Outpatient Biopsy Research Articles

PSU11 Cost-Effective Analysis of UPPER Airway Biopses in the Outpatient Clinic Compare to Operating Room

Larynx and pharynx biopsies are primarily performed in the operating theater. New technologies enable safe outpatient clinic biopsies (OCB) avoiding the operating theatre biopsies (OTB) and general anesthesia. We aim to identify the cost-effectiveness of OCB versus OTB. We conducted a cost-effectiveness analysis comparing OCB versus OTB in patients with suspicious lesions of larynx and pharynx in UKs national health system, along one year. The costs associated were derived from a payer’s perspective. Costs were obtained from Scottish Health Technology Group advice statement, a UK micro-costing study and NHS tariffs. We conducted a meta-analysis to obtain the tolerability and malignancy rate of outpatient biopsies. Discount rate was 3,5% as recommended by the NICE. The annuitization period was five years. The effect measure in the study was the risk of general anesthesia. We conducted a PSA and multiple deterministic sensitivity analyses to validate the robustness of the base-case. The base-case showed the total cost was £819 and £827 for OCB and OTB, respectively. Low sensibility and tolerability of the OCB, results in 58% of patients requiring a follow-up OTB. Implementing the OCB in Scotland will save £35.518/year while 913/2264 patients will avoid general anesthesia per year. The ICER is -115 making OCB cost-minimizing while decreasing the risk of general anesthesia. Extended dominance results in reusable endoscopes being dominant in the outpatient alternatives. However, the base-case result is sensitive to the number of reusable channeled rhinolaryngoscopes per site, resulting in a shift to single-use dominance as the number of reusable scopes shifts from 2 to 3 scopes per site. We found that OCB is dominant compared OTB. Further, the dominance of channeled reusable or single-use rhinolaryngoscopes is sensitive to the number of channeled rhinolaryngoscopes.

Comparison between Different Diagnostic Strategies in Low-Risk Reproductive Age and Pre-Menopausal Women Presenting Abnormal Uterine Bleeding.

Abnormal uterine bleeding (AUB) is a common symptom in the female population, with an estimated prevalence of 10 to 30% in fertile age and up to 90% in perimenopausal women. In most cases, AUB is due to a benign cause. However, it can also be a symptom of atypical endometrial hyperplasia or endometrial cancer, a more common disease during menopause which can also affect women in their reproductive age. Considering the high prevalence of this symptom an appropriate diagnostic algorithm is needed. Concerns about the risks, pain, and stress associated with an endometrial biopsy and its impact on the healthcare system make the choice of AUB diagnostic strategy extremely relevant. Even if the scientific community agrees on the definition of AUB, International Guidelines show some differences in the management of women of reproductive age with AUB, especially regarding the age cut-off as an independent indication for endometrial biopsy. This study compared different diagnostic strategies to identify a diagnostic pathway with high sensitivity and specificity but low impact on the health system’s resources. The analysis was based on three diagnostic algorithms defined as part of the guidelines of leading scientific societies. Women of reproductive age with AUB (n = 625) and without risk of endometrial cancer were included in the study. Results showed that the best criterion to investigate AUB in women at low risk of endometrial cancer is not age cut-off but the presence or absence of focal endometrial pathology at the ultrasound and the response to the progestin therapy. This approach makes it possible to perform fewer outpatient hysteroscopic biopsies without excluding positive cases from the examination.

Systematic Review and Meta-Analysis of Native Kidney Biopsy Complications.

Native kidney biopsies are commonly performed in the diagnosis of acute kidney diseases and CKD. Because of the invasive nature of the procedure, bleeding-related complications are not uncommon. The National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases-sponsored Kidney Precision Medicine Project requires that all participants undergo a kidney biopsy; therefore, the objective of this analysis was to study complication rates of native kidney biopsies performed using automated devices under kidney imaging. This is a systematic review and meta-analysis of the literature published from January 1983 to March 2018. The initial PubMed search yielded 1139 manuscripts. Using predetermined selection criteria, 87 manuscripts were included in the final analysis. A random effects meta-analysis for proportions was used to obtain combined estimates of complication rates. Freeman-Tukey double-arcsine transformations were used to stabilize variance as complications were rare. A total of 118,064 biopsies were included in this study. Patient age ranged from 30 to 79 years, and 45% of patients were women. On the basis of our meta-analysis, pain at the site of biopsy is estimated to occur in 4.3% of biopsied patients, hematomas are estimated to occur in 11%, macroscopic hematuria is estimated to occur in 3.5%, bleeding requiring blood transfusions is estimated to occur in 1.6%, and interventions to stop bleeding are estimated to occur in only 0.3%. Death attributed to native kidney biopsy was a rare event, occurring only in an estimated 0.06% of all biopsies but only 0.03% of outpatient biopsies. Complication rates were higher in hospitalized patients and in those with acute kidney disease. The reported complications varied on the basis of study type and geographic location. Although the native kidney biopsy is an invasive diagnostic procedure, the rates of bleeding complications are low. Albeit rare, death can occur postbiopsy. Complications are more frequently seen after kidney biopsies of hospitalized patients with AKI.

