Enlarged Retroperitoneal Lymph Nodes Research Articles

Persistent Abdominal Pain with an Uncommon Presentation of Multiple Myeloma: A Case Study

Multiple myeloma (MM) is a widespread malignant condition characterized by the proliferation of transformed plasma cells in the bone marrow, disrupting its normal functions and infiltrating adjacent bone tissues. While typically confined to the bone marrow, in rare instances, patients may develop extramedullary disease. In these uncommon scenarios, the involvement of lymph nodes poses a diagnostic challenge for practitioners in their daily routines. This report details the case of a 49-year-old male experiencing chronic abdominal pain. A computed tomography (CT) scan revealed enlargement of retroperitoneal and mesenteric lymph nodes. Biopsies confirmed a plasma cell infiltrate positive for CD138 and kappa light chain, leading to the diagnosis of multiple myeloma with extramedullary localization in lymph nodes. Our case underscores the rare presentation of extramedullary involvement in multiple myeloma, characterized by an atypical clinical manifestation.

Retroperitoneal lymphadenopathy: An underappreciated contributor to acute kidney failure in patients with cancer

Introduction: Retroperitoneal lymphadenopathy represents a unique and infrequent complication within various malignancies. This case report exemplifies the intricate diagnostic challenges that arise when identifying nondilated obstructive nephropathy in the context of retroperitoneal lymphadenopathy due to diffuse large B-cell lymphoma (DLBCL), particularly when conventional imaging fails to reveal the hallmark feature of hydronephrosis. Case description: We present a 66-year-old male with relapsed chronic lymphocytic leukemia post-allogeneic stem cell transplantation. His direct admission to the hematology/oncology service was due to failure to thrive. Despite the absence of hydronephrosis on imaging, the patient developed volume overload and increased serum creatinine levels. An ultrasound unveiled mild bilateral collecting system dilation, while laboratory findings did not provide valuable insight into the underlying etiology. A Lasix renal scan confirmed split renal function with minimal bilateral excretion. High clinical suspicion resulted in an MRI scan showing interval enlargement of retroperitoneal lymph nodes and pelvicaliectasis, which prompted urological and interventional radiology involvement. Conclusions: This case underscores the complexity of diagnosing retroperitoneal lymphadenopathy and pelvicaliectasis, in DLBCL, particularly when hydronephrosis is absent on imaging. It emphasizes the significance of clinical acumen, collaboration among specialties, and the use of advanced imaging techniques. Timely recognition of nondilated obstructive nephropathy in the setting of retroperitoneal lymphadenopathy is pivotal for guiding appropriate management strategies and optimizing patient outcomes in the intricate clinical setting.

Imaging Appearance of Enlarged Cisterna Chyli Mimicking Retroperitoneal Nodal Disease; A Rare Case Report

It is very common to see enlarged retroperitoneal lymph nodes. However there are circumstances where we report an enlarged retroperitoneal lymph node that is actually not pathological rather an enlarged cisterna chyli mimicking retroperitoneal nodal disease. A case report of a patient with known hepatocellular carcinoma, CT scan triphasic liver was performed and a finding was made with enlarged retroperitoneal lymph node involved by the disease process, however MRI and FNAC correlation was advised, which turned out to be an enlarged cisterna chyli rather than enlarged retroperitoneal node.

