Mid Lobe Research Articles

Bulbophyllum bokodense (section Polymeres, Orchidaceae), a new species from Benguet Province, Luzon Island, Philippines

A new species of orchid, Bulbophyllum bokodense, is herein described and illustrated from Benguet Province, Luzon Island, Philippines. It closely resembles Bulbophyllum rinkei endemic to New Guinea, but is distinct by having a broader leaf, a shorter inflorescence, an acute petal apex, glabrous auricles, a slightly canaliculate labellum, mid lobe and apex of labellum devoid of concavity, and a longer stelidia. A detailed description, photographs, and illustration are also provided. Preliminary conservation assessment of the new species following IUCN guidelines suggest a conservation status of data deficient (DD).

A neonatal rat model of pulmonary vein stenosis

ObjectivesPulmonary vein stenosis (PVS), one of the most challenging clinical problems in congenital heart disease, leads to secondary pulmonary arterial hypertension (PAH) and right ventricular (RV) hypertrophy. Due to the lack of a rodent model, the mechanisms underlying PVS and its associated secondary effects are largely unknown, and treatments are minimally successful. This study developed a neonatal rat PVS model with the aim of increasing our understanding of the mechanisms and developing possible treatments for PVS.MethodsPVS was created at postnatal day 1 (P1) by banding pulmonary veins that receive blood from the right anterior and mid lobes. The condition was confirmed using echocardiography, computed tomography (CT), gross anatomic examination, hematoxylin and eosin (H&E) staining, fibrosis staining, and immunofluorescence. Lung and RV remodeling under the condition of PVS were evaluated using H&E staining, fibrosis staining, and immunofluorescence.ResultsAt P21, echocardiography revealed a change in wave form and a decrease in pulmonary artery acceleration time—indicators of PAH—at the transpulmonary valve site in the PVS group. CT at P21 showed a decrease in pulmonary vein diameter in the PVS group. At P30 in the PVS group, gross anatomic examination showed pulmonary congestion, H&E staining showed wall thickening and lumen narrowing in the upstream pulmonary veins, and immunofluorescence showed an increase in the smooth muscle layers in the upstream pulmonary veins. In addition, at P30 in the PVS group, lung remodeling was evidenced by hyperemia, thickening of pulmonary small vessel walls and smooth muscle layers, and reduction of the number of alveoli. RV remodeling was evidenced by an increase in RV free wall thickness.ConclusionsA neonatal rat model of PVS was successfully established, showing secondary lung and RV remodeling. This model may serve as a useful platform for understanding the mechanisms and treatments for PVS.

ODP510 Pseudolymphoma of the Thyroid Gland in Association with Hashimoto's Thyroiditis: A Benign Lesion in Whitish Thyroid Gland

Abstract Background Pseudolymphoma or reactive lymphoid hyperplasia is a benign localized tumor-forming lymphoid hyperplasia found in various organs. Its occurrence in the thyroid gland is rare and could mimic malignant lesion. Here, we present a case of pseudolymphoma of the thyroid in a patient with Hashimoto's Thyroiditis. Case description A 24-year-old woman without underlying disease presented with incidentally found thyroid nodule. Ultrasound revealed mild thyroid enlargement with diffuse heterogeneous parenchymal echotexture. A 5×7×8.5-mm hypoechoic solid nodule with irregular margin was found in the left upper pole. No microcalcification was detected. Multiple subcentimeter lymph nodes at bilateral cervical group VI and left cervical group IV were also detected, measuring up to 5 mm in short axis. Fine-needle aspiration was performed and suggested malignancy (Bethesda class V). Laboratory testing showed euthyroid state with positive anti-thyroglobulin antibodies and anti-thyroid peroxidase antibodies. The blood test and ultrasound findings suggested the underlying of Hashimoto's thyroiditis. The patient underwent total thyroidectomy and lymph node dissection without postoperative complication. Gross examination of the thyroid showed multiple well-demarcated whitish nodular lesions, ranging from 2-10 mm, in the upper pole of both thyroid lobe and a well-circumscribed area of a 7-mm greyish nodule in left thyroid lobe. Microscopically, the whitish lesion in both lobe composed of hyperplastic lymphoid tissues with many follicular centers on the background of lymphocytic thyroiditis. The immunohistochemistry study revealed a polyclonal nature of the plasma cell infiltrates. No abnormal staining with AE1/AE3 or cyclin D1 was found. Pseudolymphoma was diagnosed based on these findings. Papillary thyroid microcarcinoma (6 mm) without capsular invasion was also diagnosed in the lesion of left mid lobe. The cervical lymph nodes showed metastatic papillary thyroid carcinoma (1.5 mm) in level III cervical lymph nodes. No perinodal extension was found. Postoperative course was unremarkable and the patient was in stable condition at 18 months after the operation. Conclusion Although primary thyroid lymphoma is often considered in patients with Hashimoto's thyroiditis. The possibility of pseudolymphoma characterized by the presence of well-demarcated pearly white nodules and polyclonal cell populations should also be considered. Presentation: No date and time listed