S3508 A Rare Case of Juvenile Hemochromatosis

INTRODUCTION: Juvenile hemochromatosis is a rare phenomenon seen in patients who have a severe overload of iron in the first three decades in life. It is the most severe form of hereditary hemochromatosis and can cause further clinical complications of cardiomyopathy, hypogonadism, and liver fibrosis. The disease process can progress and cause signs of fatal heart failure. Both male and female populations are equally represented. Lab studies usually reveal elevated serum ferritin and transferrin saturation and gene transformation for HFE mutation is often positive. Phlebotomy is pursued in order to achieve iron depletion which greatly reduces morbidity and mortality. We present a 19 year old male who arrived at an outpatient hematologist office for evaluation of his fatigue. CASE DESCRIPTION/METHODS: This is a 19 year African American old male with no PMH history who arrived at an outpatient hematologist office after having routine blood work for his symptoms of fatigue. Referral labs indicated a ferritin of 1322 associated with an elevated total bilirubin of 3.5 and direct bilirubin that was mostly indirect. On physical examination, the patient had mild scleral icterus but a benign examination. Outpatient lab work revealed a total bilirubin of 5.2, direct bilirubin less than 0.2, Combs test negative, ferritin 1301, haptoglobin at 18. Hemoglobin electrophoresis showed a decreased MCV secondary to a beta thalassemia trait. A hemochromatosis DNA analysis revealed that the patient had a homozygous trait of C2827 locus further indicating a diagnosis of hemochromatosis. A MRI of the liver demonstrated increased iron overload and tiny gallstones. The patient proceeded with an outpatient cholecystectomy and liver biopsy. He was started on a regular phlebotomy program every 2 weeks with the goal of getting his serum ferritin level below 100. DISCUSSION: Juvenile hemochromatosis is a rare inherited autosomal recessive manner. Juvenile hemochromatosis shares numerous features with adult hemochromatosis, but iron deposition occurs at an accelerated rate. It is important to note that there is no gender disparity. Clinicians should refer to an outpatient hepatologist for further management and seek early treatment with phlebotomy as it can prevent and even reverse secondary complications of organ damage. In our particular case, the patient was identified early in the disease course and significantly improved his outcomes.

ATYPICAL TERRITORY FOR LUNG ADENOCARCINOMA

SESSION TITLE: Medical Student/Resident Lung Cancer Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Metastasis is a complex aspect of malignancy that is constantly being studied and monitored in advanced cases. In most cases, different types of cancers can be predictable in how they metastasize, and this can affect management and treatment. CASE PRESENTATION: In this case, a 67-year-old male with a past medical history of hypertension, lung mass, and hypothyroidism, presented to the hospital with a chief complaint of constant, excruciating right gluteal pain. A CT scan of the abdomen and pelvis showed a heterogeneous mass within the right gluteus medius muscle along with nodular masses in the abdomen and pelvic regions. In conjunction to these findings, the MRI of pelvis showed that the right gluteal mass was invading into the right piriformis muscle and extending into the pelvic bowel, which is suggestive of a sarcomatous process. A CT guided biopsy of the gluteal mass was performed which revealed poorly differentiated sheets of polygonal cells with vacuolated eosinophilic cytoplasm, pleomorphic nuclei, prominent nucleoli, inflammation and necrosis. These findings along with positive stains for CK7, vimentin, EMA, pankeratin support a diagnosis of pulmonary adenocarcinoma with rhabdoid features. As the patient’s hospital course progressed, collateral notes were obtained from his outpatient office revealing that prior to hospital admission he received an outpatient CT-guided lung biopsy and PET scan. The lung biopsy revealed poorly differentiated adenocarcinoma with rhabdoid morphology and the PET showed metabolic activity in the right gluteal region and adjacent nodes. The patient was scheduled for his first oncology consult one week after his hospital admission, and he was unaware of pertinent details related to his condition. DISCUSSION: In general, skeletal muscle metastasis is a rare occurrence in a non-small cell lung cancer (1). Lung cancer is the leading cause of cancer death and second most common cancer in both genders in the United States. More specifically, adenocarcinoma of the lung is the most prevalent type of lung cancer, accounting for approximately 40% of all cases of lung cancer. Lung cancer is highly malignant with the capability of widespread metastasis. The most common sites of metastasis for lung cancer include: the contralateral lung, adrenal glands, bones, brain and liver. The clinical picture presented was suggestive of sarcoma. The case was reviewed by multiple healthcare professionals who all suspected sarcoma with metastasis to lung, which is common finding in medical practice. It wasn’t until the biopsy was performed that a rare scenario unfolded. CONCLUSIONS: The case reminds us as physicians to be cognizant of the unpredictable nature of lung malignancies and to avoid making premature assumptions. This article supports that biopsy is an imperative diagnostic modality and can help guide treatment. Reference #1: Sridhar KS, Rao RK, Kunhardt B. Skeletal muscle metastases from lung cancer. Cancer. 1987;59:1530–4. DISCLOSURES: No relevant relationships by christian ALMANZAR ZORRILLA, source=Web Response No relevant relationships by Paul Jones, source=Web Response No relevant relationships by Kishankumar Patel, source=Web Response No relevant relationships by Jan Sambataro, source=Web Response No relevant relationships by Vishal Singh, source=Web Response No relevant relationships by Riddhi Upadhyay, source=Web Response

