Large Glands Research Articles

Beaver Tail Liver: A Morphological Study of Variation in the Left Lobe of the Liver.

The liver, the largest gland in a wedge-shape, is situated in the right hypochondrium, and exhibits variation in its lobes. Knowledge of variations in the lobes of the liver is crucial for accurate radiological diagnosis and successful abdominal surgeries. The elongation of the left lobe of the liver has gained significant attention in segmentectomy and liver transplant surgeries. During October and November 2023, cross-sectional observational research was done on 53 human cadaveric liver specimens obtained from different medical colleges in Gujarat, India. The livers were meticulously examined to determine the prevalence of Beaver tail liver and measurements such as length, breadth, and thickness were recorded and statistically analyzed. The study revealed that out of the 53 livers examined, 29 (54.72%) were classified as normal, while 19 (35.85%) fell into Netter's type 2 to 7 based on Netter's classification. Interestingly, 5 (09.43%) livers exhibited an elongated left lobe, referred to as a "sliver liver," which did not fit into any of the Netter's types. The beaver tail liver was found to be longer and broader compared to normal liver of the same size and weight (p<0.001). This study highlights the wide range of variations that can be observed in the lobes of the liver. The findings of this study will serve as a valuable resource for radiologists, anatomists, and surgeons, aiding them in accurate diagnoses and surgical procedures, thus minimizing the risk of misdiagnosis.

Clinical evaluation of CoolSeal - a new, safe, and fast vessel sealing device in total thyroidectomy.

Objective. CoolSeal is a new vessel sealing system for dissection and hemostasis during surgery. No clinical studies have investigated safety, advantages or disadvantages regarding the use of this device. The aim of the present study was to investigate the safety of CoolSeal and compare it with conventional ligation technique or LigaSure during the total thyroidectomy. We hypothesized that the use of CoolSeal would reduce the operating time and bleeding without complications increase. Study design represents a retrospective cohort study with a tertiary reference center setting. Methods. We analyzed total thyroidectomy data from January 2021 to June 2023. We recorded patients' characteristics, surgical information, and postoperative outcome. Results. We performed 221 total thyroidectomies in the study period. Analysis was restricted to 171 patients operated by only two surgeons. Hemostasis was secured by conventional ligation in 117 patients (68%), LigaSure in 34 patients (20%) and CoolSeal in 20 patients (12%). Median thyroid weight and bleeding were 67 g and 50 ml, respectively. Procedures using LigaSure or Cool-Seal were on larger glands (median 205 g) without increased bleeding (50 ml). Operating time was shortest with CoolSeal (96 min, p=0.003) compared with LigaSure (117 min) or conventional ligation (115 min). Bleeding was reduced with CoolSeal compared with LigaSure (45 vs. 100 ml, p=0.003). With CoolSeal, median hospitalization was one postoperative day, no patients required re-operation. There was no palsy of recurrent laryngeal nerves and no permanent hypoparathyroidism. Conclusion. In our first clinical experience, CoolSeal was safe and efficient for total thyroidectomy. With a small sample size, we saw a clinical benefit with reduced operating time without post-operative complications increase.

From Neck to Mid-Chest: Unravelling the Anatomical Extent of Medullary Thyroid Cancer- A Case Report

Medullary thyroid cancer, or MTC, is an uncommon type of thyroid malignancy. It originates from a specific group of cells within the thyroid gland called calcitonin-producing C cells. An even rarer complication of MTC is when the cancer extends beyond the thyroid gland and reaches the area behind the breastbone, known as the retrosternal space. This specific scenario is estimated to occur in only 0.2-0.8% of all thyroid cancers associated with MEN syndromes or a positive family history We report the case of an older man who had difficulty breathing and a large swelling on the right side of his neck. A needle aspiration biopsy revealed MTC, and he was treated accordingly. While large thyroid glands have been documented, our case of MTC with extension from the upper right neck to the mid-chest, not associated with MEN syndrome additionally, is one of the infrequent cases to account as the prognosis for retrosternal MTC is generally worse than for MTC that occurs in the neck only. However, early diagnosis and treatment can improve the chances of survival.

Analysis of the adhesive secreting cells of Arion subfuscus: insights into the role of microgels in a tough, fast-setting hydrogel glue.