ODP503 Non-Small Cell Lung Cancer Metastatic to the Thyroid Gland

Abstract Introduction Metastatic disease affecting the thyroid gland is an uncommon phenomenon, with the most common primary sites being kidney, breast, lung and gastrointestinal tract. Thyroid metastases frequently occur simultaneously with spread to other sites and are rarely symptomatic. Clinical case: 73-year-old female with remote history of stage IA (T1c, N0, M0) invasive lobular carcinoma of the right breast treated with lumpectomy, radiation and tamoxifen, previous tobacco use, remote exposure to radiation during Chernobyl nuclear accident, developed progressive dyspnea on exertion. She was found to have a large left-sided pleural effusion. Thoracentesis was performed, and the cytology revealed adenocarcinoma with features favoring lung primary. Further imaging showed a left lower lobe mass with central necrosis and left hilar adenopathy, multiple pleural masses, and a small solitary brain lesion. PET-CT also demonstrated, amongst other findings, an FDG avid left lower pole thyroid nodule. Thyroid ultrasound was obtained to further characterize the lesion, which demonstrated a 0.8×1.3×1.3 cm solid hypoechoic nodule in the left mid lobe, which was thought to be corresponding to the PET avid nodule. Two additional nodules, a mixed cystic and solid measuring 1.7×2.1×2.9 cm on the right lobe, and another left-sided solid isoechoic measuring 0.8×0.7×0.9 cm, were noted. Thyroid FNA of the 1.3 cm PET avid nodule revealed rare cells in clusters, with large pale nuclei and prominent nucleoli, some with intracytoplasmic vacuoles, morphologically similar to those seen in the prior pleural fluid. Thin prep was stained with antibody to thyroglobulin, and the malignant cells showed lack of staining, supporting the diagnosis of metastatic lung cancer. Thyroid function tests were normal. Given lack of compressive symptoms, patient was maintained on her primary oncologic treatment with carboplatin and pemetrexed, and stereotactic radiation for the brain metastasis. Repeat PET-CT, performed approximately 8 months after the initial scan, showed mildly decreased focal FDG activity in the thyroid lesion. Discussion In this scenario, a patient with primary lung malignancy was found to have an FDG avid thyroid nodule which on FNA proved to be a metastatic lesion. Per some studies, such lesions can be seen in 1.4%–3% of patients who undergo surgery for suspected malignancy in the thyroid gland. Management of metastatic thyroid cancers depends on multiple factors including the primary malignancy location and staging, patient comorbidities, compressive symptoms, etc. Surgical management may be of benefit in isolated lesions in the thyroid. Conclusion When evaluating thyroid nodules in patients with known history of malignancy, it is important to consider the differential of metastatic lesions and to perform a thorough evaluation including fine-needle aspiration for clinical elucidation and management. Presentation: No date and time listed

Analysis of normal lung irradiation in radiosurgery treatments: a comparison of lung optimized treatment (LOT) on cyberknife, 4D target volume on helical tomotherapy, and DIBH on linear accelerator.

Quantitative retrospective analysis of the normal lung irradiation due to the variations of the ITV volume based on the techniques used for upper lobe (UL), mid lobe (ML), and lower lobe (LL) lung tumours when used with 2-view, 1-view, 0-view based LOT technique on Cyberknife, AveIP on Helical Tomotherapy, and DIBH on VMAT systems. In the treatment of lung tumours, patients medically inoperable or those who are unwilling to undergo surgery have the option to be treated using radiation therapy. There are many motion control techniques available for the treatment of the moving target, such as movement encompassment, respiratory gating, breath-hold, motion reduction, and tumour monitoring. ITV generation is dependent on technique and hence the volume of the PTVs will differ based on the technique used. This study aimed to determine the influence of these ITVs on the irradiated normal lung volume for UL, ML, and LL lung tumours for 23 patients. The mean difference in the PTV volumes generated with the 0-view technique was significant with that of 2-view and DIBH techniques (p-value < 0.04). The mean difference in the PTV volumes generated by 2-view and DIBH was small for UL, ML, and LL tumours. V5 of the combined lung with the 0-view method was 5% compared to the 2-view method for UL tumours (p-value = 0.04) and the same was 9.5%, and 16.8% for ML and LL tumours (p-value < 0.04). In contrast to all other techniques, lung volume parameters V5, V10, V20, and V30 for the 0-view technology were consistently higher irrespective of the tumour location in the lung. The observed maximum mean lung dose (MLD) was 6.2Gy ± 2.7Gy with the 0-view technique and the minimum was 3.85Gy ± 1.75Gy with the DIBH technique. The difference in MLD between DIBH and 2-view was negligible (p-value = 0.67). The MLD increased for LL tumours from 4Gy to 6.5Gy from the 2-view to 0-view technique (p-value = 0.009). There was a significant increase in MLD for LL tumours with the 0-view technique compared to AveIP (1.9Gy, p-value = 0.04) and DIBH (2.0Gy, p-value = 0.003) technique. For ML and UL tumours, except for 0-view and 1-view, the difference in the MLD between the rest of the methods was not significant (p-value > 0.11). In the treatment of lung tumour patients with SBRT, this study has demonstrated 2-view with Cyberknife and DIBH with VMAT treatment techniques have optimal normal lung tissue sparing. There was a significant increase in the average lung volume receiving 5%,10%, 20%, and 30% dose when comparing the 1-view, 0-view, AveIP, and DIBH techniques to the 2-view technique. However, DIBH with VMAT was dosimetrically advantageous for ML and LL tumours, while providing significantly shorter treatment times than any other technique studied.

