Complex Cystic Mass Research Articles

Diagnostic Contrast-Enhanced Mammography Performed Immediately Prior to Same-Day Biopsy: An Analysis of Index Lesion Enhancement Compared to Histopathology and Follow-up in Patients With Suspicious Ultrasound Findings.

To measure the diagnostic performance of contrast-enhanced mammography (CEM) for the index lesion when it is performed the same day prior to biopsy in patients with suspicious findings at US. This IRB-approved retrospective study compared radiologist original reports of the presence or absence of index lesion enhancement on CEM to biopsy results and follow-up. The most suspicious lesion or the larger of equally suspicious lesions recommended for biopsy by US after a diagnostic workup including mammography was considered the index lesion. CEM exams were performed the same day, immediately prior to the scheduled biopsy, as requested by the radiologist recommending the biopsy. Numeric variables were summarized with means and standard deviations, or medians and the minimum and maximum, where appropriate. Biopsy demonstrated cancer in 64.7% (200/309) of index lesions. Of these, 197/200 demonstrated enhancement for a sensitivity of 98.5% (95% CI: 95.7%-99.7%) (197/200) and the negative predictive value of CEM for non-enhancing index lesions was 95.1% (58/61; 95% CI: 86.1%-98.4%). The three false negative exams were two grade 1 ER+ HER2- invasive ductal cancers that were 6 mm and 7 mm in size, and a 3-mm grade 2 ductal carcinoma in situ in a complex cystic and solid mass. False positive exams made up 20.6% (51/248) of the positive exams. Diagnostic CEM showed high sensitivity and specificity for cancer in lesions with suspicious US findings. CEM may reduce the need for some biopsies, and negative CEM may support a true negative biopsy result.

A Woman With a Complex Cystic Pelvic Mass.

A Woman With a Complex Cystic Pelvic Mass.

Volumetric Quantitative Contrast-enhanced Ultrasonography Evaluation of Complex Renal Cysts: An Adjunctive Metric to the Bosniak Classification System to Predict Malignancy

BackgroundManagement of complex renal cysts is guided by the Bosniak classification system, which may be inadequate for risk stratification of patients for intervention. Fractional tumor vascularity (FV) calculated from volumetric contrast-enhanced ultrasound (CEUS) images may provide additional useful information. ObjectiveTo evaluate CEUS and FV calculation for risk stratification of patients with complex renal cysts. Design, setting, and participantsThis was a pilot prospective study with institutional review board approval involving patients undergoing surgery for Bosniak IIF–IV complex renal cysts. CEUS was performed preoperatively on the day of surgery with two-dimensional (2D) and three-dimensional (3D) imaging and sulfur hexafluoride lipid-type A microspheres as the ultrasound contrast agent. Outcome measurements and statistical analysisA custom MATLAB program was used to select regions of interest on CEUS scans. FV was calculated according to FV = 1 − (total nonenhancing area/total lesion area). We assessed the ability of 2D- and 3D-derived percentage FV (2DFV%, and 3DFV%) and Bosniak classification schemes (pre-2019 [P2019B] and post-2019 [B2019]) to predict malignancy, aggressive histology, and upstaging on surgical pathology. Performance was assessed as area under the receiver operating characteristic curve (AUC). Results and limitationsTwenty eligible patients were included in final analysis, of whom 85% (n = 17) had Bosniak IV cysts and 85% (n = 17) had malignant disease on final pathology. Four (24%) of the malignant lesions were International Society of Urological Pathology grade 3–4. The AUC for predicting malignancy was 0.980, 0.824, 0.863, and 0.824 with P2019B, B2019, 2DFV%, and 3DFV%, respectively. When the Bosniak classification was combined with FV%, three models had an AUC of 1, while the combined 2DFV% + B2019 model had AUC of 0.980. ConclusionsFV is a novel metric for evaluating complex cystic renal masses and enhances the ability of the Bosniak classification system to predict malignancy. This metric may serve as an adjunct in risk stratification for surgical intervention. Further prospective evaluation is warranted. Patient summaryCysts in the kidney are currently classified using a scheme called the Bosniak system. We assessed measurement of the percentage of vascular tissue (called fractional vascularity) in cysts on a special type of ultrasound scan. This promising test adds information when combined with the Bosniak system and can help in guiding appropriate treatment.

