Head Mass Research Articles

An Unusual Case Report of Adult Cervical Cystic Hygroma

Cystic Lymphangioma (CL) is a rare condition that is typically observed as a congenital malformation in the head and neck. These congenital lesions usually appear before the age of two. Adult occurrences are extremely unusual, and only a few cases have been mentioned in the literature. CL is characterised by the collection of an epithelial lining of lymphatic fluid, which can be caused by lymphatic abnormalities, trauma, or surgery. In the present case report, the authors present the findings of a 49-year-old adult female who had painless, gradually increasing left-sided neck swelling for three years, with no other relevant medical history. The initial ultrasound revealed a large cystic lesion extending from the left sternocleidomastoid muscle to the left submandibular gland. The lesion measured 8×7×3 cm and exhibited narrow septae and loculation at the periphery. Avascularity was noted within the cyst wall and interlobular septae. The diagnosis favoured macrocytic lymphangioma/Congenital Lymphangioma (CH). During the surgical procedure, the cyst was dissected, and it was found to be located over the internal jugular vein, carotid artery, and spinal accessory nerve. The cyst was completely removed, and a surgical drain was left in place. The wound was sutured in two layers, and a sterile dressing was applied. The drain was removed on the third postoperative day, and the dressing with sutures was removed on the seventh postoperative day, revealing a healthy wound. The diagnosis was confirmed by histopathological examination {Haematoxylin and Eosin (H&E)} of the tissue specimen, which showed flattened epithelium lining the inside of the cyst. The cyst contained dilated gaps in a fibrocollagenous stroma infiltrated by lymphocytes. Therefore, CH can be considered as a differential diagnosis for head and neck masses in adults.

Fine needle aspiration cytology of head and neck masses: a twenty year’ experience in a tertiary centre in northwestern Nigeria: implication on clinical diagnosis

Fine needle aspiration cytology of head and neck masses: a twenty year’ experience in a tertiary centre in northwestern Nigeria: implication on clinical diagnosis

Kimura Disease: A Diagnostic Perplexity

Introduction: Kimura disease (KD) is a rare condition of unknown etiology and pathogenesis. This is more common in young males of Asian descent. The most common clinical presentation is presence of unilateral subcutaneous mass in the head and neck region, especially in post-auricular area. We present a case of KD in 26- year- old Asian man who presented with subcutaneous mass behind both auricles. Case report: A 26- year- old man presented to ORL-HNS outpatient department of tertiary care centre with chief complaint of mass behind both ear for 5 months. Incisional biopsy was performed under local anesthesia. Histopathological examination report confirmed the case as KD. Patient was managed with intralesional triamcinolone injection. Conclusion: Kimura disease, though rare, should be considered in differential diagnosis of head and neck subcutaneous masses. A high-index of suspicion and tissue biopsy confirmation is essential to diagnose this condition.

Kimura's disease: A clinicopathological study of 23 cases.

Kimura's disease (KD) is an uncommon lymphoproliferative fibroinflammatory disorder. Patients present with head and neck subcutaneous nodules with or without lymphadenopathy. Peripheral blood eosinophilia and elevated serum immunoglobulin E (IgE) levels are typical. This study was designed to delineate the clinicopathological features, pattern of care, and disease course of 23 Taiwanese patients with KD. We retrospectively analyzed the clinical data of 23 consecutive cases (16 male and 7 female; age at diagnosis: 12-77 years) of KD diagnosed at our institution from 2015 to 2020. The median time from presentation to diagnosis was 1 month. Twenty-one patients presented with unilateral or bilateral head and neck masses. The remaining two presented with right flank and right arm lesions, respectively. Peripheral blood eosinophilia was observed in nine, and elevated IgE levels were observed in four. All were diagnosed using either excisional or core-needle biopsy. Seven patients underwent fine needle aspiration without a diagnostic yield. Salivary gland and lymph node involvement was observed in three and seven patients, respectively. Most lesions showed tissue eosinophilia (100%) and florid follicular hyperplasia (78.26%). Three cases had histological KD-IgG4-RD overlap and three had comorbid IgG4-RD were recognized. Thirteen patients underwent surgical resection, one received adjuvant therapy, and two received prednisolone monotherapy. KD should be considered in patients with subcutaneous masses, eosinophilia, and elevated IgE levels. Biopsy remains the gold standard of diagnosis. Increased recruitment of IgG4+ plasma cells is a common feature. Consideration of IgG4-RD in all KD patients may be prudent.

