Needle Aspiration Of Lymph Nodes Research Articles

A RARE CASE OF PAPILLARY CARCINOMA OF THYROID IN A YOUNG FEMALE: A CASE REPORT

Background: The papillary carcinoma thyroid is a rare disease in adolescents and children. A high level of suspicion should arouse as soon as the physician comes across swelling in neck. Appropriate management yields a good survival rate.
 Case history: We present a case of the papillary carcinoma thyroid in a 13-year old girl presented to outdoor of Jinnah Hospital, Lahore with painless swelling in right side of neck for three months. There were associated smaller swelling matted on palpation. No history of palpitations, fever, weight loss and family history of tuberculosis contact or cancer in family. Initial radiology and blood investigations showed an euthyroid goitre. The fine needle aspiration of lymph node only showed reactive hyperplasia. The matted lymph node was partially excised for histopathology as suspicion of tuberculosis existed due to its endemic feature. Later, it was found to be papillary carcinoma of thyroid. Total thyroidectomy was done with neck dissection followed by treatment at nuclear medicine department.
 Conclusion: Thyroid cancer is quite uncommon in adolescents but strong suspicion should arise when dealing with neck swelling even in this age group. Thorough history, watchful physical examination and timely investigations can save clinician from missing the diagnosis.

Factors contributing to discordance between clinical and pathological staging of operable non-small cell lung cancer

Background: Clinical staging of non-small cell lung cancer (NSCLC) by CT and PET, with or without endobronchial ultrasound-guided transbronchial needle aspiration of lymph nodes (EBUS-TBNA), is essential for prognostication and to direct treatment. Our study investigated the accuracy of clinical staging compared to definitive pathological staging. Methods: Retrospective audit of clinical and pathological staging of all surgical lung cancer cases 2016–present (484 cases). Results: Discordance of clinical and pathological TNM staging (excluding sub-staging) was identified in 93 (25.9%) cases where complete data was available. This included clinical understaging in 61 (17%) and N2 disease in 20 (5.6%) cases. EBUS-TBNA was performed in 14 of the cases with N2 disease, and in five of these cases, involvement of N2 nodes detected post-surgery had been called benign at EBUS-TBNA. Factors contributing to clinical understaging may include delays between clinical staging studies and surgery [CT: median 110 days (IQR 82.5-151), PET: 81 days (59–119), EBUS-TBNA 62 days (43–95)], with significantly longer delays evident during the COVID-19 pandemic. Conclusions: Improved technical quality of lung cancer clinical staging studies and hospital management workflows will potentially increase concordance between clinical and pathological staging of operable NSCLC, improving outcomes for early stage disease. My contribution to this work has focused on the 2022 cases, analysis of which has elucidated the impact of COVID-19 on the lung cancer staging process in comparison to pre-COVID results.

Ultrasonographic and cytological characterization of ultrasound-guided fine-needle aspiration cytology of cervical lymph nodes for false-negative and false-positive diagnosis.

The primary goal of this study was to examine the ultrasound and cytological characteristics of inconsistent cases (false negatives and false positives)of ultrasound-guided fine-needle aspiration cytology (US-FNAC) of cervical lymph nodes, to investigate factors influencing the diagnostic accuracy of fine-needle aspiration, and to improve diagnostic efficiency. The results of US and FNAC of cervical lymph nodes in 562 cases treated at our institution from February 2019 to June 2021 were retrospectively analyzed. FNAC cytology results were compared with the final diagnostic results (242 surgical resections/core-needle biopsy, 320 cases followed up for more than 1year), and the final diagnostic results were taken as the gold standard, and the ultrasound features and clinicopathology-related features were systematically retrospectively analyzed in cases of inconsistency. The overall diagnostic accuracy of US-FNAC for cervical lymph nodes was 94.9%, with a false-negative rate of 6.7% and a false-positive rate of 3.8%. Analyzing the cases, sampling error due to factors associated with ultrasound features, such as larger, more numerous nodes, non-solid, hypoechoic, inhomogeneous, and increased vascularity are the main causes of false-negative diagnosis, while smaller nodules, overlapping cytologic patterns, and overinterpretation by pathologists are associated with false-positive FNAC results. Proper interpretation of cytomorphologic and ultrasound features can improve diagnostic accuracy, and diagnostic misdiagnosis should be carefully observed, the identification of both features should be enhanced to reduce interpretation errors and sampling errors and to reduce the rate of misdiagnosis and missed diagnoses in fine needle aspiration of lymph nodes.

