Nodular Areas Research Articles

Central fibrous areas: changes in glomerular vascular pole lesions associated with age and disease

PurposeCentral fibrous areas (CFAs) are small, hyalinotic, monotonous nodular areas observed in glomerular vascular pole lesions. We attempted to clarify the relationship between CFA formation and age in healthy kidneys and in those affected by immunoglobulin A (IgA) nephropathy.MethodsZero-hour biopsy specimens from living renal donors (135 cases) and IgA nephropathy biopsy specimens (67 cases) were collected retrospectively. We observed each biopsy specimen and determined the total number of glomeruli, total level of glomerulosclerosis, number of observable glomerular vascular poles, number of glomeruli with CFAs, serum creatinine level, and estimated glomerular filtration rate (eGFR). Additionally, we calculated the glomerular sclerosis rate (GSR), vascular pole appearance rate (PAR), and CFA rate (CFAR) to evaluate the relationship between these factors and patient age.ResultsThere was a significant negative correlation between patient age and eGFR for both the zero-hour (p < 0.0001 in Spearman, p = 0.0009 in multiple regression, the same hereafter) and IgA (p = 0.0022, p = 0.0001) groups. In the zero-hour group, we observed a significant positive correlation between patient age and GSR (p = 0.0001, p < 0.0001); however, there was no such correlation in the IgA group. In both groups, there was a significant positive correlation between patient age and CFAR (zero-hour group: p = 0.0003, p = 0.0091, IgA group; p < 0.0001, p = 0.0004). The slope of the regression line of the IgA group formula was also significantly higher than that of the zero-hour group formula (p < 0.01).ConclusionThese findings indicate that CFA may be a useful indicator of kidney aging, especially in patients with kidney disease caused by IgA nephropathy.

Clinical Scenario and Imaging with Illustrations of Giant Cell Tumor of Bone: A Retrospective Analysis.

The giant cell tumour of the bone has a spectrum of clinical-radiological presentation. This study aims to describe this varied presentation in our institution. This retrospective study was conducted on twenty-nine pathologically labelled cases of giant cell tumours of the bone. The medical records for their clinical presentation and diagnostic imaging studies were studied and evaluated. Mean age of the patients at presentation was 35.3±12.9 years. Pain, local swelling and restricted joint function were seen in 93 %, 58.6 % and 52 % patients, respectively. The cortical breach was seen in 15 (51.7 %) and 22 (75.9 %) lesions on plain radiographs and CT images, respectively. 14(48.3 %) cases had soft tissue invasion on MRI at presentation. 26 (89.7 %) lesions were located within 1 cm from the articular cartilage. The solid tumour component was hypo to iso-intense in signal intensity in 27 (93.1 %) lesions in T1 weighted and 21 (72.4 %) in T2 weighted images. 14 (48.3 %) had hyperintense cystic areas, and fluid-fluid levels, suggestive of aneurysmal bone cysts, were seen in 4 (13.8 %) cases on T2 weighted images. Hypo-echoic nodular areas in solid tumour component, suggestive of hemosiderin deposits, were present in 3 (10.3 %) lesions on T1 and T2 weighted images. The tumour classically presents as an epiphysial-metaphyseal, eccentric, expansile, lytic lesion in a skeletally mature patient. The MRI picture is variable and the surgeon should have a sound knowledge of these variations to obtain a biopsy sample from a proper site of the lesion and to avoid misdiagnosis especially of a primary ABC.

Development and validation of a preoperative CT-based radiomic nomogram to predict pathology invasiveness in patients with a solitary pulmonary nodule: a machine learning approach, multicenter, diagnostic study

ObjectivesTo develop and validate a preoperative CT-based nomogram combined with radiomic and clinical–radiological signatures to distinguish preinvasive lesions from pulmonary invasive lesions.MethodsThis was a retrospective, diagnostic study conducted from August 1, 2018, to May 1, 2020, at three centers. Patients with a solitary pulmonary nodule were enrolled in the GDPH center and were divided into two groups (7:3) randomly: development (n = 149) and internal validation (n = 54). The SYSMH center and the ZSLC Center formed an external validation cohort of 170 patients. The least absolute shrinkage and selection operator (LASSO) algorithm and logistic regression analysis were used to feature signatures and transform them into models.ResultsThe study comprised 373 individuals from three independent centers (female: 225/373, 60.3%; median [IQR] age, 57.0 [48.0–65.0] years). The AUCs for the combined radiomic signature selected from the nodular area and the perinodular area were 0.93, 0.91, and 0.90 in the three cohorts. The nomogram combining the clinical and combined radiomic signatures could accurately predict interstitial invasion in patients with a solitary pulmonary nodule (AUC, 0.94, 0.90, 0.92) in the three cohorts, respectively. The radiomic nomogram outperformed any clinical or radiomic signature in terms of clinical predictive abilities, according to a decision curve analysis and the Akaike information criteria.ConclusionsThis study demonstrated that a nomogram constructed by identified clinical–radiological signatures and combined radiomic signatures has the potential to precisely predict pathology invasiveness.Key Points• The radiomic signature from the perinodular area has the potential to predict pathology invasiveness of the solitary pulmonary nodule.• The new radiomic nomogram was useful in clinical decision-making associated with personalized surgical intervention and therapeutic regimen selection in patients with early-stage non-small-cell lung cancer.

