Left Lesion Research Articles

접형동의 함기화 정지 2예 및 문헌고찰

Arrested pneumatization of the sphenoid sinus is normal developmental variant. Radiological find-ing on computed tomography (CT) or magnetic resonance image (MRI) may be confused with bony lesions of paranasal sinuses or invasive tumors of the skull base. A 43-year-old woman visited our hospital with headache, and an MRI scan performed at other hospital showed abnormal findings in the right sphenoid sinus. When the additional CT images were evaluated, it was diagnosed as an arrested pneumatization of the sphenoid sinus. A 46-year-old woman visited the neurologist with diplopia and had a brain MRI. Due to abnormal findings in the left sphenoid sinus, the patient was transferred to the otorhinolaryngology department. The left sphenoid sinus lesion was confirmed as an arrested pneumatization on CT and MRI. Both patients decided to follow-up without any special treatment. Differential diagnoses for this developmental variant would reduce treatment cost and exploratory surgery.

Lymphoma of the cerebellopontine angle mimicking metastasis lesion: A case report

Primary lymphoma of the cerebellopontine angle (CPA) is rare and uncommon in the central nervous system, accounting for approximately 0.2-2% of all brain tumors. To our knowledge, there have only been 32 cases reported worldwide so far. Here, we report a rare case of B-cell lymphoma in a 56-year-old woman who presented with seizure, dysphagia, and dizziness and showed a lesion involving the left CPA, right frontal horn and septum pellucidum on magnetic resonance imaging (MRI). The primary diagnosis was metastatic tumor; however, Stereotactic biopsy on left CPA lesion was done, and the histological features confirmed the diagnosis of B-cell malignant lymphoma. The patient was treated with chemotherapy, with complete resolution of symptoms after the first chemotherapy session.

Benign incidental lesion of the calcaneus: the calcaneal vascular remnant.

The calcaneal vascular remnant, first described by Fleming et al. in 2005, is a benign intramedullary lesion of the calcaneus with a vascular origin. To determine the prevalence and magnetic resonance imaging (MRI) characteristics of incidental calcaneal vascular remnant on routine ankle MRI. We retrospectively reviewed 457 ankle MRI scans for the presence of calcaneal vascular remnant. MRI was considered positive when a focal cyst-like area was seen on a T2-weighted sequence, and a low signal intensity was identified on a T1-weighted image beneath the calcaneal sulcus. Patients with calcaneal vascular remnants were further evaluated for age, gender, right or left foot location, size, and lesion characteristics. The prevalence of incidental calcaneal vascular remnant was 21.7% on our consecutive ankle MR examinations. The average lesion size was 5.5 mm. No statistically significant difference was noted in the frequency of lesion detection between gender, age, and side of the lesions (P > 0.05). Multilobulated lesions were detected predominantly in women (P = 0.013) and classic type lesions were detected predominantly in men (P = 0.036). This report is the first to determine the prevalence and MRI characteristics of calcaneal vascular remnants. Detecting and reporting this lesion on routine MRI is essential to avoid confusion with other pathologic entities.

Single-stent strategy for left coronary artery bifurcation lesions in patients with chronic ischemic heart disease: protocol of a randomized trial

Aim. This study aims to compare the intraoperative, immediate postoperative and long-term postoperative results of stenting followed by final kissing balloon angioplasty (FKB) and without FKB for left coronary artery (LCA) bifurcation lesions in patients with chronic ischemic heart disease.Material and methods. We plan to perform an open-label, prospective, randomized, single-center, cohort trial that will include 40 patients with left main coronary artery bifurcation lesion, who will undergo stenting procedure followed by FKB or without FKB, using the second-generation drug-eluting stents. Randomization into two groups will be done after performing coronary angiography, confirming the inclusion criteria and the absence of non-inclusion criteria and signing a written consent in 2 copies. Group 1 — stenting followed by FKB. Group 2 — stenting without FKB. The total follow-up period is 24 weeks. It is planned to contact by phone on 30th and 180th day (±7 days) of postoperative period to obtain the information about patient condition, general survival rate, the events of combined controlled points and drug therapy. During 2d phone contact, on 180th day (±7 days), a patient will be invited to undergo multispiral computed tomography of the coronary arteries.The primary combined end-point: cardiac death, nonfatal myocardial infarction, acute cerebrovascular accident and the repeat target vessel revascularization. The secondary combined end-point: thrombosis and stent restenosis.Conclusion. Our study will optimize the approach to the choice of stenting strategy (with or without FRB) for left main coronary artery bifurcation lesions in patients with chronic ischemic heart disease.