Value of Immediate Post-Kidney Biopsy Ultrasound in Excluding Late Hemorrhagic Complications.

Hemorrhage is the most serious potential complication of percutaneous kidney biopsy. Patients are typically observed for at least 6-8 hours after a kidney biopsy, with serial measurements of vital signs and hemoglobin to monitor for major hemorrhage. This study assessed whether an immediate postbiopsy ultrasound can reliably exclude delayed major hemorrhage. We retrospectively evaluated the clinical outcomes in 147 patients undergoing an outpatient native kidney biopsy with an 18-gauge needle at a large medical center during a 2.5-year period (January 2017 to June 2019). All patients underwent a standardized postbiopsy ultrasound to assess for active extravasation of blood. We extracted from the medical records vital signs and hemoglobin values obtained before the biopsy and at 2, 4, and 6 hours after the procedure. We ascertained whether any patients with a negative postbiopsy ultrasound developed a delayed major hemorrhage. Each patient underwent two or three biopsy passes. The mean patient age was 48±17 years, 49% were female, 37% were black, 53% had hypertension, and 16% had diabetes. Of the 142 patients without evidence of active extravasation on ultrasound, the BP, heart rate, and hemoglobin remained stable during 6 hours of observation. All were discharged after 6 hours, and none had a late bleeding complication. If the immediate postkidney biopsy ultrasound does not show active bleeding, the patient is extremely unlikely to develop a late major hemorrhagic complication (negative predictive value, 100%). Such patients can be discharged home safely after a 2-hour observation, thereby simplifying their management.

Profiling trial burden and patients\u2019 attitudes to improve clinical research in epidermolysis bullosa

BackgroundEpidermolysis bullosa (EB) comprises inherited mechanobullous dermatoses with considerable morbidity and mortality. While current treatments are symptomatic, a growing number of innovative therapeutic compounds are evaluated in clinical trials. Clinical research in rare diseases like EB, however, faces many challenges, including sample size requirements and recruitment failures. The objective of this study was to determine attitudes of EB patients towards clinical research and trial participation as well as the assessment of contextual motivating and discouraging factors in an effort to support patient-centered RD trial designing.MethodsA 53-items questionnaire was handed over to EB patients (of all types and ages) in contact with the EB House Austria, a designated national center of expertise for EB care. Main categories included level of interest in and personal knowledge about clinical studies, pros/cons for participation and extent of individual expenses considered acceptable for participation in a clinical study. Descriptive subgroup analysis was calculated with SPSS 20.0 and Microsoft Excel.ResultsThirty-six individuals (mean age 25.7 years), diagnosed for recessive dystrophic EB (36.1%), EB simplex (33.4%), junctional EB (8.3%), dominant dystrophic EB (2.8%) and acral peeling syndrome (2.8%) participated. Motivation for participation in and the desire to increase personal knowledge about clinical trials were (outmost) high in 57.2 and 66.7%, respectively. Altruism was the major motivating factor, followed by hope that alleviation of the own symptoms can be achieved. The greatest hurdle was travel distance, followed by concerns about possible adverse reactions. Patients diagnosed for severe subgroups (RDEB, JEB) were more impaired by the extent of scheduled invasive investigations and possible adverse reactions of the study medication. Patients with generally milder EB forms and older patients were accepting more frequent outpatient study visits, blood takes, skin biopsies and inpatient admissions in association with trial participation.ConclusionsThis study provides additional indications to better determine and address attitudes towards clinical research among EB patients as well as guidance to improve clinical trial protocols for patient centricity.

Multicentre clinical evaluation of the safety and performance of a simple transperineal access system for prostate biopsies for suspected prostate cancer: The CAMbridge PROstate Biopsy DevicE (CamPROBE) study.

