Hilar Mass Research Articles

Vogt‐Koyanagi‐Harada disease‐like uveitis induced by nivolumab in metastatic renal cell carcinoma

IntroductionNivolumab can cause various immune‐related adverse events; it rarely induces Vogt‐Koyanagi‐Harada‐disease‐like uveitis. Vogt‐Koyanagi‐Harada‐disease is reported to be closely associated with human leukocyte antigen‐DR4.Case presentationA 68‐year‐old man with metastatic renal cancer underwent nephrectomy. Computed tomography showed multiple lung tumors, raising suspicion of lung metastases. However, one lung hilar mass was suspected to be primary lung cancer, leading to a lobectomy, which subsequently revealed lung metastases of renal cancer. The patient underwent nivolumab treatment but developed Vogt‐Koyanagi‐Harada‐disease‐like uveitis as an immune‐related adverse event. Human leukocyte antigen‐DR4 alleles were identified, and the uveitis improved with topical steroids. He maintained partial response of lung metastases after nivolumab resumption. Immunohistochemical staining revealed significantly higher human leukocyte antigen‐DR4 expression in lung metastasis than primary renal cancer.ConclusionDespite inducing Vogt‐Koyanagi‐Harada‐disease‐like uveitis, nivolumab controlled cancer progression effectively. Immunohistochemical staining results suggest the potential involvement of human leukocyte antigen‐DR4 expression in both the onset of Vogt‐Koyanagi‐Harada‐disease‐like uveitis and nivolumab efficacy.

Splenic Epidermoid Cyst arising within an Intrapancreatic Accessory Spleen Masquerading as a Pancreatic Mucinous Cystic Neoplasm-a diagnostic enigma

Abstract Introduction/Objective Accessory spleens are congenital embryological aberrations usually found within the splenic hilum with no clinical significance. An IntraPancreatic Accessory Spleen (IPAS) is an uncommon benign pancreatic lesion encountered clinically. A splenic epidermoid cyst arising within an IPAS is exceedingly rare and is discussed below. Methods/Case Report A 68-year-old male presented with intermittent post-prandial epigastric pain radiating to the left flank for >1.5 years. Radiological imaging identified a 5.2 cm calcified cyst in the pancreatic tail with a differential of mucinous pancreatic neoplasm/ pancreatic pseudocyst. Additionally, a 2.8cm lobulated solid hypoechoic mass was seen at the porta hepatis with a differential of enlarged lymph node/benign neoplasm. Laboratory biochemical tests were within normal limits except for mildly elevated ferritin. Fine needle aspiration biopsy was indeterminate. The patient elected to proceed with surgical resection. A laparoscopic distal pancreatectomy with splenectomy and excision of the hilar mass was performed. The hilar mass was analyzed by hematopathology and revealed a hyaline- vascular variant of Castleman disease. On gross examination of the distal pancreatic/splenectomy specimen, a well- demarcated cystic lesion with brownish fluid was noted within the pancreatic tail. Microscopic examination revealed a nonpathological pancreas separated by a fibrous capsule with a large cyst arising within an intrapancreatic accessory spleen. The cyst was lined with multilayered non-keratinized CK5/6, and p63 positive squamous epithelium with no lymphocytic infiltrates and absent hair/ dermal appendages confirming a splenic epidermoid cyst. Post-operative follow-up at 6 weeks was uneventful. Results (if a Case Study enter NA) NA Conclusion An epidermoid cyst arising within an intrapancreatic accessory spleen (ECIAS) is extremely rare thus precluding accurate preoperative diagnosis as this entity shares similar radiological imaging characteristics as other cystic lesions such as mucinous pancreatic cysts. It is important for anatomic pathologists to recognize and consider the intrapancreatic compartment as a possible location for accessory spleens. Accurate preoperative diagnosis can prevent unnecessary surveillance and/or extensive surgical resection.

