Large Nodules Research Articles

ODP018 A Case of Cushing's Syndrome due to Primary Bilateral Macronodular Adrenal Hyperplasia

Abstract Introduction Primary bilateral macro-nodular adrenal hyperplasia (PBMAH) is a rare cause of Cushing's syndrome, characterized by a high clinical heterogeneity, both with regards to the severity of cortisol excess and the morphologic appearance of the adrenals. We present an interesting case of Cushing's syndrome caused by Primary bilateral macro-nodular adrenal hyperplasia. Case presentation A 61-year-old female with Graves’ disease status post I-131 therapy was incidentally found to have two left adrenal adenomas of sizes 2 cm and 1.9 cm on CT imaging. Her laboratory workup revealed Cushing's syndrome evidenced by abnormal 1 mg dexamethasone suppression test (DST) with cortisol of 7.8 mcg/dl (8-19 mcg/dl), 24-hour urinary cortisol (UFC) of 50 mcg/24hr (0-50 mcg/24hr) with ACTH 6.2 pg/ml (7.2 -63 pg/ml) and DHEAS 79.8 mcg/dl (29.4-215 mcg/dl). Her MRI brain revealed meningioma and she underwent gamma knife therapy. Over time she developed uncontrolled hypertension, pre-diabetes, weight gain and easy bruising. On examination she has a plethoric face, ruddy complexion, and central obesity. Her repeat blood work showed 1 mg DST cortisol of 6.7 mcg/dl (8-19 mcg/dl), UFC 76 mcg/dl (6-42 mcg/dl) and normal late night salivary cortisol 0. 071, 0. 067 mcg/dl (<0. 010-0. 090 mcg/dl). Her repeat CT abdomen showed bilateral adrenal nodules with larger nodule on the left side measuring 2.4 cm. She underwent adrenal vein sampling using epinephrine as control which showed bilateral cortisol secretion. She did not tolerate medical therapy with Mifepristone. Testing for aberrant receptors was negative. She eventually underwent left adrenalectomy which improved her clinical co-morbidities and normalized cortisol levels. Her postoperative DST cortisol is 1.5 mcg/dl (8-19 mcg/dl) and UFC is 8 mcg/24hr (6-42 mcg/24hr). Her genetic testing is still pending. Discussion The conventional treatment of PBMAH is adrenalectomy. Unilateral adrenalectomy of larger adrenal gland is now considered a reasonable alternative to bilateral adrenalectomy in selected patients due to risk of adrenal insufficiency and lifetime steroid dependency with bilateral surgery (1). Cortisol secretion in PBMAH can be regulated by aberrant adrenal expression of receptors and all patients should be evaluated for these receptors as there is potential for medical therapy in them. PMBAH is also caused by ARMC5 mutations in familial cases, and it is commonly associated with intracranial meningiomas suggesting a possibility of new syndrome which needs to be further studied. Cranial imaging should be offered to these patients to exclude a coexisting meningioma (2).

ODP512 Renal Cell Carcinoma Metastatic to Thyroid: A Case Report

Abstract Introduction The thyroid gland is an uncommon site (0.7%) among all distant metastasis from renal cell carcinoma (RCC). Here we report a case of metastasis from RCC to the thyroid gland, diagnosed 15 years after treatment. Clinical Case A 63-year-old female, was referred to endocrine for evaluation of neck mass of several months’ duration. Thyroid function test revealed mildly low TSH and normal free T4. Recent thyroid ultrasound showed multinodular thyroid, the largest nodule was in mid to upper left thyroid lobe and measured 6cm in max diameter. Biopsy of 4 thyroid nodules was performed. Three nodules were benign (Bethesda 2), but the left mid to upper 6cm thyroid nodule showed Atypia of Undetermined Significance (Bethesda 3). Due to concern of large size, potential for further growth and gradual development of local compressive symptoms, total thyroidectomy was recommended. Patient was initially hesitant, however, within several months, she developed dysphagia and progressive neck swelling, and eventually had total thyroidectomy. Surgical pathology revealed metastatic RCC involved left thyroid lobe (8.4cm in greatest dimension) and right thyroid lobe (0.3cm in greatest dimension). Immunohistochemical stain were positive for CA9, CD10, PAX8, while negative for CKIT, CK7, TFT-1, thyroglobulin, synaptophysin, chromogranin, calcitonin, and PTH. Patient reported a history of right nephrectomy in 2005 and did not require adjuvant therapy at that time. Post-operative workup including CT neck/chest/abdomen/pelvis revealed a 2.4cm left superior mediastinum mass suspicious for metastasis. Patient was evaluated by genitourinary oncology and the decision was to continue surveillance with CT every three months. A new gallbladder lesion was detected after six months, laparoscopic cholecystectomy was performed, and pathology showed metastatic RCC. Conclusion This is an unusual case of metastatic RCC to thyroid gland, diagnosed 15 years after initial presentation with RCC that required only a nephrectomy. The cytology – pathology discrepancy in our case highlights the limitation of FNA in diagnosing rare thyroid masses of extra-thyroidal origin. A study has showed thyroid cytology was only diagnostic in 29.4% of population with RCC metastatsis(1). Especially when rapid growth is seen, surgery needs to be considered regardless of FNA results. Reference: 1. Khaddour K, Marernych N, Ward WL, Liu J, Pappa T. Characteristics of clear cell renal cell carcinoma metastases to the thyroid gland: A systematic review. World J Clin Cases. 2019 Nov 6;7(21): 3474-3485. doi: 10.12998/wjcc. v7. i21.3474. PMID: 31750330; PMCID: PMC6854394. Presentation: No date and time listed

