Intraoperative Biopsy Research Articles

Intraoperative Confocal Laser Endomicroscopy Ex Vivo Examination of Tissue Microstructure During Fluorescence-Guided Brain Tumor Surgery.

BackgroundNoninvasive intraoperative optical biopsy that provides real-time imaging of histoarchitectural (cell resolution) features of brain tumors, especially at the margin of invasive tumors, would be of great value. To assess clinical-grade confocal laser endomicroscopy (CLE) and to prepare for its use intraoperatively in vivo, we performed an assessment of CLE ex vivo imaging in brain lesions.MethodsTissue samples from patients who underwent intracranial surgeries with fluorescein sodium (FNa)–based wide-field fluorescence guidance were acquired for immediate intraoperative ex vivo optical biopsies with CLE. Hematoxylin-eosin–stained frozen section analysis of the same specimens served as the gold standard for blinded neuropathology comparison. FNa 2 to 5 mg/kg was administered upon induction of anesthesia, and FNa 5 mg/kg was injected for CLE contrast improvement. Histologic features were identified, and the diagnostic accuracy of CLE was assessed.ResultsOf 77 eligible patients, 47 patients with 122 biopsies were enrolled, including 32 patients with gliomas and 15 patients with other intracranial lesions. The positive predictive value of CLE optical biopsies was 97% for all specimens and 98% for gliomas. The specificity of CLE was 90% for all specimens and 94% for gliomas. The second FNa injection in seven patients, a mean of 2.6 h after the first injection, improved image quality and increased the percentage of accurately diagnosed images from 67% to 93%. Diagnostic CLE features of lesional glioma biopsies and normal brain were identified. Seventeen histologic features were identified.ConclusionsResults demonstrated high specificity and positive predictive value of ex vivo intraoperative CLE optical biopsies and justify an in vivo intraoperative trial. This new portable, noninvasive intraoperative imaging technique provides diagnostic features to discriminate lesional tissue with high specificity and is feasible for incorporation into the fluorescence-guided surgery workflow, particularly for patients with invasive brain tumors.

The Effect of Diagnostic Ureterorenoscopy on Intravesical Recurrence in Patients Undergoing Nephroureterectomy for Primary Upper Tract Urinary Carcinoma

Objective: The objective of this study is to evaluate the effect of diagnostic ureterorenoscopy (URS) prior to radical nephroureterectomy (RNU) on intravesical recurrence (IVR), in patients with primary upper urinary tract urothelial carcinoma (UTUC). Materials and Methods: Retrospective analysis of 354 patients, who underwent RNU for UTUC from 10 urology centers between 2005 and 2019, was performed. The primary endpoint was the occurrence of IVR after RNU. Patients were divided into URS prior to RNU (Group 1) and no URS prior to RNU (Group 2). Rates of IVR after RNU were compared, and a Cox proportional hazards model was used to evaluate potential predictors of IVR. Results: After exclusion, a total of 194 patients were analyzed: Group 1 n = 95 (49.0%) and Group 2 n = 99 (51.0%). In Group 1, a tumor biopsy and histopathological confirmation during URS were performed in 58 (61.1%). The mean follow-up was 39.17 ± 39.3 (range 12–250) months. In 54 (27.8%) patients, IVR was recorded after RNU, and the median recurrence time within the bladder was 10.0 (3–144) months. IVR rate was 38.9% in Group 1 versus 17.2% in Group 2 (p = 0.001). In Group 1, IVR rate was 43.1% in those undergoing intraoperative biopsy versus 32.4% of patients without biopsy during diagnostic URS (p =0.29). Intravesical recurrence-free survival (IRFS) was longer in Group 2 compared to Group 1 (median IRFS was 111 vs. 60 months in Groups 2 and 1, respectively (p< 0.001)). Univariate analysis revealed that IRFS was significantly associated with URS prior to RNU (HR: 2.9, 95% CI 1.65–5.41; p < 0.001). In multivariate analysis, URS prior to RNU (HR: 3.5, 95% CI 1.74–7.16; p < 0.001) was found to be an independent prognostic factor for IRFS. Conclusion: Diagnostic URS was associated with the poor IRFS following RNU for primary UTUC. The decision for a diagnostic URS with or without tumor biopsy should be reserved for cases where this information might influence further treatment decisions.

Early Failures of Total Knee Patients with Nickel Allergies Secondary to Carbon Fiber Debris

