Mass In Tail Research Articles

COVID-19 AS A PROBABLE CAUSE OF PANCREATIC INJURY

COVID-19 AS A PROBABLE CAUSE OF PANCREATIC INJURY

S1676 Things Are Not Always What They Seem: A Rare Case of Pancreatic Carcinoma Manifesting Through Cutaneous Metastasis

Introduction: Pancreatic cancer is an aggressive disease that commonly metastasizes to the liver, lung, and peritoneum. Cutaneous metastasis is a rare occurrence with an incidence of only 2.0%. We present a case of metastatic pancreatic adenocarcinoma primarily presenting as a cutaneous nodule. Case Description/Methods: A 50-year-old male was undergoing outpatient evaluation for a raised, left scalp lesion along with neck nodules. Associated symptoms included an unintentional 30lb weight loss. Outpatient CT soft tissue neck revealed numerous necrotic lateral neck lymph nodes, lytic lesion with epidural soft tissue extension at C2-4, and occlusion/thrombosis of the left subclavian, brachiocephalic, and left internal jugular veins (Figure). Given these findings, the patient was referred to the Emergency Department (ED). At time of ED arrival, vital signs were stable along with initial laboratory values. CTA PE study showed no pulmonary embolism but revealed numerous pulmonary and bilateral adrenal nodules, multifocal liver and osseous lesions, and widespread lymphadenopathy. Additionally, CT head demonstrated a left scalp soft tissue lesion. Follow up CT abdomen/pelvis revealed a 2.8 x 2.2 x 1.8 cm ill-defined pancreatic lesion and confirmed widespread metastasis including to the muscles. Additional testing revealed elevated cancer markers with Cancer antigen 19-9 (CA 19-9) of 5418 U/mL and carcinoembryonic antigen (CEA) of 63.8 ng/mL. Pathology from initial scalp lesion biopsy showed fragments of necrotic dermis with small foci of poorly differentiated carcinoma. Biopsies of the right and left neck masses revealed poorly differentiated adenocarcinoma of uncertain primary. Therefore, liver biopsy was performed and confirmed non-small cell carcinoma of pancreatobiliary origin. Further imaging to determine treatment course discovered intracranial metastasis and cervical spine disease resulting in cord compression. Ultimately, the patient underwent 4 out of 10 fractions of palliative radiation to the cervical spine but passed away after transitioning to comfort care one month after diagnosis. Discussion: There are less than 25 documented cases of pancreatic cancer with cutaneous involvement; however, it is even more rare that cutaneous involvement prompts initial diagnosis. The umbilicus is the most common site of cutaneous involvement and is referred to as the Sister Mary Joseph Nodule. Involvement of the soft tissue of the scalp and neck is much less common and poorly documented making this case extremely unique.Figure 1.: Axial contrast enhanced CT of the abdomen shows a 2.8 cm ill-defined hypoattenuating mass in the pancreatic tail (A) with multifocal metastatic liver lesions and bilateral adrenal metastasis (B). Axial CT image of the pelvis shows a metastatic lesion in the right rectus femoris muscle (C). On liver biopsy, H&E, 40X,(S21-41666) revealed high grade carcinoma with vesiculated nuclei, prominent nucleoli (D), CA 19-9 IHC 20X diffuse positivity in tumor cells (E) and CK AE1/3 IHC, 20X, diffusely positivee for pancytokeratin in tumor cells confirming carcinoma (F). Axial CT of the head shows a 2.4 cm nodular left parietal scalp soft tissue lesion (G) which was also seen on clinical examination (H). Biopsy of the scalp lesion (H&E, 40X) demonstrated high grade carcinoma with vesiculated nuclei, prominent nucleoli and mitoses (I), histologically similar to liver biopsy findings.

S3084 Metastatic Pancreatic Tail Adenocarcinoma Presenting With Multiple Hepatosplenic Abscesses: A Case Report