RF11 | PMON26 A Lump By Any Other Name: A Case of Diffuse Large B Cell Lymphoma of the Thyroid

Abstract Patient is a 49-year-old female with a past medical history of hypothyroidism who presented to the endocrinology office for evaluation of a neck mass. A thyroid ultrasound in 2020 had shown significantly enlarged and diffusely heterogenous thyroid gland compatible with diffuse thyroid goiter without nodules. Her neck swelling worsened and therefore a thyroid ultrasound was repeated and showed a large hypoechoic nodule in the left thyroid gland. She had no symptoms such as night sweats, fevers, or weight loss. A computed tomography (CT) scan of the neck with contrast was obtained on 7/20/2020 showing a markedly enlarged thyroid gland with multiple >1 centimeter (cm) thyroid nodules, with a suspected exophytic extension nodule medial to the left lobe. Multiple adenopathy was present with an enlarged left lower cervical lymph node and a right-sided level 4 lymph node concerning for thyroid malignancy with local metastatic disease. She underwent a fine needle aspiration (FNA) with flow cytometry of the lymph node on 9/2/2020 which was benign. Her goiter continued to increase in size and she was referred to endocrine surgery for fine needle core biopsy of the left thyroid nodule which was favorable for diffuse large B cell lymphoma (DLBCL) with a germinal center phenotype on 4/5/2021. Flow cytometry was positive for CD-10 mature B cells. FNA biopsy of the left lower cervical lymph node showed polymorphic lymphocytes and rare macrophages. She was staged IIE. She underwent 4 cycles of rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) and received 18 rounds of consolidation radiation after completion of chemotherapy. She had near-complete response to treatment and is now monitored through routine follow-ups. Primary thyroid lymphoma is a rare condition characterized as a lymphomatous process involving the thyroid gland without any contiguous spread or distant metastasis at the time of diagnosis. It comprises nearly 1% to 5% of all thyroid malignancies and is more common in women. DLBCL is the most common histiotype and accounts for 50% to 70% of all cases. Patients may notice a unilateral or bilateral rapidly enlarging neck mass with compressive symptoms, but B symptoms are less common. Nearly 30% to 40% of patients carry a diagnosis of hypothyroidism at the time of diagnosis as the lymphomatous process replaces the normal thyroid parenchyma. Diagnosis is made usually via core needle biopsy and flow cytometry since FNA biopsy is frequently inconclusive. Treatment is with chemotherapy, usually R-CHOP, and radiation therapy with an overall 5-year prognosis of 34.5%. Surgical decompression may be necessary if compressive symptoms are present. While this is a rare disease, providers should be cognizant of DBLCL especially when faced with a presentation such as the one summarized in this report. Presentation: No date and time listed

