Mass In Left Upper Quadrant Research Articles

Metaplastic Carcinoma of Breast with Osteosarcomatous Differentiation: A Rare Case Diagnosed by Fine Needle Aspiration Cytology

Metaplastic carcinoma is a rare form of breast cancer. It constitutes a distinct aggressive form of invasive breast cancer with histological evidence of epithelial to mesenchymal transition towards spindle, chondroid or osseous cell type. Osseous metaplasia is an exceptionally rare component in metaplastic breast carcinoma. We present a case of 40 yr old female who was diagnosed with Metaplastic carcinoma of breast on fine needle aspiration cytology (FNAC) and subsequently confirmed by histopathological examination. The patient reported to our institution with complaints of painless left breast lump of 5 yr duration. USG findings revealed large infiltrative hypoechoic mass in left upper quadrant of breast suggestive of malignancy. FNAC of lump showed loosely cohesive clusters of malignant spindle cells along with multinucleated giant cell in background of chondroid stroma. A tentative diagnosis of metaplastic carcinoma breast was made. Modified radical mastectomy was performed. Histopathological examination of specimen revealed presence of osteoid lined by malignant osteoblasts like cells interspersed with multinucleated giant cells. A diagnosis of metaplastic carcinoma of breast with osteosarcomatous differentiation was confirmed on histopathological examination. Metaplastic breast carcinoma are heterogenous group of tumors constituting 0.2% of breast carcinomas. Age group and clinical features and radiographic features are similar to other invasive breast carcinomas. Cases is presented for its rarity and utility of FNAC in diagnosing such cases having divergent histological features.

Laparoscopic Marsupialization of a Giant Non-Parasitic Splenic Cyst (Npsc) in the Paediatric Age Group

AbstractNonparasitic splenic cysts are rare clinical lesions of the spleen. The management has entailed partial or total splenectomy via an open approach. Recently, laparoscopic approaches have been developed. In this report, we describe laparoscopic marsupialization of a giant splenic cyst (diameter > 15 cm).A 15-year-old Indian child presented with a four and a half year history of mass in upper left quadrant associated with left upper quadrant pain which increased since 2 days. Physical examination revealed a large, nontender left upper quadrant mass with minimal movement on respiration. Computed tomography scan confirmed a cyst arising from the spleen, measuring 20 x 15 cm suggestive of a primary splenic cyst. Echinococcus and Entamoeba histolytica serologies were negative. Laparoscopic exploration was performed. three liters of brown fluid were aspirated and intraoperative cytology confirmed a nonparasitic cyst. The cyst wall was excised, preserving the spleen. The patient's recovery was uneventful, and he was discharged, tolerating a regular diet on postoperative day 3. At follow-up, the patient was asymptomatic and showed no evidence of recurrence. Non-parasitic splenic cysts are rare lesions. Laparoscopic marsupialization is safe and effective and should be considered the treatment of choice even for giant splenic cyst.

Surgical Treatment for Hypoglycemia: A Case Report

A 55 year old female presented large left upper quadrant mass and episodes of recurrent hypoglycemia. Preoperative laboratory testing revealed normal insulin, IGF-I and IGF-II levels. Big-IGF-II levels were unable to be measured because the laboratory test was unavailable. A CT scan of her abdomen and pelvis revealed a large 19 × 15 × 12 cm left upper quadrant mass appearing to involve the pancreas, spleen, and left kidney. The mass was surgically extirpated and was consistent with a hemangiopericytoma. Subsequently, her hypoglycemic attacks along with abdominal symptoms resolved. We hypothesize that this patient’s hypoglycemic attacks were a consequence of tumor secretion of a pro-hormone form of IGF-II called ‘Big IGF-II’.

Endometrial stromal sarcoma presenting as large bleeding left upper quadrant mass.

Endometrial stromal sarcoma (ESS) represents only 0.2% of all uterine malignancies. Even fewer cases have been reported on patients presenting with symptomatic disease. We report the case of young lady presenting with a large bleeding abdominal mass. At the time of surgery, an en bloc excision of the mass with a partial pancreatectomy, splenectomy, transverse colectomy, left nephrectomy, left adrenalectomy and resection of the diaphragm was performed. The final pathology revealed a malignant spindle and epithelial cell neoplasm with features favoring a variant of ESS. ESS can present in an atypical fashion as an intra-abdominal mass; a multi-disciplinary treatment approach for patients with this disease is crucial.