9183 Pituitary Metastasis Of Lung Adenocarcinoma Presenting As Anterior Pituitary Dysfunction

Abstract Disclosure: O. faour: None. M. Kinaan: None. S.K. Suryanarayanan: None. Introduction: The pituitary should not be overlooked as a site for metastasis and can be the first presentation of neoplastic disease in some patients. Most common presenting symptoms: headache, ophthalmoplegia, visual field defect and Arginine Vasopressin Deficiency (AVP-D). We present a case of pituitary metastasis of lung adenocarcinoma presenting as anterior Pituitary dysfunction that also showed partial AVP-D unmasked after starting steroids. Case Description: A 63-year-old male with history of tobacco use, COPD, and hypertension presented with syncope. He reported a 30lbs weight loss within prior 2 months, low energy, increased thirst, and polyuria. Physical exam was significant for cachexia, normal visual field on confrontation, and vital signs of BP 100/61, HR 83, and Weighing 180 lbs. Since he had syncope, Cortisol checked was undetectable and Free T4 was low, He was started on hydrocortisone and levothyroxine. CTA chest revealed a right hilar mass measuring 2.7 x 3 cm. Endobronchial biopsy was consistent with lung adenocarcinoma. MRI of pituitary gland revealed solid hypointense lesion with glandular thickening and diffuse heterogeneity involving most of the pituitary gland measuring up to 16 mm. No cavernous sinus invasion. Pituitary infundibulum showed diffuse thickening and enhancement of the pituitary stalk throughout with Intact posterior pituitary bright spot. Labs showed low LH, cortisol, ACTH, GH, TSH, and ADH. Initially, the patient was able to maintain a euvolemic status through increased water intake; however, he was later found to have partial central AVP-D when steroids were introduced. He responded to the use of Desmopressin, developed hyponatremia after 3 doses. He was started on a combination of carboplatin/pemetrexed/pembrolizumab but had no response and was transferred to palliative care/hospice and passed away within 7months after diagnosis.Discussion:Pituitary metastasis is rare and most commonly occurs in lung and breast cancers. Unfortunately, they are associated with poor prognosis. MRI findings of loss of posterior pituitary bright spot, thickening of the stalk, and dumbbell shape can be helpful in distinguishing between primary pituitary tumors and metastases. PET-FDG scan has limited value. Pituitary metastasis commonly presents with posterior pituitary dysfunction due to direct blood supply. Unmasking or worsening of AVP-D can happen with steroid replacement in patients requiring initiation or intensification of Desmopressin therapy. Treatment involves combination of surgery, radiation therapy, and systemic treatment for the primary cancer which can improve symptoms only but does not improve mortality. Presentation: 6/1/2024

Large cell carcinoma of the lung: LDCT features and survival in screen-detected cases.

To investigate the early radiological features and survival of Large Cell Carcinoma (LCC) cases diagnosed in low-dose computed tomography (LDCT) screening trials. Two radiologists jointly reviewed the radiological features of screen-detected LCCs observed in NLST, ITALUNG, and LUSI trials between 2002 and 2016, comprising a total of 29,744 subjects who underwent 3-5 annual screening LDCT examinations. Survival or causes of death were established according to the mortality registries extending more than 12years since randomization. LCC was diagnosed in 30 (4%) of 750 subjects with screen-detected lung cancer (LC), including 15 prevalent and 15 incident cases. Three additional LCCs occurred as interval cancers during the screening period. LDCT images were available for 29 cases of screen-detected LCCs, and 28 showed a single, peripheral, and well-defined solid nodule or mass with regularly smooth (39%), lobulated (43%), or spiculated (18%) margins. One case presented as hilar mass. In 9 incident LCCs, smaller solid nodules were identified in prior LDCT examinations, allowing us to calculate a mean Volume Doubling Time (VDT) of 98.7±47.8 days. The overall five-year survival rate was 50%, with a significant (p=0.0001) difference between stages I-II (75% alive) and stages III-IV (10% alive). LCC is a fast-growing neoplasm that can escape detection by annual LDCT screening. LCC typically presents as a single solid peripheral nodule or mass, often with lobulated margins, and exhibits a short VDT. The 5-year survival reflects the stage at diagnosis.

PE056 Robot-assisted partial nephrectomy for hilar renal masses: comparison of perioperative, oncological and functional results in a multicentric prospective cohort (NEPRAH study, UROCCR N°175)

PE056 Robot-assisted partial nephrectomy for hilar renal masses: comparison of perioperative, oncological and functional results in a multicentric prospective cohort (NEPRAH study, UROCCR N°175)

Comparative Efficacy of Magnetic Resonance Cholangiopancreatography vs. Percutaneous Transhepatic Cholangiography With Percutaneous Transhepatic Biliary Drainage Stenting in Evaluating Obstructive Jaundice: A Prospective Study in South India.