The slug Arion subfuscus produces a tough, highly adhesive defensive secretion. This secretion is a flexible hydrogel that is toughened by a double network mechanism. While synthetic double network gels typically require extensive time to prepare, this slug creates a tough gel in seconds. To gain insight into how the glue forms a double-network hydrogel so rapidly, the secretory apparatus of this slug was analyzed. The goal was to determine how the major components of the glue were distributed and mixed. Most of the glue comes from two types of large unicellular glands; one secretes polyanionic polysaccharides in small, membrane-bound packets, the other secretes proteins that appear to form a cross-linked network. The latter gland shows distinct regions where cross-linking appears to be occurring. These regions are darker, more homogeneous and appear more solid than the rest of the secretory material. The enzyme catalase is highly abundant in these regions, as are basic proteins. These results suggest that a rapid oxidation event occurs in this protein-containing gland, triggering cross-linking before the glue is released. The cross-linked microgels would then join together after secretion to form a granular hydrogel. The polysaccharide-filled packets would be mixed and interspersed among these microgels and may contribute to joining them together. This is an unexpected and highly effective way to form a tough gel rapidly.

Integrative taxonomy of Anaporrhutum mundae sp. nov. (Trematoda: Gorgoderidae), a parasite of the Munda round ray Urotrygon munda (Urotrygonidae) in Costa Rica.

A new species of trematode of anaporrhutine gorgoderid, from the gill chambers of the Munda round ray Urotrygon munda in Costa Rica is described, based on an integrative taxonomic approach that includes the use of light and scanning electron microscopy, ITS2 and 28S rDNA sequencing, and phylogenetic analysis. Anaporrhutum mundae sp. nov. can be distinguished from congeneric species by a combination of morphological traits and particularly by having the genital pore opening at the level of the intestinal bifurcation. The new species also can be distinguished from all other species of Anaporrhutum, except A. euzeti Curran, Blend & Overstreet, 2003, by having fewer testicular follicles per testis. Anaporrhutum mundae sp. nov. also differs from A. euzeti in its forebody shape and by having different morphology and location of the vitellaria. The study of the tegumental surface of A. mundae sp. nov., as revealed by scanning electron microscopy, allowed detection of new morphological characters for a member of Anaporrhutinae that may be of taxonomic value. These are: a stylet cavity dorsal to the oral sucker with a large penetration gland opening on each side of the cavity and small penetration gland openings located ventral to the stylet cavity, arranged in a circle around the mouth. This represents the first record of an Anaporrhutum species from Costa Rica. Further, A. mundae sp. nov. represents the first parasite described or reported in this host.

Comparison of Holmium Laser Enucleation of Prostate versus Bipolar Resection of Prostate in Patients with Benign Prostatic Hyperplasia: A Prospective Interventional Study

Introduction: Surgical treatment for Benign Prostatic Hyperplasia (BPH) has advanced significantly in recent years. Transurethral Resection of the Prostate (TURP) is a minimally invasive procedure associated with a low risk of complications and clinical limitations, including life-threatening Transurethral Resection (TUR) syndrome, as, well as higher costs due to longer hospital stays and challenges in managing large glands. Aim: To compare the safety and effectiveness of prostate enucleation using Holmium Laser Enucleation of the Prostate (HoLEP) with bipolar resection of the prostate in cases of BPH. Materials and Methods: A hospital-based prospective interventional study was conducted in the Department of Urology, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Pune, Maharashtra, India, from January 2020 to July 2022. The study included 60 patients, divided into two groups of 30 each. Males aged ≥45 years with recurrent Lower Urinary Tract Symptoms (LUTS) secondary to BPH, with or without Acute Urinary Retention (AUR) (drug-refractory) or with failed medical therapy (alpha-blockers, 5-alpha reductase inhibitors), were included in the study. In the first group, HoLEP was performed (Group I), while in the second group (Group II), patients underwent bipolar resection. Data were analysed and statistically evaluated using Statistical Package for the Social Sciences (SPSS) software version 21.0. A p-value of less than 0.05 was considered statistically significant. Results: The mean age of patients in the HoLEP group was 60.25 years, while in the Bipolar TURP (B-TURP) group, it was 59.67 years. Both groups had similar proportions of patients with moderate urinary symptoms {International Prostate Symptom Score (IPSS)} and large prostates (&gt;80 grams). The mean amount of irrigation fluid used (40.83±9 litres vs. 21.2±5.9 litres) and the duration of surgery (106.33±14.24 min vs. 67.4±9.73 minutes) were significantly higher in the HoLEP group compared to the B-TURP group (p-value&lt;0.001). Postoperative catheterisation time (1.003±0.23 days vs. 2.38±0.52 days) (p&lt;0.001) and length of hospital stay (3.2±0.65 days vs. 4.67±1.32 days) (p&lt;0.001) were significantly longer in the B-TURP group compared to the HoLEP group. Both the HoLEP and bipolar resection of the prostate groups did not experience significant intraoperative or immediate postoperative complications; however, one patient in the HoLEP group developed urethral stricture as a late complication. Conclusion: The B-TURP procedure is an equally effective and feasible method for treating BPH patients, with a smaller learning curve and lesser financial burden.

