Initial Needle Research Articles

Strategic insights into the cultivation of pancreatic cancer organoids from endoscopic ultrasonography-guided biopsy tissue

BACKGROUND The frequent suboptimal efficacy of endoscopic ultrasound-guided fine-needle biopsy (EUS-FNB) to culture pancreatic cancer (PC) organoids (PCOs) poses a major challenge in the advancement of personalized medicine for advanced PC. AIM To explore how to obtain appropriate puncture tissues from EUS-FNB and optimize the strategy for efficiently constructing PCOs, providing an efficient tool for the advancement of personalized medicine. METHODS Patients who underwent EUS-FNB for the diagnosis of PC tissue were prospectively enrolled. We refined the endoscopic biopsy procedures and organoid cultivation techniques. All tissue specimens verified by on-site pathological assessment were cultured in a semi-suspended medium in a microfluidic environment. We assessed differences in PCOs cultured beyond and below five generations examining patient demographics, specimen and organoid attributes, and the sensitivity of organoids to a panel of clinical drugs through cell viability assays. RESULTS In this study, 16 patients with PC were recruited, one sample was excluded because onsite cytopathology showed no tumor cells. Successful organoid generation occurred in 93.3% (14 of 15) of the EUS-FNB specimens, with 60% (9 of 15) sustaining over five generations. Among these patients, those with a history of diabetes, familial cancer, or larger tumors exhibited enhanced PCO expandability. The key factors influencing long-term PCOs expansion included initial needle sample quality (P = 0.005), rapid initiation of organoid culture post-isolation (P ≤ 0.001), and high organoid activity (P = 0.031). Drug sensitivity analysis revealed a partial response in two patients following therapeutic intervention and surgery and stable disease in four patients, indicating a moderate correlation between organoid response and clinical outcomes. CONCLUSION Optimal initial needle sampling, rapid and precise biopsy sample processing, process isolated samples as soon as possible, and sufficient cellular material are crucial for successful cultivating PCOs. High organoid activity is an important factor in maintaining their long-term expansion, which is essential for shortening the time of drug sensitivity analysis and is the basis of PC research.

8062 Uncommon Presentation of Multiple Myeloma as a Rapidly Growing Thyroid Goiter Initially Thought to be Hashimoto's Thyroiditis

Abstract Disclosure: M.S. Shah: None. S. Humayon: None. K.P. Sanu: None. C. Peñaherrera: None. We present a unique case of an 85-year-old female with rapidly growing anterior neck swelling and subclinical hyperthyroidism, initially suggestive of Hashimoto's thyroiditis. The goiter initially responded well to steroids but rebounded back in size despite two courses of prednisone. This prompted further diagnostic workup which revealed unexpected findings, ultimately leading to the diagnosis of multiple myeloma involving the thyroid parenchyma and lymph nodes. The patient had no history of thyroid disorders or recent upper respiratory tract infections. She exhibited sudden neck swelling, mild subclinical hyperthyroidism, and positive TPO antibodies. Initial fine needle aspiration suggested lymphoid tissue with Hurthle cell differentiation, raising suspicion of Hashimoto's thyroiditis. Flow cytometry supported this diagnosis, but the potential for a Hurthle cell neoplasm persisted. Prednisone temporarily reduced thyroid size, but disease recurrence necessitated surgical excisional and incisional biopsies. Subsequent biopsies revealed plasma cell neoplasms consistent with multiple myeloma. The pathologic report confirmed MYC rearrangement, indicative of multiple myeloma involvement in lymph nodes and thyroid tissue. Protein electrophoresis revealed two restricted bands migrating in the gamma globin region. The patient experienced subclinical hyperthyroidism that evolved into euthyroidism over a month. Incidental findings included non-invasive, low grade papillary urothelial carcinoma. Disease progression was evident in a follow-up PET/CT, prompting oncology consultation. The patient initiated Revlimid with chemotherapy. Levothyroxine was prescribed for postoperative hypothyroidism, with adjustments based on thyroid panel results. This case report illustrates the intricate diagnostic challenges posed by multiple myeloma masquerading as a thyroid disorder. The unexpected evolution of the disease, marked by MYC rearrangement and metastatic spread, emphasizes the need for heightened vigilance in managing such cases. Clinicians should consider alternative diagnoses when treatment efforts fail to provide adequate response. This will ensure timely and appropriate management in clinical practice. This report contributes valuable insights into the diagnostic complexities and multidisciplinary considerations for addressing similar presentations in endocrine and oncology settings. Presentation: 6/1/2024

