Hilar Nodes Research Articles

July 2024 Medical Image of the Month: Vocal Cord Paralysis on PET-CT

No abstract available. Article truncated after 150 words. A 60-year-old woman with a past medical history of hypertension, rheumatoid arthritis, and a significant smoking history (40+ pack-years) presented with a 3-month history of hoarseness of voice as well as a 10 lb weight loss over a 5-month period. Chest CT revealed a spiculated left upper lobe nodule (Figure 1A). Additionally, there was evidence of bulky mediastinal and left hilar lymphadenopathy (Figure 1B). A subsequent 17-FDG PET-CT (Figure 2) demonstrated marked metabolic activity in the left upper lobe nodule with an SUV maximum of 9.1. Metabolically active mediastinal and left hilar lymphadenopathy was also noted with an SUV maximum of 5.9. Interestingly, increased metabolic activity of the right vocal cord compared to the left was noted on the PET scan (Figure 2B). Direct laryngoscopy, performed during intubation for a diagnostic bronchoscopy and endobronchial ultrasound, confirmed left vocal cord paralysis. EBUS sampling of multiple mediastinal hilar lymph node stations, including …

Utility of PET for Nodal Staging in Subsolid Clinical Stage IA (T1 N0) Lung Adenocarcinoma

BackgroundPositron emission tomography (PET) is the standard of care for non-small cell lung cancer (NSCLC) clinical staging, but it may have limited utility in evaluating subsolid lung adenocarcinomas that can have relatively indolent behavior without hypermetabolic activity. MethodsThe sensitivity and specificity of PET for determining pathologic lymph node status and disease-free survival were assessed in patients operated on for cT1 N0 subsolid lung adenocarcinoma from January 2006 to June 2022 (at Stanford University School of Medicine, Stanford, CA). Patients with clinical or pathologic tumor size >30 mm, hilar or mediastinal lymph node size >1cm, and purely solid tumors were excluded. ResultsPET was available in 498 of 534 (93.2%) patients and more often was used in older patients with larger and more solid tumors. The overall pathologic lymph node–positive rate was 8.4% (45 of 534). PET specificity was 95.1%, but sensitivity was only 20.0%. A tumor diameter of 18.5 mm and a solid component percentage of 62.5% had the maximum predictive accuracy for pathologic lymph node positivity, with a 0% and 1.5% rate of pathologic and PET lymph node positivity, respectively, for tumors with values lower than those thresholds. There was no significant difference in 5-year disease-free survival between individuals who did and did not undergo PET scanning (76.6% vs 96.8%; P = .07). Conversely, 134 (26.9%) patients who underwent PET scanning had 171 incidentally detected hypermetabolic lesions unrelated to lung cancer, with only 13 of 134 (9.7%) patients identified as having non-NSCLC premalignant or malignant conditions requiring further therapy. ConclusionsPET scan use for subsolid lung adenocarcinoma has high specificity but limited sensitivity for predicting pathologic lymph node positivity. PET also has no association with disease-free survival and often detects clinically unimportant findings rather than changing lung cancer management, particularly for patients with smaller and less solid tumors.

Feasibility and comparative prognosis of segmentectomy versus lobectomy in centrally located small and solid dominant cN0 non–small cell lung cancer

ObjectivesTo determine the feasibility of segmentectomy in patients with central, whole tumor size ≤2 cm and radiologically solid-dominant cN0 non–small cell lung cancer (NSCLC). MethodsWe retrospectively reviewed 1240 patients who underwent lobectomy or segmentectomy for small and radiologically solid-dominant cN0 NSCLC between January 2010 and December 2022. The inclusion criteria encompassed centrally located tumors, defined as tumors located in the inner two-thirds of the pulmonary parenchyma. Propensity score matching was applied to balance the baseline characteristics in the 2 study groups. ResultsAmong the 299 eligible patients, no significant differences in recurrence-free survival (RFS) and overall survival (OS) were observed between the segmentectomy (n = 121) and lobectomy (n = 178) groups (P = .794 and .577, respectively). After propensity score matching, no significant differences in hilar and mediastinal lymph node upstaging were found among the 93 matched patients (P = 1.00), and locoregional recurrence was comparable in the segmentectomy (n = 4) and lobectomy (n = 4) groups. RFS and OS did not differ significantly between the 2 groups (P = .700 and .870, respectively). Propensity score–adjusted multivariable Cox analysis for RFS and OS indicated that segmentectomy was not an independent prognostic factor (RFS: hazard ratio [HR], 0.89; 95% confidence interval [CI], 0.43-1.85; P = .755; OS: HR, 1.09; 95% CI, 0.38-3.14; P = .860). ConclusionsSegmentectomy may be a viable treatment option, with local control and prognosis comparable to that of lobectomy in appropriately selected patients with central, small (≤2 cm), and radiologically solid-dominant NSCLC.

