Peritoneal Deposits Research Articles

Pre treatment and post treatment positron emission tomography–computed tomography (PET–CT) to evaluate treatment response in tuberculous Tubo-Ovarian masses

PurposeFemale genital Tuberculosis (FGTB) causes infertility and formation of Tubo-ovarian (TO) masses. The study showed treatment response of PET-CT in evaluation of anti-tubercular treatment response in patients of infertility with tuberculous TO masses. MethodIt’s a Prospective study on 47 confirmed cases of FGTB with infertility having TO masses. All patients were subjected to 18F-FDGPET/CT to see the glucose uptake by the TO mass and extent of the disease. Category I treatment under DOTS was given for 6 months. All underwent follow-up of PET/CT to see the response to ATT. Results of pre ATT PET/CT were compared with post ATT PET/CT. ResultsTO masses was in 42 (89.36%); bilateral in 18 (38.29%) FDG uptake in 14 (29.78%) and without FDG uptake in 4 (8.51%) cases. Right sided mass in 13 (27.65%) FDG uptake in 9 (19.14%) and without FDG uptake in 4 (8.51%) cases. Left sided mass in 11 (23.40%) FDG uptake in 7 (14.89%) and without FDG uptake in 4 (8.51%) cases. Post ATT, there was significant decrease in most parameters. Repeat PET-CT done in 44 cases showed TO mass in 9 (20.45%); bilateral in 4 (9.09%) (FDG uptake in 2.27%) (p < 0.001), right sided in 3 (6.85%) (FDG uptake in 2.27%) (p < 0.002) and left side in 2 (2.27%) FDG uptake in 1 case (p < 0.004). Pelvic and mesenteric lymphadenopathy without FDG uptake was in 1 case (p value = 0.03) while omental and peritoneal deposits without FDG uptake in 1 and 2 cases, respectively. ConclusionPET-CT is useful in treatment response evaluation of tubercular TO masses.

FC 102PD INDUCED ARTERIOLAR AND PERITONEAL PATHOMECHANISMS ARE PARTIALLY REVERSED AFTER KIDNEY TRANSPLANTATION

Abstract Background and Aims Due to the unphysiological composition of PD fluids, chronic peritoneal dialysis (PD) induces progressive peritoneal fibrosis, hypervascularization, and vasculopathy. The evolution of the PD membrane and vasculopathy following kidney transplantation (KTx) is largely unknown. Method Arteriolar and peritoneal tissues were obtained from 107 children with chronic kidney disease (CKD5), 72 children on PD (treated with neutral pH PD fluids, with low glucose degradation product content, GDP) and 21 children, who underwent KTx 4-5 weeks after a median 21 months of PD. Specimen underwent standardized digital quantitative histomorphometry. Molecular mechanisms were studied in omental arterioles microdissected from surrounding fat by multi-omics followed by Gene Set Enrichment Analysis (GSEA); key findings were validated in parietal tissues of independent, matched cohorts by quantitative immunohistochemistry (n=15/group). Results Arteriolar transcriptome and proteome GSEA revealed suppression of leucocyte migration and T-cell activation / secretory pathways regulation, of sprouting angiogenesis biological processes and of epithelial proliferation and cell cycle after KTx as compared to PD. Lipid / fatty acid metabolism, autophagy and ATP synthesis pathways were activated. Transcriptome analysis including KTx, PD and CKD5 specifically attributed regulation of arteriolar lipid and fatty acid metabolism to transplantation and comprised 140 transcripts; their regulation was confirmed on the proteome level. Hub gene fatty acid synthase was identified by protein interaction analysis (string-db.org). 15 arteriolar genes activated by PD were inactivated after KTx and included glucose metabolisms and cytoskeleton related transcripts. 24 transcripts and 10 corresponding proteins induced by PD were still active after KTx and associated with biological processes related to TGF-ß signaling, fibrosis and mineral absorption. In line with arteriolar multi-omics findings, peritoneal hypervascularization induced by chronic PD was reversed after Tx to CKD5 level. CD45 positive tissue infiltrating leucocytes count was reduced by 40% and was independently associated with microvessel density in multivariable analysis including PD vintage, daily GDP exposure and recent KTx. Peritoneal lymphatic vessel density, submesothelial thickness, activated fibroblast, fibrin deposit, macrophage and EMT cell counts remained unchanged after KTx compared to PD. Arteriolar lumen to vessel ratios (a marker of vasculopathy) were similar in both groups. Vessel-homeostasis-related proteins in independent, matched cohorts demonstrated increased caspase-3 abundance in peritoneal arterioles after KTx. Arteriolar VEGF-A, thrombospondin, angiopoietin1/2, and hypoxia-inducible factor-1 (HIF-1a) were unchanged, while submesothelial HIF-1a and angiopoietin1/2 were decreased after Tx, favoring vessel maturation. The abundance of the key driver of fibrosis, TGF-ß-effector pSMAD2/3, was unchanged in the peritoneum and arterioles after Tx. Conclusion Our multi-omics analyses of fat covered omental arterioles, not directly exposed to PD fluids, demonstrate inhibition of PD induced immune response and angiogenesis pathways, of glucose metabolism and cytoskeleton regulation to levels similar as seen in children with CKD5. Arteriolar lipid and fatty acid metabolism is selectively altered after KTx. Reversal of low GDP PD induced hypervascularization and inflammation of the parietal peritoneum after KTx, mirror molecular changes in omental arterioles, while profibrotic activity persists after KTx in omental arterioles and in the parietal peritoneum.

