Cyst Aspiration Research Articles

Clinically Benign Cystic Lesions of the Lateral Neck: Road to Malignant Discoveries

Solitary cystic neck lesions as the only presenting feature in adult patients may present diagnostic challenges as the aetiology may be malignant or non-malignant entities. Investigation is usually through radiology and tissue sampling. Subsequent diagnosis of malignancy requires thorough exploration for localization of primary tumour for complete treatment. We report 2 cases of solitary cystic neck lesion subsequently diagnosed as malignancy. First case is a 70-year-old man presented clinically with left branchial cyst. Excision of the cyst revealed papillary thyroid carcinoma. He underwent total thyroidectomy, central and left neck dissection despite no obvious nodule on physical examination or ultrasound. Histologically, no tumour was found on the thyroid or lymph node specimen. The second case is a 48-year-old man presented with painless right neck swelling. Excision showed squamous cell carcinoma arising in a right branchial cyst. Extensive examination did not show any other mass within the head and neck region. However, one year later his right neck swelling recurred. Histological examination confirmed metastatic squamous cell carcinoma to the neck lymph node. He underwent bilateral tonsillectomy and modified radical neck dissection following the finding of occult malignancy. Primary tumour was identified at the tonsil. Malignant cystic neck lesions are not uncommon. Solitary, painless lateral neck cyst in an adult warrant careful and detailed work-up. Aspiration of lateral neck cyst is an effective primary investigation tool prior to embarking on more costly or invasive examination.International Journal of Human and Health Sciences Supplementary Issue-2: 2021 Page: S9

A clinicopathological study of ovarian endometriotic cysts

Endometriosis is an important gynecologic disorder with multifactorial causes, primarily affecting women during their reproductive years. Pathologically, it is the result of functional endometrium located outside the uterus which may vary from microscopic endometriotic implants to large cysts. Endometriotic cysts and infertility is a well-known association. Some patients are asymptomatic while others present with disabling pelvic pain, infertility, or adnexal masses. Cyst aspiration, fenestration and ablation of cyst wall are commonly performed surgical procedures. Excision of the cyst wall is an accepted surgical treatment owing to the low recurrence rates. A total of 35 patients who underwent ovarian cystectomy for endometriotic cysts between January 2019 and December 2020 were retrospectively identified. The clinical findings, gross and histopathological features were noted in each case. Microscopically, the presence or absence of ovarian tissue adjacent to the cyst wall was evaluated. If ovarian tissue was present, the morphologic characteristics were graded on a semi-quantitative scale of 0-4 as described by Muzii et al. The age group of patients ranged between 22-28yrs. Right side cysts accounted for the majority, however 6 cases had bilateral endometriotic cysts. Majority of patients presented with primary infertility (46.2%). The maximum weight recorded for these cysts was 35gm, size ranging between 4.5 to 18cm and median thickness of the cyst wall being 0.7cm. 68% of the cysts showed a lining epithelium, few showing atypia and oncocytic change. Fibrosis and hemosiderin laden macrophages were present in more than 70% of cases and endometrial glands and stroma in more than 50%. Inflammation when present was predominantly lymphocytic. On evaluation of the ovarian tissue, 42.8% of cases showed no follicles and the rest showing grades ranging from 1 to 4, with grade 1 accounting for majority. The present study further emphasizes endometriosis to be an important cause of primary infertility which needs to be recognized and treated appropriately. Recognition of these cysts on histopathological examination can be challenging at times when endometrial stroma is scant and in cases of tubo-ovarian masses where these lesions could mimic malignancy. The excision of endometriotic cyst wall may cause loss of functional ovarian tissue in patients with primary infertility and thus could effect the response to ovarian stimulation, ocyte recovery, implantation and fertilization rates in these patients.

RADI-01. Cystic brain metastases managed with reservoir placement and stereotactic radiosurgery

BackgroundStereotactic radiosurgery (SRS) has become a mainstay of treatment for patients with metastatic brain tumors. However, metastatic tumors with a large cystic component often exceed the size limit for safe and effective SRS. In such cases, surgical resection may not be the preferred first method of treatment, due to tumor location, patient co-morbidities, and patient preference. In such cases volume reduction by cyst aspiration followed by SRS may be a preferred option.MethodsSeven patients were treated with this method. We performed reservoir insertion for the aspiration of cystic component in each patient and followed that with outpatient SRS.ResultsMean overall volume reduction from this treatment method was 80% (range 46.5–94.9). Mean volume reduction from the cyst aspiration alone was 60.7% (range 3.5–90.9), and after SRS a further 71.6% (range 34.6–94.4), accounting for some cyst reaccumulation between the time of surgery and SRS. The interval between those two procedures were 24 days on average (range 11–58 days). Repeat reservoir aspiration was done a total of 10 times in 5 patients.ConclusionCyst aspiration with reservoir placement followed by SRS is a good option for patients with large cystic brain metastases. The reservoir allows for repeat aspiration if needed. Catheter placement at the center of the cyst, and SRS within 2–3 weeks of surgery, can maximize the likelihood of a successful outcome.

