Retroperitoneal Lymphadenopathy Research Articles

Association between MRI Findings and Histopathological Examination in Carcinoma Cervix: A Retrospective Study

Introduction: Staging of cervical cancer plays a major role in the treatment and prognosis of the patients. Preoperative Magnetic Resonance Imaging (MRI) is widely reviewed as a method to stage cervical cancer. Aim: To evaluate the role of MRI in the staging of cervical cancer in correlation with Histopathological Examination (HPE). Materials and Methods: A retrospective observational hospital- based study was done on 48 patients with Carcinoma Cervix attending the Velammal Medical College Hospital and Research Institute, Madurai, Tamilnadu. The patients, who had undergone MRI (on 1.5 Tesla Unit) of abdomen and pelvis from June 2018 to July 2019 were included in the study. Tumour location, size, vaginal, parametrial extension, pelvic sidewall involvement, pelvic and retroperitoneal lymphadenopathy, spread to adjacent pelvic organs and distant organs following retroperitoneal lymphadenopathy were reviewed from reports, and histopathology reports were analysed. International Federation of Gynaecology and Obstetrics (FIGO) staging was done for all the cases. HPE findings and MRI findings were assessed for correlation. IBM SPSS version 22.0 was used for statistical analysis. Descriptive analysis was carried out, and values were represented as mean with standard deviation for quantitative variables, frequency and proportion for categorical variables. Results: The mean age was 54.46±9.29 years. The majority 42 (87.5%) of the patients had Squamous cell carcinoma of the cervix on HPE. The majority 23 (47.91%) of the patients had stage IB carcinoma of the cervix. MRI revealed pelvic lymphadenopathy in 04 (8.33%) of cases, pelvic lymph nodal metastasis was seen in 02 (4.16%) of the HPE cases. Conclusion: MRI is useful in staging of Carcinoma cervix in stage IB or greater and for planning of treatment. Hence, MRI has the potential to be used as a one-stop-shop diagnostic tool for cervical cancer.

DIAGNOSTIC CAPABILITIES OF FINE NEEDLE ASPIRATION OF LYMPH NODES METASTASES OF PRIMARY PULMONARY LYMPHOEPITHELIAL CARCINOMAS

Introduction. Primary pulmonary lymphoepithelial carcinoma is a poorly differentiated squamous cell carcinoma admixed with variable amounts of lymphoplasmacytic infiltrate, frequently associated with EBV. It is a rare cancer and have a better prognosis than other non-small cell lung cancer. The tumor can mimic metastatic non-keratinizing SCC of the naso-pharynx, poorly differentiated non-small cell carcinoma and NUT carcinoma arising in the lung, and non-Hodgkin lymphomas. Materials and methods. A 75-year-old man presented with peripheral mass of left lower lobe, maximal diameter was 5.1 cm, involving lingula and medial pleura, with mediastinal, and retroperitoneal lymphadenopathy revealed by computer tomography. Fine needle aspiration-EBUS was performed from hilar and interlobar lymph nodes. Papanicolaou smears and cell blocks were prepared. Additional CT-guided cor-needle biopsy and FNA were performed from lung lesion later. Results. A few large malignant epithelial cells, consistent with non-small lung cancer, were found on a background of lymphocytes in fine-needle aspiration from lymph nodes. Immunostain results: Pan-CK (AE1/AE3), p63 and Ki67 were positive in malignant cells, leukocyte common antigen (CD45) was positive in lymphocytes (negative in tumor cells), and negative markers were TTF1, chromogranin and synaptophysin. Cytological diagnosis was metastatic non-small lung cancer, favor squamous cell carcinoma. Biopsy and aspiration from left lung showed syncytial groups of large malignant epithelial cells with scant cytoplasm and prominent nucleoli on a background of prominent inflammatory infiltrate,consistent with lymphoepithelial carcinoma. Conclusion. It is impossible to correctly diagnose metastasis of lymphoepithelial carcinoma in lymph node by FNA only without FNA or biopsy of primary lesion, because cytological features and immunostains are identical to non-keratinizing squamous cell carcinoma.

Magnetic resonance versus computed tomography for the detection of retroperitoneal lymph node metastasis due to testicular cancer: A systematic literature review

IntroductionIt is essential to see if MRI can be used as an alternative to CT for the detection of retroperitoneal lymphadenopathy in patients with testicular neoplasms. By doing so, the amount of radiation received by these young patients might be reduced. Material and methodsA systematic literature review was carried out in 5 databases between January 1984 until December 2020. The articles included were randomized and non-randomized clinical trials, cross-sectional studies, cohort, case and control, and retrospective studies that compare the accuracy of MRI against CT to detect retroperitoneal lymph nodes in patients with testicular neoplasms. ResultsThe search string initially retrieved 222 non duplicated papers from which a total of 3 studies of diagnostic accuracy were included for analysis. These articles evaluated a total of 127 patients with testicular neoplasm; the sample size per study ranged from 25 to 52 patients, with a mean age between 29–34 years. MRI presented a sensitivity ranging from 98−80% and specificity of 100 % when read by an experienced radiologist. However, when it was read by a radiologist with 1 year of experience, the sensitivity dropped to 78 % and specificity to 91%. ConclusionThis systematic literature review shows a knowledge gap since not much has been published regarding this topic; therefore, randomized clinical trials are mandatory. Research on when to use MRI over CT is necessary to reduce radiation exposure. The authors strongly suggest that readers start researching on this subject.