Incidental encounter of intraperitoneal tuberculosis during renal surgeries: A surgeon's dilemma

Tuberculosis is a major healthcare burden in India, which accounts for the maximum number of cases worldwide. Due to its non-specific features, peritoneal tuberculosis has been dubbed as the great mimicker of various other abdominal pathologies. This case series highlights the importance of incidental intra operative detection of peritoneal tuberculosis in cases being operated for renal pathologies. Diagnostic and therapeutic dilemma is bound to occur when surgeon is faced with such an unexpected finding. Incidental peritoneal tuberculosis was defined as peritoneal tubercular lesions (ascites or tubercles) detected intraoperatively in patients being operated for non-tuberculosis related indications and no prior preoperative suspicion of abdominal tuberculosis. We here review 3 cases with different renal pathologies and no prior history or exposure to tuberculosis in which intraperitoneal tuberculosis was encountered incidentally at the time of surgery. Case 1 was a suspected case of right renal cell carcinoma and underwent right robotic nephron sparing surgery. Case 2 underwent robotic assisted lap simple nephrectomy for a right nonfunctioning kidney due to obstructive ureteric calculus. Case 3 was a suspected case of left upper tract urothelial carcinoma who underwent robotic nephroureterectomy with bladder cuff excision. In all 3 cases, on encountering the peritoneal lesions, an intraoperative decision to continue with the proposed surgery was made after frozen section biopsies from the multiple peritoneal and omental deposits revealed no malignant cells. Histopathology of these lesions in all 3 cases revealed caseating granulomas consistent with a diagnosis of disseminated peritoneal tuberculosis. None of the resected specimen had features suggestive of tuberculosis. ATT was started and on follow up the patients are doing well. Peritoneal tuberculosis although uncommon is not a rare presentation of active tuberculosis. Surgeons on encountering such lesions during non-related surgeries should always have a high suspicion of tuberculosis. Despite the existing literature favoring abandoning the procedure in such situations, we successfully completed the proposed surgeries.

A145 ENDOSCOPICALLY NON-VISIBLE INTERVAL COLONIC ADENOCARCINOMA DESPITE HIGH-QUALITY SURVEILLANCE.