The results of the first 100 minimal invasive lobectomy in our department

Patients and methods: Between 1st November 2013 and 30th June 2019 we performed 112 VATS lobectomies with isolated intubation and anterior approach. In 98 cases lobectomies were performed for malignant lesions, while in 9 cases for benign changes. 78 men and 34 women were operated on. The average age was 60.5 years (42–63). In 5 cases the left upper lobes were resected, in cases 36 the left lower lobes, in 15 cases the right upper lobes, in 11 cases the mid lobes, in 44 cases the right lower lobes, and in one case pneumonectomy was performed. Results: there was no postoperative mortality. Conversion was required in three 3 patients. The average time of surgery was 150 minutes (70–215). Re-operation was needed in two cases due to bleeding and air leakage. Out of the 112 operations, primary lung cancer was demonstrated on pathology in 88 cases, while benign lesions /inflammation in 9 cases. The stages of primary lung cancer were the following: I.a:57, I.b:22, II.a:6, II.b:3 patients. Tumour subtypes were the detailed as 52 adenocarcinoma, 23 squamous cell cc., 2 small cell cc., 5 large cell cc., and 6 carcinoid. 10 patients underwent VATS lobectomy for metastatic disease. Conclusion: As a result of an adequate learning period, VATS lobectomies have become a routine surgery in our unit. Currently 65% of the thoracotomies and more than 50 percent of the lobectomies are performed by the VATS method. Our results are comparable to national as well as international data.

A super-resolution framework for the reconstruction of T2-weighted (T2w) time-resolved (TR) 4DMRI using T1w TR-4DMRI as the guidance.

The purpose of this study was to develop T2-weighted (T2w) time-resolved (TR) four-dimensional magnetic resonance imaging (4DMRI) reconstruction technique with higher soft-tissue contrast for multiple breathing cycle motion assessment by building a super-resolution (SR) framework using the T1w TR-4DMRI reconstruction as guidance. The multi-breath T1w TR-4DMRI was reconstructed by deforming a high-resolution (HR: 2×2×2mm3 ) volumetric breath-hold (BH, 20s) three-dimensional magnetic resonance imaging (3DMRI) image to a series of low-resolution (LR:5×5×5mm3 ) 3D cine images at a 2Hz frame rate in free-breathing (FB, 40s) using an enhanced Demons algorithm, namely [T1BH →FB] reconstruction. Within the same imaging session, respiratory-correlated (RC) T2w 4DMRI (2×2×2mm3 ) was acquired based on an internal navigator to gain HR T2w (T2HR ) in three states (full exhalation and mid and full inhalation) in ~5min. Minor binning artifacts in the RC-4DMRI were automatically identified based on voxel intensity correlation (VIC) between consecutive slices as outliers (VIC<VICmean -σ) and corrected by deforming the artifact slices to interpolated slices from the adjacent slices iteratively until no outliers were identified. A T2HR image with minimal deformation (<1cm at the diaphragm) from the T1BH image was selected for multi-modal B-Spline deformable image registration (DIR) to establish the T2HR -T1BH voxel correspondence. Two approaches to reconstruct T2w TR-4DMRI were investigated: (A) T2HR →[T1BH →FB]: to deform T2w HR to T1w BH only as T1w TR-4DMRI was reconstructed, and combine the two displacement vector fields (DVFs) to reconstruct T2w TR-4DMRI, and (B) [T2HR ←T1BH ]→FB: to deform T1w BH to T2w HR first and apply the deformed T1w BH to reconstruct T2w TR-4DMRI. The reconstruction times were similar, 8-12min per volume. To validate the two methods, T2w- and T1w-mapped 4D XCAT digital phantoms were utilized with three synthetic spherical tumors (ϕ=2.0, 3.0, and 4.0cm) in the lower or mid lobes as the ground truth to evaluate the tumor location (the center of mass, COM), size (volume ratio, %V), and shape (Dice index). Six lung cancer patients were scanned under an IRB-approved protocol and the T2w TR-4DMRI images reconstructed from the two methods were compared based on the preservation of the three tumor characteristics. The local tumor-contained image quality wasalso characterized using the VIC and structure similarity (SSIM)indexes. In the 4D digital phantom, excellent tumor alignment after T2HR -T1HR DIR is achieved: ∆COM=0.8±0.5mm, %V=1.06±0.02, and Dice=0.91±0.03, in both deformation directions using the DIR-target image as the reference. In patients, binning artifacts are corrected with improved image quality: average VIC increases from 0.92±0.03 to 0.95±0.01. Both T2w TR-4DMRI reconstruction methods produce similar tumor alignment errors ∆COM=2.9±0.6mm. However, method B ([T2HR ←T1BH ]→FB) produces superior results in preserving more T2w tumor features with a higher %V=0.99±0.03, Dice=0.81±0.06, VIC=0.85±0.06, and SSIM=0.65±0.10 in the T2w TR-4DMRI images. This study has demonstrated the feasibility of T2w TR-4DMRI reconstruction with high soft-tissue contrast and adequately-preserved tumor position, size, and shape in multiple breathing cycles. The T2w-centric DIR (method B) produces a superior solution for the SR-based framework of T2w TR-4DMRI reconstruction with highly preserved tumor characteristicsand local image features, which are useful for tumor delineation and motion management in radiation therapy.

