Heterogeneous Hypoechoic Lesion Research Articles

Fibroid uterus: A case study

Fibroid uterus, also known as Uterine leiomyoma, represents a common gynecological disorder affecting women, particularly those in their reproductive years. This paper presents a case study focusing on the clinical manifestation, diagnosis, management, and nursing care of a 43-year-old woman with fibroid uterus. Fibroids, benign neoplasms of the uterine wall, are classified based on their location within the uterus. Risk factors for fibroid development include early puberty, obesity, genetic predisposition, and oral contraceptive use. Diagnosis often involves ultrasound imaging, revealing characteristic features such as heterogeneous hypoechoic lesions. Management options range from medical to surgical interventions, with considerations for patient age, fertility preservation, and symptom severity. Surgical procedures like myomectomy and hysterectomy may be necessary, while non-surgical alternatives such as uterine artery embolism and myolysis offer alternatives. Nursing care focuses on pain management, nutritional support, infection prevention, and patient education. Early detection and appropriate management are essential to mitigate the risk of complications and preserve fertility in affected women.

FRI531 IgG4 Related Mass -forming Thyroid Disease: Two Case Reports

Abstract Disclosure: R.S. Braham: None. C. Droumaguet: None. M. Vitellius: None. J. Tran-van-nhieu: None. E. Béquignon: None. P. Desgranges: None. N. Limal: None. M. Mahevas: None. B. Godeau: None. IgG4 thyroiditis is an invasive fibrotic process involving the thyroid in a systemic disease. It is a rare inflammatory autoimmune disease with insidious presentation and nonspecific symptoms.We describe two unusual cases of mass forming IgG4 thyroiditis that were diagnosed recently in our department. The first case is about a 42-year-old woman who has a history of Hashimoto thyroiditis with hypothyroidism presenting with a rapid goiter growth, neck pain, dysphagia and hoarseness. A lymphoma was suspected. Ultrasonography shows heterogeneous hypoechoic lesions that may infiltrate the perithyroid muscles. Fine-needle aspiration (FNA) was suspicious of IgG4 infiltrative disease which was confirmed by microbiopsy. Only the thyroid was hypermetabolic on fluorine-18 fluorodeoxyglucose (FDG) positron emission tomography (PET) Scan. No improvement under corticosteroid treatment and Rituximab. Surgery was planified to relieve pressure symptoms. The thyroid surgery was very difficult because of the extensive fibrosis and only a biopsy was performed, confirming the diagnosis and excluding malignancy. The second case is about a 68-year-old woman with a history of hypertension and Graves disease presented with a neck right mass that was suspected to be a paraganglioma, hypermetabolic on FDG PET scan with no other localisation. This mass was surrounding the right primitive carotid artery, associated with thrombi of the internal jugular vein. FNA and microbiopsy found a fibrotic non specific tissue. Thyroidectomy and surgical biopsy of the neck mass were performed with histopathology confirming IgG4 disease on the thyroid gland with fibrosis. There were no hypocalcemia in the two cases and no other localisation. IgG4 related mass-forming thyroiditis is an extremely rare disease. It is now a recognizable pattern of IgG4 thyroiditis, and has as differential diagnosis Hashimoto’s thyroiditis, Graves disease and thyroidal carcinoma.We will discuss through these cases the different clinical presentation of this rare disease, the diagnostic tools, the treatment and the long term follow up. Presentation: Friday, June 16, 2023

A rare spontaneous breast abscess due to Mycobacterium chelonae: a case report

BackgroundMycobacterium chelonae, a nontuberculous mycobacterium, commonly causes skin, soft tissue, eye, pulmonary, catheter-related, and post-surgical infections in patients with immunosuppression or trauma. M. chelonae breast infections are rare, and most cases occur following cosmetic surgery. Here, we report the first case of spontaneous breast abscess due to M. chelonae.Case presentationA 22-year-old Japanese woman presented at our hospital with swelling and pain in the right breast for the past 2 weeks without any fever. She had a 19-month-old child and stopped breastfeeding 1 month after giving birth. The patient had no history of trauma or breast surgeries, no family history of breast cancer, and was not immunocompromised. Breast ultrasonography revealed a heterogeneous hypoechoic lesion with multiple fluid-filled areas suspected to be abscesses. Dynamic contrast-enhanced magnetic resonance imaging revealed a 64 × 58 × 62 mm, ill-defined, high-signal-intensity lesion with multiple ring enhancements in the upper half of the right breast. The first diagnosis was inflammatory breast cancer or granulomatous mastitis with abscess. A core needle biopsy led to drainage of pus. Gram staining did not reveal any bacteria in the pus, but the colonies from the biopsy grew on blood and chocolate agar cultures. Mass spectrometry detected M. chelonae in these colonies. Histopathological findings revealed mastitis without malignancy. The patient's treatment regimen was oral clarithromycin (CAM) based on susceptibility. Three weeks later, although the pus had reduced, the induration in the breast did not resolve; therefore, multidrug antibiotic treatment was initiated. The patient received amikacin and imipenem infusion therapy for 2 weeks, followed by continuation of CAM. Three weeks later, tenderness in the right breast recurred with slight pus discharge. Hence, minocycline (MINO) was added to the treatment. The patient stopped CAM and MINO treatment 2 weeks later. There was no recurrence 2 years after treatment.ConclusionWe report a case of M. chelonae breast infection and abscess formation in a 22-year-old Japanese woman without obvious risk factors. M. chelonae infection should be considered in cases of intractable breast abscess, even in patients without immunosuppression or trauma.

