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Villart A, Burban P, Mosnino E, Derouich M. Subcapsular liver hematoma complicating HELLP syndrome: A case report and review of management strategies. Case Rep Womens Health 2023; 40:e00561. [PMID: 37954515 PMCID: PMC10637892 DOI: 10.1016/j.crwh.2023.e00561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Revised: 10/26/2023] [Accepted: 10/27/2023] [Indexed: 11/14/2023] Open
Abstract
Subcapsular liver hematoma is a life-threatening complication of pregnancy. It is associated with preeclampsia and HELLP syndrome. We present the case of a 36-year-old Caucasian nulliparous woman who was diagnosed at 29 weeks and 6 days of gestation with mild preeclampsia. After brief hospitalization she was discharged. During a daily follow-up, at 31 weeks and 3 days of gestation, she complained of mild abdominal pain and blood tests revealed HELLP syndrome. The cervix was unripe. A healthy baby was delivered by emergency cesarean section. The following day, the patient complained of persistent abdominal pain, and at the same time the hepatic cytolysis worsened dramatically. A computed tomography (CT) scan revealed a significant subcapsular hematoma without any active bleeding or breach of Glisson's capsule. We treated the patient conservatively and she was discharged home 10 days after the diagnosis was made. The symptoms of subcapsular liver hematoma are non-specific. They include nausea, vomiting and epigastric pain, and pain in the right upper quadrant or shoulder. Biological analyses can show hepatic cytolysis, haemolysis and coagulation disorders. Medical imaging can confirm the diagnosis. The management of subscapular liver hematoma may depends on whether there is hemodynamic stability, active bleeding or breach of Glisson capsule's. If the patient is stable and in the absence of active bleeding, management should be purely symptomatic.
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Affiliation(s)
- Agnès Villart
- Department of Gynecology and Obstetrics, Argenteuil Hospital, 69 Rue du Lieutenant Colonel Prudhon, 95107 Argenteuil, France
| | - Pauline Burban
- Department of Gynecology and Obstetrics, Argenteuil Hospital, 69 Rue du Lieutenant Colonel Prudhon, 95107 Argenteuil, France
| | - Elie Mosnino
- Department of Gynecology and Obstetrics, Argenteuil Hospital, 69 Rue du Lieutenant Colonel Prudhon, 95107 Argenteuil, France
| | - Mohamed Derouich
- Department of Gynecology and Obstetrics, Argenteuil Hospital, 69 Rue du Lieutenant Colonel Prudhon, 95107 Argenteuil, France
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2
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Calvo A, Monge E, Bermejo L, Palacio-Abizanda F. Spontaneous subcapsular hepatic hematoma in pregnant patients. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2023; 70:169-177. [PMID: 36842697 DOI: 10.1016/j.redare.2021.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 11/10/2021] [Indexed: 04/12/2023]
Abstract
Spontaneous subcapsular hepatic hematoma (SSHH) with or without previous history of preeclampsia and/or HELLP syndrome represents a very rare pathological condition in pregnancy and postpartum, (1/45,000-1/225,000 pregnancies). Its importance for the anesthesiologist lays in its association with high morbidity and mortality for the mother (60-86%, 39%) and newborn (42%). After a high clinical suspicion, the certainty clinical diagnosis is settled by different imaging techniques. However, in most cases the diagnosis of SSHH is a casual intraoperative finding associated to a maternal or foetal compromise. Nowadays the obstetric and anaesthetic management of a SSHH is not standardized and depends on its integrity, hemodynamic stability and the gestational period when diagnosed. The possibility of an acute critic haemorrhage with necessity of massive transfusion, makes advisable to provide updated protocols for the treatment of obstetric hemorrhage, adapting them to the clinical peculiarities of these patients. After the acute phase, close attention should be kept on thromboembolic complications.