Tropheryma whipplei: an unusual cause of the accumulation in positron emission tomography

A 51-year-old man presented with watery diarrhea and 7-kg weight loss for six months. As computed tomography scans showed multiple mesenteric and retroperitoneal lymphadenopathy, 18F-fluoro-deoxyglucose positron emission tomography was performed, showing marked accumulation in the jejunum. Enteroscopy disclosed diffuse yellow-white swollen villi in the jejunum and biopsies revealed clubbed villi with marked periodic acid-Schiff-positive foamy macrophages. The electron microscopic examination showed numerous extracellular bacilli and bacillary forms of degradation in the macrophages. 16S rRNA PCR revealed Tropheryma whipplei in the mucosal specimens, making the diagnosis of Whipple's disease. Therapy with ceftriaxone followed by long-term trimethoprim-sulfamethoxazole was effective. Whipple's disease is briefly discussed.

Hemopericardium with subsequent cardiac tamponade secondary to rivaroxaban treatment: a case report.

BackgroundThe use and utility of novel oral anticoagulants has been increasing in clinical practice due to their relatively lower incidence of side effects such as intracranial haemorrhage, particularly in the elderly, when compared with vitamin K antagonists. Rivaroxaban is a factor Xa and prothrombinase inhibitor indicated for stroke and venous thromboembolism prophylaxis in non-valvular atrial fibrillation as well as treatment of venous thromboembolism.Case summaryA patient with history of paroxysmal atrial fibrillation on Rivaroxaban presented with generalized malaise, lightheadedness, and dizziness. The patient was found to be in profound cardiogenic shock despite unremarkable cardiac enzymes. Electrocardiogram revealed rate controlled atrial fibrillation and T-wave inversions in the inferolateral leads without associated electrical alternans. Bedside echocardiogram revealed a large pericardial effusion consistent with cardiac tamponade physiology. Following anticoagulation reversal, the patient underwent urgent pericardiocentesis yielding haemorrhagic fluid, with subsequent improvement in haemodynamic status. Despite the presence of retroperitoneal lymphadenopathy on previous computed tomography of the abdomen and concern for underlying malignant effusion secondary to lymphoma, cytology of the fluid revealed no evidence of malignant cells and follow-up flow cytometry and bone marrow biopsy were unremarkable.DiscussionWhile hemopericardium is not listed as a known side effect of Rivaroxaban, previous cases of hemopericardium secondary to Rivaroxaban have been described in the literature secondary to pre-disposing risk factors including CYP450 drug interactions or cardiac device implantations. In this case, the patient experienced a spontaneous hemopericardium on Rivaroxaban without any previously elucidated risk factors or evidence of malignancy.

Next Generation Sequencing of Renal Medullary Carcinoma Diagnosed Concurrently with Sickle Cell Trait: A Case Report and Literature Review

Abstract Casestudy We present a 33-year-old African American male with 4 months of intermittent right flank pain and gross hematuria with hypermetabolic retroperitoneal lymphadenopathy, persistent right-sided hydronephrosis, perinephric fat stranding and a 5.5-cm hypermetabolic right lower pole mass demonstrated on imaging. Results Core needle biopsies of the mass contained atypical glands composed of epithelioid cells with pleomorphic nuclei, prominent nucleoli, eosinophilic cytoplasm and abundant mitoses infiltrating through desmoplastic stroma. Immunohistochemical staining demonstrated CK7 and PAX8 reactivity of the tumor cells, and negative staining for CK20, WT1, PSA, PLAP and CD10. The patient underwent a radical right nephrectomy; microscopic examination illustrated invasion of the renal sinus, perirenal fat, and lymphovascular space by the neoplastic glands and sickling erythrocytes in the vasculature. Further IHC staining revealed intact mismatch repair proteins (MLH1, PMS2, MSH2, and MSH6) and a loss in expression of INI1 (SMARCB1), leading to the concurrent diagnoses of renal medullary carcinoma and sickle cell trait (confirmed with hemoglobin fractionation). Next generation sequencing of 144 clinically significant genes detected no mutations. Conclusion Renal medullary carcinoma is a rare, aggressive neoplasm that accounts for less than 0.5% of all renal cell carcinomas and presents at an advanced stage. Patients are usually young males who are of African or Mediterranean descent with comorbid sickling disease. Although loss of SMARCB1/INI-1 gene expression is associated with this neoplasm, no effective therapeutic targets have yet been established. Renal medullary carcinomas are usually resistant to chemotherapy and radiotherapy, making the identification of an immunotherapy target paramount. With a median survival of four months from diagnosis, additional genetic studies of these malignancies may identify an effective treatment option for renal medullary carcinoma.

Rosai-Dorfman disease with renal involvement and associated autoimmune haemolytic anaemia in a 12-year-old girl: A case report

BackgroundRosai- Dorfman Disease (RDD) is a benign condition of unknown aetiology which is characterized by non-neoplastic proliferation of histiocytes. Pathophysiology and natural history remain obscure due to the low prevalence of disease. It is known to present with nodal or extranodal involvement and occurrence in the genitourinary system could lead to dreadful complications. RDD is diagnosed by demonstrating emperipolesis on histology and supported by S100 positivity in immunohistochemistry. Treatment is tailored individually and includes expectant monitoring, steroids, surgery, chemotherapy and radiotherapy. Prognosis will be poor if there is involvement of vital organs. We report a rare case of renal Rosai-Dorfman Disease in a 12-year-old girl which also associated with cold type autoimmune haemolytic anaemia (AIHA).Case presentationA previously healthy, 12-year-old girl presented with low grade fever and cough over one month. On examination, she was pale, mildly icteric and had a firm mass in the left hypochondrial region.Her blood count revealed significant eosinophilia, normocytic normochromic anaemia and thrombocytosis. Further laboratory investigations revealed reticulocytosis, positive urine urobilinogen, positive direct antiglobulin test and red blood cell agglutination on blood picture suggestive of autoimmune haemolytic anaemia.Ultrasound scan of abdomen revealed paraaortic and left side retroperitoneal lymphadenopathy with left renal mass. It was further evaluated by Contrast Enhanced Computed Tomography (CECT). Biopsy was done and that concluded sinus histiocytosis with massive lymphadenopathy (SHML) with positive S100 and CD1a in immunohistochemistry. Child was treated with steroids however there was no significant response as assessed by repeat CT and has been commenced on chemotherapy.ConclusionRDD is believed to be due to host immune dysregulation and precise diagnosis is imperative. It should be considered as differential diagnosis in a child presenting with massive lymphadenopathy and AIHA. Association between RDD and AIHA may possibly be explained by abnormal immune response of the host.