Airborne Aluminum as an Underestimated Source of Human Exposure: Quantification of Aluminum in 24 Human Tissue Types Reveals High Aluminum Concentrations in Lung and Hilar Lymph Node Tissues.

Aluminum (Al) is the most abundant metal in the earth's crust, and humans are exposed to Al through sources like food, cosmetics, and medication. So far, no comprehensive data on the Al distribution between and within human tissues were reported. We measured Al concentrations in 24 different tissue types of 8 autopsied patients using ICP-MS/MS (inductively coupled plasma-tandem mass spectrometry) under cleanroom conditions and found surprisingly high concentrations in both the upper and inferior lobes of the lung and hilar lymph nodes. Al/Si ratios in lung and hilar lymph node samples of 12 additional patients were similar to the ratios reported in urban fine dust. Histological analyses using lumogallion staining showed Al in lung erythrocytes and macrophages, indicating the uptake of airborne Al in the bloodstream. Furthermore, Al was continuously found in PM2.5 and PM10 fine dust particles over 7 years in Upper Austria, Austria. According to our findings, air pollution needs to be reconsidered as a major Al source for humans and the environment.

Imaging findings in a rare case of alveolar, hepatic and splenic sarcoidosis presenting with thrombotic thrombocytopenic purpura

Thrombotic thrombocytopenic purpura (TTP) is an acute haematological disorder characterized by severe ADAMTS13 enzyme deficiency, leading to consumptive thrombocytopenia, mechanical haemolysis, and organ damage. Its association with multisystemic sarcoidosis is extremely rare and, to the best of our knowledge, described in only two cases so far. We present the case of a 52-year-old woman with TTP and antibodies anti-ADAMTS13, showing computed tomography (CT) and magnetic resonance imaging (MRI) evidence of pulmonary, hepatic, and splenic lesions initially reported as ischemic/inflammatory changes. A follow-up MRI of the abdomen revealed increased evidence of the liver lesions, focal intrahepatic bile duct dilatation, splenic lesions, and enlarged hepatic hilar nodes. The follow-up chest CT showed increased evidence of the parenchymal lung consolidations. Given the radiological persistence of those alterations and the history of TTP, the hypothesis of an IgG4-related disease was then made. The IgG4 levels were found to be normal, while the histological examination of the liver revealed non-necrotizing granulomatous chronic inflammation. Elevated levels of angiotensin-converting enzyme were found, and the QuantiFERON-TB Gold test was negative for tuberculosis infection. Thus, the overall clinical picture was consistent with multisystemic sarcoidosis (alveolar, hepatic, and splenic). The diagnosis of sarcoidosis, already challenging due to the variability of its clinical presentation, can become even more complicated when it manifests with uncommon haematological manifestations such as TTP, along with non-specific extra-pulmonary involvement. While imaging aids in documenting organ damage, the definitive diagnosis of sarcoidosis necessitates histologic confirmation of noncaseating granulomas and the exclusion of other possible granulomatous diseases.

Stage I and II nonsmall cell lung cancer treatment options.

Chest radiography, computed tomography (CT) and positron emission tomography (PET)-CT are required for staging nonsmall cell lung cancers. Stage I cancers may be up to 4 cm in maximal diameter, with stage IA tumours being up to 3 cm and stage IB up to 4 cm. A lung cancer becomes stage II if the tumour is between 4 and ≤5 cm (stage IIA), or it spreads to ipsilateral peribronchial or hilar lymph nodes (stage IIB). Stage IA tumours should be surgically resected, ideally using minimally invasive methods. Lobectomy is usually performed, although some studies have shown good outcomes for sublobar resections. If surgery is not possible, stereotactic body radiotherapy is a good alternative. This involves delivering a few high-dose radiation treatments at very high precision. For stage IB to IIB disease, combinations of surgery, chemotherapy or immunotherapy and radiotherapy are used. There is evidence that neoadjuvant treatment (immunotherapy with nivolumab and chemotherapy for stage IB and II) optimises outcomes. Adjuvant chemotherapy with a platinum-based doublet (typically cisplatin+vinorelbine) should be offered for resected stage IIB tumours and considered for resected IIA tumours. Adjuvant pembrolizumab is used for stage IB-IIIA following resection and adjuvant platinum-based chemotherapy. Osimertinib may be used for resected stage IB to IIIA cancers which have relevant mutations (epidermal growth factor receptor exon 19 deletions or exon 21 (L858R) substitution). There are no fixed guidelines for follow-up, but most centres recommend 6-monthly CT scanning for the first 2-3 years after definitive treatment, followed by annual scans.

Five-year survival outcomes from the PIT-1 trial: Pemetrexed-cisplatin plus bevacizumab or concurrent thoracic radiation therapy followed by surgery in stage IIIA (N2) nonsquamous non-small cell lung cancer.

