Upper Quadrant Abdominal Mass Research Articles

S3022 Hepatic Cerebrospinal Fluid Pseudocyst: A Rare Complication of Ventriculoperitoneal Shunt

Introduction: Ventriculoperitoneal shunts (VPS) are commonly used in the management of hydrocephalus to drain cerebrospinal fluid (CSF) into the peritoneal cavity. The placement of VPS has prolonged the survival of patients with hydrocephalus. Abdominal pseudocysts are long-term complication of VPS that are identified later in life. Hepatic CSF pseudocyst is a rare long-term complication of VPS that should be differentiated from other cystic lesions of liver. Case Description/Methods: A 49-year-old man with intellectual disability from congenital hydrocephalus s/p placement of right and left-sided VPS at age of 3 months and 7 years respectively presented with exertional dyspnea and abdominal distension. On presentation his vitals were unremarkable except tachycardic (115/min)., He had abdominal distention, hepatomegaly but no tenderness. Initial labs showed D-dimer 2.20 mcg/mL, AST 27 u/L, ALT 38 u/L, alkaline phosphate 126 u/L and total bilirubin 0.5 mg/dL. Chest CT with IV contrast was negative for pulmonary embolism, however revealed a large 18x13x13.5 cm cyst in right hepatic lobe. CT abdomen and pelvis demonstrated a 17.5x12.6x12.7 cm cystic lesion in the right hepatic lobe with the tip of VP shunt catheter within cyst cavity. Hepatobiliary nuclear scan was unremarkable for any biliary leak or sphincter of oddi dysfunction. CT head was negative for any acute abnormalities. Shunt series x-rays were negative for disruption of VPS catheter. Robotic laparoscopic cyst fenestration with partial hepatectomy was performed and catheter was repositioned to the right lower quadrant of abdomen. Patient was discharged home two days later with significant reduction of cyst size on follow up imaging. (Figure) Discussion: This case illustrates a rare complication of VPS that result in hepatic CSF pseudocyst. If hydrocephalus is absent, patients with hepatic CSF pseudocyst are asymptomatic at earlier stages., or they may present with abdominal pain, distention, or palpable right upper quadrant abdominal mass. A subset of patients with hepatic CSF pseudocyst are complicated with bacterial or parasitic infection and present with abdominal pain, distention, or right upper quadrant mass. Abdominal ultrasound and CT scan assist in diagnosis by identifying the tip of VPS catheter in the pseudocyst cavity. Asymptomatic patients are managed conservatively while surgical repositioning of VPS catheter with or without cyst fenestration or surgical excision of cyst may be required for complete resolution of symptoms.Figure 1.: CT of abdomen showing a large right hepatic lobe cyst with evidence of tip of right VPS catheter within the cavity of the cyst (arrows) on transverse (A), axial (B) and lateral (C) views. CT scan of the head (D) showing VPS catheters both in right and left lateral ventricles without evidence of ventricular dilation. Shunt series x-ray (E) shows now distortion of VPS catheter. Robotic laparoscopic cyst fenestration (F) shows VPS catheter within cyst cavity containing CSF.

MON-372 Asymptomatic Pheochromocytoma Masquerading as Right Upper Quadrant Abdominal Mass

Introduction: Pheochromocytomas (PCCs) are rare catecholamine-producing neuroendocrine tumors, mostly arising from the adrenal medulla (85%). We present an interesting case of a young woman with developmental delay who was diagnosed with pheochromocytoma after presenting with abdominal distention as the only initial complaint. Case presentation: A 44-year-old non-communicative Caucasian female with h/o severe developmental delay and seizure disorder presented to clinic with her caregiver for significant abdominal distention that developed over the last few days. On examination, abdomen was distended and firm to palpation. Abdominal ultrasound revealed 10.1 x 8.6 x 6.6 cm heterogenous mass in the right upper quadrant (RUQ), abutting and possibly contiguous with the liver. MRI abdomen revealed heterogenous mass originating from the caudate lobe measuring 8.5 x 6 x 12 cm. However, during CT guided biopsy, a large mass just right and anterior to the vertebral column and posterior to the liver raising suspicion for renal origin of the mass. Pressure was applied over the biopsy site to stop bleeding after obtaining core biopsies. She immediately developed hypertension with BP 240/164 mm hg, HR 123 bpm, RR 19, temperature 38.3°C concerning for catecholamine-secreting tumor. She became hypoxic and stat CXR revealed flash pulmonary edema. She was intubated for acute hypoxic respiratory failure. EKG showed sinus tachycardia. Her BP decreased to 150/70, HR 100/min after giving her IV labetalol. Labs showed serum sodium 141, potassium 4.9, bicarb 15, AG 15, hemoglobin 17.6, lactic acidosis of 6.1, AST 4670 U/L (N: 14-36), ALT 2955 U/L (N: 9-52), creatinine 2.1 mg/dl, troponin 0.61 ng/ml (Ref: < 0.05 ng/mL) and CK 2351 U/L (N: 30-175). Transthoracic echocardiogram showed normal findings. Serum metanephrines revealed elevated total metanephrines (26 nmol/L), norepinephrine (49 nmol/L) and 24-hour urine catecholamines: total metanephrines level 33635 mcg/24 h and normetanephrines 17850. She improved clinically, was extubated and discharged on phenoxybenzamine and metoprolol. She underwent surgical resection of the abdominal mass with no postoperative complications and the biopsy report confirmed PCC. Discussion: In a young patient presenting with RUQ abdominal mass, it is imperative to rule out secondary causes such as adrenal tumors (PCC), especially in patients with limited history. Initial biochemical testing to exclude conditions like PCC should always be considered prior to invasive procedures involving masses close to the adrenal gland, as manipulation or biopsy of a pheochromocytoma may have dreadful consequences. Our case illustrates the necessity of maintaining a broad differential when evaluating cases with RUQ abdominal masses which are close to the adrenal gland, and to consider other modalities of testing depending on the index of suspicion prior to biopsy of the mass.

