Initial Presentation Research Articles

PD-1 Inhibitor Induced Hypertrophic Lichen Planus: A Case Report.

PD-1 inhibitors have revolutionized cancer therapies and are being used to treat an expanding array of cancers. To best serve patients, clinicians should be familiar with the spectrum of skin manifestations associated with PD-1 inhibitor therapy. Here, we report a unique case of hypertrophic lichen planus (HLP) in a 64-year-old man treated with pembrolizumab; the presentation initially suggested a squamous cell carcinoma (SCC) morphology, then evolved into a morphology more typical of hypertrophic lichen planus. This case underscores the need for caution in diagnosing eruptive SCCs associated with PD-1 inhibitor therapy. In such instances, maintaining a high suspicion for lichenoid reactions as sequelae of PD-1 inhibitor treatment and starting an empiric trial of therapy for lichenoid dermatitis may be warranted to ensure timely management of lesions. We describe a case of hypertrophic lichen planus mimicking squamous cell carcinoma in the setting of PD-1 inhibitory therapy with pembrolizumab. A PubMed literature review was conducted to identify other cases and determine the incidence of lichenoid reactions imitating squamous cell carcinoma in the setting of PD-1 inhibitor use. Our case is one of the few available pieces of literature describing eruptive hypertrophic lichen planus imitating SCC in the setting of PD-1 inhibitor use. Initial skin nodule biopsy appeared histologically compatible with squamous cell carcinoma. Repeat biopsy of the skin lesions revealed histological features consistent with hypertrophic lichen planus. Over time, lower extremity lesions evolved into a more typical appearance of hypertrophic lichen planus. Treatment with topical 0.05% clobetasol ointment and oral acitretin 25mg led to complete resolution of lesions within 2-3 months. This case underscores the significance of maintaining vigilance for lichenoid reactions as potential sequelae of PD-1 inhibitor therapy. It highlights the variability in initial presentation and the potential for lesions to transform over time. Timely recognition and appropriate management, including high-potency topical corticosteroids and oral acitretin, are crucial for achieving favorable outcomes in patients experiencing such reactions. More studies are necessary to fully analyze the rate of HLP occurrence as a consequence of PD-1 inhibitor use.

Chasing shadows: Investigating X chromosome mediation in late-onset Alzheimer’s disease

Alzheimer’s disease (AD) is a major cause of dementia. While maternal inheritance has been recognized for late-onset AD (LOAD), risk factors have not been identified consistently on the X chromosome. We recently developed a new method to identify an apparent risk of 70% mediated by the X chromosome in newly-presenting cognitive disorders clinic patients with amnestic mild cognitive impairment (aMCI) or early LOAD with unilateral parental lineage for AD or dementia. We sought to confirm our preliminary findings in the Utah Population Database (UPDB). We obtained previously published aggregate data on the risk of AD in the UPDB based on family history, stratified the data by the sex of the proband, and analyzed them using the new method. The X chromosome-attributable relative risk was estimated by calculating the following: Odds ratio (OR) = (women with paternal lineage: Women with maternal lineage)/(men with paternal lineage: Men with maternal lineage). The proportion of genetic risk attributable to the X chromosome is equal to (OR-1)/OR. The analysis did not reveal any risk mediated by the X chromosome, and the null result could be attributed to methodological limitations. Factors that impact the initial or early presentation (incidence) of LOAD, which are appropriate for consideration as risk factors, may not be detectable in a (prevalent) population of deceased individuals. Thus, epidemiological evidence for the contribution of the X chromosome to the development of LOAD will need to be sought prospectively in incident patient populations with newly diagnosed, biologically-confirmed aMCI or LOAD.

