Pelvic Computed Tomography Research Articles

S1896 Not Your Average Diverticulum: A Unique Case of a Massive Esophageal Diverticulum After Laparoscopic Gastric Banding

INTRODUCTION: Food impactions are a common gastrointestinal emergency, occasionally requiring urgent retrieval of an obstructing food bolus from the esophagus. This is a case of food impaction in a large esophageal diverticulum that developed as a long-term complication of laparoscopic adjustable gastric banding (LAGB) for obesity. CASE DESCRIPTION/METHODS: A 76-year-old woman presented to the emergency room complaining of dysphagia and neck discomfort after eating turkey. Her medical history includes gastroesophageal reflux disease, heart failure and morbid obesity, treated with LAGB several years prior and subsequently removed four years prior to the current presentation. She had previous food impactions that resolved spontaneously without endoscopic intervention. On presentation she was anxious, uncomfortable-appearing, mildly hypoxic, but able to handle her oral secretions. Computed tomography (CT) imaging of the chest showed a dilated esophagus with a right lateral diverticulum containing an impacted 10 cm × 7.4 cm food bolus and lung opacities concerning for aspiration pneumonia. The patient underwent an endoscopy with partial removal of the massive food bolus that was lodged in the diverticulum. The GIF-190 and GIF- XP scopes could not be advanced into the true esophageal lumen due to compression of the lumen by the huge diverticulum. Three days later, an endoscopy was performed with removal of the remnant bolus from the esophageal diverticulum, and placement of an orogastric tube over a guidewire. The mucosa of the upper esophagus was noted to be dusky-appearing, likely from pressure necrosis. The patient had a month-long ICU stay for chronic hypoxic respiratory failure due to aspiration pneumonia and inability to wean off mechanical ventilation. Surgical intervention to repair the esophageal diverticulum was discussed, but was deferred given the patients age, morbid obesity and medical comorbidities. Ultimately a tracheostomy was placed for long-term mechanical ventilation and a gastrostomy tube was placed under fluoroscopic guidance for enteral nutrition. The patient was discharged to a long-term care facility. DISCUSSION: This is a case of a large esophageal diverticulum that developed as a late complication of LAGB. Patients with prior LAGB presenting with dysphagia require imaging and possibly manometric evaluation to assess for pseudoachalasia. This directs need for endoscopic or surgical intervention to avoid progression to large esophageal diverticular disease and subsequent complications.Figure 1.: CT abdomen and pelvis with out contrast demonstrating an axial view of a large esophageal diverticulum with 10 cm food bolus.Figure 2.: CT abdomen and pelvis with out contrast demonstrating a coronal view of a large esophageal diverticulum and right sided aspiration pneumonia.Figure 3.: The upper third of the esophagus with dusky appearing mucosa in the large diverticulum seen during second endoscopy.

S2662 An Unexpected Cause of Refractory Liver Abscesses

INTRODUCTION: We report a case of multifocal liver abscesses with recurrent fevers refractory to prolonged antibiotic therapy and catheter drainage due to penetration of a toothpick into the portal vein. CASE DESCRIPTION/METHODS: A 72-year-old male with type II diabetes presented with fever, confusion, and right upper quadrant pain associated with malaise and unintentional weight loss. Objective findings were consistent with septic shock and acute liver injury. Computed tomography (CT) and Magnetic Resonance Imaging (MRI) showed a 6.9 × 8.0 × 5. hepatic abscess and several scattered fluid collections (Figure 1). Immediate broad-spectrum antibiotics and percutaneous catheter drainage resulted in clinical improvement. Abscess fluid and blood cultures grew actinomyces odontolyticus and streptococcus viridans, respectively. Amebic serology was negative. Transition to appropriate outpatient antibiotics resulted in two readmissions for recurrent fevers with persistent drainage output for weeks. A repeat CT showed a shrunken abscess and a 4.6 cm radio-opaque linear foreign body penetrating through the gastric antrum into a branch of the left portal vein (Figure 2). Review of previous imaging confirmed the foreign body was present since first admission. Upper endoscopy showed a patch of erythematous mucosa in the antrum encircling a pinpoint opening to a fistulous tract and exuding purulent fluid (Figure 3). Exploratory laparotomy revealed a 4.5 cm wooden toothpick in the portal vein surrounded by a dense fibrotic scar. Foreign body removal and porto-enteric fistula repair were performed. Follow up CT showed complete resolution of the abscess. DISCUSSION: Penetrating foreign body is a rare cause of liver abscess. To our knowledge, penetration of a foreign body into the portal vein resulting in liver abscesses has never been reported. Discovery of foreign body requires a high index of suspicion as patients rarely remember ingesting the object, and it can be easily missed on CT. When suspected, a non-contrast CT is recommended with attention to coronal/sagittal views with signs such as thickened antral wall and fistulous tract. Non-specific clinical features such as hematemesis, subacute/chronic abdominal pain, and failure of antibiotic therapy can be suggestive. In the setting of any of these findings, foreign body should be considered in patients with unexplained liver abscess.Figure 1.: A large dominant hepatic abscess measuring 6.9 × 8.0 × 5.3cm, involving segments 4A and 4B of the liver, extending to and involving the anterior wall of the gallbladder, as well as several scattered small fluid collections (MRI of liver without contrast).Figure 2.: A 4.6cm radio-opaque linear foreign body penetrating through the gastric antrum into a branch of the left portal vein (CT of abdomen and pelvis without contrast).Figure 3.: A patch of erythematous mucosa in the pre-pyloric antrum encircling a pinpoint opening to a fistulous tract and scant purulent liquid; the foreign body was not visible (upper endoscopy).

