Unilateral Mass Research Articles

High Diagnostic Accuracy of Arterial Phase CT in Differentiating Pheochromocytoma in Good/Poor Washout Adrenal Masses

Abstract Introduction Differentiating pheochromocytomas from other adrenal masses based on CT characteristics remains challenging, particularly in lipid-poor lesions with variable washout patterns. This study evaluated CT features for distinguishing pheochromocytomas in good and poor washout sub-cohorts. Methods We prospectively analyzed 72 patients with unilateral lipid-poor adrenal masses. CT protocol included basal, bolus-tracked arterial, early venous (45 seconds post-arterial), and delayed (15 minutes post-arterial) phases. Masses were categorized into good and poor washout groups. Histopathology provided the final diagnosis. CT characteristics and calculated indices were compared between pheochromocytomas and other masses in each washout category. Results The cohort included pheochromocytomas (n=35), adrenocortical carcinoma (ACC, n=15), lipid-poor adenomas (n=13), and metastatic infiltration/infection (n=9). In the good washout group, pheochromocytomas (n=15) showed larger diameters (6.00 vs. 3.45 cm, p=0.001), higher necrosis frequency (73.3% vs. 30%, p=0.049), and greater arterial attenuation (173.2 vs. 74.5 HU, p<0.001) compared to adenomas (n=9). Arterial attenuation provided a high discriminatory value (AUC: 0.967), with 100% sensitivity at 87.6 HU and 100% specificity at 139.9 HU. In the poor washout group, pheochromocytomas (n=20) exhibited higher arterial attenuation (99.2 vs. 59.2 HU, p<0.001; AUC: 0.844) compared to ACC (n=14), metastatic infiltration (n=9), and adenomas (n=4), with 85% sensitivity and 78% specificity at 73.3 HU. Normetanephrine-secreting/non-secretory pheochromocytomas showed higher arterial enhancement than metanephrine-secreting ones (132.0 vs. 90.5 HU, p=0.020) within the poor washout group. Conclusion Arterial phase attenuation on CT has good diagnostic accuracy for differentiating pheochromocytomas from other adrenal masses in both good and poor washout categories, potentially guiding hormonal workup.

Feasibility of extracellular volume fraction derived from single-phase spectral CT for differentiating between adrenal metastases and adenomas.

The extracellular matrix of adrenal metastases could be different from that of the adrenal adenomas, which may be characterized by the extracellular volume (ECV) fraction. This study aimed to assess the feasibility of ECV fraction derived from single-phase spectral CT for differentiating between adrenal metastases and adenomas. This retrospective study included 163 patients with unilateral nodules, including lipid-poor adrenal adenoma (n = 52, group A), lipid-rich adrenal adenoma (n = 65, group B) and adrenal metastasis (n = 46, group C). All patients underwent contrast-enhanced spectral CT of the adrenal gland with a 10-minute delayed phase. The iodine density of each lesion was assessed and ECV fraction was examined. Various parameters were compared among the three groups. Diagnostic performance was evaluated by quantifying the area under the receiver operating characteristic curve (AUC). The ECV fraction in group C (33.81 ± 11.94%) was significantly higher than that in group A (20.86 ± 10.22%) and group B (11.44 ± 6.26%) (p < 0.001), while iodine density in group C (0.93 ± 0.41mg/mL) was also higher than that in group A (0.61 ± 0.33mg/mL) and group B (0.33 ± 0.19mg/mL) (p < 0.001). ECV fraction showed significantly higher AUC (AUC = 0.790, 95%CI 0.691-0.869) for differentiating between group A and C than iodine density (AUC = 0.717, 95%CI 0.612-0.808; p = 0.002). Simultaneously, ECV fraction had significantly higher AUC (AUC = 0.945, 95%CI 0.858-0.986) for differentiating between group B and C than iodine density (AUC = 0.897, 95%CI 0.795-0.959, p = 0.03). Based on single 10-minute delayed phase spectral CT, ECV fraction showed high diagnostic performance in differentiating between adrenal metastases and adrenal adenomas, both for lipid-poor or lipid-rich adenomas. The ECV fraction could help recognize metastases in unilateral or bilateral adrenal masses for better treatment planning, especially in patients with a history of extra-adrenal malignancy.

Bilateral Parotid Gland Oncocytoma Mimicking Oropharyngeal Cancer Metastasis: A Case Report from a Radiation Oncologist's Perspective.