Shoulder Pain - Dodgeball

HISTORY: 39-year-old right-handed man presented to clinic for right shoulder pain. Symptoms were present for 4-5 months prior and began several days after playing in a dodgeball tournament. There was no trauma or clear inciting event. Pain was localized to the top of the right shoulder and worse with reaching across the body and with overhead activities. The 3-4 weeks prior to presenting to clinic he noticed a lump and swelling over the top of the shoulder and clavicular region that was not painful to touch. His pain was rated overall 3/10 intensity. PHYSICAL EXAM: Full range of motion of the shoulder in abduction, flexion without pain. Negative empty can test, Hawkins and Neers tests on the right. Speeds test negative on the right. Fullness and bony prominence noted at the distal clavicle on the right shoulder. No focal tenderness at the AC joint. Mild discomfort with scarf test on the right. DIFFERENTIAL DIAGNOSIS: 1. Acromioclavicular joint sprain 2. Acromioclavicular joint arthralgia 3. Distal clavicle osteolysis 4. Osteoid osteoma. TESTS AND RESULTS: Ultrasound right shoulder: Cortical irregularity of the distal right clavicle. XR right shoulder: Distal clavicular ill-defined lytic lesion with apparent cortical breakthrough superiorly and possibly inferiorly. MRI right shoulder: Indeterminate 3.6 cm expansile enhancing lesion with fluid. Biopsy right clavicle with USP6 genotype testing: consistent with an aneurysmal bone cyst FINAL/WORKING DIAGNOSIS: Aneurysmal bone cyst in the distal clavicle TREATMENT AND OUTCOMES: 1. Patient referred to orthopedic oncology and underwent biopsy 2. Underwent aspiration of aneurysmal bone cyst with injection of doxycycline 3. 2 months post-operatively continued to have pain and tightness in the shoulder 4. 5 months post-operatively reported resolution in shoulder pain and improved mobility, interval sclerosis noted of aneurysmal bone cyst on imaging

Shoulder Weakness- Basketball And Weight Lifting

HISTORY: A 32-year-old left handed male with history of two left shoulder dislocations in 2011, managed conservatively, presented to the outpatient sports medicine clinic for evaluation of acute left shoulder weakness. Four days prior he was playing basketball and noted consistently short shots with air balls despite adjustments. Thereafter, he noted left shoulder instability and unsteadiness with front to side lateral shoulder raises, overhead lifting program, and difficulty tightening his belt. The 2-3 months prior he had noted mild dull, achy pain over his left posterolateral shoulder mainly with shoulder presses and running 2-3 miles. PHYSICAL EXAMINATION: Exam demonstrated normal cervical spine range of motion and palpation. Reflexes, sensation, and strength of bilateral upper extremities were normal except for 4-/5 external rotation strength on the left. Bilateral shoulder range of motion was normal. On the left, O’Brien’s, Hawkins, and load and shift were positive. DIFFERENTIAL DIAGNOSIS: . Shoulder labral tear2. Rotator cuff tear3. Brachial neuritis 4. Cervical radiculopathy TESTS AND RESULTS:Left shoulder US:-Glenohumeral joint effusion-Posterior labral tear-Prominent spinoglenoid notch paralabral cyst Left Shoulder MRI:-Posteroinferior glenoid labral tear -Two paralabral cysts. Largest extending into spinoglenoid notch abutting the suprascapular neurovascular bundle, but no supraspinatus or infraspinatus atrophy or edema-Diffuse teres minor muscle edema, which could reflect traction of terminal axillary nerve muscular branch to teres minorLeft upper extremity EMG/NCS-Nerve conduction studies were normal-Needle EMG of deltoid, triceps, biceps, FDI, FCR, and infraspinatus were normal. Teres minor showed evidence of axonal injury, no active denervation, and likely early neurogenic reinnervation. FINAL/WORKING DIAGNOSIS: Neurogenic quadrilateral space syndrome with axillary nerve injury and reinnervation TREATMENT AND OUTCOMES: 1. Meloxicam 15 mg daily for seven days 2. US guided spinoglenoid notch cyst aspiration and steroid injection (done prior to EMG/NCS) 3. Paused upper body weight lifting and running for 1 month 4. Initiated posterior capsule stretching and external rotation strengthening program with improved strength and pain

