CT-guided Biopsy Research Articles

CT Attenuation of Hepatic Pancreatic Cancer Metastases Correlates with Prognostically Detrimental Metastatic Necrosis

Percutaneous CT-guided biopsy is a frequently performed procedure for the confirmation and molecular workup of hepatic metastases of pancreatic ductal adenocarcinoma (PDAC). Tumor necrosis of primary PDAC has shown a negative prognostic impact in recent studies. This study aims to examine predictability in CT scans and the prognostic impact of necrosis in hepatic metastases of PDAC. In this tertiary-center retrospective cohort study, we included 36 patients with hepatic metastases of PDAC who underwent CT-guided hepatic biopsies. Normalized attenuation of the biopsied metastasis was determined in venous phase contrast-enhanced planning scans obtained prior to biopsy by automatic, threshold-based 3D segmentation and manual, blinded 2D segmentation. A board-certified pathologist specialized in hepatic pathology histologically quantified the tumor necrosis and cellularity of the biopsy cylinders. We found a significant inverse-linear correlation between normalized attenuation and the fraction of necrosis (Pearson’s r = 0.51, p < 0.001 for automatic 3D segmentation or Pearson’s r = 0.52, p < 0.001 for manual 2D segmentation), whereas no correlation was found with tumor cellularity. Additionally, we discovered that patients with a fraction of necrosis ≥ 20% in metastases had a significantly shorter overall survival (p < 0.035). In summary, tumor necrosis of PDAC metastases can be estimated from contrast-enhanced CT scans, which could help to improve biopsy sample pattern planning. In addition, liver metastatic necrosis may serve as a prognostic biomarker in PDAC.

Computed Tomography-guided Percutaneous Lung Biopsy With Electromagnetic Navigation Compared With Conventional Approaches: An Open-label, Randomized Controlled Trial.

The purpose of this study was to assess the efficiency and safety of computed tomography (CT)-guided percutaneous biopsy of lung lesions with electromagnetic (EM) navigation and compare them with those of conventional approaches. Seventy-nine patients with lung or liver lesions who needed biopsies were enrolled in this trial. All patients were randomly assigned to the E group underwent CT-guided percutaneous biopsies with the EM navigation system or to the C group treated with conventional approaches. In total, 27 patients with lung lesions were assigned to the E group, and 20 patients were assigned to the C group. The diagnostic success rate was 92.6% and 95% in both groups, respectively ( P >0.9999). The median number of needle repositions in the E group was less than that in the C group (2.0 vs. 2.5, P =0.03). The positioning success rate with 1 or 2 needle repositions for the E group was significantly higher than the C group (81.5% vs. 50%, P =0.03). The median accuracy of the puncture location in the E group was better than that in the C group (2.0 vs. 6.6mm, P <0.0001). The total procedure time lengthened in the E group compared with the C group (30.5±1.6 vs. 18.3±1.7min, P <0.0001), but the number of CT acquisitions was not significantly different ( P =0.08). There was no significant difference in complication incidence between the 2 groups ( P =0.44). The EM navigation system is an effective and safe auxiliary tool for CT-guided percutaneous lung biopsy, but lengthen the procedure time. ChiCTR2100043361, registered February 9, 2021-retrospectively registered ( http://www.medresman.org.cn/uc/project/projectedit.aspx?proj=7591 ).

Stereotactic brain Interventions: Identifying risks for biopsy failures and hemorrhage

BackgroundThe advent of computed tomography (CT) and magnetic resonance imaging (MRI) has revolutionized stereotactic brain interventions, which enabled precise targeting of deep brain structures and enhanced patient safety in modern neurosurgery. This study aims to investigate the risk factors associated with biopsy failure and hemorrhage in CT-guided brain stereotactic surgeries. MethodsIn the current study, we present a retrospective descriptive analysis of cases that showed biopsy failures and hemorrhage after CT-guided stereotactic brain biopsy surgeries at our department from January 2019 to January 2021. Biopsies were obtained using a Sedan-type needle. ResultsOut of the 80 patients who underwent CT-guided stereotactic surgeries, two patients (2.5 %) experienced biopsy failure, necessitating a repeat procedure. There was a notably higher risk of biopsy failure when fewer than four biopsy attempts were made (adjusted odds ratio = 6.4, 95 % CI 1.8 to 16.7). A postprocedural CT scan revealed intracranial hemorrhage in five patients (6.25 %); four of these cases were silent, with no accompanying neurological complications. Four out of the five hemorrhage cases were associated with astrocytoma. ConclusionsStereotactic surgery provides a precise and minimally invasive approach to target lesions with a relatively low risk of biopsy failures and hemorrhage.

A case of lung adenocarcinoma with markedly elevated amylase in airway secretions

A 45-year-old male patient was admitted to the hospital because of intermittent cough and expectoration for more than 1 year, worsened by dyspnea for 2 months, and was finally diagnosed with lung adenocarcinoma. The CT scan of the chest revealed lesions of diversity with fibrosis, mass and effusion, but his severe cough limited biopsy of the lesions. The difficult process of diagnosis was aided by the further analysis of the sputum, which showed significantly elevated amylase without any evidence of pancreatic disease. The cough was relieved by intravenous pumping octreotide acetate, and both CT-guided lung biopsy and transbronchial biopsy revealed the lung adenocarcinoma. The diagnostic process of this case provided a helpful diagnostic thinking and demonstrated the rare clinical features of lung adenocarcinoma.