P211 BLEEDING AND THROMBOSIS: A MULTIDISCIPLINARY SLALOM

Abstract GG is a 75 kg and 75 years old smoker man with metabolic syndrome, potus, OSAS and LBBB. In 1/2022 the echo imaging showed EF 35%, high dissincrony and PVCs so a myocardial SPECT had been recommended but not carried out by the patient. In 6/2022 new exertional dyspnea, orthopnea and peripheral oedema lead the patient to the Emergency Department: the ECG indicated new onset AF 75 bpm, at laboratory tests creatinine 1.8 mg/dL and NTproBNP 6200 pg/ml and echocardiography confirmed hypokinetic cardiopathy with EF 35%, mild–moderate mitral and tricuspidal regurgitation with pulmonary hypertension and vascular congestion. Admitted for heart failure and new onset AF, diuretic and levosimendan ev, MRA, BB and LMWH started with benefit. At the end of inotropic therapy, ARNI, SGLT2 and inhaled cortisone began. Myocardial SPECT proved moderate fixed inferior wall hypoperfusion. Hospitalization was complicated by ecchymoses and hematomas of abdomen superficial soft tissues during LMWH and proximal saphenous vein and III middle left thigh thrombophlebitis, so apixaban 5mg BID and elastic stockings started with resolution. The onset of paresthesias, pain and left leg progressive hyposthenia led to diagnosis of a partial hematoma of the ilio–psoas muscle resulting in a complete left femoral nerve lesion and severe obturator nerve and left lumbosacral trunk suffering plus further right iliac and rectus abdominis muscles hematomas. Discontinued apixaban, after 72 hours the hematoma was surgically removed without complications and fast recovery thanks to FKT. 9 days later left leg DVT recurrence was observed: in absence of absolute contraindications to anticoagulant therapy and blood count stability, without evident new bleedings, heparin infusion was set with maintenance of the aPTT values at the lower therapeutic range limits. One week later radiological imaging demonstrated reduction of left retroperitoneal hematoma so dabigatran 150 mg BID was initiated. Control echo showed EF 42%, mild MR and TR. Regular the subsequent rehabilitation course: the patient was discharged with dabigatran 110 mg twice daily to limit long–term bleeding risk. The thrombotic/bleeding risks require a complex therapeutic modulation in a multidisciplinary teamwork.

C43 RELATIONSHIP BETWEEN ECHOCARDIOGRAPHIC DATA AND CARDIOPULMONARY EXERCISE TEST PARAMETERS IN ADULT CONGENITAL HEART DISEASE PATIENTS: A RETROSPECTIVE CLINICAL STUDY

Abstract Introduction The interpretation of cardiopulmonary exercise test (CPET) in adult congenital heart disease (ACHD) is challenging because of the high variability in cardiac lesions and because the poor exercise tolerance is often associated with abnormal heart function. The aim of this work is to study the correlation between echocardiographic evaluation and CPET parameters in ACHD population. Methods This is a retrospective clinical study enrolling all ACHD patients afferent to our institution from March 2016 to February 2020 collecting clinical, CPET and echocardiographic data. Population was divided into three groups and compared: patients with prevalent left heart lesions (L group), patients with prevalent right heart lesions (R group) and patients with single ventricle physiology (SV group). Finally, correlation analysis were performed to assess any relationship between echocardiographic and CPET data. Results 60 patients were included in the study, 20 were male, median age was 36 [30–46.75] years old, 23 had a prevalent left side pathology, 31 a prevalent right side pathology and 6 had a single ventricle physiology. L group had a significantly lower predicted peak VO2 in comparison to SV group (p=0.03). Statistical analysis showed a correlation between the right ventricular function and the ventilatory reserve in the R group (R2 0.517). In SV group we found correlation between ventricular–arterial coupling and Cardiac mechanical efficiency with the ventilatory reserve (R2 0.6 and 0.65, respectively) and the oxygen pulse (R2 0.97 and 0.98, respectively), and a correlation between the ejection fraction and the Oxygen pulse (R2 0.52). Finally, a correlation between the TAPSE/PAPs index and the ventilation (R2=0.79), the ratio between the oxygen uptake and the workload (R2=0.61) and the oxygen consumption (R2=0.72) was found. Coclusion:In our preliminary experience, echocardiographic parameters of cardiocirculatory efficiency correlate with the oxygen consumption per heart beat evaluated at the CPET in single ventricle patients, and the breath rate is influenced not only by ventricular function but also by the coupling between the ventricle and the arterial system. In patients affected by right–side disease, the breath rate correlate with the right ventricular function. Finally, in the left heart lesion population, a correlation between the TAPSE/PAPs index with the ventilation, the oxygen consumption per beat and the oxygen consumption was found.