Introduction: Pancreatic cancer is the third leading cause of cancer-related deaths in the United States. It is often detected in advanced stages and may present in unusual ways such as pyogenic liver abscesses (PLA) or splenic abscesses which may be a diagnostic and therapeutic challenge. Case Description/Methods: A 78-year-old dialysis-dependent man with a history of end stage renal disease, hypertension and cerebrovascular accident was evaluated for diffuse abdominal pain and altered mental status for one day. The examination was pertinent for generalized weakness and altered sensorium. Laboratory tests revealed transaminitis and leukocytosis. Computed tomography (CT) of the abdomen and pelvis showed multiple hypoattenuating hepatic foci with hepatosplenomegaly. A set of blood cultures grew Clostridium inoculum. A pyogenic liver abscess was diagnosed, drained percutaneously and the culture grew pansensitive Escherichia coli. A follow up CT of the abdomen and pelvis revealed a large splenic abscess. Exploratory laparotomy, splenectomy, liver biopsy and peritoneal lavage were performed. Immunostaining of the sample was positive for CK7, CK20 and CDX2. Pancreaticobiliary adenocarcinoma metastatic to the spleen and liver was confirmed by pathology. CA 19-9 and CA 125 were elevated. A repeat CT of the abdomen with pancreatic protocol showed a pancreatic tail mass. Vancomycin resistant Enterococcus faecium grew on peritoneal fluid culture. Daptomycin and ceftriaxone were started. The patient improved clinically but he was deemed unsuitable for further invasive procedures or chemotherapy. (Figure) Discussion: Uncommon presentations of pancreatic adenocarcinoma include gastrointestinal (GI) bleeding from metastasis and acute abdomen from splenic infarct. PLA is associated with GI malignancies including pancreatic cancer. Some experts recommend cancer evaluation for GI malignancies in patients with PLA. Mucosal barrier breach by cancer cells, translocation of bacteria into the circulation and inoculation at metastatic sites are possible explanations for developing liver and splenic abscesses. Dialysis is also a risk factor for hepatosplenic abscess. In an elderly patient with hepatosplenic abscess and elevated tumor markers, a thorough evaluation for GI malignancies including pancreatic cancer should be done.Figure 1.: Image 1 shows cancer in the spleen. Images 2-3 show positive immunostains for CK7 in image 2, CK20 in image 3. Image 4 shows the cancer in the liver biopsy (no normal liver is present). Image 5 shows non-enhancing hypoattenuated foci in the right and left lobes of the liver most consistent with multifocal liver abscesses. Image 6 shows splenomegaly with multiple hypoattenuated foci and a mass within the tail of the pancreas.

Microcystic serous cystadenoma mimicking pancreatic neuroendocrine neoplasm: report of a resected case with preoperative diagnostic difficulty and review of the literature

BackgroundMicrocystic pancreatic serous cystadenoma (SCA) can be managed without surgery in selected patients. However, the preoperative diagnosis of microcystic SCA remains challenging, and it is potentially misdiagnosed as other pancreatic cystic neoplasms or solid tumors, especially small microcystic SCA.Case presentationThis was a case of a 27-year-old male patient with microcystic SCA causing difficulty in the differential diagnosis from pancreatic neuroendocrine neoplasm (pNEN). A pancreatic tail mass was incidentally discovered on abdominal ultrasound (US). A contrast-enhanced computed tomography (CT) scan revealed a solid tumor measuring 13 mm with early enhancement in the arterial phase at the pancreatic tail. The tumor showed low intensity on T1-weighted magnetic resonance image, high intensity on T2-weighted image, and a slightly hyperechoic mass on endoscopic US (EUS). EUS-fine needle aspiration (EUS-FNA) did not lead to a definitive diagnosis. The tumor was clinically diagnosed as a pNEN, and a laparoscopic spleen-preserving distal pancreatectomy using the Warshaw technique was performed. The final histopathological diagnosis was microcystic SCA.ConclusionSmall microcystic SCA is difficult to distinguish from a hypervascular pancreatic tumor such as pNEN on imaging studies, and it is necessary to focus on the tumor echogenicity of EUS to differentiate microcystic SCA from pNEN preoperatively.

The great masquerader of pancreatic tuberculosis

BackgroundPancreatic tuberculosis is a rare clinical entity. It represents a diagnostic challenge as the clinical presentation may mimic pancreatic malignancy.Case presentationA 66-year-old gentleman presented with an incidental finding of a pancreatic tail mass on routine ultrasonography of the abdomen whilst working up on chronic kidney disease. He denied abdominal pain, fever, night sweats, constitutional symptoms or tuberculosis contact. On examination, there was no palpable mass per abdomen. The tumour marker of Ca 19-9 was normal. Ultrasonography revealed a lobulated heterogeneous hypovascular and hypoechoic mass at the tail of the pancreas. Contrast-enhanced computed tomography (CT) of the thorax and abdomen revealed a thickened right pleura, right pleural effusion with right lung collapsed consolidation and multiple mediastinal lymph nodes. There is an ill-defined hypodense mass seen in the tail and body of the pancreas measuring 3 × 7 × 3 cm with the presences of calcification within. The constellation of CT findings suggests a pancreatic malignancy with metastasis to the lungs. Endoscopic ultrasonography (EUS) assessment showed an irregular hypoechoic mass measuring 3.0 × 2.7 cm at the tail of the pancreas. Multiple rounded hypoechoic lesions were also seen scattered within the body of the pancreas with multiple enlarged para-aortic lymph nodes. A fine-needle aspiration biopsy of the lesion was consistent with granulomatous inflammation. The diagnosis of disseminated tuberculosis was made. The patient was subsequently started on antitubercular medication and recovered well.ConclusionA high index of suspicion is needed to diagnose pancreatic tuberculosis, especially in patients whose radiological imaging shows a pancreatic mass with necrotic peripancreatic lymphadenopathy in endemic countries. EUS-guided fine-needle aspiration is the diagnostic modality of choice, and vigorous attempts should be made at obtaining a preoperative histological or bacteriological diagnosis to avoid unnecessary surgery.