Parotid oncocytomas typically present as benign, unilateral, slow-growing, painless, and solitary masses that are histologically firm and multilobulated. They are often misdiagnosed as pleomorphic adenomas, hemangiomas, or other forms of oncocytosis. However, in our case, the parotid oncocytomas initially mimicked bilateral parotid gland metastasis of advanced oropharyngeal cancer. Here, we present a case of oropharyngeal cancer with bilateral parotid oncocytomas treated with chemoradiotherapy (CCRT). We report the case of a 74-year-old man with a sore throat, neck pain, right earache, oropharyngeal cancer, and bilateral parotid gland oncocytoma. Head and neck computed tomography and magnetic resonance imaging (MRI) showed soft-tissue swelling in the right tonsillar fossa and several enlarged level II neck lymph nodes. MRI revealed enhancing masses in both parotid glands, initially suspected to be metastatic lymph nodes. A biopsy of the right palatine tonsil confirmed squamous cell carcinoma with human papilloma virus-16 positivity. A positron emission tomography scan was performed, and biopsy-proven malignant lesions were observed in the right tonsillar region with metastatic lymph nodes in the right and left neck. Focal hypermetabolism was observed in the parotid glands, suspected to be pathological lesions such as metastatic intra-parotid lymph node or Warthin's tumor. An ultrasonography-guided biopsy of the left parotid gland confirmed an oncocytoma. Based on these results, the patient was scheduled for CCRT. After pathological confirmation of parotid oncocytoma, CCRT was administered, excluding the parotid glands within the radiotherapy field. This is a case of bilateral parotid gland oncocytoma mimicking oropharyngeal cancer.

Internal Jugular Phlebectasia; A Challenging Neck Mass in Children

Cystic neck masses are uncommon in children, and a minority of them are soft. Internal jugular vein phlebectasia (IJVP) is a rare cause of soft neck cysts. It presents usually as a unilateral soft neck mass of changing size. In most cases it is unilateral, right sided and predominantly in males. Imaging study modalities are diagnostic and helpful for observation and follow up. In the vast majority of cases, it decreases in size with time requiring only conservative treatment. However, surgery might be necessary in large or complicated phlebectasia. IJVP is underdiagnosed or misdiagnosed especially in pediatrics, with few cases documented in medical literature. To improve awareness of presentation and management-plan of this rare case, the authors present an extremely rare case of huge left internal jugular phlebectasia in a 14 year-old boy worsened and complicated over years of wait and see approach that needed surgical treatment.

A Case Series of a Rare Parotid Gland Oncocytic Mucoepidermoid Carcinoma

Abstract Introduction/Objective We analyzed two cases of oncocytic mucoepidermoid carcinoma (OMEC) of the parotid gland which highlight the diagnostic challenges of oncocytic salivary gland neoplasms. OMEC’s are a rare type of salivary gland tumor commonly arising from the parotid gland that can easily be mistaken as benign. Proper pathologic diagnosis of these masses is critical, as it guides therapeutic intervention and has prognostic significance. Methods/Case Report In this case series, two patients were analyzed retrospectively for unilateral parotid masses. Results (if a Case Study enter NA) In a 67-year-old female, an MRI and biopsy were performed. Only a differential diagnosis could be provided, which favored oncocytoma or oncocytic carcinoma. Due to this uncertainty, a complete excision of the mass was performed. Considering the cytomorphology, immunohistochemistry (CK5/6 and P63 in oncocytes), and mucicarmine special stain highlighting scattered mucocytes, the patient was diagnosed with a low- grade OMEC. In our second case, an 80-year-old female, FNA of a posterior left ear mass 1 year prior revealed a low- grade oncocytic proliferation. With the presence of a left parotid mass one year later, additional imaging was performed and showed increased T2 hyperintensity on MRI, which caused concern for the clinicians. A superficial limited parotidectomy was performed and a differential of oncocytoma versus oncocytic variant of mucoepidermoid carcinoma was rendered. Further tumor characterization with fluorescence in situ hybridization (FISH) demonstrated a MAML2 translocation which guided diagnosis of OMEC. Conclusion With approximately 30% of all malignant salivary gland tumors being constituted by mucoepidermoid carcinoma, the ability to accurately diagnose even this rare subtype, oncocytic mucoepidermoid carcinoma, is of significant importance and relevance to pathologists in many practice settings. Herein we demonstrate the utility of H&amp;E morphology, immunohistochemistry, and MAML2 FISH in diagnosing OMEC in the setting of oncocytic salivary gland lesions. Future avenues, including tumor molecular profiling, will aid in elucidating clinicopathologic characteristics of this entity.

Surgical Experience and Functional Outcomes after Laparoscopic and Robot-Assisted Partial Nephrectomy: Results from a Multi-Institutional Collaboration