Discordance between clinical and post-surgical staging of patients with operable non-small cell lung cancer: a retrospective audit of lung cancer surgery with curative intent from a single pathology practice

Clinical staging of non-small cell lung cancer (NSCLC) by CT and PET, with or without endobronchial ultrasound-guided transbronchial needle aspiration of lymph nodes (EBUS-TBNA), is essential for prognostication and to direct treatment. Clinical understaging can lead to inappropriate radical excision of the primary tumour with no clinical benefit, whereas overstaging might deprive patients of beneficial or potentially curable treatments. Although not widely documented, several reports have indicated a suboptimal concordance between clinical and post-surgical staging. This study has investigated the incidence of discordance between clinical and post-surgical staging of operable NSCLC cases evaluated at PathWest Fiona Stanley Hospital (Perth, WA, Australia). The study formed part of an approved Quality Improvement Activity and included patients with NSCLC who underwent lobectomy between Jan 1, 2016, and Dec 31, 2021, at hospitals serviced by the PathWest anatomical pathology department at Fiona Stanley Hospital. Data from pathology, imaging, and EBUS-TBNA or biopsy reports were retrieved from digital medical records databases and multidisciplinary meeting notes. A project database designed and established in REDCap was used to collect and analyse data. 419 patients (216 [52%] women, 203 [48%] men) in the age range of 20·5-85·8 years (median 69·2 years [IQR 63·3-74·5]) were included. EBUS-TBNA was done for 121 (29%) patients and imaging results (from CT, PET, or both) were available for 406 (97%) patients. Discordant clinical and post-surgical T and N staging were evident; post-surgical T stage was higher in 96 (23%) cases and lower in 54 (13%) cases. Eight tumours staged post-surgically as N1 had been clinically staged as N0. For ten cases with unforeseen N2 involvement, clinical staging was N0 (n=4), N1 (n=3) or not available (n=3); surgery might not have been necessary for these patients. Median times between CT and lobectomy (105 days [IQR 77·0-143·0]), PET and lobectomy (79 days [56·0-109·0]), and EBUS-TBNA and surgery (59 days [42-94]) were outside of Australian guidelines, which recommend a time to start of treatment for lung cancer of less than 42 days from initial referral. Time intervals between final screening study (imaging or EBUS-TBNA) and lobectomy before and during the COVID-19 pandemic (2016-19 and 2020-21, respectively) were significantly different (p=0·019). It is noteworthy that Western Australia had not recorded high numbers of COVID-19 cases during that time. This study has identified substantial disagreement between clinical and post-surgical staging of NSCLC. Discordance between clinical and post-surgical T and N staging might have led to different treatment pathways for some patients. To improve the accuracy of clinical staging of NSCLC, the sensitivity, specificity, and interpretation of imaging and lymph node cytology, as well as the timeliness of treatment (clinical care pathway) would each need to be evaluated. Strengths of this study include the large number and lack of selection of cases, and the small number of medical service providers. Weaknesses include the absence of outcomes data for these patients. Overall results are consistent with previous and historical investigations of hospital and clinical trial cohorts. OT is the recipient of a student scholarship from the Royal College of Pathologists of Australasia that funded this work.

Utility of PCR in the Diagnosis of Tubercular Lymphadenitis on Fine Needle Aspirates

Background
 Extra-pulmonary tuberculosis is a diagnostic and therapeutic challenge. Diagnosing tubercular lymphadenitis includes identification of epithelioid granulomas, positive Acid Fast Bacilli detected with Ziehl Neelsen’s stain. The disadvantage is the time taken for formation of granulomas. With the advent of RT-PCR, the diagnosis of tubercular lymphadenitis can be made with ease [1].
 Aims and objectives: To utilize PCR and mycobacterial culture on samples obtained from Fine needle aspiration of lymph nodes in order to aid in early diagnosis of extra-pulmonary tuberculosis.
 Materials and methods: Observational descriptive prospective study; Patients with lymphadenopathy >1 cm, above the age of 2 years were included ; FNA was performed, material was used for routine cytological studies (PAP, MGG and Ziehl Neelsen-stained slides), PCR and culture (wherever possible); Comparative values of PCR and culture were utilized for statistical analysis
 Results: Out of 80 cases studied, M. Tuberculosis by PCR was detected on 36 cases (45%); PCR and culture demonstrated MTB in 42.55% of the cases. 9 cases (11.25%) of reactive lymphadenitis were found to be of tubercular etiology on PCR analysis. The Chi-squared test was highly significant. PCR has been found to have a sensitivity, specificity, PPV and NPV of 100%, 92.59%, 90.91% and 100%, respectively. Positive RT-PCR was more common in cases with chronic granulomatous inflammation when compared against reactive lymphoid hyperplasia with a chronic inflammatory infiltrate.
 Conclusion: From this study, we conclude that RT-PCR is a useful ancillary technique to conclusively identify Mycobacterium tuberculosis in samples obtained from fine needle aspiration of lymph nodes.