English

Venous thrombosis and hypercoagulable state has been described in patients with acute and chronic pancreatitis. Though this is commonly observed in splanchnic vessels, thrombosis of IVC is not frequently encountered. 1 CASE REPORT: A 32years old male with alcoholic pancreatitis with previous episode of acute pancreatitis three months ago, presented to us with acute abdomen. Examination of the abdomen revealed a 8x15cms mass in left upper quadrant extending into right upper quadrant, non-mobile, not moving with respiration, mildly tender and dull on percussion. Investigations revealed mildly elevated serum and urinary amylase. CT abdomen revealed pseudocyst pancreas measuring 8x16cms pushing stomach anterolaterally, extending anteriorly up to anterior abdominal wall with features consistent of chronic pancreatitis. An unusual finding was large intraluminal thrombus within IVC extending up to confluence of iliac veins. The patient did not have lower limb edema or abdominal collaterals despite involvement of intra-abdominal IVC. DISCUSSION: Vascular complications in pancreatitis are well documented. Acute pancreatitis has also found to generate thrombosis of the inferior vena cava. 2,3 The pathogenesis of IVC thrombosis in pancreatitis is not well understood, but the contributing factors could be-inflammation, edema and cellular infiltration adjacent to IVC, hypercoagulable state, mass effect and compression due to pseudocyst and bulky pancreas, intimal injury caused by pancreas.4 Although inferior vena cava thrombosis in the setting of pancreatitis is rare, this clinical entity may account for an unexplained deterioration in the status of a patient with pancreatitis. And this can be effectively treated with anticoagulation and hence mortality related to complication such as pulmonary embolism can be prevented.5

Malignant Angiomyolipoma and Tuberous Sclerosis: A Case Report

A 32-year-old male patient presented at the emergency room with a palpable left upper quadrant mass. Ultrasound and computed tomography examinations revealed a left upper quadrant mass displacing the left kidney and spleen, but were not able to rule out malignancy. The patient’s other clinical signs and symptoms were deemed suspicious for tuberous sclerosis complex (TSC). After several other tests and a referral to a dermatologist, the suspicion was confirmed. A biopsy identified the lesion as a malignant angiomyolipoma (AML) associated with TSC. The patient has been referred to a cancer centre for treatment and will be seen regularly for radiation therapy sessions. AML is typically a benign renal lesion that is easily diagnosed with computed tomography or sonography. However, AML may occasionally mimic malignant lesions in its appearance, or can become malignant itself. Patients with TSC are more likely to develop malignant renal lesions than the general population. There are multiple treatment options for AML, and the course of action is dependent on the size of the lesion and the patient’s symptoms. This case perfectly illustrates the importance of using diagnostic imaging modalities in a complementary manner to correctly diagnose patients and provide optimal care and treatment.

Hemangiomatosis of the spleen in a patient with Klippel-Trénaunay syndrome

Klippel-Trenaunay syndrome is a rare disorder characterized by a triad of port-wine stains, varicose veins, and bony and soft tissue hypertrophy usually involving an extremity. Visceral involvement in Klippel-Trénaunay syndrome is rare, but has been described in the colon, small bowel, bladder, kidney, spleen, liver, mediastinum and brain. In this paper we present the case of a 45-year-old woman with Klippel-Trenaunay syndrome in whom routine physical examination unexpectedly revealed the presence of a left upper quadrant mass. Abdominal US, contrast enhanced CT and whole-body PET-CT demonstrated multiple large cystic lesions within a massively enlarged spleen. Based on the clinical history and imaging findings diffuse hemangiomatosis of the spleen was suspected. This diagnosis was confirmed by pathologic examination after splenectomy.

