Bilateral Lung Lesions Research Articles

Correlation between clinical classification of COVID-19 and imaging characteristics of MSCT volume scanning of the lungs

To investigate the correlation between the clinical classification of coronavirus disease 2019 (COVID-19) and the imaging characteristics of multislice spiral computed tomography (MSCT) volume scanning of the lungs. The clinical data and thoracic MSCT volume scanning data were analyzed retrospectively for 102 patients with COVID-19 diagnosed and hospitalized in the First Affiliated Hospital of Bengbu Medical College between January 18 and February 26, 2020. According to the Fifth Edition of the Diagnosis and Treatment Guidelines by the National Health Commission, the patients were divided into common type, severe type and critical type. The imaging characteristics including the lung sides of the lesions, lung segment involved, lesion distribution, and lesion number and density were compared among the patients with different clinical types of COVID-19. Seventy-seven of the patients had common type, 18 had severe type and 7 had critical type of COVID-19. The main clinical manifestations included fever, cough and fatigue. Severe and critical types were more frequently seen in elderly patients, who were more prone to show such symptoms as asthenia, breathing difficulty and dyspnea. Two patients presented with no obvious abnormality in the first CT examinations; in the remaining 100 patients, 89.0% had bilateral lung lesions, 16.0% had diffuse lesions, involving a mean of 6.56±4.22 lung segments. Compared with the patients with the common type, the severe and critical patients had a significantly greater number of lung segments involved (P < 0.05), and were also more likely to show diffuse lesions (P < 0.05). The lesion side, lesion number or lesion density did not differ significantly among the patients with different clinical types of COVID-19 (P > 0.05). MSCT volume scanning not only allows early diagnosis of COVID-19 but also provides evidence for evaluating the severity of COVID-19 to assist in the clinical treatment of the patients.

Dandelion clock-like sign on CT for diagnose of COVID-19

To explore the value of the "dandelion clock-like" sign on chest CT for diagnosis of SARS-CoV-2-associated pneumonia. This retrospective analysis was conducted based on the data of 119 cases from the Department of Fever and the Department of Infection undergoing chest high-resolution CT examinations in Sanshui District People's Hospital between January, 24 and February 10, 2020. The cases with no abnormality on chest CT were excluded. Twenty-three patients were diagnosed to have pneumonia, including 9 with SARS-CoV-2-associated pneumonia and 14 with other types of pneumonia. We comparatively analyzed the CT signs, location of the lesions and the dandelion clock-like sign among different types of pneumonia. Among the 23 patients with pneumonia, 9 (39.1%) had common or severe SARS-CoV-2- associated pneumonia with a positive epidemiological history and corresponding respiratory symptoms. Seven of the SARSCoV-2-associated pneumonia patients had multiple lesions in bilateral lungs, compromising mainly the lung field and the subpleural area and showing patchy, lumpy, and umbrella-shaped ground glass opacity, often accompanied by pulmonary vascular thickening and increased microvessels, interlobular septal thickening and fibrosis and lined with grid-like and small-bubble-like "crazy-paving" patterns. The dandelion clock-like sign was found in all the 9 patients with SARSCoV-2-associated pneumonia, with a total of 46 lesions (60.5%, 76 total lesions); 9 of the lesions presented with a "dandelion clek-like" sign and 37 with a "dandelion seed sign". These signs were not found in the 14 patients with other types of pneumonia. The dandelion clock-like sign is a common and characteristic chest CT finding in patients with SARS-CoV-2-associated pneumonia, and can help to distinguish SARS-CoV-2-associated pneumonia from other types of pneumonia.

Clinical analysis of 30 cases of Castleman disease with different types of thoracic involvement

目的总结不同类型胸部受累Castleman病（CD）的临床、影像学、病理及诊治特征，以提高临床医师对CD的认识。方法回顾性分析广州医科大学附属第一医院自2009年6月至2019年5月收治入院的胸部受累CD患者30例，将其分为闭塞性细支气管炎（BO）组、不伴BO的单中心型Castleman病（UCD）组及不伴BO的多中心型Castleman病（MCD）组，分析其临床资料并总结其特征。结果30例患者中，5例（16.7%）纳入BO组，18例（60.0%）纳入不伴BO的UCD组，7例（23.3%）纳入不伴BO的MCD组。不伴BO的MCD组中位年龄明显大于BO组[（49.29±5.39）岁对（27.20±3.76）岁，P=0.005]和不伴BO的UCD组[（49.29±5.39）岁对（37.17±2.87）岁，P=0.034]。胸部症状在BO组（100%）和不伴BO的MCD组（71.4%）多见，而不伴BO的UCD组无胸部症状。贫血及IgG增高仅在不伴BO的MCD组出现（发生率均为57.1%），红细胞沉降率增快及低氧血症在BO组（发生率分别为40.0%和60.0%）及不伴BO的MCD组（发生率分别为57.1%和28.6%）均可出现。BO组患者的肺功能均表现为极重度混合性通气功能障碍。胸部CT所示肺实质受累率：BO组为100%；不伴BO的MCD组为57.1%，表现为双肺弥漫性病变；不伴BO的UCD组为11.1%，表现为孤立性肺结节。不伴BO的MCD组的淋巴结短径明显小于BO组[（1.83±0.51）cm对（4.73±1.63）cm，P=0.006]和不伴BO的UCD组[（1.83±0.51）cm对（3.62±0.26）cm，P=0.011]。BO组病理类型均为透明血管型（100%），不伴BO的UCD组88.9%为透明血管型，而不伴BO的MCD组以浆细胞型为主（57.1%）。BO组患者均出现口腔溃疡，在肿物切除术后予免疫调节剂治疗，溃疡症状缓解，但肺部症状仍进行性加重。不伴BO的UCD组主要治疗方式为胸腔镜下肿物切除，不伴BO的MCD组主要治疗方式为化疗、免疫调节剂、靶向治疗等。结论三组患者的年龄、临床症状、实验室检查、肺功能、影像学表现、病理类型、治疗及预后均有所不同，此分类能促进临床医师对本病的认识。