Discordance between clinical and post-surgical staging of non-small cell lung cancer

Clinical staging of non-small cell lung cancer (NSCLC) by CT and PET, with or without endobronchial ultrasound guided fine needle aspiration of lymph nodes (EBUS-TBNA), underpins the clinical management of patients and informs disease prognosis. Discordance between the clinical and post-surgical staging of NSCLC can lead to treatment failure and increased morbidity, with no mortality benefit. In this study, we compared the clinical and post-surgical staging of 136 lobectomies performed for NSCLC at Royal Perth and Fiona Stanley Hospitals between 2016 and 2021.

Implications of the 8th TNM Classification on the Bronchoscopist, a future perspective

Primary lung malignancy remains the leading cause of cancer related deaths globally. A better understanding of the disease process with advancing diagnostic modalities has led to a change in the standard of care. Endobronchial ultrasound (EBUS) with transbronchial lymph node needle aspiration allows for mediastinal and hilar lymph node sampling for accurate staging and prognostication. In the latest 8th edition of the TNM classification, several changes were made including redefining T based on size, redefinition of metastasis (M) and changes were made to stage groupings. Nodal staging has remained the same as of the 7th edition of the TNM classifications. In this review, we are reemphasizing the importance of the extra step of nodal staging and its clinical significance. Furthermore, we highlight the necessity of more aggressive nodal staging using EBUS-TBNA in stage 1 lung cancer.

SARCOID MASQUERADING AS MALIGNANCY ON IMAGING

TOPIC: Imaging TYPE: Medical Student/Resident Case Reports INTRODUCTION: Sarcoidosis is a multi-system inflammatory disease that predominantly affects the lungs and histopathologically characterized by non-caseating granulomas. A comprehensive evaluation must be pursued to diagnose Sarcoidosis as some findings can overlap with other compatible conditions. CASE PRESENTATION: A-44-year-old woman presented with chronic fatigue, shortness of breath, left sided chest pain, and cough. CT chest revealed left hilar, anterior mediastinal, right paratracheal, and subcarinal lymphadenopathy. An 18-F-fluorodeoxyglucose (FDG) positron emission tomography (PET) CT showed extensive mediastinal and hilar PET avid adenopathy. Notable lymph nodes include a 25mm subcarinal node with a Standardized Uptake Value (SUV) of 32.6 and 11mm left hilar node with a SUV of 27.7. The PET CT findings were highly concerning for lymphoma. Patient subsequently underwent an Endobronchial Ultrasound-guided transbronchial needle aspiration of lymph nodes, and forceps biopsy of station 7. Pathology of the lymph nodes was significant for non-caseating granulomas. Ziehl–Neelsen and silver stains were negative for acid fast bacilli and fungi, respectively. Patient was diagnosed with Sarcoidosis and treatment with Methotrexate and folic acid was initiated. Steroids were avoided in the setting of morbid obesity (BMI >40), prediabetes and history of psychiatric disease. DISCUSSION: This case illustrates the potential for misdiagnosis based on high Standardized Uptake Values on FDG PET-CT scan and the value of a comprehensive evaluation involving tissue biopsy. A SUV of >2.5 is suggestive of malignancy however, false positives due to 18-FDG uptake by inflammatory cells in infectious and granulomatous diseases have been reported in a few case series. Sarcoidosis is characterized by non-caseating granulomas that are formed by the recruitment of multiple inflammatory cells such as activated macrophages and lymphocytes which can lead to increased radiotracer uptake. Other causes of granulomatous disease such as fungal and mycobacterial infections, foreign bodies, pneumoconiosis and vasculitis should be explored. Newer nuclear imaging modalities using alternate radio-tracers have been developed to improve specificity however, low accessibility has rendered a paucity of available data. CONCLUSIONS: FDG PET-CT can aid in the detection and monitoring of various pathologies including Sarcoid. Due to the lack of specificity of any one diagnostic evaluation currently, it is important to obtain pathological confirmation in addition to imaging, and rule out other causes of non-caseating granulomas, prior to starting treatment. REFERENCE #1: Anjali Shetty, M., and John D Carter, MD, Sarcoidosis mimicking lymphoma on FDG-PET imaging. Radiology Case Reports 2011. REFERENCE #2: Paul E. Kinahan, P.a.J.W.F., MD, PET/CT Standardized Uptake Values (SUVs) in Clinical Practice and Assessing Response to Therapy. Semin Ultrasound CT MR., 2010. REFERENCE #3: Miyakubo M, Oriuchi N, Tsushima Y, Higuchi T, Koyama K, Arai K, et al. Diagnosis of maxillofacial tumor with L-3-[F-18]-fluoro-alpha-methyltyrosine (FMT) PET: a comparative study with FDG-PET. Ann Nucl Med. 2007. DISCLOSURES: No relevant relationships by Hamna Ahmad, source=Web Response No relevant relationships by Sarah Dubin, source=Web Response No relevant relationships by Ashraf Gohar, source=Web Response No relevant relationships by Sindhuja Palle, source=Web Response