Prune belly syndrome, splenic torsion, and malrotation: A case report

An 18 year old male with a history of prune belly syndrome (PBS) presented with acute abdominal pain and palpable left upper quadrant mass. Computed tomography (CT) of the abdomen revealed a medialized spleen with a “whirl sign” in the splenic vessels, consistent with splenic torsion. Coincidentally, the small bowel was also noted to be on the right side of the abdomen, while the colon was located on the left, indicative of malrotation. Emergent diagnostic laparoscopy confirmed splenic torsion and intestinal malrotation. Successful laparoscopic reduction of the splenic torsion was achieved, however, conversion to an open procedure by a vertical midline incision was necessary owing to the patient's unique anatomy. Open splenopexy with a mesh sling and Ladd's procedure were subsequently performed. Malrotation and wandering spleen are known, rare associated anomalies in PBS; however, both have not been reported concurrently in a patient with PBS in the literature. In patients with PBS, acute abdominal pain, and an abdominal mass, high clinical suspicion for gastrointestinal malformations and prompt attention can result in spleen preservation and appropriate malrotation management.We present a case of a teenager who presented with a history of PBS, acute abdominal pain, and a palpable abdominal mass. The patient was found to have splenic torsion and intestinal malrotation. The clinical findings, diagnostic imaging, and surgical treatment options of splenic torsion are reviewed.

A Case of Colorectal Cancer during Pregnancy: A Brief Review of the Literature

The incidence of colorectal cancer (CRC) during pregnancy is so rare. Herein we present a case of colorectal cancer that was missed by pregnancy all over the pregnancy period. The patient was a 37-year-old woman (gravid 4, para 2) referred with the complaints of vaginal discharge and suspicious rupture of membrane (ROM). The patient was pale and the initial physical examination revealed dilation of two fingers, effacement about 30%. She underwent emergent cesarean section which showed adhesions surrounding the uterus, the bladder, and the abdominal wall. Forty days postoperatively, the patient presented with abdominal pain in the left upper quadrant (LUQ). Imaging confirmed a mass in LUQ. Partial colectomy of transverse colon (20 cm) was performed. Postoperative histopathologic study revealed a 7 ∗ 6 ∗ 5 cm mass in transverse colon compatible to stage IIa of the Duck class (T3, N0, Mx). Adjuvant chemotherapy was applied and the patient showed improvements during 7 months followup after surgery. Colorectal cancer in pregnancy is associated with diagnostic and therapeutic challenges which mostly lead to late diagnosis in advanced stages and poor prognosis. A targeted program to improve the general population knowledge and the establishment of a national consultant and screening program particularly for women with a planned pregnancy in the high risk group might be beneficial.

An Unusual Left Upper Quadrant Mass: A Bronchopulmonary Foregut Malformation

We report a case of a lady who presented with epigastric discomfort. Physical examination revealed a large left upper quadrant mass filling the left upper quadrant. Following extensive preoperative evaluation, she underwent resection of this 9 × 10 × 11 centimeter mass with en bloc excision of a portion of the left hemidiaphragm. She made an uneventful postoperative recovery. Histopathology revealed a bronchopulmonary foregut malformation with pulmonary sequestration. This developmental anomaly of the foregut typically occurs in the thoracic cavity; however, it can occur below the diaphragm. Herein we report a case and a detailed review of the embryology, clinical features, and management of these extremely rare clinical entities.

Unsuspected cystic left upper quadrant mass

A 27-year-old African American female with no significant medical history presented with left upper quadrant pain radiating to the back, which had been worsening over several months. She had an inability to tolerate oral intake, progressive nausea and vomiting. A review of her symptoms revealed palpitations, mild shortness of breath and two episodes of recent bilious vomiting without haematemesis. Physical examination showed diffuse abdominal tenderness on palpation and mild tachycardia. Laboratory evaluation showed no significant abnormalities, including normal pancreatic and liver enzymes. The chest radiograph was normal. A contrast-enhanced CT of the abdomen was performed with a 64-MDCT scanner (Aquilion 64; Toshiba Medical Systems, Nasu, Japan) with the following scanning parameters: rotation time, 0.5 s; beam collimation, 3261.0 mm; section thickness and interval, 5 mm; helical pitch, 27; 120 kV and tube current in the automatic milliampere exposure setting. Coronal reconstructions were obtained at 4 mm thickness and 4 mm intervals. The patient received 100 ml of intravenous (iv) iohexol (Omnipaque 300, Nycomed, Amersham, UK) administered via a mechanical injector at 3.0 ml s with a scanning delay determined by real-time contrast tracking, starting at 70 HU added to unenhanced liver. What are the CT findings? What is the most likely diagnosis?

