Head Mass Research Articles

Parallels between computed tomography and clinical observations in diagnosing obstructive pancreatic masse

Aim. To identify the underlying causes of complications in distinguishing the origin of head masses through a comparative analysis of CT findings and clinical observations.Materials and methods. A retrospective analysis of radiological imaging for pancreatic cancer (36 cases) and chronic pancreatitis (24 cases) was conducted. Pancreaticoduodenectomy was performed in 23 cases (14 for cancer and 9 for chronic pancreatitis), while drainage interventions were carried out in 35 cases.Results. On pre-contrast images, pancreatic cancer appeared isodense in 97 % of cases, while in the arterial phase, it was hypodense in 94 %. For chronic pancreatitis, these percentages were 67 % and 46 %, respectively. The density curves of the pancreatic head and normal parenchyma were nearly identical across all phases, but the density gradient difference was more pronounced in pancreatic cancer (27 HU compared to 15 HU). Bile duct strictures with interruption were observed more frequently in cancer (44 %), along with arterial vessel invasion (25 %). CT signs indicative of chronic pancreatitis included wirsugolithiasis (21 %) and portal hypertension (42 %). Both diseases exhibited similar CT features, such as cystic lesions, peripancreatic tissue infiltration and peripancreatic lymphadenopathy. In six cases of pancreatic head cancer and seven of chronic pancreatitis, identical pathological changes were identified during intraoperative revision: pseudocysts (2 in cancer and 4 in chronic pancreatitis), infected necrosis and abscesses (3 and 2, respectively) and similar views of the head mass cut plane (1 each).Conclusion. The overlap in CT features due to similar pathomorphological changes presents an objective challenge in differentiating pancreatic head masses

Langerhans cell histiocytosis of the skull in 23 children

ObjectiveTo explore the clinical features, diagnosis, treatment and prognosis of Langerhans cell histiocytosis (LCH) of the skull in children.MethodsThis study retrospectively summarized the clinical manifestations, treatment methods and follow-up status of children with skull LCH who were admitted to the Department of Neurosurgery of Shanghai Children’s Hospital from January 2014 to June 2021.ResultsA total of 23 patients confirmed by histology as LCH received hospitalization treatment, including 14 males and 9 females, aged (5.76 ± 3.86) years old. The clinical manifestations were mostly incidentally discovered head masses that gradually enlarged (19 cases, 82.61%). Only 2 cases are affected by multiple systems, while the rest are affected by single systems. 9 patients were involved in multiple skull lesions, and 14 patients had local skull lesions. All patients underwent surgical intervention, with 17 patients undergoing total resection and 6 patients undergoing biopsy. 21 patients received chemotherapy after surgery. The median follow-up was 2.46 years (range 0.33–6.83 years). 21 patients had their symptoms and signs under control or even resolved, and 2 patients experienced recurrence during follow-up. The overall control rate reached 91.30%.ConclusionPersonalized treatment plans according to different clinical types. Regular outpatient follow-up is crucial to monitor disease recurrence and late effects.

Non-invasive intraductal oncocytic papillary neoplasm forming a protruding lesion toward the duodenum from the accessory papilla: a case report

BackgroundIntraductal oncocytic papillary neoplasm (IOPN), previously classified as a subtype of intraductal papillary mucinous neoplasm (IPMN), has been described as an independent disease by the WHO since 2019. IOPN is a rare tumor, with few reported cases. Herein, we report a case of resected non-invasive IOPN that formed a lesion protruding toward the duodenum from the accessory papilla.Case presentationAn 80-year-old woman was referred to our hospital because of a giant mass in the pancreatic head detected on abdominal contrast-enhanced computed tomography (CT) performed for a close examination of a mass in the right breast. CT revealed a 90-mm-sized tumor with a mixture of solid and cystic components, with contrast enhancement in the pancreatic head, and a dilated main pancreatic duct. Esophagogastroduodenoscopy revealed a semi-circumferential papillary tumor protruding toward the duodenal lumen, which did not protrude from the papilla of Vater. Transpapillary biopsy led to a preoperative diagnosis of IPMN with an associated invasive carcinoma. As there were no distant metastasis, open subtotal stomach-preserving pancreaticoduodenectomy was performed. Analysis of the surgical specimen and histopathological examination revealed that the tumor was an IOPN that protruded toward the duodenal mucosa from the accessory papilla while replacing the duodenal mucosa with no obvious stromal invasion.ConclusionIOPN is a rare and poorly recognized tumor with few reported cases. There have been no reports describing IOPN forming a protruding lesion toward the duodenum from the accessory papilla. Therefore, further accumulation of cases such as this one is important to advance the study of IOPN.

