Well-defined Hypoechoic Mass Research Articles

Epithelioid extragastrointestinal stromal tumor in the pelvic cavity: A rare case at a rare location

ABSTRACT Extraintestinal gastrointestinal stromal tumors (EGISTs) are rare stromal tumors involving mesentery, omentum, and retroperitoneum. EGISTs of the pelvic cavity are extremely uncommon, and till date, no case of pure epithelioid type arising from the pelvic cavity has been reported. They pose a diagnostic pitfall as they may mimic ovarian malignancy. We present a unique case of an epithelioid extraintestinal stromal tumor arising from the pelvic cavity. A 43-43-year-old woman presented with complaints of abdominal pain and menstrual irregularities. Ultrasound examination revealed a large well-defined hypoechoic mass in the right pelvic cavity with a possible site of origin from the right ovary. A total hysterectomy with bilateral salpingo-oophorectomy was done. Histopathological examination revealed an encapsulated tumor comprising predominantly of nests and lobules of epithelioid cells with round-to-oval nuclei, vesicular chromatin, and moderate amount of eosinophilic to clear cytoplasm. Mitotic activity was brisk along with focal areas of necrosis. On immunohistochemistry, tumor cells were diffusely and strongly positive for DOG1 and CD117. They were negative for smooth muscle actin, vimentin, S-100, and HMB-45. Based on these findings, a final diagnosis of the high-grade GIST epithelioid variant was made. It is crucial to make the correct preoperative diagnosis of GIST, since these patients may benefit from neoadjuvant imatinib, especially in case of large tumor size.

S1744 Idiopathic Non-Caseating Pancreatic Granuloma Mimicking Neuroendocrine Tumor: A Challenging Diagnostic Dilemma

Introduction: Pancreatic granuloma is rare. Caseating granuloma is usually caused by tuberculosis, while non-caseating granuloma is mainly secondary to systemic diseases such as sarcoidosis, rheumatoid arthritis, fungal infection, and Crohn’s disease. Idiopathic etiology can present a diagnostic challenge, requiring further investigation to differentiate it from malignancy. We present an interesting case of a patient who presented with a concern for a neuroendocrine tumor before diagnosing idiopathic non-caseating pancreatic granuloma. Case Description/Methods: A 75-year-old female presented with left upper quadrant pain, chronic diarrhea, and palpitations. The physical exam was unremarkable. Workup was significant for elevated serum chromogranin 3,123 ng/ml, with mildly elevated urine metanephrines. Magnetic resonance imaging showed a stable 2.5 cm cystic lesion in the tail of the pancreas communicating with the main pancreatic duct and hypointense area in the tail. 68Ga DOTATATE scan was negative for neuroendocrine tumor. Endoscopic ultrasound showed a multi-cystic lesion in the tail of the pancreas with thick septations consistent with branch-duct intrapapillary mucinous neoplasm (BD-IPMN), and a 2.7 cm homogenous well-defined hypoechoic area in the tail of pancreas along with multiple enlarged peripancreatic lymph nodes (Figure). Fine needle biopsy showed multiple non-caseating granulomas with benign pancreatic and lymphoid tissue. There was no evidence of malignancy, and stains for acid-fast bacilli, FITE stain, and fungal cultures were negative. A benign idiopathic etiology was concluded. At the 6-months follow-up, the patient was doing well. Discussion: Non-caseating pancreatic granuloma has been described in a few case reports. Sarcoidosis was the most common cause, followed by rheumatoid arthritis and Crohn’s disease. Other cases were associated with granulomatosis with polyangiitis (formerly Wegener's granulomatosis), xanthogranulomatous disease, insulin-dependent diabetes mellitus, or foreign body (Talc). Patients may present with epigastric pain, sometimes associated with weight loss, jaundice, fever, or nausea. Further workup and sampling, or even surgery, might be necessary before reaching a solid diagnosis and ruling out malignancy. Therefore, it is essential to rule out other etiologies before confirming the diagnosis of idiopathic pancreatic non-caseating granuloma.Figure 1.: Endoscopic ultrasound (EUS) showing a homogenous & well-defined hypoechoic mass in the tail of the pancreas, measuring 11 x 27 mm.