S3450 Metastatic Diffuse B-Cell Lymphoma Presenting With Gastrointestinal (GI) Bleeding

INTRODUCTION: Diffuse B-Cell Lymphoma (DBCL) is an aggressive, high-grade cancer that arises from neoplastic proliferation of B cells. Primary gastrointestinal (GI) lymphoma is the most common type of extranodal lymphoma and occurs in 30-40% cases. This case report is unique in that it highlights a patient who presented with GI bleeding due to metastatic DBCL. CASE DESCRIPTION/METHODS: A 64 yearold male with a history of coronary artery disease (CAD) status and atrial fibrillation on apixaban, clopidogrel, and aspirin presented to the emergency room with a one day history of hematemesis and melena. He denied a loss of consciousness, fall, chest pain, headache, fevers, or recent weight loss. Patient had no endoscopic history. The patient was tachycardic, hypotensive, and tachypneic on presentation. Physical exam was notable for diffuse lymphadenopathy. Lab findings included an initial hemoglobin of 9.4 g/dL, a blood urea nitrogen (BUN) of 62 mg/dL, and creatinine of 1.51 mg/ dL. Computed tomography (CT) abdomen and pelvis showed extensive lymphadenopathy, multiple small splenic lesions, and pulmonary nodules concerning for lymphoma (Figure 1). Esophagogastroduodenoscopy (EGD) showed a medium-sized ulcerated bleeding mass on the greater curvature of the stomach (Figure 2a). Hemostasis was achieved with epinephrine and two hemostatic clips (Figure 2b). Gastric ulcer biopsy showed diffuse large B-cell lymphoma. Excisional biopsy of a left axillary lymph node showed large B-cell lymphoma. The patient received chemotherapy with rituximab, cyclophosphamide etoposide, vincristine, and prednisone (R-CHOP) with plans for continued oncology treatment and follow-up. DISCUSSION: Cases of gastric DBCL are rare.This case report highlights a patient who presented with gastrointestinal bleeding due to metastasis of DBCL to the stomach. DBCL is aggressive and first line treatment is with R-CHOP. Surgery is second-line treatment for cases with perforation and severe bleeding. Clinicians should consider metastatic DBCL as a rare cause of GI bleeding with other supportive findings such as lymphadenopathy. Earlier diagnosis and treatment of DBCL will lead to improved prognosis.Figure 1.: CT abdomen and pelvis shows extensive adenopathy.Figure 2.: Figure 2a. Bleeding ulcer on greater curvature of stomach.Figure 3.: Figure 2b. Hemostasis of ulcer with clips.

S2555 Longstanding Hepatosplenomegaly in an Undiagnosed Sarcoidosis Patient

INTRODUCTION: Sarcoidosis, a multisystem granulomatous disease, typically affects the lungs and lymph nodes. Although there is hepatic involvement in approximately 66% of cases, the liver is rarely the cause of symptoms.We present a case of longstanding sarcoidosis in a young patient whose delayed diagnosis likely resulted in worsened portal hypertension and severe pancytopenia. CASE DESCRIPTION/METHODS: In 2015, a 25 year-old Panamanian woman was referred to Hepatology for elevated liver tests. Initial workup ruled out autoimmune hepatitis and viral hepatitis. She was lost to follow-up until 2017 when she saw a different hepatologist for elevated liver tests. As noted in Table 1, she developed significant cholestasis during that interval. Serologic studies for primary cholestatic liver disease were negative. Imaging showed hepatosplenomegaly but she was again lost to follow-up. In 2019, she presented to the Emergency Department with severe abdominal pain. Labs showed pancytopenia and computed tomography (CT) of the abdomen/pelvis showed hepatosplenomegaly. She was referred to Hematology/Oncology. Bone marrow biopsy was negative. She was again referred to Hepatology. She reported a chronic rash on her lower extremities, but was otherwise asymptomatic. Skin biopsy suggested erythema nodosum. Physical exam was notable for massive splenomegaly, confirmed by CT (Figure 1). Labs revealed pancytopenia and persistent cholestasis. An extensive workup for granulomatous diseases and systemic fungal, viral and mycobacterial infections was completed. Angiotensin converting enzyme (ACE) was markedly elevated (Table 1). Ultimately, liver biopsy was performed. Results confirmed granulomatous hepatitis. (Figure 2). After referral to the Sarcoidosis team, she was noted to have significantly elevated interleukin-2 (IL-2) level, consistent with the diagnosis. DISCUSSION: This case nicely illustrates the natural history of hepatic sarcoidosis. Our patient presented with a normal hematologic profile and mildly elevated liver tests, however she progressed to develop significant cholestasis, portal hypertension and pancytopenia. Earlier recognition and treatment may have hindered progression of portal hypertension. Sarcoidosis should be strongly considered in the diagnostic workup of elevated liver tests, especially in young patients who are at highest risk . In addition to ACE, absolute lymphocyte count and IL-2 level are highly sensitive for sarcoidosis and were also abnormal in our patient.Table 1.: Lab values from 2015-2020. Abbreviations: VCA: Viral Capsid Antigen; EBNA: Epstein-Barr Nuclear AntiigenFigure 1.: CT abdomen and Pelvis showing hepatosplenomegaly.Figure 2.: Liver biopsy pathology showing granulomatous hepatitis.

