Hilar Mass Research Articles

EXTRAMEDULLARY PULMONARY PLASMACYTOMA AS A COMPLICATION OF RELAPSED MULTIPLE MYELOMA

TOPIC: Pulmonary Manifestations of Systemic Disease TYPE: Fellow Case Reports INTRODUCTION: Extramedullary plasmacytoma (EMP) are rare manifestations of multiple myeloma (MM). We report a case of pulmonary EMP presenting as hilar mass. CASE PRESENTATION: A 51 year old female presented with hearing loss and right facial palsy. Medical history was significant for MM diagnosed 2 years prior, treated with bortezomib-prednisone therapy. 6 months ago, thoracic spine plasmacytoma were found requiring surgical resection and local radiation. Remission was perceived and she was maintained on Thalidomide. MRI brain and spine revealed meningeal enhancement with lytic bony lesions, concerning for metastatic disease. CT chest abdomen pelvis revealed a 4.5 x 5.5 cm right hilar mass with complete right lower lobe (RLL) bronchus occlusion, post-obstructive pneumonia, right pleural effusion, pleural thickening and nodularity. She underwent bronchoscopy with endobronchial biopsy of RLL bronchial nodules and EBUS guided transbronchial needle aspiration of right hilar mass. Pathology was consistent with plasma cell myeloma with plasmablastic features. Given her MM history and absence of EBV, primary plasmablastic lymphoma was less likely. A bone marrow biopsy showed >10% myeloma cells, thus her diagnosis was consistent with relapsed MM with extramedullary plasmacytoma (EMP) rather than primary pulmonary plasmacytoma (PPP). Subsequently she underwent systemic and intrathecal second line chemotherapy, but her course was complicated by rapidly progressive refractory disease and patient chose to pursue hospice care. DISCUSSION: EMP are seen in 7 % patients with MM at the time of diagnosis, whereas another 6% develop it later in the course of illness; these portend poor prognosis. Among them, pulmonary EMP are extremely rare. Other pulmonary complications of multiple myeloma include pneumonia, including organizing pneumonia like consolidation, multiple pulmonary nodules, interstitial infiltrates and pleural thickening and effusion. In contrast, primary solitary extramedullary plasmacytoma is a rare discrete plasma cell neoplasm within soft tissue, without bone marrow involvement or other systemic features of MM. They commonly occur in the aero-digestive tract, of which solitary PPP is a rare type. PPP have better prognosis and longer survival rates compared to EMP associated with MM. Their management also differs, EMP associated with MM are treated aggressively with chemotherapy and local radiation or surgery as needed, whereas solitary PPP are treated with radiation only. CONCLUSIONS: Knowledge of pulmonary EMP and its clinical course is important for physicians, such that the etiology of pulmonary abnormalities in patients with multiple myeloma are evaluated and determined in order to ensure appropriate therapy and patient counseling. REFERENCE #1: Bladé J, et al. Soft-tissue plasmacytomas in multiple myeloma: incidence, mechanisms of extramedullary spread, and treatment approach. J Clin Oncol. 2011;29(28):3805-3812 REFERENCE #2: Varettoni M, Corso A, Pica G, Mangiacavalli S, Pascutto C, Lazzarino M. Incidence, presenting features and outcome of extramedullary disease in multiple myeloma: a longitudinal study on 1003 consecutive patients. Ann Oncol. 2010;21(2):325-330. doi:10.1093/annonc/mdp329 REFERENCE #3: Prasad R, Verma SK, Sodhi R. Multiple myeloma with lung plasmacytoma. Lung India. 2011 Apr-Jun; 28(2): 136-138. DISCLOSURES: No relevant relationships by Jyotirmayee Lenka, source=Web Response No relevant relationships by Naman Sharma, source=Web Response