A Pancreatic Tumor With Homogeneous Hyper-Enhancement Under Contrast-Enhanced Endosonography Showing an Unexpected Pathology Finding

Question: A 35-year-old man without past systemic disease presented with epigastralgia for 1 week and weight loss of 10 kg during the past few months. Abdominal sonography found a suspicious lesion over pancreatic body-tail, and contrast-enhanced computerized tomography (CE-CT) showed one 3.0-cm well-circumscribed mass in pancreatic tail, with hypo-density in the precontrast phase and progressive peripheral enhancement in the arterial phase (Figure A). Endosonography was performed, which showed a 30.6-mm x 21.9-mm isoechoic tumor at pancreatic tail, and homogeneous hyper-enhancement of the lesion was noted 12 seconds after sonazoid 0.5-mL injection, without evident washout during the procedure (the observation time lasted up to 210 seconds; Figure B).

Characterizing the complex shear modulus of materials with an iPhone

Dynamic mechanical analysis (DMA) is a technique that accurately measures the mechanical properties, such as stiffness and damping, of a material as a function of frequency, temperature, and time. However, DMA is expensive, requires significant training to operate, and must be performed on-site, lending itself impractical for hands-on classroom activities or research during the early stages of a global pandemic. To characterize the complex shear modulus of seagrass during the COVID-19 shelter-in-place order in May 2020, an iPhone XS Max was used as the tail mass of a freely oscillating torsional pendulum. The Vibrations application (Diffraction Limited Design, LLC) acquired the angular velocity of the underdamped system during oscillation, and the damped natural frequency and decay rate were later extracted from the time series. By measuring the cross-section and length of the material under test, the natural frequency and decay rate were used to determine the complex shear modulus. A strip of 1-cm-wide polyethylene film (McMaster Carr #85655K13) was first used to test the measurement technique. iPhone-obtained shear modulus of the strip was within the range of tabulated values, and was in agreement with DMA-obtained shear modulus measured after COVID-19 restrictions were relaxed. Uncertainty analysis and instructional applications will be discussed.

Skeletal Metastases of Unknown Primary: A Rare Presentation of Carcinoma Pancreas on Fludeoxyglucose Positron Emission Tomography-Computed Tomography.

Skeletal metastases of unknown primary represent skeletal metastases where primary tumors remain obscure. They usually arise from lung and prostate cancer. We present a case of a young male who presented with severe bone pains, weight loss, and generalized weakness. Fludeoxyglucose positron emission tomography–computed tomography reveals extensive skeletal metastases, a mass in the pancreas tail, and other metastatic lesions. He had no liver or lung metastases. This case presents a rare presentation of carcinoma pancreas.

S1555 Stage IV Tail of the Pancreas Tumor Presenting With Obstructive Jaundice Secondary to Liver Metastasis

