Left Supraclavicular Node Research Articles

Adult-onset Still\u2019s disease with multiple lymphadenopathy: a case report and literature review

BackgroundAdult-onset Still’s disease (AOSD) often presents with systemic multiple lymphadenopathy. In addition to the common paracortical and mixed patterns in AOSD lymph node histopathological features, other morphological patterns include diffuse, necrotic, and follicular patterns. However, to date, there have been few reports on the histopathological description of AOSD lymph nodes.Case presentationAn 18-year-old woman presented 2 months earlier with pain in her large joints with painless rash formation; bilateral posterior cervical lymph node, left supraclavicular lymph node, and left posterior axillary lymph node enlargement, and no tenderness. Left cervical lymph node resection was performed for pathological examination. The lymph node structure was basically preserved, and subcapsular and medullary sinus structures were observed. Many histiocytes in the sinus were observed, the cortical area was reduced, a few lymphoid follicles of different sizes were observed, and some atrophy and hyperplasia were noted. The lymphoid tissue in the paracortical region of the lymph node was diffusely proliferative and enlarged, mainly comprising histiocytes with abundant cytoplasm, immunoblasts and numerous lymphocytes with slightly irregular, small- to medium-sized nuclei. Nuclear karyorrhexis was easily observed, showing a few nuclear debris and the “starry sky” phenomenon, accompanied by abundantly branching high endothelial small vessels with few scattered plasma cells and eosinophil infiltration. Lymphoid follicle immunophenotype with reactive proliferative changes was observed. Approximately 40% of the cells in the paracortical region were positive for Ki-67, and the histiocytes expressed CD68, CD163, and some expressed S-100, with the absence of myeloperoxidase. The immunoblasts expressed CD30 and CD20, not ALK or CD15. Background small- to medium-sized T cells expressed CD2, CD3, CD5, CD7, CD4, and CD8; the number of CD8-positive T cells was slightly predominant, and a small number of T cells expressed granzyme B and T-cell intracellular antigen 1. The patient received a comprehensive medical treatment after the operation, and her condition was stable without progression at the 11-month follow-up evaluation.ConclusionsThe pathological features of AOSD lymphadenopathy raises the awareness of AOSD among pathologists and clinicians and aids in the diagnosis and differential diagnosis of AOSD lymphadenopathy from other reactive lymphadenopathies (lupus lymphadenitis, etc.) and lymphomas.

Safety and Tolerability of Neoadjuvant Radiotherapy Combined With Anti-PD-1 Antibody Toripalimab for Locally Advanced, Resectable Esophageal Squamous Cell Cancer: A Prospective Phase IB Trial

Safety and Tolerability of Neoadjuvant Radiotherapy Combined With Anti-PD-1 Antibody Toripalimab for Locally Advanced, Resectable Esophageal Squamous Cell Cancer: A Prospective Phase IB Trial

STUDY OF RECURRENCE AND SITE OF RECURRENCE IN PATIENTS WITH ADVANCED EPITHELIAL OVARIAN CANCER - A SINGLE CENTER EXPERIENCE

OBJECTIVE– Study of recurrence and pattern of recurrence in Stage III epithelial ovarian cancer. METHODOLOGY – A prospective observational, study was conducted at a tertiary hospital in Bangalore, India from April 2017 to April 2019. Informed and written consent was taken before including the patient in the study. All patients diagnosed with stage III epithelial ovarian with no residual disease following cytoreductive surgery (primary, interval and secondary) with or without Hyperthermic Intraperitoneal Chemotherapy (HIPEC) were included in the study. Patients were followed every 3-6 months up to maximum period of 24 months from the date of surgery. Last date of follow up was on 30/04/19. During follow up patient symptoms, physical examination and serum CA-125 were recorded to detect recurrence. If patient symptoms, physical examination and rising serum CA-125 are suggestive of recurrence, imaging in form of CECTabdomen/ PETCT was done for detection of recurrence. Patients were monitored for two types of recurrence. Biochemical recurrence dened as rising CA125 in absence of clinical evidence of recurrence either by physical examination or by imaging. Clinical recurrence dened as recurrence in any part of body noted on physical examination or imaging and then proving it by biopsy with or without rise in serum CA-125.Site of rst recurrence was recorded. RESULTS- A total of 84 patients were included in the study. 45 patients underwent interval, 25 patients underwent primary and 14 patients underwent secondary cytoreductive surgery. Mean duration of follow up was 18.25 months. 4 patients lost follow up. 2 patients died following surgery. Recurrence was noted in 14 patients (16.66%). Clinical recurrence was noted in 13 patients (15.47%) and biochemical recurrence was noted in 1 patient (1.19%). 8 patients had recurrence in peritoneal cavity (57.14%). 1 patient each had recurrence right inguinal lymph node, paraaortic lymph node+ peritoneum, left iliac lymph node, left supraclavicular lymph node and left inguinal lymph node. CONCLUSION – In this study clinical recurrence was more common than biochemical recurrence. Peritoneal cavity was most common site for recurrence. This study shows importance of optimal cytoreductive reductive surgery in preventing recurrence in carcinoma ovary as peritoneal cavity is most common site of recurrence

