Multiple Nodes Research Articles

8126 PTH-independent, Calcitriol-mediated Hypercalcemia in Renal Cell Carcinoma

Abstract Disclosure: G.K. Rai: None. A. De Rosairo: None. K. Madani: None. D. Sacoto: None. A.A. Franco-Akel, MD: None. R. Belokovskaya: None. Hypercalcemia of malignancy is a known complication of advanced cancer. It occurs through various mechanisms, one of which is via 1,25-dihydroxyvitamin D (calcitriol). Calcitriol-mediated hypercalcemia accounts for approximately 1% of cases of hypercalcemia in the setting of malignancy and is usually seen in lymphomatous solid tumors. We present a gentleman with clear cell renal cell carcinoma associated with hypercalcemia with normal levels of intact parathyroid hormone (PTH), PTH-related protein (PTHrP), and 25-hydroxyvitamin D but elevated calcitriol levels. A 48 year-old-male with no significant past medical history with complaints of fatigue, hematuria, and weight loss of 38 pounds in 3 months was following urology for an elective right-sided nephrectomy. MRI of the abdomen and pelvis found a 16.1 cm renal mass with necrotic areas, causing mass effects on the liver, pancreas, and IVC. Preoperative laboratory showed hypercalcemia of 13.7 mg/dL (corrected 13.9 mg/dL) with microcytic anemia (hemoglobin 8.8 g/dL, MCV 72 fl). Workup showed low iPTH (3 pg/dL), 25-hydroxyvitamin D (16.9 ng/dL), and phosphorus level (1.7mg/dL) with elevated calcitriol (94.3 pg/dL) and a normal PTHrP. CT chest showed multiple pulmonary nodules on bilateral lobes, with the largest nodule ∼ 4.5 mm. Hypercalcemia was managed with IV fluids, calcitonin 300 units Q12 for two days, Denosumab IV infusion, prednisone 60 mg for three days, and oral ergocalciferol 50,000 units weekly. Calcium levels normalized, after which the patient underwent nephrectomy. Pathology revealed renal cell carcinoma grade G4 with mixed features of clear cell carcinoma with sarcomatoid and rhabdoid features. We report an incidental finding of hypercalcemia in a patient with renal mass. The elevated calcitriol levels can be attributed to ectopic calcitriol production through the renal mass. Post nephrectomy calcium levels remained within normal range for consecutive weeks. With this, we concur that hypercalcemia most likely originated from the renal mass that had ectopic production of calcitriol. Dysregulated calcitriol production is a well-known complication of lymphomas and granulomatous disease but is seldom reported with solid tumors. Usually, the etiology for hypercalcemia in patients with renal cell carcinoma is the overproduction of PTHrP, which was not the case with our patient. The ultimate resolution of hypercalcemia of malignancy was attained by treating the underlying malignancy. Presentation: 6/1/2024

6918 A Unique Case of Oncocytic Thyroid Cancer with an NBN Gene Pathogenic Variant

Abstract Disclosure: A. Grover: None. S. Jhawar: None. S. Shekhar: None. S.A. Avadhanula: None. G. Al-Naqeeb: None. G. Thota: None. P. Veeraraghavan: None. C. Cochran: None. M.Y. Kao-Hsieh: None. A. Gharib: None. F.E. Escorcia: None. J. Del Rivero: None. J. Klubo-Gwiezdzinska: None. S. Gubbi: None. Introduction: Oncocytic thyroid carcinoma (OTC), previously known as “Hürthle cell” carcinoma, makes up less than 5% of all thyroid cancers. OTCs are often aggressive with a high risk of metastasis, and a poorer prognosis compared to other forms of differentiated thyroid carcinoma (DTC). Molecular drivers of OTC include pathogenic variants (PVs) in NRAS, DAXX, CDKN1A, the mitochondrial genome and chromosomal alterations. PVs in the NBN gene in OTC have not been previously reported. Case: A 53-year-old male was noted to have a thyroid nodule on a routine physical examination. Patient denied any hyper/hypothyroid or compressive symptoms, and family history was unremarkable. Cytopathologic analysis of the fine needle aspiration biopsy of the nodule was consistent with a thyroid follicular neoplasm (Bethesda IV). A total thyroidectomy with central compartment neck dissection was performed. Histopathologic examination demonstrated a 7 cm x 4 cm x 4 cm OTC with capsular and lymphovascular invasion, but without extra-thyroidal extension or lymph node metastasis (pT3aN0Mx). Subsequently, adjuvant radioiodine (RAI) I131 therapy with 165 mCi was administered and post-therapy scan revealed neck uptake. One-year post-therapy RAI diagnostic scan was negative. Three years following the initial thyroid surgery, elevated serum thyroglobulin (Tg) levels were noted. A computed tomogram of the chest revealed multiple bilateral lung nodules. Further imaging ruled out involvement of other distant sites. A diagnostic lower lung wedge resection demonstrated metastatic OTC. The tumor stained positive for CK7, PAX8, TG, TTF-1 and negative for CK20 on immunohistochemistry. Next-generation sequencing of the tumor tissue (Oncomine Comprehensive Assay v3) revealed a PV in the NBN gene (c.2166_2167delGCinsAT; p.Trp722Ter). A year later, the serum Tg levels continued to rise, and the lung nodules had increased in size. Due to disease progression, lenvatinib was initiated. A [F18]-fluorodeoxyglucose positron emission tomography performed one year later demonstrated persistent pulmonary tumor burden with new osseous metastasis in the right scapula, left acetabulum, and the sternum. Zoledronic acid was initiated for the treatment of the skeletal metastases, and palliative external beam radiation (2000 cGy in 5 fractions) was administered to the sternal lesion to alleviate the bone pain. Conclusion: The NBN gene encodes for the protein nibrin, a member of the MRE11/RAD50 complex that is involved in DNA repair. PVs in NBN are commonly identified in non-thyroidal malignancies such as breast and lung carcinomas. While NBN PVs are rarely reported in DTCs, as per our knowledge, this is the first described case of OTC with a PV in NBN as the molecular driver, manifesting with an aggressive disease course. Identification of this novel PV therefore adds to the current knowledge of the molecular landscape of OTC. Presentation: 6/3/2024

