Large Heterogeneous Mass Research Articles

Osteoblastoma Recurring as High-grade Osteosarcoma

Abstract Introduction/Objective Osteoblastoma is a benign, bone-forming neoplasm that presents as a well-circumscribed lesion amenable to excision. The prognosis is good despite a 20% recurrence risk. Malignant transformation is very rare. Osteoblastoma-like osteosarcoma is a rare form of osteosarcoma that shares similar clinical, radiographic, and pathological characteristics Methods/Case Report A 24-year-old female presented with a large palpable mass in the posterior occiput. The lesion progressively enlarged over 2 years, finally becoming symptomatic. Magnetic resonance imaging demonstrated an extradural posterior fossa expansile skull mass measuring 6.0 x 5.7 x 4.7 cm that showed multiple fluid/fluid levels. The mass was resected. Pathology demonstrated a well-circumscribed neoplasm that was cellular and composed of large polyhedral osteoblasts with eccentric oval nuclei and abundant amphophilic cytoplasm. Tumor cells were intimately associated with numerous small interconnecting, irregular bony trabeculae. Scattered mitotic figures of normal configuration were noted. The findings were compatible with an epithelioid osteoblastoma with prominent secondary aneurysmal bone cyst-like changes. The patient was lost to follow-up but presented 3 years later with severe migraines. Imaging demonstrated a large heterogeneous enhancing mass centered about the occipital cranioplasty with both intracranial and extracranial components. Reexcision was performed. Sections showed a well- circumscribed tumor, delineated by a rim of subperiosteal reactive bone, with an epithelioid morphology. However, it also demonstrated areas of necrosis, extensive sheet-like growth, conspicuous mitoses, and cytological atypia not seen in the previous specimen. Therefore, diagnosis of osteoblastoma-like osteosarcoma was rendered after expert consultation. Results (if a Case Study enter NA) NA Conclusion This case highlights the exceedingly rare evolving nature of osteoblastomas and their high-grade transformation potential.

Intra-abdominal nocardiosis and scedosporiosis in a dog: case report and literature review.

A 2-y-old, intact female, mixed-breed dog was presented to the veterinary hospital with abdominal distension, anemia, and lethargy following a chronic history of nonspecific gastrointestinal signs. CBC and serum biochemistry revealed moderate nonregenerative anemia with neutrophilia, hypoalbuminemia, hyperglobulinemia, hypoglycemia, decreased urea and creatinine, and hypercholesterolemia. Abdominal radiographs and ultrasound revealed a large heterogeneous mesenteric mass and ascites. Abdominocentesis confirmed septic peritonitis with filamentous bacteria. Fine-needle aspiration of the mass yielded pyogranulomatous inflammation and hyphae. An exploratory laparotomy revealed a large cranial abdominal mass with granulomas present throughout the abdominal cavity. Due to the poor prognosis and disseminated disease, the owner elected euthanasia. Postmortem and histologic examinations detected intralesional mycetomas and bacterial colonies within the mesenteric masses. 16S ribosomal RNA gene PCR and sequencing using formalin-fixed, paraffin-embedded sections identified Nocardia yamanashiensis, Nocardioides cavernae, and Nocardioides zeicaulis. Fungal culture, PCR, and sequencing confirmed Scedosporium apiospermum. Our report highlights the importance of molecular methods in conjunction with culture and histologic findings for diagnosing coinfections caused by infrequent etiologic agents. Additionally, we provide a comprehensive literature review of Scedosporium apiospermum infections in dogs.