RAI Refractory Differentiated Thyroid Cancer Treated with Lenvatinib: Case Report

Background: Differentiated thyroid carcinoma (DTC) is the most common malignant tumor of the thyroid gland and causes local and/or distant metastases. Differentiated thyroid carcinoma (DTC) is the most common form, representing more than 90% of all thyroid cancers and derives from the follicular cells of the thyroid. Choroidal metastasis from DTC is extremely rare. Only a few cases have been reported in literature. Case Summary: We report the case of a 43-year-old man with differentiated thyroid cancer. He underwent a total thyroidectomy plus a right latero-cervical lymphoadenectomy. Histological examination revealed a 7 mm papillary thyroid cancer, pT3N1b. Firstly treated with locoregional treatment. In February 2012 computer tomography (CT) scan and WBS showed a progression of disease with bilateral lung lesions, bilateral multiple jugular carotid lymphnodes and bone metastases localized in the IV thoracic rib. After progression disease he was treated with Lenvatinib 24 mg daily. Symptomatic choroid metastases were diagnosed 4 years after initial diagnosis, and were treated with external-beam radiation. Although treatment reduced local masses, a rapid progression of multiple metastatic lesions was observed. Conclusion: In our case, progression free survival with lenvatinib was in agreement with data of SELECT trial, this is a rare case of choroidal metastases from DTC.

Особливості клінічного перебігу негоспітальної пневмонії у хворих із супутньою хронічною серцевою недостатністю

SummaryThe purpose of the work is to determine the features of the clinic, diagnosis and course ofcommunity-acquired pneumonia (P) in patients with chronic heart failure (CHF).Material and methods. 88 patients with P were examined, the average age of whichwas (61.3±2.2) years, who were admitted and examined at the pulmonology clinic ofNational Military Medical Clinical Center «The Main Military Clinical Hospital» of theMinistry of Defense of Ukraine. The main group included 45 persons with P and CHF,and the comparison group – 43 persons with P without signs of CHF, matched by ageand sex. In order to determine the place of treatment and the development of adverseeffects of P for all patients, a disease severity index on the PORT (PSI) and CRB-65scales was calculated.Results and discussion. In the main group of patients, a significantly higher body massindex was observed, in the majority of cases compensated or subcompensated type 2 diabetesmellitus, chronic kidney disease of I–II study were found as well as a significantly higherpercentage of persons, who have been taking antibacterial drugs for the past three months. Inthe main group of patients there were no patients with grade 1–2 risk of adverse pneumonia,because all patients had two or more comorbidities. It was found that there were significantly among those who had a severe course of P in the main group with multiple concomitantpathology of two or more systems. According to the results of X-ray chest examination, a -significantly higher percentage of patients with bilateral lesions (35.6%, p<0.05) and multiplesection pneumonic infiltration (22.2%, p<0.05) were found in patients of the main group. At thesame time, the comparison group was characterised by domination of patients with unilateralpneumonic infiltration (62.8%, p<0.05).Conclusions. It was found that the clinical course of P in patients with CHF has ahigher score for risk of death from P by the PSI pneumonia severity scale (r=0.635,p<0.05). Patients with P with concomitant CHF were found to have a higher percentageof severe cases with bilateral (35.6%) or multiple partial lung lesions (22.2%).

