancement, raising suspicion for tumor recurrence. This enhancement was consistent with hypervascular tumors such as HCC. However, when VNC images were generated

imaging for extended periods, making it identifiable through DECT. In the non-contrast CT phase, the lesion appeared unchanged, which further supported the hypothesis that the enhancement was due to residual contrast material rather than tumor activity.

Fig. 3 Non-contrast CT, the lesion appeared unchanged, no enhancement was observed, indicating that the further suggesting that the enhancement was due to residual contrast material rather than tumor activity. apparent enhancement in the arterial phase was not due to active tumor tissue. No enhancement was seen in the venous phase, which would typically be expected in the presence of a true tumor recurrence. These findings confirm that the apparent lesion enhancement in the arterial phase was caused by residual Lipiodol, highlighting the diagnostic value of DECT in distinguishing between Lipiodol artifacts and true tumor recurrence.

4. Discussion 4.1. Role of Lipiodol in TACE for HCC

Lipiodol is a crucial component in the management of HCC, particularly for patients undergoing TACE.

Fig. 2 DECT findings. A : In the early arterial phase, the lesion in the 4th liver area showed strong enhancement, As an iodine-based contrast agent, Lipiodol aids in which was a finding suggesting HCC recurrence. B: After visualizing the tumor vasculature, facilitating the generating the VNC image, we confirmed that there was no enhancement of the lesion, indicating that the enhancement embolization of blood vessels feeding the tumor. Its seen in the arterial phase was not due to actual tumor tissue. ability to enhance HCC lesions makes it an Further analysis using the iodine map revealed areas invaluable tool, especially for hypervascular tumors of residual Lipiodol in the treated lesion. Lipiodol, like HCC. However, a significant limitation is the known for its high iodine content, remains visible on prolonged retention of Lipiodol within the liver

10 SJMI(2024) 01;7-11

which can lead to imaging artifacts that may mimic patients with a history of TACE, where the risk of enhancing lesions, complicating the interpretation of misdiagnosing Lipiodol artifacts as tumor recurrence is high. Additionally, DECT provides detailed follow-up scans[7]. information about tumor vascularity, which can 4.2. Challenges in Diagnosing HCC inform treatment decisions in cases requiring further Recurrence Post-TACE intervention[10]. Post-treatment surveillance is essential for monitoring tumor recurrence and assessing the efficacy of TACE. However, differentiating between This case demonstrates the value of dual-energy CT enhancing lesions caused by residual Lipiodol and (DECT) in differentiating between residual Lipiodol true tumor recurrence can be challenging. and true enhancing lesions in post-TACE Conventional CT and MRI may lack sufficient surveillance for hepatocellular carcinoma (HCC). sensitivity to accurately distinguish between Lipiodol, although essential for TACE success, can Lipiodol-induced artifacts and actual tumor cause diagnostic challenges by mimicking enhancing recurrence, potentially leading to false positives and lesions on follow-up imaging. DECT’s ability to unnecessary interventions[8]. generate iodine maps and virtual non-contrast images is crucial for distinguishing between Lipiodol- 4.3. Role of Dual-Energy CT in Post-TACE Surveillance induced artifacts and actual tumor recurrence. This case highlights the potential of DECT to improve DECT represents a significant improvement in diagnostic accuracy, reduce the risk of misdiagnosis, imaging technology, offering enhanced tissue and prevent unnecessary interventions. The characterization through the use of two distinct X-ray application of DECT in HCC surveillance represents energy levels. DECT allows for the generation of a promising advancement in imaging technology, iodine maps and VNC images, which are particularly contributing to better patient management and more useful in distinguishing between areas of residual effective follow-up care. Lipiodol and active tumor lesions. In the presented case, DECT was instrumental in differentiating Acknowledgments Lipiodol artifacts from viable tumor tissue, We would like to thank the clinical and radiology significantly improving diagnostic accuracy staff for their assistance in this case report, and the compared to conventional imaging methods[9]. patient for providing informed consent for the use of her data in this study. 4.4. Clinical Implications of DECT in HCC Surveillance Conflict of Interest

5. Conclusion

The use of DECT in post-TACE surveillance for The authors declare that they have no conflicts of interest. HCC offers several clinical advantages. DECT accurately differentiates between residual Lipiodol and true tumor recurrence, helping prevent [1] Rawla P, Sunkara T, Muralidharan P, Raj JP. unnecessary treatments and enabling clinicians to “Update in global trends and aetiology of make more informed decisions about patient hepatocellular carcinoma”, Contemp Oncol (Pozn). management. This is particularly important for

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2018;22(3):141-150. doi: 10.5114/wo.2018.78941. 3;7(4):249-260. doi: 10.1002/jgh3.12879.. [2] Yang JD, Hainaut P, Gores GJ, Amadou A, [9] Borges AP, Antunes C, Caseiro-Alves F. “Spectral Plymoth A, Roberts LR. “A global view of CT: Current Liver Applications. Diagnostics”, hepatocellular carcinoma: trends, risk, prevention (Basel), 2023 May 9;13(10):1673. doi: and management”, Nat Rev Gastroenterol Hepatol. 10.3390/diagnostics13101673. 2019 Oct;16(10):589-604. doi: 10.1038/s41575-019- [10] Yamane A, Yasui D, Itoh H, Kobayashi M, 0186-y. Kumita SI. “An experimental study on the diagnostic [3] Yuri Cho, Jin Woo Choi, Hoon Kwon, Kun Yung advantage of dual-energy computed tomography over Kim, Byung Chan Lee, et al, “Transarterial single-energy scan to evaluate the treatment effect chemoembolization for hepatocellular carcinoma: following transcatheter arterial chemoembolization”, 2023 expert consensus-based practical PLOS One. 2024 Nov 12;19(11):e0313543. doi: recommendations of the Korean Liver Cancer 10.1371/journal.pone.0313543. Association”, Journal of Liver Cancer, 2023, 23(2), pp. 241-261. doi: 10.17998/jlc.2023.05.22

[4] Letzen BS, Malpani R, Miszczuk M, de Ruiter QMB, Petty CW, Rexha I, Nezami N, Laage-Gaupp F, Lin M, Schlachter TR, Chapiro J. “Lipiodol as an intra-procedural imaging biomarker for liver tumor response to transarterial chemoembolization: Post- hoc analysis of a prospective clinical trial”, Clin Imaging. 2021 Oct;78:194-200. doi: 10.1016/j.clinimag.2021.05.007. [5] Parakh A, Lennartz S, An C, Rajiah P, Yeh BM, Simeone FJ, Sahani DV, Kambadakone AR. “Dual- Energy CT Images: Pearls and Pitfalls”, Radiographics. 2021 Jan-Feb;41(1):98-119. doi: 10.1148/rg.2021200102.

[6] Foti G, Ascenti G, Agostini A, Longo C, Lombardo F, Inno A, Modena A, Gori S. “Dual- Energy CT in Oncologic Imaging. Tomography”, 2024, Vol. 10, No. 3, PP:299-319. doi: 10.3390/tomography10030024. [7] Idée JM, Guiu B. “Use of Lipiodol as a drug- delivery system for transcatheter arterial chemoembolization of hepatocellular carcinoma: a review”, Crit Rev Oncol Hematol. 2013 Dec;88(3):530-49.

doi: 10.1016/j.critrevonc.2013.07.003. Epub 2013 Aug 6. PMID: 23921081. [8] Cox DRA, Chung W, Grace J, Wong D, Kutaiba N, Ranatunga D, Khor R, Perini MV, Fink M, Jones R, Goodwin M, Dobrovic A, Testro A, Muralidharan V. “Evaluating treatment response following locoregional therapy for hepatocellular carcinoma: A review of the available serological and radiological tools for assessment”, JGH Open. 2023 Apr

SJMI(2024) 01;13-18 ISSN : 2635-4608

DOI http://dx.doi.org/10.31916/sjmi2024-01-03 _________________________________________________________________________________________________________

Personal Data Protection Issues in the Era of Artificial Intelligence

Researcher: Giljae Lee, Ph.D.

