Peripancreatic Nodes Research Articles

AYURVEDIC MANAGEMENT OF NON-SPECIFIC MESENTERIC LYMPHADENITIS – CASE STUDY

Mesenteric lymphadenitis is one of the common causes of abdominal pain in children. Features of mesenteric lymphadenitis include abdominal pain, often centred on the lower right side and fever with mesenteric lymph node enlargement. It arises due to several factors responsible for inflammatory response within mesenteric lymph nodes, including viral or bacterial infections, inflammatory bowel disease, lymphoma, etc.; sometimes the cause is unidentified. The features of Mesenteric lymphadenitis in Ayurveda may be correlated with Granthi (~Cyst), Gulma (~lump), Grahani (~disorder of lower G.I.T), Tuni (~ bladder pain radiating to anus and pe-nis) and Anaha (~tympanites) but resemble more with Vatika and Paittika Gulma (lump due to Vata and Pitta). A known case of non-specific mesenteric lymphadenitis, age 14 years male child, weighing 39.0 kg, presented with pain abdomen with feverish body, few scent-metric sized lymph nodes in right iliac fosse, few peri-portal and peri-pancreatic lymph nodes measuring 17/9 mm and 20/8 mm on HRSG, Interventions given were Chaushathpraharipippali, Ras sindur, Panchammrita Parpati, Sutshekhar ras, Ashwagandha Ghanvati, Jeerkadyarista, and Patoladikasaya showed curative effect due to their Vata-Pitta Pacifying, Vatanulomak, Shrotoshodhaka, Balya and Brimhana effect. No adverse effect was seen. Further studies may be taken up for diseases involving mesenteric lymphadenopathy for the collection of evidence.

Pancreatic pseudotumor due to peripancreatic lymphadenitis: case report and literature review

The pancreas has exocrine and endocrine glandular tissue, the latter accounting for only 1-2% of the gland. Pancreatic disorders are common but difficult to diagnose due to their anatomical location and vague symptoms. Pancreatic pseudotumors are enlarged pancreas without neoplasia and can be mistakenly diagnosed as malignant, complicating treatment. One study demonstrated that 9.2% of pancreatic resections suspected of malignancy were benign. In the clinical case presented, a 35-year-old male patient presented with severe abdominal pain, jaundice, weight loss, as well as fever, nausea, and vomiting. Laboratory tests showed significant changes in liver enzymes, bilirubin, and blood count. The differential diagnosis included lymphoma, tuberculosis, and other pathologies. Laparotomy revealed peripancreatic lymph nodes with caseous necrosis, which were confirmed as tuberculosis. Pancreatic tuberculosis is rare and can be confused with neoplasms due to similar symptoms. Accurate diagnosis requires a high degree of suspicion and methods such as image-guided biopsy. Treatment involves the use of tuberculostatics. In endemic regions, tuberculosis should always be considered in cases of peripancreatic lesions.

Extrahepatic cholestasis associated with paracoccidioidomycosis: Challenges in the differential diagnosis of biliopancreatic neoplasia.

Paracoccidioidomycosis (PCM) may involve the hepatic pedicle and peripancreatic lymph nodes, cause damage to the bile duct and manifest, exceptionally, in combination with extrahepatic cholestasis (EHC), making investigation and treatment challenging. To investigate the management of patients with visceral PCM admitted with EHC. All patients diagnosed with PCM treated in a public, tertiary teaching hospital between 1982 and 2020 were retrospectively evaluated. Those also identified with EHC were allocated to two groups according to the treatment approach for the purpose of comparing clinical, laboratory, and imaging findings, resources used for etiological diagnosis, treatment results, and prognosis. Statistical analyses were performed using the linear mixed-effects model (random and fixed effects), which was adjusted using the PROC MIXED procedure of the SAS® 9.0 software, and Fisher's exact test. Of 1645 patients diagnosed with PCM, 40 (2.4%) had EHC. Of these, 20 (50.0%) lived in the rural area and 29 (72.5%) were men, with a mean age of 27.1 years (3-65 years). Jaundice as first symptom and weight loss of at least 10 kg were observed in 16 patients (40.0%), and a mass in the head of the pancreas was observed in 8 (20.0%). The etiological diagnosis was made by tissue collection during surgery in 4 cases (10.0%) and by endoscopic methods in 3 cases (7.5%). Twenty-seven patients (67.5%) received drug treatment alone (Group 1), whereas 13 (32.5%) underwent endoscopic and/or surgical procedures in combination with drug treatment (Group 2). EHC was significantly reduced in both groups (40.7% in Group 1, with a mean time of 3 months; and 38.4% in Group 2, with a mean time of 7.5 months), with no statistically significant difference between them. EHC recurrence rates, associated mainly with treatment nonadherence, were similar in both groups: 37% in Group 1 and 15.4% in Group 2. The mortality rate was 18.5% in Group 1 and 23% in Group 2, with survival estimates of 71.3% and 72.5%, respectively, with no statistically significant difference. Although PCM-related EHC is rare, it needs to be included in the differential diagnosis of malignancies, as timely treatment can prevent hepatic and extrahepatic sequelae.

Prediction of tumor recurrence after surgical resection of ampullary adenocarcinoma using magnetic resonance imaging.