A Unique Case of Large Pelvic Non-Hodgkin Lymphoma

Introduction: Non-Hodgkin lymphoma (NHL) represents a diverse group of malignancies arising from lymphocytes and lymphoid tissues. It encompasses multiple subtypes, including the aggressive diffuse large B-cell lymphoma (DLBCL), which is the most common type of NHL in adults. DLBCL typically presents as a rapidly growing mass in the lymph nodes or extranodal sites. While DLBCL can affect various regions of the body, its occurrence in the pelvic region is infrequent and poses unique diagnostic and therapeutic challenges. Case Description: We present a rare and intriguing case of a 51-year-old female admitted for acute on chronic microcytic anemia, with accompanying symptoms of decreased oral intake due to nausea, and vomiting, significant weight loss, night sweats, and lower quadrant abdominal pain. Additionally, she reported decreased urinary frequency, urgency. CT imaging of the abdomen and pelvis revealed a large soft tissue mass measuring 7.6 x 4.6 x 5.7 cm in the posterior right pelvic region, resulting in severe hydroureteronephrosis, along with bilateral iliac chain adenopathy, retroperitoneal lymph node enlargement, and severe splenomegaly. CT chest revealed several small lung nodules indicating distant metastasis. Additionally, the patient exhibited elevated levels of LDH, CA 199, and CRP, and decreased hemoglobin levels, indicating the presence of systemic disease. A CT-guided biopsy of the right pelvic mass confirmed the diagnosis of non-Hodgkin malignant lymphoma, specifically of the diffuse large B-cell type. Immunohistochemistry and flow cytometry demonstrated CD20 positivity in the proliferating large cells, consistent with DLBCL, and revealed a kappa-restricted B-cell population expressing CD19, CD20, and kappa surface immunoglobulin light chains. The PET scan showed prominent splenomegaly, adenopathy, and retroperitoneal involvement, corroborating the lymphoma diagnosis. The patient was discharged for outpatient follow-up with oncology with a treatment plan of R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone) administered every 3 weeks, omitting rituximab during the first cycle. Discussion: This case stands out due to the unusual presentation of a large DLBCL in the pelvic region, which is a relatively rare occurrence. The localization of DLBCL in the pelvis poses a diagnostic challenge, as symptoms may overlap with various other conditions. Moreover, the extensive involvement of the retroperitoneal lymph nodes and splenomegaly added complexity to the management of the disease. The rarity of DLBCL in the pelvis highlights the importance of considering lymphoma in the differential diagnosis of patients presenting with non-specific pelvic symptoms and acute anemia. Early recognition of such cases is crucial for timely intervention and optimal treatment planning. Understanding the immunophenotypic characteristics of the tumor is essential for tailoring effective therapeutic strategies. This unique case sheds light on the need for further research and evidence-based guidelines for managing NHL in uncommon anatomical locations, promoting better patient outcomes and quality of life.

Diagnostic role of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) in abdominal lymphadenopathy of unknown etiology.

Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is an established method for the evaluation of abdominal organ lesions. However, there are few studies on EUS-FNA for abdominal lymph node (LN) lesions. The purpose of this study was to evaluate the diagnostic role of EUS-FNA in isolated abdominal lymphadenopathy (LAP). A retrospective analysis was performed on patients with isolated abdominal LAP who underwent a EUS-FNA examination. The diagnosis was made based on cytology, histology, and immunohistochemical (IHC) studies. The area under curve (AUC) value, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy were calculated. A total of 99 patients were included in this study. The final diagnoses were metastatic tumor (n = 32), lymphoma (n = 32), tuberculosis (n = 17), sarcoidosis (n = 5), castleman's disease (n = 1), and reactive LAP (n = 12). The AUC value, sensitivity, specificity, PPV, NPV, and accuracy of EUS-FNA in the diagnosis of malignant LAP were 0.9531, 90.6, 100, 100, 85.4, and 93.9%, respectively. For the diagnosis of lymphoma, the accuracy of EUS-FNA combined with IHC staining was 94.9%. Retroperitoneal LN enlargement is more commonly associated with lymphoma, while hepatic hilar LN enlargement predominantly suggests benign conditions or metastatic tumors. Malignant lymph nodes are more likely to be regular border, circular/quasi-circular, and fusion. Lymphomas are more likely to present with fusion and heterogeneous echogenicity than metastatic tumors. EUS-FNA is a safe and effective method to diagnose isolated abdominal LAP.

Retroperitoneal germ cell tumor, primary or secondary: A diagnostic conundrum

Abstract Germ cell tumor, seminoma, is the most common cancer in young men’s testis. However, a small subset of tumors (1%–2%) originate in other locations and are referred to as primary extragonadal germ cell tumors. But such type of tumors’ origin is thought to be controversial as a significant bulk may represent metastases from primary occult/regressed testicular germ cell tumors. The entire primary extragonadal germ cell tumor is mostly non-seminomatous and present in higher ages than primary testicular germ cell tumors, most of which are seminoma. A 50-year-old male presented with a brief history of abdominal pain for 10 days. Ultrasonography of his abdomen revealed multiple enlarged retroperitoneal lymph nodes. Biopsy and immunohistochemistry of the left iliac node showed features consistent with metastatic seminoma. Ultrasound of the left testis showed a hypoechoic lesion. Positron emission tomography scan showed increased tracer uptake in both the testes without any abnormal enhancing mass lesion and increased fluorodeoxyglucose uptake in the retroperitoneal lymph nodes. A high left inguinal orchidectomy revealed no tumor but a fibrotic scar tissue showing atrophic and ghost tubules, dense lymphoplasmacytic cells, and increased vascularity, implying regressed (burnt-out) seminoma. Regression of testicular seminoma shows a distinct constellation of findings permitting its diagnosis as a primary testicular tumor, which is imminent from a prognostic and therapeutic perspective.