AB050. P-18. Rare adenocarcinoma arising from mucinous cystic neoplasm of liver: case report and literature review

Methods: This 71-year-old female presented in our institution with a palpable right upper quadrant abdominal mass. Computed tomography showed large multi-lobular complex cystic lesions of the right liver lobe with thick and irregular septa, raising the suspicion of a biliary cystadenoma.

Retained gastric band port and tube 5\u2009years after gastric band removal and laparoscopic Roux-en-Y gastric bypass: a case report

BackgroundWhile LAGB has become uncommon in the bariatric surgery practice, band removal with or without revision surgery is still common. Retained postoperative foreign body, of which surgical sponges are the most common, is a rare condition. We report a rare case of retained gastric band port and the attached tube.Case presentationA 31-year-old Caucasian female presented to the outpatient clinic, 5 years after her last surgery, complaining of a left upper quadrant abdominal mass over the last 2 years. She had a history of 2 weight loss operations. She had no significant family history nor smoking. CT of the abdomen and pelvis revealed a retained foreign body. On exploration, the port with 10 cm of the connected tube was found and removed through a small incision without laparotomy. The patient made an uneventful recovery.ConclusionA bariatric surgeon should be involved in the evaluation of any patient who complains of abdominal pain and/or palpable mass if she/he has a previous weight loss procedure because the bariatric surgeon is fully aware of the possible complications of the bariatric surgeries.

When Physical Examination Signs Point to Sinister Causes

A 55-year-old male presented with mild abdominal discomfort. On physical examination, a right upper quadrant abdominal mass was palpable and an obstructed right varicocele was evident. Ultrasonography and computed tomography revealed a 15 cm right renal tumor with a 2 cm aortocaval lymph node. The patient underwent an uneventful laparoscopic transperitoneal radical nephrectomy and lymphadenectomy and was discharged after 2 days. No complications or recurrence were noted at 6 months follow-up. This report signifies the importance of physical examination and attention to cardinal clinical signs and also the feasibility of laparoscopy in large renal tumor in expert hands.

Extrarenal Wilms' Tumor With Intraspinal Extension : A Case Report

This report illustrates a proven rare case of retroperitoneal extrarenal Wilms’ tumor, and discusses the radiological features of this tumor, for a 19 month old female patient referred to our radiology department with an abdominal mass for further evaluation. Abdominal Ultrasound, Computed Tomography and abdominal Magnetic Resonance Imaging were performed and showed right upper quadrant abdominal mass, displaying right kidney upward and extended to the spinal canal at that level. The case was discussed thoroughly. Our preliminary diagnosis was in favor of neurogenic tumor and neuroblastoma was on the top of our differential diagnosis. Histopathological examination of the surgically excised tumor confirmed the diagnosis of extrarenal Wilms' tumor. Postoperative adjuvant chemotherapy was performed. During the following 24 months, no local recurrence or distant metastasis were detected.

Primary angiosarcoma of the spleen: an oncological enigma.