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Affiliation(s)
- A Calvo
- Servicio de Anestesiología y Reanimación, Hospital General Universitario Gregorio Marañón, Madrid, Spain.
| | - E Monge
- Servicio de Anestesiología y Reanimación, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - L Bermejo
- Servicio de Anestesiología y Reanimación, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - F Palacio-Abizanda
- Servicio de Anestesiología y Reanimación, Hospital General Universitario Gregorio Marañón, Madrid, Spain
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3
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Grigorakis S, Tzimas GN, Alexakis C, Morea BE, Kontomitros N. Subcapsular Liver Hematoma: A Rare Complication of Hemolysis, Elevated Liver Enzymes, and Low Platelets (HELLP) Syndrome Managed Conservatively. Cureus 2022; 14:e22058. [PMID: 35340458 PMCID: PMC8916545 DOI: 10.7759/cureus.22058] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/08/2022] [Indexed: 01/04/2023] Open
Abstract
HELLP syndrome is an acronym used, since 1982, to describe a combined disorder of the liver and coagulation cascade defined as pre-eclampsia in pregnant women with hemolytic anemia, an increase in liver enzymes, and a decrease in platelet count. Spontaneous liver rupture is an exceptionally rare and extremely severe, occasionally lethal, complication of pre-eclampsia - eclampsia and especially hemolysis, elevated liver enzymes, low platelets (HELLP) syndrome. The following report describes a case of a 48-year-old woman diagnosed with HELLP syndrome complicated by spontaneous liver rupture who was treated conservatively.
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Affiliation(s)
| | | | - Chalent Alexakis
- Obstetrics and Gynaecology, Carol Davila University of Medicine and Pharmacy, Athens, GRC
| | - Beatrice E Morea
- Obstetrics and Gynaecology, Carol Davila University of Medicine and Pharmacy, Colorado, USA
| | - Nikolaos Kontomitros
- Obstetrics and Gynaecology, Carol Davila University of Medicine and Pharmacy, Athens, GRC
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4
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Postpartum Spontaneous Subcapsular Hepatic Hematoma (SSHH)- Conservative Management. Case Report and Review of Literature. CURRENT HEALTH SCIENCES JOURNAL 2018; 44:387-391. [PMID: 31123617 PMCID: PMC6421484 DOI: 10.12865/chsj.44.04.11] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/21/2018] [Accepted: 11/20/2018] [Indexed: 11/24/2022]
Abstract
Spontaneous subcapsular hematoma of the liver, with no history of preeclampsia and HELLP syndrome (Hemolysis, Elevated Liver enzymes, and Low Platelet count.), represents an exceptionally rare clinical condition in pregnancy and postpartum. The complications can be devastating in terms of fetal and maternal mortality. We hereby present a case of a 33-year-old female that underwent an emergency Cesarean section (C-section) at term with the extraction of a live foetus. Few hours after delivery, she complained of intense epigastric and abdominal pain. The diagnostic work-up suggested a SSHH. The condition was managed conservatively in a multidisciplinary team.
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Chen W, Qi J, Shang Y, Ren L, Guo Y. Amniotic fluid embolism and spontaneous hepatic rupture during uncomplicated pregnancy: a case report and literature review. J Matern Fetal Neonatal Med 2018; 33:1759-1766. [PMID: 30394159 DOI: 10.1080/14767058.2018.1526915] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Amniotic fluid embolism (AFE) and spontaneous hepatic rupture both are extremely rare complications of pregnancy that can be fatal to mother and/or child. AFE is characterized by a sudden collapse of the cardiovascular system, a change in mental status, and disseminated intravascular coagulation (DIC), occurring immediately during labor, delivery, or postpartum, caused by the inflow of amniotic components into the maternal circulation. Spontaneous hepatic rupture during pregnancy which is most often occurs alongside hypertensive disorders, eclampsia, or HELLP syndrome. We report on the case of a 28-year-old woman (G3P2) who is suffering from AFE and spontaneous hepatic rupture, without history of hypertensive disorders, preeclampsia/eclampsia, or HELLP syndrome, and she died suddenly after delivering of a severe asphyxial neonate within 1 h with postpartum of hepatic rupture and massive hemorrhage. The lack of typical clinical signs and symptoms resulted to the difficulty of early diagnosis. If AFE and hepatic rupture is highly suspected in a pregnant patient, a collaborative multidisciplinary approach is mandatory. Pregnancy women is simultaneously complicated in amniotic fluid embolism and spontaneous hepatic rupture, similar cases are infrequent in the literature, which is reviewed in this report, explore the pathophysiological changes, we hope that can be helpful for the prevention, diagnosis and treatment of similar cases.