Received: 16 October 2024 / Accepted: 6 December 2024 / Published online: 30 December 2024 The Author(s) 2024 ⓒ

Abstract

This paper discusses the challenges associated with personal data protection in the era of artificial intelligence (AI). While AI technologies enable personalized services by collecting and analyzing large amounts of data, concerns regarding privacy and data protection are growing. The methods AI systems use to process data are often opaque, which poses a potential risk to individual rights and freedoms. Therefore, exploring data protection measures suitable for the AI era is crucial. Personal data protection is essential to comply with legal requirements and maintain individual privacy and trust. In the digital era, personal data is used in various ways, leading to issues such as data breaches, misuse, and discriminatory algorithms. These problems can erode trust and negatively affect innovation and economic growth. Strengthening personal data protection has thus become a socially important task. As AI technologies advance, existing

1. Introduction

To address these issues, companies must establish clear data protection policies, policymakers to develop flexible regulations, and engineers to adopt principles that consider personal data protection in system design. These efforts will help reinforce personal data protection and enhance the reliability of AI systems. In conclusion, for AI technologies to respect privacy and have a positive societal impact, a trust-based data protection framework is necessary. Companies and governments must cooperate to strengthen data protection and build societal trust.

Keyword: Personal data, Information protection, Artificial intelligence era, Personal data protection, Personal information protection issue

The rapid advancement of artificial intelligence (AI) data protection laws are proving insufficient to technologies is transforming our daily lives, but it address new challenges. Regulations such as the has also raised concerns regarding personal data European General Data Protection Regulation protection. AI is a powerful tool that collects and (GDPR) and the California Consumer Privacy Act (CCPA) have been enacted to strengthen personal analyzes vast amounts of data to offer personalized data protection, but they face limitations in keeping services, but there is often a lack of clear up with the complexities of AI technology. The understanding about how personal data is used in the complexity of AI algorithms makes it difficult to process. Particularly, the way AI systems process ensure transparency in data collection and processing, hindering trust in the use of personal data. personal data is often opaque, posing potential risks ___________________________________________ to individuals' rights and freedoms[1]. Personal data Information Security Management Team, National protection goes beyond merely meeting legal Research Foundation of Korea requirements; it is essential for maintaining individual privacy and societal stability[2]. However, *Corresponding author ( ) current data protection laws are struggling to keep up

14 SJMI(2024) 01;13-18

with the rapid pace of AI advancements, leading to individuals from engaging with digital services, problems such as data breaches, misuse, and ultimately stalling innovation and economic growth. discriminatory algorithms[3]. Therefore, finding If users perceive their data as unsafe, they may appropriate personal data protection measures for the restrict their online activities, hindering the AI era has become an urgent issue. This paper development of new technologies and services that analyzes the impact of AI on personal data and the rely on data-driven insights. The European Union’s various problems that arise from it, proposing privacy policies, particularly the General Data effective data protection strategies. By doing so, it Protection Regulation (GDPR) enacted in 2018, are aims to lay the groundwork for protecting individual among the most stringent and comprehensive in the rights while enabling AI technologies to contribute world. The GDPR ensures the protection of personal data and requires high levels of transparency, positively to society. accountability, and trust in how companies handle personal information. This regulation applies not only to companies operating within the EU but also to any company processing the personal data of EU In today’s digital era, personal data protection is an citizens[4]. Moreover, the legal landscape important issue affecting individuals, organizations, surrounding personal data protection is evolving and society as a whole[4]. As technology advances rapidly. Data protection laws across regions, such as and the volume of data generated increases the GDPR and other local regulations, emphasize exponentially, the importance of safeguarding transparency, accountability, and the importance of personal information cannot be overstated[4]. user consent. Organizations are now required to Personal data protection is essential for maintaining implement strong data protection measures and privacy and building trust between users and service inform individuals about their rights concerning their providers. The core of personal data protection is data. Failure to comply can result in substantial fines privacy rights. Individuals have the fundamental and reputational damage[4]. Therefore, personal data right to control how their personal information is protection is more than just a legal obligation; it is collected, used, and shared. When these rights are critical to maintaining privacy and trust in the digital violated, it can lead to negative outcomes such as world. With ongoing risks posed by data breaches identity theft, financial loss, and emotional distress. and misuse of personal information, individuals, Data breaches, which involve unauthorized access to organizations, and policymakers must prioritize data sensitive information, are becoming increasingly protection efforts. By fostering a culture of respect common. High-profile incidents involving major for personal data, society can create a safer and more corporations highlight the vulnerabilities in data trustworthy digital environment, benefiting all security systems and the potential consequences of stakeholders. such breaches[5]. The misuse of personal information can also have widespread effects. For instance, when data collected for one purpose is repurposed without the individual’s consent, it can To address personal data protection issues in the AI lead to targeted advertising, discrimination, or even era, it is important to examine existing regulations surveillance. Such erosion of trust may deter such as the General Data Protection Regulation

2. The Importance of Personal Data Protection

3. An Overview of Existing Regulations

SJMI(2024) 01;13-18 15

(GDPR)[3]and the California Consumer Privacy Act stricter standards to address issues like algorithmic bias and data confidentiality in AI systems. The (CCPA) [7]. GDPR and CCPA play a crucial role in preventing AI technologies from infringing on privacy, and they provide ethical guidelines that companies must follow when utilizing AI[9]. In the Republic of Korea, the issue of personal data protection in the AI era is becoming increasingly significant. As AI technology advances, vast amounts of personal data are being collected and analyzed, raising concerns about Fig. 1. The European Union's General Data Protection privacy and information security. In particular, the Regulation (GDPR), adopted in April 2016, came into effect on May 25, 2018[3]. use of personal data by businesses and governments to offer personalized services or policies increases The GDPR, which was enacted in 2018, sets strict the risk of data breaches and misuse[10]. While the standards for personal data processing within the EU, Republic of Korea has strengthened personal guaranteeing the rights of data subjects and clarifying information protection through its Personal the responsibilities of data processors. The regulation Information Protection Act, legal regulations lag also establishes notification obligations in case of behind the rapid development of AI technology. data breaches[8]. On the other hand, the CCPA, Furthermore, the lack of clear standards for data which came into effect in January 2020, grants collection and usage has led to instances where data California residents rights over their data and is used without individuals' consent[10]. demands transparency from businesses about how they collect and use consumer data. The CCPA ensures that consumers can access and delete their data and provides them with the option to opt out of data sales[7].

Fig. 3. The Personal Information Protection Act of the Republic of Korea has been revised from March 15, 2024. https://www.private-ai.com/en/2024/03/18/south-korea- pipa/

Therefore, a new legal framework and technological solutions are needed for the AI era. Efforts must be

Fig. 2. The CCPA principles safeguard privacy and empower consumers. They establish accountability and made to increase transparency in data collection and promote responsible data handling[7]. usage, while continually working to protect Both regulations aim to address the impact of AI on individuals’ rights. By doing so, it is essential to personal data, incorporating efforts to tackle new create an environment in which AI technologies challenges brought on by AI advancements. For respect privacy and drive innovation. example, regulatory bodies are now demanding

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4. Ethical Considerations in AI and Data Privacy

The development of AI technologies has made ethical considerations in data processing even more important. This section explores the ethical implications of AI, focusing on issues such as consent, transparency, and accountability. It is essential to obtain the data subject's consent when processing personal data through AI systems. However, due to the complexity and opacity of AI, users often find it difficult to understand how their data is being used. This lack of understanding can infringe upon the rights of data subjects, and businesses must provide clear, easily understandable information to address these issues[11]. Additionally, organizations using AI must recognize the ethical responsibility associated with data processing. If an AI system makes incorrect decisions or produces biased outcomes, the question arises: who is accountable? These ethical issues are becoming central to the use of AI technologies. Companies must ensure that data collected through AI is securely managed, the rights of data subjects are respected, and transparent data processing policies are established[12]. Thus, personal data protection in the AI era involves more than just legal compliance; it is essential for building ethical responsibility and societal trust. Companies and regulators must collaborate to ensure that AI technologies respect and protect individuals' privacy.

5. Challenges in Implementing Data Protection Measures

There are several key challenges in implementing data protection measures in AI systems. First, algorithms are complex. AI systems often operate based on intricate algorithms, and when these algorithms are opaque, it becomes difficult to

7. Conclusion

effectively apply data protection measures. Second, there is a lack of transparency. Many AI systems function as "black boxes," offering no clear understanding of how data is collected and processed. This makes it hard to establish trust in the use of personal data. Third, there are challenges related to regulatory compliance. With differing data protection laws across countries, ensuring that AI systems comply with these regulations is a complex task. These challenges act as significant obstacles to implementing effective data protection measures[13].

