Intra-abdominal Mass Research Articles

A Rare Medicolegal Cause of Acute Abdomen: Gossypiboma Causing Enteroenteric and Enterocutaneous Fistula

Gossypiboma are surgical tampons that are forgotten in the operation area and cause serious complications in the patient. The most frequently forgotten foreign body in operations are surgical tampons. Early recognition of gossypiboma is important to minimize the risk of morbidity and mortality in the patient. While they may be asymptomatic, they may cause complications such as perforation, obstruction, peritonitis, intra-abdominal or enterocutaneous fistula, abscess and sepsis. In the differential diagnosis, hematoma, pseudocyst and tumors should be considered. In computed tomography (CT), the spongy appearance formed as a result of the air trapped in the cotton pad is characteristic. Its treatment is surgery. If possible, the use of radiopaque labeled tampons can be avoided by taking preventive measures such as careful counting of surgical materials before and after each surgical operation. It should be kept in mind in the differential diagnosis of gossypiboma in patients with a history of previous surgery and diagnosed with an intra-abdominal mass.

A Rare Case of Oligodendroglioma in Sacrococcygeal Mature Teratoma Diagnosed in Preterm Infant

Sacrococcygeal teratoma is the most common congenital tumor in neonates, and is reported in approximately 1/35,000 to 1/40,000 live births. Oligodendroglioma is a rare central nervous system tumor that is usually found in the cerebral hemisphere of young and middle aged adults. When associated with a teratoma, it is mainly identified in ovarian teratoma in adolescents and adults. We describe a rare case of a preterm infant with oligodendroglioma in a mature sacrococcygeal teratoma. The male neonate was born at a gestational age of 30 weeks with a protruding mass in the sacrococcygeal region. Pelvic magnetic resonance imaging showed a sacrococcygeal teratoma of approximately 11 cm comprising fat components and skeletal structure, that extended from the anterior part of the sacrum to the abdominal cavity. Radical resection was performed at 36 days of age. Macroscopically, the resected intra-abdominal mass had the characteristics of a cystic lesion, and the intrapelvic mass was a predominantly solid mixed cystic-solid lesion. Histologically, this solid lesion in the intrapelvic mass was composed of mature glial tissue, which comprised as a proliferation of monotonous cells with small and round nuclei, surrounded by a perinuclear halo (“fried egg” appearance). Additionally, these cells were immunohistochemically positive for glial fibrillary acidic protein. These findings confirmed the diagnosis of oligodendroglioma in sacrococcygeal mature teratoma. After the treatment, no recurrence was observed during the follow-up period, and no additional intervention was required. However, the patient is undergoing treatment for voiding dysfunction caused by a neurogenic bladder.

Intra-abdominal ectopic bronchogenic cyst with a mucinous neoplasm harboring a GNAS mutation: A case report

BACKGROUNDBronchogenic cysts are congenital cysts caused by abnormal sprouting from the ventral foregut during fetal life. They usually occur in the mediastinum or lung, but there are very rare cases of ectopic bronchogenic cysts that develop in the abdominal cavity. A unique intra-abdominal ectopic bronchogenic cyst with a mucinous neoplasm that was producing carcinoembryonic antigen (CEA), harboring a GNAS mutation, is reported. The present case may contribute to clarifying the mechanism of tumorigenesis and malignant transformation of ectopic bronchogenic cysts.CASE SUMMARYIn 2007, a man in his 50s was incidentally found to have an intra-abdominal cystic mass, 8 cm in diameter. Surgical resection was recommended, but he preferred to remain under observation. In 2020, his serum CEA level increased to 26.7 ng/mL, and abdominal computed tomography showed a 15 cm × 12 cm, multifocal, cystic mass located predominantly on the lesser curvature of the stomach. Since malignancy could not be ruled out, he finally underwent surgical resection. Histologically, the cystic wall was lined by ciliated columnar epithelium, accompanied by bronchial gland-like tissue, bronchial cartilage, and smooth muscle. Part of the cyst consisted of atypical columnar epithelium with an MIB-1 index of 5% and positive for CEA. Moreover, a GNAS mutation (p.R201C) was detected in the atypical epithelium, leading to a diagnosis of an ectopic bronchogenic cyst with a low-grade mucinous neoplasm. The patient is currently undergoing outpatient follow-up without recurrence.CONCLUSIONAn extremely rare case of an abdominal bronchogenic cyst with a low-grade mucinous neoplasm harboring a GNAS mutation was reported.