Persistent and fatal severe acute respiratory syndrome coronavirus 2 infection in a patient with severe hypogammaglobulinemia: a case report

BackgroundViruses are constantly changing as a result of mutations, and new viral variants are expected to appear over time. The virus that causes coronavirus disease 2019, severe acute respiratory syndrome coronavirus 2, is not excluded from this condition. Patients with some types of immunodeficiency have been reported to experience symptoms that vary from mild to severe, or even death, after being infected with severe acute respiratory syndrome coronavirus 2. We report a case of a woman with severe hypogammaglobulinemia who developed a prolonged and fatal severe acute respiratory syndrome coronavirus 2 infection.Case presentationA 60-year-old mestizo female with a previous history of severe hypogammaglobulinemia manifested by recurrent pulmonary infections and follicular bronchiolitis. She received a monthly treatment of intravenous immunoglobulins and was admitted after report of a neurological manifestation related to a left thalamic inflammatory lesion, for a duration of 2 weeks of hospitalization, indicated for the study of her neurological condition, including brain biopsy. Both on admission and 1 week later, nasopharyngeal polymerase chain reaction tests for severe acute respiratory syndrome coronavirus 2 were performed and reported negative. In the third week of hospitalization, she developed pulmonary symptoms, and a positive test result for severe acute respiratory syndrome coronavirus 2 was evidenced. On Day 3, the patients’ condition worsened as the infection progressed to respiratory failure and required mechanical ventilation. On Day 8 after the coronavirus disease 2019 diagnosis, the polymerase chain reaction test for severe acute respiratory syndrome coronavirus 2 showed persistent detection of the virus. Various bacterial coinfections, including Klebsiella pneumoniae and Enterobacter cloacae, were diagnosed and treated. On Day 35, her pulmonary symptoms worsened, and the results of the severe acute respiratory syndrome coronavirus 2 polymerase chain reaction test remained positive. On Day 36, despite all the respiratory support, the patient died. The severe acute respiratory syndrome coronavirus 2 virus was sequenced at the beginning and 8 days after the onset of the disease, and the strain, without obvious mutations in the gene that encodes spike protein, was identified.ConclusionsThis clinical case showed persistent severe acute respiratory syndrome coronavirus 2 detection after 35 days of infection in a patient with severe hypogammaglobulinemia. The sequencing of the virus showed no mutations on the spike protein at 8 days, indicating that, in this case, the persistence of the viral detection was associated with immunodeficiency instead of changes in the viral components.

Thoracoscopic Surgical Ablation of Lone Atrial Fibrillation: Long-term Outcomes at 7 Years