Introduction Obstructive jaundice due to proximal biliary obstruction presents significant diagnostic and therapeutic challenges. Accurate and timely diagnosis is essential for effective management. Objective/aim This study aimed to evaluate and compare the diagnostic accuracy of magnetic resonance cholangiopancreatography (MRCP) and percutaneous transhepatic cholangiography (PTC) along with percutaneous transhepatic biliary drainage (PTBD) stenting in obstructive jaundice, while also incorporating the comparison of ultrasonography (USG) and computed tomography (CT) findings. Materials and methods A prospective study was conducted at a tertiary healthcare center in South India from January 2020 to June 2022. Comprehensive diagnostic evaluations were performed using USG, contrast-enhanced computed tomography (CECT), MRCP, and PTC. The diagnostic outcomes from USG and CECT were initially assessed, followed by MRCP for every patient. These results were then compared with PTC, focusing on identifying the causes and levels of biliary obstruction. Results Fifty patients with suspected obstructive jaundice were included in the study. The study predominantly involved patients aged between the fourth and eighth decades (80%). Choledocholithiasis was identified as the leading cause (30%). MRCP demonstrated superior sensitivity in identifying both the cause (80%) and level (88%) of obstruction. It was particularly effective in detecting hilar masses with 100% sensitivity. Conversely, PTC, while less sensitive in detection, offered the advantage of simultaneous therapeutic intervention through stenting, with a sensitivity rate of 93% in detecting hilar masses. Conclusion MRCP outperforms PTC in diagnostic sensitivity for obstructive jaundice caused by proximal biliary obstruction. However, the advantage of PTC lies in its capacity for immediate therapeutic intervention via stent placement, addressing both diagnostic and treatment needs.

Robot-assisted Partial Nephrectomy for Hilar and Nonhilar Renal Masses: Comparison of Perioperative, Oncological, and Functional Results in a Multicentre Prospective Cohort (NEPRAH Study, UroCCR 175)

Background and objectiveA hilar location for a renal tumour is sometimes viewed as a limiting factor for safe partial nephrectomy. Our aim was to evaluate perioperative, oncological, and functional outcomes of robot-assisted partial nephrectomy (RAPN) for hilar tumours (RAPN-H) in comparison to RAPN for nonhilar tumours (RAPN-NH). MethodsWe conducted an observational, multicentre cohort study using prospectively collected data from the French Research Network on Kidney Cancer (UroCCR). The registry includes data for 3551 patients who underwent RAPN for localised or locally advanced renal masses between 2010 and 2023 in 29 hospitals in France. We studied the impact of a hilar location on surgery, postoperative renal function, tumour characteristics, and survival. We also compared rates of trifecta achievement (warm ischaemia time [WIT] <25 min, negative surgical margins, and no perioperative complications) between the groups. Finally, we performed a subgroup analysis of RAPN without vascular clamping. Variables were compared in univariable analysis and using multivariable linear, logistic, and Cox proportional-hazards models adjusted for relevant patient and tumour covariates. Key findings and limitationsThe analytical population included 3451 patients, of whom 2773 underwent RAPN-NH and 678 underwent RAPN-H. Longer WIT (β = 2.4 min; p < 0.01), longer operative time (β = 11.4 min; p < 0.01) and a higher risk of postoperative complications (odds ratio 1.33; p = 0.05) were observed in the hilar group. Blood loss, the perioperative transfusion rate, postoperative changes in the estimated glomerular filtration rate, and trifecta achievement rates were comparable between the groups (p > 0.05). At mean follow-up of 31.9 mo, there was no significant difference in recurrence-free survival (hazard ratio [HR] 0.82, 95% confidence interval [CI] 0.58–1.2; p = 0.3), cancer-specific survival (HR 1.1, 95% CI 0.48–2.6; p = 0.79), or overall survival (HR 0.89, 95% CI 0.52–1.53; p = 0.69). Conclusions and clinical implicationsPatient and tumour characteristics rather than just hilar location should be the main determinants of the optimal surgical strategy for hilar tumours. Patient summaryWe found that kidney tumours located close to major kidney blood vessels led to a longer operation and a higher risk of complications during robot-assisted surgery to remove the tumour. However, tumours in these locations were not related to a higher risk of kidney function loss, cancer recurrence, or death.

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.