An Unusual Presentation of Primary Hepatic Lymphoma

Primary hepatic lymphoma (PHL) is a rare disease that usually manifests as a heterogenous solitary intrahepatic mass, multiple lesions or a diffuse infiltrative form. PHL presenting as a small focal area of hepatic involvement and a large predominant extrahepatic component is uncommon. We report a histopathologically proven case of primary hepatic lymphoma that caused significant diagnostic dilemma on contrast-enhanced computed tomography due to its unusual imaging appearance as a hypo-enhancing intra-abdominal solid mass with relatively small area of hepatic parenchymal involvement and a large exophytic component.

Fatal Case of EBV-negative Posttransplant Lymphoproliferative Disorder With Hemophagocytic Lymphohistiocytosis in an Adult Kidney Transplant Recipient.

Fatal Case of EBV-negative Posttransplant Lymphoproliferative Disorder With Hemophagocytic Lymphohistiocytosis in an Adult Kidney Transplant Recipient.

Fetal Disseminated Malignant Rhabdoid Tumor.

Fetal Disseminated Malignant Rhabdoid Tumor.

Not Your Typical Cyst: A Periduodenal Chylous Cyst Diagnosed via Endoscopic Ultrasound

Chylous mesenteric cysts represent a subgroup of uncommon, mostly benign intra-abdominal masses often identified incidentally on radiographs. Diagnosis is often challenging because these lesions cannot be reliably distinguished from hematomas or other cystic lesions without direct tissue sampling. In addition, data remains scarce regarding nonsurgical diagnostic and therapeutic options for these cysts. This case describes an endoscopic option for a uniquely located chylous cyst.

Congenital urinary incontinence in a 4-year old girl due to isolated epispadias: A case report and literature review

Epispadias is a congenital anomaly in which the urethral meatus opens dorsally on top of the penis, medial to the glands, or with absent or bifid clitoris in females. It often occurs as part of a complex anomaly called the bladder extrophy epispadias complex (BEEC) along with exposed bladder and bifid pelvic brim. The diagnosis of bladder extrophy epispadias complex is often clinical with identifications of the various component of the anomalies. Although this condition is rare it present with wide spectrum of deformities which ranged from mild to more complex anomalies, its management especially the complex variety has been a major challenge to pediatric surgeons worldwide. With a male to female ratio of 2-3:1, the occurrence of isolated epispadias in female patient is even rarer. Our patient is a 4-year old girl who presented with urinary incontinence since birth. She has never achieved urinary continence up to the age of 4-years, there is no history of any prior urethral procedures, no history of any trauma to the perineum, no passage of stone or blood in the urine. Child is the second of her mother’s three children and her younger ones has achieved urinary continence. Pregnancy, delivery and puerperal history were essentially uneventful. On examination, we found a young girl, calm, but apprehensive otherwise stable, abdomen was full, moves with respiration, no area of tenderness, no palpable organomegaly, no intra-abdominal masses felt, there was distorted female genitalia with bifid clitoris and patulous urethral meatus. There was a normal vaginal orifice with intact hymen with poorly developed mons pubis and labia. A clinical diagnosis of isolated epispadias with urinary incontinence to rule out ectopic ureter in a 4-year old girl was made. She was worked up and prepared for surgical repair, and had a single stage procedure done. Post-operative cosmetic appearance of the genitalia was acceptable. Urethral catheter was removed on the postoperative day 10 and patient had achieved some continent of urine. She generally did well and has been on outpatient follow up visits at the pediatrics surgical outpatient clinic.

Leiomyosarcoma with widespread metastases in a capybara.

A 10.5-y-old intact female capybara (Hydrochoerus hydrochaeris) with a history of chronic weight loss was euthanized following discovery by palpation of a large intra-abdominal mass. Postmortem examination revealed a large, firm, tan mass expanding the uterine body and extensively adhered to the jejunum and abdominal wall. Numerous pinpoint to 3-cm diameter, tan-to-red, raised masses were present throughout the parietal peritoneum, liver, lungs, and intestinal serosa. Histologic examination of the uterine mass revealed well-differentiated smooth muscle intermixed with abundant collagen, interspersed with a highly anaplastic spindle cell population extending to the serosa; the masses in the lung, liver, and peritoneum were histologically very similar to the anaplastic uterine spindle cells. Immunohistochemical staining of the uterus and lung confirmed smooth muscle origin of the anaplastic cells. To our knowledge, leiomyosarcoma has not been reported previously in a capybara, and the widespread metastases in this case represent an unusually aggressive presentation of this rare malignancy. The animal also had an incidental dermal histiocytoma, a tumor that has also not been reported previously in this species, to our knowledge.