Case Report: Kikuchi-Fujimoto Disease: A case of supraclavicular lymphadenopathy

Kikuchi-FujimotoDisease (KFD), also known ashistiocyticnecrotizinglymphadenitis, is a rare cause of cervical lymphadenopathy. Patients usually present with localized lymphadenopathy, fever and fatigue. Because of the poorly understood etiology, it can be mistaken for an infectious disease or even malignance. Here we discuss a case of KFD that initially presented with left sided cervical lymphadenopathy that later progressed to left supraclavicular lymph nodes. Due to its characteristic overlap with other disorders like tuberculous lymphadenitis and lymphoma, KFD remains an arduous diagnosis for physicians. Therefore, one should be made aware of symptoms that can lead to misdiagnosis in patients.

FDG Uptakes at Unilateral Axillary and Supraclavicular Lymph Nodes and Deltoid Muscle on [18F] FDG PET/CT After COVID-19 Vaccination: A Potential Pitfall for Metastatic Lymph Nodes in Colon Cancer Patient

Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has caused the ongoing global pandemic. It can manifest a wide range of complications depending upon the severity of infection and comorbidities of the patient. Vaccines are very important measure to provide protection against COVID-19. We report a case of 73-year-old female who underwent [<sup>18</sup>F]F-2-fluoro-2-deoxyd-glucose (FDG) positron emission tomography/computed tomography (PET/CT) and contrast-enhanced CT for staging of her rectosigmoid colon cancer and was found to have hypermetabolic uptakes in the deltoid muscle of the left shoulder and hypermetabolic left axillary and supraclavicular lymph nodes due to adenovirus vectored vaccine (ChAdOx1 nCoV-19, AstraZeneca) administrated 18 days ago prior to PET/CT scan.

P52-9 Hard diagnosis and treatment in a patient with HER-2 and TTF-1 positive adenocarcinoma

TTF-1 immunoreactivity in breast cancer has been reported to be rare. We experienced the patients with TTF-1 and HER2(+) adenocarcinoma in both pulmonary and breast lesions. Herein, we reported the case in which the treatment strategy of HER2(+) breast cancer was successful after the failure of the chemotherapy for advanced lung adenocarcinoma. A 60-year-old woman visited our institute with cough and shortness of breath. Inflammatory change of left breast with ipsilateral left axillary and supra-clavicular lymphadenopathies was observed by physical examinations. CT revealed a tumor in the left lung, bilateral pleural effusion and skin thickening in the breast. Histological analysis of the left supra-clavicular lymph node led to the diagnosis of lung adenocarcinoma (CK7 +, TTF-1 +, EGFR wt, no ALK and ROS1 rearrangement, PD-L1 TPS <1%, HER2 IHC 3+, ER -, PR -, mammaglobin-), which was also confirmed in the skin biopsy of left breast. The tumor was classified as clinical T4N3M1, stage IV. She received 4 cycles of CBDCA, pemetrexed and pembrolizumab. Partial response was achieved, but she experienced progressive disease due to cancerous pericarditis after 2 cycles of a maintenance therapy. The second line chemotherapy of docetaxel and ramucirumab was performed immediately. After 2 cycles, new lesions appeared in right mammary gland and left parotid gland. The histological diagnosis in a core needle biopsy of the right breast lesion was as same as in the left supra-clavicular lymph node. Because a possibility of TTF-1 positive breast cancer as a primary tumor could not be denied, we adopted the chemotherapy of trastuzumab, pertuzumab and paclitaxel according to the treatment strategy of HER2 (+) breast cancer. Partial response was obtained after 2 cycles and continued for 8 months. The tumor agnostic approach is important not only for drug development but also for daily clinical practice in the field of medical oncology.