IMPROVING THE DIAGNOSIS OF SPINAL TUBERCULOSIS AND OUR UNDERSTANDING OF ITS PATHOPHYSIOLOGY AND INTERACTION WITH HIV-1 CO-INFECTION

Specific and rapid detection methods for spinal tuberculosis, with sufficient sensitivity in HIV-1 co-infected individuals, are needed, to ensure early initiation of appropriate treatment to prevent physical disability and neurological fallout. In addition, understanding the systemic and local pathophysiology of spinal tuberculosis, and its interaction with HIV-1 infection, is crucial to guide future therapeutic interventions.We prospectively enrolled adult patients presenting with signs and symptoms of suspected spinal tuberculosis, at Groote Schuur Hospital, between November 2020 and December 2021. TB diagnostic testing was performed on open and CT-guided spinal biopsies using Xpert MTB/RIF Ultra compared to gold standards TB culture and histology. A highly sensitive droplet digital PCR assay for detecting and quantifying Mycobacterium tuberculosis complex (MTBC) and HIV-1 DNA was tested. Plasma inflammatory proteins were measured to assess systemic inflammation.Xpert Ultra had a high sensitivity of 94.7% and specificity of 100% for STB against TB culture and histology in both open and CT-guided biopsy samples. The ddPCR assay confirmed TB detection in 94% of patients with positive Xpert Ultra results. Four patients with negative TB diagnostic results had MTBC DNA detected by ddPCR. HIV-1 DNA was detected in the spinal tissues from all HIV-1-infected patients. MTBC DNA levels were significantly higher in HIV-1-co-infected spinal tissue samples (p&lt; 0.01). We identified four biomarkers significantly associated with higher bacterial burden at the disease site (p&lt; 0.01).Xpert Ultra and MTBC ddPCR improve the detection of STB. DdPCR can be utilized as an additional, highly sensitive tool for detecting and quantifying Mtb, in pathological samples that may be paucibacillary. These findings provide novel diagnostic and pathophysiologic insight into STB, in the context of HIV-1 infection, and provide rationale to include these tests in hospital and research settings for patients from communities burdened by TB and HIV-1.

Abstract 14933: A Rare Case of Cardiac Angiosarcoma Presenting as Hemorrhagic Pericardial Effusion

Cardiac sarcomas are exceptionally rare, with an incidence of only 0.02% and comprising less than 1% of all primary cardiac tumors. Consequently, diagnosis of the disease can be challenging due to non-specific presenting symptoms and diverse clinical manifestations. We present a unique case of cardiac sarcoma that highlights these challenges. A 70-year-old man with a history of hypertension, hyperlipidemia, and latent tuberculosis presented with palpitations, chest pain, and dyspnea, was found to have hemorrhagic pericardial effusion with tamponade. Pericardial fluid studies were negative for malignancy, and echo not suggestive of cardiac mass or pericardial abnormalities. He presented several months later with hemoptysis and was found to have innumerable pulmonary nodules on CT chest and a mediastinal mass adjacent to the right atrium. Bronchoscopy was negative for infection or malignancy. Ultimately the patient underwent CT-guided lung biopsy, which showed a malignant spindle cell neoplasm with a positive stain for vimentin and vascular markers suggestive of angiosarcoma of unknown primary. Given unclear relation of his mediastinal mass, cardiac MRI was done which showed a rapidly enhancing bulky neoplasm with abnormal contrast enhancement arising from the lateral right atrium (Figure 1) consistent with metastatic cardiac angiosarcoma. Patient was started on systemic anthracycline-based chemotherapy; however the overall prognosis remains poor. Given the rarity of cardiac sarcomas, prognosis is generally poor due to the advanced stage at the time of diagnosis. These tumors exhibit aggressive behavior and have a high propensity for metastasis. Due to their infrequency, knowledge and research is limited regarding effective treatments. This case highlights the significance of considering cardiac angiosarcoma in cases of hemorrhagic pericardial effusion even in the absence of obvious cardiac mass or pericardial nodularity on initial presentation.