Optical coherence tomography features in vitreoretinal lymphoma compared with non-infectious uveitis

BackgroundVitreoretinal lymphoma (VRL) is a rare intraocular malignancy that poses a diagnostic challenge due to the non-specific clinical presentation that resembles uveitis. The use of spectral domain optical coherence tomography (SD-OCT) has emerged as a valuable imaging tool to characterize VRL. Therefore, we sought to determine the specific OCT features in VRL compared to the uveitides.MethodsRetrospective chart review of patients who were seen at Mayo Clinic from January 1, 2010 through December 31, 2022.The medical records and SD-OCT images at time of initial presentation were reviewed in patients with biopsy-proven VRL, intermediate uveitis, or biopsy-confirmed sarcoid posterior uveitis. Patients with VRL or similar uveitides including intermediate uveitis or sarcoid posterior uveitis were included.ResultsThere were 95 eyes of 56 patients in the VRL group and 86 eyes of 45 patients in the uveitis group, of whom 15 (33.3%) were diagnosed with intermediate uveitis and 30 (66.7%) with sarcoid chorioretinitis. The SD-OCT features more commonly seen at initial presentation in VRL patients (vs. uveitis) included preretinal deposits (31.6% vs. 9.3%, p = 0.002), intraretinal infiltrates (34% vs. 3.5%, p < 0.001), inner retinal hyperreflective spots (15.8% vs. 0%, p < 0.001), outer retinal atrophy (22.1% vs. 2.3%, p < 0.001), subretinal focal deposits (21.1% vs. 4.7%, p = 0.001), retinal pigmented epithelium (RPE) changes (49.5% vs. 3.5%, p < 0.001), and sub-RPE deposits (34.7% vs. 0%, p < 0.001). Features more frequently seen in uveitis included epiretinal membrane (ERM) (82.6% vs. 44.2%, p < 0.001), central macular thickening (95.3% vs. 51.6%, p < 0.001), cystoid macular edema (36% vs. 11.7%, p < 0.001), subretinal fluid (16.3% vs 6.4%, p = 0.04), and subfoveal fluid (16.3% vs. 3.2%, p = 0.003). Multivariate regression analysis controlling for age and sex showed absence of ERM (OR 0.14 [0.04,0.41], p < 0.001) and absence of central macular thickening (OR 0.03 [0,0.15], p = 0.02) were associated with VRL as opposed to uveitis.ConclusionOCT features most predictive of VRL (vs. uveitis) included absence of ERM and central macular thickening.

Open Microsurgical Cerebral Aneurysm Treatment After Failed Endovascular Therapy: An Evaluation of Aneurysm Treatment Frequencies in All Neurovascular Centers Across Austria and the Czech Republic Over 20 Years.

Endovascular treatment of cerebral aneurysms has tremendously advanced over the past decades. Nevertheless, aneurysm residual and recurrence remain challenges after embolization. The objective of this study was to elucidate the portion of embolized aneurysms requiring open surgery and evaluate whether newer endovascular treatments have changed the need for open surgery after failed embolization. All 15 cerebrovascular centers in Austria and the Czech Republic provided overall aneurysm treatment frequency data and retrospectively reviewed consecutive cerebral aneurysms treated with open surgical treatment after failure of embolization from 2000 to 2022. All endovascular modalities were included. On average, 1362 aneurysms were treated annually in the 2 countries. The incidence increased from 0.006% in 2005 to 0.008% in 2020 in the overall population. Open surgery after failed endovascular intervention was necessary in 128 aneurysms (0.8%), a proportion that remained constant over time. Subarachnoid hemorrhage was the initial presentation in 70.3% of aneurysms. The most common location was the anterior communicating artery region (40.6%), followed by the middle cerebral artery (25.0%). The median diameter was 6 mm (2-32). Initial endovascular treatment included coiling (107 aneurysms), balloon-assist (10), stent-assist (4), intrasaccular device (3), flow diversion (2), and others (2). Complete occlusion after initial embolization was recorded in 40.6%. Seventy-one percent of aneurysms were operated within 3 years after embolization. In 7%, the indication for surgery was (re-)rupture and, in 88.3%, reperfusion. Device removal was performed in 16.4%. Symptomatic intraoperative and postoperative complications occurred in 10.2%. Complete aneurysm occlusion after open surgery was achieved in 94%. Open surgery remains a rare indication for cerebral aneurysms after failed endovascular embolization even in the age of novel endovascular technology, such as flow diverters and intrasaccular devices. Regardless, it is mostly performed for ruptured aneurysms initially treated with primary coiling that are in the anterior circulation.