Correlation between subcutaneous adipose tissue of the head and body mass index in children and young adults aged 8-19 years: implications for functional neuroimaging.

High body mass index (BMI) is presumed to signify high amounts of fat (subcutaneous adipose tissue) distributed across the body. High amounts of fat co-occurring with increased BMI has been cited as a potential neuroimaging barrier. Presence of increased fat may result in high electrical impedance and increased light diffusion-resulting in low signal to noise ratios during electroencepholography (EEG), functional near-infrared spectroscopy (fNIRS), and transcranial direct current stimulation (tDCS) measurements. Examining if subcutaneous fat in the head increases with respect to total body fat percentage and BMI in school-aged children and adolescents is an essential next step in developing possible mathematical corrections for neuroimaging modalities. We hypothesized that percentage of subcutaneous adipose tissue in the head region would increase with respect to both total body fat percentage and BMI. Increased subcutaneous head fat percentage was associated with a positive linear relationship with BMI and a quadratic relationship with total body fat. The data indicate that participant age, sex, and adiposity should be considered in the development of model corrections for neuroimaging signal processing in school-aged children and adolescents. Strength of regression coefficients in our models differed from those in adults, indicating that age-specific models should be utilized.

Giant Cervical Lymphangioma Extending from Skull Base to Clavicle- A Rare Case.

Lymphangiomas are congenital benign lesions commonly seen in pediatric age group with a rare occurrence in the region of head and neck, commonly presenting as asymptomatic masses. Cervical lymphangioma is a rare entity among adults, and giant sized lymphangiomas in this region have sparse mention in literature. This case report describes the rare presentation of a giant cervical lymphangioma and the challenges involved to treat such masses in the region of head and neck. We encountered a rare case of a 52 year old female who presented with a 10 × 5cm swelling in the right posterior triangle of neck swelling since 6 months extending from skull base up till clavicle. Pathological and radiological entities confirmed the lesion as a "giant cervical lymphangioma". Head and neck lymphangiomas are congenital lesions of benign origin. Lymphangiomas have been classified as macrocystic if larger than 2cm, and microcystic if less than 2cm. Our description of a macrocystic 10 × 6 cm lesion is hence definitely one of the largest cervical lymphangiomas encountered till date. It's a problematic and arduous plan of treatment for such masses in head and neck with a high chance of recurrence if incompletely removed.

Abstract A071: Definitive radiation therapy for treatment of non-metastatic pancreatic ductal adenocarcinoma: Practice patterns and outcomes