BackgroundAntiarrhythmic drugs and transcatheter ablation in atrial fibrillation (AF) provide suboptimal rhythm control with a not negligible rate of failure in paroxysmal AF (PAF) and nonparoxysmal AF (n-PAF) at midterm and long-term follow-up. This study evaluated the safety profile and long-term efficacy of thoracoscopic ablation in patients with lone AF. MethodsA consecutive 153 patients with lone AF were prospectively enrolled and underwent thoracoscopic surgical ablation. Inclusion criteria were symptomatic AF refractory to pharmacologic therapy (Vaughan-Williams class I-III), age >18 years, and absence of left atrial thrombosis. Exclusion criteria were long-standing AF >5 years, left atrial diameter >55 mm, and contraindication to oral anticoagulation. The “box lesion set” (encircling of pulmonary veins) was always used. Exclusion of the left atrial appendage was performed only in selected cases. The primary study end point was freedom from AF. Secondary end points were overall survival and cumulative incidence function of cardiac event–related death, cerebrovascular accidents, and pacemaker implantation. ResultsThere was no in-hospital mortality. Early postoperative complications were pacemaker implantation (4/153 [2.6%]), cerebrovascular accident (2/153 [1.3%]) with full recovery of both, and bleeding requiring surgical revision (2/153 [1.3%]). Overall freedom from AF at 7 years was 86% ± 4% (76.9% in n-PAF, 96.1% in PAF). Survival freedom from AF in patients without antiarrhythmic drugs in PAF and n-PAF groups was 79.1% and 52.2%, respectively. ConclusionsThoracoscopic surgical ablation of lone AF by means of an isolated left atrial box lesion provided an excellent long-term rhythm outcome, even in long-standing persistent AF. The isolated left atrial ablation showed an excellent safety profile with low incidence of pacemaker implantation and postoperative complications.

PO-01-105 PRECLINICAL EVALUATION OF ACUTE AND CHRONIC CIRCUMFERENTIAL, LINEAR AND FOCAL PULSED FIELD ABLATION LESION SETS CREATED USING A “MAP & ABLATE” SPHERICAL MULTIELECTRODE ARRAY CATHETER

A multielectrode spherical array catheter (Globe PF System, Kardium Inc., Canada) capable of both cardiac mapping and ablation with either pulsed field (PF) or radiofrequency (RF) energy has been developed. To assess efficacy and safety of creating flexible PFA lesion sets. Healthy canines (n=12) underwent transeptal access under general anesthesia. Electroanatomic maps with ostial tags, contact maps based on blood flow detection, and animated voltage maps were created. PFA was delivered at two strengths (1.7 & 1.8kV)and two pulse train designs (6 x 1.5-2 sec pulse-time or 3 x 3-4 sec pulse-time) to isolate a minimum of 2 pulmonary veins (PVs) (∼1 application) and to create linear/focal lesions. Animals survived in acute (n=6; 3±1 days survival) and chronic (n=12; 30±3 days survival) cohorts. In the chronic cohort, a repeat electrophysiological study was performed followed by detailed necropsy. In 12 animals, all targeted PVs (25/25, 100%) were acutely and durably isolated (13/13,100%). Discrete ablation on the roof and on the posterior wall was also successful in all 12 animals. Phrenic activation was only seen at one ablation site in one animal in each cohort. All 12 animals completed their survival period and gross pathological analysis revealed contiguous pink to dark-red lesions and pale-homogenous lesions in the acute and chronic cohorts, respectively. No thrombus or char was observed on the catheter. Histology revealed mean transmurality rates of 95.7% and 91% for the 74 and 75 sections analyzed in the acute and chronic cohorts, respectively. The lesion mean depths were 3.0±1.8 and 1.6±0.9 mm in the acute and chronic cohorts, respectively. There were variable amounts of hemorrhage and a minimal to moderate acute inflammatory response in the acute cohort. In the 2/6 canines that underwent necropsy on day 4 (the other 4 underwent necropsy on day 2 or 3), fibroblast proliferation was noted in addition to the above findings. In the chronic group, the entire lesion was replaced with fibrous connective tissue. No ablation damage to extracardiac structures was found. There were no signs of thromboembolism in any downstream organs, including no brain infarcts. This multielectrode spherical array catheter can deliver pulsed field ablation to both isolate PVs and deliver extra-PV left atrial lesions. These data provide the basis for ongoing and future clinical trials.