A CASE OF POST-OBSTRUCTIVE NECROTIZING PNEUMONIA IN THE SETTING OF METASTATIC NON-SMALL CELL LUNG CANCER

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Necrotizing pneumonia (NP) is a rare condition that is characterized by pulmonary liquefaction and necrosis. Associated symptoms are fever, chills, shortness of breath and cough. Advanced sequelae include pulmonary gangrene, empyema, abscess and hemoptysis. Prognosis is poor with an overall mortality rate of 56% [1]. Here, we present an unusual case of metastatic pulmonary adenocarcinoma complicated by NP leading to the patient's demise. CASE PRESENTATION: A 70 year old male smoker with no known PMH presented with productive cough, unintentional weight loss and hemoptysis. CT chest showed narrowing of the left main bronchus and left main pulmonary artery due to a possible hilar mass (Figure 1,2). There was also an extensive left-sided consolidation with pleural effusion. The patient's significant leukocytosis was poorly responsive to antibiotic therapy. No infectious etiology could be identified on extensive testing. The patient developed acute respiratory distress requiring mechanical ventilation. Bronchoscopy showed severe bleeding from an unidentifiable source in the left lung. BAL showed possible lung carcinoma with post-obstructive PNA. CT abdomen showed right adrenal metastasis. IR-guided bronchial artery embolism was attempted twice to control bleeding; however, no source of bleeding could be identified. The chest tube drained a considerable amount of serosanguinous fluid. The patient underwent segmentectomy after worsening bleeding through the ETT and was found to have extensive metastatic disease in the chest. Lobectomy could not be performed due to the inability to access hilum and was deemed unsafe. Biopsy showed poorly differentiated adenocarcinoma with venous invasion and thrombosis and NP with scattered bacterial colonies. The patient received compassionate care given a high likelihood of imminent death. DISCUSSION: The purpose of this case report was to describe a rare case of post-obstructive NP secondary to poorly differentiated metastatic lung adenocarcinoma. Current management of NP involves the surgical removal of the necrotic tissue along with a long course of broad-spectrum antibiotics to treat the underlying polymicrobial infection [2,3]. Our patient's prognosis was very poor because of the extent of his NP and malignancy. An early approach to endobronchial stenting would have stabilized the airway which was being severely compromised by the tumor, whereas a pneumonectomy would have made it easier to control the patient's fatal hemorrhage. This is why we believe that an early and aggressive intervention would have improved the patient's outcome. CONCLUSIONS: NP in the setting of advanced pulmonary adenocarcinoma is a rare phenomenon that is poorly described in current literature. If a patient with advanced lung cancer develops NP, an early surgical intervention with palliative stenting should be considered to minimize complications. REFERENCE #1: Gillet Y, Vanhems P, Lina G, Bes M, Vandenesch F, Floret D, Etienne J. Factors predicting mortality in necrotizing community-acquired pneumonia caused by Staphylococcus aureus containing Panton-Valentine leukocidin. Clin Infect Dis. 2007 Aug 1;45(3):315-21. doi: 10.1086/519263. Epub 2007 Jun 15. PMID: 17599308. REFERENCE #2: Cengiz AB, Kanra G, Caĝlar M, Kara A, Güçer S, Ince T. Fatal necrotizing pneumonia caused by group A streptococcus. J Paediatr Child Health. 2004 Jan-Feb;40(1-2):69-71. doi: 10.1111/j.1440-1754.2004.00296.x. PMID: 14718011. REFERENCE #3: Kohno S, Koga H, Oka M, et al: The pattern of respiratory infection in patients with lung cancer. Tohoku J Exp Med 173:405-411, 1994. DISCLOSURES: No relevant relationships by Frantzcess Compas, source=Web Response No relevant relationships by Zarwa Idrees, source=Web Response No relevant relationships by Vikram Sumbly, source=Web Response No relevant relationships by Theo Trandafirescu, source=Web Response

Trifecta and pentafecta outcomes following robot-assisted partial nephrectomy for hilar versus nonhilar tumors: A propensity-matched analysis.

Introduction:Hilar tumors are a unique subset of complex renal masses posing a potential surgical challenge during partial nephrectomy. The outcomes of hilar masses have not been compared to non-hilar renal masses of similar RENAL nephrometry score (RNS). In this study, we analyzed the outcomes of hilar versus nonhilar masses after a propensity score matching.Methods:Prospectively maintained database of patients who underwent robot assisted PN between November 2014 and December 2018 was abstracted for hilar and nonhilar tumors. We performed propensity matching for baseline variables such as age, sex, body mass index, comorbidities, preoperative glomerular filtration rate, and RNS for each patient on the basis of propensity scores.Results:We included 48 patients with hilar tumors and 153 with nonhilar tumors. On propensity matching, 41 patients were included in each group. The mean operative time (162.4 ± 48.9 min vs. 144.1 ± 38.8 min, P = 0.48), warm ischemia time (29.0 ± 8.8 min vs. 24.4 ± 8.2 min, P = 0.12), and the estimated blood loss (201.8 ± 184.7 ml vs. 150.6 ± 160.5 ml, P = 0.37) were not significantly different between the hilar and the nonhilar groups. Trifecta was achieved in only 14/41 (34.1%) of the patients in the hilar group as compared to 24/41 (58.5%) in the nonhilar group (P = 0.027). Logistic regression analysis identified that hilar location of the tumors was not an independent predictor of overall complications (OR 6.37, confidence interval [CI] 0.5–69.4, P = 0.4), trifecta (OR 0.38, CI 0.14–1.0, P = 0.051), and pentafecta outcomes (OR 0.4, CI 0.1–1.51, P = 0.17).Conclusions:Hilar location was associated with poorer trifecta outcomes compared to the nonhilar tumors. However, hilar location per se was not an independent predictor of overall complications and trifecta and pentafecta outcomes.