Clinicopathological, Endoscopic and Radiological Evaluation of Intestinal Tuberculosis among Nepalese Patients at a Tertiary Care Center

Background: Intestinal tuberculosis is often difficult to diagnose due to its insidious onset and nonspecific and protean manifestations. Delay or failure of diagnosis is associated with significant complications like perforation, abscess, fistula and strictures. The objective of the study was to provide a descriptive analysis of clinical, endoscopic, radiological and pathological findings in these patients. Methods: A prospective study including 52 hospitalized patients was done between April 2018 to 2020 at Tribhuwan University Teaching Hospital. Statistical analyses were done by Microsoft excel version 16. Results: Males were 63% while females were 37 %. The average age was 37 years. 84% had abdominal pain followed by abdominal distension (50%), chronic diarrhea (51%) and cough (21%). Abnormal chest X-Ray was found in (37%) among whom (53%) had sputum positive for tubercular Bacilli. Common CT scan findings were thickening and heterogenous enhancement of bowel loops (79%), lymphadenopathy (56%) and ascites (44%). Endoscopically, commonly involved sites were terminal Ileum (95%), cecum (77%) and ascending colon (42%). Frequent finding were ulcers (83%), patulous and deformed Ileocecal valve (33%), mucosal nodularity (38%), hypertrophic mucosa (21%) and strictures (11%). Biopsies revealed granulomas in (77%) specimens. (65%) of them had central caseous necrosis. Among 10 subjects undergoing needle aspiration of lymphnodes, (70%) had central caseous necrosis. Those with coexisting peritoneal involvement had a mean ascitic fluid adenosine deaminase level of 73 ± 8 IU/L. Conclusion: Intestinal tuberculosis remains a major concern in developing countries. A composite analysis of the clinical manifestations, CT scan, endoscopic findings and pathological examination of the biopsies aid in making a proper and timely diagnosis so as to prevent complications and mortality.

Leishmania infantum Infection in a Domestic Cat: A Real Threat or an Occasional Finding?

Visceral Leishmaniasis (VL) has been considered one of the most important neglected zoonosis in the world. In Brazil, this disease passed for an urbanization process and currently pets (dogs and cats) animals have acquired a great importance on its epidemiology. Studies on dogs have been extensively performed throughout the country, but information about infection in cats has been concentrated in few areas. Therefore, the aim of this study was to investigate the occurrence of infection by Leishmania infantum in domestic cats living in endemic areas for Canine Visceral Leishmaniasis (CVL) in the state of Pernambuco, Northeastern Brazil. Domiciled cats (n = 128) were sampled for different biological samples (i.e., blood, conjunctival swab and fine needle aspiration of lymph nodes) that were microscopically and molecularly analyzed through PCR and sequencing. Amastigote forms of Leishmania sp. were detected in a single animal (fine needle aspiration of lymph node). This same animal scored positive at molecular examination (blood and lymph node) and the sequence analysis revealed an identity higher than 99% with L. infantum sequences DNA available in Genbank database. This is the first molecular characterization of L. infantum infecting domestic cats in Pernambuco. Therefore, veterinary practitioners should consider this putative infection in cats living in areas where canine and human Leishmaniasis has been reported.