DEVELOPMENT OF PATHOLOGICAL CHANGES IN THE ORAL CAVITY ORGANS OF ANIMALS UNDER CONDITIONS OF POLYNEUROPATHIES OF DIFFERENT GENESIS

The aim of our research is to study the effect of polyneuropathy of different genesis on the development of pathological changes in the large salivary glands and periodontal tissues of animals. Methods. The study was conducted on 62 laboratory rats of both sexes. Toxic polyneuropathy was induced by paclitaxel injection, experimental type 1 diabetes mellitus was modeled by streptozocin injection, and alcoholic polyneuropathy was induced by chronic administration of increasing concentrations of ethanol. The development of polyneuropathy was confirmed by a change in the the pain sensitivity threshold (PST) using the Randall-Selitto tensoalgometric method. In the homogenate of oral cavity organs, total proteolytic and total antitryptic activity, catalase activity, content of TBARS, average mass molecules, oxidatively modified proteins, fucose and glycosaminoglycans (GAG), and amylase activity were determined. The level of total, protein-bound and non-protein sulfhydryl groups, activity of superoxide dismutase, glutathione peroxidase, glutathione transferase, glutathione reductase; content of reduced and oxidized glutathione, diene conjugates and Schiff bases were determined in blood serum. Results. We established the increasing of PST in animals that were simulated neuropathies of different genesis. All three types of polyneuropathies are accompanied by the development of carbonyl-oxidative stress in the soft tissues of the periodontium and large salivary glands of rats, which is evidenced by a probable increase in the content of oxidatively modified proteins and the content of TBARS, as well as average mass molecules compared to these indicators in intact animals . Under the conditions of modeling all three polyneuropathies, the protein-synthetic activity in the large salivary glands is suppressed, as evidenced by a decrease in the activity of α-amylase. Under conditions of experimental diabetic and toxic neuropathy in the salivary glands of animals, changes in the proteinase-inhibitor balance of the compensatory type are observed. We found that polyneuropathies of different genesis cause increased catabolism of biopolymers of the extracellular matrix of the periodontal connective tissue of rats, which confirms the increase in the content of GAG and fucose compared to these indicators in control animals. Conclusions. Under conditions of diabetic, toxic and alcoholic neuropathy, the amylolytic activity of the large salivary glands of animals is suppressed, the balance of the pro- and antioxidant system changes. When modeling peripheral polyneuropathy in animals by administration of paclitaxel, streptozocin, and ethanol, the development of periodontal syndrome is observed, the leading pathogenetic mechanisms of which are increased catabolism of connective tissue glycoconjugates and the development of oxidative stress and proteinase-inhibitor imbalance.

Фармакогностическое исследование сырья Nepeta pannonica

Фармакогностический анализ лекарственного растительного сырья является важным этапом введения вида в официальное использование. Объектом исследования являлись надземные органы Nepetapannonica(семейство Lamiaceae), для которого выполнен макро- и микроскопический анализ. Определены следующие диагностические признаки на макроскопическом уровне: лист — форма листовой пластинки, тип жилкования; стебель — тип ветвления побега, окраска, супротивное расположение листьев, слабое опушение; соцветие — расположение цветков; чашечка цветка — форма зубцов, тип опушения, мелкая ребристость; венчик цветка — форма и размеры, окраска. В качестве микроскопических признаков сырья определены форма клеток эпидермиса верхней и нижней сторон, участков над жилками; диацитные устьица, наличие мелких многоклеточных трихом и крупных эфирномасличных железок в строении листа, стебля, чашечки и венчика цветка; разделение мезофилла на столбчатую и губчатую ткани на поперечном срезе листа.

Primary squamous cell carcinoma of the parotid salivary gland: a clinical observation