6657 A rare case of a composite pheochromocytoma and ganglioneuroma in a 47-year-old male

Abstract Disclosure: C. Ekladios: None. M.J. Levine: None. Introduction: Pheochromocytoma is a rare tumor that originates from adrenal chromaffin cells. It remains a diagnostic challenge due to its diverse clinical manifestations. We present a case of pheochromocytoma, shedding light on its atypical presentation and diagnostic complexity.Case reportA 47-year-old male was referred to our clinic with a recent diagnosis of pheochromocytoma. Patient started having symptoms approximately two months prior to referral to our office. He initially presented to the emergency department (ED) with generalized weakness for three days, accompanied by feelings of “rushing of blood to the head” and a “rush of blood in the arms” every time he laid down. Symptoms would last for a few seconds and resolve without intervention. Vitals signs and physical examination (PE) were within normal limits. He had basic laboratory studies including BMP and CBC without any abnormalities. He was discharged home with instructions to follow-up outpatient. He returned to the ED two days after with a chief complaint of left sided chest pain associated with palpitations, pain was non-persistent, lasting a few seconds. On presentation his blood pressure was 142/89 mmHg, Pulse: 66 bpm, Temperature: 98.4 °F, and oxygen Saturation 100%. On PE, he had clear bilateral air entry and regular heart rate with no murmurs noted, EKG demonstrated no ischemic changes. Chest Xray showed no evidence of cardiopulmonary disease. A CTA revealed no pulmonary embolism, pleural effusion, or pneumothorax. However, a large heterogeneous adrenal mass was partially visualized, measuring 8.3 cm anteroposteriorly concerning for adrenal cortical carcinoma. His labs were pertinent for Metanephrine level of 0.52 nmol/L (nl:0-0.49) and Normetanephrine of 4.22 nmol/L (nl:0-0.89). Aldosterone level is 16.2 ng/dL and Renin activity was 0.1ng/mL. An abdominal CT scan confirmed a left adrenal mass measuring approximately 9.2 x 8.8 cm transaxially and 9.9 cm craniocaudal. He was seen in our office after discharge, at that time he was still experiencing tingling in both lower extremities that sometimes would wake him up from sleep. His blood pressure at the office was 125/83 mm Hg. In preparation for the surgery, we started treatment with Prazosin, followed by addition of Metoprolol succinate. Further work-up included a dexamethasone suppression test that ruled out Cushing’s syndrome and a negative RET proto-oncogene, ruling out MEN 2. Patient underwent laparoscopic left adrenalectomy without complications. Pathology results interestingly showed a composite pheochromocytoma and ganglioneuroma constituting 5 % of the mass volume, Ki-67 proliferative index was less than 1% for the pheochromocytoma and overall findings were consistent with a benign tumor.ConclusionOur case report emphasizes the necessity of a high index of suspicion for diagnosing pheochromocytoma in the absence of the classic symptoms. Presentation: 6/2/2024

Horseshoe kidney with teratoid type of Wilms tumor: a rare case report

BackgroundHorseshoe kidney is the most common renal fusion anomaly, and Wilms tumor is the most frequent renal malignancy in children. The occurrence of Wilms tumor in association with horseshoe kidney is a scarce anomaly. However, the arising of a teratoid type, which is a rare variant of Wilms tumor in a horseshoe kidney, is exceptionally unique.Case presentationThis report presents a 5-year-old male admitted with horseshoe kidney involved by a large heterogeneous calcified mass that was diagnose on biopsy as Wilms tumor blastemal dominant. According to the local and regional extension and metastatic tumor in the lungs, the patient underwent neoadjuvant chemotherapy and then surgery. Post-operative pathologic findings confirmed the diagnosis of teratoid Wilms tumor.ConclusionsThe occurrence of renal anomalies associated with a malignancy might be more frequent in the clinical environment. There are numerous differential diagnoses for renal tumors and masses, but the possibility of exceptional anomalies should not be denied, and clinicians should be prepared for these occasions. Although studies propose that chemotherapy has a trivial effect on teratoid Wilms tumors, it is essential to evaluate the tumor for any possibility of regression in non-teratoid regions before proceeding to upfront tumoral resection.

Fibrous dysplasia of sphenoid wing with secondary aneurysmal bone cyst: a rare case report

