Discrete Nodules Research Articles

Reappraisal of Tumor Deposit as a Prognostic Factor in Pancreatic Cancer.

Tumor deposits (TDs) are discrete tumor nodules within the lymphatic drainage area of the primary tumor without histological evidence of lymph node tissue or identifiable vascular or neural structure. This study aims to analyze the prognostic impact of TDs in patients with pancreatic ductal adenocarcinoma (PDAC) and explore their potential role in staging system. The prospectively maintained database from the Fudan University Shanghai Cancer Center was queried for patients undergoing resection for PDAC. Patients with TDs were matched by propensity score with those without TDs. The cumulative prevalence of recurrence was estimated using the cumulative incidence function. Overall survival was estimated using Kaplan-Meier curves. A total of 123 patients (9.7%) had TDs, of whom 108 were matched at a 1:3 ratio with 324 patients without TDs. The cumulative incidence of recurrence was significantly higher for TD-positive patients than TD-negative patients (P = 0.04). The median overall survival was significantly shorter for patients with TDs than for those without TDs (15.9 versus 21.8 months, P < 0.001). The presence of TDs attenuated the effect of lymph node metastasis on survival, with no significance between node-negative and node-positive subpopulations (P = 0.165). Patients with TDs had comparable survival to N2 patients without TDs (15.9 versus 17.1 months, P = 0.383). TD is an important prognostic factor for recurrence and survival in patients undergoing resection for PDAC. We suggest that patients presenting TDs be classified into the stage III category in the next edition of the staging system.

Submucosal Necrotic Nodule of the Colon: An Enigmatic Entity Potentially Related to Anisakis Infection.

Discrete submucosal necrotic nodules may rarely manifest as colon polyps. To characterize the clinical and pathologic features of this lesion, which has been under-studied in the literature. We conducted an international search to compile a series. For each potential case, photomicrographs were centrally reviewed to confirm the diagnosis. We gathered clinical and pathologic information on each confirmed case. The final cohort included 25 patients, with 23 having 1 lesion and 2 having several (31 lesions total). Mean patient age was 62 years; 13 patients (52%) were male. Symptoms were nonspecific, although 4 patients (16%) had blood in stool; 14 patients were asymptomatic. Patient history and medications appeared noncontributory. Most cases were located in the right colon (n = 18; 58%). Mean lesion size was 0.4 cm (range, 0.1-1.7 cm). Histology typically showed a centrally necrotic nodule with peripheral fibrosis, chronic inflammation, and sometimes palisading granulomatous inflammation. Percent necrosis ranged from 5% to 95% (average, 70%), and percent fibrosis ranged from 3% to 70% (average, 25%). In 3 cases, degenerated parasitic structures consistent with Anisakis could be seen on hematoxylin-eosin and trichrome special stain. No patient experienced disease recurrence. Submucosal necrotic nodules can present as colon polyps. Most cases are unifocal, and patients do well on follow-up. At least some examples appear to be caused by Anisakis, implicating patient diet. Patients are often asymptomatic, and many cases show no histologic evidence of the causative agent.

Constant p.L424H Mutation in GTF2I in Micronodular Thymomas With Lymphoid Stroma: Evidence Supporting Close Relationship With Type A and AB Thymomas

Micronodular thymoma with lymphoid stroma is a rare thymic neoplasm characterized by discrete nodules of epithelial tumor cells separated by abundant lymphoid stroma. The genetic features of micronodular thymoma with lymphoid stroma remain largely unexplored. Owing to the interference of abundant intratumoral, nonneoplastic lymphoid cells, a highly sensitive approach is necessary to study genetic changes in these tumors. In this study, we used a highly sensitive next-generation sequencing assay using the molecular barcoding Ion AmpliSeq HD technology to study the most commonly mutated genes in thymomas, including GTF2I, HRAS, NRAS, KRAS, and TP53. A total of 12 cases of micronodular thymomas with lymphoid stroma were tested, and 2 cases also had areas of type A thymoma in their tumor bed. Two micronodular thymic carcinomas with lymphoid stroma, a histological mimic of micronodular thymoma, were also included for comparison. Recurrent p.L424H mutations in GTF2I were found in all the cases of micronodular thymoma with lymphoid stroma but not in the cases of micronodular thymic carcinomas. In addition, 3 cases of micronodular thymoma with lymphoid stroma also had concomitant HRAS and/or KRAS mutations. Our study showed that p.L424H mutations in GTF2I is a constant genetic feature of micronodular thymoma with lymphoid stroma. This finding strongly suggests that micronodular thymoma with lymphoid stroma is closely related to type A and AB thymomas because they all share p.L424H mutations in GTF2I.