AN UNUSUAL CASE OF SARCOIDOSIS PRESENTING AS A LUNG MASS AND CARDIAC TAMPONADE

TOPIC: Diffuse Lung Disease TYPE: Fellow Case Reports INTRODUCTION: Sarcoidosis is a multisystem granulomatous disease whose etiology remains elusive yet nevertheless has classic pulmonary and extrapulmonary findings that may aid in the diagnosis. The proceeding case demonstrates however the difficulty in diagnosing this masquerader when rare presentations instead form the clinical picture. CASE PRESENTATION: We present a 63-year-old male with a history of treated active tuberculosis who presented with abdominal pain and incidentally found to have innumerable bilateral pulmonary nodules accompanying a right hilar mass with confluent lymphadenopathy (Figs 1&2). Despite these findings, he denied cough, hemoptysis, dyspnea, fevers, chills, night sweats, and weight loss. He had a notable history of particulate exposure as a contractor but was otherwise a lifetime non-smoker. Diagnostic bronchoscopy with endobronchial ultrasound guidance revealed both necrotizing and non-necrotizing granulomata but no evidence of malignancy. Before additional studies could be performed, the patient was hospitalized at an outside facility for dyspnea and found to be in cardiac tamponade requiring a pericardial drain. Microbiology from his initial bronchoscopy grew Cryptococcus prompting empiric fluconazole at the outside facility. His parenchymal findings and dyspnea persisted however and with an interval discovery of pulmonary emboli (Fig 3), therapy was switched to prednisone and anticoagulation leading to near-resolution of his pulmonary nodularity and asymmetric lymphadenopathy. DISCUSSION: Pulmonary sarcoidosis generally manifests as symmetric, bilateral, hilar lymphadenopathy with micronodules along the peribronchovascular bundle and interlobular septa or in the upper and middle lobes when parenchymal involvement is present. Extrapulmonary sarcoidosis occurs much less frequently, often involving extrapulmonary lymphatics or presenting with dermatologic, ophthalmologic, and hepatic findings. Our patient's pulmonary sarcoid was unique in both its appearance as a basilar predominant nodularity seemingly randomly distributed with areas of confluence mimicking a malignant mass with hematogenous dissemination as well as the presence of asymmetric hilar lymphadenopathy without significant mediastinal involvement. Furthermore, the development of cardiac tamponade and unprovoked pulmonary embolism hints at highly atypical cardiac sarcoid and sarcoid-related thromboembolic disease that is only just gaining recognition in the nascent literature. CONCLUSIONS: In the correct epidemiologic and clinical context alongside radiographic and pathologic correlation, sarcoidosis can be diagnosed after the exclusion of etiologies like malignancy, infection, or autoimmune disease. However, as this case demonstrates, clinical suspicion remains the most powerful tool when synthesizing seemingly discordant data from rarely seen presentations of the disease. REFERENCE #1: Criado E, Sanchez M, Ramirez J et al. Pulmonary sarcoidosis: typical and atypical manifestation at high-resolution CT with pathologic correlation. Radiographics. 2010;30(6):1567-1586. REFERENCE #2: Ungprasert P, Crowson CS, Matteson EL. Association of sarcoidosis with increased risk of VTE: a population-based study, 1976-2013. CHEST. 2017;151(2):425-430. REFERENCE #3: Ungprasert P, Ryu JH, Matteson EL. Clinical manifestations, diagnosis, and treatment of sarcoidosis. Mayo Clin Proc Innov Qual Outcomes. 2019;3(3):358-375. DISCLOSURES: No relevant relationships by Christine Choi, source=Web Response No relevant relationships by Julien Nguyen, source=Web Response No relevant relationships by Janine Vintch, source=Web Response

PULMONARY SARCOMATOID CARCINOMA: A CASE REPORT AND REVIEW OF LITERATURE

TOPIC: Lung Cancer TYPE: Medical Student/Resident Case Reports INTRODUCTION: Pulmonary sarcomatoid carcinomas are a rare subtype of poorly differentiated non-small cell lung cancer that accounts for less than 1 percent of primary lung malignancies. This case highlights the clinical presentation & diagnostic evaluation undertaken to identify this rare lung cancer. CASE PRESENTATION: A 77-year-old male with a medical history of tobacco abuse, hypertension & mutism was evaluated for pleuritic chest pain, cough and subjective fevers. Initial vitals were stable and pulmonary examination revealed focal expiratory wheezes auscultated on the right anterior chest with a prolonged expiratory phase throughout. CXR demonstrated a mass-like opacity in the inferior right hilum and the patient was treated with antibiotics for presumed community-acquired pneumonia. Chest CT was obtained due to persistent symptoms which showed a right hilar mass encasing the right pulmonary artery with calcific mediastinal lymphadenopathy. Bronchoscopy with endobronchial ultrasound was performed and samples for cytology were taken from the culprit endobronchial lesion. Lymph node surveillance revealed enlarged left paratracheal, right paratracheal & right hilar lymph nodes from which FNA samples were taken, respectively. Rapid onsite pathological evaluation demonstrated the presence of atypical cells and ultimately revealed sarcomatoid carcinoma. Oncology, radiation oncology, and palliative care were consulted. After a lengthy discussion concerning the treatment options, the patient & family elected to transition to comfort care. The patient was discharged home with hospice. DISCUSSION: Pulmonary sarcomatoid carcinoma is a rare non-small cell carcinoma accounting for approximately 0.1-0.4% of all primary pulmonary malignancies. The disease has a predilection for older males with a prolonged smoking history. Morphologically, sarcomatoid carcinoma is a heterogeneous group of neoplasms that originate from epithelial & mesenchymal tissue containing intermingled elements of carcinoma & sarcoma. There are five recognized subtypes: pleomorphic carcinoma, spindle cell carcinoma, giant cell carcinoma, carcinosarcoma & pulmonary blastoma. Given the immense histological variability, a pathologic diagnosis frequently requires a generous tissue sample and can often pose a diagnostic challenge. The clinical course is aggressive with early metastasis rendering the overall prognosis is poor despite therapy. Surgical resection offers the best therapeutic option in early disease and remains the standard of care. Targeted therapies & immunotherapy remain a promising option, but additional research & clinical experience is needed in this patient population. CONCLUSIONS: This case highlights the clinical presentation & diagnostic evaluation undertaken to identify sarcomatoid carcinoma, a rare and aggressive lung cancer with heterogeneous pathology & limited response to traditional therapy. REFERENCE #1: Rajdev K, Siddiqui AH, Ibrahim U, Agarwal S, Ding J, Chalhoub M. Sarcomatoid Carcinoma of the Lung Presenting as Localized Bronchiectasis: A Case Report and Review of Literature. Respir Med Case Rep. 2018;24:143-146. Published 2018 May 17. doi:10.1016/j.rmcr.2018.05.016 REFERENCE #2: Shen XY, Lin ZF, Lin Q, et al. Pulmonary sarcomatoid carcinoma: a case report. Contemp Oncol (Pozn). 2013;17(2):210-213. doi:10.5114/wo.2013.34375 DISCLOSURES: No relevant relationships by Kari McCoy, source=Web Response No relevant relationships by Caroline Mears, source=Web Response No relevant relationships by Xian Qiao, source=Web Response