Background: In patients treated with partial nephrectomy, prior evidence showed that peri-operative outcomes, such as complications and ischemia time, improved as a function of the surgical experience of the surgeon, but data on functional outcomes after surgery are still scarce. Methods: We retrospectively analyzed data of 4011 patients with a single, unilateral cT1a-b renal mass treated with laparoscopic or robot-assisted partial nephrectomy. The operations were performed by 119 surgeons at 22 participating institutions between 1997 and 2022. Multivariable models investigated the association between surgical experience (number of prior operations) and acute kidney injury (AKI) and recovery of at least 90% of baseline estimated glomerular filtration rate (eGFR) 1 yr after partial nephrectomy. The adjustment for case mix included age, Body Mass Index, preoperative serum creatinine, clinical T stage, PADUA score, warm ischemia time, pathologic tumor size, and year of surgery. Results: A total of 753 (19%) and 3258 (81%) patients underwent laparoscopic and robot-assisted partial nephrectomy, respectively. Overall, 37 (31%) and 55 (46%) surgeons contributed only to laparoscopic and robotic learning curves, respectively, whereas 27 (23%) contributed to the learning curves of both approaches. In the laparoscopic group, 8% and 55% of patients developed AKI and recovered at least 90% of their baseline eGFR, respectively. After adjusting for confounders, we did not find evidence of an association between surgical experience and AKI after laparoscopic partial nephrectomy (odds ratio [OR]: 0.9992; 95% confidence interval [CI]: 0.9963, 1.0022; p = 0.6). Similar results were found when 1-year renal function was the outcome of interest (OR: 0.9996; 95% CI: 0.9988, 1.0005; p = 0.5). Among patients who underwent robot-assisted partial nephrectomy, AKI occurred in 11% of patients, whereas 54% recovered at least 90% of their baseline eGFR. On multivariable analyses, the relationship between surgical experience and AKI after surgery was not statistically significant (OR: 1.0015; 95% CI: 0.9992, 1.0037; p = 0.2), with similar results when the outcome of interest was renal function one year after surgery (OR: 1.0001; 95% CI: 0.9980, 1.0022; p = 0.9). Virtually the same findings were found on sensitivity analyses. Conclusions: In patients treated with laparoscopic or robot-assisted partial nephrectomy, our data suggest that the surgical experience of the operating surgeon might not be a key determinant of functional recovery after surgery. This raises questions about the use of serum markers to assess functional recovery in patients with two kidneys and opens the discussion on what are the key steps of the procedure that allowed surgeons to achieve optimal outcomes since their initial cases.

A Decade of Insights into Bilateral Adrenal Masses: Epidemiology, Clinical Profiles, and Therapeutic Approaches

Bilateral adrenal masses (BAMs) are rare, accounting for 10-15% of adrenal masses. Their diagnostic and therapeutic approaches differ from those of unilateral masses. This study aimed to analyze the epidemiological, clinical, paraclinical, and therapeutic profiles of BAMs. It is based on a retrospective analysis of 30 patient records from the Endocrinology, Diabetology, and Nutrition Department at CHU Hassan II in Fez, over a 12-year period. The average age of the patients was 53 years, with a male predominance (53.3%). BAMs were symptomatically revealed in 46.7% of cases, incidentally discovered in 23.3%, identified during tumor staging in 20%, and associated with a genetic syndrome in 10% of cases. Clinical examination revealed hypertension in 23.3% of patients, an abdominal mass in 10%, signs of adrenal insufficiency in 10%, hypercortisolism in 6.67%, and hyperandrogenism in 16% of cases. Biological assessment showed elevated urinary or plasma metanephrine derivatives in 9 patients, hypercortisolism in 3 patients, adrenal insufficiency in 3 patients, 11-β-hydroxylase enzyme block in 3 patients, and primary hyperaldosteronism in 1 patient. Adrenal computed tomography (CT) was performed in 29 patients. A staging workup, including PET scan, was requested in 20% of cases. MIBG scintigraphy was performed in 23.3% of patients. The investigations revealed 53% of BAMs were secreting and 47% non-secreting. There were 9 cases of pheochromocytomas, including 5 associated with a syndrome (3 MEN2a, 1 MEN2b, 1 VHL), 8 cases of non-secreting adenomas, 3 cases of congenital adrenal hyperplasia due to 11-β-hydroxylase enzyme block, 2 cases of adrenal metastases, 2 cases of adrenocortical carcinoma, 2 cases of adrenal cysts, 1 case of Conn’s adenoma, 1 case of cortisol-secreting adenoma, 1 case of primary adrenal lymphoma, and 1 case of adrenal hematoma. Treatment included the management of emergencies and preoperative preparation for patients eligible for surgery. Bilateral adrenalectomy was performed in 33.3% of patients, and unilateral adenectomy in 1 case of cortisol-secreting adenoma. Medical treatment was initiated in 16.6% of cases, and palliative treatment in 13.33% of cases. Surveillance alone was implemented in the remaining 33.3%. Prognosis depends on the type of adrenal mass, with outcomes marked by the death of one case of malignant adrenocortical carcinoma and one case of primary adrenal lymphoma. Our study, involving 30 cases of BAMs, highlights their clinical, biological, radiological, therapeutic, and prognostic characteristics. Data in the literature are limited compared to unilateral adrenal masses. Future larger studies are desirable for optimal management.