Construction of a nomogram model for predicting peritoneal metastasis in gastric cancer: focused on cardiophrenic angle lymph node features

BackgroundA different treatment was used when peritoneal metastases (PM) occurred in patients with gastric cancer (GC). Certain cancers' peritoneal metastasis could be predicted by the cardiophrenic angle lymph node (CALN). This study aimed to establish a predictive model for PM of gastric cancer based on the CALN.MethodsOur center retrospectively analyzed all GC patients between January 2017 and October 2019. Pre-surgery computed tomography (CT) scans were performed on all patients. The clinicopathological and CALN features were recorded. PM risk factors were identified via univariate and multivariate logistic regression analyses. The receiver operator characteristic (ROC) curves were generated using these CALN values. Using the calibration plot, the model fit was assessed. A decision curve analysis (DCA) was conducted to assess the clinical utility.Results126 of 483 (26.1%) patients were confirmed as having peritoneal metastasis. These relevant factors were associated with PM: age, sex, T stage, N stage, enlarged retroperitoneal lymph nodes (ERLN), CALN, the long diameter of the largest CALN (LD of LCALN), the short diameter of the largest CALN (SD of LCALN), and the number of CALNs (N of CALNs). The multivariate analysis illustrated that the LD of LCALN (OR = 2.752, p < 0.001) was PM’s independent risk factor in GC patients. The area under the curve (AUC) of the model was 0.907 (95% CI 0.872–0.941), demonstrating good performance in the predictive value of PM. There is excellent calibration evident from the calibration plot, which is close to the diagonal. The DCA was presented for the nomogram.ConclusionCALN could predict gastric cancer peritoneal metastasis. The model in this study provided a powerful predictive tool for determining PM in GC patients and helping clinicians allocate treatment.

Intriguing Umbilical Nodule.

A 68-year-old male patient presented with an asymptomatic hyperpigmented lesion on the umbilicus for the last 2 months. The patient complained of a vague feeling of lower abdominal discomfort and significant weight loss for a few months. On examination, there was a hyperpigmented non-tender, stony hard noduloplaque with peripheral erythema and oozing, crusting on the surface, in the umbilical region. No lymph nodes were palpable [Figure 1]. Biopsy revealed diffuse infiltration of the dermis by neoplastic cells arranged in variable-sized solid cords and at places having an ill-formed glandular pattern with lumina containing necrotic debris, findings consistent with cutaneous metastasis from an adenocarcinoma [Figures 2 and 3]. The CT scan of the abdomen/pelvis revealed primary involvement of the body of the pancreas with metastatic deposits involving the liver, perihepatic soft tissues, mesentery, seminal vesicles with extension into adjacent mesentery abutting the anterior surface of the rectum/rectosigmoid junction and umbilicus/peri-umbilical region. A few enlarged retroperitoneal lymph nodes were seen close to the mass. Similarly, enlarged lymph nodes were also present bilaterally in the inguinal region. The clinicians must keep in mind the possibility of cutaneous metastasis from an internal organ whenever they come across an unusual nodule or a seemingly eczematous plaque in the umbilical region.[1,2]Figure 1: Nodular lesion with a hyperpigmented oozy crusted surface and peripheral erythemaFigure 2: Diffuse infiltration of the dermis with solid cords and ill-formed glandular structures [H&E × 40]Figure 3: Ill-formed glandular structures with cells showing cytological atypia [H&E × 400]Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Aorto-enteric fistula: a case report

A case report focused on imaging aspects of an aorto-enteric fistula (AEF) in a 39-year-old patient with a recent diagnosis of classic Hodgkin Lymphoma with multiple enlarged retroperitoneal lymph nodes. AEF is a pathologic communication between the aortic lumen and any portion of the gastrointestinal tract. Without prompt intervention, the associated mortality approaches 100%. Early clinical suspicion is essential for a successful outcome and the role of imaging is fundamental to diagnose it. Owing to its widespread availability, short acquisition time, and high resolution, CT with intravenous contrast has become the first-line modality for imaging evaluation of suspected aorto-enteric fistula.