Dermoscopy of Cylindroma in Fitzpatrick Type IV Skin: A Case Report and Review of Literature.

Dermoscopy of Cylindroma in Fitzpatrick Type IV Skin: A Case Report and Review of Literature.

Clinicopathological and molecular features of multinodular and vacuolating neuronal tumors of the cerebrum

Objective: To investigate clinicopathological features of multinodular and vacuolar neurodegenerative tumor (MVNT) of the cerebrum, and to investigate its immunophenotype, molecular characteristics and prognosis. Methods: Four cases were collected at the General Hospital of Southern Theater Command, Guangzhou, China and one case was collected at the First People's Hospital of Huizhou, China from 2013 to 2021. Clinical, histological, immunohistochemical and molecular characteristics of these five cases were analyzed. Follow-up was carried out to evaluate their prognoses. Results: There were four females and one male, with an average age of 42 years (range, 17 to 51 years). Four patients presented with seizures, while one presented with discomfort on the head. Pre-operative imaging demonstrated non-enhancing, T2-hyperintense multinodular lesions in the deep cortex and superficial white matter of the frontal (n=1) or temporal lobes (n=4). Microscopically, the tumor cells were mostly arranged in discrete and coalescent nodules primarily within the deep cortical ribbon and superficial subcortical white matter. The tumors were composed of large cells with ganglionic morphology, vesicular nuclei, prominent nucleoli and amphophilic or lightly basophilic cytoplasm. They exhibited varying degrees of matrix vacuolization. Vacuolated tumor cells did not show overt cellular atypia or any mitotic activities. Immunohistochemically, tumor cells exhibited widespread nuclear staining for the HuC/HuD neuronal antigens, SOX10 and Olig2. Expression of other neuronal markers, including synaptophysin, neurofilament and MAP2, was patchy to absent. The tumor cells were negative for NeuN, GFAP, p53, H3K27M, IDH1 R132H, ATRX, BRG1, INI1 and BRAF V600E. No aberrant molecular changes were identified in case 3 and case 5 using next-generation sequencing (including 131 genes related to diagnosis and prognosis of central nervous system tumors). All patients underwent complete or substantial tumor excision without adjuvant chemoradiotherapy. Post-operative follow-up information over intervals of 6 months to 8 years was available for five patients. All patients were free of recurrence. Conclusions: MVNT is an indolent tumor, mostly affecting adults, which supports classifying MVNT as WHO grade 1. There is no tumor recurrence even in the patients treated with subtotal surgical excision. MVNTs may be considered for observation or non-surgical treatments if they are asymptomatic.

ODP456 A rare case of massive goiter with overlapping features of Riedel's thyroiditis and Fibrous Variant of Hashimoto's thyroiditis

Abstract Background Hashimoto's thyroiditis is the most common autoimmune disorder of the thyroid gland associated with hypothyroidism. It is distinguished by painless inflammation and elevated titers of TPO antibodies. Fibrous Variant of Hashimoto's Thyroiditis is a rare condition occurring in about 10% of cases, mainly middle-aged individuals, and characterized by an extensive fibrous proliferation without extension into the surrounding structures. Riedel's thyroiditis is a rare generalized autoimmune disorder involving B lymphocytes and IgG4-secreting plasma cells, clinically characterized by extension of the fibrous process to surrounding tissues in the neck, as well as compression symptoms like dysphagia and dyspnea. It is usually associated with mediastinal and retroperitoneal fibrosis. There is significant clinical, pathological, and laboratory test overlap between these two entities that makes the differential diagnosis difficult. Case report A 54-year-old male diagnosed with hypothyroidism on Levothyroxine, and a large goiter seen with new onset of compressive symptoms including dyspnea and dysphagia since March/April 2021. He complains of having pressure on his neck, difficulty swallowing, and worse symptoms when lying flat on a bed. His thyroid is noted to be extremely large and firm, without evident nodularity on examination. Laboratory exams were significant for TSH 3.21 (0.36-3.74), T4 0.94 (0.76-1.46), vitamin D level 13 (30-100), TPO &amp;gt; 9000 (0-9), IgG4 81.9 (4. 0-86. 0), and a negative ANA screen. Thyroid ultrasound showed an enlarged heterogeneous thyroid gland with no discrete nodules. Given the compressing symptoms the patient presented, he was referred to surgery for total thyroidectomy. Surgery could not be completed due to the inability to safely mobilize the gland and adherence to surrounding tissues. He then underwent a right thyroid lobule core biopsy, showing an inflammatory infiltrate composed primarily of lymphocytes and plasma cells. Atrophic thyroid follicles with prominent fibrosis were noted. IgG4 immunostaining highlights &amp;lt;5 positive plasma cells/HPF and IgG4/IgG &amp;lt;30%, excluding IgG4-related fibrosing disease in this core biopsy material. There was no evidence of malignancy. Considering the prominent fibrosis, very high TPO Ab titer, and a seeming lack of extrathyroidal involvement, Fibrous Variant of Hashimoto's Thyroiditis seems more likely, but Riedel Thyroiditis cannot be completely ruled out. He was placed on Prednisone 40 mg daily, with modest improvement of symptoms. Tamoxifen 20mg daily was later added given literature reports of additional improvement in symptoms associated with its use. Referral to a tertiary center for possible isthmusectomy may be considered if symptoms worsen. Presentation: No date and time listed