6. Potential Solutions and Best Practices

This section suggests potential solutions and best practices for strengthening personal data protection in the AI era. First, organizations should establish clear policies for data processing and privacy protection and adhere to them. This can enhance transparency in the collection, storage, and processing of data. Second, policymakers should develop flexible and appropriate regulations that keep pace with technological advancements, strengthening data protection without stifling innovation. Third, engineers should adopt design principles that consider data protection, integrating privacy safeguards into AI systems from the outset. These practices will contribute to strengthening data protection and improving the reliability of AI systems[14].

This paper discussed the impact of AI technologies on personal data protection and proposed solutions to address the associated challenges. While AI enables personalized services by collecting and analyzing vast amounts of data, privacy and data protection concerns are becoming more pronounced. Specifically, the opaque nature of AI data processing

SJMI(2024) 01;13-18 17

poses a risk to individual rights and freedoms, consensus and ethical responsibility. affecting trust and societal stability. Existing legal regulations are struggling to keep pace with the rapid development of AI, highlighting the need for new [1] J. Curzon, T. A. Kosa, R. Akalu and K. El-Khatib, "Privacy and Artificial Intelligence," in IEEE solutions to prevent issues such as data breaches and , vol. 2, no. 2, Transactions on Artificial Intelligence misuse. Personal data protection is essential to meet pp. 96-108, April 2021, doi:10.1109/TAI.2021.3088084. legal requirements and maintain individual rights and [2] Chatsuwan P, Phromma T, Surasvadi N, societal trust. Although various legal regulations Thajchayapong S. Personal data protection address AI-related data issues, the regulatory compliance assessment: A privacy policy scoring frameworks across countries are inconsistent, and approach and empirical evidence from Thailand's SMES. Heliyon. 2023 Oct 17;9(10):e20648. doi: practical enforcement remains challenging. 10.1016/j.heliyon.2023.e20648. PMID: 37886776; Furthermore, challenges such as algorithm PMCID: PMC10597812. complexity, lack of transparency, and regulatory [3] https://www.europarl.europa.eu/RegData/etudes/ compliance difficulties are major obstacles in STUD/2020/641530/EPRS_STU(2020)641530_EN. effectively implementing data protection measures in pdf AI systems. Therefore, data protection measures [4] https://worldlawyersforum.org/ suitable for the AI era must go beyond technological solutions and include ethical considerations and [5] https://www.edps.europa.eu/data-protection/data- social responsibility. Companies and governments protection_en should work together to approach personal data [6] Zlatan Mori ć , Vedran Dakic, Daniela Djekic, protection from the design stage of AI systems. For Damir Regvart, “Protection of Personal Data in the instance, improving algorithm transparency and Context of E-Commerce”, J. Cybersecur. 2024, 4 (3), 731-761; doi:10.3390/jcp4030034 Priv. ensuring users understand how their data is processed will help address potential bias issues. Additionally, [7] https://home.bigid.com/demo flexible regulations must be established to keep up [8] https://www.cigionline.org/about/ with AI advancements, and the importance of privacy [9] https://www.zendata.dev/post/privacy- protection should be consistently emphasized. observability-data-context-ai-models Ultimately, the key to ensuring that AI technologies [10] respect privacy while driving innovation lies in https://www.pipc.go.kr/eng/user/itc/itc/greetings.do building a trust-based data protection framework. Companies must establish and strictly adhere to [11] Nagadivya Balasubramaniam, Marjo Kauppinen, Antti Rannisto, Kari Hiekkanen, Sari Kujala, transparent data processing policies, and “Transparency and explainability of AI systems: governments must integrate AI technologies with From ethical guidelines to requirements”, data protection laws. This will help create an Information and Software Technology, Vol.159, 2023, 107197,ISSN 0950-5849, doi: environment in which AI has a positive impact on 10.1016/j.infsof.2023.107197.. society while protecting individual rights. The issue of personal data protection in the AI era cannot be [12] Chen, Z. Ethics and discrimination in artificial intelligence-enabled recruitment practices. Humanit solved solely through technical solutions but requires 10, 567 (2023). Soc Sci Commun ongoing collaboration underpinned by social https://doi.org/10.1057/s41599-023-02079-x

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[13] Waddah Saeed, Christian Omlin, “Explainable AI (XAI): A systematic meta-survey of current challenges and future opportunities”, Knowledge- Based Systems, Vol. 263, 2023, 110273, ISSN 0950- 7051, doi: 10.1016/j.knosys.2023.110273.

[14] Xiongbiao Ye, Yuhong Yan, Jia Li, Bo Jiang, “Privacy and personal data risk governance for generative artificial intelligence: A Chinese perspective”, Telecommunications Policy, Vol. 48, Issue 10, 2024, 102851, ISSN 0308-5961, doi: 10.1016/j.telpol.2024.102851.

SJMI(2024) 01;19-27 ISSN : 2635-4608 DOI http://dx.doi.org/10.31916/sjmi2024-01-04 _________________________________________________________________________________________________________

The Role of Molecular Imaging in Predictive Medicine: A Review

1+

2+

Gippem Park MD , Muzaffar Annaev MD , Juyeon Kim Ph.D , Gyehwan Jin Ph.D *

Received: 4 July 2024 / Accepted: 26 September 2024 / Published online: 30 December 2024 The Author(s) 2024 ⓒ

Despite challenges such as high costs and the need for specialized expertise, the integration of molecular

Molecular imaging is emerging as a cornerstone of predictive medicine, offering imaging into clinical practice promises to advanced diagnostic capabilities that enable early revolutionize healthcare by enabling timely, detection, risk assessment, and personalized personalized care and potentially reducing long-term treatment strategies for a range of diseases. Unlike healthcare costs. The future of predictive medicine traditional imaging methods that focus on anatomical lies in further advancements in molecular imaging structures, molecular imaging visualizes biochemical technologies, making them integral to the prevention, and molecular changes, providing a detailed view of early detection, and management of diseases. disease mechanisms in real time. This review explores the critical role of molecular imaging in Key word: Molecular imaging, predictive medicine, oncology, cardiology, and neurology, highlighting its identifying biomarkers, genetic predispositions, potential for identifying biomarkers indicative of Molecular imaging modality disease risk, including genetic predispositions. By combining molecular imaging with genomic data and other predictive tools, clinicians can more effectively Predictive medicine represents a paradigm shift in stratify risks and tailor preventive interventions. ___________________________________________ healthcare, aiming not only to treat diseases after

1. Introduction

their onset but also to predict and prevent diseases Samarkand State Medical University, Department of Internal Medicine, 18 Amir Temur Street, Samarkand, before they manifest[1]. In this context, molecular Uzbekistan imaging is becoming increasingly important for the

Kimyo International University in Tashkent, School of early detection, monitoring, and personalized Medicine, 3, M.Ulugbek Street, Tashkent 100077, treatment of various diseases, particularly in Uzbekistan oncology, cardiology, and neurology. Molecular Korea Basic Science Institute, Gwahak-ro, Yuseong-gu, imaging employs advanced imaging technologies to Daejeon, 34133, Republic of Korea visualize molecular and cellular processes in vivo[2]. Nambu University, Department of Radiology, 91, By providing a detailed and real-time view of disease Nambudae-ro, Gwangsan-gu, Gwangju 62211, Republic of Korea. processes at the molecular level, molecular imaging enables more accurate diagnoses, improved + First Author, * Corresponding author ( ) monitoring of disease progression, and enhanced

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treatment planning[2]. This review discusses the Predictive medicine focuses on identifying critical role of molecular imaging in predictive individuals at high risk for specific diseases to medicine, exploring its applications in identifying prevent or delay the onset of those diseases. The individuals at risk for specific diseases, the current foundation of predictive medicine lies in the research landscape, and the prospects for integrating identification of biomarkers that may indicate the these technologies into clinical practice.

2. The Role of Molecular Imaging in Predictive Medicine

presence or risk of disease [6].