8788 Implications of NTRK gene fusion in Papillary thyroid cancer

Abstract Disclosure: W. Medina-Torres: None. L. El Musa Penna: None. J. Segarra-Villafane: None. L.R. Sepulveda-Garcia: None. Z. Maisonet -Feliciano: None. I.C. Arroyo: None. M. Ramirez: None. M. Alvarado: None. L.A. Gonzalez-Rodriguez: None. V.J. Carlo: None. Thyroid cancer (TC) is the most common endocrine cancer. Papillary thyroid carcinoma (PTC) is the predominant contributor of this occurrence, comprising approximately 80% of all thyroid carcinomas. PTC has a good prognosis with a 5-year survival rate of more than 90% after resection. Nonetheless, factors such as tumor size, multifocality, nodal and distant metastases, characterize more aggressive cases including tall cell variant, columnar cell variant, and hobnail variant Aside from staging parameters, PTC behavior is mostly determined by morphologic variant. This is the case of 31 y/o female without known past medical history who was evaluated at endocrinology clinic due to a fine needle thyroid aspiration (FNA) positive for PTC, tall cell variant. Total thyroidectomy with central compartment dissection was performed. Pathology report presented a main tumoral mass of 3 cm but permeating multinodular pattern involving the entire gland with focal extrathyroidal extension, positive margins and six level VI positive lymph nodes. As per report, the tumor presented both papillary and follicular patterns of growth and other findings including oncocytic change, foci of clear cell change, low mitotic rate, and most notably "reverse polarization”. This pattern has the pathological features suggestive of the novel NTRK gene fusion mutation. The patient was treated with radioactive iodine (RAI) and one year post treatment there was evidence of elevated Thyroglobulin level at 904 ng/mLand thyroglobulin Ab at 2.48 IU/mL. A WBS +SPECT was done resulting in small uptake at left posterior thyroid bed and pulmonary intake. A chest CT revealed multiple bilateral sub centimeter nodules. Based on this result, a second course of RAI was given. Follow up neck ultrasound and chest CT presented persistent left level VI lymph nodes, increased amount of bilateral sub-centimeter pulmonary nodules and new thoracic(T11) lesion. FNA of left neck lymph nodes were positive for metastatic PTC for which left neck dissection was performed. Evaluation for actionable somatic mutations was requested based on resistance behavior, remarkable for TRIM33-NTRK1 chromosomal rearrangement. Patient was evaluated by Oncology service who started Larotrectinib treatment since it was approved for NTRK driven malignancies. Six-month post therapy patient achieved clinical and biochemical improvement. In the thyroid, NTRK-driven malignancies are rare and aggressive but treatable, in the evolving genomic era. As reviewed in the literature, NTRK fusion-positive TC exhibits distinctive clinicopathological features that could aid in identifying potential patients. Thus, in such patients who have PTC with non-classic pathologic patterns, specific molecular profile of the main tumor may have significant prognostic value that must be integrated into stratification system in order to provide target therapy on time. Presentation: 6/3/2024

12205 Challenging Case Of Anaplastic Thyroid Cancer With Unusual Histological Features: A Diagnostic Dilemma With High Grade Sarcoma