Type 2 Autoimmune Pancreatitis and Ulcerative Colitis an Uncommon Association: About One Case

Autoimmune pancreatitis is one of the less recognised associations and remains poorly understood. The overall reported prevalence of autoimmune pancreatitis in inflammatory bowel disease patients is 0.4% [5, 6] considering the only two studies in the literature specifically examining this issue, and that concern Asian populations. Autoimmune pancreatitis in the setting of inflammatory bowel disease is challenging to diagnose but a clinically important entity to recognize and treat. Here we report a case of a 43-year-old women followed for ulcerative colitis, presented with epigastric pain and dyspepsia symptoms associeted to steatorrhea and 12 kg weight loss in 2 months. Laboratory tests found fasting plasma glucose at 1.27 g/l. HbA1c was 8%, IgG4 Levels were normal and the fecal elastase level was low. Magnetic resonance imaging of abdomen revealed a swollen pancreas especially in the uncus. The Bilio-pancreatic endoscopic ultrasound showed heterogeneous hypoechoic lesion of the pancreas head. And the biopsy of the pancreas revealed signs compatible with autoimmune pancreatitis type 2. A final diagnosis of ulceratice colitis associated autoimmune pancreatitis type 2 was made and the patient was treated with corticosteroids, with impressive improvement during his follow-up. In the context of inflammatory bowel disease, autoimmune pancreatitis is a rare and challenging to identify condition. The creation of clear guidelines and diagnostic standards for autoimmune pancreatitis is anticipated to improve awareness of the condition and result in a rise in the number of confirmed cases during the ensuing years.

PSAT048 Management of a Unilateral Testicular Tumor in a Patient with Congenital Adrenal Hyperplasia – Malignancy or Testicular Adrenal Rest Tumor?

Abstract Male patients with Congenital Adrenal Hyperplasia (CAH) are at risk of developing testicular adrenal rest tumors (TART). Late presentations are rare and often misdiagnosed as primary testicular germ cell tumors or other more common benign testicular lesions. We describe the case of a patient with CAH and a unilateral testicular tumor with regression in size after initiation of dexamethasone. A 24-year-old male with salt-wasting form of 21-hydroxylase deficiency underwent testicular U/S for evaluation of TART. While aware of a painless firm nodule on the latero-posterior aspect of his left testicle, his main concern was new onset infertility as he had conceived previously. He denied personal or family history of malignancy. Testicular U/S showed a 1.1×0.7×0.8 cm ill-defined, heterogeneously hypoechoic lesion with scattered calcifications and internal vascularity. He was referred to urology to undergo evaluation for possible for testicular cancer. CT abdomen/pelvis showed no evidence of metastatic disease. AFP was less than 2.5 ng/mL (reference range < 9.0 ng/mL), hCG was less than 1.0 mIU/mL (reference range<5.0 mIU/mL), and LDH was 221 U/L (reference range 140-271 U/L). The patient declined surgical intervention at this point and requested medical management. After discussion with the patient, we opted to trial dexamethasone to help suppress the nocturnal surge of ACTH in addition to his physiological dose of prednisone and fludrocortisone for CAH. He was started on 0.25 mg of dexamethasone followed closely with serial imaging and labs. Prior to initiation of dexamethasone, ACTH was 90.3 pg/mL (reference range 7.2–63.3 pg/mL). Two months after initiation of dexamethasone, ACTH decreased to 10.0 pg/mL. LH after initiation of dexamethasone was 8.58 mIU/mL (reference range 1.24–8.62 mIU/mL), FSH was 11.90 (reference range 1.27–19.26 mIU/mL), and testosterone level was 177 ng/dL (reference range 259-818 ng/dL). Testicular U/S six months after starting dexamethasone showed a 50% reduction in size of the heterogeneous hypoechoic left testicular lesion measuring 0.5×0.5×0.4 cm consistent with TART. However, he continued to have concerns regarding infertility, with work-up currently underway. TARTs are thought to arise from aberrant adrenal cells that may descend with the testes during embryogenesis. High ACTH levels in CAH due to lack of negative feedback can cause proliferation of these undifferentiated adrenal cells. Infertility is a predominant symptom due to local mass effect on the testes. Treatment of TART to prevent infertility requires elucidating an optimal steroid regimen that suppresses ACTH production, without suppression of LH and FSH. Moreover, most of the TARTs (around 80%) are bilateral and never malignant. Our patient's testicular tumor poses a diagnostic challenge given the late and atypical presentation of a unilateral tumor. The response to dexamethasone is very reassuring but continued surveillance is warranted. Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