8064 Background: Personized Induction Therapy-1 (PIT-1) is a multicenter, randomized phase II selection design trial of pemetrexed-cisplatin plus bevacizumab (BEV arm) or concurrent thoracic radiation therapy (TRT arm) followed by surgery in patients with stage IIIA (N2) nonsquamous non-small cell lung cancer (NSCLC). The TRT arm was chosen as the investigational induction treatment strategy for a future phase III study based on the results of a numerically higher 2-year progression-free survival (PFS, primary endpoint) in the TRT arm and fatal postoperative complications observed only in the BEV arm. We report updated, exploratory analyses of survival, approximately 5 years after the last patient was randomly assigned. Methods: Patients with stage IIIA (N2) nonsquamous NSCLC were randomly assigned (1:1) induction therapy consisting of pemetrexed and cisplatin plus bevacizumab (n = 44) or concurrent TRT (n = 44) followed by surgery. Among them, 38 patients in the BEV arm and 37 patients in the TRT arm underwent surgery. Five-year overall survival (OS), 5-year PFS, and patterns of postoperative recurrence were compared between arms. Prognostic factors of OS were analyzed in surgically resected patients using Cox’s proportional hazard model. Results: The median follow-up was 66.4 months. In 82 treated patients, the 5-year OS and PFS rates were 63.5% (95% CI: 46.9-76.1) and 26.2% (95% CI: 14.1-40.0) in the BEV arm (n = 42), and 57.2% (95% CI: 40.5-70.8) and 27.5% (95% CI: 14.9-41.7) in the TRT arm (n = 40), respectively. There were no statistical differences in OS ( P = 0.572) and PFS ( P = 0.356). In 75 surgically resected patients, pathological nodal down stage was the only significant prognostic factor of OS ( P = 0.014). Age, sex, smoking status, clinical T stage, clinical N stage based on a computed tomography scan, preoperative serum CEA and CYFRA level, EGFR mutation status, pathological complete response, and major pathological response did not have a significant prognostic impact on OS. The patterns of postoperative recurrence were different between arms: locoregional only, in four (11%) and one (3%); distant metastasis only, in 16 (42%) and 21 (57%); and both, in five (13%) and four (11%) in the BEV and TRT arms, respectively. The recurrence rate of ipsilateral hilar or mediastinal lymph nodes (the irradiation field) was significantly lower in the TRT arm (3%) than in the BEV arm (21%, P= 0.01). Conclusions: Five-year survival outcomes were not different between the BEV and TRT arms. The TRT arm demonstrated sufficient local control, but insufficient control of distant metastasis so this is an important issue that requires improvement in the future. Clinical trial information: s031180402.

Clinicopathologic and treatment characteristics of mixed hepatocellular carcinoma-intrahepatic cholangiocarcinoma (HCC-ICC).

e16218 Background: Mixed hepatocellular carcinoma-intrahepatic cholangiocarcinoma (HCC-ICC) represents a rare subtype of primary hepatic malignancy demonstrating morphological and biological features characteristic of both Hepatocellular Carcinoma (HCC) and Intrahepatic Cholangiocarcinoma (ICC). In this study, we describe the clinical and tumor characteristics of survival in HCC-ICC by using a large cohort. Methods: We selected patients diagnosed with HCC‐ICC, HCC, or ICC between 2011 and 2018 and were identified from the National Cancer Data Base (NCDB) using the International Classification of Diseases for Oncology codes. Baseline characteristics were delineated using percentages. Median overall survival (OS) was calculated using the Kaplan-Meier method. Demographic variables (age at diagnosis, gender, race, insurance status), comorbidity score, and treatment features were included. Short‐ and long‐term outcomes were evaluated through univariate analysis. Results: Out of 124,723 patients, 84.6% were diagnosed with HCC, 14.5% with ICC, and 1% with HCC‐ICC. Median survival was significantly better in HCC compared to HCC-ICC and ICC patients (16.2 months, 10.8 months, and 9.4 months, respectively, p < 0.001). Surgical intervention was used by 26.3% of HCC-ICC cases, 19.2% of ICC cases, and 9% of HCC cases. Multiagent chemotherapy was notably more utilized in ICC compared to HCC-ICC and HCC (42.6%, 22.8%, and 5.4%, respectively, p < 0.001). Meanwhile, single-agent chemotherapy was more commonly administered in HCC than in HCC-ICC and ICC (32.3%, 16.5%, and 11.4%, respectively, p < 0.001). Conclusions: HCC-ICC is an aggressive primary liver malignancy with a worse prognosis than HCC and ICC. The primary treatment approach for operable cases continues to be major hepatectomy combined with resection of hilar lymph nodes. Further research is urgently needed to better understand the exact role of the systemic therapies in managing HCC-ICC.

