Hypoechoic Mass Research Articles

S1910 A Rare Metastatic Lesion in the Pancreas Presenting With Biliary Obstruction

Introduction: Pancreatic malignancies can originate from either endocrine or non-endocrine cells of the pancreas. Ductal carcinoma is the most common type of non-endocrine tumor, of which adenocarcinomas constitute the most common pancreatic malignancy. Squamous cell carcinoma (SCC) is the other ductal tumor that is very rare as the pancreas is generally devoid of squamous cells. Primary SCC of the pancreas is thought to arise from the squamous metaplasia of the ductules secondary to chronic inflammatory conditions, however, metastasis remains the most common etiology. We present a patient with history of recurrent poorly differentiated SCC of the cervix complicated by pancreatic head metastasis and biliary obstruction. Case Description/Methods: A 46-year-old female diagnosed with poorly differentiated SCC of the cervix stage IIB, status post multiple rounds of chemotherapy over a period of 4 years, was started on a new medication – Tisotumab. Four months following the initiation of this medication, patient experienced abdominal pain and was noted to have a lipase level of 1160 U/L. She was diagnosed with acute pancreatitis and treated accordingly. Subsequent labs showed continued up trending of her liver chemistry, withalkaline phosphatase of 520 U/L and total bilirubin of 9.7 mg/dl. A CT abdomen performed revealed dilation of both common bile duct (CBD) and pancreatic duct (PD) with subtle hypodense area in the head of pancreas. Endoscopic ultrasound (EUS) was performed which revealed a 3 cm x 2 cm ill-defined hypoechoic and heterogenous mass in the pancreas head (Figure). Fine needle biopsy of the lesion revealed SCC, most likely metastatic from the cervix. ERCP was performed and a 10mm x 8cm fully covered metal CBD stent was placed with normalization of liver enzymes. Palliative immunotherapy with Keytruda is currently being pursued. Discussion: Metastasis to the pancreas is an uncommon clinical condition and accounts for 0.5-5% of all pancreatic malignancies. Because of the rarity, primary sources should always be excluded. Only a handful of reports of uterine and cervical cancer metastasis to pancreas have been reported, most of them being adenocarcinoma. We report a very rare case of SCC cervix metastasizing to the pancreas. Unfortunately, curative surgery is not an option with metastatic disease, and chemoradiation can be used palliatively. The median survival is generally poor with median rates of 4.8% and 1% at 1-yr and 5-yrs, respectively.Figure 1.: A - EUS image showing dilated CBD measuring up to x mm. B – EUS image demonstrating a 3 x 2 cm hypoechoic pancreatic head mass. C– H&E stain showing neoplastic clusters (black arrows) of metastatic SCC.

S1951 An Uncommon Case of Smoldering Pancreatitis

Introduction: We describe a rapid onset, poorly differentiated, invasive pancreatic carcinoma with histiocytoid features diagnosed post-pancreaticoduodenectomy, after endoscopic ultrasound (EUS) guided fine needle biopsy failed to identify it. Case Description/Methods: A 69-year-old male with a history of alcohol abuse, and tobacco use, initially presented with epigastric pain and early satiety, diagnosed with acute pancreatitis. Computed tomography (CT) scan and Magnetic resonance imaging (MRI) of the abdomen/pelvis at this time were significant for a cystic lesion in the tail of the pancreas with fat stranding (Figure A). EUS was performed however had extremely limited visibility given inflammatory changes, main pancreatic ductal dilation was noted but no clear mass was identified. Fine needle aspiration (FNA) of the cystic structure was suggestive of a pseudocyst on cytology (CEA 25 ng/ml, amylase 3250 units/L). A portal lymph node was appreciated, and fine needle biopsies (FNBx) yielded only inflammatory cells. Clinical course continued to deteriorate over the next few months with non-resolving smoldering pancreatitis symptoms and >80 lb weight loss. Repeat CT abdomen/pelvis was significant for a 2.7 x 2.1 cm lesion of the head of the pancreas (Figure B). EUS was repeated and revealed a 32 x 29 mm hypoechoic mass in the head of the pancreas with upstream pancreatic ductal dilation to 13 mm with significant parenchymal atrophy as well as an enlarged porta hepatis lymph node. FNBx were obtained and were sent for analysis at a tertiary care center which revealed chronic inflammation with necrohistiocystic debris with atypical cells at both sites (Figure C). Due to clinical deterioration and after multidisciplinary discussion, patient underwent a pancreaticoduodenectomy for smoldering pancreatitis involving the head of pancreas and concerning atypical cells. The final pathology report revealed a poorly differentiated, invasive pancreatic carcinoma with histiocytoid features that extensively involved 6/16 regional lymph nodes after multiple reviews by multiple pathologists. Discussion: To our knowledge, poorly differentiated, invasive pancreatic carcinoma with histiocytoid features has not been previously documented. This presentation with smoldering pancreatitis significantly delayed the diagnosis due to the marked inflammatory changes compromising initial imaging (CT, MRI, EUS). This case highlights the importance of a multidisciplinary approach in managing complicated non resolving pancreatitis cases.Figure 1.: A - Cystic lesion with inflammatory changes near the tail of the pancreas; B - Mass in the head of the pancreas with upstream pancreatic duct dilation; C - Endoscopic Ultrasound with fine needle biopsy of the mass in the head of pancreas

S2345 Metastatic, Poorly-Differentiated Neuroendocrine Tumor of the Esophagus: Case Report and Literature Review of a “Rare Rarity”!