S1694 Atypical Presentation of Pancreatic Serous Cystadenoma

Introduction: Pancreatic serous cystadenomas (PSCA) which represent one-third of pancreatic cystic neoplasms are typically benign asymptomatic lesions usually found incidentally on imaging studies at the body or tail of the pancreas. When symptomatic, presents typically with abdominal pain and a palpable mass. We report a case with PSCA presented as chronic diarrhea due to pancreatic duct (PD) obstruction with further enlargement over the years leading to biliary and partial duodenal obstruction. Case Description/Methods: A 65-year-old man with chronic diarrhea and a remote history of Hodgkin’s Lymphoma treated with Mantle and pelvic radiation. Initially diagnosed as radiation enteritis, presented to our clinic with worsening diarrhea, flatulence, bloating, and weight loss. Endoscopic evaluation was negative for celiac disease or microscopic colitis. Diarrhea responded to empiric trial of pancreatic enzymes and he regained weight. CT scan of abdomen done to determine the etiology of exocrine pancreatic insufficiency (EPI) revealed a 3.7 cm complex cystic mass in the in the head of the pancreas with PD dilation and atrophy of the body and tail (Figure). Endoscopic ultrasound showed pancreatic mass with involvement of SMA and portal vein. Fine needle aspiration was not diagnostic. CT-guided biopsy was consistent with PSCA. 4 years later he complained of pale stools and dark urine; labs revealed ALT 495, alkaline phosphatase 463, bilirubin 4.5. MRI showed cyst enlargement to 5.7 cm with biliary dilation. Surgical consultation deemed him not to be a surgical candidate because of radiation induced vascular disease. ERCP with fully covered stent placement led to resolution of symptoms and normalization of liver tests. A year later ERCP with stent exchange showed compression of the duodenum distal to the stent leading to partial obstruction. Discussion: PSCA is usually an incidental finding on imaging studies. EPI is most commonly a result of chronic pancreatitis. Our patient presented with chronic diarrhea due to EPI as a result of PD obstruction by a PSCA. This case underscores the importance of imaging the pancreas in all patients with EPI to evaluate for potential underlying neoplasm causing obstruction of the PD. Our case also highlights that PSCA although benign if in the head of the pancreas can grow in size leading to gastric outlet obstruction and obstructive jaundice which can be associated with significant morbidity if the patient is not a surgical candidate.Figure 1.: There is an approximately 4.0 cm x 3.7 cm ill-defined complex mass in the head of the pancreas.

S1926 A Young Female With Acute Cholangitis Due to Type IVa Choledochal Cyst With an Undifferentiated Spindle and Giant Cell Carcinoma Hiding Inside

Introduction: This patient is being presented to demonstrate the rarity and severity of extrahepatic biliary cystic masses as the primary etiology of acute cholangitis in a young patient, after failing endoscopic stent placement. Case Description/Methods: A 29-year-old female with no medical history presented with 2 days of sharp, epigastric pain radiating to the back associated with fevers and non-bilious vomiting. Patient’s exam noted scleral icterus and abdominal exam showed tenderness to palpation in the right upper quadrant. Labs showed a WBC of 26,300, AST of 114, ALT of 289, ALP of 343 IU/L, and total bilirubin of 9.76 mg/dL. Computed tomography (CT) of the abdomen showed dilated proximal extrahepatic CBD with a large complex cystic mass in the porta hepatitis measuring 10 cm x 9 cm x 8 cm and this was contiguous with gallbladder and proximal common bile duct with mass effect on duodenum and pancreatic head concerning for Type I choledochal cyst. An ERCP showed a significantly dilated CBD with cystic dilation and balloon sweep with 9-10-12 mm balloon catheter was performed with passage of a small stone and pus. Two plastic stents 10 Fr x 7 cm and 10 Fr x 9 cm were placed with appropriate bile drainage. Fevers continued and total bilirubin increased to 14.2 mg/dL and ALP reached 535 IU/L, therefore patient was taken for laparoscopy which showed large choledochal cyst intimately involved with the head of the pancreas and duodenum, necessitating a Whipple procedure for distal margin. Proximal margin entered the left and the right hepatic ducts, consistent with a type IVa choledochal cyst. Anatomic pathology of the 7.0 cm x 6.0 cm x 3.0 cm mass in the cyst showed an undifferentiated spindle and giant cell carcinoma, confined to the bile duct histologically, with lymphovascular and perineural invasion present. There was no gallbladder involvement and 25 lymph nodes were negative for malignancy. The patient improved and was discharged to home after extended recovery (Figure). Discussion: Undifferentiated carcinoma of the extrahepatic biliary system is extremely rare and has been previously found on middle-age to elderly patients. Diagnosis of undifferentiated carcinoma of the extrahepatic biliary system is difficult because the exact diagnosis cannot be determined prior to surgical resection. Patients with undifferentiated carcinoma of the extrahepatic bile duct may have a relatively better prognosis due to the early appearance of jaundice, compared to those with gallbladder involvement.Figure 1.: MRCP of Type IV choledochal cyst