Ultrasonography of IgG4-related dacryoadenitis and sialadenitis: Imaging features and clinical usefulness.

To clarify the ultrasonographic features of immunoglobulin G4 (IgG4)-related dacryoadenitis and sialadenitis (IgG4-DS) and their usefulness in clinical diagnostic sessions. By re-evaluating 96 consecutive patients with IgG4-related disease, we identified 54 patients (male:female = 37:17; median age, 69.5 years) who underwent lacrimal or submandibular gland (LG or SG, respectively) ultrasonography and computed tomography (CT). Their clinical and ultrasonographic features were retrospectively analysed. Radio-pathological correlations were also examined in LG (23 cases) and SG lesions (20 cases). Additionally, the diagnostic accuracy of CT for LG/SG lesions was evaluated. Abnormal ultrasonographic findings were detected in 33 (LGs) and 38 (SGs) patients, and most of them were observed bilaterally. All lesions were well demarcated and demonstrated diffuse low-echoic areas (rocky pattern) or multiple low-echoic nodules surrounded by high-echoic linear shadows (cobblestone pattern) corresponding to intra-lobular inflammation and inter-lobular fibrosis. Moreover, 42% (LGs; 14/33) and 42% (SGs; 16/38) patients had glandular lesions without clinical symptoms associated with the affected glands. The diagnostic accuracy of CT was ∼80% for LG and 55% for SG. Ultrasonographic findings in IgG4-DS included diffuse or nodular low-echoic areas with linear high-echoic structures corresponding to inflamed lobules and inter-lobular fibrosis. These findings can help detect IgG4-DS.

S1483 A 20-Year-OId Female With Obstructive Jaundice and a Pancreatic Head Mass: A Case Report of Type 2 Autoimmune Pancreatitis

Introduction: Autoimmune pancreatitis (AIP) is a form of chronic pancreatitis that may be associated with IgG4 laden lymphoplasmacytic infiltration and fibrosis in multiple organs. It accounts for only a small percentage of all patients with chronic pancreatitis. It can present with abdominal pain, jaundice, recurrent acute pancreatitis, or clinical findings similar to pancreatic cancer. Radiologic findings can also be similar to the above. Therefore, it is important to fully understand the radiologic and histologic nuances of AIP. We review a case of a 20-year-old female who presented with abdominal pain and jaundice who was subsequently diagnosed with Type 2 AIP. Case Description/Methods: A patient with no known past medical history presented with one week of abdominal pain. Imaging demonstrated a normal appearing pancreas with a nodular area of soft tissue fullness at the junction of the pancreatic head and body. Patient returned a few weeks later with jaundice. Endoscopic retrograde cholangiopancreatography (ERCP) revealed a significant biliary stricture which was stented. EUS with biopsies demonstrated mild acute on chronic inflammation of the ampulla and mild acute inflammation of the pancreatic head as well as benign pancreatic parenchyma with edema, very focal fibrosis, and focal neutrophilic infiltrate in acini and intralobular small ducts. Steroids were prescribed leading to resolution of signs and symptoms. Discussion: Initial presentation of AIP can mimic that of other pancreatic pathology so further imaging with biopsy is necessary to make a final diagnosis. Type 1 and Type 2 AIP both have histologic findings of periductal infiltration of plasma cells and lymphocytes, peculiar storiform fibrosis, and venulitis. Type 1 typically has a high number of IgG4 positive plasma cells and can be associated with various systemic lesions related to IgG4 positive cell infiltrates. Type 2 is known for intraluminal and intraepithelial neutrophils in small to medium ducts and acini causing destruction of the duct lumen and is considered a pancreatic specific disease. In both types imaging tends to show diffuse parenchymal enlargement with delayed enhancement and ductal strictures without significant upstream dilatation. Treatment of AIP consists of steroids with Type 1 known to have relapses requiring re-treatment. Based on the histologic and radiologic findings a presumptive diagnosis of Type 2 AIP was made. Response to steroid treatment and no evidence of relapse confirmed the diagnosis.Figure 1.: A single severe stenosis seen in the lower third of the common bile duct.