Molecular imaging allows for the visualization of molecular and cellular functions within organisms. Unlike traditional imaging methods that primarily focus on anatomical structures, molecular imaging technologies can reveal changes at the biochemical or molecular level, providing valuable insights into disease mechanisms and progression[3]. This ability to identify and monitor diseases at a fundamental level holds tremendous potential for predictive Figure 1 Schematic of the liquid biopsy composition. Liquid biopsy obtained from peripheral blood is composed medicine. It not only enables the early detection of of different tumoral components such as circulating tumor diseases before they become clinically apparent but cells (CTCS), circulating cell-free DNA (CFDNA), extracellular vesicles (EVS), and micro-RNA (MIRNA). also provides essential data for predicting disease These elements can be isolated for the identification of progression and tailoring personalized treatment various tumor-specific genomic aberrations including point mutations, copy number variations, structural strategies[4]. rearrangements, or epigenetic patterns[6]. In predictive medicine, molecular imaging can be These biomarkers can be genetic, proteomic, or utilized to identify biomarkers—specific molecules metabolic, and their detection often necessitates that indicate the presence or risk of disease. For advanced diagnostic techniques [6]. instance, in cancer, molecular imaging can detect tumor-specific biomarkers at early stages, long before the tumor grows large enough to be identified by conventional imaging techniques such as CT or MRI scans. By identifying these biomarkers early, clinicians can intervene much sooner, improving patient outcomes and potentially preventing the onset of disease altogether[5].

3. Recent Research on Molecular Imaging in Predictive Medicine

3.1. Predictive Medicine

Figure 2 Summary of the DDPCR alterations screening process. The purified CFDNA is divided into thousands of oil droplets together with specific primers and probes. The DDPCR currently has several applications such as cancer

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diagnosis, prognosis, personalized treatment administration, genomic alterations present in circulating tumour DNA[9]. and disease monitoring[6]. . Molecular imaging stands as one of the most Molecular imaging encompasses several techniques, powerful tools in predictive medicine, facilitating the including positron emission tomography (PET), noninvasive detection of these biomarkers within single photon emission computed tomography organisms, thereby enabling early diagnosis and risk (SPECT), magnetic resonance imaging (MRI), and assessment [7]. optical imaging. These techniques employ specific tracers or contrast agents designed to interact with particular molecular targets in the body to visualize disease processes [10].

Figure 3 Spontaneously grown breast tumors in MMTV mice over express CCND1 oncogene MRNA. Tumors (arrow) were detectable by PET imaging with Cu-64 labeled CCND1 specific probe. (These tumors were not imaged with F-18-FDG)[8].

Recent advancements in genomic medicine, which can identify genetic predispositions to various diseases, have further underscored the importance of

3.2. Molecular Imaging

Figure 5. Contrast agents used for molecular imaging are composed of at least 2 entities: one component such as an integrating molecular imaging with other predictive antibody, peptide, nucleic acid, or a small molecule for binding to the molecular target, and a label for readout by techniques. By combining genetic information with an imaging modality. More sophisticated contrast agents molecular imaging data, clinicians can achieve a can include multiple parts for targeting several molecules at once, as well as, several labels for multimodality more comprehensive understanding of an imaging. Drugs can also be attached/encapsulated for individual’s disease risk and tailor preventive targeted therapy[11]. strategies accordingly [9]. Among the various molecular imaging modalities, PET and SPECT are the most widely utilized for detecting metabolic and molecular changes in tissues [12]. For instance, PET employs radioactive tracers such as fluorodeoxyglucose (FDG) to evaluate cellular glucose metabolism, a common marker for various cancers[12].

Figure 4. Liquid biopsy assays enable the monitoring of

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Radionuclides C

Energy (keV) 511

T

T

Table 1. Most common used PET radioisotopes.

N O F

20.39 m 9.97 m 2.04 m 109.77 m 13 h 67.63 m 1.27 m 27 h

Table 2. Most common used SPECT radioisotopes.

67 99m

Radionuclides Ga Cu Tc In I Sm Gd Ho Lu

Energy (keV) 93 185 140 245 159 103 363 80 208

3.26 d 3 d 6.06 h 2.83 d 13.2 h 47 h 20 h 26 h 7 d

Cu Ga Rb Ho

detection of disease and for monitoring disease progression in real time [14].

Figure 6. The F-FDDNP-PET, MRI, and FDG-PET images for a representative AD patient (the top row) and an HC (the bottom row). The F-FDDNP images were acquired by summing frames 12-14, corresponding to 25- 54 minutes post- F-FDDNP injection. The FDG images were obtained by summing frames corresponding to 20-60 Figure 7. Mechanism of action for lymphotropic minutes post-FDG administration. The arrows display that superparamagnetic nanoparticles, one of the first clinically brain areas with FDG low glucose metabolism are matched used cellular MR contrast agents. Systemically injected with the localization of NFTS and Aps resulting from F- particles gain access to the interstitium and are drained FDDNP binding. Reproduced with the permission from ref. through lymphatic vessels. In a normal lymph node, iron (14). PET, positron emission tomography; MRI, magnetic oxide nanoparticles are taken up by phagocytic cells, which resonance imaging; AD, Alzheimer’s disease; HC, healthy cause the lymph node to become dark on T2-weighted control; NFTS, neurofibrillary tangles; Aps, β -amyloid images due to susceptibility artifacts from iron. If a lymph plaques[13]. node is partially or fully replaced by metastatic cells, fewer nanoparticles are retained in the lymph node, which Similarly, MRI can provide insights into tissue therefore remains bright on T2-weighted images[14]. properties and molecular interactions at the cellular level using molecularly targeted contrast agents. These imaging modalities are crucial for the early

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Figure 9. An improved knowledge of how a person’s Figure 8. Chemical structure of activatable MR molecular particular molecular and genetic profile renders them prone probe (left) and mechanism of action (right). The probe, to various diseases has resulted from scientific gadolinium-5-hydroxytryptamide–diethylene triamine developments in customized medicine. The assessment of pentaacetic acid (Gd- bis -5-HT-DTPA) has a relatively low disease heterogeneity and progression planning, treatment, relaxivity (low visibility on MR images) in its native state molecular features, and long-term follow-up are all (blue spheres). When the probe reaches an environment common uses for molecular imaging techniques. The rich in myeloperoxidase (MPO) , an enzyme secreted by following illustration presents the key findings of this white blood cells in inflammation, its monomers undergo review[17] . rapid condensation into paramagnetic oligomers (purple spheres), leading to an increase in atomic relaxivity. This In cardiology, molecular imaging has made change in relaxivity is due to modulation of the rotational significant advancements in predicting correlation time τ . Likewise, the relaxivity and therefore the MR signal increase even further when the probe binds cardiovascular disease. By imaging specific to proteins[14]. molecules involved in inflammation or plaque accumulation in the arteries, individuals at risk for heart attacks or strokes can be identified. This The integration of molecular imaging and predictive predictive capability can facilitate early intervention, medicine presents the potential to develop targeted including lifestyle modifications, medications, or prevention strategies and personalized treatments other preventive measures, which can substantially [15]. For example, in oncology, molecular imaging is reduce the risk of serious cardiovascular events [18]. employed not only to detect tumors at an early stage but also to identify individuals at risk of developing cancer due to genetic predisposition or environmental factors. By visualizing molecular changes associated with cancer, such as the overexpression of specific receptors, molecular imaging can assist in determining the likelihood of disease development before it becomes clinically apparent [16].

r

3.3. Integrated Approach

Figure 10. Imaging of activated myofibroblasts after myocardial infarction in rats using the fibroblast activation protein (FAP) targeted Ga-FAPI-04. At 6 days after

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coronary artery occlusion, FAPI PET signal is increased in the infarct and border zone territory defined by reduced 18F-FDG uptake (upper panel, left) and confirmed ex vivo by PET/MR (upper panel, right). High-resolution autoradiography and adjacent hematoxylin and eosin (H&E) histology localized the strongest FAPI signal to the border zone surrounding the center of the infarct (lower panel) [19].

