Post-surgical Histopathology Research Articles

Endoscopic Ultrasound Assessment of Solid Pseudopapillary Neoplasm of the Pancreas: Case Series in Latin American Population

Introduction: Solid pseudopapillary tumors of the pancreas (SPN) are uncommon lesions. Endoscopic ultrasound is considered the standard examination because of its capability to acquire a suitable core tissue sample. This study details the experience of eleven cases within a Latin American population diagnosed with SPNs through the endoscopic ultrasound-guided fine needle biopsy (EUS-FNB) approach. Methods: Retrospective reviews of records from a 6-year period, from January 2018 to December 2023, were performed at Clínica Reina Sofía in Bogotá, Colombia. We included eleven patients with surgically proven solid pseudopapillary tumors who had undergone preoperative EUS−FNB. The clinical history, EUS findings, biopsies, and immunohistochemical profile were reviewed. Results: In this study of eleven SPN patients (median age: 31.9 years, 90.1% female, all Hispanic), abdominal pain (63.6%) was the predominant symptom. The indication for EUS was predominantly a pancreas-dependent mass (90.1%). Tumors were located more frequently on the pancreatic neck, with regular morphology, well-defined borders, and predominantly hypoechoic and heterogeneous appearances on EUS. The average tumor diameter was 4.3 cm [range 1.2- 10 cm]. Most tumors were solid (63.6%), and elastography revealed a mixed pattern. EUS-Doppler indicated hypovascularity in all cases. Vascular compression occurred in three patients. No lymph nodes were observed. There were no complications related to the procedure. The histopathological analysis using EUS-FNB yielded consistent results with post-surgical biopsies. Conclusion: In the context of diagnostic evaluation for SPNs, EUS-FNB emerges as a pivotal procedure. In this descriptive study, EUS-FNB showed a remarkable preoperative diagnostic yield of 100% compared to post-surgical histopathology for solid pseudopapillary tumors.

7914 Staged Treatment with Radioiodine Following Lobectomy in a Case of High Risk Papillary Thyroid Carcinoma

Abstract Disclosure: L. Pathak: None. A. Sharma: None. K. Rao: None. M.G. Jakoby: None. Introduction: Radioiodine ([1]3[1]I ) is usually reserved for patients with differentiated thyroid carcinoma (DTC) who are at high risk of persistence or recurrence after thyroidectomy. We present a case of papillary thyroid carcinoma (PTC) with extrathyroidal extension managed by lobectomy and staged [1]3[1]I ablation of the contralateral lobe and metastases due to comorbidities that made oncologic resection prohibitive. Case Description: A 58-year-old male had a 2.2 cm focus of PTC in the left thyroid lobe that extended into extrathyroidal soft tissue, adjacent trachea, and completely compromised the left recurrent laryngeal nerve. Due to left vocal cord paralysis and subglottic tracheal stenosis, left lobectomy was performed but oncologic resection (total thyroidectomy and tracheal resection) was deferred. The patient underwent recombinant human TSH (rhTSH) stimulated treatment with 30 mCi (1.1 GBq) of [1]3[1]I for right thyroid lobe ablation followed 60 d later by 180 mCi (6.7 GBq) of [1]3[1]I to treat metastases. Response to treatment was incomplete, with unstimulated thyroglobulin level falling from 293.9 to 18.9 ng/mL 1 y after [1]3[1]I and CT of the neck notable for a 2.7 cm left thyroid bed mass with invasion of adjacent trachea and a 1.0 cm right paratracheal mass, both of which exhibited hypermetabolism on PET imaging and yielded cytology consistent with poorly differentiated thyroid carcinoma (PDTC). A cluster of left supraclavicular lymph nodes showed both hypermetabolism on PET and radioiodine uptake on rhTSH scan. This patient is being prepared for surgical resection of the left thyroid bed and right paratracheal tumors and left lateral lymph node dissection. Discussion: Radioiodine lobar ablation is an alternative to completion thyroidectomy in patients with an unexpected diagnosis of DTC after lobectomy, with a recent meta-analysis finding a success rate of 69%. No difference in thyroid cancer recurrence rates was found in nearly 500 matched pairs of patients undergoing completion thyroidectomy or radioiodine lobar ablation. Unfortunately, staged lobar ablation followed by high dose [1]3[1]I was not successful in treating this high-risk PTC patient. Cases of coexisting PTC and PDTC are reported, and [1]3[1]I treatment was unsuccessful at treating PDTC that was not apparent on postsurgical histopathology. This case indicates that surgery is preferable to staged [1]3[1]I treatment of patients with aggressive PTC, especially if there are no comorbidities that make total thyroidectomy a high-risk procedure. Presentation: 6/2/2024

Abstract 1031: Targeting genomic biomarker in voided urine for prostate cancer detection

