Multifocal Nodules Research Articles

Simultaneous intrathyroidal parathyroid adenomas and multifocal papillary thyroid carcinoma in a patient with kidney transplantation: a case report

BackgroundPersistent hyperparathyroidism after kidney transplantation has been associated with adverse outcomes. Parathyroidectomy is the definitive treatment approach, but the success of parathyroidectomy relies on the accurate preoperative localization of the culprit parathyroid lesions. Simultaneous intrathyroidal parathyroid adenomas and multifocal papillary thyroid carcinoma present important diagnostic challenges. Here, we describe a patient with kidney transplantation who underwent successful surgery after being evaluated with functional and structural imaging.Case presentationA 53-year-old man presented with potentially malignant multifocal thyroid nodules by ultrasonography 2 years after kidney transplantation. The patient had hypercalcaemia and persistent hyperparathyroidism. Thyroid papillary carcinoma was confirmed in the left thyroid nodules by fine-needle aspiration biopsy. The right superior thyroid hypoechoic nodule was 1.2 cm in size and showed marked uptake of the tracer 99mTcO4-sestamibi during single-photon emission computed tomography/computed tomography (SPECT/CT); additionally, a cystic parathyroid lesion without tracer uptake was present behind the left superior pole of the thyroid. The histological examination demonstrated the coexistence of right intrathyroidal parathyroid adenomas, left cystic parathyroid nodular hyperplasia and multifocal papillary thyroid carcinoma. At the 6-month follow-up, the serum calcium levels were within the normal range, and the patient’s kidney function remained stable.ConclusionsSimultaneous intrathyroidal parathyroid adenomas and multifocal papillary thyroid carcinoma in a patient with kidney transplantation is a rare clinical scenario. Physicians must be aware that the combination of functional (SPECT/CT) and structural (ultrasonography) imaging is highly successful in diagnosing patients with coexistent intrathyroidal parathyroid adenomas and papillary thyroid carcinoma.

Synchronous multiple lung cancers presenting as multifocal pure ground glass nodules: are whole-body positron emission tomography/computed tomography and brain enhanced magnetic resonance imaging necessary?

Multifocal ground glass nodules (GGNs) represent a special radiological pattern indicative of synchronous multiple lung cancers (SMLCs), especially adenocarcinoma. However, the necessity of performing whole-body positron emission tomography/computed tomography (PET-CT) scanning and brain enhanced magnetic resonance imaging (MRI) as a staging workup for multifocal pure GGN (pGGN) patients remains unclear. The purpose of this study was to determine the utility of these two imaging scans for patients with multifocal pGGNs. This retrospective study was reviewed and approved by the ethics committee of the Cancer Hospital of the Chinese Academy of Medical Sciences. The study cohort was retrospectively selected from patients with multifocal pGGNs who underwent whole-body PET-CT examinations and/or brain enhanced MRIs between January 2010 and February 2019 at our institution. The additional value of the two exams for detecting nodal and distant metastases was evaluated. In total, 73 patients (male-to-female ratio, 20:53; median age, 57 years) with multifocal pGGNs who underwent whole-body PET-CT (55 patients) and/or brain enhanced MRI (25 patients) were enrolled. No clearly metastatic lesions were detected. Among the enrolled patients, 53 (128 pGGNs) underwent complete surgical resection. All pGGNs were adenocarcinomas and/or preneoplasias, and no lymph node metastases were found on final pathology. Whole-body PET-CT and brain enhanced MRI added no definite benefit compared with chest CT alone before surgery. Whole-body PET-CT scans and brain enhanced MRIs are not necessary for patients with multifocal pGGNs.