8062 Uncommon Presentation Of Multiple Myeloma As A Rapidly Growing Thyroid Goiter Initially Thought To Be Hashimoto's Thyroiditis

Abstract Disclosure: M.S. Shah: None. S. Humayon: None. K.P. Sanu: None. C. Peñaherrera: None. We present a unique case of an 85-year-old female with rapidly growing anterior neck swelling and subclinical hyperthyroidism, initially suggestive of Hashimoto's thyroiditis. The goiter initially responded well to steroids but rebounded back in size despite two courses of prednisone. This prompted further diagnostic workup which revealed unexpected findings, ultimately leading to the diagnosis of multiple myeloma involving the thyroid parenchyma and lymph nodes. The patient had no history of thyroid disorders or recent upper respiratory tract infections. She exhibited sudden neck swelling, mild subclinical hyperthyroidism, and positive TPO antibodies. Initial fine needle aspiration suggested lymphoid tissue with Hurthle cell differentiation, raising suspicion of Hashimoto's thyroiditis. Flow cytometry supported this diagnosis, but the potential for a Hurthle cell neoplasm persisted. Prednisone temporarily reduced thyroid size, but disease recurrence necessitated surgical excisional and incisional biopsies. Subsequent biopsies revealed plasma cell neoplasms consistent with multiple myeloma. The pathologic report confirmed MYC rearrangement, indicative of multiple myeloma involvement in lymph nodes and thyroid tissue. Protein electrophoresis revealed two restricted bands migrating in the gamma globin region. The patient experienced subclinical hyperthyroidism that evolved into euthyroidism over a month. Incidental findings included non-invasive, low grade papillary urothelial carcinoma. Disease progression was evident in a follow-up PET/CT, prompting oncology consultation. The patient initiated Revlimid with chemotherapy. Levothyroxine was prescribed for postoperative hypothyroidism, with adjustments based on thyroid panel results. This case report illustrates the intricate diagnostic challenges posed by multiple myeloma masquerading as a thyroid disorder. The unexpected evolution of the disease, marked by MYC rearrangement and metastatic spread, emphasizes the need for heightened vigilance in managing such cases. Clinicians should consider alternative diagnoses when treatment efforts fail to provide adequate response. This will ensure timely and appropriate management in clinical practice. This report contributes valuable insights into the diagnostic complexities and multidisciplinary considerations for addressing similar presentations in endocrine and oncology settings. Presentation: 6/1/2024

Puncture Cube Patient-Mounted Navigation System versus Freehand Method for CT-Guided Needle Placement: Study on a Neoprene Covered Elliptical Cylinder Gelatin Phantom.

The study aims to show how the "Puncture Cube" (PC) (Medical Templates, Egg, Switzerland) compares to the freehand method (FHM) for CT-guided punctures. The PC is a patient-mounted disassemblable cube consisting of an upper and lower template with multiple holes each to predefine puncture trajectory. A total of 80 punctures (FHM in-plane, FHM off-plane, PC in-plane, PC off-plane) was performed by 4 radiologists on a target 9.1cm below surface level of a neoprene covered elliptical cylinder gelatin phantom. The PC was never disassembled. Evaluated parameters were procedure time, number of CT-scans, euclidean distance (ED) and normal distance (ND). Respective parameters of FHM and PC were compared using the Wilcoxon signed-rank test and Levene test with significance levels of 5%. PC achieved smaller ED and ND values after initial needle insertion without corrections for both in-plane and off-plane punctures (P > 0.05). Variance of initial NDs was off-plane significantly larger for FHM. Final ED after needle path corrections was smaller for FHM both in- and off-plane (P < 0.05). Final off-plane ND was significantly lower for FHM with no significant difference in final in-plane ND. FHM off-plane punctures were significantly faster. There was no significant difference in CT-scans between both methods. Utilizing the PC may improve initial needle positioning and safety especially off-plane. However, better final needle positioning after correction with the greater freedom of movement method may suggest need for disassembly of the cube.

Initial needle tracking with the first standalone combined infrared camera - CT system for brachytherapy-analysis of tracking accuracy and uncertainties.

