Thick-walled Mass Research Articles

S2836 Gastrohepatic Ligament Bronchogenic Cyst Diagnosed by EUS FNA

Introduction: Bronchogenic cysts pose diagnostic and therapeutic challenges due to its varied locations and presentations. Case Description/Methods: 58-year-old woman presented with two weeks of epigastric and RUQ abdominal pain. Presenting labs: TB 4.3 mg/dL, DB 3.4 mg/dL, AP 328 U/L, AST 1,265 U/L, ALT 1,890 U/L. Workup was negative for pancreatitis, acute hepatitis, and acetaminophen toxicity. CT scan showed biliary duct dilatation with a 5mm stone in the common bile duct, and a 3.5 x 3.6 cm thick-walled mass with rim enhancement and hypodense central component within the gastrohepatic ligament (GHL) (A). EUS characterized the mass as a hypoechoic cystic lesion with a concentric 4mm thick wall (B). Fine needle aspiration (FNA) of the cyst produced 14ml of brown and viscous fluid. After cyst aspirate, FNA of the decompressed cyst wall was also performed. Cyst fluid amylase was < 3 U/L, CEA was 157 ng/mL, and cytology was negative for malignancy. Cytology of the cyst wall showed benign ciliated columnar epithelial cells consistent with a bronchogenic cyst (C). ERCP was performed during EUS for stone extraction. She then underwent cholecystectomy with improvement of symptoms and liver enzymes. Her asymptomatic bronchogenic cyst is undergoing active surveillance. (Figure) Discussion: Bronchogenic cysts are foregut-derived malformations of the respiratory tract and while relatively rare, is the most common primary cyst of the mediastinum accounting for 6-15% of primary mediastinal masses. The location depends on the embryological stage of development when the anomaly occurs. Most are in the mediastinum and uncommonly in the lung parenchyma, esophagus, heart, subdiaphragm, and retroperitoneum. Only one other case has been reported of a bronchogenic cyst in the GHL. Reported prevalence is 1:42,000-68,000 admissions in two hospital series. Some present with symptoms such as cough, fever, pain, and dyspnea. Complications can arise with compression of mediastinal structures, recurrent infection, hemorrhage, rupture, and malignant degeneration. Others are asymptomatic and incidentally found on chest radiograph or cross-sectional imaging. No standard exists for treatment. Traditionally, patients underwent surgical excision for definitive diagnosis and management. EUS FNA serves as a less invasive method for diagnosis. Controversy still exists regarding management of asymptomatic cysts with several reports advocating for complete removal due to likelihood of development of symptoms and potential for serious illness.Figure 1.: CT, EUS, Cytology.

Ovarian cysts

Ovarian cysts

Adult residual rectourethral fistula and diverticulum presenting decades after imperforate anus repair: a\xa0case report

BackgroundThis report describes a rare surgical case of an intraabdominal mass in a middle-aged patient 40 years after imperforate anus repair.Case presentationA 44-year-old Latino male with history of repaired anorectal malformation presented with recurrent urinary tract infections and rectal prolapse with bothersome bleeding and fecal incontinence. During his preoperative evaluation, he was initially diagnosed with a prostatic utricle cyst on the basis of magnetic resonance imaging findings, which demonstrated a cystic, thick-walled mass with low signal contents that extended inferiorly to insert into the distal prostatic urethra. However, at the time of surgical resection, the thick-walled structure contained an old, firm fecaloma. The final pathology report described findings consistent with colonic tissue, suggesting a retained remnant of the original fistula and diverticulum.ConclusionsAlthough rare, persistent rectourethral fistula tracts and rectal diverticula after imperforate anus repair can cause symptoms decades later, requiring surgical intervention. This is an important diagnostic consideration for any adult patient with history of imperforate anus.