ODP477 Ectopic Cushing's Syndrome Due to Medullary Thyroid Cancer

Abstract Introduction Medullary thyroid carcinoma (MTC) is an uncommon aetiology of ectopic ACTH syndrome. Ectopic ACTH secretion has been reported in 0.7% of MTCs; it usually occurs in metastatic MTC and has been associated with increased mortality. Case presentation A 65-year-old male with a history of diabetes, hypertension and schizophrenia presented with confusion and upper respiratory symptoms. Initial evaluation showed hypokalaemia, hypocalcaemia, hypomagnesaemia and metabolic alkalosis with random plasma cortisol of 1045 nmol/L. He did not have any cushingoid features on examination. Clubbing of the fingers and proximal myopathy were noted on examination. 24-hour urinary free cortisol was elevated at 3536 nmol/day [NR 50-270] and midnight plasma cortisol was high 856 nmol/L. Low-dose dexamethasone suppression testing showed a cortisol of 1195 nmol/L at baseline and 983 nmol/L [NR &amp;lt;50] at 48 hours. ACTH was significantly elevated at 275 ng/. Plasma metanephrines were normal. A pituitary MRI was normal and an adrenal CT showed bilateral hyperplastic adrenal glands with no discrete nodules. FDG PET/CT revealed nodularity in both upper lung lobes and 2 cm metabolically active left supraclavicular lymph node. He was started on potassium chloride, calcium carbonate with Ergocalciferol. Hypokalaemia worsened in spite of potassium replacement. He was commenced on Metyrapone and prednisolone as a block-and-replace. Ketoconazole has been avoided due to derangement of liver biochemistry. Normalisation of cortisol led to resolution of his confusion. Rivaroxaban 10mg once daily was started as DVT prophylaxis. Eplerenone was added for better control of the hypokalaemia. He underwent ultrasound-guided biopsy of his supraclavicular/cervical mass which showed findings consistent with metastatic MTC. Calcitonin was significantly elevated at 28,400 ng/L(NR &amp;lt;11.8) and CEA level was 340ug/L (NR 0-5). Cytogenetics showed a somatic RET mutation. An attempted total thyroidectomy had to be abandoned as his disease was found to be too locally advanced with fixed area of tumour in the left root of the neck encasing the great vessels and extending down into the sternum. He was commenced on Cabozantinib with plan to re-explore total thyroidectomy option if the tumour shrinks. At follow up, biochemical and radiological assessment showed good response to treatment. The patient remains in good physical condition and is continuing treatment for his mental health problems. Conclusion MTC may infrequently present with paraneoplastic syndrome such as ectopic ACTH secretion. A high index of clinical suspicion is essential in diagnosing atypical cases of Cushing syndrome presenting with rapidly progressive clinical features of hypercortisolaemia, severe hypokalaemia, normal or high ACTH in the absence of a pituitary lesion on imaging. Targeted therapy such as Tyrosine kinase inhibitors (TKI) or selective RET inhibitors have led to improved treatment outcomes. Presentation: No date and time listed

ODP280 A Unique Case of Coexisting Paraganglioma, Primary Hypoaldosteronism and Primary Hyperparathyroidism in a Single Patient