Abstract Introduction: Prostatic cancer (PCa) is the second most prevalent disease in men globally. In 2020 it lead to >14 million new cases and >375,000 deaths worldwide. Despite numerous detection methods, detecting PCa reliably and non-invasively continues to be challenging. PCa malignant cells (MC) express VPAC (combined for Vasoactive Intestinal Peptide and Pituitary Adenylate Cyclase Activating Peptide) in high density. A VPAC specific PACAP analogues (Kd=3.1 × 10−8M) developed in our laboratory was conjugated with a fluorophore and named TP4303. The goal was to assess if TP4303 will image PCa-MC shed in voided urine and present severity of PCa as grade group (GG). Method: Consenting PCa patients (N=110) scheduled for radical prostatectomy provided voided urine. Urine was cyto-centrifuged. Cells on glass slide were fixed, incubated with TP4303, washed, treated with DAPI (4,6-diamidodino-2-phenylindole), cover slip placed and analyzed with Zeiss Axio Observer microscope, coupled with ZENN Microscopy software. The software determined percentage of PCa MC shed by each patient. The results were corroborated as per GG, determined by post-surgical histopathology and analyzed statistically. Results:TP4303 imaged PCa in all subjects. The percent MC shed in urine increased from 13.1±14.4% for GG1 to 25.3±21.07% for GG3 (p=0.05) to 50.5±26.7% for GG5 (p=0.002). Similarly, the fluorescence intensity increased from 43.8±2.2 for GG1 to 48.8±7.0 for GG3 (p=0.01) to 51.5±14.4 for GG5 (p=0.15). Conclusions: The data strongly suggests that TP4303 may not only detect PCa reliably and noninvasively, but may also predict the severity of PCa. Supported by NIH: NC5R01CA249921 Citation Format: Mathew L. Thakur, Vivek S. Tomar, Emma Dale, Leonard G. Gomella, Hector T. Navarro, Oleksandr Kolesnikov, Joon Yau Leong, Olivia Dahlgren, Edouard J. Trabulsi. Targeting genomic biomarker in voided urine for prostate cancer detection [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 1031.

Abstract #1400148: Anterior Cervical Liposarcoma Masquerading as a Thyroid Nodule

Primary sarcomas of the head and neck account for < 1% of tumors in this anatomic region. We present a case of a large anterior neck mass initially thought to originate from the thyroid gland but diagnosed as a cervical liposarcoma closely adjacent to the thyroid. A 64-year-old woman was referred for a right anterior neck mass that she first noticed about 6 weeks prior to evaluation. The patient reported mild degrees of dysphagia and dyspnea. Examination was notable for a large, painless, right anterolateral neck mass that was mobile on deglutition. Serum TSH level was unremarkable. Neck ultrasound revealed a well circumscribed 6.0 x 3.7 x 5.4 cm isoechoic mass that appeared to largely replace the right thyroid lobe. Fine needle biopsy yielded a specimen composed only of peripheral blood elements. Computed tomography of the neck revealed a 9.1 x 6.2 x 6.0 cm hypodense (- 4 Hounsfield units) mass originating in the right carotid space and displacing the trachea, larynx, and esophagus to the left of midline, the right sternocleidomastoid muscle anteriorly, and the right carotid artery and jugular vein laterally. Cytology on a core biopsy was notable for a pleomorphic spindle cell neoplasm with lipoid differentiation and positive staining for CD34 and vimentin felt to be consistent with a liposarcoma. The mass was removed during a right modified radical neck dissection, and postsurgical histopathology revealed an encapsulated tumor with negative surgical margins and MDM2 amplification by fluorescent in situ hybridization (FISH), making the final diagnosis a well-differentiated liposarcoma. Neck masses adjacent to the thyroid may appear to arise from thyroid parenchyma. Several tumors, including paragangliomas, very large parathyroid tumors, lipomas, and a case of low-grade fibromyxoid sarcoma are reported as mimicking thyroid nodules on initial evaluation. There is limited literature on liposarcomas of the head and neck, with 30 patients seen at M.D. Anderson from 1945-2005 the largest published case series. Well-differentiated liposarcomas accounted for approximately 25% (7/30) of cases, and painless neck mass as in this case was the most common presenting symptom. No patients with well-differentiated extrathyroidal liposarcomas died of their tumors in the M.D. Anderson series, in contrast to a tumor-related mortality rate of approximately 30% in the rare (N=13) cases of liposarcoma arising from the thyroid. A PubMed search failed to reveal any cases of liposarcoma mimicking a thyroid nodule. This case illustrates that large anterior neck masses require careful imaging evaluation to confirm apparent origin from the thyroid gland.