A Case of Kikuchi-Fujimoto Disease in a 7-Year-Old African American Patient: A Case Report and Review of Literature

Patient: Female, 7-year-old FinalDiagnosis: Kikuchi-Fujimoto lymphadenitisSymptoms: LymphadenopathyMedication:—Clinical Procedure: BiopsySpecialty: Immunology • RheumatologyObjective:Rare diseaseBackground:Kikuchi-Fujimoto disease (KFD) is a rare self-limited necrotizing lymphadenitis which is likely under-diagnosed in pediatric patients who present with fever of unknown origin and lymphadenopathy. Definitive diagnosis is challenging as it requires an invasive open lymph node biopsy or lymph node needle aspiration cytology that shows pathologic findings of histiocytic necrotizing lymphadenitis.Case Report:We report the case of one of the youngest patients diagnosed with KFD in the United States, at the age of 7 years. KFD has a higher prevalence in patients of Asian descent, but this patient was an African American. This case report shows the often convoluted and complicated course these patients undergo with their presenting complaints of fever of unknown origin and lymphadenopathy and highlights particular clinical findings that suggest KFD.Conclusions:This patient is one of the youngest persons diagnosed with KFD in the United States, with an atypical ethnic background. It is likely that KFD is under-recognized and under-diagnosed in this population. With a broad differential diagnosis for fever of unknown origin and lymphadenopathy, awareness of KFD as a potential diagnosis may reduce other unnecessary investigations. The increased risk of patients with KFD of developing systemic lupus erythematosus (SLE) accentuates the importance of an accurate diagnosis and appropriate referral for heightened surveillance after recovery.

SQUAMOUS CELL CARCINOMA PRESENTING WITH OBSTRUCTION OF THE SUPERIOR VENA CAVA AND CENTRAL AIRWAYS

SESSION TITLE: Tuesday Fellows Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM INTRODUCTION: One mechanism by which cancer causes morbidity/mortality is by mass effect with distortion, compression, or occlusion of nearby anatomical structures. Within the chest, tumors can exert these effects on the airways and vascular structures. This case illustrates the need for urgent intervention in a patient presenting with severe compression of multiple intrathoracic structures. CASE PRESENTATION: A 54 year-old man with chronic tobacco use and limited exposure to healthcare presented to the hospital with gradually progressive shortness of breath over several months, followed by facial swelling, severe wheezing, and recurrent syncope over the past few days. Exam was remarkable for facial flushing and diffuse inspiratory/expiratory wheezing. Laryngoscopy was performed, which did not suggest critical airway edema. Computed tomography (CT) of the chest demonstrated a large right-sided suprahilar mass, with severe compression of the superior vena cava (SVC) and right mainstem bronchus (RMB) and bronchus intermedius, narrowing of the right pulmonary artery and vein, and complete collapse of the right upper lobe. The patient underwent urgent placement of an 11x59mm balloon-expandable covered stent within the SVC, after which the patient reported improvement in facial swelling but minimal improvement in dyspnea. Next, he underwent bronchoscopy, which demonstrated significant extrinsic compression within the right mainstem bronchus; transbronchial needle aspirates of lymph nodes from Stations 4R and 7 were obtained, from which pathology results were consistent with squamous cell carcinoma (SCC). Because of the degree of bronchial compression, and the need for chemotherapy and radiation therapy which could temporarily cause tumoral inflammation and worsen compression/collapse of the right lung, bronchoscopy was repeated, and this time a 12x40mm self-expandable partially-covered stent was placed within the right mainstem bronchus. After this, the patient reported significant improvement in dyspnea, and was discharged to home in stable condition. DISCUSSION: This case describes pulmonary SCC presenting with symptoms of acute SVC syndrome and central airway compression. Lung cancer associated with either of these conditions has dramatically increased morbidity/mortality. In malignant SVC syndrome, stent placement has been shown to reduce SVC pressure and improve symptoms; there is moderate risk of stent re-obstruction. Though not free of risks, endobronchial stent placement can prevent the impending occlusion of a central airway, when surgical or endobronchial resection/debulking is not possible. In recent years, there have been numerous advances in the technology and variety of endobronchial stents for multiple indications. CONCLUSIONS: Malignant extrinsic compression of the SVC and central airways is associated with high morbidity/mortality and can be managed urgently and safely with stent placement. Reference #1: Avasarala SK, Freitag L, & Mehta AC. Metallic endobronchial stents: A contemporary resurrection [published online ahead of print December 11, 2018]. CHEST. doi:10.101/j.chest.2018.12.001. Reference #2: Niu S, Xu YS, Cheng L, & Cao C. Stent insertion for malignant superior vena cava syndrome: Effectiveness and long-term survival. Vascular and Interventional Radiology 2017, 122: 633-638. Reference #3: Mudambi L, Miller R, & Eapen GA. Malignant central airway obstruction. Journal of Thoracic Disease 2017, 9(10): 1087-1110. DISCLOSURES: No relevant relationships by Gabriel Ryan, source=Web Response

METASTATIC CAVITARY ADENOCARCINOMA OF THE LUNG IN A PATIENT WITH RECENT AGGRESSIVE SQUAMOUS CELL CARCINOMA OF THE CHEST WALL