A CASE OF DISSEMINATED NOCARDIA INFECTION IN AN ADULT WITH PANCYTOPENIA

SESSION TITLE: Monday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Nocardia is an infrequent cause of bacterial infection caused by weakly acid-fast actinomycete Nocardia. It causes opportunistic infections in immunocompromised hosts, including those with lymphomas, malignancies, HIV and those receiving steroids. Here, we present a case of Nocardia lung abscess that progressed to brain abscesses in an immunocompromised state. CASE PRESENTATION: 65-year-old male with history of CKD from glomerulonephritis/p-ANCA vasculitis presented with pancytopenia. He worked as a pipe fitter with significant exposure to soil. He had been treated with prednisone and cyclophosphamide for 7 months, and then switched to azathioprine. There was concern of thrombotic microangiopathy given elevated LDH and presence of schistocytes on peripheral blood smear, however, ADAMST13 level was normal. He received plasma exchanges and started on eculizumab for treatment of presumptive atypical Hemolytic Uremic Syndrome (HUS). Clinical status deteriorated, and he developed worsening anemia, thrombocytopenia and renal function requiring hemodialysis. Thrombocytopenia and renal function failed to improve with eculizumab, and his vasculitis was thought to be the culprit. He was then found to have a pleural effusion, which was drained and revealed exudative fluid with cytology showing acute inflammatory cells. CT chest showed left lower lobe consolidation, left upper lobe airspace opacity and scattered pulmonary nodules. He received supportive blood and platelet transfusions. 25 days later, cultures from pleural fluid grew Nocardia. He had progressive decline in neurological status, and MRI revealed innumerable small enhancing lesions throughout brain and brainstem, likely from Nocardia. Subsequently, he developed seizures and intraparenchymal bleed due to the low platelets. Family eventually opted for comfort care measures only. DISCUSSION: Radiographic findings for Nocardia can be variable, including multifocal disease, nodules, infiltrates or cavitary lesions. Differentiating Nocardia from other filamentous fungi or mycobacteria can be challenging based on radiological finding alone. Pleural effusions can also occur in 10-33% of cases. Dissemination from the lungs can present as bacteremia, empyema, pericarditis, or can involve the CNS. CNS involvement of nocardia most commonly presents as brain abscesses. It has a high morbidity, and the mortality rate can be close to 30% versus 10% for other bacterial abscesses. CONCLUSIONS: We report how an immunocompromised state due to medications can be a reason for the development of Nocardia lung abscess. Failure of early detection and aggressive treatment can result in dissemination of the bacteria. Nocardia may have an indolent presentation and detection may be challenging, but with the risk factors and soil exposure taken into account, it should be considered a differential to help avoid significant morbidity and mortality. Reference #1: Beaman B.L., Burnside J., Edwards B., Causey W. Nocardial infections in the United States, 1972-1974. J Infect Dis. (1976);134(3):286–289 Reference #2: Saubolle, Michael A., and Den Sussland. “Nocardiosis: Review of Clinical and Laboratory Experience.” Journal of Clinical Microbiology 41.10 (2003): 4497–4501 Reference #3: Mamelak AN, Obana WG, Flaherty JF, Rosenblum ML. Nocardial brain abscess: Treatment strategies and factors influencing outcome. Neurosurgery. 1994;35:622-31 DISCLOSURES: No relevant relationships by Aqsa Amin, source=Web Response No relevant relationships by Ming-Yan Chow, source=Web Response