Abstract Disclosure: B. Gautam: None. B. Tiwari: None. M.S. Hossain: None. S. Hossain: None. S.C. Kumar: None. H. liao: None. Introduction: Anaplastic thyroid carcinoma (ATC) is a rare but highly aggressive thyroid cancer accounting for < 2% of cases, characterized by its rapid growth, extensive local invasion, and poor prognosis. Distinguishing ATC from other high-grade sarcomas, such as leiomyosarcoma, is challenging due to shared morphological features and overlapping immunoprofiles. We present a case involving a 73-year-old male presenting with rapidly growing neck mass, leading to diagnostic challenges differentiating between ATC and high-grade sarcomas. Case presentation: A 73-year-old male presented to ED with a rapidly growing painful neck mass for last 3 months, associated with dysphagia, dyspnea & dysphonia. He denied any fever, chills, weight loss and symptoms of hyperthyroidism or hypothyroidism. No personal or family history of thyroid cancer. On physical exam: vitals were normal, Neck exam revealed a left sided neck mass, mobile with deglutition, hard in consistency associated with hoarseness of voice. No stridor or wheeze noted on auscultation. Physical exam was otherwise normal. Laboratory tests showed normal CBC, CMP and TSH 1.45 mIU/L, T4 9.7 ug/dl. CT neck with contrast showed 5.4 x 5.6 x 8.2 cm large lobulated left thyroid mass with rightward airway deviation & substernal extension. Ultrasonogram of thyroid showed 9.6 x 5.3 x 3.3 cm left thyroid lobe with internal calcifications & extrathyroidal extension with several abnormal appearing cervical lymph node, largest measuring 4.9 x 2.4 x 3.3 cm. CT chest/abdomen/pelvis with contrast showed multiple bilateral lung nodules measuring up to 1.5 cm and 1.4 x 1.3 cm left gluteal soft tissue mass. IR-guided left neck mass biopsy was suggestive of primary spindle cell neoplasm with initial immunoprofiles consistent with a high-grade sarcoma, favoring leiomyosarcoma. Given the rapid growth of the neck mass with associated dyspnea, left thyroidectomy was performed and surgical pathology was suggestive of a high-grade sarcoma. However, subsequent pathology review made a final diagnosis of ATC, based on morphologic & immunohistochemical profile showing tumor cells strongly positive for p53 and Desmin with few cells positive for PAX-8, Cam 5.2 and CD68, and negative thyroglobulin, TTF-1, CK7, CK20, CK MNF116, pancytokeratin AE1/AE3 and CK5/6. Thyroseq revealed a distinctive molecular profile specifically positive for TERT and TP53 supporting diagnosis of ATC. Discussion: This case highlights the diagnostic dilemma posed by the resemblance between ATC and high-grade sarcomas due to overlapping clinical, morphological and immunohistology features. While both malignancies may exhibit similar morphological features, specific immunohistochemistry profiles along with molecular testing aid in distinguishing between them and guiding appropriate treatment strategies. Presentation: 6/1/2024

6564 A Case Of Severe Hypercalcemia In Carney's Complex

Abstract Disclosure: J. Chippior: None. M. Rayan: None. L. Wright: None. L.S. Kirschner: Grant Recipient; Self; Medpace, Sparrow, Corcept Therapeutics, Corcept, Spruce, CinCor, Crinetics, Adrenas. S.W. Ing: Grant Recipient; Self; Alexion Pharmaceuticals, Inc., Amgen Inc, Radius Health, Inc, Takeda, Ultragenyx, Amolyt, Bridge Bio. Carney complex is a rare syndrome with fewer than 750 reported cases, characterized by lentigniosis, myxomas, and the occurrence of both endocrine and non-endocrine tumors. An inactivating mutation PRKAR1A, which encodes for the type 1A regulatory subunit of Protein kinase A, is responsible for over 70% of familial cases and 37% of sporadic cases. A 31-year-old female with a history of Carney complex, Cushing syndrome due to primary pigmented nodular adrenocortical disease (PPNAD), facial lentigines, spinal Schwannomas, and recent ischemic stroke secondary to embolization of a cardiac atrial myxoma, was transferred to our medical center for hyperemesis and severe hypercalcemia. Albumin-corrected serum calcium measured 15.4 mg/dL (8.6-10.5 mg/dL), ionized calcium 7.8 mg/dL (4.6-5.3 mg/dL) associated with suppressed PTH, normal PTH-related protein, and elevated bone turnover markers, C-telopeptide 4,273 pg/ml (150-635) and Procollagen Type 1 N-terminal Propeptide 222 mcg/L (19-83). Evaluation for etiology of hypercalcemia revealed elevated 1,25 dihydroxy vitamin D at 107.0 pg/ml (20-79) and elevated interleukin-6 at 11 pg/ml (<6.4). IL-6 is expressed by cardiac myxomas. Serum angiotensin-converting enzyme level was 50 U/L (16-85) and infectious workup was negative for potential granulomatous causes of elevated calcitriol (including testing for tuberculosis, histoplasma, blastomyces, bartonella, and coccidioides). CT angiogram of the abdomen and pelvis (completed in preparation of atrial myxoma resection) revealed ground-glass opacities in bilateral posterior lung fields and multiple pulmonary nodules, with the largest measuring 8 mm. After treatment with aggressive intravenous fluid resuscitation, intramuscular calcitonin, and intravenous zoledronic acid, corrected calcium normalized to 9.4 mg/dL at discharge. Urinary cortisol was 6.2 mcg per 24-hr (3.5-45), for which she started hydrocortisone 20 mg daily to treat suspected adrenal insufficiency as excess cortisol secretion in PPNAD may be episodic. Thus remission of hypercortisolism may have unmasked an underlying hypercalcemia, and adrenal insufficiency itself may have contributed to this finding. She had excision of left atrial myxoma and has continued to exhibit normal calcium levels on steroid replacement therapy. Repeat chest CT to further characterize these pulmonary findings is planned. This case illustrates a unique constellation of endocrine features associated with severe hypercalcemia in Carney complex. Presentation: 6/1/2024