Low risk of new dysplastic lesions in an inflammatory bowel disease population study with dye chromoendoscopy

Background and study aims Rates of new dysplastic lesions or cancer progression after first dye chromoendoscopy in the era of high-definition endoscopy have yet to be determined. Patients and methods A multicenter, population-based, retrospective cohort study was performed in seven hospitals in Spain. Patients with inflammatory bowel disease and fully resected (R0) dysplastic colon lesions under surveillance with high-definition dye-based chromoendoscopy were sequentially enrolled between February 2011 and June 2017, with a minimum endoscopic follow-up of 36 months. The aim was to assess the incidence of developing more advanced metachronous neoplasia by analyzing possible associated risk factors. Results The study sample included 99 patients and 148 index lesions (145 low-grade dysplasia lesions and three high-grade dysplasia [HGD] lesions with a mean follow-up of 48.76 months [IQR: 36.34-67.15]). The overall incidence of new dysplastic lesions was 0.23 per 100 patient-years, 1.15 per 100 patients at 5 years and 2.29 per 100 patients at 10 years. A history of dysplasia was associated with a higher risk of developing any grade of dysplasia during follow-up ( P = 0.025), whereas left colon lesions were associated with a lower risk ( P = 0.043). The incidence of more advanced lesions at 1 year and 10 years was 1 % and 14 % respectively, with lesion size > 1 cm being a risk factor ( P = 0.041). One of the eight patients (13 %) with HGD lesions developed colorectal cancer during follow-up. Conclusions The risk of dysplasia progressing to advanced neoplasia and, specifically, the risk of new neoplastic lesions after endoscopic resection of colitis-associated dysplasia, are both very low.

Abstract #1406603: An Atypical Clinical Presentation of a Parathyroid Adenoma

Parathyroid adenomas usually appear as well-defined, homogeneous, hypoechoic masses on ultrasound (US). However, atypical features on US including heterogeneity, cystic changes, and calcifications raise suspicion of malignancy. We present a patient with a suspicious atypical clinical presentation of a parathyroid adenoma. A 29-year-old female presented after a fall with a new right nondisplaced proximal tibial pathologic fracture through a large lytic bone lesion. Prior to bone biopsy and operative fixation of the fracture, lab work was significant for a calcium level of 14.8 mg/dL, albumin 4 g/dL, intact parathyroid hormone (PTH) 1,176 pg/mL, 25-hydroxy vitamin D 14 ng/mL, magnesium 1.6 mg/dL, alkaline phosphatase level 483 U/L and phosphorus 2.2 mg/dL. She denied any personal or family history of hypercalcemia, nephrolithiasis, osteoporosis, excessive calcium or vitamin D intake, malignancy or symptoms of abdominal pain, nausea, vomiting, constipation, or dysuria. Of note, the patient had a prior biopsy of the left lytic hip bone lesion eight months prior. Pathology initially revealed a benign process concerning for hemangioma of the bone or fibrous dysplasia; however, retrospective review was consistent with osteitis fibrosa cystica. A thyroid US revealed a heterogeneous 3.9 x 2.4 x 3.0 cm complex solid and cystic mass in the neck posterior to the thyroid between the trachea and carotid, concerning for a malignant neoplasm. Parathyroid scan revealed an intense nodular focus of radiotracer uptake at the inferior pole of the right thyroid lobe suspicious for parathyroid neoplasm. She required intravenous (IV) normal saline, calcitonin, and IV pamidronate due to persistent hypercalcemia. She underwent a right hemithyroidectomy and inferior parathyroidectomy with a closed treatment of her tibial fracture. A pre-excision intraoperative PTH level was 1,473 with a post-excision PTH level of 114. Pathology revealed a cystic parathyroid adenoma. Hungry bone syndrome was prevented postoperatively with calcium carbonate 1 g three times daily, calcitriol 0.5 mg twice daily, and vitamin D3 50,000 IU weekly. This atypical presentation of a parathyroid adenoma is significant because it highlights similarities it can share with parathyroid carcinomas. Initial imaging was highly suspicious for features of malignancy, but surgical pathology was consistent with a parathyroid adenoma. Furthermore, this case is unique because the pathologic finding of osteitis cystica is unusual in the early biochemical diagnosis of hyperparathyroidism. Therefore, clinicians should be aware of this form of disease and include it in their differential in a patient with multiple bone cysts.