Rectal Gastrointestinal Stromal Tumors: Usefulness of Endoscopic Ultrasound

Rectal gastrointestinal stromal tumors (GIST) account for 0.1% of all rectal tumors. They are generally diagnosed in adults over 50 years of age with non-specific symptoms. Immunohistochemistry performed on biopsy tissue sample confirms the diagnosis. In this study, we report two cases of histologically and immunohistochemically confirmed rectal GISTs diagnosed using Endoscopic ultrasound (EUS) with fine needle aspiration (FNA), a procedure of crucial value in the diagnosis of these tumors. Both patients were male, presenting with non-specific symptoms. Standard endoscopy showed a rectal mass in both cases, biopsies were negative. EUS showed a well-defined hypoechoic mass and evaluated adjacent organs and of blood/lymphatic nodes involvement. EUS-FNA was performed in both cases. Cytology and immunocytochemistry studies showed spindle cell pattern with positive immunohistochemical staining for CD117, typical of GISTs.

The ultrasonographic characteristics of female periurethral solid masses.

Studies on the imaging of female periurethral masses are sparse, and most are focused on cystic lesions. In this article, we studied female periurethral solid masses and reported their ultrasonographic features. Fifteen women with periurethral solid masses pathologically diagnosed between January 2008 and April 2021 were assessed. Each patient had only one mass. The pathological types included urethral caruncle (5 patients), urethral leiomyoma (3 patients), urethral malignant tumor (MT) (3 patients), periurethral spindle tumor (3 patients) and cartilage necrosis of pubic symphysis (PS) (1 patient). On ultrasound, all urethral caruncles were located at the urethral meatus. They were hypoechoic/isoechoic and rich in blood flow signal. Each leiomyoma presented as a well-defined hypoechoic mass with an oval shape. The urethral MT had inhomogeneous/isoechoic echoes, with medium to abundant blood flow signal. The spindle cell tumors had regular/irregular shapes, moderate/high density echogenicity and little/rich blood flow signals. The articular cartilage necrosis of PS was regular in shape, with mixed echogenicity and no blood flow. Ultrasound imaging is a convenient and useful method to evaluate the morphological characteristics of female periurethral solid masses.

A case of hemobilia caused by pancreatic metastasis of renal cell carcinoma treated with a covered metallic stent

We present the case of an 86-year-old man who had undergone left nephrectomy for renal cell carcinoma (clear cell carcinoma) 22 years ago. He visited the emergency department complaining of right hypochondrial pain and fever. He was eventually diagnosed with acute cholangitis. Abdominal contrast-enhanced computed tomography showed multiple tumors in the pancreas. The tumor in the pancreatic head obstructed the distal bile duct. Endoscopic retrograde cholangiopancreatography detected bloody bile juice flowing from the papilla of Vater. Therefore, he was diagnosed with hemobilia. Cholangiography showed extrinsic compression of the distal bile duct; a 6 Fr endoscopic nasobiliary drainage tube was placed. Endoscopic ultrasound showed that the pancreas contained multiple well-defined hypoechoic masses. Endoscopic ultrasound-guided fine-needle aspiration was performed using a 22 G needle. Pathological examination revealed clear cell carcinoma, and the final diagnosis was pancreatic metastasis of renal cell carcinoma (RCC) causing hemobilia. A partially covered metallic stent was placed in the distal bile duct. Consequently, hemobilia and cholangitis were resolved.