Imaging and Pathological Correlation in Spectrum of Fibrocystic Breast Disease and its Mimics – our Experience

Background: Fibrocystic change (FCC) of the breast is one of the most common benign breast diseases commonly observed between 20-50 years, with a peak in the perimenopausal age group. Patients present with various symptoms such as lump in the breast, mastalgia (commonly related to the menstrual cycles) or nipple discharge. Materials and Methods: In our retrospective study, which included 172 patients, the imaging findings were observed by ultrasound and X-ray mammogram. Based on the Breast Imaging Reporting and Data System (BI-RADS) guidelines given by the American college of Radiology (ACR), our imaging findings were classified as BI-RADS 2 in benign lesions, complicated cysts were classified as probably benign - BI-RADS 3. Indeterminate findings were classified as suspicious lesions and BI-RADS 4a/b/c. Imaging and histopathological correlation was performed. Results: Ultrasound findings revealed diffuse/ bilateral abnormalities with the most common finding being simple cysts followed in descending order by complicated cysts, clustered cysts, complex solid cystic masses, solid lesions, duct ectasia, and intraductal lesions. Mammogram showed dense (type C or D) fibro glandular pattern obscuring the lesions, followed by well-defined / partly obscured opacities. Simple cysts and complicated cysts showed predominant features of cyst formation on HPE. Atypical hyperplasia was seen in ductal and complex solid cystic mass lesions. Conclusion: It is essential for radiologists to be familiar with imaging and pathological findings of fibrocystic disease of the breast for further workup and management.

Undifferentiated embryonal sarcoma of liver arising within mesenchymal hamartoma in a child "case report"

BackgroundPrimary pediatric liver tumors are scarce. Undifferentiated embryonal sarcoma of the liver (UESL) embraces nine to fifteen percent of the pediatric hepatic neoplasms. Mesenchymal hamartoma of the liver (MHL) is the second most prevalent benign pediatric hepatic neoplasm following infantile hemangioendothelioma.Case presentationA 6-year-old female child presented with vague diffuse abdominal pain and palpable right lumbar mass by clinical examination. The US showed a well-circumscribed large right hepatic complex multilocular cystic lesion with multiple internal septations and some turbid loculi. The constellation of CT and dynamic MRI findings raised the presence of atypical suspicious complex cystic hepatic mass lesion with hemorrhagic, calcific entities and internal soft tissue enhancement. The histopathological correlation proved UESL on the background of MHL.ConclusionsA case of a pediatric hepatic complex cystic lesion, which had typical ultrasound features of MHL, however, CT and MRI had atypical suspicious criteria. Finally, our case is presented as UESL in the background of MHL based upon pathological diagnosis. The radiologists must be familiar with overlapped entities between MHL, UESL, and other differential diagnosis entities regarding pediatric hepatic neoplasms.

Pediatric Hepatic Cystic Lesions: Differential Diagnosis and Multimodality Imaging Approach.

When a pediatric hepatic cystic lesion is identified at imaging, the differential diagnosis may be broad, including developmental, infectious, neoplastic, and posttraumatic or iatrogenic causes. The location of a cystic lesion and its number, size, composition, and relationship to the biliary system are features that help in narrowing the differential diagnosis. An incidentally detected simple hepatic cyst is the most commonly encountered. Ciliated foregut cysts are typically located in hepatic segment IVa. The presence of multiple cysts should raise suspicion for fibropolycystic liver disease, a group of related lesions-including biliary hamartoma and choledochal cyst-caused by abnormal embryologic development of the ductal plate. Communication of the cystic lesion with the biliary tree can confirm the diagnosis of choledochal cyst. In a neonate with jaundice, a cystic lesion at the porta hepatis should raise suspicion for choledochal cyst versus cystic biliary atresia. Hepatic abscess can appear cystlike, though typically with internal contents. In an immunocompromised child, multiple cystlike lesions should raise concern for fungal microabscesses. A complex cystic mass in a young child should raise suspicion for mesenchymal hamartoma, which can evolve into undifferentiated embryonal sarcoma if untreated. Hepatic hematoma and biloma can appear cystlike in children with a history of trauma or recent intervention. In neonates with an umbilical vein catheter (UVC), an intrahepatic cyst along the course of the UVC should raise concern for infusate extravasation. Familiarity with imaging findings and clinical features is essential for achieving accurate diagnosis of pediatric hepatic cystic lesions, which in turn can guide appropriate clinical management. Online supplemental material is available for this article. ©RSNA, 2022.