Aprototype infrared camera - cone-beam computed tomography (CBCT) system for tracking in brachytherapy has recently been developed. We evaluated for the first time the corresponding tracking accuracy and uncertainties, and implemented atracking-based prediction of needles on CBCT scans. Amarker tool rigidly attached to needles was 3D printed. The precision and accuracy of tool tracking was then evaluated for both static and dynamic scenarios. Euclidean distances between the tracked and CBCT-derived markers were assessed as well. To implement needle tracking, ground truth models of the tool attached to 200 mm and 160 mm needles were matched to the tracked positions in order to project the needles into CBCT scans. Deviations between projected and actual needle tips were measured. Finally, we put our results into perspective with simulations of the system's tracking uncertainties. For the stationary scenario and dynamic movements, we achieved tool-tracking precision and accuracy of 0.04 ± 0.06 mm and 0.16 ± 0.18 mm, respectively. The tracked marker positions differed by 0.52 ± 0.18 mm from the positions determined via CBCT. In addition, the predicted needle tips in air deviated from the actual tip positions by only 1.62 ± 0.68 mm (200 mm needle) and 1.49 ± 0.62 mm (160 mm needle). The simulated tracking uncertainties resulted in tip variations of 1.58 ± 0.91 mm and 1.31 ± 0.69 mm for the 200 mm and 160 mm needles, respectively. With the innovative system it was possible to achieve ahigh tracking and prediction accuracy of marker tool and needles. The system shows high potential for applicator tracking in brachytherapy.

Abstract PO4-20-12: Case Report: Should core needle biopsy showing primary leiomyosarcoma of the breast warrant a second look for accurate diagnosis and management?

Abstract A 68-year-old female with unknown medical history presented to the emergency department with an exceptionally large necrotic mass of the right breast. Initial core needle biopsy showed morphology consistent with the exceedingly rare leiomyosarcoma of the breast. This patient’s necrotic, fungating tumor with abscess warranted urgent surgical excision. The pathology report that followed revealed malignant phyllodes tumor as her final diagnosis. The patient did well after surgery with no sign of metastasis and continued to follow-up with oncology. Lack of clinical guidance for breast leiomyosarcoma begs the question as to when further workup is indicated since it is known to imitate the histological and radiological features of other breast lesions. We discuss the need for updated guidance from prospective future studies to change national guidelines. Citation Format: Amanda Ritter, Sergey Shimunov. Case Report: Should core needle biopsy showing primary leiomyosarcoma of the breast warrant a second look for accurate diagnosis and management? [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 PO4-20-12.

Abstract PO3-07-09: B3 breast lesions in Asian Centers: malignant upgrade rates and risk factors

Abstract Background Lesions of uncertain malignant potential in the breast (B3 lesions) are composed of a wide spectrum of pathologies with differing risks of breast cancer. With the widespread implementation of screening programs globally, the incidence of these lesions has increased substantially. Asian women tend to have smaller and denser breasts than Western women, making identifying and treating these lesions more challenging. Previous papers quote an upgrade of B3 lesions to malignancy such as ductal carcinoma in situ (DCIS) or cancer at rates of 9.9% to 35.1%. Malignant upgrade on final histology increases patient anxiety and healthcare costs as a second surgical intervention is often required for pathological clearance or lymph node staging. This study aimed to assess the malignant upgrade rate of B3 lesions in Asian women and to evaluate any key factors that may predict the risk of a malignant upgrade. Materials and Methods A retrospective multicentre international study was done on patients at Seoul National University Hospital (SNUH), South Korea, from April 2021 to 2023, and Tan Tock Seng Hospital (TTSH), Singapore, between March 2006 and 2023. Patients who were diagnosed with a B3 lesion on initial breast core needle biopsy and underwent surgical open excision were included in the study. Results A total of 1049 patients were diagnosed with B3 lesions, with 154 (14.7%) upgrading to malignancy. The most common malignancy was DCIS, 118 (76.6%), followed by invasive ductal carcinoma (IDC), 20 (13.0%) and papillary carcinoma, 4 (2.6%). Within the types of B3 lesions, the malignant upgrade rates were found: atypical ductal hyperplasia (ADH), 88/252 (35%); intraductal papilloma (IDP) with atypia, 16/55 (29%); lobular neoplasia (LN), 9/34 (26%); and radial scar (RS), 5/21 (24%). Most patients had both ultrasound and mammographic evaluation, and all lesions in the study were graded BIRADS 4A and above. Univariate analysis showed that age &amp;gt;50 (OR 2.30 [1.61-3.31], p&amp;lt; 0.001), BMI &amp;gt;23 (OR 2.21 [1.20-4.12], p=0.01), post-menopausal status (OR 2.43 [1.34-4.34], p&amp;lt; 0.001), lesion being identified on mammography (OR 3.00 [2.04-4.51], p&amp;lt; 0.001) and presence of microcalcifications on mammography (OR 0.63 [0.41-0.98], p=0.04) were risk factors for malignant upgrade. Conclusion Based on our analysis of Asian women, post-menopausal patients with microcalcifications on mammography and a B3 biopsy result should be treated with a higher degree of suspicion for underlying malignancy. Surgical excision with adequate margins should be routinely considered for B3 lesions such as ADH, IDP with atypia, LN and RS. Avoidance of surgery or vacuum-assisted removal can be considered for younger patients with only ultrasound findings and diagnosis of FEA and IDP. Table 1. Malignant upgrade after excision Table 2. Clinical characteristics of all patients according to malignant upgrade Table 3. Univariate and multivariate analysis for malignant upgrade Citation Format: Wei Wen Ang, Ji-Jung Jung. B3 breast lesions in Asian Centers: malignant upgrade rates and risk factors [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 PO3-07-09.