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: Simultaneous existence of two histologically different primary malignancies, although rare, has been reported in literature1. This represents a diagnostic dilemma especially when the first detected primary malignancy is aggressive, therefore, the second primary is often deemed to be a metastatic lesion, until proven otherwise on biopsy. We present a case of a 62 year old male, with a recent aggressive squamous cell carcinoma (SCC) of the chest wall, who developed metastatic cavitary adenocarcinoma of the lungs. CASE PRESENTATION: A 62-year old gentleman, with past medical history significant for basal cell carcinoma of the nose and a recent aggressive SCC of the chest wall, status post Mohs surgery, was referred to the outpatient pulmonology clinic after a CT scan of the chest showed persistent dense consolidation of the left upper lobe, multiple bilateral lung nodules with central necrosis and cavitation, and left sided hilar and mediastinal lymphadenopathy. He presented with low-grade fever and a productive cough, unresponsive to antibiotics, for the past three weeks prompting the CT scan of the chest. Diagnostic work-up, for infection (including fungal studies), vasculitis or any other autoimmune disorder, was started and urgent bronchoscopy was arranged. PET/CT scan showed a hyper-metabolic left upper lung mass, multiple hypermetabolic cavitary lung lesions. Bronchoscopy with endobronchial ultrasound revealed a reversible external compression of the right middle lobe bronchus with mediastinal lymphadenopathy. Bronchoalveolar lavage from the left upper lobe showed atypical cells, suspicious for malignancy while negative for fungal organisms. Fine needle aspiration of lymph nodes, station 7 and 4L, revealed non-small cell carcinoma with tumor cells being positive for CK-7 and TTF-1 and negative for CK20, CDX-2 and NKX3.1. With the recent aggressive SCC history and multiple cavitary lung lesions, biopsy of one of the cavitary lesions was recommended by the tumor board, to determine if they were SCC vs adenocarcinoma. Results of the biopsy were consistent with an invasive lung adenocarcinoma. DISCUSSION: Cavitary lesions shown on chest imaging can have several etiologies. Although various radiological features of these cavitations, including wall thickness, have been studied to differentiate benign from non-benign etiologies2, the final diagnosis in many instances is made on serological investigations or biopsy. 22% of primary lung cancers can cause cavitation with squamous cell carcinoma being the most common type of lung cancer associated with cavitary lesions followed by adenocarcinoma and large cell carcinoma3. CONCLUSIONS: Our case emphasizes that cavitary lesions on imaging, in patients with a prior history of malignancy, should prompt investigation for possible malignancy. Early biopsy, in such cases, becomes crucial for a timely and accurate diagnosis, and appropriate management. Reference #1: Jena A, Patnayak R, Lakshmi AY, Manilal B, Reddy MK. Multiple primary cancers: An enigma. South Asian J Cancer. 2016;5(1):29-32. Reference #2: Parkar AP, Kandiah P. Differential Diagnosis of Cavitary Lung Lesions. Journal of the Belgian Society of Radiology. 2016;100(1):100. DOI: http://doi.org/10.5334/jbr-btr.1202. Reference #3: Gill, R. R., Matsusoka, S. & Hatabu, H. Cavities in the lung in oncology patients: imaging overview and differential diagnoses. Applied Radiology 39, 10 (2010). DISCLOSURES: No relevant relationships by Huthayfa Ateeli, source=Web Response No relevant relationships by Mahum Shahid, source=Web Response

Hodgkin and Non-Hodgkin Lymphoma: Flowcytometric Immunophenotyping on Fine Needle Aspirate of Lymph Node

Hodgkin and Non-Hodgkin Lymphoma: Flowcytometric Immunophenotyping on Fine Needle Aspirate of Lymph Node