Termination of Pregnancy with Pseudomyxoma Peritonei Secondary to Ovarian Mucinous Adenocarcinoma: A Video Case Report

A 27-years-old primigravida, at 30 weeks of gestation, was transferred to our tertiary care obstetric centre. On initial assessment, she was found to have fever (38.5 °C), dyspnoea (26 breaths per minute), altered mental status (drowsiness), tachycardia (110 beat per minute) and hypotension (80/50 mmHg). The patient started feeling sick following percutaneous ultrasound (US) guided ovarian cyst aspiration that was performed at an outpatient clinic 2 days before her presentation.

Percutaneous Drainage in Hepatic Hydatidosis-The PAIR Technique: Concept, Technique, and Results

Over decades, surgery has been the only accepted mode of treatment for liver hydatid cysts. It had been a surgical dogma for a long that hydatid disease is an absolute contraindication for needle puncture/aspiration as it can cause anaphylaxis, death, and dissemination. We envisaged prospectively perform percutaneous drainage as a primary form of treatment for hepatic hydatidosis. Through extensive and very careful experimentation, we proved that aspiration of hydatid cysts can be performed safely and is the ideal way to manage a subset of patients with hydatid cysts in the liver. The patient and cyst characteristics good and not good for percutaneous drainage were carefully selected. The procedure of percutaneous drainage of hepatic hydatid cysts involves four sequential steps as defined in the alphabets of the title PAIR, denoting puncture (P), Aspiration (A), Instillation (I), and Reaspiration (R). During and postprocedure, we enforced strict monitoring given the anticipated anaphylaxis. The first PAIR procedure was performed in June 1988. The results of percutaneous drainage of 21 cysts in 12 patients were reported in 1991. Next, a prospective study was done to show that concomitant Albendazole therapy is recommended as an adjuvant to percutaneous drainage for hepatic hydatidosis. In a seminal prospective study comparing percutaneous drainage and surgery, we showed that percutaneous drainage is as good as surgery in the management of uncomplicated hydatid cysts with fewer complications and shorter hospital stays. Lastly, long-term follow-up results of percutaneous drainage on a large cohort of patients with hepatic hydatid cysts were reported, with excellent results and no evidence of local, peritoneal or systemic dissemination. Based on these data percutaneous drainage, the so-called PAIR technique has established itself as a novel therapeutic advance in hepatic hydatid disease.

Percutaneous Ethanol Injection as Treatment for Thyroid Cystic Nodules

Background: Thyroid cystic nodules are common and frequently benign. Aspiration of thyroid cyst decreases compression symptoms and volume. However, they commonly recur, and usually, surgery is required for definitive treatment. A less invasive approach, done less frequent, is percutaneous ethanol injection (PEI), which has shown fewer recurrences than simple aspiration and is well-tolerated with few side effects. We present 2 patients that where treated in our clinic with PEI. Clinical Case: 41-year-old female with a history of primary hypothyroidism on Levothyroxine, with neck discomfort, and no risk factors for thyroid cancer had a cystic thyroid nodule 1.5 x 1.8 x 2.8 cm over the right thyroid lobule. Cytology results reported as Bethesda II. One year later, her thyroid nodule was 1.9 x 2.6 x 3.3 cm. Underwent FNA and 6 cc of dark brown liquid was drained from the cyst which was reported again as Bethesda II. The patient was monitored with thyroid ultrasound after a year, and the cystic nodule was 2.2 x 2.9 x 3.1 cm. PEI was decided as the next approach. After six cc was aspired, 0.5 cc of desiccated ethanol was injected into the remained cystic. Eight months after PEI, cystic size was 0.7 x 0.9 x 0.8 cm. The second case is a 40-year-old female who presented complaining of neck discomfort without changes in her voice. The patient did not have any risk factors for thyroid cancer. Thyroid ultrasound was done, which showed a 2.3 x 2.7 x 3.3 cm cyst on her right thyroid lobe. PEI was arranged and 9 cc of dark fluid was aspirated with a posterior injection of 0.5 cc of desiccated ethanol. Symptoms resolved, and the patient was lost to follow up. Five years later, she was seen again. Neck ultrasound showed a cyst of 0.4 x 0.6 x 0.8 cm on her right thyroid lobe. Neither of the two patients had a side effect associated, and the procedure was well tolerated. Conclusions: Percutaneous ethanol injection is a good alternative in the treatment for cystic thyroid nodules due to decrease in cystic size, which we observed that continued for five years of follow up in one of our patients. These will avoid frequent cystic aspiration secondary to recurrence or invasive surgical management.