Bullous pemphigoid as a paraneoplastic manifestation of metastatic adenocarcinoma of the lung

A 73-year-old male smoker presented with complaints of fever and multiple clear fluid-filled lesions for 3 months. He was initially being treated for primary bullous pemphigoid but lesions recurred. On a chest X-ray, he was found to have a right hilar mass, and contrast-enhanced computed tomography of the chest revealed a right lung mass lesion with cervical, hilar, and mediastinal lymphadenopathy. A bronchoscopy was done, and bronchoalveolar lavage cytology was suggestive of lung adenocarcinoma. An excision biopsy of the left supraclavicular lymph node showed features consistent with adenocarcinoma lung. Hence, he was diagnosed with metastatic adenocarcinoma of the lung with bullous pemphigoid as a paraneoplastic manifestation. He was subsequently treated with chemotherapy, and his skin lesions resolved.

Abstract 946: Landscape of HRD aberration in EGFR mutated lung cancer and the role of PARP-inhibitor in EGFR mutated lung cancer with HRD aberration

Abstract Introduction: Olaparib, an oral poly polymerase (PARP) inhibitor has received approval for treating malignancies displaying homologous recombination deficiency (HRD). Current data is insufficient in establishing the role of PARP inhibitors in non-small cell lung cancer (NSCLC) in the setting of third generation EGFR tyrosine kinase inhibitor (TKI) use. Preclinical investigation suggests heightened PARP inhibitor sensitivity of TKI-resistant EGFR mutant NSCLC cells compared to TKI-sensitive cells. Methods: We utilized The Cancer Genome Atlas (TCGA) to investigate the prevalence of HRD gene mutations in patients with NSCLC harboring EGFR mutations. We also present a case demonstrating a favorable response to the dual therapy of olaparib and osimertinib in NSCLC harboring EGFR, RAD50, and ARID1A mutations that progressed on osimertinib. Results: There were 2298 patients in the NSCLC cohort (MSKCC database). Among 687 patients with EGFR mutations, 24 patients (3.5%) exhibited ARID1A mutations, 8 patients (1.2%) had BRCA1 mutations, 11 patients (1.6%) had BRCA2 mutations, and 5 (0.7%) had RAD50 mutations. A 71-year-old female presented with stage IV adenocarcinoma of the lung. She had recurrent malignant pericardial effusion requiring pericardiocentesis for previous cardiac tamponade. Computed tomography (CT) of the chest revealed a 3cm irregular left hilar mass with bilateral mediastinal and hilar lymph nodes. Tissue next generation sequencing (NGS) at baseline identified EGFR exon19 deletion along with RAD50 R726H which is a HRD pathway gene. Circulating tumor DNA (ct-DNA) NGS (Guardant360) showed EGFR E746_A750del 4.8%. The patient achieved partial response to osimertinib for 28 months. Follow-up CT showed disease progression. Olaparib 200mg twice daily was added to osimertinib based on repeat ct-DNA NGS indicating a new ARID1A alteration (splice site SNV) along with the known BRCA1 mutation. Follow up scans currently have consistently demonstrated ongoing partial response for 19 months. Combining olaparib with osimertinib can be effective in an osimertinib-resistant NSCLC patient with EGFR mutation and HRD aberration. The favorable response could be attributed not only to pre-existing RAD50 mutation but also to acquired mutations in ARID1A HRD genes. Conclusion: HRD aberrations are uncommon in EGFR mutated lung cancer patients. Further investigation on the role of PARP inhibitor in EGFR mutated lung cancer is warranted. Citation Format: Jinah Kim, Horyun Choi, Liam Il-Young Chung, Young Kwang Chae. Landscape of HRD aberration in EGFR mutated lung cancer and the role of PARP-inhibitor in EGFR mutated lung cancer with HRD aberration [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 946.

Renal Collision Tumor: A Case of Small Cell Lung Cancer Metastasis to Renal Angiomyolipoma.

A 68-year-old woman presented with chest pain and shortness of breath. Imaging revealed a left hilar mass biopsy-proven as small cell cancer. Concurrently, a macroscopic fat-containing renal lesion consistent with an angiomyolipoma was observed. Systemic therapy achieved stability in the lungs and bones, and palliative radiation targeted the left hilum. However, progressive lung disease and brain metastases necessitated stereotactic radiosurgery for brain lesions. Notably, the renal angiomyolipoma exhibited increased soft tissue component and new focal uptake on FDG PET/CT. Biopsy confirmed metastatic small cell lung cancer within the renal lesion. This case highlights a rare occurrence of a renal collision tumor involving small cell cancer and angiomyolipoma.