Abstract Background: Advances in radiation therapy (RT) have allowed for increased biologically effective doses, or ablative RT, to be safely administered to pancreatic tumors. Pancreatic ductal adenocarcinoma (PDA) is diagnosed as local disease without metastasis in roughly 45% of patients (pts) however only 20-25% of pts are candidates for upfront surgical resection, and many are medically unfit to undergo surgery. In such patients, ablative RT can be given with curative intent, termed definitive RT (dRT). Defining practice patterns and outcomes of dRT is needed. Methods: A retrospective chart review was performed on pts with non-metastatic PDA who underwent dRT, defined as > = 100Gy BED over a protracted hypofractionation course, for treatment at our institution. Data collected included: age, gender, primary tumor location, resectability status, surveillance scan frequency and modality, chemotherapy (chemo) used, site of recurrence, cancer antigen (CA) 19-9 levels pre and post dRT, adverse events, and vital status. Neoadjuvant (NA) and adjuvant chemo was defined as chemo received within 6 weeks prior to dRT and 6 weeks after dRT, respectively. Time from diagnosis and dRT until death (OS and dRT-OS, respectively) and time from diagnosis and dRT until progression (PFS and dRT-PFS, respectively) was calculated. Time from diagnosis and dRT until metastasis (MFS and dRT-MFS, respectively) was also calculated. Results: A total of 25 pts who received dRT were identified. Median dose of RT given was 6750 cGY (range 3750-6750) in 15 fractions. Median age at receipt of dRT was 71.5 years (range 50-91), 50% were female. 76% of pts had pancreatic head mass and 24% of pts were considered resectable at time of diagnosis. 2 patients received dRT after isolated local recurrence after surgical resection. 80% of pts received chemo of any kind prior to dRT and 65% of those patients as NA chemo. 35% of patients received 2 chemo regimens prior to dRT; 55% and 65% of patients received mFOLFIRINOX and gemcitabine-based therapy, respectively. 12% of pts received adjuvant chemo. 43% of patients had at least 1 surveillance PET scan. 80% of patients had progression of any kind; of which 85% and 40% experienced distant and local recurrence, respectively. The median OS and dRT-OS was 17.3 months (95% CI 12.2-NA) and 10.1 months (95% CI 6.5-NA), respectively. The median PFS and dRT-PFS was 14.7 months (95% CI 10.3-17.9) and 5.1 months (95% CI 3.6-9.3), respectively. The median MFS and dRT-MFS was 14.7 months (95% CI 10.3-18.0) and 5.6 months (95% CI 3.6-11.3), respectively. Median CA 19-9 pre dRT was 85 (range 4.3-1790) and post-dRT was 42 (range 1.2-1673). 56% of pts had RT-associated toxicity of any kind. Conclusions: Of a single-institutional cohort of 25 patients with non-metastatic PDA who received dRT, more than half of patients received NA chemo; adjuvant chemo was rarely given. dRT provided high rates of local control while MFS was nearly identical to PFS, emphasizing the importance of systemic therapy to reduce distant recurrence in pancreatic cancer treated with dRT. Citation Format: Michael M. Caplan, Brian W. Labadie, Hope Choy, Albert Lee, Weijia Fan, David P. Horowitz. Definitive radiation therapy for treatment of non-metastatic pancreatic ductal adenocarcinoma: Practice patterns and outcomes [abstract]. In: Proceedings of the AACR Special Conference in Cancer Research: Pancreatic Cancer; 2023 Sep 27-30; Boston, Massachusetts. Philadelphia (PA): AACR; Cancer Res 2024;84(2 Suppl):Abstract nr A071.

CT-guided core needle biopsies of head and neck tumors: a comprehensive monocenter analysis of safety and outcomes.

Although core needle biopsy is an important tool in minimally invasive tissue sampling and diagnostics for head and neck masses, comprehensive data about safety and outcomes is lacking. To retrospectively evaluate the diagnostic performance and safety of computed tomography (CT)-guided percutaneous core needle biopsy of head and neck masses. This retrospective single-center study included patients from 04/2007 to 12/2021, and a total of 156 core needle biopsies were evaluated. The initial histopathological results were compared with the long-term final diagnosis to evaluate the diagnostic yield of CT-guided core needle biopsies. The patients' age, sex, and history of malignancy, as well as procedural complications and radiation exposure were collected. A total of 156 biopsies of 150 patients (mean age 56years ± 17; 89 men) were evaluated. 57.3% (86/150) of patients had a history of malignancy. 55.1% (86/156) of the lesions were accessed by an infrahyoid needle approach. 92.9% (145/156) of biopsies yielded conclusive results. There were no false positives and 4 false negatives, resulting in a total false negative rate of 2.7% (4/145) and a total diagnostic yield of 90.4% (141/156). There were nine puncture-related complications (9/156-5.7%). None of the complications required further reintervention. The average dose length product was 311.3mGy × cm. CT-guided core needle biopsies of head and neck masses showed excellent results with high diagnostic yield and clinical safety. General anesthesia for open biopsy carries a higher risk for elderly patients, and fine needle aspiration has a poor reputation in terms of its diagnostic yield. This study focuses on safety and diagnostic yield of CT-guided core needle biopsies. • CT-guided core needle biopsy in head and neck tumors was a reliable and safe procedure. • The most common cause for an inconclusive biopsy result was a shortage of tissue collected during the biopsy. • During our study period of nearly 15years, the radiation exposure of head and neck biopsies decreased.