Introduction: Neuroendocrine tumors (NET) most commonly develop in the lungs, appendix, bowel and pancreas. Esophageal NET is extremely rare, comprising < 2% of all NETs. The most common symptom is dysphagia although patients may be asymptomatic. We present a case of metastatic esophageal NET and a literature review. Case Description/Methods: A 61-year-old female with 5-month history of progressively worsening chest tightness, weight loss and diarrhea underwent abdominal CT scan which revealed enlarged gastrohepatic lymph nodes (LN). EGD showed a 3cm ulcerated lesion at the gastroesophageal junction (GEJ). Biopsies suggested high-grade NET in the background of high-grade dysplasia. PET/CT confirmed a 3.0 x 2.3cm ill-defined, hypermetabolic, soft tissue mass at the GEJ (SUV max 9.0) and several hypermetabolic, enlarged gastrohepatic LNs, largest measuring 2.8 x 2.0cm (SUV max 8). The patient was referred to our center for further management. Repeat EGD revealed a 3cm distal esophageal lesion with central ulceration extending across the GEJ into the high cardia (Figure). On endoscopic ultrasound (EUS), a hypoechoic mass is seen with involvement of the muscularis propria (T2). Peri-gastric lymphadenopathy was present. Transgastric fine needle aspiration (FNA) of the largest LN confirmed metastatic neuroendocrine tumor (T3N1). Repeat endoluminal biopsies from the esophageal lesion confirmed poorly-differentiated NET, CD56 and synaptophysin positive, Ki-67 > 90%. Multidisciplinary tumor board recommended chemotherapy with carboplatin and etoposide. No evidence of disease progression noted after the first 3 cycles; patient remains on treatment. Discussion: Metastatic poorly-differentiated high-grade NET of the esophagus is very rare. First-line therapy is chemotherapy. Average prognosis with treatment is 12-18 months. Immunotherapy may provide additional survival benefit however data is extremely limited so this is typically reserved for second-line therapy (if progression on chemotherapy). Given the rarity and aggressiveness of these lesions, accurate pathological diagnosis and multidisciplinary discussion is critical for optimal management of these patients.Figure 1.: Large distal esophageal lesion with central ulceration.

S1792 Painless Obstructive Jaundice: Pancreatic Adenocarcinoma Cannot Be Excluded

Introduction: Autoimmune pancreatitis (AIP) is a chronic inflammatory condition typically presenting with abdominal pain, jaundice and weight loss. AIP is an uncommon cause of pancreatitis and diagnosis may be challenging, but it is highly responsive to corticosteroids. We present a case of painless obstructive jaundice complicated by a mass on the pancreatic head. Case Description/Methods: A 57-year-old Indian male with no past medical history presented with vague abdominal pain, pruritus, and clay colored stools. Vital signs were unremarkable and laboratory investigations revealed alkaline phosphatase 515 U/L, alanine transaminase 732 IU/L, and total bilirubin 7.6 mg/dL. The patient underwent a right upper quadrant ultrasound which showed an enlarged gallbladder and dilated common bile duct (1.9 cm) down to the level of the pancreatic head. An endoscopic ultrasound (EUS) revealed a 3.2 x 3.7 cm hypoechoic mass in the head of the pancreas obstructing the bile duct, 2 enlarged lymph nodes in the area near the bile duct, marked bile duct dilation, and an enlarged sludge-filled gallbladder. Of note, unlike most ductal tumors the pancreatic duct upstream of the mass was not dilated. Fine needle aspiration (FNA) was unsuccessful due to the obstruction by the lymph nodes. Endoscopic retrograde cholangiopancreatography (ERCP) showed stricture of bile duct consistent with a pancreatic head mass, and was stented. Abdominal and pelvic computed tomography (CT) confirmed a 3 cm pancreatic head mass. Pathology result from the attempted FNA was inconclusive. Further labs revealed normal IgG4 and CA 19-9 level of 194; indicative of possible pancreatic malignancy. The patient developed jaundice, scleral icterus and rapid weight loss. EUS with FNA with repeat biopsies revealed rare degenerated epithelial cells. The patient was treated with high dose steroids, with planned pancreaticoduodenectomy. Follow-up CT revealed resolution of the pancreatic mass and was confirmed by repeat EUS/ERCP and normal CA 19-9 level. Discussion: Although painless obstructive jaundice with a pancreatic mass is a typical presentation for a pancreatic neoplasm; it is not the only possible diagnosis. Despite biochemical and radiographic evidence suggesting a malignancy; if AIP remains in the differential, a trial of steroids may be warranted to avoid unnecessary surgical intervention and associated morbidity.

S1892 A Double Take on a 20-Year Double J-Stent

Introduction: The double J biliary stent is commonly used to relieve obstructions and aid in draining of pancreatic fluid. Indwelling or forgotten stents are rarely seen and their sequelae are unknown. We present the case of a patient who was lost to follow-up over twenty years ago following cholecystectomy and placement of double J stent. A routine esophagogastroduodenoscopy (EGD) for variceal surveillance was performed and discovered an ampullary fungating mass. Case Description/Methods: A 79 y/o female with a history of hypertension presented to the ED with worsening abdominal distention. She was a poor historian but denied alcohol use, drug use, or any history of liver disease. Her workup included an abdominal paracentesis removing greater than 7 liters of fluid with a SAAG indicating portal hypertension. She had abnormal liver function tests (LFTs) and CT imaging was consistent with cirrhotic morphology of the liver and a double-J stent present in CBD (Figure A). An EGD for further evaluation and for variceal vein monitoring was done revealing grade 2 varices but more significantly, at the site of ampulla of vater a large fungating mass was noted. The mass was medium-sized and polypoid with no bleeding. The CBD stent was in place with noted hyperproliferation of the tissue of the ampulla vs a periampullar duodenal mass (Figure B). A repeat EDG with EUS was performed, finding the hypoechoic non-circumferential mass endosonographically within the ampulla. The mass measured 24 mm by 14 mm in maximal cross-sectional diameter (Figure C). The lesion extended from the mucosa to the muscularis mucosa. The endosonographic borders were well-defined. There was sonographic evidence suggesting invasion into the deep mucosa (Layer 2). Filamentous microorganisms were identified on HE and GMS stain. No individual atypical AE1/AE3 positive epithelial cells were identified. Discussion: This case highlights the unusual sequelae of a retained double-J stent in a patient who was lost to follow up. It’s unknown why the stent was placed, likely during an intraoperative cholangiogram, and the patient did not recall her follow-up instructions. Several questions arise surrounding the mass such as, did it have malignant potential and what role, if any, did the stent have in the formation of the mass? Did colonization represent an increased risk of ascending cholangitis? The stent was left in at the conclusion of the case and the patient was extensively educated about follow-up and maintenance endoscopy.Figure 1.: CT evidence of pneumobilia, ampullary fungating mass, and EUS imaging.