Objectives:To report the prospective multicentre clinical evaluation of a first-in-man disposable device, Cambridge Prostate Biopsy Device, to undertake local anaesthetic outpatient transperineal prostate biopsies.Material and methods:Disposable single-use Cambridge Prostate Biopsy devices were manufactured based on a previous prototype. The lead site developed a user training course and disseminated the method to other sites. The Cambridge Prostate Biopsy Device (CamPROBE) was offered as an alternative to transrectal ultrasound guided biopsy to men due for a biopsy as part of their clinical management. Data on safety (infections and device performance), clinical utility, patient reported experience, biopsy quality and cancer detection were collected. Procedure time and local anaesthetic use was recorded in the lead site. The study was funded by a United Kingdom National Institute for Health Research (NIHR) i4i product development award.Results:A total of 40 patients were recruited (median age 69 y) across six sites; five sites were new to the procedure. Overall, 19/40 were first prostate biopsies and 21/40 repeat procedures. Both image-targeted and systematic biopsy cores taken. There were no infections, device deficiencies or safety issues reported. The procedure was well tolerated with excellent patient-reported perception and low pain scores (median of 3, scale 0–10). Histopathology quality was good and the overall cancer diagnosis rate (first diagnostic procedures) was 68% (13/19) and for significant cancers (⩾ histological Grade Group 2), 47% (9/19). In the lead centre (most experienced), median procedure time was 25 minutes, and median local anaesthetic use 11 ml (n=17).Conclusions:Data from this device evaluation study demonstrate that the United Kingdom-developed Cambridge Prostate Biopsy Device/method for transperineal biopsies is safe, transferable and maintains high diagnostic yields. The procedure is well tolerated by patients, suited to the local anaesthetic outpatient setting and could directly replace transrectal ultrasound guided biopsy.Level of evidence:Level III

Outpatient Thoracoscopic Mediastinal Biopsy: A Safe and Cost-Effective Approach

Most mediastinal biopsy patients are managed with an overnight inpatient stay and chest drainage. We sought to determine the safety, accuracy, and cost of outpatient thoracoscopic mediastinal biopsy by reviewing operative techniques, perioperative outcomes, and admission charges for this procedure. This single-institution retrospective study reviewed all patients who underwent elective thoracoscopic mediastinal biopsy between 2012 and 2017. Patients were assigned to outpatient or inpatient management preoperatively based on surgeon judgment and preference. The procedures were performed in the supine or lateral decubitus position using ports only. Patients discharged on postoperative day 0 (outpatient) were compared with those discharged on postoperative day 1 or greater (inpatient). A total of 46 patients were included. Thirty-one patients were outpatients, and 15 were admitted. The outpatient cohort was younger than the inpatient group (48 years of age vs 66 years of age; P= .001). Therewas no statistically significant difference in other baseline characteristics. The operative time was longer (P= .001) and the total charges were higher (P= .003) in the inpatient cohort. One patient in each group hada nondiagnostic procedure. One patient in the outpatient group returned to the emergency department for pain but was discharged. There were no complications. Outpatient thoracoscopic mediastinal biopsyis a safe and effective procedure that has lower charges compared with inpatient management and should be considered for patients undergoing this procedure.

Anxiety and Pain in Patients Undergoing Pipelle Endometrial Biopsy: A Prospective Study [11F

INTRODUCTION: Pipelle biopsy is a minimally invasive endometrial sampling procedure, important for early diagnosis of endometrial pathology and treatment planning. While generally well tolerated, some women experience considerable pain. The prospective study reported here provides a first critical test of the hypothesis that heightened anxiety may contribute to the risk of severe pain in women undergoing Pipelle biopsy. METHODS: Pain and anxiety levels immediately prior to, during, and after the Pipelle biopsy were assessed (0-10 numeric rating) in a sample (n=113) of consecutively recruited women undergoing outpatient Pipelle biopsies in a tertiary care facility. Personal and clinical data were extracted from medical records and from surveys administered to providers. Multivariable logistic regression models and generalized estimating equations examined associations between severe (≥7) pain and anxiety prior to, during, and after the biopsy. RESULTS: Severe pain was reported by 9%, 43%, and 13% of participants prior to, during and after the procedure (respectively), while severe anxiety was reported by 30%, 38% and 12%. Pain was significantly associated with anxiety levels at all times assessed. Adjusting for covariates (e.g., age, BMI, biopsy indication), the odds of severe pain prior to, during, and after biopsy were 5.9, 2.3, and 11.0 times higher (respectively) for patients with severe anxiety prior to the procedure. CONCLUSION: The strong relationships between anxiety prior to Pipelle biopsy and patients’ experiences of severe pain associated with the procedure suggest that interventions aimed at reducing anxiety might substantially improve the patient experience of this widely-used procedure for endometrial biopsy.

Accomplishing an adaptive clinical trial for cancer: Valuation practices and care work across the laboratory and the clinic.