STENT-IN-STENT TECHNIQUE FOR MANAGEMENT OF PERIPHERAL MALIGNANT ENDOBRONCHIAL OBSTRUCTION

TOPIC: Procedures TYPE: Medical Student/Resident Case Reports INTRODUCTION: Airway stenting is used to restore patency of airways with malignant obstruction. Stent-in-stent (SIS) technique has been used in central airway obstruction. We describe a case of malignant endobronchial obstruction in the right upper lobe (RUL) managed with SIS technique. CASE PRESENTATION: 56-year-old male with history of Laryngeal Carcinoma managed with surgical resection and chemo-radiation was transferred for management of recurrent hemoptysis and right lung atelectasis. He was tachypneic and hypoxic requiring 2L oxygen. Labs revealed leukocytosis, hemoglobin of 9.6gm/dl and no coagulopathy. CT Chest showed right lung atelectasis due to right mainstem endobronchial mass. Rigid bronchoscopy (RB) demonstrated a friable mass in the right main stem with frank blood in the central airway. Initially Diode laser was employed for removal of the pedunculated tumor originating in the RUL, followed by debulking with RB and cryoprobe from the right main stem and bronchus intermedius (BI). Rigid tamponade and argon plasma coagulation were used for hemostasis. BF-P190 Olympus scope was used to identify the distal airway in the RUL posterior segment and a 7x22 mm iCAST stent was placed for airway patency. Right middle lobe (RML) and lower lobe (RLL) airways were not localized at the time. A staged RB was performed a few days later. BF-P190 Olympus scope was used for inspection which revealed occlusion of distal end of stent with tumor, advancement of scope with mild pressure through the tumor revealed sub segmental airways, under fluoroscopy guidance a second 7x22mm iCAST stent was placed overlapping with the first stent. Additional tumor debulking from the BI revealed RLL segmental branches. Under direct visualization a 10x38 mm iCAST stent was placed to restore airway patency to the RLL. He remained stable off oxygen post procedure, with reinflation of the right lung. He was discharged with bronchodilators and hypertonic saline with significant improvement in his quality of life. DISCUSSION: Rigid bronchoscopy and airway stenting is commonly used for management of complex central airway obstruction. iCAST stent is a balloon expandable stainless steel stent that is fully encapsulated in two layers of polytetrafluoroethylene. The stent deployment is through the scope with the smallest size of 5x16mm and largest 10x38mm. The smaller size stent can be upsized with a larger sized balloon with the stent shortening in length. We present a SIS placement of two 7x22 mm iCAST stents in the airway likely traversing through the right hilar mass to establish airway patency, resulting in complete reexpansion of the lung. CONCLUSIONS: Peripheral airway stenting of occluded airway due to malignancy can result in lung reinflation, resulting in increased pulmonary reserves for patient to tolerate chemotherapy and radiation. We used SIS technique for customization and appropriate stenting of distal airway. REFERENCE #1: Sethi, Sonali, et al. "Clinical Success Stenting Distal Bronchi for 'Lobar Salvage’ in Bronchial Stenosis:” Journal of Bronchology & Interventional Pulmonology, vol. 25, no. 1, 2018, pp. 9–16, doi:10.1097/LBR.0000000000000422. REFERENCE #2: Majid A, Kheir F, Chung J, Alape D, Husta B, Oh S, Folch E.. Covered Balloon-Expanding Stents in Airway Stenosis. J Bronchology Interv Pulmonol. 2017 Apr;24(2):174-177. doi: 10.1097/LBR.0000000000000364.J Bronchology Interv Pulmonol. 2017. PMID: 28323735 DISCLOSURES: No relevant relationships by Muhammad Arif, source=Web Response no disclosure submitted for Ali Saeed; No relevant relationships by Hursh Sarma, source=Web Response No relevant relationships by Andrew Talon, source=Web Response No relevant relationships by Cindrel Tharumia Jagadeesan, source=Web Response