Combined Direct and Indirect Revascularization for Adults with Moyamoya Disease: A Single-Center Retrospective Study

Abstract Background Moyamoya vasculopathy is a rare neurological disease characterized by the progressive constriction of major intracranial vessels and secondary collateral formation. In the past decade, the popularity of combined bypass surgery has increased. They take advantage of the quick perfusion of direct bypass and collaterals ingrowth from indirect bypass. Objective This study aimed to describe a single-center experience with surgical management of moyamoya disease (MMD) and moyamoya syndrome (MMS) over 7 years. Materials and Methods In this retrospective medical records review, we enrolled patients diagnosed with MMD and MMS who were treated with combined surgical revascularization at the Hamad Medical Corporation center between 2015 and 2022. SPSS 26.0 was used to analyze the data. Results A total of 20 patients were included, with 15% having MMS. The mean age was 37.4 ± 10.26 years, and 60% of them were males. The mean follow-up period was 13.6 months. The modified Rankin score was significantly decreased by 1.9 ± 2.1, p = 0.0001. Following surgery, no deficits were observed in 16 cases, whereas three were not improved, and one died. Following up on the stroke status, one patient developed a hemorrhagic stroke, and another showed right-side numbness. The postoperative status was substantially linked with the initial clinical presentation (p = 0.004). Conclusion Combined direct and indirect surgical revascularization procedures have favorable outcomes in MMD and MMS patients. Additional rigorous, prospective, controlled, high-quality trials with large-sample are needed to support our results.

Clinical and Laboratory Diagnosis of Antiphospholipid Syndrome: A Review.

The antiphospholipid syndrome (APS) manifests through venous or arterial thrombosis, with or without pregnancy complication alongside the continuous presence of antiphospholipid antibodies (aPL). APS classification relies on three aPL subtypes: anticardiolipin (aCL), anti-β2-glycoprotein I antibodies (anti-β2GPI), and lupus anticoagulants (LA) antibodies. Given that thrombosis and pregnancy issues are not unique to APS, the precise and reliable identification of aPL forms the basis for diagnosis. Semi-quantitative solid-phase assays identify two antibodies, aCL and anti-β2GPI, while LA detection occurs through various phospholipid-dependent coagulation assays that are based on antibody behaviour. LA, specifically, is conclusively associated with thrombosis, prompting discussions around the serological criteria for APS. Despite advancements in LA detection, the standardisation of all aPL detection assays remains imperative. The combined presence of aCL and anti-β2GPI with thrombosis inconsistently triggers concern. Initial presentations by APS patients commonly exhibit a heightened risk of stroke, miscarriages in the later stages of pregnancy, positive results of LA tests, and widespread thrombosis across multiple organs, often leading to adverse outcomes. Correctly diagnosing this condition is pivotal to avoid unnecessary long-term secondary thromboprophylaxis.

Vessel Wall Imaging in Angiogram-Negative Diffuse Subarachnoid Hemorrhage Reveals a Ruptured Lenticulostriate Aneurysm.

A patient presented with acute onset headache and subsequent unconsciousness. The neurologic exam showed left-sided myoclonic jerking and right flaccid hemiparalysis. Noncontrast computed tomography revealed diffuse subarachnoid hemorrhage (SAH) with acute hydrocephalus. Initial digital subtraction angiography (DSA) showed no culprit source for SAH. Repeat DSA on day 7 after initial presentation raised suspicion for left internal carotid artery ophthalmic segment and left lateral lenticulostriate artery (LSA) aneurysms. A magnetic resonance vessel wall imaging (VWI) exam was performed given the presence of multiple potential culprit aneurysms. Vessel wall enhancement around the dome of the left LSA aneurysm suggested rupture, which then facilitated treatment with surgical clipping. LSA aneurysms are exceedingly rare and challenging to treat. Given the associated high degree of morbidity, expedient diagnosis is critical to direct management. VWI could be a valuable tool for detecting ruptured aneurysms in the setting of angiogram-negative SAH.

Haemophagocytic lymphohistiocytosis: A rare initial presentation of microscopic polyangiitis in a three-year-old girl

No abstract available

Impact of Circulating Anti-Spike Protein Antibody Levels on Multi-Organ Long COVID Symptoms.