Abstract Introduction To date, case reports have shown an association between paraganglioma and primary hyperaldosteronism, and primary hyperparathyroidism with primary aldosteronism, but not for all three of the aforementioned endocrinopathies combined. Clinical Case A 54-year-old woman with history of uncontrolled HTN, hypokalemia, DM2, CKD stage III, Takotsubo cardiomyopathy and primary hyperparathyroidism presented to the hospital with back pain. CT scan showed a 4.3 cm necrotic retroperitoneal mass. Due to her labile blood pressure, ranging from 194/102 mmHg to 106/60 mmHg, endocrinology was consulted for evaluation of secondary hypertension. Plasma normetanephrines were 3447 pg/mL (n ≤ 57 pg/mL), 24-hour urine normetanephrines 5954 mcg/24 hours (n 122-676 mcg/24 hours) and 24-hour urine norepinephrines 476 mcg/24 hours (n 15-100 mcg/24 hours). 24-hour urine cortisol and 24-hour urine metanephrines were within normal limits. Plasma aldosterone level and plasma renin activity (PRA) were 19 ng/dL and 0.78 ng/mL/h (n 0.25-5.82 ng/mL/h),. However, the patient was also taking spironolactone and telmisartan which interfered with results, and withdrawal of interfering medications was considered unsafe. 68Ga-DOTATATE PET/CT showed mild uptake in a left para-aortic mass. Genetic testing did not show pathogenic mutations of AP2S1, CASR, MEN1, NF1, RET, SDHA, SDHAF2, SDHB, SDHC, TMEM127 or VHL genes. The patient was started on doxazosin and underwent successful removal of the left retroperitoneal mass consistent with paraganglioma. Six months later, surveillance testing showed normalization of fractionated plasma metanephrines and of 24-hour urine metanephrines. However, due to blood pressure of 152/100 mmHg and K of 2.8 mmol/L (n 3.5-4.7 mmol/L), concern was raised for primary hyperaldosteronism. After potassium repletion, labs showed plasma aldosterone of 37 ng/dL, PRA of 0.2 ng/mL/h (n 0.25-5.82 ng/mL/h) and ARR of 185 with potassium of 4.1 mmol/L (n 3.5-4.7 mmol/L) consistent with primary hyperaldosteronism. MRI of adrenal glands showed a left adrenal gland that was thickened and nodular but without discrete nodules &amp;gt; 1 cm. The patient was referred for adrenal vein sampling. Five years previously, the patient had been diagnosed with primary hyperparathyroidism, with PTH of 188.5 pg/mL (n 14-64 pg/dL), Calcium of 10.6 mg/dL (n 8.5-10.1 mg/dL) and GFR of 39. Pre-operative imaging with MRI neck had shown enlargement of two parathyroid glands. She had undergone two-gland parathyroidectomy with intraoperative PTH decrease of &amp;gt; 50% and normalization of calcium. However two weeks later, her PTH returned to pre-operative levels (with normal 25(OH)D) and continues to remains elevated. This has been attributed to underlying secondary hyperparathyroidism from her chronic kidney disease. Conclusion To our knowledge, this is a unique case of combined paraganglioma, primary hyperaldosteronism and primary hyperparathyroidism, as thorough literature review has not shown such a coexistence in the past. Presentation: No date and time listed

PSAT347 New Onset of Graves’ Disease after COVID-19 Vaccination

Abstract Introduction Adjuvants are substances that are commonly found in vaccines. They can enhance the efficacy and potency of a vaccine via an immunological response. However, in some susceptible individuals, these adjuvants can lead to a serious autoimmune response known as autoimmune/inflammatory syndrome induced by adjuvants (ASIA). This can lead to the onset of autoimmune disorders following vaccination. There are many case reports of the onset of autoimmune disorders following COVID-19 vaccination. However, new onset of Graves’ disease within one day after COVID-19 vaccination, is of rare occurrence. Clinical Case We present the case of a 33-year-old Caucasian male who presented to his primary care physician with chief complaints of fever ranging between 99.2F to 101.3F, palpitations and hand tremors which started one day after he received his first dose of COVID-19 vaccine. Initial laboratory evaluation included a negative throat swab for Group A Streptococcus, a negative nasal swab for Influenza A &amp; Influenza B and a negative nasopharyngeal swab for SARS-COV-2 RNA. On physical examination, he was afebrile, pulse rate 101/min, blood pressure 125/74 mm Hg and oxygen saturation 98%. Due to persistence of tachycardia, an EKG was done which showed a normal sinus rhythm with no other abnormalities. Further laboratory testing was remarkable for a suppressed TSH 0.005 (0.300-4.00 uUI/ml), elevated FT4 2.36 (0.80-1.80 ng/dl) and an elevated TSH receptor Antibody (TRAb) 8.67 (0.00-1.75 IU/L), which confirmed the diagnosis of Graves’ disease. Subsequently, patient established care at our endocrinology clinic. Labs were repeated which showed persistence of hyperthyroidism with TSH &amp;lt;0.005, high normal FT4 1.56 and an elevated FT3 5.36 (2.00-4.40 pg/ml). Thyroid ultrasound was remarkable for mild thyromegaly with increased vascularity and no discrete nodules. Patient was initiated on Methimazole 10 mg daily and propranolol 10 mg twice daily. During the first follow-up visit, the dose of Methimazole was reduced to 5 mg daily based on improved labs. However, it had to be increased back to 10 mg daily due to subsequent worsening of labs. Since then, patient has been maintained on a stable dose of Methimazole 10 mg once daily and the beta-blocker has been discontinued. It has been almost 1 year since the diagnosis and the Graves’ disease specific Thyroid Stimulating Immunoglobulin (TSI) antibody is still elevated at 1.31 (0.00-0.55 IU/L). Conclusion Graves’ disease should be considered high in the differential diagnosis in a patient presenting with fever and tachycardia following COVID-19 vaccination. Our unique case supports the current literature available on the various autoimmune conditions caused by the autoimmune/inflammatory syndrome induced by adjuvants, also known as ASIA. Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m., Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.