Huge inflammatory pseudotumor of the spleen with postoperative portal vein thrombosis: report of a case

We report the rare case of a splenic inflammatory pseudotumor associated with massive splenomegaly, diagnosed after surgery. A 51-year-old woman was admitted to our hospital for investigation of anemia. Physical examination revealed a palpable left upper quadrant mass. Computed tomography and magnetic resonance imaging showed a splenic mass, 20cm in diameter. We performed splenectomy for both diagnosis and treatment. The spleen weighed 2400g, and histologic examination of the mass confirmed an inflammatory pseudotumor. Portal vein thrombosis (PVT) developed the day after surgery, but resolved with anticoagulation therapy. This case highlights that there is a risk of PVT after splenectomy in patients with massive splenomegaly, and that anticoagulant therapy should be initiated promptly.

Pancreatic Pseudocyst with Colonic Perforation Complication

Pancreatic pseudocyst is one of complications of both acute and chronic pancreatitis. It is a rare clinical condition. The incidence is low ranging between 1.6 and 4.5%, or 0.5-1 per 100,000 adults annually. The clinical manifestations range from asymptomatic to severe acute abdomen due to complications. Acute complications may include bleeding, infection, rupture and perforation of the gastrointestinal tract; while chronic complications are gastric and biliary obstruction as well as thrombosis of portal vein. We present a case report of a 38-year-old male with complaints of abdominal pain, fatigue, nausea and vomiting containing undigested food and yellow liquid. On clilnical examination, the patient was found to be fatigue, having enlarged abdomen, unpalpable liver and spleen, no signs of shifting dullness was detected. We found an abdominal mass in the left upper and lower quadrant sized 20 x 10 cm accompanied with epigastric pain on palpation. Abdominal ultrasonography revealed a cystic lesion on the head of pancreas with differential diagnosis of pseudocyst. The abdominal computed tomography (CT-scan) showed a lesion arising from pancreas, extending into abdominal cavity and part of left groint and attaching to left intestinal in the abdomen, part of gastric region and left diaphragm. A diagnosis of pancreatitis was suspected with differential diagnosis of pancreatic mass and peritonitis. It is a case report of pancreatic pseudocyst with acute complication of colonic perforation. Keywords: pseudocyst, pancreatitis, pancreatitis complication, colonic perforation

25. Peliosis of the spleen presenting as spontaneous splenic rupture – report of two cases

Background Peliosis is a rare acquired condition characterised by the presence of multiple blood-filled cavities most commonly in the liver and less frequently in the spleen and other organs. The clinical presentation of splenic peliosis is varied. Some patients remain asymptomatic and peliosis is an incidental finding at autopsy. Others present with abdominal pain or a left upper quadrant mass. The most serious manifestation is splenic rupture which may be fatal. Splenic peliosis is associated with tuberculosis, solid organ and haematological malignancies, chronic renal failure, and medications including androgenic steroids, oral contraceptives and erythropoietin. There are no reported associations with amyloidosis. Aim To highlight diagnostic features of splenic peliosis. Methods We present two cases of isolated splenic peliosis leading to spontaneous splenic rupture and outline clinical and pathological features of the condition. Case 1 – A 59-year-old man presented with spontaneous splenic rupture on a background of excessive alcohol intake, a bleeding diathesis, plasma cell dyscrasia and a lung lesion metastatic to liver and small bowel. Case 2 – A 33-year-old man presented with spontaneous splenic rupture on a background of excessive alcohol intake, depression and schizophrenia. Neither patient reported use of steroid medications. Results Macroscopically both spleens contained numerous blood filled cystic spaces that histologically lacked an endothelial lining. In Case 1 amyloid deposition was confirmed in the spleen and this is the first reported case of splenic peliosis in association with amyloidosis. Conclusion Peliosis should be considered in the pathological differential diagnosis of a spontaneously ruptured spleen.

Blastomycosis Presenting as Multiple Splenic Abscesses: Case Report and Review of the Literature

A 31-year-old Canadian Aboriginal man from northwestern Ontario presented with left upper quadrant pain and a tender left upper quadrant mass. Evaluation with a computed tomography scan showed multiple lesions within the spleen, a collection between the splenic tip and splenic flexure of the colon, and several small adrenal lesions. Computed tomographic-guided needle biopsy showed necrotizing granulomatous inflammation and multinucleated giant cells. Gomori's methenamine silver stain showed broad-based budding yeast consistent with Blastomyces dermatitidis. Abdominal symptoms resolved after two months of oral itraconazole. Multiple splenic abscesses are a rare presentation of blastomycosis and should be considered in the differential diagnosis of left upper quadrant abdominal pain in a patient with a history of travel or residence in a region endemic for B dermatitidis.