Fine Needle Aspirate Flow Cytometry's Ancillary Utility in Diagnosing Non-Hodgkin Lymphoma in the Head and Neck.

While ultrasound-guided fine-needle aspiration cell block (FNACB) is a cost-effective, expeditious, and reliable procedure used routinely in the initial evaluation of head and neck masses, it has limited efficacy in diagnosing lymphoproliferative disorders such as non-Hodgkin lymphoma (NHL). Flow cytometry performed on an fine-needle aspiration (FNA) sample [ultrasound-guided fine-needle aspirate flow cytometry or flow cytometry performed on an FNA sample (FNAFC)], has been shown to be a valuable adjunct to FNACB in the diagnosis of lymphoproliferative disorders of the spleen, kidney, and thyroid. The objective of this study was to appraise FNAFC's utility as an ancillary tool to detect NHL arising in the head and neck region in adult patients. This is a retrospective study involving 52 adult patients with head and neck lymphadenopathies and masses suspicious for lymphoproliferative disorders, who underwent ultrasound-guided FNACB and ultrasound-guided FNAFC between January 2017 and November 2022. Patient demographics, FNACB histopathological and immunophenotypic results, postoperative histopathology results (when available), and follow-up information until May 2023 were reviewed. Of the 52 FNACB samples, 23 samples (44.2%) yielded a diagnosis negative for carcinoma, 20 samples (38.5%) were nondiagnostic on account of scant cellularity, 8 samples (15.4%) were suspicious for malignancy, and a single sample (1.9%) was compatible with malignancy. Regarding FNAFC samples, 37 samples (71.2%) were diagnosed as showing no evidence for a lymphoproliferative disorder, 4 samples (7.7%) as nondiagnostic because of insufficient cell count, 4 samples (7.7%) as suspicious for a lymphoproliferative neoplasm, and 7 samples (13.5%) as compatible with a lymphoproliferative neoplasm, most frequently a B-cell lymphoma. 7 of the 11 patients (63.6%) with a suspicious/positive FNAFC result underwent excisional biopsy for additional work up. Postoperative histopathology reports corroborated FNAFC's findings in 6 patients (85.7%), while the remaining patient's (14.3%) suspicious FNAFC result was discordant with postoperative histopathology results. The other 4 patients (36.4%) did not require excisional biopsy as the hemato-oncologist deemed the information provided by the FNAFC as sufficient for the diagnosis and treatment of an NHL in the specific clinical contexts of those patients. All patients with nondiagnostic (due to insufficient cell count), inconclusive, or negative FNAFC (ie, nondiagnostic of a lymphoproliferative disorder) were followed up for a mean follow-up period of 11.9 months (range: 61.2 months; SD: 10.2 months), during which no new lymphadenopathies/masses nor progression was observed. FNAFC is a useful and practical supplementary tool in the diagnosis of lymphoproliferative disorders in the head and neck region, principally B-cell lymphoma. While conventional FNACB offers a valuable insight into the initial work up of head and neck masses, FNAFC can routinely detect small abnormal cell populations. Furthermore, in specific clinical contexts, it can reliably diagnose NHL, thereby averting the need for an excisional biopsy in a subset of patients.