THYMOMA MIMICKING A LUNG MASS

TOPIC: Lung Pathology TYPE: Fellow Case Reports INTRODUCTION: We present a diagnostic challenging case of spindle cell thymoma mimicking a left lung upper lobe mass along the mediastinal pleura. CASE PRESENTATION: A 54-year-old female is hospitalized with hypoxic respiratory failure due to COVID 19 pneumonia. Patient developed ARDS, pneumomediastinum, and septic shock with secondary bacterial infection requiring mechanical ventilator support and antibiotic therapy. Patient had a prolonged complicated hospital course with multiorgan failure including kidney injury, lacunar stroke and developed severe critical illness myopathy. Patient underwent tracheostomy and was discharge to long term acute care facility to wean from the ventilator. Due to persistent need of supplemental oxygen and intermittent tachycardia, chest X ray was performed which showed alveolar and interstitial infiltrates . Subsequently, CT angiogram chest was performed which showed no pulmonary embolism but a 7 cm left lung upper lobe mass extending from hilum along the mediastinum. Positron emission tomography (PET) performed showed minimal uptake in the mass without enhanced uptake in any other location. Percutaneous biopsy was pursued which showed numerous oval spindle cells clusters with rare lymphocyte suggestive of spindle cell thymoma. During rehabilitation, patient was later diagnosed with myasthenia gravis and planned to undergo thymectomy after functional status of the patient improves. DISCUSSION: Thymomas are the most common epithelial cell tumor of the anterior mediastinum composed of neoplastic epithelial cells with a variable number of lymphocytes which determines various histologic subtypes of thymic neoplasms based on Worl Health Organization (WHO) classification. Histologic subtyping of thymoma need complete resection of tumor but core biopsy can differentiate thymoma from carcinoma. Our patient had WHO type A spindle cell thymoma which is composed of fusiform or oval spindle cells with rare lymphocytes. It accounts for 22% of all thymomas with no gender predilection and mean age of diagnosis is sixth decade. Thymomas are commonly located in prevascular anterior mediastinum but, rarely, as described in our patient it can present as hilar mass extending along the mediastinal pleural into the left upper lobe which can mimic lung tumor. Prognosis is based on resectability of tumor, staging and histologic features. CONCLUSIONS: Thymomas can mimic lung malignancy on imaging studies and need histologic exam to confirm the diagnosis. REFERENCE #1: The histomorphologic spectrum of spindle cell thymoma. Annikka Weissferdt MD, FRCPath, Cesar A. Moran MD, PMID: 23260329 DISCLOSURES: No relevant relationships by Yusra Ansari, source=Web Response No relevant relationships by Priyanka Bhat, source=Web Response No relevant relationships by Tahir Muhammad Abdullah Khan, source=Web Response No relevant relationships by Karan Singh, source=Web Response

V04-04 CLINICAL APPLICATION OF 3D ANATOMICAL MODELING SOFTWARE (IRIS TM ) DURING ROBOT-ASSISTED PARTIAL NEPHRECTOMY (RAPN) FOR COMPLEX RENAL MASSES

You have accessJournal of UrologyAdrenal & Renal Oncology I (Nephron Sparing Surgery) (V04)1 Sep 2021V04-04 CLINICAL APPLICATION OF 3D ANATOMICAL MODELING SOFTWARE (IRISTM) DURING ROBOT-ASSISTED PARTIAL NEPHRECTOMY (RAPN) FOR COMPLEX RENAL MASSES Ahmed Ghazi, Tyler Holler, Thomas Frye, William Tabayoyong, Jonathan Bloom, Hani Rashid, and Jean Joseph Ahmed GhaziAhmed Ghazi More articles by this author , Tyler HollerTyler Holler More articles by this author , Thomas FryeThomas Frye More articles by this author , William TabayoyongWilliam Tabayoyong More articles by this author , Jonathan BloomJonathan Bloom More articles by this author , Hani RashidHani Rashid More articles by this author , and Jean JosephJean Joseph More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002000.04AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: IRISTM is an interactive three dimensional (3D) anatomic modeling software allowing functional manipulation of anatomical models for the surgical planning of renal masses. The software represents converted DICOM files of CT images to 3D virtual anatomical models, viewed on an iOS device during preoperative surgical planning and the da Vinci surgical system TilePro input for intraoperative navigation. The objective of this video is to demonstrate the clinical utility and application of IRISTM as a preoperative planning and intraoperative navigation tool during RAPN in two patients with highly complex renal masses. METHODS: The first case is a 73 year old male patient with a 2.7 cm right, completely endophytic hilar renal mass. Nephrometry score was 10h. The second case was a 45 years old male presenting with a 7.8 by 7.6 cm, exophytic, left hilar posterior renal mass with a nephrometry score of 11p. Preoperative planning was completed utilizing axial imaging and IRIS on an iOS device and a surgical plan put forth. Intraoperative navigation was via the da Vinci surgical system TilePro input. Perioperative and intraoperative patient data was collected. RESULTS: In the first case, IRIS helped visualize the resection cavity exposing the surrounding vascular branches that could be injured during tumor resection, identifying the feeding vessels perfusing the tumor and predicting structures encountered during suturing at the base of the resection bed during renoprraphy. Estimated Blood loss (EBL) was 100cc, Warm ischemia time (WIT) 17 minutes, with minimal change in postoperative renal function. Final pathology was positive for an Oncocytoma with negative margins. In the second case with an exophytic tumor, the transparency function allowed for identification of vital structures that would be encountered at the resection base. In this case a large portion of the pelvicaliceal system (PCS) abutting the tumor base and a feeding branch to the tumor from the renal artery were accurately localized by altering parenchyma and tumor transparency in the IRIS model. EBL was 60cc, WIT 28 minutes and renal function was maintained postoperatively. Pathology was positive for clear cell carcinoma with negative margins. CONCLUSIONS: IRISTM technology with its interactive features, offered valuable preoperative and intraoperative information not attainable by standard axial imaging in the robotic approach for surgical management of complex renal masses. Source of Funding: Inuititive Inc. Clinical trial © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e292-e292 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ahmed Ghazi More articles by this author Tyler Holler More articles by this author Thomas Frye More articles by this author William Tabayoyong More articles by this author Jonathan Bloom More articles by this author Hani Rashid More articles by this author Jean Joseph More articles by this author Expand All Advertisement Loading ...