Abstract Background Colonoscopy remains the gold-standard for screening and surveillance of colorectal cancer (CRC). Regular colonoscopy with polypectomy has been associated with reduced CRC incidence and mortality. However, interval CRC, defined as cancer diagnosed between initial screening and subsequent surveillance colonoscopies, occurs at rates of 2–14%. Identified risk factors for interval cancers include patient-related factors (older age, diverticular disease, proximal CRC), endoscopy-related factors (colonoscopy by non-gastroenterologists or in an outpatient setting; endoscopists with low rates of completion, adenoma detection or polypectomy) and biologic factors (microsatellite instability (MSI), CpG island methylation). We report a patient with interval metastatic ileo-cecal adenocarcinoma despite multiple, high-quality surveillance colonoscopies, not endoscopically visible as no visible intra-luminal mucosal component was present. Aims To describe a case of an interval CRC without an endoscopically visible intra-luminal component. Methods Case description and literature review. Results A 69-year-old male, with a history of multiple advanced colonic polyps requiring multiple surveillance colonoscopies and polypectomies, presented with symptoms of bowel obstruction. An abdominal CT scan revealed findings of terminal ileitis and upstream small bowel obstruction. Colonoscopy was performed, revealing obstruction of the ileo-cecal valve with a firm cecal submucosal lesion without abnormal overlying mucosal abnormalities. Exploratory laparoscopy revealed a mass at the ileo-cecal valve with associated peritoneal deposits. A right hemicolectomy was performed, and pathological examination demonstrated metastatic invasive adenocarcinoma involving the cecum, the terminal ileum and ileo-cecal valve without extension into the lumen or formation of an overt polypoid mass. The tumour extended into the wall of the distal ileum in a circumferential fashion, involving the immediate deep serosa, but with only minimal, focal mucosal ileal involvement and no overt polypoid mass. An independent review of the case and resection specimen by a second pathologist confirmed absence of significant ileal or colonic mucosal involvement and no obstructing intraluminal component. Conclusions This case illustrates a rare presentation of an interval CRC that was not identified despite several high-quality surveillance colonoscopies, as only minimal mucosal involvement was present. As endoscopy remains the gold-standard for early detection and removal of pre-malignant lesions and early malignancy, the patient’s presentation with interval malignant bowel obstruction and metastatic disease, despite adequate quality surveillance, demonstrates an inherent limitation of colonoscopy. To our knowledge, this is only the third documented case of endoscopically non-visible interval CRC. Funding Agencies NoneNone

Evaluation of Peritoneal Deposits in Undiagnosed Ascites by Advanced Endoscopic Ultrasound Imaging Techniques

AbstractEtiology of ascites can be usually determined with ascitic fluid cytological and biochemical evaluation. Occasionally, the cause of ascites cannot be determined despite repeated ascitic fluid evaluations. These patients with undiagnosed ascites usually undergo diagnostic laparotomy/laparoscopy for etiological diagnosis. Endoscopic ultrasound (EUS) can help in resolving the diagnostic conundrum of undiagnosed ascites by visualizing as well as sampling peritoneal and omental deposits/thickening. However, rarely fine-needle aspiration from deposits may be falsely negative and patient may need repeat sampling. Newer EUS imaging techniques such as elastography and contrast-enhanced harmonic EUS by providing additive information on stiffness and enhancement pattern of the lesion can help in differential diagnosis.

Transrectal endoscopic ultrasound in undiagnosed ascites: is it a peritoneal deposit?

Transrectal endoscopic ultrasound in undiagnosed ascites: is it a peritoneal deposit?

Hyperthermic intraperitoneal chemotherapy in ovarian cancer: Qui Bono?

Ovarian cancer is a major cause of cancer related-death in women around the world. Recent statistics on the worldwide cancer burden by the International Agency for the research on Cancer revealed ovarian cancer being both the eighth most frequent malignancy in the west countries. Peritoneal metastasis from ovarian cancer is a major challenge in the clinical management. Despite the evidence of the benefit of Intraperitoneal Chemotherapy in ovarian cancer with peritoneal deposits it has not been widely adopted, mainly due to logistical difficulties and less to the logoregional morbidity as pain. The role of hyperthermic intraperitoneal chemotherapy (HIPEC) in patients during the end of cytoreductive surgery (CRS) is a more tolerable feasible method with potential advantages as drug distribution, combination with hyperthermia and application before tumor regrowth. The aim of this article is to investigate the potential benefits of HIPEC explains the rationale, data of major clinical trials meta-analyses and recent randomized trial are presented and explains the indications patient selection and the best time to applicate of this aggressive logo regional treatment.