Tenosynovitis in a renal transplant recipient: Making the diagnosis firsthand

A 63-year-old man presented with 2 months of right upper extremity (RUE) redness and swelling 17 months after deceased donor renal transplant. He underwent hemodialysis for hypertension-induced renal failure for 3 years pretransplant via a left upper extremity radiocephalic arteriovenous fistula. Although not sensitized pretransplant, he received thymoglobulin induction for anticipated delayed graft function. Allograft function did not recover. He remained on dialysis and relisted for transplantation, while maintained on tacrolimus, mycophenolic acid, and prednisone. Two months before presentation, he noted gradual swelling involving his right hand second and fourth digits. This progressed to involve the right palm, wrist, and elbow with associated pain and erythema. He denied RUE trauma, fever, or systemic symptoms. He denied exposures to animals, gardening, caves, freshwater bodies, or construction sites. He lived in North Carolina with no travel outside the region. Examination revealed erythematous, tender, and fluctuant nodules involving the right wrist and palm, second and fourth digit dactylitis (Figure 1), and right olecranon bursitis. RUE joint range of motion was intact. His examination was otherwise unremarkable. Laboratory data: white blood cell count 1300 cells/mm3 (neutrophils 1058 cells/mm3, lymphocytes 138 cells/mm3), hemoglobin 7.6 g/dl, platelets 176 000/µl, and normal liver functions. RUE magnetic resonance imaging (MRI) demonstrated full-thickness soft tissue edema with large nodular areas of heterogeneous signal abnormality correlating with his examination, without abscess or osteomyelitis. Hypothenar eminence skin biopsy demonstrated extensive dermal and subcutaneous tissue necrosis (Figure 2). Periodic-acid Schiff stain and cultures from the olecranon bursa fluid aspirate and skin biopsy showed Histoplasma capsulatum. 1How do most transplant recipients acquire histoplasmosis?aEnvironmental fresh water exposurebInhalation of airborne sporescPerson to person transmissiondTransmission through an animal biteeTransmission via the donor allograft2Which study is most likely to reveal an additional site of infection in this case?aBone marrow biopsybEchocardiographycChest computed tomography (CT)dMRI braineMRI spine3Which clinical feature supports tenosynovitis with concomitant deeper soft tissue infection of the wrist and hand?aConcomitant olecranon bursitisbDactylitis with intact joint range of motioncLack of discrete abscess formation on imagingdSubacute progression of clinical findingseSubcutaneous tissue necrosis on skin biopsy4Despite discontinuing immunosuppression and administering liposomal amphotericin B (AMB) for 3 weeks, the patient’s right-hand abnormalities failed to demonstrate significant clinical improvement. What is the best next step in the management of this patient’s infection?aContinue with liposomal AMB to allow more time for a clinical responsebAdd an azole antifungal agent to the treatment regimencAdd empiric antibacterial coverage for possible superinfectiondAdminister high dose steroids to treat immune reconstitution syndromeePerform surgical exploration and debridement

The role of molecular diagnostics in aneurysmal and simple bone cysts – a prospective analysis of 19 lesions

Aneurysmal (ABC) and simple bone cysts (SBC) have been traditionally distinguished by radiological and histopathological features. However, there is some radiological and histopathological overlap between ABC and SBC. ABC is characterised by USP6 fusions while, recently, NFATC2 fusions have been found in a large proportion of SBC. Identifying these fusions may assist in confirming the diagnosis of either ABC or SBC. To elaborate the potential benefit of molecular testing, we report a prospective series of 19 consecutive bone cysts with comprehensive radiological, histopathological and molecular diagnostics. Integrating radiological, histopathological and molecular findings, 11 cysts were diagnosed as SBC and 8 as ABC. Radiologically, 6 of 11 SBC and 6 of 8 ABC were diagnosed as ABC. Fibrin-like collagen deposits were identified in 8 of 11 (73%) SBC and 3 of 8 (38%) ABC. Nodular fasciitis-like areas were identified in 6 of 8 (75%) ABC and in 7 of 11 (64%) SBC. A USP6 fusion was identified in all 8 ABC, including a novel RBM5-USP6 fusion. An NFATC2 fusion was found in 7 of 11 SBC (FUS-NFATC2 fusion in 5 and EWSR1-NFATC2 in 2 cases). There is radiological and histopathological overlap between SBC and ABC in a significant proportion of cases. A diagnosis of ABC is frequently suggested radiologically in SBC, and fibrin-like deposits, thought to be specific for SBC, may be found in some ABC. Molecular testing may significantly improve diagnostic accuracy in bone cysts.