Neurological diseases, such as Alzheimer's disease Figure 12. Not only can molecular imaging using PET help show the pathologic hallmarks of Alzheimer disease and and Parkinson's disease, also benefit from molecular assess loss of dopaminergic terminals in parkinsonian imaging [20]. For instance, in Alzheimer's disease, disorders, but the development of novel tracers for neuroinflammation and synaptic density further allows for molecular imaging can detect amyloid plaque elucidation of the molecular pathologic characteristics of accumulation in the brain, a hallmark of the disease, dementia disorders[20]. years before clinical symptoms manifest. Early Moreover, utilizing molecular imaging in detection of these molecular changes can enable conjunction with other predictive tools, such as timely treatment initiation, potentially slowing genetic testing and lifestyle assessments, can enhance disease progression or even preventing its onset in accuracy and predictive power [21]. The combination genetically predisposed individuals [20] of molecular imaging with other diagnostic techniques can facilitate more precise risk stratification and the development of personalized prevention and treatment plans for patients [21].

Table 3. Advantages and disadvantages of different diagnostic methods for Non-small cell lung cancer[22]. Diagnostic Method

MRI

PET

CT

Advantages

No ionizing radiation exposure

Detailed imaging of soft tissues Lower sensitivity for detecting small lesions

Detects metabolic and molecular changes

High sensitivity for detecting metastasis Potential for false positives due to FDG accumulation

Widely available and rapid access Exposes the patient to ionizing radiation

High spatial resolution and early tumor Potential for false positives due to benign detection

Disadvantages

Limited availability and restricted access

Higher cost and limited availability

lesions

FISH Biomarkers Provides genetic information about Requires specialized laboratory analysis

25SJMI(2024) 01;19-27 25

Diagnostic Method

Advantages

specific cancer subtypes

Disadvantages

PCR Biomarkers Provides genetic information about Requires specialized laboratory analysis specific cancer subtypes

IHC Biomarkers

Next Generation Sequencing Biomarkers

Liquid Biopsy

Tissue Biopsy

Provides protein expression

Requires specialized personnel and information, Helps differentiate cancer equipment, results may vary depending on subtypes

Provides comprehensive genetic information

Non-invasive and lower risk for the Lower sensitivity compared to tissue biopsy patient

Enables monitoring of genetic changes Potential for false negatives due to low over time

Provides tissue samples for histopathological analysis

High precision and detection of genetic Potential complications such as bleeding or mutations

the method used

Requires specialized laboratory analysis

concentration

Invasive procedure with associated risks

infection

associated with imaging technologies, the need for expertise in interpreting imaging results, and the development of novel molecular probes that can more precisely target disease biomarkers. The integration of molecular imaging into predictive Additionally, further research is required to establish medicine has the potential to revolutionize healthcare. clear guidelines for the use of molecular imaging for Molecular imaging can enhance patient outcomes predictive purposes and to evaluate its long-term through early disease detection and intervention, as impact on patient outcomes. In the future, the well as personalized treatment strategies by combination of molecular imaging with other providing insights into disease mechanisms at the predictive tools, such as genomics and artificial molecular level. Furthermore, it holds promise for intelligence, will further enhance their utility. reducing healthcare costs by preventing disease onset Personalized predictive medicine driven by before extensive and costly treatments become molecular imaging promises to significantly improve necessary. However, several challenges remain for healthcare delivery by providing tailored prevention the widespread adoption of molecular imaging in and treatment strategies based on each individual’s clinical practice. These include the high costs molecular profile. As these technologies continue to

4. Conclusion and Prediction

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advance, molecular imaging is expected to become Biomedicines. 2021 Jul 28;9(8):906. doi: 10.3390/biomedicines9080906. an indispensable tool in the quest to more effectively predict, prevent, and treat disease. This review [7] Malik MMUD, Alqahtani MM, Hadadi I, Kanbayti I, Alawaji Z, Aloufi BA. “Molecular highlights the critical role that molecular imaging Imaging Biomarkers for Early Cancer Detection: A plays in advancing predictive medicine and its Systematic Review of Emerging Technologies and potential to transform healthcare. With ongoing Clinical Applications”, Diagnostics (Basel). 2024 Nov 3;14(21):2459. doi: research and development, molecular imaging 10.3390/diagnostics14212459. technologies will provide unprecedented insights into disease prediction, ultimately leading to more [8] Thakur ML. “Genomic biomarkers for molecular imaging: predicting the future”, Semin Nucl Med. personalized and effective healthcare solutions. 2009 Jul;39(4):236-46. doi: 10.1053/j.semnuclmed.2009.03.006.

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[19] Thackeray, J.T. “Molecular Imaging Using Cardiac PET/CT: Opportunities to Harmonize Diagnosis and Therapy”, Curr Cardiol Rep

23, 96 (2021). https://doi.org/10.1007/s11886-021-01526-y. [20] Villemagne VL, Barkhof F, Garibotto V, Landau SM, Nordberg A, van Berckel BNM. “Molecular Imaging Approaches in Dementia”, Radiology. 2021 Mar;298(3):517-530. doi: 10.1148/radiol.2020200028.

[21] Johnson KB, Wei WQ, Weeraratne D, Frisse ME, Misulis K, Rhee K, Zhao J, Snowdon JL. “Precision Medicine, AI, and the Future of Personalized Health Care”, Clin Transl Sci. 2021 Jan;14(1):86-93. doi: 10.1111/cts.12884. [22] Juan Carlos Restrepo, Diana Dueñas, Zuray Corredor, Yamil Liscano, “Advances in Genomic Data and Biomarkers: Revolutionizing NSCLC Diagnosis and Treatment”, Cancers 15

2023, (13), 3474; doi:10.3390/cancers15133474

SJMI(2024) 01;29-34 ISSN : 2635-4608 DOI http://dx.doi.org/10.31916/sjmi2024-01-05 _________________________________________________________________________________________________________

A case study of pancreatic cystadenomas in an old woman

4,5,6*

Guppeum Park M.D , Soe Lwin Aye MD , Sobirjon Mamarajabov M.D.Ph.D. , Hwunjae Lee M.D.Ph.D.

Received: 25 October 2024 / Accepted: 3 December 2024 / Published online: 30 December 2024 The Author(s) 2024 ⓒ

Abstract

Serous cystadenoma of the pancreas is a rare, benign neoplasm that is often discovered incidentally during imaging studies for unrelated health concerns. These tumors are typically asymptomatic and characterized by multiple small cysts filled with clear serous fluid. Despite their benign nature, accurate diagnosis is crucial to distinguish them from other pancreatic cystic lesions, particularly those with malignant potential, such as mucinous cystadenomas, pseudocysts, and intraductal papillary mucinous neoplasms (IPMN). This report presents a case of a 67- year-old female who was referred for further evaluation of a pancreatic mass identified incidentally on a routine CT scan . _______________________________________________

Department of Internal Medicine, Samarkand State Medical University, 18 Amir Temur Street, Samarkand, Uzbekistan

Mohawk Valley Health System, 111 Hospital drive, Utica, New York 13502, United States

International Department, Samarkand State Medical University, 18 Amir Temur Street, Samarkand, Uzbekistan

I. Introduction

The patient was asymptomatic, with no gastrointestinal symptoms, and had a medical history significant for controlled hypertension and diabetes. A contrast- enhanced MRI confirmed a well-defined, multicystic lesion in the head of the pancreas, exhibiting typical imaging features of serous cystadenoma, including a "honeycomb" appearance without evidence of ductal dilation or surrounding tissue invasion. A comprehensive diagnostic approach, including imaging findings and laboratory results, led to the diagnosis of a serous cystadenoma. While these tumors are non- invasive and rarely cause symptoms, it is important to monitor them over time to ensure no change in size or behavior. This report also reviews the epidemiology, pathophysiology, clinical presentation, and management strategies for serous cystadenomas. The prognosis for patients with serous cystadenomas is excellent, with low risk of malignant transformation and recurrence following surgical removal. Regular follow-up imaging is typically recommended for monitoring. Keywords: Serous cystadenoma, pancreas, imaging, benign tumor, case report

The advancement of imaging technologies, such as computed tomography (CT) and magnetic resonance YUHS-KRIBB Medical Convergence Research Institute, Yonsei University College of Medicine, Seoul 03722, imaging (MRI), has significantly improved the Republic of Korea detection of pancreatic cystic lesions[1]. Among Interdisciplinary Program of Biomedical Engineering, these lesions, serous cystadenomas are benign Yonsei University College of Medicine, Seoul 03722, neoplasms typically characterized by multiple small Republic of Korea *Corresponding author ( ) cysts filled with clear serous fluid[2]. These tumors