Outcomes and Techniques of Robotic-Assisted Partial Nephrectomy (RAPN) for Renal Hilar Masses: A Comprehensive Systematic Review.

Background: Robot-assisted partial nephrectomy (RAPN) is increasingly being employed in the management of renal cell carcinoma (RCC) and it is expanding in the field of complex renal tumors. The aim of this systematic review was to consolidate and assess the results of RAPN when dealing with entirely central hilar masses and to examine the various methods used to address the surgical difficulties associated with them. Methods: A thorough literature search in September 2023 across various databases focused on RAPN for renal hilar masses, adhering to PRISMA guidelines. The primary goal was to evaluate RAPN's surgical and functional outcomes, with a secondary aim of examining different surgical techniques. Out of 1250 records, 13 full-text manuscripts were reviewed. Results: Evidence is growing in favor of RAPN for renal hilar masses. Despite a predominance of retrospective studies and a lack of long-term data, RAPN shows positive surgical outcomes and preserves renal function without compromising cancer treatment effectiveness. Innovative suturing and clamping methods are emerging in surgical management. Conclusions: RAPN is a promising technique for managing renal hilar masses in RCC, offering effective surgical outcomes and renal function preservation. The study highlights the need for more long-term data and prospective studies to further validate these findings.

Misleading wheeze in a case of atypical large cell neuroendocrine carcinoma of lung - A deadly variety

Neuroendocrine tumors are neoplasms arising from cells of endocrine and nervous system containing special secretory granules with biogenic amines and polypeptide hormones. One of the varieties that occurs commonly in the lung is large cell neuro endocrine carcinoma. The replicative potential of these neuroendocrine malignancies is so rapid that the patients usually present with metastatic disease. We describe a case of 29-year-old-male presented with nocturnal wheeze which led on to a misdiagnosis of bronchial asthma and finally found to be LCNEC with endobronchial obstruction. They are usually peripherally located lesions, mostly in the upper lung zones of an elderly male smoker. But he had a hilar mass with right lower lobe collapse due to endobronchial obstruction. Hence careful examination of wheeze whether unilateral or bilateral, monophonic or polyphonic, random or fixed, inspiratory or expiratory or biphasic may help in early identification of the endobronchial lesions.

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA): revolutionizing the landscape of lung disease diagnostics.

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has emerged as a revolutionary diagnostic tool for lung diseases, including lung cancer, sarcoidosis, and lymphoproliferative diseases. This minimally invasive procedure offers a superior diagnostic yield while ensuring maximum patient safety when compared to traditional invasive techniques such as mediastinoscopy and thoracoscopy. By enabling real-time imaging and sampling of mediastinal and hilar lymph nodes and masses directly from the bronchoscope, EBUS-TBNA has redefined the precision of diagnostic bronchoscopy. This comprehensive review explores the origins, development, and current status of EBUS-TBNA, highlighting its successes and identifying potential areas for improvement. Technological advancements have continuously enhanced the reliability and efficacy of EBUS-TBNA over time. The mechanisms underlying the superior diagnostic yield of EBUS-TBNA are thoroughly discussed, further solidifying its position as the gold standard for lung cancer staging and diagnosis. Furthermore, this review delves into the crucial role of EBUS-TBNA in lung cancer diagnosis, supported by studies comparing its accuracy, safety, and cost-effectiveness to other diagnostic tools. Looking ahead, ongoing research aims to expand the applications of EBUS-TBNA and improve its diagnostic performance. Notable advancements in needle design and sampling techniques hold promise for further enhancing its efficacy. Maximizing its potential through comprehensive training and continuous technological developments will enable broader clinical applications, ultimately leading to improved patient outcomes. As EBUS-TBNA continues to evolve, its diagnostic impact is expected to increase, solidifying its position as an indispensable tool in the diagnosis and management of lung diseases.