BackgroundAn aneurysmal bone cyst is a locally destructive benign lesion affecting mostly the long bones. Aneurysmal bone cyst of the skull bones is a very rare phenomenon and the involvement of the sphenoid bone of the skull with extension into the orbit is even rarer. We present a case of 15-year-old adolescent with fibrous dysplasia of the sphenoid wing with secondary aneurysmal bone cyst.Case presentationA 15-year-old male presented to us with chief complaints of headache with swelling in the left temporal region of the face and proptosis of the left eye associated with decreased vision for the past 2 months. NCCT showed a large heterogeneous mass in the left temporal region extending into left orbit. Gadolinium-enhanced MRI showed a well-defined multiloculated osteo-expansile lesion in the left middle cranial fossa extending into the anterior cranial fossa consistent with the fibrous dysplasia of the sphenoid bone with associated aneurysmal bone cyst. Digital subtraction angiography brain to look for any feeders to the lesion was done followed by microsurgical gross total excision of the tumor. The histopathology report confirmed it to be fibrous dysplasia secondary to aneurysmal bone cyst.ConclusionAneurysmal bone cyst is a rare entity, commonly affecting the long bones of the body. The involvement of sphenoid wing of skull is very rare occurrence. It can be primary or secondary to fibrous dysplasia, chondroblastoma, giant cell tumor, fibromyomas, etc. Fibrous dysplasia with secondary aneurysmal bone cyst should be kept in mind as one of the differential diagnoses while dealing with osteolytic bone lesions of skull.

Adrenal Cavernous Hemangioma: A Rare Incidental Finding from A Routine Ultrasound Assessment

Cavernous hemangioma of the adrenal gland is a very rare benign vascular tumour. Its rarity and non-specific presentation pose a challenge to the radiologists and surgeons in making the correct diagnosis. We report a case of adrenal cavernous hemangioma in a 76 years old gentleman, in which a large heterogeneous mass was incidentally found at his left hypochondriac region during a routine KUB and prostate ultrasound assessment for benign prostatic hyperplasia. A multiphasic CT study performed and revealed a large mass with a maximum diameter of 18 cm occupying the left suprarenal area. Considering the large size of the left suprarenal mass with mass effect to the surrounding structures, the patient undergone left adrenalectomy. His final histopathological diagnosis revealed a cavernous hemangioma. This case highlighted literature review and role of imaging in this extremely rare benign tumour as one of the differential diagnosis of an adrenal incidentaloma.

Ovarian Low-Grade Papillary Serous Cystadenocarcinoma with Osseous Metaplasia- Case Report and Review of Literature

Introduction: The stromal osseous metaplasia is extremely rare finding in serous cystadenocarcinoma of the ovary. Case report: A 45-year old female presented with pain in lower abdomen of about 2 months, breathlessness of 10days. On physical examination per abdomen, a large pelvic mass identified. She had pleural and pericardial effusion. Pericardiocentesis was done. Abdomen and pelvis ultrasound revealed a large heterogeneous right adnexal ovarian mass measuring 13.5 × 13.1 × 10.8cm, volume about 916 ml. It was well defined, oval, cystic, partially solid mass, the impression of ovarian neoplasm was given. There was no significant lymphadenopathy. The left ovary, uterus, cervix, fallopian tubes and rest of abdominal organs were normal. Serum CA 125 was 75.5 U/ml. She underwent total abdominal hysterectomy. On histopathological findings reported as right ovarian low-grade papillary serous cystadenocarcinoma with osseous metaplasia. Conclusion: The osseous metaplasia in ovarian serous cystadenocarcinoma is extremely rare.

Cotyledonoid dissecting leiomyoma of the uterus: a case report and review of the literature

BackgroundCotyledonoid dissecting leiomyoma, also named Sternberg tumor, is a rare variant of uterine leiomyoma. The tumor is benign, but the appearance and growth pattern are unusual and alarming. In this article, we report a case of cotyledonoid dissecting leiomyoma in a 55-year-old woman as well as review relevant literature.Case presentationWe report a case of cotyledonoid dissecting leiomyoma in a 55-year-old Iranian woman who presented with vaginal bleeding 4 months after menopause. Ultrasound showed two heterogeneous hypoechoic masses on the uterine fundus. Total abdominal hysterectomy and bilateral salpingo-oophorectomy were performed for the patient. Macroscopically, a large heterogeneous intramural mass (140 mm × 120 mm × 120 mm) with a grape-like exophytic mass on the fundus was observed. Her health status was good after surgery, and the patient was discharged from the hospital after 2 days. In a 1-year follow-up period, no recurrence or any other related complications were found.ConclusionIt is important to recognize this rare variant of leiomyoma to prevent aggressive and inappropriate overdiagnosis and overtreatment. It is suggested to try to use frozen sections for better diagnosis and to preserve fertility in young women suffering from this lesion.

Unusual Case of Primary Hepatic Squamous Carcinoma on 18F-FDG PET/CT.