Incidental Diffuse Sclerosing Variant Papillary Thyroid Cancer in Grave’s Disease

The diffuse sclerosing variant papillary thyroid carcinoma (DSPTC) is an uncommon form of this neoplasm. Some studies describe its high propensity for tumor invasion, metastasis, and mortality compared with classic papillary thyroid carcinoma. Histologic features of DSPTC may resemble diffuse inflammation as seen with Grave’s or Hashimoto’s thyroiditis, which makes initial diagnosis challenging.A 27-year-old female with Noonan’s Syndrome was evaluated on an outpatient basis after developing atrial fibrillation de novo. Thyroid function tests were consistent with hyperthyroidism with TSH: <0.005 (n: 0.300-3.000 uIU/mL), FT4: 3.59 (0.71-1.85 ng/mL) and FT3: 16.77 (n: 2.0-7.0 pmol/L). Diffuse goiter was noted on physical exam, but no ophthalmopathy or dermopathy was present. TRAB and TSI were elevated at 38.4 (n: <16%) and 423% (n: <140%) respectively. A twenty-four-hour radioiodine uptake was 48% (n:10-35%) and described as essentially homogenous with two foci of decreased radiotracer concentration suggestive of cold nodules. Thyroid ultrasound showed diffuse nodularity bilaterally with associated clusters of calcifications and no discrete nodules. No abnormal appearing lymph nodes were identified. Fine-needle aspiration of both nodular areas was positive for DSPTC. Total thyroidectomy with central neck dissection was performed. Gross and microscopic post-surgical pathology confirmed the presence of diffuse sclerosing papillary thyroid cancer, along with local metastasis to one central lymph node. Patient was scheduled for radioactive iodine therapy.Diffuse sclerosing variant is considered an aggressive histotype of papillary thyroid cancer. Ultrasound features include diffuse scattered microcalcifications with or without discrete nodules that may be confused with chronic inflammatory changes. Despite the limited number of cases, DSPTC is recognized to have specific characteristics, a high female to male ratio, and a young patient age. DSPTC has a high potential for aggressive biologic behavior if not treated promptly at the time of diagnosis. When suspected, total thyroidectomy with lymph node excision followed by radioiodine therapy has been proposed as the correct management to decrease the risk of persistent or recurrent disease.

Coincidence? - Graves’ Disease &amp; Thyroid Cancer

Abstract Background: DG coincidently with thyroid carcinoma has been reported as a rare phenomenon. It was thought that DG would be a protective condition in the development of cancer. However, published studies indicate the opposite, reporting an increased prevalence of differentiated thyroid cancer in DG compared to the general population. Some authors even report greater aggressiveness of this type of cancer in the presence of DG, with higher rates of, multifocality, metastatic disease and with a higher risk of recurrence. Clinical Case: Female, 46 years old, smoker 10 U.M.A., sent to the Endocrinology consultation due to symptomatic hyperthyroidism. No history of exposure to cervical radiotherapy, contact with iodinated products or cervical pain. Analytically, TSH &amp;lt;0.008 uUI / mL (0.27-4.2), free T4 4.09 ng/dL(0.93-1.70), free T3&amp;gt;20 pg/mL(2.57-4, 43), high levels of anti-thyroid and anti-TSH receptors 11.4IU/L (N &amp;lt;1.75), diagnosing with Graves’ disease. The thyroid ultrasound revealed a globose and hypervascularized thyroid. In the right hemithyroid, an echogenic nodular area of ​​ill-defined limits of about 12mm was identified, associated with some hyperechogenic elements. Bilateral cervical and submandibular lymph nodes were visualized with a short 8 mm axis, highlighting a ganglion in the right jugular chain, questioning the presence of millimeter echogenic foci. She started metibasol, with improved thyroid function and opted for ultrasound surveillance. Four months later, she repeated the ultrasound of the thyroid, maintaining a hypercogenic area, with ill-defined limits in the right lobe, with a 13mm longest axis. She also maintained adenopathies in the right jugulo-carotid chain, rounded, without hilum, the largest one with 13x9x17mm, and it was performed a fine needle aspiration of the ganglion. There was no measurement of thyroglobulin in the wash. The morphological changes were compatible with ganglion metastasis due to papillary thyroid carcinoma with a predominantly follicular pattern. She started 5% lugol solute, 7 drops every 8 hours for 8 days before surgery and underwent total thyroidectomy and central and lateral lymphadenectomy, with the identification of a mixed, multifocal papillary carcinoma. in the right lobe and isthmus, the microscopic size of the largest focus was 40mm, without invasion of the capsule or vascular invasion, with ganglion metastases in the lateral (9/46) and central district (6/6) (pT2N1b). She underwent treatment with I131 at a dose of 120mCi. Conclusion: This clinical case stands out for its uniqueness, given the simultaneity of Graves’ disease and thyroid cancer. The presence of cervical adenomegaly, which is rare in DG, increased clinical suspicion. Due to the increase of the adenopathy in a short period of time, we decided to perform a biopsy, which in this case was essential for the diagnosis and subsequent treatment.