Variation in Body Mass and Skeletal Muscle Indices in Head and Neck Cancer Patients Undergoing (Chemo)Radiotherapy and Nutritional Intervention.

The aim of this study was to analyze variation in body mass index (BMI) and skeletal muscle index (SMI) in head and neck squamous cell carcinoma (HNSCC) patients who underwent exclusive radiotherapy (RT) or concurrent chemo-radiotherapy (RT-CHT). We enrolled 73 HNSCC pts treated with definitive or post-operative RT (14 pts) or RT-CHT (59 pts). At the time of diagnosis (t0) and 3 months after treatment completion (t3), CT scans were retrieved to measure skeletal muscle at the level of the C3 vertebra. Median follow-up was 16 months. Nine disease progressions with distant metastases and eleven local relapses were observed. Fifty-three pts were free from progression at 1 year. At t0, average BMI was 25.8 (SD 4.1), while at t3 it was 24.5, with no reduction in 54 pts. A BMI decrease of -1.3 (p-value < 0.0001) between t0 and t3 was found with the Wilcoxon signed-rank test. SMI was 57.1 and 59.2 at t0 and t3, respectively (p-value = 0.005). According to our analysis, SMI variation seems to reflect the effect of an appropriate nutritional intervention and may represent a reliable, simple tool for muscle mass analysis.

Scaling of ear morphology across 127 bird species and its implications for hearing performance

The dimensions of auditory structures among animals of varying body size can have implications for hearing performance. Larger animals often have a hearing range focused on lower frequencies than smaller animals, which may be explained by several anatomical mechanisms in the ear and their scaling relationships. While the effect of size on ear morphology and hearing performance has been explored in some mammals, anurans and lizards, much less is known about the scaling relationships for the single-ossicle, internally-coupled ears of birds. Using micro- and nano-CT scans of the tympanic middle and inner ears of 127 ecologically and phylogenetically diverse bird species, spanning more than 400-fold in head mass (2.3 to 950 g), we undertook phylogenetically-informed scaling analyses to test whether 12 morphological traits, of functional importance to hearing, maintain their relative proportions with increasing head mass. We then extended our analysis by regressing these morphological traits with measures of hearing sensitivity and range to better understand morphological underpinnings of hearing performance. We find that most auditory structures scale together in equal proportions, whereas columella length increases disproportionately. We also find that the size of several auditory structures is associated with increased hearing sensitivity and frequency hearing limits, while head mass did not explain these measures. Although both birds and mammals demonstrate proportional scaling between auditory structures, the consequences for hearing in each group may diverge due to unique morphological predictors of auditory performance.

LONG-TERM OUTCOMES FOLLOWING FREY'S PROCEDURE FOR CHRONIC PANCREATITIS – A TEN-YEARS OF SINGLE-CENTER EXPERIENCE FROM A TERTIARY CARE CENTER IN SOUTH INDIA

Background/Aim: Chronic pancreatitis (CP) is surgically treated in selected patient populations. Frey's procedure (FP) is the most commonly described procedure for CP with head mass. This study is being conducted to determine the long-term outcome and efcacy of FP in patients with CP in South India of various etiologies. Methods: This is a retrospective study of patients who underwent FP at our institution. Clinical features, perioperative ndings, and follow-up results were evaluated. A subgroup analysis of pain relief was performed between alcoholics and non-alcoholic groups and between patients receiving FP alone and FP with additional procedures. Results: Of the 181 patients, alcohol was the causative factor in 99 (54.69%), gallstones in 20 (11.04%), and idiopathic in 62 (34.25%). With a median follow-up of 43.49 months (range 12-72 months), 78 (43.09%) patients experienced complete pain relief. Due to persistent pain and the presence of preoperative diabetes mellitus (DM), pain relief in patients with postoperative complications was incomplete. New DM and exocrine dysfunction were reported in 25 years (13.81%) and 15 (8.28%) patients. Patients with a history of alcohol abuse, smoking, weight loss, and postoperative complications are associated with newly developed diabetes. Conclusion: FP is a safe surgical option for CP with acceptable perioperative complications and appropriate short-term and long-term pain management in properly selected patients. Continuous pain and preoperative DM were independent predictors of incomplete pain relief after FP. Symptoms associated with alcohol abuse, smoking, and weight loss were associated with the development of post-FP DM in the study population.