S3613 Gastric Spindle Cell Leiomyosarcoma Is Associated With Chronic Helicobacter pylori Infection

Introduction: Chronic Helicobacter pylori (HP) infection has been shown to be strongly associated with development of gastric malignancies, mostly gastric adenocarcinomas and lymphomas. We present a case of primary gastric leiomyosarcoma in a patient with persistent epigastric pain and HP infection. Case Description/Methods: A 59-year-old female presented to clinic with persistent, postprandial epigastric pain. Cardiopulmonary workup was negative. She had a history of esophageal leiomyoma resected endoscopically with negative margins 10 years ago. She was treated in the past for HP infection but never had repeat testing to confirm eradication. Abdominal computed tomography showed focal hepatic infiltration. She was advised to have a repeat upper endoscopy for surveillance but was lost to follow-up due to psychiatric comorbidities. She presented 6 years later with epigastric pain. Repeat CT abdomen showed a new 2.8 cm hypoattenuating lesion in the lesser curvature of the stomach. Patient did not follow up due to psychosocial issues. Two years later, she returned to clinic for epigastric pain and underwent repeat upper endoscopy and endoscopic ultrasound (EUS) with fine needle aspiration (FNA). EGD showed sub-gastric nodule attached gastric wall, about 30 mm in maximal dimension and gastric biopsy confirmed active HP infection. The EUS showed a 31.7x23.5 mm hypoechoic homogeneous gastric mass along the lesser gastric curvature. Cytology showed cellular spindle cell neoplasia with myogenic differentiation concerning for possible leiomyoma or leiomyosarcoma. Abdominal magnetic resonance imaging and chest computed tomography revealed no evidence of abdominal or thoracic metastasis. Subsequently, partial underwent sleeve gastrectomy. Pathology revealed Grade 1 myxoid leiomyosarcoma with negative margins. (Figure) Discussion: Prior studies demonstrated associations between HP infection and gastric malignancies - typically gastric adenocarcinoma or lymphomas. Few studies investigated the relationship between HP infection and gastric leiomyosarcomas.4,5 Importantly, this patient never had clearance of HP infection and may have allowed a leiomyosarcoma to develop. It is imperative that clinicians confirm eradication of HP infection given risk of leiomyosarcoma development in addition to other malignancies HP infections are known to cause.Figure 1.: Endoscopic and histologic examination of gastric leiomyosarcoma. (A) Endoscopic ultrasound visualization demonstrating tumor within lesser curvature of stomach. (B) Upper endoscopy revealing tumor approximately 4 cm from gastroesophageal junction. (C) Hematoxylin and eosin (H&E) stain of gastric tumor biopsy demonstrating spindle cell proliferation in a myxoid background with significant nuclear atypia and pleomorphism consistent with myxoid leiomyosarcoma. Magnification x400. (D) Immunohistochemical staining of gastric lesion biopsy demonstrating strong immunoreactivity to desmin. Not shown are positive stains for smooth muscle actin (SMA) as well as negative stains for Cytokeratin AE1/AE3, Myogenin, MyoD1, DOG-1, CD117, S100, SOX10, CD34, ALK-1 and ER. Positive and negative controls stained appropriately but are not included.

S2175 Now You See Me, Now You Don’t: A Case of Campylobacter Jejuni Colitis Presenting as a Colonic Mass

Introduction: Campylobacter jejuni is responsible for 3-6% of diarrheal illnesses in the United States. Inoculation follows ingestion of a contaminated source such as poultry, unpasteurized milk, or drinking water. The presentation of a C. jejuni infection may radiographically and endoscopically mimic other pathologies such as colonic malignancy and inflammatory bowel disease (IBD). Case Description/Methods: A 66-year-old man with a past medical history of prostate cancer in remission and a 6mm colonic polyp removed 5 years prior presented to the emergency department with 5 days of watery diarrhea. He complained of 6 watery bowel movements per day associated with colicky abdominal pain and bloating. He was hemodynamically stable with a physical exam notable for severe tenderness in the right lower quadrant. Serum chemistries did not reveal any abnormalities. Computed tomography revealed severe, focal bowel wall thickening in the ascending colon and a 1.7cm hypodense lesion in the right hepatic lobe which was confirmed on magnetic resonance of the abdomen. The radiologist’s interpretation emphasized concern for colonic malignancy with metastasis to the liver (Figure). Endoscopic evaluation revealed diffusely erythematous, granular and ulcerated mucosa throughout the colon with concern for infectious vs inflammatory colitis. Histologic evaluation of ascending colonic mucosal biopsy revealed moderately active chronic colitis with extensive cryptitis and crypt abscesses. Stool polymerase chain reaction was notable for C. jejuni infection and the patient achieved clinical and endoscopic remission without antimicrobial therapy. Discussion: In patients with C. jejuni enterocolitis, radiographic imaging may reveal signs of bowel wall edema or ulcerations which may resemble colonic malignancy or IBD. Endoscopic findings of campylobacter enterocolitis are non-specific, however, may reveal edematous, erythematous, and friable mucosa which may be associated with hemorrhage. Inflamed mucosa can be either isolated or discontinuous. Colonic ulcers may present as either aphthous or linear (may resemble cobblestoning as seen in Crohn's Disease). Histologic evaluation can reveal cryptitis and crypt abscess formation similar to findings of ulcerative colitis. This case highlights the range of radiographic and endoscopic presentations of C. jejuni Colitis. Infectious colitis should remain on the differential for radiographic evidence of colonic edema in the right clinical setting.Figure 1.: A and B: CT Abdomen/Pelvis showing ascending colon wall thickening resembling mass; C: CT of Hypoechoic liver mass; D: T2-weighted MRI Abdomen of ascending colon wall thickening resembling a mass; E: Colonoscopy image revealing inflamed mucosa of ascending colon; F: Ulcerated mucosa of the sigmoid colon.