Prediction of Pleural Invasion in Challenging Non-Small-Cell Lung Cancer Patients Using Serum and Imaging Markers.

Introduction. Preoperative detection of pleural invasion in lung cancer patients is key to curative surgical treatment. We tried to predict pleural invasion in non-small-cell lung cancer patients with <100 ml pleural fluid. Methods Patients admitted from August 1, 2011, to December 31, 2018, were retrospectively retrieved. Records of serum and imaging markers were analyzed. Results Among 7004 patients who received surgery, 43 cases with <100 ml pleural fluid who had pleural invasion were included, and another 108 cases without pleural invasion were enrolled as controls. There were no differences in squamous cell carcinoma antigen (SCC) or neuron-specific enolase (NSE) values between the pleural invasion and noninvasion groups (p = 0.30 and 0.14, respectively), but there were significant differences in carcinoembryonic antigen (CEA) and cytokeratin 19 fragment (CYFRA21-1) values (p = 0.30 and 0.14, respectively), but there were significant differences in carcinoembryonic antigen (CEA) and cytokeratin 19 fragment (CYFRA21-1) values (p = 0.30 and 0.14, respectively), but there were significant differences in carcinoembryonic antigen (CEA) and cytokeratin 19 fragment (CYFRA21-1) values (p = 0.30 and 0.14, respectively), but there were significant differences in carcinoembryonic antigen (CEA) and cytokeratin 19 fragment (CYFRA21-1) values (p = 0.30 and 0.14, respectively), but there were significant differences in carcinoembryonic antigen (CEA) and cytokeratin 19 fragment (CYFRA21-1) values (p = 0.30 and 0.14, respectively), but there were significant differences in carcinoembryonic antigen (CEA) and cytokeratin 19 fragment (CYFRA21-1) values (p = 0.30 and 0.14, respectively), but there were significant differences in carcinoembryonic antigen (CEA) and cytokeratin 19 fragment (CYFRA21-1) values (Conclusions Serum CEA and CYFRA21-1, location of original lung cancer (right mid lobe), maximum diameter, CT-detectable pleural fluid, pleural sign by CT, and PET/CT-predicted pleural invasion were good markers for the prediction of pleural invasion in non-small-cell lung cancer patients.