To predict tumor recurrence in patients who underwent surgical resection of ampullary adenocarcinoma using preoperative magnetic resonance (MR) imaging findings combined with clinical findings. In this multicenter study, a total of 113 patients (mean age, 62.9 ± 9.8 years; 58 men and 55 women) with ampullary adenocarcinoma who underwent preoperative MR imaging and surgery with margin-negative resection between 2006 and 2017 were retrospectively included. The MR imaging findings were evaluated by two radiologists. Preoperative clinical findings were obtained. Cox proportional regression analyses were used to identify the independent prognostic factors for recurrence-free survival (RFS). A nomogram was created based on the multivariable analysis and was internally validated. Multivariable analysis revealed that presence of infiltrative tumor margin (hazard ratio [HR]: 2.18, p = 0.019), adjacent organ invasion (HR: 3.31, p = 0.006), adjacent vessel invasion (HR: 5.42, p = 0.041), peripancreatic lymph node enlargement (HR: 2.1, p = 0.019), and jaundice (HR: 1.93, p = 0.043) were significantly associated with worse RFS of ampullary adenocarcinoma after surgical resection. These MR imaging and clinical findings were used to construct a nomogram. On internal validation, the calibration plots showed excellent agreement between the predicted probabilities and the actual rates of tumor recurrence, with Harrell's c-index of 0.746. Combination of preoperative MR imaging and clinical findings can be useful for predicting tumor recurrence after surgical resection of ampullary adenocarcinoma. Identifying these features before surgery may aid in better treatment planning and management of these patients. A predictive nomogram using preoperative MR imaging and clinical findings can be useful in estimating the recurrence-free survival after surgical resection of ampullary adenocarcinoma. • Presently, tumor size on imaging is the only non-invasive factor that correlates with recurrence-free survival from ampullary adenocarcinoma; other factors are obtained postoperatively. • Infiltrative tumor margin, adjacent organ invasion, adjacent vessel invasion, peripancreatic lymph node enlargement on MRI, and jaundice are significant predictors for recurrence. • A nomogram incorporating significant MR imaging and clinical findings showed good performance in predicting recurrence-free survival, which can help in treatment planning.

SAT052 Prolonged Nursing Augments Short Chain Fatty Acid Levels And Leads To Amelioration Of Type 1 Diabetes

Abstract Disclosure: S. rafiqi: None. Z. Zahid: None. R. Lamendella: None. O. aghogho: None. E. Gionfriddo: None. Y. Tao: None. J.C. Jaume: None. S. Imam: None. The infant gut microbiome essentially shifts to a diverse and complex microbial system during weaning on separation from the mother and any perturbations lead to pathological imprinting with lifelong implications. Apart from breast milk, the microbiota of the skin and the intimate niche between mother and offspring contribute to gut microbial composition. Gut microbiome dysbiosis has been ascribed in the initiation and/or perpetuation of type 1 diabetes (T1D) in human and animal models. The gut microbial diversification is manifested as change in microbial metabolites particularly short-chain fatty acids (SCFAs) that have direct and indirect roles in immune regulation and epithelial barrier integrity. In this study, we try to decipher the role of prolonged nursing of newborn mice (upto 45 days) in the amelioration of type 1 diabetes in the context of changes in the gut microbiome and microbial metabolites. The humanized T1D mice used in the study spontaneously develop T1D at 3-4 weeks of age and are normally weaned at 21 days. Our results revealed mice subjected to prolonged nursing had consistent increments in levels of butyric acid from 60 to 150 days of age as compared to normal weaned mice, owing to a stable population of SCFA-producing bacteria developed during prolonged nursing with the mother. The normal weaned mice had a transient increase of butyric acid at 60 days but it didn’t sustain till the 150th day. The steady levels of butyrate in prolonged nursed mice exerted immunoregulatory roles which manifested in the enrichment of regulatory T cells (Tregs) in the intestinal mesenteric epithelium, payer’s patches, peri pancreatic lymph nodes (PLN), pancreas (PN) and spleen. The enrichment of Tregs leads to the regulation of diabetogenic Th1, Th17, and interferon gamma-producing CD8 T cells (cytotoxic lymphocytes, CTLs) at PLN, PN, and spleen. This increased immune tolerance was mirrored by improved glucose homeostasis and fasting blood glucose levels in the prolonged nursing group. Prolonged nursing preserved the pancreatic islet architecture and significantly maintained the increased number of islets per pancreas as observed in H&E sections. Also, it could be inferred from the results that SCFA’s promoted intestinal integrity with increased submucosal thickening, longer villi, and shallower crypts in the intestine of prolonged nursed mice. In conclusion, prolonged nursing accounts for gradual and steady gut microbiota succession in infants that augments SCFA production leading to enrichment of T regulatory cells and less aggressive diabetes. Presentation: Saturday, June 17, 2023

Somatostatin Receptor PET Imaging in Diffuse Pancreatic Neuroendocrine Tumor.

Somatostatin receptor imaging findings of pancreatic neuroendocrine tumor with diffuse involvement of the pancreas are rarely reported. We present somatostatin receptor PET imaging findings in 3 cases of diffuse pancreatic neuroendocrine tumor. One case showed diffuse swelling and diffusely intense activity of the pancreas with multiple metastases in the peripancreatic lymph nodes and liver. The other 2 cases showed diffusely intense activity of the pancreas without metastasis. The pancreatic tumor extended into the duodenum in all the 3 cases. Familiarity with this rare pattern of radiotracer uptake in pancreatic neuroendocrine tumor may be helpful for the diagnosis.

Analysis of the treatment outcome of ampulla of Vater carcinoma and the usefulness of postoperative adjuvant chemotherapy.