S1697 Biliary Schwannoma in a Post-Liver Transplant Patient Presenting as Biliary Obstruction

Introduction: Schwannomas are benign, mesenchymal-derived neoplasms which present as solid, slow growing tumors. They can rarely be observed in the gastrointestinal (GI) tract, with very limited reports of them occurring in the biliary system. In this case, we describe a bile duct schwannoma in a post-liver transplant patient. Case Description/Methods: A 77-year-old man with a history of alcohol-related cirrhosis with hepatocellular carcinoma treated with orthotopic liver transplantation 16 years prior, and end stage renal disease on hemodialysis presented with jaundice. Labs demonstrated new elevations in his liver enzymes: AST 181 U/L, ALT 189 U/L, alkaline phosphatase 625 U/L, total bilirubin (TB) 7.9 mg/dL, and direct bilirubin 5.0 mg/dL. A magnetic resonance cholangiopancreatography was performed and demonstrated a 16 x 15 x 11 mm enhancing mass causing abrupt narrowing of the mid common bile duct (CBD) with upstream duct dilation to 10 mm ( Figure A) without other discrete mass identified. A follow-up endoscopic ultrasound confirmed a hypoechoic mass in the mid CBD and fine needle biopsy was obtained. An endoscopic retrograde cholangiopancreatography was subsequently performed, which demonstrated a severe biliary stricture at the level of the prior biliary anastomosis which was treated with balloon dilation and placement of a covered metal stent. The procedure was complicated by post-sphincterotomy bleed and mild post-ERCP pancreatitis. His liver enzymes failed to improve, and his TB progressively worsened to 23.3 mg/dL. Pathology returned showing a low-grade spindle cell tumor (Figure B), with staining positive for S100 (Figure C) and negative for CD117 and desmin, consistent with a diagnosis of schwannoma. Surgical intervention was not pursued, in line with his goals of care, and he was ultimately transitioned to comfort-oriented care and passed 5 days after admission. Discussion: Schwannomas are rare neoplasms which can arise from the nonepithelial wall of the GI tract containing nerve fibers. They are composed of highly cellular spindle cells which stain positive for vimentin (marker of mesenchymal origin) and S100 protein (marker of nerve sheath origin), and negative for CD117 (marker of GI stromal tumors) and desmin (muscle cell marker). Neoplasms can often be suspected in late presentations of post-transplant biliary obstruction. To our knowledge, this is the first case report of a biliary schwannoma occurring at the site of a biliary anastomosis in a liver transplant patient.Figure 1.: A) MRCP T1-weighted coronal image demonstrating a 16 x 15 x 11 mm enhancing mass with diffusion restriction (yellow arrow) at the mid common bile duct causing an abrupt biliary stricture with upstream dilation, B) 10x magnification H&E showing spindled, wavy nuclei in a fibroblastic stroma consistent with a spindle cell neoplasm in a background of unremarkable columnar biliary epithelium, C) 10x magnification S100 immunohistochemical stain showing diffuse nuclear and granular cytoplasmic positivity consistent with nerve sheath origin.

S2840 Hepatic Tuberculoma Caused by Mycobacterium Fortuitum: A Rare Case Diagnosed by EUS-FNA

Introduction: Mycobacterium fortuitum is a type of nontuberculous mycobacteria belonging to a group classified as Rapidly Growing Mycobacteria (RGM), along with Mycobacterium abscessus and Mycobacterium chelonae. M. fortuitum is predominantly associated with skin, soft tissue, and surgical-wound infections. Catheter-related sepsis and disseminated disease can also occur. Isolated liver involvement by atypical mycobacterial infection is exceedingly rare. Here we describe a case of M. fortuitum presenting as an asymptomatic liver mass. Case Description/Methods: A 67-year-old male was referred for endoscopic ultrasound (EUS) to evaluate a gastric body subepithelial lesion (SEL) and a 3 cm incidental liver mass. He was asymptomatic. Percutaneous CT-guided biopsy was performed, but pathologic results were nondiagnostic. Patient was thus referred for EUS to evaluate the gastric SEL and determine if the liver mass represented metastasis. A 14 by 4 mm elongated intramural hypoechoic mass arising from the muscularis propia highly suggestive of a leiomyoma or GIST was identified. A heterogeneous mass with cystic spaces and echogenic foci in the left liver lobe measuring 27 by 20 mm was sampled using a 22g FNA needle. Pathology revealed granulomatous inflammation with necrosis. An AFB stain was positive for acid fast bacilli. PCR analysis of the specimen detected M. fortuitum DNA. Patient was treated with levofloxacin 750 mg daily plus trimethoprim and sulfamethoxazole (Septra DS) 800 mg - 160 mg twice daily. Follow-up contrast-enhanced MRI revealed complete resolution of liver lesion after 3 months of antibiotics. Discussion: Isolated liver involvement by nontuberculous mycobacteria is uncommon, usually asymptomatic, and its diagnosis can easily be missed or mistaken. We report the first case of a hepatic tuberculoma caused by M. fortuitum diagnosed by EUS-FNA. Precise and accurate recognition by a minimally invasive technique via EUS-FNA resulted in prompt treatment and resolution of the disease.