Metastastic Melanoma in a Goat

Background: Melanoma is one of the 5 neoplasia types of that most frequently affect skin and subcutaneous tissue, es-pecially in Northeastern Brazil, where there is a high incidence of solar rays. It is a tumor that affects melanocytes and is characterized by diverse morphologies ranging from round to polygonal cells, including epithelioid cells, spindle cells, star-shaped or with a mesenchymal appearance, and presenting large amounts of melanin in the cytoplasm. The pigment can be found in the cytoplasm of macrophages, indicating the phagocytic activity at the site. The nucleus is basophilic, and mitotic figures are not numerous.Case: A 12-year-old female goat with a history of nodular lesion in the nasal region with progressive increase and recur-rence was submitted to clinical evaluation. The tumor presented suggestive characteristics of melanoma, such as elevated irregular and surface with a central region of black colored skin. After surgical removal of the nodule, recurrence was observed in infra-orbital and parotid regions with infiltration of the mandible. Hence, the malignant behaviour of the tumor indicated euthanasia of the animal. The owner authorized the procedure and the individual was then submitted to necropsy at the Animal Pathology Sector of the Federal Rural University of Pernambuco, Academic Unit of Garanhuns (UAG/UFRPE). At necropsy, findings included a tumor in the parotid region with infiltration to the mandible, multiple tumors of black or grayish-white color in liver, multifocal nodules of grayish color in the right kidney and left kidney also had tumors of the same colorations, in the thoracic cavity, blackened spots were observed in the sternum. The lungs had several black colored nodules distributed throughout the organ. Microscopic examination revealed metastatic cells with intracytoplasmic brown pigments, in addition to granular and pleomorphic aspect. The lymph nodes presented the higher number of metastatic foci. Tumor cells were observed in metastatic nodes surrounded by disorganized tissue in organs, such as liver, right kidney, mandible and lungs.Discussion: The diagnosis was concluded based on the metastatic foci found in the several organs along with macroscopic aspects of the tumors and the histopathological evaluation. In addition, the findings were also confirmed with data found in the scientific literature. The clinical evolution and the appearance of new metastatic foci in only three weeks indicated that it was a tumor with a high degree of invasiveness. The evolution period was shorter than the reports described in the literature. Also in an unusual manner, the numerous metastatic foci in several organs compromised the general status of the animal. The involvement of the liver and lung parenchyma by the tumor, considerably diminishing the functionality of these organs, and the macroscopic characteristics with darkened aspect, microscopically correspond to areas of metastatic foci. The histopathological evaluation of the white or yellow areas revealed necrosis with adjacent tissue disorganization. The alterations described in the kidney, sternum and mandible were also described in the literature as possible sites of metastasis. However, there are few reports describing elevated numbers of metastases in a single animal, and in such rich detail with macroscopic and microscopic records, allowing the conclusion of this case as a malignant melanoma.

Multi-region exome sequencing reveals genomic evolution from preneoplasia to lung adenocarcinoma

There has been a dramatic increase in the detection of lung nodules, many of which are preneoplasia atypical adenomatous hyperplasia (AAH), adenocarcinoma in situ (AIS), minimally invasive adenocarcinoma (MIA) or invasive adenocarcinoma (ADC). The molecular landscape and the evolutionary trajectory of lung preneoplasia have not been well defined. Here, we perform multi-region exome sequencing of 116 resected lung nodules including AAH (n = 22), AIS (n = 27), MIA (n = 54) and synchronous ADC (n = 13). Comparing AAH to AIS, MIA and ADC, we observe progressive genomic evolution at the single nucleotide level and demarcated evolution at the chromosomal level supporting the early lung carcinogenesis model from AAH to AIS, MIA and ADC. Subclonal analyses reveal a higher proportion of clonal mutations in AIS/MIA/ADC than AAH suggesting neoplastic transformation of lung preneoplasia is predominantly associated with a selective sweep of unfit subclones. Analysis of multifocal pulmonary nodules from the same patients reveal evidence of convergent evolution.

Fatal parasite-induced enteritis and typhlocolitis in horses in Southern Brazil.

Diseases related to the alimentary system are the main cause of death in horses. This retrospective study aimed to describe the pathological findings of fatal parasite-induced enteritis and typhlocolitis caused by cyathostominae, Eimeria leuckarti, Balantidium coli, and Strongyloides westeri in horses. The records of parasite-induced intestinal lesions in horses necropsied in Southern Brazil between 2005 and 2017 were reviewed. Ten horses had fatal parasitic enteritis and/or typhlocolitis, and the main causes were: cyathostominae typhlocolitis (6/10), E. leuckarti enteritis (1/10), S. westeri enteritis (1/10), B. coli colitis related to cyathostominae (1/10), and infection by multiple agents (1/10). Cyathostominae typhlocolitis showed marked mucosal thickening, with multifocal elevated nodules containing tangled filiform parasites. Microscopic examination revealed that the mucosa and submucosa had encysted parasitic structures surrounded by eosinophilic and granulomatous inflammation. E. leuckarti enteritis was microscopically characterized by macrogamonts, microgamonts, and oocysts inside the host cells. S. westeri enteritis showed microscopic atrophy of the villi with numerous mucosal encysted parasitic structures. B. coli typhlocolitis showed severe diffuse mucosal reddening, with microscopic superficial mucosal necrosis associated with multiple protozoan trophozoites. Fatal parasite-induced enteritis and typhlocolitis are important causes of death in horses in Southern Brazil.