Aim: Currently, there are not many studies on the long-term outcomes of the specific implants used in patients with metal hypersensitivities. The purpose of this study is to report a significant number of TKA revision failures with the CFR-PEEK prosthetic knee implant with an anatomic hinge. Background: Patients can experience multiple issues following a primary Total Knee Arthroplasty (TKA). A growing body of research is finding a correlation between primary TKA failure and metal hypersensitivity, most commonly with nickel and cobalt. Because of this, knee prosthetics are being made from hypoallergenic metals, such as zirconium nitride (ZrN), to minimize the number of failures due to metal allergy. Given the relatively new development of the hypoallergenic prostheses, there is sparse data about their overall success. Objective: The purpose of this study is to report a significant number of TKA revision failures with the CFR-PEEK prosthetic knee implant with an anatomic hinge. Methods: In this study, we analyzed the sequelae of 84 patients between May 2015 to June 2020 who received a total knee revision due to a failed primary TKA with metal hypersensitivity. These patients were revised with the rotating anatomic hinge knee system, which consisted of Carbon Fiber Reinforced Poly-Ether-Ether-Ketone (CFR-PEEK implant) coated with a ZrN, Zirconium, and Chrome Nitride multi-layer surface coating with 30% polyacrylonitrile fiber content. The patients requiring an additional revision operation presented with increasing pain that showed evidence of osteolysis on plain radiographs, CT imaging, positive indium labeled WBC scans and increased uptake on bone scan. Intraoperatively, an open incisional biopsy of the surgical bed was obtained, followed by radical debridement and implantation of porex knee prosthesis. In addition, intraoperative findings included black debris that grossly stained the surrounding synovial tissue black, indicative of wear and debris from carbon fiber bearings and the anatomic hinge. Histology of the intraoperative biopsy showed the accumulation of black debris in the histiocyte, fibrosis, and perivascular cuffing of lymphocytes and multinucleated giant cells stained with black debris. Results: Of the 84 patients, 22 failed, requiring an additional revision procedure, equating to a 26 percent failure rate of the CFR-PEEK implant, averaging 25 months to failure. Conclusion: This study was meant to report the extremely high failure rate of the anatomic hinge secondary to carbon fiber debris. Perhaps carbon fiber-laden implants are not as good an option for total knee revision prosthesis because of the high failure rate compared to those with polyethylene in their hinge mechanism.

Effectiveness of transfer learning for enhancing tumor classification with a convolutional neural network on frozen sections

Fast and accurate confirmation of metastasis on the frozen tissue section of intraoperative sentinel lymph node biopsy is an essential tool for critical surgical decisions. However, accurate diagnosis by pathologists is difficult within the time limitations. Training a robust and accurate deep learning model is also difficult owing to the limited number of frozen datasets with high quality labels. To overcome these issues, we validated the effectiveness of transfer learning from CAMELYON16 to improve performance of the convolutional neural network (CNN)-based classification model on our frozen dataset (N = 297) from Asan Medical Center (AMC). Among the 297 whole slide images (WSIs), 157 and 40 WSIs were used to train deep learning models with different dataset ratios at 2, 4, 8, 20, 40, and 100%. The remaining, i.e., 100 WSIs, were used to validate model performance in terms of patch- and slide-level classification. An additional 228 WSIs from Seoul National University Bundang Hospital (SNUBH) were used as an external validation. Three initial weights, i.e., scratch-based (random initialization), ImageNet-based, and CAMELYON16-based models were used to validate their effectiveness in external validation. In the patch-level classification results on the AMC dataset, CAMELYON16-based models trained with a small dataset (up to 40%, i.e., 62 WSIs) showed a significantly higher area under the curve (AUC) of 0.929 than those of the scratch- and ImageNet-based models at 0.897 and 0.919, respectively, while CAMELYON16-based and ImageNet-based models trained with 100% of the training dataset showed comparable AUCs at 0.944 and 0.943, respectively. For the external validation, CAMELYON16-based models showed higher AUCs than those of the scratch- and ImageNet-based models. Model performance for slide feasibility of the transfer learning to enhance model performance was validated in the case of frozen section datasets with limited numbers.

Treatment of Calcific Tendinitis around the Elbow

Purpose: This study was performed to evaluate surgical outcomes in calcific tendinitis around the elbow due to persistent pain despite conservative treatment.Methods: The study retrospectively reviewed seven consecutive patients who visited Jeju National University Hospital due to pain around the elbow and underwent operative treatment due to persisting calcific lesion evidenced by radiographs and ultrasonography. The patients’ mean age was 40 years, and the average follow-up was 5 years and 10 months. Surgical procedures were performed under brachial plexus block anesthesia to remove calcific deposits at the common extensor tendon with incision around the lesion along with repair of partially ruptured tendons during the removal using nonabsorbable sutures. The patients were immobilized with a long-arm splint in a neutral position for 2 weeks after operation, followed by rehabilitation involving continuous passive motion and physical therapy for elbow joint range of motion and muscle strengthening, respectively. Intraoperative biopsy revealed inflammatory cells and microcalcification indicative of calcific tendinitis in all patients. Surgical outcome was evaluated based on patient’s subjective satisfaction under five-point grading scale, Mayo Elbow Performance Index (MEPI) score, and the Disabilities of the Arm, Shoulder and Hand (DASH) score.Results: The patient’s subjective satisfaction scale revealed “very satisfactory” in three cases and “satisfactory” in four cases. The median MEPI and DASH score were preoperatively 45 and 88.8, which improved to 85 and 36.2 at final follow-up, respectively.Conclusion: In patients with persistent pain despite aggressive conservative treatment in calcific tendinitis, direct surgical removal of calcific deposit is an effective way to resolve symptom and prevent recurrence.