Laparoscopic retroperitoneal heminephrectomy for renal cell carcinoma in horseshoe kidney: a case report and review of the literature

IntroductionIn this case report, we demonstrate our technique of a retroperitoneal laparoscopic heminephrectomy for a T1b right hilar tumor in a horseshoe kidney.Case presentationA 77-year-old Vietnamese woman presented to the hospital because of right flank pain. On presentation, her serum creatinine was 0.86 mg/dL and glomerular filtration rate was 65.2 mL/minute/1.73 m2. According to her renal scintigraphy, glomerular filtration rates of the right and left moieties were 24.2 and 35.5 mL/minute, respectively. Computed tomography imaging demonstrated a 5.5 × 5.0 cm solid hilar mass with a cT1bN0M0 tumor stage was in the right moiety. After discussion, the patient elected a minimally invasive surgery to treat her malignancy. The patient was placed in a flank position. We used Gaur’s balloon technique to create the retroperitoneal working space, and four trocar ports were planned for operation. Three arteries were dissected, including two arteries feeding the right moiety, one artery feeding the isthmus, and one vein, which was clipped and divided by Hem-o-lok. The isthmusectomy was performed with an Endostapler. Consequently, the ureter was clipped and divided. Finally, the whole right segment of the horseshoe kidney was mobilized and taken out via the flank incision.ResultsThe total operative time was 250 min with an estimated blood loss of 200 mL. The patient's serum creatinine after surgery was 1.08 mg/dL, and glomerular filtration rate was 49.47 mL/minute/1.73 m2. The patient was discharged on postoperative day #4 without complication. Final pathologic examination of the tumor specimen revealed a Fuhrman grade II clear cell renal cell carcinoma, capsular invasion, with negative surgical margins. After a three-month follow-up, the serum creatinine was 0.95 mg/dL, and glomerular filtration rate was 57.7 mL/minute/1.73 m2. Local recurrence or metastasis was not detected by follow-up computed tomography imaging.ConclusionsRetroperitoneal laparoscopic heminephrectomy is a safe and feasible technique for patients with renal cell carcinoma in a horseshoe kidney and may be particularly useful in low income settings without access to robotic technology.

Using AI to Improve Radiologist Performance in Detection of Abnormalities on Chest Radiographs.

Background Chest radiography remains the most common radiologic examination, and interpretation of its results can be difficult. Purpose To explore the potential benefit of artificial intelligence (AI) assistance in the detection of thoracic abnormalities on chest radiographs by evaluating the performance of radiologists with different levels of expertise, with and without AI assistance. Materials and Methods Patients who underwent both chest radiography and thoracic CT within 72 hours between January 2010 and December 2020 in a French public hospital were screened retrospectively. Radiographs were randomly included until reaching 500 radiographs, with about 50% of radiographs having abnormal findings. A senior thoracic radiologist annotated the radiographs for five abnormalities (pneumothorax, pleural effusion, consolidation, mediastinal and hilar mass, lung nodule) based on the corresponding CT results (ground truth). A total of 12 readers (four thoracic radiologists, four general radiologists, four radiology residents) read half the radiographs without AI and half the radiographs with AI (ChestView; Gleamer). Changes in sensitivity and specificity were measured using paired t tests. Results The study included 500 patients (mean age, 54 years ± 19 [SD]; 261 female, 239 male), with 522 abnormalities visible on 241 radiographs. On average, for all readers, AI use resulted in an absolute increase in sensitivity of 26% (95% CI: 20, 32), 14% (95% CI: 11, 17), 12% (95% CI: 10, 14), 8.5% (95% CI: 6, 11), and 5.9% (95% CI: 4, 8) for pneumothorax, consolidation, nodule, pleural effusion, and mediastinal and hilar mass, respectively (P < .001). Specificity increased with AI assistance (3.9% [95% CI: 3.2, 4.6], 3.7% [95% CI: 3, 4.4], 2.9% [95% CI: 2.3, 3.5], and 2.1% [95% CI: 1.6, 2.6] for pleural effusion, mediastinal and hilar mass, consolidation, and nodule, respectively), except in the diagnosis of pneumothorax (-0.2%; 95% CI: -0.36, -0.04; P = .01). The mean reading time was 81 seconds without AI versus 56 seconds with AI (31% decrease, P < .001). Conclusion AI-assisted chest radiography interpretation resulted in absolute increases in sensitivity for all radiologists of various levels of expertise and reduced the reading times; specificity increased with AI, except in the diagnosis of pneumothorax. © RSNA, 2023 Supplemental material is available for this article.