S2126 Metastatic Testicular Embryonal Carcinoma Presenting as Gastrointestinal Hemorrhage

INTRODUCTION: Metastatic testicular embryonal carcinoma presenting as gastrointestinal hemorrhage is an uncommon phenomenon. While testicular cancer is the most common malignancy in males 20–35 years of age, metastases to the gastrointestinal tract occur at an incidence of less than 5%. In a young man with otherwise unexplained gastrointestinal hemorrhage, it is important to consider the possibility of underlying malignancy. CASE DESCRIPTION/METHODS: A previously healthy 27-year-old male presented with two weeks of abdominal pain and three days of melena and hematemesis. He was found to be in hemorrhagic shock with a hemoglobin of 5.3 and resuscitated aggressively with blood products and fluids. A CT abdomen/pelvis showed a large 15.1 cm × 13.9 cm × 8.6 cm hypervascular soft tissue mass with a necrotic center and multiple foci of contrast blush located adjacent to the third portion of the duodenum, extensive peritoneal and retroperitoneal lymphadenopathy, and multiple lung masses (Figure 1). Esophagogastroduodenoscopy (EGD) revealed an exophytic mass-like obstruction in the duodenum that when traversed, revealed a large cavity filled with necrotic tissue and old blood extending from the third portion of the duodenum deep into the subperitoneal space (Figure 2) with slow hemorrhage from friable tissue treated with coagulation graspers. The patient's clinical course was complicated by multiple episodes of recurrent hemorrhage requiring repeat endoscopic treatment with bipolar coagulation, epinephrine injection, and hemostatic powder application. A diagnosis of germ cell tumor was made based on scrotal US showing multiple masses and a significantly elevated beta-HCG. He was treated with chemotherapy with subsequent decrease in the size of his abdominal mass and resolution of bleeding. DISCUSSION: Testicular cancer is the most common malignancy in males 20–35 years of age, usually presenting with painless scrotal swelling. Metastases can involve retroperitoneal lymph nodes, which drain the testes. Gastrointestinal metastases are rare, and metastatic disease may not initially be considered in a young male presenting with gastrointestinal hemorrhage. This case demonstrates the importance of testicular imaging and exam should there be concern for underlying malignancy, especially if other causes of gastrointestinal hemorrhage have been ruled out. Early diagnosis and intervention may often lead to improved clinical outcomes.Figure 1.: CT abdomen showing a large heterogeneously enhancing hypervascular soft tissue mass which appears to be contiguous with the third part of the duodenum. Large necrotic central component present.Figure 2.: EGD showing duodenal lumen immediately proximal to the cavity. Note the adherent clot at the top of the abnormal tissue directly in front.Figure 3.: Necrotic cavity in duodenum.

S2962 Hepatoid Adenocarcinoma - A Rare Malignancy

INTRODUCTION: Hepatoid adenocarcinoma (HAC) is a rare subtype of gastric cancer. It histologically resembles hepatocytes and can produce alpha fetoprotein (AFP). We present a case of HAC with metastasis to the liver, thus mimicking a hepatocellular carcinoma (HCC). Clinical history and immunohistochemical stains are the key to diagnosis. CASE DESCRIPTION/METHODS: We report a 67-year-old male with a history of hypertension who presented to the hospital with epigastric abdominal pain, nausea, and vomiting that was progressively worsening for the past 4 months. Physical exam was remarkable for mild epigastric tenderness with palpation. Laboratory tests showed a hemoglobin of 9.5 gm/dL with iron studies consistent with iron deficiency anemia. The AFP, CA 19-9, and CEA were normal. CT showed extensive mural thickening of the stomach with extensive mediastinal and retroperitoneal lymphadenopathy as well as a hypo-enhancing mass in the left lobe of the liver measuring 3.3 × 3.2 × 2.7 cm. There were no exam, lab, or imaging findings suggestive of chronic liver disease. We performed an upper endoscopy which revealed a large fungating, infiltrative and ulcerated circumferential mass involving the gastric body and fundus. Multiple biopsies were taken which showed fragments of gastric mucosa infiltrated by a poorly differentiated neoplasm. Immunohistochemical stains supported hepatoid differentiation of the neoplasm. Specifically, CK19 and B72.3 stains favored HAC over HCC. Liver biopsy was subsequently performed and showed a similar histologic appearance. Thus, the patient was diagnosed with stage IV HAC with metastasis to the liver. He was followed up by oncology as an outpatient and started on FOLFOX chemotherapy. DISCUSSION: HAC of the stomach with metastasis to the liver can be difficult to diagnose as it can mimic HCC. Our case is even more unusual in that the AFP was normal, although this does not exclude either HAC or HCC. Unfortunately, HAC is an aggressive cancer that carries a poor prognosis. Like in our case, many are diagnosed at an advanced stage and there are no guidelines for the optimal chemotherapy regimen. Since our patient’s AFP levels were normal, he can only be monitored by interval imaging. Fortunately, our patient had excellent baseline functional status, which will hopefully improve his outcomes and tolerance to treatment. With HAC, clinical context and specialized immunohistochemical stains must be considered to make the correct diagnosis and prevent delay in treatment.Figure 1.: Endoscopic picture of Antrum with Mass.Figure 2.: Endoscopic picture of Endoscopy of the body of the stomach.Figure 3.: Endoscopic picture of the Fundus.