Adnexal Mass with an Unknown Histology

Background: Ovarian malignancy is a common malignancy in women. Most malignancies are adenocarcinoma. However, adnexal metastases from squamous cell carcinoma (SCC) of the cervix are uncommon. Case: We present a 53-year-old nulliparous postmenopausal woman who presented with pain in abdomen, adnexal mass, and high CA125 levels. On local examination, vagina and cervix were apparently healthy with retroverted uterus of normal size, and bilateral (B/L) forniceal thickening was present. Pouch of Douglas and rectal mucosa were free. Clinicoradiologic diagnosis was an ovarian malignancy. Results: Intraoperatively, ∼150 mL mucinous ascites and omental caking with subcentimeter deposits on right subhepatic peritoneum were noted. Uterus was apparently normal and B/L adnexal masses with stretched and dilated B/L tubes were seen, ovaries could not be visualized separately (right = 6 × 5 cm, left = 7 × 4 cm). B/L pelvic lymph nodes were grossly enlarged with pelvic peritoneal deposits. A total abdominal hysterectomy with B/L pelvic lymph node dissection with total omentectomy with excision of pelvic and subhepatic peritoneal deposits with appendicectomy was done and a Sugarbaker's completeness cytoreduction score 0 (CC-0) was achieved. Final histopathologic examination postsurgery revealed disseminated SCC of the cervix. Conclusions: Before confirming a diagnosis of primary SCC of the ovary, a consideration of possible origin from a cervical tumor should be made, unless overt features of primary neoplasia are immediately obvious.

Computed tomographic characterization of adnexal masses

Aims: To evaluate the computed tomographic scan features of benign and malignant adnexal masses.&#x0D; Methods: Retrospective descriptive study of CT scan features of adnexal masses were evaluated at Department of Radiology of Nobel Medical College from April to September 2020. Initial ultrasound or clinical diagnoses of adnexal masses were referred for the CT scan. Incidental adnexal findings on abdominal-pelvic CT scan performed for other diagnosis were also included.Descriptive parameters were calculated.&#x0D; Results: Total 46 cases were studied where mean age was 41.3 years with range 10-74 years. Most common age group with adnexal masses were in between 30 and 50 years (56.6%); 86% had benign features and rest were associated with either ascites (66%) or peritoneal deposits (13%). Complex cysts (60%) was the most common consistency with simple cyst (26%) followed by solid (6%). Amongst the benign neoplastic lesions most of them were dermoid cysts (35%).&#x0D; Conclusions: CT scan can be used as a supplementary diagnostic tool for cystic and solid componentcharacterization of adnexal masses and help in evaluation of the nature and extent of disease.&#x0D; Keywords: adnexal mass, computed tomography, simple cyst, complex cyst

Confronting a rare ovarian cancer during lockdown

Confronting a rare ovarian cancer during lockdown

Role of Staging Laparoscopy in Gallbladder Cancer

Background Preoperative accurate staging of gallbladder cancer is still difficult. A number of patients with gallbladder cancer who undergo laparotomy for curative resection are ultimately found to have unresectable disease. The benefit of staging laparoscopy is its ability to find out the radilogical occult intraperitoneal metastasis and to spare from non-theraputic laparotomy. The role of staging laparoscopy has been extensively studied in hepatobiliary and pancreatic malignancies and found to be useful. But in recent time its utility in biliary cancers is sceptical probably because of the advent of positron emission tomography. However in gallbladder cancer it is still recommended.&#x0D; Objective To identify the utility of staging laparoscopy in gall bladder cancers.&#x0D; Method Hospital based study conducted at Nepalgunj Medical College, Nepal from October 2014 to June 2020. The patients with resectable gallbladder cancers on computed tomography were included. All patients underwent single stage staging laparoscopy. Staging laparoscopy was considered positive if the surface lesions (liver and/or peritoneal deposits) were detected. The surgery was terminated if positive. Patients with negative staging laparoscopy were proceeded with laparotomy.&#x0D; Result Staging laparoscopy was done in 47. The yield of staging laparoscopy was 14 (29.78%) and its accuracy was 58.33% (14/24). Out of 33 (70.21%) with negative staging laparoscopy, 10 (30.3%) had unresectable disease in laparotomy. The yield was higher in locally advanced in comparison to early disease (78.57% Vs 21.42%).&#x0D; Conclusion We recommend routine staging laparoscopy in gallbladder cancer, particularly when the disease is locally advanced.