An Unusual Cause of Recurrent Subepithelial Mass in the Stomach

Question: A 58-year-old woman presented with a subepithelial tumor, approximately 2 cm in size, incidentally detected in the posterior wall of upper body of the stomach during a screening endoscopy (Figure A). The sample from an endoscopic ultrasound-guided fine-needle biopsy revealed spindle-shaped cells arranged in a fascicular pattern. The spindle cells were immunopositive for c-Kit, cluster of differentiation 34, DOG-1, and smooth muscle actin. The patient was diagnosed with a gastrointestinal stromal tumor (GIST) and underwent laparoscopic wedge resection. The tumor was completely resected with clear margins. The maximal tumor size was 2.3 cm, and the mitotic count was 2 per 50 high-power fields; therefore, it was diagnosed as a GIST with a low risk of malignant potential. Follow-up abdominal computed tomography after 2 years showed a new low-density mass in the previous resection site (Figure B, arrow). Endoscopy showed no definite lesion at the resection site (Figure C), and endoscopic ultrasound revealed a 1.5-cm heterogeneous hypoechoic lesion originating from the muscularis propria (Figure D). Laparoscopic wedge resection was performed again for a definitive diagnosis and treatment. What is your diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. Histopathologic examination of the resected specimen revealed sweeping fascicles of bland and uniform spindle cells with collagenous stroma and compressed, thin-walled vessels (Figure E). The spindle cells were immunonegative for c-Kit (Figure F), cluster of differentiation 34 (Figure G), DOG-1 (Figure H), and S-100 protein, and were immunopositive for smooth muscle actin (Figure I), which suggested the exclusion of GIST. Therefore, additional immunohistochemistry was performed for the differential diagnosis. The tumor cells were negative for anaplastic lymphoma kinase but positive for nuclear β-catenin (Figure J). Based on morphologic and immunohistochemical findings, a diagnosis of a desmoid tumor occurring at the previous resection site of the gastric GIST was made. No further treatment was provided because the tumor was completely resected. No signs of recurrence or metastasis were found during 12 months of follow-up. Desmoid tumors are rare mesenchymal tumors occurring in patients with risk factors, such as a previous history of abdominal surgery, familial adenomatous polyposis, or pregnancy, and they can be easily mistaken for GIST because both tumors show similar clinical presentation and morphology.1Murshid A.A. Al-Maghraby H.Q. Subsequent development of desmoid tumor after a resected gastrointestinal stromal tumor.Case Rep Pathol. 2018; 2018: 1082956Google Scholar The desmoid tumor and GIST are both microscopically characterized by spindle-cell proliferation, and the differential diagnosis of these two tumors is performed mainly by immunohistochemistry. Because desmoid tumors usually have activating mutations in β-catenin, abnormal nuclear positivity of β-catenin is seen in most desmoid tumors.2Lu Q. Wang K. Liu D. et al.Stomach desmoid tumor: a case report and review of the literature.Int J Clin Exp Pathol. 2017; 10: 10531-10538Google Scholar Surgical resection with a negative margin is currently the treatment of choice. When local recurrence occurs or complete surgical resection is not feasible, radiotherapy, chemotherapy, and other comprehensive therapies, such as estrogen receptor antagonists and nonsteroidal anti-inflammatory drugs, should be provided.2Lu Q. Wang K. Liu D. et al.Stomach desmoid tumor: a case report and review of the literature.Int J Clin Exp Pathol. 2017; 10: 10531-10538Google Scholar Owing to the rarity of gastric desmoid tumors, information about their prognosis is very limited. According to a review of the literature on gastric desmoid tumors, no recurrence was reported during follow-up assessments,2Lu Q. Wang K. Liu D. et al.Stomach desmoid tumor: a case report and review of the literature.Int J Clin Exp Pathol. 2017; 10: 10531-10538Google Scholar indicating a good prognosis. However, considering the local recurrence rate of 13% for intra-abdominal sporadic desmoid tumors,3Wilkinson M.J. Fitzgerald J.E. Thomas J.M. et al.Surgical resection for nonfamilial adenomatous polyposis-related intraabdominal fibromatosis.Br J Surg. 2012; 99: 706-713Google Scholar regular follow-up is mandatory.