Patients with long COVID syndrome present with various symptoms affecting multiple organs. Vaccination before or after SARS-CoV-2 infection appears to reduce the incidence of long COVID or at least limit symptom deterioration. However, the impact of vaccination on the severity and extent of multi-organ long COVID symptoms and the relationship between the circulating anti-spike protein antibody levels and the severity and extent of multi-organ symptoms are unclear. This prospective cohort study included 198 patients with previous PCR-verified SARS-CoV-2 infection who met the criteria for long COVID syndrome. Patients were divided into vaccinated (n = 138, 69.7%) or unvaccinated (n = 60, 30.3%) groups. Anti-spike protein antibody levels were determined at initial clinical presentation and compared between the groups. Long COVID symptoms were quantified on the basis of the number of affected organs: Class I (mild) with symptoms in three organs, Class II (moderate) with symptoms in four to five organs, and Class III (severe) with symptoms in six or more organ systems. Associations between time to infection and vaccination with anti-spike protein antibody levels were assessed. The anti-spike protein antibody levels were 1925 ± 938 vs. 481 ± 768 BAU/mL (p < 0.001) in the vaccinated vs. unvaccinated patients. The circulating anti-spike antibody cutoff of 665.5 BAU/mL allowed us to differentiate the vaccinated from the unvaccinated patients. Vaccinated patients had fewer class II and class III multi-organ symptoms (Class II 39.9% vs. 45.0%; Class III 10.1% vs. 23.3%, p-value 0.014). Anti-spike antibody level correlated negatively with multi-organ symptom classes (p = 0.016; 95% CI -1.229 to -0.126). Anti-spike antibody levels in unvaccinated patients declined markedly with time, in contrast to the persistence of high anti-spike antibody levels in the vaccinated patients. Multi-organ symptoms were lower in vaccinated long-COVID patients, especially in those with higher anti-spike antibody levels (≥665.5 BAU/mL). Classifying the symptoms on the basis of the number of affected organs enables a more objective symptom quantification.

18F-AlF-NOTA-octreotide PET/CT in the localization of tumor-induced osteomalacia: case series and literature review.

This study explores tumor-induced osteomalacia (TIO) through a case series and literature review, assessing the diagnostic potential of 18F-AlF-NOTA-octreotide (18F-OC) positron emission tomography/computed tomography (PET/CT). We analyzed TIO patients who underwent 18F-OC PET/CT. Parameters such as tumor dimension, the maximum standardized uptake value (SUVmax), the mean standardized uptake value (SUVmean) and metabolic tumor volume (MTV) were meticulously assessed. Clinical features and imaging characteristics pertinent to TIO were reviewed. 6 patients with clinical suspicion of TIO exhibited hypophosphatemia (0.25 to 0.64 mmol/L), elevated alkaline phosphatase (ALP) levels (142 to 506 U/L), and increased parathyroid hormone (PTH) levels (92.9 to 281.7 pg/mL). Of these patients, two underwent FGF-23 testing, with results of 3185.00 pg/ml and 17.56 pg/ml, respectively. Conventional imaging modalities depicted widespread osteoporosis, with several cases demonstrating fractures indicative of osteomalacic and associated pathological fractures. Subsequent 18F-OC PET/CT facilitated the accurate localization of causative tumors, with histopathological examination confirming the diagnosis of phosphaturic mesenchymal tumor (PMT). The interval from initial clinical presentation to definitive TIO diagnosis spanned approximately 2.5 years (range: 1 - 4 years), with tumors varying in size (maximum diameter: 7.8 to 40.0mm), SUVmax (5.47 to 25.69), SUVmean (3.43 to 7.26), and MTV (1.27 to 18.59 cm3). The implementation of whole-body 18F-OC PET/CT imaging emerges as a critical tool in the identification of occult tumors causing TIO. Future investigations incorporating a broader cohort are imperative to further delineate the diagnostic and therapeutic implications of 18F-OC PET/CT in managing TIO.

Safety of pressurized intraperitoneal aerosolized chemotherapy (PIPAC) in patients (pts) with biliary tract cancer with peritoneal metastases.