Introduction. Malignant tumors of the salivary glands account for 3–5 % of all cases of head and neck cancer. Squamous cell carcinoma is the rarest histological variant of this pathology. It accounts for an average of 1.6 %. Among large salivary gland tumors, squamous cell carcinoma most often occurs in the parotid salivary gland.Aim. To present a clinical case of primary disseminated cancer of the parotid salivary gland with squamous cell structure.Clinical observation. A 70-year-old patient was under observation who was diagnosed with a primary squamous cell tumor of the parotid salivary gland with multiple metastases during a complex examination. He was sick for about 6 months when asymmetry of left half of the face appeared due to a painful neoplasm in the parotid salivary gland. Recently, the patient has noted increased tumor growth. Objective examination revealed peripheral paralysis of the facial nerve on the left. In the parotid-masticatory region on the left, with a transition to the zygomatic region, there is a dense painful immobile exophytic tumor with infiltration into soft tissues of the face and skin 6.5 × 5.0 cm in size with an ulcer in the center. Laterally, it reaches the tragus, and at the bottom-the angle of the lower jaw. In the submandibular region on the left, metastatic lymph nodes 2.5 × 2.0 cm in size are palpated. A biopsy was collected. Histological conclusion: non-keratinizing squamous cell carcinoma. Expression of the programmed death receptor ligand (PD-L1) in the tumor is negative. Mutations of genes Her2-neu and BRAF were not detected. According to medical imaging methods, multiple metastases were found in the lungs, liver, zygomatic bone and tumor growth in the maxillary sinus on the left. The diagnosis was established: cancer of the parotid salivary gland, stage IVC, cT4N1M1, with metastases to the liver, lungs and bones. Polychemotherapy was prescribed according to the scheme: 5-fluorouracil + cisplatin + cetuximab + bisphosphonates. After 3 cycles, a partial regression is obtained.Conclusion. The primary squamous cell carcinoma is prone to an aggressive course and has an unfavorable prognosis, especially in patients over 60 years of age with skin and facial nerve damage, as well as the presence of regional and distant metastases. Differential diagnosis is necessary to exclude the secondary nature of the tumor. The presented case is a rare example of primary squamous cell carcinoma of the parotid salivary gland with extensive metastatic lesion and regression of the pathological process after polychemotherapy in combination with targeted therapy.

GIANT BARTHOLIN CYST CASE REPORT

Bartholin gland cysts are common masses in the vulvar region that can range from asymptomatic to large and infected, requiring treatment [1]. In this case report, we wanted to discuss a case of a large Bartholin gland cyst that presented with painful genital swelling to our clinic and its treatment. A woman in perimenopausal age presented with a large mass in the vulva, and physical examination revealed an 18x10 cm mass originating from the left labia minora. MRI confirmed the mass, and the initial diagnosis was Bartholin gland cyst. The cyst was surgically excised totally under the operating room conditions and sent for histopathological examination. Although Bartholin gland cysts can present in various sizes and clinical features, cysts of this size are rare and can be confused with malignant masses.

Large cribriform glands (> 0.25 mm diameter) as a predictor of adverse pathology in men with Grade Group 2 prostate cancer.

A recent outcome-based, radical prostatectomy study defined > 0.25 mm diameter to distinguish large versus small cribriform glands, with > 0.25 mm associated with worse recurrence-free survival. This study evaluates whether identification of > 0.25 mm cribriform glands in Grade Group 2 patients at biopsy is associated with adverse pathology at radical prostatectomy. Tumours containing biopsy slides for 133 patients with Grade Group 2 prostate cancer with subsequent radical prostatectomy were re-reviewed for large cribriform glands (diameter > 0.25 mm). The primary outcome was adverse pathology (Grade Groups 3-5; stage pT3a or greater, or pN1). The secondary outcome was recurrence-free survival. Cribriform pattern was present in 52 of 133 (39%) patients; of these, 16 of 52 (31%) had large cribriform glands and 36 of 52 (69%) had only small cribriform glands. Patients with large cribriform glands had significantly more adverse pathology at radical prostatectomy compared to patients with small cribriform glands and no cribriform glands (large = 11 of 16, 69%; small = 12 of 36, 33%; no cribriform = 25 of 81, 31%; χ2 P-value 0.01). On multivariate analysis, large cribriform glands were also associated with adverse pathology, independent of age, prostate-specific antigen (PSA)/PSA density at diagnosis, year of diagnosis and biopsy cores percentage positive (global P-value 0.02). Large cribriform glands were also associated with increased CAPRA-S surgical risk score (Kruskal-Wallis P-value 0.02). Large cribriform glands using a diameter > 0.25 mm definition in Grade Group 2 patients on biopsy are associated with increased risk of adverse pathology at radical prostatectomy. The presence of large cribriform histology should be considered when offering active surveillance for those with Grade Group 2 disease.