Reduced Biliverdin Reductase-A Expression in Visceral Adipose Tissue is Associated with Adipocyte Dysfunction and NAFLD in Human Obesity

Biliverdin reductase A (BVR-A) is an enzyme involved in the regulation of insulin signalling. Knockout (KO) mice for hepatic BVR-A, on a high-fat diet, develop more severe glucose impairment and hepato-steatosis than the wild type, whereas loss of adipocyte BVR-A is associated with increased visceral adipose tissue (VAT) inflammation and adipocyte size. However, BVR-A expression in human VAT has not been investigated. We evaluated BVR-A mRNA expression levels by real-time PCR in the intra-operative omental biopsy of 38 obese subjects and investigated the association with metabolic impairment, VAT dysfunction, and biopsy-proven non-alcoholic fatty liver disease (NAFLD). Individuals with lower VAT BVR-A mRNA levels had significantly greater VAT IL-8 and Caspase 3 expression than those with higher BVR-A. Lower VAT BVR-A mRNA levels were associated with an increased adipocytes’ size. An association between lower VAT BVR-A expression and higher plasma gamma-glutamyl transpeptidase was also observed. Reduced VAT BVR-A was associated with NAFLD with an odds ratio of 1.38 (95% confidence interval: 1.02–1.9; χ2 test) and with AUROC = 0.89 (p = 0.002, 95% CI = 0.76–1.0). In conclusion, reduced BVR-A expression in omental adipose tissue is associated with VAT dysfunction and NAFLD, suggesting a possible involvement of BVR-A in the regulation of VAT homeostasis in presence of obesity.

MIP image derived from abbreviated breast MRI: potential to reduce unnecessary sub-nipple biopsies during nipple-sparing mastectomy for breast cancer.

To determine the value of a maximum-intensity projection (MIP) image derived from abbreviated breast MRI for excluding occult nipple-areolar complex (NAC) involvement in patients with breast cancer. This prospective study included breast cancer patients with clinically normal NACs between April 2016 and May 2019. Abbreviated breast MRI was performed, and an MIP image was generated for each patient. MIP images were examined for the following features: asymmetric nipple enhancement, tumor-nipple distance (TND), tumor diameter, lesion type, location, and multifocality. Independent predictive MIP features for occult NAC involvement were identified by univariable and multivariable logistic regression analyses. Models based on independent predictive MIP features were developed, and their diagnostic performances were evaluated using ROC analysis. The utility of an MIP image for excluding occult NAC involvement was assessed by considering NPVs across patient subgroups. Eight hundred forty-three patients (67 NAC-positive and 776 NAC-negative) were enrolled. On MIP images, asymmetric nipple enhancement (odds ratio, 6.098; p < 0.001) and TND (odds ratio, 0.564; p = 0.003) were independent predictors of occult NAC involvement. A parallel test model of "asymmetric nipple enhancement or TND ≤ 15 mm" yielded the highest AUC value (0.838) among prediction models. The NPV of MIP images for excluding occult NAC involvement was 99.5%, which was applicable across various patient subgroups. A single MIP image derived from abbreviated breast MRI has utility for excluding occult NAC involvement in breast cancer patients and reducing the number of unnecessary sub-nipple biopsies in nipple-sparing mastectomy. • On MIP images derived from abbreviated breast MRI, asymmetric nipple enhancement and tumor-nipple distance were independent predictors for occult nipple involvement in patients with breast cancer. • Negative findings on MIP image can help select patients at minimal risk of occult nipple involvement, for whom unnecessary intraoperative sub-nipple biopsies in nipple-sparing mastectomy can be omitted.

Correlation between ferromagnetic and isotopic tracers for sentinel lymph node detection in cutaneous melanoma: IMINEM study.

The usefulness of sentinel lymph node biopsy (SLNB) in staging cutaneous melanoma has been proven. Therefore, different tracers have been used to identify the sentinel lymph nodes (SLNs). The use of isotopic tracers together with radioactivity detectors allowed a much more precise and direct approach to the SLNs. However, not all centres have access to a Nuclear Medicine department hindering sentinel lymph node detection (SLND) and consequently, other markers such as ferromagnetic tracers have been evaluated looking for the same advantages and effectiveness as isotopic tracers. Ferromagnetic tracers have proven their usefulness in other cancer entities such as breast, prostate and thyroid cancer. The objective was to assess the detection and concordance rates between isotopic and ferromagnetic techniques for SLNB in cutaneous melanoma. Isotopic SLNB technique and ferromagnetic tracer were compared for cutaneous melanoma in a non-inferiority multicentre prospective study carried out in six Spanish hospitals. A total of 60 patients were recruited and 133 lymph nodes removed. The detection rate was slightly higher with ferromagnetic tracer in head-neck and trunk melanomas, and with isotopic tracer in limbs. The patients' and nodes' concordance rates between both techniques for ex vivo samples were 95% and 86% for head-neck and trunk tumours and 97% and 93% for limbs tumours, respectively. The concordance rates for involved nodes were 100% and 88.2% for patients and nodes, respectively. The intraoperative detection and biopsy of SLN in cutaneous melanoma using a ferromagnetic was a reliable alternative method to the isotopic technique in cutaneous melanomas.