S1744 Idiopathic Non-Caseating Pancreatic Granuloma Mimicking Neuroendocrine Tumor: A Challenging Diagnostic Dilemma

Introduction: Pancreatic granuloma is rare. Caseating granuloma is usually caused by tuberculosis, while non-caseating granuloma is mainly secondary to systemic diseases such as sarcoidosis, rheumatoid arthritis, fungal infection, and Crohn’s disease. Idiopathic etiology can present a diagnostic challenge, requiring further investigation to differentiate it from malignancy. We present an interesting case of a patient who presented with a concern for a neuroendocrine tumor before diagnosing idiopathic non-caseating pancreatic granuloma. Case Description/Methods: A 75-year-old female presented with left upper quadrant pain, chronic diarrhea, and palpitations. The physical exam was unremarkable. Workup was significant for elevated serum chromogranin 3,123 ng/ml, with mildly elevated urine metanephrines. Magnetic resonance imaging showed a stable 2.5 cm cystic lesion in the tail of the pancreas communicating with the main pancreatic duct and hypointense area in the tail. 68Ga DOTATATE scan was negative for neuroendocrine tumor. Endoscopic ultrasound showed a multi-cystic lesion in the tail of the pancreas with thick septations consistent with branch-duct intrapapillary mucinous neoplasm (BD-IPMN), and a 2.7 cm homogenous well-defined hypoechoic area in the tail of pancreas along with multiple enlarged peripancreatic lymph nodes (Figure). Fine needle biopsy showed multiple non-caseating granulomas with benign pancreatic and lymphoid tissue. There was no evidence of malignancy, and stains for acid-fast bacilli, FITE stain, and fungal cultures were negative. A benign idiopathic etiology was concluded. At the 6-months follow-up, the patient was doing well. Discussion: Non-caseating pancreatic granuloma has been described in a few case reports. Sarcoidosis was the most common cause, followed by rheumatoid arthritis and Crohn’s disease. Other cases were associated with granulomatosis with polyangiitis (formerly Wegener's granulomatosis), xanthogranulomatous disease, insulin-dependent diabetes mellitus, or foreign body (Talc). Patients may present with epigastric pain, sometimes associated with weight loss, jaundice, fever, or nausea. Further workup and sampling, or even surgery, might be necessary before reaching a solid diagnosis and ruling out malignancy. Therefore, it is essential to rule out other etiologies before confirming the diagnosis of idiopathic pancreatic non-caseating granuloma.Figure 1.: Endoscopic ultrasound (EUS) showing a homogenous & well-defined hypoechoic mass in the tail of the pancreas, measuring 11 x 27 mm.

Synchronous invasive ductal breast cancer with clear cell renal carcinoma: a rare case report with review of literature

Introduction: Multiple cancer refers to the emergence of 2 or more cancers in a single patient. This study aims to report a rare case of clear cell renal cancer associated with invasive breast ductal carcinoma. Case presentation: A 56-year-old female presented with a left breast mass. Clinical examination revealed a mobile left side breast mass at the left upper quadrant. An irregular hypoechoic mass was seen on ultrasound, and mammography showed a unifocal spiculated mass seated on the pectoralis muscle. Computed tomography of the chest and abdomen revealed a cystic mass lesion in the cortex of the lower pole of the left kidney. Partial nephrectomy and wide local breast mass excision with sentinel lymph node biopsy were done. Histopathologic results confirmed associated invasive ductal breast carcinoma with clear renal cell carcinoma. Discussion: In the treatment of renal cell carcinoma with multiple tumors, several factors should be interpreted, including the tumor stage, evaluation for the presence of metastasis, and whether the kidney tumor is accessible for operation. Conclusion: The term multiple cancer refers to the development of more than one tumor in a single patient that could be synchronous or metachronous. The association of invasive ductal breast cancer with clear renal cell carcinoma is a sparse entity.

S2548 An Unusual Case of Abdominal Hematoma Presenting After Long Quiescence Period

Introduction: Incidental abdominal masses are often detected during routine imaging for abdominal pain. Abdominal hematomas usually present a few days after recent trauma and are associated with peritonitis requiring surgical intervention. We report a case of symptomatic abdominal hematoma, presenting as an abdominal mass, 1 year after motor vehicle accident (MVA). Case Description/Methods: 24-year-old female presented with sudden onset sharp epigastric and left upper quadrant (LUQ) abdominal pain, radiating to bilateral shoulders, along with decreased oral intake, nausea, and bilious vomiting. On physical exam, she was hemodynamically stable, abdomen was soft, non-distended, with epigastric and LUQ tenderness, bowel sounds normal, otherwise unremarkable exam. Initial blood work was unremarkable. Computed tomography of abdomen and pelvis (CTAP) revealed a 5.6x 2.1x 5.4 cm mass located between stomach and spleen without associated adenopathy, suspicious for gastrointestinal stromal tumor (Figure). On EUS, the lesion appeared poorly defined, multicystic and likely originating outside the gastric wall. There was also a moderate amount of free fluid in the abdomen. A fine needle biopsy was obtained, but the sample was largely blood clot. The next day, the patient developed sharp abdominal pain with guarding, blood work revealed hemoglobin levels drop from 12.9 to 7.6 g/dl. CTAP angiography showed development of large amount of intraperitoneal free fluid, without active extravasation, and grade 1 splenic laceration, likely chronic. The non-enhancing hyperdense mass was again noted, unchanged in size and location. Laparoscopy revealed a ∼6cm hematoma and evacuated 2L old blood. Postoperative diagnosis was spontaneous hemoperitoneum secondary to trauma of short gastric vessel. Pathology result showed blood, inflammation, and rare degenerated epithelial cells. Upon further interrogation, patient endorsed MVA 1 year ago but did not seek medical care due to no symptoms. Patient was monitored after surgery and upon significant improvement in her symptoms and blood work, she was discharged. Discussion: It is rare for abdominal hematomas to be quiescent for one year and then suddenly present as peritonitis without any further inciting event. Our patient could have suffered from major morbidity, given the drastic drop in hemoglobin level, without urgent intervention. Physicians should have high clinical suspicion and investigate for possible trauma, in acute abdominal pain cases with an incidental abdominal mass on imaging.Figure 1.: Computed tomography of abdomen and pelvis revealing a hypo-echoic mass located medially adjacent to the spleen and laterally adjacent to the stomach. No surrounding fat stranding or lymphadenopathy noted.