7205 Anaplastic Thyroid Carcinoma Presenting as New-Onset Thyrotoxicosis and Hypoparathyroidism in a Young Patient: A Diagnostic Dilemma between Hashitoxicosis and Anaplastic Thyroid Cancer

Abstract Disclosure: M. Sulehri: None. E.G. Bustamante: None. A. Elmaaz: None. A. Chaudhuri: None. Introduction: This case report explores the complex diagnostic challenges encountered in a young patient presenting with anaplastic thyroid carcinoma (ATC) manifested by thyrotoxicosis and hypoparathyroidism. Case report: A 29-year-old male who sought multiple emergency room visits for shortness of breath, was initially misdiagnosed with pneumonia. On the third visit, exacerbated respiratory distress led to intubation, CT of the neck and thyroid US unveiling an infiltrative mass centered within the region of the thyroid gland. Initial thyroid function tests showed TSH <0.02 uIU/mL, free thyroxine 6.91 ng/dL, and total T3 204 ng/dL indicating hyperthyroidism, promptly managed with Methimazole and beta blockade. Elevated TPO antibodies (194 unit/mL) were observed, whereas thyroglobulin antibodies and thyroid receptor antibodies were undetected. Concurrently, hypoparathyroidism was noted, marked by low calcium levels (7.9 mg/dL) with albumin of 3.4 g/dL (corrected Calcium 8.4), and low parathyroid hormone (PTH) (<6 pg/mL). Other labs showed ionized calcium 4.30 mg/dL, phosphate 4.6 mg/dL, magnesium 1.8 mg/dL, and vitamin D 54 ng/dl. The patient received calcium carbonate supplement, calcitriol and IV calcium gluconate. Thyrotoxicosis then transitioned to hypothyroidism and levothyroxine replacement therapy was initiated. Definitive diagnosis was delayed due to the patient's overall condition and a low suspicion of malignancy. Left thyroidectomy and tracheostomy were performed, revealing dense subplatysmal necrosis with tumor involvement of both thyroid lobes and isthmus with multiple enlarged nodes. Final surgical pathology confirmed the presence of anaplastic thyroid carcinoma. Due to poor prognosis, the patient was transferred to hospice care where the patient succumbed to his condition within a day. Conclusion: Anaplastic thyroid cancer is considered one the most aggressive and fastest growing tumors. Although it is usually seen in patients after the age of 60, we present a very rare case of ATC in a young patient in the third decade who was presented with infiltrative thyroiditis and hypoparathyroidism. The case underscores the importance of considering rare etiologies in patients with atypical clinical presentation. Presentation: 6/1/2024

8161 A Rare Case of Malignant Melanoma Metastatic to the Thyroid Gland

Abstract Disclosure: J. Ferri-Guerra: None. O. Abdulhussein: None. E. Kasper-Guerra: None. G. Madrigal Loria: None. L. El Hage: None. 69 yo female presented with neck swelling in 2014. TSH was normal. Thyroid ultrasound showed multiple nodules with a right 2.9 x 2.3 x 2.1 cm that was cold on subsequent thyroid uptake scan. FNA of the right nodule in 08/2014 showed malignant cells with spindle cell pattern thought to be medullary thyroid cancer. She was scheduled for total thyroidectomy but presented with small bowl obstruction prior to her surgery and was diagnosed with metastatic melanoma (BRAF +). Initial PET scan showed a 4.1 x 2.8 x 2.8 cm hypermetabolic right thyroid lobe lesion in addition to other multiple hypermetabolic lesions consistent with known melanoma. The thyroid FNA specimen correlated with the small bowel excision specimen and showed similar features diagnosing metastatic melanoma to the thyroid gland.She was started on ipilimumab with subsequent scan in 04/2015 showing increase in right thyroid mass size to 5.4 x 4.2 x 9 cm with mixed results of other metastatic locations. She was switched to pembrolizumab and later dobrafenib/trametinib in 05/2015. Imaging thereafter showing significant improvement including a decrease in the right thyroid nodule size to 1.6 cm x 2.5 cm x 2.4 cm with no hypermetabolic activity on further PET scans. Repeat thyroid ultrasound in 2021 showed multiple nodules with a 2.2 x 1.5 x 1 cm nodule in the right. Repeat FNA of the right nodule was benign. Last imaging in 2023 showed stable nodules. Conclusion: metastasis to thyroid gland from malignant melanoma is a rare finding and should be considered in rapidly growing thyroid nodules. These lesions can be treated with targeted therapy that can spare affected individuals surgery. Presentation: 6/1/2024