Endometriosis-induced massive hemoperitoneum misdiagnosed as ruptured ectopic pregnancy: a case report

BackgroundEndometriosis, an estrogen-dependent inflammatory disease, is commonly observed in gynecologic practice. Spontaneous hemoperitoneum is a rare but serious complication of endometriosis. Most cases of endometriosis-induced hemoperitoneum are attributable to a ruptured endometrioma or utero-ovarian vessel hemorrhage. We report a case of massive hemoperitoneum secondary to intra-abdominal bleeding from the peritoneal endometriotic deposits with spontaneous abortion that was misdiagnosed as a ruptured ectopic pregnancy.Case presentationA 36-year-old Korean woman was admitted to our hospital for acute abdominal pain and vaginal bleeding. She was suspected of ruptured ectopic pregnancy on the basis of a positive serum human chorionic gonadotropin test result and ultrasonographic evidence of pelvic fluid collection. During hospitalization, her symptoms deteriorated with peritoneal irritation sign on physical examination, hypotension, and tachycardia. Emergency exploratory laparoscopy was performed and revealed active bleeding from the peritoneal endometriotic deposit, which was treated with laparoscopic electrocoagulation. The patient’s postoperative course was uneventful. Spontaneous abortion was diagnosed on the basis of decreased serial serum human chorionic gonadotropin level estimation.ConclusionsAlthough rare, gynecologists should consider endometriosis-induced hemoperitoneum with spontaneous abortion in the differential diagnosis in women of reproductive age presenting with a positive serum human chorionic gonadotropin test result and acute abdomen with intra-abdominal bleeding.

The Role of Diffusion Weighted Imaging in suspected cases of ovarian cancer

BackgroundOvarian cancer is a common gynecological malignancy and often diagnosed late with extensive peritoneal and nodal metastasis. Diffusion-weighted imaging (DWI) provides valuable information about the structural properties of the tissue and has shown great value in cancer imaging. Recently developed post-processing three-dimensional apparent diffusion coefficient (3D ADC) map has a significant value in variable tumors yet its role in ovarian cancer is not well established. We aim to evaluate the added value of DWI and 3D ADC maps in the diagnosis of ovarian masses, detection of nodal and peritoneal deposits, and so appropriate management planning.ResultsConventional MRI and DWI were performed to fifty-one patients with complex cystic or solid adnexal lesions depicted by gynecological ultrasonography. Results were compared with surgical and histopathologic findings revealing 23/51 (45%) had malignant ovarian tumors and 28/51 (55%) had benign ovarian pathologies. The mean 3D ADC values were 0.977 ± 0.32, 0.934 ± 0.27, and 0.956 ± 0.25 × 10−3 mm2/s for ovarian, nodal, and peritoneal malignancy respectively which were significantly lower than the mean 3D ADC values of benign ovarian lesions, non-metastatic lymph nodes and benign peritoneal lesions/fat which were measured 1.516 ± 0.6, 1.208 ± 0.25, and 1.46 ± 0.43 × 10−3 mm2/s respectively.ConclusionAdding DWI and 3D ADC maps to routine MRI improves the sensitivity, specificity, and accuracy for detecting ovarian malignancy, nodal, and peritoneal metastasis. They also provide qualitative data helping in the differentiation of malignant and non-malignant entities.

Su1294 CONTRAST ENHANCED ENDOSCOPIC ULTRASOUND IN EVALUATION OF PERITONEUM IN UNDIAGNOSED ASCITES

Endoscopic ultrasound (EUS) can directly visualize as well as sample peritoneal deposits/thickening. Contrast enhanced EUS (CEUS) is an image enhancement technique that provides high resolution images of the microcirculation of the target lesions. The peritoneal deposits/thickening have not been previously evaluated with CEUS. To assess the CEUS features of malignant peritoneal deposits/thickening in patients with undiagnosed ascites and compared them with the CEUS features of tubercular deposits. Records of 12 patients (10 males; mean age: 54.0 ±11.1 years) with undiagnosed ascites who underwent EUS and CEUS followed by EUS guided fine needle aspiration (FNA) were retrospectively retrieved from our data base and analysed. The peritoneal nodules were seen as heteroechoic nodules hanging from the peritoneum into the anechoic ascites. CEUS was performed done at low output power (MI = 0.2) after injecting a 2.4-mL bolus of the US contrast agent Sonovue (Bracco, Milan, Italy) followed by flushing with 10 mL of normal saline. The contrast enhancement of nodules was classified as enhancing, hypo-enhancing, or no enhancement. All the included 12 patients had exudative ascites with low serum ascitic albumin gradient (SAAG). CT revealed omental thickening in 2 patients and only ascites in remaining 10 patients. The final diagnosis was: tuberculosis in 4 patients and malignant ascites in 8 patients. EUS revealed peritoneal nodules only in 10 patients and both thickened omentum as well as peritoneal nodules in two patients. The peritoneal deposits were noted as echogenic rounded lesions hanging out clearly in the presence of anechoic ascites (Fig 1). The peritoneal nodules were larger and well defined in malignant ascites as compared to tubercular ascites (4.6 ± 1.2 mm vs. 2.1 ± 0.5 mm respectively; p=0.003). On CEUS, the peritoneal deposits were enhancing in all 8 patients with malignant ascites whereas they were enhancing in only 1 patient with tubercular ascites (p=0.01). There were no complications of the procedure. CEUS, by demonstrating the enhancement pattern of peritoneal nodules, appears to be a good diagnostic modality for accurately differentiating tubercular from malignant ascites.