Vibrations of Cylindrical Shell Structures Filled With Layered Viscoelastic Material

A thin-walled shell and a thick-walled mass (cylinder) in contact with it, made of a different material, are structural elements of many machines, apparatus, and structures. The paper considers forced steady-state vibrations of cylindrical shell structures filled with a layered viscoelastic material. The study aims to determine the damping properties of vibrations of a structurally inhomogeneous cylindrical mechanical system under the influence of harmonic loads. The dynamic stress-strain state of a three-layer cylindrical shell filled with a viscoelastic material under the action of internal time-harmonic pressure is investigated. The oscillatory processes of the filler and the bonded shell satisfy the Lamé equations. At the contact between the shell and the filler, the rigid contact conditions are satisfied. Dependences between stresses and strains for a linear viscoelastic material are presented in the form of the Boltzmann-Voltaire integral. The method of separation of variables, the method of the theory of potential functions (special functions), and the Gauss method are used to solve this problem. Based on the analysis of the numerical results, it was found that the dependence of the resonant amplitude of the shell displacements on the viscous properties of the filler is 12-15%. Analysis of the results obtained shows that the study of vibrations of shells containing fillers according to the rod theory will lead to rather large erroneous results (up to 20%).

S3544 What's That Cyst?

INTRODUCTION: Pancreatic cysts are rare in children and consist of six classifications: congenital, retention, duplication, pseudocyst, neoplastic, or parasitic. Most pancreatic cysts are asymptomatic but can be symptomatic if causing mass effect on adjacent structures. This is a case of a pediatric pancreatic cyst. CASE DESCRIPTION/METHODS: An 11-year-old Caucasian Female presented for progressive acute on chronic abdominal pain with associated nausea, vomiting, and weight loss for 2 to 3 years. The patient had no previous medical, surgical, or travel history. Right upper quadrant abdominal ultrasound demonstrated a complex cystic mass measuring 7.41 × 7.11 × 7.17 cm with a focal solid area representing hemorrhage, concerning for a complex mesenteric cyst or duplication cyst. Given this finding, the patient underwent a computed tomography scan of the abdomen and pelvis that re-demonstrated the same thick-walled mass, abutting the anterior medial aspect of the second portion of the duodenum, concerning again for a duplication cyst. Of note, there was no biliary ductal dilatation or pancreatic ductal dilation. Comprehensive metabolic panel was significant for only mild elevation of total bilirubin to 0.8 mg/dl. Magnetic resonance imaging of the abdomen again showed a large cystic mass with a diameter of 6.3 cm, contiguous with the pancreatic head and neck with local mass effect on the duodenum, and a moderately thick wall and internal debris. Endoscopic ultrasound demonstrated a septate cystic mass with internal debris measuring 7.2 × 6.0 cm. Given these findings, the decision was made to forego fine needle aspiration of the sterile mass. The patient ultimately underwent a pancreaticoduodenectomy. Final pathology demonstrated a benign pancreatic cyst or congenital pancreatic cyst with no definite epithelial lining. Lymph nodes were negative for malignancy. DISCUSSION: This case highlights a pancreatic cyst that was discovered due to obstructive symptoms. The patient underwent a noninvasive multi-modal imaging technique consisting of ultrasound, CT scan, and MRI leading to endoscopy and eventually surgery to delineate the final pathology of the cyst. Unlike most congenital pancreatic cysts which originate at the pancreatic neck or tail, our patient had a cyst in the pancreatic head with close proximity to the duodenum. As demonstrated in this patient, pancreatic cysts are rare in children and involve a multi-disciplinary approach for appropriate evaluation and management.

Primary hepatic leiomyosarcoma presenting as a thick-walled cystic mass resembling a liver abscess

Rationale:Hepatic leiomyosarcoma is a rare malignant tumor, and in rare instances, its combination with fever may lead to misdiagnosis of liver abscess. In our case, the presence of the tumor was considered by the presence of blood vessels through the observation of hepatic tumor wall.Patient concerns:A 38-year-old woman who had been diagnosed with a liver abscess in a local hospital consulted our institution by complaining left upper quadrant pain and fever. The diagnosis was questioned in our workup, since no obvious inflammatory marker was found in the circulation, and contrast-enhanced computed tomography revealed a huge thick-walled mass in the right liver with multiple tortuous vessels within the wall.Diagnosis:Imaging revealed a neoplastic lesion rather than liver abscess. The enhancement of the solid tumor tissues was reduced during the portal phase and delayed phase, which was consistent with a wash-out enhancement. The histopathologic and immunohistochemical results confirmed the diagnosis was primary hepatic leiomyosarcoma. A pulmonary nodule during the postoperative follow-up was diagnosed as metastatic leiomyosarcoma tumor through surgery.Interventions:A right hepatectomy was performed to cure the hepatic mass. In the follow-up, a metastatic tumor in the lung was resected, followed by chemotherapy.Outcomes:Lung metastasis and liver recurrence occurred at 25 and 39 months after liver surgery, respectively. Then the patient was lost to follow-up.Lessons:Leiomyosarcoma is associated with a dismal prognosis, but outcomes for these patients may be improved by the combined surgical resection and chemotherapy.