Cytomegalovirus Colitis Leading to Recto-vaginal Fistula in Immunocompetent Patien

Cytomegalovirus (CMV) is a double-stranded DNA virus member of Herpesviridae family. Majority of the population is exposed to CMV, based on sero-prevalence. CMV establishes latent infection and may re-activate later and cause significant clinical manifestations, especially in immunocompromised patients, like those on immunosuppressant drugs and chemotherapy, post organ transplantation and acquired immunodeficiency syndrome. The clinical manifestations of CMV in immunocompetent people are due to primary infection and vary from mild and self-limiting to severe and debilitating. CMV colitis in immune-competent people is uncommon. The complication of CMV infection leading to colonic perforation and recto-vaginal fistula is rare in immunocompetent subjects. We report case 67 year old female who was admitted with road traffic accident with tibia and T10 vertebral fracture without any abdominal injury. She underwent spinal fixation. She later developed diarrhea with abdominal pain. Whilst investigations were underway, she developed signs of intestinal obstruction. Urgent CT scan of abdomen and pelvis confirmed intestinal obstruction with rectal perforation. Urgent laparotomy was done which confirmed diagnosis of recto-vaginal iula. Adhesiolysis and Hartmann’s procedure was performed. Intraoperative biopsy specimen of the rectum confirmed the diagnosis of CMV. She recovered after undergoing rehabilitation and treatment with Ganciclovir. She is awaiting reversal of colostomy.

Invasive and non-invasive quantification of myocardial fibrosis in primary mitral regurgitation: prognostic implications for post-operative remodelling, symptom burden and exercise capacity

Abstract Chronic primary mitral regurgitation (MR) exposes the left ventricle (LV) to volume overload and is associated with evidence of fibrosis on non-invasive imaging. It is not known whether fibrosis predicts outcome from surgery. This study aimed to 1) quantify myocardial fibrosis on histology and non-invasive imaging, 2) investigate any association between fibrosis and LV size and function, 3) determine the impact of fibrosis on post-operative outcome. Methods In a prospective observational multicentre study, 105 patients with severe MR (N=65/32/8 NYHA Class I/II/III respectively; mean age 63.1±13.4 years; male 73%; VO2max 91.2±22.4%) had multiparametric cardiac magnetic resonance (CMR), symptom assessment (Minnesota Living with Heart Failure Questionnaire (MLHFQ)) and cardiopulmonary exercise testing before and at 9 months following repair. Patients consented for up to 3 intraoperative LV biopsies for histological collagen volume fraction (CVF) quantification. Results 234 LV biopsies were feasible from 86 patients with median CVF of 14.6% [IQR 7.4–20.3]. Fibrosis was present even in NYHA Class I patients (13.6% [6.3–18.8]), and was significantly higher than the 3.3% [2.6–6.1] obtained from 8 autopsy controls without cardiac disease (P&amp;lt;0.001). Pre-operatively, there was no relationship between CVF and LV size, systolic function, ECV, late gadolinium enhancement, although it did correlate with MLHFQ (R=0.23, P=0.034). Conversely, ECV (27.4±3.3%) correlated with systolic (LVEF Rho=−0.22, P=0.029; LVESVi Rho=0.22, P=0.025, GCS Rho=0.31, P=0.002) and diastolic function (E/e' R=0.25, P=0.022), exercise capacity (%VO2max R=−0.22, P=0.030), with borderline correlation to MLHFQ (R=0.19, P=0.058). Post-operatively, although LVEF remained normal (defined as &amp;gt;50%) in all but 6 patients (LVEF pre 69.1±8.0 vs post 63.3±8.3%, P&amp;lt;0.001), there was a reduction in ECV (27.4±3.3 vs 26.6±2.8%, P=0.027) that was proportionate to its pre-operative expansion (Figure1), suggesting that fibrosis was reversible within our patients. Neither histological CVF nor ECV predicted change in LVESVi, LVEF, symptom burden or exercise capacity following repair. GCS was an independent predictor of post-operative LVESVi and LVEF on multiple linear regression models. Whilst improvements in symptom burden and exercise capacity was observed in NYHA II-III patients, this sub-group of patients failed to achieve the same level of fitness and symptom-free status as NYHA I patients (VO2max 92.2±18.8% vs 102.9±21.1%, P=0.017; MLHFQ 12 [5–26] vs 3 [0–10], P&amp;lt;0.001). Conclusions Myocardial fibrosis is present in primary MR, before the onset of symptoms. Due to its patchy nature, ECV but not fibrosis on histology is a better marker of pre-operative myocardial function and symptom status. Despite ECV reduction following successful MR surgery, symptomatic patients fail to regain exercise fitness and symptom-free status – providing further support for the benefits of early surgery. Funding Acknowledgement Type of funding source: Foundation. Main funding source(s): British Heart Foundation