Introduction. Primary splenic angiosarcoma is an extremely unusual neoplasm originating from sinusoidal vascular endothelium. Surgical extirpation is the mainstay of treatment of this highly malignant disease. Case Presentation. An 82-year-old woman was admitted with left pleural effusion and a palpable left upper quadrant abdominal mass, secondary to splenomegaly by two large splenic tumors. Classic open splenectomy was performed and angiosarcoma of the spleen was the final histopathological diagnosis, which was primary since no other disease site was revealed. Discussion. The incidence of the disease is 0.14–0.23 cases per million, with slight male predominance. Etiology is not established and clinical presentation may confuse even experienced physicians. Imaging modalities cannot differentiate the lesion from other vascular splenic neoplasms and the correct diagnosis is mainly set after histopathological examination of the resected spleen. As with other sarcomas, surgery is the only curative approach, while chemo- and radiotherapy have poor results. Prognosis remains dismal.

Androgen-secreting adrenocortical carcinoma

A 47-year-old woman presented with abdominal pain. She had recently noticed increased growth of facial hair and loss of scalp hair, and her menstrual cycle had become erratic. Abdominal examination revealed a right upperquadrant abdominal mass. A CT scan of the abdomen revealed a 10 cm adrenal mass (fi gure, A, B; green arrows) that was well encapsulated and heterogeneous. Endocrine studies were ordered to exclude a functioning adrenal neoplasm. The serum total testosterone concentration was 8·6 nmol/L (reference range 0·13–2·53 nmol/L) and the serum dehydroepiandrostenedione sulphate (DHEAS) con cen tration was 22 μmol/L (reference range 1·0–11·6 μmol/L). The free androgen index (ratio of testosterone to sex-hormone-binding globulin) was 30·2% (reference range 75% of tumour cells, and necrosis; fi gure, C [haematoxylin and eosin staining]). Immuno histochemistry was positive for melan-A, vimentin, synaptophysin, and epithelial membrane antigen. Cytoplasmic staining was positive with calretinin (fi gure, D) and inhibin (fi gure, E). The Ki-67 proliferative index was 32%. Mitotane was recommended as adjuvant therapy for 2 years. No evidence of recurrence or metastatic disease was recorded 12 months postoperatively and androgen concentrations remain suppressed. Women presenting with hirsutism or virilisation are more likely to have polycystic ovarian syndrome than an androgen-secreting adrenal neoplasm. Assessment of patients requires thorough hormonal investigation and imaging, including CT, MRI, and FDG-PET.

Primary splenic angiosarcoma in a 2.5-year-old boy with hepatic metastasis

Primary splenic angiosarcoma in children is extremely rare and has a very poor prognosis. We reported a 2.5-year-old boy who had this rare entity and hepatic metastasis. The patient presented with left upper quadrant abdominal mass and anemia. The patient received multidisciplinary treatment and died 32 months after splenectomy.

Subdural hemorrhage as a first symptom in an infant with a choledochal cyst

Choledochal cysts are not rare in East Asia. The classic symptoms of these cysts are intermittent abdominal pain, jaundice, and a right upper quadrant abdominal mass. The authors report the case of an infant with a choledochal cyst presenting with intracranial hemorrhage. This 2-month-old girl with a partial coma presented at the authors' hospital. A brain CT scan revealed right-sided subdural hemorrhage. The routine preoperative survey found coagulopathy. After correcting the bleeding disorder, an emergency craniectomy was performed. Further examination found a choledochal cyst during abdominal ultrasonography and CT. Choledochal cysts are a cause of neonatal cholestasis but rarely produce vitamin K deficiency bleeding.

8-year survival in a patient with several recurrences of renal cell carcinoma after radical nephrectomy

We describe the case of a patient with a large renal cell carcinoma (RCC) who underwent cytoreductive nephrectomy utilizing liver mobilization techniques similar to those used in transplantation. Despite recurrent metastases, our patient continues to survive eight years later with several metastasectomies and adjuvant chemotherapy.We report the case of a 48-year-old Hispanic American man who presented with a 4-month history of an enlarging right upper quadrant abdominal mass and hematuria. Computerized tomography revealed a 13 x 14 x 14 centimeter mass suspicious of RCC with possible metastasis to the lungs. The patient subsequently underwent radical nephrectomy. Pathological analysis confirmed the mass as RCC. Over the following eight years, the patient developed metastases to the pulmonary lobes, buccal mucosa, thoracic spine, and second rib, which were all treated with metastasectomy. The patient continues to survive today with a reasonable quality of life.Palliative measures in patients with large RCC tumors with distant metastases require persistent, aggressive therapeutic modalities.