Xanthogranulomatous Salpingooophoritis: The Youngest Documented Case Report.

Background. Xanthogranulomatous inflammation is an uncommon affection of the female genital tract. The youngest case reported of xanthogranulomatous salpingooophoritis in literature was by Shilpa et al. in 2013 in an eighteen-year-old female. Case Report. We report a case of 2-year-old female child with right-sided xanthogranulomatous salpingooophoritis presented as mass in abdomen. This is a case report of the youngest documented case of xanthogranulomatous salpingooophoritis in literature. As per abdominal examination, there was generalized distention of abdomen and a mass was palpable which was arising out of pelvis more on the right side. The ultrasonography (USG) abdomen and pelvis revealed a thick-walled mass measuring 9.2 cm × 6.0 cm × 7.6 cm in pelvis. We did right salpingooophorectomy of the patient. On histopathology, the diagnosis of xanthogranulomatous salpingooophoritis was confirmed. Conclusion. Clinical presentation, radiological appearance, and gross features of xanthogranulomatous lesions of ovary can mimic neoplastic lesions and lead to misdiagnosis. Though, it is very rare in pediatric age group, xanthogranulomatous salpingooophoritis as one of the differential diagnoses should be kept in mind while dealing with tuboovarian masses in this age group.

Noncommunicating cystic pancreatic lesions (i.e. serous and mucinous cystadenoma + rare lesions)

Mucinous cystic neoplasm (MCN) occurs predominantly in women (>95%) with a mean age of approximately 45 years and most commonly is located in the pancreatic body or tail. The mass is lined by mucin-producing columnar epithelium with a fibrous ovarian-type stroma. The epithelial lining can contain various degrees of atypia, ranging from adenoma to invasive carcinoma. The CT and MR appearance is that of at hick walled cystic mass with septa and/or mural nodules. The contour of the mass is smooth, and the wall or septa may contain calcification. Endoscopic ultrasound with fine needle aspiration of the cyst fluid to assess CEA level may be helpful in distinguishing MCN from serous cystadenoma. CEA 192 ng/mL favors MCN, with an accuracy of approximately 80% [1]. The overall risk of malignancy in one series was 17.5%, and all malignant tumors were either >4 cm or contained mural nodules [2]. Treatment of MCN is surgical resection, and patients without extracapsular or diffuse intracapsular infiltration have an excellent prognosis [2]. Serous cystadenoma (SCA) also occurs predominantly in women (approximately 75%), but the mean age is older (mid 50s to early 60s). It is lined by glycogen-rich cuboidal epithelium and is considered a benign neoplasm, although rare cases of malignant SCA have been reported. The typical appearance is that of a lobulated mass consisting of numerous tiny cysts which give it a honeycomb appearance. Larger lesions may contain a central stellate scar and calcifications. Oligocystic or macrocystic SCA is an uncommon variant comprised of a small number of larger cysts. Distinction between macrocystic SCA and MCN can be made based on the lobulated contour of SCA, its multiple clustered cyst configuration and homogeneity of each locule on T1 weighted MR images [3]. Surgical resection generally is reserved for symptomatic patients, although some authors recommend periodic imaging to assess the rate of growth, with consideration given to surgical resection of lesions with doubling time of 80%), with a median age 30-38 years [5,6]. It is not a true cystic neoplasm in that the cystic component lacks an epithelial lining. Rather, the cystic component represents necrotic degeneration of the mass, with various amounts of internal blood and debris. SPN appears as a well-circumscribed round or oval thick-walled mass with solid and cystic components, but it can appear completely solid or completely cystic. CT demonstrates calcification in nearly half of SPNs [6]. MR often demonstrates a thick T2 hypointense or enhancing rim and internal blood products. Treatment is surgical resection, and the prognosis is excellent, with metastases developing in <5% of patients [6]. Cystic neuroendocrine neoplasm of the pancreas most commonly occurs in patients with multiple endocrine neoplasia type I and usually is nonfunctional [7]. It generally appears as a cystic mass with an enhancing rim and may contain septa or a solid component. Treatment usually is surgical resection, although observation may be a viable alternative approach [8].