Incidental Anaplastic Lymphoma in a Case of Herpetic Hepatitis

Abstract Introduction/Objective The role of Herpes Simplex Virus (HSV) virus in the development of lymphomas is unclear and poses a diagnostic challenge along with limited literature explaining the relationship between HSV and Anaplastic large-cell lymphoma (ALCL). Methods A 26-year-old female admitted for intractable fever (103.7 F), chills, and dysuria; her urine analysis was suggestive of a mild urinary tract infection. During the admission, she developed abdominal pain with subsequent CT- scan showing thickening of the gallbladder and possible cholecystic fluid. Her liver function tests were: albumin 2.8 g/dL, AST 394 U/L, ALT 303 U/L, ALP 156 U/L, total bilirubin 0.3 INR 1. A subsequent Magnetic Resonance Cholangiopancreatography (MRCP) showed heterogeneous enhancement pattern of the liver without any masses following which she underwent cholecystectomy, during which her liver was abnormal along with an enlarged peri- cholic lymph node. Intraoperative biopsy of the liver showed patchy hepatocyte necrosis and occasional hepatocytes with ground-glass nuclei. The morphologic features were suggestive for Herpes Simplex Virus (HSV) hepatitis, and an HSV immunohistochemical stain confirmed this diagnosis. Removal of the lymph node showed a sinusoidal infiltrate of atypical lymphohistiocytic cells with abundant pale cytoplasm and large moderately irregular nuclei and occasional prominent amphophilic nucleoli. A few “hallmark”-like cells with curved nuclei were noted with rare mitosis. A panel of adequately controlled immunohistochemical stains showed positivity for CD4, CD30 (variable), and CD45. CD2, CD3, CD5, CD7, CD8, CD10, CD15, CD20, CD68 (positive in adjacent macrophages), BCL2, ALK1 were negative. Results Flow cytometry was negative for a neoplastic leukocyte population with a polytypic B-cell population. Taken together, a diagnosis of ALK1 negative, ALCL was made. A subsequent CT scan revealed borderline enlarged para- aortic lymph nodes along with an increased number of non-enlarged lymph nodes in the bilateral axillary, mediastinal, lower neck, and subpectoral regions. A bone marrow biopsy performed was negative for lymphoma. Conclusion Off note, her hepatitis serology panel, CMV, and HIV screens were negative. Thus, with her unusual presenting symptoms and no signs of malignancy led to numerous workups, which further led to an infectious cause, however, the patient was ultimately discovered to have an occult ALCL.

Spontaneous Raman spectroscopy for intracranial tumors diagnostics ex vivo

Neurosurgery of intracranial tumors, especially of glial origin, is a non-trivial task due to their infiltrative growth. In recent years, optical methods of intraoperative navigation have been actively used in neurosurgery. However, one of the most widely used approaches based on the selective accumulation of fluorescent contrast medium (5-ALA-induced protoporphyrin IX) by the tumor cannot be applied to a significant number of tumors due to its low accumulation. On the contrary, Raman spectroscopy, which allows analyzing the molecular composition of tissues while preserving all the advantages of the method of fluorescence spectroscopy, does not require the use of an exogenous dye and may become a method of choice when composing a system for intraoperative navigation or optical biopsy. This work presents the first results of using the principal component method to classify Raman spectra of human glioblastoma with intermediate processing of spectra to minimize possible errors from the fluorescence of both endogenous fluorophores and photosensitizers used in fluorescence navigation. As a result, differences were found in the principal component space, corresponding to tissue samples with microcystic components, extensive areas of necrosis, and foci of fresh hemorrhages. It is shown that this approach can serve as the basis for constructing a system for automatic intraoperative tissue classification based on the analysis of Raman spectra.

S3045 An Obscure Cause of Epigastric Pain: Endometriosis

INTRODUCTION: Endometriosis is caused by endometrial gland implantation outside of the uterus. The prevalence of abdominal endometriosis is rare (0.03%–1.5% in the general population) and is commonly associated with cesarean delivery. Here we present a case of endometriosis as the cause of epigastric pain without typical symptoms or history of abdominal surgeries. CASE DESCRIPTION/METHODS: A 27-year-old female with past medical history of occasional pyrosis presented to Gastroenterology for evaluation of intermittent epigastric pain. The pain worsened with activity but was not associated with meals. She underwent esophagogastroduodenoscopy (EGD) which was negative for any abnormal findings. A CT scan with oral and IV contrast was done which was unremarkable except for fatty liver and 5 mm appendicolith without inflammatory changes. Gynecologic evaluation including ultrasound of the abdomen and pelvis was normal. She was seen in the office one month later where she continued to complain of a sharp pain near the umbilicus. Physical exam revealed a very small hernia palpable superior to umbilicus with mild tenderness on palpation. Unfortunately, she continued to experience worsening periumbilical pain which prompted her to consult with surgery one year later. Interestingly, her pain had progressed to a cyclical nature and was more noticeable just after her menstrual cycles which were reported to be normal. Patient deferred surgery of presumed umbilical hernia as she was planning on having children in the near future and pregnancy could cause recurrence. One year later, the patient opted for surgery due to the worsening of pain and increase in umbilical lesion size. Intraoperative biopsy of the umbilical lesion revealed endometriosis. DISCUSSION: Patients with endometriosis often present with dull or crampy abdominopelvic pain that begins a few days before menses and lasts for a few days afterward. However, endometriosis can present with a variety of non specific manifestations which makes the diagnosis challenging. The mean delay in diagnosis of endometriosis was 6.7 ± 6.2 years with a median delay of 5 years in a Norwegian study. Abdominal wall endometriosis is a rare cause of chronic abdominal pain in adult patients, most of which had vicinal surgical incision. In our patient, suspicion of endometriosis was initially low due to her nulliparous status and lack of abdominal surgeries. A high clinical alertness is warranted while evaluating female patients with abdominal pain of unclear etiology.Figure 1.: Cytology smear demonstrating columnar cells.Figure 2.: Ectopically located endometrial tissue consisting of both endometrial type glands and stroma.