P040 Post-transplant De-novo donor specific antibody to HLA-B8, of unknown clinical significance

Clinical History: A 62 year-old male with chronic glomerulonephritis underwent kidney transplant from a donation after cardiac death donor in Jan 2017. Cold ischemia time was 8 h. The recipient had no donor specific antibody detected in any pretransplant sera tested since 2012. Flow-cytometric crossmatch (FCXM) was negative with the day of transplant sample. He received induction with Thymoglobulin, methylprednisolone, mycophenolate mofetil, and tacrolimus. Post-op day (POD)#1 creatinine was 7.90 mg/dl. He experienced delayed graft function, but otherwise no complications. He was discharged on POD#7 with a creatinine of 2.82 mg/dl. On POD#8 his creatinine was 1.7 mg/dl. De novo HLA-B8 antibody (14,365 MFI) was detected on a Thymo-absorbed and heat inactivated sample from the same day. The patient began therapeutic plasma exchange (TPE) and IVIG treatments on an every other day schedule. The kidney biopsy showed no evidence of antibody-mediated rejection. The Anti-HLA-B8 levels decreased to ∼ 2,000MFI. To understand the nature of this antibody, the FCXM was repeated using the POD#8 sample and was negative (T cell channel shift = 36 and B cell = 65). Therefore TPE/IVIG was stopped after 2 cycles. An incidental cavitary lesion was identified in the mid lobe of his right lung post-transplant. Quantiferon gold test was intermediate positive, but AFB culture was negative. 15 months post transplant, he continues to have HLA-B8 antibody 1500–3000 MFI, a stable creatinine ∼ 1.2 mg/dl, no proteinuria, and protocol biopsy in March 2018 showed no evidence of rejection. Discussion: The single antigen bead (SAB) assay is a very sensitive and specific antibody assay. During the manufacturing process, HLA antigens can become denatured and unfolded. This artificial unfolding allows for unmasking of cryptic epitopes on the recombinant HLA antigens. These cryptic epitopes may cross-react with epitopes found in microorganisms or allergens and may generate antibodies that react with denatured HLA proteins. False positive SAB assay may lead to unnecessary procedures in patients, and may limit patients’ to access to organ transplantation. Therefore, it is of utmost importance to recognize these artifacts and when possible utilize different platforms of testing to confirm the presence of artifactually denatured antibodies.

Results of the video-assisted thoracic surgery lobectomy at our department in the last five-year periode

Herein we present the results of lobectomies performed with minimally invasive approach (video-assisted thoracic surgery - VATS) at our department during a period of five years. Between 1 January 2011 and 31 December 2015, 197 lobectomies (malignant lesions: 176 cases, benign lesions: 21 cases) were performed by three thoracic surgeons and one resident. Demographical data are as follows: 119 female/78 male, mean age: 62.4 years (range: 41-82 years). In 2011 three VATS lobectomies were performed, equaling 2.2 % of all lobectomies in that year. During the upcomig years the number of VATS lobectomies were as follows: 2012: 7 (7.3%), 2013: 13 (12%), 2014: 59 (34.5%) and 2015: 119 (68.5%). In 153 cases multiportal (78%) and in 44 cases uniportal (22%) anterior approach was performed. The resected lobes showed the following distribution: right upper: 85, mid lobe: 5, right lower: 28, left upper: 44, left lower: 34, upper bilobectomy: 1. In two cases sleeve lobectomy was performed. In 8 cases (4%) conversion to thoracotomy was needed and among the 46 uniportal procedures, 5 cases needed to be expanded into biportal approach (11%). During the study period, no intraoperative, or perioperative mortality occured. Mean operative time was 123 minutes (range: 60-135 minutes) and mean time of chest drainage was 4.3 days (range: 1-27 days). Air leakage lasting more than 7 days was present in 11.7%. Reoperation was needed in 4 cases (2%), in two cases due to bleeding, and in two cases because of expansive difficulties due to extended subcutaneous emphysema. Among the 176 VATS lobectomies performed due to malignant lesions, 169 lung cancers and 7 metastases were removed. The distribution according to the stage and histology of lung cancers was as follows: IA: 100 cases, IB: 28 cases, IIA: 17 cases, IIB: 3 cases, IIIA: 16 cases, IIIB: 1 case, and IV: 4 cases; adenocarcinoma: 128 cases, squamous cell carcinoma: 26 cases, large cell carcinoma: 3 cases, small cell lung cancer: 1 case, typical carcinoid: 10 cases, and atypical carcinoid: 1 case. Over the years VATS lobectomy became a rutin procedure at our institution. Nowadays more than two-thirds of lobectomies are performed with minimally invasive technique. Taking the learning curve of the four thoracic surgeons into consideration, our results correlate with international data.

CT findings in viral lower respiratory tract infections caused by parainfluenza virus, influenza virus and respiratory syncytial virus.