Changes in anti-müllerian hormone after ultrasound guided aspiration and ethanol sclerotic therapy of ovarian cyst

ObjectiveTo evaluate the effect of transvaginal ultrasound-guided aspiration and ethanol sclerotherapy on anti-müllerian hormone (AMH) in patients with ovarian endometriomas. Setting: Teaching hospital affiliated with Chang Gung University, Taipei. Material and methodsWe retrospectively reviewed 124 patients, with ovarian endometriomas who underwent transvaginal aspiration and sclerotherapy of endometrioma(s) at a tertiary medical center, Chang Gung Memorial Hospital, Taipei, Taiwan. Preoperative evaluation included AMH, midcycle serum CA-125 level, and ultrasonography to exclude possibility of malignancies. Patients underwent ultrasonographic guided transvaginal aspiration and sclerotherapy with 95% ethanol irrigation of the cystic cavity. Patients were grouped into group 1, n = 44, retention of ethanol, and group 2, n = 80, no retention. Serum AMH level was checked at 6 months after aspiration. Those who were infertile prior to therapy were followed up for subsequent pregnancies (either by assisted reproductive technologies, or by natural conception). ResultsThe mean pre-operative AMH levels for the group without retention of ethanol and with ethanol retention were 3.80 and 3.06 respectively (p > 0.05). The change in AMH at 6-month follow up for retained group patients was significantly more than for non-retained group patients, with mean decrease of 0.72 (23.6%) and 0.10 (2.7%) respectively (p < 0.05). 54.5% (retained) and 47.2% (non-retained) of patients failed to achieve pregnancy during the observation period. ConclusionsTransvaginal aspiration of endometriomas followed by sclerotherapy with ethanol can be effective in preserving ovarian reserve, provided that no ethanol is left in situ.

Prophylactic Antibiotics Do Not Prevent Infectious Complications of Endoscopic Ultrasound Fine-Needle Aspiration of Pancreatic Cysts: A Systematic Review and Meta-Analysis.

Despite limited evidence, endoscopic societies recommend routine use of antibiotic prophylaxis for endoscopic ultrasound fine-needle aspiration of pancreatic cystic lesions. Recent studies suggest lack of benefit in this setting. Our objective is to conduct a systematic review and meta-analysis to assess the efficacy of antibiotics in prevention of infectious complications after ultrasound fine-needle aspiration of pancreatic cystic lesions. A bibliographic search of digital dissertation databases was performed from inception until March 2020. Randomized controlled trials, cohort, and case-control studies that compared prophylactic antibiotics with placebo or no therapy were included in the analysis. The primary outcome was the development of cyst infections. Secondary outcomes were incidence of fever; procedural complications such as bile leak, pancreatitis, or bleeding; and medication-related adverse events. Six studies with a total of 1683 patients were included. The overall incidence of cyst infections was 0.53%. For the primary outcome, there was no significant difference between the 2 groups (odds ratio, 0.54; 95% confidence interval, 0.16-1.82; P = 0.32). No significant difference was noted regarding other complications like fever, pancreatitis, or bile leak. In conclusion, the rate of infectious complications is very low, and antibiotic prophylaxis does not seem to confer any additional benefit in their prevention.

Safety of transvaginal aspiration of cysts in pregnancies complicated with ovarian endometrioma

Pregnancy complicated with ovarian endometrioma is a risk factor for preterm delivery and rupture or infection during pregnancy. This study aimed to clarify the effectiveness and safety of transvaginal aspiration during pregnancy for endometrioma diagnosed in the first trimester. This retrospective observational study included 8 pregnant women with endometrioma who underwent transvaginal cyst aspiration at 12-14 weeks (aspiration group) between March 2011-March 2018 and 23 pregnant women with endometrioma who refused aspiration during the same period (observation group). Characteristics of patients were compared in both groups. Safety, feasability and complications of transvaginal cyst aspiration were reported. Complications and obstetrical outcomes were reported and compared in both groups. The maximum cyst diameter was 8.9±1.5cm (mean ± standard deviation) in the aspiration group, which was significantly larger than that in the observation group (4.7±0.2cm). Four preterm deliveries (17.3%) occurred in the observation group and none in the aspiration group. The emergency cesarean section rate during delivery was 14.2% in the aspiration group and 43.7% in the observation group. The aspiration group tended to have lower rate of preterm deliveries and emergency cesarean sections, suggesting that cyst aspiration could be an effective, minimally invasive, and safe management option for endometrioma during pregnancy.