Bilateral tension pneumothoraces in a preterm low-birthweight newborn: tube thoracostomy using four 7-French latex catheters performed by an emergency physician

Neonatal tension pneumothorax is life-threatening. A tension pneumothorax on the right side was detected on a newborn boy weighing 2,380 g, who was born at 35 weeks of gestation. Given the unavailability of an on-duty thoracic surgeon and appropriately sized chest tubes in the neonatal intensive care unit, an emergency physician performed closed thoracostomy using two 7-French latex catheters. Immediately after the re-expansion of the right lung, left tension pneumothorax was newly detected. Two more 7-French latex catheters were inserted, relieving the left lesion. We consider that the right pneumothorax occurred due to the mixture of spontaneous rupture of the subpleural blebs and barotrauma during the initial positive pressure ventilation, while the left lesion did due to the high-flow oscillatory ventilation. Despite the limited availability of devices in the present case, a favorable outcome was achieved by the use of alternative catheters, which were chosen by the emergency physician.

Functional architecture of executive processes: Evidence from verbal fluency and lesion mapping in stroke patients

The functional organization and related anatomy of executive functions are still largely unknown and were examined in the present study using a verbal fluency task. The objective of this study was to determine the cognitive architecture of a fluency task and related voxelwise anatomy in the GRECogVASC cohort and fMRI based meta-analytical data.First, we proposed a model of verbal fluency in which two control processes, lexico-semantic strategic search process and attention process, interact with semantic and lexico-phonological output processes. This model was assessed by testing 404 patients and 775 controls for semantic and letter fluency, naming, and processing speed (Trail Making test part A). Regression (R2 = .276 and .3, P = .0001, both) and structural equation modeling (CFI: .88, RMSEA: .2, SRMR: .1) analyses supported this model.Second, voxelwise lesion-symptom mapping and disconnectome analyses demonstrated fluency to be associated with left lesions of the pars opercularis, lenticular nucleus, insula, temporopolar region, and a large number of tracts. In addition, a single dissociation showed specific association of letter fluency with the pars triangularis of F3. Disconnectome mapping showed the additional role of disconnection of left frontal gyri and thalamus. By contrast, these analyses did not identify voxels specifically associated with lexico-phonological search processes.Third, meta-analytic fMRI data (based on 72 studies) strikingly matched all structures identified by the lesion approach.These results support our modeling of the functional architecture of verbal fluency based on two control processes (strategic search and attention) operating on semantic and lexico-phonologic output processes. Multivariate analysis supports the prominent role of the temporopolar area (BA 38) in semantic fluency and the F3 triangularis area (BA 45) in letter fluency. Finally, the lack of voxels specifically dedicated to strategic search processes could be due to a distributed organization of executive functions warranting further studies.

Peripheral T-Cell Lymphoma Manifesting as Multifocal Central Nervous System Disease with Prominent Spinal Cord Involvement (P2-13.001)

<h3>Objective:</h3> To emphasize the need for timely and wide-reaching diagnostic testing in the evaluation of acute-onset multifocal CNS disease with prominent spinal cord involvement. <h3>Background:</h3> Metastatic CNS neoplasms, although rare, should be considered early in rapidly declining patients with multifocal disease in whom immune-mediated or infectious etiologies have been excluded. <h3>Design/Methods:</h3> N/A <h3>Results:</h3> A 53-year-old male with Celiac disease on azathioprine presented with one-week of vertigo, diplopia, and dysarthria upon one-year of malaise and cachexia. The patient’s examination revealed right eyelid ptosis, bilateral abducens palsies, restricted up-gaze, dysarthria, and diffuse dysmetria and hyporeflexia. MRI showed a right T2 hyperintense contrast-enhancing cerebellar lesion and a small left cerebellar diffusion-restricting lesion. CSF was inflammatory (nucleated cell 6 cells/mcL, protein 181 mg/dL, glucose 30 mg/dL). Workup for autoimmune encephalitis, myelin-oligodendrocyte-glycoprotein-IgG, aquaporin-4-IgG, and infections etiologies were negative. He was empirically treated with intravenous methylprednisolone and immunoglobulin without benefit. He continued to decline and repeat CSF was again inflammatory (28 cells/mcL, protein 494 mg/dL), without clonal cells. Repeated MRI showed new left frontal leptomeningeal and cauda equina enhancement extending into the adjacent musculature. Electromyography showed proximal myopathy and subsequent biopsy was unrevealing. A bone marrow and brain biopsy were declined due to development of pulmonary embolism and multiorgan failure. He continued to decline and developed multifocal strokes, expiring 6 weeks after presentation. Autopsy demonstrated peripheral T cell lymphoma (PTLC). <h3>Conclusions:</h3> Intramedullary non-CNS spinal metastases represent less than 8.5% of all metastatic tumors and 3% of all spinal metastases. PTCL represents 15% of non-Hodgkin lymphomas and can rarely involve the CNS parenchyma or leptomeninges. Persistent enhancement, elevated protein, and minimal response to steroids or subsequent rebound should raise suspicion for neoplasm, especially considering these patients’ rapid decline can make CNS biopsy inadvisable later in the disease course. <b>Disclosure:</b> Dr. Singh has nothing to disclose. Dr. Carozza has nothing to disclose. Dr. Misulis has received publishing royalties from a publication relating to health care. Dr. Shah has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Horizon. Dr. Shah has received publishing royalties from a publication relating to health care.