TPS4186 Background: Biliary tract cancers are rare with the majority of pts diagnosed with metastatic disease at initial presentation. Up to 20% of pts will have peritoneal metastases, resulting in symptoms of ascites, abdominal pain, and potential bowel obstruction. Despite advances in standard of care systemic treatments such as combination gemcitabine, cisplatin, and durvalumab (gem/cis/durva), penetration to peritoneal metastases may be poor. While addition of nab-paclitaxel to gem/cis increased objective response in a phase 2 study (1), SWOG 1815 did not demonstrate a significant improvement in survival with the triplet combination compared to gem/cis (2), possibly due to added toxicity. PIPAC directly delivers treatment to the peritoneal space, which could potentially reduce toxicity and improve efficacy. We aim to investigate the safety of PIPAC nab-paclitaxel plus systemic gem/cis/durva in biliary tract cancer pts with peritoneal metastases. Methods: This is an investigator-initiated, non-randomized phase 1 trial enrolling up to 12 evaluable pts using a modified phase 1 queue 3+3 design. Eligible pts must have treatment-naïve histologically or cytologically confirmed intra/extra-hepatic cholangiocarcinoma or gallbladder cancer with documented metastatic disease and visible peritoneal disease on imaging or laparoscopy. Gem/cis (800/25 mg/m2) will be administered on Days 1 and 8 of 3-week cycles; durva (1500 mg) will be administered on Day 1. Pts will receive PIPAC nab-paclitaxel (90 mg/m2) on Day 3 of Cycles 1, 3, and 5. If dose-limiting toxicities (DLTs) occur, nab-paclitaxel may be reduced to 70 mg/m2; the DLT window for each pt is 42 days after the first PIPAC. After eight 3-week cycles, durva (1500 mg) will be continued on Day 1 of 4-week cycles until disease progression or unacceptable toxicity. The primary endpoint is treatment-related adverse events (AEs) graded by NCI Common Terminology Criteria for Adverse Events version (v) 5.0. AEs will be monitored during treatment and for 4 weeks after the last dose of treatment with any agent. Secondary endpoints include objective response per Response Evaluation Criteria in Solid Tumors v1.1, peritoneal regression grading score at each PIPAC, peritoneal carcinomatosis index at time of laparoscopy, post-operative surgical complications, progression-free/overall survival, PIPAC technical failure rate, EQ-5D-5L and MD Anderson Symptom Inventory responses before/during treatment, and number of daily steps taken before/during treatment. Exploratory endpoints include characterization of sub-clonal tumor evolution/tumor microenvironment changes and PIPAC nab-paclitaxel pharmacokinetics/pharmacodynamics. Enrollment began 6/2023 and is ongoing. 1. Shroff et al, JAMA Oncol 2019. 2. Shroff et al, JCO 2023 LBA490. Clinical trial information: NCT05285358 .

Establishing palliative care in tribal and rural Indian setting: A participatory action research approach.

e24085 Background: We established a palliative care center in the tribal area of Santhal Pargana, India, under a tertiary care facility, as a crucial step in addressing the palliative needs of oncology patients. This study assesses the center's inaugural year, focusing on referral patterns, morphine consumption, and pain management. Methods: Data from all patients visiting the palliative care outpatient department (OPD) in 2023 were prospectively collected and analyzed. The study focused on key palliative care indicators, including morphine consumption, patient referrals, and the mean Numeric Rating Scale (NRS) pain score after initial consultation. The PAR approach was utilized to tailor services to the community's needs. Results: The center observed an increase in patient referrals, from 8 new patients in January to 19 by December. The patient demographic primarily comprised individuals with head and neck cancer (43%), followed by breast cancer (28%) and gall bladder cancer (12%), alongside other types such as cervix, sarcomas, lung, and adult hematolymphoid malignancies. Bone metastasis was present in 46 (55.4%) patients at initial presentation. Morphine consumption demonstrated a notable rise, from 840 mg in May to 2860 mg in December, totaling 9800 mg for the year. The mean NRS pain score improved significantly from 6.5 in January to 4.3 post-initial consultation. The center maintained an overall median of 3 consultations per patient, and bereavement support was provided to 13 (15.7%) patients. Conclusions: The integration of the Participatory Action Research approach, specifically the CTC-5, was instrumental in the successful initiation and expansion of palliative care services within the center. The structured training, mentorship, and organizational restructuring, facilitated by the program, were crucial in establishing a modest palliative care infrastructure. This comprehensive approach not only enhanced care delivery but also ensured the sustainability and adaptability of palliative services, effectively addressing the gap in palliative care in rural, tribal settings.