Radiologically guided percutaneous aspiration and sclerotherapy of symptomatic simple renal cysts: a systematic review of outcomes.

Simple renal cysts are common benign lesions of the kidney with up to 4% of patients developing symptoms necessitating intervention including pain and haematuria. We conducted a systematic review of the literature to determine the efficacy and safety of aspiration-sclerotherapy of symptomatic simple renal cysts. A systematic review using Cochrane guidelines was conducted on published literature from 1990 to 2020. RCTs, cohort studies and case series meeting the inclusion criteria were reviewed and cumulative analysis of outcomes was performed. A total of 4071 patients from 57 studies underwent aspiration ± sclerotherapy for their simple renal cysts. 87.7% of patients who had aspiration with sclerotherapy demonstrated 'treatment success' with a >50% reduction in cyst size and complete resolution of symptoms. 453 minor, transient complications occurred (11.2%) whilst a major complication rate of less than 0.1% (4 patients) was reported. Pooled analysis of all available current literature demonstrates that aspiration-sclerotherapy is a safe and effective first-line therapy for symptomatic simple renal cysts. Although we are unable to compare those undergoing aspiration alone to aspiration-sclerotherapy, it is evident the use of a sclerosing agent is integral to treatment success; however, the optimum agent, volume, injection frequency, and dwelling time are yet to be defined. Cyst size should be considered when discussing treatment options; however, we conclude it reasonable for aspiration-sclerotherapy to be used in the first instance in all cases of symptomatic simple renal cysts. Furthermore, we propose definitions of treatment outcome measures in order to allow direct comparative analysis across future studies.

Immunological detection of human and camel cystic echinococcosis using different antigens of hydatid cyst fluid, protoscoleces, and germinal layers.

Background and Aim:Cystic echinococcosis (CE)/hydatidosis is one of the most prevalent neglected zoonotic diseases. It is initially asymptomatic and does not produce any clinical signs until the cyst becomes enlarged, causing localized pressure on internal organs and tissues. Therefore, the detection of Echinococcus granulosus antibodies is highly essential. This study evaluated the antigens of hydatid cyst fluid, protoscoleces, and germinal layers for efficient immunological diagnosis of CE in humans and camels.Materials and Methods:Hydatid cyst fluid (FLc), protoscoleces (Psc), and the germinal layer (GLc) antigens were prepared from camel-lung hydatid cysts. In the same way, hydatid cyst fluid (FLh) and protoscoleces (Psh) antigens from human-liver cyst aspirate were produced. The comparative immunodiagnostic efficacy of the prepared antigens was verified using indirect enzyme-linked immunosorbent assay (ELISA), SDS-PAGE, and immunoblotting.Results:ELISA proves that FLc and GLc antigens were higher than FLh and Psh antigens. This shows that binding reactivity in naturally infected human sera, camel sera, and Psc is the most potent, exhibiting 100% sensitivity with 78.26% and 76.47% specificity in camel and human sera, respectively. The CE prevalence using diagnostic Psc was 54.79% and 61.32% in tested human and camel sera, respectively. The electrophoretic profiles of all shared antigens showed similarities at 52, 41, and 22 kDa. Immunoblotting demonstrated common immune-reactive bands in all antigen types at 52 and 41 kDa against positive human and camel sera.Conclusion:This immunological study introduces camel hydatid cyst Psc as a potent diagnostic antigen and new immune-reactive fractions of 52 and 41 kDa for diagnosing hydatidosis in humans and camels.

Case Report: Resolution of Hypoglossal Nerve Palsy Following Aspiration of a Branchial Cyst

Abstract Cranial nerve palsies caused directly by branchial cysts is a rare entity. We report a case of hypoglossal nerve palsy in a 47-year-old female with a right anterior neck mass presenting with symptoms of speech disturbances, altered tongue sensation and deviation on protrusion. An ultrasound scan showed a cystic lesion highly suspicious for a branchial cyst, which was confirmed with a head and neck MRI. An ultrasound guided aspiration of the cyst resulted in resolution of the nerve palsy in our patient. There have been cases reported in literature whereby the nerve palsies resolve following surgical excision of the branchial cyst.