S3328 An Unfortunate Case of Synchronicity

INTRODUCTION: Gastrointestinal stromal tumors (GISTs) account for less than 1% of GI tumors. They originate from the interstitial cells of Cajal and are the most common group of mesenchymal neoplasms. GISTs may occur in any portion of the alimentary tract. Recent literature suggests that GISTs may occur synchronously with other cancers more frequently than expected. CASE DESCRIPTION/METHODS: We present a case of a 78-year-old female with past medical history of hyperlipidemia who underwent an outpatient computed tomography (CT) for evaluation of abdominal pain. CT scan revealed three lesions: (1) 7.2 cm well-circumscribed hypodense hepatic lesion in segment 7 consistent with hydatid cyst (Figure 1a), (2) 3.6 cm ill-margined heterogeneous lesion of uncinate process (Figure 1a), and (3) 5.1 cm partially cystic intramural gastric body mass with exophytic extension (Figure 1b). The patient underwent esophagogastroduodenoscopy (EGD) and endoscopic ultrasonography (EUS). No intraluminal component of gastric mass was visualized on EGD. A 26.5 × 21.6 mm hypoechoic, heterogeneous and well-circumscribed lesion with several anechoic components was identified adjacent to gastric cardia on EUS. Fine needle biopsy (FNB) was performed with pathology revealing spindle cell tumor (Figure 2) and immunohistochemical staining consistent with GIST (CD 117 positive, S100 negative and SMA focally positive). Additionally, a 21.7 × 21.6 mm heterogeneous hypoechoic lesion with ill-defined borders was identified in an uncinate process. FNB was performed (Figure 3a) with pathology revealing adenocarcinoma (Figure 3b). Finally, a large hepatic lesion with multiple anechoic components surrounded by hyperechoic rims with acoustic shadowing was identified in the left lobe. DISCUSSION: Our case presents a rare finding of synchronous gastric GIST and pancreatic adenocarcinoma. The percentage of GIST occurring with other neoplasms is reported to range between 3% and 33%. There is no recognized pattern to ascertain whether the coexistence of these tumors is incidental or related to a genetic or pathologic process. The etiology of synchronous occurrence of GISTs with histologically unrelated tumors remains unclear, however, some authors have suggested that they may share common genetic mutations with proliferation of different cell lines. As there is a limited number of cases, future studies are needed to evaluate this link, but it is important for both pathologists and surgeons to be aware that this phenomenon does exist.Figure 1.: (a) CT scan with pancreatic head mass and left hepatic lobe lesion; (b) CT scan with proximal gastric mass.Figure 2.: Pathology slide displaying spindle cells obtained from FNB of gastric mass.Figure 3.: (a) EUS image showing FNB of pancreatic mass; (b) Pathology slide displaying malignant adenocarcinoma.

Clinical and endoscopic features of esophageal tuberculosis: a 20-year retrospective study

Background Tuberculosis of the esophagus is a rare clinical entity. There is a paucity of data on esophageal tuberculosis. This study aims to analyze the clinical and endoscopic features of esophageal tuberculosis over the last 20 years. Methods We retrospectively analyzed the data of 14 patients with esophageal tuberculosis between January 1999 to January 2019 at Nanfang Hospital. Tuberculosis was considered diagnostic if histopathological results showing epithelioid granuloma with or without caseous necrosis. Records of clinical features, imaging findings, endoscopic features and outcome of antitubercular treatment were evaluated. Results A total of 14 patients with definite esophageal tuberculosis were included. 7 patients (50%) presented with dysphagia, followed by 6 patients (42.86%) had retrosternal pain and another had cough (7.14%). On endoscopy, involvement of esophagus was observed at mid-segment mostly and findings included bulging lesions in 10 patients (71.43%), ulcer in 3 patients (21.43%), and tracheoesophageal fistula in 1 patient (7.14%). Endoscopic ultrasound showed a heterogeneous hypoechoic lesion with indistinct margins or interruption of the five layers structure of esophageal wall. Endoscopic ultrasound demonstrated mediastinal lymphadenopathy adjacent to esophageal pathology in 7/11(63.64%). Antitubercular treatment resulted in a good response with complete remission in all patients. Conclusions Esophageal tuberculosis is rare and frequently misdiagnosed due to the lack of diagnostic signs. There needs to be a high index of clinical suspicion among patients with dysphagia or retrosternal pain. Endoscopic biopsy and endoscopic ultrasound-guided FNA can help in achieving the correct diagnosis in esophageal tuberculosis.