6701 Bilateral Adrenal Hematomas As Initial Presenting Sign Of Lung Adenocarcinoma

Abstract Disclosure: S. Gumireddy: None. R. Panta: None. Y. Shaikh: None. Introduction: Lung cancer typically presents with dyspnea, chest pain, hemoptysis, weight loss, or recurrent pulmonary infections. This case illustrates primary lung adenocarcinoma presenting with abdominal pain and bilateral adrenal hematomas. Clinical Case: 51-year-old male presented to the emergency department with left sided abdominal pain persisting for one week. CT abdomen showed a left suprarenal mass measuring 4.5 x 5 x 4.3cm indicating an acute adrenal hematoma. An MRI showed a partially solid left adrenal lesion that had hemorrhaged and a 1.3cm hemorrhagic nodule in the right adrenal gland. The patient remained hemodynamically stable. Hormonal evaluation done while patient was in the hospital showed renin level 0.417ng/mL/hr, aldosterone level &amp;lt;1.0ng/dL, epinephrine level 312pg/mL, norepinephrine level 333pg/mL, cortisol 11.3, ACTH level 13, plasma metanephrine levels 93pg/mL, plasma normetanephrine levels 111.7pg/mL, DHEA-S 151mcg/dL, potassium 4.1mmol/L, raising concern for hypersecretion. Patient was discharged with plans for outpatient follow-up but was readmitted in two months due to worsening abdominal pain. Repeat imaging revealed an increase in size of adrenal lesions, measuring 3.3 x 3.6 cm within the right adrenal gland and a 6.7 x 6.3 cm heterogeneously enhancing lesion within the left adrenal gland concerning for metastatic disease to bilateral adrenals and to the ileum causing small bowel obstruction. Chest imaging showed a 2.2cm irregular right apical nodule. Subsequent hormonal evaluation showed normalization of plasma metanephrine levels at 15.8pg/mL, renin level 3.314ng/mL/hr, aldosterone level 4.3ng/dL, deoxycorticosterone level 4.8ng/dL, androstenedione level 40ng/dL, plasma normetanephrines 146.4pg/mL. The patient underwent left adrenal gland mass biopsy which showed metastatic poorly differentiated adenocarcinoma of pulmonary origin. Tumor cells were positive for keratin cocktail, TTF1 and synaptophysin supporting the morphologic interpretation. Patient is currently receiving treatment with carboplatin, pemetrexed, and pembrolizumab. Conclusion: Adrenal masses can be unilateral (85%) or bilateral (15%). While most unilateral adrenal masses are benign and nonfunctional, bilateral adrenal masses are likely to be metastatic disease, hemorrhage, infiltrative disease, congenital adrenal hyperplasia, macronodular Cushing’s syndrome, or bilateral cortical adenomas. Although uncommon, our case highlights the importance of considering metastatic disease to the adrenal glands as a potential initial manifestation of primary cancers. The most likely primary cancers to metastasize to the adrenal glands are breast, lung, colon, kidney, and esophagus. Presentation: 6/1/2024

6744 Clinical Profile And Outcomes Of Medically And Surgically Managed Patient With Primary Hyperaldosteronism In A Third-World World Setting

Abstract Disclosure: A.A. Apa-ap: None. E.P. Pacheco: None. Background: Assessing therapeutic response in Primary hyperaldosteronism (PA) has previously been significantly hampered by a lack of standardized outcome markers. Although most participants in observational studies benefit from both medical and surgical therapy, comparative analyses have been limited. To date, no available Filipino data comparing therapeutic responses have been published. This paper aims to answer the clinical profile and outcomes of patients with PA in a third-world setting. Method: This is a retrospective cohort study that includes adult patients diagnosed with PA in the Philippine General Hospital seen at the outpatient department and admitted from January 1, 2013, until December 31, 2022. Result: 57 patients with PA were identified on chart review. A total of 40 (70%) patients were included in the study. 17 patients were excluded due to missing data. All patients had a unilateral adrenal mass. 23 patients underwent adrenalectomy and grouped under surgical management. 17 patients were treated with antihypertensive including MRA and grouped under medical management. Out of the 40 patients included: 83% were women, mean age was 40, hypertension averaged 6 years and 92.5% had hypokalemia. Radiologic profile showed mean tumor size 1.7cm and and mean tumor density 11.7 HU, mean absolute washout of 68.8 HU, and mean relative washout 54.8 HU. Comparing the post-treatment clinical outcome between surgical and medical management showed that patients who underwent surgical treatment had significantly lower systolic (difference=-11.12, p=0.0012) and diastolic blood pressure (difference= -6.03, p=0.0264), mean number of antihypertensive medication (difference= -2.30, p&amp;lt;0.001), mean daily dose of antihypertensive(difference= -3.43, p&amp;lt;0.001). Both groups had normal serum K post-treatment, but patients who underwent surgical treatment had significantly higher mean serum K (difference= 0.41, p=0.0025) and none had required MRA post-op. There was a lower number of patients with left ventricular hypertrophy and a significantly higher ejection fraction (difference= 5.81, p=0.0038) post-op compared to patients who underwent medical management. In terms of biochemical profile, there was a significantly lower mean plasma aldosterone concentration (difference= -31.95, p&amp;lt;0.001), and mean aldosterone/renin activity (difference= -211.51, p=0.0013) and significantly higher mean plasma renin activity (difference= 0.43, p&amp;lt;0.001) after surgery compared to those who underwent medical management. All surgical patients had a histopathologic diagnosis of adrenocortical adenoma. 9 patients complete clinical success and 14 had partial clinical success post-op; 22 had complete biochemical success and 1 had partial biochemical success based on PASO consensus. Conclusion: This study showed better clinical outcomes in patients with PA who underwent surgical management. Presentation: 6/1/2024

Comparative performance of video-otoscopy and CT in the diagnosis of external ear disease in cats.