Outcomes of very young women and adolescent (VYWAA) with breast cancer (BC) in rural and urban Saskatchewan: A population-based cohort study.

1571 Background: BC is uncommon in VYWAA (≤ 35 years) and accounts for about 1.8% of all BC. As BC screening is typically recommended for women aged 50-74 years there is a risk of delayed diagnosis of BC in VYWAA especially those with rural residence. The current study aims to assess outcomes of a cohort of VYWAA with BC in relation to their place of residence in the province of Saskatchewan over a period of 20 years. Methods: In this population-based retrospective cohort study all women ≤ 35 years with histologically documented epithelial BC during 2000-2019 were evaluated. Survival of the entire cohort and its subgroups was estimated using the Kaplan−Meier method, and the survival distribution of different groups was compared by the log rank test. A multivariate Cox proportional hazard model was performed. Various clinical and demographic variables were examined for their prognostic importance of overall survival (OS) for all stages and disease-free survival (DFS) for early-stage BC. Results: 248 eligible women with a median age of 32 years were identified, 24% were &lt;30 years of age. Of all patients, 51% had node positive disease, 7% had DCIS, 15% stage I, 42% stage II, 22% stage III and 11% had stage IV disease at initial presentation. Among them 42% had hormone receptor +, 28% had HER2 + and 23% had triple negative BC (TNBC).16% developed BC within 1-year of pregnancy. 53% were rural resident and 47% were urban resident. Significant differences were noted between the two groups regarding smoking history (42 vs. 25%), HER2+BC (35% vs. 20%) and mean platelet count (285 vs. 258). Median follow up for all women was 91 months with a total follow up period of 294 months. Median DFS of VYWAA with stage I to III disease has not reached. 10-year estimated DFS of all women was 66%. 10-year DFS for stage I and II was 73% and 75%, respectively, vs. 43% for stage III (p&lt;0.001). Median OS of entire cohort with stage 0-IV BC has not reached. 10-year OS of all VYWAA was 69%. 10 years OS of urban women was 79% compared to 65% for rural resident (p=0.041). 10-year OS of women age &gt;30 years was 74% compared to 62% for age 26-30 years and 55% for age &lt;26 (p=0.35).10 years OS of VYWAA with non-TNBC was 73% compared to 63% for with TNBC (p=0.028). On multivariate analysis for women with early-stage disease, stage III BC, HR, 3.0 (1.80-4.92) and grade III BC were significantly correlated with inferior DFS. On a multivariate analysis for OS of all VYWAA with stage 0 to IV disease, rural residence, HR, 1.75 (1.08-2.81); TNBC, HR, 2.25 (1.34-3.80), and stage IV disease, HR, 8.1 (4.72-13.94) were correlated with inferior OS. Conclusions: Very young women and adolescent with BC have a high incidence of node-positive disease and HER2+ and TNBC subtypes. TNBC and grade III disease were associated with inferior DFS in stage I-III disease whereas stage IV BC, TNBC and rural residence were correlated with inferior survival in women with stage 0-IV disease.

Large Medically Resistant Intramuscular Fast-Flow Vascular Anomaly in a Young Adult Patient Managed With Embolization and Cryoablation

Background: Mitogen-activated protein 2 kinase (MAP2K) intramuscular high-flow vascular anomaly is a benign vascular lesion, thought to be congenital, with an indolent course. Years after initial presentation, symptoms may manifest due to abrupt growth. Case presentation: This report describes a case of a young female who presented with a MAP2K high-flow vascular anomaly with recalcitrant pain, resistant to a trial of Sirolimus and Trametinib. Significant lesion size reduction and pain resolution were achieved with a combination of preablation embolization followed by cryoablation. Follow-up of 5 years informs lesion reduction and stability. Conclusion: Using a multi-method approach (embolization then ablation) can be considered in the treatment of MAP2K high-flow vascular malformations resistant to medical therapy.