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Affiliation(s)
- Wei Chen
- Department of Forensic Science, School of Basic Medical Sciences, Central South University, Changsha, China
| | - Jialin Qi
- Department of Pathology, School of Basic Medical Sciences, Central South University, Changsha, China
| | - Yanjie Shang
- Department of Forensic Science, School of Basic Medical Sciences, Central South University, Changsha, China
| | - Lipin Ren
- Department of Forensic Science, School of Basic Medical Sciences, Central South University, Changsha, China
| | - Yadong Guo
- Department of Forensic Science, School of Basic Medical Sciences, Central South University, Changsha, China
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Shakya VC, Regmi MC, Sah P, Khaniya S, Adhikary S. An alarming but self-limited case of isolated large spontaneous liver hematoma in pregnancy. Pan Afr Med J 2013; 14:36. [PMID: 23560119 PMCID: PMC3612875 DOI: 10.11604/pamj.2013.14.36.1829] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2012] [Accepted: 01/21/2013] [Indexed: 12/04/2022] Open
Abstract
Spontaneous subcapsular liver hematoma is rare but potentially life-threatening complication of pregnancy usually associated with severe preeclampsia and HELLP syndrome (hemolysis, elevated liver enzymes, and low platelets). We present here a case of such a large spontaneous liver hematoma presenting in pregnancy, but without other known associated abnormalities, which has not been described before and it resolved on itself without any intervention.
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Affiliation(s)
- Vikal Chandra Shakya
- Department of Surgery, B. P. Koirala Institute of Health Sciences, Dharan, Nepal
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7
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Jaffar R, Pechet L, Whalen GF, Banner BF. Spontaneous hepatic hemorrhage secondary to prolonged use of oral contraceptives. Pathol Res Pract 2010; 206:318-21. [DOI: 10.1016/j.prp.2009.05.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2008] [Revised: 02/13/2009] [Accepted: 05/19/2009] [Indexed: 11/30/2022]
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8
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Tyagi V, Shamas AG, Cameron AD, Cameron AD. Spontaneous subcapsular hematoma of liver in pregnancy of unknown etiology--conservative management: a case report. J Matern Fetal Neonatal Med 2009; 23:107-10. [PMID: 20001572 DOI: 10.3109/14767050903314184] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Mrs. AB, a 40-year-old woman, in her second pregnancy had a spontaneous hematoma of liver of unknown etiology that was managed successfully conservatively under the umbrella of the multidisciplinary care. The subcapsular hematoma was diagnosed at 31 weeks gestational age while she was being investigated because of sudden and gross drop of hemoglobin from 12.8 to 8 g/dl in 2 weeks duration. The dilemma remains as how to manage her future pregnancies and what are the risks of recurrence.
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Affiliation(s)
- Veenu Tyagi
- Department of Obstetrics and Gynecology, Queen Mother's Hospital Glasgow, Glasgow, UK
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9
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Page IJ, Roberts LJ. Obstetric case reports: Pregnancy in a woman with spina bifida and an ileal bladder. J OBSTET GYNAECOL 2009. [DOI: 10.3109/01443618909151068] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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10
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Gyang AN, Srivastava G, Asaad K. Liver capsule rupture in eclampsia: treatment with hepatic artery embolisation. Arch Gynecol Obstet 2006; 274:377-9. [PMID: 16708223 DOI: 10.1007/s00404-006-0179-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2006] [Accepted: 04/26/2006] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Spontaneous hepatic rupture associated with pregnancy is a rare and very serious complication associated with eclampsia or pre-eclampsia. CASE REPORT We report a case of hepatic rupture following eclampsia at 27 weeks gestation which was managed successfully by selective hepatic artery embolisation as an adjunct to liver packing. CONCLUSION Selective embolisation of the hepatic artery is an effective means of therapy for hepatic artery bleeding and is an adjunct to liver packing in spontaneous hepatic rupture in eclamptic patients.
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Affiliation(s)
- Anthony N Gyang
- Department of Obstetrics and Gynaecology, Prince Charles Hospital, Gurnos Estate, Merthyr Tydfil, Mid Glamorgan, CF47 DT, UK.