Massive enteric necrosis caused by histiocytic sarcoma embolism: a case report

BackgroundHistiocytic sarcoma (HS) is a rare disease characterized by the presence of neoplastic histiocytes. We herein report an unusual case of HS that caused massive tumor embolism-related transmural necrosis of the small intestine.Case presentationA 64-year-old man presented with multiple nodules in the lungs, bone, mediastinum, and subcutaneous tissues that were incidentally detected on preoperative computed tomography for early transverse colon cancer. Approximately two months later, the patient presented with signs of peritoneal irritation suggestive of small intestinal necrosis. Emergency surgery was performed and the necrotic small intestine was resected. Pathological examination revealed small bowel necrosis due to multifocal HS embolism. The postoperative course was uneventful. The patient was unsuccessfully treated with chemotherapy for HS and died 122 days postoperatively.ConclusionsHS can cause massive enteric necrosis due to tumor embolism. Clinicians should be aware of this rare presentation of HS.

High-grade mucinous tubular and spindle cell carcinoma of the kidney in a patient on hemodialysis: a case report and literature review

BackgroundEnd-stage renal disease is a risk factor for renal cell carcinoma. However, mucinous tubular and spindle cell carcinoma of the kidney is rare. We report a patient on hemodialysis who had high-grade mucinous tubular and spindle cell carcinoma of the kidney.Case presentationA 62-year-old Japanese woman had end-stage renal disease and had been on hemodialysis for the previous 4 years. However, periodic imaging examinations to detect kidney cancer had not been conducted. The patient visited our department of urology complaining of general fatigue and dyspnea. Computed tomography with enhancement revealed a solid renal mass with a diameter of 66 mm. It had invaded the right psoas muscle and had multiple lymph node metastases. In addition, the patient had massive ascites and right-sided predominant pleural effusion. We drained the pleural effusion, but she died 11 days after admission. An autopsy was performed. Pathological examination revealed high-grade mucinous tubular and spindle cell carcinoma of the right kidney; multiple organ metastases to the bilateral lungs, liver, gall bladder, uterus, ovary, and inferior vena cava; cancerous pleuritis; and cancerous peritonitis. Our case indicates that high-grade mucinous tubular and spindle cell carcinoma emerging in end-stage kidney causes a detrimental clinical course.ConclusionHigh-grade mucinous tubular and spindle cell carcinoma of the kidney had a severe clinical course. We recommend periodic screening of patients with end-stage renal disease, using computed tomography or ultrasound.

AN ANALYSIS OF APACHE SPARK AND GPU PERFORMANCES ON DATABASE SQL QUERIES FOR DISTRIBUTED NETWORKS

The use of GPU in different fields and its successful results initiate efforts to use GPU in database systems. It is also effective in distributed systems and computer networks in that accelerates computational tasks by leveraging parallel processing capabilities across multiple nodes and for tasks that require high computational power, such as network traffic analysis and real-time data processing. Digital transformation in all areas of life has led to the emergence of needs such as increased data diversity and faster data analysis. Upgrading the hardware capacity of the system or software-based studies are possible solutions to analyze this data for meeting the needs. In this study, Apache Spark and GPU performance differences are examined in commonly used SQL queries on big data. In this context, SQL queries such as grouping, sorting, and filtering, which are commonly used in data analysis, are used. While the queries performed with the GPU showed similar results in simple queries compared to the queries performed with Apache Spark, the GPU was completed 3x faster in queries requiring calculation.

Diagnostic performance of ultrasound vs. ultrasound-guided FNAc in thyroid nodules: data from the ElaTION trial.

ElaTION is a large multi-centre pragmatic randomised controlled trial, performed in 18 secondary/tertiary hospitals across England, comparing elastography ultrasound-guided fine needle aspiration cytology (EUS-FNAC) with ultrasound-guided FNAC (US-FNAC) alone in the diagnostic assessment of thyroid nodules. Secondary trial outcomes, reported here, assessed the accuracy of ultrasound-alone (US) compared with US-guided FNAC to inform and update current practice guidelines. Adults with single or multiple thyroid nodules who had not undergone previous FNAC were eligible. Radiologists assessed all thyroid nodules using US alone, thereby enabling assessment of its accuracy (sensitivity and specificity) versus US-FNAC. Of the 982 participants, a final definitive diagnosis was obtained in 688, who were included in the final analyses. The sensitivity of US-alone was the same as US-FNAC (0.91, [95% CI 0.85, 0.97] vs 0.87 [95%CI 0.80-0.95], p=0.37). US alone had statistically significant lower specificity than US-FNAC alone (0.48 vs 0.67 respectively, p<0.0001). The malignancy rate on histology in a nodule classified as benign on ultrasound (U2) was 9/263 (3.42%) and on cytology (Thy2) was 15/353 (4.25%), whereas the malignancy rate in a nodule that was benign on both (U2, Thy2) was 3/210 (1.43%). Malignancy risk for U3, U4, and U5 nodules was 68/304 (22.4%), 43/83 (51.8%), and 29/38 (76.3%) respectively (p<0.0001). Yet 80/982 (8%) patients were discharged despite having U3-U5 scans with Thy1 (non-diagnostic) FNAC and no definitive diagnosis.Malignancy risk was higher in smaller nodules: <10mm 23/60 (38.3%), 10-20mm 46/162 (28.4 %), and >20mm 80/466 (17.2%) (p<0.0001). Nodules with indeterminate cytology with atypical features (Thy3a) carried a similar malignancy risk to those with indeterminate cytology (Thy3/3f): 27/95 (28.4%) versus 42/113 (37.2%) respectively (p=0.18). Ultrasound alone appears to be an effective diagnostic modality in thyroid nodules, confirming the recommendations of recent guidelines and the BTA classification. However, findings also suggest caution regarding existing recommendations for conservative management of non-diagnostic (Thy1/Bethesda I) and atypical (Thy3a/Bethesda III) nodules. In those cases, ultrasound (U3-5) features may help identify high-risk subgroups for more proactive management.