A new generation of adaptive, multi-arm clinical trials has been developed in cancer research including those offering experimental treatments to patients based on the genomic analysis of their cancer. Depending on the molecular changes found in patients’ cancer cells, it is anticipated that targeted and personalised therapies will be made available for those who have reached the end of standard treatment options, potentially extending survival time. Results from these trials are also expected to advance genomic knowledge for patients in the future. Drawing on data from a qualitative study of one such trial in the UK, comprising observations of out-patient clinic appointments, out-patient biopsy procedures, laboratory work, and interviews with practitioners, this paper explores how the clinical and research value of one such trial was accomplished in everyday practice by focussing on the work of clinical trials and laboratory staff across recruitment, laboratory analysis, and results management. In the face of numerous potential set-backs, disappointments and failure, we explore how practitioners worked to balance the need to meet established measures of value such as numbers of patients recruited into the trial, alongside cultivating the value of positive affects for patients by managing their expectations and emotions. This care work was performed primarily by practitioners whose roles have historically been devalued in healthcare practice and yet, as we show, were critical to this process. We conclude by arguing that as complex multi-arm adaptive trials become more commonplace, we need to attend to, and render visible, the dynamic and care-full valuation practices of backstage practitioners through which experimental biomedicine is accomplished, and in doing so show that care both achieves clinical and research value, and is also a series of practices and processes that tends to tissue, patients and staff in the context of ever-present possibility of failure.

Abstract No. 631 Comparison of diagnostic yield and procedural time with and without the presence of on-site pathology for image-guided percutaneous biopsies

The aim of having on-site pathology (OSP) service for percutaneous biopsies is to maximize diagnostic yield and minimize the risk of repeat biopsies. The use of OSP is standard procedure at our institution’s main hospital where the pathology department is based, but due to resource limitations a member of the pathology team is not always available for our biopsies at our neighboring hospital where we recently started performing outpatient biopsies. Our hypothesis is that the added time and logistical difficulties of transporting a pathology representative to our neighboring hospital may not be outweighed by improved diagnostic yield. We retrospectively reviewed data from January to December 2018 for percutaneous biopsies performed at our neighboring hospital with and without OSP, only including lesional biopsies that would typically qualify for OSP. The main endpoints were diagnostic yield and procedure time. Secondary variables included target organ. Statistical analysis (chi-square and comparison of means) was performed. A biopsy was considered diagnostic if a pathologic diagnosis was determined from the provided samples in the final pathology report. Biopsies were categorized by target organ (e.g., liver, kidney, soft tissue, lymph node, etc.) and technique (US guided vs. CT guided). A total of 170 biopsies were included. 96 were with OSP present, and 74 without OSP present. Diagnostic yield was not statistically significant between the OSP and non-OSP groups (P = 0.435). Mean procedure time was longer using OSP than without OSP (41.1 vs. 36.2 minutes, P = 0.05). Mean sedation time was also longer when OSP was used than without OSP (36.7 vs. 32.7 minutes, P = 0.01). Our study shows that there is no statistically significant increase in diagnostic yield when OSP is present during lesional biopsies, and that using OSP increases procedure time and sedation time. Our results question the routine use of on-site pathology at our neighboring hospital where transporting a pathology representative is logistically challenging. Further studies are needed to identify lesional characteristics that may confer a higher risk of obtaining non-diagnostic samples.Tabled 1Diagnostic Yield with or without On-Site Pathology (P = 0.435)DiagnosticNondiagnosticPathology present906Pathology not present677 Open table in a new tab

Outpatient Kidney Biopsy: A Single Center Experience and Review of Literature

Background: A kidney biopsy is an important tool in managing kidney diseases. Bleeding is the most significant complication. The biopsy can be performed as an inpatient or an outpatient procedure with a shorter post-biopsy bed rest and monitoring period. It is cost-effective, but raises some questions about patient safety. At Helsinki University Hospital, the majority of elective kidney biopsies have been performed as outpatient procedures since 2010. The aim of this study was to retrospectively evaluate the safety and risk factors of this protocol. Methods: We collected data from all patients undergoing an elective outpatient biopsy of a native or transplanted kidney following the outpatient protocol between January 2011 and February 2016. We recorded the data on the biopsy procedure and complications: bleeding (hematoma or macrohematuria), severe pain, death, or “other” (infection, accidental puncture of another organ). A complication was classified as major, if it required interventions such as transfusion or radiological or surgical intervention. Results: Over a 5-year period, 824 (448 native and 326 transplant kidney) patients were biopsied. In total, 94 (11.4%) had a complication, but only 4 patients (0.5%) had a major complication; no deaths were recorded. All major and 70 minor complications emerged during post-biopsy monitoring (4–6 h). Patients with complications were younger (p = 0.001), female (p < 0.001), and had lower hemoglobin (p = 0.001) than those without. Transplant biopsies were associated with fewer complications than native kidney biopsies (p= 0.002). Conclusions: In selected patients, an outpatient kidney biopsy is a relatively safe procedure.