A case report on pancreatic plasmacytoma presenting as obstructive jaundice

Background: Extramedullary solitary plasmacytomas (EMD) are an uncommon manifestation of plasma cell disorders. The median survival rate is less than 6 months. EMD rarely involves the digestive tract, the liver is the most common site with only a 2.3% incidence rate for pancreatic involvement. Case Presentation: We report a case of a patient with a history of multiple myeloma who presented with painless obstructive jaundice and EUS findings of hypoechoic, solid irregular mass in the pancreatic head with surrounding peripancreatic lymphadenopathy. Fine needle aspirate (FNA) confirmed malignant infiltration of plasma cell neoplasm. The patient rapidly deteriorated and succumbed to his illness within 6 weeks of diagnosis. Conclusion: Extramedullary plasmacytomas (EMD) involving the pancreas are uncommon and associated with a poor prognosis. Our case highlights the importance of considering extramedullary plasmacytoma when a patient with MM presents with a pancreatic mass, particularly one showing a rapid interval growth. This rate of growth is not seen with primary pancreatic parenchymal diseases such as cancer, cysts, and so on. This case highlights the importance of considering rare differentials while evaluating patients with pancreatic mass.

Pancreatic Ductal Adenocarcinoma with Autoimmune Pancreatitis: A Case Report and Literature Review.

A 50-year-old man was diagnosed with type 1 autoimmune pancreatitis (AIP) following endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) and a histopathological examination. After six months of untreated follow-up, the serum IgG4 level decreased, and the diffuse pancreatic enlargement improved; however, a pancreatic head mass became apparent. EUS-FNA of this mass revealed pancreatic ductal adenocarcinoma (PDAC) with IgG4-positive plasma cells. In addition, the resected specimen revealed PDAC, without any features of AIP. After pancreatoduodenectomy, AIP did not recur. The development of AIP in this case could be related to paraneoplastic syndrome.

Feeding and Swallowing Trends in Infants Born via Exit Procedure for Giant Head and Neck Masses

Feeding and Swallowing Trends in Infants Born via Exit Procedure for Giant Head and Neck Masses

Role of fine needle aspiration cytology (FNAC) in head and neck lesions in coastal population at a tertiary care hospital – A study of 500 cases

Head and neck swellings are a very common presentation encountered by clinicians and patients across all age groups. Various lesions give rise to head and neck lumps. Swellings can arise from soft tissues, lymph nodes, thyroid gland, salivary glands etc. FNAC being minimally invasive, quick and inexpensive helps in differential diagnosis of head and neck masses.A retrospective study was conducted at Karwar institute of medical sciences Karwar from January 2018 to December 2021 in coastal population, to evaluate the role of FNAC in palpable head and neck masses and also to study their distribution and To evaluate the diagnostic accuracy, sensitivity and specificity of FNAC in diagnosing Head and neck lesions and cyto-histopathological correlation (wherever possible). 500 patients with head and neck swelling underwent FNAC. FNAC diagnosis was correlated with detailed clinical history and investigations. Out of 500 fine needle aspiration procedures 35.6% (178) were of lymph node, 33.8% (169) were of thyroid, 9.6% from salivary gland (48), 17.8% (89) from skin and soft tissue swellings and 3.2% (16) inconclusive. The present study concluded that most of the swellings in head and neck region are benign and affect females more than males. Overall accuracy rate more than 90% and diagnostic accuracy in differentiating non-neoplastic lesions from neoplastic lesions is well established. Our study found that fine needle aspiration cytology to be an easy, safe, rapid, convenient, least invasive, accurate and relatively complication-free outpatient method for diagnosis of lesions of the head and neck

Role of artificial intelligence in the characterization of indeterminate pancreatic head mass and its usefulness in preoperative diagnosis