Fine needle aspiration cytology of infantile haemangioendothelioma of the liver: a report of two cases

Fine needle aspiration cytology (FNAC) of infantile haemangioendothelioma of the liver (IHL) has not previously been described because routine use of FNAC is contraindicated due to the risk of bleeding. Two patients presented with progressively increasing right upper quadrant abdominal mass. The index case was a girl aged two and a half years with a large single mass in the right lobe of the liver. The second was a 3-month-old girl in whom ultrasonography revealed multiple hypoechoic lesions in the liver. Ultrasound-guided fine needle aspiration had been performed on both patients. May-Grünwald-Giemsa stained smears from these two patients were reviewed and correlated with histopathology. Both aspirates showed predominantly normal hepatocytes and bile ductules amongst which tumour cells were admixed. The latter were oval to spindle-shaped with scant cytoplasm and wavy, kinked and indented nuclear outlines. The non-epithelial character of the tumour cells was apparent and helped to rule out hepatoblastoma. One case showed extramedullary haemopoiesis. The diagnosis of IHL was established on subsequent excision in the first case and a wedge biopsy in the second case. CD34 and factor VIII R antigen were positive in the tumour cells. Radiological diagnosis of IHL is possible in a majority of cases, but sometimes features may overlap with hepatoblastoma and fine needle aspiration may be performed inadvertently. Characteristic kinked nuclei and intermixed normal liver tissue might suggest IHL in the differential diagnosis of a spindle cell vasoformative tumour.

Peritoneal mesothelioma – a case report

Peritoneal mesothelioma is a very rare diagnosis with an incidence of 1 case per 4–5 million of the population. It accounts for 20–30% of all mesothelioma type cancers. There is great interest in this disease entity amongst the medical community and indeed the general population due to the well-substantiated link between asbestos related exposure and mesothelioma. In this article we report a case of a 77 year old man who presented with a one week history of breathlessness and a right pleural effusion. An incidental right upper quadrant abdominal mass was noted leading to ultrasound and subsequent CT scans. A large subhepatic mass was identified, in addition to pleural calcification and thickening. Biopsy and histological examination of the abdominal mass suggested a spindle cell tumour, most likely a mesothelioma. Thoracocentesis and cytology of the pleural fluid confirmed the diagnosis of a malignant mesothelioma. Our patient is a retired dairy farmer. A detailed occupational history revealed likely asbestos exposure when he worked as a plumber, approximately 50 years ago. Patients with peritoneal mesothelioma often present late, and as a result treatment is often palliative. Interventions include cytoreductive (debulking) surgery and intraperitoneal chemotherapy or radiotherapy. Peritoneal mesothelioma is a very rare disease entity, yet a diagnosis to be considered in a patient with an abdominal mass, previous asbestos exposure, and pleural calcification.

Adult choledochal cyst

A 30-year-old woman presented with a 6-week history of upper abdominal pain and jaundice. Her history was unremarkable except for an abdominal operation at the age of 2 years, the details of which were unknown to the patient. On physical examination the patient was noted to be icteric and her abdomen revealed a midline surgical scar. A palpable right upper quadrant abdominal mass was present. The direct bilirubin level was 4.3 mg/dL (normal = 0–0.4 mg/dL). An abdominal ultrasound showed dilated intrahepatic bile ducts and a 5.5-cm sub-hepatic cystic mass.

Bisphosphonate Treatment of Tumor-Induced Hypercalcemia in a Toddler: Case Report and Review of Related Literature

To describe the initial manifestations and treatment of parathyroid hormone-related peptide (PTH-rP)-induced hypercalcemia in a toddler with a malignant rhabdoid tumor. We report a case of a 2-year-old boy presenting with poor appetite, lethargy, and a 1.5-kg weight loss during a 2-week period. On examination, the child was found to have a right upper quadrant abdominal mass. Laboratory studies revealed severe hypercalcemia. We review the patients' clinical course and management of hypercalcemia. Initial evaluation revealed no cardiovascular instability. An abdominal mass was identified on physical examination. Initial laboratory studies revealed elevated levels of total and ionized calcium, low phosphorus, microcytic anemia, and elevated erythrocyte sedimentation rate. Saline diuresis with furosemide was begun. Abdominal ultrasonography revealed a large right renal tumor. Because of refractory hypercalcemia, intravenously administered bisphosphonate was used. Within 12 hours after bisphosphonate infusion, the serum calcium level declined from 14.9 mg/dL to 10.9 mg/dL. The furosemide dose was decreased and finally discontinued 2 days after bisphosphonate administration. Because of development of a femoral thrombosis, definitive surgical intervention was delayed. During that time, serum calcium levels again increased and necessitated administration of a second bisphosphonate dose. At surgical treatment, a right renal tumor was identified, and frozen section pathology revealed a rhabdoid tumor. After tumor resection, calcium levels were stable. Other laboratory studies performed at admission revealed suppressed PTH, normal vitamin D and calcitonin levels, and elevated PTH-rP. Hypercalcemia in a toddler is a rare event and can be attributable to humoral factors released by malignant tumors. Hypercalcemia in the pediatric population can be treated effectively with bisphosphonates when conservative measures fail.