Recurrent Vulvar Melanoma – a Case Report

Abstract Melanoma rarely develops in the genital area. It is responsible for 5% of all vulvar malignancies. Postmenopausal women are usually more affected and the main differential diagnosis is vulvar melanosis and vulvar nevi. There are limited numbers of studies on dermoscopic features of mucosal melanoma, particularly early-stage lesions. Dermoscopic criteria have been described for the diagnosis of vulvar melanosis, and observational studies have been conducted to define the dermoscopic features of nevi and melanoma on the vulva. We are presenting the case of a 69-year old female with suspected recurrence of vulvar melanoma who previously had surgical removal of mucosal lentiginous melanoma on the left labia minor in June 2017. Five months after the primary melanoma surgery, the patient noticed de novo pigmentation at the left and right labia minor and urethral opening. On clinical examination, irregular light-brown pigmentation with ill-defined borders was evident on the labia minora of the vulva and around the external urethral orifice. On dermoscopy, irregular pigmented network, with white scar-like and structureless pinkish areas was evident. Incisional biopsy of the vulvar mucosa revealed melanoma in situ, confirming the local recurrence. CT scans of the head, thorax, abdomen and pelvis and gynaecological examination revealed no secondary deposits. Ultrasound of the regional inguinal lymph nodes revealed enlarged suspected pathologic involvement of the lymph nodes in both inguinal regions. Lymph node fine needle aspiration of lymph nodes in the left and right inguinal area revealed pleomorphic infiltrate of lymphoid cells with hemosiderin or melanoma pigment in the cytoplasm. Cystoscopic findings were within normal range. Interdisciplinary tumour board indicated wide excision of melanoma with margins of 1 cm and resection of the urethra, as well as biopsy of the enlarged left inguinal lymph node. Histopathological analysis of the resected mucosa revealed lentiginous spread of melanocytes showing moderate atypia, with focal pagetoid spread, without mitoses and ulceration and without invasion of lamina propria. The resection margins were tumour-free. Non-specific lymphadenitis was diagnosed on lymph node histopathological analysis. The patient was regularly monitored by a dermatologist and urologist, and had no recurrence. The accurate and prompt diagnosis is essential in the case of the vulvar melanoma which has unfavourable and unpredictable prognosis, with a tendency of local recurrences and regional and distant metastases in the case of invasive melanoma. In order not to miss early mucosal melanoma, dermatologists and gynaecologists should not avoid biopsy of lesions that demonstrate any clinical or dermoscopic feature of atypical melanocytic lesion, especially in case of the development of irregular pigmentation that expands and changes over time, the appearance of a solitary amelanotic papule or nodule requires excision or, in case of large diameter lesions, incision biopsies. Larger studies are needed to define more rigorously clinical and dermoscopic criteria that accurately distinguish early mucosal melanomas from benign skin lesions.

The ability of isolated fine needle aspiration of lymph nodes to provide complete diagnostic information without necessitating additional diagnostic procedures: A retrospective cohort study.

e18341 Background: Diagnostic fine needle aspiration (FNA) of pathologically enlarged lymph nodes is a relatively safe, quick, and well-tolerated procedure that can be quickly analyzed to identify the presence of malignant cells. Though proven very useful to assess for the presence or absence of malignancy for staging purposes, the procedure’s ability to provide adequate tissue to appropriately diagnose a new malignancy and perform all necessary predictive and prognostic studies has not been explored. Methods: We retrospectively reviewed clinical records of patients who underwent FNA of a pathologically enlarged lymph node for the purpose of obtaining a tissue diagnosis at our institution between January 2010 and December 2015. We then assessed the percentage of patients that required a second diagnostic procedure independent of the FNA result. Procedures done for therapeutic purposes (such as resection) were not counted as a second procedure. We also collected data on the type of procedure used to obtain FNA, patient history of malignancy, and whether the diagnosis was benign or malignant. Results: We identified 594 FNA procedures that fit the study criteria. Of these, 277 (46.6%) required an additional diagnostic procedure. Among the 277 that required a second procedure, 237 (85.6%) were benign and 40 (14.4%) were malignant on primary FNA (P < 0.0001). Of the 237 benign FNAs that required a second procedure, 84 (35.5%) had the diagnosis changed to malignant after the second procedure (P < 0.001). There was no difference between procedure used to obtain the FNA (bronchoscopy, endoscopy, percutaneous) or patient age in the need for a second procedure. Conclusions: Though fine needle aspiration is a useful procedure for establishing the presence or absence of metastatic disease, our analysis suggests that the ability of the procedure to reliably diagnose or provide sufficient tissue for ancillary testing is limited. Nearly half of the patients in this study were subjected to the risks, cost, and diagnostic delay associated with a second procedure.

Current status of diagnostic and therapeutic bronchoscopy in Japan: 2016 national survey of bronchoscopy.