1303 More Than Meets the Eye: Pancreatic Panniculitis as Presenting Sign of Invasive Pancreatic Adenocarcinoma

INTRODUCTION: Despite its first description by Chiari in 1883, pancreatic panniculitis remains an atypical manifestation of pancreatic disease, appearing in only 0.3-2% of patients. Although the pathogenesis remains unclear, biopsy-proven subcutaneous liquefactive fat necrosis has implicated elevated lipase, amylase, and trypsin in dissemination and subcutaneous deposition/lipolysis, manifesting as edematous, erythematous superficial nodules of the lower extremities, thigh, and buttock. CASE DESCRIPTION/METHODS: A 91-year-old male presented with 2-week history of painful erythematous nodular rash of bilateral anterior lower extremities. Rash began as small singleton lesion, approximately 1 cm each in size, which grew in diameter with progressively worsening tenderness. Outpatient punch biopsy revealed lobular fat necrosis and local inflammatory infiltrate, consistent with pancreatic panniculitis. Labs were significant for amylase 1026 U/L (ULN 100), lipase of 4366 U/L (ULN 78), CA 19-9 1600 U/mL, and CEA of 9.4 ng/mL. CT-abdomen/pelvis without contrast showed a normal appearing liver, atrophic pancreas with 1.5 cm cystic structure at the pancreatic head, and a 9 mm cystic structure within the pancreatic body. EUS/ERCP for suspected choledocholithiasis with concomitant malignancy revealed 5 mm dilation of the main pancreatic duct with associated 21 mm × 17 mm mass of mixed solid and cystic consistency with multiple anechoic lesions throughout the pancreas suggestive of cysts. Fine needle biopsy revealed invasive ductal adenocarcinoma with associated high grade intraductal papillary mucinous neoplasm. He completed staging work-up and underwent Whipple Procedure with negative margins. DISCUSSION: Although a rare dermatologic manifestation of underlying pathology, pancreatic panniculitis serves as a herald of severe pancreatic pathology. Subcutaneous biopsy of suspicious lesions is invaluable in identifying the etiology and ultimately diagnosing underlying pancreatic pathology. Histologic evaluation following punch biopsy of nodules reveals liquefactive fat necrosis, surrounded by a neutrophil-rich mixed inflammatory infiltrate with pathognomonic “ghost cells”. Treatment of the underlying disease process can lead to resolution of the nodules. Our patient presented with pancreatic panniculitis as the initial manifestation of internal occult malignancy in the absence of typical symptoms. Prompt recognition and biopsy of suspicious nodules led to an expedient diagnosis of locally resectable disease.

An interventional image-guided microdevice implantation and retrieval method for in-vivo drug response assessment.

Recently developed implantable microdevices can perform multi-drug response assessment of cancer drugs in-vivo, with potential to develop highly optimized personalized cancer treatment strategies. However, minimally invasive/interventional image-guided methods of in-vivo microdevice implantation, securement, and retrieval are needed for broad clinical translation. Here we demonstrate proof-of-concept of an interventional microdevice implantation and retrieval method for personalized drug response assessment, using ex-vivo phantom, ex-vivo tissue, and in-vivo murine models. A method for minimally-invasive microdevice implantation and retrieval was developed, by which a custom-prototyped 6mm retrievable microdevice can be implanted into a live tumor, deliver drugs into 10 discrete regions of adjacent tissue, and retrieved along with the adjacent drug-exposed tissue with a custom-prototyped retrieval needle device to allow in-vivo multi-drug response assessment. Computed tomography (CT) and ultrasound (US)-guided minimally invasive microdevice implantation and retrieval were tested in ex-vivo phantom and tissue models. Successful retrieval was defined as retrieval of the microdevice and adjacent core phantom/tissue sample containing at least 4/10 drug delivery sites. Subsequently, 10 implantation and retrieval trials in phantom models were performed using bi-axial and tri-axial retrieval needles; success rates were calculated and compared using a two-proportion z-test and the number of successfully retrieved drug release sites per microdevice was calculated and compared using a one-tailed independent t-test. Finally, five microdevices, each containing ten reservoirs preloaded with chemotherapy agent Doxorubicin, were implanted into mouse tumors in-vivo, secured for 24-h during drug release, and microdevice/tissue retrieval was performed under ultrasound guidance. Fluorescence microscopy of the retrieved tissue was used to confirm drug delivery and apoptosis staining assessed in-vivo tissue response; correlation of drug release and apoptosis staining were used to assess in-vivo drug efficacy. Image-guided microdevice implantation and retrieval were successful in ex-vivo phantom and tissue models with both US and CT guidance. Bi-axial retrieval success rate was significantly higher than triaxial retrieval in ex-vivo phantom trials (90% vs 50%, z=1.95, P=0.026), and had nonsignificantly higher number of retrieved drug-release sites per microdevice (8.3 vs 7.0, t=1.37, P=0.097). Bi-axial retrieval was successful in all five in-vivo mouse tumor models, and allowed in-vivo drug response assessment at up to ten discrete drug delivery sites per microdevice. An average of 6.8/10 discrete tumor sites containing micro-doses of delivered drug were retrieved per in-vivo attempt (min 5, max 10, std 1.93). Tissue regions of drug delivery, as assessed with fluorescent Doxorubicin drug signal, correlated with regions of apoptosis staining in all in-vivo models, indicating drug efficacy. No bleeding, microdevice migration, or other complications were noted during implantation, 24-h observation, or retrieval. The demonstrated image-guided minimally invasive microdevice implantation and retrieval method is similar to routine outpatient biopsy procedures, obviates the need for surgery, and can be performed at varying depths under CT and/or US guidance. There is potential for this method to enable clinical translation of in-vivo personalized drug response assessment/prediction in a much larger number of patients than currently possible.