Deep learning-based automatic pipeline for 3D needle localization on intra-procedural 3D MRI

PurposeAccurate and rapid needle localization on 3D magnetic resonance imaging (MRI) is critical for MRI-guided percutaneous interventions. The current workflow requires manual needle localization on 3D MRI, which is time-consuming and cumbersome. Automatic methods using 2D deep learning networks for needle segmentation require manual image plane localization, while 3D networks are challenged by the need for sufficient training datasets. This work aimed to develop an automatic deep learning-based pipeline for accurate and rapid 3D needle localization on in vivo intra-procedural 3D MRI using a limited training dataset.MethodsThe proposed automatic pipeline adopted Shifted Window (Swin) Transformers and employed a coarse-to-fine segmentation strategy: (1) initial 3D needle feature segmentation with 3D Swin UNEt TRansfomer (UNETR); (2) generation of a 2D reformatted image containing the needle feature; (3) fine 2D needle feature segmentation with 2D Swin Transformer and calculation of 3D needle tip position and axis orientation. Pre-training and data augmentation were performed to improve network training. The pipeline was evaluated via cross-validation with 49 in vivo intra-procedural 3D MR images from preclinical pig experiments. The needle tip and axis localization errors were compared with human intra-reader variation using the Wilcoxon signed rank test, with p < 0.05 considered significant.ResultsThe average end-to-end computational time for the pipeline was 6 s per 3D volume. The median Dice scores of the 3D Swin UNETR and 2D Swin Transformer in the pipeline were 0.80 and 0.93, respectively. The median 3D needle tip and axis localization errors were 1.48 mm (1.09 pixels) and 0.98°, respectively. Needle tip localization errors were significantly smaller than human intra-reader variation (median 1.70 mm; p < 0.01).ConclusionThe proposed automatic pipeline achieved rapid pixel-level 3D needle localization on intra-procedural 3D MRI without requiring a large 3D training dataset and has the potential to assist MRI-guided percutaneous interventions.

Cylindroma of the Breast: A Rare Differential for Breast Cancer on Core Biopsies, Case Report and Review of Literature.

Breast cancers of either ductal or lobular pathology make up the vast majority of breast malignancies. Other cancers occur rarely in the breast. Benign pathology can at times mimic breast cancers on imaging and initial needle biopsies. We report a rare breast pathology of cylindroma. Cylindromas are usually benign, rare dermatologic lesions most commonly associated with head or neck locations. They more commonly occur as sporadic and solitary masses. Less commonly is an autosomal-dominant multi-centric form of this disease. Malignant cylindromas are very rare. We present a patient with findings of a cylindroma of the breast after excision. This was initially felt to be concerning for breast cancer on imaging and core biopsy. Treatment of cylindromas of the breast is excision. Sentinel lymph node dissection is not indicated, nor are adjuvant therapies when identified in the breast. This lesion needs to be included in the differential diagnosis for breast cancer. If cylindromas can be accurately diagnosed preoperatively, this would negate the need for consideration of axillary nodal surgery and adjuvant therapies.

High‐Speed Video Observations of Needles Evolving Into Negative Leaders in a Positive Cloud‐To‐Ground Lightning Flash

AbstractHigh‐speed video records of a single‐stroke positive cloud‐to‐ground (+CG) flash were used to examine the evolution of eight needles developing more or less radially from the +CG channel. All these eight needles occurred during the later return‐stroke stage and the following continuing current stage. Six needles, after their initial extension from the lateral surface of the parent channel core, elongated via bidirectional recoil events, which are responsible for flickering, and two of them evolved into negative stepped leaders. For the latter two, the mean extension speed decreased from 5.3 × 106 to 3.4 × 105 and then to 1.3 × 105 m/s during the initial, recoil‐event, and stepping stages, respectively. The initial needle extension ranged from 70 to 320 m (N = 8), extension via recoil events from 50 to 210 m (N = 6), and extension via stepping from 810 to 1,870 m (N = 2). Compared with needles developing from leader channels, the different behavior of needle flickering, the longer length, the faster extension speed, and the higher flickering rate observed in this work may be attributed to a considerably higher current (rate of charge supply) during the return‐stroke and early continuing‐current stages of +CG flashes.