S2932 Ectopic Spleen Tissue Mimicking Gastrointestinal Stromal Tumor, a Case Report of a Gastric Subepithelial Lesion

INTRODUCTION: Gastric subepithelial lesions (SEL) are found as often as 1 in 300 endoscopies. Indolent growing gastric splenosis mimicking a gastrointestinal stromal tumor (GIST) is rare. We present a case of a patient with a gastric SEL with growth concerning for a GIST that ultimately was diagnosed as ectopic splenic tissue (splenosis). This case highlights the importance of considering splenosis as a possible etiology for enlarging gastric SEL in patients with prior splenectomy. CASE DESCRIPTION/METHODS: A 52-year-old female with a remote history of solid pseudopapillary neoplasm (SPN) of the pancreas who received distal pancreatectomy and splenectomy 15 years ago presented with dyspepsia. 10 years ago, an esophagogastroduodenoscopy (EGD) revealed a 10-mm SEL in the gastric fundus. On endoscopic ultrasound (EUS) the lesion was described as a hypoechoic mass in the muscularis propria. Fine needle aspiration (FNA) was not performed given its challenging location. The patient opted for 4 years of annually computed tomography surveillance with stability of the lesion which was thought to be an accessory spleen. However, one year ago she presented to our clinic with dyspepsia. EUS revealed growth of the mass to 22.5 × 13.5 mm in the fourth layer with minimal vascularity suggestive of a GIST. Again, FNA was unsuccessful given its location in the greater curvature of the gastric fundus. Exploratory laparotomy was performed, the mass was excised, and pathology showed benign splenic tissue, consistent with splenosis. DISCUSSION: Splenosis and accessory spleen were considered initially as differential diagnoses in our patient given her splenectomy history. However, the indolent growth of the SEL and EUS appearance raised the concern of GIST. It is imperative to distinguish a GIST from other types of tumors to assess its malignant potential and treatment. Surgical excision was ultimately performed in our patient and the diagnosis of splenosis was made. Splenosis is a subtype of ectopic splenic tissue differentiated from accessory spleen, in that splenosis is acquired heterotopic autotransplantation and implantation of splenic tissue (usually after splenic trauma or splenectomy) while accessory spleen is a congenital anomaly with splenic arterial supply. Clinicians should be aware of the growth potential of splenosis as a mimicker of GISTs and other gastric SELs and consider ectopic splenic tissue a cause of SEL in patients without spleen.Figure 1.: EGD findings: Subepithelial nodule in the gastric fundus (year 0 vs year 9).Figure 2.: EUS findings (year 9): 22.5 × 13.5 mm well-defined hypoechoic and homogeneous mass arising from the fourth layer.Figure 3.: Histopathologic findings of subepithelial lesion: Benign splenic tissue, consistent with splenosis. (Hematoxylin-eosin x 100).

Amyloid tumor of the breast

BackgroundAmyloid tumor of the breast is a rare disease, which was first reported in 1973. To date, only six cases have been reported in Japan.Case presentationA 45-year-old woman who had a medical history of Sjogren’s syndrome presented with a lump of 3 cm in diameter on the outer side of the right breast. Mammography showed no abnormality. Ultrasonography showed a well-defined and rough hypoechoic mass of 32 mm in diameter at the site of the lump. With suspicion of breast cancer, an ultrasound-guided vacuum-assisted breast biopsy was performed. For pathological diagnosis, hematoxylin and eosin staining showed deposits of nonstructural substances in the interstitium. The specimen stained red with Congo red staining and showed green birefringence under a polarizing microscope. Thus, the mass was diagnosed as an amyloid tumor. Since the patient had Sjogren’s syndrome, it was considered a breast finding of autoimmune disease. We considered further therapy to be unnecessary, and annual follow-up was recommended.ConclusionsWe diagnosed the mass as an amyloid tumor by an ultrasound-guided vacuum-assisted breast biopsy without resection. The patient had no systemic symptoms suspected systemic amyloidosis, and we diagnosed localized amyloidosis. An amyloid tumor of the breast may show findings suggestive of breast cancer. Pathological diagnosis before surgery is important to avoid excessive invasion. If deposits of nonstructural substances are observed by hematoxylin and eosin staining, Congo red staining should be added.