Primary Renal Hydatid in Children

Isolated renal hydatid disease, caused by the larvae of the parasitic tapeworm Echinococcus granulosus is a rare phenomenon and accounts for only 2% of all reported cases. The authors report a case of a 12-year-old female who presented with right flank pain. Initial abdominal ultrasound revealed a complex cystic mass in the upper pole of the right kidney. A contrasted CT scan better defined it as a well-circumscribed cyst with multiple thin septations. Laboratory investigations showed eosinophilia and a positive IgG Echinococcus serology. Considering these radiological and laboratory findings, a tentative diagnosis of primary renal hydatid was made. With perioperative antihelmintic therapy, the authors used a combination of an open puncture-aspiration-injection-reaspiration technique pericystectomy to manage the isolated renal hydatid. Renal hydatid can easily be misinterpreted pre-operatively for more sinister renal cystic pathology, including cystic renal cell carcinoma. An accurate pre-operative diagnosis requires a high index of suspicion, especially in endemic regions. Surgical therapy, with perioperative antihelmintic therapy, offers the best chance of cure.

Primary Renal Hydatid in Children

Isolated renal hydatid disease, caused by the larvae of the parasitic tapeworm Echinococcus granulosus is a rare phenomenon and accounts for only 2% of all reported cases. The authors report a case of a 12-year-old female who presented with right flank pain. Initial abdominal ultrasound revealed a complex cystic mass in the upper pole of the right kidney. A contrasted CT scan better defined it as a well-circumscribed cyst with multiple thin septations. Laboratory investigations showed eosinophilia and a positive IgG Echinococcus serology. Considering these radiological and laboratory findings, a tentative diagnosis of primary renal hydatid was made. With perioperative antihelmintic therapy, the authors used a combination of an open puncture-aspiration-injection-reaspiration technique pericystectomy to manage the isolated renal hydatid. Renal hydatid can easily be misinterpreted pre-operatively for more sinister renal cystic pathology, including cystic renal cell carcinoma. An accurate pre-operative diagnosis requires a high index of suspicion, especially in endemic regions. Surgical therapy, with perioperative antihelmintic therapy, offers the best chance of cure.

Active surveillance versus initial surgery in the long-term management of Bosniak IIF–IV cystic renal masses

There may be surgical overtreatment of complex cystic renal masses (CRM). Growing evidence supports active surveillance (AS) for the management for Bosniak IIF–III CRMs. We aimed to evaluate and compare oncological and pathological outcomes of Bosniak IIF–IV CRMs treated by initial surgery (IS) or AS. We identified retrospectively 532 patients with CRM counseled during 2006–2017. IS and AS were delivered to, respectively, 1 and 286 patients in Bosniak IIF, to 54 and 85 patients in III and to 85 and 21 patients in Bosniak IV. Median follow-up was 66 months (IQR 50–96). Metastatic progression occurred for 1 (0.3%) AS patient in Bosniak IIF, 1 IS (1.8%) and 1 AS (1.2%) patient in Bosniak III and 5 IS (3.5%) patients in Bosniak IV, respectively. Overall 5-year metastasis-free survival was 98.9% and cancer-specific survival was 99.6% without statistically significant difference between IS and AS in Bosniak IIF–IV categories. AS did not increase the risk of metastatic spread or cancer-specific mortality in patients with Bosniak IIF–IV. Our data indicate AS in Bosniak IIF and III is safe. Surgery is the primary treatment for Bosniak IV due to its high malignancy rate.