Improving LDCT screening rates within a large multidisciplinary community based practice using integrated ACR accredited imaging centers.

e13582 Background: Lung cancer remains the leading cause of cancer-related death in the US, accounting for about 22% of such deaths. Lung cancer detected by low-dose computed tomography (LDCT) screening is discovered at an early stage 64-85% of the time. The benefits of LDCT screening have been demonstrated in numerous trials, but there has been difficulty in establishing programs that screen a high percentage of eligible patients. We present data from the first 18 months of our lung cancer screening program that is designed to provide the highest quality screening, follow-up and access to prevention, diagnosis, and treatment including clinical trials within their local communities. Methods: New York Cancer and Blood Specialists (NYCBS) is a community practice with over 50 locations across NY. While most lung cancer screening programs are hospital-based, NYCBS has a series of American College of Radiology (ACR) accredited imaging centers that perform these screenings and are closely affiliated with oncology, primary care, Ob-Gyn, nephrology, urology and other specialty medical and surgical practices. These centers are strategically located in areas that have high rates of tobacco use as suggested by heat map data from the NY City Community Health Survey . Upon initial patient presentation, all NYCBS and affiliated sites screen patients with tablet-based questionnaires that prompt additional questions during follow-up appointments. Patients with positive findings are discussed during a monthly, system-wide multidisciplinary lung nodule review conference. Follow-up interventions include referrals to pulmonology, interventional radiology, or further imaging with PET/CT. Per ACR guidelines, patients not requiring acute intervention continue with follow-up CT. Results: In 2023, 29,501 patients were screened with an in-office questionnaire. Of those patients, 3,606 were eligible for screening, 225 declined, and 896 (29%) high risk patients proceeded to undergo LDCT screening. In screened patients, 128 underwent follow-up CT, 36 patients had findings requiring immediate intervention, and 6 were diagnosed with lung cancer. 5 of these patients were diagnosed with stage I and 1 patient was diagnosed with stage IV lung cancer. Conclusions: LDCT screening is a proven method to discover early stage lung cancer and improve the survival rate of diagnosed patients but has not been well adopted in practice. With access to a diverse array of multidisciplinary practices across NY and integrated accredited imaging centers, we have increased the accessibility of lung cancer screening and improved transitions to follow-up care. Nationally, only 4.5% of patients at high risk are screened, however, we found that with our approach to patient care, we have achieved among the highest reported screening rates in eligible individuals.

A case of multiple myeloma misdiagnosed as seronegative rheumatoid arthritis: a rare case report

Introduction: Multiple myeloma (MM) is a malignant plasma cell proliferation producing large numbers of monoclonal immunoglobulins. Typical MM symptoms include anemia, bone pain, hypercalcemia, and renal failure. Atypical presentations like joint involvement were rarely reported in the literature and may cause significant delays in treatment and adverse outcomes. Case presentation: The authors report a case of a 54-year-old female who presented with symmetrical polyarthritis and was misdiagnosed with rheumatoid arthritis. The diagnosis of MM was made after failing many treatments of rheumatoid arthritis and with further laboratory tests and procedures. Conclusion: This rare manifestation of MM carries a diagnostic challenge and causes a significant delay in treating such patients. Here, the authors report this unusual initial presentation with a review of several cases in the literature describing similar presentations.

Disparities in the initial presentation of melanoma across two socioeconomically diverse New York City neighborhoods.