Utility of SHOX2 and RASSF1A gene methylation detection on the residual cytology material from endobronchial ultrasound-guided transbronchial needle aspiration.

This study aims to assess the effectiveness of Short Stature Homeobox 2 (SHOX2) and RAS Association Domain Family 1 Isoform A (RASSF1A) gene methylation detection in residual liquid-based cytology (LBC) materials from Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration (EBUS-TBNA) and investigate the diagnostic accuracy of a comprehensive diagnostic approach. Between June 2022 and May 2023, a total of 110 cases that underwent EBUS-TBNA were enrolled in the study. SHOX2 and RASSF1A genes methylation detection using the residual cytological material, LBC, and cell block (CB) were conducted for each EBUS-TBNA case. The sensitivity and specificity of cytology, CB histopathology, SHOX2, and RASSF1A methylation in diagnosing EBUS-TBNA samples were determined based on follow-up data. Among the 72 cases confirmed as pulmonary carcinomas, the methylation test yielded positive results in 24 adenocarcinoma cases, 10 squamous cell carcinoma cases, and 14 small cell carcinoma cases. The sensitivity of the comprehensive diagnosis (combining LBC, CB, and methylation detection) in distinguishing metastatic pulmonary epithelial malignancies in mediastinal and hilar lymph nodes or masses from benign lesions was higher (97.22%, 70/72) than that of morphological diagnosis alone (LBC and CB) (88.89%, 64/72; P < 0.05). SHOX2 and RASSF1A methylation detection demonstrates a high sensitivity and negative predictive value in the identification of pulmonary epithelial malignancies and holds promise as a valuable ancillary approach to enhance morphological diagnosis of EBUS-TBNA.

Neurosarcoidosis-Induced Winging Scapula: Efficacy of Infliximab Treatment in Addressing Multifaceted Challenges.

Sarcoidosis, a systemic granulomatous disease primarily affecting the respiratory and lymphatic systems, can rarely manifest as neurosarcoidosis either in isolation or alongside other systemic symptoms. Here, we describe the case of a 45-year-old male with a history of recurrent sinusitis refractory to antibiotics, who presented to the emergency department with sinus congestion and dysphagia. Clinical examination revealed left lower motor neuron facial palsy and enlarged submandibular salivary glands. Despite obtaining negative results from various antibody panels, the patient exhibited elevated Angiotensin Converting Enzyme levels of 83 nmol/kg/min. Additionally, computed tomography chest scans revealed bilateral hilar and mediastinal lymph node enlargement, findings consistent with sarcoidosis. Otorhinolaryngology evaluation for dysphagia confirmed left vocal cord palsy. Following a negative infectious disease workup, submandibular salivary gland biopsy confirmed sarcoidosis. Treatment with mycophenolate mofetil and oral steroids led to gradual improvement in salivary gland swelling, dysphagia, and facial palsy. However, worsening left shoulder pain prompted further investigation, revealing winging of the left scapula on repeat examination. Magnetic resonance imaging (MRI) of the cervical spine revealed a six mm hyperintensity in the left dorsal cord at the C5 level, suggesting possible neurosarcoidosis vs. demyelinating disease. Subsequently, the patient was prescribed anti-tumor necrosis factor alpha inhibitor infliximab. Subsequent MRI of the cervical spine, conducted six months after initiating Infliximab therapy, indicated resolution of the lesions. This positive outcome was supported by the patient's report of symptom improvement, notably reduced shoulder pain and improvement in left scapular winging. This case underscores the unusual co-occurrence of Bell's palsy and vocal cord palsy in the same patient, along with the potential contribution of neurosarcoidosis to the winged scapula. Additionally, it sheds light on the positive response of neurosarcoidosis to Infliximab therapy.

Characterisations and Scan Findings of Non-Small Cell Lung Cancer Seen on Staging FDG PET-CT: Contemporary Review and Institutional Experience