DISSEMINATED PULMONARY HISTOPLASMOSIS IN AN IMMUNOCOMPETENT PREVIOUSLY HEALTHY INDIVIDUAL

SESSION TITLE: Medical Student/Resident Chest Infections Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Histoplasmosis infection is clinically silent in over 99% of immunocompetent individuals in endemic areas. If symptoms occur most are non-specific and self-limited. However, disseminated histoplasmosis can develop in immunocompetent patients with devastating consequences including significant mortality. CASE PRESENTATION: A previously healthy 45-year-old man presented after 2-3 weeks of worsening dyspnea, non-productive cough, and 20lb weight loss. Outpatient work up showed concern for atypical pneumonia, necessitating treatment with three escalating oral antibiotics showing no improvement prompting admission. He was transferred from an outside hospital intubated progressing toward ARDS requiring vasopressor support. On imaging there was diffuse bilateral peribronchovascular consolidation, groundglass opacities with septal thickening, hepatosplenomegaly, and retroperitoneal lymphadenopathy. Testing included respiratory viral panel positive for rhinovirus, fungitell, fungal blood cultures, urine antigens for histoplasmosis and blastomyces, and bronchoscopy. He was placed on broad spectrum antibiotics and itraconazole. The following day his fungal regimen was advanced to amphotericin B. Three days later his urine histoplasmosis antigen returned positive followed by a positive fungitell and lastly bronchoscopy cultures grew histoplasmosis. He required a month long hospital stay with aggressive ventilator support requiring tracheostomy, severe fevers requiring external cooling, and significant ATN that all slowly improved. Work up for an underlying etiology for possible immunosuppression was unrevealing. He was discharged to an extended care facility where he was liberated from the ventilator within a few days of hospital discharge with later tracheostomy decannulation. He remains on itraconazole 9 months later. He has returned to his regular activities. Most recent imaging shows mild scarring and residual consolidative and nodular opacities. DISCUSSION: Initial generalized symptoms and the rarity of disseminated histoplasmosis in immunocompetent patients can cause it to be overlooked on the differential, leading to significant delays in care. Further delays can occur as testing typically takes multiple days to result and may require bronchoscopy. In this case, a broad differential was considered with a decisive plan of starting the patient on amphotericin days prior to test results likely significantly improving overall prognosis. CONCLUSIONS: Timely diagnosis and treatment of disseminated histoplasmosis requires a broad differential diagnosis coupled with a high level of clinical suspicion. Aggressive treatment may need to begin prior to definitive diagnosis in patients with significant disease burden. Reference #1: Kauffman CA. Histoplasmosis: a clinical and laboratory update. Clin Microbiol Rev. 2007;20(1):115-132. doi:10.1128/CMR.00027-06 Reference #2: Ling Q, Zhu W, Lu Q, Jin T, Ding S. Disseminated histoplasmosis in an immunocompetent patient from an endemic area: A case report. Medicine (Baltimore). 2018;97(29):e11486. doi:10.1097/MD.0000000000011486 DISCLOSURES: No relevant relationships by Benjamin Ramser, source=Web Response No relevant relationships by Joy Wang, source=Web Response No relevant relationships by Steven Young, source=Web Response

S1380 A Rare Case of Pancreatic Plasma Cell Myeloma Presenting as Obstructive Jaundice: A Case Report and Review of Literature

INTRODUCTION: Hematological malignancies affect the pancreas very rarely, with lymphomas being the most common. Pancreatic plasma cell myeloma (PCM) is exceptionally uncommon. We present a case of obstructive jaundice in a patient due to pancreatic PCM. CASE DESCRIPTION/METHODS: A 50-year old man with a history of hypertension, hyperlipidemia, and nephrolithiasis presented to the emergency department with a 3-month history of worsening mid-epigastric pain, weight loss, and jaundice. Initial laboratory workup showed low hemoglobin (11.0 g/dL), hyperbilirubinemia, and elevated protein gap. C-reactive protein and erythrocyte sedimentation rate were elevated, while vitamin B-12 and folate levels were found normal. Computed tomography revealed intra and extrahepatic biliary ductal dilatation and a hyperenhancing mass within the pancreas and porta hepatis with portal vein compression (Figure 1). Multiple enlarged retroperitoneal lymph nodes, splenomegaly, and lytic lesions in the right pubic bone were also noted. Prostate-specific antigen (PSA) and carcinoembryonic antigen (CEA) levels were normal, while CA-19-9 was found to be 191 (Normal: 0-37 U/mL). Endoscopic retrograde cholangiopancreatography (ERCP) and stenting were performed for a malignant appearing common bile duct stricture (Figure 2). Urine protein electrophoresis (UPEP) revealed a monoclonal M spike (4.7 g/dL) and gamma globulins with lambda light chains in the urine. Immunofixation confirmed the monoclonality and demonstrated IgG lambda protein. Quantitative testing showed a high level of IgG at 6.5 g/dL (Reference range: 0.7-1.6 g/dL) with decreased IgA and IgM. Biopsy of pancreatic mass and bone lesions revealed plasmacytoma with lambda light chain restriction. Bortezomib and dexamethasone were initiated with the resolution of the biliary obstruction (Figure 3). The presence of extramedullary plasmacytoma (EMP), lytic bone lesions, anemia, and monoclonal immunoglobulin production was suggestive of multiple myeloma. DISCUSSION: Pancreatic PCM typically presents with obstructive jaundice, but pancreatitis, gastrointestinal bleeding, and nausea can also occur. Pancreatic PCM offers a diagnostic challenge and should not be overlooked when evaluating hyperbilirubinemia due to obstructive jaundice if retroperitoneal lymphadenopathy and osteolytic lesions are present.Figure 1.: Arrow pointing towards pancreatic mass.Figure 2.: Arrow pointing towards common bile duct stricture.Figure 3.: Arrow pointing towards resolution of common bile duct stricture.