A case of pseudotumorous lesion of the CNS caused by herpes simplex virus type 1 in a patient with secondary immunodeficiency

Pseudotumorcerebri is a general term for a number of non‑neoplastic CNS lesions of various origins that resemble neoplasia clinically and/or radiologically, often cause serious diagnostic mistakes and prescribing unreasonable treatment that may harm the patient. There are currently three types of pseudotumors of the brain, including inflammatory granulomatous lesions, idiopathic or symptomatic intracranial hypertension, and large demyelinating foci in the white matter of the cerebral hemispheres.This scientific publication describes the medical history of a patient with pseudotumor granulomatous temporal lobe encephalitis HSV‑1/2‑etiology, which developed against the background of secondary cellular immunodeficiency caused by long‑term use of methylprednisolone for rheumatoid arthritis. Initially, a misdiagnosis of brain glioma was made due to the similarity of clinical and radiological manifestations of encephalitis with brain tumor. Diagnostic error was identified only during neurosurgery to remove the probable tumor. Histological and immunohistochemical analysis of a brain tissue sample from a pseudotumorous lesion obtained by intraoperative biopsy showed signs of granulomatous macrophage inflammation with moderate microcystosis and a small amount of tissue detritus. The diagnosis of HSV‑1/2 neuroinfection was verified on the basis of PCR of cerebrospinal fluid obtained during neurosurgery. The patient was discontinued previously planned radiation therapy, which was categorically contraindicated in this case, and was prescribed treatment with acyclovir to inhibit the reproductive activity of the virus and dialysable extract of blood leukocytes to eliminate secondary immunodeficiency. Neurosurgical intervention was found to be unjustified. Methylprednisolone was discontinued, and the patient was transferred to an aminoquinolone series drug for the treatment of rheumatoid arthritis. Only after performing these interventions it was possible to achieve a significant improvement in the patient's condition.

SUBCUTANEOUS EMPHYSEMA WITH AIRWAY COMPROMISE FOLLOWING OCCULT GI MICROPERFORATIONS CAUSED BY FOREIGN-BODY INGESTION

SESSION TITLE: Medical Student/Resident Imaging Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Traumatic pharyngeal perforation leading to subcutaneous emphysema following ingestion of sharp foreign objects is well described in the literature. We present the case of a man who presented in respiratory distress with evidence of extensive subcutaneous emphysema who was subsequently diagnosed with occult pharyngeal microperforations. CASE PRESENTATION: A 76-year-old man with a history of essential hypertension, type 2 diabetes mellitus, schizophreniform disorder, and multiple myeloma presented to the hospital with acute onset shortness of breath, facial swelling, dysphagia, and fever. Clinically, the patient was in respiratory distress, with evidence of stridor and with palpable crepitus extending over his neck and face. Neck and chest (Figure 1) CT showed soft tissue emphysema throughout his face and neck that extended into the mediastinum. Indirect laryngoscopy revealed diffuse pharyngeal wall and epiglottic edema, with an inability to visualize the glottis and without evidence of mural tears. The patient underwent an emergent tracheostomy given the concerns for airway compromise. Based on the initial concern of possible necrotizing fasciitis, the patient received broad spectrum antibiotics. Intraoperative biopsies of the laryngopharynx showed extensive necrosis and acute inflammation without bacterial growth. Given to the patient’s rapid clinical improvement a decision was made to hold off on emergent debridement. Barium swallow demonstrated no evidence of gastrointestinal perforation. One week after admission, the patient had a bowel movement in which he was observed to have passed numerous nuts, bolts, screws, and keys from his rectum. Abdominal imaging was performed and showed that further objects were traversing through the colon (see Figures 2–3). On questioning, the patient admitted to having ingested these objects in an attempt to aid his chronic constipation. At this point, it was determined that the consumption of these foreign bodies led to transient esophageal microperforations causing initial airway compromise. DISCUSSION: Our patient underwent traumatic pharyngeal perforation which is well described in the literature, secondary to ingestion of sharp foreign objects. Although initially it was thought that the presentation was due to a necrotizing infection, the patient’s improvement after airway management and negative culture data went against this interpretation. The subsequent passage of foreign objects and confirmatory imaging allowed us to make the final diagnosis of occult pharyngeal microperforations. CONCLUSIONS: This case emphasizes the need to approach patients based on their clinical appearance. It is important to maintain a broad differential based on the clinical presentation and to have a high index of suspicion once other possible causes have been excluded. Reference #1: Lynn De Roeck, Lauranne Van Assche, Veronique Verhoeven, Ina Vrints, Jana Van Thielen, Thierry Tondu & Filip Thiessen (2019) Progressive subcutaneous emphysema of unknown origin: a surgical dilemma, Acta Chirurgica Belgica, 119:4, 251-253, DOI: 10.1080/00015458.2018.1438560 DISCLOSURES: No relevant relationships by Jason Bofinger, source=Web Response no disclosure on file for Calli Dogon; No relevant relationships by Shahrzad Zonoozi, source=Web Response