LBODP103 Ectopic Thyroid Tissue In A Pediatric Patient After Total Thyroidectomy

Abstract Introduction Ectopic thyroid tissue is defined as any functional thyroid tissue outside the normal anatomical location. It is rare and occurs with a frequency of 1 in 100,000-300,000. Most commonly, it is located along the normal track of thyroid development along the floor of the primitive gut to the pre-tracheal region of the neck; however, rarely it has been found in other areas. Malignancy is very rare in ectopic thyroid tissue (<1%) and when it occurs, papillary carcinoma is the most common type. Maki et al have reported multiple cases of lateral neck ectopic thyroid tissue in the presence of an orthotopic thyroid gland in the adult population. Only 2 pediatric cases have been reported in the literature so far. Clinical Case A 11-year-old male presented with concerns of morbid obesity and a neck swelling. He endorsed a previous history of thyroid nodules measuring over 2 cm that were being monitored by his previous endocrinologist. On exam, he was noted to have a goiter. Labs were obtained which indicated normal thyroid function tests (TSH 3. 040 uIU/mL, nl 0.45-4.5 uIU/mL and free T4 0.96 ng/dL, nl 0.93-1.6 ng/dL) and negative anti thyroid antibodies (TPO antibody <9 IU/mL, nl 0-26 IU/mL and thyroglobulin ab <1 IU/mL, nl 0. 0-0.9 IU/mL). His previous medical records revealed that a FNA was completed 2 years prior which was reported as benign. A repeat thyroid ultrasound revealed a multinodular goiter with 5 nodules measuring 3.3 x1.5×1.3cm and 5×6×5mm in the right lobe and 7×6×4cm, 2.4×2.1×1.8cm, and 5×6×5cm in the left lobe. After reviewing different management approaches, the family preferred thyroidectomy. He was referred to general surgery and subsequently underwent total thyroidectomy. Post-operatively, he was started on levothyroxine and calcium carbonate supplementation. The calcium supplementation was subsequently weaned and discontinued. Final pathology was reported as benign. Unfortunately, he was lost to follow up and presented to his primary care provider 6 months post-operatively with continued weight gain and a right sided neck mass. Labs obtained showed an elevated TSH (9.820 uIU/mL, nl 0.45-4.5 uIU/mL) and normal free T4 (1. 07 ng/dL, nl 0.93-1.6 ng/dL). Ultrasound of the neck revealed a 2.5 cm heterogeneous nodule in the right neck adjacent to the thyroid bed, concerning for recurrent/residual disease. FNA was completed and was consistent with normal appearing thyroid tissue. Ultrasound monitoring will continue to assess for change in size and need, if any for surgical removal in the future. Discussion Ectopic thyroid tissue with an orthotopic thyroid is a very rare finding in the pediatric population. Ectopic thyroid tissue outside of the thyroglossal duct is rare as well. We present an 11-year-old male who underwent thyroidectomy for multiple large thyroid nodules and subsequently developed a new neck mass diagnosed as ectopic thyroid tissue. Presentation: No date and time listed

Robotic Disc Excision with Sutured Repair for Full Thickness Deep Infiltrating Endometriosis of the Sigmoid Colon.

<h3>Study Objective</h3> To clearly demonstrate technique for full thickness disc resection and sutured closure for deep infiltrating endometriosis of the sigmoid colon. <h3>Design</h3> N/A. <h3>Setting</h3> Community Hospital. <h3>Patients or Participants</h3> A 36-year-old patient with deep infiltrating endometriosis of the rectovaginal septum, left ovary, and sigmoid colon. <h3>Interventions</h3> A robotic surgery was performed with TLH and LSO, as well as shave resection of rectal endometriosis. A large nodule of sigmoid deep infiltrating endometriosis is identified. Full thickness excision with sutured closure is demonstrated. We include instruction on proper technique for stay suture placement and mucosal suture placement to ensure a wide-lumen closure perpendicular to the axis of the colon. <h3>Measurements and Main Results</h3> N/A. <h3>Conclusion</h3> Full thickness disc resection of the sigmoid colon is both feasible and reproducible using these techniques, either robotically or laparoscopically. Conservative excision techniques such as this allow full excision of diseased tissue while preserving the continuity of the bowel.

RF05 | PSUN364 A Rare Case of Bilateral Parathyroid Carcinoma in the Setting of Multiple Endocrine Neoplasia Type 1