Microbial spectrum, patient-specific factors, and diagnostics in implant-related postoperative spondylodiscitis

AimsImplant-related postoperative spondylodiscitis (IPOS) is a severe complication in spine surgery and is associated with high morbidity and mortality. With growing knowledge in the field of periprosthetic joint infection (PJI), equivalent investigations towards the management of implant-related infections of the spine are indispensable. To our knowledge, this study provides the largest description of cases of IPOS to date.MethodsPatients treated for IPOS from January 2006 to December 2020 were included. Patient demographics, parameters upon admission and discharge, radiological imaging, and microbiological results were retrieved from medical records. CT and MRI were analyzed for epidural, paravertebral, and intervertebral abscess formation, vertebral destruction, and endplate involvement. Pathogens were identified by CT-guided or intraoperative biopsy, intraoperative tissue sampling, or implant sonication.ResultsA total of 32 cases of IPOS with a mean patient age of 68.7 years (37.6 to 84.1) were included. Diabetes, age &gt; 60 years, and history of infection were identified as risk factors. Patient presentation upon admission included a mean body temperature of 36.7°C (36.1 to 38.0), back pain at rest (mean visual analogue scale (VAS) mean 5/10) and when mobile (mean VAS 6/10), as well as elevated levels of CRP (mean 76.8 mg/l (0.4 to 202.9)) and white blood cell count (mean 9.2 units/nl (2.6 to 32.8)). Pathogens were identified by CT-guided or conventional biopsy, intraoperative tissue sampling, or sonication, and Gram-positive cocci presented as the most common among them. Antibiotic therapy was established in all cases with pathogen-specific treatment in 23 (71.9%) subjects. Overall 27 (84.4%) patients received treatment by debridement, decompression, and fusion of the affected segment.ConclusionCases of IPOS are rare and share similarities with spontaneous spondylodiscitis. While procedures such as CT-guided biopsy and sonication are valuable tools in the diagnosis of IPOS, MRI and intraoperative tissue sampling remain the gold standard. Research on known principles of PJI such as implant retention versus implant exchange need to be expanded to the field of spine surgery.Cite this article: Bone Jt Open 2023;4(11):832–838.

A Small And a Large Solitary Fibrous Tumors of the Pleura

Solitary Fibrous Tumor of the Pleura (SFTP) is an exceptionally rare mesenchymal tumor that typically originates from the visceral pleura and constitutes less than 5% of all pleural tumors. While it often displays benign histological features, the tumor’s behavior remains enigmatic and less comprehensively understood, primarily owing to its limited incidence and case studies. We present two cases of SFTP. The First one was a small pleural nodule a nodule in a 61 year old patien, confirmed as a SFTP through CT-guided biopsy. Successful tumor resection was performed, with histopathological confirmation, and the patient remained recurrence-free for two years. The second one was incidental finding in a 68-year-old patient of a huge pleural mass with necrotic regions and microcalcifications on imaging. Surgical removal revealed an encapsulated tumor with myxoid features, classified as an intermediate-risk SFTP. The patient experienced no complications and had no local recurrence 16 months post-surgery. Solitary fibrous tumors within the pleura are uncommon. The preferred treatment approach is surgical resection, with diligent post-operative monitoring.

A Unique Case of Large Pelvic Non-Hodgkin Lymphoma

Introduction: Non-Hodgkin lymphoma (NHL) represents a diverse group of malignancies arising from lymphocytes and lymphoid tissues. It encompasses multiple subtypes, including the aggressive diffuse large B-cell lymphoma (DLBCL), which is the most common type of NHL in adults. DLBCL typically presents as a rapidly growing mass in the lymph nodes or extranodal sites. While DLBCL can affect various regions of the body, its occurrence in the pelvic region is infrequent and poses unique diagnostic and therapeutic challenges. Case Description: We present a rare and intriguing case of a 51-year-old female admitted for acute on chronic microcytic anemia, with accompanying symptoms of decreased oral intake due to nausea, and vomiting, significant weight loss, night sweats, and lower quadrant abdominal pain. Additionally, she reported decreased urinary frequency, urgency. CT imaging of the abdomen and pelvis revealed a large soft tissue mass measuring 7.6 x 4.6 x 5.7 cm in the posterior right pelvic region, resulting in severe hydroureteronephrosis, along with bilateral iliac chain adenopathy, retroperitoneal lymph node enlargement, and severe splenomegaly. CT chest revealed several small lung nodules indicating distant metastasis. Additionally, the patient exhibited elevated levels of LDH, CA 199, and CRP, and decreased hemoglobin levels, indicating the presence of systemic disease. A CT-guided biopsy of the right pelvic mass confirmed the diagnosis of non-Hodgkin malignant lymphoma, specifically of the diffuse large B-cell type. Immunohistochemistry and flow cytometry demonstrated CD20 positivity in the proliferating large cells, consistent with DLBCL, and revealed a kappa-restricted B-cell population expressing CD19, CD20, and kappa surface immunoglobulin light chains. The PET scan showed prominent splenomegaly, adenopathy, and retroperitoneal involvement, corroborating the lymphoma diagnosis. The patient was discharged for outpatient follow-up with oncology with a treatment plan of R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone) administered every 3 weeks, omitting rituximab during the first cycle. Discussion: This case stands out due to the unusual presentation of a large DLBCL in the pelvic region, which is a relatively rare occurrence. The localization of DLBCL in the pelvis poses a diagnostic challenge, as symptoms may overlap with various other conditions. Moreover, the extensive involvement of the retroperitoneal lymph nodes and splenomegaly added complexity to the management of the disease. The rarity of DLBCL in the pelvis highlights the importance of considering lymphoma in the differential diagnosis of patients presenting with non-specific pelvic symptoms and acute anemia. Early recognition of such cases is crucial for timely intervention and optimal treatment planning. Understanding the immunophenotypic characteristics of the tumor is essential for tailoring effective therapeutic strategies. This unique case sheds light on the need for further research and evidence-based guidelines for managing NHL in uncommon anatomical locations, promoting better patient outcomes and quality of life.