Indigenous way of hyperthermic intraperitoneal chemotherapy

Introduction: Hyperthermic Intraperitoneal Chemotherapy (HIPEC) is a form of highly concentrated, heated chemotherapy that is delivered directly to the abdomen intra-operatively. Currently for peritoneal surface malignancy (PSM), either primary or secondary from gastrointestinal (GI) or gynecologic cancers, cytoreductive surgery (CRS) combined with peri-operative HIPEC therapy is recommended. Aims &amp; objectives: The primary objective of this case report is to show that in the current era of malignancy, resource poor centers can adopt our innovative way of HIPEC therapy and can treat peritoneal neoplasms which were considered to have only palliative treatment. Methods: After proper pre-operative work up, 61 year old lady diagnosed with adenocarcinoma of the sigmoid colon with peritoneal deposits was taken up for cytoreductive surgery and HIPEC. In the absence of a proper HIPEC machine, we used the hotline fluid warmer used by Anesthesiologists to heat the chemotherapy solution which was then re-circulated manually. Results: The patient had an excellent post-operative recovery and was discharged in a hemodynamically stable condition on post-operative day (POD) 6. She has completed 18 months of follow-up and has no signs of recurrence. Conclusions: To treat cancer like peritoneal neoplasm in resource-poor centers, the hotline machine can be a good option.

Pure T3 thyrotoxicosis from a Struma Ovarii characterised by a paradoxical rise in thyroxine on treatment.

SummaryA 33-year-old female presented with a right 11.6 cm ovarian cyst. Routine pre-operative thyroid function tests showed thyroid stimulating hormone (TSH) of less than 0.02 mU/L (0.3–3.05) and a free thyroxine (FT4) of 5.5 pmol/L (10–28.2) suggesting either assay interference, triiodothyronine (T3) ingestion or hypopituitary hypothyroidism. A free triiodothyronine (FT3) level was requested which was high normal 6.9 pmol/L (3.1–8.1). Parallel assays on a different platform were similar but with a raised FT3 of 7.2 pmol/L (3.1–6.8). TSH receptor stimulating antibody (TSHAb) and thyroid peroxidase antibodies (TPO) were negative. Antithyroglobulin antibody (TgAb) was positive at 155.6 IU/mL (0–115). She was clinically euthyroid. Thyroid ultrasound showed a normal sized mildly heterogeneous gland with low blood flow and a solitary 1.5 cm U3 (BTA) nodule with higher blood flow. Thyroid Tc99m uptake was very low 0.2% (0.6–3.0) with no nodule uptake. These results demonstrated an extrathyroidal source of excessive autonomous T3 production resulting in the low thyroxine (T4). With carbimazole her TSH rose to 11.9 mU/L, FT4 rose to 7.7 pmol/L and FT3 reduced to 3.6 pmol/L. Histological diagnosis was Struma Ovarii. Her TSH, FT4 and FT3 remained normal thereafter. In conclusion, an extrathyroidal source of high T3 secretion was diagnosed using routine thyroid tests and scans. We believe this is the first description of a Struma Ovarii exclusively secreting T3 hormone characterised by the paradoxical rise of a low FT4 to normal with treatment. Two years later she developed non-secreting peritoneal deposits of highly differentiated follicular carcinoma.Learning points:Abnormally low TSH and FT4 levels suggestive of possible T3 ingestion, or less likely, hypopituitary hypothyroidism should always be followed by an assay of FT3.The diagnosis of an extrathyroidal source of T3 can be made using conventional thyroid tests, thyroid ultrasound scanning and technetium thyroid uptake and scan imaging. In a pre-menopausal patient this avoids a radiation dose to the pelvis.Pelvic radioisotope scanning of a suspected Struma Ovarii causing thyrotoxicosis can be reserved for patients whose thyroid function remains abnormal after initial surgery.Carbimazole is effective in the treatment of extrathyroidal autonomous T3 hormone production from a Struma Ovarii.The pathological appearance of a Struma Ovarii is not a guide to its malignancy. Even with a benign appearance they can disseminate to peritoneum, as highly differentiated follicular carcinoma (previously known as peritoneal strumosis).Hyperthyroid secretion by a Struma Ovarii may not be replicated in the metastatic follicular carcinoma in the peritoneum.