S3442 A Trip Through the Pylorus - A Rare Case of a Gastric Adenocarcinoma Invading the Duodenum and Literature Reivew

INTRODUCTION: We present a rare case in a 61-year-old African American who shows one such case an interesting case of multiple gastric adenocarcinoma involving the gastric antrum and pylorus that extended into the duodenum. CASE DESCRIPTION/METHODS: A 61-year-old male without medical history presented with abdominal pain of one month acutely worsening over the 2 weeks. The pain was diffuse in nature, 9/10 in severity, with decreased appetite and 25lbs weight loss without exacerbating or relieving factors. Physical exam showed for RUQ and LUQ tenderness. Hepatomegaly was present with a firm mass palpated below the epigastrium. Labs were unremarkable. CT of abdomen and pelvis with contrast revealed hypoattenuating lesions in liver and spleen. An enlarged, heterogeneous pancreatic head with dilated duct and multiple enlarged lymph nodes, including a necrotic lymph node were found with the latter causing mass effect of structure. The stomach had a suspicious gastric mass with irregular wall thickening along the greater curvature and mesenteric stranding. There were multiple omental masses, peritoneal masses in RUQ and LUQ with significant retroperitoneal and pelvic lymphadenopathy. Subsequent upper endoscopy showed an abnormal nodular mucosal area in the junction of gastric body and antrum with a large gastric polyp in the adjacent area that was biopsied. Initially the top differential was lymphoma on accord that it does not respect the gastric-duodenal junction however, the pathology report of the abnormal gastric tissue revealed a poorly differentiated gastric adenocarcinoma that also involved duodenal mucosa with loss of nuclear expression of PMS-2 and MLH-1. Helicobacter Pylori testing was also noted be positive. Patient was started on FOLFOX therapy without benefit. Treatment was switched to Pembrolizumab therapy as tumor was MMR deficient with good response. DISCUSSION: The incidence of duodenal invasion in lower stomach cancer ranges from 13.5 to 33.2% mainly based on populations of Asian heritage, where the prevalence of gastric cancers is much higher than the rest of the world. Our patient is an African American male, and at the time of writing this case report our search showed that there are a handful of published cases of gastric cancer invading the duodenum in which highlights this rarity. We hypothesize that the reduced presentation of similar presentations may be low due to overall low incidence of gastric cancer in the United States, which has rapidly declined over the past 50 years.Figure 1.: Gastric antrum polyp.Figure 2.: Pre-pyloric tissue extending through pylorus into duodenal bulb.Figure 3.: Duodenal Bulb – Abnormal mucosa.

S1455 A Rare Case of Poorly Differentiated Metastatic Extra-Pulmonary Neuroendocrine Tumor in an HIV Patient

INTRODUCTION: HIV infected individuals have an increased risk of malignancies such as Kaposi sarcoma, primary central nervous system lymphoma, non-Hodgkin lymphom, and cervical cancer. The incidence of non-AIDSdefining tumors such as Neuroendocrine Tumor (NET) has not been well reported in the literature. Majority of NETs occur in the gastrointestinal tract (almost 68%) and bronchopulmonary tree (about 25%). Of the GI NETs, most are in the small intestine with less than 1% of pancreatic origin. We present an HIV patient with primary pancreatic NET with metastasis to the liver. CASE DESCRIPTION/METHODS: A 56-year-old African American male with history of HIV currently on antiretrovirals presented with complaints of non-radiating chest pain, shortness of breath, back pain, dizziness, night sweats, nausea, constipation, and recent weight loss. Patient is a current non-smoker with 30 pack year history, no recent travel or sick contacts. Initial workup, including CBC, CMP, EKG, and chest x-ray on admission were unremarkable. Physical exam and vital signs were within normal limits; however, due to the presenting symptoms, CTA of the chest was obtained revealing an incidental finding of a hypodense soft tissue mass highly suspicious for lymphoma. Follow up CT Abdomen and Pelvis with contrast revealed retroperitoneal and periportal lymphadenopathy along with a 3.7 cm Liver mass, suggestive of lymphoma with soft tissue metastasis. In view of these findings the primary working diagnosis was HIV associated lymphoma. However, CT guided liver and lymph node biopsy pathology favored metastatic large cell neuroendocrine carcinoma, most probable primary in pancreas. DISCUSSION: Even though there are malignancies commonly associated with HIV and AIDS, it is important to keep a broad differential when working up a patient with HIV. The incidence of ADC decreased 2-3 folds since 1998 while NADC increased in incidence but no variance of standardized in the same time frame. This has been attributed to the introduction of combination antiretroviral therapies that increased HIV patients life expectancy and allowing them to be at the same risk of developing age-related cancers as the general population. NET in HIV positive patients in sites other than lungs and skin has not been well characterized. Previous study has shown a correlation between Merkel Cell carcinoma and concurrent HIV infection, and it is unclear if our pancreatic cancer is sporatic or associated with HIV infection.