Introduction: Pancreatic cancer is an aggressive disease with a poor prognosis. It is most commonly found in the head of the pancreas and 20-25% in the body and tail. The clinical manifestations vary based on the location and spread of the tumor. Case Description/Methods: Our patient is a 55-year-old male with a past medical history of hypertension and nicotine use disorder who presented with dull epigastric abdominal pain of 3-month duration. The review of systems was significant for anorexia, unintentional weight loss of 40 pounds, tea-colored urine, and acholic stool. He was vitally stable. Physical examination showed scleral icterus and a diffusely tender abdomen without peritoneal signs. Laboratory work showed elevated AST, ALT, alkaline phosphatase, total bilirubin, direct bilirubin, and lipase. A computerized tomography (CT) scan of the abdomen revealed a mass in the pancreatic tail, multiple heterogeneous hypodense hepatic masses, and basilar lung nodular opacities. An abdominal ultrasound (US) showed ascites, multiple hepatic masses, intrahepatic biliary dilatation, and a common bile duct of 7 mm. US-guided liver and pancreas biopsies were performed. Magnetic resonance cholangiopancreatography (MRCP) revealed a 3.5 cm mass in the tail of the pancreas, multiple hepatic masses that were compressing the common hepatic duct, and retroperitoneal lymphadenopathy (Figure 1). Histopathology studies confirmed stage IV pancreatic adenocarcinoma with metastasis to the liver, lung, and peritoneum. Given the patient's extensive metastatic disease, he was not a candidate for chemotherapy or surgical intervention. Hospice and palliative care were pursued. Discussion: Tumors of the body and tail of the pancreas have been associated with poor outcomes with a 0-25% 5-year survival rate even after surgical resection. Its late presentation prompts an increased risk of distant lymphatic and hematogenous dissemination when compared with pancreatic head neoplasms. Consequently, patients with tumors originating in the head of the pancreas often present early with symptomatic obstructive jaundice. Interestingly, our patient presented with obstructive jaundice, but it was caused by intrahepatic cholestasis secondary to liver metastasis compressing the common hepatic duct. This case highlights that even as obstructive jaundice is most frequently related to pancreatic head malignancies, pancreatic body/tail neoplasms may have this clinical presentation in the presence of liver metastasis.Figure 1.: MRCP of abdomen showing a mass in the tail of the pancreas (Black arrow) and multiple hepatic masses (White arrow).

S1521 Solid Pseudopapillary Neoplasm: Case Report of a Rare Pancreatic Tumor

Introduction: Solid pseudo-papillary neoplasm (SPN) is a rare low-grade malignant cystic exocrine neoplasm of the pancreas with a distinctive pathologic architecture. It is usually diagnosed incidentally, and complete resection is mainly curative with excellent long-term prognosis despite a small malignant potential. Case Description/Methods: A 28 yo female with history of lumbar disc herniation and subsequent micro-discectomy, presented to the emergency department with a 1-day history of severe left upper quadrant abdominal pain, nausea, and vomiting. She denied any other symptom or previous trauma. On physical examination, the abdomen was soft with mild tenderness in LUQ, and no rebound or palpable mass. Lab evaluation showed a mild leukocytosis (16.5K), but otherwise liver tests and pancreatic enzymes were within normal limits. CT scan showed an obstructing ureteral calculus and a large 7.1 cm incidental mass in the pancreatic tail with chronic splenic vein occlusion. MRCP later confirmed a 6.8 x 7.5 x 7.7 cm heterogeneous but well defined/encapsulated arising from the pancreatic tail/distal body. The lesion had heterogeneous enhancement, diffusion restriction, and areas of T1 hyperintensity. The patient successfully underwent a laparoscopic distal pancreatectomy and splenectomy and was discharged home after 3 days. Pathology confirmed the suspected diagnosis of SPN of the pancreas with samples negative for foci of malignancy. Immuno-histochemical stains revealed tumor cells to be positive for beta-catenin, cyclin D1, CD10 and synaptophysin, while negative for chromogranin. Discussion: SPN is considered a low-grade malignant pancreatic tumor according to the WHO Classification of Digestive System Tumors, with reported malignant transformation of around 15-16%. Despite this, SPN still has a generally excellent long-term prognosis. SPNs have a characteristic appearance on cross-sectional imaging, appearing as a mixed solid and cystic pancreatic lesion, however cytologic analysis is usually done for confirmation of the diagnosis. The use of pre-operative biopsy or EUS-FNA has been controversial and is felt to be of limited benefit. In our patient, the post-operative cytologic diagnosis after surgery proved valuable for establishing the diagnosis with no need for pre-operative EUS-FNA. Treatment usually is surgical resection, which is curative; appropriate clinical follow-up is warranted due to risk of local recurrence. There is no clear role for systemic chemotherapy, hormonal therapy, or radiotherapy.Figure 1.: A. MRI abdomen and pelvis with contrast T2 Coronal showing a heterogenous well defined and encapsulated partially exophytic mass arising from the pancreatic tail/distal body. B. Axial LAVA (3D T1 weighted sequence with Fat Suppression) pre-contrast. C. LAVA post-contrast Figure 2-D. Solid sheet of uniform tumor cells showing focal loosely cohesive pseudopapillary architecture (Hematoxylin & Eosin, x 100). E. Nuclear and cytoplasmic immunoreactivity for B-catenin (B-catenin immunohistochemical stain, x 200).