Objective: Fluorodeoxyglucose (FDG) PET-CT scan is extensively being applied in oncology including lung cancer staging and treatment response assessment by depicting glucose consumption of malignant cells. Non- small cell lung cancer (NSCLC) cases such as adenocarcinoma and squamous cell carcinoma (SCC) are more prevalent. We aimed to determine the FDG uptake avidity based on semiquantitative maximum Standardise Uptake Value (SUVmax) observed on staging PET-CT of newly diagnosed NSCLC and associated contributing factors. Methods: Retrospective review of 125 cases of biopsy proven lung cancer referred for FDG PET-CT in our institution over the past 2 years. Staging PET-CT scans (n=54) were included for analysis. Clinical parameters and PET-CT findings (SUVmax of primary lesion, presence of nodal and metastatic disease) were investigated. SUVmax of primary lesion for SCC and adenocarcinoma was compared. Association between SUVmax of primary lesion and extrapulmonary FDG- avid lesions presence was also determined. Results: Males were predominant (60%). Average age was 62.5 years. Majority were adenocarcinoma (65%) followed by SCC (22%) and others (13%). Mean tumour size was 5.1 cm. Lung SCC demonstrated intensely increased FDG uptake that was significantly higher compared to adenocarcinoma (average SUVmax 24.4 vs SUVmax 15.6, p&lt;0.05). FDG-avid ipsilateral hilar nodal involvement seen in 63%, mediastinal nodes in 70% while distant metastatic disease in 33%. Patients having primary lesion with SUVmax 20.0 and above were significantly associated with larger tumour size and FDG-avid ipsilateral hilar nodal uptake (p&lt;0.05). Conclusion: Lung SCC was intensely FDG-avid and had higher SUVmax compared to adenocarcinoma. Primary lesions with SUVmax 20.0 and above were associated with larger tumour size and presence of hypermetabolic ipsilateral hilar nodal spread. Information obtained from this review will provide valuable insight into PET-CT scan characteristics of newly diagnosed NSCLC cases in our institution that may influence not only scan reporting formulation but also patient management.International Journal of Human and Health Sciences Supplementary Issue 01: 2024 Page: S46

Robotic spleen‑preserving suprapancreatic and splenic hilar lymph node dissection using the preemptive retropancreatic approach in total gastrectomy for gastric cancer.

Advanced gastric cancer that has not invaded the greater curvature is a good indication for total gastrectomy (TG) with spleen-preserving suprapancreatic and splenic hilar lymph node dissection (LND). However, the suprapancreatic and splenic hilar LND increases the area of dissection of the pancreas, and prolonged pressure drainage of the pancreas is required to maintain a clear operative view. This can lead to an increased risk of postoperative pancreatic complications. To report the efficacy of our novel preemptive retropancreatic approach (PRA) for the suprapancreatic and splenic hilar LND in robotic TG (RTG). We report our experience with nine patients with gastric cancer who underwent spleen-preserving splenic hilar LND using PRA during RTG at Hokkaido University from October 2018 to November 2021. The PRA involves initial dissection of the left side of the retropancreatic space, followed by the release of the adherence between the retroperitoneum surface and the pancreas (fusion fascia), which provides a good operative field and prevents contact with the pancreas during the suprapancreatic and splenic hilar LND in RTG. The median operating time was 488min (254-564min). The median intraoperative bleeding was 55mL (0-115mL). One patient had postoperative complications (above grade II of the Clavien-Dindo classification), but there were no postoperative pancreatic complications. The spleen-preserving suprapancreatic and splenic hilar LND using PRA could help to reduce the postoperative pancreatic complications associated with RTG.Trial registration number and date of registration The Hokkaido University Hospital institutional review board approved the data collection and analysis. The trial registration number and date of registration are No. 021-0022 and July 26, retrospectively registered.

A Review of Type 1 and Type 2 Intraductal Papillary Neoplasms of the Bile Duct.

Intraductal papillary neoplasm of the bile duct (IPNB) is a heterogeneous disease similar to intraductal papillary mucinous neoplasm of the pancreas. These lesions have been recognized as one of the three major precancerous lesions in the biliary tract since 2010. In 2018, Japanese and Korean pathologists reached a consensus, classifying IPNBs into type l and type 2 IPNBs. IPNBs are more prevalent in male patients in East Asia and are closely related to diseases such as cholelithiasis and schistosomiasis. From a molecular genetic perspective, IPNBs exhibit early genetic variations, and different molecular pathways may be involved in the tumorigenesis of type 1 and type 2 IPNBs. The histological subtypes of IPNBs include gastric, intestinal, pancreaticobiliary, or oncocytic subtypes, but type 1 IPNBs typically exhibit more regular and well-organized histological features than type 2 IPNBs and are more commonly found in the intrahepatic bile ducts with abundant mucin. Due to the rarity of these lesions and the absence of specific clinical and laboratory features, imaging is crucial for the preoperative diagnosis of IPNB, with local bile duct dilation and growth along the bile ducts being the main imaging features. Surgical resection remains the optimal treatment for IPNBs, but negative bile duct margins and the removal of lymph nodes in the hepatic hilum significantly improve the postoperative survival rates for patients with IPNBs.