Multifocal pleomorphic dermal sarcoma and the role of inflammation and immunosuppression in a lung transplant patient: a case report

BackgroundPleomorphic dermal sarcoma is the cutaneous variant of undifferentiated pleomorphic sarcoma. It is a rare malignancy of unclear histogenesis; it is a diagnosis of exclusion that requires extensive use of immunohistochemistry to rule out other malignancies. Pleomorphic dermal sarcoma typically presents as a solitary tumor in sun-exposed areas and may have unpredictable clinical behavior, with some tumors associated with metastasis and death.Case presentationWe present an unusual case of multifocal pleomorphic dermal sarcoma arising in the areas of alpha-1-antitrypsin deficiency panniculitis in a lung transplant patient. Our patient was a 58-year-old white woman whose initial presentation was consistent with alpha-1-antitrypsin deficiency panniculitis. She then developed extensive multifocal, bleeding, and ulcerated nodules in the areas of the panniculitis. A skin biopsy was consistent with a diagnosis of pleomorphic dermal sarcoma. Her immunosuppressive regimen was decreased, and she was treated with liposomal doxorubicin 40 mg/m2 every 3 weeks with some initial improvement in the size of her tumors. However, soon after beginning therapy, she developed pneumonia and septic shock and ultimately died from multi-organ failure.ConclusionsWe hypothesize that chronic, multifocal inflammation in the skin in the setting of immunosuppression led to simultaneous, malignant transformation in numerous skin lesions. We discuss the challenges of diagnosing pleomorphic dermal sarcoma, therapeutic options, and stress the need for multidisciplinary management of these cases.

Amoebic Encephalitis Caused by Balamuthia mandrillaris.

We present the case of a 71-year-old man who was diagnosed with amoebic encephalitis caused by Balamuthia mandrillaris. He had rheumatic arthritis for 30 years and had undergone continuous treatment with immunosuppressants. First, he complained of partial spasm from the left thigh to the left upper limb. Magnetic resonance imaging revealed multifocal enhancing nodules in the cortical and subcortical area of both cerebral hemispheres, which were suggestive of brain metastases. However, the patient developed fever with stuporous mentality and an open biopsy was performed immediately. Microscopically, numerous amoebic trophozoites, measuring 20 to 25 µm in size, with nuclei containing one to four nucleoli and some scattered cysts having a double-layered wall were noted in the background of hemorrhagic necrosis. Based on the microscopic findings, amoebic encephalitis caused by Balamuthia mandrillaris was diagnosed. The patient died on the 10th day after being admitted at the hospital. The diagnosis of amoebic encephalitis in the early stage is difficult for clinicians. Moreover, most cases undergo rapid deterioration, resulting in fatal consequences. In this report, we present the first case of B. mandrillaris amoebic encephalitis with fatal progression in a Korean patient.

Primary Pulmonary Adenocarcinoma in a Cow

Background: Primary neoplasms of the respiratory tract are rare in cattle, and they present with nonspecific clinical signs and are usually found at post-mortem. Pulmonary adenocarcinoma of the acinar type is uncommon, and information about this neoplasm in cattle is scarce. This paper aims to describe the clinical, laboratory, and pathological findings in a cow with this neoplasm.Case: A 10-year-old, adult, mixed-breed Holstein cow weighing 300 kg was referred to the Garanhuns Cattle Clinic of the Campus of Federal Rural University of Pernambuco, Brazil, with a history of decreased appetite, tiredness, weight loss, and difficulty in breathing for two months. The animal had been treated at the farm of origin with enrofloxacin, florfenicol, and flunixin meglumine. The animal’s appetite improved, but no improvement in the respiratory symptoms was observed. On examination at our center, the cow was in an orthopedic position, with neck extension and elbow abduction; and it remained in a recumbent position. The cow had neutrophilia, normochromic normocytic anemia, and hyperfibrinogemia. The body condition score (BCS) was 1 (BCS ranges from 1 to 5), and the cow had moderate enophthalmia, serous secretions in nostrils, tachycardia, and tachypnea. It also had increased breathing intensity; increased breath sounds in the cranial regions of both lungs; areas of reduced breath sounds in the medial portions of the lungs; intermittent wheezing in the cranial region of the left lung medially and in the cranial region of the right lung medially; intermittent crepitations in the cranial region of the right lung medially; reduced thoracic expansion; and expiratory dyspnea. Pulmonary ultrasonography revealed hyperechogenic multifocal structures in both lungs. In view of the severe clinical condition and unfavorable prognosis, the owner opted for euthanasia. Necropsy revealed that there was a significant amount of yellow fluid in the thoracic cavity, and the cut surfaces of the lungs were covered with fibrin and pleural adhesions. The lungs had irregular surfaces with multifocal nodules of various sizes and firm consistency. The texture of the cut nodules was solid, and the nodules had a yellowish color. Histologically, the pulmonary nodules were composed of neoplastic cells. They were pleomorphic, infiltrative epithelial cells with little cytoplasm; large and spherical nuclei with abundant euchromatin; occasional anisokaryosis; visible nucleolus; and numerous mitotic figures. Results of anti-cytokeratin immunohistochemistry were strongly positive for cytokeratin in the lungs and lymph nodes. Discussion: The diagnosis of acinar pulmonary adenocarcinoma was based on clinical, laboratory, histopathological, and immunohistochemical findings. Clinical signs and lung ultrasound suggested a severe respiratory disease. Pulmonary tumors are usually solid, and they show areas of central necrosis that resemble granulomas. However, the histopathological findings in the current case were compatible with a primary pulmonary neoplasm. Primary pulmonary neoplasms, although rare, should be considered in the differential diagnosis of weight loss, cachexia, and respiratory symptoms in adult cattle. The morphological pattern and the strong immunoreactivity on immunohistochemical examination were conclusive for a diagnosis of a primary pulmonary adenocarcinoma of the acinar type because these tumors specifically contain cytokeratin.