Pediatric Head and Neck Malignancies

Head and neck masses represents a common clinical entity in pediatric age group. In general, these masses are classified in to developmental, inflammatory, or neoplastic. Having a working knowledge of these lesions in head and neck region & conducting a thorough history & physical examinations generally enable the clinician to simplify an appropriate workup and establish a diagnosis. The differential diagnosis is wide-ranging, and expeditiously distinguishing the benign from malignant masses is difficult for instituting a timely multidisciplinary approach to the management of malignancy. Malignancy of the head and neck account for approximately 5% of all childhood carcinomas. This review aims to discuss the most common head and neck malignancies in childhood. The evidence for the diagnosis and management of childhood, head and neck malignancy is summarized. The rarity of these tumors are inevitably results in a paucity of high-level evidence to guide the treatment. Keywords: Children, Head and neck malignancy, Lymphoma, Malignancy, Rhabdomyosarcoma

Early experience with robot-assisted Frey's procedure surgical outcome and technique: Indian perspective.

Robotic surgery for pancreatic diseases is currently on the rise, feasible, well-accepted, and safe. Frequently performed procedures in relation to pancreatic diseases include distal pancreatectomy and pancreatoduodenectomy. The literature commonly describes robotic lateral pancreaticojejunostomy; however, data on robot-assisted Frey's is scarce. We herein, describe our series and technique of robot-assisted Frey's procedure at our tertiary care center between November 2019 and March 2022, and its short-term outcomes in comparison to the open Frey's. Patients with chronic pancreatitis having intractable pain, dilated duct, and no evidence of inflammatory head mass or malignancy were included in the study for robot-assisted Frey's. In our study, out of 32 patients, nine patients underwent robot assisted Frey's procedure. The duration of surgery was significantly longer in robotic group (570 minutes vs. 360 minutes, p = 0.003). The medians of intraoperative blood loss and postoperative analgesic requirement were lower in robotic group, but the difference was not statistically significant (250 mL vs. 350 mL, p = 0.400 and 3 days vs. 4 days, p = 0.200, respectively). The median length of hospital stay was shorter in the robotic group, though not significant (6 days vs. 7 days, p = 0.540). At a median follow-up of 28 months, there was no significant difference in the postoperative complications and short-term outcomes between the two groups. Robotic surgery offers benefits of laparoscopic surgery in addition it has better visualization, magnification, dexterity, and ergonomics. Frey's procedure is possible robotically with acceptable outcomes in selected patients.

Influence of Seed Treated by Plasma Activated Water on the Growth of Lactuca sativa L.

The aim of this work was to determine if PAW (Plasma Activated Water) seed treatment and growing conditions could have positive effects on lettuce seedlings and growth. The paper presents the results of a pot experiment on lettuce (Lactuca sativa L.) cultivation in greenhouse and field conditions after seed treatment with PAW. The experiment was conducted in two consecutive seasons in 2021 and 2022 and the following growth parameters were measured: head mass, rosette height, rosette width, number of leaves, root mass and root length. As a result of the study, it was found that lettuces grown in the greenhouse from PAW treated seeds had higher results in the first measurement for both cultivars (mass 32.26%, diameter 19.01%, number of leaves 13.49% and height 24.01%), while there were no statistically significant effects on the root system. The lowest results were obtained in untreated and field-grown plants. In addition, plant dry matter was measured and it was found that plants grown from PAW treated seeds had a higher percentage of dry matter (11.51% in 2021, and 11.58% in 2022). It was also found that cultivation in greenhouse resulted in a better quality of plants than the cultivation in the open field.