Cytomorphological study of intraabdominal lesions by FNAC

Fine Needle Aspiration Cytology (FNAC) is a simple, safe, low-cost and rapid procedure for diagnostic purpose which makes surgical intervention and exploratory laparotomy unnecessary. The deep seated organs like gall bladder, spleen, pancreas, retroperitoneum and ovary are sampled safely and routinely aspirated using the fine needle under radiological guidance. To assess the utility of FNAC in the diagnosis of intraabdominal lesions, to study the cytomorphological features and to determine the reliability of ultrasonography guided FNAC in distinguishing neoplastic from non-neoplastic intraabdominal mass lesions. The study included 48 intra-abdominal lesions which were detected clinically or radiologically. USG guided FNA was done whenever indicated. The smears were stained with Haematoxylin and eosin (H and E), May Grunwald Giemsa (MGG) and Papanicolaou’s stains. Among 48 cases, 45 cases were usg-guided, 2 cases were blind and one case was intraoperative. The diagnostic yield of usg-guided FNAC was 84.4%.Majority of aspirations were done in the age group of 51-60 years with male:female ratio of 1:1.53. Most common organ subjected to FNA was Liver followed by ovary. Majority of the lesions were found to be malignant. The most common lesion encountered in the whole study was metastastatic carcinoma. Fine needle aspiration cytology is a repeatable and rapid diagnostic procedure that has application in the evaluation of deep seated abdominal mass lesions. With the help of radiological guidance, diagnostic accuracy of FNAC of deep seated lesions dramatically increases.

Gastric Adenocarcinoma of the Remnant Stomach Presenting With a Cystic Intra-abdominal Mass 11 Years After Roux-en-Y Gastric Bypass.

CASE REPORT Morbid obesity defined as a body mass index of ≥ 40 kg/m2 is associated with increased morbidity and all-cause mortality.1 Roux-en-Y gastric bypass (RYGB) is the desired surgical intervention because of its proven benefits.1,2 Morbid obesity is associated with increased risk of gastric cancer; however, the altered anatomy of the stomach after bypass is challenging for ongoing surveillance of the remnant stomach.2 To date, only 17 cases of gastric remnant malignancy after RYGB are reported.2 We present a rare case of gastric remnant adenocarcinoma 11 years after RYGB presenting with abdominal pain and weight loss due to a large intra-abdominal cystic mass abutting the gastric remnant. Abdominal computed tomography without contrast revealed a large cystic structure abutting the stomach and pancreas (Figure 1). An esophagogastroduodenoscopy was normal. An endoscopic ultrasound (EUS) revealed a single round anechoic lesion >100 mm in size in the peripancreatic and perigastric peritoneal space (Figure 2). Typical mucosal, submucosal, and muscular propria layers were noted within the wall of the cystic structure without communication to the excluded stomach (Figure 3). Fine-needle aspiration of fluid (Expect 19 Gauge Flex Needle [Boston Scientific, Marlborough, MA]) demonstrated 750 mL of brown fluid with unremarkable cytology and normal lipase and amylase levels. The carcinoembryonic antigen (CEA) level in the cystic fluid was markedly elevated at 2,358 ng/mL when compared with serum CEA of 76.6 ng/mL.Figure 1.: Axial images of the abdomen and pelvis show the cystic dilation.Figure 2.: The cystic structure seen before fine-needle aspiration (FNA) (thick arrow).Figure 3.: Endoscopic ultrasound (EUS) images revealing the wall layers of the cystic structure (thick arrow) is seen after cyst fluid fine-needle aspiration (FNA), which demonstrates that it is not a cyst but a gastrointestinal structure.A second EUS performed because of recurrent abdominal distension showed a persistent cystic structure. Injection of contrast within the cystic structure demonstrated communication between the cyst and the excluded stomach. Fine-needle biopsy (Acquire 25 Gauge Needle [Boston Scientific]) of an area of the thickened gastric wall demonstrated poorly differentiated adenocarcinoma (Figure 4).Figure 4.: The area of the excluded stomach (thick arrow) with abnormal thickening of the stomach wall was biopsied revealing adenocarcinoma.Diagnosis of gastric remnant malignancy is usually confirmed at a median of 9 years after RYGB (range is 1–22 years) with abdominal computed tomography scans.2 EUS and transgastric endoscopy may be considered as alternatives to double-balloon enteroscopy for tissue biopsy in the setting of technically difficult access of the gastric remnant.3,4 Prevention and surveillance methods including remnant gastrectomy proposed in regions with a high prevalence of gastric cancer remain controversial and not well established. More studies are needed to determine whether CEA can be considered for screening of the cancer in the excluded stomach in patients with a history of morbid obesity and RYGB.5 DISCLOSURES Author contributions: GW Khneizer and BL Bick conceived and drafted the work. N. Mahendraker designed and critically revised the work, and all authors gave final approval of the version to be published and agreed to be accountable for all aspects of the work. GW Khneizer is the article guarantor. Financial disclosure: None to report. Informed consent could not be obtained from the family of the deceased. All identifying information has been removed from this case report to protect patient privacy.