Mediastinal Mass with Unusual Etiology.

Mediastinal Mass with Unusual Etiology.

Functional and Oncological Outcomes of Renal Surgery for Hilar Tumors: Informing the Decisions in Risk-Adapted Management

To describe the safety and efficacy of partial nephrectomy (PN) in comparison to radical nephrectomy (RN) for surgically managed renal hilar tumors. We retrospectively reviewed institutional records of patients with a small (<5 cm) solitary renal (hilar or non-hilar) mass who underwent PN or RN between 2008 and 2018. Hilar tumors were defined as those at medial position, abutting the renal vessels. Recurrence-free, cancer-specific, and overall survival were estimated using the Kaplan-Meier method. Of 1,951 eligible patients, 399 had hilar tumors (292 scheduled for PN, 107 RN) and 1,552 had non-hilar tumors (scheduled for PN). We found no significant differences in survival measures between hilar and non-hilar tumors in patients selected for PN. Patients scheduled for PN for hilar tumors had higher rates of ≥grade II postoperative surgical complications compared to patients scheduled to receive PN for non-hilar tumors (13% vs 8.6%; log-rank P=.018) and non-statistically significantly elevated rates of ≥grade II complications compared to patients scheduled for RN for hilar tumors (13% vs 6.5%; difference 6%, 95% CI 0.4%, 13%; log-rank P=.07). PN for hilar and non-hilar renal masses (<5cm) experience comparable oncologic outcomes though increased risk of complications for hilar masses. PN for hilar tumors was associated with better renal function and overall survival with non-statistically elevated risk of grade II or higher complications than RN. A renal tumor located at the hilum should not be a contra-indication for performing PN.

Nodal metabolic tumour volume on baseline 18F‐FDG PET/CT and overall survival in stage II and III NSCLC patients undergoing curative‐intent chemoradiotherapy/radiotherapy

This study aims to investigate whether nodal metabolic tumour volume (nMTV) and nodal total lesion glycolysis (nTLG) on Fluorine-18 fluoro-deoxy-glucose positron emission tomography-computed tomography (18 F-FDG PET/CT) in inoperable node-positive stage II and III non-small cell lung cancer (NSCLC) are independent predictors of overall survival (OS) in patients undergoing curative-intent chemoradiotherapy/radiotherapy (CRT/RT). Data from two prospective trials between 2004 and 2016 were analysed retrospectively. Primary, nodal and total metabolic tumour volume and total lesion glycolysis (pMTV, nMTV, tMTV, pTLG, nTLG and tTLG, respectively) were derived from baseline 18 F-FDG PET/CT. Cox regressions were used to model OS by 18 F-FDG PET/CT parameters adjusting for overall stage. 89 patients with stage II (8%) and stage III (92%) were included. The median age at diagnosis was 67years; 62% were male. The median follow-up was 6.9years; the median OS was 2.2years (95% CI 1.7-3.1). The median pMTV, nMTV and tMTV were 14mL (range 0-360), 8mL (range 0-250) and 34mL (range 3-384), respectively. In 3 patients, the primary lesion could not be delineated from the central hilar mass. There was no association between nMTV (adjusted HR 1.04, 95% CI 0.95-1.15, P-value 0.43), pMTV (adjusted HR 1.0, 95% CI 0.96-1.04, P-value 0.92), tMTV (adjusted HR 1.0, 95% CI 0.97-1.04, P-value 0.88), nTLG, pTLG or tTLG and OS. Consistent results were noted when patients with central hilar lesions were excluded from analysis. In node-positive stage II and III NSCLC patients who underwent 18 F-FDG PET/CT-guided target delineation curative-intent concurrent CRT/RT, metabolic parameters did not appear to provide independent prognostication.