Ecthyma gangrenosum with Pseudomonas aeruginosa bacteremia in an immunocompromised patient

Abstract Rationale: Ecthyma gangrenosum is an uncommon cutaneous manifestation and recognized for its association with Pseudomonas aerugninosa sepsis in immunocompromised patients, particularly if there is neutropenia. These lesions follow a certain pattern of presentation, from erythematous nodules to necrotizing ulcers with surrounding erythema. Patient concerns: We describe a case of an immunocompromised woman with recent breast cancer diagnosis, under chemotherapy treatment, who on admission presented painful erythematous nodules on her right thigh with 5 days of evolution and hemodynamically stable. The computed tomography scan of chest, abdomen, and pelvis showed nodular areas of densification of the subcutaneous tissue predominantly in the abdominal wall and nodular peripheral lesions in the pulmonary parenchyma, with recent onset, suggestive of possible septic embolization. Diagnosis: The diagnosis of ecthyma gangrenosum was confirmed after the isolation of Pseudomonas aeruginosa from the blood and wound culture samples, while a punch biopsy excluded other possible etiologies. Interventions: The patient completed 30 days of antibiotherapy, initially with piperacillin/tazobactam that was narrowed after 14 days of treatment to ciprofloxacin. Outcomes: Favorable evolution with complete clinical resolution was observed after 3months. Lessons: The early recognition and the prompt treatment with broad spectrum empiric antibiotic are the key for a good outcome in patients with ecthyma gangrenosum.

Subtype-Specific Analyses Reveal Infiltrative Basal Cell Carcinomas Are Highly Interactive with their Environment

Little is known regarding the molecular differences between basal cell carcinoma (BCC) subtypes, despite clearly distinct phenotypes and clinical outcomes. In particular, infiltrative BCCs have poorer clinical outcomes in terms of response to therapy and propensity for dissemination. In this project, we aimed to use exome sequencing and RNA sequencing to identify somatic mutations and molecular pathways leading to infiltrative BCCs. Using whole-exome sequencing of 36 BCC samples (eight infiltrative) combined with previously reported exome data (58 samples), we determine that infiltrative BCCs do not contain a distinct somatic variant profile and carry classical UV-induced mutational signatures. RNA sequencing on both datasets revealed key differentially expressed genes, such as POSTN and WISP1, suggesting increased integrin and Wnt signaling. Immunostaining for periostin and WISP1 clearly distinguished infiltrative BCCs, and nuclear β-catenin staining patterns further validated the resulting increase in Wnt signaling in infiltrative BCCs. Of significant interest, in BCCs with mixed morphology, infiltrative areas expressed WISP1, whereas nodular areas did not, supporting a continuum between subtypes. In conclusion, infiltrative BCCs do not differ in their genomic alteration in terms of initiating mutations. They display a specific type of interaction with the extracellular matrix environment regulating Wnt signaling.

CTA Evaluation of Basilar Septations: An Entity Better Characterized as Aberrant Basilar Fenestrations.

A basilar artery intraluminal septation is an exceedingly rarely reported, presumed congenital abnormality. In our clinical practice, we have occasionally noticed an intraluminal band within the inferior aspect of the basilar artery on CTA. Furthermore, we have noticed, at times, the presence of a punctate calcification associated with this finding. We hypothesized that what previous studies have called "basilar septations" in fact represent miniature and thus aberrant basilar fenestrations. We retrospectively reviewed CTA studies obtained between January 1, 2017, and August 31, 2019. Identified intraluminal basilar abnormalities were classified as either basilar septations or basilar fenestrations. Association with other posterior circulation abnormalities was documented. A total of 3509 studies were examined. A basilar intraluminal abnormality was evident in 80 patients (2.3%). Of these 80 patients, 59 were classified as having a basilar fenestration (1.7%) and 21 were classified as having basilar septations (0.6%). Associated calcification was evident in 3 of the basilar fenestration cases and 13 of the basilar septation cases. Basilar septations most likely represent and should be referred to as aberrant basilar fenestrations. They should be interpreted as benign congenital incidental findings and should not be misinterpreted as focal dissections or arterial webs. Important variations in the morphology of aberrant basilar fenestrations exist, including areas of thinning, varying thickness, and nodularity. Therefore, when associated with calcification or nodularity, aberrant basilar fenestrations should not be confused with focal intraluminal thrombi or calcified or noncalcified emboli.

Bilateral spontaneous carotid-cavernous fistulae

A man in his late fifties had right-sided retro-orbital pain and diplopia for 1 month. There was no preceding head trauma. On examination, he had a right abducens palsy with...