MP33-04 CONTRAST-ENHANCED ULTRASONOGRAPHY FOR THE EVALUATION OF COMPLEX RENAL CYSTS

You have accessJournal of UrologyCME1 May 2022MP33-04 CONTRAST-ENHANCED ULTRASONOGRAPHY FOR THE EVALUATION OF COMPLEX RENAL CYSTS Cassra Clark, Corinne Wessner, Shuo Wang, Andrew Denisenko, Andrew Shumaker, Joonyau Leong, Andrea Quinn, Erica Mann, Lydia Glick, Timothy Han, Kibo Nam, Katherine Smentkowski, John Eisenbrey, Leonard Gomella, Edouard Trabulsi, Costas Lallas, Mark Mann, James Mark, Flemming Forsberg, Andrej Lyshchik, Ethan Halpern, and Thenappan Chandrasekar Cassra ClarkCassra Clark More articles by this author , Corinne WessnerCorinne Wessner More articles by this author , Shuo WangShuo Wang More articles by this author , Andrew DenisenkoAndrew Denisenko More articles by this author , Andrew ShumakerAndrew Shumaker More articles by this author , Joonyau LeongJoonyau Leong More articles by this author , Andrea QuinnAndrea Quinn More articles by this author , Erica MannErica Mann More articles by this author , Lydia GlickLydia Glick More articles by this author , Timothy HanTimothy Han More articles by this author , Kibo NamKibo Nam More articles by this author , Katherine SmentkowskiKatherine Smentkowski More articles by this author , John EisenbreyJohn Eisenbrey More articles by this author , Leonard GomellaLeonard Gomella More articles by this author , Edouard TrabulsiEdouard Trabulsi More articles by this author , Costas LallasCostas Lallas More articles by this author , Mark MannMark Mann More articles by this author , James MarkJames Mark More articles by this author , Flemming ForsbergFlemming Forsberg More articles by this author , Andrej LyshchikAndrej Lyshchik More articles by this author , Ethan HalpernEthan Halpern More articles by this author , and Thenappan ChandrasekarThenappan Chandrasekar More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002587.04AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Complex renal cysts are evaluated using the Bosniak classification system. However, they remain difficult to manage because inter-reader variability and subjective interpretation of the Bosniak system. This pilot study intends to evaluate the use of contrast-enhanced ultrasonography (CEUS) to differentiate the solid and cystic components of complex renal cysts and compare these results to the final surgical pathology report. METHODS: 23 patients undergoing surgery for Bosniak 2F-4 lesions participated in this IRB-approved pilot study. Patients were scanned prior to surgery with both 2D and 3D ultrasound exams. Each injection consisted of a 2.0 mL bolus injection of Lumason contrast (Bracco Imaging, Monroe Township, NJ) followed by a 10 mL saline flush. A custom MATLAB program was used for selection of regions of interest (ROIs) (Figure 1). Fractional tumor vascularity (FTV in %) was then calculated and compared to estimated solid component on the final pathology report.Fractional Tumor Vascularity = 1 − (Total Non-enhancing area/Total lesion area) The primary endpoint of this study was the correlation of 2D/3D-derived fractional vascularity with pathological estimation and tumor staging on explant. RESULTS: No adverse events were observed during any contrast agent administration. Data was analyzed on 22 of 23 patients (Patient 22 excluded due to poor image quality). Mean age was 60.9±15.0 years (range 30 to 85) and mean preoperative lesion size was 4.0±1.6 cm (range 1.2 to 8.3 cm). Nine patients had radical nephrectomies and 14 had a partial nephrectomy. On final pathology, 4 lesions were benign and 19 were malignant. The results of 2D and 3D analysis as well as final pathology are included in Table 1. In general, malignant lesions and more aggressive histology had higher FTV. CONCLUSIONS: Quantitative 2D and 3D CEUS can evaluate FTV of potentially malignant complex cystic renal masses, which may be able to augment current radiographic classification systems. Source of Funding: N/A © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e570 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Cassra Clark More articles by this author Corinne Wessner More articles by this author Shuo Wang More articles by this author Andrew Denisenko More articles by this author Andrew Shumaker More articles by this author Joonyau Leong More articles by this author Andrea Quinn More articles by this author Erica Mann More articles by this author Lydia Glick More articles by this author Timothy Han More articles by this author Kibo Nam More articles by this author Katherine Smentkowski More articles by this author John Eisenbrey More articles by this author Leonard Gomella More articles by this author Edouard Trabulsi More articles by this author Costas Lallas More articles by this author Mark Mann More articles by this author James Mark More articles by this author Flemming Forsberg More articles by this author Andrej Lyshchik More articles by this author Ethan Halpern More articles by this author Thenappan Chandrasekar More articles by this author Expand All Advertisement PDF DownloadLoading ...