Scrotal cystic mass as a late presentation of neonatal testicular torsion

Summary We present the case of a 1-year-old boy who had had a right scrotal enlargement for 9 months. He experienced a sudden onset of right scrotal enlargement and irritability at 3 months of age. No testis but hydrocele was identified at 5 months by sonography at another hospital. On admission, an elastic mass in the right scrotum measuring 3 cm × 2 cm × 2 cm was noted. Sonography showed a cystic, thick-walled mass, wherein no testis was identified. Magnetic resonance imaging failed to reveal his right testis along the descending route of the right testicle. During the operation, the mass was found to be cystic with a thick wall, and the cyst contained a yellowish clear fluid. The spermatic cord was connected to the mass and the junction between the two was constricted. The pathology of the cyst wall revealed atrophic testicular tissues, including stromal fibrosis and small tubules that were focally filled with small cuboidal cells. The atrophic cystic change in the testis in this case was considered to be due to previous testicular torsion. Late-stage cystic change after testicular torsion must be rare as a late presentation because it has never been reported in the literature.

Bronchogenic Squamous Cell Carcinoma Mass with Central Photopenia on FDG-PET Scan

A 77-year-old man underwent chest imaging with a hybrid fluoro-deoxyglucose (FDG) positron emission tomography (PET)/computed tomography (CT) scan. The study demonstrated a 5 cm mass on standard CT images (figure 1). The FDG-PET images demonstrated a thick-walled mass characterized by intense FDG uptake with a maximum standardized uptake value of 15.9 (figure 2). A large central region of the mass demonstrated photopenia (ie, normal FDG uptake). Volumetric analysis revealed 30% of the mass showed normal FDG uptake, or photophenia. Biopsy of the mass showed squamous cell carcinoma. The findings were consistent with carcinoma that had outgrown its vascular supply resulting in central tumor necrosis. Figure 1 Thoracic computed tomography image showing right lower lobe mass. Figure 2 Hybrid fluoro-deoxyglucose (FDG) positron emission tomography/computed tomography image showing a thick-walled mass characterized by FDG uptake with a maximum standardized uptake value of 15.9 in the wall of the mass and central photopenia, consistent ... Central necrosis is most commonly observed in primary bronchogenic carcinomas of squamous cell origin, with one series reporting squamous cell origin in 82% of cases of necrotizing lung cancer.1 In an analysis of patterns of FDG uptake in lung cancer based on histologic classification, both large cell and squamous cell carcinomas were significantly more likely to demonstrate central cavitation compared with adenocarcinoma.2 The pathogenesis of cavitary malignancies has not been fully elucidated. It has been postulated that cavity formation in tumors is a consequence of rapid tumor growth which exceeds the supporting blood supply resulting in tumor necrosis and cavitation.3 This hypothesis is supported by reports that have shown tumor-associated vasculature inhibition by antiangiogenesis agents causing central necrosis and cavity formation in patients with squamous cell carcinoma of the lung.4, 5 The development of cavitation may have clinically significant consequences. Cavitating lung tumors may initially simulate an infectious process leading to delayed work up, late diagnosis, and presentation with advanced disease. In previous analyses of patient populations with heterogeneous stages of bronchogenic carcinoma, no difference in survival or response to therapy was found between lung cancers with cavitation and those without cavitation.1,6 However, in a more recent analysis of 72 patients with stage I non-small cell lung cancer, cavitation within the primary tumor was associated with significantly shorter disease-free survival time and overall survival time.7 In this analysis, cavitary lesions were significantly more common in squamous cell carcinomas than in adenocarcinomas and in epidermal growth factor receptor (EGFR)-overexpressing tumors than in tumors that did not overexpress EGFR. Accordingly, the presence of cavitation may have therapeutic implications in helping identify patients likely to benefit from targeted treatment with an anti-EGFR agent. In summary, clinicians should be aware that large bronchogenic carcinomas may develop central cavitation and necrosis, likely resulting from compromised vascular supply, resulting in central photopenia on FDG-PET imaging. This finding may have prognostic and therapeutic implications.