Abstract 13693: Left Atrial Sarcoma Mimicking Myxoma in Embolic Stroke

Background: Myxomas cause about 0.5% of strokes. Cardiac sarcomas are rare, may mimic myxomas, and are also associated with stroke. Imaging can provide clues to diagnosis. Case: A 53-year-old woman with diabetes, hypertension and prior strokes was admitted with new left hemiparesis. Computed tomography (CT) of the head revealed large middle cerebral artery infarct with petechial hemorrhages. Transthoracic echocardiogram (TTE; panel A) revealed large left atrial (LA) mass suspicious for myxoma protruding through the mitral valve. CT of the chest (panel B) revealed hilar adenopathy and LA mass concerning for myxoma or thrombus with stalk attachment to the right pulmonary vein (PV). Decision-making: Following heart team meeting decision was to remove the mass surgically given its embolic potential. Intraoperative transesophageal echocardiogram (TEE; panel C) revealed a large LA mass with multiple papillary protrusions and attachment via a stalk to the right lower PV. The mass was successfully removed and the patient recovered and was discharged. Follow up pathology returned as cardiac sarcoma. Conclusion: Pulmonary vein intimal sarcomas are rare tumors with poor prognosis, presenting early with chest pain, dyspnea and hemoptysis, or late with stroke. They can mimic myxomas and are therefore often diagnosed post-operatively. Preoperative diagnosis however is imperative to plan treatment and for prognostication. TEE and cardiac magnetic resonance imaging are the modalities of choice to diagnose sarcomas and evaluate extent of cardiac structure involvement.

FRI232 Importance Of Rapid Treatment Initiation In Ectopic Cushing Syndrome: Abstract

Abstract Disclosure: D. Mendez: None. M.G. Fernandez: None. D.J. Selen: None. Background: Endogenous Cushing syndrome may result from an ectopic non-pituitary tumor. Severe hypercortisolism has high mortality, so prompt medical management to acutely decrease cortisol levels is necessary when no surgical options are available. Clinical Case: A 67-year-old male presented to the hospital with four weeks of fatigue and was found to have a right hilar mass with unsuppressed cortisol levels for which an ectopic tumor was suspected. On initial evaluation, the patient presented with hypokalemia, acute kidney injury, and metabolic alkalosis. In addition, a CT of the chest and abdomen with contrast revealed a right hilar mass with multiple liver lesions concerning for metastasis. These findings prompted workup for hypercortisolism, including 1mg and 8 mg dexamethasone suppression tests. Both tests demonstrated unsuppressed cortisol levels above 150 (reference range [RR] 5.5-20 ug/dl and assay maximum&amp;gt;150) and elevated 24-hour urinary cortisol of 8125 (RR &amp;lt;60 ug/dl), suspicious for an ACTH-secreting tumor. Subsequently, he underwent a liver biopsy to characterize the tumor further and was started on Bactrim for Pneumocystis pneumonia prophylaxis. Metyrapone and osilodrostat were considered for treatment but not available at our facility such that treatment was initiated with ketoconazole 200 mg orally twice daily with subsequent dose titration. He had a mild elevation of AST 52 (RR 7-42 IU/L) and ALT 52 (RR 10-45); therefore, his liver profile was monitored daily due to his elevated risk for hepatotoxicity. With the initiation of ketoconazole, cortisol serum levels decreased to 145 ug/dl after two days of treatment. The pathology report revealed small lung cell carcinoma as the etiology for ectopic Cushing’s syndrome, for which the oncology team-initiated etoposide and carboplatin. Unfortunately, on day 6 of the initiation of treatment, the patient rapidly deteriorated and passed away from pneumonia and septic shock. Conclusion: Severe hypercortisolism leads to an immunosuppressed state resulting in high mortality. Therapeutic options depend significantly on the accessibility of first-line treatment options and prompt initiation of medical treatment. When no other agents are available, ketoconazole should be started at high doses despite the mild elevation of liver enzymes with close monitoring of LFTs. While it is unclear if the patient’s deterioration was due to his cancer burden, chemotherapy, severe hypercortisolism, or a combination, given that osilodrostat and metyrapone are first-line treatment options, standardized systems should be reviewed in hospitals for faster acquisition of these medications to avoid delays in treatment initiation. In addition, the decision to transfer patients to the intensive care unit for etomidate infusion while awaiting the acquisition of the above medications should be considered promptly. Presentation: Friday, June 16, 2023

SAT316 Severe Cushing’s Syndrome Due To Ectopic ACTH In Newly Diagnosed Small Cell Lung Cancer: The Pivotal Role Of Etomidate In Acute Treatment