S2790 Mycobacterium avium Complex Enteritis Mimicking Whipple's Disease in a Patient With Advanced AIDS

INTRODUCTION: Acquired Immunodeficiency Syndrome (AIDS) patients are susceptible to numerous opportunistic infections, including Mycobacterium avium complex (MAC). MAC infection usually presents as a disseminated disease with fever, nights sweats, diarrhea as well as lymphadenopathy which can be the presenting symptoms of various other diseases, such as Whipple's disease (WD). We present a case of MAC infection initially diagnosed as Whipple’s Disease in a patient resulting in delay in MAC treatment. CASE DESCRIPTION/METHODS: A 37 year old homosexual male presented with a one year history of progressively worsening abdominal pain accompanied by intermittent non bloody, non bilious vomiting, chronic diarrhea, fatigue and 60 lbs unintentional weight loss over several months. He underwent an elective EGD where abnormal appearing duodenal mucosa was seen with duodenal biopsy showing villous atrophy and period acid Schiff (PAS) stain positive macrophages, while abdominal imaging showed retroperitoneal and mesenteric lymphadenopathy (Image 1). Despite initiation on treatment for WD, he continued to clinically decline. Given his high risk social history and significant constitutional symptoms, HIV infection was considered as an alternative diagnosis. He was found to have HIV/AIDS (viral load of >100,000 copies/mL and CD4 count 9/μL) and blood cultures positive for MAC. On further review, his duodenal biopsies were positive for acid fast bacillus (AFB) confirming MAC enteritis. A CT chest revealed a 4.6 cm right lung mass with biopsy positive for AFB stain(Image 2). Patient was then initiated on appropriate treatment for disseminated MAC infection (azithromycin, rifabutin, ethambutol) as well as antiretroviral therapy resulting in clinical improvement. DISCUSSION: The differential diagnoses for villous atrophy include malabsorptive diseases, infections, malignancy, pancreatic insufficiency but other less common infectious entities such as MAC should be considered in the right clinical settings. MAC infections have become increasingly uncommon since the advent of highly effective antiretroviral therapy, control of HIV infection and appropriate antimicrobial prophylaxis. Due to the relative rarity, diagnosis and treatment may be delayed, especially when presenting symptoms are non-specific, which can result in morbidity and mortality.Figure 1.: View of duodenum during endoscopy which shows white color plaques in the second and third part of the duodenum (A). H&E stain (20X) of duodenal biopsy shows mildly blunted villi due to expansion of lamina propria by foamy macrophages in a patchy fashion (B). No fat vacuoles or increased intraepithelial lymphocytes seen. AFB stain (20X) of duodenal biopsy shows many positive bacillary forms confirming the presence of Mycobacterium avium intracellular complex (C). Abdominal lymphadenopathy noted on computed tomography of abdomen (red circle) (D).Figure 2.: Computed Tomography of Lung mass (red circle) (A). H&E stain (40X) lung mass biopsy shows florid lympho-histiocytic reaction (B) while CD68 stain (40X) shows many macrophages (C), and AFB stain (40X) confirms presence of mycobacterial organisms (D).

S2942 Rare Case of Primary Gastric Small Cell Carcinoma in a Renal Transplant Recipient

INTRODUCTION: Small cell carcinoma is a rapidly progressive, poorly differentiated neuroendocrine cancer that most often originates in the lungs; however, an estimated 2.5-5% of cases originate elsewhere. Extrapulmonary small cell carcinoma (ESCC) arising from the stomach is rare. Cases occurring in renal transplant recipients are even more uncommon. Here we present a case of metastatic ESCC from a gastric primary in a renal transplant recipient. CASE DESCRIPTION/METHODS: A 52-year-old Vietnamese male presented with 1 week of epigastric pain. He had a history two renal transplantations requiring multiple thymoglobulin inductions and long-term immunosuppression. Vital signs were normal. Physical exam revealed hepatomegaly. Labs were significant for Hgb 10.0 g/dL, ALP 155 U/L, AST 71 U/L, ALT 21 U/L. CT scan of the abdomen revealed hepatomegaly, innumerable hepatic masses up to 9 cm in diameter, retroperitoneal and portal lymphadenopathy and splenic and portal varices. MRI of the abdomen revealed suspicious circumferential gastric antral wall thickening up to 2.4 cm with adjacent nodularity (Figure A). Liver core biopsy was diagnostic for metastatic small cell carcinoma. Subsequent EGD revealed a large circumferential, infiltrative, fungating and ulcerated mass in the gastric antrum (Figure B) with biopsy confirming the diagnosis of primary gastric small cell carcinoma (GSCC). The patient completed 4 cycles of palliative chemotherapy and transitioned to hospice due to lack of significant response and severe neutropenic complications. DISCUSSION: Primary GSCC are rare, representing 0.1% of extrapulmonary small cell cancers and < 0.1% of all gastric cancers. These often present with early, widespread metastasis with a 5-year survival rate of 13-20%. An increased risk of de novo cancer and gastric cancers in renal transplant recipients has been well-described, however the overwhelming majority presenting as gastric adenocarcinomas. Extrapulmonary small cell carcinomas in renal transplant patients are also rare with most cases arising from genitourinary primaries, often from the donor kidney. There are reported cases of gastrointestinal primaries from the rectum, appendix, and duodenum. To our knowledge, this represents the first reported case of metastatic GSCC in a renal transplant patient that sheds a light on the association between immunosuppression and cancer risk. The absence of well-established epidemiological data, prognostic factors and treatment guidelines necessitates reporting these rare GSCC cases.Figure 1.: Hepatic masses with 2.4cm circumferential gastric antral wall thickening (red arrow).Figure 2.: Gastric antral mass.