Association between needle track bleeding and postoperative immediate pneumothorax in CT-guided percutaneous transthoracic lung biopsies: a cross-sectional study

The relationship between Needle Track Bleeding (NTB) and the occurrence of postoperative immediate pneumothorax remains unclear. In our cross-sectional study, we conducted a retrospective collected of data from 674 consecutive patients who underwent CT-guided percutaneous transthoracic lung biopsies between 2019 and 2022. A logistic regression model was employed to explore the association between NTB and postoperative immediate pneumothorax, and restricted cubic spline curves was used to investigate the link and its explicit curve shape. A sensitivity analysis was performed by transforming the continuous NTB into categorical variable and calculated an E-value. A total of 453 participants (47.90% male) were included in our analysis. The postoperative immediate pneumothorax rate was 41.05% (186/453). We found a negative correlation between NTB and postoperative immediate pneumothorax (OR = 0.91, 95%CI 0.88–0.95) after adjusting for confounding factors. This relationship was nonlinear, with a key inflection point at NTB of 8 mm. No significant link was noted for NTB > 8 mm (OR = 0.98, 95%CI 0.95–1.02), while a protective association was observed for NTB ≤ 8 mm (OR = 0.74, 95%CI 0.66–0.81). NTB showed a nonlinear, protective correlation with postoperative immediate pneumothorax. However, when NTB exceeded 8 mm, the protective association was not observed.

Pathologically confirmed spontaneous regression of small cell lung cancer after computed tomography-guided percutaneous transthoracic needle biopsy followed by surgery

BackgroundSpontaneous regression of malignant tumors is a rare phenomenon, especially in primary lung cancer. The underlying mechanisms remain unclear, but they may often involve immunological mechanisms.Case presentationIn January 2020, a 78-year-old female underwent examination during follow-up of interstitial pneumonia. Chest X-ray and computed tomography (CT) scan revealed a 1.2 × 1.2 cm nodule in the left lower lobe. Based on CT-guided percutaneous transthoracic needle biopsy (PTNB), it was diagnosed as small cell lung cancer (SCLC). Immunohistochemical staining showed that tumor cells were positive for CD56, synaptophysin, and chromogranin A. Twenty-three days after the CT-guided PTNB, repeat CT scan showed that the tumor size regressed to 0.6 × 0.6 cm. The tumor showed positive uptake in fluorodeoxyglucose (FDG) positron emission tomography (PET)–CT. The maximum standardized uptake value of the nodule was 2.24. PET–CT and enhanced magnetic resonance imaging of the brain showed no distant or lymph node metastasis. The patient’s preoperative disease was diagnosed as cT1aN0M0, stageIA1, SCLC. In March 2020, she underwent left lower lobectomy and mediastinal lymph node dissection. Pathological examination of the resected specimen showed that the small tumor cells were dense with a high nucleus to cytoplasm ratio, and the morphological diagnosis was small cell carcinoma. The resected tumor size regressed to 0.05 × 0.02 cm, and no lymph node metastasis was observed. Because it was extremely small, immunohistochemical staining could not be conducted. Active fibrosis and inflammation were present around the tumor. Finally, the patient was pathologically diagnosed as SCLC pT1miN0M0, stage IA1. The patient is alive without recurrence 23 months after surgery with no adjuvant therapy.ConclusionsWe present a rare surgical case of pathologically confirmed spontaneous regression of SCLC after CT-guided PTNB. Although spontaneous regression is extremely rare, we should recognize this phenomenon.

Tumor seeding following CT- guided transthoracic needle biopsy in lung cancer. A case report

As a result of advances in the treatment of lung cancer, the life expectancy of lung cancer patients has improved significantly, but it remains the leading cause of cancer death worldwide. For decades, most of the initial tumor biopsies have been obtained by bronchoscopy or computed tomography (CT)-guided transthoracic lung biopsy without concerning reports of cancer seeding following the latter. In this case report we discuss the patient history of a 56-year old women with low-differentiated squamous cell lung cancer who developed tumor seeding following a CT-guided transthoracic biopsy 11 months after the intervention. This is put into context reviewing former and current literature.

Routine radiology-pathology concordance evaluation of CT-guided percutaneous lung biopsies increases the number of cancers identified.