The aim of the study was to compare CT with video-otoscopy for detecting external ear canal masses in cats and to describe CT features of feline external ear disease. This retrospective study evaluated the external ear canals of cats that underwent both CT and video-otoscopy. Two blinded observers reviewed the CT scans and their findings were compared with video-otoscopy results evaluated by one blinded observer. Of the 32 examined ears, 13 had an external ear canal mass detected by both CT and video-otoscopy. No false positives were identified. All 19 ears without masses were correctly identified as true negatives, resulting in perfect agreement for mass detection (kappa = 1.000). On histopathology, 9/13 masses were diagnosed as polyps, 1/13 masses was diagnosed as carcinoma, 2/13 did not undergo histopathology and 1/13 masses seen on video-otoscopy was diagnosed as otitis externa with granulomatous tissue formation. Of the 16 cats examined, 12 had a mass in the external ear canal diagnosed by video-otoscopy: six domestic shorthairs, five Maine Coons and one Oriental Shorthair cat. Of these cats, 11 had a unilateral mass and one had a bilateral mass. There was very low agreement between CT and video-otoscopy for ear canal wall enhancement and erythema (kappa = 0.033), as well as for ear canal thickening and stenosis (weighted kappa = 0.056). There was no significant difference between chronic and non-chronic clinical signs in terms of the presence of ear canal wall mineralisation (P = 0.223). There is high agreement between video-otoscopy and CT in detecting external ear canal masses in cats. However, there is very low agreement between CT and video-otoscopy for ear canal wall enhancement, erythema, thickening and stenosis. The presence of external ear canal mineralisation did not correlate with the chronicity of clinical signs.

Unilateral maxillary mass on a 4-year-old male alpaca.

Unilateral maxillary mass on a 4-year-old male alpaca.

Diagnosis and Management of Adrenocortical Carcinoma with co-secretion of Cortisol and Aldosterone

Adrenocortical carcinoma (ACC) accounts for 0.05-2% of all malignant tumors. Forty-five percent of ACCs with secretory function have excess glucocorticoids alone and only less than 1% secrete aldosterone. This is a case of a 44-year-old Filipino female with hypertension and a 12-year-history of an incidentaloma of the left adrenal gland, with recent-onset complaints of increasing abdominal girth, purple striae, amenorrhea, moon facies and a dorsocervical fat pad. Laboratory findings revealed low potassium levels, non-suppressed cortisol on dexamethasone test suggesting Cushing’s syndrome and elevated aldosterone-renin ratio and plasma aldosterone concentration pointing to primary hyperaldosteronism. A computed tomography scan revealed a left-sided adrenal mass measuring approximately 23 cm in largest diameter suggestive of carcinoma without metastasis or lymph node involvement. Complete resection via open adrenalectomy was performed and histopathologic assessment revealed Adrenocortical Carcinoma with Weiss score of 4. The Ki-67 proliferative index was found to be &gt;20%. Radiotherapy was done as an adjuvant treatment. Although rare, co-secretion of cortisol and aldosterone can occur in functional tumors of adrenocortical carcinoma. Malignancy should always be considered in patients who present with a history of a unilateral adrenal mass and/ or in those with signs and symptoms of adrenal hormone excess. Thus, a proper assessment derived from a thorough medical history, physical examination and laboratory work-up is warranted in patients with an adrenal mass to ascertain the diagnosis and provide adequate management.

Cytomorphological Spectrum of Ocular Surface Squamous Neoplasia in Elderly Age Group and Its Clinicopathological Correlation

ABSTRACT Background: Ocular surface squamous neoplasia (OSSN) encompasses a range of dysplastic changes from mild dysplasia to invasive carcinoma. This research aims to elucidate the cytomorphological spectrum of OSSN in the elderly age group and correlate these findings with clinical and pathological features. Methods: A retrospective analysis was conducted on elderly patients (&gt;60 years) diagnosed with OSSN over a 5 year period. Cytological and histopathological findings were analyzed and correlated with clinical data. Results: The cytomorphological spectrum of OSSN in the elderly age group exhibited a broad range of cellular changes, from mild dysplasia to invasive squamous cell carcinoma. The predominant cytological features included increased nuclear–cytoplasmic ratio, pleomorphism, and abnormal mitotic figures. Clinically, OSSN presented most commonly as a unilateral conjunctival mass with a history of chronic irritation. Histopathologically, there was a significant correlation between the degree of dysplasia and the depth of invasion (P &lt; 0.05). Conclusion: This research highlights the diverse cytomorphological spectrum of OSSN in the elderly age groups and emphasizes the importance of comprehensive clinicopathological correlation for accurate diagnosis and management. The predominant cytological features observed, including increased nuclear–cytoplasmic ratio, pleomorphism, and abnormal mitotic figures, reflect the underlying dysplastic alterations and provide valuable insights into the diagnosis and the classification of OSSN. Further studies are warranted to explore the potential role of impression cytology in the diagnosis and management of OSSN and to evaluate the efficacy of different treatment modalities in the elderly age group.