Novel case report of primary osteosarcoma of the maxilla in an adult: An important differential diagnosis

Craniofacial osteosarcoma accounts for 10% of osteosarcoma malignancies, typically affecting the 4-5th decade of life, with the maxilla being the second-most common site.We report a 58-year-old male, non-smoker, with a lump of his upper jaw which occasionally bled during mastication. Clinical examination revealed an exophytic mass in the upper left tuberosity of the maxilla and no lymphadenopathy, where initial differential diagnosis was squamous cell carcinoma.Radiological investigations revealed a metabolically active left maxillary lesion with maxillary sinus destruction, representing primary malignancy. Histological analyses initially suggested a fibro-osseous lesion; further immunohistochemistry showed cytokeratin AE1/AE3/CK(MNF.116) positivity with 60% ki67 proliferation index; diagnostic of grade 2–3 osteosarcoma. Management included neoadjuvant chemotherapy prior to total maxillectomy and dental prosthetic rehabilitation.We report a novel case of primary osteosarcoma of the maxilla in an adult. Osteosarcoma is challenging to diagnose and an important differential to consider where the mainstay of treatment is early invention.

Clinical efficacy of PD-1 inhibitor combined with radiotherapy in a multi-drug resistant patient with liver metastasis from gastric cancer.

A 54-year-old male was diagnosed with extensive liver metastasis and small nodule metastasis in the lungs from gastric adenocarcinoma [Her-2 (-)]. The patient achieved significant partial response (PR) after chemotherapy combined with anti-angiogenesis therapy but developed progressive disease (PD) after 5 months. Then, the chemotherapeutic and anti-angiogenic drugs were replaced. Meanwhile, the delivery route of some chemotherapeutic drugs was changed, and some chemotherapeutic drugs were given via transcatheter arterial chemoembolization (TACE) to achieve PR, and PD developed after 3 months of remission maintenance. During chemotherapy combined with anti-angiogenesis, the application of programmed cell death-1 (PD-1) inhibitor achieved PR again and maintained for 5 months before disease progression. The progression of the lesions in the left lobe of the liver and the hepatic hilar lymph nodes was significant. Hence, chemotherapy was terminated and gamma stereotactic body radiation therapy (SBRT) was performed on left lobe lesions and hilar lymph nodes. The lesions both inside and outside the radiation field regressed significantly, reaching PR and abscopal effects. The immune-related adverse events (irAEs) occurred, including erythema and black and luster hair. The abscopal effects of lesion reduction in the radiation field and the enhancement of the immune function stimulated by radiation are a highlight of the combination of radiation and immunotherapy. In the end, the patient died of gastrointestinal failure, with overall survival of 18 months.

Renovascular Hypertension with Progressive Atherosclerotic Renal Artery Stenosis in an Elderly Patient with Known Fibromuscular Dysplasia: A Case Report.