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11
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Merchant SH, Mathew P, Vanderjagt TJ, Howdieshell TR, Crookston KP. Recombinant factor VIIa in management of spontaneous subcapsular liver hematoma associated with pregnancy. Obstet Gynecol 2004; 103:1055-8. [PMID: 15121606 DOI: 10.1097/01.aog.0000127943.68645.96] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Spontaneous subcapsular liver hemorrhage is a rare but life-threatening complication of pregnancy. Optimal management of an expanding hematoma or ruptured capsule has not been established. CASES We report 3 patients with preeclampsia and hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome with spontaneous subcapsular liver hematomas. The first 2 patients with ruptured liver hematomas experienced life-threatening hemorrhage. The third patient experienced uncontrollable vaginal bleeding, liver hemorrhage, and was in imminent danger of capsule rupture. Despite aggressive surgical intervention and traditional blood component therapy, adequate hemostasis could not be achieved in any of these patients. Recombinant factor VIIa was used to achieve hemostasis in all three patients. CONCLUSION Recombinant factor VIIa is an effective adjunct in the treatment of preeclamptic patients with expanding or ruptured subcapsular liver hematoma.
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Affiliation(s)
- Shakil H Merchant
- Department of Pathology, University of New Mexico, Albuquerque, New Mexico 87131, USA
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12
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Irvine LM. Massive non-obstetric postpartum haemorrhage. J OBSTET GYNAECOL 2004; 24:179-80. [PMID: 14766463 DOI: 10.1080/01443610410001648340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- L M Irvine
- Department of Obstetrics and Gynaecology, West Hertfordshire Hospitals NHS Trust, Watford General Hospital, UK.
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13
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Rosen SA, Merchant SH, VanderJagt TJ, Crookston KP. Spontaneous subcapsular liver hematoma associated with pregnancy. Arch Pathol Lab Med 2003; 127:1639-40. [PMID: 14632557 DOI: 10.5858/2003-127-1639-sslhaw] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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14
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Chedid AD, Klein PW, Tiburi MF, Villwock MM, Bassani LE, Chedid MF. Spontaneous rupture of hepatocellular carcinoma with haemoperitoneum: a rare condition in Western countries. HPB (Oxford) 2001; 3:227-30. [PMID: 18333020 PMCID: PMC2020622 DOI: 10.1080/136518201753242262] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Haemoperitoneum secondary to non-traumatic liver rupture is a rare but potentially fatal condition. It may result from several neoplastic and non-neoplastic diseases such as primary benign or malignant tumours, peliosis hepatis, polyarteritis nodosa, systemic lupus erythematosus, pre-eclampsia and metastatic carcinoma. CASE OUTLINES Three cases of spontaneous haemoperitoneum caused by rupture of hepatocellular carcinoma are described. All three patients (two men, one woman) had cirrhotic livers, and all were submitted to an urgent operation.One patient re-bled on a second occasion. Emergency operation was undertaken four times in three patients and was successful on all but one occasion. DISCUSSION The prognosis for patients with haemoperitoneum is generally poor. Although this condition is relatively frequent in some regions of Asia and Africa, it has rarely been reported in Western countries.The present experience shows that emergency laparotomy can be life-saving.
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Affiliation(s)
- AD Chedid
- Surgery Service, Hospital Ernesto DornellesPorto AlegreBrazil
| | - PW Klein
- Surgery Service, Hospital Ernesto DornellesPorto AlegreBrazil
| | - MF Tiburi
- Surgery Service, Hospital Ernesto DornellesPorto AlegreBrazil
| | - MM Villwock
- Surgery Service, Hospital Ernesto DornellesPorto AlegreBrazil
| | - LE Bassani
- Surgery Service, Hospital Ernesto DornellesPorto AlegreBrazil
| | - MF Chedid
- Surgery Service, Hospital Ernesto DornellesPorto AlegreBrazil
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15
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Rinehart BK, Terrone DA, Magann EF, Martin RW, May WL, Martin JN. Preeclampsia-associated hepatic hemorrhage and rupture: mode of management related to maternal and perinatal outcome. Obstet Gynecol Surv 1999; 54:196-202. [PMID: 10071839 DOI: 10.1097/00006254-199903000-00024] [Citation(s) in RCA: 82] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
This article is a critical review of the obstetric literature concerning preeclampsia-associated hepatic hemorrhage to develop guidelines conducive to optimal maternal and perinatal outcomes. An English literature search was performed for reports of hepatic hemorrhage or hepatic rupture in pregnancy during 1960 to 1997. Data were analyzed by Statmost packages using ANOVA, Chi-square, and Fisher's exact tests. One hundred forty-one patients with hepatic rupture/hemorrhage were reported. The three most common presenting findings were epigastric pain, hypertension, and shock. With rare exception, patients had evidence of preeclampsia. Diagnosis was elusive and most frequently accomplished at laparotomy. When utilized, ultrasound and computed tomography (CT) were helpful diagnostic modalities. Maternal survival was highest in the arterial embolization treatment group. Maternal and perinatal survival improved considerably during the study interval. Route of delivery did not seem to impact survival rates. It was concluded that the application of ultrasound and CT for diagnosis and the use of hepatic artery embolization for treatment of hepatic hemorrhage/rupture seem to be beneficial management options for this rare event.