Evaluation of the effectiveness of histopathological verification of the endometrium by means of an outpatient aspiration biopsy

Evaluation of the effectiveness of histopathological verification of the endometrium by means of an outpatient aspiration biopsy

Hysteroscopic morphological pattern reflects histological grade of endometrial cancer.

To examine the hysteroscopic morphological features in each histological grade of endometrial cancer, and to distinguish high- and low-grade cancer and low-grade cancer and atypical endometrial hyperplasia (AEH), using hysteroscopy. In total, 135 patients who underwent hysterectomy after hysteroscopy were analyzed. They were divided into four categories: benign lesion; AEH; low-grade cancer, including endometrioid carcinoma grades 1 and 2 (G1/2); and high-grade cancer, including endometrioid carcinoma grade 3 and other high-grade carcinomas (G3/others). Three blinded gynecologic oncologists independently evaluated hysteroscopic video images for abnormal vessels, surface smoothness, papillary structure and polypoid structure. Prevalence rates of each finding were compared between the four categories. The accuracy of blind biopsy in outpatient settings and hysteroscopic endometrial biopsy in the four categories were also investigated. The number of patients with benign lesions, AEH, G1/2 and G3/others was 8, 7, 84 and 36, respectively. Patients with G3/others exhibited more polypoid (86% vs 61%, P = 0.0095) and less papillary (59% vs 80%, P = 0.023) structures than those exhibited by patients with G1/2. AEH and G1/2 were indistinguishable using hysteroscopy. Hysteroscopic biopsy was more accurate than outpatient biopsy in patients with G3/others (84% vs 52%, respectively, P = 0.010). Both biopsies were not sufficiently accurate to diagnose AEH (outpatient; 0%, hysteroscopic; 57%). Hysteroscopic papillary and polypoid structures can help distinguish between high- and low-grade cancer. Hysteroscopic differentiation between AEH and low-grade cancer is difficult. These findings are considerable in preoperative assessment to determine adequate surgical strategies.

SUN-326 Hypoglycemia and Lactic Acidosis: The Deadly Signs of Untreated Non-Hodgkin's Lymphoma

Introduction The presentation of hypoglycemia with lactic acidosis is rare, though well-described. It is most commonly associated with hematologic malignancies and is attributed to the Warburg effect in which cells consume large amounts of glucose through the glycolytic pathway with lactic acid production, even in aerobic conditions. Clinical Case 64yo WM with cirrhosis due to hemochromatosis, atrial fibrillation, type 2 diabetes mellitus managed by diet, initially presented with weakness, malaise and thrombocytopenia. Imaging revealed splenomegaly, bilateral adrenal masses, and diffuse lymphadenopathy. He was admitted, given IV fluid hydration, and discharged to have outpatient lymph node biopsy. Prior to biopsy he developed worsening weakness, fatigue, shortness of breath, and hypoxia. Lactate was 8.1mmol/L, n=0.7-2.1. He was admitted for sepsis secondary to pneumonia. During hospitalization, he was noted to be hypoglycemic (serum glucose 40mg/dL), requiring continuous dextrose infusion and dextrose 50% boluses. Evaluation was consistent with insulin independent hypoglycemia with labs as follows: Insulin <1 microU/mL (2-25), c-peptide 0.65ng/mL (0.78-5.19), proinsulin 4.2pmol/L (3.6-22), beta-hydroxybutyrate 4.07mg/dL (0.2-2.8), glucose 49mg/dL then 44mg/dL 30 minutes after administration of glucagon. ACTH 8.1pg/mL (7.2-63) and cortisol 11mcg/dL then 14.8mcg/dL after cosyntropin stimulation. He was started on stress dose steroids. Lactic acidosis persisted and worsened (>15mmol/L). Repeat CT imaging was obtained to search for potential source of lactic acidosis, though none was found. It was later noted that increasing lactate levels occurred with increased dextrose administration. A perirenal lymph node biopsy was performed. Shortly after the procedure, the patient rapidly decompensated. He was started on continuous renal replacement therapy and given rasburicase for suspected tumor lysis syndrome. Despite these efforts, the patient died. Pathology later returned positive for Non-Hodgkin’s Lymphoma. Discussion In this case, hypoglycemia was initially confounded by a history of cirrhosis and possible adrenal insufficiency. However, no improvement with steroids and worsening of lactic acidosis with increasing dextrose administration demonstrated that hypoglycemia was due to the Warburg effect in the setting of undiagnosed Non-Hodgkin’s Lymphoma. Recognizing this phenomenon is imperative as it coincides with high mortality, and the treatment of underlying disease may be the only effective option. References Georges C. Elhomsy, et al; “Hyper-Warburgism,” a Cause of Asymptomatic Hypoglycemia with Lactic Acidosis in a Patient with Non-Hodgkin's Lymphoma, The Journal of Clinical Endocrinology & Metabolism, Volume 97, Issue 12, 1 December 2012, Pages 4311-4316.