Abstract Disclosure: H. Belal: None. G.Y. Gandhi: None. Introduction: Ectopic ACTH syndrome can present as an endocrine emergency. Etomidate, the only parenteral steroidogenesis inhibitor, can rapidly treat critically ill patients with Cushing’s syndrome (CS) and concurrent significant metabolic derangements, severe hypertension, or psychosis. Case Description: A 66-year-old female presented with abdominal pain, vomiting, proximal muscle weakness, and confusion for 6 months. Physical exam revealed hypertension, bilateral supraclavicular fat pads, and abdominal distention, while laboratory evaluation uncovered severe hypokalemia &amp;lt;1.5 mmol/L, metabolic alkalosis, and elevated proBNP. A hilar soft tissue mass with mediastinal lymphadenopathy and bilaterally enlarged adrenal glands were seen on CT imaging. Serum cortisol was high at 114 mcg/dL. ACTH was inappropriately elevated at 111 pg/mL. MRI revealed a normal pituitary gland. She developed hypertensive emergency and status epilepticus, requiring intubation. Due to her life-threatening presentation, a guideline-based hypercortisolism workup was forgone for emergent treatment with continuous etomidate infusion. Serum cortisol normalized after 4 days of etomidate therapy. Due to concerns of reduced seizure threshold with etomidate therapy, it was weaned off after 14 days and replaced by ketoconazole. She subsequently developed recurrent hypercortisolism (serum cortisol 92 mcg/dL). After 14 days of etomidate, 9 days of ketoconazole, and 3 days of chemotherapy for biopsy-proven small-cell lung carcinoma, serum cortisol reached a trough of 22 mcg/dL. At this point, hydrocortisone therapy was initiated (block-and-replace). Recurrent clinical hypercortisolism then developed, and hydrocortisone was discontinued. Hypercortisolism comorbidities were treated appropriately: trimethoprim-sulfamethoxazole for pneumocystis pneumonia prophylaxis, anticoagulation for DVT prophylaxis, antibiotics for acute diverticulitis, and insulin for hyperglycemia. Despite treatment, her condition worsened; she was transitioned to comfort care one month after admission and died 4 days later. Discussion: Etomidate inhibits steroidogenesis through 11 beta-hydroxylate blockade and works rapidly (within 12-24 hours) to decrease cortisol levels versus ketoconazole (several days) and has a reduced risk of hepatic injury. Side effects of etomidate include respiratory depression, myoclonus, and reduced seizure threshold. Several experts have suggested a block-and-replace strategy in severe CS treatment. While effective, this strategy poses risks of etomidate toxicity and makes serum cortisol interpretation unreliable. Etomidate analogs are on the horizon that retain the potent adrenostatic action of etomidate without its sedative-hypnotic activity, offering an alternative treatment option for treating patients with severe CS in non-ICU hospital settings. Presentation: Saturday, June 17, 2023

Squamous cell carcinoma of lung presenting as “Sunray sign” in chest radiograph

Lung cancer is usually diagnosed at a late stage due to a lack of awareness of symptoms to the patient, absence of screening trends by performing chest imaging, and lack of sensitization to the most common radiological signs of lung malignancy to family physicians. Radiological signs will help in suspecting lung cancer earliest and important role in guiding for a protocolized workup to rule out underlying malignancy. “Sunray sign” in chest radiograph is the first time described in the literature and constitutes hilar mass or radiopacity with inhomogeneous linear opacities spreading toward peripheries like sunrays which is the marker of interstitial lymphatic involvement due to the malignant spread of disease. “Sunray sign” is an indicator of underlying lung malignancy with central airway or mainstem bronchus involvement with lymphatic dissemination in linear opacities. In this case report, we have reported a 51-year male presented with cough and hemoptysis with progressive worsening of shortness of breath. Chest X-ray documented round opacity occupying left hilum with linear opacities emerging toward peripheries in lung parenchyma showing typical “Sunray sign.” Bronchoscopy was done after clinical stabilization and showed endobronchial polypoidal growth in the left mainstem bronchus causing partial occlusion of the bronchial lumen. Endobronchial needle aspiration cytology and forceps-guided histopathology suggestive of “squamous cell” type of lung malignancy for “Sunray sign” in our case. A high index of suspicion is a must to rule out underlying malignancy and Bronchoscopy is a “gold standard” test in cases with Sunray signs to confirm the diagnosis.