S1398 Biliary Stricture in a Patient With Metastatic Mixed Germ Cell Tumor (MGCT) of the Testis: A Case Report

INTRODUCTION: Testicular cancer is the most common malignancy in American males between the ages of 15–35. Up to 95% of testicular cancers are GCTs and the most common site for metastatic spread is the retroperitoneal lymph nodes. However, the spread of the retroperitoneum rarely involves the biliary tree. We present an unusual case of MGCT of the testis with metastases to the retroperitoneal lymph nodes causing biliary stricture and common bile duct dilation. To the best of our knowledge, this is the first reported case of biliary stricture caused by metastatic testicular cancer. CASE DESCRIPTION/METHODS: An 18-year-old man with no significant past medical history presented to our emergency department with a two-week history of progressive abdominal pain and weight loss. A complete physical examination was normal except for a tender abdomen without rebound tenderness. Laboratory findings on admission revealed signs of obstructive jaundice with elevated transaminases and elevated total bilirubin. CT of the abdomen showed large retroperitoneal masses measuring 14.2 cm extending into porta hepatis region with dilatation of the biliary ducts. Further evaluation including testicular palpation and ultrasound revealed a small testicular nodule. There was an abnormal elevation of testicular markers (serum beta-human chorionic gonadotropin level was 77,193 IU/ml) which subsequently led to suspicion of testicular cancer. He underwent a biopsy of the retroperitoneal mass, which confirmed a metastatic MGCT with embryogenic and choriocarcinoma components originating from the testis. He underwent a cycle of chemotherapy with etoposide, ifosfamide, and cisplatin during his hospital stay. ERCP performed showed a severe irregular biliary stricture over the lower third of the main bile duct with malignant appearance, and the upper third of the main bile duct was severely dilated secondary to stricture. A biliary sphincterotomy was performed and biliary tree balloon sweep was conducted with no significant findings. A plastic stent was placed into the common bile duct to maintain patency and demonstrated good flow. Follow-up labs demonstrated improvement in LFTs and bilirubin levels. DISCUSSION: This is a rare case of obstructive jaundice and biliary stricture in a patient with a MGCT (non-seminomatous) of the testis that metastasized to the retroperitoneal space. After ERCP with endoscopic bile duct stenting, it was noted that the jaundice and bile duct dilation resolved and symptoms improved.Figure 1.: Coronal contrast – enhanced CT image of upper abdomen demonstrates intra- and extra hepatic biliary dilation with abrupt cut-off at the upper common bile duct (black arrow), caused by confluent retroperitoneal lymphadenopathy extending into the hepatic hilum (white arrow).

S2214 Unusual Initial Presentation of HIV With Disseminated Kaposi Sarcoma (KS) as Rectal Bleeding

INTRODUCTION: Kaposi's sarcoma (KS) is a cancer that develops from the cells that line lymph or blood vessels. It usually appears as tumors on the skin or on mucosal surfaces such as inside the mouth, but these tumors can also develop in other parts of the body, such as in the lymph nodes, the lungs or digestive tract. KS involvement of GI tract may remain asymptomatic in the beginning or may present with mild non-specific abdominal symptoms, unlikely to be diagnosed in late stage. Here we are presenting a case of disseminated KS presented with rectal bleed in homosexual undiagnosed HIV patient. CASE DESCRIPTION/METHODS: A 33 yr old male with no significant past medical history, presented with 3-month history of constipation and progressive unintentional weight loss (40 lbs in 3 months). Lately, patient noticed his stool mixed with blood and mucus, early satiety and fatigue. Patient has family history significant for breast cancer and biliary cancer in mother. Patient is sexually active with 5 male partners. On presentation, vitals were stable and physical examination revealed multiple purple non-blanchable lesions on his extremities and trunk, a mass on the hard palate, supraclavicular and inguinal lymphadenopathy, external hemorrhoids, and a palpable mass in the rectum. Labs showing normocytic anemia with Hb of 10.3, ESR of 95 and CRP of 9.88. Patient was found to be positive for HIV with viral load of 118,255 and CD4 count of 236. Patient also had high IgG titers for Chlamydia trachomatis and CT abdomen and pelvis showed rectosigmoid mass with perirectal lymphadenopathy, inguinal adenopathy, and mild retroperitoneal lymphadenopathy. CT chest showed pulmonary metastasis and colonoscopy showed mild non-specific ileitis, nodule in descending colon and neoplasm in the rectum. Biopsy from the descending colon and rectal mass showed ulcerated Kaposi’s sarcoma and positive immunostaining for human herpes virus -8 (HHV-8). Patient was diagnosed with disseminated KS and started on anti-retroviral therapy (ART) and systemic chemotherapy. DISCUSSION: AIDS-associated disseminated KS is a rare entity. ART has resulted in marked decline in the incidence of KS. Due to the rapid and progressive nature of AIDS related KS, early diagnosis and institution of ART is crucial to achieving favorable prognosis. In addition, co-infection of HHV-8 with HIV promotes the oncogenicity of HHV-8 leading to rapid onset and progression of KS. Above patient responding well to the ART and Chemo going for surveillance Colonoscopy.Figure 1.: Kaposi Sarcoma on Hard Palate.Figure 2Figure 3.: Kaposi Sarcoma in Rectum.