S1484 Masquerading Masses

INTRODUCTION: Amongst isolated solid pancreatic masses identified radiologically in middle aged adults, common diagnoses rendered on histology include adenocarcinoma and neuroendocrine tumors. Ninety percent of all pancreatic solid masses are pancreatic adenocarcinomas which carry a grim prognosis. Herein, we present two cases of isolated solid pancreatic masses radiologically masquerading as carcinomas that highlight the importance of clinico-pathologic correlation in directing management of patients with pancreatic lesions. CASE DESCRIPTION/METHODS: Case 1 is of a 51-year-old male with benign prostatic hyperplasia who presented to his urologist for recurrent urinary tract infection. Computed tomography (CT) was performed and showed a 9.5 × 4.9 cm mass in the pancreatic body and tail concerning for adenocarcinoma. Magnetic resonance image (MRI) showed enhancing rind of soft tissue in the body and tail without peripancreatic vascular attenuation (Figure 1a) and endoscopic ultrasound (EUS) showed diffuse heterogeneous echogenicity suggestive of autoimmune pancreatitis. IgG4 serum levels were within normal range. Fine needle aspiration (FNA) of the mass showed a CD10+ B-cell lymphoproliferative disorder and final pathologic diagnosis of low-grade follicular lymphoma was rendered (Figure 2a). The patient is currently on chemotherapy and responding favorably. Case 2 is of a 70-year-old male who presented with abdominal discomfort. A CT abdomen and pelvis revealed a well-delineated 1.9 × 1.5cm distal pancreatic tail mass. MRI showed that the lesion was isointense to the spleen and pancreas with prominent solid arterial phase enhancement and moderate diffusion restriction suggestive of a neuroendocrine tumor. PET NETSPOT scan also supported a somatostatin receptor avid tumor. An EUS with FNA demonstrated benign splenic tissue consistent with the diagnosis of intrapancreatic accessory spleen (Figure 2b). DISCUSSION: Increased use of imaging has led to a growing number of identified pancreatic abnormalities. While ductal adenocarcinoma of the pancreas is commonly encountered in the presence of isolated solid pancreatic masses, rare malignant entities such as lymphoma and non-malignant entities such as intrapancreatic accessory spleen should remain on the differential diagnosis. These cases illustrate that despite characteristic radiologic findings, tissue diagnosis is prudent prior to management of any pancreatic lesion as consequences of erroneous therapy can be dire.Figure 1a.: MRI abdomen showing normal diameter pancreatic duct with thickening of pancreatic tail and encasement of splenic vein.Figure 2a.: Pancreatic body/tail mass biopsy showing small atypical lymphocytic infiltrate surrounding pancreatic parenchyma, immunophenotypically consistent with low grade follicular lymphoma.Figure 3b.: Pancreatic tail mass fine needle aspiration showing benign splenic tissue. CD8 highlights splenic sinusoidal cells in the secondary image.

S1728 COVID-19-Induced Colitis: A Novel Relationship During Troubling Times

INTRODUCTION: In December 2019, a novel coronavirus was identified known as acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and the resulting disease called coronavirus disease 2019 (COVID-19). The majority of patients with COVID-19 primarily present to the hospital with respiratory symptoms, it is particularly important that physicians are familiar with rare extrapulmonary manifestations in the effort to reduce the delay of diagnosis, treatment and exposure to healthcare workers. CASE DESCRIPTION/METHODS: An 80-year-old Caucasian woman with a history of hypertension, hyperlipidemia and hypothyroidism presented to the ER with 5-days of fever, abdominal discomfort, nausea, diarrhea and hematochezia. The patient denied symptoms of chills, shortness of breath, cough, recent travel or ill-contacts, including exposure to COVID-19. Physical examination revealed a temperature of 100.6 F, a blood pressure of 130/65 mmHg, pulse of 83 bpm, respiratory rate of 15 bpm, and oxygen saturation of 96%. Lung auscultation was clear bilaterally. Abdominal examination revealed a soft abdomen, with positive bowel sounds and tenderness in the lower abdominal quadrants. Rectal exam was positive for bright red blood. A computed tomography (CT) scan of the abdomen revealed thickening of the descending colon with fat stranding- suggestive of an acute colitis (Figure 1). Outpatient colonoscopy completed 3 years prior, was normal. A white-blood count (WBC) of 6.4 K/uL. Liver function tests, lactic acid, lactic acid dehydrogenase (LDH) and coagulation profile were normal. C. difficile and influenza A and B testing were negative. COVID-19 RT-PCR testing returned positive. Rectal bleeding and diarrhea resolved and hemoglobin remained stable. Empiric antibiotic therapy and supportive measures were continued. In the setting of an active colitis, colonoscopy was deferred to the outpatient setting. The patient was discharged home with 10 days of metronidazole therapy and instructed to continue 14 days of home self-isolation. DISCUSSION: This case report highlights the significance of limiting fecal-oral transmission along with adding to the body of evidence that SARS-CoV-2 has the potential to directly infect the gastrointestinal tract in the absence of pulmonary involvement. With mounting evidence, we underline the importance of instituting appropriate precautions in patients who present with respiratory, digestive or other rare clinical presentations.Figure 1.: CT abdomen and pelvis showing thickening of the descending colon along with peri-colic fat-standing consistent with acute colitis.