UNILATERAL NASAL MASS: CASE SERIES WITH REVIEW OF DIFFERENTIAL DIAGNOSIS

Introduction: Unilateral nasal masses present diverse manifestations, posing risks of benign or malignant transformation if improperly diagnosed. A probe test is a basic clinical test to have an idea about the origin and nature of the polyp. Imaging studies such as computed tomography may give a detailed knowledge regarding origin and extent of polyposis. Material &amp; Methods: We discuss a case series of 5 patients with diverse presentations and diagnosis for unilateral nasal polyposis. A brief review on differential diagnosis of unilateral nasal masses is also discussed in a tabular form with easy to remember mnemonic. Conclusion: There are diverse presentations and diagnosis of identically looking unilateral nasal masses. An excisional biopsy should always be sent for histopathological examination to know for the nature of disease and decide regarding further treatments. KEYWORDS: Unilateral, Mnemonic, Pyogenic granuloma, Vestibule

Feasibility of laparoscopic adrenalectomy in adrenal masses greater than 5 centimeters: a systematic review and meta-analysis.

Laparoscopic adrenalectomy (LA) has emerged as the primary treatment for adrenal masses. This systematic review and meta-analysis assessed LA's feasibility, safety, effectiveness, and complications for adrenal masses exceeding 5 cm. The study was conducted using PRISMA guidelines with PROSPERO registration No. CRD42023462901. Adults with unilateral adrenal masses >5 cm who underwent unilateral LA were included. Intraoperative and postoperative measurements and complications were assessed. A systematic literature review employed a comprehensive search strategy which was last searched on September 8, 2023, through PubMed, Google Scholar, Web of Science, and ProQuest databases. Meta-analysis was utilized to analyze the outcomes. Risk of bias was assessed using the Newcastle-Ottawa scale. This systematic review encompassed 25 studies involving 963 patients who underwent LA. Tumor size varied 7.05 cm [95% confidence interval (CI): 6.24-7.70], with 50% on the right and 45% on the left. The subgroup meta-analysis comparing the transperitoneal and retroperitoneal approaches revealed the transperitoneal approach h was utilized for the largest tumor size with a mean of 12.10 cm (95% CI: 11.30-12.96), compared to the retroperitoneal approach 5.83 cm (95% CI: 5.52-6.14). Notably, the mean operative time across studies was 137.4 minutes (95% CI: 113.36-150.94), bleeding prevalence was 0.02% (95% CI: 0.01-0.03%), and average blood loss was 110.6 mL (95% CI: 78.2-156.3). Postoperative complications such as pulmonary edema, pulmonary embolism, gastric dysfunction, and wound infection were very low, ranging from 0.03% to 0.4%. Out of 963 patients, only 49 were converted to open surgery. Patient hospital stay averaged 3.72 days (95% CI: 2.97-4.66); blood transfusion was required in 1.3% (95% CI: 0.30-8.88%). The feasibility and safety of LA for tumors exceeding 5 cm in size have notable implications for intraoperative and postoperative outcomes. Underreporting in the included studies may impact the generalizability of findings.

Unveiling the mille-feuille sign: a key to diagnosing ovarian carcinosarcoma in addition to ovarian metastasis from colorectal carcinoma on MRI.

To clarify the diagnostic utility and formation of the Mille-feuille sign for ovarian carcinosarcoma (OCS) on MRI, and to evaluate the other MRI findings and serum markers compared to ovarian metastases from colorectal carcinoma (OMCRC). Three blinded radiologists retrospectively reviewed MR images of 12 patients with OCS, 18 with OMCRC, and 40 with primary ovarian carcinoma (POC) identified by the electronic database of radiology reports. The interobserver agreement was analyzed using Fleiss' kappa test. Their MRI characteristics and tumor markers were compared using Fisher's exact test and Mann-Whitney's U test. Receiver operating characteristic curve analyses were used to determine the cutoff points for the ADC value. This study was approved by the institutional ethics committee. Interobserver agreement analysis was moderate or higher for all MRI characteristics. The frequency of Mille-feuille sign was comparable for both OCS and OMCRC groups, and predominantly higher than that of the POC group (p < 0.001, p < 0.001), respectively. Pathologically, the Mille-feuille sign in OCS reflected alternating layers of tumor cells with stroma and necrosis or intraluminal necrotic debris. Compared to OMCRC, intratumoral hemorrhage (p = 0.02), margin irregularity (p = 0.048), unilateral adnexal mass (p = 0.02), and low ADC values (p < 0.01) were more frequently observed and serum CEA levels was significantly lower (p = 0.007) in the OCS group. Under setting of the cutoff value of ADC at 0.871 × 10-3mm2/s, the discriminative ability for OCS showed 66.7% sensitivity, 94.4% specificity, and 81.0% accuracy, respectively. The Mille-feuille sign was seen in both OCS and OMCRC. MR findings of intratumoral hemorrhage, margin irregularity, unilateral adnexal mass, low ADC values, and low serum CEA levels can be useful in differentiating OCS from OMCRC.