30 SJMI(2024) 01;29-34

are generally asymptomatic and often discovered no personal or family history of malignancy. On incidentally during imaging studies conducted for physical examination, the patient appeared well, with unrelated medical conditions. While serous no palpable abdominal masses or signs of acute cystadenomas are non-invasive and carry a low risk distress. Laboratory results were unremarkable, of malignancy, distinguishing them from other cystic except for a mildly elevated lipase level, which did lesions with potential malignant features is essential not correlate with symptoms suggestive of acute for effective patient management[3]. Differentiating pancreatitis. Contrast-enhanced abdominal MRI serous cystadenomas from other pancreatic cystic revealed a well-defined, multicystic lesion located in lesions, such as mucinous cystadenomas, the head of the pancreas, without ductal dilation or pseudocysts, and intraductal papillary mucinous abnormal enhancement of surrounding tissues. neoplasms (IPMNS), is crucial due to the varying clinical implications and treatment strategies associated with these conditions. Mucinous cystadenomas and IPMNS, for instance, have a higher potential for malignancy and require more intensive monitoring and management compared to benign serous cystadenomas[4]. This case report presents a 67-year-old woman diagnosed with a serous cystadenoma. Through a comprehensive review of her clinical presentation, diagnostic imaging findings, and management strategies, we aim to highlight the importance of accurate diagnosis Fig. 1 MRI of a 67-year-old woman. (A) T1-weighted and appropriate follow-up care in the management of contrast-enhanced image, (B) T2-weighted image, (C) Diffusion weighted image, (D) Apparent Diffusion serous cystadenomas. The report emphasizes how Coefficient iimage advanced imaging techniques can assist in 2. Imaging Findings distinguishing these benign lesions from other more concerning pancreatic cystic lesions, thus optimizing MRI demonstrated multiple small cystic lesions in patient care and treatment outcomes. the head of the pancreas, exhibiting high signal intensity on T2-weighted imaging. Importantly, no aggressive features were present, such as solid components, significant enhancement, or surrounding 1. Case Presentation tissue invasion. A 67-year-old female presented for further evaluation following the incidental discovery of a pancreatic lesion during a routine CT scan. The patient reported no gastrointestinal symptoms, including abdominal pain, nausea, or vomiting. Her medical history included well-controlled hypertension and diabetes, managed with pharmacological therapy. There was

II. Materials and Methods

SJMI(2024) 01;29-34 31

The differential diagnosis for cystic pancreatic lesions includes several conditions, each with distinct imaging characteristics: Serous Cystadenoma: Typically presents as a multicystic lesion with a "honeycomb" appearance filled with clear serous fluid. These lesions lack solid components and exhibit no significant enhancement. They rarely show ductal dilation or invasion of Fig. 2 MR imaging shows multiple T2 hyperintense lesions surrounding structures[5]. in the pancreatic head without associated main pancreatic duct dilatation. Mucinous Cystadenoma: Usually presents as a The cysts showed no abnormal diffusion restriction unilocular or multilocular cystic lesion with thicker on apparent diffusion coefficient (ADC) maps, walls and internal septations. These lesions have a helping rule out malignant pancreatic lesions. higher malignancy potential compared to serous Additionally, there was no enlargement of the main cystadenomas and require careful imaging evaluation pancreatic duct, which would be indicative of IPMN to distinguish the two[6]. or other malignant entities. Pseudocysts: Often resulting from previous episodes of pancreatitis, pseudocysts present as well-defined cystic lesions, typically with a history of pancreatic inflammation or injury, which is absent in serous cystadenomas[7].

Intraductal Papillary Mucinous Neoplasm (IPMN): IPMNS affect the main pancreatic duct and its branches, presenting as cystic lesions with ductal dilation and papillary growth. These lesions have an Fig. 3 There is no abnormal diffusion restriction, as the increased malignancy risk, and the presence of ductal ADC(apparent diffusion coefficient) map shows high diffusion values on T2, indicating penetration. The mass involvement should raise suspicion[8]. remains within the pancreatic head without aggressive invasion or engulfment of adjacent vascular structures. In patient, the absence of ductal involvement, solid components, and the typical "honeycomb" The imaging features were consistent with a appearance on imaging made serous cystadenoma the diagnosis of serous cystadenoma, exhibiting the most likely diagnosis. characteristic "honeycomb" appearance. Given the benign nature of the lesion, no immediate intervention was recommended, and the patient was advised to undergo regular follow-up imaging to 1. Pathophysiology monitor any changes. Serous cystadenomas are benign pancreatic tumors 3. Differential Diagnosis that arise from epithelial cells lining the ducts of the

III. Discussion

32 SJMI(2024) 01;29-34

pancreas. These tumors are characterized by multiple cystadenomas and differentiating them from other small cysts filled with clear, serous fluid. Unlike pancreatic cystic lesions. On CT and MRI, serous other pancreatic neoplasms, such as mucinous cystadenomas typically appear as well-defined, cystadenomas or IPMNS, serous cystadenomas have multicystic lesions filled with clear serous fluid. The no malignant potential. They do not invade characteristic "honeycomb" or "vesicular" surrounding tissue or metastasize, making them low- appearance is often visible on T2-weighted images. risk lesions. These tumors are typically well- There are no solid components, and the cysts show encapsulated and composed of a single layer of minimal enhancement after contrast administration. There is typically no ductal dilation or tissue cuboidal or flattened epithelial cells[9]. invasion[12]. 2. Epidemiology

Serous cystadenomas account for approximately 1–2% of all pancreatic tumors. They are most commonly diagnosed in older women, with a female-to-male ratio of about 4:1. These tumors predominantly occur in individuals over the age of 60, with the highest Fig. 4 Characteristics of pancreatic cystadenoma by imaging. (A) Endoscopic ultrasound (EUS): EUS provides incidence in those aged 60-70 years. While serous high-resolution images and is useful for evaluating the cystadenomas can develop anywhere in the pancreas, internal features of a cyst and guiding a biopsy if necessary, they are most often found in the body and tail, (B) CT scan: A characteristic “honeycomb” appearance is often seen, with multiple small, well-circumscribed cysts. although they can also occur in the head of the The lesions are usually homogeneous and lack solid pancreas, as in this case[10]. components, (C) Contrast-enhanced MRI: Magnetic resonance imaging (MRI) can provide detailed images and is useful in confirming the diagnosis. Seborrheic 3. Clinical Presentation cystadenomas appear as polycystic lesions with clear fluid contents. Endoscopic ultrasound (EUS) is also a valuable The majority of patients with serous cystadenomas tool, providing high-resolution images and guiding biopsy when necessary. However, in most cases, the diagnosis can are asymptomatic, with the lesions often discovered be made through imaging alone, and biopsy is rarely incidentally during imaging studies for unrelated required[13]. conditions. Some patients may experience 5. Management and Treatment nonspecific abdominal symptoms, such as discomfort or bloating, though it is unclear whether these For asymptomatic serous cystadenomas with no symptoms are directly related to the cystadenoma. concerning features, treatment is generally Large tumors or those located near vital structures conservative. These lesions usually do not require may cause symptoms, such as pain, nausea, or surgery, and periodic imaging is recommended to jaundice, but these presentations are rare[11]. In the monitor for any changes. Surgical intervention is patient, the lesion was asymptomatic, and the considered for symptomatic cases or when there is discovery was incidental. uncertainty about the diagnosis, particularly if imaging features suggest a more aggressive 4. Imaging Features lesion[14]. Surgical options, such as pancreaticoduodenectomy or distal pancreatectomy, Imaging is crucial in diagnosing serous

SJMI(2024) 01;29-34 33

depend on the tumor's location. If surgery is not interest. required, follow-up imaging at regular intervals is recommended to ensure the lesion remains stable and does not undergo malignant transformation, though [1] Rogowska J, Semeradt J, Durko Ł, Małecka- Wojciesko E. Diagnostics and Management of the risk of malignancy in serous cystadenomas is Pancreatic Cystic Lesions-New Techniques and extremely low[11, 14]. Guidelines. J Clin Med. 2024 Aug 8;13(16):4644. doi: 10.3390/jcm13164644. 6. Prognosis [2] Brugge WR, Lauwers GY, Sahani D, Fernandez- The prognosis for patients with serous cystadenoma del Castillo C, Warshaw AL. Cystic neoplasms of the pancreas. N Engl J Med. 2004 Sep 16;351(12):1218- is excellent, owing to the benign nature of these 26. tumors. These lesions do not undergo malignant transformation, and once surgically removed, they [3] Hu S, Zhang H, Wang X, Sun Z, Ge Y, Yan G, Zhao C, Chen K. Asymptomatic versus symptomatic have a low recurrence rate. Most patients experience solid pseudopapillary tumors of the pancreas: clinical a normal post-resection recovery, with long-term and MDCT manifestations. Cancer Imaging. 2019 survival comparable to the general population[15]. Mar 7;19(1):13. doi: 10.1186/s40644-019-0198-4. PMID: 30845987; PMCID: PMC6407219.