Prospective Randomized Study Comparing the Intra-Operative and Postoperative Outcomes of Bipolar Enucleation of the Prostate Versus Thulium Laser Enucleation

Background: Benign prostatic hyperplasia (BPH) is an age-dependent patho-physiological condition. Bipolar enucleation of prostate (BipolEP) is now considered a rather effective method for the management of BPH patients. Aim and objectives: to assess the functional outcome of patients post plasma-kinetic enucleation in patients with large size prostate glands more than 80 cc as measured by Trans-rectal ultrasound. Patient and method: Our study involved 40 patients with symptomatic BPH who underwent endoscopic enucleation of the prostate using bipolar energy. Result: As regard the intraoperative complications our study showed that there were two patients (6.7%) complicated by small bladder perforation during morcellation and four patients (13.3%) had intra-operative bleeding necessitating blood transfusion and in the early postoperative period (the first 48 hours); one patient (3.33%) developed postoperative hematuria. After one month follow up we found that: 12 patients (30%) developed urge incontinence, 7 patients (17.5%) developed stress urinary incontinence and 5 patients (12.5%) developed mixed incontinence one with predominant urge and the other with predominant stress Conclusion: Bipolar enucleation (BipoLEP) is very effective for managing patients with symptomatic or complicated BPH with large gland size above 80 cc, having a high safety profile and low complications rate. Bipolar enucleation proved to be a very effective technique of endoscopic enucleation of the prostate and can stand out as a strong alternative to laser enucleation whenever laser facilities are not available with comparable results.

Stereotactic Body Radiation Therapy for the Curative Treatment of Prostate Cancer in Ultralarge (≥100 cc) Glands

PurposeHistorically, toxicity concerns have existed in patients with large prostate glands treated with radiotherapy (RT), particularly brachytherapy. There are questions whether this risk extends to stereotactic body radiation therapy (SBRT). In this retrospective review, we examine clinical outcomes of patients with prostate glands ≥100 cc treated curatively with SBRT. Methods and MaterialsWe retrospectively analyzed a large institutional database to identify patients with histologically confirmed localized prostate cancer in glands ≥100 cc, who were treated with definitive-robotic SBRT. Prostate volume (PV) was determined by treatment planning magnetic resonance imaging (MRI). Toxicity was measured using CTCAE version 5.0. Many patients received the Expanded Prostate Cancer Index Composite (EPIC) Quality of Life (QOL) questionnaires. Minimum follow-up (FU) was 2 years. ResultsSeventy-one patients were identified with PV ≥100 cc. Most had grade group (GG) 1 or 2 (41% and 37%, respectively) disease. All patients received a total dose of 3500-3625 cGy in 5 fractions. A minority (27%) received ADT, which was used for gland size downsizing in only 10% of cases. Nearly half (45%) were taking GU medications for urinary dysfunction prior to RT. Median toxicity FU was 4.0 years. Two-year rates of Grade 1+ genitourinary (GU), Grade 1+ gastrointestinal (GI), and Grade 2+ GU toxicity were 43.5%, 15.9%, and 30.4%, respectively. Total Grade 3 GU toxicities were very limited (2.8%). There were no Grade 3 GI toxicities. On logistic regression analysis, pretreatment use of GU medications was significantly associated with increased rate of Grade 2+ GU toxicity (OR = 3.19, p = 0.024). Furthermore, PV (analyzed as a continuous variable) did not have an effect on toxicity, QOL, or oncologic outcomes. ConclusionsWith early FU, ultra-large prostate glands do not portend increased risk of high-grade toxicity following SBRT but likely carry an elevated risk of low-grade GU toxicity.

Three Dimensional Bioprinting for Hepatic Tissue Engineering: From In Vitro Models to Clinical Applications.

Fabrication of functional organs is the holy grail of tissue engineering and the possibilities of repairing a partial or complete liver to treat chronic liver disorders are discussed in this review. Liver is the largest gland in the human body and plays a responsible role in majority of metabolic function and processes. Chronic liver disease is one of the leading causes of death globally and the current treatment strategy of organ transplantation holds its own demerits. Hence there is a need to develop an in vitro liver model that mimics the native microenvironment. The developed model should be a reliable to understand the pathogenesis, screen drugs and assist to repair and replace the damaged liver. The three-dimensional bioprinting is a promising technology that recreates in vivo alike in vitro model for transplantation, which is the goal of tissue engineers. The technology has great potential due to its precise control and its ability to homogeneously distribute cells on all layers in a complex structure. This review gives an overview of liver tissue engineering with a special focus on 3D bioprinting and bioinks for liver disease modelling and drug screening.