PSAT282 A Case of Papillary Thyroid Cancer in a Thyroglossal Duct Cyst

Abstract Background Thyroglossal duct cysts (TGDC) are common congenital neck anomalies. They persist through adulthood in 7% of the general population. Associated malignancy is rare, occurring in &amp;lt;1% of cases. Over 90% of such malignancies are papillary thyroid carcinoma (PTC). Twenty to 60% of patients with TGDC malignancies are found to have concomitant cancer in the thyroid. The rarity of TGDC malignancy make its management particularly challenging, given limited long term outcome data. We describe a case of a 4cm TGDC PTC. Case A 49-year-old female with a history of autoimmune thyroid disease presented for evaluation of a goiter. She reported 6 months of painful midline neck swelling. No family history of thyroid cancer and she had no history of radiation to her head or neck. She denied swallowing, dyspnea, or hoarseness. Physical exam was notable for a mildly tender, firm 2.5 cm submental midline neck mass overlying the hyoid. TSH was normal and thyroid peroxidase antibody was &amp;gt;1000 (n: &amp;lt;5 IU/mL). Neck ultrasound showed a 3.7×2.5×1.6 cm mixed solid/cystic midline neck mass and a mildly enlarged, heterogeneous, and vascular thyroid without discrete intrathyroidal nodules. A neck CT with contrast indicated that the midline mass was heterogeneously enhancing with tiny internal cystic spaces. The differential diagnosis included an infected thyroglossal duct cyst versus malignant transformation. Fine needle aspiration of the mass was suggestive of PTC. The patient underwent the Sistrunk procedure, with excision of the thyroglossal duct cyst, the middle of the hyoid bone, and the tissue surrounding the thyroglossal tract. Final pathology was consistent with a 4 cm PTC, classical type, without lymphatic, vascular or perineural invasion. Surgical margins were negative for malignancy. Two months postoperatively, TSH remained normal, and the thyroglobulin (TG) level was 78 with negative TG antibodies. She declined a thyroidectomy. Conclusion To date, there is no consensus guideline regarding optimal management for malignancy involving TGDC. Studies suggest that surgical decision making be based on patient risk stratification. High risk factors include age older than 45 years, tumor &amp;gt;4 cm in size, extension of tumor to adjacent soft tissue, and/or the presence of nodal or distant metastases. In high-risk patients, treatment with Sistrunk procedure combined with thyroidectomy, neck dissection and radioactive iodine therapy have shown excellent results. In younger than 45 years with tumor size &amp;lt;1.5 cm, without extension beyond cyst wall and normal thyroid ultrasound Sistrunk procedure alone might be sufficient. Despite low risk factors patients should still be advised to have thyroidectomy as there could be a 20% risk of coexisting thyroid cancer. Additional longitudinal studies are needed to confirm that this approach leads to optimal long-term outcomes for patients with TGDC-associated malignancy. Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

Total spleen calcification - a rare clinical manifestation in systemic lupus erythematosus

Splenomegaly, infarction, spontaneous rupture and hyposplenism are among the frequently manifestations of splenic involvement in systemic lupus erythematosus (SLE) patients. Exceptionally, extensive splenic calcifications are found in SLE. This aspect is due to the periarterial thickening in an “onion-skin” model. Discrete, small, circular and diffuse nodules that are distributed at the level of the parenchyma, but that are missing at the capsular and subcapsular level, are the main characteristics of these calcifications. The aim of this report is to present the case of a SLE patient with this rare splenic calcifications association.

Cervicomedullary Purely Solid, Giant Pilocytic Astrocytoma

AbstractPilocytic astrocytomas are well-circumscribed, predominantly cystic mass lesions that have a discrete mural nodule. Giant, solid pilocytic astrocytoma is uncommon. Its characteristic imaging features are described.