Disseminated peritoneal leiomyomatosis: A case report and literature review

Introduction: Disseminated peritoneal leiomyomatosis (DPL) is a rare medical entity, only about 200 cases have been reported in literature. It is characterized by the presence of multifocal nodules composed of proliferating smooth muscle tissue, disseminated in the pelvic cavity.

Angiostrongylosis inCerdocyon thous(crab-eating fox) andLycalopex gymnocercus(Pampas fox) in Southern Brazil

The objective of this study was to identify species of Angiostrongylus spp. infecting wild carnivores in Southern Brazil, as well as to describe gross and histopathological findings associated with the infection. Necropsy was conducted in 16 wild carnivores parasitized by Angiostrongylus spp. Analysed lungs revealed multifocal dark-red areas of consolidation; in one case, multifocal firm white nodules spread in all pulmonary lobes were observed. In one animal, a focally extensive area of malacia associated with haemorrhage was noted in the encephalon. Histologically, multifocal granulomatous pneumonia or bronchopneumonia, associated with eggs and larvae in blood vessels, lung interstitium, alveoli, and sometimes in bronchi and bronchioles was observed. Adult nematodes were seen within blood vessels. The lesion observed in the brain was characterized as a focally extensive area of malacia associated with gitter cells, haemorrhage, thrombosis and a free intralesional larva. Through molecular techniques, seven positive samples of Angiostrongylus cantonensis were obtained, including the brain sample, and a positive sample of Angiostrongylus vasorum-like, all in Cerdocyon thous. The positive sample for A. vasorum showed 97% similarity with sequences deposited in GenBank, suggesting a new species or subspecies of Angiostrongylus sp. Infection of Lycalopex gymnocercus by Angiostrongylus spp. was confirmed by histological evaluation.

The sonographic characteristics of papillary thyroid microcarcinoma and its risk evaluation of cervical lymphatic metastasis

Objective To investigate the sonographic characteristics of papillary thyroid microcarcinoma(PTMC) and the preoperative prediction value for cervical lymphatic metastasis of PTMC. Methods Three hundred and fifty-eight PTMC patients who were confirmed by pathology and accepted partly or totally thyroidectomy and neck dissection were collected to analyze the sonographic characteristics, all patients were classified according to multifocal carcinoma nodules and solitary carcinoma nodules; cervical lymphatic metastasis or not; the maximum diameter of carcinoma nodules. Univariate analysis and Logistic regression analysis were used. Results Compared with solitary PTMC, multifocal PTMC was prone to emerge blood flow signals, heterogeneity, cervical lymphatic metastasis(all P 1 cm, irregular edge, irregular shape, microcalcification, capsular invasion(all P<0.05). With Logistic regression analysis, the independent risk factors of cervical lymphatic metastasis in PTMC were multifocality and capsular invasion. Combining multifocality and capsular invasion, which area under the ROC(AUC) was 0.807. Conclusions Combining multifocality and capsular invasion significantly improves the risk of cervical lymphatic metastasis in PTMC by ultrasonography. Key words: Ultrasonography; Thyroid neoplasms; Lymphatic metastasis

