1), which was equal to the level in liver parenchyma, and contiguous with the liver. Figure 3 Percutaneous needle biopsy of the mass. The biopsy needle penetrated the mass (arrow). Figure 4 Histological findings of the tumor. Histological examination revealed inflammatory learn more cell infiltration around normal liver cells and fibrosis of Glisson’s

sheath (H & E: A ×50; inset, ×100. Masson-Trichrome stain: B ×50). Figure 5 Intraoperative findings of the herniated liver. A A defect in the right diaphragm. B The herniated portion of the liver. The herniated liver surface was congested, compared with surrounding normal liver surface. Discussion Traumatic rupture of the right diaphragm following blunt trauma is uncommon. The extent of herniation varies, from a small portion of liver, to the entire

liver plus other abdominal organs. Small herniations are typically asymptomatic, and diagnosis can be delayed for many years [[5–7]]. The diagnosis can be made when a defect of the diaphragm and/or liver parenchyma is observed on imaging studies such as ultrasonography (US) [8], CT [9], isotopic liver tomogram [10] or magnetic resonance imaging (MRI) [11]. Herniation may be difficult to differentiate from an intrathoracic tumor, especially when only a small portion GSK2245840 order of the liver is herniated. In our case, several factors contributed to the difficulty in

making an accurate diagnosis of diaphragmatic hernia. These include small herniation of the liver, concomitant lung cancer with suboptimal resection, and elevated CT density in the herniated portion of the liver. At first, as an intrathoracic tumor or metastasis from a lung cancer was suspected, a PET study was performed. Identical FDG uptake in the intrathoracic lesion to that in the liver was seen, leading to a diagnosis of liver herniation. However, since the patient’s previous lung cancer showed from little FDG uptake, and other neoplasms could not be differentiated solely by PET findings, additional supportive evidence was needed to make a definite diagnosis. US and MRI could not be performed, because of difficulties with the patient’s control of breathing during the examination. As the tumor was adherent to the chest wall, we decided to perform a needle biopsy. This provided a conclusive finding of liver cells without neoplastic tissue thus confirming the diagnosis of liver herniation. The CT findings could be explained by strangulation of the herniated liver likely inducing congestion, which was confirmed at operation. This might have led to the higher density in the herniated portion on CT. Increased FDG uptake in PET is an important finding for differentiating benign lesions from malignant ones and is interpreted by calculation of the SUV [12].