Routine concordance evaluation between pathology and imaging findings was introduced for CT-guided biopsies. To analyze malignancy rate in concordant, discordant, and indeterminate non-malignant results of CT-guided lung biopsies. Concordance between pathology results and imaging findings of consecutive patients undergoing CT-guided lung biopsy between 7/1/2016 and 9/30/2021 was assessed during routine meetings by procedural radiologists. Concordant was defined as pathology consistent with imaging findings; discordant was used when pathology could not explain imaging findings; indeterminate when pathology could explain imaging findings but there was concern for malignancy. Recommendations for discordant and indeterminate were provided. All the malignant results were concordant. Pathology of repeated biopsy, surgical sample, or follow-up was considered reference standard. Consecutive 828 CT-guided lung biopsies were performed on 795 patients (median age 70years, IQR 61-77), 423/828 (51%) women. On pathology, 224/828 (27%) were non-malignant. Among the non-malignant, radiology-pathology concordance determined 138/224 (62%) to be concordant with imaging findings, 54/224 (24%) discordant, and 32/224 (14%) indeterminate. When compared to the reference standard, 33/54 (61%) discordant results, 6/30 (20%) indeterminate, and 3/133 (2%) concordant were malignant. The prevalence of malignancy in the three groups was significantly different (p < 0.001). Time to diagnosis was significantly different between patients who reached the diagnosis with imaging follow-up (median 114days, IQR 69-206) compared to repeat biopsy (33days, IQR 18-133) (p = 0.01). Routine radiology-pathology concordance evaluation of CT-guided lung biopsy correctly identifies patients at high risk for missed diagnosis of malignancy. Repeat biopsy is the fastest method to reach diagnosis. A routine radiology-pathology concordance assessment identifies patients with non-malignant CT-guided lung biopsy result who are at greater risk of missed diagnosis of malignancy. • A routine radiology-pathology concordance evaluation of CT-guided lung biopsies classified 224 non-malignant results as concordant, discordant, or indeterminate. • The percentage of malignancy on follow-up was significantly different in concordant (2%), discordant (61%), and indeterminate (20%) (p < 0.001). • Time to definitive diagnosis was significantly shorter with repeat biopsy (33days), compared to imaging follow-up (114days), p = 0.01.

Factors affecting the success of CT-guided core biopsy of musculoskeletal lesions with a 13-G needle

ObjectiveTo determine the value of CT-guided bone core biopsy and investigate factors that affect diagnostic yield and biopsy outcome.Materials and methodsThe single-centre retrospective analysis included 447 patients who had CT-guided core biopsy with a 13-G needle (Bonopty®) from January 2016 to December 2021. Histological results or ≥ 6 months of clinical and radiological follow-up served as outcome references. A successful biopsy was classified as “diagnostic” when a definitive diagnosis was made and “adequate” when only the malignant or benign nature of the tumour could be determined. Biopsies were “nondiagnostic” when the nature of the lesion could not be determined. The occult lesions were defined as not seen on CT but visible on other modalities.ResultsIn 275 (62%) females and 172 (38%) males, the overall success rate was 85% (383 biopsies), with 314 (70%) diagnostic biopsies and 69 (15%) adequate biopsies. There was no relationship between biopsy success and the localisation of the lesion, length of biopsy material, or number of biopsy attempts. The lesions’ nature had a statistically significant effect on biopsy success with lytic and mixed lesions having the highest success rate. Occult lesions had the lowest success rate.ConclusionCT-guided bone core biopsy is an effective method in the workup of musculoskeletal diseases with the highest success rate in lytic and mixed lesions. No apparent relationship was found between biopsy success and biopsy length, number of attempts, or localisation of the lesion.

Ultrasound versus computed tomography-guided transthoracic biopsy for pleural and peripheral lung lesions: a systematic review and meta-analysis.

An accurate diagnosis of peripheral lung and pleural lesions using image-guided transthoracic biopsy procedure becomes a good diagnostic performance protocol. To examine the difference between ultrasonography (USG)-guided versus computed tomography (CT)-guided transthoracic biopsy for pleural and peripheral lung lesions by pooling data from published studies. PubMed, CENTRAL, Scopus, Web of Science, and Embase were searched for comparative studies up to 20 February 2023 irrespective of the language of publication. The outcomes were adequacy of the sample and complications (pneumothorax and hemothorax). Two randomized controlled trials (RCTs) and eight non-RCTs were eligible. The total sample size was 1618. Meta-analysis showed that there was no difference in the adequacy of the sample obtained by USG- or CT-guided biopsies; however, an analysis of only non-RCTs indicated better adequacy with USG. On pooled analysis of any pneumothorax, there was a lower risk associated with USG-guided biopsies, but the risk of pneumothorax requiring interventional treatment was not different in the two groups. Similarly, the pooled analysis also demonstrated a reduced risk of hemothorax with USG-guided biopsies. While there seems to be no difference in the adequacy of the sample obtained with either imaging modality, retrospective data show that USG guidance offers better diagnostic yield compared to CT guidance for peripheral lung and pleural biopsies. The risk of pneumothorax and hemothorax is also significantly lower with USG-guided biopsies. Results should be interpreted with caution owing to selection bias among studies. There is a need for large-scale RCTs to enhance current evidence.