A case of primary hepatic neuroendocrine tumor

Introduction: A 48-year-old woman visited our hospital because a liver tumor was detected by medical checkup. Method: Ultrasonography revealed a well-defined hypoechoic mass with a partial anechoic area in segment 5 of the liver. Contrast-enhanced multidetector-row computed tomography revealed a 55mm low-density mass in segment 5 of the liver, which was contrasted strongly in the arterial phase and the contrast effect disappeared in the portal phase. Contrast-enhanced magnetic resonance imaging revealed a high intensity mass on T2-weighted images, which was contrasted strongly in the arterial phase, and the contrast effect was completely lost in the hepatobiliary phase. We diagnosed her with primary or metastatic neuroendocrine tumor (NET) of the liver. Hepatic hemangioma or hepatocellular carcinoma were considered as differential diagnosis. Result: We performed partial hepatectomy for tumor resection. She had a good postoperative course and was discharged on day 9 after the surgery. Macroscopic analysis of the resected specimen revealed a white solid tumor. Histological examination revealed that the tumor cells with circular nuclei containing fine granular chromatin and pale eosinophils were proliferating. Immunohistochemical examination revealed that the tumor cells were positive for Chromogranin A, synaptophysin, ER, CD56 and CK7, and that the Ki-67 labeling index was 5%. The histological diagnosis was hepatic NET G2. After we diagnosed her histologically, we performed 111In-Pentetreotide Somatostatin Receptor Scintigraphy (Octreoscan®) and 18-Fluorodeoxyglucose positron emission tomography to make the liver lesion clear whether primary or metastatic tumor, but there were no lesions. Finally, we diagnosed her with primary hepatic NET. She has been alive without recurrence for 15 months after the surgery. Conclusion: Primary hepatic NET is rare and we report this case with short discussion.

Renal clear cell carcinoma metastasis to the breast ten years after nephrectomy: a case report and literature review

BackgroundRenal cell carcinoma most commonly metastasizes to the lungs, skeleton or liver. Metastatic renal cell carcinoma to the breast is very rare, especially for clear cell carcinoma, and few cases regarding this condition have been reported.Case PresentationThe case we presented was a 68-year-old Chinese female with metastatic renal clear cell carcinoma of the left breast 10 years after a nephrectomy. Identification of the metastatic renal clear cell carcinoma in the breast required multiple breast imaging modalities. Imaging showed a single, ovary-shaped, well-defined hypo-echoic mass, with abundant blood flow on ultrasound images. The mass was enhanced early on MRI, and it was hypointense on a T1-weighted image and hyperintense on a fat-saturated T2-weighted image. Following surgical excision of the tumor, a routine immunohistochemistry antibody panel on the tumor cells revealed negative staining for estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor-2 (Her-2). Strong positive staining for the cluster of differentiation 10 (CD10) and vimentin was present.ConclusionThis case is unusual because of the site of metastatic progression. It is important for physicians to be aware of this progression so early diagnoses can be made, and appropriate therapeutic planning can be initiated.

Hydrocele of the canal of Nuck presenting as a sausage-shaped mass

A 23-year-old woman presented with a painless vulval swelling. On physical examination, a soft fluctuant sausage-shaped mass was found, measuring approximately 4 cm, extending from the right inguinal region to...

A rare case of synchronous association of chromophobe renal cell carcinoma with urothelial carcinoma of urinary bladder

IntroductionChromophobe renal cell carcinoma accounts for 3–5% of all RCCs. However, its association with urothelial carcinoma of urinary bladder has never been reported. We report a case of synchronous association of chromophobe RCC with low grade urothelial carcinoma of urinary bladder. ObservationsA 64-year old gentleman, presented with a dull aching pain in right loin region of one month duration. General physical and abdominal examinations were unremarkable. Ultrasonography of abdomen showed a well-defined hypoechoic mass lesion involving the lower pole of right kidney. CECT abdomen revealed a partially exophytic mass lesion of size 4cm×4.3cm×5.1cm arising from lower pole of right kidney. Surprisingly, urinary bladder also showed a polypoidal mass lesion measuring 15mm×12mm×13mm in posterior wall inferior to right vesico-ureteric junction. We proceeded with right partial nephrectomy followed by transurethral resection of bladder tumor. Histopathology report revealed chromophobe RCC and low grade urothelial carcinoma of urinary bladder. The patient is under regular follow-up. ConclusionSynchronous association of chromophobe RCC with urothelial carcinoma of urinary bladder has not been reported so far, hence there is no scientific consensus in the management of these lesions.