Abstract Background Multiple Endocrine Neoplasia type 1 (MEN1) is an autosomal dominant disorder classically characterized by parathyroid gland tumors, anterior pituitary adenomas, and tumors of the gastro-entero-pancreatic tract. The majority of MEN1 cases involving lesions of the parathyroid gland causing hyperparathyroidism are almost always benign. It is extremely rare for hyperparathyroidism to be caused by parathyroid carcinomas. We report a very rare case of parathyroid carcinoma presenting in MEN1 syndrome. Case Report We present the case of a 45 year old male with a history of untreated hypertension, nephrolithiasis, and CKD, who became suddenly unresponsive, was intubated, and found to have a severe acute intraparenchymal hemorrhage secondary to severe hypertension on Head CT. Secondary causes of hypertension were ruled out, with renin activity, aldosterone levels, and urine metanephrines unremarkable; abdominal ultrasound with doppler was also negative for renal artery stenosis. Stroke protocol was initiated, with CTA Head negative for any acute findings. However, CTA Neck showed bilateral large nodules posterior to the thyroid lobes measuring 4.0×3.2 cm on the right and 3.9×2.5 cm on the left, with mass effect on the thyroid and adjacent carotids. Routine labs showed hypercalcemia of 13.3 (8.4-10.2 mg/dL) in the setting of elevated PTH levels of 1085 (15-65 pg/mL), with repeat PTH level of 1106 confirming primary hyperparathyroidism. Other causes of hypercalcemia were investigated, with levels of Calcitonin and Calcitriol/1,25 vitamin D within normal limits, but a decreased level of 25 hydroxy vitamin D of &amp;lt;12.8 (30-100 pg/mL). Maxillofacial CT was negative for any ossifying fibromas, ruling out jaw tumor syndrome. CT Abdomen showed hyperdense nodular areas in the pancreas, and MRI Brain was negative for any discrete pituitary gland lesions. Thyroid US was performed and revealed mixed cystic and solid masses posterior to both lobes of the thyroid; as a result, FNA of the thyroid and posterior mass was done, confirming hypercellular parathyroid tissue and benign thyroid tissue. Due to high suspicion for parathyroid carcinoma, the patient underwent a parathyroidectomy, with pathology confirming bilateral parathyroid carcinoma. Genetic testing was positive for MEN1, with a frameshift variant mutation of c.1299_1312del (p.Val434Leufs*10). Conclusion This is a very rare case of bilateral parathyroid carcinoma presenting in MEN1. To the best of our knowledge, this genetic mutation has not been reported in online databases or published literature. The clinical presentation of parathyroid lesions and pancreatic nodules in the setting of hypercalcemia should prompt further evaluation of genetic disorders such as MEN1. In this context, it is essential that MEN1 patients be managed with a multidisciplinary approach given the disorder's complexity of diagnosis and treatment. Presentation: Saturday, June 11, 2022 1:18 p.m. - 1:23 p.m., Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.

Root Nodule Categorization and Their Relation with Plant Growth in Peanut Crop Grown in Alfisols

To investigate the relationship between nodule category and plant growth characteristics in peanut, nodules were classified into three categories: large size nodule (LSN) ( greater than 2 mm), medium size nodule (MSN) (1-2 mm) and small size nodule (SSN) ( less than 1 mm) and their position on roots (primary and lateral roots). The number of LSNs on primary roots was found to be much higher than on lateral roots. The number of MSN developed on primary and lateral roots was comparable, whereas, lateral roots had a higher SSN number. In addition, when comparing the LSN and MSN numbers to SSN number, the plant growth parameters showed a high positive correlation. Multivariate regression analysis yielded similar results. This nodule classification technique aids in the identification of peanut nodules and their role in quantification of plant growth characteristics. Further, this technique can be used in identifying/screening of efficient nodulating peanut genotypes.

Significance of radiofrequency ablation in large solid benign thyroid nodules.

The aim of this study is to explore efficacy and safety for radiofrequency ablation (RFA) among cases attacked by large benign solid thyroid nodules, mainly focusing on volume reduction, complication rate, and thyroid function. From June 2015 to November 2019, 24 patients with 25 large benign solid thyroid nodules (more than 25 ml) underwent single or sequential RFA in our institution. Eleven nodules achieved complete ablation after single RFA, whereas the other 14 nodules received sequential RFA. Volume reduction in large nodules was evaluated. Following single or sequential RFA, all patients received clinical and ultrasound evaluations, and the median follow-up duration among them was 23.5 months. Technical success, complication rate, and recurrence rate were assessed as well. In single RFA group, volume reduction ranged from 62.6% to 99.4% (mean ± SD, 93.6 ± 9.9%) 6 months after RFA. In sequential RFA group, volume reduction ranged from 30.6% to 92.9% (mean ± SD, 67.4 ± 17.8%) after the first RFA and was between 83.4% and 98.4% (mean ± SD, 94.8± 3.8%) 6 months after the second RFA. The concentrations of FT3 and FT4 increased slightly 1 day after RFA and returned to normal level 1 month after. Single or sequential RFA is safe and effective in treating large benign solid thyroid nodules (more than 25 ml) that cause obvious compressive symptoms. Hence, compression symptoms and cosmetic conditions could be effectively improved through single or sequential RFA without marginal recurrence.