SAT-379 Giant Parathyroid Adenoma

Giant parathyroid adenoma Background: Primary hyperparathyroidism is the most common cause of hypercalcemia. On ultrasound PTH adenomas are typically homogenous, hypoechoic, oval or bean-shaped with peripheral vascularity. Clinical Case: A 60 year old woman with a history of calcium oxalate nephrolithiasis presented with fatigue, worsening depression, body aches of 3 months duration. Labs showed a serum calcium 11.1 mg/dl (normal range 8.5–10.1 mg/dl), PTH 114.3 pg/ml (normal range 12–88 pg/ml), 25 OH Vitamin D 11 ng/ml (normal range above 29 ng/ml), alkaline phosphatase 137IU/L (normal range 27–120 IU/L), spot urine calcium 34.8 mg/dl, spot urine creatinine 92.1 mg/dl (estimated 24 hour urine calcium 415 mg/dl). She was started on Vitamin D 1000 IU daily. A PTH scan with SPECT/CT showed a right parathyroid adenoma and possible thyroid nodules. A neck ultrasound demonstrated a left 1.5 cm thyroid nodule and a right 3cm lesion. She underwent FNA of the left thyroid nodule and pathology was suggestive of a benign follicular nodule. She underwent parathyroid gland exploration with resection of the right lesion which was a 3.5 x 2.5 x 1.4 cm right superior 5.68 gm PTH adenoma. Postoperatively her serum calcium normalized to 10.1 mg/dl, PTH was 8.4 pg/ml, 25 OH vitamin D was 15 ng/ml. Her Vitamin D dose was increased. Clinical Lessons: A normal parathyroid gland typically weighs 30–60 mg and is 3–4 mm in size. The differential diagnosis for large parathyroid lesions is parathyroid carcinoma vs giant parathyroid adenoma. Although there is not a definitive size cutoff to define giant parathyroid adenomas, a size greater than 3.5 gm has been used (1). On ultrasound giant parathyroid adenomas are homogenous with smooth borders whereas parathyroid carcinomas are large lobulated heterogeneous hypoechoic lesions (2). A depth/width ratio on ultrasound may be the ultrasound parameter with greatest discriminatory capacity as a depth/width ratio greater than or equal to 1 had 94% sensitivity and 95% specificity for parathyroid carcinoma (2). Whether vitamin D deficiency is a risk factor for the development of large parathyroid glands is controversial as there has been conflicting data on this (1,3). Because there is no serum calcium level that distinguishes parathyroid carcinoma from a parathyroid adenoma neck ultrasound may be a helpful tool in evaluating these patients.

SAT-324 An Unusual Association between Pheochromocytoma and Hyperparathyroidism in a Patient with Neurofibromatosis Type 1: A Possible Co-Occurrence of Two Hereditary Endocrine Tumor Syndromes

Background: Patients with neurofibromatosis type 1 (NF1) have increased risk of developing various types of endocrine tumors including pheochromocytoma; however, an association with hyperparathyroidism is a rare entity. We present an unusual combination of pheochromocytoma and hyperparathyroidism in a NF-1 patient; a double mutation or digenic inheritance in hereditary endocrine syndromes is proposed. Clinical case: A 66-year-old woman with clinical features of NF1 presented with alteration of consciousness. Physical examination was unremarkable except a large lower abdominal mass and normotension. Severe hypercalcemia (15.02 mg/dL) with markedly elevated parathyroid hormone (PTH 1,550.6 pg/mL; 15-68.3) levels was revealed. A neck ultrasonography showed a 1.6-cm well-defined heterogeneous hypoechoic lesion at postero-inferior aspect of right thyroid lobe corresponding to the result from Tc99m MIBI parathyroid scintigraphy suggestive of parathyroid adenoma. CT whole abdomen revealed a huge uterine myoma and an accidental finding of a 2.5-cm well-defined enhancing nodule at right adrenal gland. Pheochromocytoma was diagnosed by an elevated of 24-h urine metanephrine (771.1 ug; < 276.1) with a normal level of 24 h-urine normetanephrine (273.7 ug; < 668.7). Genetic study showed a heterogeneous mutation at Gly681Ser in exon 11 of RET gene. The co-existence of NF1 and multiple endocrine neoplasia type 2A (MEN2A) was proposed. Laparoscopic right adrenalectomy was performed and its pathological findings confirmed the diagnosis of pheochromocytoma. Subsequently, total parathyroidectomy with thyroidectomy was done with its pathological study showing a parathyroid adenoma, multinodular goiter without the evidence of medullary thyroid carcinoma. The patient refused to perform the treatment for her myoma uteri. During the follow-up period, she has remained asymptomatic with calcium/vitamin D and thyroid hormone replacement without an evidence of pheochromocytoma or hyperparathyroidism recurrence. Conclusion: Our patient has the distinctive features of pheochromocytoma and primary hyperparathyroidism in the patient carrying the double mutations in NF1 and RET gene. This gene-gene interaction may explain the phenotype variability among the affected patients with the hereditary endocrine tumor syndromes.