S3723 A Rare Cause of Upper Gastrointestinal Bleeding: Gastric Synovial Sarcoma

Introduction: Synovial sarcoma is an uncommon type of malignant mesenchymal neoplasm commonly found within joints of the extremities and very rarely found in the GI tract. Genetic sequencing techniques used as an adjunct to histochemical markers have proven indispensable for diagnosis following biopsy. We present a rare subtype of soft tissue neoplasm called primary gastric synovial sarcoma as cause for gastrointestinal bleeding in a middle-aged Hispanic patient. Case Description/Methods: A 51-year-old male with a medical history of Hypertension, and Diabetes was brought to the ER due to a syncopal episode. Patient denied abdominal pain, weight loss, hematemesis, hematochezia, hematuria, or melena. Physical exam was remarkable only for pale conjunctiva. Laboratory results remarkable for a hemoglobin of 5 g/dL warranting multiple packed red blood cell transfusions. Colonoscopy was performed with normal findings. Following upper GI endoscopy, a mid gastric body 3 cm polypoid irregular mass with shallow ulcerations was found. The patient was referred for endoscopic ultrasound revealing a 25 by 21 mm heterogenous hypoechoic mass in the greater curvature confined to mucosal layer. The acquired specimen displayed characteristics of a high-grade tumor with multiple negative markers (table 1). Therefore, an SS18 FISH test (18q11.2 probe) was performed and the results show the presence of translocation t(X,18) (p11.2;q11.2), consistent with a poorly differentiated synovial sarcoma, a spindle cell monophasic subtype. Completeness of resection of the tumor could not be documented so the patient was referred to surgery for partial gastrectomy of the involved area. The remaining tumor measured 0.7 cm, invaded the submucosal layer but all margins and lymph nodes were uninvolved. A subsequent PET/CT scan did not reveal evidence or residual or metastatic disease. (Figure) Discussion: This is the first known case of a primary gastric synovial sarcoma, in a patient of Puerto Rican ethnicity, without family history of genetic disorders, radiation exposure or previous malignancy. Prognosis remains challenging due to the small number of reported cases with surgical resection as the mainstay of treatment. Therefore, it is crucial to continue to identify and diagnose this rare malignancy to better inform treatment and prognostic decisions going forward.Figure 1.: Figure A: Friable lobular mass at greater curvature of stomach. Figure B: Endoscopic ultrasound revealed 2.5 by 2.1 cm heterogeneous hyperechoic mass at greater curvature of stomach confined to mucosal layer. Figure C: Picture of specimen following endoscopic mucosal resection. Table 1. - histochemical stains / Fluorescence in situ Hybridization performed for identification of tumor Tumor Marker Result Lymphoma CD20, CD23 Negative Gastrointestinal stromal tumor CD117, CD34, DOG-1 Negative Angiosarcoma CD34 Negative Leiomyosarcoma caldesmon, MSA, SMA, Desmin Negative Sarcomatoid carcinoma AE1, AE3 Negative Spindle cell melanoma S100, SMB 45 Negative Synovial Sarcoma SS18 FISH test (18q11.2) t(X;18)(p11.2;q11.2)

S2406 A Case of Cervical Esophageal Adenocarcinoma Arising From Gastric Inlet Patch: A Benign Lesion With Malignant Potential

Introduction: Esophageal adenocarcinoma is typically localized to the distal third of the esophagus. It is associated with long-standing acid reflux and resultant Barrett’s esophagus. In contrast, adenocarcinoma in the proximal esophagus without Barrett’s metaplasia is extremely rare. A gastric inlet patch (GIP) is a lesion of ectopic gastric mucosa usually found in the cervical esophagus and is considered a benign lesion. However, albeit rare, malignant transformation of GIP can occur. Here, we present a case of cervical esophageal adenocarcinoma arising from gastric inlet patch. Case Description/Methods: A 50-year-old male with GERD presented with a 6-month history of progressive dysphagia to solids and liquids and 20-pound weight loss. He reported a 1 pack-year smoking history but quit 30 years prior and consumed alcohol socially. Family history was negative for esophageal cancer. Upper endoscopy (HQ190F) showed a malignant stricture (2 cm long, 6mm diameter) at 18 cm from the incisors and a gastric inlet patch adjacent to the stricture. The endoscope was downsized (XP190N), and the stricture was dilated (24F) and traversed. The Z-line was at 40 cm with Barrett’s esophagus extending from 36 cm to 40 cm. Pathology of biopsies from the stricture showed acute and chronic inflammation with increased intraepithelial eosinophils suggestive of acid reflux. CT scan of the neck with contrast showed a heterogeneously enhancing ill-defined mass involving the cervical esophagus below the cricoid cartilage indenting the posterior margin of the trachea. Bronchoscopy was negative for bronchogenic cancer. Endoscopic ultrasound showed a non-circumferential hypoechoic mass in the cervical esophagus 18 cm from the incisors extending to 20 cm. The mass was predominantly extrinsic but was also noted to have a luminal component and poorly defined endosonographic borders. Pathology of FNAB showed moderately differentiated adenocarcinoma (Figure). Discussion: Proximal esophageal adenocarcinoma is extremely rare, making up less than 1% of esophageal cancers. Case studies have been published associating GIP and esophageal adenocarcinoma, but the pathogenesis of malignant transformation remains unclear. There are no established screening guidelines for ectopic gastric mucosa and routine biopsies are not recommended as dysplasia within GIP is rare. GIP may be overlooked during EGD and NBI exam may improve detection rates. Our case re-emphasizes careful examination of GIP and to strongly consider biopsy if abnormal.Figure 1.: A) Endoscopic view of malignant stricture 18 cm from incisors. Gastric inlet patch (arrow) adjacent to stricture. B) Endoscopic ultrasound image at the level of esophageal stricture showing irregular hypodensity suggestive of malignancy. C) Pathology of biopsy performed through fine needle aspiration (EUS) of upper esophageal mass demonstrating moderately differentiated adenocarcinoma, cribriform pattern, with mild nuclear pleomorphism, abundant mitoses, and apoptosis (H&E, 10x).