S3356 What Came First, the IBD or the Worm?

INTRODUCTION: At the turn of the 21st century, inflammatory bowel disease (IBD) became a global issue. Patients present with diarrhea, hematochezia, and colicky abdominal pain. Diagnosis is made based on clinical presentation, endoscopy and biopsy results. Helminths have been used in the therapy of IBD. CASE DESCRIPTION/METHODS: A 63-year-old female presented with periumbilical abdominal pain, vomiting and hematochezia of one week. Family history notable for Crohn’s disease in her mother and a travel history to Peru 1 year prior to presentation. Labs showed neutrophil predominant leukocytosis with WBC 23000/uL. Stool culture was negative, including Clostridium difficile stool PCR. Computed tomography (CT) scan of the abdomen and pelvis showed extensive circumferential thickening of the colonic wall with peri-colonic inflammatory changes. She was diagnosed with infectious colitis and discharged on a course of ciprofloxacin and metronidazole. She presented a week later with recurrent symptoms. Absolute eosinophil count 149/uL. Erythrocyte sedimentation rate (ESR) 55 mm/hr and C-reactive protein (CRP) 15 mg/L. Stool calprotectin 95 mcg/g. Stool cultures were again unrevealing. Repeat CT abdomen and pelvis showed segmental wall thickening and peri-colonic stranding from the distal descending colon to the rectum. Colonoscopy notable for segmental inflammation from the rectum to the cecum. Pathology reported this as focal architectural distortion with granulation tissue in the lamina propria. Additionally, there were discontinuous areas of nonbleeding ulcerated mucosa in the sigmoid colon, hepatic flexure and ascending colon with pathology consistent with ischemic colitis. On follow up, she reported generalized urticarial rash, persistent altered bowel habits and weight loss. Repeat colonoscopy showed healing of previous segmental colitis but notable for parasites in the cecum. This was reported as Trichuris trichiura and she was treated with mebendazole with complete clinical resolution. DISCUSSION: The diagnosis of IBD is based on clinical presentation, inflammation on endoscopy and chronic changes on biopsy. Our case describes inflammatory changes on endoscopy and biopsy which had spontaneously resolved; but also, with an incidental diagnosis of Trichuris infection. It poses an interesting question of whether the initial presentation concerning for possible IBD was due to the helminthic infection or whether the helminthic infection coincided with the colitis and was therapeutic against existing colitis.Figure 1.: Pathology of sigmoid colon remarkable for extensive erosion with fibrinopurulent exudate, fibrosis of lamina propria and atrophic glands, consistent with ischemic changes image showing changes of ischemic changes.Figure 2.: Parasite noted on colonoscopy.