SUN-LB095 Hashimoto's and Riedel's Thyroiditis: A Case Report

Riedel's thyroiditis is a rare form of chronic thyroiditis, predominantly characterized by a fibrotic process associated with mononuclear cell inflammation that classically extends beyond the thyroid into the perithyroidal soft tissue. It can occur in association with Hashimoto's thyroiditis, with elevated serum antithyroid antibody concentrations and lymphocytic infiltration seen in thyroid FNA. We report a case of 53-year-old Caucasian female patient with a clinical history of slowly growing painless multinodular goiter. The patient was referred to the Endocrinology department where physical examination revealed a non-suspicious diffusely enlarged goiter. An ultrasound guided fine-needle aspiration biopsy of the dominant nodule (2 cm in size) was performed, and cytologic findings were suggestive of chronic inflammatory process, with intense lymphocytic infiltration. Hypothyroidism and elevated serum thyroid peroxidase antibody (692 U/mL) were detected in blood work-up and hormone replacement therapy ensued. The diagnosis of Hashimoto's thyroiditis was then established ant the patient was discharged to the general practitioner. Four years after this diagnosis the patient complained of severe flank and lower abdominal pain and returned to our hospital. Abdominal CT scan identified a retroperitoneal periaortic and periureteral mass causing ureteral obstruction and acute renal failure. Amongst other diagnostic tests concurrently excluding malignant or infectious disease, CT scan guided biopsy was performed and revealed retroperitoneal fibrosis with vasculitis and hyaline rings surrounding small retroperitoneal vessels and nerves. Serum IgG4 was negative and erythrocyte sedimentation rate was marginally elevated. Whole body CT scan confirmed mediastinal diffuse fibrosis. Cervical ultrasound showed heterogeneous hypoechoic lesions infiltrating perithyroid muscles and a thyroid biopsy showed dense, hyalinized fibrous tissue that contained few lymphocytes, plasma cells, and eosinophils and almost no thyroid follicles, confirming the diagnosis of Riedel’s thyroiditis. Phospho-calcium metabolism disorders were excluded. Empiric therapy with Tamoxifen 10 mg daily and glucocorticoids was initiated. One-year follow-up imaging indicated disease stabilization. This case portraits the diagnostic challenge of clearly differentiating Riedel’s and Hashimoto’s thyroiditis in the same patient, as the results of imaging, laboratory and cytology studies are often similar. Unless otherwise noted, all abstracts presented at ENDO are embargoed until the date and time of presentation. For oral presentations, the abstracts are embargoed until the session begins. s presented at a news conference are embargoed until the date and time of the news conference. The Endocrine Society reserves the right to lift the embargo on specific abstracts that are selected for promotion prior to or during ENDO.

Imaging findings of metallic implants associated lymphoma

Purpose Chronic inflammatory condition such as metallic implants insertion state has relevance to develop diffuse large B-cell lymphoma (DLBCL). The purpose of this study is to introduce the imaging features of the metallic implants associated lymphoma. Materials and Methods In 2016 September, a 58 years-old male underwent high tibial osteotomy at right leg after took a knee magnetic resonance image (MRI). After 15 months later, he underwent hardware removal operation. 2 weeks later after operation, he complained right leg pain and swelling. He was hospitalized and radiologic studies including ultrasound (US) and MRI were performed. Soft tissue mass in right popliteal fossa was seen and US-guided biopsy was done to confirm the mass. Results MRI which was taken after hardware removal, showed iso to slightly low signal intensity on T1 weighted image(WI), high signal intensity on T2WI with diffuse marrow involvement and heterogeneous patchy enhancement in right proximal tibia. Also extensive extraosseous soft tissue component was seen, with relatively preserved trabecular pattern in proximal tibia. This intraosseous and extraosseous lesions were not seen in previous MRI which taken before high tibial osteotomy. On US image, it was showed heterogeneous hypoechoic and hypervascular lesion in popliteal fossa of left lower leg. US guided biopsy was done on extraosseous soft tissue mass in left popliteal fossa. It was histologically confirmed as DLBCL. Conclusion Hypoechoic and hypervascular disproportionally large extraosseous soft tissue mass without prominent bone destruction is preferential finding of bone lymphoma. Lymphoma should be considered above all, when these findings were seen in patient who has metallic implant.

Rare Presentation of Solid Pseudopapillary Tumor in a Young Male

Introduction: Solid Pseudopapillary Tumors (SPT) of the pancreas is a rare non-functioning tumor. Almost exclusively found in females in the 2nd or 3rd decade of life. It has a low-grade malignant potential and is curable with complete surgical excision in most instances. Here, we present a case of SPT in a young male patient discovered incidentally on imaging. Case Presentation: 26 year-old Hispanic male presenting to GI clinic for evaluation of incidental 8.3 x 7.8 cm heterogeneous pancreatic mass seen on CT Abdomen and Pelvis. The patient initially presented with complaints of left flank pain and was treated for an obstructive left renal calculus status post lithotripsy and urethral stent. Patient underwent endoscopic ultrasound (EUS) with fine needle aspiration (FNA). EUS revealed a heterogeneous hypo-echoic mass lesion consistent with solid and cystic components abutting the body and tail of the pancreas with FNA cytology revealing branching papillary fronds with monomorphic tumor cells with a palisaded appearance and fibrovascular core. Patient subsequently underwent a laparoscopic distal pancreatectomy and splenectomy. Surgical pathology of the specimen and immunohistochemistry confirmed the diagnosis of SPT and the patient was referred to Oncology for follow-up.Figure 1Figure 2Figure 3Discussion: SPT account for 1%-3% of pancreatic tumors and have a low-grade malignant potential, with metastatic disease occurring in 5%-10% of patients. Complete surgical excision can achieve a favorable prognosis, with a 5-year survival rate of 95%. This case was unique as this patient was a young male. SPT typically occurs in the 2nd and 3rd decade has a female to male ratio of 10:1. There have been controversies regarding whether male patients were shown to have distinct patterns of onset or aggressiveness compared to female patients and consideration for more radical surgical approaches. However, literature review of 116 cases of SPT with 16 of the patients being male revealed radical resection was not necessary in male patients compared to female patients. Surgical strategies should be tailored based on tumor location, size and adjacent organ compromise, not gender.