Intraoperative Evaluation of a Serous Cystadenofibroma of the Fallopian Tube in a 13-Year-Old Female

Background: Cystadenofibromas (CAFs) are defined as benign mixed mullerian tumors. They are diagnosed mainly in the ovary. Nonetheless, extraovarian locations, such as endometrium, uterine cervix, fallopian tube, and parasalpinx, were reported. Clinical course is commonly asymptomatic, and tumors are often diagnosed on histology after adnexal cyst surgery for benign indications. Case: A 13-year-old female was admitted into our emergency room with acute lower right abdominal pain as her main complaint. Abdominopelvic ultrasonography showed a right adnexal unilocular cyst with small papillary projections on the inner wall of the cyst, with no apparent solid component. Result: During laparoscopy, two cystic masses dependent on the distal region of the right fallopian tube were seen. After fluid aspiration of the first cyst, capsule was opened to see the nodular formations (papillary projections) previously described by ultrasonography. Right salpingectomy was performed due to high suspicion of a borderline tumor. Histopathologic diagnosis was compatible with a serous CAF. Conclusion: In our case we tried an intraoperative evaluation of the inner surface of the cyst, observing papillary projections that were regular and well adhered to their wall. However, microscopic pathology assessment of the tumor is mandatory to have definitive diagnosis. Surgical treatment, especially in child and youth population, should be conservative and adnexectomy should be avoided. Laparoscopic approach is often successful and can be considered in these cases. Although previous published cases were diagnosed in an incidental manner, our case highlights the importance of a thorough intraoperative assessment of adnexal tumors in child and adolescent patients.

CYSTIC BRAIN METASTASIS AS PRESENTATION FOR SMALL CELL LUNG CANCER IN A 25 YEAR OLD FEMALE

SESSION TITLE: Fellows Lung Cancer Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: October 18-21, 2020 INTRODUCTION: Extensive stage small cell lung cancer (SCLC) is associated with brain metastases in 40-50% of cases, usually presenting as solid lesions. Cystic brain metastases in SCLC, however, are extraordinarily rare. We present a case of a previously healthy, non-smoking female who was diagnosed with SCLC with widespread metastatic disease, including cystic brain metastasis. CASE PRESENTATION: A 25 year old female with history of asthma presented with a one month history of headaches, right sided weakness, and episodic twitching. The patient denied smoking and illicit drug use, but admitted to social alcohol intake. Travel history included a trip to Mexico several years prior, but she had no other international travel. After sustaining several unintentional falls at home, she sought neurology evaluation, where brain MRI was performed, which demonstrated multiple ring-enhancing cystic lesions. Lab work was notable for negative HIV testing and negative fungal serologies. Computed tomography of the chest, abdomen, and pelvis revealed an irregular 1.8 x 1.1 x 2.0 cm left upper lobe nodule with a 4.5 x 3.2 x 5.5 cm left hilar mass, numerous liver lesions, and right inguinal lymphadenopathy suspicious for malignancy. The patient underwent liver lesion biopsy which uncovered metastatic, high-grade neuroendocrine carcinoma, and a diagnosis of metastatic SCLC cancer was made. For symptomatic treatment, the patient underwent craniotomy with removal of a 3 x 3 x 1 cm left frontal mass, also consistent with metastatic SCLC. She was referred to oncology and received multiple cycles of systemic chemo-immunotherapy with carboplatin, etoposide, and Atezolizumab. Her most recent brain imaging demonstrates progression despite maintenance immunotherapy for 6 months after initial diagnosis. DISCUSSION: The differential diagnosis for cystic brain lesions includes malignancy, infectious causes, and inflammatory causes such as multiple sclerosis and sarcoidosis. Although cystic brain lesions from NSCLC are a known entity, cystic brain lesions secondary to SCLC are exceptionally rare with only three cases reported in the literature. Treatment of cystic brain metastasis is especially challenging, due to decreased responsiveness to radiotherapy. Treatments may include a combination of whole brain radiation, radiosurgery, neurosurgery, cyst aspiration, and chemotherapy. Combination of cyst aspiration plus radiosurgery is one possible method that may improve morbidity and mortality rather than radiosurgery alone, especially in cases of cysts larger than 10 mL in volume. Based upon experiences with other malignancies, cystic brain metastases confer worse prognosis. CONCLUSIONS: Cystic brain metastases are a rare complication in SCLC and likely associated with poorer outcomes. Currently, there are no general treatment guidelines for cystic brain metastasis. Reference #1: Quan AL, Videtic GM, Suh JH. Brain metastases in small cell lung cancer. Oncology (Williston Park). 2004;18(8):961-987. Reference #2: Kim M, Cheok S, Chung LK, et al. Characteristics and treatments of large cystic brain metastasis: radiosurgery and stereotactic aspiration. Brain Tumor Research and Treatment. 2015 Apr;3(1):1-7. DOI: 10.14791/btrt.2015.3.1.1. Reference #3: Sun B, Huang Z, Wu S, et al. Cystic brain metastasis is associated with poor prognosis in patients with advanced breast cancer. Oncotarget. 2016;7(45):74006-74014. doi:10.18632/oncotarget.12176 DISCLOSURES: No relevant relationships by Sunjay Devarajan, source=Web Response No relevant relationships by Todd Schlossman, source=Web Response