IV. Conclusion

[4] Cunningham SC, Hruban RH, Schulick RD. Differentiating intraductal papillary mucinous Serous cystadenomas are benign pancreatic lesions neoplasms from other pancreatic cystic lesions. often detected incidentally during imaging for World J Gastrointest Surg. 2010 Oct 27;2(10):331-6. doi: 10.4240/wjgs.v2.i10.331. PMID: 21160839; unrelated conditions. In our case, the lesion was PMCID: PMC2999201. asymptomatic, and the imaging features supported a [5] Hu F, Hu Y, Wang D, Ma X, Yue Y, Tang W, Liu diagnosis of serous cystadenoma. These tumors are W, Wu P, Peng W, Tong T. Cystic Neoplasms of the low-risk, and management typically involves Pancreas: Differential Diagnosis and Radiology conservative monitoring with follow-up imaging. Correlation. Front Oncol. 2022 Mar 1;12:860740. doi: 10.3389/fonc.2022.860740. PMID: 35299739; Accurate diagnosis is essential to differentiate serous PMCID: PMC8921498. cystadenomas from other cystic pancreatic lesions, particularly those with malignant potential. [6] Gore RM, Wenzke DR, Thakrar KH, Newmark GM, Mehta UK, Berlin JW. The incidental cystic Understanding the clinical presentation, imaging pancreas mass: a practical approach. Cancer Imaging. characteristics, and management strategies of serous 2012 Sep 28;12(2):414-21. doi: 10.1102/1470- cystadenomas is critical for optimizing patient care. 7330.2012.9054. PMID: 23022726; PMCID: PMC3460559. Acknowledgments [7] Habashi S, Draganov PV. Pancreatic pseudocyst. World J Gastroenterol. 2009 Jan 7;15(1):38-47. doi: We would like to thank the clinical and radiology 10.3748/wjg.15.38. PMID: 19115466; PMCID: staff for their assistance in this case report, and the PMC2653285. patient for providing informed consent for the use of her data in this study. [8] Grützmann R, Niedergethmann M, Pilarsky C, Klöppel G, Saeger HD. Intraductal papillary Conflict of Interest mucinous tumors of the pancreas: biology, diagnosis, and treatment. Oncologist. 2010;15(12):1294-309. The authors declare that they have no conflicts of

34 SJMI(2024) 01;29-34

doi: 10.1634/theoncologist.2010-0151. Epub 2010 Dec 8. PMID: 21147870; PMCID: PMC3227924. [9] Tseng JF, Warshaw AL, Sahani DV, Lauwers GY, Rattner DW, Fernandez-del Castillo C. Serous cystadenoma of the pancreas: tumor growth rates and recommendations for treatment. Ann Surg. 2005 Sep;242(3):413-9; discussion 419-21. doi: 10.1097/01.sla.000017-****-21193.2c. 16135927; PMCID: PMC1357749.

[10] Basturk O, Askan G. Benign Tumors and Tumorlike Lesions of the Pancreas. Surg Pathol Clin. 2016

Dec;9(4):619-641.

doi: 10.1016/j.path.2016.05.007. PMID: 27926363; PMCID: PMC5599111. [11] Kylie Ning, Ashley Salamone, Lindsey Manos, et al., “Serous Cystadenoma: A Review on Diagnosis and Management”, Journal of Clinical Medicine, 2023, 12(23), 7306; https://doi.org/10.3390/jcm12237306

[12] Abstract. Virchows Arch. 2010;457(2):91–281. doi: 10.1007/s00428-010-0947-z. Epub 2010 Jul 30. PMCID: PMC7102354. [13] Ang TL, Kwek ABE, Wang LM. Diagnostic Endoscopic Ultrasound: Technique, Current Status and Future Directions. Gut Liver. 2018 Sep 15;12(5):483-496. doi: 10.5009/gnl17348. PMID: 29291601; PMCID: PMC6143442.

[14] Kadiyala V, Lee LS. Endosonography in the diagnosis and management of pancreatic cysts. World J Gastrointest Endosc. 2015 Mar 16;7(3):213-23. doi: 10.4253/wjge.v7.i3.213. PMID: 25789091; PMCID: PMC4360439. [15] Sun Y, Lu X, Xu Y, Mao Y, Yang Z, Sang X, Zhong S, Huang J. Spontaneous rupture of a giant hepatobiliary serous cystadenoma: report of a case and literature review. Hepatol Int. 2010 Oct 12;5(1):603-6. doi: 10.1007/s12072-010-9221-3. PMID: 21442059; PMCID: PMC3034005.

PMID

1,*

SJMI(2024) 01;35-39 ISSN : 2635-4608

DOI http://dx.doi.org/10.31916/sjmi2024-01-06 ________________________________________________________________________________________________________

Diagnosis of Hepatic Hemangioma in a 35-Year-Old Female with an Incidental Liver Lesion Detected on Ultrasound Examination

1+

Davronov Oybek M.D. Muzaffar Annaev M.D. Uralboev Ikromjon Erkinovich M.D.

5,6,7*

Byungju Ahn Ph.D , Hwunjae Lee M.D.,Ph.D.

Received: 15 October 2024 / Accepted: 28 November 2024 / Published online: 30 December 2024 The Author(s) 2024 ⓒ

Abstract

Hepatic hemangiomas are the most prevalent benign lesions of the liver, often discovered incidentally during imaging for unrelated reasons. We report a case of a 35-year-old woman with an incidental liver lesion detected during a routine ultrasound. The lesion was diagnosed as a hepatic hemangioma based on imaging findings, including non-contrast CT, 99mTc-labeled red blood cell (RBC) SPECT/CT, and clinical assessment. _______________________________________________

Department of Urology, Samarkand State Medical University, 18 Amir Temur St, Samarkand, Uzbekistan

Kimyo International University in Tashkent, Shota Rustaveli street, 156, 100121, Tashkent

Department of Orthopedic-Thoracic, Children multibranch medical center of Samarkand, Uzebekistan

Ultrasound revealed a well-defined hyperechoic lesion, consistent with a hemangioma, and non- contrast CT imaging showed a low-density lesion. 99mTc-RBC SPECT/CT demonstrated characteristic radiotracer uptake, supporting the diagnosis. The patient had no symptoms and no identifiable risk factors for liver disease. The patient did not use oral contraceptives, had an allergy to iodinated contrast agents, and had metallic implants incompatible with MRI. This case highlights the importance of recognizing the typical imaging features of hepatic hemangiomas, which include well-defined, hyperechoic lesions on ultrasound, low-density areas on non-contrast CT, and specific uptake patterns on SPECT/CT. These diagnostic tools are essential for distinguishing hepatic hemangiomas from other hepatic lesions, including hepatic adenomas, focal nodular hyperplasia, and malignant tumors. While most hepatic hemangiomas are asymptomatic and require no treatment, accurate diagnosis is crucial to

Nambu University, Department of Radiology, 91, Nambudae-ro, Gwangsan-gu, Gwangju 62211, Republic of avoid unnecessary interventions. This case Korea. demonstrates the value of multiple imaging techniques in ensuring correct diagnosis and guiding Department of Radiology, Yonsei University College of Medicine, Seoul 03722, Republic of Korea appropriate management.