Abstract A19: Establishment of in vitro and in vivo models of inflammatory myofibroblastic tumor

Abstract Inflammatory myofibroblastic tumors (IMTs) are sarcomas of soft tissue that most commonly arise in children, adolescents, and young adults. If not cured by surgery, IMT has a high propensity for local recurrence as multifocal nodules, and may rapidly progress to fatal disease. Anaplastic Lymphoma Kinase (ALK) driven tumorigenesis is implicated in approximately 50% of IMT cases. IMT patients with ALK rearrangement have been reported to respond to the ALK inhibitor, crizotinib, but with the possibility of relapse with resistant disease. The second-generation ALK inhibitor ceritinib showed improved specificity and potency toward crizotinib-resistant tumors; however, resistant disease may still emerge. Thus, there is an urgent need for identifying alternative treatment options for ALK-driven IMT. In this study, we utilized fresh malignant ascites collected from a 9-year-old boy (IMT-1) with epithelioid inflammatory myofibroblastic sarcoma (eIMS), at diagnosis (IMT-1A) and third relapse (IMT-1D) to establish the in vitro cell culture and in vivo orthotopic patient-derived xenograft (PDX) model. Primary cell cultures were successfully established from both samples with confirmed ALK rearrangement. The PDX was established by intraperitoneal injection of cultured IMT-1D cells into nonobese diabetic severe combined immune-deficient mice with IL-2 receptor gamma chain deficiency (NSG) mice. Within 6-8 weeks of inoculation, 100% of the mice became moribund due to robust multifocal intraperitoneal tumors that grew in close association with abdominal organs, including the pancreas and small bowel. The xenograft recapitulated both morphologic and immunohistochemical features of the tumor within the patient. Positive immunohistochemical staining for ALK in a characteristic perinuclear membrane pattern and ALK gene rearrangement were also demonstrated in tumor cells cultured from peritoneal fluid of the xenografted mice. Our in vitro cultures and in vivo PDX models provide a valuable opportunity to undertake a detailed characterization of ALK-driven IMT at diagnosis and following ceritinib failure. They are ideal models for preclinical evaluation of new therapeutic approaches to the treatment of ALK-driven IMT. Citation Format: Jinhan (Angela) Xie, Emily V. A. Mould, Ashleigh Fordham, Andrew J. Gifford, Toby Trahair, Karen L. Mackenzie. Establishment of in vitro and in vivo models of inflammatory myofibroblastic tumor [abstract]. In: Proceedings of the AACR Conference on Advances in Sarcomas: From Basic Science to Clinical Translation; May 16-19, 2017; Philadelphia, PA. Philadelphia (PA): AACR; Clin Cancer Res 2018;24(2_Suppl):Abstract nr A19.

Curved multiplanar reconstruction of CT scans for demonstration of multifocal metastatic lung nodules in children in a single image

Curved multiplanar reconstruction of CT scans for demonstration of multifocal metastatic lung nodules in children in a single image

Severe Cushing’s syndrome and bilateral pulmonary nodules: beyond ectopic ACTH

Cushing’s syndrome is a rare disease that results from prolonged exposure to supraphysiological levels of glucocorticoids. Severe and rapidly progressive cases are often, but not exclusively, attributable to ectopic ACTH secretion. Extreme hypercortisolism usually has florid metabolic consequences and is associated with an increased infectious and thrombotic risk. The authors report on a case of a 51-year-old male that presented with severe Cushing’s syndrome secondary to an ACTH-secreting pituitary macroadenoma, whose diagnostic workup was affected by concurrent subclinical multifocal pulmonary infectious nodules. The case is noteworthy for the atypically severe presentation of Cushing’s disease, and it should remind the clinician of the possible infectious and thrombotic complications associated with Cushing’s syndrome.Learning points:Severe Cushing’s syndrome is not always caused by ectopic ACTH secretion.Hypercortisolism is a state of immunosuppression, being associated with an increased risk for opportunistic infections.Infectious pulmonary infiltrates may lead to imaging diagnostic dilemmas when investigating a suspected ectopic ACTH secretion.Cushing’s syndrome carries an increased thromboembolic risk that may even persist after successful surgical management.Antibiotic and venous thromboembolism prophylaxis should be considered in every patient with severe Cushing’s syndrome.