Primary hepatic squamous carcinoma is an extremely rare liver tumor type with high malignancy and poor prognosis. We present 18F-FDG PET/CT findings of primary squamous carcinoma of the liver in a 65-year-old man, who was admitted to the hospital with subxiphoid pain in the epigastric region radiating to the left lower back for 2 months. 18F-FDG PET/CT demonstrated a large heterogeneous mild enhancing mass in the left lobe of the liver, with intense circumferential 18F-FDG activity.

Abstract 17356: Recurrent Hemorrhagic Pericardial Effusion Requiring a Multimodality Imaging Approach: A Case Report

Background: A 24-year-old female with no medical history presented to the ED with chest pain and dyspnea. Vitals were notable for tachycardia to 120s. Physical examination was unremarkable. Clinical Course: Initial evaluation was notable for thrombocytopenia, NT-proBNP of 151 and high sensitivity troponin T of 18. Transthoracic echocardiogram (TTE) revealed a small pericardial effusion with tamponade physiology prompting urgent pericardiocentesis. Bloody pericardial fluid was drained and fluid studies were consistent with hemorrhagic effusion with no evidence of infection or malignancy on cytology. Surveillance TTEs showed rapid reaccumulation of pericardial fluid within 72 hours of the initial intervention. Urgent pericardial window with drain placement was performed and intraoperative transesophageal echocardiogram (TEE) revealed a right atrial (RA) mass not detected on prior TTE. Cardiac MRI confirmed the presence of a large (50 mm x 31 mm) immobile and heterogeneous mass in the superior aspect of the RA suggestive of a malignant etiology with invasion to the adjacent pericardium. Positron Emission Tomography (PET) scan demonstrated hypermetabolic activity concerning for malignancy with no evidence of mediastinal, hilar adenopathy, or distant disease. She underwent mini-sternotomy and biopsy with pathology suggestive of primary cardiac angiosarcoma. Due to the high-risk nature and location of the tumor, she was unable to undergo primary surgical resection. Neoadjuvant chemotherapy was initiated with plan for subsequent surgical reassessment. Conclusion: Workup of recurrent hemorrhagic pericardial effusions require a multimodal imaging approach.

Congenital neuroblastoma presenting as profound neonatal metabolic acidosis with systemic hypertension: Case report.

Clinical collapse in the newborn most often occurs secondary to sepsis, delivery complications, congenital cardiac defects, or inborn errors of metabolism. We report on a neonate with respiratory, cardiac, and hepatic failure, with disproportionate metabolic acidosis and systemic hypertension, found to be caused by a congenital neuroblastoma. A term infant presented to our Level IV NICU via emergent transport at 12 hours of life with clinical and laboratory findings consistent with respiratory, cardiac, and hepatic failure. Typical workup for sepsis and cardiac etiology was unrevealing. The infant was noted to have systemic hypertension despite prolonged capillary refill. A profound metabolic acidosis led the primary team to pursue a genetics consult. In the course of the workup for disorders of metabolism, a urine organic acids panel revealed an elevated HVA (homovanillic acid) and VMA (vanillylmandelic acid), the metabolites of the neurotransmitters epinephrine, norepinephrine and dopamine. Subsequent abdominal ultrasound and chest/abdomen CT revealed a large heterogeneous mass with internal vascular flow and scattered calcifications arising from the medial limb of the left adrenal gland, consistent with neuroblastoma. Although rare, neuroblastomas can present clinically in the perinatal period in a manner requiring immediate life-saving intervention. Providers should consider the diagnosis in the setting of a newborn with a sepsis-like syndrome or profound metabolic acidosis presenting along with systemic hypertension without clear underlying etiology.