CHYLOTHORAX AS A RARE MANIFESTATION OF METASTATIC GASTRIC ADENOCARCINOMA

SESSION TITLE: Medical Student/Resident Pulmonary Manifestations of Systemic Disease Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Chylothorax is a pleural effusion characterized by a chyle containing intestinal lymphatic fluid in the pleural space. It usually occurs secondary to disruption of flow within the lymphatic system or thoracic duct. A triglyceride count of >200 mg/dL or a cell count and differential >70% lymphocytes on fluid analysis aids with diagnosis, however, the presence of chylomicrons is the gold standard. Metastatic malignancy accounts for only 2.4% of cases. CASE PRESENTATION: A 51-year-old female presented with complaints of abdominal pain and shortness of breath. Physical examination revealed a non-distended abdomen, tender to palpation in bilateral lower quadrants. Lungs were clear to auscultation bilaterally with reduced air entry in the left lung base. Chest x-ray was remarkable for a left sided pleural effusion with left basilar atelectasis. Computed Tomography (CT) chest showed a left sided pleural effusion. CT abdomen and pelvis revealed gastric wall thickening with upper abdominal and retroperitoneal adenopathy, as well as retrocrural nodes extending into the chest. 18F-Fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) scan revealed gastric wall thickening, diffuse lymphadenopathy and bilateral pleural based nodules. Left sided thoracentesis was performed and 1100 cc of milky-white fluid was obtained. The effusion contained 300 mg/dL of triglycerides, 104 mg/dL Cholesterol, and 696/mcL white blood cells with 47% lymphocytes. Medical cytology of the pleural fluid was significant for poorly differentiated adenocarcinoma. Patient opted for hospice care and chose not to undergo chemotherapy. DISCUSSION: Chylothorax as a manifestation of gastric adenocarcinoma is rare. Approximately 50% of chylothorax are as a result of malignancy, however only 2.4% are secondary to metastasis. Signs and symptoms of chylothorax are nonspecific, often presenting like an upper respiratory infection. In most cases, respiratory symptoms precede the diagnosis of gastric cancer. Lymphedema is a common concomitant finding. Chylothorax secondary to malignancy usually presents as a result of direct invasion of the thoracic duct, metastasis into the lymphatic capillaries, or external compression of the thoracic duct. In chylothorax of unknown origin where carcinoma is highly suspected, FDG-PET/CT as a form of imaging can be used as an adjunct to help with diagnosis. Management of chylothorax usually involves treating the underlying cause. Methods may be operative or non-operative. Chemotherapy, irradiation and surgery may be employed to treat the underlying gastric adenocarcinoma, however, unless a high level of suspicion is employed and the gastric carcinoma is recognized early, prognosis is generally poor. CONCLUSIONS: Underlying gastric cancer should be considered as a differential, in those with chylothorax of unknown origin, allowing for early diagnosis and better outcomes. Reference #1: Doerr, C., Allen, M., Nichols, F., Ryu, J. Etiology of Chylothorax in 203 Patients, Mayo Clinic Proceedings 2005; 80(7): 867-870 Reference #2: Maldonado, F., Hawkins, F., Daniels, C., Doerr, C., Decker, P., Ryu, J. Pleural Fluid Characteristics of Chylothorax, Mayo Clinic Proceedings 2009; 84(2): 129 Reference #3: Majoor, C., Aliredjo, P., Dekhuijzen, P., Bulten, J., van der Heijden, H. A Rare Cause of Chylothorax and Lymph Edema, Journal of Thoracic Oncology 2007; 2(3): 247-248 DISCLOSURES: No relevant relationships by Akwe Nyabera, source=Web Response

Tumour texture features from preoperative CT predict high-risk disease in endometrial cancer

To enable more individualised treatment of endometrial cancer, improved methods for preoperative tumour characterization are warranted. Texture analysis is a method for quantification of heterogeneity in images, increasingly reported as a promising diagnostic tool in oncological imaging, but largely unexplored in endometrial cancer AIM: To explore whether tumour texture features from preoperative computed tomography (CT) are related to known prognostic histopathological features and to outcome in endometrial cancer patients. Preoperative pelvic contrast-enhanced CT was performed in 155 patients with histologically confirmed endometrial cancer. Tumour ROIs were manually drawn on the section displaying the largest cross-sectional tumour area, using dedicated texture analysis software. Using the filtration-histogram technique, the following texture features were calculated: mean, standard deviation, entropy, mean of positive pixels (MPP), skewness, and kurtosis. These imaging markers were evaluated as predictors of histopathological high-risk features and recurrence- and progression-free survival using multivariable logistic regression and Cox regression analysis, including models adjusting for high-risk status based on preoperative biopsy, magnetic resonance imaging (MRI) findings, and age. High tumour entropy independently predicted deep myometrial invasion (odds ratio [OR] 3.7, p=0.008) and cervical stroma invasion (OR 3.9, p=0.02). High value of MPP (MPP5 >24.2) independently predicted high-risk histological subtype (OR 3.7, p=0.01). Furthermore, high tumour kurtosis tended to independently predict reduced recurrence- and progression-free survival (HR 1.1, p=0.06). CT texture analysis yields promising imaging markers in endometrial cancer and may supplement other imaging techniques in providing a more refined preoperative risk assessment that may ultimately enable better tailored treatment strategies.

The Impact of 18F-DCFPyL PET-CT Imaging on Initial Staging, Radiation, and Systemic Therapy Treatment Recommendations for Veterans With Aggressive Prostate Cancer