Embryology, anatomy and physiology of the liver: Review

The liver, located within the peritoneal cavity, is in the right upper quadrant of the abdomen. Additionally, it should be noted that the liver holds the distinction of being the largest gland within the human body, as well as the most extensive visceral tissue situated within the abdominal cavity. One of the factors contributing to the early migration of the developing intestines to an extracoelomic location during fetal development is their relatively bigger size in children, weighing between 1400 and 1800 g in adults. It contributes to the development of a distended abdomen in pediatric populations. The liver is situated in the right upper quadrant of the abdomen and spans across the midline to the left upper quadrant. The heart remains susceptible to regular injuries despite the protective presence of ribs and cartilage. The liver, functioning as an accessory organ in digestion, undertakes several metabolic processes, including drug metabolism, bile production, and bilirubin synthesis, alongside numerous other functions. For a considerable period, medical professionals and anatomists have encountered challenges in comprehending the complex functions of the liver. Significant advancements in the comprehension of liver anatomy have contributed significantly to the notable progress observed in various surgical and interventional radiologic procedures involving hepatic artery infusion pumps, liver ablation, transplantation, transarterial chemoembolization, selective internal radiation therapy, and portal vein embolization. The existence of hepatic structure is crucial for developing and implementing gradual therapies. This page aims to provide an academic overview of the embryology, anatomy, and function of the liver.

Transcriptome analysis of anuran breeding glands reveals a surprisingly high expression and diversity of NNMT-like genes

Abstract In many amphibians, males have sexually dimorphic breeding glands, which can produce proteinaceous or volatile pheromones, used for intraspecific communication. In this study we analyse two types of glands in the Mexican treefrog Ptychohyla macrotympanum (Hylidae)—large ventrolateral glands and small nuptial pads on their fingers—using histology, whole-transcriptome sequencing, and phylogenetic analyses. We found strong differences in glandular tissue composition and gene expression patterns between the two breeding gland types. In both glands we only found low expression of protein pheromone candidates. Instead, in the ventrolateral glands, gene expression was strikingly dominated by nicotinamide N-methyltransferase (NNMT)-like genes. The diversity of these genes was remarkably high, with at least 68 distinct NNMT-like genes. Our comparative phylogenetic analysis of the diversity of NNMT-like genes across vertebrates indicates that the extreme diversity of this gene is largely a frog-specific phenomenon and can be traced to large numbers of relatively recent gene duplications occurring independently in many lineages. The strong dominance and astonishing diversity of NNMT-like genes found in anurans in general, and in their sexually dimorphic breeding glands specifically, suggests an important function of NNMT-like proteins for anuran reproduction, possibly being related to volatile pheromone production.

SAT486 A Case of Superior Vena Cava Syndrome Caused by Untreated Multinodular Goiter

Abstract Disclosure: K. Blanchard: None. C. Musurakis: None. A. Ojha: None. C.P. Barsano: None. A. Havrylyan: None. A 92-year-old female with heart failure, COPD, obstructive sleep apnea, longstanding exertional dyspnea, and a 15-year history of a toxic multinodular thyroid on methimazole presented to our emergency department with one week of right arm swelling. Physical exam showed a 4 cm midline goiter with right-sided jugular venous distention and right upper extremity pitting edema. On admission, TSH, free T4 and free T3 levels were within normal limits on methimazole 5 mg daily. PTT, PT and INR were normal. Thyroglobulin antibodies and TSI measured two years prior were normal. Right arm venous duplex was negative for acute deep venous thrombosis (DVT) but showed heterogenous structures in the right neck with collateral vessels, likely related to a large multinodular thyroid gland with substernal extension. Left arm venous duplex showed chronic sequela of DVT in the left central subclavian vein. Chest x-ray revealed right-sided tracheal deviation due to goiter. A CT chest performed 6 months prior revealed a massive multinodular goiter with mass effect on the trachea, narrowing the tracheal opening to only 7 mm (ref 10-21 mm in females) and significant mass effect upon adjacent venous structures with resultant collateralized flow. Of note, the patient has a 15-year documented history of this goiter and repeatedly declined aggressive surgical intervention. We recommended ENT consultation for minimally invasive treatment options. ENT recommended thoracic surgery evaluation at a tertiary center and suggested tracheal stenting as a possible solution. Regarding the chronic left subclavian vein thrombosis, the patient opted to forego anticoagulation therapy after discussion of risk versus benefit. She again declined surgical evaluation and was discharged home with primary care and Endocrinology outpatient follow-up. Superior vena cava (SVC) syndrome is the result of either a partial or complete obstruction of the SVC, resulting in symptoms such as upper extremity swelling, dyspnea, cough, face or neck swelling, and dilated venous collaterals in the chest. Compression of the SVC by a mediastinal malignancy is the most common cause of SVC syndrome. However, retrosternal goiter as a cause is extremely rare, with only a few cases previously reported in the literature. Interestingly, the incidence of malignancy in retrosternal goiters is reported to be as high as 35 percent. Large intrathoracic goiters are primarily seen in long periods of neglected disease, as in our patient. The presence of a substernal goiter, regardless of symptoms, is an indication for thyroidectomy, as this is the only way to prevent mediastinal enlargement of the goiter. Non-surgical treatment options documented in the literature include temporary tracheal stent placement followed by radiofrequency thyroid ablation and ultrasound-guided needle aspiration of a dominant thyroid cyst. Presentation Date: Saturday, June 17, 2023

