Large Heterogeneous Mass Research Articles

Trichobezoar with duodenal perforation: a rare occurrence

Trichobezoar is an intraluminal mass formed from the accumulation of undigested hair. It is a rare condition that is typically seen in young females with trichophagia and trichotillomania. When not recognized, it may present with complications such as obstruction, ulceration and in some rare cases, perforation. While most trichobezoar perforations are located in the stomach, however, duodenal perforation has not been reported before. We report a case of a 13-year-old girl who presented to the emergency with signs and symptoms of peritonitis and perforated viscus. Radiological investigation revealed a large heterogenous intraluminal mass with mottled gas pattern suspicious of bezoar. Oral contrast was seen tracking from the gastric pylorus into the peritoneum suggestive of a perforation. The girl was brought to theatre for emergency laparotomy and a trichobezoar was found extending from the stomach down to the level of D1. There is a perforation in D1 on its antero-superior surface measuring 1×1 cm. The bezoar was removed via a gastrostomy and the perforation was primarily repaired and patched with omentum. Post operatively, her recovery was complicated with wound breakdown and was subsequently discharged after 1.5 months of hospitalization with outpatient referral for psychiatry consults.

S1755 Intrahepatic Cholangiocarcinoma in a Patient With Alcoholic Liver Cirrhosis and Markedly Elevated Serum Alpha-Fetoprotein

Introduction: Intrahepatic cholangiocarcinoma (ICC) represents 5% of all primary liver malignancies, second only to hepatocellular carcinoma (HCC). Although risk factors such as primary sclerosing cholangitis, hepatolithiasis, and asbestos have been reported, the etiology of ICC is not well understood. An elevated serum AFP accompanied by a space-occupying solid lesion in a cirrhotic patient is typically indicative of HCC. In high-risk patients, such as those with chronic liver disease, AFP > 400 ng/mL has a high positive predictive value for HCC and a specificity of >95%. An elevated serum AFP greater than 20 ng/mL is seen in < 25% of ICC. Case Description/Methods: We present a patient with a past medical history of alcoholic liver cirrhosis Child-Pugh Class C presenting with acute change in mental status. On arrival, he was hemodynamically stable with classic stigmata of chronic liver disease on the exam. Non-contrast CT Head was non-revealing. Laboratory investigations revealed an obstructive pattern of transaminitis with a normal ammonia level, negative hepatitis panel, and serum AFP of 1955.8 ng/mL. EGD demonstrated portal hypertensive gastropathy. CT Abdomen/Pelvis demonstrated a large infiltrative heterogeneous mass involving the entire right hepatic lobe with a non-occlusive thrombus extending to the portal vein. Ultrasound-guided liver biopsy and immunohistochemical analysis demonstrated positive expression for cytokeratin 20, and CA 19-9. Neoplastic cells were negative for Hep-Par1, Glypican 3, and Arginase 1. The histological pattern (Figure) was consistent with poorly differentiated adenocarcinoma, most likely pancreaticobiliary in origin consistent with intrahepatic cholangiocarcinoma (ICC). Discussion: Elevated serum AFP accompanied by a space-occupying solid lesion in a cirrhotic patient is typically indicative of HCC. However, Xiong et al reported an increased risk by 3.92-fold of cholangiocarcinoma in patients with alcoholic liver disease. Even though, an increase in AFP has been reported in patients with ICC, an elevation higher than 20 ng/mL was seen in approximately 20% of the patients according to Wang et al. In our patient, surprisingly, the histopathological report showed findings consistent with ICC and negative hepatic markers, hence a high suspicious index should be held by clinicians for this entity upon approaching a patient with a solid liver mass associated with significantly elevated AFP levels.Figure 1.: On the left, histology of poorly differentiated adenocarcinoma composed of duct-like structures with high pleomorphism. H&E 400X. On the right, immunohistochemical study shows positive CA 19-9 stain of adenocarcinoma.