The safety management committee of the Japan Society for Respiratory Endoscopy (JSRE) conducted national surveys to clarify the state of diagnostic and therapeutic bronchoscopy in 2016. Questionnaire forms were mailed to 532 JSRE-accredited facilities throughout Japan. We surveyed the actual condition of clinical practice and cases of bronchoscopy during 2016. Four hundred and thirty-three facilities responded giving a response rate of 81.4%; 67.6% held more than 400 beds. The average number of board accredited senior Fellows and Fellows per facility was 1.9 and 3.2, respectively. Diagnostic bronchoscopy was performed in a hospitalized setting in 74.6% of all facilities. The radial type ultrasound probe was operated in 51.7% of all facilities. The number of facilities has markedly increased compared with that reported in the 2010 survey (19.6%). The bronchoscopic navigation system had been in operation in 41.7% of all facilities. Antithrombotic drugs were adjusted before biopsy in 96.8% of all facilities. For intravenous sedation, midazolam was the first choice in 76.9% of all facilities. Endobronchial ultrasound guided transbronchial lymph node needle aspiration (EBUS-TBNA) has become popular over the decade (19.6% in 2010 to 68.1% in 2016). The mean number of the board accredited senior Fellows and board accredited Fellows increased in comparison with that in 2010. As a new technique, radial type ultrasound-guided peripheral approach has become popular. Through this survey, the advanced safety of bronchoscopic examination has been secured in many facilities. A continuous monitoring of bronchoscopic practices with respect to safety management is recommended.

A bright and colorful future for DNA cell cycle analysis.

A bright and colorful future for DNA cell cycle analysis.

Abstract 547: Diagnosis of lung tumor types based on metabolomic profiles in lymph node aspirates

Abstract Lung cancer is the leading cause of cancer-related deaths in the US and worldwide. The majority of lung cancer patients are diagnosed with an advanced stage, precluding curable surgical resection, and therapy is limited to thoracic radiation and chemotherapy. The efficacies have improved in recent years due to patient pre-selection based on the cytology of fine needle aspirates of lymph nodes, which harbor circulating tumor cells. We report herein the evaluation of lymph node aspirates for the presence of metabolite features that are suitable to distinguish patients with lung cancer from patients without malignancies and to separate patients with adenocarcinoma from patients with squamous cell carcinoma. The results provide evidence that patient groups can be separated based on their metabolite profiles. Multivariate statistical analyses (PLS and OPLS) produce a set of consensus features that can be further developed into clinical biomarkers. Two of the features were identified as kynurenine and oxidized glutathione, and their identities were confirmed in a second larger sample set. In addition, the accompanying metabolites glutamate, glutamine and tryptophan were included in the validation experiment to utilize relative metabolite ratios as indicators for corresponding enzyme activities. The validation results demonstrate significant differences in metabolites and metabolite ratios between lymph node aspirates harboring a circulating tumor cell and aspirates negative for malignancy. Subsequently, a second set of lymph node samples were analyzed for an extended panel of metabolites and of these 42 were suitable biomarker to be statistically significant to distinguish between at least one of the pair wise comparisons. Together the results demonstrate that metabolite profiles in lymph node aspirates are suitable to differentiate patients with adenocarcinoma from patients with squamous cell carcinoma. Citation Format: Daniel R. Sappington, Scott A. Helms, Eric Siegel, Susanne K. Jeffus, Teka Bartter, Thaddeus Bartter, Gunnar Boysen. Diagnosis of lung tumor types based on metabolomic profiles in lymph node aspirates. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 547. doi:10.1158/1538-7445.AM2015-547

Canine leishmaniosis: an update

Canine leishmaniosis caused by the protozoan parasite Leishmania infantum has entered the UK. Entry appears linked to pet dogs accompanying their owners (on vacation) to the Mediterranean basin where this vector-borne canine disease is prevalent. The parasite resides in the superficial dermis of infected dogs, either within macrophages or free in host tissue. L. infantum is transmitted naturally through sandfly bites. Sandflies are not currently present in the UK. Vertical transmission from infected bitches to puppies and transmission through blood transfusion have been confirmed, while sharing of hypodermics have only been proven experimentally. Some infected dogs remain asymptomatic with this resistance to disease development being associated with a strong cell-mediated immune response. Diseased dogs present with varied symptoms including generalised enlargement of lymph nodes, scaly dermatitis, anaemia, anterior uveitis and renal dysfunction. Clinically suspect dogs should be tested by fine needle aspiration of lymph nodes and/or bone marrow to perform cytology and polymerase chain reaction (PCR). Blood PCR lacks a certain degree of sensitivity. Indirect diagnosis through serology while routine is problematic in interpreting results and antibody titres. The recommended treatment protocol is a combination of the antimoniate N-metilglucamine subcutaneously, and allopurinol orally. Direct parasite transmission from dogs to humans has not been demonstrated. A commercial vaccine has emerged that offers options for prevention, which is useful for pets travelling to areas where the infection is endemic, particularly if they are staying for an extended period during the season when sandflies are active. Practitioners need to evaluate each individual case, based on client compliance, response to treatment and follow-up evaluation before deciding whether or not to consider euthanasia.