S2583 Dedifferentiated Retroperitoneal Liposarcoma Presenting as Upper Gastrointestinal Bleeding

Introduction: Dedifferentiated retroperitoneal liposarcoma (RPLS) is a rare, biologically heterogeneous tumor that presents with a morphological spectrum and is histologically challenging to diagnose. The tumors typically consist of a single tumor characterized as both poor and well dedifferentiated liposarcoma and non-lipomatous sarcoma. Presentation is typically symptomatic with abdominal pain, ascites, palpable mass, or the rare lower gastrointestinal bleed. Treatment consists of neoadjuvant radiation, surgery, and chemotherapy based on different staging systems used to identify the subtype and histology grade. The success of therapy depends on staging and grading of the tumor. We report a case of dedifferentiated RPLS presenting as upper gastrointestinal bleeding.1 Case Description/Methods: A 68-year-old male presented to the emergency department with three days of melena and shortness of breath. On exam, the patient was alert and oriented × 3. Afebrile. Blood pressure was 109/67 and heart rate 95 BPM. Oxygenation saturation of 93% on 3 L of oxygen by nasal cannula. The abdomen was soft, nontender, with a firm mass-like structure palpated in the right upper quadrant. Labs revealed hemoglobin of 7.9. CT imaging showed a large mass abutting the duodenum, right kidney, measuring 18 × 13 × 15 cm. Margin with duodenum very difficult to discern suggesting may be invading or rising from duodenum. Due to anemia with melena and CT findings, an EGD and upper EUS with FNA were completed. EGD revealed a large fundating mass in the third portion of the duodenum with fresh blood and appeared to be causing narrowing of the lumen. EUS revealed a large circumferential periduodenal hypoechoic mass not involving the pancreas. Origin of mass not identified, but appeared soft and vascular. Pathology of the small bowel periduodenum consistent with dedifferentiated liposarcoma, MDM2 FISH- amplified (Figure 1). Discussion: The patient was evaluated by medical, radiation, and surgical oncology given the pathology confirming dedifferentiated RPLS, grade two. Therapy includes neoadjuvant radiation prior to surgical intervention. Due to the anemia, hemoglobin levels are monitored often. This case indicates that the rarely diagnosed dedifferentiated RPLS can in fact present as an upper gastrointestinal bleed and not as mass effect.Figure 1.: Duodenal Mass with Associated Blood.

A descriptive study of chronic granulomatous mastitis in Central India

Background: Chronic granulomatous mastitis is a rare benign breast condition that can mimic breast cancer. The present study was undertaken to assess the demographics, clinical presentation, etiology, diagnostic tools and management of patients with CGM.Methods: This descriptive observational study was conducted in total 83 women who presented with breast lump with tenderness associated with fever for more than 4 weeks of duration in the Department of General Surgery at Tertiary Care Centre from June 2018 to December 2020.Results: In all cases breast lump was chief complaint, of maximum (38.5%) had this illness since last 1 to 4 months. 48 patients had past history of tuberculosis. Axillary lymph node was enlarged in 24.1% and body temperature was raised in 57.8% of cases. Skins over the lump were presented with indurated with multiple pus discharging sinuses (50.6%) and palpable mass with erythema and ulcerative skin lesion (49.4%). On biopsy all the patients presented with granulomatous mastitis and on USG, hypoechoic mass was presents in all cases. Patients were managed medically by IV antibiotic and AKT (57.8%) and IV antibiotic with oral corticosteroid (42.2%). Incision and drainage were done in 74 cases while 8 required wide local excision and in 1 patient mastectomy was done.Conclusions: The histopathology remains the optimal diagnostic tool. Corticosteroid therapy has been shown to be efficacious for CGM, but in the existence of many complications, surgical treatment has been first method of choice. We consider that wide local excision is the better treatment choice if possible.

Gastrointestinal: Pitfalls of an abruptly elevated alpha-fetoprotein in a chronic hepatitis B carrier.