Congenital Intrahepatic Vascular Anomaly in a Clinically Normal Laboratory Beagle

Routine necropsy examination of a clinically normal, ten-month-old male beagle dog identified disruption of the dorsal aspect of the right median liver lobe by a multiloculated, pale tan-white, thick-walled mass, with diffuse hypertrophy of the left and caudate liver lobes. The nature of the lesion was investigated using a variety of immunohistochemical and histochemical techniques. Histologically, the lesion was characterized by marked, focally extensive vascular hyperplasia and ectasia with lobular atrophy, periportal fibrosis, and biliary hyperplasia. The endothelium of proliferating vessels was positive for von Willebrands factor, and proliferating bile ducts were positive for pancytokeratin. Based on the gross and histologic appearance, this lesion was identified as a vascular hamartoma with arteriovenous fistula. It is important to note that this spontaneous lesion may occur in the laboratory beagle in the absence of clinical signs.

A Novel Endoscopic Treatment of a Gastric Duplication Cyst

A 30 year old previously healthy male presented with one week of severe chest burning, diminished oral intake, and fifteen pound weight loss. Exam revealed a non-tender abdomen with left upper quadrant distension. Chest x-ray showed an air fluid level in the left upper quadrant. CT scan showed a markedly distended stomach filled with fluid and a round, thick walled mass with central fluid density at the pylorus measuring 3.2 by 2.4 by 2.6 centimeters. A nasogastric tube was placed for gastric decompression. The EGD showed an extrinsic bulge occluding the lumen of the pylorus. 8 cc of clear fluid was aspirated via EUS showing benign columnar mucinous epithelial cells. Provisional diagnosis was gastric duplication cyst. Endoscopic therapy was undertaken. A needle knife was used to cut through the wall of the pyloric channel and into the duplication cyst. This allowed fluid to drain from the cyst and partially collapse the cyst. The track into the cyst was then dilated with a 10 – 12 mm wire guided CRE balloon. The interior of the cyst was examined with the endoscope and showed a smooth wall with an unremarkable lining. Following this, two clips were placed along the sides of the cut surface to facilitate extension with a needle knife cut. The opening was then further dilated with a 12 – 15 mm CRE balloon. In order to marsupialize the cyst, the roof was partially excised as follows. A double channel endoscope was introduced. A snare was used to grasp one of the clips and through the second channel a needle knife was used to cut an elliptical piece of tissue around the clip. Hot biopsy forceps were used to control bleeding. The forceps were also used to avulse tissue from the margins of the orifice. Four weeks post-procedure the patient had regained the fifteen pounds he had lost and had resumed a regular diet. Currently, twenty six weeks since endoscopy the patient continues to maintain his weight on a regular diet. A duplication cyst is an enteric cystic structure that is in intimate contact with the stomach, sharing with the stomach a common blood supply and all muscle layers. It is often lined by gastric columnar mucosa and it is unusual for a duplication cyst to remain asymptomatic until adulthood. In the past, management of gastric duplication cysts relied primarily on surgical intervention.

Transvaginal Ultrasonographic Identification of Appendicitis in a Setting of Chronic Pelvic Pain and Endometriosis

Our patient had a history of chronic endometriosis and pelvic pain and complained of recent onset of right-sided abdominal pain, nausea, and vomiting. Transvaginal ultrasonography revealed a thick-walled mass superior and medial to the right ovary, which was thought to be an inflamed appendix. The woman was not pregnant, and the structure appeared to be anatomically separate from the uterus. Subsequent laparoscopy confirmed the diagnosis of acute appendicitis; uncomplicated laparoscopic appendectomy followed. In the setting of chronic endometriosis, other nongynecologic sources of acute pelvic pain must be considered. Surgical intervention is appropriate whenever clinical suspicion for an acute abdomen is high, and the a priori diagnosis of endometriosis should not result in operative delay.

Sclerosing encapsulating peritonitis in chronic ambulatory peritoneal dialysis

Sclerosing encapsulating peritonitis is now a well-recognised, but uncommon, complication of chronic ambulatory peritoneal dialysis. Patients present with impaired ultrafiltration capacity, abdominal pain, nausea, vomiting and episodes of small bowel obstruction. Barium studies of the small bowel are characteristic, showing varying lengths of intestine tightly enclosed in a 'cocoon' of thickened peritoneum, proximal small bowel dilatation and an increased transit time. Ultrasonography may show a thick-walled mass containing bowel loops, loculated ascites and fibrous adhesions. With the increasing use of ambulatory peritoneal dialysis in the treatment of end-stage renal failure, it is important that this condition is recognised. The prognosis is poor when the bowel becomes obstructed; before this happens the offending 'sclerotic' membrane may be amenable to surgical removal.