Pancreatic follicular dendritic cell sarcoma: one case report and literature review

Pancreatic follicular dendritic cell sarcoma (FDCS) is a rare neoplasm with unclear pathological characteristics. In this study, we report one case of pancreatic FDCS and review published cases to summarize the characteristics and treatment of pancreatic FDCS. A man in his early 30 s was admitted for jaundice, abdominal fullness, and weight loss for 15 days. Computed tomography revealed a large capsule solid mass in the pancreatic head together with a dilated bile duct and enlarged retroperitoneal lymph nodes. Serum biochemistry revealed high total bilirubin levels (313.9 μmol/L) and normal tumor marker levels. Pancreatoduodenectomy was performed, but no chemotherapy was administrated at the patient's behest. The pathologic diagnosis was pancreatic FDCS infiltrating the duodenal seromuscular layer and common bile duct. The patient presented with liver metastasis 3 months after surgery and died 8 months after surgery from multiorgan failure. Pancreatic FDCS is a rare disease with high invasiveness. Our previous case exhibited paraneoplastic syndrome together with this disease, and further investigation is needed to confirm whether paraneoplastic syndrome is a typical syndrome of pancreatic FDCS.

Impact of Low Skeletal Muscle Mass on the Prognosis of Patients with Head and Neck Cancer Treated Nonsurgically

Introduction: Sarcopenia, characterized by low skeletal muscle mass, and the outcome of cancer therapy are closely related based on recent research. This study aimed to evaluate the correlation between skeletal muscle mass and prognosis in head and neck cancer (HNC) patients. Methods: In this study, 51 male patients with HNC treated nonsurgically between January 2016 and April 2018 at Shinshu University Hospital were evaluated. Skeletal muscle mass was assessed using bioelectrical impedance analysis, and the skeletal mass index (SMI) was calculated to classify the patients. Results: The low-SMI group had a significantly worse overall survival (OS) than the normal-SMI group (3-year OS: 72.0% vs. 93.0%, p = 0.014), and there was a trend toward worse progression-free survival (PFS) in the low-SMI group (3-year PFS: 49.6% vs. 79.3%, p = 0.064). Multivariate analysis also showed that low SMI (p = 0.04) and severe N stage (p = 0.009) were significantly associated with poorer OS. Conclusion: The pretreatment assessment of SMI using bioelectrical impedance analysis is useful for identifying patients with poor prognoses. To improve the treatment outcome in HNC, we need to think of the intervention, such as cancer rehabilitation and nutritional support, during or before treatment, especially for patients with low SMI.

Pancreatic cancer in chronic pancreatitis – the diagnostic and therapeutic dilemma; an overview of cases

Introduction: Any mass in chronic pancreatitis (CP) is a difficult diagnostic and therapeutic problem. The aim of the study is a) to use our own group to determine the actual incidence of non-malignant masses in CP where any mass is highly suspected of being malignant; and b) to determine the actual incidence of malignant tumors in CP. Methods: We present a retrospective analysis of our group of patients operated in 2015–2019 for CP, a mass in CP and suspected malignancy in the mass in CP. Additionally, we present difficult cases in terms of preoperative diagnosis. Results: Thirty-three of 340 (9.7%) pancreatic resection were done due to any form of chronic pancreatitis in 2015–2019. A mass in the pancreatic head was present in 16 (48%) patients; of these, pancreatic ductal adenocarcinoma (PDAC) was suspected in 10 (62%) patients based on EUS, CT or PETCT, and also based on positive tissue diagnosis using EUS-FNA in 6 cases. Bypass or Frey procedure were done in 59 patients (HJA, PJA, Frey). Preoperative tissue sampling was done in 8 (13%) patients and malignancy was suspected in 25%. Intraoperatively, malignancy was confirmed only in one patient assessed as non-malignant in the preoperative period. The clinical course in 3 other patients undergoing HJA, although tumor-free at the time of the surgery, indicated PDAC in CP. Conclusion: The ability to detect malignant cells in a mass in CP remains poor even using all of the available sophisticated methods and the success depends on many variable factors. The rate of “unnecessary” right-sided resections of a mass in CP reached 48% in our patient group, while the rate of resections which should have been performed instead of bypass procedures was 7%. A certain percentage of the so-called excessive pancreatic resections, as well as the failure to perform a resection due to an undetected/unrecognized pancreatic tumor in CP should continue to be expected.