Design of wideband tonpilz transducers for underwater SONAR applications with finite element model

This paper describes the designing and optimization of tonpilz type transducers based on number of layers, width and thicknesses and type of active materials, dimensions of head and tail mass by exploiting finite element models for their effective and optimized usage in underwater SONAR applications. Geometry parameters of tonpilz transducers have been studied in terms of active piezoelectric stack and associated components comprised of head and tail masses and optimized structure is explored. Piezoelectric stack including piezoceramic material (PZT-4) and single crystal (PMNPT), is utilized for underwater acoustic generation, while Aluminum is taken as head mass and highly attenuated material stainless steel is used for tail mass. Performance of tonpilz transducer has been investigated and evaluated in terms of total radiating power (TRP), transmitting voltage response (TVR), directivity index and specific acoustic impedance for all designed structures. Comparison is carried out for the optimized structure that provides high sensitive frequency region in form of constant TVR and maximum sound directivity used for accurate under water detection applications. TVR in the sensitive region using PMNPT as the stack material shows enhanced results as compared to PZT-4. Sound intensity level in terms of TRP peaks also rises with a greater number of layers for both PMNPT and PZT-4 driving stack materials. Furthermore, it has been observed that Driving stack material is more effective than the other components of Tonpilz transducer because it effects the flat response and also enhances the TVR response. Secondly, head mass of the Tonpilz transducer is more effective than the remaining because resonance and flexural frequency depend on it.

A Pancreatic Tail Mass in a Young Male

A Pancreatic Tail Mass in a Young Male

Two Extremes of Dysglycemia- a Rare Case of Diabetes Complicated With a Non-Functional Pancreatic Neuroendocrine Tumor Transforming to an Insulinoma

Background: Diabetes is characterized by hyperglycemia with heterogeneous pathophysiological features and varied presentation and consequences. Here, we present a rare case of diabetes that was complicated with insulinoma making glycemia management complicated. Clinical Case: A 48-year-old white man was diagnosed with diabetes when he presented with weight loss, polyuria and polydipsia and HbA1c of 11%. He was treated with oral agents for few months without a good response then switched to insulin. He was assumed to have type 1 diabetes and had fairly well controlled glycemia on multi daily injection of insulin. He was diagnosed with a metastatic non-functional pancreatic neuroendocrine tumor (PTEN) 9 years later. He presented with epigastric pain and CT scan showed a mass in the pancreas tail and multiple lesions in liver. The tumor was immunopositive for S100, synaptophysin, and chromogranin. He was first treated with sunitinib and later switched to Everolimus. He underwent treatment with SIR-spheres which was complicated with post-embolization syndrome and Diabetes Ketoacidosis (DKA). He was switched back to Everolimus and referred to the endocrinology clinic for management of diabetes with a recent DKA. At the initial evaluation by the endocrinology team, he had BMI of 25 kg/m2, no significant family history of diabetes, no diagnosis of dyslipidemia or hypertension. He had low C-peptide < 0.1 ng/mL (n: 0.8 - 5.2 ng/mL) and negative GAD antibody suggestive of non-immune mediated insulin deficient diabetes. He was treated with basal plus prandial insulin regimen and required about 0.6–0.7 unit/kg of insulin each day. Due to progression of PTEN, he was started on monthly Lanreotide while later Pembrolizumab was added resulting in hypothyroidism with a TSH of 75 mIU/L (n: 0.45 - 5.33 mIU/L) that was treated with Levothyroxine. Meanwhile, his diabetes care was complicated by recurrent hypoglycemic episodes and hypoglycemia unawareness. He gradually decreased the dose of insulin, stopped taking prandial insulin, and finally discontinued basal insulin due to recurrent hypoglycemia. He continued to have hypoglycemia despite stopping insulin. His C-peptide was found to be 3.3 ng/mL with a low BG of 62 mg/dl. Diazoxide was started and despite maximizing the dose, the patient continued experiencing hypoglycemia. He therefore decided to stop taking Diazoxide and only continued monthly Lanreotide. The patient is currently avoiding hypoglycemia by eating frequently (every 3 hours) and has regained his hypoglycemia awareness. Conclusion: This is a rare case of non-immune mediated insulin deficient diabetes complicated by recurrent episodes of hypoglycemia due to a non-functioning PNET converting to a functional tumor producing insulin.