SAT572 Concomitant Metastatic Hurthle Cell Carcinoma And Rectal Cancer, Challenges In Diagnosis And Management

Abstract Disclosure: D. Khurram: None. R. Pansare: None. S.L. Mokshagundam: None. Hurthle cell carcinomas (HCC) are aggressive tumors and account for 5% of follicular cell thyroid malignancies. Tumor size, extra-thyroid extension and distant metastases indicate poor prognosis. 20-30% of HCCs have mets at initial diagnosis, frequent sites being lungs and bones. Metastatic HCCs are exceedingly difficult to manage. Detecting two primary cancers concomitantly is uncommon and poses additional challenges in diagnosis and management. We present an interesting case of HCC with mets to the manubrium, vertebrae, lungs and concomitant rectal adenocarcinoma. A 69-year-old male had MRI spine for back pain which showed multiple lytic osseous lesions within T3 and L1 vertebrae. Further imaging revealed a large lesion in the manubrium. Manubrial mass biopsy was positive for poorly differentiated carcinoma, immunohistochemical staining for CAM5.2, cytokeratin, CD 138, CD56 and TTF-1 (weak). He underwent 6 cycles of palliative chemotherapy with carboplatin and Taxol for carcinoma of unknown origin. PET scan following chemotherapy showed a large heterogenous thyroid mass with intense FDG uptake, along with a suspicious rectal mass. Left thyroid nodule FNA reported Bethesda IV follicular neoplasm, Hurthle cell type. Rectal mass biopsy reported moderately differentiated adenocarcinoma. Histology after total thyroidectomy showed unifocal oncocytic HCC, with lymphovascular invasion but no extrathyroidal extension. Molecular markers showed low TMB, stable microsatellite status, negative PDL-1, negative NTRK fusion and positive ATM E839. He received suppressive dose levothyroxine. Radio-iodine ablation was postponed owing to prioritization of radiation therapy for rectal cancer. Thyroglobulin level increased from 53 ng/ML to 216 ng/ML. He received 149 milli Curies of I131 after Thyrogen stimulation. There was mild radioiodine uptake in the thyroid bed, but the metastatic lesions were not radioiodine avid. Follow-up scans showed multiple bilateral pulmonary nodules with worsening osseous mets. Endoscopic biopsy was consistent with HCC, TTF-1 and PAX8 positive. He was started on Lenvatinib but developed diarrhea, hence switched to Pembrolizumab. Thyroglobulin level improved on Pembrolizumab but was complicated by adrenal insufficiency. For rectal cancer, he received radiation therapy and capecitabine. Our case is interesting for several reasons. Firstly, although bone mets are commonly seen in HCC, manubrial mets, especially as the presenting feature is rare. Secondly, concomitant rectal cancer delayed the treatment of the thyroid cancer. Thirdly, there is no major consensus regarding management of HCC, especially metastatic HCC. HCCs are often not radioactive iodine avid. Combination therapy with Lenvatinib and Pembrolizumab is currently under trial for aggressive thyroid malignancy. It will be interesting to follow the clinical outcomes in this individual. Presentation: Saturday, June 17, 2023

Jejunal gastrointestinal stromal tumor that developed in a patient with neurofibromatosis type 1: a case report

BackgroundNeurofibromatosis type 1 (NF1) is known to be associated with the frequent occurrence of unique gastrointestinal stromal tumors (GISTs), preferably occurring in the small intestine, with no mutations in the c-kit proto-oncogene or platelet-derived growth factor receptor-alpha (PDGFRA), with a high tendency for multifocal development, indolent nature, with low proliferation activity and favorable prognosis.Case presentationA woman in her forties visited her local doctor complaining of menstrual pain; a large mass was detected in her lower abdomen, and she was referred to our hospital. The patient had hundreds of skin warts and café au lait spots. The patient’s mother had been diagnosed with type 1 neurofibromatosis. The patient met the diagnostic criteria for NF1 and was diagnosed with NF1. Ultrasonography showed a large heterogeneous cystic mass with various echo patterns, solid compartments and multiple septations. Magnetic resonance imaging showed a multilocular cystic mass with liquid content exhibiting various intensities, including that of blood. A small round solid mass was also observed close to the cystic tumor. Contrast-enhanced computed tomography showed that the round solid mass showed strong enhancement in the early phase, unlike the cystic tumor component. Open laparotomy revealed a multicystic exophytic tumor measuring 11.5 cm originating from the jejunal wall, 20 cm distal to the duodenojejunal flexure. A solid tumor measuring 2.1 cm was also found on the anal side of the large tumor. We resected the short segment of the jejunum, including the two lesions. Microscopic findings revealed that the cystic and solid tumors consisted of spindle-shaped tumor cells showing little atypia with a fascicular or bundle arrangement. Nuclear mitosis was scarce. Immunostaining of the tumor cells showed positive staining for KIT and DOG1 and negative staining for S100 and desmin. The NF1 patient was diagnosed with multiple GISTs accompanied by intratumoral hemorrhagic denaturation arising from the jejunum. The TNM staging was pT4N0M0, stage IIIA.ConclusionWe report a case of GISTs associated with NF1 that showed a jejunal origin, multifocal development and few mitotic figures. The recurrence risk, survival prognosis and need for adjuvant chemotherapy, particularly in cases where the initial GIST exhibits a very indolent pathology in NF1-related GISTs, remain to be elucidated.