Artificial intelligence (AI) has been used in various fields of day-to-day life and its role in medicine is immense. Understanding of oncology has been improved with the introduction of AI which helps in diagnosis, treatment planning, management, prognosis, and follow-up. It also helps to identify high-risk groups who can be subjected to timely screening for early detection of malignant conditions. It is more important in pancreatic cancer as it is one of the major causes of cancer-related deaths worldwide and there are no specific early features (clinical and radiological) for diagnosis. With improvement in imaging modalities (computed tomography, magnetic resonance imaging, endoscopic ultrasound), most often clinicians were being challenged with lesions that were difficult to diagnose with human competence. AI has been used in various other branches of medicine to differentiate such indeterminate lesions including the thyroid gland, breast, lungs, liver, adrenal gland, kidney, etc. In the case of pancreatic cancer, the role of AI has been explored and is still ongoing. This review article will focus on how AI can be used to diagnose pancreatic cancer early or differentiate it from benign pancreatic lesions, therefore, management can be planned at an earlier stage.

P032 Oral misinterpretation of head and neck masses can delay the correct diagnosis. A two-step demolitive-reconstruction surgery for saving a patient’s life

P032 Oral misinterpretation of head and neck masses can delay the correct diagnosis. A two-step demolitive-reconstruction surgery for saving a patient’s life

Comprehensive transcriptomic analysis of tissue and serum samples of patients with benign and malignant pancreatic head mass to find out potential biomarker

Comprehensive transcriptomic analysis of tissue and serum samples of patients with benign and malignant pancreatic head mass to find out potential biomarker

Invasive Pancreatic Adenocarcinoma with Squamous Differentiation Arising in an IOPN with Novel MDM2 Amplification

Abstract Introduction/Objective Intraductal oncocytic papillary neoplasms (IOPNs) are rare pancreatic tumors that are genetically distinct from intraductal papillary mucinous neoplasms (IPMNs). Morphologic and molecular characterization of invasive adenocarcinomas associated with IOPNs remains limited due to the rarity of this entity. Methods/Case Report We present a 68-year-old female who initially presented with abdominal pain and jaundice. MRI revealed a 2.6 cm mass in the pancreatic head with abutment of the superior mesenteric vein and dilation of the biliary and pancreatic duct. Biopsy revealed adenocarcinoma with mucinous features. The patient was started on gemcitabine and abraxane. Her treatment course was complicated by biliary and duodenal obstruction requiring common bile duct and duodenal stenting. Surgical management with pancreaticoduodenectomy was performed six months following initial diagnosis. Gross examination revealed a 2.5 cm ill-defined tumor surrounding the main pancreatic duct adjacent to the common bile duct. Microscopy revealed an IOPN arising within the pancreatic duct exhibiting a complex papillary growth pattern. There was an associated moderately to poorly differentiated invasive carcinoma with mucinous and squamous differentiation with lymph node metastasis. Molecular testing (FoundationOne®CDx) revealed ARID1A mutation and amplification of MDM2, CDK4, and ERBB3. Patient is alive and without radiologic evidence of disease recurrence at 6 months follow-up. Results (if a Case Study enter NA) NA Conclusion To our knowledge, our case is the first report of an invasive pancreatic adenocarcinoma with squamous differentiation arising in association with an IOPN. In addition, our case showed MDM2 amplification which has not been previously identified in pancreatic adenocarcinoma arising in IOPNs. Although recent literature demonstrated that less than 30% of IOPN showed invasive disease and even fewer cases with lymph node metastasis, our case showed extensive invasion with metastases to 2 lymph nodes. This may suggest that MDM2 amplification may play a role in more aggressive disease since it is implicated with poorer outcome in conventional pancreatic adenocarcinoma. Further molecular studies of IOPN may help to identify prognostic features of this entity.