FRI239 Oncocytic Adrenocortical Neoplasm Of Uncertain Malignant Potential

Abstract Disclosure: K. Barnett: None. A. Sandhu: None. F. Hasan: None. Introduction: Oncocytic adrenocortical neoplasms are a rare histological subtype of adrenal mass, characterized by their abundant eosinophilic cytoplasm. Like other adrenal masses, they can be functional, or hormone-producing, and present on a spectrum from benign to malignant. Case: Our patient is a 31 year old female with a past medical history of anxiety who presented to the ER for right upper quadrant abdominal pain. She described it as a colicky, aching pain, lasting for several minutes at a time. She could identify no known trigger. A CT abdomen with contrast showed cholelithiasis and a hypodense lesion on the right adrenal gland. Her primary care physician (PCP) ordered a follow-up MRI abdomen with contrast that showed an indeterminate, 2.9 cm x 2 cm mass on the right adrenal gland without evidence of microscopic fat. After consultation with an oncologist, her PCP then recommended a PET scan, which showed that the mass was mildly hypermetabolic. She presented to the endocrinology office for further evaluation shortly thereafter. Though her abdominal pain had subsided, she did endorse a 7 lb weight loss, attributed to decreased appetite from anxiety. Additional review of systems was grossly negative. Hormonal work-up, including DHEA, renin, AM cortisol, ACTH, aldosterone, and plasma metanephrines was normal. CT-guided biopsy was deferred in favor of a repeat CT abdomen with adrenal protocol, which showed the adrenal nodule measured 40 HU on unenhanced images, with an absolute contrast washout of 50%. As this was less than the 60% threshold typically utilized to indicate a lipid-poor adenoma, the nodule was deemed indeterminate. Given the concerning features of the mass: its lipid-poor nature on unenhanced CT, metabolic activity on PET scan, and washout that was below the threshold for an adenoma, adrenalectomy was recommended. She underwent a laparoscopic right adrenalectomy, with final pathology showing oncocytic adrenocortical neoplasm of uncertain malignant potential, based on Lin-Weiss-Bisceglia criteria. She was seen by oncology, and they recommended no adjuvant treatment at this time. A repeat CTAP abdomen with adrenal protocol is planned for 1 year after this procedure. Discussion: Given the rarity of oncocytic adrenocortical neoplasms, their classification into benign, uncertain malignant potential, or malignant using Lin-Weiss-Bisceglia criteria is essential to determining appropriate treatment and surveillance. A recent retrospective cohort study showed oncocytic neoplasms with uncertain malignant potential have favorable outcomes, however, patients require continued radiographic surveillance due to the risk of late recurrence. Reference: Shirali AS, et al. Differences in Clinicopathologic Behavior of Oncocytic Adrenocortical Neoplasms and Conventional Adrenocortical Carcinomas. Ann Surg Oncol. 2022;29(9):5555-5563. doi:10.1245/s10434-022-11626-w Presentation: Friday, June 16, 2023

SAT337 Maternal Cell free DNA Testing Reveals Incidental Finding Of Adrenocortical Carcinoma

Abstract Disclosure: F. Akanbi: None. S. Raja: None. T. Else: None. Maternal Cell-free DNA Testing Reveals Incidental Adrenocortical Carcinoma IntroductionAdrenocortical carcinoma (ACC) is rare; with 1 to 2 cases per million. It is unclear if ACC in pregnancy represents a specific association though 150 cases have been reported. We report a case of ACC detected during fetal sex determination using cell free DNA (cfDNA). Case Report: A 30 year old G1P0 woman presented at GA of 25 weeks with results of non-invasive prenatal screening (NIPS) done for fetal sex determination, which noted atypical findings concerning for possible maternal neoplasm. Pregnancy had been uncomplicated; she had no significant past medical history or features of hypercortisolism. Family history was positive for lung and prostate cancer. Physical examination revealed healthy looking female with no Cushingoid facies, abdomen matched stated GA. Full body MRI revealed 5.5 cm right adrenal mass with lymph nodes metastases. CT-guided retroperitoneal lymph node biopsy showed ACC.She was asymptomatic with significantly elevated urine free cortisol 3648 (3.5-45 mcg/24 hour), serum cortisol 67.5 (5-25 ug/dl), 11-deoxycortisol 3910 (10-79 ng/dl), and suppressed ACTH &amp;lt;5 (5-52 pg/ml). Electrolytes were normal, DHEAS 342 (35-430 ug/dl), aldosterone &amp;lt; 3 (4-31 ng/dl), renin mass 5 (4-44pg/ml), urinary free normetanephrine 0.23 (&amp;lt; 0.9 nmol/l), urinary free metanephrine &amp;lt; 0.2 (&amp;lt; 0.5 nmol/l). MRI of the chest and brain did not show metastases. She developed at GA 29 weeks, hypertension, proteinuria, and transaminitis. Cesarean section was done at GA 30 weeks followed the next day by right adrenalectomy, IVC repair and retroperitoneal lymph node resection. Pathology showed high-grade adrenal cortical carcinoma (12 cm size) with negative margins, vascular invasion and lymph node involvement (T3, N1, M0), no caval involvement, stage III ACC. During chemotherapy planning, metastases were noted, mitotane and pembrolizumab were initiated, but discontinued after 2 cycles on account of generalized rash and elevated liver enzymes. The tumor progressed on etoposide, doxorubicin and cisplatin (EDP), and second line therapy (gemcitabine and capecitabine) was initiated. Conclusion: Physiologic changes of pregnancy mimic clinical features of ACC and pregnancy associated changes in the HPA axis also make ACC diagnosis challenging. Short fragments of DNA (cfDNA) released into the maternal bloodstream can be detected after 7 weeks of gestation. Approximately 2-20% of total cfDNA is placental, it is used for sex determination and detection of congenital genetic abnormalities, cfDNA can also originate from maternal neoplasms and has been shown to detect lung, breast and colon while case series in patients with ACC showed detection of only 1 out of 3 cases. Surgery remains first line therapy for ACC, but adjuvant therapy, surveillance and hormone replacement are also vital in ACC management. Presentation: Saturday, June 17, 2023