A case report of fire needle treatment for Recalcitrant Eczema

This case report presents a patient with recalcitrant eczema who underwent fire needle therapy. The patient experienced recurrent eczema exacerbations that were unresponsive to conventional Western medical treatments, which also caused significant adverse effects and increased the disease burden. The patient opted for traditional Chinese external therapy using fire needles. After the initial fire needle treatment, the patient exhibited noteworthy exudation, and pruritus significantly diminished. The therapy was administered weekly for eight consecutive weeks, resulting in marked symptom improvement. Subsequently, the treatment frequency was reduced to biweekly sessions for an additional seven treatments, culminating in a total of 15 fire needle sessions. A Follow-up after one month revealed no recurrence of eczema symptoms.

SAT558 Papillary Thyroid Carcinoma With Anaplastic Transformation in a Filipino Male Treated With Radioactive Iodine and Radiotherapy: A Case Report

Abstract Disclosure: A.A. Apa-ap: None. P. Abarquez: None. M.B. Sedurante: None. A. Ongbit: None. P. Carlos Miguel: None. F. Acenas: None. J. Gacula: None. V. Lee: None. S. Estreller: None. INTRODUCTION. Papillary thyroid carcinoma (PTC) is an epithelial malignancy showing follicular differentiation and distinctive nuclear features, with a generally excellent prognosis. On the other hand, anaplastic thyroid cancer (ATC) is rare and highly lethal, with an incidence of only 0.7% in the Philippines. CASE DESCRIPTION. This paper describes a 43year old Filipino male with a 3-year history of anterior neck mass with an initial fine needle aspiration biopsy read as probable PTC. He underwent total thyroidectomy and bilateral radical lymph node dissection and histopathology revealed conventional PTC, solid variant with 5% focal anaplastic transformation. Metastatic workup revealed multiple sub-centimeter pulmonary nodules and a tiny hypodense nodule on left adrenal gland on CT scan. Bone scintigraphy showed increased tracer uptake in the posterior 10th rib and the sphenoid's greater wing. While the multidisciplinary team wanted to proceed with Radiation therapy (RT) first to address the more aggressive histology, this was not possible logistically and thus RAI was performed first. This slight deviation from guidelines was deemed acceptable by Nuclear Medicine due to the possible decrease in iodine absorption from post radiation fibrosis. After a dose of 150 mci, 4 weeks after surgery, patient then completed 33 fractions of RT. Surveillance revealed stable pulmonary nodules and adrenal mass but increasing TSH-stimulated thyroglobulin and antithyroglobulin. Patient underwent another cycle RAI and is currently stable on his 16th month from diagnosis, 15th month post initial RAI, and 13th month post-RT. DISCUSSION. In several case series, patients with minor anaplastic component had 1- and 2-year survival rates of 88% and 43%, respectively with a median survival of 17 months. The overall prognosis of patients with PTC with minor ATC component points to the value of active surveillance compared to more aggressive treatment modalities in the setting of conventional ATC. Presentation Date: Saturday, June 17, 2023

Efficacy of spinal anesthesia—ultrasound guided versus landmark-based, in patients undergoing spinal anesthesia: a prospective cross-sectional study

Abstract Objective: This research aims to assess the effectiveness and practical value of ultrasound imaging (US group) in minimizing the discomfort and potential hazards associated with spinal anesthesia compared to traditional landmark-based (LM group) approaches. Materials and Methods: In this prospective, randomized comparative investigation, 80 patients were enrolled to undergo spinal anesthesia using either the landmark-based or ultrasound-guided method, with an equal distribution of 40 patients in each respective group. The study recorded various parameters, including evaluation duration, count of needle insertion attempts, instances of redirection, duration of spinal anesthesia, overall procedure time (comprising assessment and administration of spinal anesthesia), and measurement of intrathecal space depth. Patient comfort was evaluated employing a visual analog scale (VAS). Results: Demographic characteristics, including age, gender, and body mass index, exhibited no notable differences. The overall procedure time was approximately 2–3 min for the LM group and 3–4 min for the US group, with a statistically significant difference (P &lt; 0.0001). The initial successful needle insertion rate was considerably more critical in the US group (52.5%) than in the LM group (10%). The distance from the skin to the subarachnoid space was notably more remarkable in the US group, with a statistically significant distinction from the LM group (P = 0.034). The successful spinal needle placement rate was 77.5% in the US group, significantly surpassing the LM group’s rate of 25% (P &lt; 0.05). Regarding patient comfort assessed using the VAS, the US group demonstrated significantly greater comfort levels than the LM group. In the US group, every patient reported a VAS score of &lt;4, whereas only 27.5% achieved the same level of comfort in the LM group. Conclusion: Our study provides evidence supporting the utility of pre-procedural ultrasound evaluation of the subarachnoid space as an effective tool for achieving successful lumbar punctures in patients receiving spinal anesthesia. Compared to the traditional landmark technique, this approach reduces the number of attempts required while enhancing patient comfort.