S1821 Rare Case of Recurrent Liver Abscess Caused by Choledocodoudenal Fistula in Ampullary Diverticulum

Introduction: Choledocodoudenal Fistula is a rare condition that may be caused by Choledocholithiasis, surgical or laparoscopic cholecystectomy, duodenal ulcer and tumor invasion. Choledocodoudenal fistula has no specific symptoms and may be accidentally discovered during upper GI endoscopy; but in some cases, it may lead to recurrent cholangitis and liver abscess. In this article, a case of recurrent liver abscess caused by Choledocodoudenal fistula in ampullary diverticulum is reported. Case Description/Methods: A 68-year-old male was admitted to outside facility because of abdominal pain and liver lesion on ultrasound. The abdominal CT showed large heterogeneous mass measuring more than 16*11 cm with single porta hepatis enlarged lymph node measuring about 2*1cm. Hepatocellular Carcinoma was suspected, but liver biopsy revealed active hepatitis with areas of necrosis and supportive inflammation. He was Referred to ALAhli Hospital for evaluation of liver abscess (Table). ERCP showed Tiny Ampullary orifice in large diverticulum (Figure). The injection of the contrast revealed a fistula at the apex of diverticulum with good drainage through it. In cases of liver abscess secondary to fistula complication, surgical or medical management may be needed. The liver abscess in this case study was treated medically. Discussion: A management strategy for CDF depends on correcting the underlying cause. As this condition is most commonly stone induced Endoscopic sphincterotomy is the gold standard for CBD stone extraction, however this approach has been found to be successful in only 12% of cases of large stone extraction, usually requiring additional therapies. Endoscopic papillary balloon dilation is an alternative approach to maintain the function of the sphincter and to reduce the morbidity associated with traditional endoscopic sphincterotomy. Currently, the approach of sphincterotomy followed by balloon dilation has provided the best outcomes. Patients with multiple abscesses should receive antibiotics for 4–6 weeks. Percutaneous drainage is the treatment of choice for liver abscesses. Operative drainage is indicated for patients with an identified intra-abdominal focus of infection and for those in whom percutaneous drainage is not feasible or has failed. Anatomic liver resection is rarely required and is withheld for cases of underlying surgical hepatobiliary pathology. In our patient we choose the medical treatment with antibiotics in combination with image-guided percutaneous drainage with excellent outcome.Figure 1.: Ampulla in large Diverticulum. Table 1. - Laboratory results of the patient upon admission to Al-Ahli Hospital WBC 7.8K/ul S. Albumin 2.1g/dl Sodium 133mEq/L HCT 50% SGPT 6mg/dl Potassium 3.7 mEq/L Hemoglobin 16.8% SGOT 15mg/dl Cholride 107mmol/l Platelets 173K/ul Bilirubin(T) 0.6mg/dl S. Creatinine 0.85mg/dl ESR 75mm/hour Bilirubin(D) 0.4mg/dl BUN 17mg/dl INR 1.3 ALK.PHOS 171 U/L CRP 190mg/l

Renal primitive neuroectodermal tumor. The first case series from Syria.

Primitive neuroectodermal tumor (PNET) mainly arises from soft tissues of the extremities such as humerus, femur, C tibia. It rarely arises from kidney; less than 200 cases have been reported in the literature. The clinical presentation and radiography findings are not specific. Here we first report two cases of renal primitive neuroectodermal tumor in Syria.the first patient was 26-year-old- female that presented to urology clinic complaining of right flank pain. Ultrasonography of the abdomen showed a large mixed heterogeneous mass in the right kidney with no hemorrhage or calcification and MSCT of abdomen and pelvis demonstrate a mixed well-demarcated heterogeneous mass measuring (74*117) mm in the right kidney right radical nephrectomy was performed.The second patient 19-year-old-male presented with left flank pain. Ultrasonography of the abdomen showed mixed large mass involving the left kidney, with unmarked border. The CT of the abdomen and pelvis demonstrating a (30*110*90) mm left renal mass and periaortic lymphadenopathy measuring (45*28) mm. The patient underwent Left radical nephrectomy with periaortic lymphadenectomy dissection. The final diagnosis for both cases was Renal PNET based on microscopic and immunohistochemistry examination.In patient with suspected renal mass in the radiographic images, the diagnosis of renal primitive neuroectodermal tumor should be kept in the mind despite its rarity. The final diagnosis is done by histopathological study in association with immunohistochemical examination.