A clinically applicable model more suitable for predicting malignancy or benignity of pulmonary ground glass nodules in women patients

BackgroundIn recent years, clinicians often encounter patients with multiple pulmonary nodules in their clinical practices. As most of these ground glass nodules (GGNs) are small in volume and show no spicule sign, it is difficult to use Mayo Clinic Model to make early diagnosis of lung cancer accurately, especially in large numbers of nonsmoking women who have no tumor history. Other clinical models are disadvantaged by a relatively high false-positive or false-negative rate. Therefore, there is an urgent need to establish a new model of predicting malignancy or benignity of pulmonary GGNs for the sake of making accurate and early diagnosis of lung cancer.MethodsIncluded in this study were GGNs surgically resected from patients who were admitted to Yiwu Central Hospital from January 2018 to March 2024, including both male and female patients, there is no gender specific issue. The nature of all these GGN tissues was confirmed pathologically. The case data were statistically analyzed to establish a mathematical prediction model, the prediction performance of which was verified by the pathological results.ResultsAltogether 261 GGN patients met the inclusion criteria. Using the results of logistic regression analysis, a mathematical prediction equation was established as follows: Malignant probability (mP) = ex/ (1 + ex); when mP was > 0.5, the GGN was considered as malignant, and when mP was ≤ 0.5, it was considered as benign. x= -2.46 + 1.032*gender + 1.85*mGGN + 1.40*VCS-0.0027*mean CT value of the nodule + 0.078*maximum diameter of the nodule, where e represents the natural logarithm; if the patient was a female, gender = 1 (otherwise = 0); if the pulmonary nodule was a mixed GGN, mGGN = 1 (otherwise = 0); if the pulmonary nodule had vascular convergence sign, VCS = 1 (otherwise = 0). The prediction performance of the mathematical prediction model was verified as follows: the negative prediction value was 0.97156 and the positive prediction value was 0.3800 in the model group versus 1 and 0.25 in the verification group.ConclusionIn this study, we identified female gender, mGGN, VCS, mean CT value and maximum nodule diameter as five key factors for predicting malignancy or benignity of pulmonary nodules, based on which we established a mathematical prediction model. This novel innovation may provide a useful auxiliary tool for predicting malignancy and benignity of pulmonary nodules, especially in women patients.

How does AI perform in industry chain? A patent claims analysis approach

The development trajectory of AI within the industry chain can offer valuable insights for managers and policymakers. Because the industry chain includes multiple complex nodes, it becomes difficult to showcase the subtle changes in AI at each node. Since patent claims are authoritative legal documents describing technology, we first theoretically demonstrate that integrating them with deep learning can effectively reveal the development of AI within complex nodes. And then, based on claim types and dependencies, we construct a more robust AI Recognition Multiple Attention Mechanism (A&C-Mechanism). Finally, using the battery industry chain (BIC) as a case study, the A&C-Mechanism reveals differences in AI development within the industry chain: (1) The A&C-mechanism can calculate the adjustment weights of patent claims based on variations in claim types and dependencies. Therefore, integrating the A&C-mechanism into NLP models can enhance the models' robustness and sensitivity to the nuanced variations of AI within patent claims; (2) Based on the A&C mechanism, our analysis indicates that AI indeed drives technological upgrades within four BIC nodes of mineral resource extraction (MRE), raw material processing (RMP), finished product manufacturing (FPM), usage, and recycling (UR). However, there is a phenomenon of non-uniform AI development emerging across these nodes; (3) Analyzing the patent application volume and growth rates across the four nodes, we identify that AI development progresses through distinct stages within the industrial chain: early, mid-term, and improvement. With the establishing two coefficients, the AI claim dependency variation coefficient and the AI-NE variation coefficient, we demonstrate that each stage exhibits unique characteristics. AI is used directly in the early stages. As the mid-term stage approaches, AI starts to be optimized and enhanced. During the improvement stage, AI structures, procedures, etc., are adaptively adjusted to better serve each company's goals; (4) Constructing an interaction network of AI with the four nodes based on high-frequency AI named entities within patent claims, we discover that AI development within the industrial chain exhibits iteration and continuity. Moreover, Convolutional Neural Networks (CNNs) and Recurrent Neural Networks (RNNs) remain the cornerstone, serving as the foundation upon which many cutting-edge technologies are built. Digital image processing and machine learning enhance problem-solving across multiple nodes. We discuss our findings and derive implications for research, managers and policymakers.