Two Cases of Duodenal Neuroendocrine (Carcinoid) Tumor Concurrent with Invasive Gastric Adenocarcinoma and Pancreatic Intraductal Papillary Mucinous Neoplasm

Abstract Introduction/Objective Neuroendocrine (carcinoid) tumors of the duodenum are extremely rare and account for only 2-4% of gastrointestinal tract neuroendocrine tumors. We report two cases of incidentally discovered duodenal neuroendocrine tumor which respectively occurred in a patient with invasive gastric adenocarcinoma and in a patient with pancreatic intraductal papillary mucinous neoplasm (IPMN). Methods/Case Report The first case involved a 60-year old male who presented with melena and symptomatic anemia and was found on EGD to have a large circumferential mass at the gastric antrum/pylorus, which was revealed to be an invasive gastric adenocarcinoma on biopsy. At the time of distal gastrectomy for this malignancy, a concurrent, 0.6 cm-sized, low grade neuroendocrine tumor was incidentally discovered at the duodenal margin. The duodenal tumor consisted of nests and trabeculae of monotonous cells with ovoid/round nuclei, finely speckled “salt and pepper” chromatin, and low mitotic rate (< 2 mitoses/2 mm2), and invaded only into submucosa. The tumor cells were strongly and diffusely positive for neuroendocrine markers chromogranin, synaptophysin, and CD56, positive for CK7 and CDX2, negative for CK20, and with low Ki67 proliferation index (< 3%). The second case involved a 69-year old female who presented with epigastric pain and was found on abdominal CT to have a 4 cm-sized cystic mass in the pancreatic head. While biopsy of the pancreatic mass revealed an IPMN, a separate biopsy of an incidentally discovered, 1 cm-deep ulcer in the duodenum bulb revealed a low-grade neuroendocrine tumor with similar morphologic features, mitotic rate, and immunohistochemical staining pattern as the prior case while also negative for IMP3 stain. The patient had normal serum gastrin and urine HIAA levels, but elevated serum chromogranin-A levels. Results (if a Case Study enter NA) NA. Conclusion Duodenal carcinoids are rare (1-3% of primary duodenal tumors) and are mostly non-functional and unifocal. The duodenum is also the least common site (2-4%) for GI tract neuroendocrine tumors. The pathophysiology of these tumors is still poorly understood, with the majority occurring sporadically and a minority in the setting of hereditary cancer syndromes. This report documents two very rare instances of duodenal neuroendocrine tumor incidentally discovered with invasive gastric adenocarcinoma and pancreatic IPMN.

“OUTCOME OF FREY'S PROCEDURE FOR CHRONIC PANCREATITIS”