Imaging Findings in Patients with Granulomatous Mastitis.

BackgroundGranulomatous mastitis (GM) is a rare inflammatory breast disease that may mimic the clinical characteristics and radiologic imaging findings of breast carcinoma. Considering the importance of making a correct diagnosis, careful radiologic evaluations and recognition of imaging features are necessary.ObjectivesThe aim of this study was to review the radiological findings and diagnostic value of the imaging in GM.Patients and MethodsThis retrospective study involved a total of 29 patients who were diagnosed with GM between 2009 and 2013 and who underwent mammography (MG) and/or ultrasound (US) examination in addition to magnetic resonance imaging (MRI) before diagnosis.ResultsAmong 14 patients over 35 years of age who underwent MG imaging, focal asymmetric, ill-defined nodular, or diffusely increased densities were detected in nine (64.3%), two (14.3%), and one (7.1%) subjects, respectively, while there were no pathological findings in two (14.3%) patients. In the overall group of 29 patients, US showed heterogeneous hypoechoic lesions with tubular extensions in 16 (55.2%), well-demarcated heterogeneous hypoechoic lesions in eight (27.6%), parenchymal heterogeneous appearance in three (10.3%), and a heterogeneous hypoechoic lesion with irregular margins in one (3.4%), with another (3.4%) patient having normal US findings. MRI findings included lesions consistent with solitary or multiple separate or confluent abscesses with marked peripheral ring enhancement in 25 (86.2%) patients, accompanied by intensity changes suggesting edematous inflammation in the peripheral parenchyma, as well as non-mass-like heterogeneous segmental and regional contrast enhancement. Four (13.8%) patients had non-mass-like segmental and regional contrast enhancement only. A histopathological diagnosis of GM was established in all patients with biopsy.ConclusionGM presents with a wide range of conventional radiological findings, hampering the diagnosis. In patients with inconclusive conventional findings, MRI may assist in the differential diagnosis and assessment of the extent of disease. However, a definitive diagnosis and relevant treatment require histopathological confirmation.

Unusual Presentation of Brucellosis in Baker's Cyst

A 55-year-old diabetic male came with history of left knee pain and swelling for 7 days, fever for 3 days, and no history of trauma. He was complaining of tenderness on the left popliteal fossa, and the surrounding area was red and soft to firm swelling; he was limping, and could not bear weight on the left leg. The ultrasound showed that there was a well-defined heterogeneous hypoechoic cystic lesion. Under aseptic technique, continuous US guidance and local anesthesia, we aspirated almost all the fluid of the left calf collection, which was reported as complicated baker cyst. The patient was put on ciprofloxacin, gentamycin, and doxycycline. The patient was cleared from infectious diseases’ team and discharged after 7 days. J Med Cases. 2015;6(10):450-452 doi: http://dx.doi.org/10.14740/jmc2252w

Recurrent Psoas Abscess associated with Retrocecal Appendicitis in an Adolescent Female

Psoas abscess (PA) is encountered infrequently in children. Pyogenic psoas abscess is most commonly a primary process associated with Staphylococcus aureus in children. Herein we present a female adolescent of secondary psoas abscess associated with ruptured retrocecal appendicitis, and it was successfully treated by broadspectrum antibiotics and prompt surgical intervention. The patient was a case of ruptured appendicitis with successful conservative treatment. The patient missed the follow-up schedule for elective interval appendectomy. Two years later, she presented with fever, limping gait, and right flank pain. Ultrasound revealed fixed dilated bowel loops, a fecalith and a heterogeneous hypoechoic lesion (3.7×3.6×3.3 cm) at right psoas muscle, suspecting PA. The patient received intravenous antibiotics for 2 weeks and made an excellent recovery. A follow-up ultrasound showed complete resolution of the abscess. The patient missed the schedule for interval appendectomy again, and same symptoms recurred 4 months later. Laboratory data indicated leukocytosis and marked elevation of serum Creactive protein. Computed tomography scan of the abdomen showed a gas-containing fluid collection within the right psoas muscle, and connecting with a dilated appendix. Laparotomy with appendectomy and tube drainage of the abscess was done, and the patient had uneventful recovery. The bacterial culture of pus grew Enterobacter cloacae. The patient discharged eight days after surgery. Neither abdominal symptoms nor evidence of recurrent PA on follow-up ultrasound was observed in the later years.