In situ ascending aortic thrombus in a patient with metastatic lung adenocarcinoma and no aortic atherosclerosis or cisplatin exposure: a case report

BackgroundAn ascending aortic thrombus is exceedingly rare. Two instances have been reported in the setting of lung cancer, but only after cisplatin use, which is associated with hypercoagulability. We present the first case of a patient with lung cancer who developed an ascending aortic thrombus without structural risk factors or chemotherapy use.CaseA 60-year-old white female with significant smoking history presented with several weeks of malaise. A chest computed tomography scan revealed a 2.2-cm right upper lobe mass. As an outpatient, right hilar lymph node immunohistochemistry (IHC) samples via endobronchial ultrasound confirmed thyroid transcription factor-1 adenocarcinoma. After the procedure, the patient endorsed dyspnea and was advised to go to the emergency department. A chest computed tomography angiography identified a new 2.4 × 1.1 × 1.1 cm thrombus within the proximal aortic arch. No pulmonary emboli or intrapulmonary shunts were identified. A hypercoagulable workup was negative. Transthoracic echocardiogram was without left ventricular thrombus, akinesis or hypokinesis, left atrial dilation, or intracardiac shunts. A lower extremity ultrasound was negative for deep vein thrombosis. Given the procedural risk, thrombectomy was deferred. The patient was transitioned to enoxaparin, and a repeat computed tomography for resolution is in process.ConclusionTo our knowledge, this is the only case detailing an in situ ascending aortic thrombus in the setting of lung cancer, without structural risk factors, chemotherapy use, or other hypercoagulable comorbidities. Optimal management for an aortic thrombus and malignant disease is less clear. Clinicians should be vigilant for unusual arterial thromboses in patients with high metastatic burden.

An Overview of Lung Cancer

Lung cancer is characterised by unregulated cell growth. The most prevalent cancer killer worldwide is lung cancer. Lung cancer diagnoses and deaths are rising worldwide. Males and females over 70 have the highest lung cancer risk. Since 50% of lung cancer patients acquire a new cough, smokers or former smokers should be concerned. Lung cancer's complex pathogenesis is yet unknown. Smoking and carcinogen exposure can cause lung epithelial dysplasia. The most prevalent lung cancer diagnosis methods are flexible bronchoscopy and transthoracic sampling. Immunotherapy helps the immune system recognise and fight cancer cells as foreign intruders. Radiation and four to six chemotherapy cycles are usual for mediastinal or hilar lymph node LS-SCLC.

Abstract PO4-20-10: Value of 16α-18F-fluoro-17β-fluoroestradiol PET imaging in ER-positive breast cancer: a case report

Abstract Introduction: An appropriate use criteria workgroup recently recommended the use of PET imaging utilizing the 16α-18F-fluoro-17β-fluoroestradiol (FES) radiotracer as a measure of disease progression and endocrine treatment response for ER-positive breast cancers. Past studies report limitations of decreased FDG uptake, the most common PET radiotracer, when measuring low Ki-67 scoring tumors; FES-PET may noninvasively address this shortcoming in FDG activity detection. Its benefit of detecting low-grade, ER-positive tumor activity was demonstrated in a patient with breast cancer who exhibited tumor growth only on FES-PET while FDG-PET showed no measurable disease. Clinical Case: A 57-year-old postmenopausal woman presented in December 2017 with de novo metastatic invasive ductal carcinoma that was ER+ (100%), PR+ (100%), and HER2- involving the right breast, bone, lungs, and internal mammary, subcarinal, and right hilar lymph nodes. She received nab-paclitaxel and radiation to the right breast, regional lymph nodes, and T11 bone. In March 2019, she underwent a right mastectomy with pathology that noted residual disease in the breast measuring &amp;lt;5 mm and was placed on exemestane in April 2019. She transferred her care to City of Hope and follow-up FDG-PET restaging showed no evidence of new metabolically active metastatic disease. Her cancer antigen 27.29 levels were also within normal limits. In the absence of measurable disease growth, she continued to be treated with single agent exemestane. Due to persistent back discomfort that she attributed to breast asymmetry, she requested the left breast to be removed. One week prior to surgery, both FDG-PET/CT and bloodwork inclusive of tumor markers were normal. She underwent a left mastectomy in March 2023. Pathology identified an incidental 1.4 cm lymph node in the 2000 g specimen that was ER+ (&amp;gt;95%), PR-, and HER2- with a Ki-67 of 1-3%. Somatic gene testing of the tumor revealed an ESR1 D538G mutation. As her progressive disease was not evident on previous FDG-PET imaging, an FES-PET/CT was performed and demonstrated uptake in the ilium, T10, and T12 bones that was not identified on FDG-PET/CT. With objective evidence of evaluable disease, exemestane was discontinued and fulvestrant and ribociclib were initiated. Clinically, she has evidence of early response to therapy with improvement in back pain. Discussion: This case demonstrates the value of FES-PET/CT in identifying disease that was not appreciated on FDG-PET/CT or by cancer antigen 27.29 monitoring. Additionally, ESR1 status has not been consistently reported in studies of patients undergoing FES-PET imaging that investigate the radiotracer’s value in predicting response to subsequent endocrine therapy. Our patient has a documented ESR1 mutation, her disease was clearly identified only on FES-PET/CT, and FES uptake predicted for response to subsequent endocrine therapy. Incorporating FES-PET in routine staging should be considered in patients with metastatic breast cancer that is low-grade and ER-positive. Further evidence of response prediction in patients with ESR1 mutations will enhance the utility of FES-PET in the clinical management of these patients. Citation Format: Megan Wong, Veronica Jones, Dave Yamauchi, Joanne Mortimer. Value of 16α-18F-fluoro-17β-fluoroestradiol PET imaging in ER-positive breast cancer: a case report [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO4-20-10.