692 Background: Patients with ampulla of Vater carcinoma with lymph node metastasis reportedly have a poor prognosis and require postoperative adjuvant therapy. However, due to the small number of published cases, the efficacy of postoperative adjuvant therapy has not yet been established with a high level of evidence. Objective: The aim of this study was to describe the outcome of patients surgically treated for ampulla of Vater carcinoma in our department, evaluate the effectiveness of adjuvant chemotherapy (AC), and clarify which patient groups may benefit from AC. Methods: The study cohort comprised 46 patients who underwent surgery for ampulla of Vater carcinoma in our department from October 2005 to March 2022. We evaluated the clinicopathological background characteristics (tumor size, gross morphology, pancreatic/duodenal invasion, peripancreatic head lymph node metastasis), overall survival (OS), and relapse-free survival (RFS), and compared the OS and RFS in patients with versus without AC. We then analyzed the factors related to the long-term outcome of patients treated for ampulla of Vater carcinoma. Results: During a median observation period of 33.7 months, the 5-year OS and RFS were 63.1% and 61.7%, respectively. Recurrence was observed in 14 patients (30%), with recurrence occurring less than 1 year postoperatively in seven patients (15%). Fifteen patients received AC (chemotherapy regimen: S-1 in 11 patients, GEM in four). The 5-year OS rates with and without AC were 70.3% and 48.2%, respectively (p=0.093). The 5-year RFS rates with and without AC were 72.5% and 42.8%, respectively (p=0.058). Univariate analysis of the total patient cohort showed that the factors related to 5-year RFS were pancreatic invasion (p=0.01), duodenal invasion (p=0.03), and N+ (p=0.004). In multivariate analysis, the only factor related to 5-year RFS was N+ (HR 3.53; 95% CI, 0.99–12.6; p=0.03). The 5-year OS rates in patients with and without N+ were 77.1% and 42.7%, respectively (p=0.04). The 5-year RFS rates in patients with and without N+ were 80.4% and 32.1%, respectively (p=0.004). Conclusions: AC showed a tendency to be effective in preventing postoperative recurrence of ampulla of Vater carcinoma. AC may be particularly beneficial in N+ cases.

The influence of the extent of lymph node metastasis on the prognosis for patients with intrahepatic cholangiocarcinoma.

Reports showed that some of intrahepatic cholangiocarcinoma (ICC) patients with lymph node metastasis (LNM) may also gain survival benefit undergone resection. However, the effect of the extent of LNM on prognosis and surgical indication is barely discussed. From September 1994 to November 2018, primary ICC patients undergone initial curable surgery were enrolled. Based on the extent of LNM, we divided these patients into 4 groups, including patients with no LNM (group N0), LNM to hepatoduodenal ligament or common hepatic artery (region A, group A), LNM to gastrohepatic lymph nodes for left liver ICC and periduodenal and peripancreatic lymph node for right liver ICC (region B, group B), or LNM beyond these regions (region C, group C). Multivariable Cox regression analysis was performed to identify the prognostic factors for recurrence-free survival (RFS) and overall survival (OS) in all groups. A total of 133 patients were enrolled. There were 56, 21, 17, and 39 patients in groups N0, A, B, and C, respectively. There was significant difference between groups N0 and C in RFS (P < 0.001) and OS (P = 0.002). When we compared group N0 + A + B with group C, we also found that RFS (P < 0.001) and OS (P = 0.007) were significantly different. In multivariable analysis, the extent of LNM was an independent risk factor for RFS (P < 0.050). ICC patients with the LNM to regions A and B could still achieve good prognosis with resection. Surgery should be carefully considered when LNM to region C.

Prognostic Predicting Model of Pancreatic Body Tail Carcinoma Using Clinical and CT Radiomic Data.

Objective: To collect the clinical, pathological, and computed tomography (CT) data of 143 accepted surgical cases of pancreatic body tail cancer (PBTC) and to model and predict its prognosis. Methods: The clinical, pathological, and CT data of 143 PBTC patients who underwent surgical resection or endoscopic ultrasound biopsy and were pathologically diagnosed in Xiangyang No.1 People's Hospital Hospital from December 2012 to December 2022 were retrospectively analyzed. The Kaplan-Meier method was adopted to make survival curves based on the 1 to 5 years' follow-up data, and then the log-rank was employed to analyze the survival. According to the median survival of 6 months, the PBTC patients were divided into a group with a good prognosis (survival time ≥ 6 months) and a group with a poor prognosis (survival time < 6 months), and further the training set and test set were set at a ratio of 7/3. Then logistic regression was conducted to find independent risk factors, establish predictive models, and further the models were validated. Results: The Kaplan-Meier analysis showed that age, diabetes, tumor, node, and metastasis stage, CT enhancement mode, peripancreatic lymph node swelling, nerve invasion, surgery in a top hospital, tumor size, carbohydrate antigen 19-9, carcinoembryonic antigen, Radscore 1/2/3 were the influencing factors of PBTC recurrence. The overall average survival was 7.4 months in this study. The multivariate logistic analysis confirmed that nerve invasion, surgery in top hospital, dilation of the main pancreatic duct, and Radscore 2 were independent factors affecting the mortality of PBTC (P < .05). In the test set, the combined model achieved the best predictive performance [AUC 0.944, 95% CI (0.826-0.991)], significantly superior to the clinicopathological model [AUC 0.770, 95% CI (0.615-0.886), P = .0145], and the CT radiomics model [AUC 0.883, 95% CI (0.746-0.961), P = .1311], with a good clinical net benefit confirmed by decision curve. The same results were subsequently validated on the test set. Conclusion: The diagnosis and treatment of PBTC are challenging, and survival is poor. Nevertheless, the combined model benefits the clinical management and prognosis of PBTC.