PurposeOur purpose was to study the effect of 2-(3-{1-carboxy-5-[(6-[18F]fluoro-pyridine-3-carbonyl)-amino]-pentyl}-ureido)-pentanedioic acid (18F-DCFPyL) positron emission tomography (PET)-computed tomography (CT) on staging/treatment recommendations of previously untreated prostate cancer. We report here results of a prospective single center single arm imaging trial within Veterans Affairs (Greater Los Angeles): the frequency of patients upstaged to M1 disease (primary endpoint) and the frequency of patients with change in treatment recommendations (secondary endpoint). This is the first report of prostate-specific membrane antigen PET-CT exclusive to U.S. veterans. Methods and MaterialsVeterans with Gleason ≥4 + 3, clinical stage ≥T2c, or prostate-specific antigen >10 ng/mL were eligible. Patients underwent conventional imaging (99mTc-methyl diphosphonate bone scan or 18F-NaF PET-CT; and pelvic CT or pelvic magnetic resonance imaging) in addition to 18F-DCFPyL PET-CT. The effect of 18F-DCFPyL PET-CT on treatment change was determined by applying prespecified treatment recommendations based on National Comprehensive Cancer Network guidelines and modern clinical practice. ResultsOne hundred patients underwent 18F-DCFPyL PET-CT. Nineteen out of 84 (23%) patients initially thought to be nonmetastatic were upstaged to M1; 8/16 (50%) patients initially thought to have M1 disease were downstaged to M0. In total, 39/100 (39%) had a change in prespecified treatment recommendations, including change of radiation therapy volume/dose in 39/100 (39%) and starting abiraterone in 22/100 (22%). ConclusionsIncorporation of 18F-DCFPyL PET-CT into the initial conventional imaging workup for prostate cancer can substantially affect staging/treatment recommendations.

E-cigarette, or Vaping, Associated Lung and Hepatic Injury.

E-cigarette, or Vaping, Associated Lung and Hepatic Injury.

Quantifying the decrease in emergency department imaging utilization during the COVID-19 pandemic at a multicenter healthcare system in Ohio.

PurposeTo illustrate the change in emergency department (ED) imaging utilization at a multicenter health system in the state of Ohio during the COVID-19 pandemic.MethodsA retrospective observational study was conducted assessing ED imaging volumes between March 1, 2020, and May 11, 2020, during the COVID-19 crisis. A rolling 7-day total value was used for volume tracking and comparison. Total imaging utilization in the ED was compared with new COVID-19 cases in our region. Utilization was first categorized by modality and then by plain films and computed tomography (CT) scans grouped by body part. CT imaging of the chest was specifically investigated by assessing both CT chest only exams and CT chest, abdomen, and pelvis (C/A/P) exams. Ultimately, matching pair-wise statistical analysis of exam volumes was performed to assess significance of volume change.ResultsOur multicenter health system experienced a 46% drop in imaging utilization (p < 0.0001) during the pandemic. Matching pair-wise analysis showed a statistically significant volume decrease by each modality and body part. The exceptions were non-contrast chest CT, which increased (p = 0.0053), and non-trauma C/A/P CT, which did not show a statistically significant volume change (p = 0.0633).ConclusionED imaging utilization trends revealed through actual health system data will help inform evidence-based decisions for more accurate volume predictions and therefore institutional preparedness for current and future pandemics.

Unusual localization of chondrocalcinosis: The sternoclavicular joint: Case report and review of the literature

BackgroundChondrocalcinosis is a metabolic arthropathy rarely affecting the anterior chest wall (ACW). Aim of the workTo report here a case of a polyarticular chondrocalcinosis with an uncommon localization in the sternoclavicular joints (SCJs), revealed by computed tomography (CT). Case reportA 76-year old female presented to the Rheumatology outpatient clinic Kassab orthopedics institute with low back pain. The history goes back to 4 months prior to her presentation when she developed mechanical back pain that progressively worsened during the last month, becoming inflammatory with prolonged morning stiffness. She had no history of fever or weight loss and no symptoms in the cervical spine, shoulders, chest wall, hips or knees. Physical examination revealed limited range of motion of hips, cervical and lumbar spine and bilateral swelling of SCJs without tenderness on pressure or mobilization. Biochemical investigations showed normal levels of inflammatory markers, phosphorus and calcium. Conventional radiographs showed multiple areas of calcification in the intra-vertebral discs, joint space narrowing of sacroiliac (SI) and coxofemoral joints. Chest wall radiograph appeared normal. ACW and pelvic CT were done to further delineate the cause. It showed intra-cartilaginous bilateral calcifications of SCJs, sacroilliac, intervertebral discs, coxofemoral joints and pubic symphysis. The final diagnosis was polyarticular chondrocalcinosis. The patient received analgesics, non-steroidal anti-inflammatory drugs and had functional rehabilitation sessions. Conclusion: This case points to the rare localization of chondrocalcinosis in the SCJ and should be considered especially in an elderly female. Early recognition is necessary in order to initiate an appropriate and prompt treatment.

SUN-LB1 Atypical Presentation Of Myocardial Infarction In A Young Patient With Polycystic Ovarian Syndrome