The Diagnosis and Management of a Rare ACTH-Producing Neuroendocrine Tumor Causing Cushing’s Syndrome

A 57-year-old woman presented with a three-month history of worsening lethargy, weight gain, central adiposity, proximal muscle weakness, and hypokalemic hypertension. Initial investigations were consistent with ACTH-dependent Cushing’s Syndrome. 24-hour urine cortisol: 711nmol/day (normal<275), cortisol after 1 mg dexamethasone suppression test 960nmol/L (normal<50)), 2-day dexamethasone suppression cortisol: 575 and ACTH: 19 pmol/L. MRI sella was normal. She required several hospital admissions for worsening proximal muscle weakness and falls. She was started on ketoconazole and spironolactone. Basal insulin was started for dysglycemia. Petrosal vein sampling indicated ectopic ACTH production. CT scan of chest/abdomen/pelvis showed no intrathoracic or intra-abdominal abnormality. Thyroid ultrasound and whole-body octreotide scan showed no abnormalities. A Gallium 68-dotatate PET scan showed focal tracer uptake in the pancreatic tail suspicious for a well-differentiated neuroendocrine tumor (NET). MRI pancreas showed a slightly truncated pancreatic tail with no discrete lesion. We proceeded with Endoscopic Ultrasound (EUS) which revealed an irregular hypoechoic mass in the pancreatic tail. EUS–guided fine-needle biopsy (EUS-FNB) using a 22G SharkCore needle, revealed a neuroendocrine neoplasm staining positively for ACTH. She underwent distal pancreatectomy with pathology showing a 1.4cm well-differentiated NET, staining positive for ACTH with a Ki67 index of 10%. Postoperatively, her ketoconazole, spironolactone, and insulin were discontinued. Her dysglycemia, hypertension and other clinical symptoms gradually improved. Immediately post-operatively, her AM cortisol was 403 and her 24-hour urine cortisol was elevated 959nmol/day. Repeat AM cortisol and 24-hour urine cortisol one-month post-surgery were 392 nmol/L and 72 nmol/day respectively, confirming biochemical remission. Discussion: ACTH-producing pancreatic NETs are rare, accounting for less than 15% of reported cases of EAS. They are often aggressive, with 78.7% of reported cases having distant metastasis at diagnosis (1). They are associated with significant morbidity and mortality. Diagnosis and management can be difficult and require multiple investigations and multidisciplinary team involvement. In our case, we utilized endoscopic ultrasound to ensure a correct preoperative localization. We discuss the systematic approach for diagnosis and the management of an ACTH-producing pancreatic NET.

A Rare Presentation of Multiple Endocrine Neoplasia Type 1

Background: Multiple endocrine neoplasia type 1 (MEN1) is a rare, autosomal dominant inherited syndrome caused by mutations in the MEN1 tumor suppressor gene with a reported incidence of 2 in 100,000.Clinical Case: A 26-year-old Caucasian female was seen for surveillance screening given positive familial mutation in the MEN1 gene. She had a significant family history of pathogenic MEN1 in her son, brother, father and paternal aunt. On presentation, she denied any history of headache, nipple discharge, kidney stones, fractures, heart burn, abdominal pain, diarrhea, hypoglycemia, flushing, lightheadedness. She was on hormonal IUD for contraception and had not had menstrual cycles for the last 6 months. Vital signs and physical examination were unremarkable. Her initial evaluation included a normal calcium of 9.8mg/dL (RR:8.6-10.6mg/dL), PTH of 70pg/ml (RR:12-88pg/ml), 25OH-vitamin-D of 11ng/ml (RR:20-80ng/ml). She had normal gastrin, chromogranin A, glucagon, and vasoactive intestinal peptide levels. Prolactin was 17.6ng/ml (RR:3.3-26.7 ng/ml). MRI pituitary showed a 6mm lesion representing a Rathke’s cleft cyst, not compressing surrounding structures.Two months following the initial encounter, she presented with abdominal pain, nausea, vomiting. She was found to have an obstructing renal stone requiring stent placement. Calcium was 10.1mg/dl. She was also noted to have an incidental pancreatic tail mass of 4.2cm on CT abdomen. She underwent laparoscopic robotic distal spleno-pancreatectomy. Surgical pathology showed a well differentiated 3.5cm neuroendocrine tumor with negative margins, which stained positively for insulin. She had not reported symptoms of weight gain or any episodes suspicious for sympathoadrenal activation or neuroglycopenia, and was again confirmed after surgery.Patient was re-admitted to the hospital for right-sided flank pain and was found to have a new 6mm obstructing calculus with moderate hydronephrosis of the right kidney. Corrected calcium level was found to be mildly elevated at 11.1mg/dL. Repeat PTH was stable at 81pg/ml, and urinary calcium was elevated at 447.3mg/24h (RR:50-250mg/24h). Subsequently, she underwent 3.5 gland parathyroidectomy and thymectomy. On POD20, PTH was 29pg/ml and calcium was 8.6mg/dl.Conclusion: This case highlights a rare presentation of MEN1 with an asymptomatic insulinoma and nephrolithiasis, despite having normal calcium and PTH levels initially. Primary hyperparathyroidism is the most common presentation of MEN1, seen in up to 90% of patients. The second most common finding in MEN1 patients, reported in 70% of the cases, are entero-pancreatic tumors, the most common being gastrinoma. Insulinoma, which is less common and is seen in only 10-30% patients, needs documentation of Whipple’s triad. Interestingly, our patient never had any history of hypoglycemia.