FRI146 Stereotactic Ablative Radiotherapy As A Local Valuable Therapeutic Procedure To Control Aldosterone-Secreting Adrenocortical Carcinoma

Abstract Disclosure: L.M. Mermejo: None. R.H. Zanella: None. L. Cocicov: None. C.A. Molina: None. S. Tucci Jr: None. J. Elias Jr: None. V.F. Muglia: None. G. Viani: None. P.C. Elias: None. A.C. Moreira: None. M. De Castro: None. Aldosterone-secreting adrenocortical carcinomas (ACC) are rare and usually described as large tumors. We report the case of a 44-year-old man referred to our University Hospital presenting back pain, muscular weakness and hypokalemia. A year earlier, hypertension had been diagnosed triggered by the investigation of daily headaches. Throughout this period, hypertension had been refractory to antihypertensives and patient also showed progressive weight loss of 10 kg. At the time of presentation, the patient had no signs of cortisol or androgen excess, his blood pressure was 180x120 mmHg, and there was no peripheral edema or abdominal mass detected. Due to abdominal pain and liver enzymes abnormalities, an abdominal CT was performed and revealed a heterogeneously 10 x 8 x 6 cm (volume: 256 cm³) left adrenal mass compressing the left renal vein with invasion through the inferior cava vein and extending to the liver caudate lobe. He also had a sodium of 143 mmol/L, potassium of 1.2 mmol/L and metabolic alkalosis. The serum aldosterone level of 75 ng/dL and plasma direct renin concentration &amp;lt; 2 mIU/L whereas urinary fractionated metanephrines were within normal limits, suggesting a probable aldosterone-secreting ACC. His family history was negative for hypertension or adrenal diseases. The patient was initially treated with spironolactone and potassium replacement with clinical improvement and an open adrenalectomy was proposed. However, patient professed to be Jehovah's Witnesses and refused the surgery due to the risk of blood transfusions. Therefore, the patient received mitotane but owing to hepatotoxity, the drug was withdrawn after two months of follow-up. A follow up abdominal MRI after 10 months of diagnosis revealed an increase in the mass (12 x 8 x 9 cm; volume: 460 cm³) and, now, extending to the left kidney. A CT-guided percutaneous biopsy showed an ACC with a Weiss score of three and the immunohistochemistry was positive for vimentin, inhibin and MART-1/ Melan A. After a multidisciplinary discussion, it was proposed to use stereotactic ablative radiotherapy (SABR) as an alternative option. The patient accepted SABR, being treated with 35Gy/5 fractions. During the follow-up, the patients had a progressive improvement of pain complaints, reduction of tumor burden after eighteen months on control abdomen CT (9.1 x 4.9 x 8.7 cm; volume of 202 cm³), improvement of blood pressure and hypokalemia levels, reduction of antihypertensive drugs defined daily dose and potassium replacement as well as reduction of a serum aldosterone to 13 ng/dL and increased of paired renin to 25 mU/L. This is the first published report of a pure aldosterone-producing ACC patient receiving SABR. The response was significant, indicating that the use of SABR should be considered as an alternative for local treatment of aldosterone-secreting ACC when the surgery cannot be indicated. Presentation: Friday, June 16, 2023