Papillary Thyroid Carcinoma With Axillary Lymph Node Metastasis

Papillary thyroid carcinoma (PTC) is typically known to be a non-aggressive form of thyroid follicular epithelial-derived cancer. It is characterized histologically by classic and variant forms. Metastases are uncommon and spread mainly via lymphatic channels to cervical lymph nodes and less commonly via hematogenous spread to lungs and bone. Axillary lymph node (ALN) metastasis is a rare sequela of disease presentation. A 59-year-old female presented for evaluation of shortness of breath and chest pain for one week. She had a longstanding history of hypothyroidism due to chronic lymphocytic thyroiditis which was stable on levothyroxine. Her physical exam revealed a firm mass on the inferior aspect of the left neck. Computed tomography (CT) angiogram ruled out pulmonary embolism but noted a superior mediastinal mass and significant left axillary and subpectoral adenopathy. Mammogram was negative for breast malignancy. Left axillary ultrasound showed a 1.1 x 1.8 x 1.9 cm enlarged lymph node. Thyroid ultrasound showed a 3 mm nodule on the left lower pole and a 3.7 x 2.9 x 2.1 cm heterogeneous and irregular mass in the left neck. Positron emission tomography/CT showed increased uptake in left lower paratracheal, left supraclavicular and axillary lymph nodes. Fine needle aspiration of the left neck mass and left ALN confirmed metastatic papillary carcinoma. She underwent total thyroidectomy, left modified neck, central neck, and left ALN dissection along with partial esophageal wall excision. Intraoperatively, she was found to have a multifocal tumor in the left thyroid lobe with the largest dimension of 1 cm. Surgical pathology noted that the primary tumor in the left thyroid was classic type of papillary carcinoma, and the metastatic tumor in the lymph nodes was of tall cell variant. I-123 thyroid uptake and scan after surgery showed low residual thyroid uptake of 0.6%. She underwent adjuvant ablation with 155 millicuries (mCi) of radioiodine (RAI or I-131) following levothyroxine withdrawal protocol. Post ablation therapy thyroid uptake and scan showed no radiotracer uptake within the thyroidectomy bed. According to the American thyroid association (ATA) risk stratification system, she was categorized as high risk. This case illustrates that PTC may exceptionally spread to axillary lymph nodes. Physiologic flow is centripetal to the jugulosubclavian junction and there is no communication between cervical and axillary lymphatics. However malignant tumors can alter and partially block lymphatic pathways, resulting in ALN metastasis in a retrograde direction. This case also demonstrates that PTC can be transformed into aggressive forms associated with worse prognosis such as tall cell variant. Further comprehensive monitoring and management approaches are needed to plan treatment and gauge prognosis of patients with PTC who present with ALN metastasis.

Abstract PS16-31: SKT11 loss drives rapid cancer progression and fatal pulmonary tumor thrombotic microangiopathy (PTTM) in a breast cancer patient: A case report