Lymphoepithelial cyst mimicking pancreatic cancer: a case report and literature review

BackgroundPancreatic lymphoepithelial cyst (LEC) is a rare nonmalignant cyst consisting of a benign collection of keratinizing squamous epithelial cells with lymphoid tissue. Diagnosing LEC preoperatively is considered difficult because of its non-specific clinical features; therefore, LEC is generally treated the same as a malignant tumor.Case presentationOur case was a 65-year-old man who underwent pancreatoduodenectomy 3 years previously for carcinoma arising from the ampulla of Vater. A pancreatic mass in the remnant pancreatic tail was detected through follow-up abdominal contrast-enhanced computed tomography (CT). This revealed two adjacent ring-enhanced masses that had been in tight contact with the left diaphragm and were enlarged. The tumors had high signal intensity in diffusion-weighted images of magnetic resonance imaging, and fluorodeoxyglucose-positron emission tomography (FDG-PET) showed abnormal uptake (standardized uptake value maximum: 17.4). Therefore, we conducted a partial resection of the remnant pancreas with concomitant resection of the left diaphragm. Microscopically, one of the tumors revealed rare fragments of apparently benign squamous epithelium on a background of keratinous debris, cyst contents, and scattered lymphocytes, and the adjacent mass revealed infiltrated neutrophils. The histopathological diagnosis was an LEC with chronic abscess. The patient recovered uneventfully and was discharged on postoperative day 10.ConclusionsWe reported a rare case of LEC with chronic abscess that was positively visualized on FDG-PET. When a pancreatic malignancy cannot be excluded, surgical resection is considered inevitable.

Breast cancer in multiple endocrine neoplasia type 1 (MEN1).

SummaryA 38-year-old female was identified as carrying a heterozygous pathogenic MEN1 variant (c.1304delG) through predictive genetic testing, following a diagnosis of familial hyperparathyroidism. Routine screening for parathyroid and pituitary disease was negative. However, cross-sectional imaging by CT revealed a 41 mm pancreatic tail mass. Biopsy via endoscopic ultrasound confirmed the lesion to be a well-differentiated (grade 1) pancreatic neuroendocrine tumour (pNET) with MIB1<1%. Biochemically, hyperinsulinaemic hypoglycaemia was confirmed following an overnight fast, which was subsequently managed by diet alone prior to definitive surgery. Pre-operative work-up with octreotide SPECT CT demonstrated avid tracer uptake in the pancreatic lesion and, unexpectedly, a focal area of uptake in the left breast. Further investigation, and subsequent mastectomy, confirmed ductal carcinoma in situ pT2 (23 mm) grade 1, N0 (ER positive; HER2 negative). Following mastectomy, our patient underwent a successful distal pancreatectomy to resect the pNET. Loss of heterozygosity (LOH) at the MEN1 locus was found in both the breast tumour and pNET, thereby in keeping with a 'two-hit' hypothesis of oncogenesis, a suggestive but non-definitive clue for causation. To obtain further support for a causative relationship between MEN1 and breast cancer, we undertook a detailed review of the published literature which overall supports the notion that breast cancer is a MEN1-related malignancy that presents at a younger age and histologically, is typically of ductal subtype. Currently, clinical guidance regarding breast cancer surveillance in MEN1 does not exist and further research is required to establish a clinical and cost-effective surveillance strategy).Learning pointsWe describe a case of pNET and breast cancer diagnosed at a young age of 38 years in a patient who is heterozygous for a pathogenic MEN1 variant. Loss of the wild-type allele was seen in both breast tissue and pNET specimen.Breast cancer may be an under-recognised MEN1-associated malignancy that presents at a younger age than in the general population with a relative risk of 2–3.Further research is required to determine the cost-effectiveness of breast cancer surveillance approach at a younger age in MEN1 patients relative to the general population .