FRI254 Unconventional Pre-operative Management Of Congenital Adrenal Hyperplasia

Abstract Disclosure: M.A. Ortiz-Rivera: None. L.N. Madera Marin: None. A. Rosado-Burgos: None. L. El Musa Penna: None. W. Medina-Torres: None. L.R. Sepulveda-Garcia: None. L.A. Gonzalez-Rodriguez: None. M. Ramirez-Vick: None. M. Alvarado-Santiago: None. A.J. Grana Santini: None. M. Feliciano-Emmanuelli: None. Management of classic salt-wasting congenital adrenal hyperplasia [CAH] warrants suppression of the hypothalamic-pituitary-adrenal axis through glucocorticoid and mineralocorticoid supplementation. Preferred glucocorticoid replacement is generally hydrocortisone [HC] 3 times daily but caring for these patients often involves unconventional choices of glucocorticoid preparation regimens tailored to meet patient needs. A 41-year-old female with history of long-standing poorly controlled classic salt-wasting CAH associated to secondary amenorrhea and hypothyroidism, presenting with bilateral myelolipomas was consulted to our service for pre-op optimization. She underwent evaluation by Urology due to worsening right-sided back pain for which an abdominal-pelvic CT was performed showing large bilateral adrenal gland lesions (left mass measuring 11.5 x 10.3 x 10.6 cm and right mass measuring 8.1 x 10.4 x 7.7 cm) consistent with adrenal myelolipomas. Endocrine surgeon favored adrenalectomy due to mass effect brought about by massive adrenal growth secondary to inadequate therapeutic regime. Patient had been lost to follow-up after transitioning from pediatric to adult Endocrinology and was managed by her primary care physician who kept her on an unmodified therapeutic regime. During a pharmacy shortage of HC, she was switched from HC 25 mg TID to 5 mg daily. Furthermore, use of fludrocortisone 0.1 mg daily had been inadvertently halted in the past year. There had been progressive skin hyperpigmentation since the age of 20, significant hirsutism and salt cravings which made her add soy sauce to meals. At the age of 12 a vaginoplasty was performed, with menstrual periods ceasing at age 15. Physical examination was remarkable for grave voice, broad shoulders, bronze skin and coarse terminal hairs on chin, upper lip, sides of face and upper back. Hormonal workup revealed a direct renin &amp;gt; 300 pg/mL (nl 3.6 – 81.6), ACTH 463 pg/mL (nl 0.00 – 46.00), androstenedione &amp;gt; 10 ng/mL (nl 0.6 – 3.10), total testosterone [TT] 419 ng/dL (nl 13 – 53) and 17-hydroxyprogesterone [17-OHprog] &amp;gt; 20 ng/mL (nl 0.20 – 2.6). Frequent increases in medication dosing, up to HC 20mg TID and fludrocortisone 0.1mcg BID, did not attain adequate hormonal control. Dexamethasone 0.25 mg was then added at bedtime and the patient was finally able to achieve restoration of menses, resolution of salt cravings and hormonal profile control with decreases in renin to 23.02 pg/mL, androstenedione to &amp;lt; 0.30 ng/mL, TT to 11 ng/dL and 17-OHprog to 3.15 ng/mL. Alternative treatment strategies are sometimes warranted to achieve control of CAH. In this patient with prominent androgen excess and amenorrhea who failed to meet goals on high doses of hydrocortisone and fludrocortisone, combination therapy with a small dose of long-acting glucocorticoid at bedtime achieved the desired goal. Presentation: Friday, June 16, 2023

Distinct Adverse Clinical Outcomes of Small and Large Cribriform Patterns on Gleason 7 Prostate Cancer: A Preliminary Study.