S1407 A Rare Case of Pancreaticobiliary IgG4-Related Disease and Eosinophilic Granulomatosis With Polyangiitis (Churg-Strauss Syndrome)

INTRODUCTION: IgG4-Related Disease (IgG4-RD) is a rare but increasingly recognized condition. It can manifest as pancreatitis and sclerosing cholangitis. Eosinophilic granulomatosis with polyangiitis (EGPA) may increase IgG4 levels but is not associated with IgG4-RD. CASE DESCRIPTION/METHODS: A 42 year old white male with longstanding EGPA on chronic prednisone had progressive malaise, sinopulmonary symptoms, and brief bouts of abdominal pain. He was admitted for an EGPA flare and abnormal liver enzymes. His exam was benign except for RUQ tenderness. Work-up revealed AST 280 U/L, ALT 330 U/L, Alkaline Phosphatase 727 U/L, bilirubin 1.6 mg/dL, ESR 82 mm/hr, and 1220 eosinophils/microL. Autoimmune, viral hepatitis, and infectious workup was negative. Chest x-ray was normal. Ultrasound showed cholelithiasis without cholecystitis or biliary dilation. MRCP showed non-visualization of a 2 cm segment in the common bile duct (CBD), and a 2.1 cm pancreatic tail cyst, prompting EUS/ERCP. Initial EUS was notable for diffuse thickening of the cystic and common bile duct, and intra- and extrahepatic bile duct dilatation and stricturing with a dominant 2 cm CBD stricture without associated mass. Following sphincterotomy, the CBD was brushed and ampulla biopsied (both benign), and CBD and pancreatic duct stented. IgG4 returned 1658 mg/dL (17x normal), and liver enzymes only mildly improved. Follow-up EUS/ERCP showed the 2.2 cm pancreatic tail cyst adjacent to a 21 × 19 mm pancreatic tail mass. Cyst aspirate was consistent with a pseudocyst. Fine needle biopsies of the pancreatic mass showed lymphocytic invasion, fibrosis and sclerosis, consistent with IgG4-RD. Cholangioscopy with Spybite sampling of the CBD stricture showed non-specific inflammatory changes. A percutaneous liver biopsy noted only hepatic steatosis. His sinopulmonary symptoms remained uncontrolled and liver enzymes remained elevated. Rituximab infusions were initiated for both EGPA and IgG4-RD. He had symptom resolution and his liver associated enzymes returned to normal. DISCUSSION: This case demonstrates IgG4-RD with pancreaticobiliary disease in a patient on chronic steroids for EGPA. Bile duct, pancreatic, and liver biopsies all lacked features of EGPA. Pancreatitis and cholangitis are not associated with EGPA. Thus, it is likely the patient had two distinct and rare processes. His chronic steroid treatment for EGPA may have masked longstanding IgG4-RD. Rituximab was shown to be an effective second-line treatment modality for both conditions.Figure 1.: EUS - Significant common bile duct wall thickening at the level of the common bile duct stricture.Figure 2.: ERCP - Areas of dilatation and stricturing/narrowing involving the intra- and extrahepatic bile ducts consistent with cholangitis. A 2cm dominant stricture is noted in the common bile duct.Figure 3.: EUS - A 21 mm × 19 mm distal body/tail mass which underwent fine needle biopsy. Biopsies returned with features of lymphocytic invasion, fibrosis, and sclerosis consistent with autoimmune pancreatitis (IgG4-RD).