Viral lower respiratory tract infections (LRTIs) can present with a variety of computed tomography (CT) findings. However, identifying the contribution of a particular virus to CT findings is challenging due to concomitant infections and the limited data on the CT findings in viral LRTIs. We therefore investigate the CT findings in different pure viral LRTIs.All patients who underwent bronchoalveolar lavage (BAL) and were diagnosed with LRTIs caused by parainfluenza virus (PIV), influenza virus, or respiratory syncytial virus (RSV) between 1998 and 2014 were enrolled in a tertiary hospital in Seoul, South Korea. A pure viral LRTI was defined as a positive viral culture from BAL without any positive evidence from respiratory or blood cultures, or from polymerase chain reaction (PCR), or from serologic tests for bacteria, fungi, mycobacteria, or other viruses.CT images of 40 patients with viral LRTIs were analyzed: 14 with PIV, 14 with influenza virus, and 12 with RSV. Patch consolidation (≥1 cm or more than 1 segmental level) was found only in PIV (29%) (P = 0.03), by which CT findings caused by PIV could resemble those seen in bacterial LRTIs. Ground-glass opacities were seen in all cases of influenza virus and were more frequent than in PIV (71%) and RSV (67%) (P = 0.05). Bronchial wall thickening was more common in influenza virus (71%) and RSV (67%) LRTIs than PIV LRTIs (21%) (P = 0.02). With respect to anatomical distribution, PIV infections generally affected the lower lobes (69%), while influenza virus mostly caused diffuse changes throughout the lungs (57%), and RSV frequently formed localized patterns in the upper and mid lobes (44%).The CT findings in LRTIs of PIV, influenza virus, and RSV can be distinguished by certain characteristics. These differences could be useful for early differentiation of these viral LRTIs, and empirical use of appropriate antiviral agents.

Cough and dyspnea in a renal transplant patient.

A 38-year-old male presented with cough and dyspnea for approximately one month. He had a past medical history of hypertension, end-stage renal disease secondary to unspecified glomerulonephritis, and living-donor renal transplant 15 years ago. He had no history of exposure to tobacco or occupational toxins. His blood tests revealed increased serum creatinine (3.0 mg/dL), normal phosphate (4.0 mg/dL) and calcium levels (9.7 mg/dL), increased parathyroid hormone (95 pg/mL), and low calcidiol (10.2 ng/mL) and calcitriol (8.1 ng/mL) levels. The patient underwent bronchioalveolar lavage, which was negative for mycobacterial or fungal infection. Chest radiograph revealed fluffy densities involving the upper and mid lobes bilaterally with sparing of the subpleural region (Fig. 1). An axial computed tomographic scan of the chest showed extensive, upper lobe predominant ground glass opacities in an acinar distribution with areas of calcification. (Fig. 2, a and b) Figure 1 Chest radiograph showing fluffy densities involving the upper lobes bilaterally with sparing of the cortex (black arrow). Figure 2 Coronal computed tomographic scan of chest in a) Mediastinal window b) lung window showing extensive, upper and middle lobe predominant ground glass opacities in an acinar distribution with areas of calcification with subpleural sparing (black arrows). ... Questions What is the diagnosis? How do you treat it? To access the full article, please complete the quiz online at www.omjournal.org Articles from Oman Medical Journal are provided here courtesy of Oman Medical Specialty Board Formats: Article | PubReader | ePub (beta) | PDF (570K) | Citation Share Facebook Twitter Google+ You are here: NCBI > Literature > PubMed Central (PMC) Write to the Help Desk External link. Please review our privacy policy. NLM NIH DHHS USA.gov Copyright | Disclaimer | Privacy | Browsers | Accessibility | Contact National Center for Biotechnology Information, U.S. National Library of Medicine 8600 Rockville Pike, Bethesda MD, 20894 USA

C-09 * SPECT Differences between Those with Higher and Lower Levels of Aggression: An Exploratory Analysis

OBJECTIVE: To determine which areas of the brain were most associated with level of aggression as measured via SPECT scans. METHOD: Participants were selected based on their scores on an aggression factor from a symptom checklist, and had a mean age of 40.97 years (SD = 16.34), and consisted of 56.9% males and 43% females. Subjects were stratified based on upper (n = 2537) and lower (n = 2600) quartiles. Digitally derived blood flow measures from areas throughout the brain were examined at activation. RESULTS: A MANOVA was conducted at the.05 level, revealing significant group differences, Wilks' λ =.966; F(16, 6692) = 1.465, p =.001. Those scoring in the upper quartile of the aggression factor yielded significantly lower blood flow than those in the lower quartile in the following areas: amygdala, angular gyrus, calcarine, caudate, specific areas of the cerebellum, cingulum, cuneus, frontal inferior operculum, fusiform, Heschl's gyrus hippocampus, insula, lingual gyrus, mid and superior occipital lobe, olfactory cortex, globus pallidus, parahippocampal gyrus, parietal lobe, left pre- and post-central gyri, precuneus, putamen, rolandic operculum, supramarginal gyrus, temporal lobe, thalamus, and vermis. CONCLUSION(S): Analyses revealed higher levels of self-reported aggression differed significantly in terms of perfusion to various areas relative to lower levels of aggression. These findings suggest many areas mediate symptoms of aggression and that SPECT scans may be a fruitful tool in identifying those susceptible to high levels of aggression. Future research will try to differentiate which areas show the greatest contribution to aggressiveness. Language: en