Correlation analysis of the clinical and sonographic characteristics of papillary thyroid microcarcinomas with its aggressiveness

Objective To compare the clinical and sonographic characteristics of aggressive and nonaggressive papillary thyroid microcarcinomas (PTMC) in order to improve the preoperative predictive value of aggressive PTMC. Methods A total of 309 patients with PTMC from January 2014 to December 2016 were included in this study. Patients with lymphatic metastasis, extrathyroidal invasion, reccurence, distant metastasis and death were classified into aggressive PTMC group, and patients without above characteristics were classified into nonaggressive group. Clinical and sonographic features were reviewed and compared between the two groups. Results Among the 309 patients, 76 cases (24.6%) were aggressive PTMC, and 233 cases (75.4%) were nonaggressive. Patients were younger and larger cancerous nodules, microcalcification, capsular inconnection and multifocality were seen more frequently in aggressive PTMC group compared with nonaggressive group. The best cut-off value of age and diameter were 44.5 years and 0.66 cm respectively. Advanced age was the protective factor and larger tumor size and multifocality were independent risk factors for PTMC aggressiveness. The capsular invasion was related with the lateral cervical lymph node metastasis while other features were not. Conclusions Extra attention should be paid to patients with age 0.66 cm and multifocal cancerous nodules because their PTMCs are more likely to be aggressive. Thyroid capsule adjacent to the cancerous nodule should be observed carefully. If there is interruption in the capsule, lateral cervical lymph nodes should be carefully examed. Key words: Ultrasonography; Papillary thyroid microcarcinomas; Aggressiveness; Clinical characteristics

Hepatic Mastocytosis in Japanese Black Cattle.

In 5 Japanese Black steers (2-2.4 years old) that originated from 5 different feedlots, the livers were found at slaughter to have multiple nodular or cordlike lesions (5 steers) and an extensive fibrotic area (1 steer). Microscopic changes included extensive fibroplasia in the portal tracts and chronic proliferative endophlebitis-like lesions confined to the portal vein branches. Fibroplasia was much more prominent in the macroscopic fibrotic lesion of 1 steer. Portal vein branches presented irregular variciform dilation of the vascular lumen and fibroplastic changes in the subendothelial areas that showed occasional hemorrhage and were simultaneously infiltrated with large numbers of mast cells and moderate to large numbers of eosinophils. Within these subendothelial regions, not only did mast cells exhibit cytologically atypical features, but they also formed multifocal nodules. The venous lesions may represent a variant of mastocytosis with specific involvement of the hepatic portal vein branches in cattle.

Unusual Presentation of Bronchiolitis Obliterans Organizing Pneumonia Mimicked Pulmonary Metastases: A Case Report