Ultrasound-guided aspiration of anterior cruciate ligament mucinous cysts in the posterior intercondylar notch: Technique and short-term outcomes.

To describe our technique of aspirating symptomatic anterior cruciate ligament (ACL) mucinous cysts in the posterior intercondylar notch with ultrasound guidance, and to detail short-term patient outcomes. We identified 13 patients from February 2008 to May 2020 who underwent ultrasound-guided aspiration of symptomatic ACL mucinous cysts in the posterior intercondylar notch. Post-procedural imaging was reviewed to evaluate the degree of cyst decompression. Needle size was noted. Post-procedural symptomatology was also assessed. No or minimal fluid was initially aspirated in 11/13 (84.6%) patients. For the two patients in which the cysts were aspirated completely with initial needle placement, with no need for lavage, a 13-gauge trocar was utilized. Of the remaining cysts, 10/11 were aspirated with an 18-gauge needle and one with a 20-gauge needle. Subsequent lavage was performed in 10 of the remaining 11 patients. After lavage, in eight there was a reduction of at least 50% volume by retrospective image interpretation; of 25% to 50% volume in one patient and of less than 25% volume in one patient. Five of the 13 patients reported immediate post-procedural symptomatic relief. In the other patients, immediate efficacy or post-procedural symptomatology was not documented. Aspiration of symptomatic ACL mucinous cysts is a safe procedure and can provide symptomatic relief that may be temporary, but useful clinically. We recommend needles larger than 18 gauge for the best chance of successful aspiration.

Endoscopic versus stereotactic biopsies of intracranial lesions involving the ventricles

Stereotactic biopsies of ventricular lesions may be less safe and less accurate than biopsies of superficial lesions. Accordingly, endoscopic biopsies have been increasingly used for these lesions. Except for pineal tumors, the literature lacks clear, reliable comparisons of these two methods. All 1581 adults undergoing brain tumor biopsy from 2007 to 2018 were retrospectively assessed. We selected 119 patients with intraventricular or paraventricular lesions considered suitable for both stereotactic and endoscopic biopsies. A total of 85 stereotactic and 38 endoscopic biopsies were performed. Extra procedures, including endoscopic third ventriculostomy and tumor cyst aspiration, were performed simultaneously in 5 stereotactic and 35 endoscopic cases. In 9 cases (5 stereotactic, 4 endoscopic), the biopsies were nondiagnostic (samples were nondiagnostic or the results differed from those obtained from the resected lesions). Three people died: 2 (1 stereotactic, 1 endoscopic) from delayed intraventricular bleeding and 1 (stereotactic) from brain edema. No permanent morbidity occurred. In 6 cases (all stereotactic), additional surgery was required for hydrocephalus within the first month postbiopsy. Rates of nondiagnostic biopsies, serious complications, and additional operations were not significantly different between groups. Mortality was higher after biopsy of lesions involving the ventricles, compared with intracranial lesions in any location (2.4% vs 0.3%, p = 0.016). Rates of nondiagnostic biopsies and complications were similar after endoscopic or stereotactic biopsies. Ventricular area biopsies were associated with higher mortality than biopsies in any brain area.

Use of antibiotic prophylaxis is not needed for endoscopic ultrasound-guided fine-needle aspiration of pancreatic cysts: a meta-analysis

ABSTRACT Background There is limited evidence on the use of antibiotic prophylaxis prior to endoscopic ultrasound-guided fine-needle aspiration of pancreatic cysts. The aim of this meta-analysis was to evaluate the efficacy of antibiotic prophylaxis in this setting. Research design and methods Bibliographic search was performed through January 2020. The primary outcome was infection rate. Additional endpoints were severe infection rate and overall rates of adverse events. Results Six studies, of which one was a randomized controlled trial and five were retrospective, with 1706 patients were included. Most patients were female, and body/tail was the most frequent location of cystic lesions. Overall, eight infectious events were observed in the antibiotic group (0.77%), whereas 12 events were registered in the control group (1.7%), with no difference in terms of infection rate (odds ratio 0.65, 95% confidence interval 0.24–1.78; p = 0.40). Again, no difference was observed between the two study groups in terms of either severe infection (odds ratio 0.88, 0.13–5.82; p = 0.89) and overall adverse event rate (odds ratio 1.09, 0.73–1.65; p = 0.67). Conclusions Prophylactic antibiotics do not seem to substantially reduce the risk of infections after endoscopic ultrasound-guided fine-needle aspiration of pancreatic cystic lesions, and routine use of prophylactic antibiotics should be questioned.