TAKOTSUBO CARDIOMYOPATHY AS AN ADVERSE EVENT POST BRONCHOSCOPY

SESSION TITLE: Wednesday Fellows Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Takotsubo cardiomyopathy (TTC) is an acute cardiac syndrome characterized by acute dilated cardiomyopathy following emotional or physical stress. It presents with sudden onset of cardiac symptoms with electrocardiogram(ECG) changes and left ventricular dysfunction. Echocardiogram findings are characteristic of apical ballooning with a wide base and long thin neck at end-diastole. The prevalence of TTC in patients with known vasculitis is not well described. CASE PRESENTATION: Our patient is a 46 Chinese lady with known history of migraine and anxiety. She first presented with non-resolving oto-mastoditis despite multiple courses of antibiotics. She subsequently developed bilateral cavitary lung lesions for which a bronchoscopy was performed. The work-up was negative for microbiology including mycobacterium and fungal organisms. Her antiPR3 antibodies were markedly raised and a diagnosis of Granulomatosis with Polyangiitis (GPA) was made. She was treated with intravenous pulsed steroids and cyclophosphamide. However, she developed fever and cough with worsening of bilateral cavitary lung lesions and neutrophilia. Bronchoscopy and transbronchial lung biopsy were repeated in view of concerns of infection in a immunocompromised host. 2 hours post procedure, she developed sinus tachycardia and type 1 respiratory failure requiring intubation and mechanical ventilation. Cardiac enzymes trended were not suggestive of myocarditis or acute myocardial infarct. ECG showed new T-wave inversions in the anterior leads. A bedside echocardiogram showed dilated cardiomyopathy with an ejection fraction(EF) of 10-15%. She was subsequently extubated and a repeat echocardiogram confirmed the characteristic findings of TTC with apical ballooning and akinesia and improvement in EF to 30-35%. DISCUSSION: One of the proposed pathophysiology behind TTC is the abnormally high levels of catecholamines resulting in catecholamine-associated cardiotoxicity post physical or emotional stressors. Previous papers have described TTC post bronchoscopy to be more common in post-menopausal women, history of asthma; and in more invasive procedures such as transbronchial lung biopsies and adrenaline administration intra-tracheally; therefore benefit-risk ratio for adrenaline administration needs to be considered in patients at risk. Treatment is usually supportive with treatment of heart failure and reassurance. CONCLUSIONS: TTC post bronchoscopy is an uncommon but life threatening adverse event. This case highlights the need to identify patients who are at risk of developing TTC post bronchoscopy and ensure preventive measures such as adequate counselling are carried out pre-procedure. The diagnosis of TTC should be suspected in high risk patients with cardiac symptoms and close monitoring post procedure should also be implemented as the complications of TTC can be severe and life threatening as demonstrated in our patient. Reference #1: Nyquist KE, Abramson DW, Huffman JC. Apical ballooning syndrome: the "broken heart" syndrome. Prim Care Companion J Clin Psychiatry. 2010;12(5):PCC.10r00949. Reference #2: Four cases of clinical analysis with Takotsubo cardiomyopathy associated with bronchoscopy: Manabu Suzuki et al. European Respiratory Journal 2017 50: PA3803; https://doi.org/10.1183/1393003.congress-2017.PA3803 Reference #3: Takotsubo Cardiomyopathy and Subsequent Seizures Induced by Flexible Bronchoscopy Shion Miyoshi MD, Yuichiro Takeda MD PhD, Shoki Ro MD, Haruna Masaki MD, Masayuki Hojo MD, and Haruhito Sugiyama MD PhD. DISCLOSURES: No relevant relationships by Adrian Kwok Wai Chan, source=Web Response No relevant relationships by Sandra HUI, source=Web Response No relevant relationships by Keng Leong TAN, source=Web Response

Subxiphoid versus intercostal uniportal video-assisted thoracoscopic surgery for bilateral lung resections: a single-institution experience.

Subxiphoid uniportal video-assisted thoracoscopic surgery (SUVATS) is a technically difficult and challenging operation that can help decrease pain around the incision after traditional intercostal uniportal video-assisted thoracoscopic surgery (IUVATS), and can also treat bilateral lesions through the same incision. We aimed to compare perioperative outcomes and pain scores after SUVATS and IUVATS in patients receiving synchronous treatment of bilateral lung lesions. Patients who received SUVATS and IUVATS bilateral lung resections from September 2014 to February 2018 were analysed. Ultimately a total of 381 cases were analysed after using one-to-one propensity score matching to match baseline characteristics between the 2 groups. The 381 patients included 56 with SUVATS and 325 with IUVATS. After matching, 54 SUVATS and 54 IUVATS cases were analysed. The 2 groups had similar preoperative factors and did not differ with respect to duration of chest tube placement, length of stay in hospital and incidence of postoperative complications. SUVATS was associated with a significantly longer operative time (212.3 vs 154.6 min, P < 0.001) and more blood loss (190.9 vs 72.7 ml, P < 0.001), lower pain score on the first day after operation (2.6 vs 3.0, P = 0.03) and before discharge (0.8 vs 1.4, P < 0.001). Furthermore, less patients in group SUVATS requested for additional analgesic therapy (P = 0.03). Compared with IUVATS, despite the longer operative time and greater blood loss, SUVATS for bilateral lung lesions is a safe surgical procedure associated with significantly less postoperative pain and a similar incidence of postoperative complications in selected patients.

Utility of CT assessment in hematology patients with invasive aspergillosis: a post-hoc analysis of phase 3 data