What Is the Justification for the Practice of Examination Under Anesthesia Plus Biopsy for Suspected Cervical Cancer?

Background: Management of suspected cervical cancer involve diagnosis by way of histologic evaluation of biopsy specimen and subsequent staging to determine spread to guide the choice of treatment modality. It is not uncommon to find examination under anesthesia plus biopsy as a single procedure in an operating theater list in Nigeria. The rationale for combining diagnostic procedure with staging procedure is hereby queried. Aim: To understand the rationale for the practice of combining examination under anesthesia with biopsy of suspected cervical cancer in Nigeria and project possible impact of such practice on quality of care to the patient. Methods: The study adopted combination of structured questionnaire and key informant interview. Structured questionnaires were administered to doctors below the level of consultants in departments of obstetrics and gynecology of 2 tertiary health institutions where examination under aneasthesia plus biopsy is being practiced. The questions were in four domains to assess the following; 1. Demographics 2. Any difference between knowledge and the practice of evaluation of suspected cervical cancer 3. Why combine examination under anesthesia with biopsy 4. Willingness to perform outpatient biopsy while key informant interview was conducted on randomly selected 10 consultants with interest in gynae-oncology. Results: Fifteen doctors from 2 departments of obstetrics and gynecology in 2 tertiary health institutions completed the questionnaire. Majority of the respondent were male 12/15 (80%), with average year of practice experience of 4.7 years (SD 3.5). While 100% of the respondents are duly aware of the role of cervical biopsy in confirming diagnosis of cervical cancer, none, 0% have done or witnessed cervical biopsy as an outpatient procedure. Majority 87% were not comfortable to perform outpatient biopsy of the cervix mainly because of fear of bleeding. While all the consultants were willing to perform outpatient cervical biopsy none routinely does it because of logistics. Conclusion: There is no evidence to support routine combination of examination under anesthesia and biopsy of suspicious cervical lesion. Unfounded fear of uncontrollable bleeding and lack of outpatient biopsy services are the major factors promoting the practice. Consequently, there is need for sensitization of gynecologic departments on safety of outpatient biopsy services.

Dehydration Secondary to Acute Olmesartan Associated Enteropathy with Concomitant Lymphocytic Colitis

Introduction: Olmesartan is an angiotensin II receptor blocker recently described to cause a spruelike enteropathy. Duodenal biopsies are identical to those of Celiac disease (CD), however the patient will be negative for transglutaminase. Unlike Olmesartan associated enteropathy (OAE), CD has been associated with lymphocytic colitis (LC). LC can cause significant diarrhea, although it typically does not cause dehydration. Case Report: 84-year-old Caucasian female with a past medical history of dementia and hypertension was hospitalized for diarrhea. She was noted to have an acute kidney injury (AKI) with a creatinine of 1.79 mg/dL. Her C. diff screen was positive and the patient was treated with oral vancomycin. Her AKI resolved with rehydration and she was discharged home. At home she began to have 20 liquid bowel movements daily and was taken to another local hospital. Repeat C. diff screening was negative; however, she was again treated with oral Vancomycin. She was discharged home despite still having diarrhea. Outpatient esophagogastroduodenoscopy and colonoscopy were performed for follow up evaluation. Further, she was noted to have been recently started on Olmesartan which was discontinued prior to endoscopic evaluation. Endoscopy revealed negative gross evaluation of the duodenum and biopsy revealed blunted villous architecture with increased intraepithelial lymphocytes and focal neutrophilic infiltrates. Colonic biopsies revealed lymphocytic colitis. Shortly after, the patient had altered mental status and hypotension and was sent to the emergency department. Initial vital signs were significant for temperature of 91.7 °F and a blood pressure of 72/57 mm Hg. Physical exam was unremarkable besides altered mentation. Initial bloodwork revealed an AKI with a creatinine of 7.74 mg/dL. She continued to have profound diarrhea and outpatient biopsy results were not immediately available. Repeat C. diff screening, stool cultures, Shiga toxins, and ova and parasites were checked and found to be negative. Computer tomography of the abdomen showed diverticulosis. With the duodenal biopsy results transglutaminase IgA and IgG were checked and were negative. The AKI resolved with rehydration and the diarrhea improved with budesonide. Discussion: Celiac sprue enteritis is associated with LC, OAE has not been described to be associated with it. Clinicians should suspect a concomitant process in patients with LC presenting with dehydration.