Pancreatic Tuberculosis: A Diagnosis Dilemma; About A Case Report and Review of the Literature

Pancreatic tuberculosis is a rare entity despite the high prevalence of tuberculosis in the world and in Morocco in particular. The pancreas, an organ normally protected against this infection, is only affected by hematogenous diffusion or not by contiguity through the peripancreatic lymph nodes. Its clinical expression can be either in the form of a pancreatic mass simulating a cancer, or an obstructive jaundice. The diagnosis, difficult to make, is often made only after surgical exploration. Here, we report a case of pancreatic pseudo-tumoral tuberculosis, presented with abdominal pain and weight loss.

PSUN374 Casting a Wide NET: A Case Report of Recurrent Hypoglycemia and 'Malignant' Insulinoma

Abstract Introduction Insulinomas are rare neuroendocrine tumors, with an incidence of 4 cases per one million patient-years. Malignant insulinomas are even rarer, with a paucity of data for specific treatment modalities. Surgery, the mainstay of treatment, needs to be determined by the disease extent prior to resection. Here, we describe a patient who presented to a Federally Qualified Health Center with a diagnosis of hypoglycemia and the barriers related to the evaluation and treatment of his insulinoma. Case Presentation A 40-year-old Hispanic man with no past medical history presented to the clinic with an 8-year history of syncopal episodes. Continuous glucose monitoring revealed nocturnal hypoglycemia with BG &amp;lt;50 mg/dL, but he discontinued its use due to frequent low blood glucose alerts. Physical exam was notable for central obesity and acanthosis nigricans. Labs showed a fasting glucose of 63 mg/dL, proinsulin 419.9 (&amp;lt;18.8 pmol/L), insulin 11.3 (&amp;lt;19.6 uIU/ml), C-peptide 2.24 (0.80-3.85 ng/mL), A1C 4.3%, and negative urine sulfonylurea screen. A diagnosis of insulinoma was suspected and he was started on acarbose. CT abdomen showed a centrally calcified, peripherally enhancing 24 mm lesion in the pancreatic head. 68Ga-DOTATATE PET/CT scan was recommended for further evaluation but was denied by his insurance. Biopsy of the mass using endoscopic ultrasound (EUS) was positive for neuroendocrine tumor with metastasis to a peripancreatic lymph node. Given the concern for metastatic insulinoma, he underwent a pancreaticoduodenectomy. Surgical pathology confirmed the diagnosis of insulinoma but without evidence of tumor in the lymph nodes. The most likely explanation for the tumor cells previously noted in the lymph node was the passage of the needle through the tumor during biopsy. The postoperative course was complicated by hyperglycemia requiring insulin infusion and a pancreatic fistula. The patient was followed in clinic where his repeat proinsulin level was normal. He had resolution of his hypoglycemic episodes, his fistula healed, and he is back at work. Discussion Our case reinforces the need for an accurate diagnosis and localization of neuroendocrine tumors prior to surgical intervention. A preoperative 68Ga-DOTATATE PET/CT would have demonstrated an absence of tumor outside the pancreatic mass and prompted a less invasive surgical approach. Because of insurance denial, the EUS biopsy findings suggesting metastatic insulinoma could not be confirmed and he underwent a pancreaticoduodenectomy. Patients with metastatic insulinoma are at risk for recurrence of hypoglycemia in the postoperative period. Persistence of postoperative hyperglycemia suggests either new-onset diabetes due to insulin deficiency or resistance and suppression of residual endogenous insulin secretion as a result of insulinoma-induced chronic hyperinsulinemia. Decreases in insulin requirements post-operatively can be explained by recovery of remnant pancreatic insulin production after alleviation of chronic suppression, and reduction in insulin resistance induced by surgery. Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.

S3640 Myoclonic Jerks and Chronic Diarrhea; The Challenges of Zollinger-Ellison Syndrome

Introduction: Zollinger-Ellison Syndrome (ZES) is a rare disorder caused by hypersecretion of gastrin, causing peptic ulcer disease (PUD) and diarrhea. In most cases, inappropriate gastrin secretion is from duodenal or pancreatic neuroendocrine tumors (gastrinoma). Diagnosis of gastrinoma can be delayed as symptoms are nonspecific and can be misdiagnosed as other GI disorders. Case Description/Methods: A 79yo female with DM, HTN, and peptic ulcer disease presented with myoclonic jerks and watery diarrhea. She was found to have severe hypomagnesemia and acute kidney injury (AKI). Notably she had diarrhea for months with several admissions with similar symptoms. Prior workup including celiac serology, vasoactive intestinal peptide level, fecal calprotectin, and colonoscopy were inconclusive. Lomotil was started for possible irritable bowel syndrome (IBS) with partial response. On this admission, stool osmolar gap was < 50, chromogranin A 8224 ng/mL and gastrin 596 pg/mL. MRI of the abdomen showed a 2.5cm mass-like thickening in the distal gastric antrum. Endoscopy showed gastritis and duodenal ulcers. EUS with FNA of the mass was inconclusive. Octreoscan revealed a somatostatin receptor-bearing neuroendocrine tumor (NET) in the distal stomach. She underwent distal gastrectomy and peri-pancreatic LN resection after hospitalization. Histopathology confirmed a well-differentiated NET with metastasis. Her diarrhea resolved and chromogranin A and gastrin normalized, 90 ng/mL and 43 pg/mL respectively. (Figure) Discussion: Chronic diarrhea is a main symptom of gastrinomas. Diagnosis can be challenging due to the rarity of ZES and as many disorders cause diarrhea. Many patients are diagnosed with more common conditions such as IBS and GERD. Initial evaluation in suspected cases includes Gastrin levels which can be falsely elevated in patients on chronic PPI. Most gastrin-producing tumors arise in the duodenum (75%) and pancreas (20%). Less than 5% of patients have a tumor in the stomach, peri-pancreatic lymph nodes, liver, bile ducts, or ovary. EGD can show prominent gastric folds and pathology can be nonspecific. In patients with suspected ZES, chest and abdominal imaging can identify intra or extra-abdominal lesions. Octreoscan can localize the tumor’s primary location and any metastasis. Consideration of ZES in patients with chronic diarrhea with timely evaluation and treatment can prevent the complications such as electrolyte abnormality, PUD, and decreases risk of metastasis.Figure 1.: a,b. Duodenal Ulcers. Image c. 2.5 cm mass-like thickening with restricted diffusion in the distal gastric antrum suspicious for neoplasm with an adjacent 1.5 cm lymphadenopathy.