CALCIFYING FIBROUS TUMOUR OF MESENTERY – A DIAGNOSTIC DILEMMA

Mesenteric masses comprise a rare variety of intra-abdominal mass. These masses frequently cause diagnostic dilemma due to their rarity and multitude of differentials. Herewith, we report a case of spindle cell tumour of mesentery in an elderly male who presented with pain in abdomen. The tumour was successfully resected in toto by laparoscopic approach. A brief case report with review of literature is presented here.

Spectrum of Diagnosis and Yield of Endoscopic Ultrasound Guided Fine Needle Aspiration Cytology

Endoscopic ultrasound gives high resolution images of the mediastinum and abdominal organ and improves visualization for obtaining tissue sample for cytology. In our study 112 subjects underwent EUS guided FNAC, out of them 51 were diagnosed as carcinoma (45.5%), 15 as tuberculosis (13.39%), reactive adenitis is 13 (11.6%), other benign disease is 27 (24.1%). So overall diagnosis we made in (106/112) (94.6%). 6 (5.3%) were inconclusive. We suggest that EUSFNAC should be the first line investigation for suspected mediastinal and intra-abdominal malignant masses.

Small bowel intussusception secondary to intestinal submucosal cyst in an infant

We experienced an infant with small bowel intussusception due to a rare pathological lead point. The two-month-old baby has admitted to our center with because of vomiting and bloody stool. Although an intraabdominal multicystic mass was suspected by abdominal ultrasonography, other examinations did not detect any abnormal findings. The infant was discharged but was readmitted one week later because of vomiting and transient impairment of consciousness. Although no ileocolic intussusception was visible by enema, abdominal computed tomography and ultrasonography clearly showed intestinal invagination. Emergency laparotomy was performed, whereupon a small bowel intussusception was observed. After surgical reduction, a small, palpable intramural mass was found at the lead point of the invagination, and the section of the intestine containing the mass was removed by wedge resection. The mass was multicystic and was diagnosed by immunohistochemistry as an intestinal submucosal cyst.

A CASE REPORT ON GIANT LIPOSARCOMA OF OMENTUM – SURGICAL EXCISION WITH OMENTECTOMY.

Liposarcomas are a subtype of soft tissue sarcomas that often appear in the fth and sixth decades and can occur in a range of anatomical places. However, liposarcomas of omental origin are uncommon, with only a few examples reported worldwide. The following is a case report of a 32- year-old woman who presented with abdominal pain and early satiety, as well as an abdominal mass. She underwent investigations, which revealed a 20x15-cm intraabdominal mass, and was scheduled for surgical exploration, which revealed a 20x8x18-cm mass arising from the omentum with no capsulation or feeding vessel. The lump, together with the greater omentum, was excised and sent for histological investigation, which revealed it to be a liposarcoma of the omentum. In conclusion, our case report demonstrates that liposarcoma of the omentum has vague clinical symptomatology and that omentectomy may be recommended to prevent metastasis, but further research studies are needed before it can be adopted as the therapy of choice.

Segmental cystic dilatation of the ureter in a Sudanese adult. A case report

Objective: Segmental cystic dilatation of the ureter is extremely rare in adults. This article presents a case of segmental cystic dilatation of the left ureter with proximal dilated upper left ureter and ipsilateral atrophied kidney, while the distal ureter with normal calibration. Case: Excision of the cyst with proximal ureter and kidney was done. Segmental cystic dilatation of the ureter should be considered in the differential diagnosis of intra-abdominal cystic mass.

The diagnostic performance of combined conventional cytology with smears and cell block preparation obtained from endoscopic ultrasound-guided fine needle aspiration for intra-abdominal mass lesions.

Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is the primary method for tissue acquisition of intra-abdominal masses. However, the main limitation of cytology alone is the lack of tissue architecture and inadequate samples. This study aimed to evaluate the diagnostic performance of combined conventional cytology and cell block preparation obtained from EUS-FNA of intra-abdominal masses without Rapid On-site Evaluation (ROSE). Cytologic smears and cell block slides of 166 patients undergoing EUS-FNA during 2010-2015 were reviewed by an experienced cytopathologist blinded to clinical data. 125 patients had neoplastic lesions. Pancreatic adenocarcinoma was the most common etiology (35.5%), followed by lymph node metastasis (27.7%). The mean mass size was 2.5±1.3 cm. The mean number of passes was 1.9±1.28. Tissue adequacy for conventional cytology and cell block preparation was 78.9% and 78.1%, respectively. Factors associated with tissue adequacy were assessed. For cytology, lesions of > 2.1 cm, masses in the pancreatic body or tail, malignancy, and pancreatic cancer were positively associated with adequate cellularity. For cell block preparation, lesions of > 3 cm and malignancy were associated with increased tissue adequacy. The conventional cytology alone had a sensitivity of 68.5%, a specificity of 95.7%, and an area under the receiver operating characteristics (AUROC) of 0.821. The cell block preparation alone had a sensitivity of 65.4%, a specificity of 96%, and an AUROC of 0.807. The combined conventional cytology and cell block preparation performed significantly better than either method alone (p<0.05), as demonstrated by an increased AUROC of 0.853. Furthermore, cell block detected malignancy in 9.3% of cases where the cytologic smears failed to identify malignant cells. The combined conventional cytology and cell block preparation increased the diagnostic accuracy of EUS-FNA compared to either method alone. This approach should be implemented in routine practice, especially where ROSE is unavailable.

Spontaneous Gastric Intramural Hematoma: Case Report and Literature Review

Spontaneous gastric intramural hematoma is a rare disease. Herein, we present a case of a previously healthy 28-year-old male patient who presented with diarrhea and diffuse abdominal pain of one-week duration. The patient was diagnosed with spontaneous gastric intramural hematoma post urgent partial gastrectomy for a bleeding gastric tumor. Six other cases of spontaneous gastric intramural hematoma are published in the literature; therefore, when encountering a case of intra-abdominal mass attached to the gastric wall, gastric intramural hematoma should be considered in the differential even when no cause is present.

Chylo-lymphatic mesenteric cyst in a 7-year-old

Mesenteric cysts are rare intra-abdominal masses that usually remain asymptomatic and present incidentally on radiological imaging. As the incidence is low, with paucity of data, careful pre-operative assessment and execution of surgical procedure often present a challenge to the treating clinician. A 7-year-old female child presented with gradual distention of abdomen and dull abdominal ache. On clinical examination, a huge mass measuring 1812 cm was detected in the lower abdomen. On radiological imaging, a diagnosis of mesenteric cyst was made. Intra-operative findings were consistent with mesenteric cyst, and complete surgical excision was carried out by laparotomy. The histopathology report revealed a chylo-lymphatic type of mesenteric cyst. Huge, benign abdominal masses in pediatric patient may represent mesenteric cysts, and the diagnosis can be confirmed by radiological imaging modalities such as abdominal contrast-enhanced computed tomography. Complete surgical removal of the cyst remains the treatment of choice, as the literature is against marsupialization or aspiration of cyst owing to a higher chance of infection and morbidity.

Guided Needle Aspirations of Intra-Abdominal Masses: Analogy between Liquid-Based and Conventional Smear Preparation Methods

Objective: Image-guided fine needle aspiration cytology with conventional smear (CS) preparation offers onsite cellular adequacy evaluation; however, it still provides false negatives due to faulty smear preparations. Liquid-based cytology (LBC) can be advantageous in these scenarios. Hence, with an aim to investigate utility of LBC in these samples, we carried out the above study with objectives to find diagnostic accuracy of LBC and agreement of LBC with CS methods in guided aspiration samples from intra-abdominal masses. Methods: A prospective observational study, of 113 patients with clinical or radiological diagnosis of intra-abdominal masses, was carried out. SurePath BD™ was used for LBC smear preparation, and the standard protocol was used for CS preparation. Results: LBC alone was diagnostic in 80.8% of the cases, and CS alone was diagnostic in 71.2% cases (agreement was 83.7%, p = 0.03). Cellular morphology was better preserved in LBC; however, interpretation was easier in CS. Conclusion: CS may be complimented with LBC sample collection method to enhance the sensitivity of intra-abdominal FNA.