The dilemma in management of desmoid tumour: A case report

IntroductionDesmoid tumours are rare benign tumours. The tumours may develop sporadically or they may be linked to familial adenomatous polyposis (FAP) in Gardner’s syndrome.AimThis article highlights a young lady with an intra-abdominal desmoid tumour that manifested as an acute abdomen and we discuss our management strategy.Case studyA 24-year-old lady with a known FAP who had undergone a panproctocolectomy with an ileal pouch-anal anastomosis and total thyroidectomy, later was complicated with acute abdomen for symptomatic desmoid tumour. Computed tomography of the abdomen showed a large intraperitoneal heterogenous mass with small bowel displacement and was confirmed by magnetic resonance imaging. An exploratory laparotomy and en-bloc resection of the tumour with an end ileostomy were performed.Results and discussionIntra-abdominal desmoid tumours usually present as a painless slow-growing mass, however, in severe form, it can cause bowel ischemia, intestinal obstruction, or deterioration of function in the ileoanal anastomosis, among post total colectomy. Surgery is indicated upfront in specific clinical scenarios namely complications (occlusion, perforation, or bleeding) or major cosmetic issues.ConclusionsDesmoid tumour, despite being benign, is challenging to manage due to its compressing nature. As a key point, the diagnosis of a desmoid tumour should be suspected and followed up closely in patients with a previous history of FAP in combination with extracolonic manifestation.

Functional Investigation of the Tumoural Heterogeneity of Intrahepatic Cholangiocarcinoma by In Vivo PET-CT Navigation: A Proof-of-Concept Study.

Intra-tumoural heterogeneity (IH) is a major determinant of resistance to therapy and outcomes but remains poorly translated into clinical practice. Intrahepatic cholangiocarcinoma (ICC) often presents as large heterogeneous masses at imaging. The present study proposed an innovative in vivo technique to functionally assess the IH of ICC. Preoperative 18F-FDG PET-CT and intraoperative ultrasonography were merged to perform the intraoperative navigation of functional tumour heterogeneity. The tumour areas with the highest and the lowest metabolism (SUV) at PET-CT were selected, identified during surgery, and sampled. Three consecutive patients underwent the procedure. The areas with the highest uptake at PET-CT had higher proliferation index (KI67) values and higher immune infiltration compared to areas with the lowest uptake. One of the patients showed a heterogeneous presence of FGFR2 translocation within the samples. Tumour heterogeneity at PET-CT may drive biopsy to sample the most informative ICC areas. Even more relevant, these preliminary data show the possibility of achieving a non-invasive evaluation of IH in ICC, paving the way for an imaging-based precision-medicine approach.

Spontaneous rupture of an intratumoral pseudoaneurysm in a giant renal angiomyolipoma

We reported a rare case of a spontaneous rupture of an intratumoral pseudoaneurysm in a giant renal angiomyolipoma of a 52-year-old lady. The initial presentation was a sudden onset of right hypochondriac pain, nausea, and vomiting. CT scan revealed large heterogenous exophytic enhancing mass with mixed solid and fat density within, arising from the right kidney likely represent a giant right renal angiomyolipoma. There is associated right perinephric hematoma and active bleeding within the mass. No features suggestive of tuberous sclerosis. Subsequent right renal angiogram revealed a pseudoaneurysm of an inferior segmental right renal artery and emergency embolization was done with successful obliteration of the aneurysmal sac and devascularization of the mass.

961 Surgery for Stage IVA Metastatic Thymoma Found Incidentally Post-COVID-19

Abstract Background Thymic epithelial tumours (TET) are rare thoracic cancers with reported annual incidence of 1.3–3.2 per million. TETs are histologically classified as thymomas or thymic carcinomas. Thymomas are slow-growing tumours that comprise the majority of lesions found in the anterior mediastinum. They can be associated with autoimmune disorders such as Myasthenia Gravis. Contrast CT is the standard for diagnosis. Surgery is treatment of choice depending on resectability of the tumour. The Masaoka-Koga staging system is correlated with overall survival and is utilised post-surgical resection to guide adjuvant treatment. Case Presentation A 50-year-old male presented with cough, shortness of breath, myalgia, sore throat, and reduced sense of smell that was diagnosed as COVID-19. CT chest and abdomen showed a large heterogeneous mediastinal mass (11cm) invading the innominate vein and left upper lobe with two left pleural deposits, and diaphragmatic disease. CT biopsy confirmed thymoma. MDT recommended surgery due to patient age and resectability of tumour with post-operative chemotherapy. The sites of disease necessitated a left thoracotomy and median sternotomy. The pleural and diaphragmatic deposits were resected, followed by left upper lobe anatomical dissection enbloc with invaded pericardium, phrenic and vagus nerve, followed by median sternotomy to resect the thymic mass along with the innominate vein. Final staging was stage IVA thymoma (B2 and B3) (T3N0M1aR0). A CT scan at 1 year showed no recurrence despite patient declining adjuvant chemotherapy. Conclusion Surgical resection is a viable treatment option for patients with stage IVA thymoma who present with resectable primary and metastatic disease.