A84 LINITIS PLASTICA FROM A NON-GASTROINTESTINAL PRIMARY TUMOR: A CASE REPORT

Abstract Background Infiltrative malignancies to the stomach are unusual and are difficult to detect. Linitis Plastic is a syndrome caused by submucosal invasion of the gastric wall. It represents Bormann type III or IV of gastric adenocarcinoma. Uncommonly, the latter can be a manifestation of lobular breast cancer. Aims To present a case report of lobular breast cancer that manifested primarily as Linitis Plastica (LP). We review the literature of LP as a clinical syndrome and the diagnostic challenges associated with this condition. We aim to increase the awareness of LP as a non-gastric tumor and its endoscopic features. Methods - Results A seventy-two-year-old female patient, previously healthy, presented with general deconditioning and distended abdomen. Basic laboratory testing such as complete blood count, electrolytes and kidney function were normal. Computed tomography of the abdomen and pelvis revealed moderately sized peritoneal carcinomatosis deposits on the abdominal wall. Her family history was non-contributary for any gastrointestinal or gynecological malignancies. On review of system, the patient noted a history of successful eradication of Helicobacter pylori infection remotely. Additionally, no preceding age-appropriate malignancy screening tests were reported. A gastroscopy was done looking for a primary gastrointestinal tumor exhibited abnormally stiff gastric wall, erythematous thickened mucosal folds, and non-distensible stomach. No clear lesions, submucosal masses or ulcers were visualized. The duodenal mucosa was noted to be normal. Twelve deep random biopsies were retrieved from the mucosal body and fundus. Following immunohistochemistry, the histological diagnosis revealed lobular adenocarcinoma of the breast. Conclusions Linitis Plastica (leather bottle stomach) or Brinton disease is a rare entity of diffuse gastric mucosa infiltrating tumor. LP depicts 3–10% of primary gastric carcinoma, whilst less than 10% are secondary breast cancer. Endoscopically, breast cancer-related LP can be divided into two morphologies: nodular pattern with ulceration, which is the typical presentation of ductal breast carcinoma and diffuse mural pattern in lobular breast carcinoma. LP is a unique condition with challenging diagnostic features. Many biopsies can result in negative histopathological diagnoses. This can be explained partially by 1. The scirrhous and fibrous stroma that forms LP tumors. 2. The deep location in the submucosa and muscular layer of the gastric wall. 3. Inability to identify this entity endoscopically. In one case report, Endoscopic Ultrasound-Fine Needle Aspirate (EUS-FNA) was incorporated after negative obtained biopsies. There are no standardized diagnostic approaches for LP. Further studies inquiring rates of missed malignant diagnoses and optimum diagnostic assessments in the setting of LP are needed. Funding Agencies None

Multicenter phase I/II study of intravenous gemcitabine + nab-paclitaxel combined with intraperitoneal paclitaxel for pancreatic ductal adenocarcinoma patients with peritoneal metastasis.