BackgroundPulmonary computed tomography (CT) scans are commonly used as part of the clinical criteria in diagnostic workup of invasive fungal diseases like invasive aspergillosis, and may identify radiographic abnormalities, such as halo signs or air-crescent signs. We assessed the diagnostic utility of CT assessment in patients with hematologic malignancies or those who had undergone allogeneic hematopoietic stem cell transplantation in whom invasive aspergillosis was suspected.MethodsThis post-hoc analysis assessed data from a prospective, multicenter, international trial of voriconazole (with and without anidulafungin) in patients with suspected invasive aspergillosis (IA; proven, probable, or possible, using 2008 European Organisation for Research and Treatment of Cancer/Invasive Fungal Infections Cooperative Group and the National Institute of Allergy and Infectious Diseases Mycoses Study Group criteria) [NCT00531479]. Eligible patients received at least one baseline lung CT scan.ResultsOf 395 patients included in this post-hoc analysis, 240 patients (60.8%) had ‘confirmed’ proven (9/240, 3.8%) or probable (231/240, 96.3%) invasive aspergillosis (cIA) and 155 patients (39.2%) had ‘non-confirmed’ invasive aspergillosis (all nIA; all possible IA (de Pauw et al., Clin Infect Dis 46:1813–21, 2008)). Mean age was 52.3 and 50.5 years, 56.3 and 60.0% of patients were male, and most patients were white (71.7 and 71.0%) in the cIA and nIA populations, respectively. Median baseline galactomannan was 1.4 (cIA) and 0.2 (nIA), mean Karnofsky score was 65.3 (cIA) and 66.8 (nIA), and mean baseline platelet count was 48.0 (cIA) and 314.1 (nIA). Pulmonary nodules (46.8% of all patients), bilateral lung lesions (37.5%), unilateral lung lesions (28.4%), and consolidation (24.8%) were the most common radiographic abnormalities. Ground-glass attenuation (cIA: 24.2%; nIA: 11.6%; P < 0.01) and pulmonary nodules (cIA: 52.5%; nIA: 38.1%; P < 0.01) were associated with cIA. Other chest CT scan abnormalities (including halo signs and air-crescent signs) at baseline in patients with hematologic malignancy or hematopoietic stem cell transplantation, and suspected IA, were not associated with cIA.ConclusionsThese findings highlight the limitations in the sensitivity of chest CT scans for the diagnosis of IA, and reinforce the importance of incorporating other available clinical data to guide management decisions on individual patients, including whether empirical treatment is reasonable, pending full evaluation.Trial registrationNCT00531479 (First posted on ClinicalTrials.gov on September 18, 2007)

SAT-312 A Rare Case of Metastatic Paraganglioma with Positive SDHB Mutation: An Incidentally Found Silent Monster

Introduction: Although paragangliomas (PG) are derived from extra-adrenal chromaffin cells of sympathetic paravertebral ganglia in the thorax, abdomen, and pelvis, they can also arise from parasympathetic ganglia located along the glossopharyngeal and vagal nerves in the neck and at the base of the skull. Non-secretory PG have a low prevalence, are often silent, and can present as a malignant tumor with mass effects. Symptoms often include: unilateral hearing loss, pulsatile tinnitus, cough, hoarseness, pharyngeal fullness, swallowing difficulty, pain, and/or problems with tongue motion. Case: A 25 year old African American woman presented with 2 yrs of exertional presyncope, night sweats, subjective fevers, 20 lb. weight loss and a nontender enlarging left neck mass. Family history: Mother had thyroid cancer. Physical exam- BMI 21 kg/m2, BP 118/72 mmHg, HR 74, with indurated, fixed, nontender mass in left upper neck, inferior to mandibular angle. Laboratory-Hgb 6.9 g/dl, MCV 71.7, Iron 137 mcg/dl, TIBC 151 mcg/dl, Ferritin 155 ng/ml, CRP 65.20 mg/dl, ESR 122 mm/hr, AST 107 U/l, ALT 7 U/L, Alk Phos 81 U/l. EGD and Colonoscopy-normal. CT scan of neck, abdomen and pelvis: 6.0x3.5x2.7 cm heterogeneously enhancing mass in left neck involving skull base at carotid canal level, within the internal carotid space, causing external compression of left internal jugular vein, with multiple hypervascular lesions in bilateral lungs, liver and spleen, as well as cervical, thoracic, lumbar and sacral spine. Packed red blood cells were transfused. Liver Biopsy-metastatic paraganglioma with SDHB mutation. Laboratory tests- normal plasma catecholamines, thyroid function tests, prolactin, cortisol, ACTH, LH, FSH. A few weeks later, she reported new onset left sided tinnitus, orbital pain and vision changes. MRI Brain/orbit- 10 x 11 mm enhancing lesion centered in left cavernous sinus near orbital apex without intra or extraconal lesion. Chemotherapy was started with vincristine, cyclophosphamide and dacarbazine. After 12 weeks of chemotherapy, the left neck mass size decreased, tinnitus, and vision changes resolved. She was referred for genetic counseling and multidisciplinary care. Discussion: Our patient had malignant head and neck PG with SDHB mutation. Mutations in the gene encoding SDH subunit B (SDHB) can lead to metastatic disease in ≥ 40% of patients, are frequently familial, and are associated with other malignancies (renal cell carcinoma, pituitary adenoma, breast and thyroid cancer). Although there are current guidelines regarding diagnosis and management of non-malignant secretory paraganglioma/pheochromocytoma, screening and management of metastatic disease is not clear. Therefore, it is important to have a low threshold of suspicion for early diagnosis. Provider awareness and education regarding diagnosis and management is needed.