Age-related Epstein-Barr Virus-associated Lymphoproliferative Disorder Presenting as Renal Mass

A 61-year-old man who had undergone bilateral hip replacements for degenerative joint disease suffered a fall on ice in March 2008. He was examined in a local emergency room for an orthopedic evaluation. During workup, plain radiographs of the pelvis showed an incidental calcified left upper quadrant mass. Subsequently, a contrast-enhanced CT scan of the abdomen-pelvis displayed an exophytic renal mass of size 7.7 × 5.9 cm arising from the posterolateral aspect of the left kidney with incomplete calcification in the wall (Fig. 1).

Review of solid‐pseudopapillary tumour of the pancreas with case illustration

Solid‐pseudopapillary tumour of the pancreas (SPT) is a rare neoplasm known to affect predominantly young women. The presenting symptoms can be vague and non‐specific. The case is described of SPT in a 46‐year‐old Chinese man who presented with postprandial bloatedness and a left upper quadrant mass. A review of the literature on the clinical characteristics, pathology and management of SPT is presented.

I-123 MIBG Scan of Metastatic Neuroblastoma Mimicking a Bone Scan

A 21-year-old man presented to an outside institution with longstanding right hip pain. Magnetic resonance imaging revealed diffuse marrow infiltration in the lumbar spine, sacrum, ilium, and right proximal femur. Biopsy of a left upper quadrant mass was consistent with stroma poor neuroblastoma with differentiation. The patient underwent left radical adrenalectomy, left retroperitoneal lymph node dissection with gross resection of residual tumor and 5 cycles of high-dose chemotherapy (cyclophosphamide, doxorubicin, and vincristine) with evidence of disease progression. A short course of irinotecan was given for palliation. A protocol with low-dose 1-131 MIBG was started for symptomatic control.

Laparoscopic Decapsulation Using a Harmonic Scalpel of a Giant Splenic Cyst with a Raised Serum CA-125

Non-Parasitic splenic cysts are rare. Some of these cysts have been noted to produce tumour markers: CA-19.9, CEA and CA-125. Treatment has progressed from open splenectomy to minimally invasive, spleen-preserving techniques. We report the case of a 39 year old builder who presented with epigastric discomfort and a large left upper quadrant mass. CT revealed 20 x 25cm unilocular cystic lesion arising from the spleen. This was treated by laparoscopic aspiration and decapsulation using a harmonic scalpel which allowed for the secure maintenance of haemostasis throughout the operation. Histological examination of the cyst wall revealed a benign epithelial cyst. Pre-operative CA-125 levels were raised but returned to normal post operatively. Immunohistochemical staining for CA-125 was positive in the cyst wall epithelium. We suggest that laparoscopic decapsulation using a harmonic scalpel should be the preferred treatment modality for such splenic cysts and monitoring of tumour markers is helpful pre & postoperatively.

A case of mistaken identity: Giant cystic pheochromocytoma

A 39-year-old Marshall Islands woman was referred for evaluation of an abdominal mass. Medical history was significant only for pulmonary tuberculosis and scrofula. The patient denied a personal or family history of pancreatic or endocrine disease. Physical examination revealed normal vital signs and a 12-cm mildly tender left upper quadrant mass. A computed tomography scan revealed an 11-cm cystic mass contiguous with the distal pancreas and closely associated with the hilum of the spleen and the left kidney. Based on these findings and the patient's history, a cystic neoplasm of the pancreas was suspected, and she was subsequently taken to the operating room for exploration. Intraoperatively, the patient became markedly hypertensive with manipulation of the mass, requiring intravenous nitroprusside. Histopathological evaluation confirmed the diagnosis of cystic pheochromocytoma (PCC). The patient's postoperative course was uncomplicated. Cystic PCCs may not present with the classic prodromal symptoms associated with solid PCCs. This case represents the complex and unsuspected presentation of an extremely rare functional cystic neoplasm. A high index of suspicion for cystic PCC is necessary when confronted with cystic lesions in the vicinity of the adrenal glands. Failure to recognize cystic PCC before resection may lead to uncontrollable hypertension in the operating room, with potentially serious consequences.