Ruptured endometrioma in a nonpregnant patient: a case report

BackgroundEndometriomas are a type of ovarian cyst composed of degenerated blood products from hemorrhage of ectopic endometrial tissue. Endometriomas can rupture, causing hemoperitoneum, and present with signs and symptoms similar to other, more common abdominal emergencies. Therefore, they are not often diagnosed preoperatively. Ultrasound and cross-sectional imaging can assist in diagnosis of endometriomas. We present a case of ruptured endometrioma causing massive hemoperitoneum that was initially suspected to represent malignancy with carcinomatosis.Case presentationA 32-year-old Hispanic woman presented with sharp abdominal pain and 15-pound unintentional weight loss over 6 months. Laboratory work was significant for a negative pregnancy test and elevated cancer antigen-125. Computed tomography of the abdomen and pelvis demonstrated a 13-cm complex cystic mass in the left adnexa with moderate hyperdense ascites and omental nodularity. Ultrasound demonstrated a large left adnexal complex cystic structure with internal echoes, and chest computed tomography showed no signs of intrathoracic neoplastic or infectious processes. Her presentation was concerning for malignancy with carcinomatosis. Fluid from a paracentesis was sent for culture and cytology. Diagnostic laparoscopy revealed that the left ovary had been completely replaced by an endometrioma, which had a small ruptured area superiorly. Brown deposits of endometriosis were present on the cyst, omentum, and various peritoneal linings. Tissue samples of the endometrium, myometrium, cervix, ovaries, fallopian tubes, peritoneum, omentum, and paracolic spaces were taken and showed no hyperplastic, dysplastic, or malignant cells on pathology.ConclusionsRuptured endometrioma and ruptured hemorrhagic cyst should be included in the differential diagnosis when a premenopausal female presents with hemoperitoneum in combination with complex adnexal cystic masses in the absence of trauma. Cancer antigen-125 and cancer antigen 19-9 can be falsely elevated in the setting of ruptured endometrioma.

Complex Cystic Breast Masses: An Ultrasound Imaging Review

Cystic lesions are very commonly encountered entities in the breast. Among these, Complex Cystic Breast Masses (CCBMs), which contain both anechoic and echogenic components, can result in a variety of imaging appearances. These include cystic lesions with thick walls and/or internal septa, intracystic nodular lesions, and solid-cystic masses of varying compositions. Ultrasound is the mainstay for evaluating cystic lesions, and thus recognizing the imaging features appropriately and suggesting suitable interventional procedures are included in their management. In this pictorial essay, we describe the wide range of ultrasound appearances of CCBMs with a number of clinically encountered examples from our institution. This article would enhance the understanding of readers in possible differentials to be included in their clinical practice and to suggest appropriate further intervention, when deemed necessary.

A Prospective Evaluation of Laparoscopic Management of Renal Hydatidosis: Our Experience

Introduction: Hydatid cyst is a parasitic disease affecting various organs like liver, lungs, spleen or rarely kidneys, caused by the tapeworm Echinococcus granulosus. Its presentation may be atypical leading to diagnostic and management difficulties. A high index of suspicion for hydatid disease should be maintained while evaluating complex cystic renal masses. Accurate diagnosis of primary renal hydatid disease is difficult in spite of latest imaging modalities. With the technological advancements and increasing experience in laparoscopy, nowadays renal hydatid disease has been reported to be managed by transperitoneal and retroperitoneal laparoscopic approach. Objective/Aim: To present a prospective evaluation of renal hydatidosis managed laparoscopically. Material Methods: All 22 consecutive patients underwent laparoscopic management of renal hydatid disease from August 2019 to July 2021. Prior to surgery all patients were preoperatively evaluated with CT urography. All patients were operated with total laparoscopic transperitoneal route by standard three ports as for renal surgery. Patients demographic and perioperative data were recorded prospectively and analysed. Outcome measures were demographic data, perioperative data, complications and follow-up at 12 months. Results: The mean operative time was 190.3 minutes and average blood loss was 180.4 ml in our study. There were 4 cases converted to open method in our study. There were 7 cases managed with cyst excision, 3 cases managed with cyst deroofing and marsupilisation, 9 cases required pericystectomy and 3 cases required nephrectomy as there was no salvageable parenchyma in our study. Conclusion: Laparoscopic treatment of renal hydatid cyst is safe, feasible and effective due to its advantages to open surgery, if surgical expertise is available. It can minimize morbidity, as surgery is the treatment of choice.