A retrospective analysis of simultaneous bilateral uniportal thoracoscopic surgeries for multiple primary bilateral pulmonary nodules

BackgroundThere are no standard treatment options for bilateral multiple pulmonary nodules requiring resection. This study aimed to summarize the experience of simultaneous bilateral uniportal video-assisted thoracoscopic surgery for the treatment of bilateral multiple primary pulmonary nodules.MethodsThe clinical data of 65 cases of simultaneous bilateral uniportal thoracoscopic surgery for bilateral multiple primary pulmonary nodules treated were retrospectively analyzed. These cases were treated within The Ninth Medical Center of PLA General Hospital between January 2018 and November 2020. Parameters related to the surgery, perioperative aspects, surgical techniques, pathology results, and postoperative complications were examined.ResultsAll surgeries were conducted through uniportal video-assisted thoracoscopic surgery, with no instances of intraoperative conversion to thoracotomy. Fifty-three patients further underwent CT-guided Hookwire localization for the localization of pulmonary nodules. A total of 189 nodules were resected using multiple surgical procedures, with a malignancy rate of 86.2%. The average operation time was 226 ± 77.4 min, the average thoracic drainage duration was 3.1 ± 1.5 days, the average 24 h pleural drainage was 385.9 ± 157.4 mL, the average postoperative hospital stay was 8.6 ± 2.4 days, and the average blood loss was 77.2 ± 33.8 mL. Post-surgery, all patients were transferred to the ward safely within 12 h. 15.38% of patients have prolonged drainage time, and 12.31% of patients experience complications such as lung infection, arrhythmia, and venous thrombosis.ConclusionThe selected cases undergoing simultaneous bilateral uniportal video-assisted thoracoscopic surgery for the management of bilateral multiple primary pulmonary nodules demonstrated favorable outcomes. Our observations indicate the safety and feasibility of this procedure, providing an individualized and precise treatment approach for affected patients.

Metastatic Malignant Pseudomyogenic Hemangioendothelioma: An Exceedingly Rare Entity That Challenges Conventional Paradigms.

Pseudomyogenic hemangioendothelioma (PMHE), a rare soft tissue tumor predominantly affecting young adults, often presents as multiple nodules in various tissue planes of a limb. Malignant transformation and metastatic disease are unusual and pose diagnostic and therapeutic challenges. A 17-year-old patient from Western India, with a history of recurrent excisions for a toe swelling presented to our center for evaluation and management. A below-knee amputation was performed, and histopathology revealed PMHE. Adjuvant therapy was deemed unnecessary given the borderline nature of the tumor. Shortly thereafter, he developed features of local recurrence and underwent above-knee amputation. An expert histopathological review confirmed the diagnosis and noted features of malignant transformation-progression to a higher grade with greater cytological atypia, confluent growth, and increased mitotic activity over time. Upon further distant progression in the lung, he was started on a palliative regimen of weekly paclitaxel, vinblastine, and propranolol but eventually succumbed to his illness. In contrast to conventional descriptions of low mitotic activity, minimal nuclear atypia, and absence of necrosis, our patient exhibited increased mitotic rates, nuclear atypia, and evolving necrosis in serial histopathological evaluations. The fulminant clinical progression within a short interval was also atypical. Our patient's clinical course underscores the need for meticulous histopathological and molecular characterization and vigilant clinical surveillance after resection in patients with PMHE. Providing the standard of care for malignant disease in the adjuvant setting is challenging owing to the rarity and the lack of treatment guidelines.

Postmenopausal Shrinkage of Uterine Myomas: A Retrospective Study of 97 Cases Monitored Annually for 10 Years.