Abstract Introduction: Pulmonary tumor thrombotic microangiopathy (PTTM) is a rare cancer-associated respiratory complication characterized by widespread tumor cell emboli in small arteries and arterioles of the lung. Breast cancer is the second most common cancer causing PTTM. The pathogenesis and molecular background of PTTM have not been clarified. Here we present a case of breast cancer that experienced early onset of liver metastasis after surgical resection of the primary tumor and rapid progression leading to death due to severe respiratory distress. Autopsy was performed and it revealed that the main cause of her death was PTTM. Comprehensive next generation sequencing (NGS) analysis of the tissue obtained serially during the clinical course was performed. Case Presentation: A 48-year-old woman was diagnosed with invasive ductal carcinoma of the left breast, which was ER positive, PgR negative, and HER2 negative. FEC followed by docetaxel was administered as preoperative chemotherapy. Her tumor dramatically shrunk with chemotherapy and left partial mastectomy with left axillary lymph node dissection was performed. Histopathological analysis of the resected breast tissue revealed that there were a lot of residual cancer cells, which were ER negative, PgR negative, HER2 negative, and the result indicated that response to preoperative chemotherapy was insufficient. Additional two courses of FEC therapy were performed. Postoperative radiation therapy including the left supraclavicular lymph node area was given and adjuvant endocrine therapy with anastrozole started at the same time. At 3 months of anastrozole administration, she presented hepatic dysfunction and abnormal CT findings in the liver. Liver biopsy revealed multiple liver metastasis of breast cancer. Unresponsive to weekly paclitaxel and bevacizumab, she developed rapid respiratory failure leading to her death in two weeks. Postmortem microscopic analysis revealed an intimal fibrocellular proliferation in the pulmonary arterioles regardless of microscopic tumor emboli and extensive sinusoidal metastasis of the whole liver. NGS Analysis: We analyzed four specimens, breast cancer biopsy specimen at diagnosis, surgical resection specimen, liver needle biopsy specimen, and liver specimen obtained at autopsy, with the Ion AmpliSeq Comprehensive Cancer Panel (Thermo Fisher). The results were compared with NGS analysis of her normal lung tissue to exclude single nucleotide polymorphisms. Deep sequencing revealed that only TP53 R213* was detected as an oncogenic mutation in all four specimens. There were no mutations associated with the development of liver metastasis and her death. Comparison of the samples obtained between before and after liver metastasis revealed that STK11 loss and IKBKE amplification were harbored only in the specimens after liver metastasis. RNA sequencing analysis with the samples of initial biopsy and liver biopsy showed that the RNA expression associated with apoptosis and adhesion molecules was strongly suppressed in the liver sample. Conclusion: STK11 encodes a serine/threonine kinase, which organizes cell polarity and inhibits tumor growth. In the present patient, STK11 loss had occurred during the treatment and could induce rapid progression of her disease and PTTM. Citation Format: Fumie Fujisawa, Kei Kunimasa, Rieko Kano, Hiroki Kusama, Minako Nishio, Saki Matsui, Tetsuhiro Yoshinami, Nobuyoshi Kittaka, Shigenori Nagata, Toshinari Yagi, Takahiro Nakayama, Yasuhiro Tamaki, Fumio Imamura. SKT11 loss drives rapid cancer progression and fatal pulmonary tumor thrombotic microangiopathy (PTTM) in a breast cancer patient: A case report [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS16-31.

Cervical lymph node enlargement as the initial manifestation of rectal cancer

BackgroundColorectal cancer is a very common malignant tumor worldwide. The clinical manifestations of advanced colorectal cancer include the changes in bowel habits, hematochezia, diarrhea, local abdominal pain and other symptoms. However, the colorectal cancer with an initial symptom of cervical lymph node enlargement is extremely rare. In this article, we report a case of rectal cancer presenting with cervical lymph nodes enlargement as the initial symptom.Case presentationA 57-year-old woman was admitted to our hospital for cervical lymph node enlargement which was accidentally detected during physical examination. Computed tomography scan revealed multiple enlarged lymph nodes in the neck. Cervical ultrasound showed normal thyroid gland and multiple left supraclavicular lymph nodes enlargement. The patient underwent lymph nodes biopsy and pathologic results showed metastatic adenocarcinoma. The subsequent lower gastrointestinal endoscopy revealed a mucosal bulge lesion located at rectus and biopsy revealed adenocarcinoma. The patient underwent rectal cancer resection. She is alive with no evidence of recurrence or new tumors 2 years after surgery.ConclusionsCervical lymph node metastasis is a rare metastatic way in colorectal cancer. This is the first case of rectal cancer presenting with cervical lymph nodes metastases as the initial symptom. Surgical resection combined with postoperative chemotherapy improved long-term prognosis of the patient. This rare metastatic way of rectal cancer should be paid attention for clinicians.

Blue Round Small Cell tumor: A Surgical Update of DSRCT with review of literature ‘A Grim Affair’

Desmoplastic small round cell tumor (DSRCT) is a tumor derived from the Greek desmos referring to knot and plasis to formation an uncommon soft tissue malignant tumor, mesenchymal in origin and aggressive with a prelidiction for males and advanced at presentation. It was first described as a distinct clinical entity by Gerald WL and Rosai J (7). There are fewer than 200 reported to date. Depending on the primary site of location the Clinical manifestations vary. As most arise from the abdomen and pelvis they remain asymptomatic till they attain a huge size. Other reported sites are the skull, thorax, and paratesticular region (10,13). We report the case of a 19 yr old male who had non specific abdominal discomfort with asthenia for a period of six months and was referred to us for evaluation of left supraclavicular nodes. The prognosis of Desmoplastic small round cell tumor (DSRCT) is poor with few surviving less than two years.