Giant adrenal ganglioneuroma: Case report and literature review

Adrenal ganglioneuroma is a benign tumor of the sympathetic nervous system, composed of gangliocytes and mature neural stroma. The tumor is asymptomatic in the majority of cases and mostly accidentally detected in diagnostic imaging due to health check. When the tumor is large, it causes the symptom such as abdominal pain or discomfort. We report a case of adrenal ganglioneuroma incidentally detected in a 25-year-old male patient. The physical examination and laboratory tests were in normal ranges. However, abdominal magnetic resonance imaging showed a large heterogeneous right adrenal mass measuring 16.8 x 14.1 cm. Histological examination of biopies confirmed an adrenal ganglioneuroma. A right adrenalectomy by laparotomy was carried out. The right renal artery was injured during the dissection of tumor and repaired with an end-to-end anastomosis. During postoperative period, the patient experienced a pleural effusion requiring a needle aspiration. No recurrence occurred during the 6-month follow-up.

Severe hypercalcemia due to metastatic pancreatic neuroendocrine tumor: a case report

BackgroundHypercalcemia of malignancy, as a paraneoplastic syndrome, is the most common metabolic disorder that accounts for 30% of malignancies and usually has a poor prognosis. Neuroendocrine tumors are uncommon and arise from neuroendocrine cells throughout the body. Actually, paraneoplastic hypercalcemia in neuroendocrine tumors is unusual and mostly associated with parathyroid hormone-related protein (PTHrP) secretion.Case presentationWe report a 51-year-old Iranian man who presented with nausea, vomiting, and significant weight loss for 1 month. Laboratory data revealed calcium of 26 mg/dl, accompanied by low level of PTH. Octreotide scan revealed a large donut-shaped octreotide avid lesion in the epigastric region at the right side of the mid-abdomen, with multiple varying size foci of abnormally increased radiotracer uptake in the epigastric region and both lobes of the liver. Endoscopic ultrasonography demonstrated a large heterogeneous mass lesion with irregular outline and good demarcation in the body of the pancreas with diffuse foci of calcification. Percutaneous biopsy of the liver mass demonstrated a well-differentiated neuroendocrine tumor (low grade) confirmed by immunohistochemistry with strongly positive chromogranin and synaptophysin stain. Hypercalcemia was treated with hydration, few sessions of hemodialysis, calcitonin, and denosumab injection. However, the patient developed symptomatic hypocalcemia. Oncology consultation led to prescription of long-acting octreotide 30 mg monthly and everolimus daily.ConclusionPancreatic neuroendocrine tumor could lead to malignant hypercalcemia; secretion of PTHrP is the most common cause, and signs and symptoms are usually milder than paraneoplastic syndrome due to hematologic and solid tumor. Generally, survival is better; however, its treatment is challenging, and primary debulking surgery is often required. A team approach to management is important at all points.

Giant retroperitoneal liposarcoma measuring 27 × 29 × 36 cm: a case report

Retroperitoneal tumors are rare neoplasms that can reach great dimensions due to a slow growth pattern. Although these tumors rarely metastasize, they have a great risk of recurrence, and majority of times these lesions are a challenge for the surgeon. We report the case of a 63-year-old woman who presented with symptoms of large bowel obstruction and was diagnosed with a large heterogenous mass located in the retroperitoneal space. The fine needle biopsy revealed the histology of liposarcoma. The purpose of this article is to report our approach in management of this kind of tumor. Tumor size (27.1 × 29.1 × 36.1cm) and involvement to the adjacent organs was a challenge for us in order to reach safe oncological margins. In these cases, the risk of recurrence is high; therefore, the patient should be screened at 6, 12 and 24months post procedure. Chemotherapy or radiotherapy for this tumor is not yet defined, and if operable, surgery is the treatment of choice.