Background:- Chronic pancreatitis is (CP) is a progressive inammatory disease of the pancreas associated with disabling abdominal pain and gradual deterioration of exocrine and endocrine function. Up to 50% of patients with CP may require surgery during the course of the disease. The main indication for surgery is intractable abdominal pain not amenable to medical and endoscopic therapy. The type of surgery depends on pancreatic ductal diameter and associated parenchymal pathology like inammatory head mass. Frey procedure (FP) is an effective method for control of pain in patients with enlarged pancreatic head. FP can be performed with a very low mortality and an acceptable morbidity. Compared with pancreaticoduodenectomy (PD), FP has favourable outcomes in terms of operation time, blood loss, morbidity, post-operative hospital stay, intensive care unit stay, and quality of life. FP has shorter operation time and lower morbidity in comparison to Beger procedure. But, long-term pain control and exocrine and endocrine dysfunctions are comparable between PD, Beger and FP. FP is technically easier than PD and Beger procedure. FP is thus a widely acceptable procedure for CP with enlarged pancreatic head in absence of a neoplasia. Methods: Prospective observational study conducted in R. D. GARDI MEDICAL COLEGE UJJAIN (M.P.) 1AUGUST 2018 TO 1 AUGUST 2019. The diagnosis of chronic pancreatitis was based on the ndings of clinical history, physical examination and radiological investigation. Radiological investigation consisted of a combination of ultrasonography (US), computed tomography (CT) and MRCP.Surgically treated cases of Chronic Pancreatitis who underwent Frey's procedure and had minimum 3 months and maximum 12 months of follow up were included in the study A total number of 17 patients were studied in one year. Post-operatively all patients were a Results: sked to classify their pain as mild, moderate and severe or no pain. Patients were also asked to repeat endocrine and exocrine function tests. Only patients with at least 12 months of post-operative follow-up were included. At the time of the last follow-up visit, 91%(n = 15) of patients described complete pain relief, 7% (n = 2) described occasional episodic pain but did not take analgesics routinely. Only one patient had pain recurrence 1year after surgery; he had been abusing alcohol and drugs. Conclusions- The results of the study conrmed that local resection of the head with longitudinal pancreatojejunostomy as proposed by Frey has high effectiveness in the treatment of pain in long-term follow-up, combined with little interference in the disease course (endocrine and exocrine function).Frey's procedure should be considered as the primary operation in patients with disabling pain as a result of CP because it is safer, easier and presents less morbidity and mortality than alternative techniques.

Prediction model based on preoperative CT findings for carotid artery invasion in patients with head and neck masses.

ObjectivesTo investigate the performance of a model in predicting carotid artery (CA) invasion in patients with head and neck masses using computed tomography (CT).MethodsThis retrospective study included patients with head and neck masses who underwent CT and surgery between January 2013 and July 2021. Patient characteristics and ten CT features were assessed by two radiologists. The patients were randomly allocated to a training cohort (n=106) and a validation cohort (n=109). Independent risk factors for CA invasion were assessed by univariate and multivariate logistic regression analyses. The predictive model was established as a nomogram using the training cohort. In addition, the calibration, discrimination, reclassification, and clinical application of the model were assessed in the validation cohort.ResultsA total of 215 patients were evaluated, including 54 patients with CA invasion. Vascular wall deformation (odds ratio [OR], 7.17; p=0.02) and the extent of encasement to the CA (OR, 1.02; p<0.001) were independent predictors of CA invasion in the multivariable analysis in the training cohort. The performance of the model was similar between the training and validation cohort, with an area under the receiver operating characteristic curve of 0.93 (95% confidence intervals [CI], 0.88-0.98) and 0.88 (95% CI, 0.80-0.96) (p=0.07), respectively. The calibration curve showed a good agreement between the predicted and actual probabilities.ConclusionA predictive model for carotid artery invasion can be defined based on features that come from patient characteristics and CT data to help in improve surgical planning and invasion evaluation.

FNAC of neoplastic lesions of head and neck

Background: Lesions of the head and neck region are routinely encountered by clinicians, in patients across all age groups and diagnoses range from reactive hyperplasia of lymph nodes to malignancies1. Among the most frequently sampled palpable head and neck lesions are lymph nodes, thyroid and major salivary glands along with other rarely encountered lesions like subcutaneous tissue swellings, lumps of skin appendages and oral cavity lesions2. FNAC, today is one of the most important diagnostic modalities used universally in the initial assessment of patients presenting with palpable head and neck region masses. It is an inexpensive, safe, outdoor procedure, with rapid reporting and requires minimal equipment.Aims and Objectives1.To diagnose neoplastic lesions of head and neck using FNAC.2.To find out the incidence rate of different head and Neck lesions. 3.To classify this lesions under different categories. e. g benign, malignant etc.4.To study various factors related to the lesions. E.g. age, sex, etc.Materials and Method: This study will be a retrospective observational study of all patientss coming to Cytopathology department, B. J. Medical College, Civil Hospital Ahmedabad from January 2022 to August 2022. The data was retrieved from Laboratory Information System. Fine needle aspiration diagnosis was correlated with detailed clinical findings and investigations. Results: Out of 88 fine needle aspiration procedures 38.6% (34 cases) were of lymph node, 15.9% (14 cases) were of thyroid, 22.7% (20 cases) from salivary gland, 22.7% (20 cases) from skin and soft tissue swellings. Out of total 88 lesions, 31 cases (35.2%) benign and 57 cases (64.7%) were malignant.Conclusion: FNAC is simple, quick, inexpensive and minimally invasive first line investigation for differential diagnosis of head and neck masses and also serves as a guide to the appropriate therapeutic management of the patient whether to locally excise a benign tumor or plan radical surgery.