Cervical extradural metastasis from follicular carcinoma thyroid after 14 years post-thyroidectomy with Elsberg phenomenon

Background. Follicular carcinoma thyroid usually metastasises to bone. Common sites of bone metastasis include skull and spine. Spinal metastasis are more common in the cervical region followed by dorsolumbar spine. Cervical extradural lesions present with progressive quadriparesis, sensory loss, dysautonomia, and respiratory distress. Typical Elsberg phenomenon in a cervical extradural lesion is rare. Elsberg phenomenon involves the involvement of ipsilateral upper limb, ipsilateral lower limb followed by contralateral lower limb and contralateral upper limb. Case presentation. We are reporting a case of 47-year-old lady presented with progressive quadriparesis of 1-month duration. Her weakness started in left upper limb followed by left lower limb, right lower limb and right upper limb weakness. She also had sensory loss below the level of C7. She had undergone near-total thyroidectomy for solitary thyroid nodule 14 years back and was on thyroid supplementation since then. Histopathology at that time was reported as follicular adenoma with Hashimoto thyroiditis. Her right upper limb power was grade 4- Left upper limb grade 1 right lower limb Grade 3, left lower limb grade 2 with hypertonia of both upper and lower limbs. She was evaluated with MRI Spine which showed a dumb bell-shaped extramedullary lesion involving the C5-C6 vertebra with significant cord compression and encasement of the left vertebral artery. USG neck showed left supraclavicular lymph node enlargement and small residual thyroid tissue in the left side of the thyroid. USG guided FNAC from the thyroid tissue and neck nodes were inconclusive. The patient underwent C4 and C5 laminectomy and subtotal excision from the cervical lesion. Histopathology was reported as metastasis from follicular carcinoma thyroid. Postoperatively patient limb power improved to grade 3 left upper and lower limbs and was discharged and later referred for radioiodine ablation Conclusion. Cervical extradural metastasis from follicular carcinoma thyroid can present with Elsberg syndrome even without any neck swelling even after decades of post thyroidectomy status for a benign aetiology. Laminectomy and decompression may lead to clinical improvement.

Optimum Treatment Planning Technique Evaluation For Synchronous Bilateral Breast Cancer With Left Side Supraclavicular Lymph Nodes

Background: the Bilateral breast cancer cases are classified as a complex in radiotherapy treatment especially those with the left side mastectomy and right-side lumpectomy with left side supraclavicular lymph nodes patients. The purpose of this study is to find the optimum treatment planning technique among the three available techniques: 3D-CRT, IMRT, and VMAT.Materials and Methods: Ten Bilateral breast cancer included in this study with left side mastectomy and right-side lumpectomy with left side supraclavicular lymph nodes. The cross-sectional clinical study conducted in Baghdad ‎radiotherapy and nuclear medicine and Al-Andalus privet radiotherapy ‎hospital, Baghdad, Iraq. The patients are delineated by oncologists and prepare for radiation planning by MONACO 5.1 treatment planning system (TPS) with an X-ray photon beam of 6 MV or 10 MV energy using ‎ELEKTA‏’‏s Agility linear accelerator. The prescribed dose set at (4005 cCy per 15 fractions. Results: The treatment with 3D-CRT, IMRT, and VMAT show a significant difference in the results. VMAT give high dose distribution for the left mastectomy breast and it’s regional supraclavicular lymph nodes while the IMRT gives a higher value for the right side breast with lumpectomy. The good homogeneity index acquired with IMRT while VMAT gives a better conformity index. The 3D-CRT planning technique lowers the dose tho the heart and lunges better than the other techniques.Conclusion: Depending on the patient health and stage, the optimum treatment planning applied. Generally, VMAT is the optimum treatment planning technique for the studied group of SBBC patients. IMRT give effective coverage results better than the 3D-CRT.