Predictive Values of Preoperative Markers for Resectable Pancreatic Body and Tail Cancer Determined by MDCT to Detect Occult Metastases.

To evaluate the clinical value of preoperative markers in predicting occult metastases in resectable pancreatic body and tail cancer judged by a recent multidetector computed tomography (MDCT) scan of the abdomen. The data from a retrospective collected database from 2010 to 2019 with 699 patients who had MDCT scan predicted resectable mass in pancreatic body and tail and were pathological confirmed as adenocarcinoma after surgery. Receiver operating characteristic (ROC) curve was plotted for serum CA19-9, CA125, CEA and tumor size measured by MDCT. The optimal cut-off point-related sensitivity and specificity were calculated, respectively. Occult metastases were found in 73 (73/699, 10.4%) pancreatic body and tail cancer patients underwent exploration. The area under curve (AUC) for CA19-9, CA125, CEA and tumor size were 0.624, 0.733, 0.561 and 0.697, respectively. The optimal cut-off for CA19-9, CA125 and tumor size is 226 U/ml, 22.1 U/ml and 3.3cm, respectively. The sensitivity and specificity of CA19-9 for predicting occult metastases were 67.1% and 60.4%, 72.6% and 64.7% for CA125, 80.8% and 51.4% for tumor size. CA125 is superior to CA19-9 and tumor size for predicting occulting metastases in MDCT scan suggested resectable pancreatic body and tail cancer. The high level of CA125 (≥ 22.1 U/ml) is regarded as high risk for occulting metastases, and laparoscopy should be applied for these patients.

Spontaneous Rupture of Pancreatic Acinar Cell Carcinoma: Report of a Case

Introduction Pancreatic acinar cell carcinoma (ACC) is a relatively rare neoplasm. Furthermore, tumor rupture is extremely rare. Only 1 case of ruptured pancreatic ACC has been reported, and the long-term outcome of the case is unknown. Here, we present a case of spontaneously ruptured ACC with long-term survival after successful resection. Case Presentation A 67-year-old man was brought to our hospital by ambulance, presenting with progressive left abdominal pain. Laboratory data showed an increased inflammatory response, and contrast-enhanced computed tomography showed a mass in the pancreas tail with nonuniform enhancement in the early phase. Fluid collection was detected around the spleen to the left kidney. Spontaneous rupture of a pancreatic tumor was strongly suspected. After improvement of his general condition, the patient underwent resection of the pancreas and adjacent organs. The resected tumor was surrounded by organs and adipose tissue, so obvious exposure was not observed in the surgical margins. Pathologically, neither exposure of tumor cells at the surgical margins nor lymph node involvement was detected. The patient has survived 80 months since initial diagnosis without any evidence of recurrence. Conclusion Although ruptured pancreatic ACC has the potential for dissemination, surgical resection including adjacent organs remains an option for curative treatment.

Application of Shear Wave Elastography to Evaluate the Stiffness of Normal Testes and Inflammatory Epididymal Tail Masses.

This study aimed to investigate the application value of shear wave elastography in examining normal testes and inflammatory epididymal tail masses. We examined 110 healthy male volunteers (with a total of 220 testes) and 25 patients with epididymitis via conventional scrotal ultrasonography and shear wave elastography. The mean (Emean), minimal (Emin), maximal (Emax), and standard deviation (ESD) values of elasticity were acquired. The inflammatory masses were assessed at initial diagnosis, at weeks 1 and 2 of standard anti-inflammatory treatment, upon remission, and at 2 weeks after remission. The Emean values of different regions in testes varied in the following order: center region (3.14 ± 0.35 kPa) < upper- or lower-pole capsule (upper, 3.94 ± 0.90 kPa; lower, 3.94 ± 0.97 kPa) < posterior capsule (5.96 ± 1.46 kPa) < anterior capsule (6.27 ± 1.58 kPa). The Emean value of the center of the testicular parenchyma in the short axis was significantly larger than that in the long axis (3.47 ± 0.32 vs 3.14 ± 0.35 kPa; P < 0.05). There were significant differences in the Emean value between inflammatory epididymal tail masses at initial diagnosis, at 1 and 2 weeks after treatment, upon remission, and at 2 weeks after remission (P < 0.05). Shear wave elastography can be used to reflect the relative hardness of normal testes and inflammatory epididymal tail masses.