S1671 Sarcoidosis Masquerading as Pancreatic Adenocarcinoma: A Case Report

Introduction: Sarcoidosis is a multisystem, idiopathic disease characterized by granulomatous inflammation. Symptomatic involvement of the GI tract occurs in less than 1% of cases, and of those, the stomach is most involved. Pancreatic involvement is exceedingly rare. The diagnosis of pancreatic sarcoidosis remains difficult, as pancreatic involvement may manifest as direct invasion of the organ, obstruction of the pancreatic or biliary ducts, or as a mimicker of pancreatic adenocarcinoma. We present a rare case of suspected pancreatic malignancy revealed as pancreatic sarcoid after surgical resection, in a patient without known history of sarcoidosis. Case Description/Methods: A 50-year-old male presented to the GI clinic reporting 3-4 years of epigastric pain with 30 pound weight loss. CT demonstrated a 2.6 cm mass-like lesion with infiltrative margins in the pancreatic head and uncinate process with mild biliary and pancreatic ductal dilation, highly suspicious for pancreatic adenocarcinoma. He twice underwent EUS which each revealed biliary dilatation with a mass in the head of the pancreas, with pathology showing chronic inflammation. Follow up PET scan, however, revealed a lesion in the pancreatic head that had mild FDG uptake suspicious for malignancy. Patient underwent Whipple without complication. Pathology was fortunately negative for malignancy, however revealed granulomatous inflammation in the pancreas (Figure). Findings suggestive of sarcoidosis. At follow up, patient had no evident additional manifestations of sarcoidosis. Discussion: Pancreatic involvement in sarcoidosis can manifest in many ways, including mimicking pancreatic adenocarcinoma. Given that pancreatic cancer typically portends a poor prognosis, there is greater urgency in diagnosis and treatment for suspicious pancreatic masses. A high degree of clinical suspicion is necessary to consider sarcoidosis in this setting. Our case was particularly interesting because this patient had no personal or family history of sarcoidosis and experienced no other signs or symptoms of sarcoidosis after his Whipple procedure. This patient had 2 separate EUS procedures with no evidence of malignancy, however a PET scan was concerning for pancreatic malignancy. This provided a difficult clinical circumstance, as this patient suffered from debilitating abdominal pain with no definitive diagnosis and thus no definitive treatment option. Ultimately, patient underwent Whipple procedure with relief of symptoms, and a situationally fortunate diagnosis of sarcoidosis.Figure 1.: Pathology slide revealing non-necrotizing granulomas within a peripancreatic lymph node.

S2204 A Rare Case of Medullary Carcinoma of the Colon With Lymphatic Metastasis

Introduction: Medullary carcinoma of the colon (MAC) is a rare cancer encompassing only .03% of all colorectal carcinomas. We present a rare case of MAC occurring in an older adult with a strong tobacco use history. Case Description/Methods: A 76-year-old female with PMHx of tobacco use disorder, COPD, and known pulmonary nodules presented to the ED for surveillance of her pulmonary nodules. A review of systems was positive for chronic shortness of breath and cough. A CT scan of the chest revealed enlarging lung nodules and mediastinal adenopathy. A PET scan revealed a hypermetabolic 2.5 x 2.5 cm soft mass in the distal ascending colon and hypermetabolic lymph nodes in the right upper quadrant (Figure). Colonoscopy revealed an infiltrative 2 cm mass at the hepatic flexure, and pathology revealed an invasive, poorly differentiated adenocarcinoma with normal expression of MSH2 and MSH6 and absence of MLH1 and PMS2. These findings were consistent with medullary carcinoma of the colon. Endoscopic ultrasound with biopsy of peripancreatic and porta-hepatis lymph nodes favored metastatic medullary carcinoma. The patient underwent a right hemicolectomy and follows closely outpatient. Discussion: MAC is a rare cancer associated with a high level of microsatellite instability and deficient mismatch repair proteins. It is a non-gland forming cancer composed of large polygonal eosinophilic cells growing in solid sheets and infiltrated with small lymphocytes. The majority of reported cases revealed a lack of MLH-1 and PMS2, just as our patient did. They instead express markers that are not commonly associated with colorectal cancers, such as calretinin, CK7, SATB2, and CDH17. MACs were previously difficult to differentiate from poorly differentiated adenocarcinomas due to their unique tumor marker expression and histopathology. The current standard for diagnosis of MAC therefore requires distinct microscopic morphology and molecular staining patterns. There are no current treatment guidelines due to the rarity of MACs, although MACs do have a favorable prognosis when compared to other adenocarcinomas and surgical resection and FOLFOX chemotherapy have been used successfully in some studies. Although MACs have been sporadically reported in case reports, further studies are required to determine guidelines for both diagnosis and treatment of this rare disease.Figure 1.: Endoscopic Visualization with Final Needle Aspiration of Abnormal Lymph Node.