1593 Background: Disparities in stage at diagnosis among melanoma patients are often seen between urban and rural communities, with patients in rural areas being diagnosed with more advanced tumors. Factors contributing to the disparities include decreased access to dermatologists in rural areas, and lower socioeconomic status (SES). We investigated urban disparities in melanoma T stage at diagnosis among patients residing in 2 New York City (NYC) neighborhoods of differing SES and receiving care within the NYU Langone Health System. The neighborhoods were: Upper East Side (UES) and Brighton Beach/Coney Island (BB/CI). Methods: We conducted a retrospective chart review (NYU IRB 23-01020) of melanoma patients (N=243) diagnosed from 2018-2022 using ICD-10-CM codes: C43 (malignant melanoma of skin); D03 (melanoma in situ); and Z85.820 (personal history of malignant melanoma of skin). For community-level data we used the American Academy of Dermatology’s “Find a Dermatologist” search function to locate member-dermatologists; New York State Cancer Registry data (2016-2020) to determine annual melanoma incidence; and the United States Census Bureau Public Use Microdata Areas to determine the proportion of Non-Hispanic Whites (NHW), income levels, and educational attainment. The distribution of T stages was compared using a chi-square test. A two-sample test was used to assess equality of proportions. Results: In UES, the annual melanoma incidence was 30.2/100,000 (95% CI: 27.4-33.2); NHW comprised 74.6% of the population; the median household income was $135,820; 78% attained education higher than high school; and there are 190 dermatologists within a 0.5-mile radius. In BB/CI the annual melanoma incidence was 14/100,000 (95% CI: 11.6-16.9); NHW comprised 55.1% of the population; the median household income was $43,118; 46% attained education higher than high school; and there is 1 dermatologist within a 0.5-mile radius. There are 15 dermatologists within a 3.0-mile radius. 155 and 88 patients met inclusion criteria in UES and BB/CI respectively. The distribution of T stages (i.e. Tis to T4) was significantly different between UES and BB/CI with higher proportions of advanced stage tumors in BB/CI (p=0.0002). Specifically, the proportion of (T2+T3+T4) tumors/total melanomas was 35/155 (23%) in UES; and 41/88(47%) in BB/CI (p&lt;0.0001). For reference, the proportion of T2+T3+T4 melanomas in the United States is 30%. Conclusions: We identified substantial disparities in the initial presentation of melanoma in 2 NYC neighborhoods, with proportionately more advanced stage tumors in the community of low educational attainment, less access to dermatologic services, and lesser household income. Neighborhood-based approaches to uncover melanoma disparities can identify areas for community outreach and engagement efforts to improve melanoma awareness and access to dermatologic care.

Area Postrema Syndrome as the Initial Presentation of CNS Tuberculosis.

Area Postrema Syndrome as the Initial Presentation of CNS Tuberculosis.

Evaluation of an ambulatory care pathway for patients with nitrous oxide-induced myeloneuropathy

IntroductionCases of nitrous oxide (N2O)-induced myeloneuropathy are increasing at UK hospitals. At our centre, a dedicated ambulatory care pathway, endorsed nationally, was established to treat and monitor patients with N2O-myeloneuropathy...

Conversion surgery for initially unresectable locally advanced biliary tract cancer: A multicenter collaborative study conducted in Japan and Korea.

Although surgical resection is the only curative treatment for biliary tract cancer, in some cases, the disease is diagnosed as unresectable at initial presentation. There are few reports of conversion surgery after the initial treatment for unresectable locally advanced biliary tract cancer. This study aimed to evaluate the efficacy and safety of conversion surgery in patients with initially unresectable locally advanced biliary tract cancer. We retrospectively collected clinical data from groups of patients in multiple centers belonging to the Japanese Society of Hepato-Biliary-Pancreatic Surgery and Korean Association of Hepato-Biliary-Pancreatic Surgery. We analyzed two groups of prognostic factors (pretreatment and surgical factors) and their relation to the treatment outcomes. A total of 56 patients with initially unresectable locally advanced biliary tract cancer were enrolled in this study of which 55 (98.2%) patients received chemotherapy, and 16 (28.6%) patients received additional radiation therapy. The median time from the start of the initial treatment to resection was 6.4 months. Severe postoperative complications of Clavien-Dindo grade III or higher occurred in 34 patients (60.7%), and postoperative mortality occurred in five patients (8.9%). Postoperative histological results revealed CR in eight patients (14.3%). The median survival time from the start of the initial treatment in all 56 patients who underwent conversion surgery was 37.7 months, the 3-year survival rate was 53.9%, and the 5-year survival rate was 39.1%. Conversion surgery for initially unresectable locally advanced biliary tract cancer may lead to longer survival in selected patients. However, more precise preoperative safety evaluation and careful postoperative management are required.