702 Background: Pancreatic ductal adenocarcinoma (PDAC) patients with peritoneal metastasis (peritoneal deposits and/or positive peritoneal cytology) have an extremely poor prognosis, and an effective treatment strategy remains elusive. Methods: The aim of this study were to determine the recommended dose (RD) for a combination of intravenous (IV) gemcitabine, intravenous nab-paclitaxel, and intraperitoneal (IP) paclitaxel in chemotherapy-naive PDAC patients with peritoneal metastasis and to evaluate the clinical efficacy and safety. Gemcitabine and nab-paclitaxel was administered IV combined with paclitaxel IP on days 1, 8 and 15, followed by 1 week of rest. The frequency of dose-limiting toxicity was evaluated and the RD was determined. The primary endpoint of the phase II part was 1-year overall survival (OS) rate. The secondary endpoints were antitumor effect, symptom relief effect, safety and OS. Results: In the phase I part, RD for IV gemcitabine, IV nab-paclitaxel and IP paclitaxel were determined as 800 mg/m2, 75 mg/m2, and 20 mg/m2, respectively. A total of 46 patients were enrolled in the phase II part and drugs were delivered at the RD. All patients had positive intraperitoneal cytology and 29 patients (63.0%) had the peritoneal dissemination. The median treatment period was 6.0 (0-22.6) months. The response rate and disease control rate were 45.7% and 95.7%, respectively. Ascites disappeared in 40.0% and cytology turned negative in 67.4%. Median CA19-9 decrease ratio was 84.4 (16.9-99.1) %. The median survival time was 12.8 (3.1-32.7) months, and the 1-year survival rate was 52.2%. Finally, conversion surgery was performed in 8 (17.4%) patients and those who received conversion surgery survived significantly longer than those who did not (not reached vs. 11.7 months, P = 0.0070). Grade 3/4 hematologic toxicities occurred in 76.0% and nonhematologic adverse events in 15.0%, of which 6.5% were bowel obstructions. Conclusions: This regimen has shown promising clinical efficacy with acceptable tolerability in chemotherapy-naive PDAC patients with peritoneal metastasis. Clinical trial information: 000018878.

FDG-PETCT versus contrast-enhanced computed tomography in diagnosis of post-therapeutic colorectal cancer recurrence and metastases

BackgroundThis study was designed to assess the role of 18F-FDG CT was able to detect additional/CT in post-therapeutic surveillance of colorectal cancer patients as compared with contrast-enhanced CT to allow early detection of recurrent and metastatic cases amenable for curative surgery and thus improve the overall survival of patients.ResultsOf the total 100 patients, 70 proved to have metastasis or local recurrent disease by the standard reference modalities. One hundred eighty-two diseased regions were detected in these 70 patients. PET/CT was positive in 174 regions (95.6%) whereas CECT was positive in 118 regions (64.8%). PET/CT was superior to CECT in detection of hepatic focal lesions, metastatic lymph nodes, pulmonary metastases, and peritoneal and suprarenal metastases whereas both were equal in detection of osseous deposits. CECT detected four lesions that were missed by PET/CT, and these were hepatic metastases from mucinous adenocarcinoma.ConclusionPET/CT is a better method to evaluate post-therapeutic colorectal cancer patients. It detected viable residual tumor cells in operative bed scar, small LNs, hepatic focal lesions, peritoneal deposits, pulmonary masses, bone deposits, and suprarenal deposits with significantly higher specificity and sensitivity than CECT avoiding unnecessary surgeries.

Identification of Key Gene and Pathways for the Prediction of Peritoneal Metastasis of Gastric Cancer by Co-expression Analysis.

Peritoneal metastasis is the most common pattern in advanced gastric cancer and can predict poor disease prognosis. Early detection of peritoneal tumor dissemination is restricted by small peritoneal deposits. Therefore, it is critical to identify a novel predictive marker and to explore the potential mechanism associated with this process. In the present study, one module that correlated with peritoneal metastasis was identified. Enrichment analysis indicated that the Focal adhesion and the PI3K-Akt signaling pathway were the most significant pathways. Following network and Molecular Complex Detection (MCODE) analysis, the hub-gene cluster that consisted of 19 genes was selected. Methionine sulfoxide reductase B3 (MSRB3) was identified as a seed gene. Survival analysis indicated that high expression levels of MSRB3 were independent predictors of peritoneal disease-free survival (pDFS) as determined by univariate (HR 8.559, 95% CI; 3.339-21.937; P<.001) and multivariate Cox analysis (HR 3.982, 95% CI; 1.509-10.509; P=.005). Furthermore, patients with high levels of MSRB3 exhibited a significantly lower Overall Survival (OS) (log-rank P = 0.007). The external validation was performed by the (The Cancer Genome Atlas (TCGA)) (log-rank P = 0.037) and Kaplan Meier-plotter (KMplotter) (log-rank P = 0.031) data. In vitro experiments confirmed that MSRB3 was a critical protein in regulating gastric cancer cell proliferation and migration. In conclusion, High expression levels of MSRB3 in GC can predict peritoneal metastasis and recurrence as well as poor prognosis. Furthermore, MSRB3 was involved in the regulation of the proliferation and migration of GC cells.