Vibrating toothbrush, ice, or topical anesthetic agent to reduce pain of local anesthetic injection in 5- to 12-year-old children undergoing dental procedures — a randomized controlled trial

BackgroundApplication of topical anesthetic agent prior to injection is the most commonly used method to control initial needle penetration pain of local anesthetic injection. Ice and vibration stimulus application are other nonpharmacologic methods used to reduce painful sensations of injection. The present study aims to verify and compare topical anesthetic, ice pretreatment, and electric toothbrush as a vibratory device, to reduce the pain of local anesthetic injections.The study was conducted on children aged 5–12 years, requiring extraction of a maxillary primary tooth. A randomized control trial design was used wherein each child was randomly assigned by permuted block randomization design method to receive either lignocaine 5% as topical anesthetic or ice pretreatment or motorized toothbrush as a vibratory device during local anesthetic injections. Sound, eye, and motor (SEM) scale was used for objective evaluation of pain during injection, and Faces Pain Scale (FPS) was used for subjective evaluation. For statistical analysis, nonparametric test — Kruskal Wallis/ANOVA test for three groups and between two groups Mann–Whitney U-test, was used to compare SEM and FPS values. Level of significance chosen was p < 0.05.ResultsSEM (palatal) and FPS (palatal) scores were slightly higher in topical anesthetic group as compared to ice pretreatment or vibration group, but the differences were not statistically significant. There were no statistically significant differences among SEM (buccal) and FPS (buccal) scores in all the three groups.ConclusionsIce cooling and electric toothbrush-induced vibration were as effective as topical anesthetic for reduction in pain due to injection.Trial registrationThe CTRI number of the trial is CTRI/2021/03/032046.

Benign Adenomyoepithelioma of the Breast: Imaging Characteristics.

This study aimed to evaluate the radiological and clinical characteristics of benign adenomyoepitheliomas of the breast. Over the last 20 years, 120 patients were histologically diagnosed with breast adenomyoepithelioma (AME) at our institution. We excluded 43 patients who were incidentally diagnosed during mastectomy for breast cancer, 28 who underwent percutaneous biopsy without further excision, and 8 who had biopsy-confirmed benign AME and were found to have another pathology after complete excision. We retrospectively reviewed the clinical records and radiological findings of the remaining 41 patients with histologically diagnosed benign breast AMEs after complete excision. All 41 patients underwent US; 38 underwent mammography (MG) and US; and 18 underwent MG, US, and MRI. MG detected 38 cases with a round or oval shape (56%), and mass (89%), were non-circumscribed (62%), hyperdense (53%), and without microcalcifications (95%). Breast US revealed suspicious masses (98%) with a non-circumscribed margin (66%), hypoechogenicity (43%), and intratumoral vascularity (63%). All lesions on breast MRI showed suspicious masses (100%) with ill-defined margins (61%), and 84% showed wash-out kinetics. Benign AMEs showed suspicious features of Breast Imaging Reporting and Data System (BI-RADS) category 4 or 5 in 83%-95% of the MG, US, and MRI. Sixteen of the 41 cases were misdiagnosed on the initial core needle biopsy and two were diagnosed as malignancy. Benign breast AME often shows suspicious radiological features mimicking a malignant mass on MG, US, and MRI. Differentiating benign AME from other pathologies might be difficult on core needle biopsy, and complete excision is needed for a correct diagnosis.