S122 Endoscopic Ultrasound Evaluation of Primary Pancreatic Lymphoma Compared to Adenocarcinoma: A Case-Control Study

Introduction: Primary pancreatic lymphoma (PPL) is a rare extranodal lymphoma representing 0.5% of all pancreatic neoplasms. Prognosis and treatment strategies of PPL vastly differ from pancreatic ductal adenocarcinoma (PDAC), therefore making an accurate diagnosis is vital. Our aim is to describe the presentation, endoscopic ultrasound (EUS) features, and the role of fine needle aspiration (FNA) in the diagnosis of PPL compared with PDAC. Methods: Out of 1,946 patients who underwent EUS-FNA of solid pancreatic lesions, 11 were diagnosed with PPL. Patients who had peripancreatic lesions, lymph nodes, or bile duct masses were excluded. Age and gender- matched controls with a diagnosis of PDAC were identified in a 1:3 ratio. Presenting symptoms, demographics, and EUS characteristics were evaluated. Results: There were 11 patients with PPL and 33 age and gender-matched controls with PDAC. The median age was 65 years (60-76) and 63.6% were males. There was no difference between two groups in smoking, alcohol consumption, or history of a second malignancy. PPL patients were more likely to present with abdominal pain (81.8% vs 26.4%, p=0.01). Pancreatic head location was most common in both groups. Both PPL and PDAC tended to be hypoechoic and poorly defined on EUS, while PPL were more commonly described as heterogeneous (36.4% vs 6.1%, p=0.01). PPL were significantly larger on EUS (45.8 mm vs 31 mm, p< 0.01) and less likely associated with pancreatic duct dilation. A higher number of FNA passes was required for the diagnosis of PPL compared to PDAC (5 vs 3, p< 0.01). Conclusion: While PPL remains rare, making an accurate distinction with PDAC is critical as treatment and prognosis radically differ. On presentation, PPL is more likely to cause abdominal pain. Certain EUS features were found to be beneficial in differentiating PPL from PDAC in our study, as PPL tend to be larger, more likely heterogeneous, and are less likely associated with pancreatic duct dilation compared to PDAC. Tissue diagnosis is more challenging in PPL as reflected by a significantly higher number of passes obtained on EUS- FNA. Table 1. - Adenocarcinoma (n=33) Primary Pancreatic Lymphoma (n=11) P value Ethnicity, white n (%) 21 (63.6) 8 (72.7) 0.58 Smoking history ( >15 pack-years), n (%) 9 (27.3) 5 (45.5) 0.26 Alcohol history ( >1 drink/day), n (%) 7 (21.2) 2 (18.2) 0.83 History of cancer diagnosis, n (%) 10 (30.3) 3 (27.3) 0.85 Multiple pancreatic lesions, n (%) 1 (3) 0 0.56 Presenting symptoms Abdominal pain, n (%) 12 (36.4) 9 (81.8) 0.01 Jaundice, n (%) 11 (33.3) 6 (54.5) 0.21 Weight loss, n (%) 8 (24.2) 3 (27.3) 0.84 Incidental, n (%) 5 (15.2) 1 (9.1) 0.61 Located in the head of the pancreas, n (%) 23 (69.7) 9 (81.8) 0.43 Regional lymphadenopathy on imaging, n (%) 20 (60.6) 10 (90.9) 0.06 EUS features Hypoechoic, n (%) 31 (93.9) 9 (81.8) 0.23 Heterogeneous, n (%) 2 (6.1) 4 (36.4) 0.01 Poorly defined, n (%) 23 (69.7) 8 (72.7) 0.85 Common bile duct dilation, n (%) 14 (42.4) 5 (45.5) 0.86 Pancreatic duct dilation, n (%) 23 (69.7) 3 (27.3) 0.01 Number of passes on FNA, mean (IQR) 3 (1-3) 5 (2-7) 0.008 Largest diameter on EUS (mm), median (IQR) 31 (25-38.8) 45.8 (35.5-56) 0.001 Treatment Chemotherapy, n (%) 29 (87.9) 10 (90.9) 0.78 Radiation therapy, n (%) 17 (51.5) 2 (18.2) 0.053 Surgery, n (%) 7 (21.2) 1 (9.1) 0.37

S1744 Idiopathic Non-Caseating Pancreatic Granuloma Mimicking Neuroendocrine Tumor: A Challenging Diagnostic Dilemma