Enfermedad de Rosai-Dorfman con afección ganglionar y extraganglionar

Introduction: Rosai-Dorfman disease, known as sinus histiocytosis with massive lymphadenopathy, is a very rare variety of reactive histiocytosis of unknown origin. Case presentation: a 32-year-old female patient who consulted for a five-year history of respiratory distress, dysphonia, stridor and multiple swollen areas in the neck and trunk. Physical examination revealed large, firm, and mobile submandibular lymph nodes and numerous nodules on the trunk. Histological examination showed the characteristic features of Rosai-Dorfman disease with nodal and extranodal involvement. Discussion: Rosai-Dorfman disease is a pathological process which affects cervical lymph nodes, although lesions may develop in several sites, organs, and systems, and may be confused with other neoplasms. It should be considered in the differential diagnosis of soft tissue histiocytic lesions and other lymphoproliferative disorders. Death is related to organs and systems dysfunction rather than to the disease itself. Conclusion: Rosai-Dorfman disease including nodal and extranodal involvement, is a very rare benign proliferative histiocytic disorder. It should always be included in the differential diagnosis of other histiocytic proliferative disorders. It carries a variable relatively benign prognosis.

Maximization of lung segmentation of generative adversarial network for using taguchi approach

ABSTRACT Conditional generative adversarial network (c-GAN) is one of the best-performing convolutional neural networks (CNN) for the segmentation of lung computed tomography (CT). However, lung segmentation from CT images becomes complicated in the presence of various dense abnormalities. The performance in the presence of dense abnormalities can be improved by tuning the c-GAN architecture and parameters of the network. This study focuses on maximizing lung segmentation performance of a c-GAN segmentation algorithm by configuring and tuning the network using the Taguchi optimization method. We have considered the benchmark interstitial lung disease (ILD) dataset for evaluating the performance of the proposed approach. The comparative performance analysis of the proposed algorithm shows that the proposed algorithms outperform the existing state-of-the-art methods, even in the presence of dense abnormalities in lung CT scans. Furthermore, the proposed approach has been demonstrated for lung segmentation in the presence of large nodules.

OPTIMIZING THE RESECTION PATHWAY: CAN MINIMALLY INVASIVE DIAGNOSIS AND SURGERY (MIDAS) GUIDE PATIENT SELECTION?

OPTIMIZING THE RESECTION PATHWAY: CAN MINIMALLY INVASIVE DIAGNOSIS AND SURGERY (MIDAS) GUIDE PATIENT SELECTION?

LIVING WITH EHLERS-DANLOS SYNDROME: FOLLOWING A YOUNG BOY THROUGH HIS UPS AND DOWNS ON HIS JOURNEY INTO ADULTHOOD

LIVING WITH EHLERS-DANLOS SYNDROME: FOLLOWING A YOUNG BOY THROUGH HIS UPS AND DOWNS ON HIS JOURNEY INTO ADULTHOOD

Primary Thyroid Neoplasm with Fetal Morphology Associated with DICER1 Mutations: Expanding the Diagnostic Profile of Thyroblastoma.

Introduction: Thyroblastoma, a primary thyroid neoplasm with histological features of primitive thyroid tissue has recently been described and is included as a distinct entity in the most recent edition of the World Health Organization (WHO) Classification of Tumors (5th edition). In this study, we expand the clinical, morphological, and molecular profile of this aggressive neoplasm. Patient Findings: The patients are females, 19 and 45 years of age, referred for large thyroid nodules. Tumor morphology is biphasic, composed of nests and follicles of epithelial cells, some with colloid-like secretions reminiscent of fetal thyroid follicles intertwined with a primitive stromal spindle cell component. By immunohistochemistry, the epithelial component is diffusely positive for PAX8 and TTF1 markers. Molecular studies showed DICER1 aberrations. Conclusion: A primary primitive thyroid malignancy reminiscent of early fetal embryology with no teratoid element, recently reported as thyroblastoma represents a unique entity, novel in its description, and is likely underdiagnosed.

EVALUATION OF WATER STRESS AND CO-INOCULATION OF AZOSPIRILLUM BRASILENSE AND RHIZOBIUM TROPICI IN BEANS (PHASEOLUS VULGARIS L.)