Ancillary findings on high resolution CT chest associated with typical features of COVID-19 pneumonia (Observational descriptive study at a tertiary care hospital).

To determine the frequency of ancillary pulmonary signs and their relation to the severity of disease seen on high-resolution computed tomography of chest in patients of coronavirus disease-2019 pneumonia. The observational descriptive study was conducted at the Armed Forces Institute of Radiology and Imaging, Rawalpindi, Pakistan, from March to July 2020, and included in place of comprised all coronavirus disease-2019 patients who were found positive on reverse transcription-polymerase chain reaction-and were referred to have high-resolution computed tomography of chest. Ancillary pulmonary findings in addition to typical features of coronavirus disease-2019 pneumonia were recorded. These included vacuole sign, halo sign, reverse halo sign, subpleural white line, subpleural translucent line, microvascular dilatation, fibrotic streaks and bronchiectasis. Relative frequency of these signs were determined for mild versus and severe disease, as determined by the computed tomography severity score. Data was analysed using SPSS 26. Of the 1645 patients, 1286(78.2%) were males and 359(21.8%) were females. The overall mean age was 47.5±15.7 years (range: 1-92). High-resolution computed tomography was normal in 418(25.4%) patients, typical findings for coronavirus disease-2019 were seen in 1110(67.5%), indeterminate in 113(16.9%) and atypical in 4(0.2%). Vacuole sign, subpleural white line, subpleural translucent sign, microvascular dilatation and fibrotic streaks were more commonly seen in severe disease (p<0.001), while discrete pulmonary nodule was identified more in the milder form (p<0.05). Halo and reverse halo signs as well as bronchiectatic changes demonstrated no significant propensity to the degree of disease severity (p>0.05). Coronavirus disease-2019 pneumonia demonstrated various ancillary pulmonary features on high resolution computed tomography of the chest in addition to typical findings more commonly described; radiologists should be aware of these signs and their relation to disease severity.

Vocal nodules in children: Laryngoscopic morphological classification aids prognostic judgment.

ObjectiveVocal fold nodules (VFNs) are benign lesions, occurring at the junction of the anterior and middle thirds of bilateral vocal cords, for which pediatric prognosis and treatment remains controversial. There is a requirement for a correlation indicator to assess the prognosis by pediatric otolaryngologists.Materials and methodsPatients with VFNs, who were admitted to the department of otolaryngology, were enrolled. The patient’s gender, age, duration of dysphonia, laryngoscopy results and related diseases [allergic rhinitis, sinusitis, laryngopharyngeal reflux (LPR)] were collected and recovery from dysphonia followed up. Correlations between clinical factors and type of laryngoscopic morphology of VFNs were analyzed.ResultsA total of 432 patients with dysphonia were identified, 208 agreed to undergo laryngoscopy and 194 were diagnosed with VFNs as a result. The modal age of patients with dysphonia was between 3 and 7 years with a male: female ratio of 2.1:1 (294:138) and 116 (26.85%; 116/432) had symptoms of allergic rhinitis. The boy to girl ratio among the 194 children with VFNs was about 2.6:1 (140:54) and modal age was consistent with dysphonia. Vocal nodules were the cause of most phonation disorders (93.27%; 194/208) and those with long duration of dysphonia presented more mature (p = 0.026) and discrete types (p = 0.022). Boys were more likely to have mature (p = 0.050) and discrete nodules (p = 0.008). Dysphonia recovery time was closely related to age (p = 0.000), duration of dysphonia (p = 0.000) and morphology of vocal nodules under laryngoscopy (p = 0.000).ConclusionVocal nodules are the most frequent cause of phonation disorders in children. The morphological classification by endoscopy may help with clinical diagnosis and therapy choice. In the case of the older child with longer duration of dysphonia and the appearance of mature, large, discrete nodules by laryngoscopy, active treatment is recommended, such as drug therapy, voice therapy or surgical treatment.

Abstract 2480: A more sensitive approach to cancer imaging using cancer-activated PET reporters