Fetal Disseminated Malignant Rhabdoid Tumor.

Fetal Disseminated Malignant Rhabdoid Tumor.

Aggressive Osteoblastoma in adolescents: Radiological case report

In this article we represent an 18-year-old female with progressive back pain and neurologic symptoms due to a large heterogenous mass centered in posterior elements of lower thoracic vertebrae with prominent soft tissue extension into paravertebral and epidural space and subsequent central cord compression along with severe adjacent inflammatory changes. Considering patient age, lesion location and characteristics, aggressive Osteoblastoma, eosinophilic granuloma, and with lower probability of Ewing sarcoma were included in the differential list, which aggressive Osteoblastoma was confirmed after pathologic examination.

ATRT-18. Atypical Teratoid/Rhabdoid Tumor in Children: Case Reports from Indonesia

Atypical teratoid/rhabdoid tumor (AT/RT) of the central nervous system is a sporadic and highly malignant tumor that usually affects very young children and is typically deadly despite very aggressive treatment. The optimal treatment for AT/RT remains unclear, including surgery, radiotherapy, and chemotherapy. Here we report cases of AT/RT in Indonesia. Case 1: A three-year-old girl came with worsening intermittent headaches with projectile vomiting, progressive and insidious right spastic hemiparesis, and slowly progressive weight loss three months before admission. She had septate multiloculated hydrocephalus. Head MRI demonstrates a solid lobulated mass with heterogeneous enhancement and MRS shows an aggressive metabolite pattern, arising from posterior fossa extending into the cerebellum and cerebellopontine angle, causing severe obstructive hydrocephalus. She underwent tumor resection with a midline suboccipital approach, then continued with craniospinal irradiation with dose of 36 Gy in 20 fractions then followed by 18 Gy in 10 fractions booster to posterior fossa, making the total dose to posterior fossa (the tumor) to be 54 Gy. Case 2: A twenty-month-old baby with a history of recurrent seizures, tremors, and less activity in the last two months. She had spasticity with hyperreflexia. She has been referred to our center for further evaluation and management after biopsy and VP shunt surgery at the previous hospital. Head CT scan demonstrates a large solid heterogeneous mass in the right hemisphere cerebral, causing midline shift and hydrocephalus. After the VP shunt was repaired, she underwent Head Start III chemotherapy protocol cycle 1. Both pathology examinations of the patients revealed a hypercellular tumor with prominent hyperchromatic nucleoli and loss of INI-1 staining on immunohistochemistry consistent with an ATRT diagnosis. Unfortunately, both patients died due to severe sepsis after treatment. Although AT/RT has become increasingly recognized, prognosis of ATRT is generally unfavorable, especially in developing countries.

HGG-55. An adolescent with a High-Grade Glioma: persuing a specific diagnosis

BACKGROUND: Recognizing the value of molecular parameters provides evidence with repercussions on diseases classification. CLINICAL CASE: A thirteen-year-old girl was admitted in coma at the Intensive Care Unit due to a hemorrhagic stroke. CT revealed an expansive left frontal lobe lesion with perilesional edema and compression signs by an extensive hematoma. She underwent an emergency decompressive craniotomy for hematoma drainage, and the lesion was biopsied. The subsequent MRI showed a large heterogeneous mass with a cystic component. A first subtotal resection of the lesion was performed considering the language area. The histopathological examination showed tumor cells organized in perivascular pseudorosettes around the central hyalinized thickened blood vessel throughout the tumor, a pattern typically encountered in astroblastoma. Immunochemistry stains revealed a positive reactivity for GFAP, Olig2, and synaptophysin. The molecular study found a BRAFV600E mutation and homozygous CDKN2A e CDKN2B deletions; no TERT amplification, BCORL1, nor MN1 gene rearrangements were identified. She completed six weeks of radiotherapy without neurological signs/symptoms. A new surgical intervention was done 12 weeks later due to a slight increase of residual lesion. The rapid growth and the presence of viable tumor cells justified the therapy with irinotecan and bevacizumab, with mild adverse effects. One year after diagnosis, the adolescent is clinically well, without neurologic deficits and the MRI without evidence of residue or tumor recurrence. DISCUSSION: We began therapy based on morphological diagnosis. Complete resection and radiotherapy proved to be beneficial as in other high-grade gliomas, but the value of other therapies is still unknown. The BRAF gene variant would allow treatment with dabrafenib (in association with trametinib) or vemurafenib; however, she presents molecular findings associated with poor prognosis (CDKN2A deletion) that may impair the effectiveness of these therapies. According to the new WHO classification, the absence of MN1 alterations precludes the diagnosis of astroblastoma.