Radiological findings of retroauricular dermoid with intra-calvarial extension

Dermoid cysts are rare in head and neck region. A dermoid cyst arising in the retroauricular region over the mastoid can be easily misdiagnosed as a lymph node, thus posing significant diagnostic challenges. We present a case report of two year old boy with retroauricular dermoid showing intracalvarial extension. The child presented with the swelling in the right retro-auricular region with no associated hearing loss, tinnitus or vertigo. Provisional diagnosis clinically made was that of a large necrotic post auricular lymph node. On ultrasonography, well defined heterogeneous hypoechoic lesion showing few hyperechoic areas with scalloping and extension into the underlying temporal bone. On computed tomographic scan, heterogeneous non enhancing lesion showing areas of negative attenuation value seen in retroauricular region with extension into the temporal bone. Final diagnosis was confirmed by histopathological examination of the surgically resected specimen.

Patient with Liver Cirrhosis and Hemorrhagic Ascites

A 54-year-old male presented with progressive abdominal distension and loss of appetite for 2 months. Prior to being admitted at this institute, patient got evaluated for abdominal distension at a local hospital. Diagnostic ascites aspiration was done, which was hemorrhagic. Ultrasound abdomen showed features suggestive of chronic liver disease. The patient had mild pallor. Abdomen was distended with no visible veins. Liver and spleen were not palpable. Moderate ascites was present. His hemoglobin was 8.6 g/dL, total leukocyte count was 8800/mm3, and platelet count was 313 × 103/mm3. Liver function tests showed normal serum bilirubin level but elevated aspartate (150 IU/L) and alanine (70 IU/L) aminotransferase levels. His prothrombin time was four seconds prolonged with an INR of 1.2. His ultrasound abdomen had features suggestive of liver cirrhosis with a large heterogeneous hypoechoic lesion in right lobe of liver with multiple tiny hypoechoic liver nodules. Ascitic fluid aspiration was repeated, which showed hemorrhagic fluid. Ascitic fluid cytology showed red blood cells in full field but no malignant cells. Further, patient was found to be hepatitis B surface antigen (HBsAg) positive, and had a high HBV DNA viral load of 3.4 × 106 IU/mL. Serum alpha feto protein was 1210 ng/mL. Patient was started on antiviral therapy with Tab Tenofovir 300 mg daily. Triple phase contrast enhanced CT abdomen was done. Shown below are (Figure 1A) contrast enhanced CT axial image taken at the level of upper abdomen and (Figure 2A) sagittal reconstructed contrast enhanced CT Image showing the right lobe of liver. Figure 1A Case investigation – imaging. Figure 2A Case investigation – imaging. What does the CT scan image show? (Answer on the page 188).

A case of solitary necrotic nodule treated with laparoscopic hepatectomy: spontaneous regression of hepatocellular carcinoma?

Solitary necrotic nodule of the liver is a rare benign lesion with a completely necrotic core and a hyalinized fibrotic capsule containing elastic fibers. The pathogenetic mechanism is still unclear. We here describe a case of SNN, whose central reticulin fibers within the nodule suggest the origin as hepatocellular carcinoma or other hepatocyte-origin tumors, treated with laparoscopic anatomical segmentectomy of the liver. A 76-year-old Japanese female, with no prior medical history and no symptom, visited our hospital with the heterogeneous hypoechoic lesion in the liver segment VI incidentally pointed out in abdominal ultrasonography. Computed tomography with contrast demonstrated a 1.1 cm sized low-density lesion with mild ring enhancement on the rim in the arterial phase. Since the possibility of malignant tumor with necrotic change could not be ruled out, she underwent laparoscopic anatomical segmentectomy of the liver. In the histological examination of the surgical specimen, the liver nodule was necrotic tissue without viable cells and signs of inflammation, which had fibrous capsule and central cystic change and showed trabecular pattern alignment of ghost cells and reticulin fibers orthogonal to the capsule. Also, the findings of chronic hepatitis were observed in the background liver.

Nerve Sheath Tumor of Stomach: Two Cases Report

Nerve sheath tumors of stomach are a group of benign tumors of gastrointestinal tract . Here two cases of this tumor are presented and imaging features are described. A large, irregular well-defined margin mass is demonstrated. Sonography showed heterogeneous hypoechoic lesions. CT features are mainly a large irregular mass with well-defined margin and hetero geneous density, and some calcification can be seen. Contrast-enhanced CT images showed slight inhomogeneous enhancement. On MR images these lesions are demarcated associated with hypointense on T1 weighted imaging and moderate to markedly hyperintense on T2 weighted imaging. Contrast enhanced MRI demonstrated the mass hetero geneous enhancement. doi:10.4021/jmc452w