Undifferentiated Embryonal Sarcoma of the Liver: A Case Report

Undifferentiated embryonal sarcoma of the liver((UESL) is a very rare primary hepatic tumor, of mesenchymal origin. Primary malignant mesenchymal tumors of the liver are relatively rare compared with carcinomas originating from hepatocytes or cholangiocytes. UESL is usually observed in children, and cases of adults are very uncommon. It was first reported in 1978. Because of rarity of the disease, there were few reported cases. Herein we report an our experience of UES of the liver patient. A 33-year-old woman visit our outpatient department presented with epigastric pain for 2 weeks. Huge complex cystic mass of the left liver(about 12cm) was identified on computed tomography(CT) of the abdomen. Compared with CT of 8 months ago, the size of the lesion was increased by 5 cm. Her laboratory study including tumor marker at initial presentation revealed no abnormal findings. We considered the lesion to be a complicated hepatic cyst. Since an increase in the size of the lesion was observed and she also had epigastric pain, we decided to proceed with surgery. We performed laparoscopic left hepatectomy. Microscopically, the tumor was composed of spindle cell proliferation, nuclear pleomorphism, myxoid stroma and frequent mitosis. The pathologic report revealed undifferntiated embryonal sarcoma. This case presented as a cystic lesion in the liver and had typical histological features of UESL. It is a rare case of a malignant pediatric tumor occurring in an adult patient.

Case Report: Acute abdomen presentation revealing a metastatic invasive mole with uterine rupture

Gestational trophoblastic neoplasia refers to the aggressive subset of gestational trophoblastic disease, including invasive mole, choriocarcinoma, placental site trophoblastic tumor, and epithelioid trophoblastic tumor. These tumors may have atypical clinical presentations that can mislead the diagnosis. The reported case is a 48-year-old woman in perimenopause, without any history of vaginal bleedings nor molar pregnancy, who presented to the Emergency Department with acute abdominal pain. Serum beta human chorionic gonadotropin (β-HCG) was highly elevated at 261 675.23 mIU/ml. A complicated invasive mole was suspected, and an abdominal computed tomography was performed, showing a moderate hemoperitoneum associated to complex cystic and solid uterine mass, with a common left iliac adenomegaly and multiple pulmonary nodules. MRI showed a multiloculated cystic uterine mass with zones of hemorrhage recalling an invasive mole with perforation of the posterior uterus wall, associated to a high abundance hemoperitoneum. The diagnosis of a metastatic invasive mole complicated of uterine rupture and hemoperitoneum was retained. A surgical intervention was decided immediately and a subtotal hysterectomy with bilateral annexectomy was done. Pathologic examination of the specimen was positive for an invasive mole. The patient was proposed for chemotherapy. This case study will increase awareness of unusual clinical presentations of gestational trophoblastic neoplasia We believe that our case will contribute to the literature not only because of the rarity of this entity in perimenopausal period, but also due the atypical clinical presentation as acute abdomen without vaginal bleeding nor history of molar pregnancy evacuation

EP018 - Diagnostic performance of contrast-enhanced ultrasonography for the evaluation of malignancy in complex cystic masses

EP018 - Diagnostic performance of contrast-enhanced ultrasonography for the evaluation of malignancy in complex cystic masses