Pathologic quiz case: right upper quadrant abdominal mass in a young woman. Primary hepatorenal embryonal rhabdomyosarcoma with differentiation.

Pathologic quiz case: right upper quadrant abdominal mass in a young woman. Primary hepatorenal embryonal rhabdomyosarcoma with differentiation.

Metastatic liver cancer: A rare case

Hemangiopericytoma is a rare tumor especially when it rises in the peritoneal cavity. We present a case of a 60-year-old woman with an isolated recurrent hemangiopericytoma of the liver. The patient presented with a palpable right upper quadrant abdominal mass, which occurred 7 years after undergoing resection of a malignant hemangiopericytoma arising from the greater omentum. She had not followed up 6 mo after surgery. Various imaging studies showed a single large, well-capsulated liver tumor with central necrosis, accompanied by hypervascularity typical of a vascular tumor. Preoperative laboratory HBsAg and anti-HCV workup were both negative. Under the impression of recurrent malignant hemangiopericytoma, right trisegmentectomy was performed to completely resect the tumor. Pathological examination confirmed the diagnosis of recurrent hemangiopericytoma. Even though the incidence of the hemangiopericytoma is relatively low, malignant hemangiopericytoma has a tendency to recur frequently after a long-term disease-free interval. Also, the recurrent hemangiopericytoma is not easily detected early during follow-up until it becomes symptomatic because there are no specific tumor markers, and because of the diversity with regard to site of recurrence. The authors suggest that Positron Emission Tomogram (PET) may be a useful tool for the detection of recurrent hemangiopericytoma. We describe herein some characteristics and behaviors of malignant hemangiopericytoma, particularly after surgical resection.

Sarcomatoid renal cell carcinoma with massive osteosarcomatous differentiation: an unusual image in clinical urology

A 46-year-old Hispanic woman presented with a 3-year history of a gradually enlarging right upper quadrant abdominal mass. The serum alkaline phosphatase was 2496 IU/L (normal 13 to 126 IU/L). Computed tomography of the chest, abdomen, and pelvis revealed an enormous, densely calcified mass arising from the kidney with no evidence of metastases (Fig. 1). A bone scan demonstrated increased tracer activity in the area of the mass with no evidence of skeletal metastases (Fig. 2). Radical nephrectomy revealed an almost entirely ossified mass measuring 20.5 cm in its greatest dimension. The histopathologic examination revealed a high-grade malignant neoplasm with extensively calcified osteoid that had features of an osteosarcoma. On electron microscopy, the malignant neoplastic cells showed the presence of desmosomes, indicating epithelial derivation (Fig. 3). On the basis of the electron microscopy findings, the neoplasm was diagnosed as poorly differentiated sarcomatoid renal carcinoma with massive osteosarcomatous differentiation.

Pheochromocytoma presenting as a giant cystic tumor of the liver

Surgery 2000;128:482–4.

Ultrasonographic and clinical predictors of intussusception

Objective: The objective of this study was to determine the positive and negative clinical predictors of intussusception and the correlation of ultrasonography and air enema in establishing this diagnosis. Study Design: This was a prospective descriptive cohort study. Setting: This study was performed in a tertiary care pediatric emergency department. Participants: Eighty-eight of 245 candidates were assessed for clinical predictors of intussusception. All 245 cases were examined for correlation between ultrasonography and air enema. Interventions: A questionnaire, ultrasonography, and air enema were used. Results: Thirty-five of the 88 patients assessed for clinical predictors were positive for intussusception. Significant positive predictors were right upper quadrant abdominal mass (positive predictive value [PPV] 94%), gross blood in stool (PPV 80%), blood on rectal examination (PPV 78%), the triad of intermittent abdominal pain, vomiting, and right upper quadrant abdominal mass (PPV 93%, p = 0.0001), and the triad with occult or gross blood per rectum (PPV 100%, p = not significant). Significant negative predictors were a combination of ≥3 of 10 clinically significant negative features (negative predictive value 77%, p = 0.035). Of the total 245 cases, intussusception (as confirmed by doughnut, target, or pseudokidney sign) was ruled out by ultrasonography in 97.4%. Alternate ultrasound findings comprised 27% of negative cases. Conclusions: Excellent positive predictors of intussusception were identified prospectively. Although no reliable negative predictors were found, patients at low risk may be screened by ultrasonography. (J Pediatr 1998;132:836-9)