Metastatic Leiomyosarcoma in African Goose (Anser cygnoides)

Background: In birds, neoplasms are more frequently observed in Psittaciformes and Galliformes and rarely seen in Columbiformes and Anseriformes, with few reports of the occurrence of mesenchymal neoplasms such as leiomyosarcoma affecting birds. Therefore, the objective of this study was to describe a case of metastatic leiomyosarcoma in an African goose (Anser cygnoides), analyzing the epidemiological, clinical and pathological aspects. Case: A 10-month-old male African goose, was referred to the Veterinary Hospital, Universidade Federal de Campina Grande, Patos, Paraiba, Brazil, whit ataxia, tremors of intention in the head, and nystagmus about one month ago, progressing to lateral decubitus. Due to the unfavorable prognosis, animal was euthanized. Samples of the organs of the coelomic cavity and central nervous system were collected for histologic examination. The samples were fixed in 10% buffered formalin. After fixation, the organs were embedded in paraffin, cut into 4-5 μm sections, and then stained with hematoxylin and eosin. Paraffin blocks with liver, kidney and encephalon fragments were selected and sent for immunohistochemical analysis. The primary antibodies used were: alpha-smooth muscle actin (monoclonal 1A4), anti-vimentin (monoclonal, V9), CD57 (monoclonal, NK1) and cytokeratin (monoclonal, AE1/AE3) and incubated for 18 h at 4Cº. As an amplification and detection system polymer and labeled by addition of the liquid diaminobenzidine+substratechromogen system and counterstained with Harris hematoxylin. Macroscopically were observed in the liver nodular multifocal areas yellowish, sometimes coalescing, firm, and elevated to the surface that at the cut deepened to the parenchyma. In the left kidney there was a similar tumor mass. In the left frontal lobe, there was nodular focal area, well circumscribed, yellowish and protruding. To cutting surface it compressed the parietal and temporal lobe and showed surface yellowish and smooth. Microscopically, the liver was diffusely infiltrated by mesenchymal neoplasia, expansive, infiltrative, poorly circumscribed and not encapsulated, constituted by spindle cells arranged in interlaced bundles. The cells were elongated with sparse cytoplasm, slightly eosinophilic and indistinct borders with rounded to elongated nuclei, with coarse chromatin and evident nucleoli. In fragments of kidney and brain, neoplastic infiltration similar to that described in the liver was observed. In immunohistochemistry, neoplastic cells were positive with antibodies anti-vimentin and alpha-smooth muscle actin.Discussion: The diagnosis of metastatic leiomyosarcoma in an African goose was based on epidemiological, clinical and pathological findings and confirmed by immunohistochemistry. Reports of neoplasms in birds are relatively rare, however the occurrence of metastatic leiomyosarcoma affecting goose in the most varied locations has been described, from skin to organs of the coelomic cavity like kidney, ovary and intestinal wall. In this case, there is the unusual occurrence of dissemination in the liver, kidney and cerebral cortex, progressing to a neurological clinic condition. There are rare cases of metastatic leiomyosarcoma in geese African goose (Anser cygnoides). The main differential diagnoses include fibrosarcomas, neurofibrosarcomas and histiocytic sarcomas, which are similar macroscopically and histologically.Keywords: ornithopathology, mesenchymal neoplasms, anseriformes.Descritores: ornitopatologia, neoplasias mesenquimais, anseriformes.Título: Leiomiossarcoma metastáticoem ganso africano (Anser cygnoides)

Endoscopic Recognition and Management Strategies for Malignant Colorectal Polyps: Recommendations of the US Multi-Society Task Force on Colorectal Cancer.

Endoscopic Recognition and Management Strategies for Malignant Colorectal Polyps: Recommendations of the US Multi-Society Task Force on Colorectal Cancer.

Can propranolol act as a chemopreventive agent during oral carcinogenesis? An experimental animal study.

The multistep process of oral carcinogenesis provides a biological rationale for the use of chemoprevention in individuals at increased risk of developing oral cancer. We aimed to determine if low doses of propranolol can prevent the development of oral cancer using a tobacco-relevant and p53-associated animal model of cancer initiation. Twenty-six Wistar rats were randomly allocated into two groups, vehicle, and propranolol. All animals received 4-nitroquinoline N-oxide (4NQO) at 25 ppm diluted in the drinking water for 20 weeks. Animals from the propranolol group received propranolol (0.1 mg/kg) 5 days per week by gavage for 18 weeks. The clinical analysis was performed by measuring the area of the lesion and assessment of scores based on lesion appearance (papule; plaque; nodule or ulcerated). Histopathological analysis was performed to determine the presence of epithelial dysplasia or invasive squamous cell carcinoma (SCC). The average lesion area in 4NQO + vehicle and in 4NQO + propranolol groups were 0.20 and 0.28 mm2, respectively (P = 0.53). The percentage of cases clinically graded as papules, thick plaques, nodular areas, and ulcerated lesions was similar between groups (P = 0.94). Histopathological diagnosis also did not differ between groups (P = 0.65), with 54.5 and 70% of cases being diagnosed as SCC in 4NQO and in 4NQO + propranolol groups, respectively. In conclusion, daily doses propranolol at 0.1 mg/kg were not as effective as a chemopreventive therapy in an animal model of 4NQO-induced carcinogenesis.