Temporal histopathological changes in biliary atresia: A perspective for rapid fibrosis progression

Introduction and ObjectivesBiliary atresia (BA) is characterized by rapid progression of fibrosis with no definite causes. Histopathological findings have been extensively described, but very few studies have assessed temporal changes in BA. Understanding these short-term changes and their relationship with fibrosis progression could have an impact on ameliorating rapid fibrogenesis. We aimed to study the relationship between temporal histopathological changes and fibrosis progression in BA within a short time interval. Patients and MethodsForty-nine infants with BA who underwent Kasai portoenterostomy, a diagnostic liver biopsy, and an intraoperative liver biopsy were recruited. Histopathological characteristics of the two biopsies were examined. Temporal histopathological changes were assessed by comparing the two types of biopsies. Correlation of temporal changes in fibrosis with age, interval between biopsies, laboratory profiles, and temporal histopathological changes were studied. ResultsIn the univariate analysis, bile ductular proliferation (BDP), portal infiltrate, giant cells, hepatocellular swelling, and fibrosis showed significant temporal changes within a short interval (5–31 days). BDP and fibrosis showed the most frequent increase in their grades (32/49 and 31/49 cases, respectively). In the multivariate analysis, BDP was the only independent pathological feature showing a significant temporal increase (p = 0.021, 95% confidence interval: 1.249–16.017). Fibrosis progression was correlated with temporal changes in BDP (r = 0.456, p = 0.001), but not with age (p = 0.283) or the interval between the biopsies (p = 0.309). ConclusionsFibrosis in BA progresses rapidly and is significantly correlated with BDP. Assessment of targeting BDP as an adjuvant medical therapy is recommended.

Impact of Laparoscopic Sleeve Gastrectomy on the Course of Non-Alcoholic Fatty &#x0D; Liver Disease

Introduction. Non-alcoholic fatty liver disease (NAFLD) is one of the most common pathologies in obesity, at the same time the impact of bariatric operations on the course of NAFLD remains unresolved and debatable, the issue determining the relevance of this work.The aim of the study was to assess the effect of laparoscopic sleeve gastrectomy (LSG) on the course of NAFLD and determine the criteria that affect the dynamics of NAFLD after a performed bariatric intervention.Materials and methods. The study included clinical outcomes of 64 patients who underwent LSG between 2014 and 2017. Intraoperative liver biopsy, laboratory and instrumental investigations, the calculation of FibroTest in dynamics were performed to all patients. The frequency of postoperative complications was assessed. Follow up examinations including 58 (90.6%) patients were carried out during 2 years.Results. Initially, 29 (45,3%) patients manifested signs of fibrosis according to METAVIR, and 19 (29,7%) patients manifested signs of non-alcoholic steatohepatitis (NASH). Elevated transaminases were registered in 14 (21,9%) patients, elevated levels of gamma-glutamyl transpeptidase (GGTP) were registered in 47 (73,4%) patients, increased total bilirubin were registered in 12 (18,8%) patients, increased alkaline phosphatase (ALP) were registered in 21 (32,8%) patients. There was an increased level of trygliceride (TG) and decreased level of high density lipoproteins (HDL) in 54 (84,4%) patients. Ultrasound investigation of the liver revealed an increased liver size in 46 (71,9%) patients, diffuse heterogeneity of the liver in 61 (95,3%), hyperechogenicity in 60 (93,8%) patients. Manifestations of liver cirrhosis were registered in 1 (1,6%) patient.There was a significant decrease in the excess body weight in the postoperative period, and hereat, the % EBMIL (Excess Body Mass Index Loss, percentage of overweight loss) in 1 year after laparoscopic sleeve gastrectomy achieved satisfactory values and amounted to 68,30 [58,67-78,77] %. ALT, AST findings were normal in 79,7% of operated patients, cholestasis parameters - in 76,5% of operated patients, FibroTest findings - in 42,2% of cases. In 6 months after surgery there was a deterioration of the clinical and biochemical properties of non-alcoholic fatty liver disease, which was transient and regressed in one year after surgery. The mortality rate during the entire follow-up period was 0%. The effect of the surgery on the signs of non-alcoholic fatty liver disease persisted for 2 years after surgery.Laparoscopic sleeve gastrectomy demonstrated high effectiveness in patients under 45 years old compared to the patients over 45 years old, and in patients with initial stages of fibrosis F0-F2 by METAVIR compared to patients with stages F3-F4 by METAVIR. In addition, patients with BMI higher than 40 kg/m2 achieved higher FibroTest findings after 6 months compared to subjects with BMI lower than 40 kg/m2, and in fewer cases FibroTest findings normalized in 1 year after surgery, respectively.Conclusions. Therefore, it was noted the efficacy of laparoscopic sleeve gastrectomy in patients with obesity and non-alcoholic fatty liver disease; at the same time, it was revealed a transient worsening of the course of the disease in 6 months after surgery.