Severe mandibular osteomyelitis and exfoliation of a mandibular canine tooth in a Vietnamese potbellied pig

A 10-year-old male castrated Vietnamese potbellied pig presented for evaluation of a dermal mass present on the left cervico-mandibular region. The patient had a mass removed 6 years earlier from the same region, which was diagnosed as squamous cell carcinoma on histopathology. On physical examination, all vital parameters, including heart rate, respiratory rate and temperature, were within normal reference ranges, and the owner reported a normal appetite with no recent history of weight loss. Upon intubation for the dermal mass removal, a large heterogeneous mass of material was observed in the rostral aspect of the left mandible (Figure 1). Once removed, the mass appeared to be grossly composed of foodstuffs, hair, and a firm, mineralized segment of unknown material (Figure 2a). Within the contents of this debris, the left mandibular canine tooth (304) or tusk was identified. For the size of the mass of material, there was minimal inflammation associated with the gingiva and the mucosa (Figure 2b). There did not appear to be any evidence of displacement of the remaining teeth in the area. The periodontal attachment appeared to be normal in the remaining teeth. Computed tomography (CT) of the head was performed with the patient anaesthetized as previously described1 and positioned in sternal recumbency. Findings included severe, multifocal, chronic periodontal disease. The left mandibular canine tooth (304) or tusk was absent, and there was a large bony defect associated with the left mandibular body along the alveolar margin. The bony defect continued to affect the buccal aspect of the mandibular body (Figure 3). There was also extensive periapical lysis and evidence of external tooth resorption of the right mandibular canine tooth (404). The radiographic dental abnormalities were consistent with severe diffuse mandibular osteomyelitis characterized by multifocal moth-eaten bone lysis and irregular periosteal new bone formation, and multiple draining tracts from the right ventral mandible. Additional radiographic findings included absence of all premolar and molar teeth except the right first maxillary premolar (105), multifocal periapical lysis of the remaining teeth, bilateral medial retropharyngeal lymphadenopathy, and evidence of bilateral otitis externa and right otitis media. Miniature companion pigs (MCPs) are increasing in popularity as companion animal pets in North America.2 While data for exact numbers are limited, MCPs first appeared in the United States in the 1980s, with a dramatic increase in popularity over the past 17 years.3 With the increase in numbers, preventive care strategies are essential to improve animal health and welfare. Commonly reported dental pathologies in MCPs include missing teeth (most commonly the first mandibular premolar), periodontal disease, and tooth resorption.4 Early diagnosis of dental disease and mandibular osteomyelitis is important for companion animal pigs, considering their potentially long life span. Extraction of an infected tusk can be quite challenging. In cases of severe infection and disease, the integrity of the mandible can be affected to the point where it can be unstable after the extraction.5 Osteomyelitis can be managed with long-term antimicrobial therapy, including oral, injectable, and regional infusion of antibiotic-impregnated compounds, depending on lesion location.6 Removal of the infected nidus, in many cases the tooth, is critical for a positive long-term outcome. A complete oral assessment with inclusion of dental radiographs in MCPs should be considered for proper preventative dental care.4 As evidenced by our case, CT is also beneficial for a thorough oral evaluation and dental assessment. The authors declare no conflict of interest. This case represents a retrospective clinical case report and not a prospective study that requires institutional approval. The authors received no specific funding for this work. Open access funding provided by the Iowa State University Library.

Anesthetic management for large anterior mediastinal mass compressing great vessels of heart.