Climate change has caused major changes in abiotic factors, with water stress as the greatest threat to agricultural production. The measures aimed at alleviating the problems caused by this limiting production factor have occurred through the adoption of sustainable strategies, especially microbial biotechnology, which uses the interactions between the microorganism and the plant, ensuring productive quality and inducing plant resistance to stresses biotic and abiotic. The objective of the present work was to evaluate the biological nitrogen fixation and the development of bean seedlings, with co-inoculation of two types of inoculants, which were subjected to water stress by different pot capacities. The experiment was conducted in a greenhouse, at Universidade Paranaense - UNIPAR, from April to June 2019. The experimental design was completely randomized (DIC), with 5 replications, 16 treatments and 80 experimental units. The cultivar used was SCS Riqueza. The parameters evaluated were pot capacity (25%, 50%, 75% and 90%); small, large and total nodules, shoot and root length, dry and fresh weight, total carbon and nitrogen. The evaluation of the morphological parameters of the bean seedlings indicated that the co-inoculation technique promoted beneficial effects for the dry mass parameters of shoot, nodule and root. The analysis of the percentage of carbon and nitrogen in the tissues of the seedlings provided an increase in the concentration of these elements in treatments that involved co-inoculation (Azospirillum brasilensis and Rhizobium tropici) with pot capacities of 25 and 75% (CV), demonstrating that the association of microorganisms is beneficial in the limiting water situation.

An Unusual Cause of a Cecal “Seesaw” and Pneumatosis Intestinalis

Question: A 66-year-old woman with history of stroke, previous hernia surgery with mesh placement, and obstructive cholestasis due to choledocholithiasis presented with 3 days of right-sided abdominal pain, 15-lb weight loss over 1 month, and 3 weeks of constipation with thin stools. Colonoscopy was normal a few months prior. Her prior episode of choledocholithiasis in 2017 led to endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy and placement of a double pig-tail stent. She was recently admitted 1 month ago for jaundice and right upper quadrant (RUQ) pain at which time magnetic resonance cholangiopancreatography showed severe intrahepatic and extrahepatic biliary duct dilation but no liver or pancreatic lesions. The cecum was nonspecifically distended and fluid filled. Esophagogastroduodenoscopy revealed a benign-appearing intrinsic duodenal stricture felt to be related to scar tissue from the previous hernia mesh surgery. ERCP revealed an occluded biliary stent that had migrated to the major papilla and a severe burden of choledocholithiasis. The occluded stent was removed, and partial removal of stones was achieved via basket extraction. A new biliary stent was placed with a plan to follow up in 4 weeks for repeat ERCP for further stone extraction and stent removal. Before this appointment she was readmitted for worsening RUQ pain. A computed tomography scan revealed dilated loops of distal small bowel and a dilated cecum that had folded anteriorly and superiorly with extensive pneumatosis. The ascending colon was also dilated up to a decompressed hepatic flexure, where nonspecific bowel wall thickening was visualized, suggesting a transition point. No obvious mass or lesion was noted at the hepatic flexure (Figure A). Despite clinical improvement with conservative management, a lower gastrointestinal series performed a few days later showed persistent severe obstruction at the hepatic flexure with bird-beak appearance (Figure B). What is the most likely explanation for these imaging findings and how should it be managed? See the Gastroenterology website (www.gastrojournal.org) for more information on submitting to Gastro Curbside Consult. The patient’s imaging findings are consistent with cecal bascule (type III cecal volvulus). Cecal bascules are the rarest variant of cecal volvulus that involve upward folding of the cecum, without axial twisting or sigmoid involvement.1Rabinovici R. Simansky D.A. Kaplan O. et al.Cecal volvulus. Dis Colon Rectum. 1990; 33: 765-769Crossref PubMed Scopus (119) Google Scholar Bascule in French means “seesaw,” describing the pathophysiology of the cecal presentation. Surgical management was indicated given the persistent and severe hepatic flexure stricture seen on lower gastrointestinal series. Exploratory laparotomy revealed numerous omental nodules and a mass was discovered in the RUQ involving the gallbladder and liver that was causing extrinsic compression of the hepatic flexure. The largest nodule was excised and confirmed a diagnosis of metastatic cholangiocarcinoma. A distal loop ileostomy was created to decompress the colon and prevent ongoing colonic obstruction. No colonic resection was necessary. The patient began cancer staging and treatment planning, but unfortunately passed 1 month after diagnosis. This is a unique case of an extrinsic malignant obstruction causing cecal bascule. The development of a cecal bascule is usually attributed to an abnormally mobile cecum due to improper development and insufficient fixation of the mesentery to the posterior parietal peritoneum. A mobile cecum may also be acquired in pregnancy due to enlargement of the uterus or after abdominal surgery, such as open appendectomies, which require extensive division of peritoneal attachments to the cecum. Clinical presentation varies with abdominal pain, distention, and nausea being the most common symptoms but can progress to an acute abdomen and perforation.2Lung B.E. Yelika S.B. Murthy A.S. et al.Cecal bascule: a systematic review of the literature.Tech Coloproctol. 2018; 22: 75-80Crossref PubMed Scopus (14) Google Scholar Diagnosis of type III cecal volvulus requires computed tomography imaging confirming a distended cecum lying anterior to ascending colon. Treatment generally involves surgical resection of the affected bowel because colonoscopic detorsion may lead to recurrence.3Le C.K. Nahirniak P. Qaja E. Cecal volvulus. StatPearls Publishing. StatPearls Website, 2021Google Scholar