SAT-319 Long-term Follow-up of Two Unrelated Boys With SDHB-Related Malignant Paragangliomas

Background: Paragangliomas (PGLs) are rare neuroendocrine cell tumors and due to its rarity, there is no current standardized treatment and optimal long-term follow-up for metastatic disease. We report two cases of SDHB-related malignant PGL in boys with more than 5 years of follow-up. Clinical case: Patient 1 (P1) presented at the age of 13 with hypertension crisis, after a history of paroxystic tachycardia and sweating since 9. Fractionated 24-hour urinary metanephrines showed high Normetanephrine (NMT). CT showed bilateral lung lesions, the largest in right basis (6.1x5.3cm) in close contact with the 7/8th ribs and vertebrae, enlarged thoracic lymph nodes, and a 2.2 cm tumor near the left carotid. The patient went through a debulking surgery of the tumors. Patient 2 (P2) presented with abdominal pain at the age of 7. CT showed an abdominal tumor that was surgically resected. In both cases immunohistochemistry was compatible with PGL. P2 tumor was a non-secreting PGL, with high plasma chromogranin A prior to surgery. Both subsequently developed multiple bone metastases, and in case 2, additional recurrent retroperitoneal metastases. Adjuvant therapeutic 131I-MIBG, until a total dose of 900mCi (P1) and 950mCi (P2,) was performed. Over a 5- and 7-year follow-up, respectively, sustained stable disease has been documented, with control of tumor burden, despite the presence of several metastatic foci, mostly in bones. P1 has maintained mild hypertension controlled with diltiazem 30mg bid and has been annually tested for urinary NMT, which is decreasing though still mildly elevated, plus imaging (MRI and/or PET-CT). Case 2 has been clinically asymptomatic with six-monthly chromogranin A determinations currently in the normal range, and annual imaging (MIBG scintigraphy, MRI and/or PET-CT). As both cases have bone metastatic disease, 5mg intravenous zoledronic acid was recently started. Sequencing of the coding exons and exon-intron boundaries of the SDHB gene found no mutations in P1, whereas a heterozygous frameshift deletion in exon 4 was found in P2 (c393delA). In P1, complementary Multiple Ligand-Binding Probe Amplification revealed a heterozygous deletion of SDHB exon 1. P1’s mother genetic screening was negative and the father refused testing. Six P2’s relatives were found to harbor the mutation, while 3 developed PGLs so far. Conclusion: Two cases of SDHB-related malignant PGL diagnosed at early ages were presented: one apparently sporadic (P1) and one familial (P2). Despite aggressive disease, with multiple disseminated bone metastases, a long-term survival has been achieved so far, with stable disease after high cumulative I131-MIBG doses and absence of significant adverse effects. Considering the rarity of the disease especially in children, these cases significantly add to the literature regarding the long-term course of malignant PGL and treatment options.

Study of carbohydrate metabolism indicators in firstly diagnosed pulmonary tuberculosis patients

Objective — to study the indicators of carbohydrate metabolism in patients with firstly diagnosed pulmonary tuberculosis, depending on the extent of the lesion and the presence of mycobacteria excretion.Materials and methods. 78 patients with firstly diagnosed pulmonary tuberculosis were examined, including 19 patients without mycobacteria excretion — Group 1 and 59 patients with mycobacteria excretion — Group 2. The control group — 20 healthy individuals, comparable by sex and age. The examination and diagnosis were carried out in accordance with the current order of the Ministry of Health of Ukraine. Additionally, patients underwent oral glucose tolerance test (OGTT), the fasting insulin level was determined, the insulin resistance index (HOMA-IR) and the body mass index were calculated. For statistical data processing, the general-purpose data processing software package Statistica for Windows version 13.2 was used.Results and discussion. Depending on the increase in the volume of lung lesions, a monotonic increase of the level of glycated hemoglobin was observed from 4.8 % (pathological changes within the lung lobe) to 6 % (total lesion of the lung) with a maximum value of 7.1 % in bilateral lung lesions. The results of the oral glucose tolerance test demonstrated a statistically significant increase of the indicator to a median level of 5.8 mmol/l in the group of patients with mycobacteria excretion compared to 4.7 mmol/l in the group without mycobacteria excretion. In patients with firstly diagnosed pulmonary tuberculosis, the fasting plasma insulin level on an empty stomach exceeded 3.8 times compared to the control group, and the HOMA-IR insulin resistance index almost 4 times, indicating an increased insulin secretion by pancreatic β-cells.Conclusions. An increased 2 hours blood glucose level, fasting insulin level, and the HOMA-IR index was typical for firstly diagnosed pulmonary tuberculosis patients, which indicates the development of insulin resistance, a pathological condition characterized by an insufficient biological response of the cell to insulin at its sufficient concentration in the blood. Compared with patients who had limited pathological changes, patients with bilateral lesions of the lungs were characterized by a more prolonged violation of carbohydrate metabolism, as indicated by the levels of glycosylated hemoglobin upon admission to the hospitalMycobacteria excretion, as a marker of an aggravated course of the disease, was accompanied by the appearance of latent carbohydrate metabolism disorders in the form of an increase of 2 hours blood glucose level, that is, an impaired glucose tolerance.