Malignant melanoma metastatic to the gallbladder diagnosed by endoscopic ultrasonography-guided fine-needle aspiration.

Endoscopic ultrasonography-guided fine-needle aspiration (EUS-FNA) is a safe and powerful modality for diagnosis of gallbladder lesions.[123] We report an extremely rare case in which EUS-FNA was useful for the definitive diagnosis of metastatic melanoma of the gallbladder. A 53-year-old woman was treated of a vaginal malignant melanoma. Enhanced computed tomography (CT) showed a heterogeneously enhanced mass of 3.5 cm × 3.0 cm in the vagina. No other lesions were detected in the liver, gallbladder, or other organs. Three months of radiation therapy resulted in regression of the tumor revealed by image modalities. Six months after the radiation, follow-up enhanced CT revealed a heterogeneously well-enhanced mass in the neck of the gallbladder. EUS demonstrated a 12 mm × 7 mm well-defined hypoechoic heterogeneous mass with a hyperechoic-layered structure arising from the gallbladder wall. Power Doppler EUS revealed spotty increased flow on the tumor [Figure 1]. Transduodenal EUS-FNA of the gallbladder mass using a 25-gauge FNA needle was performed without any complications. Histopathological examination demonstrated a cluster of small- to medium-sized cells without melanin pigment. The nuclei were round or oval and they were hyperchromatic with inconspicuous nucleoli [Figure 2]. Immunohistochemistry was positive for S-100 protein and HMB-45 [Figure 2], consistent with malignant melanoma. The patient received chemotherapy; however, she deceased 4 months after EUS-FNA.Figure 1: Endoscopic ultrasonography image showing a well-defined hypoechoic heterogeneous mass with a hyperechoic-layered structure arising from the gallbladder wall. Power Doppler endoscopic ultrasonography revealed spotty increased flow on the tumorFigure 2: Endoscopic ultrasonography-guided fine-needle aspiration specimen from the neck of the gallbladder showing a cluster of small- to medium-sized cells without melanin pigment. Some tumor cells have intranuclear inclusion. The nuclei are round or oval and they were hyperchromatic with inconspicuous nucleoli (inset; the tumor cells are positive for S-100 protein [above] and HMB-45 [below])Since the first case of malignant melanoma from gallbladder,[4] the interest in gallbladder melanoma has been increasing. Although more cases have been reported since then, both primary and metastatic melanomas of the gallbladder are extremely rare. Because of the rarity of gallbladder melanoma, definitive diagnosis is still difficult even if clinically suspicious. To the best of our knowledge, this is the second report of metastatic malignant melanoma of the gallbladder,[3] which was successfully diagnosed by EUS-FNA. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given her consent for her images and other clinical information to be reported in the journal. The patients understand that her name and initial will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Breast metastasis from rectal adenocarcinoma: a case report with US and CT findings

Metastasis to the breast from extramammary malignancies is unusual. We describe a case of rectal adenocarcinoma metastatic to the breast. A 21 year old woman had undergone abdominoperineal and vaginal resection and hysterectomy, right inguinal lymph node dissection for presenting vaginal bleeding ten months before. The patient was readmitted to our hospital for presenting edema and masses with severe pain in her breasts. US and contrasted CT was taken but mammography could not be performed due to severe tender and pain of her breasts. Breast US revealed diffuse skin thickening and bilateral multiple well-defined hypoechoic masses whereas contrasted CT delineated multiple, oval or round, and inhomogeneous superficial and invasive deep solid masses in her breasts with strong peripheral and moderate patchy central contrast enhancement and bilateral axillary lymph nodes. Breast biopsy and immunohistochemistry revealed rectal adenocarcinoma metastasis to the breast. To our knowledge, colorectal adenocarcinoma metastasis to the breast in women is extremely rare as 17 patients in the literature. Moreover, this is the fifth patient with bilateral breast metastasis from colorectal adenocarcinoma. This report also shows that CT is helpful to define axillary metastasis, the fixation and invasion of the deep metastatic lesions to the chest wall, which is unique feature of this metastatic tumor. CT could be used for early stage breast metastasis to some extent, but CT was diagnostic in late stage.