Incidentally detected retrosternal goitre with posterior mediastinal extension causing compression of airway: a case report

<p class="abstract">Retrosternal goitre (RG) is an enlarged thyroid gland which extends below the clavicle and sternum. Most patients have slow-growing enlargement without any symptoms but may develop symptoms related to compression of aerodigestive tract like dyspnoea, choking, sleep disturbance, dysphagia and hoarseness. Surgical removal is the treatment of choice either through a cervical approach or combination with sternotomy or thoracotomy. Here we present a case of a 51 years female without any symptoms, detected incidentally to have mediastinal mass on imaging during routine health checkup. On evaluation, she was found to have no significant neck swelling or any evidence of vascular obstruction or neurological compression. Contrast enhanced computed tomography showed large heterogeneous mass lesion extending from posteroinferior aspect of (right) thyroid lobe extending into mediastinum till tracheal bifurcation. Due to the mediastinal extension, multispecialty team approach involving oncosurgeon, ear nose and throat (ENT) surgeon and cardiothoracic surgeon was done. The patient underwent (R) hemithyroidectomy with excision of posterior mediastinal component through combined cervical and mediastinal approach under general anaesthesia. Histopathological examination revealed adenomatous goitre. Post operatively patient was symptom free and is on regular follow-up.</p>

Редкий случай лейомиомы мочевого пузыря во время беременности: клиническое наблюдение

We present a rare case of leiomyoma of the urinary bladder that was diagnosed during pregnancy. The case of a 29-year-old woman primigravida at 13 weeks of pregnancy who presented with 6 months history of abdominal swelling which was gradually increasing in size. Computed tomography done revealed a large heterogenous mass(enhancing) with an area of non-enhancing (necrosis) suggestive of malignant ovarian tumor. The histological findings of the surgical specimen confirmed a leiomyoma of the urinary bladder. The clinical presentation, imaging findings, and management of this relatively rare benign tumor are discussed in this case report.

LBODP102 A Case of Unexpected Thyroid Storm Due To Acute Suppurative Thyroiditis From Klebsiella Pneumoniae

Abstract Introduction Thyroid storm is a life-threatening endocrinological emergency. It creates a hypermetabolic state caused by excessive release of thyroid hormones, causing adrenergic hyperactivity following a precipitant(s). An uncommon precipitant of thyroid storm is a thyroid abscess. Clinical Case A 48-year-old man with a PMHx of COPD on home oxygen, OSA, HTN, left thyroid lobe nodule and recent treatment for community-acquired pneumonia the prior week presented to the ED with complaints of right neck pain and swelling of 5 days duration. Patient had associated diarrhea, fever, nausea, vomiting and palpitations. VS: Temp 101.9 F, BP 164/120, RR 20 and HR 160. Physical examination revealed a right non-mobile tender neck mass, rales on the lower lobe of the left lung, and drenching sweats. CT of the neck showed a prominent soft tissue mass on the right side of the neck with irregular margins abutting the right thyroid lobe, suggesting possible abscess. A subsequent thyroid US revealed a large heterogeneous nonvascular right thyroid mass measuring approximately 12×7×7 cm. Initial labs: TSH < 0. 005 mU/L (normal range 0.45-5. 0 mU/L), FT4 2.54 mU/L (normal range 0.9 to 2.3 mU/L); TSHrAB, TSI and TPO were negative. Thyroid storm was diagnosed using the Burch Wartofsky score (45 points). He was treated with propythiouracil, hydrocortisone, propranolol and antibiotics. FT4 normalized after 2 days on admission at which time he was taken for surgical drainage of his right thyroid abscess. 80 cc of pus was aspirated and cultured with isolation of Klebsiella Pneumoniae. Blood cultures also revealed K. Pneumoniae. Repeat Thyroid US showed resolution of abscess. Patient remained in hospital for ongoing treatment of his pneumonia. Clinical Lesson: Acute suppurative thyroiditis (AST) is a rare, life-threatening infection of the thyroid gland. Thyroid gland is rich in iodine, blood supply and lymphatics with a thick capsule which is relatively resistant to infection from neighboring sites. AST is more common in women and affects the left lobe of thyroid. Our patient is a man and his thyroid abscess was on the right lobe. The most common route of infection in AST is a congenital pyriform sinus fistula which was ruled out in our patient with direct laryngoscopy. Common presenting symptoms include fever, neck pain, and dysphagia. Pathogens commonly found to cause AST include Streptococcus and Staphylococcus. Our patient presents as an interesting case of AST from K. Pneumoniae with hematogenous spread that precipitated a thyroid storm. Thyroid storm incidence is noted to be <10%; however, to our knowledge AST is a rare cause of thyroid storm resulting from a thyroid abscess. For patients presenting with thyroid storm and a neck abscess, AST should be kept in mind as a possible etiology. Reference: https://www.ncbi. nlm. nih.gov/pmc/articles/PMC5667251, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6587896/ Presentation: No date and time listed