E032 Low dose methotextrate induced leukoencephalopathy: a case report

Abstract Background/Aims Methotextrate is a widely used disease modifying anti-rheumatic drug (DMARD) used to treat connective tissue disorder and inflammatory arthritis. Methotextrate induced neurological toxicity includes vomiting, headaches, blurred vision, mood alteration, somolescence, brain fog, hyperosmia, leukoencephalopathy and pseudo-stroke like syndrome. Here we report a case of methotextrate induced headache with leptomeningeal enhancement, which reversed after stopping the methotextrate. Methods A 66 year old male with known diagnosis of sero-positive rheumatoid arthritis with past medical history of Hodgkins lymphoma in remission. He started on dual DMARD combination of 15 mg methotextrate subcutaneously once a week and 200 mg hydroxychlroquin twice daily. Thereafter he reported history of headaches, which needed hospital admission. He underwent a CT-head scan on admission which did not show any acute concerns. The case was then discussed with the haematology team and later he underwent a PET scan of the whole body which was reviewed in Lymphoma MDT which showed non-specific uptake in hilar nodes, which does not significantly increase the suspicion of lymphoma relapse. On discharge he had MRI head contrast and MRV cerebral veins, which showed a few areas of irregular nodular curvilinear foci of predominantly meningeal enhancement noted in occipital lobes and adjacent T2 /flair hypertense signal noted in relation to these. These changes were discussed in neurology MDT, given the history of lymphomas a possibility, though rare in the absence of systemic relapse. The differential included low dose (oral) methotextrate related neurotoxicity. Patient was advised to stop methotextrate, they repeated MRI scan 3 weeks later which showed disappearance of the curvilinear lesions with leptomeningeal enhancement and patient reported headaches improved. Results List of investigations 1. CSF- profile, no protein, no growth 2. CSF PCR panel for Adeno/Paracheo/Entero/Varicella Zoster/HSV type 1&amp;2-negative 3. Histology report of CSF- No evidence of lymphoma 4. Neuronal Ab: Purkinje cell/ Hu Ab/Ri Ab amd Anti-amphiphysin Ab-negative 5. Myeloma screen- no paraprotein detected 6. Virus panel- EBV- IgM-, HIV /Hep B and C, Cytomegalovirus IgM-not detected. Conclusion Methotextrate is a potent anti-metabolite preventing the formation of tetrahydrofolate, and used as immunosuppressant and anti-neoplastic medication. Though the exact mechanism of the neurotoxicity is not known, the common hypothesis include; interference with myelin synthesis or maintenance and/or interference with neurotransmitter synthesis. The case reported here reiterates the importance of recognizing the neurological side effects in patients on methotextrate even on low dose of methotextrate. It also emphasizes the fact that the neurological changes are reversible on stopping methotextrate. Headaches can still be a side effect and might mimic stroke like episode in patients treated with low dose of subcutaneous methotextrate and hence stopping the medication should be considered in such cases. Disclosure P. Doddamani: None. A. Kinder: None.

Development and validation of a preoperative radiomics-based nomogram to identify patients who can benefit from splenic hilar lymphadenectomy: a pooled analysis of three prospective trials.

The authors aimed to use preoperative computed tomography images to develop a radiomic nomogram to select patients who would benefit from spleen-preserving splenic hilar (No.10) lymphadenectomy (SPSHL). A pooled analysis of three distinct prospective studies was performed. The splenic hilar lymph node (SHLN) ratio (sLNR) was established as the quotient of the number of metastatic SHLN to the total number of SHLN. Radiomic features reflecting the phenotypes of the primary tumor (RS1) and SHLN region (RS2) were extracted and used as predictive factors for sLNR. This study included 733 patients: 301 in the D2 group and 432 in the D2+No.10 group. The optimal sLNR cutoff value was set at 0.4, and the D2+No.10 group was divided into three groups: sLNR=0, sLNR ≤0.4, and sLNR >0.4. Patients in the D2+No. 10 group were randomly divided into the training ( n =302) and validation ( n =130) cohorts. The AUCs value of the nomogram, including RS1 and RS2, were 0.952 in the training cohort and 0.888 in the validation cohort. The entire cohort was divided into three groups based on the nomogram scores: low, moderate, and high SHLN metastasis burden groups (LMB, MMB, and HMB, respectively). A similar 5-year OS rate was found between the D2 and D2+No. 10 groups in the LMB and HMB groups. In the MMB group, the 5-year OS of the D2+No. 10 group (73.4%) was significantly higher than that of the D2 group (37.6%) ( P <0.001). The nomogram showed good predictive ability for distinguishing patients with various SHLN metastasis burdens. It can accurately identify patients who would benefit from SPSHL.