Metastatic Breast Cancer Masked as Constipation

Even though screening mammography has been attributed to decreased mortality in recent decades, breast cancer is one of the leading causes of death among women in the United States. Disruption of screening protocols and variation in the presentation may alter the course of detection and management. We report a case of hormone receptor-positive breast cancer that presented as vague gastrointestinal symptoms in a patient with a delayed workup for a self-discovered breast lump during the coronavirus disease global pandemic.A 48-year-old woman with a history of gastroesophageal reflux and hypertension presented to the emergency department with primary complaints of constipation and abdominal distention with associated flatus and nausea. Vitals were within normal limits, and physical examination was notable for abdominal distention and diffuse tenderness to palpation. Labs demonstrated hypercalcemia and an unremarkable complete blood count. A chest X-ray showed a right hilar mass, and a CT chest revealed multiple lytic bone lesions diffusely scattered throughout the entire skeleton; no hilar mass was noted on the CT chest. A CT scan of the abdomen and pelvis incidentally revealed a right breast mass. A bone marrow biopsy identified invasive ductal carcinoma. Mammography and biopsy of the breast mass identified estrogen receptor/progesterone receptor-positive invasive ductal carcinoma, consistent with the bone marrow biopsy, confirming the diagnosis of metastatic breast cancer.Unpredicted disruptions in screening processes may result in delayed cancer diagnoses. This case illustrates the importance of routine self-breast examinations, screening mammography, and maintaining a broad differential diagnosis.

Electrocardiogram Findings Associated With Malignant Pericardial Effusion and Cardiac Tamponade.

Electrocardiogram Findings Associated With Malignant Pericardial Effusion and Cardiac Tamponade.

Medical Image of the Month: Metastatic Spindle Cell Carcinoma of the Breast

No abstract available. Article truncated after 150 words. Clinical Scenario: A 71-year-old woman with primary malignancy of the breast in remission post bilateral mastectomy in 2005 and 2008, presented to the emergency room with progressive shortness of breath for the past 6 months. Upon arrival to the emergency room, she described localized sharp chest pain along the right thoracic wall which had gradually worsened over the past three months. The pain was exacerbated with movement and with deep inspiration. She also endorsed significant hemoptysis, expectorating approximately 500 ml of bloody sputum on the morning of her presentation. Pertinent vitals revealed that she was both tachycardic and tachypneic, saturating 94% on room air with an increased work of breathing. Physical examination was significant for coarse breath sounds and diminished right sided lung sounds. Initial labs demonstrated a normal troponin and an unremarkable EKG. A chest radiograph demonstrated a large left mediastinal and hilar mass with numerous parenchymal nodules bilaterally. …

Lung cancer mimickers - a case series of seven patients and review of the literature.

Background: Lung is the third most frequent identified site of malignancy and lung cancer is the most lethal type of cancer in the world. Several benign lung diseases or proliferations may mimic lung carcinoma in its clinical, pathological, and radiological presentation, which makes the differential diagnosis life changing. This case series was designed to describe the main diagnosis encountered in a multidisciplinary emergency hospital during the last years in Romania. Results: The most challenging cases encountered during the recent years were those of lung hamartoma associated with eosinophilic pneumonia because of the multicentricity of the disease and the suspicion for metastasis in the clinical setting, pulmonary aspergillosis that presented as a cystic lesion with a 9 mm mural nodule, actinomycosis discovered as firm nodule showing aspects of false pleural invasion, cryptococcosis – a hilar mass for which a pneumectomy was prepared, pulmonary parasitosis that presented as a nodule with irregular borders, causing pleural retraction, one case of inflammatory myofibroblastic tumor of the lung, one case of tumorlet type neuroendocrine lesion in a patient with history of melanoma and renal oncocytoma, admitted under the suspicion of lung metastasis. Conclusions: These are some of the main mimickers of primary or secondary lung cancers and one must be aware of these similitudes to avoid higher cost procedures, psychological stress for the patient and higher mortality.

P88.03 Asymptomatic COVID-19 in a ROS1 positive Non Small Cell Lung Cancer.

COVID-19 pandemic has led to reconsider the traditional management approach in lung cancer. Oral tyrosine kinase inhibitors (TKIs) are being preferred in oncogene addicted advanced non-Small Cell Lung Cancer. A young never-smoker woman presented with left hilar mass with left pleural effusion in February 2020. There was an incidental detection of thrombus in right main and descending pulmonary artery. She was diagnosed to have ROS1 rearranged advanced NSCLC with pulmonary embolism. She was initiated on conventional chemotherapy with carboplatin and pemetrexed along with anticoagulation. After fourth cycle of chemotherapy, although there was clinical improvement attributed to reduction of amount of effusion and disappearance thrombus, RECIST 1.1 criteria suggested the progression of disease in view of appearance of adrenal metastasis. Meanwhile, she had a history of high risk exposure with a patient of COVID- 19 in July 2020. Although she was asymptomatic, RT- PCR for SARS-COV2 came out to be positive. She remained asymptomatic for next 10 days during hospitalization. Then she was started on Crizotinib and was discharged with advice on further follow up. Although patients on cancer chemotherapy are at high risk of severe COVID-19 diseases, asymptomatic cases can happen. The patients preferably should be shifted to or started on oral TKIs as per available expert recommendations.