PSAT208 A Case of Hypercalcemia From PTHrP-Producing Fibromyxoid Sarcoma Responsive to Glucocorticoid Therapy

Abstract Background Parathyroid hormone-related protein (PTHrP) is a major cause of humoral hypercalcemia of malignancy. PTHrP-induced hypercalcemia can also occur in benign disorders including pneumonia, SLE, HIV, sarcoidosis, and mammary hyperplasia. Treatment for PTHrP-induced hypercalcemia includes treating the underlying disorder and general management of hypercalcemia. Clinical Case A 70-year-old male with a chronic left thigh mass following trauma 12 years prior diagnosed as myositis ossificans, presented with worsening pain and swelling over the mass. Evaluation revealed serum calcium 18.6 mg/dl, PTH 10 ng/L (18-90), 25(OH)D 7 ng/ml (20-50), 1,25(OH)2D 15 pg/ml (20-79), PTHrP 9.3 pmol/L (≤ 4.2), negative SPEP, UPEP, serum light chains and immunofixation, and no bony lesions. MRI showed a large heterogenous mass centered in the left adductor muscle compatible with chronic hematoma with myositis ossificans. FDG PET/CT scan showed FDG avidity and calcification of the left thigh without any other site of uptake. Combination of IV hydration, denosumab and zoledronic acid lowered his calcium to 9.5 mg/dl, but levels increased again within 10 days. Repeated treatments with zoledronic acid initially led to modest lowering of calcium to 10.5 mg/dl, but he became refractory to treatment after 6 weeks, with calcium increasing to 12.3 mg/dl.Two biopsies of the mass were performed, including an open biopsy. The pathology showed nonpolarizable crystalline material with foreign giant cell reaction, without evidence for malignancy. It was concluded therefore that the patient's PTHrP-induced hypercalcemia was secondary to an inflammatory granulomatous condition. Since it had been reported that PTHrP-induced hypercalcemia in SLE and sarcoidosis responded to glucocorticoids, we initiated treatment with methylprednisolone 24 mg daily. After 7 days, the calcium declined from 12.3 to 10.5 mg/dl and PTHrP declined to 2.5 pmol/L. When the methylprednisolone dose was reduced to 12 mg daily, calcium increased to 11.4 mg/dl and PTHrP to 5 pmol/L. Increasing the methylprednisolone briefly back to 24 mg daily, and then 20 mg daily, lowered calcium to 9.0 mg/dl, increased PTH to 74 ng/L, and normalized PTHrP to 1.3 pmol/L. As long-term management with high-dose steroids was not a tenable option, a decision was made to resect the mass. The pathological diagnosis of the surgical mass was low-grade fibromyxoid sarcoma (LGFMS). Immunohistochemical studies identified PTHrP in surrounding vasculature, suggesting possible tumor-vessel interaction. Conclusion PTHrP-mediated hypercalcemia is rarely seen in sarcomas and treatments include coadministration of bisphosphonates, chemotherapy and surgery. We report here the first case of PTHrP-induced hypercalcemia from LGFMS with sustained lowering of calcium and PTHrP levels with glucocorticoid treatment. Further studies are needed to elucidate the mechanism of glucocorticoids in the treatment of PTHrP-induced hypercalcemia and could include lowering levels of inflammatory cytokines that stimulate PTHrP production from tumor cells, or by directly suppressing PTHrP gene expression. Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.