Rational and design of prophylactic cranial irradiation (PCI) and brain MRI surveillance versus brain MRI surveillance alone in patients with limited-stage small cell lung cancer achieving complete remission (CR) of tumor after chemoradiotherapy: a multicenter prospective randomized study

BackgroundProphylactic cranial irradiation (PCI) is part of standard care in limited-stage small cell lung cancer (SCLC) at present. As evidence from retrospective studies increases, the benefits of PCI for limited-stage SCLC are being challenged.MethodsA multicenter, prospective, randomized controlled study was designed. The key inclusion criteria were: histologically or cytologically confirmed small cell carcinoma, age ≥ 18 years, KPS ≥ 80, limited-stage is defined as tumor confined to one side of the chest including ipsilateral hilar, bilateral mediastinum and supraclavicular lymph nodes, patients have received definitive thoracic radiotherapy (regardless of the dose-fractionation of radiotherapy used) and chemotherapy, evaluated as complete remission (CR) of tumor 4–6 weeks after the completion of chemo-radiotherapy. Eligible patients will be randomly assigned to two arms: (1) PCI and brain MRI surveillance arm, receiving PCI (2.5 Gy qd to a total dose of 25 Gy in two weeks) followed by brain MRI surveillance once every three months for two years; (2) brain MRI surveillance alone arm, undergoing brain MRI surveillance once every three months for two years. The primary objective is to compare the 2-year brain metastasis-free survival (BMFS) rates between the two arms. Secondary objectives include 2-year overall survival (OS) rates, intra-cranial failure patterns, 2-year progression-free survival rates and neurotoxicity. In case of brain metastasis (BM) detect during follow-up, stereotactic radiosurgery (SRS) will be recommended if patients meet the eligibility criteria.DiscussionBased on our post-hoc analysis of a prospective study, we hypothesize that in limited-stage SCLC patients with CR after definitive chemoradiotherapy, and ruling out of BM by MRI, it would be feasible to use brain MRI surveillance and omit PCI in these patients. If BM is detected during follow-up, treatment with SRS or whole brain radiotherapy does not appear to have a detrimental effect on OS. Additionally, this approach may reduce potential neurotoxicity associated with PCI.

A clinicopathologic feature-based nomogram for preoperative estimation of splenic hilar lymph node metastasis in advanced proximal gastric cancer without invasion of the greater curvature

BackgroundThe indications for splenic hilar lymph node dissection in advanced proximal gastric cancer without invasion of the greater curvature are controversial. We aimed to develop a preoperative nomogram for individualized prediction of splenic hilar lymph node metastasis in non–greater curvature advanced proximal gastric cancer. MethodsFrom January 2014 to December 2021, 558 patients with non–greater curvature advanced proximal gastric cancer who underwent D2 lymphadenectomy (including splenic hilar lymph node) were retrospectively analyzed and divided into a training cohort (n = 361) and validation cohort (n = 197), depending on the admission time. A preoperative predictive nomogram of splenic hilar lymph node metastasis was established based on independent predictors identified by multivariate analysis, and the performance and prognostic value were confirmed. ResultsIn the training and validation cohorts, 48 (13.3%) and 24 patients (12.2%) had pathologically confirmed splenic hilar lymph node metastasis, respectively. Tumor located in the posterior wall, tumor size ≥5 cm, Borrmann type IV, and splenic hilar lymph node lymphadenectasis on computed tomography were preoperative factors independently associated with splenic hilar lymph node metastasis. The nomogram developed based on these four parameters had a high concordance index of 0.850 (95% confidence interval, 0.793–0.907) and 0.825 (95% confidence interval, 0.743–0.908) in the training and validation cohorts, respectively, with well-fitting calibration plots and better net benefits in the decision curve analysis. In addition, disease-free survival and overall survival were significantly shorter in the high-risk group, with hazard ratios of 3.660 (95% confidence interval, 2.228–6.011; log-rank P < .0001) and 3.769 (95% confidence interval, 2.279–6.231; log-rank P < .0001), respectively. ConclusionThe nomogram has good performance in predicting the risk of splenic hilar lymph node metastasis in non–greater curvature advanced proximal gastric cancer preoperatively, which can help surgeons make rational clinical decisions.