Abstract B31: Multiparameter profiling of abscopal effect (AbE) in a pediatric fibrosarcoma with EML4-NTRK3 fusion

Abstract Background: Abscopal effect (AbE) is a rare phenomenon in pediatric oncology, defined as regression of tumor at distal sites following radiation therapy. AbE is widely believed to result from the local activation and expansion of tumor-specific T cells in the area radiated, followed by the migration of these T cells to distant sites. We present a case of AbE in a 1-year-old with congenital fibrosarcoma (forearm) bearing a novel EML4-NTRK3 fusion who developed bilateral lung metastasis 6 months post resection of the initial forearm tumor. The patient’s lung lesions were unresponsive to chemotherapy prompting palliative, hypofractionated radiation therapy (RT) to the right lung lesion only. One month following RT, patient showed significant decrease in size of bilateral lung lesions, with no evidence of disease at 3 months post RT. Using whole-exome sequencing (WES), high-throughput sequencing of T cell receptors (TCRseq), and quantitative multiplex immunofluorescence (qmIF), we investigated the relationship between tumor progression and metastasis, the pre- and post-RT microenvironment, and the co-evolution of the tumor-infiltrating lymphocyte (TIL) populations in this patient. We believe this unusual case offers key insights into mechanisms underlying AbE. Methods: Formalin-fixed, paraffin-embedded (FFPE) tissue specimens from the initial diagnostic lesion (forearm), pretreatment lung tumor, and bilateral post-RT lung lesions (right (RT treated) and left (outside RT field) were obtained. An FFPE slide was stained for each specimen using traditional immunohistochemistry (IHC) for CD3 and CD8 and qmIF for 7 biomarkers including DAPI, CD3, CD4, CD8, CD68, HLA-DR, and Ki67. QmIF images were taken using MANTRA and cell density analysis was performed using inForm software and R. DNA was isolated, from the tissue specimens and peripheral blood, for profiling using WES and TCRseq, generating a multiplex snapshot of each site. The TIL populations were described by the complementarity determining region 3 (CDR3) of each TCR (as identified by Adaptive), followed by analysis of the bias, diversity, and divergence of these TIL populations using entropy-based statistics. Results: IHC and qmIF of the primary fibrosarcoma and pre-RT lung tumor showed very low immune cell infiltration. In contrast, immune infiltration was markedly increased (both CD4+ and CD8+) post-RT, particularly in the nonirradiated lung lesion (left). TIL populations were analyzed using TCRseq, revealing little similarity between those of the primary fibrosarcoma and the recurrent lung lesions. However, the TCR repertoires comparing the post-RT lung lesions, irradiated (right) and non-irradiated (left), showed substantial similarity, sharing a larger percentage of CDR3 sequences with each other (6.7% of combined total) than with the primary tumor (≤0.6% combined total) or the pre-RT lung tumor (≤1.6% combined total). Additionally, the extent of the TIL repertoire and its binding-associated divergence from the peripheral blood was greatest in the irradiated (right) lung tumor post RT, suggesting a direct link between the evolution of trans-acting immunity and antigen-driven immunogenicity at that site. Of note, comparative WES of the initial fibrosarcoma and subsequent lung tumors identified the same EML4-NTRK3 fusion, validating their metastatic relationship, although the number of coding mutations had expanded upon recurrence. Conclusion: Using qmIF and TCRseq, we have extensively characterized immune infiltration in the tumor microenvironment prior to and following metastasis and RT, in the first reported case of AbE in a pediatric tumor. Our data show evidence of immune stimulation elicited by RT, and antitumor T-cell specificities are shared inside and outside of the radiation field. These data offer insight into AbE and how combination of radiation and immunotherapy may be useful to induce response in pediatric tumors. Citation Format: Robyn D. Gartrell, Jennifer S. Sims, Sunjay M. Barton, Angela Kadenhe-Chiweshe, Filemon Dela Cruz, Andrew T. Turk, Andrew L. Kung, Jeffrey N. Bruce, Yvonne M. Saenger, Darrell J. Yamashiro, Eileen P. Connolly. Multiparameter profiling of abscopal effect (AbE) in a pediatric fibrosarcoma with EML4-NTRK3 fusion [abstract]. In: Proceedings of the AACR Special Conference: Pediatric Cancer Research: From Basic Science to the Clinic; 2017 Dec 3-6; Atlanta, Georgia. Philadelphia (PA): AACR; Cancer Res 2018;78(19 Suppl):Abstract nr B31.

Diagnosis and treatment of imatinib-induced interstitial lung disease and literatures review

Objective To investigate the diagnosis and treatment of imatinib induced interstitial lung disease (ILD), providing clinical reference for early diagnosis, treatment and alternative medicine selection, and improving the prognosis of patients. Methods On 3 June 2016, a case of imatinib induced ILD who was admitted to Department of Hematology, West China Hospital, Sichuan University was included in this study. The patient was diagnosed with chronic myeloid leukemia (CML) and started therapy of imatinib on 15 December 2015. When the patient was admitted, bone marrow morphology, cytogenetic, medical imageological and pathological examination were conducted and diagnosis was made base on those test results and patient′s medical history and medication history. Then imatinib discontinued on 6 July 2016 and started 30 mg/d prednisone therapy on 29 July 2016 with 6-month duration. Switched to nilotinib 300 mg twice daily on 20 December 2016. Follow-up (up to 5 September 2017) was performed to monitor the efficacy. Clinical features, diagnosis and treatment of this patient were analyzed retrospectively, and related literatures were reviewed. Results ① When the patient was admitted, results of bone marrow morphology, genetic examinations were all within normal range. Chest high resolution (HR) CT scan revealed lung marking increased, disordered, and blurred; and there were diffusely distributed multiple ground glass opacity, small patchy, and fibrous stripes. Results of lung puncture biopsy suggested chronic inflammation changed with fibrous tissue hyperplasia. ② Patient was diagnosed with imatinib-induced ILD. ③ Patient suspended imatinib were treated with prednisone, and the symptoms of cough and anhelation were significantly improved. After 6 weeks, the chest HRCT indicated a significant decrease in the bilateral lung lesions. After 6 months of nilotinib application, no significant abnormalities were observed in bone marrow morphology, genetic examination and HRCT results. And complete cytogenetic remission (CCyR) and deep molecular remission were achieved. The patient was well tolerated during follow-up. Conclusions The appearance of dyspnea after imatinib treatment should be considered the possibility of imatinib-induced ILD. Early diagnosis, discontinuation of imatinib and application of glucocorticoid can significantly improve prognosis of imatinib-induced ICD. In this case report, the patient with imatinib-induced ILD who was switched to nilotinib was well tolerated and CML treatment response was good, which could provide a reference for the clinical medication of CML. Key words: Imatinib; Interstitial pneumonia; Glucocorticoid; Nilotinib; Diagnosis