Diagnosis of Late Periprosthetic Joint Infection. Which Diagnostic Algorithm to Choose?

Background. Nowadays, according to the foreign and native registers data, the number of patients with periprosthetic infection (PJI) tends to increase. The early PJI diagnostics allows to provide timely effective treatment. Several widely used PJI diagnostic algorithms PJI exist. The objective of the study is comparative analysis of diagnostic value, accuracy and specificity of contemporary diagnostic algorithms. Materials and methods. A post-hoc analysis of 242 patients undergoing revision arthroplasty in 2018, held at FSFI FCTOE, was carried out. According to the study design, 127 patients were included in this study. PJI was diagnosed according to three known algorithms: ICM (International Consensus Meeting 2018), WAIOT (The World Association against Infection in Orthopedics and Trauma), EBJIS (The European Bone and Joint Infection Society 2018). Diagnostic sensitivity, specificity and total accuracy of each algorithm was carried out. The evaluation of ICM diagnostic algorithm was made with 2 variants: “not convincing = no infection”, “not convincing = infection”. The presence of infection was confirmed by bacteriological examination of synovial fluid aspirate, intraoperative biopsy of materials and sonification of explanted components. Results. The highest value of common accuracy was achieved in ICM 2018 algorithm — “not convincing = infection” was 91.3%, with sensibility and specificity — 89.3% and 93.0% respectively. The best specificity was shown by the algorithms WAIOT and ICM (“not convincing = no infection) – 95.8%, with sensibility and common accuracy — 80.4% and 89.0% respectively. The sensibility and specificity of EBJIS algorithm was 87.5% and 84.5%, respectively, the common accuracy — 85.8%. Conclusion. All included in investigation diagnostic algorithms showed high specificity values in diagnostics of hip and knee PJI without significant differences. Patients with subclinical PJI and low virulent pathogens have the biggest difficulties in PJI diagnostics. It seems that the selection of analyzed algorithms doesn’t play an important role, however PJI diagnostics requires complex approach with the use of different clinical and laboratory values.

Applicability and Results of Liver Stiffness Measurement and Controlled Attenuation Parameter Using XL Probe for Metabolic-Associated Fatty Liver Disease in Candidates to Bariatric Surgery. A Single-Center Observational Study.

Patients with morbid obesity are at high risk of liver fibrosis due to metabolic-associated fatty liver disease. Data on liver stiffness measurement (LSM) and controlled attenuation parameter (CAP) by vibration-controlled transient elastography (VCTE, FibroScan®) XL probe for liver fibrosis and steatosis assessment in morbid obesity are needed. LSM and CAP were measured in candidates to bariatric surgery at a single center during 12months. In patients who underwent an intraoperative liver biopsy, we compared LSM and CAP with histology findings. Comorbidities, body mass index, type of surgery, and infections after surgery were collected and analyzed. Of the eighty-three patients assessed by XL probe, 49 (59%; female in 63%, BMI 42.6 ± 5.1kg/m2) had a valid LSM and CAP measurement. LSM was 7.0 ± 3.9kPa and CAP 329 ± 57dB/m. In the 14 patients undergoing intraoperative liver biopsy, all had steatosis (severe in 50%), 6 (43%) had NASH (NAS ≥ 5), and 4 (29%) showed significant or bridging fibrosis. LSM accurately discriminated between patients with and without significant or severe fibrosis (AUROC 0.833) and CAP well-identified patients with or without ≥S2 steatosis (AUROC 0.896). Nine of 49 patients (18%) tested positive for significant/severe fibrosis by LSM (cut-off 8.9kPa). Applicability of LSM and CAP by XL probe in patients candidate to bariatric surgery was moderate. However, when technically successful, their reliability to diagnose severe steatosis and fibrosis related to MAFLD was good.

Long-Term Recurrence-Free Survival After Salivary Duct Carcinoma of the Parotid: A 10-Year Follow-Up Case Report

Salivary duct carcinoma (SDC) represents a very rare and aggressive parotid neoplasm. A 70-year-old male was admitted to the hospital with a swelling of the right parotid region, persisting for twelve weeks. Based on sonography and contrast-enhanced computed tomography, a suspicious lesion showing mass expansion and invasion of surrounding tissues was seen. Intraoperative biopsy brought evidence of SDC. In accordance, surgical treatment included parotidectomy with preservation of the facial nerve as well as ipsilateral neck dissection due to suspicious lymphatic nodes. Afterwards, an adjuvant radiation therapy was undertaken. At 10 years of follow-up, the patient was alive and free of recurrence with full function of the facial nerve. In conclusion, keeping in mind its poor prognosis, the rare parotid salivary duct carcinoma needs aggressive therapy consisting of a surgical as well as a radiation therapy approach.