Collision Tumor of the Kidney with Clear Cell Renal Cell Carcinoma and Papillary Renal Cell Carcinoma Components: Report of a Rare Case

Abstract Introduction/Objective Collision tumors refer to the phenomenon where distinct, well-defined tumor subtypes are present within a single lesion. While this phenomenon has been described in different organs, it has been rarely encountered in renal tumors outside the context of rare tumor susceptibility syndromes. Collision tumors of the kidney may encompass any known benign or malignant renal tumor types. However, a collision tumor of two different renal cell carcinoma (RCC) subtypes is remarkably rare. Methods A 43-year-old male was referred to our institution for the management of a right lower pole renal mass. The right radical nephrectomy specimen revealed a 6.5 x 5.0 x 4.0 cm well circumscribed, yellow-orange and hemorrhagic cortical mass abutting the renal capsule and extending into the renal sinus fat. A grossly distinct 1.5 x 1.4 x 1.2 cm pale, nodular area was demonstrated at the periphery of the tumor. Results Microscopically, the tumor displayed two distinct, neoplastic components within the same mass, without transitional morphology. The majority of the tumor consisted of a nuclear-grade-2 conventional clear cell RCC, while the peripheral nodule represented a type-2 papillary RCC component. Immunostains further supported these findings: The papillary component was strongly and diffusely positive for CK7 and P504S/AMACR with variable EMA and vimentin expression, and negative for CAIX, while the clear cell component was positive for CAIX, EMA and vimentin with only focal and weak staining for CK7 and faint nonspecific P5O4S/AMACR staining. TFE3 Mart1 and HMB45 immunostains were negative in the tumor. Conclusion Collision tumor of the kidney with two distinct RCC subtypes is an exceedingly rare finding. Careful gross examination may be the first clue to identify such lesions, and sampling of all grossly distinct tumor areas is crucial. The identification of collision tumors may have important therapeutic implications, given the difference in pathophysiology and outcome between RCC subtypes.

S2192 Over-the-Scope Clip as Rescue Treatment for Bleeding Gastric Varices

INTRODUCTION: We present a case of gastrointestinal bleeding in a patient with pancreatitis-induced splenic vein thrombus. This case highlights an important etiology of gastric varices, a known complication of treating them, as well as a method for treating refractory bleeding. CASE DESCRIPTION/METHODS: An 18-year-old male with ALL s/p post allogeneic HSCT, chronic pancreatitis, bowel perforations s/p ileostomy presented with gastrointestinal bleeding. The patient had hospitalizations at other institutions with intermittent melena and occasional hematemesis. After multiple upper endoscopies that did not identify the etiology of bleeding, he was referred to our hospital for double balloon enteroscopy. His hemoglobin was down to 5.9 g/dL (baseline 9-10 g/dL). EGD was performed with plan for double balloon enteroscopy, but a large blood clot was seen in the stomach. A nodular area in the fundus was actively bleeding. Given concern for an isolated gastric varix (IGV-1), EUS-guidance was used to inject coils and N-butyl-2-cyanoacrylate into the gastric varices with adequate hemostasis. Follow-up imaging noted extensive portal and splenic vein embolization from the glue. The patient developed recurrent melena and an emergent TIPS placement with coronary vein coil embolization was performed. Recurrent gastrointestinal bleeding was again noted. CT angiography was obtained and revealed a splenic vein thrombus. The patient underwent a balloon-occluded antegrade transvenous obliteration with glue/coil embolization of a smaller vessel feeding the gastric varix. However, GI bleeding was again noted. A repeat endoscopy was subsequently performed with placement of three over the scope clips (OTSC) on the varix for successful hemostasis. DISCUSSION: Gastric varices are often associated with cirrhosis but can occur in patients with non-cirrhotic portal hypertension (i.e., splenic vein thrombosis). Cyanoacrylate glue injection is recommended for acute bleeding from IGV. A known complication of glue injection is the risk of embolization (approximately 1–2%). Endoscopic ultrasound guided coil deployment can act as a scaffold at the time of glue injection to reduce this risk. OTSC have been used successfully in esophageal variceal bleeding. We report the first successful use of OTSC for gastric varices which should be considered as salvage therapy.Figure 1.: Gastric varices with hemostasis after endoscopic ultrasound-guided coil and glue injection.Figure 2.: Portal vein embolization after endoscopic ultrasound-guided coil and N-butyl-2-cyanoacrylate injection.Figure 3.: Recurrent gastric variceal bleeding with hemostasis after successful over the scope clip deployment.