YUHS-KRIBB Medical Convergence Research Institute, Keyword: Ultrasound Examination, Incidental Yonsei University College of Medicine, Seoul 03722, Detected Liver Lesion, Hepatic Hemangioma, Tc- Republic of Korea labeled RBC SPECT/CT

Interdisciplinary Program of Biomedical Engineering, Yonsei University College of Medicine, Seoul 03722, Republic of Korea *Corresponding author ( )

1. Introduction

99m

Hepatic hemangiomas are the most common benign

36 SJMI(2024) 01;35-39

tumors of the liver, with an estimated prevalence ranging from 5-10% in the general population[1]. Often asymptomatic, they are usually discovered incidentally during imaging studies performed for unrelated reasons[2]. While hepatic hemangiomas are benign, differentiating them from other hepatic lesions, such as hepatic adenomas, focal nodular hyperplasia, and malignant tumors, is crucial for appropriate management[3]. This case report presents the diagnostic approach for a 35-year-old female who

Fig. 2 Non-Contrast CT image of hepatic hemangioma Further evaluation with 99mTc-labeled RBC was found to have an incidental liver lesion during a SPECT/CT revealed radiotracer uptake within the routine ultrasound examination. The patient did not lesion, a finding that strongly supports the diagnosis of a hepatic hemangioma[6]. use oral contraceptives, had an allergy to iodinated contrast agents, and had metallic implants incompatible with MRI, which made alternative imaging necessary. The report discusses the imaging modalities used to reach a definitive diagnosis and emphasizes the importance of accurate differentiation Fig. 3 Hepatic Hemangioma (A) SPECT image (B) CT of hepatic hemangiomas from other liver lesions. Image (C) SPECT/CT image

2. Imaging Findings

On ultrasound, the liver lesion appeared as a well- defined hyperechoic (bright) area, which is typical of hepatic hemangiomas[4].

This imaging modality is highly specific for hepatic hemangiomas, although its sensitivity is somewhat lower compared to MRI. These findings, in conjunction with the patient’s clinical history and lack of symptoms, led to the final diagnosis of a benign vascular lesion. The patient did not use oral contraceptives, had an allergy to iodinated contrast agents, and had metallic implants incompatible with MRI, which necessitated the use of non-contrast CT and 99mTc-RBC SPECT/CT for further evaluation. The differential diagnosis for incidental liver lesions Fig. 1 Ultrasonography images of hepatic hemangioma. (A) Ultrasound hypoechoic image with increased around( + ) (B) includes a variety of conditions, such as hepatic Ultrasound hypoechoic image (C) color Doppler. adenoma, focal nodular hyperplasia, cystic lesions, The non-contrast CT scan showed a low-attenuation focal hepatic steatosis, biliary hamartomas, and lesion with a Hounsfield unit of 32, indicative of a malignant tumors like hepatocellular carcinoma[7]. hepatic hemangioma's characteristic imaging However, the combination of ultrasound, non- features[5]. contrast CT, and 99mTc-RBC SPECT/CT imaging strongly suggested a hepatic hemangioma[8].

3. Discussion

SJMI(2024) 01;35-39 37

Hepatic hemangiomas are composed of clusters of (arrows) during the portal phase. The density of the nodular enhancement is similar to that of the opaque aorta. (B) blood vessels lined by endothelial cells and are Delayed contrast-enhanced axial CT image of the liver typically asymptomatic, with most patients remaining shows irregular contrast fill within the lesion. unaware of their condition throughout life[1]. MRI, particularly with T2-weighted imaging, can Although larger hemangiomas may cause symptoms demonstrate high signal intensity with a "light bulb" such as right upper quadrant pain, nausea, or early appearance, further confirming the vascular nature of satiety, complications like hemorrhage or rupture are the lesion. The use of contrast agents on MRI rare[9]. The majority of hepatic hemangiomas are enhances the vascular pattern of the hemangioma, incidental findings during imaging performed for providing additional diagnostic clarity[9]. other reasons. Ultrasound is the first-line imaging modality used to diagnose hepatic hemangiomas, as these lesions typically appear as well-defined, hyperechoic areas[9,10].

Fig. 6 MRI of Hepatic Hemangioma. (A) T2 weighted image, (B) T2 weighted image enhanced However, MRI may not always be available or feasible, especially in patients with contraindications such as metal implants. In these situations, 99mTc- RBC SPECT/CT serves as a valuable diagnostic tool with high specificity for hepatic hemangiomas

Fig. 4 Ultrasonography shows the hemangioma as a though its sensitivity is lower compared to MRI[12]. hyperechoic mass with sharp margins. Non-contrast CT can further characterize these lesions, with low attenuation being a hallmark feature. When contrast is used in CT, peripheral nodular enhancement can be observed, aiding in the diagnosis[11].

Fig. 7 Hepatic Hemangioma.(A) SPECT image, (B) CT image, (c) SPECT/CT image The patient in this case had an allergy to iodinated contrast agents and had metal implants incompatible with MRI. As a result, non-contrast CT and 99mTc- RBC SPECT/CT were used for further investigation, allowing for a definitive diagnosis. Treatment for hepatic hemangiomas is generally unnecessary unless

Fig. 5 Hepatic Hemangioma. (A) Contrast-enhanced axial CT image of the liver shows a well-defined, hypointense the lesion is symptomatic or there are lesion with surrounding nodular contrast enhancement

38 SJMI(2024) 01;35-39

complications[13]. Asymptomatic lesions are often hemangiomas and their differentiation from other managed with observation, with regular imaging hepatic lesions. Regular follow-up and monitoring follow-up to monitor for changes in size or the are recommended for detecting any potential development of symptoms[14]. Surgical resection or complications or changes in lesion characteristics enucleation may be considered for symptomatic over time. lesions or those larger than 4 cm. Additionally, in Acknowledgments certain cases, preoperative embolization can be performed to reduce lesion size and mitigate surgical We would like to thank the clinical and radiology risks[15].

staff for their assistance in this case report, and the patient for providing informed consent for the use of her data in this study.

The differential diagnosis of incidental liver lesions is broad and includes benign conditions such as Conflict of Interest hepatic adenomas, focal nodular hyperplasia, and The authors declare that they have no conflicts of cystic lesions, as well as malignant tumors like interest. hepatocellular carcinoma[16]. Imaging features such as lesion characteristics on ultrasound, CT, and SPECT/CT, along with clinical history, are essential [1] Bajenaru N, Balaban V, S ă vulescu F, Campeanu I, in differentiating these lesions and avoiding Patrascu T. Hepatic hemangioma -review-. J Med unnecessary interventions[17]. Life. 2015;8 Spec Issue(Spec Issue):4-11. PMID: 26361504; PMCID: PMC4564031.

4. Conclusion

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doi: [9] Kacała A, Dorochowicz M, Matus I, Puła M, 10.1016/j.jus.2007.06.001. Epub 2007 Aug 1. PMID: Korbecki A, Soba ń ski M, Jacków-Nowicka J, 23396642; PMCID: PMC3478711. Patrzałek D, Janczak D, Guzi ń ski M. Hepatic [17] Heiken JP. Distinguishing benign from Hemangioma: Review of Imaging and Therapeutic malignant liver tumours. Cancer Imaging. 2007 Oct Strategies. Medicina (Kaunas). 2024 Mar 1;7 Spec No A(Special issue A):S1-14. doi: 8;60(3):449. doi: 10.3390/medicina60030449. PMID: 10.1102/1470-7330.2007.9084. PMID: 17921080; 38541175; PMCID: PMC10972168. PMCID: PMC2727979. [10] Jeon SK, Lee JY, Han JK. Superb microvascular imaging technology of ultrasound examinations for the evaluation of tumor vascularity in hepatic hemangiomas. Ultrasonography. 2021 Oct;40(4):538- 545. doi: 10.14366/usg.20177. Epub 2021 Feb 14. PMID: 33866773; PMCID: PMC8446495. [11] Chartampilas E, Rafailidis V, Georgopoulou V, Kalarakis G, Hatzidakis A, Prassopoulos P. Current Imaging Diagnosis of Hepatocellular Carcinoma. Cancers (Basel). 2022 Aug 18;14(16):3997. doi: 10.3390/cancers14163997. PMID: 36010991; PMCID: PMC9406360.

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