SESSION TITLE: Imaging SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: The radiological presentation of bronchiolitis obliterans organizing pneumonia (BOOP) is characterized by multiple air space consolidations with a subpleural distribution or areas of ground glass lung infiltration. We report a case of BOOP presenting with a multiple nodular pattern mimicking miliary metastasis lung infiltration. CASE PRESENTATION: A 47-year-old man presented with cough. He was a current smoker for 35 years. He had COPD and DM. Vital signs were normal. Chest X-ray showed bilateral nodular opacities. Thorax computed tomography; predominantly in the upper lobe, bilateral, multiple pulmonary nodules (the largest 20 mm) with variable border features were detected, some of which were frosted glass densities (Fig.1). Mediastinal (10 mm in diameter), right suprahiler (15 mm in diameter) and both axillar lymph nodes were present. Serological tests were normal. Mycobacterium tuberculosis was negative. PET/CT: Several millimetric lymph nodes without mediastinal pathologic FDG involvement were observed. A large number of nodules were observed in both lung parenchyma, some of which were calcified, with mildly elevated FDG uptake (Early SUV max: 2,18, Late SUV max: 3,14) (Fig.1). Lung biopsies with wedge resection were perfomed under video-assisted thoracoscopy(VATS). Histopathological analysis consistented with BOOP (Fig.2). The patient underwent steroid therapy at a dose of 48 mg / day with the diagnosis of BOOP. At 3 months of treatment, control CT completely removed. The steroid treatment was stopped at 4 months because of uncontrolled diabetes mellitus. The patient was followed-up for one year, and the disease did not relapse. DISCUSSION: Heterogenic radiologic features on X-ray and on CT scan make correct diagnosis difficult, sometimes resulting in ineffective therapy and unnecessary hospitalization. Most often, CT scan shows unilateral or bilateral airspace consolidation with a predominantly peripheral distribution in lower and middle zones. Contrary to the common radiological findings in our case, there were bilateral multifocal nodules with predominantly upper lobes. In pet ct; metastatic disease can not be excluded due to increased metabolic activity in late images. Therefore, histopathological confirmation is required. We did not find any reports that bronchiolitis obliterans organized pneumonia pet ct findings. It may be said that boop pet ct findings may interfere with malignancy. CONCLUSIONS: In conclusion, our patient had an unusual radiological pattern of bilateral pulmonary nodules associated with COP that mimicked pulmonary metastases. Its radiological and nuclear properties can lead to misdiagnosis like malignancy. Reference #1: American Thoracic Society/European Respiratory Society International Multidisciplinary Consensus Classification of the Idiopathic Interstitial Pneumonias. Am J Respir Crit Care Med. 2002;165:277-304. DISCLOSURE: The following authors have nothing to disclose: Demet Polat, Eylem Ozgur, Sibel Atis Nayci, Tuba Kara, Feramuz Apaydin, Pelin Özcan No Product/Research Disclosure Information

Onset of 26th day after birth, intermittent cough with pulmonary multifocal nodules

Objective To improve the understanding of neonatal-onset pulmonary tuberculosis. Methods The clinical features, laboratory examination and imaging were analyzed in 2 cases with neonatal-onset pulmonary tuberculosis in the Respiratory Department of Beijing Children′s Hospital, Capital Medical University. Results The 2 patients were premature twins, were born at 33+ 3 weeks of gestation, presented with intermittent cough and transient fever on 26 days after birth.Chest CT scan showed pulmonary multifocal nodules.One case was complicated with pleural effusion, atelectasis and no effectiveness with antibiotics.The untypical pathogen infection was considered.The result of PPD was negative, the result of interferon gamma release array, gastric acid fast staining and mycobacterium tuberculosis culture were positive, finally they were diagnosed with pulmonary tuberculosis. Conclusions The clinical features and imaging of neonatal tuberculosis are always untypical and PPD is negative, which brings difficulties to clinical diagnosis.We should take untypical pathogens into account, such as tuberculosis, when some diseases cannot be explained by common pathogens. Key words: Pulmonary multifocal nodules; Pulmonary tuberculosis; Interferon-γ release array

Systemic Mycobacterium kansasii Infection in a Domestic Shorthair Cat

A 1-year-old, female domestic shorthair cat was presented with anorexia, depression and weight loss, accompanied by multifocal nodules affecting the face, pinnae and periarticular tissue. Routine medical treatments were ineffective. The animal's physical condition continued to deteriorate and it finally died. Post-mortem examination revealed multifocal to coalescing firm nodules with occasional ulceration affecting the ears, peri-ocular areas, nasal planum, oral cavity and laryngopharyngeal region. Tan-coloured, firm, nodular lesions were also observed in the periarticular tissue, lungs and tracheobronchial and mediastinal lymph nodes. Impression smears of several of these lesions revealed a myriad of slender rod-shaped organisms, mainly in the cytoplasm of macrophages. Histopathological examination showed severe pyogranulomatous inflammation with or without necrosis in the nodules. Acid-fast staining revealed large numbers of acid-fast bacilli. Mycobacterium kansasii was detected in the tissues using multiplex polymerase chain reaction and DNA sequencing. No protozoal or fungal organisms were detected using special stains. On the basis of these results, the cat was diagnosed with systemic M. kansasii infection. To our knowledge, there have been few reports of M. kansasii infection, especially with systemic spread, in cats.