Recurrent follicular thyroid carcinoma metastatic to axillary lymph nodes mimicking pulmonary adenocarcinoma

Differentiated thyroid cancers generally have favorable prognoses, though follicular thyroid cancer is overall associated with a worse prognosis due in part to increased incidence of distant metastasis. We report a case of a 51-year-old woman with a history of widely invasive follicular thyroid carcinoma treated with a total thyroidectomy, radioactive iodine and external beam radiation. Five and a half years following her surgery, she was found to have an axillary lymph node mass, multiple lung masses, and a hilar mass in the setting of declining thyroglobulin (Tg) antibodies. Her metastases were initially thought to be due to a primary lung adenocarcinoma given a neoplastic cell immunophenotype that included an absence of Tg expression and co-expression of TTF-1 and Napsin A. However, PAX8 expression demonstrated that the axillary and hilar metastases were actually thyroid in origin rather than lung. Axillary metastases in differentiated thyroid carcinoma are exceedingly rare and previous reports have typically involved widely disseminated disease with extensive neck lymphadenopathy. With a decline in Tg antibodies levels in high-risk patients, one should consider progression and loss of differentiation of thyroid carcinoma rather than a response to treatment.Learning pointsAxillary metastases in differentiated thyroid carcinoma are uncommon.In patients with high-risk thyroid carcinomas, a decline in thyroglobulin antibody may not signal disease improvement, but rather a progression to a poorly differentiated form of cancer.PAX8 staining can be used to differentiate thyroid carcinomas from lung adenocarcinomas.

Rapid-onset and fatal pneumonitis from trametinib treatment of non-small cell lung cancer: A case report

Introduction: Lung cancer remains the leading cause of death in both men and women worldwide. Oral targeted therapy remains the recommended first-line approach for those with actionable mutations. The combination of trametinib and dabrafenib has shown durable responses as both a first line and second line treatment in patients with non-small cell lung cancer (NSCLC) with a BRAFV600E mutation. Respiratory complications with trametinib have rarely been documented, with an incidence of less than 2%. Case Report: A 58-year-old former female smoker who presented with dyspnea on exertion and was found to have a right hilar mass. The mass was biopsied and found to be a poorly differentiated carcinoma consistent with NSCLC. Tumor proportion score (TPS) was 100% for programmed death-ligand 1 (PD-L1) expression, and molecular analysis confirmed a BRAFV600E mutation. She was started on treatment with dabrafenib 150 mg twice daily with trametinib 2 mg once daily. After ten days, she developed fever followed by leukocytosis and hypoxia. Chest imaging was suggestive of pneumonitis, and she was initiated on high-dose steroids and antibiotics. Her cultures remained negative, though she was unable to be weaned from high-flow oxygen. She transitioned to hospice care several days later and subsequently passed in another 12 days. Conclusion: Trametinib-induced interstitial pneumonitis, while a relatively rare occurrence, can become rapidly life-threatening and should prompt immediate cessation of the medication followed by urgent supportive care measures.

Mucinous Cystic Neoplasm of the Liver (MCN-L) Presenting as Hilar Intraluminal Mass with Episodic Biliary Obstruction

Mucinous Cystic Neoplasm of the Liver (MCN-L) Presenting as Hilar Intraluminal Mass with Episodic Biliary Obstruction

Clinical analysis for 12 patients with thoracic Castleman's disease.

To explore the clinical characteristics and differential diagnosis for patients with thoracic Castleman's disease, thus to improve doctor's cognition and therapeutic level for the disease. The clinical data of 12 patients with thoracic Castleman's disease were analyzed retrospectively, including clinical features, laboratory examination, imaging finding, pathological examination, treatment outcome, and prognosis. All 12 patients were diagnosed by mass or lymph code biopsy. Seven patients with unicentric Castleman's disease were asymptomatic or oligosymptomatic. Of them, the lung imaging features were mostly solitary and well-defined pulmonary hilar soft tissue mass and infrequently invasive mass. Pathologically, 7 patients were all hyaline vascular type. Six patients underwent surgery of complete mass resection, and 1 received chemotherapy because the nidus could not be resected completely. The prognosis of 7 patients was good. The clinical manifestations of 5 patients with multicentric Castleman's disease were diverse with negative prognosis. Their radiological features mainly showed multiple mediastinal/hilum lymph node enlargement, multiple serous cavity effusion, and hepatosplenomegaly, along with multifocal lymphadenopathy. Pathological features of 3 patients' mass were hyaline vascular type, 1 was plasma cell type, and 1 was mixed type. Three patients received comprehensive treatment on the basis of chemotherapy and another 2 patients did not receive any therapy. Unicentric Castleman's disease involving the chest is mainly manifested as mediastinal or hilar soft tissue mass with single clinical manifestation, while multicentric Castleman's disease involving the chest is mainly manifested as diffuse mediastinal/hilar lymph node enlargement, multifocal lymphadenopathy and multiple clinical manifestation. For patients with mediastinal/hilum mass or with multifocal lymphadenopathy, Castleman's disease should be considered the differential diagnosis. And early mass or lymph code biopsy is of great significance for diagnosis and treatment of Castleman's disease.