Clinicopathological Characteristics of Primary Pulmonary Hodgkin Lymphoma (PPHL): Two Institutional Experiences with Comprehensive Literature Review of 115 PPHL Cases

Primary pulmonary Hodgkin lymphoma (PPHL) is an extremely rare condition. Its clinicopathological characteristics remain unclear because of the limited number of patients with PPHL. The aim of this study was to comprehensively analyze the clinicopathological characteristics of PPHL. We reviewed the electronic medical records and pathology slides of our 10 PPHL patients. The female-to-male ratio was 6:4, and the mean age was 41 years. Although three patients had no symptoms, seven had localized or generalized symptoms, including cough, sputum, chest discomfort/pain, and weight loss. Some cases had not been diagnosed as PPHL in the initial needle biopsy. Four patients underwent surgical resection. With chemotherapy, eight patients achieved complete remission. We also conducted a thorough literature review on 105 previously reported PPHL cases. Among a total of 115 PPHL cases, the most common subtype was nodular sclerosis (37.4%). More than half of the cases (55%) were clinically suspected as infectious pneumonia. Of 61 patients whose biopsies were available, 27 (44.3%) were diagnosed correctly as Hodgkin lymphoma, whereas the misdiagnoses included tuberculosis, Langerhans cell histiocytosis, solitary fibrous tumor, and adenocarcinoma. We demonstrated that PPHL represents a diagnostic challenge on small biopsies. Recognizing that this rare tumor can mimic infectious and inflammatory diseases as well as malignancies is important because the accurate diagnosis of PPHL is essential for adequate clinical management.

PO24 Presentation Time: 7:40 AM: Impact of Intra-Operative MRI-Guidance on Dose Escalation to the HR-CTV Using Advanced Gynecological Applicators

<h3>Purpose</h3> To quantify the impact of intraoperative MRI-guidance on implant quality for patients receiving brachytherapy (BT) for cervical cancer by calculating dose to the HR-CTV and OARs at three stages of the implant procedure. <h3>Materials and Methods</h3> Three patients enrolled on an IRB-approved prospective clinical trial were treated with EBRT followed by two fractions of pulsed-dose rate (PDR) brachytherapy. For each patient, one of the two PDR implants was performed in a dedicated MRI-Operating Room (MRI-OR) using 3.0 T MRI-guidance (Discovery MR750w, GE Healthcare, Waukesha, WI). An Advanced Gynecological Applicator (AGA) was used for each of the implants. Straight or straight and oblique needle trajectories were used. 3D T2-weighted MRI scans were acquired at three time points during the procedure: (1) following placement of the intracavitary components of the hybrid applicator (initial); (2) following initial needle selection and advancement (intermediate); and (3) following final modifications of implant position (final). The first scan was used to inform needle selection and estimate the appropriate advancement depth for each needle. The second scan was used to determine if modifications to the implant were necessary, including advancement of additional needles, removal of previously advanced needles, or modification of advancement depth. The final scan was used to generate a clinical plan for patient treatment. The titanium obturators used to advance the needles were replaced with C4 positive-contrast imaging markers (C4 Imaging, Houston, TX) prior to each scan to facilitate needle digitization during treatment planning. Retrospective plans were generated on the initial and intermediate scans for each of the three patients and compared to the final plans used for treatment. AGA solid applicator models were registered to the initial and intermediate MRI scans. Needles present at the time of scanning were manually digitized in the Oncentra Treatment Planning System (Elekta, Stockholm, Sweden). Clinical treatment plans were optimized to meet EMBRACE dose constraints. For a given patient, the initial and intermediate plans were optimized to escalate dose to the HR-CTV without exceeding the clinical doses delivered to the OARs. The dose-limiting structure varied based on the patient's anatomy and implant geometry. For each patient, the HR-CTV D90 and bladder, rectum, and sigmoid D2cc doses were compared between the initial, intermediate, and final plans. <h3>Results</h3> One needle was advanced during the first patient's implant. Activity was loaded into the tandem, ovoids, needle, and vaginal caps. The dose to the HR-CTV increased by 4.6 Gy between the initial and intermediate plans and 3.0 Gy between the intermediate and final plan used for treatment. The final dose to the HR-CTV was 10.2% greater than the initial HR-CTV dose. Five needles were advanced for the second patient. The dose to the HR-CTV increased by 3.8 Gy between the initial and intermediate implants and 0.96 Gy between the intermediate and final plan used for treatment. The final dose to the HR-CTV was 5.8% greater than the initial HR-CTV dose. Eight needles were advanced for the third patient. Dose to the HR-CTV increased by 8.3 Gy between the initial and intermediate implants and 5.7 Gy between the intermediate and final plans. The final dose to the HR-CTV was 19.7% greater than the initial HR-CTV dose. None of the OAR doses in the initial or intermediate plans exceeded the OAR doses delivered clinically. <h3>Conclusions</h3> Performing interstitial implants using an AGA under MRI-guidance improves implant quality, defined by dose escalation to the HR-CTV and maintenance of OAR doses.