MATURE RETROVESICAL TERATOMA IN AN ADULT MALE: A CASE REPORT AND LITERATURE REVIEW

Objective:We reported a case of mature (benign) cystic retrovesical teratoma. Retrovesical teratoma is a very rare extragonadal tumour, especially in adults, moreover in male patients. Grading and classification of teratoma is important for management and prognosis.Material & method:The patient in this study was a 49-year-old male who had chief complaints of abdominal mass and difficulty in urination. We performed Ultrasonography (USG) and Abdominal Multislice Computed Tomography (MSCT) scan on the patient. Results: USG showed a large mass in the pelvic region demonstrating a well-defined hypoechoic mass with septations at posterior of vesica urinaria. MSCT scan showed a large inhomogeneous hypodense mass with thin septations as well as multiple areas of fatty collections and coarse calcifications in pelvic region. We performed complete surgical resection per laparotomy. Grossly, the mass measured 12 x 10 x 5 cm and had rubbery consistency. Cut section of the mass revealed multilocular cystic spaces, whitish-gray walls, scattered yellowish adipose tissue collection, mucus secretions, and areas of calcifications. Pathological diagnosis of the resected tumour was a matured teratoma. The diagnosis was made because the tumour showed signs of a mature teratoma such as lined by stratified squamous and respiratory columnar eptithelium, fat and muscle tissue, nerve tissue, and calcifications. Conclusion: There were no neuroepithelium appearance. To our knowledge, this is the first retrovesical teratoma case being reported in Indonesia.

Mature (Benign) Cystic Retrovesical Teratoma in a 49-Year-Old Male: a Case Report and Literature Review

Teratomas are congenital tumours that contain derivatives of all three germ layers. Teratomas have been reported to occur in various sites and organs. Retrovesical teratoma is a very rare extragonadal tumour, especially in adults, moreover in male patients. Grading and classification of teratoma is important for management and prognosis. We report a case of mature (benign) cystic retrovesical teratoma. The patient was a 49-year-old male who had chief complaints of abdominal mass and difficulty in urination. Ultrasonography (USG) showed a large mass in the pelvic region demonstrating a well-defined hypoechoic mass with septations at posterior of vesica urinaria. Abdominal Multislice Computed Tomography (MSCT) scan showed a large inhomogeneous hypodense mass with thin septations as well as multiple areas of fatty collections and coarse calcifications in pelvic region. We performed complete surgical resection per laparotomy. Grossly, the mass measured 12 x 10 x 5 cm and had rubbery consistency. Cut section of the mass revealed multilocular cystic spaces, whitish-gray walls, scattered yellowish adipose tissue collections, mucus secretions, and areas of calcifications. Pathological diagnosis of the resected tumour was a matured teratoma. The diagnosis was made because the tumour showed signs of a mature teratoma such as lined by stratified squamous and respiratory columnar eptithelium, fat and muscle tissue, nerve tissue, and calcifications. There were no neuroepithelium appearance. To our knowledge, this is the first retrovesical teratoma case being reported in Indonesia.

Testicular leiomyoma masquerading as lymphoma

Leiomyomas are benign tumors which arise from smooth muscle cells. They are usually seen in the uterus and other organs. In the genitourinary tract, the renal capsule is most commonly involved; however, leiomyoma involving testis is extremely rare. We describe the case of a 63-year-old male patient presented with painless swelling of the right scrotum for 2 years with gradual increasing in size. Ultrasonography of scrotum revealed well-defined hypoechoic mass in the right testis just beneath the tunica albuginea layer; hence, a diagnosis of testicular lymphoma was made. However, leiomyoma was confirmed by histopathological examination. This case highlights the rare occurrence and also it can mimic as malignancy.