OP29.01: 2D/3D color Doppler and contrasted sonography of ovarian masses

therapy to decompress the lung was suggested. After extensive counselling, parents opted for fetal surgery at 25 weeks. The fetal surgery was performed in the same way the FETO procedure for congenital diaphragmatic hernia is. The normal upper right lobar bronchus was visualized and a fibrous tissue occluding thereafter was found, confirming the diagnosis of bronchial atresia affecting the middle and inferior bronchi. By ultrasound it was observed that the stop in the broncus was very close to the cystic tubular structure, which was supposed to be the inflated and mucus filled distal bronchial tree. Combining ultrasound and fetoscopy, perforation of the membranous tissue was achieved by contact laser firing. After the procedure, significant improvement of all the parameters was demonstrated at following up scans. At 35 weeks the O/E LHR was 85%. The fetus developed normally and was born at term. Postnatally, the baby had no severe respiratory distress though condensation at mid and low right pulmonary lobes was patent. Bilobectomy was performed at 12 days of life and evolution was satisfactory. The infant was discharged after 2 months without any treatment, and at 6 months of age remains healthy. To the best of our knowledge, this is the first successful fetoscopy for prenatal lung decompression in a case of lobar bronchial atresia at high risk of pulmonary hypoplasia.

Dynamic MR Based Analysis of Tumor Movement in Upper and Mid Lobe Localized Lung Cancer

Tumor motion is a very important factor in the radiotherapy of lung cancer. Uncertainty resulting from tumor movement must be considered in 3D therapy planning especially in case of IMRT or stereotactic therapy. The aim of our dynamic MR based study was to detect tumor movements in upper and mid lobe lung tumors. Twenty-four patients with newly diagnosed stage II-IV lung cancer were enrolled into the study. According to tumor localization in the right S1-S3 segments 9, in the right S4-S6 segments 2, in the left S1-S3 segments 9 and in the left S4-S6 segments 4 lesions were detected. In normal treatment position individual dynamic MR examinations were performed in axial, sagittal and coronal planes (100 slices/30 sec). For tumor motion analysis E-RAD PAC's software was used. Movements of the tumor under normal breathing conditions were registered in the three main directions. The mean antero-posterior deviation was 0,109 cm (range: 0,063 cm-0,204 cm), the mean medio-lateral deviation was 0,114 cm (range: 0,06 cm- 0,244 cm). The greatest deviation was measured in cranio-caudal direction (mean: 0,27 cm, range: 0,079 cm- 0,815 cm). The mean direction independent deviation was 0,18 cm (range: 0,09 cm- 0,48 cm). Dynamic MR is a sensitive and well tolerated method for tumor motion monitoring in high precision 3D therapy planning of lung cancer patients. Our results demonstrate that tumors located in the upper and mid lobes have moderate breath synchronous movements. The greatest deviation occur in cranio-caudal direction.

6596 POSTER Dynamic MR based analysis of tumor movement in upper and mid lobe localized lung cancer

Intracranial invasion of paranasal sinusitis is an emergency condition that requires surgical and medical intervention in order to avoid further deterioration. We surveyed patients at the Buddhist Tzu Chi Hospital (Hualien, Taiwan) who had paranasal sinusitis with intracranial invasion. A total of 505 patients with paranasal sinusitis were surveyed at Hualien Buddhist Tzu Chi Hospital over a 14-year period (2000–2013). Data on clinical presentations, microbiology, host factors, postinterventional morbidity, and postinterventional mortality are presented. Of the 505 patients, nine had intracranial invasions (incidence rate, 1.8%). The mortality rate was high among these patients (44.4%, 4/9). Among the various risk factors identified, diabetes had the greatest influence (66.7%, 6/9), which in combination with an immunocompromised condition and cirrhosis is indicative of a poor prognosis.