GRANULOMATOUS REACTION TO A MEDIASTINAL SEMINOMA

GRANULOMATOUS REACTION TO A MEDIASTINAL SEMINOMA

Study and experimental investigation of insertion force modeling and tissue deformation phenomenon during surgical needle-soft tissue interaction

Surgical needle insertion is generally used in the current advanced surgery process, particularly in the area of biopsy, MIS or minimally invasive surgery, brachytherapy, etc. During the needle insertion performance into the soft tissue, one of the most important issues is the tissue deformation that affects the needle engagement inside the tissue material. We have presented an energy-based insertion model, and the conical shape of deformed tissue is assumed. The tests are performed on PVA gel samples, and the model is analyzed to determine the tissue deformation volume during needle insertion into soft tissue. The procedures for evaluating the puncture force which creates the deformation of the contact point. With the help of the needle insertion experimental investigation, a geometric model of tissue deformation phenomenon and insertion force was investigated. The active needle-soft tissue contacts are studied, and with the help of the energy-based insertion model, the different factors like strain energy, potential, and dissipated energies are investigated. The tests are completed on the tissue mimic PVA gel samples, and the results show the volume and area of tissue deformation; at the time of initial needle insertion, the maximum tissue deformation arises and during the needle movement in the post-perforation stage, the deformation gradually decreases as the more peripheral work is altered into the vicious and degenerate energies. The maximum insertion force was noticed in 14° bevel angle needle tip and at 3 mm/s needle insertion speed, the volume of tissue deformation was maximum. The maximum deformation of the issue arises at the initial perforate position, and the distortion reduces along with the raises of the needle movement during the post-insertion period as the needle insertion work is converted into vicious and dissolute energies.

P383 ‘It's not Fungus, its Nocardia’—an elementary diagnostic challenge for draining sinus on abdominal wall (rare): a case report

Poster session 3, September 23, 2022, 12:30 PM - 1:30 PMIntroductionA rare finding of abdominal wall clinical presentation of persistent progressive tumefaction with draining sinus with no granules caused by Nocardia brasiliensis.MethodsHistory: A 22-year-old presented to the Dermatology OPD with complaints of swelling and tenderness and discharging sinuses with no granules around the periumbilical region in the lower abdominal area for three years. His initial fine needle aspiration cytology specimen report was inconclusive. He received anti-Kochs treatment based on a positive Montoux test and family history from outside the hospital.Initially punch biopsy samples were sent for fungal processing to our laboratory which was inconclusive. Repeat pus aspirate and punch biopsy samples were subjected to conventional techniques. The sample was inoculated on Sabouraud's Dextrose agar, Brain heart Infusion agar, and Lowenstein-Jensen media. Direct Smear was subjected to Gram stain and Modified Zeihl Neelson stain with 1% Sulfuric acid as decoloriser.ResultsOn Gram stain, Gram-positive filamentous bacilli against a background of pus cells in pus aspirate only (not in punch biopsy specimens).Modified Zeihl Neelson stain with 1% Sulfuric acid decoloriser was performed on all three samples. Beaded acid-fast filamentous bacilli with plenty of pus cells in the background were seen in pus aspirate only (not in punch biopsy specimens).No fungal elements were observed on the 20% KOH mount.Clinicians were notified immediately with the provisional report of possible Actinomycetoma due to Nocardia sp.Growth was observed within 9 days on SDA as well as LJ. It was a chalky white, dry colony to begin with that turned orangish-yellow in another week's time. Smear from the colony showed Gram-positive filamentous bacilli which on Modified ZN Smear were acid-fast filamentous beaded bacilli. The isolate was identified as Nocardia species. This was further confirmed as Nocardia brasiliensis by MALDI-TOF.On admission, the patient was initially started on Inj. Amikacin and then changed to Modified Raman regime of double dose Cotrimoxazole and Gentamicin. His lesions started showing improvement over 2 weeks of in-patient treatment. He was discharged on oral treatment thereafter.ConclusionAbdominal wall clinical presentation of persistent progressive tumefaction with draining sinus with no granules caused by N. brasiliensis is a rare clinical entity as Mycetoma. The differential diagnosis would lead to either bacterial or fungal etiology or neoplasia.Delay in correct diagnosis led to the chronicity of the clinical presentation with inappropriate therapy.For a chronic destructive debilitating infective mycetoma presentation, appropriate microbiological diagnostics become essential to have early correct detection with proper sampling technique to guide the appropriate therapy as per the causative pathogen.