BACKGROUND Atherosclerotic renal artery stenosis (ARAS) and renovascular fibromuscular dysplasia (FMD) are 2 of the most common etiologies of renovascular hypertension. They have different pathophysiologies, risk factors, presentations, and treatment options. However, as our population ages, it can become increasingly common to see patients who previously had FMD who develop ARAS at an advanced age, indicated by recurrent renovascular hypertension. CASE REPORT We present a case of a 66-year-old female patient who, in 2007, had presented with uncontrolled hypertension. She underwent magnetic resonance angiography and was found to have bilateral FMD, for which she received balloon angioplasty to a severe lesion on the mid-right renal artery and subsequently had normalization of blood pressures and resolution of symptoms. In 2021 she returned with uncontrolled hypertension while being treated with 3 antihypertensives. Bilateral renal arteriography revealed new severe ostial stenosis of the left renal artery and a patent right renal artery in which balloon angioplasty was performed 14 years ago. Based on the angiographic pattern of this new left RAS, we concluded this lesion was caused by atherosclerosis. The left ostial lesion was treated with a bare-metal stent and the patient was continued on antihypertensive medication and statin; at follow-up 4 months later, her blood pressures had normalized. CONCLUSIONS This case features a patient who developed severe ARAS with underlying history of bilateral renal artery FMD. Clinicians need to be aware that in patients with FMD, worsening renovascular hypertension at an advanced age could indicate the development of new hemodynamically significant ARAS. These patients need repeat diagnostic testing and treatment with medial optimization with or without endovascular revascularization in the appropriate clinical setting.

A rare case of left atrial inflammatory granuloma associated with pulmonary tuberculosis.

A 65-year-old female was accidentally found left atrial space-occupying lesion 2 days ago. The patient had a previous history of pulmonary tuberculosis for several years. Physical examination and laboratory tests were unremarkable. An electrocardiogram suggested a sinus heart rate with a left-sided electrical axis and a slightly depressed T wave in lead I and augmented vector foot. Transthoracic echocardiography showed that a solitary 18 mm × 15 mm mass was attached to the annulus root of the anterior mitral valve and protruded to the left atrium, causing mild mitral leaflet insufficiency (Panel A). Cardiac computed tomographic angiography showed a round mass located in the left atrium adjacent to the anterior mitral valve (Panel B). The patient underwent resection of the left atrial mass under extracorporeal circulation. During the procedure, a round-like mass measuring approximately 2.2 cm × 1.8 cm × 1.5 cm was found attached to the anterior mitral valve. The patient had an uneventful recovery and was discharged 5 days later. Post-operative pathology confirmed as an inflammatory granuloma (Panels C and D).

TCTAP C-061 Challenges of Short Left Main With Ostial Left Anterior Descending Artery Lesion Intervention

TCTAP C-061 Challenges of Short Left Main With Ostial Left Anterior Descending Artery Lesion Intervention

A Slice in the Right Direction – Novel use of Directional Atherectomy for Treatment of Upper Limb Vascular Insufficiency and Concurrent Diagnosis

Large-vessel vasculitides are well-recognized entities, affecting the aorta, supra-aortic branch vessels, cranial vessels, and less commonly, peripheral arteries. Giant cell arteritis (GCA) is one of the most frequent large-vessel vasculitides affecting elderly patients. Despite diagnostic criteria, the mainstay of definitive diagnosis has been temporal artery biopsies. More recently, adjuvant ultrasound has been used to identify skip lesions before the biopsy. Downstream ischemia affecting branch vessels has traditionally been managed by open revascularization due to patient age and risk of disease recurrence. Experience with endovascular strategies for the management of acute or chronic vasculitides has been steadily increasing. We present an unusual case of acute giant cell vasculitis, diagnosed and treated with the use of an endovascular atherectomy device. The patient was a 74-year-old woman, with prior history of polymyalgia rheumatica, long-standing immunosuppression, and new onset of significant left arm claudication and rest pain. She underwent treatment for a high-grade left axillary artery lesion with directional atherectomy and drug-coated angioplasty. She had a good angiographic result. The intraoperative atherectomy specimen revealed the presence of acute GCA which prompted treatment with an acute vasculitis regimen. She had good patency of the treated segment at 3-month follow-up with complete resolution of her symptoms.