OA15 A case series of idiopathic granulomatous mastitis patients and their immunosuppressive management

Abstract Background/Aims Rheumatologists are experts in managing immunosuppression and are asked to supervise immunosuppression for non-rheumatic conditions. Thus, it is important to be aware of these conditions and the regimes required. Idiopathic granulomatosis mastitis (IGM) is a rare inflammatory breast condition which can have systemic manifestations including arthritis. Methods Our index case presented with peripheral ankle synovitis/tenosynovitis, struggling to weight bear, whilst being investigated for a breast mass. Breast US, mammogram and biopsy (acute and chronic inflammatory cells including multi-nucleated giant cells) were completed and there was little response to 3 courses of antibiotics. No mycobacteria were seen on microscopy, ZN stain negative, CXR normal, T spot negative and serum ACE normal. There was no rash and no conditions associated with a seronegative spondyloarthropathy. RF, anti-CCP and ANA were negative. A moderate course of prednisolone immediately resolved the peripheral arthritis, but high-dose steroids were required to reduce the breast mass. The mass recurred upon weaning prednisolone requiring the addition of azathioprine as a steroid-sparing agent. Results Our case series includes the immunosuppressive management of 3 other IGM patients: 1) 43-year-old referred after an 8 year history of alternating breast ‘abscesses’ and sinuses treated with courses of antibiotics to little avail. High dose prednisolone and methotrexate resolved the breast mass within a month. 2) 37-year-old referred with a 14 year history of breast masses and fistulae previously treated with surgery and antibiotics. Currently asymptomatic so commenced on methotrexate. 3) 39-year-old referred with a 3 year history of recurrent sterile breast abscesses previously managed with antibiotics, incision and drainage. Recent small masses had settled with NSAIDs. Conclusion IGM is a rare benign inflammatory breast disease of unknown aetiology, commonest in Middle Eastern populations, median age 30s. The most common presentation is a unilateral painful mass, which can ulcerate, fistulate and form abscesses. Management of IGM varies from expectant/topical steroids/NSAIDs to high dose steroids and DMARDs. A literature review shows that the usual starting dose of prednisolone is 40-60mg; the addition of methotrexate and azathioprine increases likelihood of successful treatment and allows for faster steroid tapering. Surgery for specific types of IGM can also be useful; for example, where there is duct granuloma, surgical excision can be curative. IGM can associate with arthritis, erythema nodosum, and episcleritis. One case series found that 14% of patients with IGM had concomitant arthritis. Key points: In our local experience we have had four patients with IGM, all previously treated with antibiotics or surgical methods but subsequently diagnosed with IGM and referred for immunosuppressive therapy. Being a rare condition, we feel it’s important for clinicians to be aware of IGM and its link with inflammatory arthritis. Disclosure S. Islam: None. P. Stonelake: None. H. John: None.

Clinical analysis of 12 cases of ovarian yolk sac tumor

Objective: To investigate the diagnosis, treatment and prognosis of ovarian yolk sac tumor (OYST). Methods: The clinicopathological data and follow-up data of 12 patients with OYST admitted to the Affiliated Hospital of Qingdao University from January 2013 to December 2020 were retrospectively analyzed, and the diagnosis, treatment and prognosis of OYST patients were summarized. Results: (1) The age of 12 patients with OYST ranged from 11 to 37 years, with a median age of 20 years. At the first visit, all 12 patients had pelvic masses. Reasons for seeing a doctor: 6 cases of abdominal distension and abdominal pain, 4 cases of mass in the lower abdomen, 1 case of vaginal bleeding, and 1 case of appendicitis. International Federation of Obstetrics and Gynecology (FIGO) 2014 staging: 4 cases in stage Ⅰa, 2 cases in stage Ⅰc, 1 case in stage Ⅱc, 4 cases in stage Ⅲc, and 1 case in stage Ⅳb. (2) All 12 patients were examined by color Doppler ultrasound before operation, among which 10 cases showed unilateral adnexal masses and 2 cases bilateral adnexal masses. The median maximum diameter of tumor was 16.5 cm (range: 6.0-28.0 cm). The preoperative levels of alpha fetoprotein (AFP) in 12 patients (all >1 210 μg/L) were significantly higher than normal (<25 μg/L). Among the 11 patients with cancer antigen 125 (CA125) detection results, 9 patients showed elevated serum CA125 levels. (3) Among the 12 patients, 8 young infertile patients who needed to preserve their reproductive function underwent appendectomy, 3 infertile patients underwent staged surgery for ovarian malignant germ cell tumor, and only one bilateral lesion and infertile patient underwent unsatisfactory staged surgery for ovarian malignant germ cell tumor. Of the 12 patients, 11 patients were given combined chemotherapy regimen of bleomycin, cisplatin, and etoposide (BEP) after operation. One patient without chemotherapy developed metastasis 3 months after operation, and was given BEP chemotherapy, and her condition was controlled. (4) The deadline for follow-up was December 31st, 2022, and the median follow-up time was 60 months (range: 25-115 months). All the 12 patients survived without tumor during the follow-up period, and the median disease-free survival time was 84.5 months (range: 25-115 months). Conclusions: OYST mostly occurs in children and young women. Color Doppler ultrasound examination and serum AFP and CA125 detection have diagnostic value for OYST. Surgical treatment after diagnosis of OYST includes surgery to preserve reproductive function and timely and standardized chemotherapy after operation. The prognosis of patients is good regardless of stage.