Effect of thyroid nodule size on cytology reliability and incidence of malignancy: A large cohort of 1205 patients from a single center

ObjectiveThere is controversy about whether the rates of malignancy and of false-negative malignancy are greater in large nodules. The aim of this study was to determine the reliability of cytology in ≥4cm nodules and to compare malignancy rates between ≥4cm and<4cm nodules. MethodsThe study included 1205 patients who underwent biopsy and subsequent thyroidectomy with the diagnosis of nodular thyroid disease between 2014 and 2019. The patients were separated into two groups, ≥4cm and<4cm, according to the size of the index nodule on ultrasonography. ResultsTwo hundred and eleven index nodules (17.5%) were ≥4cm. Malignancy rate on definitive pathology was 51% in<4cm nodules and 30% in ≥4cm nodules. Malignancy risk was significantly lower in ≥4cm nodules than <4cm nodules (P<0.001). When<1cm nodules were excluded and 1–4cm and ≥4cm nodules were compared, malignancy risk was also significantly lower in ≥4cm nodules (P=0.001). On definitive pathology, there were 45 false-negative results among cytologically benign nodules. There was no difference in false-negative cytology rate between<4cm and ≥4cm nodules (P=0.209). ConclusionThe present study found no decrease in the reliability of cytology in ≥4cm nodules, and there may not be a linear relationship between nodule size and malignancy risk. Therefore, in asymptomatic cytologically benign ≥4cm nodules, surgery may not be recommended based on nodule size alone.

Feline pulmonary carcinoma: Gross, histological, metastatic, and immunohistochemical aspects.

Feline pulmonary carcinoma (FPC) is an uncommon neoplasm with unique morphological features. We describe the gross, histological, metastatic, and immunohistochemical aspects of FPC, based on postmortem examinations from an 11-year retrospective study. Thirty-nine cases were selected. Predispositions were observed in senior (P < .001) and Persian (P = .039) cats. There were three gross patterns of the pulmonary tumors: (a) a large nodule and additional smaller nodules, (b) a solitary nodule, and (c) small, multifocal to coalescent nodules. Extrapulmonary metastases were present in 22/39 cases (56.4%), mainly in the regional lymph nodes (17/39, 43.5%), skeletal muscles (9/39, 23%), kidneys (6/39, 15.3%), and parietal pleura (4/39, 10.2%). The primary tumor size was correlated with the occurrence of extrapulmonary metastases (P = .002). Histologically, the tumors were classified as papillary adenocarcinoma (19/39, 48.7%), adenosquamous carcinoma (ADS) (8/39, 20.5%), acinar adenocarcinoma (6/39, 15.3%), solid adenocarcinoma (3/39, 7.6%), lepidic adenocarcinoma (2/39, 5.1%), and micropapillary adenocarcinoma (1/39, 2.5%). By immunohistochemistry, 39/39 cases (100%) were positive for pancytokeratin, 34/39 (87.1%) for thyroid transcription factor-1, and 8/39 (20.5%) for vimentin. Immunoreactivity for p40 was detected in the squamous component of all ADSs (8/8, 100%) and occasionally in the glandular component of adenocarcinomas (10/31, 32.2%). Napsin A expression was absent in all feline tissue tested. The results indicate that a modified and simplified histological classification based on current human and domestic animal systems is appropriate for cats. Additionally, this study highlights the utility of p40 as an immunohistochemical marker for the diagnosis of FPC with squamous differentiation.

Genistein anticancer efficacy during induced oral squamous cell carcinoma: an experimental study