A Rare Aggressive Case of Follicular Dendritic Cell Sarcoma

Follicular dendritic cell sarcoma (FDCS) is a rare lymphoid neoplasm with indolent clinical process. However, we presented here a rare case of FDCS in aggressive pace. The case was a 48-year-old female complaining of dysphagia for half a year. She was found gastric fundus bulge under gastroscopy and diagnosed as low-differentiated gastric adenocarcinoma in the local hospital. After three courses of chemotherapy with paclitaxel combined with oxaliplatin and 5-fluorouracil, PET-CT showed progressive disease (PD) with not only gastric bulk but also invasion to the liver and multiple lymph nodes in the abdomen. The patient was admitted to the Department of Surgery of our hospital. Total gastrectomy and liver tumor resection were performed and postoperative pathology demonstrated FDCS. The patient was transferred to our department for chemotherapy. After three courses of CHOP, PET-CT showed tumor in the anastomotic site, partial liver resection margin and left adrenal gland. The patient was sent for radiotherapy. After radiation, PET-CT demonstrated PD and the puncture of left supraclavicular lymph node confirmed FDCs. Thalidomide and prednisone were given orally. At the same time, the whole exome sequencing (WES) was performed, based on which therapy response index (TRI) was analyzed by Cellworks software. According to TRI, the regimen of etoposide, carboplatin, bendamustine and chidamide was chosen for the patient. After the chemotherapy, the patient developed repeated vomiting and diarrhea. Abdominal CT showed intussusception and intestinal obstruction. She was sent for gastrointestinal surgery to relieve obstruction and postoperative pathology again confirmed FDCS. However, her abdominal pain and diarrhea occurred again one month after operation. The patient was discharged voluntarily and went to local hospital for supportive care. During a year from the onset to abandon of tumor therapy, the case was administered operation, radiotherapy and chemotherapy. The regimens of chemotherapy included paclitaxel-based chemotherapy for solid tumors, CHOP for lymphoma, and formulated regimen according to the analysis of WES. However, all of these therapeutic strategies were unable to control the progress of her disease. Hitherto, there is no guideline or consensus to guide the treatment of FDCS. The diagnosis and treatment process of this relapsed and refractory case can provide reference for clinicians to manage FDCS. Disclosures No relevant conflicts of interest to declare. OffLabel Disclosure: FDCS of this case was in the aggressive manner. Routine therapeutic strategies, including operation, radiotherapy and chemotherapy based on paclitaxel or CHOP, were not able to control the progress. Therefore, the whole exome sequencing (WES) was performed, based on which therapy response index (TRI) was analyzed by Cellworks software. According to TRI, the regimen of etoposide, carboplatin, bendamustine and chidamide was chosen for the patient under the consent of her and her family for off-label use.

RARE FINDING OF TB MENINGITIS FOLLOWING INITIATION OF METHOTREXATE

SESSION TITLE: Medical Student/Resident Chest Infections Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Mycobacterium tuberculosis (TB) is the leading infectious cause of death in adults worldwide (3). Only 1% of patients with TB infection have CNS involvement and it is exceptionally rare in North America (1,2). Typical manifestations of CNS infection include meningitis, tuberculoma, or abscess (2). The most common presenting symptoms are fever, vomiting, headache, and altered consciousness (1,2). CNS infection can have devastating consequences such as hydrocephalus, brain tissue damage, and cerebral vasculitis (2). This is a case of TB meningitis in North America with both brain and iliopsoas TB abscess formation following initiation of methotrexate. CASE PRESENTATION: 75-year-old female presented to outside ER with weakness, fatigue, and vomiting. She was discharged home and instructed to stop methotrexate as her symptoms were an adverse reaction. Methotrexate was started four days earlier for polymyalgia rheumatica. Two days later she became difficult to arouse and minimally responsive. CT abdomen and pelvis showed rim-enhancing collection in the right iliacus with brain MRI showing scattered punctate lesions. Empiric antibiotics, pan culturing including CSF, and iliopsoas abscess drainage and culture was performed. CSF showed low glucose and high protein indicating bacterial infection. However, all cultures showed no growth. Patient continued to be non-responsive with increasing oxygen requirements. Bronchoscopy was performed as well as PET scan which showed increased uptake in left supraclavicular and mediastinal nodes. Lymph node biopsy showed caseating granulomatous inflammation. With these findings, spinal fluid from prior lumbar puncture was sent for mycobacterial culture and PCR. Family reported the patient’s husband had active tuberculosis 2 years prior and the patient was treated prophylactically with 4 months of rifampin. Ultimately, PCR of spinal fluid and bronchoalveolar lavage returned positive for TB. Mycobacterial cultures of CSF fluid and iliopsoas abscess fluid also grew TB. DISCUSSION: Tuberculosis meningitis is the most common CNS manifestation of tuberculosis infection (1,5). Prompt initiation of anti-tuberculosis drugs and corticosteroids is critical as these patients often have irreversible CNS damage (4,5). The unknown exposure history was a key factor in directing the diagnosis and initiation of treatment in this case. Our patient responded well to dexamethasone, rifampin, pyrazinamide, levofloxacin and ethambutol. However, her mentation never returned to baseline, showing the severity and devastation CNS TB. CONCLUSIONS: Ultimately the patient’s latent TB was likely activated by the immunosuppression from methotrexate. This is something to contemplate in any patient before starting an immune altering drug. TB should be considered in altered mental status with CSF signs of bacterial meningitis without growth on cultures. Reference #1: 1.Chin JH. Tuberculous meningitis: Diagnostic and therapeutic challenges. Neurol Clin Pract. 2014;4(3):199–205. doi:10.1212/CPJ.0000000000000023 Reference #2: 2.Hamid Changal, K. (2014). Central Nervous System Manifestations of Tuberculosis: A Review Article. Mycobacterial Diseases, 04(02). Reference #3: 3.WHO. Treatment of tuberculosis: guidelines: 4th ed. Available at: http://www.who.int/tb/publications/2010/9789241547833/en/index.html. Accessed May 12, 2019 4.Tuberculous meningitis. Garg RK. Acta Neurol Scand. 2010;122:75–90. DISCLOSURES: No relevant relationships by Muhammad Ahmed, source=Admin input No relevant relationships by Alyson Bundy, source=Web Response No relevant relationships by Simon Meredith, source=Web Response No relevant relationships by karan Singh, source=Web Response No relevant relationships by Rodney Steff, source=Web Response