Introduction: Pancreatic granuloma is rare. Caseating granuloma is usually caused by tuberculosis, while non-caseating granuloma is mainly secondary to systemic diseases such as sarcoidosis, rheumatoid arthritis, fungal infection, and Crohn’s disease. Idiopathic etiology can present a diagnostic challenge, requiring further investigation to differentiate it from malignancy. We present an interesting case of a patient who presented with a concern for a neuroendocrine tumor before diagnosing idiopathic non-caseating pancreatic granuloma. Case Description/Methods: A 75-year-old female presented with left upper quadrant pain, chronic diarrhea, and palpitations. The physical exam was unremarkable. Workup was significant for elevated serum chromogranin 3,123 ng/ml, with mildly elevated urine metanephrines. Magnetic resonance imaging showed a stable 2.5 cm cystic lesion in the tail of the pancreas communicating with the main pancreatic duct and hypointense area in the tail. 68Ga DOTATATE scan was negative for neuroendocrine tumor. Endoscopic ultrasound showed a multi-cystic lesion in the tail of the pancreas with thick septations consistent with branch-duct intrapapillary mucinous neoplasm (BD-IPMN), and a 2.7 cm homogenous well-defined hypoechoic area in the tail of pancreas along with multiple enlarged peripancreatic lymph nodes (Figure). Fine needle biopsy showed multiple non-caseating granulomas with benign pancreatic and lymphoid tissue. There was no evidence of malignancy, and stains for acid-fast bacilli, FITE stain, and fungal cultures were negative. A benign idiopathic etiology was concluded. At the 6-months follow-up, the patient was doing well. Discussion: Non-caseating pancreatic granuloma has been described in a few case reports. Sarcoidosis was the most common cause, followed by rheumatoid arthritis and Crohn’s disease. Other cases were associated with granulomatosis with polyangiitis (formerly Wegener's granulomatosis), xanthogranulomatous disease, insulin-dependent diabetes mellitus, or foreign body (Talc). Patients may present with epigastric pain, sometimes associated with weight loss, jaundice, fever, or nausea. Further workup and sampling, or even surgery, might be necessary before reaching a solid diagnosis and ruling out malignancy. Therefore, it is essential to rule out other etiologies before confirming the diagnosis of idiopathic pancreatic non-caseating granuloma.Figure 1.: Endoscopic ultrasound (EUS) showing a homogenous & well-defined hypoechoic mass in the tail of the pancreas, measuring 11 x 27 mm.

S1860 Diffuse Large B Cell Lymphoma Presenting as Acute Recurrent Pancreatitis

Introduction: Extra-nodal Non-Hodgkin’s lymphomas are mostly made of gastrointestinal sites1. Primary pancreatic lymphomas account for < 1% of all extra-nodal lymphomas and are extremely rare. Diagnosis is often missed or delayed due to the prevalence of chronic pancreatitis or pancreatic adenocarcinoma as thought to be the main causes of any pancreatic stricture or mass seen when diagnosing a patient. We present a case of pancreatic lymphoma presenting as acute recurrent pancreatitis. Case Description/Methods: A 51-year-old male with past medical history of rheumatoid arthritis and nicotine use presented with jaundice, abdominal pain, and fatigue and 30-pound weight loss. MRCP showed intra- and extra-hepatic biliary dilation, showing double duct sign. CT suggested acute pancreatitis. ERCP was done showing a single localized biliary malignant appearing stricture in the lower third of the main bile duct with upstream dilation. EUS showed a 19 mm by 19 mm mass in the head of pancreas and 8 mm dilation of the common bile duct. EUS fine needle biopsy showed chronic pancreatitis with dense fibrosis and benign peri-pancreatic lymph nodes. PET CT showed activity in the pancreas and retroperitoneal lymph nodes. Tumor markers (AFP, CEA, CA 19-9) were within normal limits. (Figure) Patient had no known risk factors for chronic pancreatitis therefore, the acute presentation and biopsy results in congruent with the clinical history led us to repeat EUS one month later. This showed a 20 mm by 15 mm irregular mass in the head of the pancreas with upstream pancreatic duct dilation. This time, pathology was sent for flow cytometry and came back positive for lymphoid infiltrate with a preponderance of B-cells surrounded by dense fibrosis and was positive for CD 19, 20, 22 and 10. By this point, malignancy other than adenocarcinoma was suspected and IR guided biopsy of retroperitoneal lymph nodes confirmed a diagnosis of diffuse large B cell lymphoma. Patient started chemotherapy with a 70% chance of being cured. ERCP one month later showed the stricture had resolved and the stent was removed. Discussion: Keeping a broad differential in mind for pancreatic masses is essential to prevent delayed diagnoses. With that in mind, although rare, pancreatic lymphoma should always be in the differential and physicians should consider sending for flow cytometry to avoid missing this diagnosis. When patients present with recurrent pancreatitis and no risk factors, lymphoma should be kept in the differential.Figure 1.: a) CT showing inflammatory reaction of the pancreas with bile duct dilation; b) Bile duct stricture on ERCP; c) EUS image showing common bile duct stent.

S3409 Features of Recurrent Mechanical Obstruction With Nonobstructive Duodenal Neuroendocrine Tumor

Introduction: Neuroendocrine tumors (NET) are a rare cause of bowel obstruction which is usually mechanical in nature. We present an unusual case of bowel obstruction in a patient with NET where no mechanical obstruction was found despite extensive work up. Case Description/Methods: A 56-year-old male was admitted after 9-10 admissions to another facility with bowel obstruction and 50-pound weight loss over 10 months. His symptoms included abdominal pain, distention, and vomiting. He had no prior abdominal surgeries. Previous CT abdomen revealed small bowel obstruction with transition point in the terminal ileum. Current CT showed gastric outlet obstruction (Figure A). Formerly he was managed nonoperatively with nasogastric tube (NGT) decompression. Prior esophagogastroduodenoscopy and colonoscopy did not reveal an obstruction. NGT output was 2.5 L. Push enteroscopy, video capsule endoscopy did not reveal any mechanical obstruction. MR enterography showed two right mesenteric nodules, larger of which was 2.1 x 2.3 cm in size. These were moderately FDG avid on PET-CT. Endoscopic ultrasound biopsy revealed a well differentiated NET. The lesions were intensely somatostatin receptor positive on Gallium-68 DOTATOC PETCT (Figure 1B). Pancreatic polypeptide was 2145 pg/mL (0-435), chromogranin A 1458 ng/ml (0-103), serotonin 278 ng/mL (50-200), and gastrin 208 ng/mL (0-100). He underwent partial duodenal resection with primary repair and peripancreatic lymph node resection. No obstructive pathology was found intraoperatively. Histopathology confirmed well differentiated NET with metastatic peripancreatic nodes. He has had no admissions over the past 3 months and has gained 33 pounds. Discussion: NET are rare tumors and use of appropriate diagnostic modalities are key to timely diagnosis. Despite improvement and availability of diagnostic modalities, most patients have metastatic disease at diagnosis. NET presenting with bowel obstruction usually have an obstructing tumor. We wish to bring to light the unusual presentation of NET with mechanical obstruction on imaging but extensive negative work up for an actual obstructing lesion. It is possible that mesenteric inflammation and edema secondary to NET may have caused recurrent obstruction in this case. NET can present with mechanical obstruction and are often missed on conventional imaging. Gallium-68 DOTATOC PETCT may be a reasonable investigation in a patient with unexplained recurrent gastrointestinal obstruction.Figure 1.: A, CT abdomen with dilated stomach and duodenum and decompressed distal small bowel suggestive of gastric outlet obstruction (arrow) (B) Ga-68 DOTATOC PET/CT scan showing somatostatin receptor positive peripancreatic nodules consistent with metastatic neuroendocrine tumor (chevron).