Abstract Early detection and localization of primary cancers has been shown to improve clinical outcomes and overall survival. While liquid biopsy may indicate the presence of cancer and possibly provide the tissue of origin, it cannot pinpoint the exact location of cancer and its metastases. Furthermore, current imaging techniques lack the sensitivity to locate early-stage tumors, diminishing the ability for early clinical intervention. Current imaging approaches using 18F-FDG rely on increased metabolic rates of tumors vs. surrounding non-tumor tissue, often resulting in high background and inability to detect low-metabolic tumors. Earli is developing a highly sensitive, orthogonal approach that uses genetic constructs to usurp dysregulated cancer pathways to force the tumor to produce a synthetic biomarker used to detect and localize the malignancy. We previously demonstrated the utility of cancer-activated expression of blood-based biomarkers in preclinical cancer models, which are currently in an ongoing clinical study. EARLI-201 is novel genetic imaging probe comprised of a DNA construct containing a cancer-activated promoter to drive the expression of a PET Reporter Gene (PRG). The HSV-sr39TK PRG product specifically sequesters the 18F-FHBG tracer inside the cell, enabling detection by PET imaging. Initial studies for sensitivity combined H1299 lung cancer cells engineered with only two copies of the PRG were implanted subcutaneously into immunocompromised mice followed by the administration of the 18F-FHBG tracer. Results demonstrate a robust signal from as few as 62,000 injected cells. Given that a 1 mm3 tumor contains ~1,000,000 cells, suggests that we can localize tumors as small as 6.25mm3 with only a 1% transfection efficiency. EARLI-201 was tested in a variety of murine models including the metastatic “Lung Trap” and spontaneous HCC-MYC/Twist1, which produce discrete tumor nodules in the lungs or liver, respectively. A single intravenous injection of EARLI-201 given at Day 1 results in cancer-activated expression and accumulation of the PRG in tumors. 18F-FHBG PET imaging three days post dosing revealed distinct tumor foci that co-register with tumors detected by CT. Additional ex vivo techniques confirmed PRG expression only in tumor-containing tissues and not in healthy tissue. Imaging the same animals with 18F-FDG failed to produce any appreciable signal in the same tumors, likely because they are of low metabolic nature. These pre-clinical results clearly demonstrate the potential of Earli’s approach to detect and localize very small tumors currently outside the sensitivity of existing imaging modalities. Additional experiments to evaluate EARLI-201 in companion dogs diagnosed with cancer are currently in progress and provides the ability to validate the platform in larger body masses with spontaneously formed tumors. Citation Format: Alex Harwig, Morgan Wang, Ling Tong, Regina Nieu, Vy Nguyen, Dean Felsher, David Suhy. A more sensitive approach to cancer imaging using cancer-activated PET reporters [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 2480.

Refractory focal epithelial hyperplasia successfully treated with novel use of nano-pulse stimulation technology.

Focal epithelial hyperplasia (FEH), or Heck's disease, is an uncommon HPV-related dermatosis that presents with multiple discrete papules or nodules on the lips, tongue, and gingival or oral mucosa. Treatment is often sought due to cosmesis, social stigma, and functional impairment. Treatment is challenging and a variety of treatment modalities have been attempted with varying degrees of success. This report describes the novel use of nano-pulse stimulation in the successful treatment of recalcitrant FEH of the upper and lower vermillion lip.

Subacute Thyroiditis Exacerbated by the COVID-19 Pandemic

Objective: It was aimed to evaluate the etiological relationship between the SARS-CoV-2 virus and subacute thyroiditis (SAT). We also wanted to point out the fact that these two entities may have similar clinical features. Materials and Methods: During the 4th month of the Coronavirus disease-19 (COVID-19) pandemic in our country; five patients were referred to our clinic for neck ultrasonography (USG) with a suspected diagnosis of SAT based on clinical and laboratory features. Past medical history, contact history, and COVID-19 Polyerase Chain Reaction (PCR) test results of these cases were evaluated. Results: Subfebrile fever, sore throat, burning sensation in the throat, difficulty in swallowing were the presenting symptoms of the patients. All cases had abnormal thyroid hormone values and elevated erythrocyte sedimentation rate/C-Reactive Protein (CRP) values. USG showed increased thyroid gland volume in four patients. Hypovascularized heterogeneous hypoechoic patchy areas in thyroid parenchyma were observed in all patients without discrete nodules. Ultrasound elastography revealed parenchymal heterogeneity and stiffness. Low-dose non-contrast chest computerized tomography (CT) findings was normal with negative Polymerase chain reaction (PCR) test results in patients. Conclusion: Subacute thyroiditis, which is often accused by viral agents in etiology, may also be associated with SARS-CoV-2. The similarity of clinical and laboratory findings between subacute thyroiditis and COVID-19 infection may pose diagnostic challenges.