POEMS-associated Multicentric Castleman Disease: A diagnostic and Therapeutic Conundrum

Abstract Introduction/Objective A rare multisystemic, paraneoplastic hematologic disorder, POEMS syndrome (polyneuropathy, organomegaly, endocrinopathy, M-protein, skin changes) is associated with an overproduction of pro-inflammatory cytokines caused by a plasma cell proliferative disorder. Castleman disease is a rare clinical entity described as a polyclonal lymphoid proliferation, that leads to generalized lymphadenopathy. It is rarely presented in association with POEMS Syndrome. Methods/Case Report A 55-year-old hispanic male, when being evaluated for liver mass, revealed bile duct thickening and a pancreatic head mass. Endoscopic fine needle aspiration biopsies were negative; however, the cross sectional imaging identified enlarged left axillary lymph nodes. His excisional lymph node biopsy showed human herpese virus-8 (HHV-8) negative multicentric Castleman disease (MCD). Several features of POEMS syndrome were noted. The axillary lymph node biopsy demonstrated florid follicular hyperplasia, scattered regressed germinal centers and concentric rings of mantle zone lymphocytes. CD138, kappa-ISH, and lambda-ISH highlight scattered polytypic plasma cells. Our case fulfills the mandatory criteria of POEMS syndrome with the presence of neuropathy and a constellation of other major and minor criterion including, axillary Castleman, splenomegaly, hepatomegaly, skin changes, ascites and bilateral renal cortical lesions. Furthermore the patient also has a history of cerebrovascular accident and chronic cough favoring POEMS syndrome. Results (if a Case Study enter NA) NA Conclusion The complexity and multi-organ involvement, leads to frequent misdiagnosis of POEMS disease. In addition significant overlap of symptoms of POEMS syndrome makes it difficult to differentiate from other plasma cell disorders associated with MCD. Our study includes a brief review of the literature delineating the characteristics and overlap between POEMS syndrome and other diseases.

Combination of Serum CA 19-9 and Endoscopic Ultrasound Findings Can Predict Malignancy Risk in Patients With Chronic Pancreatitis Presenting With Pancreatic Head Mass: A Proof-of-Concept Study.

Inflammatory head mass of pancreas (IMP) developing in background of chronic pancreatitis (CP) is difficult to distinguish from carcinoma pancreas. We aimed to delineate natural course of IMP and predict their malignancy risk, avoiding unnecessary biopsies. In this retrospective single-center study, clinical records of patients with CP with diagnosed pancreatic head mass were reviewed. Clinical, laboratory, imaging, endoscopic findings, and follow-up details were retrieved from prospectively maintained database. A diagnostic nomogram was developed combining serum cancer antigen 19-9 and endoscopic ultrasound (EUS) findings to predict the risk of malignancy. We identified 107 patients with pancreatic head mass with CP of whom 87 (81.3%) were IMP and 20 (18.7%) were malignant. Patients with IMP were more frequently young males with alcohol-related CP and low CA 19-9 in comparison with those with malignancy (age IMP: 41.3 ± 11.3 vs carcinoma: 49.3 ± 14.5 years [ P = 0.009]; males 89.7% vs 65% [ P = 0.011]; alcoholic etiology: 71.3% vs 20% [ P < 0.001]; median CA 19-9: 25.78 [interquartile range, 7.20-120.60] vs 1034.50 [106.65-7808.25] [ P < 0.001]). A diagnostic nomogram combining CA 19-9 and EUS findings could identify malignancy with an optimism-corrected c-statistic of 0.905, which was better than both CA 19-9 (0.80) and EUS alone (0.826). Patients with IMP had relatively benign disease course with 40.2% biliary obstruction, 20.7% portal venous thrombosis, 14.9% gastric outlet obstruction, and 1-, 3-, and 5-year survival being 97.3%, 92.7%, and 92.0%, respectively. Surgery was required in only 12 patients (13.8%) with IMP. Combination of CA 19-9 and EUS best identifies malignancy risk in patients with IMP, who have otherwise benign course.