S1879 A Diagnostically Challenging Case of Primary Pancreatic Lymphoma

Introduction: Primary Pancreatic Lymphoma (PPL) is the exceedingly rare instance of extranodal Non-Hodgkin's Lymphoma developing mainly in the pancreas. We report a diagnostically challenging case of a patient presenting with a rapidly growing pancreatic mass, found to have PPL. Case Description/Methods: A 48-year-old female with past history of tobacco use presented with several months of cramping abdominal pain following COVID-19 infection. She denied weight loss, fevers, or night sweats. Her physical exam, CBC, CMP, lipase, LDH, and CA 19-9 were unremarkable. An abdominal ultrasound revealed a 2.8 x 1.9 x 3 cm cystic mass of the pancreatic head, most congruent with a pseudocyst. Worsening abdominal pain prompted repeat ultrasound one month later, which showed a doubling in size. Endoscopic ultrasound (EUS) with fine needle aspiration of the cystic mass and surrounding lymph nodes yielded cystic contents and reactive lymphadenopathy. Two months later, her abdominal pain worsened and repeat imaging showed further doubling in size with encasement of the celiac plexus. A second FNA performed via EUS redemonstrated cystic contents. An ultrasound-guided core needle biopsy of the mass revealed necrotic CD30+ diffuse large B cell lymphoma (DLBCL). PET scan was suggestive of stage IV PPL (Figure). Imaging also identified an inguinal lymph node that returned as CD10+ BCL6+ high grade follicular lymphoma, which was thought to be a distinct lesion. She was started on R-CHOP. Her clinical course was complicated by the formation and subsequent rupture of a splenic artery pseudoaneurysm, gastrointestinal bleeding, anuric kidney injury, and intestinal ischemia. She ultimately transitioned to comfort care. Discussion: Primary pancreatic lymphoma comprises 0.6% of extranodal lymphomas and 0.2% of primary pancreatic tumors. The clinical presentation is often vague and includes abdominal pain, B symptoms, jaundice, or bowel obstruction. The diagnostic criteria according to the WHO requires that the (1) majority of tumor burden be localized to the pancreas and (2) existing nearby and distant lymph node involvement should be secondary to pancreatic presentation. A biopsy is required to diagnose PPL, which is histologically most often DLBCL. Our case highlights the challenges associated with diagnosing PPL despite two EUS with FNA. Although rare, one should proceed with a high index of suspicion for PPL in any patient presenting with a rapidly enlarging pancreatic mass.Figure 1.: CT image of necrotic pancreatic mass.

S1911 A Rare Presentation of Metastatic Melanoma With Obstructive Jaundice and Pancreatitis Due to Pancreatic Metastasis With Invasion into the Common Bile Duct