Background: Polycystic ovarian syndrome (PCOS) is a very common and complex endocrine problem in women of childbearing age, with a prevalence of 4 to 12% globally. Myocardial infarction (MI) is the leading cause of death in women worldwide. PCOS increases the risk of MI because of chronic inflammation, endothelial dysfunction, impaired pulse wave velocity and its association with metabolic syndrome, and hormonal imbalance.Clinical Case: A 36-year-old female with a history of PCOS, hirsutism, severe acne on spironolactone, presented to ER with a chief complaint of lower back pain for 10 days that started after lifting a 60-pounds printer. The pain was attributed to musculoskeletal type, one dose of ketorolac intramuscularly was given and she was discharged on cyclobenzaprine. The next morning, she presented with worsening back pain and new-onset vomiting. Physical exam was normal except for BMI 34.6kg/m2; vitals were stable. Lab work showed elevated troponin of 1.43 which rose to 10.6 ng/ml (normal 0.00-0.034), cholesterol 125 mg/dL (less than 200), HDL 33 mg/dL (normal 40-59), LDL 164 mg/dL (normal 100-129). Electrocardiogram showed sinus tachycardia with Q wave changes in leads III and V1 to V3. Echocardiogram showed hypokinesia of left ventricular wall in the mid to apical anterior septum. Computed tomography (CT) scan of the thoracic spine was negative for abscess or fracture. CT of abdomen and pelvis as well as CT angiography chest were negative. Urine drug screening was also negative.As her presentation was attributed to MI, patient was started on heparin drip, aspirin, atorvastatin, and metoprolol. She underwent cardiac catheterization that showed 99% ostial left anterior descending artery stenosis; a drug-eluting stent was successfully placed. After intervention her back pain resolved. She was discharged on dual antiplatelet therapy (aspirin and Prasugrel) along with atorvastatin, metoprolol and nitroglycerin.Conclusion: This case suggests an association of PCOS with MI. A meta-analysis has shown a two-fold increase in risk of coronary artery disease in patients with PCOS (1). Future studies are need to examine opportunities for cardiovascular disease risk reduction in PCOS patients.Reference:1. de Groot PCM, Dekkers OM, Romijn JA, Dieben SWM, Helmerhorst FM. PCOS, coronary heart disease, stroke and the influence of obesity: a systematic review and meta-analysis. Human Reproduction Update 2011. 17 495-500.

Comparing IDREAM as an Iterative Reconstruction Algorithm against In Filtered Back Projection in Computed Tomography

Introduction: Recent studies of Computed Tomography (CT) conducted on patient dose reduction have recommended using an iterative reconstruction algorithm and mA (mili-Ampere) dose modulation. The current study aimed to evaluate Iterative Dose Reduction Algorithm (IDREAM) as an iterative reconstruction algorithm. Material and Methods: Two CT protocols (i.e., A: 120 KV /150 mA, FBP; B: 120KV/ (20-150) mAs, IDREAM) to scan water and acrylic phantoms. A number of 40 patients were assigned to two CT protocols (C: n=20, 120KV/160 ±10 mAs, FBP and D: n=20, 120 KV/ (30-150 mAs, IDREAM), the two groups (C and D) were then referred to abdomen and pelvis CT scan (Sinovision, insitum 16) with contrast. Image quality parameters, dose calculations were measured for all groups (i.e., A, B, C, and D). Results: Group B had a highly significant SNR with less significant noise (P 0.05) in acrylic phantom, as compared to group A. CTDIvol (A: 13.94 mGy ; B: 6.91 mGy , P<0.05 ) and DLP (A:501.76 mGy.cm ; B :248.88 mGy.cm). Noise and SNR were significantly different (P<0.05) in group D against C. CTDIvol (C: 30.3±5.2 mGy ; D : 15.4 ±2.7 mGy, P<0.05 ) , DLP (C:544±100 mGy.cm; D :272.3±50.3 mGy.cm ,P<0.05) and the effective dose (C:8.1±1.5 mSv; D :4.08±0.75 mSv,P<0.05) Conclusion: The results of the present study were indicative of the feasibility of IDREAMas an iterative reconstruction algorithm.

MP62-18 PRIMARY METASTASIS STAGING USING 18 F-PSMA-1007 PET-CT IN HIGH-RISK PROSTATE CANCER

MP62-18 PRIMARY METASTASIS STAGING USING ¹⁸ F-PSMA-1007 PET-CT IN HIGH-RISK PROSTATE CANCER

Alvarado score and computerized tomography scan as impact indicator in intervening negative appendectomy rate

Background: The objective of this study is to study the impact of combined use of Alvarado score and computed tomography (CT) scan on negative appendectomy rate.Methods: This prospective observational study comprising of patients presenting with clinical features of appendicitis admitted to department of general surgery, VIMSAR, Burla from November 2017 to October 2019, where Alvarado score and ultrasonography (USG) findings are mismatching each other. Alvarado scores calculated and categorized in 2 groups as negative (score &lt;4) and positive (score ≥4). These patients were also subjected to USG and categorized as negative (USG -ve) and positive (USG +ve). Those patients having discrepancy in both the findings were subjected to CT scan. On histopathological examination, inflamed appendix in 63 (97%) patients and non-inflamed in 2 (3%). Rest patients were either discharged (both -ve) or operated (both +ve). Results: Total 84 patients showed discrepancy between Alvarado score and USG findings and are subjected to CT scan abdomen and pelvis. CT scan was positive for appendicitis in 65 cases (where appendectomy done) and negative for appendicitis in 19 cases (where the diagnosis is different). patient. Thus, negative appendectomy (NAR) is 3% in this study.Conclusions: Alvarado score and ultrasonography could not be used as absolute tool in doubtful and equivocal cases, where combined use of CT scan with Alvarado score and USG has definitely has an edge by diagnosing the differentials and reducing NAR followed by reduction in cost and length of hospital stay.