Terato-Neuroendocrine Tumour of Testis: Review and Update

Neuro-endocrine tumours commonly emanate from intestinal and respiratory epithelium. Neuro-endocrine tumours could also on rare occasions afflict various organs of the human body. Neuro-endocrine tumour afflicting the testis is an uncommon tumour which does account for far less than one percent (&lt;1%) of all tumours of testis. To the knowledge of the author, less than 100 cases of primary neuro-endocrine tumour of the testis had been reported so far in the global literature. The reported cases of neuro-endocrine tumour of testis have ranged between 10 years and 83 years of age and the reported incidence rate had been noted to be higher within the fifth and sixth decade of life. Majority of patients who are afflicted by neuro-endocrine tumour of testis do tend to manifest with unilateral painless testicular mass. Sixteen percent (16%) of patients who are afflicted by neuro-endocrine tumour of testis do manifest with symptoms of neuroendocrine tumour syndrome. Eleven percent (11%) of primary neuroendocrine tumours of testis tend to be diagnosed initially with a contemporaneously-associated metastasis. Neuro-endocrine tumours of the testis occur as a primary testicular neuroendocrine tumour, or they may be metastatic neuroendocrine tumour to the testis with the primary tumour originating from elsewhere in the body especially from the gastrointestinal or cardiorespiratory tract system. Primary neuro-endocrine tumour of testis, could be further sub-divided into: (a) primary pure neuroendocrine tumour of testis; and (b) neuro-endocrine tumour of testis contemporaneously associated with teratoma or dermoid/epidermoid cysts. Once a neuro-endocrine tumour of testis is diagnosed, it is pivotal that clinicians should exclude a metastatic neuroendocrine tumour to the testis with the primary tumour originating from elsewhere within the human body. It has been iterated that the presence of teratomas elements within the neuro-endocrine tumour of testis does sufficiently rule out the primary site outside the testis. In order to accurately diagnose the neuro-endocrine tumour of the testis, it has been advised that it is pertinent to submit the tumour mass entirely and to look for any additional lineage of differentiation. Twenty five percent of primary neuro-endocrine tumours of testis are associated with teratoma. Histogenesis of pure neuroendocrine tumour of the testis is yet to be clarified. Two postulates had been propounded in relation to the mode origin of neuroendocrine tumour of testis including: (1) Emanation from a teratoma which is the germ cell origin postulate; (2) Emanating from argentaffin cells that are located within crypts of Lieberkühn .A study related to three pure testicular neuroendocrine tumours of testis had indicated that pure neuroendocrine tumour of testis might have different genetic background other than germ cell tumour.[11] Histopathology examination of specimens of neuro-endocrine tumour of testis has tended to demonstrate tumour cells that tend to be typified by the presence of nests of small round cells with uniform nuclei forming small acini and rosettes or sheets. The cells tend to contain eosinophilic granules within the cytoplasm and granular chromatin within the nuclei. The tumour cells do exhibit positive staining for neuroendocrine markers like chromogranin and synaptophysin as illustrated in detail in the article. Radical orchidectomy is the most adopted option of treatment; nevertheless, necessitation for the undertaking of provision of adjuvant treatment depending upon histological grading has not been clarified. Because of the possibility of development of local recurrence and or distant metastases after a long time, it is pivotal for all clinicians to carefully follow-up their patients over a long-period of time with clinical, laboratory testing and radiology-imaging testing follow-ups in order to establish early diagnosis of any local recurrence or distant metastasis to be able provide further treatment of curative intent early. There is also the possibility that neuro-endocrine tumours of testis had so far been under-reported due to mis diagnosis of the tumour upon pathology examination of the testicular tumour or the correct set of monoclonal and polyclonal antibodies had not been utilized in the immunohistochemistry study assessment of the tumours. It would be advised that all clinicians and pathologists globally should have a high index of suspicion for a neuro-endocrine tumour of testis in order to establish prompt diagnosis of the tumour and to provide appropriate assessment, treatment and follow-up of all their patients.

Pelvic Inflammatory Disease Mimicking Ovarian Cancer: A Case Series from A Tertiary Cancer Center

AbstractThe female pelvis has a complex anatomy, and benign adnexal diseases can present as malignant ovarian masses clinically and radiologically. Between 1 June 2011 and 28 September 2022, we included in this study all the patients who were diagnosed initially with suspicious ovarian masses in the Department of Surgical Oncology, Oncology Center, Mansoura University, Egypt, and after surgical exploration revealed pelvic inflammatory disease and we assessed their diagnostic, operative, and postoperative outcomes. In this case series we had 41 patients of a total of 803 cases with suspicious adnexal mass that revealed pelvic inflammatory disease after surgical exploration, abdominal pain was the common presentation in 53.7% of the cases, and low-grade fever was reported in seven cases. The serum cancer antigen 125 was elevated in 70.7% of the cases. Unilateral adnexal mass was found in 30 cases and 11 cases had bilateral adnexal masses. We followed up on the patients within 47 months (range 12–88 months); recurrent pelvic inflammatory disease has developed in one case after 62 months and ovarian cancer has developed in another case after 80 months. We concluded that benign adnexal masses such as tubo-ovarian abscess secondary to pelvic inflammatory disease should be considered a differential diagnosis in patients with radiological suspicious adnexal masses when the tumor markers such as cancer antigen 125 are normal or mildly elevated, especially in premenopausal women, and the clinical presentations are not specific to either benign or malignant adnexal diseases.