Diagnosis and Treatment of Liver Cystadenocarcinoma: Report of 18 Cases

Objective: To discuss the diagnosis and treatment of liver cystadenocarcinoma. Methods: The clinical, imaging, and pathological data of 18 patients with liver cystadenocarcinoma between January 2000 and December 2004 in our hospital were retrospectively analyzed. Results: The liver cystadenocarcinoma was seen in males and females (m/f: 9/9); mean age was 51 years. Ultrasonography revealed cystic parenchymatous mass echoes of fluid predominance with uneven margins. Nonenhanced CT revealed intrahepatic low-density space occupying shadows with nodular protrusions on the margins in all cases. Enhancement CT revealed that part of the nodular protrusions and tissues around the lesions were enhanced and the delayed phase disappeared. 66.67% (12/18) of the lesions were more than 10 cm in diameter. The diagnosis of liver cystadenocarcinoma was confirmed by postoperative pathology in all cases. Of these patients, 12 lesions were in the left lobe, 3 in the right lobe, 1 in the mid lobe, 1 in the right and left lobe, and 1 in the caudate lobe. Of the 18 patients, 6 had completely resect the cystadenocarcinoma, 2 were surgically explored, one received TAE+fine needle aspiration cytology+injection of chemotherapy drugs, and 9 underwent radical hepatectomy+choledochostomy or T-tube drainage, in which, one patient underwent choledochostomy+left hepatectomy+radical gastrectomy for cancer+lymphadenectomy; one patient underwent resection of the cystadenocarcinoma, who had relapse 20 months after the initial procedure. The patient received repeat resect for the recurrent cystadenocarcinoma+cholangio-jejunostomy. Six months later she had another relapse and received repeat resect (only PMCT) for the recurrent cystadenocarcinoma. The patient died from cholangiopleural fistula after third time operation (PMCT) was attempted perioperatively. Seven patients died of metastatic disease after operation. The remaining 10 patients were alive without cancer recurrence or metastasis (mean follow-up 20 months). Conclusion: Liver cystadenocarcinoma is rarely seen and grows slowly. It shows some typical clinical and imaging features. The crux for diagnosing and treating liver cystadenocarcinoma is how familiar the surgeon is with the pathology and clinical features of the condition. Prolonged survival can be achieved by radical resection of the tumor.

SU-FF-J-17: Free Breathing Synchronized 4D Radiotherapy: Imaging, Treatment Planning, and Delivery

Purpose: Develop four-dimensional (4D) radiotherapy to incorporate breathing motion in thorax, covering PTV adequately and reducing mean lung dose and V20 for lung. Analyze tumor and thoracic structures motion using the 4D-CT images. Method and Materials: Motion of tumor and thoracic structures of twenty lung cancer patients are studies, using a retrospective respiratory gating 4D-CT and external respiratory signal generator system. Breathing was synchronized with cine image acquisition, and retrospectively correlated based on respiratory phases. For 4D-delivery, MLCs were synchronized with respiratory motion and followed tumor with a safe margin selected based on reliability of patient breathing ranging from 100% largest static field to 0% the smallest dynamic field. Results: 4D-CT provides tumor motion in different phases of breathing cycle. The GTV/CTV delineated on helical CT without incorporating breathing motion underestimates GTV/CTV by 25–50% compare to the 4D-GTV/CTV delineated on 4D-CT image sets. The 4D radiotherapy reduces the mean lung dose by 16–32% (average 23%) and V20 reduction for ipsi lung by 16–26% (average 21%) compare to the standard protocol. The volume changes of apex, mid and inferior regions of the lung during breathing are 11%, 24%, and 65%. The motion of tumors varies with the location. Tumors located in the apex move by 3–5mm, 2–4mm, and 2–3.5mm in superior/inferior, anterior/posterior, and right/left directions. Those located in mid lobe move by 6.5–9mm, 3.5–5mm, and 4–5mm, and those in lower lobe move by 7.5–12mm, 4–8mm, and 3.5–6.5mm. The superior/inferior motions of diaphragm, rib and carina range from 7–25mm, 2–7mm, and 3.5–13mm. On 4D delivery, we tested MLC synchronization with breathing motion on phantom. Lung volume coverage is minimized by a 20% safe margin. Conclusion: 4D-CT provides tumor motion in different phases of breathing cycle. 4D delivery synchronized with respiration-induced motion reduces mean lung dose and were synchronized with respiratory motion V20 for lung.

Encarsia aseta,sp. nov. (Hymenoptera: Aphelinidae), a parasitoid ofDialeurolonga elongataDozier (Homoptera: Aleyrodidae) from India

Abstract Encarsia aseta, sp. nov. is described from India. The species belongs to the Encarsia parvella-group, and differs form all described species in the genus by the absence of setae on the mid lobe of the mesoscutum. The host of this species is Dialeurolonga elongata Dozier.

Hexalectris warnockii (Orchidaceae): primer registro para México

Se registra por primera vez la presencia en México de Hexalectris warnockii, orquídea terrestre áfila, anteriormente conocida solo del sur de los E.U.A., sobre la base de una colección procedente de cerca del extremo sur de la Península de Baja California. Con tal adición todas las especies del género actualmente aceptadas se encuentran en México. Esta planta se distingue de sus congéneres principalmente por le labelo profundamente trilobado y con cinco lamelas muy prominentes, de las cuales tres llegan al ápice del lóbulo medio.