Introduction and aim Both patients and gynecologists are concerned about how much and how quickly myomas shrink after menopause. This study aimed to elucidate clinical findings that may be associated with postmenopausal shrinkage of uterine myomas. Materials and methods This study included 97 patients who underwent menopause by August 2012, had myoma nodules with the longest diameter between 50 mm and 160 mm, and visited our specialized myoma clinic annually for at least 10 years after menopause. They underwent transabdominal ultrasonography at least once per year. An experienced gynecologist measured the longest diameter of myoma nodules with a maximum diameterbetween 50 mm and 160 mm. The shrinkage rate of myoma diameters after menopause compared to premenopausal diameters was calculated each year for 10 years. The shrinkage rate of the longest diameter of the largest nodule 10 years after menopause (10-year shrinkage rate) and its relationship with clinical findings (the age at menopause, parity, body mass index {BMI}, number of nodules, MRI findings on T2-weighted image, location of the nodule, and longest diameter of the largest nodule before menopause) were analyzed. Additionally, we examined annual changes in shrinkage rate of myomas over a 10-year period after menopause (annual trend), and the relationship between annual trends and factors such as BMI and the number of nodules. Results In this examination of 10-year shrinkage rate, the group with a BMI of less than 25 showed a significantly greater shrinkage rate compared to the group with a BMI of 25 or more (25.0% vs 15.7%, p=0.023). Additionally, the group with a single nodule showed a significantly greater 10-year shrinkage rate compared to the group withfour or more nodules(26.3% vs 15.2%, p=0.036). For annual trends, the rate of change in the first two years after menopause was significantly faster compared to the trend from the third to the 10th year (difference in slope: 3.888 points per year, p<0.001).When divided into two groups based on the number of nodules (one or two nodules groupand three or more nodules group), the group with one or two nodules showed a significant difference in the shrinkage rate between up to two years after menopause and from the period from the third to the 10th year(difference in slope: 4.590 points per year, p<0.001). However, for the group with three or more nodules, there was no significant difference in the annual trend between the first two years after menopause and the rate from the third to the 10th year (difference in slope: 1.626 points per year, p=0.107). Conclusion BMI and the number of myoma nodules were significantly related to the 10-year shrinkage rate. Although myomas shrank significantly faster within the first two years after menopause compared to the later period, the early annual trend did not differ significantly from the trend in the later period when there were multiple nodules with a maximum diameter of 50 mm or more.

Interesting Case Of Congenital Tuberculosis

Background: Mycobacterium tuberculosis (TB) is a global public health problem and is the causative organism of TB. There were 234,000 deaths of children due to tuberculosis. Since most of the pregnant women who have active TB are symptomless, diagnosis of TB is usually delayed2,3. It is difficult to differentiate between true congenital TB and postnatally acquired TB. High suspicion is needed for early diagnosis and treatment. Case: A 30-day-old girl had abdominal distension 1 week before admission and refusal to feed appeared on the 30th day. Clinically, sepsis, TORCH infection was suspected. USG abdomen showed multiple hypoechoic lesions in liver. Ct chest and abdomen showed multiple discrete non-calcified nodules in bilateral lung fields and liver. Gastric aspirate for AFB was negative. Mother was screened for TB; the TSTwas positive and TB QuantiFERON gold came positive. Hence, Tru-cut Liver biopsy was done for neonate and Biopsy for Genexpert showed low level Mycobacterium TB detected. Cerebrospinal fluid analysis for acid-fast bacilli was negative. 4 drug ATT regimen was started. Two weeks after anti-TB medication, the distension completely disappeared. Conclusion: Early diagnosis and treatment is the key for the survival of neonatal TB

P48-2 Deep learning-based artificial intelligence for multiple pulmonary nodules identification: a systematic review

P48-2 Deep learning-based artificial intelligence for multiple pulmonary nodules identification: a systematic review

The use of electromagnetic navigation bronchoscopy-guided microwave ablation in patients with multiple bilateral pulmonary nodules: a retrospective study of 26 cases

The use of electromagnetic navigation bronchoscopy-guided microwave ablation in patients with multiple bilateral pulmonary nodules: a retrospective study of 26 cases

Long-Term Survival in Canine Hepatosplenic T-Cell Lymphoma Treated with Toceranib Phosphate Following Splenectomy: A Case of Atypical Lymphoma

Toceranib phosphate (toceranib) is approved for canine mast cell tumor treatment. However, no long-term response to toceranib in canine HSTCL has been reported. Here, we describe a case of a 10-year-old castrated mixed-breed dog that presented with a 3-month history of weight loss, polydipsia, and polyuria. The clinicopathological and imaging abnormalities included icterus, biliary obstruction, and splenomegaly with multiple diffuse splenic hypoechoic nodules. On day 21, a cholecystectomy was performed to remove the obstruction, followed by a liver biopsy and splenectomy. Cytology of the spleen and liver showed many small lymphocytes with intracytoplasmic granules (sGLs). Splenic and hepatic infiltration of neoplastic CD3/granzyme B-positive small cells and lymphocytic cholecystitis with granzyme B-negative small cells were noted. T-cell receptor gene clonal rearrangements were observed in the liver tissues. The dog was diagnosed with a hepatosplenic T-cell lymphoma (HSTCL) of sGLs concurrent with lymphocytic cholecystitis. The icterus resolved after surgery, but there was progressive elevation of liver enzyme levels. Toceranib was administered from day 39, resulting in decreased liver enzyme levels, and the dog remained in good condition. The dog stayed in remission after toceranib administration and survived for 460 days. Toceranib should be considered an effective treatment option for canine HSTCL.