S1802 Obstructive Jaundice Secondary to Hepatic Hilar Tuberculosis

Introduction: Tuberculosis is an infectious disease caused by mycobacterium tuberculosis. It usually involves the lung, but extrapulmonary involvement is not uncommon. Hepatobiliary tuberculosis is a rare form of extrapulmonary tuberculosis that can be mistaken for hepatic hilar malignant tumors. Case Description/Methods: A 38-year-old gentleman, originally from India, presented to the hospital with right upper quadrant pain for 10 days that was associated with itching, and dark urine; he had no history of fever or weight loss. He was a cigarette smoker but has no history of alcohol drinking; he was not taking any medications. On examination, he was vitally stable. His sclera was icteric, and his abdomen was soft with no tenderness. His laboratory investigations were remarkable for direct hyperbilirubinemia with elevated AST, ALT, and ALP (Table). His ultrasound abdomen showed mildly prominent central intrahepatic biliary duct and prominent upper CBD (measuring 9 mm) with no obvious cholelithiasis. Magnetic resonance cholangiopancreatography (MRCP) showed narrowing in the CBD with a cluster of necrotic conglomerate peripancreatic lymph nodes. Endoscopic ultrasound (EUS) demonstrated a 24x19 mm lesion that is adjacent to the pancreatic head and neck, at the liver hilum, compressing the proximal CBD (Figure). EUS-guided fine-needle biopsy showed necrotizing granulomatous inflammation. TB PCR and culture from the same lesion were positive, and the patient was started on an anti-TB medication regimen. Discussion: Extrapulmonary tuberculosis can be associated with pulmonary tuberculosis or occur in an isolated form. The absence of constitutional and pulmonary symptoms makes the diagnosis more challenging. Few cases reported compression of the common bile duct due to tubercular hilar adenopathy leading to obstructive jaundice. In such cases, the endoscopic ultrasound plays an important role in obtaining a tissue biopsy to establish the diagnosis and to exclude malignant hepatic hilar tumors that can present in a similar fashion.Figure 1.: Endoscopic ultrasound images showing the tuberculous lymphadenopathy in close proximity to the common bile duct. Table 1. - Laboratory investigations Laboratory test Patient's value Normal range WBC 6.50 × 109/L 4.5 - 11 Hgb 15.3 gm/dL 13.0 - 17.0 Platelet 298 × 109/L 150 - 400 Creatinine 1 mg/dL 0.7 to 1.3 Total bilirubin 79.70 µmol/L 3.50 - 24 Direct 46.30 µmol/L 0.0 - 5.10 ALT 478.20 U/L 0.0 - 40.0 AST 270 U/L 0 - 37 Alkaline phosphatase 413 U/L 40.0 - 129.0 CRP 11.20 mg/L 0.0 - 5.0 Hepatitis C Ab Non-reactive Non-reactive Hepatitis B Surface Ag Non-reactive Non-reactive

Robotic modified Appleby: Case report, technical aspects and video

Introduction and importancePancreatic body and tail adenocarcinoma is a tumor of silent evolution, showing up as advanced disease at diagnosis in the majority cases.Case presentationA 60-year-old man, presenting a solid expansive lesion (3.1 × 2.8 cm) in the body of the pancreas, by imaging exams. There was 50% involvement of the celiac trunk at the level of the it's bifurcation and suspected peripancreatic lymph nodes. Clinical staging was cT4N1M0. After neoadjuvant chemotherapy (NQT), there was a small reduction of the tumor to 3.0 × 2.6 cm, an important decreasing of the celiac trunk involvement (25%), and also a reduction in the levels of C19–9 from 650 U/mL to 358 U/mL. Further on, the patient underwent a Robotic Modified Appleby procedure, without intra and postoperative complications.Clinical discussionLocally advanced pancreatic tumors should be referred to NQT, and those with good response might benefit to radical surgery. The modified Appleby technique - distal pancreatectomy with splenectomy and celiac trunk resection – is the procedure of choice when there is involvement of celiac trunk, but concern must be given to the liver vascularization. The use of robotic system on pancreatic surgery is emerging, but still, there is lower data regarding its safety in major pancreatic procedures.ConclusionThe use of neoadjuvant therapy is recommended to assess the in vivo response, improve oncological results and increase negative margins. Pre-operative imaging is mandatory for surgical planning. The robotic modified Appleby procedure is feasible and safe, with reduced of intraoperative blood loss and transfusion rate, corroborating the literature.