THROMBOEMBOLISM AS THE INITIAL MANIFESTATION OF CHRONIC LYMPHOCYTIC LEUKEMIA

THROMBOEMBOLISM AS THE INITIAL MANIFESTATION OF CHRONIC LYMPHOCYTIC LEUKEMIA

S3659 Primary Gastric Squamous Cell Carcinoma With Concurrent H. pylori Infection and Colonic Metastasis

Introduction: Primary gastric squamous cell carcinoma (PGSCC) is a rare, aggressive, malignancy that cannot be distinguished from other gastric malignancies clinically and therefore, requires EGD with biopsy and pathology. H. pylori infection is a known risk factor for gastric malignancies but, only one case has been reported with an association between the two. Case Description/Methods: 66-year-old Hispanic male, with no significant medical, family, or social history presented to the hospital with syncope. Further history revealed three weeks of melena, fatigue, exertional dyspnea, and 50 lb weight loss. Upon evaluation, the patient was found to have HGB of 3.2. CT abdomen with contrast showed a mass in the antrum of the stomach, most prominent posteriorly and around the greater curvature. EGD revealed normal esophagus and a 15 cm, oozing, fungating, and partially circumferential gastric mass. It was located in the antrum, involving the entire posterior wall with extension into the greater curvature. The gastric mass was 5 cm below the GE junction, without evidence of esophageal involvement. Biopsy of the mass revealed poorly differentiated squamous cell carcinoma and Helicobacter pylori infection. Colonoscopy then revealed a 4 cm lesion near the splenic flexure which was confirmed to also be poorly differentiated squamous cell carcinoma. The patient was placed on triple therapy for his H. pylori infection. PET scan showed known gastric and colonic mass with multiple enlarged and hypermetabolic perigastric and retroperitoneal lymph nodes consistent with metastasis. He was seen by oncology and started on systemic chemotherapy (Figure 1). Discussion: PGSCC is a rare form of gastric malignancy accounting for roughly 0.2% of primary gastric cancer reported. Compared to the more common gastric adenocarcinoma, SCC tends to be more aggressive with poorer outcomes. Unfortunately, the pathogenesis remains obscure, making early detection difficult. Our case was associated with H. pylori infection which is one of the most significant risk factors for the development of gastric cancer due to the chronic inflammation caused by infection. Additionally, metastasis to the colon is exceptionally rare with most cases metastasizing to liver, peritoneum, lung and bone. Further investigation and studies are needed to understand this rare disease.Figure 1.: Primary gastric tumor (left panel), submucosal colonic mass (right panel).

S1956 An Unsuspecting Mimicker: Pancreatic Metastases Imitating as an Autoimmune Pancreatitis

Introduction: Auto-immune pancreatitis (AIP) is an uncommon cause of recurrent pancreatitis characterized by chronic inflammation with lymphocytic infiltration on histology. It is further classified as type 1, IgG4 related and type 2, idiopathic duct-centric type, with a prevalence of 2% of chronic pancreatitis, affecting less than 1 per 100,000. We describe a case suspicious for AIP with pancreatic biopsy revealing metastatic lung adenocarcinoma. Case Description/Methods: A 56-year-old female, former 10 pack year smoker with no medical history presented with complaints of worsening abdominal pain for one day. She notes a recent stay at an outside hospital for abdominal pain 5 days prior and was managed for gallstone pancreatitis. There, she underwent an ERCP with removal of biliary sludge and was planned for outpatient cholecystectomy. On this admission, a CT Abdomen/Pelvis revealed diffuse pancreatic enlargement with fullness most prominent at the head but no identifiable mass (Figure). Additionally, multiple enlarged retroperitoneal and mesenteric lymph nodes (LNs) were noted, measuring up to 2.5 cm. Radiographic findings were concerning for AIP versus malignancy. Labs were significant for a lipase 1078 and ANA 1:360 and subsequently managed for acute pancreatitis. IgG4 was at the upper limit of normal, 96 (2-96). On Day 5, she underwent an EGD/EUS, which revealed an enlarged pancreas, with no discrete mass as well as several mesenteric LNs, which were biopsied. Pathology revealed metastatic adenocarcinoma consistent with lung primary, PDL1 positive. An outpatient CT Chest revealed few pulmonary micronodules of unclear significance and borderline sized mediastinal LNs. She is currently following outpatient with thoracic oncology and undergoing further staging studies prior to initiation of treatment. Discussion: Our patient presenting with clinical and radiographic features of AIP was diagnosed with metastatic lung cancer, a rare presentation of infiltrative metastasis mimicking autoimmune pancreatitis. While lung cancer is the 2nd leading cause of pancreatic metastasis, the literature has reported a few cases of lung cancer presenting as pancreatitis. Interestingly, 2 Japanese studies reported close temporality between AIP Type 1 diagnosis and cancer diagnosis, particularly with lung, stomach and prostate cancer, proposing the possibility that AIP can occur as an autoimmune paraneoplastic disease. Therefore, malignancy must be considered when evaluating for AIP and portends the necessity of endoscopic biopsy.Figure 1.: Enlarged heterogeneous pancreas, surrounding fat stranding and upper abdominal lymphadenopathy, suspicious for malignancy with co-existing pancreatitis.