Dear Editor, Anesthesia management for large mediastinum masses poses distinctive challenges. With the induction of anesthesia, complications are usually the consequence of extrinsic compression of the airway, obstruction of the venous return, or obstruction to the output of the heart.[1] We present a case of large mediastinal mass which necessitated the use of one-lung awake intubation with beat-to-beat hemodynamic monitoring. A 14-year-old boy presented with history of chest pain, weight loss, facial puffiness, dyspnea for 3months and Computed tomography (CT) thorax revealed a heterogeneous mass lesion of 9 × 8 × 12 cm, involving anterior mediastinum, abutting cardiac chambers, pulmonary vessels, and trachea [Figure 1]. Echo cardiography revealed shifting of heart to right hemithorax but with normal ejection fraction.He was diagnosed with mature teratoma in the anterior mediastinum and was planned for excision through left anterolateral thoractomy with one-lung ventilation. On the day of surgery, standard monitors were attached. Two large-bore intravenous (IV) access were taken. Premedication was done with midazolam 1 mg IV and fentanyl 50 μg IV. Awake intubation was done under mild sedation and recurrent laryngeal nerve block. An Eighteen G epidural catheter was placed in T9-10 space. Right radial artery was cannulated and transduced. The child was intubated using a 6.5 mm Univent single-lumen tube with bronchial blocker/fixed at 20 cm. Anesthesia was maintained with O2:N2O, sevoflurane, and intermittent dose of muscle relaxant. The right internal jugular vein was cannulated. Just before thoracotomy, the bronchial blocker was inflated and one-lung ventilation was initiated. The patient’s hemoodynamic and ventilatory parameters were maintained throughout. For analgesia, he was administered 2 mg morphine with 0.25% bupivacaine(total volume 6 ml) through the epidural catheter. At the end of the surgery, the bronchial blocker was deflated and the neuromuscular blockade was antagonized, and the trachea was extubated. A volume of 2500 ml of crystalloids was infused over 4 h with 700 ml blood loss. The patient was discharged on 8th postoperative day.Figure 1: Computed tomography thorax showing large heterogeneous mass compressing cardiac chambers, pulmonary vessels, and tracheaThe most useful information for the anesthesiologist to guide management is imaging studies. Any deviation or compression of heart, airway, or great vessels needs to be evaluated. Head elevated position and awake intubation was adopted to avoid respiratory distress and hemodynamic instability due to superior vena cava (SVC) obstruction. Maintaining spontaneous respiration may be a good alternative because positive pressure ventilation may increase the risk of hypotension. Chemotherapy with bleomyc in used in this child may have further contributed to pulmonary toxicity.[2] In case of SVC involvement, it is prudent to place a large IV cannula in the femoral vein to facilitate transfusion of blood and drug administration. In the event of complete loss of airway or cardiovascular collapse, institution of extracorporeal membrane oxygenation was kept ready.[3] Atelectasis post one-lung ventilation is the main cause of difficulty in weaning these patients off mechanical ventilation. Intraoperatively, anesthesiologist should be vigilant for excessive hemorrhage, herniation of heart or pulmonary torsion, dysrhythmias, and even cardiac arrest. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Myxopapillary Ependymoma with Anaplastic Features: A Case Series and Review of the Literature

Myxopapillary ependymomas (MPEs) with anaplastic features are rarely reported, with only 21 cases identified to date, and long-term recurrence is rarely presented. A case series is presented to expand understanding of this disease by describing 3 unique cases, including 2 that arose from MPE after a prolonged clinical course. A literature review was performed, and 3 cases of MPE with anaplastic features from our institution were included. Patient 1 was a 13-year-old boy who presented with an avidly enhancing intradural lumbar mass. On gross total resection, the tumor was found to be a solid mass with areas of myxopapillary architecture and MIB-1 (Ki-67) index of 12%. Patient 2 was a woman who initially presented at age 22 with a lumbosacral tumor that was treated with surgery and radiation. A recurrent tumor was resected at age 24. At age 50, the patient presented with a large heterogeneous exophytic mass in the sacrum extending into the presacral space and Ki-67 index of 8%. This was treated with complete resection. Patient 3 was a man who initially presented at age 35 with a lower thoracic, upper lumbar mass at L2 extending into the sacrum. Following resection and radiation, a metastatic focus followed an indolent course until causing pain at the age of 48. Ki-67 index was 16%. The presented cases of MPE with anaplastic features make a total of 24 cases on record in the medical literature and demonstrate 2 examples of late recurrence.