Ectopic Pancreas in the Duodenojejunal Flexure-Computed Tomographic and Endoscopic Ultrasonographic Images.

Ectopic pancreas is a rare entity where the pancreatic tissue has no anatomic and vascular contact with the main body of the pancreas and has its own duct system and vascular supply. A detailed clinical report with contrast-enhanced computed tomography (CT) and endoscopic ultrasonography (EUS) imaging findings of a 40-year-old male came with vague symptoms. CT showed a well-defined homogeneously enhancing mass lesion in the duodenojejunal (DJ) flexure. EUS revealed a well-defined hypoechoic mass lesion in the submucosal layer of the DJ flexure. Surgical resection of the mass was performed, and histopathological examination of specimen confirmed the pancreatic tissues. Here, we have described the CT and EUS imaging features which can help to differentiate the ectopic pancreas from the gastrointestinal submucosal tumours.

Detection of skeletal muscle metastases on initial staging of lung cancer: a retrospective case series

Estimation of skeletal muscle metastases (SMMs) at the time of diagnosis and/or initial staging of lung cancer. Retrospective evaluation of clinical charts and imaging data suggestive of SMMs of patients with histology-proved lung cancer over a 5-year period. SMMs were identified in 46 out of 1,754 patients. Single and multiple (62.9% of cases) SMMs were detected by total body multi-detector computed tomography (MDCT). They were associated with poorly differentiated (43%) and advanced adenocarcinomas (52%) without clinically relevant symptoms and/or signs. Psoas and buttock muscles were most frequently involved (33.3%). MDCT findings consisted of well-defined homogeneously hyperdense oval masses (31%), lesions with ring-like enhancement and central hypoattenuation (68%), or large abscess-like necrotic lesions (24%). Sonography revealed well-defined hypoechoic masses (41.6%), ill-defined hypoechoic lesions (33.3%), or anechoic areas with a necrotic centre (25%). Positron emission tomography revealed that all SMMs were metabolically active. SMMs are uncommon but not negligible in lung cancer, with an estimated prevalence of 2.62% in our series. Although histology remains the recommended method, use of high-performance imaging techniques and increased clinical suspicion may improve their early detection. Efforts addressing their effect on the natural history of lung cancer are needed.

Pancreatic tuberculosis presenting as an unusual head mass

A 28-year-old man presented with upper abdominal pain accompanied by loss of appetite and weight. The clinical examination was unremarkable. His laboratory investigations revealed serum alkaline phosphatase of 260 IU/l (normal range: 42 – 126 U/L) with normal serum bilirubin. Ultrasound of the abdomen showed a well-defined hypoechoic mass, measuring 3 cm, in the head and body region of the pancreas and a nondilated common bile duct and pancreatic duct. Integrated positron emission tomography (PET)–computed tomography (CT) had similar findings with the mass showing intense 18F-fluorodeoxyglucose (FDG) uptake (standardized uptake value [SUV] value of 15.7) and invading the common hepatic artery as well as the superior mesenteric vein ([Fig. 1]). The peripancreatic and precaval lymph nodes were also enlarged and showed intense FDG uptake. Endoscopic ultrasound (EUS) also had similar findings, with infiltration of the major vessels by the mass ([Fig. 2]). Following EUS-guided fine-needle aspiration from the mass, cytological analysis revealed granulomatous inflammation with negative staining for acid-fast bacilli (AFB) ([Fig. 3]). The patient started four-drug antitubercular therapy (ATT) and showed a marked improvement in symptoms. After 6 weeks of ATT he is asymptomatic with a normal appetite and complete resolution of abdominal pain.

Endoscopic Ultrasound for Diagnosis and Surveillance of Gastrointestinal Stromal Tumors in an 11‐Year‐Old Child

Endoscopic Ultrasound for Diagnosis and Surveillance of Gastrointestinal Stromal Tumors in an 11‐Year‐Old Child