A Curious Case of Severe Proctitis

Question: A 40-year-old man with well controlled human immunodeficiency virus presented to the emergency department with one week of severe rectal pain. He subsequently developed fevers and hematochezia with loose stools, prompting him to seek care. Past sexual history includes anal receptive intercourse and a previous diagnosis of anal human papilloma virus. On presentation, he was febrile to 103.2°F, but otherwise hemodynamically stable. Rectal exam was limited by severe pain, but was notable for mucopurulent discharge, perianal ulcers, and erythema (Figure A). Laboratory testing was significant for leukocytosis with white blood cell count of 12.6 /mm3 and an elevated C-reactive protein of 111 mg/L. A computed tomographic scan of his abdomen with intravenous contrast was performed and showed marked inflammatory changes of the rectum and surrounding soft tissue without abscess or other upstream colonic inflammation and multiple enlarged perirectal and retroperitoneal lymph nodes (Figure B). Extensive testing for multiple infectious diseases, including syphilis, herpes simplex virus, gonorrhea, and chlamydia, was negative. What is the diagnosis? Look on page 528 for the answer and see the Gastroenterology website (www.gastrojournal.org) for more information on submitting to Gastro Curbside Consult. Given high index of suspicion, he was placed on our standard precautions for monkeypox rule-out, which includes isolated room, gowns, gloves, eye protection, and N-95 filter. A rectal polymerase chain reaction swab for nonvariola orthopox virus returned positive, confirming a diagnosis of monkeypox virus. This was reported to the State Department of Health for contact tracing. The patient was treated with tecovirimat antiviral therapy under emergency use authorization, as approved by the Center for Disease Control and State Department of Health. He noted symptomatic improvement within a few days and was discharged to complete an oral course of 600 mg tecovirimat twice daily for a total of 14 days. Monkeypox virus is a zoonotic orthopox DNA virus that was previously endemic to Africa.1Thornhill J.P. Barkati S. Walmsley S. et al.Monkeypox virus infection in humans across 16 countries—April-June 2022.N Engl J Med. 2022; 387: 679-691Crossref PubMed Scopus (508) Google Scholar In the spring of 2022, cases outside of endemic regions began to rise and a global outbreak began. The presenting symptoms of monkeypox can be nonspecific, including fevers, myalgias, mucosal involvement, and skin lesions, which are vesicular and evolve over days to weeks.1Thornhill J.P. Barkati S. Walmsley S. et al.Monkeypox virus infection in humans across 16 countries—April-June 2022.N Engl J Med. 2022; 387: 679-691Crossref PubMed Scopus (508) Google Scholar Monkeypox has now been declared a public health emergency, and this case highlights many important considerations for diagnosis and treatment. First, the current monkeypox outbreak is disproportionately affecting men who have sex with men.2Guarner J. del Rio C. Malani P.N. Monkeypox in 2022—what clinicians need to know.JAMA. 2022; 328: 139-140Crossref PubMed Scopus (70) Google Scholar Transmission is thought to occur through to skin-to-skin contact. The lesions typically appear first at the site of inoculation, and thus anal/genital lesions may be more common. In a recent international case series published in the New England Journal of Medicine, 73% of the 528 patients with polymerase chain reaction–diagnosed monkeypox had anogenital ulcerations.1Thornhill J.P. Barkati S. Walmsley S. et al.Monkeypox virus infection in humans across 16 countries—April-June 2022.N Engl J Med. 2022; 387: 679-691Crossref PubMed Scopus (508) Google Scholar Also noted in that case series, the most common cause of hospitalization was anorectal pain.1Thornhill J.P. Barkati S. Walmsley S. et al.Monkeypox virus infection in humans across 16 countries—April-June 2022.N Engl J Med. 2022; 387: 679-691Crossref PubMed Scopus (508) Google Scholar The was true for our patient, who required intravenous pain medication on presentation. Symptomatic treatment with opioids, ibuprofen, topical anesthetics (lidocaine jelly per rectum), and stool softeners provided mild improvement while the patient was admitted. However, starting tecovirimat provided the greatest symptomatic improvement, and the patient was able to be discharged with only ibuprofen and stool softeners for pain control after 2 days of treatment. The World Health Organization believes the true number of monkeypox to be underestimated owing to lack of recognition of this infection that was previously only seen in a few countries.3World Health Organization Multi-country monkeypox outbreak: situation update. June 27, 2022.https://www.who.int/emergencies/disease-outbreak-news/item/2022-DON396Google Scholar Thus, a high degree of suspicion must be maintained for the disease, even in patients with isolated anal ulceration or proctitis