Particularités cliniques et radiologiques de la tuberculose pulmonaire chez le tabagique

Tobacco smoke alters lung defense mechanisms against infections and so increases the risk of mycobacterium tuberculosis infection. To determine the particular clinical features of tuberculosis in smokers and identify risk factors. We conducted a prospective, cross-sectional study over a period of nine months in Dakar, Senegal. The Chi-square test and multiple logistic regression were used to identify differences between smokers and non-smokers and to identify factors associated with clinical outcomes. We included 165 patients with active pulmonary tuberculosis (59 smokers versus 106 never-smokers). The average age of smokers was 43.8±12.7 versus 32.1±13.1 years (P<0.0001). Smokers were overwhelmingly male (98.3% versus 1.8%, P<0.0001). The average delay to consultation was longer among smokers (90 days [30-120] versus 60 days [30-90]; P<0.0001). In multivariate analysis, alcohol abuse, increasing age, male sex, and an unknown retroviral status were independent risk factors for pulmonary tuberculosis. Haemoptysis was observed more frequently in smokers (49.1% versus 31.1%, P=0.017). With regards to chest X-ray features, smokers presented with more advanced, bilateral and cavitating lung lesions. Diagnostic delay and haemoptysis are important characteristics of the pulmonary tuberculosis in tobacco smokers.

Subxiphoid uniportal video-assisted bilateral surgery: right upper lobectomy and left upper wedge resection S3.

Traditional approach of bilateral lesions usually involves bilateral approaches instead of classical thoracotomy or video-assisted thoracoscopic surgery (VATS) surgery, and often at two different times. During visit of Dr. Gonzalez Rivas at Master Class to Málaga, we performed right upper lobectomy and S3 wedge resection left upper lobe of a two synchronous bilateral lung lesions case with subxiphoid single incision approach. We are reporting the first case of a lobectomy combined with a wedge resection performed through an uniportal subxiphoid bilateral VATS in Spain.

Is bilateral multiple lung tumor resection an acceptable therapeutic option for pulmonary epithelioid hemangioendothelioma?

Pulmonary epithelioid hemangioendothelioma is a rare pulmonary neoplasm. No reliably effective systemic chemotherapy for this disease entity has been established yet. Surgery is usually applied for patients with a small number of lesions limited to one lung, while feasibility/efficacy/safety of this modality is controversial for patients with bilateral multiple lung lesions. Presence of cases showing rapid aggravation and those showing very gradual progression makes it difficult to evaluate validity of surgery as a suitable therapeutic approach. Herein, we present a summary on pulmonary epithelioid hemangioendothelioma and discuss the role of surgery in the treatment of this condition.

HOSPITAL-ACQUIRED PNEUMONIA ASSOCIATED WITH THE CAUSATIVE AGENT STENOTROPHOMONAS MALTOPHILIA, IN NEWBORN INFANTS

Objective: to analyze the clinical course of ventilator-associated pneumonia caused by Stenotrophomonas maltophilia in infants as a high-risk group for the development of hospital acquired infection, as well as a study of the sensitivity of the pathogen to antibiotics. Eighteen infants (14 premature and 4 mature infants) with ventilator -associated pneumonia due to (Stenotrophomonas maltophilia) were monitored. The disease occurred in the majority (72%) of infants as a monoinfection, more often in severe and acute form with severe toxicosis, trophic disorders, severe respiratory failure, bilateral lung and bronchial lesions. In 33% of children, mostly premature, there was a change in the pathogen, which increased the severity and duration of the disease. Pneumonia had complications in the form of sepsis (6%) and bronchopulmonary dysplasia (28%). Most Stenotrophomonas maltophilia retained sensitivity to ticarcillin + clavulanate, ciprofloxacin, chloramphenicol and co-trimoxazol.