Seminal vesiculitis in a Vietnamese pot‐bellied boar

AbstractAn 8‐month‐old Vietnamese pot‐bellied boar was presented with a 3‐week history of constipation and an enlarged scrotum. Abdominal and scrotal ultrasonography was performed to assess the gastrointestinal and genitourinary tracts. An obstructive gastrointestinal lesion was ruled out, although a large cavitated heterogeneous mass was identified dorsal to the body of the bladder, which was consistent with the location of the seminal vesicles. Culture of a sample of preputial discharge revealed growth of four bacterial types, includingEscherichia coliandTrueperella abortisuis. Given the clinical findings, a diagnosis of seminal vesiculitis was made and antimicrobial therapy was initiated.

A Newborn With a Mass on the Brain.

A Newborn With a Mass on the Brain.

RARE CASE OF PAZOPANIB-ASSOCIATED BILATERAL PNEUMOTHORACES IN A PATIENT WITH METASTATIC SYNOVIAL SARCOMA

TOPIC: Lung Cancer TYPE: Medical Student/Resident Case Reports INTRODUCTION: Bilateral pneumothoraces are a rare occurrence, comprising 1.4% to 7.6% of cases [1]. Secondary causes of pneumothorax include bullous emphysema, cystic parenchymal lung disease and tuberculous lung disease [2]. Malignancy is a rare cause of pneumothorax, yet sarcomas have been associated with pneumothorax in 2% of patients [3]. Pazopanib, a tyrosine kinase inhibitor used in the treatment of metastasized sarcoma, has been shown to have a 3.3% risk of developing pneumothorax [4]. CASE PRESENTATION: A 24-year-old previously healthy Yemeni female initially presented with left-sided groin pain and swelling. Computed tomography of the pelvis showed a large heterogeneous mass in the proximal left thigh. Biopsy was consistent with synovial sarcoma. Staging via chest computed tomography showed multiple pulmonary nodules concerning for metastasis. Over the course of two years, she failed multiple lines of chemotherapy and had progression of disease with new and enlarging bilateral pulmonary nodules. She was started on fourth-line chemotherapy with pazopanib (Votrient) 400 mg daily. Two months later, she presented with shortness of breath, found to be tachypneic, tachycardic and hypoxemic. Chest x-ray revealed bilateral pneumothoraces with left mediastinal shift concerning for tension pneumothorax. Two tube thoracostomies were placed; however, course was complicated by persistent air leak bilaterally, requiring video-assisted thoracoscopic surgery with bullectomy and surgical talc pleurodesis. Patient had a slow resolution of pneumothorax and subsequently discharged home without recurrence. DISCUSSION: Bilateral pneumothoraces can be life-threatening and are associated with poor long term prognosis, especially in patients with poor underlying lung function [5]. Pneumothorax is seen in approximately 2% of sarcoma patients with pulmonary metastases. In patients with sarcoma and pulmonary metastases, 41.6% of pneumothoraces were bilateral, and typically associated with multiple lung nodules, cystic or cavitary lesions, or presence of pleural nodules or thickening [3]. Additionally, cytotoxic agents have been shown to induce cavitation in pulmonary lesions and increase the risk of pneumothorax development [6]. Per the PALETTE trial which led to the approval of pazopanib for use in sarcoma, there was a 3.3% risk for pneumothorax development [4], comparable to the baseline rate of pneumothorax development in patients with sarcoma. Nevertheless, bilateral pneumothoraces carry potentially fatal consequences. CONCLUSIONS: In patients with sarcoma undergoing treatment with pazopanib, a bilateral pneumothorax, though rare, may be life threatening and should be acutely suspected. REFERENCE #1: TG Rim, JS Bae, YS Yuk. Life-Threatening Simulatenous Bilateral Spontaneous Tension Pneumothorax - A case report. Korean J Thorac Cardiovasc Surg. 2011 Jun; 44(3): 253-256.2. Mason RJ, Braoddus VC, Murray JF, Nadel JA. Murray and Nadel's Textbook of Respiratory Medicine. 4th ed. Elsevier Saunders (2005); Vol 2, Chapter 81. Philadelphia, PA. REFERENCE #2: Hoag JB, Sherman M, Fasihuddin Q, Lund ME. A comprehensive review of spontaneous pneumothorax complicating sarcoma. CHEST. 2010 Sep; 138(3);510-8.4. Van der Graaf WT, Blay JY, Chawla SP, Kim DW, et al. Pazopanib for metastatic soft-tissue sarcoma (PALETTE): a randomised, double-blind, placebo-controlled phase 3 trial. Lancet. 2012 May 19; 379(9829):1879-86. REFERENCE #3: Graf-Deuel E, Knoblauch, A. Simultaneous bilateral spontaneous pneumothorax. CHEST. 1994 Apr; 105(4):1142-6.6. Interiano RB, McCarville MB, Wu J, Davidoff AM, Sandoval J, Navid F. Pneumothorax as a complication of combination antiangiogenic therapy in children and young adults with refractory/recurrent solid tumors. J Pediatr Surg. 2015 Sep; 50(9):1484-9. DISCLOSURES: No relevant relationships by Sally Askar, source=Web Response No relevant relationships by Owais Nadeem, source=Web Response