The Role of Contrast-Enhanced Ultrasound in Differentiating Splenic Tuberculosis From Splenic Lymphoma.

AimTo summarize the features of splenic tuberculosis and splenic lymphoma by contrast-enhanced ultrasound (CEUS) and examine the application of CEUS in differentiating splenic tuberculosis from splenic lymphoma.MethodsThe ultrasound and CEUS manifestations of 30 cases of splenic tuberculosis and 19 cases of splenic lymphoma were retrospectively analyzed, and the number of lesions, degree of splenomegaly, internal echogenicity, color blood flow signal, and CEUS manifestations of the two diseases were statistically determined.ResultsA significant difference was noted in the internal echogenicity between splenic tuberculosis and splenic lymphoma lesions, particularly the strip-shaped hyperechoic areas of the lesions. The ultrasound features of perisplenic, retroperitoneal, and superficial lymph node enlargement were found to overlap (p < 0.05). Splenic tuberculosis showed heterogeneous enhancement and non-enhancement, whereas lymphoma showed low enhancement and high enhancement, and CEUS findings were statistically significant in distinguishing both, p < 0.05.ConclusionSplenic tuberculosis is characterized by a lack of blood supply, mostly heterogeneous enhancement, and non-enhancement noted in CEUS. Splenic lymphoma lesions are often characterized by a rich blood supply and homogeneous enhancement on CEUS. CEUS can help identify the microcirculation of lesions in both patients with splenic lymphoma and patients with splenic tuberculosis. Thus, CEUS has great application value.

Imaging features in extramedullary hematopoiesis - A case series

Extramedullary hematopoiesis (EMH) is a rare compensatory process associated with many hematologic disorders and bone marrow dysfunction. Through this article, we aim to present various imaging features of EMH and its complications including spinal cord compression. Three cases of EMH in hemoglobinopathies (thalassemia and sickle cell anemia) have been described. Cases 1 and 2 of our series include paraspinal masses causing cord compression. Case 1 of thalassemia intermedia presented with various skeletal deformities in long bones, skull, and facial bones (Chipmunk facies). Case 2 was diagnosed with extrapleural lung mass with other paraspinal lesions. Case 3 presented with multiple enlarged retroperitoneal lymph nodes due to EMH. Common and uncommon imaging features of EMH have been described. Lymph node involvement was difficult to diagnose as it mimicked tubercular and neoplastic etiologies; hence, histopathological diagnosis was mandatory.

The timing of initial imaging in testicular cancer: impact on radiological findings and clinical decision making.

In testicular cancer determination of clinical stage and recommendation of therapeutic strategy after inguinal orchiectomy are based on primary imaging by CT-scan of the chest and CT- or MRI-abdomen. It has not been investigated so far whether the imaging should be performed before or after primary testicular surgery. Staging before surgery means exposing all patients to CT radiation irrespective of ensured histologic malignancy while postoperative staging could pose a risk in biased clinical decision making by increased presence of unspecific lymph node enlargement caused by postsurgical effects. Therefore, we aimed to investigate the association between the timing of initial staging and occurrence of unspecific lymph node enlargement and adjuvant therapies after inguinal orchiectomy. We retrospectively evaluated clinical and radiological data from 236 patients who had undergone inguinal orchiectomy for testicular cancer at our department. Statistical analysis was performed to determine whether the occurrence of unspecific lymph node enlargement or the rate of adjuvant therapies were influenced by timing of initial staging (preoperative vs. postoperative). The postoperative imaging cohort showed significant more inguinal, pelvic and retroperitoneal unspecific lymph node enlargement than the preoperative imaging cohort. Simultaneous occurrence of inguinal or pelvic lymph node enlargement together with retroperitoneal enlargements could only be found in the postoperative imaging cohort. No difference regarding adjuvant therapies could be found. Timing of imaging affects the detection rate of unspecific lymph node enlargements but does not show a significant effect on the rate of adjuvant therapies.