A comparison of the CT-dosimetry software packages based on stylized and boundary representation phantoms

IntroductionWith the rapid development of computed tomography (CT) equipment, the assessment of effective and organ dose using suitable tools becomes an important issue and will provide health professionals with useful information regarding the radiation risks and the development of standard imaging protocols. Different clinical centres and/or institutions may use several software packages, each with different methods and algorithms for CT dose evaluation. Consequently, radiation doses calculated with these computer software packages might be different for the same patient and representative scanner models. MethodsThe effective and organ doses calculated by VirtualDose, CT-expo, and ImPACT software were compared for both males and females using kidney, chest, head, pelvis, abdomen, and whole-body CT protocols. The calculation of radiation dose in these software depends on the use of stylized and boundary representation (BREP) phantoms. ResultsIn general, the results showed that there was a discrepancy between the effective dose values calculated by the three packages. The effective dose in all examinations varied by factors ranging from 1.1 to 1.5 for male and from 1.1 to 1.3 for female. For the female phantom, the VirtualDose shows the highest effective doses in kidney and abdomen examinations while CT-expo gives the highest doses for head and pelvis examinations. For the male phantom, the VirtualDose shows the highest effective doses were for chest examinations. ConclusionVirtualDose approach gives the most accurate estimation, however, further work using a size-based method are necessary to improve the assessment of the effective and equivalent organ dose in CT examinations using these packages. Implications for practiceThe re-evaluation dosimetry software in comparison with patient size would allow for a more accurate estimation of dose and support the optimization process.

Paraspinal Fat Stranding as an Unexpected Finding on Body Computed Tomography: A Key to Early Detection of Spinal Osteomyelitis

Objective:At present, early detection of spinal osteomyelitis is a challenge. Patients may present with non-specific symptoms and diagnostic imaging studies may be obtained for seemingly unrelated complaints. Paraspinal fat stranding on body computed tomography (CT) as a sign of osteomyelitis is easily overlooked and has not been reported in the literature to our knowledge. The purpose of this study is to review findings on body CT that points to unsuspected spinal osteomyelitis.Material and Methods:A retrospective review of patients with spinal osteomyelitis who also had concomitant chest, abdominal, or pelvic CT scans between August 2013 and February 2017 yielded 10 patients who had confirmed osteomyelitis (ages between 51 and 75, mean age 64.8). Images and medical records were reviewed.Results:The age of the patients ranged from 51 to 75 years (median value, 64). All patients had multiple underlying medical illnesses, and half of them had a known preceding infection such as sepsis or urinary tract infection. At presentation, three patients had a fever and two patients had neurologic deficits. Seven out of eight patients had elevated C-reactive protein and erythrocyte sedimentation rate, five patients had leukocytosis, and four patients had positive blood cultures. Paravertebral fat stranding and endplate erosions were observed in 9 and 6 cases, respectively, on initial body CT for unrelated indications, and subsequent magnetic resonance imaging confirmed osteomyelitis discitis.Conclusion:Clinically significant, but initially unsuspected, spinal pathology such as osteomyelitis may present on body CT scans. Earlier diagnosis of spinal osteomyelitis can be made by performing a focused evaluation of the paraspinal soft tissues and including osteomyelitis in the differential diagnosis, particularly in high-risk patients.

Post-traumatic arthritis of the sacroiliac joints mimicking inflammatory sacroiliitis: analysis of consecutive computed tomography examinations

To assess the presence, prevalence and characteristics of post-traumatic, inflammatory-like changes of the sacroiliac joint (SIJ) on pelvic computed tomography (CT). Sequential CT examinations from the acute (index) and follow-up post-traumatic periods of 24 patients that underwent pelvic trauma with SIJ involvement were evaluated and compared to 32 control patients with pelvic fractures that did not involve the SIJs. Index CT was evaluated for the presence of fracture, intra-articular step, and diastasis, whereas follow-up CT was scored for periarticular sclerosis, erosions, ankylosis, and backfill. Clinical follow-up was performed by pain provocation SIJ tests and a questionnaire (study representative subgroup, n=11, 46%) and from clinical files (control group, n=26, 31%). Pearson correlation coefficient was assessed between the index and follow-up CT variables. Linear regression was used to predict the influence of trauma variables on the development of inflammatory-like structural changes. Total "structural, arthritis-like lesions' score from the follow-up CT examination was significantly higher in the study compared to the control group (3.25 versus 0.05 respectively, p<0.001). The presence of intra-articular diastasis and fracture were significant risk factors for the development of structural inflammatory-like lesions in the SIJ (1.19 and 2.1 respectively, p<0.001). Painful SIJs by physical examination were found in 50% of the clinically evaluated subgroup which was mechanical by nature in 81.8%. Traumatic SIJ fracture or diastasis is associated with the development of post-traumatic SIJ structural inflammatory-like lesions on pelvic CT, mimicking sacroiliitis. These findings may be the result of focal, post-traumatic joint inflammation, which leads to mechanical rather than inflammatory symptoms.