Cavitation and Confusion: A Puzzling Presentation of Granulomatous Disease

SESSION TITLE: Student/Resident Case Report Poster - Pulmonary Manifestations of Systemic Disease II SESSION TYPE: Student/Resident Case Report Poster PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM INTRODUCTION: A 32-year-old HIV-negative African American man presented with a 7-month history of altered mental status (AMS) and functional decline for which he underwent multiple rounds of hospitalizations and diagnostic testing before the correct diagnosis was made. CASE PRESENTATION: He was first seen at an outlying hospital for AMS, which was attributed to drug use. Chest x-ray (CXR) revealed bilateral cavitary lung lesions, and he was treated for pneumonia and discharged. He returned one month later with persistent AMS. Brain MRI showed diffuse leptomeningeal enhancement. Lumbar puncture (LP) revealed lymphocytic pleocytosis, low glucose, and elevated protein. All infectious testing was negative. Transbronchial lung biopsy showed inflammation, but no organisms. He was discharged on itraconazole for presumed disseminated fungal infection. He returned with progressive mental status changes four months later. MRI and LP were unchanged, but CSF angiotensin-converting enzyme (ACE) was four times normal. Chest imaging again showed cavitary lesions, and CT guided lung biopsy revealed necrotizing granulomatous inflammation. Microbiological tests were again negative except one serum complement fixation (CF), which was positive for histoplasmosis. The patient was treated with amphotericin and discharged on itraconazole until he presented to us two months later. By this time, the patient had developed gait abnormalities and urinary incontinence. Imaging demonstrated progression of prior lesions. Both transbronchial lung and brain biopsies revealed necrotizing and non-necrotizing granulomas. All fungal tests including histoplasmosis fungal CF were negative. Serum ACE level was elevated and, considering prior elevated CSF ACE and granulomas in the lung and brain, sarcoidosis was diagnosed. The patient was treated with high dose steroids and his clinical status, along with lung and brain lesions, improved. DISCUSSION: The elusiveness of this diagnosis in large part stemmed from the common diagnostic pitfalls of anchoring bias and reliance on general disease paradigm rather than specific clinical context. Despite the severity and progression of the patient’s symptoms on treatment, an incorrect diagnosis persisted on the basis of a single positive complement fixation test without microbiological confirmation. Additionally, the elevated CSF ACE was ignored in this unusual presentation of sarcoidosis. Although sarcoid is classically thought of as non-necrotizing, recent literature suggests sarcoidosis can cause a spectrum of granulomatous inflammatory tissue responses. CONCLUSIONS: This case illustrates the importance of ongoing diagnostic re-evaluation with consideration of atypical presentations of rare diseases when faced with discordant laboratory data or unexpected clinical progression. Reference #1: Rosen Y. Four decades of necrotizing sarcoid granulomatosis: what do we know now? Arch Pathol Lab Med. 2015;139(2):252-62. DISCLOSURE: The following authors have nothing to disclose: Meredith Greer, Udayan Shah No Product/Research Disclosure Information

Uniportal video-assisted thoracic surgery left superior segmentectomy with systematic lymphadenectomy in the semiprone position.

A 63-year-old male was referred to our hospital with two existing lesions in bilateral lungs. Computed tomography (CT) showed a 15-mm ground-glass opacity (GGO) in the superior segment of left lower lung (S6) and a 5-mm GGO in the center of the right upper lobe. The preoperative clinical diagnosis was stage I primary lung cancer for the left lesion while the right lesion needed follow-up. Uniportal video-assisted thoracic surgery (VATS) left superior segmentectomy in the semiprone position was performed in this case and the right upper lobe was kept untouched. Frozen section examination confirmed the diagnosis of lung adenocarcinoma, and systematic lymphadenectomy with non-grasping en bloc dissection technique was then performed. A chest tube was placed at the posterior part of the incision through the dorsal thoracic cavity to the apex. The postoperative pathologic diagnosis was minimally invasive adenocarcinoma, staged T1aN0M0.

Uniportal video-assisted thoracoscopic surgical (VATS) segmentectomy with preoperative dual localization: right upper lobe wedge resection and left upper lobe upper division segmentectomy.

Clinical vignette A 75-year-old male presented with abnormalities upon chest computed tomography (CT) scanning at a routine check. He had a 1.7-cm sized ground glass opacity (GGO) on the posterior segment of the right upper lung (RUL) and a 1.2-cmsized semisolid lung nodule on the left upper lung (LUL). To differentiate synchronous metastasis, sequential CT-guided core biopsy was performed for the GGO lesion on the posterior segment of the RUL and the posterior segment of the LUL. Both lesions were suspected to be adenomatous hyperplasia or non-small cell lung cancer. Adenocarcinoma was detected in situ upon pathologic examination. A positron emission tomography (PET) scan showed no lymph node metastasis or extrathoracic distant metastasis. The LUL semisolid lesion showed mild hypermetabolism, while the RUL pure GGO lesion showed no definite uptake on PET scan. Pulmonary function was as follows: forced vital capacity (FVC), 3.07 L (75%); forced expiratory volume in 1 second (FEV1), 2.34 L (88%); carbon monoxide lung diffusion capacity (DLCO), 20.7 mL/mmHg/min (116%). The patient was referred for surgical resection of bilateral synchronous lung lesions. In this case, by employment of the dual localization technique (hook-wire and lipiodol), we performed bilateral uniportal video-assisted thoracoscopic surgery (VATS) resection. Wedge resection was carried out for the GGO lesion on the posterior segment of the RUL and left upper divisional segmentectomy was carried out for the semisolid lesion on