A Rapidly Enlarging Ovarian Cyst in a Pregnant Patient: The Surprise

Introduction: More than 90% of ovarian tumors during pregnancy are less than 5 cm in size and are generally absorbed spontaneously before the 16th week of pregnancy. A big, rapidly enlarging ovarian tumor during pregnancy is an extremely rare finding and when present, should raise suspicion for malignancy. We present a case of a rapidly enlarging ovarian mass that, surprisingly, turned out to be a benign tumor. Case Presentation: 23-year-old pregnant, G3P1101, at 13 weeks of pregnancy, that came to the emergency department for evaluation of abdominal pain. Patient reported she was experiencing a left lower quadrant abdominal pain. Pain was cramping, and was radiating to the back. No vaginal bleeding, nausea, vomiting or urinary complaints associated with it. Abdominal exam demonstrated a gravid uterus, and a soft abdomen with mild left pelvic tenderness to palpation. Initial pelvic ultrasound (US) showed a single live intrauterine pregnancy along with a 9.6 cm thin walled anechoic left ovarian cyst (Image 1). At 22 weeks of gestation, her uterine height was noted to be much greater than expected for her gestational age and repeat US showed the cyst was 13 cm in size (Image 2). Subsequently, ultrasound done at 26 weeks of gestation showed a left ovarian cyst of 18 cm which contained a 7 cm multiseptated avascular daughter cyst (Image 3). CA 19-9, CA-125, and inhibin A were elevated. CEA and AFP were normal for this stage of pregnancy. After this, a transvaginal US showed a huge, complex cystic mass in the left adnexa measuring 21.6 cm, with a solid portion seen in the cranial aspect of the cystic mass. Because of the rapidly enlarging nature of this mass, a concern for malignancy was raised. Betamethasone was given for fetal lung maturation and patient underwent emergent exploratory laparotomy. A 20-cm left ovarian mass adherent to the retroperitoneum was found and removed. The pathology results were significant for a mucinous cystadenoma. The patient proceeded with the remainder of the pregnancy delivered a viable newborn at 40 weeks via spontaneous delivery. There were no complications following the delivery and both mother and baby are doing well. Discussion: There are many cases describing rapidly enlarging malignant tumors during pregnancy. But, there are not many cases describing rapidly enlarging benign tumors during pregnancy. Balci et al. published a series of 36 cases of pregnancies with adnexal masses, comprising patients over a 6-year period, and only 1 case of adnexal masses requiring surgery turned out to be a mucinous cystadenoma. The pathogenesis of mucinous cystadenomas and the mechanism by which these tumors may grow rapidly during pregnancy is unknown. A possible theory is that these tumors may be positive for hormonal receptors. However, there are cases of receptor-negative tumors that expand rapidly during pregnancy as well. More study is needed to understand the origin and mechanism by which these tumors may grow rapidly, as this is unknown and may have significant implications in terms of management. Conclusions: Even though a rapidly enlarging ovarian tumor during pregnancy may raise suspicion for malignancy, there is still a possibility to find a benign tumor. This is extremely rare, but, more study regarding these tumors is needed so that a timely management can be instituted to avoid miscarriages, intra-uterine growth restrictions, and other obstetrical complications.

S2613 Management and Outcomes of Complex Cystic Masses With Malignant Transformation

Introduction: Liver cysts are generally simple and benign; we describe the presentation and outcomes of 3 patients with rare complex cystic tumors that emphasize the broad differential diagnosis for this condition. Case Description/Methods: The records of 3 patients were reviewed with respect to presenting symptoms, their management and clinical outcomes. A 47 year old male with a history of pancreatic neuroendocrine tumor and liver metastases underwent a multivisceral transplant including the liver. Three years later he complained of postprandial right upper quadrant (RUQ) and chest pain. A new 13 cm cystic lesion was found in his liver. Surgical resection of the mass was performed revealing an angiosarcoma with epithelioid features. The patient’s condition rapidly deteriorated with weakness and muscle wasting. Given the aggressive nature of the tumor and patient debility, the patient was admitted to hospice. A 38 year old female presented with postprandial RUQ pain and CT showed a 2.5 cm complex cystic liver mass with growth compared to prior imaging. The mass was surgically removed. Pathology showed a mucinous cystic tumor with a few foci of high grade neoplasia. Follow-up imaging shows continued resolution of disease without need for adjuvant therapy. The third case, a 63 year old female, has a history of hypothyroidism and an asymptomatic 4 cm complex liver cyst for a decade until it rapidly started growing to 7.6 cm with RUQ pain. Laparoscopic marsupialization with fenestration revealed a biliary cystadenoma. Follow up imaging showed a 4 cm cystic area secondary to residual inflammation. Discussion: The majority of hepatic cysts are benign and less than 5 % are malignant. Imaging characteristics may provide insight into discerning benign epatic cysts from malignant ones. Complex cysts have many septations and contain hemorrhagic or proteinaceous fluid. Biliary cystadenoma, which is premalignant, and biliary cystadenocarcinoma usually present as complex cysts. Mucinous cystic neoplasms of the liver are very rare, usually complex, premalignant, yet definitive diagnosis is challenging. Primary hepatic angiosarcomas are seen in middle aged patients; these have a propensity for local recurrence and malignant change. These cases emphasize the importance of the follow up and an early intervention of incidentally found hepatic large complex cysts.