BackgroundAbout 7 million people die from various types of cancer every year representing nearly 12.5% of deaths worldwide. This fact raises the demand to develop new, effective anticancer, onco-suppressive, and chemoprotective agents for the future fighting of cancers. Genistein exhibits pleiotropic functions in cancer, metabolism, and inflammation. It functions as an antineoplastic agent through its effect on the cell cycle, apoptotic processes, angiogenesis, invasion, and metastasis.Aim of the studyThe current study aimed to study the genistein onco-suppressive effects during 7,12-dimethylbenz[a]anthracene (DMBA)-induced oral carcinogenesis in hamsters’ buccal pouch utilizing flow cytometry analysis (FMA), as a fast-diagnosing tool, in addition to the histopathology.Material and methodsThe buccal mucosa of adult male Syrian hamsters was painted with paraffin oil only (group 1), DMBA mixed in mineral oil (group 2), or orally administrated genistein along with painting DMBA (group 2B). The buccal mucosa was utilized for flow cytometric analysis and histopathological examination.ResultsGrossly, DMBA-induced carcinogenesis started at the 9th week. Progressive signs appeared in the following weeks reaching to large ulcerative oral masses and exophytic nodules at the 21st week. Histologically, invasive well-differentiated oral squamous cell carcinoma (OSCC) appeared in the underlying tissues from the 12th week, showing malignant criteria. Genistein had delayed clinicopathological change, which started 6 weeks later, than the DMBA-painted hamsters, as mild epithelial dysplastic changes. This became moderate during the last 6 weeks, without dysplastic changes. Flow cytometry revealed that DMBA led to considerable variation in DNA proliferation activity, aneuploid DNA pattern, in 47.22% of hamsters and significantly raised the S-phase fragment (SPF) values, which drastically reduced after genistein treatment.ConclusionTaken together, genistein could be employed as an onco-suppressive agent for carcinogenesis. Moreover, FMA could be used as an aiding fast tool for diagnosis of cancer.

Computed Tomography Comparative Analysis of Nontuberculous Mycobacterial Lung Disease in the Elderly and Secondary Pulmonary Tuberculosis.

The study aimed to explore the key points of computed tomography (CT) differential diagnosis of nontuberculous mycobacteria (NTM) and secondary pulmonary tuberculosis in elderly patients. We retrospectively analyzed 45 patients with NTM pulmonary disease and 65 patients with secondary pulmonary tuberculosis. All patients were older than 60 years. The diseases were confirmed by laboratory examination. The general data and CT images of the 2 groups were compared and analyzed using χ 2 tests, single-factor analysis, and multivariate logistic regression analysis. Single-factor analysis showed significant differences between the 2 groups in 9 factors: bronchiectasis of the left upper lobe lingual segment, bronchiectasis of the right middle lobe, small nodules, large nodules, thin-walled cavities, thick-walled cavities, nonsubpleural hollows, strip opacity, and mediastinal lymph node enlargement ( P < 0.05). Multivariate logistic regression analysis showed that thin-walled cavities, bronchiectasis of the right middle lobe, small nodules, and large nodules were important factors in the differential diagnosis of the two groups. Nontuberculous mycobacteria show certain characteristics on CT, which are helpful for differential diagnosis when coupled with clinical and sputum smear examinations.

Ovarian metastases from ALK-positive lung adenocarcinoma: a case report and review of the literature

BackgroundOvarian metastasis is an extremely rare condition in patients with lung adenocarcinoma. Lung adenocarcinoma patients with ovarian metastases were difficult to distinguish from primary ovarian cancer. Anaplastic lymphoma kinase (ALK) gene rearrangement is only found in 3–7% of patients with lung cancer. It is worth noting that the incidence of lung cancer with ovarian metastasis is extremely low, however, ALK rearrangement is often reported in these cases. Here we reported a young woman, aged 23 years, with ALK-positive lung adenocarcinoma and ovarian metastasis.Case DescriptionThe patient underwent laparoscopic bilateral ovarian tumor resection after discovering an abdominal mass accidentally. A series of lung adenocarcinoma-specific immunohistochemical features were detected postoperatively by immunohistochemistry (IHC) analysis. Then extensive-stage metastatic masses of different sizes were identified by 2-deoxy-2-[18F]fluoro-d-glucose (18F-FDG) positron emission tomography combined with low-dose computed tomography (PET/CT), among which the largest nodule was 1.7 cm × 1.4 cm located in the middle lobe of the right lung. Genetic testing of the paraffin tissue DNA revealed the fusion mutation of EML4_ALK (E14:A20) gene. The patient was pathologically diagnosed with lung adenocarcinoma with bilateral ovarian metastasis, administered with oral alectinib [600 mg twice daily (bid)] and followed-up quarterly. Currently, the patient responded to alectinib stably, with a progression-free survival (PFS) of more than 12 months, and experienced no significant adverse events. In addition, we reviewed the publications associated with the characteristics of ALK-positive lung cancer with ovarian metastases and the identification of primary and secondary ovarian tumors.ConclusionsThis case provides a meaningful reference for the possibility of adnexal metastases from lung cancer, particularly for ALK-rearranged young female patients. In addition, this case highlights the advantages of IHC together with genetic testing for identifying origin sites of ovarian metastases and provides a promising treatment option.