S2462 A Patient Presenting With Acute Hepatitis and Retroperitoneal Lymphadenopathy Due to Cytomegalovirus and Epstein-Barr Virus Co-Infection: A Rare Complication in an Immunocompetent Patient

INTRODUCTION: Acute hepatitis refers to an acute inflammation of a liver and hepatic cell necrosis. Viral infection accounts for 95% of cases. Acute viral hepatitis due to cytomegalovirus (CMV) and Epstein-Barr virus (EBV) co-infection in an immunocompetent individual is very rare. We report a patient who presented with fatigue, fever, and retroperitoneal lymphadenopathy due to EBV and CMV infection. CASE DESCRIPTION/METHODS: A 26-year-old man presented with intermittent high-grade fever, nausea, fatigue and generalized body weakness of 1-week duration. The patient noticed a pinkish rash on his abdomen and legs while he was febrile. Otherwise patient denied vomiting, hematemesis, melena, jaundice, or contact with a patient with similar illness. He was not immunocompromised and had no personal history of hematological disorders or autoimmune disease. On examination, the patient was sick looking; blood pressure was 120/68 mmHg, heart rate 110 beats/min, temperature 102 F. He had pink conjunctiva and non-icteric sclera. No palpable lymphadenopathy was felt in accessible areas. The abdomen was nontender, no organomegaly, and no sign of ascites. Laboratory tests revealed a white blood cell count 7.6K, hemoglobin 13.8gm/dl, platelet 163K. Peripheral blood smear revealed lymphocytosis (59%). Alanine transferase 279units/L, aspartate transaminases 217units/L, alkaline phosphatase 121units/L, and total bilirubin of 0.4 mg/dl. Both CMV IgM and IgG were positive, both EBV IgM and IgG were positive. Hepatitis viral panel A, B, C, human immunodeficiency virus, ANA and rheumatoid factor were all negative. Computed tomography of chest/abdomen/pelvis revealed multiple enlarged axillary and retroperitoneal lymph nodes, normal liver and spleen size. DISCUSSION: CMV and EBV are a family of herpes virus commonly encountered during childhood. CMV transmission is either congenital or contact with body secretions or blood transfusion. EBV is transmitted by close contact during child hood or by kissing in adults. Hepatitis as a manifestation of CMV/EBV is rare in an immune-competent patient, but both can present with infectious mononucleosis. Although acute hepatitis can happen in both cases, it is more likely due to CMV. This patient did not have typical symptoms of infectious mononucleosis on presentation, and lymphoma and other causes were considered. A high degree of suspicion helped us to do serology that confirmed the diagnosis. Treatment is supportive in an immune-competent patient.

Effects of pretreatment radiological and pathological lymph node statuses on prognosis in patients with ovarian cancer who underwent interval debulking surgery with lymphadenectomy following neoadjuvant chemotherapy.

To analyze whether radiological and pathological lymph node statuses affected prognosis in patients with epithelial ovarian cancer who underwent neoadjuvant chemotherapy followed by interval debulking surgery. In total, 82 patients undergoing interval debulking surgery, including systematic retroperitoneal lymphadenectomy, were eligible for this study. We retrospectively analyzed the association among radiological diagnosed retroperitoneal lymphadenopathy by computed tomographic scan before (rLN) and after (yrLN) neoadjuvant chemotherapy, pathological lymph node metastasis (pLN) and prognosis. Patient survival distribution was calculated using the Kaplan-Meier method. There were 36 rLN+ cases (44%); there were no significant differences between rLN+ and rLN- with respect to progression-free survival and overall survival. Progression-free survival and overall survival did not differ between yrLN+ cases and yrLN- cases. Thirty-nine cases (47.5%) were pLN+, and both progression-free survival and overall survival were significantly shorter in pLN+ cases than in pLN- cases (P < 0.001 and P = 0.004, respectively). In univariate analysis, FIGO stage, pLN and surgical completion were prognostic factors for overall survival. Moreover, in multivariate analysis, pLN+ was the independent prognostic factor for progression-free survival (P = 0.001, 95% confidence interval: 1.911-15.69), and pLN and surgical completion were the only independent prognostic factors for overall survival (P = 0.046, P = 0.012). Radiological lymph node status may not be a prognostic factor in patients with ovarian cancer who underwent neoadjuvant chemotherapy followed by interval debulking surgery. Pathological lymph node metastasis affects progression-free survival and overall survival.

A clinical report of Burkitt’s lymphoma

Aim. A clinical analysis of Burkitt’s lymphoma (BL) in a 4 years-old female child.Materials and methods. A retrospective analysis was conducted for the history, disease’s course, laboratory and instrumental diagnosis and treatment in patient B. with BL, 4 years old.Results. A 4-yo patient was diagnosed with BL spread to bone marrow, CNS, lymph nodes, both kidneys and spleen. Leukocytosis in common blood profile. Elevated lactate dehydrogenase (LDH) and C-reactive protein (CRP) in biochemical blood profile. Neck lymphadenopathy, mediastinum in computed tomography (CT). Splenomegaly. Multifocal lesion of both kidneys. Retroperitoneal lymphadenopathy. Positive clinical dynamics (normalisation of body weight) is observed with background therapy, LDH 335 U/L in biochemical blood profile, reduced multifocal kidney lesion and spleen size in CT.Conclusion. A clinical case of Burkitt’s lymphoma is reported affecting the bone marrow, CNS, lymph nodes, both kidneys and spleen. Intensive polychemotherapy allowed stabilisation of the patient and containment of oncological processes.