Anaplastic Large Cell Lymphoma Presenting as Haemophagocytic Lymphohistiocytosis with Underlying Coxiella burnetii and Bartonella henselae Seropositivity.

Haemophagocytic lymphohistiocytosis (HLH) is an important differential diagnosis to consider for fever of unknown origin in adults, especially in the setting of pancytopenia and hyperferritinaemia.Q fever resulting from Coxiella burnetii can cause HLH and is also postulated to increase the risk of lymphoma.Bartonella henselae infection can also trigger HLH, but the risk of lymphoma following infection by B. henselae is unknown.

Preliminary study of the clinical value of colposcopy in diagnosing vagina invasion in cervical cancer

Objective: To explore the preliminary clinical values of colposcopy in the diagnosis of vaginal invasion in cervical cancer. Methods: A retrospective review of the clinical records of patients (31 cases) with cervical cancer treated in Xuzhou Cancer Hospital from April 2015 to August 2019. For those with early-stage cervical cancer and the vagina invasion being difficult to be determined, those with advanced cervical cancer and the scope of vaginal invasion being difficult to be judged, and those with obvious vaginal tumor and underexposed cervix or inconspicuous cervical lesion and the primary location needing to be identified, colposcopy-guided vaginal and cervix biopsy were performed before treatment. Results: (1) Image characteristics of colposcopy and pathological diagnosis: among 31 cases, 30 of them had the similar images of vagina and cervix. The images were dense acetowhite and (or) thick mosaic, coarse punctate and atypical vessels. Lugol's staining was uniformly bright yellow or brown. Pathological biopsy of vaginal wall: 27 cases were metastatic carcinoma, 3 cases were vaginal intraepithelial neoplasia (VaIN) Ⅱ-Ⅲ. One case showed dense acetowhite epithelium and atypical vessels image in cervix and thin acetowhite epithelium in upper 1/3 vagina which disappeared in two minutes; the results of vaginal biopsy was chronic inflammation. (2) Vaginal invasion diagnosed by colposcopy: among 31 cases, 14 of them without invasion of uterine side, vaginal invasion was judged as followed by colposcopy, being consistent with biopsy: 1 case of chronic vaginitis, 2 cases VaINⅡ, 1 case VaINⅢ, 6 cases upper 1/3 vagina invasion, 4 cases lower 1/3 vagina invasion. Among 10 cases with invasion of uterine side, vaginal invasion were identified by colposcopy, being consistent with biopsy: 4 cases upper 1/3 vagina invasion and 6 cases upper 1/2 vagina invasion. Five cases who had clinical diagnosis of vaginal cancer were diagnosed as cervical cancer with vaginal invasion by colposcopy, being consistent with biopsy. Two cases with no obvious lesions of cervix and vagina were diagnosed as cervical cancer with vaginal invasion by colposcopy, being consistent with cervical and vaginal biopsy: 1 case with stage Ⅳ (transfer to the left supraclavicular lymph node) and 1 case with stage Ⅱ a1. Conclusions: Colposcopy and multi-point biopsy have complementary diagnostic value for the cervical cancer cases that the invasion and scope of vagina are difficult to be determined by physical examination and (or) imaging examination. Thus the range of vaginal resection for patients underwent operation and the lower boundary of pelvic radiation field for those underwent radiotherapy could be fixed, so as to make the treatment much more individualized and humanized; the indications need further discussion.