S3442 A Trip Through the Pylorus - A Rare Case of a Gastric Adenocarcinoma Invading the Duodenum and Literature Reivew

INTRODUCTION: We present a rare case in a 61-year-old African American who shows one such case an interesting case of multiple gastric adenocarcinoma involving the gastric antrum and pylorus that extended into the duodenum. CASE DESCRIPTION/METHODS: A 61-year-old male without medical history presented with abdominal pain of one month acutely worsening over the 2 weeks. The pain was diffuse in nature, 9/10 in severity, with decreased appetite and 25lbs weight loss without exacerbating or relieving factors. Physical exam showed for RUQ and LUQ tenderness. Hepatomegaly was present with a firm mass palpated below the epigastrium. Labs were unremarkable. CT of abdomen and pelvis with contrast revealed hypoattenuating lesions in liver and spleen. An enlarged, heterogeneous pancreatic head with dilated duct and multiple enlarged lymph nodes, including a necrotic lymph node were found with the latter causing mass effect of structure. The stomach had a suspicious gastric mass with irregular wall thickening along the greater curvature and mesenteric stranding. There were multiple omental masses, peritoneal masses in RUQ and LUQ with significant retroperitoneal and pelvic lymphadenopathy. Subsequent upper endoscopy showed an abnormal nodular mucosal area in the junction of gastric body and antrum with a large gastric polyp in the adjacent area that was biopsied. Initially the top differential was lymphoma on accord that it does not respect the gastric-duodenal junction however, the pathology report of the abnormal gastric tissue revealed a poorly differentiated gastric adenocarcinoma that also involved duodenal mucosa with loss of nuclear expression of PMS-2 and MLH-1. Helicobacter Pylori testing was also noted be positive. Patient was started on FOLFOX therapy without benefit. Treatment was switched to Pembrolizumab therapy as tumor was MMR deficient with good response. DISCUSSION: The incidence of duodenal invasion in lower stomach cancer ranges from 13.5 to 33.2% mainly based on populations of Asian heritage, where the prevalence of gastric cancers is much higher than the rest of the world. Our patient is an African American male, and at the time of writing this case report our search showed that there are a handful of published cases of gastric cancer invading the duodenum in which highlights this rarity. We hypothesize that the reduced presentation of similar presentations may be low due to overall low incidence of gastric cancer in the United States, which has rapidly declined over the past 50 years.Figure 1.: Gastric antrum polyp.Figure 2.: Pre-pyloric tissue extending through pylorus into duodenal bulb.Figure 3.: Duodenal Bulb – Abnormal mucosa.

S1767 Disseminated Mycobacterium avium Complex Ileitis, Duodenitis, and Pancolitis in an Immunocompromised Patient With HIV/AIDS

INTRODUCTION: Patients with human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) are at increased risk of opportunistic infections such as Mycobacterium Avium Complex (MAC); this rarely involves the gastrointestinal (GI) tract. Noncompliance with antiretroviral therapy (ART) increases susceptibility. We herein present a young female with HIV/AIDS and disseminated MAC noncompliant with antiretroviral therapy presenting with watery diarrhea and abdominal pain, ultimately diagnosed with MAC duodenitis, ileitis and pancolitis with unique endoscopic findings. CASE DESCRIPTION/METHODS: A 26-year-old female with history of congenital HIV/AIDS on ART (though poorly compliant), disseminated MAC, genital herpes simplex virus (HSV), and oral thrush presented with generalized cramping abdominal pain and watery diarrhea for three weeks. On admission, she was tachycardic and mildly hypotensive. Physical exam revealed a thin female with mild diffuse abdominal tenderness and genital and perianal ulcerations. Labs showed pancytopenia with white blood cell count 2.45 10 × 3 uL, hemoglobin 8 g/dL and platelet count 56 10*3 uL. Absolute CD4 cell count was 2 uL and HIV RNA PCR over 3 million copies/ml. GI PCR panel and Clostridioides difficile testing were negative. Cytomegalovirus PCR was negative. Sputum Mycobacterium PCR confirmed MAC. Computed tomography abdomen/pelvis showed pancolitis without terminal ileum involvement. Treatment was initiated with intravenous piperacillin/tazobactam, micafungin, and acyclovir while continuing azithromycin, ethambutol and rifabutin for disseminated MAC in the setting of HIV/AIDS. Esophagogastroduodenoscopy showed esophageal, gastric and duodenal ulcerations. Colonoscopy showed severely congested mucosa with scattered areas of nodularity and ulceration (Figure 1) throughout the entire colon and examined terminal ileum. Gastric, duodenal, ileal and colonic biopsies were notable for acid-fast bacilli, consistent with known history of disseminated MAC (Figures 2 and 3). Her prognosis remains guarded given comorbidities and overall poor compliance with therapy. DISCUSSION: Although MAC is a common opportunistic infection seen in immunocompromised hosts, colonic and small bowel dissemination has rarely been reported. The diagnosis may be missed, as the clinical manifestations may be nonspecific. This case highlights the importance of including MAC in the differential of an immunocompromised patient presenting with GI manifestations.Figure 1.: Colon with diffuse areas of severely congested mucosa, scattered nodularity, and ulcerations.Figure 2.: Prominent lamina propria expansion by foamy histiocytes within the mucosa and villi of the ileum with notable absence of distended lacteals, characteristic of Mycobacterium Avium Complex (H&E stain, 100x).Figure 3.: AFB stain highlights acid-fast bacilli within foamy macrophages (AFB stain, 600x).