SAT539 Thyroid Cancer Presenting as Aspiration Pneumonia

Abstract Disclosure: S. Aslam: None. M. Asif: None. I. Nadeem: None. W.J. Khan: None. Background Goiter, most often, is first noticed as a visible neck mass; however, some patients may present with signs and symptoms of hypothyroidism, or hyperthyroidism. Retrosternal extension can cause compression of the trachea, esophagus, and jugular veins resulting in dysfunction of these viscera. CaseA 68-year-old male presented with SOB, and weakness for 5 days. He had SaO2 79% on room air requiring oxygen, RR 28/min, HR 78/min and Temp.101.6 F, BP 94/48 mmHg. The lung exam revealed bilateral rhonchi and coarse crypts. Minimal non-tender nodularity was noted on the thyroid palpation not previously noticed by the patient or his family. Chest x-ray showed bilateral airspace opacities. CT chest revealed a large upper mediastinal mass displacing the trachea and esophagus to the right, a nodule in the left lobe of thyroid, subcarinal and right hilar lymphadenopathy and bilateral dependent consolidative opacities suggesting aspiration pneumonia but no PE. A barium esophagogram showed a 7.5 cm mediastinal mass causing 50% narrowing and displacement of esophagus and compression with left sided deviation of trachea. A barium swallow study was done, and the patient was found to have aspiration with all administered food types due to an abnormal swallowing mechanism. The patient was advised NPO and placed on NG tube feeding to prevent further aspiration. The patient underwent bronchoscopy and EBUS from station 4 lymph node, the pathology of which did not show any malignant cells. However, due to high clinical suspicion of a malignant process, the patient underwent a CT-guided biopsy of the mediastinal mass that showed bland thyroid tissue. Ultrasound of thyroid revealed multiple right and left lobe nodules. TSH and free T4, and calcitonin were WNL. The patient's hypoxia and fever resolved after completion of the antibiotics including ceftriaxone and doxycycline and being nothing per oral within 7 days. Due to persistent dysphagia, he was placed on PEG tube feeding and discharged from the hospital to a nursing home. The patient underwent ultrasound-guided fine needle biopsy of 1 right-sided and 2 left-sided thyroid nodules that resulted as papillary thyroid cancer. He underwent a successful right-sided thoracotomy and removal of large sized thyroid mass. The patient is seeing endocrinology as an outpatient for radioactive iodine and hormone replacement therapy. Conclusion We treated a patient of follicular carcinoma who presented with extrathyroidal symptoms. Retrosternal or ectopic thyroid tumors can present as euthyroid state without obvious enlargement of the normal thyroid gland. A meticulous clinical evaluation should include the differential diagnosis of retrosternal goiter or ectopic thyroid with cancer when treating patients who preset with sign and symptoms concerning for mediastinal disease. Presentation Date: Saturday, June 17, 2023

THU517 Aggressive Cushing’s: A Rare Case Of Pancreatic ACTHoma In A Young Female

Abstract Disclosure: O.C. Reyes: None. A. Sison: None. M. Villa: None. D. Dimayuga: None. Introduction: Adrenocorticotropic hormone-producing pancreatic neuroendocrine neoplasm (ACTHoma) is a rare type of pancreatic neuroendocrine tumor that causes ectopic adrenocorticotropic hormone syndrome. Cushingoid manifestations and metabolic abnormalities can occur rapidly. High index of suspicion is required for early diagnosis. Case: A 31-year-old Filipino female presented with facial and ankle swelling that occurred 6 weeks before the visit. She also had acne, easy bruising, amenorrhea and frequent mood swings. There was reported weight gain of 3 kg a month prior. She had no history of hypertension and diabetes, and had no unusual family history. At the time of admission, vital signs were blood pressure of 130/80mmHg, pulse of 92/min, respiratory rate 20/min and body temperature of 37.2C. Her body mass index was 28kg/m2. She had muscle atrophy of the upper and lower extremities, facial flushing, posterior cervical fat pad, abdominal violaceous striae, and skin pigmentation. Her external genitalia was normal, Tanner Stage 5 consistent with adult pattern. Neurologic exam was unremarkable. She was examined for Cushing’s syndrome. On initial tests, glucose was 406 mg/dl, HbA1C 10.7%, thyroid stimulating hormone 0.122 (NV: 0.55-4.78), Free T3 0.77 (NV: 2.3-4.2), Free T4 0.58 (NV: 0.89-1.76). Creatinine was 0.86 mg/dL, sodium was 140 mEq/L, potassium was 2.1 mEq/L showing hypokalemia. There was leukocytosis on her blood count, white blood cells 15,310/mm3 (neutrophils 94%, lymphocytes 3%). In the low-dose dexamethasone suppression test (DST), the serum cortisol concentration was 991.03nmol/L. Her adrenocorticotrophic hormone (ACTH) level was elevated at 577pg/mL. After high-dose DST, the serum cortisol concentration was &amp;gt; 1750 nmol/L. No tumor was observed on pituitary magnetic resonance imaging. On abdominal computed tomography (CT), a large, lobulated, heterogeneously-enhancing mass arising from the pancreatic body and tail measuring 7.5cm x 10cm x 10.9cm was seen. The mass had infiltrated the gastric fundus, and encased the splenic artery. Multiple non-calcified subcentimeter pulmonary nodules were observed on chest CT. CT-guided biopsy of the pancreatic mass was done. On microscopic examination, numerous atypical cells arranged with small clusters and sheets and scattered singly were found in the tumor. The cells had small to enlarged, hyperchromatic, ovoid to round nuclei and scant to ample delicate cytoplasm. On immunohistochemical staining, the tumor cells were stained positive for synaptophysin and chromogranin A, which are both neuroendocrine markers, as well as ACTH. However, the patient died prior to any definitive management. Conclusion: ACTHoma is a very rare disease that causes hypercortisolemia. Reporting of similar cases will provide insight into its clinical features, immunohistochemical characteristics, diagnosis, therapy, and prognosis. Presentation: Thursday, June 15, 2023