Left Supraclavicular Lymph Node Metastasis from Ovarian Cancer Associated with Papillary Thyroid Microcarcinoma, a Confusing Pathology-Essential Role of Functional Imaging

The revolution of imaging in medicine leads to new standards of care, mostly in specialties like oncology, neurology, or endocrinology. We present a review of the literature and a case report of a 62-year-old patient initially treated for a benign gynecologic pathology and followed-up for 7 years clinically, with serologic and with multiple imaging techniques. There is an actual growing use of highly sensitive functional imaging methods, like fluoro-deoxy-glucose (F18-FDG) positron emission tomography/computed tomography (PET/CT) in the evaluation of oncologic pathologies, staging, follow-up, and therapy response monitoring. This is the first case report described in the literature presenting the association of thyroid papillary microcarcinoma (MPTC) and supraclavicular metastasis of ovarian cancer. The study aims to underline the necessity of a complex and careful evaluation of each oncologic patient, due to the unexpected clinical presentation and rare association of diseases, sometimes leading to confusing management.

Use of p16 immunohistochemical stain to help differentiate inflamed melanocytic nevi from metastatic melanoma in the setting of immunotherapy

A 45 year-old woman with a history of metastatic melanoma (left supraclavicular lymph node with unknown primary) undergoing treatment with nivolumab presented with a suspicious new pink papule on her right upper arm. Histopathology revealed an intradermal proliferation of nonpigmented oval-to-spindled melanocytes admixed with numerous lymphocytes (Fig 1, A and B). Cytologic detail was somewhat obscured by the infiltrating lymphocytes. The differential diagnosis included metastatic melanoma vs an atypical inflamed melanocytic nevus in the setting of immunotherapy.

Case Report: Kikuchi-Fujimoto Disease: A case of supraclavicular lymphadenopathy

Kikuchi-Fujimoto Disease (KFD), also known as histiocytic necrotizing lymphadenitis, is a rare cause of cervical lymphadenopathy. Patients usually present with localized lymphadenopathy, fever and fatigue. Because of the poorly understood etiology, it can be mistaken for an infectious disease or even malignance. Here we discuss a case of KFD that initially presented with left sided cervical lymphadenopathy that later progressed to left supraclavicular lymph nodes. Due to its characteristic overlap with other disorders like tuberculous lymphadenitis and lymphoma, KFD remains an arduous diagnosis for physicians. Therefore, one should be made aware of symptoms that can lead to misdiagnosis in patients.

COMPLETE RESPONSE OF BULKY LYMPH NODE METASTASES TREATED WITH ENZALUTAMIDE AFTER CHEMOTHERAPY WITH DOCETAXEL IN CASTRATION-RESISTANT PROSTATE CANCER: A CASE REPORT

A 74-year-old man was initially diagnosed as having cT4N0M0 and Gleason score 5+4 prostate adenocarcinoma in 2012. Systemic therapy was initiated with luteinizing hormone-releasing hormone (LH-RH) agonist and bicalutamide, and serum prostate-specific antigen (PSA) levels fell to a nadir of 0.02 ng/ml from 25.55 ng/ml.After 3 years of initial treatment, the patient presented with metastatic castrate-resistant prostate cancer (mCRPC) with extensive bulky lymphadenopathy and a serum PSA of 4.81 ng/ml. Open biopsy of the left supraclavicular lymph node revealed metastasis by poorly-differentiated adenocarcinoma of prostatic origin. He continued to receive LH-RH agonist and bicalutamide and underwent seven courses of docetaxel (DOC) chemotherapy plus prednisolone. Computed tomography showed partial response in all but one metastatic pelvic lymph node, which gradually increased in size. The mCRPC response to DOC was heterogeneous, and DOC chemotherapy was stopped because of toxicity and progressive disease.Second-line hormonal therapy with enzalutamide and LH-RH agonist was started and after 6 months, computed tomography revealed complete response in the metastatic lymph nodes based on response evaluation criteria in solid tumors (RECIST); PSA levels decreased to 0.01 ng/ml. The patient has been in complete remission for 28 months.