Surgical management of cellular congenital mesoblastic nephroma in a neonate: a case report and review of literature

BackgroundCongenital mesoblastic nephroma (CMN) is the most common type of renal stromal tumor in neonates. It is classified into cellular, classical, and mixed types. The multidisciplinary management approach is the mainstay of management. We are reporting a case of neonatal congenital mesoblastic nephroma in a full-term boy with intrauterine growth restriction and hypertension managed effectively in our institution.Case presentationA full-term boy with intrauterine growth restriction (IUGR) with a birth weight of 2.3 kg, referred at birth with an abdominal mass. His antenatal scan at 35 weeks showed a cystic abdominal mass. On delivery, a huge visible abdominal mass of cystic consistency and smooth surface was noticed at the right side of the abdomen. blood pressure was 98/75 mmHg. It was responsive to hydralazine. Aldosterone and renin were significantly elevated at more than 100 and 500 ng/dl, respectively. Serum neurone-specific enolase (NSE) was 35 ng/ml while alfa feto protein was (AFP) 50,000 kIU/L. An abdominal ultrasound scan revealed an ill-defined large heterogeneous mass of 6.09 × 6.5 × 5.77 cm that arises from the right kidney. A computed tomography scan confirmed a right kidney mass with peripheral claw sign of the normal right renal tissue. It was crossing the midline and causing a mass effect on the adjacent structures. The right renal artery and vein were compressed and shifted posteriorly and inferomedially. Right radical nephrectomy was performed via a right lower transverse incision. The tumor was completely excised with a tumor weight of 270 g and a size of 10.5 × 8 × 5.5 cm. Histopathological diagnosis was mesoblastic nephroma of a cellular type which was confirmed by immunohistochemistry. Post-operatively, the blood pressure has significantly reduced and antihypertensive medications were eventually weaned off. The multidisciplinary team decided to preserve chemotherapy only in case of recurrence. At 3 months follow-up, no features of recurrence were noticed based on surveillance ultrasonography.ConclusionMesoblastic nephroma should be considered in any newborn with renal mass. The multidisciplinary team approach with aggressive management of hypertension, detailed radiological investigation, and complete tumor resection is fundamental for obtaining an excellent outcome for such entities.

The Management of the Cotyledonoid Leiomyoma of the Uterus: A Narrative Review of the Literature

Cotyledonoid leiomyoma is an unusual uterine myoma due to some ultrasound features that mimic a malignant lesion facilitating the choice of radical surgery. This study aims to summarize the ultrasound and the magnetic resonance imaging aspects of this atypical lesion, and also discuss surgical treatment and pathological exam. It included all English case reports or case series until August 2021 found through PubMed, Google Scholar, and Scopus. A total of 94 cotyledonoid leiomyomas were reported, with a median tumor size of 12 cm. The typical ultrasound image is characterized by a large solid heterogeneous mass, with high vascularity, no shadowing, and indistinct margins within the myometrium. Magnetic resonance imaging shows the presence of merging isointense nodules to the myometrium in T1-weighted images, hyperintense in T2-weighted images, and contrast agent enhancement. Surgical treatment consists of hysterectomy (75 cases, 80%) or myomectomy (19 cases, 20%), without evidence of recurrence if complete. The placenta-like appearance observed during surgery supports this rare fibroid hypothesis. The intraoperative frozen section can be considered. Microscopically, no atypical cells, signs of mitotic activity or cell necrosis are found. To conclude, some preoperative and intraoperative aspects of this lesion are distinctive and may lead surgeons to opt for conservative surgery.