Introduction: Malignant melanoma is a highly aggressive cancer with high rates of metastasis. Here we present a case of metastatic melanoma of the pancreas which invaded into the common bile duct leading to a unique presentation of obstructive jaundice and pancreatitis. Case Description/Methods: An 84-year-old male presented with epigastric abdominal pain. 3-years prior he had wide local excision for cutaneous malignant melanoma of the upper back (R0 resection). His abdominal pain had worsened over the last 4-weeks and was preceded by jaundice and unintentional weight loss. Initial studies were significant for elevated alkaline phosphatase (1295), AST (270) ALT (212), total bilirubin (10.1) and lipase (12085). Computed tomography (CT) showed a 2.4 cm lesion in the pancreatic head along with dilated pancreatic duct and biliary dilation. Carbohydrate antigen 19-9 (CA19-9) was elevated (628). Cholangiogram showed a 15 mm distal biliary stricture with upstream dilation. Brushings of the biliary stricture were unsatisfactory due to insufficient cells. Subsequent endoscopic ultrasound (EUS) demonstrated a 25mm by 25mm mass in the pancreatic head invading the distal CBD. Fine-needle aspiration (FNA) showed a poorly differentiated malignancy with epithelioid and focal spindle cell features with positive S100 and SOX-10 immunophenotype. Findings consistent with melanoma. Additional imaging did not reveal other potential sites of metastasis. The patient has since been discharged and is undergoing further evaluation. Discussion: Approximately one-third of patients with malignant melanoma develop metastases. However, metastatic melanoma of the gastrointestinal system is only seen in 2-4% of patients affected by cutaneous melanoma. This patient had a unique presentation with invasion of his pancreatic lesion into the distal common bile duct which lead to obstructive jaundice and pancreatitis. Pancreatitis as a result of metastatic melanoma is a rare presentation only described in a few case reports. Based on imaging it appears the patient initially had isolated metastatic disease of the pancreas which then invaded into the common bile duct. Isolated pancreatic metastasis represents less than 1% of all metastatic melanomas. It is difficult to differentiate a primary cancer from metastatic disease of the pancreas based on imaging alone. The use of EUS-FNA is essential for diagnosis. Though the exact prognosis of metastatic melanoma of the pancreas is unclear, generally metastatic melanoma carries a poor prognosis.

S1766 Metastatic Renal Cell Cancer with Pancreatic Mass

Introduction: Pancreas is an uncommon site of metastatic disease. Almost 63% of pancreatic metastasis arise from renal cell cancer. We report a case of metastatic renal cell cancer to pancreas, with contralateral adrenal metastasis 15 years after a radical nephrectomy. Case Description/Methods: 61 years old man with past medical history of renal cell cancer, status post left radical nephrectomy fifteen years ago, presented with dull pain in right lower abdominal for one day. He denied any other abdominal symptoms or weight loss. He smokes up to half a pack of cigarettes daily. His examination was unremarkable but he was noted to have elevated lipase (213U/L) and a bilirubin of 1.1 mg%. On computer tomography abdomen he had bulky, enhancing, soft tissue mass (∼6.7 cm), with dilated pancreatic duct of 1.5 cm with right adrenal mass (Figure). On EUS, the lesion appeared well circumscribed and previously known pancreatic duct dilation was seen. Fine needle biopsy of the mass, which showed numerous atypical cells with round irregular nuclei with prominent nucleoli with clear cytoplasm suggestive of clear cell renal cell carcinoma (Figure). On immune -histochemistry, the tumor was positive for CD10, renal cell carcinoma antigen and PAX 8( Figure) Discussion: Metachronous renal cell cancer to pancreas fifteen years after radial nephrectomy is rare. Our patient had pancreatic metastasis with adrenal involvement and presented with vague abdominal symptoms. .He was noted to have elevated lipase and dilation of main pancreatic duct. Due to a remote history of nephrectomy and the presenting complaints, pancreatic primary was suspected. However, on endoscopic ultrasound the patient was noted to have a well circumscribed lesion in the head of pancreas with dilated pancreatic duct(Figure). Regular borders and absence of pancreatic duct dilation suggested metastatic disease. Our patient had well circumscribed lesion but with a dilated duct. Most pancreatic metastasis are reported to occur within 10 years after treatment of the primary disease but our patient had metastasis fifteen years later without any loco-regional recurrence. Endoscopic ultrasound is extremely important and allows to evaluate the extent of the disease, involvement of portal vein/ superior mesenteric artery, presence of enlarged lymph nodes, which are a must for evaluating the surgical candidature besides providing tissue diagnosis which helped us establish the diagnosis of metastasis.Figure 1.: CT(A,B,C) and EUS(D,E) findings. Image A shows the mass in the Pancreatic head(arrow with red head) with a dilated pancreatic duct seen in imageB( arrow with red head). Adrenal metastasis is seen in image C marked with a red arrow. On EUS, the mass appears well circumscribed( blue arrow, image D) with dilated pancreatic duct seen ( green arrow) in the head of pancreas in E.