The Challenges of Diagnosing Nondilated Obstructive Uropathy: A Case Report

Rationale:Nondilated obstructive uropathy (NDOU) is a rare cause of acute renal failure reported in less than 5% of cases of obstructive uropathy. It is typically associated with intrapelvic malignancies and diseases causing retroperitoneal lymphadenopathy and retroperitoneal fibrosis. As these conditions may prevent radiographic dilation of the collecting system, the diagnosis of NDOU may be missed by usual diagnostic testing.Presenting concerns of the patient:We present a case of acute anuric renal failure in a middle-aged woman with metastatic breast cancer associated with abdominal and retroperitoneal lymphadenopathy. Acute kidney injury was initially deemed secondary to drug-induced acute tubular necrosis (ATN) from bisphosphonate; however, there remained a high clinical suspicion of NDOU due to the presence of enlarged retroperitoneal lymph nodes on CT abdomen and pelvis with concerns for encasement of bilateral renal pelvic regions and ureters.Diagnoses:The patient underwent a retrograde pyelogram which demonstrated questionable narrowing bilaterally at the level of the renal pelvices. This led to an even stronger clinical suspicion of NDOU and urology service was consulted for evaluation.Intervention:Bilateral ureteral stents were placed by urology which led to robust urine output and rapid reversal of renal failure over the next 24 to 48 hours.Outcomes:Despite 2 weeks of anuria and hemodialysis, this patient’s creatinine came back to her baseline. She was able to discontinue hemodialysis and her creatinine stabilized at 88.4 μmol/L (1 mg/dL).Teaching points:Nondilated obstructive uropathy is rare but important diagnosis that requires a high clinical suspicion in the appropriate clinical scenario. The lack of dilatation is believed to be related to encasement of the collecting system by tumor, fibrosis, or as in our case metastatic retroperitoneal lymphadenopathy. As this diagnosis cannot be overlooked, aggressive direct visualization or even intervention with internal or external stenting may be required to both diagnose and treat this condition.

S3468 Atypical Presentation of Newly Diagnosed Diffuse Large B Cell Lymphoma

Introduction: Acute pancreatitis is caused by inflammation of the pancreas due to the obstruction of pancreatic secretory transport ducts and sequential activation of inflammatory pancreatic enzymes. Both alcohol use and gallstones remain among the leading risks. Pancreatic involvement is frequently report but diffuse large B cell lymphoma presenting as pancreatitis is rare. Case Description/Methods: A 69 y/o male with no PMH presented to the Emergency room complaining of a 3-week history of worsening sharp epigastric pain associated with dysphagia and odynophagia to solid foods. He denied fever, weight loss, night sweats, nausea, vomiting, diarrhea, melena, smoking, alcohol use, recent steroid use, surgery, trauma or autoimmune disease. Physical exam was notable for tenderness in the epigastric region, lower abdomen and hypoactive bowel sounds. Laboratory analysis is appreciated in figure A. Lipid panel was unremarkable and Covid was negative. CT abdomen/pelvis showed peripancreatic inflammatory changes with trace fluid along both anterior parietal fasciae. A 21 x 14 mm right sided distal esophageal mass, and an ill-defined 40 x 26 mm bilobed necrotic mass at the inferior margin of gastric pylorus. Also multiple ill-defined enlarged periportal and retroperitoneal lymph nodes, appreciated mainly in periportal and infrarenal retrocaval lymph nodes. Esophagogastroduodenoscopy was performed with findings of large fungating ulcerating mass that was oozing blood in the cardia, which can be appreciated in figure B. Biopsy revealed diffuse proliferation of lymphoid cells strongly positive for CD 45, CD20, CD79a, BCL 6 which suggested diffuse large B cell lymphoma. CEA, CA 19-9 were within normal limits. Patient was treated with Lactate Ringer's solution on day 1 with resolution of pancreatitis within 1 week. He was discharged and lost to follow up for management of DLBCL. Discussion: Although he had no signs of pancreatic metastasis, he presented with features that fulfill diagnostic criteria for pancreatitis. This case report provided key information into the various possibilities that could initially present with abdominal pain, and why it is essential to keep various diagnoses in mind, even when there is one already established.Due to the proximity and small space of the abdominal compartment, many of these can present with overlapping symptoms. A key takeaway from this review is to follow up with each symptom individually and explore all needed diagnosis tests, in order to rule in or out other possible causes..