We aimed to evaluate the effect of large and small cribriform morphology on survival following radical prostatectomy. We included 30 patients who underwent radical prostatectomy with curative intent between 2015 and 2022. Patients with the final pathology of Gleason 7 were included. Patients' radical prostatectomy specimens were reviewed by an experienced genitourinary pathologist. The diverse growth patterns of Gleason grade 4 were specified as poorly formed/fused glands, cribriform glands, and glomeruloid glands. The cribriform morphology was subdivided into small and large cribriform. Large cribriform growth morphology was defined by its size, which was double that of benign prostate glands. Small and large cribriform glands' percentages were indicated semiquantitatively. The cribriform morphology subtype present at 50% and higher was defined as the dominant pattern. The effect of histopathological patterns on biochemical recurrence and clinical progression was analyzed. Thirteen patients were small cribriform pattern dominant (group 1), whereas 14 of the patients were large cribriform pattern dominant (group 2). Pathological T, N stages, and surgical margin positivity were similar between groups. Biochemical recurrence and clinical progression rates were significantly higher in group 2. The large cribriform dominant patients had worse 2-year biochemical recurrence-free survival than small cribriform dominant patients (45.5% vs. 66.7%). In the univariate analysis, International Society of Urological Pathology grade, Gleason pattern 4 percentage, large cribriform pattern dominancy, and pT stage were predictors for biochemical recurrence-free survival. International Society of Urological Pathology grade was the only independent predictor for biochemical recurrence-free survival. Large cribriform pattern dominancy is associated with worse biochemical recurrence-free survival in Gleason 7 prostate cancer.

Gastrogastric intussusception and acute pancreatitis caused by a large pyloric gland adenoma treated with endoscopic submucosal dissection

Video 1Gastrogastric intussusception and acute pancreatitis caused by a large pyloric gland adenoma treated with endoscopic submucosal dissection: A 75-year-old woman with a several-week history of intermittent postprandial nausea and vomiting presented to the emergency room after experiencing syncope, following several hours of persistent abdominal pain, nausea, and vomiting. A contrast-enhanced CT scan of the abdomen and pelvis was arranged. Axial images show gastrogastric intussusception with the intussusceptum, indicated by the dashed lines, telescoping into the intussuscipiens indicated by the arrowheads. There is a lobulated mass indicated by the asterisk, serving as the lead point for the intussusception, and there is also a small volume of fluid indicated by the arrow, which delineates the mass from the duodenum. In the coronal images, we can again see a long-segment intussusception indicated by the dashed line with a lobulated mass indicated by the asterisk serving as the lead point and extending into the proximal duodenum. Then the lobulated mass occupying and expanding the duodenal lumen can be seen, indicated by the asterisk. Upon entry into the stomach through endoscopy, the gastrogastric intussusception can be seen. The lobulated mass serving as the lead point can be seen being pulled distally. With air insufflation, the intussusception spontaneously resolved. With continued insufflation, within a few minutes, the native confirmation of the polyp was established. It was located in the proximal body along the greater curve with a lobulated appearance with a Paris 1sp morphology. In addition, there was panatrophy in the background mucosa, which was consistent with autoimmune atrophic gastritis that was subsequently confirmed on histopathology and positive anti-parietal cell antibiotics. An EUS was performed and did not show any evidence of T2 disease. Doppler showed large central feeding vessel. A plan was made for endoscopic submucosal dissection (ESD). The strategy for the ESD was an initial circumferential incision and trimming with subsequent application of multipoint traction. After a circumferential incision, a rich vascular supply is seen. After completion of the incision and trimming, the snare was advanced over the scope and the clip advanced through the instrument channel. Multiple clips were then used to secure the snare to the distal end of the lesion. With traction applied, access to the submucosa became much easier and the ESD proceeded easily. For the final remnant of submucosa, it was more easily dissected in a forward view. Chess is one of the merits of multipoint traction in that traction can be applied both proximally and distally to the lesion. The lesion was resected en bloc. The specimen was retrieved using the attached snare, but unfortunately, some of the friable head was fragmented because of its large size, yet the base remained intact. Final pathology demonstrated PGD+HGD with clear margins vertically and laterally along the base. This case of gastrogastric intussusception, causing gastric outlet obstruction and acute pancreatitis secondary to a large pyloric gland adenoma, highlights several rare clinical entities. First, gastrogastric intussusception in adults is an exceptionally rare phenomenon, with only a few documented cases reported in the literature. Second, in the case of large gastric neoplasms causing intussusception, rarely the neoplasm may extend down into the duodenum and obstruct the ampulla of Vater causing acute pancreatitis. Furthermore, pyloric gland adenomas are rare gastric neoplasms that tend to be polypoid in morphology and are associated with autoimmune gastritis, predominantly occurring in female patients, as in this case. Lastly, the traditional management for lesions causing gastroduodenal intussusception is surgical because of the risk of malignancy. However, in this case, the patient underwent successful curative and therapeutic endoscopic resection with ESD.