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Affiliation(s)
- B K Rinehart
- Department of Obstetrics and Gynecology, University of Mississippi Medical Center, Jackson 39216-4505, USA
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16
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Abstract
Liver hematoma and rupture is a rare but devastating complication of pregnancy. The majority of cases have been associated with severe preeclampsia, but unlike typical preeclampsia, it is a disease of older, multiparous patients. Although there are predictable findings on liver pathology, the underlying pathophysiology is poorly understood. Early recognition and prompt surgical intervention are crucial to reduce the high fetal and maternal mortality rate associated with this disease.
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Affiliation(s)
- S J Ralston
- Department of Obstetrics & Gynecology and Surgery, New England Medical Center, Tufts University School of Medicine, Boston, MA, USA
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17
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Abstract
In evaluating the pregnant patient with abdominal pain, the physician is presented with a wide range of diagnostic possibilities, including disorders that can occur in nonpregnant individuals and disorders that are unique to pregnancy. The development of modern laboratory testing methods and diagnostic imaging techniques has led to a decline in the morbidity and mortality from many of these disorders. With an understanding of the physiologic changes occurring during pregnancy, a careful history and physical examination, and judicious use of laboratory tests and imaging studies, the physician should be able to determine the cause of the patient's pain in the great majority of cases and, in the words of Babler, avoid "the mortality of delay."
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Affiliation(s)
- I E Mayer
- Division of Gastroenterology, Maimonides Medical Center, Brooklyn, New York, USA
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18
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Stain SC, Woodburn DA, Stephens AL, Katz M, Wagner WH, Donovan AJ. Spontaneous hepatic hemorrhage associated with pregnancy. Treatment by hepatic arterial interruption. Ann Surg 1996; 224:72-8. [PMID: 8678621 PMCID: PMC1235249 DOI: 10.1097/00000658-199607000-00011] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
OBJECTIVE The authors determined the effectiveness of hepatic arterial interruption in treating patients with spontaneous hepatic hemorrhage associated with pregnancy. BACKGROUND DATA This rare syndrome frequently is seen with eclampsia/preeclampsia and is associated with high maternal mortality. The recommended treatment has been the use of local hemostatic measures. METHODS The authors reviewed their experience managing eight patients by hepatic arterial interruption. RESULTS Operative hepatic artery ligation was the initial method of controlling hepatic hemorrhage in three patients. One patient recovered, a hepatic sequestrum developed in one, and one patient died. Three patients survived after hepatic arterial embolization, but a sequestrum developed in one. Two patients died when hepatic arterial interruption was used after failed local hemostatic measures. CONCLUSIONS The authors believe that hepatic arterial interruption is the preferred treatment for spontaneous hepatic hemorrhage associated with pregnancy. If the diagnosis is made at the time of cesarean section delivery, operative hepatic arterial ligation is indicated. If the diagnosis is made postpartum, percutaneous angiographic embolization should be performed.
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Affiliation(s)
- S C Stain
- Department of Surgery, University of Southern California, School of Medicine, Los Angeles 90033, USA
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19
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Lundell CJ. Spontaneous hepatic rupture in postmenopausal women receiving oral estrogen replacement. J Vasc Interv Radiol 1993; 4:245-9. [PMID: 8386959 DOI: 10.1016/s1051-0443(93)71845-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Affiliation(s)
- C J Lundell
- Department of Diagnostic Radiology, City of Hope National Medical Center, Duarte, CA 91010
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