Diagnostic challenge in an individual with Paracoccidioidomycosis during hospitalization in times of COVID-19

Paracoccidioidomycosis (PCM) is a deep fungal infection, endemic with considerable morbidity in South America, whose first symptoms can occur in the oral cavity. A 47-year-old male patient, leucoderma, living on the streets, presenting dyspnea, pain during the speech, and dysphagia, was referred for admission to the ICU for suspected COVID-19 infection. The intensive care physician's evaluation revealed a tongue lesion with suspected carcinoma. By dentist investigation, was observed the presence of moriform lesions with high borders delimitation in the tongue. Also, granulomatous ulcers with irregular texture, suggesting moriform stomatitis, the chest tomography revealed diffuse thickening of the bronchial walls, indicating chronic bronchopathy with discrete centrilobular nodules, sometimes confluent. Incisional tongue biopsy associated with lung imaging confirmed the diagnosis of PCM, and the patient was referred to the referral center for the treatment of fungal diseases. The involvement of the oral environment as a region to the appearance of detectable first symptoms of PCM suggests the need for the oral evaluation by a specialist as a diagnostic tool.

A 57-year-old alcoholic woman with soft neck mass

A 57-year-old woman was diagnosed with an anterior cervical mass (figure 1). No peripheral neuropathy or cervical lymph nodes were detected from the physical examination. The mass has slowly and painlessly grown for 30 years with no dyspnea or dysphagia. She had a history of chronic alcohol consumption and heavy tobacco use for 25 years. No standard medications were taken.&#x0D; Multiple symmetric lipomatosis is a disease characterized by the accumulation of multiple, benign, symmetric, and nonencapsulated fatty tissue masses. This is more common in males (15:1) and in the Mediterranean population. Malignancy is rarely observed in this case. Masses can be found on the head and neck, including the upper trunk, shoulders, upper back, mediastinum, perineum, scrotum, and tongue. Besides the aesthetic effects, masses can cause airways or digestive compressive symptoms, as well as limitations in head or neck movements, urinating, or sexual intercourse. The involvement of peripheral nerves can cause neurological symptoms.&#x0D; &#x0D; Alcohol abuse has been long associated with this disease. A genetic cause has been suggested, but a hereditary pattern has not been identified in most cases. A link was suggested with liver disease, but there is no mention of liver abscess in the literature.&#x0D; &#x0D; The diagnostic is based on image finds. Solitary lipoma is a benign soft tissue tumor, rarely found in the neck region. It mostly occurs in females and obese patients, and it is enclosed by a fibrous capsule that helps to differentiate it from other fat aggregations. Liposarcoma represents 1% of neck and head sarcomas. Patients are mostly men and the medium age is 70 years. Familial multiple lipomatosis is a rare autosomal dominant disease that is manifested in the thirties and is more prevalent in females (2:1). In this case, the discrete multiple subcutaneous nodules are movable, painless, and soft and have no associated conditions.&#x0D; &#x0D; Lipectomy is the concerned treatment, but recurrence is common. Liposuction is an alternative to extensive lipectomy. No medicinal therapy is effective; however, alcohol abstinence can reduce the recurrence frequency.&#x0D; &#x0D; Clinics must be aware of this uncommon disease in order to diagnose it and treat it appropriately.&#x0D; &#x0D; Statement of Ethics&#x0D; Written informed consent was obtained from the patient for publication of this case report and any accompanying images.&#x0D; &#x0D; Conflict of Interest Statement&#x0D; The authors have no conflicts of interest to declare.&#x0D; &#x0D; Funding Sources&#x0D; The authors had no funding sources in the preparation of data or the manuscript.

Polarity Dependence of Transport of Pharmaceuticals and Personal Care Products Through Birnessite-Coated Porous Media

Pharmaceuticals and personal care products (PPCPs) have drawn increasing concern of environmental health as they are continuously released into the environment. This study examined the effects of birnessite (δ-MnO2) on the transport and retention of five PPCPs in porous media under steady saturated flow conditions. Considering that natural birnessite occurs as discrete particles and small nodules, birnessite-coated sand was used to mimic the natural regime of birnessite in the environment. Batch isotherm experiments were conducted using uncoated and birnessite-coated sand; results showed that the difference in the affinity of the five PPCPs was correlated to their polarity characteristics. Column experiments were conducted by mixing 0, 10, and 20% birnessite-coated sands with the uncoated sands. These three percentages are equivalent to three contents of manganese (Mn) in the experimental columns (0, 55, and 109 μg Mn g−1 sand). Results suggested that polar compounds (such as bisphenol-A, tetracycline, and ciprofloxacin) had a higher affinity to birnessite-coated sands than the weak polar compounds (such as ibuprofen and carbamazepine) because the polarity was favorable to electrostatic attraction and oxidative reaction. Overall, birnessite decreased the mobility of polar PPCPs but exerted no significant effect on the mobility of weak polar PPCPs under continuous flow conditions. The polarity-based correlation extended traditional electrostatic theory while well interpreting the complicated effects of birnessite on the adsorption and transport of PPCPs, especially neutral or non-dissociated compounds like carbamazepine.