Varied presentation of tuberculosis adenopathy: an immunological and diagnostic contemplation

Tuberculous lymphadenitis is the most common presentation of extra pulmonary tuberculosis EPTB. Clinical and radiological presentation of disease may vary and differential diagnosis includes both benign and malignant conditions such as lymphomas and sarcoidosis. We present two case reports of tuberculous lymphadenitis with varied presentation. In case report Ⅰ, patient had undergone splenectomy due to traumatic splenic rupture had classical symptoms of tuberculosis, chest X-ray, CT thorax showed mediastinal and cervical lymphadenopathy. FNAC showed a picture of granulomatous lesion. In case report ⅠⅠ patient came with complaints of abdominal pain in hypochondriac region. CT and USG abdomen showed multiple enlarged retroperitoneal lymph nodes which led to a provisional diagnosis of lymphoma after which lymph node biopsy showed a granulomatous picture. This case report stresses the importance of early and quick diagnosis of tuberculosis in immunocompromised patients and highlights the risk of misdiagnosis of tuberculous lymphadenitis with other benign and malignant causes of lymphadenopathy and the importance of humoral mediated immunity in tuberculosis.

TCL-224: Not All Pancreatic Masses Are Pancreatic Adenocarcinomas

Introduction T-cell acute lymphoblastic leukemias (T-ALL) and T-cell lymphoblastic lymphomas (T-LBL) are both lymphoblastic neoplasms involving the blood and bone marrow, respectively. T-LBL typically present with lymphadenopathy and/or a mediastinal mass. We describe a case of T-LBL, which presented as a pancreatic malignancy. Case Report A 42-year-old man with no significant past medical history presented with jaundice of 10 days duration. Physical examination was unremarkable, while CT of the abdomen showed a pancreatic head mass 3.2 x 2.9 cm engulfing the superior mesenteric vein with retroperitoneal lymph node enlargement. Significant labs included total bilirubin 16.3 mg/dL, direct bilirubin 9.5 mg/dL, CA19-9 10 U/mL, LDH 161 units/L, and no cytopenia. He underwent an endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA), along with ERCP with distal common bile duct stent placement. Initial pathology was indeterminate. Chest CT revealed a 7.8 x 5.1 cm lobulated heterogeneous anterior mediastinal mass involving the anterior and lateral pericardial surface, thus precluding biopsy due to high risk of vascular injury. Repeat EUS-guided FNA of the pancreatic mass revealed T-LBL. Cerebrospinal fluid (CSF) analysis showed clonal T lymphocytes positive for CD3, CD4, and CD5, and T-cell rearrangement, while bone marrow biopsy revealed no lymphomatous involvement. After the diagnosis of stage IVA extramedullary T-LBL with CNS involvement, he received six cycles of Hyper-CVAD chemotherapy and intrathecal methotrexate. After achieving complete remission, he next underwent autologous stem cell transplant (ASCT) with a conditioning regimen of total body irradiation and etoposide. At five years follow-up, the patient remained in remission but developed worsening cytopenia and a bone marrow biopsy revealed treatment-related myelodysplastic syndrome (T-MDS) with monosomy 7. Subsequently, he underwent a haploidentical allogeneic stem cell transplant, with a follow-up bone marrow biopsy showing no evidence of MDS. Discussion The differential diagnoses of pancreatic masses include pancreatic adenocarcinoma, chronic pancreatitis, neuroendocrine tumor, or lymphoma. To our knowledge, this is possibly the first case of extramedullary T-LBL presenting as a pancreatic mass. Risk-adaptive treatment strategy incorporating hyper-CVAD chemotherapy and early ASCT was effective in achieving long-term remission and is potentially an effective treatment strategy in T-LBL.