A 31-year-old male with a history of diabetes mellitus and viral hepatitis B was admitted to our hospital in March 2021 for epigastric pain, steatorrhea, and increased alpha-fetoprotein (AFP). He had a history of excessive drinking for more than a decade. Two years ago, he was admitted to another institution due to abdominal distention, and computed tomography (CT) showed enlargement of the pancreas. He then received endoscopic ultrasonography-guided fine-needle aspiration (EUS-FNA) and was diagnosed with chronic pancreatitis. Since then, he lost 25 kg, despite relief of associated symptoms after medical treatment, including pancreatic enzyme preparations and prokinetics. Physical examination showed tenderness in the upper abdomen. Laboratory examination revealed the following abnormalities: white blood cell count (11.01 × 109/L), erythrocyte sedimentation rate (120 mm/h), alkaline phosphatase (163 U/L; reference range, 45–125 U/L), γ-glutamyl transpeptidase (223 U/L; reference range, 10–60 U/L), CEA (9.32 ng/mL; reference range, 0–5.00 ng/mL), AFP (3473 ng/mL; reference range, 0–20 ng/mL). Measurements of CA19–9 (21.70 U/mL; reference range, 0–34.00 U/mL) and IgG4 (0.263 g/L, reference range, 0.030–2.100 g/L) were normal. A plain/contrast CT of the abdomen revealed diffuse enlargement of the pancreas with hypodensity, focal coarse calcifications, and a capsule rim sign (Fig. 1a). Positron emission tomography demonstrated an increased uptake of 18F-FDP in the pancreatic head and uncinate process (Fig. 1b). Endoscopic ultrasound examination showed a hypoechoic mass located at the pancreatic head, and fine needle aspiration was performed (Fig. 2a–d). Based on the patient's symptoms and history (male, alcohol consumption, viral hepatitis and significantly increased AFP), the initial consultant doctor focused on screening for hepatocellular carcinoma (HCC). However, CT and positron emission tomography revealed no obvious abnormality of the liver but showed a suspicious pancreatic tumor and chronic pancreatitis (Fig. 1a,b). Though the IgG4 level was normal, considering the “sausage-like” appearance and capsule rim sign of the pancreas revealed by CT, we considered the differential diagnosis of autoimmune pancreatitis. Therefore, EUS-FNA was scheduled for further assessment. Ultrasonographic imaging showed a 4.5 × 4.2 cm hypoechoic mass in the pancreatic head, with an ill-defined border, heterogenous internal echogenicity, and diffusely scattered calcifications (Fig. 2a). Cytological examination revealed the morphology and size of the tumor cells were relatively consistent but moderately enlarged with salt-and-pepper nuclei, which are characteristics of pancreatic neuroendocrine tumors (Fig. 2b). Histopathologic findings showed a heterogenous gland pattern with irregular enlarged nuclei (Fig. 2c). The abnormal cells were found to be positive for CK7 and negative for Hep-par 1 (Fig. 2d), chromogranin A, synaptophysin, or CD56 by immunohistochemical staining (IHS). After a multidisciplinary discussion, final diagnosis was determined as pancreatic ductal adenocarcinoma (PDAC) based on histology and IHS. The patient eventually received chemotherapy consisted of gemcitabine plus capecitabine. After one cycle of treatment, the serum level of AFP rapidly decreased to 1347 ng/mL and related symptoms were relieved significantly. The patient has not returned for follow-up since then. AFP is generally used as a biomarker for HCC, yolk sac tumor, gonadal tumors, and certain types of gastric carcinomas. There are also some reports of AFP-producing pancreatic tumors, usually hepatoid carcinoma and acinar cell carcinoma. The reports of AFP-producing PDAC are rare. One possible explanation for AFP production in pancreatic cancer is the activation of the hepatic gene within the pancreas during carcinogenesis. To identify the diagnosis, histopathology and immunohistochemistry can be crucial. The level of AFP after treatment of the AFP-producing pancreatic tumor may serve as an indicator to monitor therapeutic response and recurrence.

Right breast schwannoma in a male: A rare case report

IntroductionSchwannoma are benign neoplasms of peripheral nerve sheath. They usually occur in the head, neck and the extremities. Breast is a rare location of Schwannoma.Case presentationOur case describes the occurrence of Schwannoma in the right breast, in a 60-year-old male, who has had a breast lump since the last 6 years. After ultrasonography (showed 3.4 × 2.3 × 2.0 cm heteroechoic mass in the upper outer quadrant of the right breast), and mammography (showed 2.5 × 3.2 cm sized high density mass in upper outer quadrant of right breast), an excisional biopsy was performed, and on histopathologic examination, the diagnosis of breast schwannoma was confirmed.DiscussionClinical and pathological features resemble that of other benign tumors. On ultrasonography they present a well-defined, solid, hypoechoic mass, with some degree of posterior acoustic enhancement. Diagnosis is usually based on histopathologic examination. Microscopically, it exhibits hypercellular antony A areas along with hypocellular antony B areas. Treatment is usually surgical excision.ConclusionThough Schwannomas in breast are rare, they must be considered as differential diagnoses in patients presenting with breast lumps.

Young patients with unilateral breast cancer arising in fibroadenoma

The incidence of breast cancer with fibroadenoma (FAM) in young patients is a rarely reported case, &lt;1% of all cases of women suffering from breast cancer. This case report aims to highlight the importance of considering the presence of FAM and breast cancer at the same time at a young age to be treated comprehensively. A 31-year-old woman with complaints a lump in the breast and pain. Mother has a history of breast lumps. There were no menstrual disturbances and the use of hormonal contraception. The results of breast ultrasound revealed a solid mass with a diameter of 4 cm in the central quadrant of the breast with a hypoechoic mass with malignant features in it according to the Breast Imaging Reporting and Data System (BIRADS) C-4 and enlarged right axillary lymph nodes. Results Fine Needle Aspiration Biopsy (FNAB) unspecified, finally, a wide excision was performed and it was found that there was a solid mass and a smooth mass with a clear capsule. Histopathological report shows invasive carcinoma in right breast fibroadenoma. Young patients with lumps in the breast are not only suspected of being FAM but can be considered an image towards invasive carcinoma.

Pseudoangiomatous Stromal Hyperplasia: Radiologic-Pathologic Correlation.

Pseudoangiomatous stromal hyperplasia (PASH) is a benign mesenchymal proliferative lesion of the breast. PASH is postulated to be hormonally induced and predominantly occurs in premenopausal women and postmenopausal women on menopausal hormone therapy. Clinical presentation varies from screen-detected lesions to palpable masses. Imaging findings of PASH are nonspecific. The most common mammographic findings are an oval or round circumscribed non-calcified mass or developing asymmetry. On US, PASH is often seen as an oval hypoechoic mass that may be circumscribed and can have an echogenic rim, or, when manifest as mammographic asymmetry, US may show a corresponding non-mass focal area of echogenic tissue. Limited studies have investigated the MRI appearance, with PASH most often manifesting as non-mass enhancement, or, less often, as an oval or irregular mass with persistent kinetics. Histopathologically, PASH can be mistaken for a fibroadenoma or phyllodes tumor and has features overlapping low-grade angiosarcoma. Assessment of radiologic-pathologic concordance is particularly important as PASH is often an incidental finding, adjacent to the targeted lesion at histopathology. Surgical excision or repeat core-needle biopsy is necessary for discordant suspicious cases. After a benign, concordant diagnosis of PASH, the patient may resume routine screening.