Pancreatic pseudoaneurysm mimicking pancreatic tumor: A case report and review of literature

BACKGROUND Pancreatic pseudoaneurysm is a rare vascular complication of chronic pancreatitis (CP) or necrotizing pancreatitis with an incidence of 4% to 17%, but it is potentially life-threatening. It is well known that most pancreatic pseudoaneurysms are clinically associated with pancreatic pseudocysts and are usually in the peripancreatic body-tail. A minority of intrapancreatic pseudoaneurysms occur in the absence of pseudocyst formation. Noninvasive computed tomography (CT) and magnetic resonance imaging (MRI) are most commonly used examinations for screening pancreatic pseudoaneurysms. Notably, the rare intrapancreatic pseudoaneurysm in the pancreatic head can mimic a hypervascular solid mass and be misdiagnosed as a pancreatic tumor. CASE SUMMARY We report the case of a 67-year-old man who had been admitted to our hospital due to recurrent abdominal pain for 1 mo that was aggravated for 5 d. CT and MRI revealed a mass in the pancreatic head with significant expansion of the main pancreatic duct and mild atrophy of the pancreatic body-tail. He was admitted to the department of hepatobiliary and pancreatic surgery due to the possibility of a pancreatic tumor. The patient was then referred for endoscopic ultrasonography (EUS) with possible EUS-FNA. However, EUS showed a cystic lesion in the pancreatic head with wall thickness and enhancing nodules, which was doubtful because it was inconsistent with the imaging findings. Subsequently, color doppler flow imaging demonstrated turbulent arterial blood flow in the cystic lesion and connection with the surrounding vessel. Therefore, we highly suspected the possibility of CP complicated with intrapancreatic pseudoaneurysm, combined with the patient's long-term drinking history and the sonographic features of CP. Indeed, angiography revealed an oval area of contrast medium extravasation (size: 1.0 cm × 1.5 cm) at the far-end branch of the superior pancreaticoduodenal artery, and angiographic embolization was given immediately at the same time. CONCLUSION EUS is an important differential diagnostic tool when pancreatic pseudoaneurysm mimics the imaging appearance of a hypervascular pancreatic tumor.

Concordance and Discordance between Radiology Resident’s and Radiologist’s Interpretation of Brain MRI in Patients with Head Masses

Diagnosis of head masses involves clinical examination, neurological signs, and radiological imaging. MRI is the preferred imaging tool for detailed assessment of tumor, its extent and treatment plan. Objective: To find the level of concordance and discordance between radiology resident’s and consultant’s interpretation of MRI (Magnetic Resonance Imaging) done for brain masses. Methods: A cross sectional study was conducted at the radiology department of Rehman Medical Institute, Peshawar. Simple random sampling was done and sample size was calculated using kappa coefficients (Donner and Rotondi) n=100. 100 patients who visited department of Radiology over a period of two years were assessed by prospective analysis of their radiology reports. Senior resident’s and consultant’s reports were compared. All pre-op patients were included irrespective of age or gender. Data were collected and recorded on a specially designed proforma and entered into Microsoft excel and analyzed using SPSS (Version 22.0. IBM Corp., Armonk, NY). Results: MRI brain reports of 58 male and 42 female patients were evaluated. The most common tumors were gliomas, making up 52% of the total tumors. Metastasis being second most common tumor making 16%, meningiomas in 15%, pituitary tumors in 10% and vestibular schwannomas in 7% of the patients. Concordance, discordance, and Cohen’s Kappa values in different masses were gliomas. (Concordance=88.46%, Discordance=11.54%, k=0.336), Meningiomas (Concordance=86.66%, Discordance=13.34%, k=0.423), Metastasis (Concordance=81.25%, Discordance=18.75%, k=0.294), Pituitary Tumors (Concordance=80%) Discordance=20%, k=0.375) and Vestibular Schwannomas (Concordance=85.71%, Discordance= 14.29% k=0.588). Conclusions: There was no statistically significant difference between senior resident’s and consultant radiologist’s report of MRI brain masses.