Correlation between thyroid fine needle aspiration cytology and postoperative final histopathology: a 5-year single-centre retrospective study

Background: Thyroid nodules are common problems encountered in our routine practice. Fine needle aspiration cytology (FNAC) is the most accurate and cost-effective method for evaluating thyroid nodules. It is the procedure of choice for identifying patients who require surgical excision. Methods: This is a retrospective single-center observational study in Salmaniya Medical Complex, a tertiary care center, in Kingdom of Bahrain that aims to to correlate preoperative FNAC results with the post-surgical histopathology report, and to compare our diagnostic performance results to previously published literature. Results: The post-operative histology was reported as benign in 62% of patients and malignant in 38% of patients. Bethesda II was the most common category in our sample, with 14.3% having a final histopathological diagnosis of malignancy (false negative results). Malignancy was found in 84% and 96.8% of Bethesda V and VI, respectively. Our FNAC data achieved an 80.95% sensitivity, specificity of 93.51% specificity, and a total accuracy of 87.86%. The positive predictive value was 91.07%, and an 85.71% negative predictive value, which were comparable to data from published series. Conclusions: FNAC remains the most accurate and cost-effective method for evaluating thyroid nodules. However, its diagnostic value varies among different institutions. Our results demonstrated higher rates of malignancy compared to other published series in both category I and II. Due to the chance of false negative rates in these categories and the slow-growing nature of thyroid malignancy, it is important that patients with benign FNAC should have periodic clinical and radiological follow up.

Histopathological analysis of chronic paronychia.

Chronic paronychia is an inflammatory process of the nail folds lasting more than 6 weeks. Clinically, there is hypertrophy and retraction of the folds and absence of the cuticle. Treatment involves clinical measures and, when there is no response or the hypertrophy of the folds is very pronounced, surgical treatment is indicated. Post-surgical histopathology is little studied in the literature. In this sense, we believe that the histopathological study is important not only for the individualized understanding of the patient's chronic disease, avoiding relapses, but also for the understanding of its pathophysiology and treatment possibilities. To describe the histopathological changes found in biopsies of the proximal nail fold of patients with chronic paronychia undergoing surgical treatment. A histopathological study of 16 nail folds from 6 patients after surgery was performed at 2 study centers. The most prevalent epidermal findings were orthokeratosis, hypergranulosis, acanthosis and spongiosis and the dermal findings were fibrosis and mononuclear inflammatory infiltrate. The histopathological study allowed us to conclude that chronic paronychia is primarily an inflammatory process, but it is not possible to conclude whether microorganisms such as Candida and bacterial cocci are part of the etiology or just secondary and opportunistic agents.

Value of 99m Tc-MIBI SPECT/CT in the localization of recurrent lesions in patients with suspected recurrent parathyroid carcinoma.

Accurate preoperative localization of tumor-bearing lesions is crucial for the successful surgical management of suspected recurrent parathyroid carcinoma. The purpose of this study was to evaluate the diagnostic value of 99m-technetium-labeled methoxyisobutylisonitrile ( 99m Tc-MIBI) single-photon emission computed tomography/computed tomography (SPECT/CT) and cervical ultrasound, individually and in combination, for preoperative localization of recurrent/metastatic lesions. We also analyzed the value of 99m Tc-MIBI SPECT/CT in detecting ectopic lesions in patients with suspected recurrent parathyroid carcinoma. Twenty-nine patients with suspected recurrent parathyroid carcinoma were included in this retrospective cohort study. Patients underwent preoperative 99m Tc-MIBI SPECT/CT and cervical ultrasound. The reference standard was postsurgical histopathology. The sensitivity, specificity, positive predictive value (PPV), negative predictive value, and accuracy of the two diagnostic modalities alone and in combination were analyzed. Of the 29 patients, histopathological results revealed 48 metastases/recurrent lesions in 26 patients. The diagnostic value of 99m Tc-MIBI SPECT/CT, cervical ultrasound, and the two modalities in combination were compared for the 27 patients who underwent new cervical surgery. Patient-level analysis of the combined use of 99m Tc-MIBI SPECT/CT and cervical ultrasound had the highest sensitivity (100.00%) and accuracy (96.30%). At the lesion level, 99m Tc-MIBI SPECT/CT had the highest specificity and PPV, at 100.00% respectively, whereas the combined use of 99m Tc-MIBI SPECT/CT and cervical ultrasound had the highest sensitivity, at 97.62%. Moreover, 99m Tc-MIBI SPECT/CT detected six ectopic lesions, and five of them showed increased 99m Tc-MIBI uptake. The combined use of 99m Tc-MIBI SPECT/CT and cervical ultrasound is the most efficient strategy in the diagnosis of parathyroid carcinoma relapse, whereas 99m Tc-MIBI SPECT/CT is the preferred method for localizing and analyzing cervical and extra-cervical lesions before the new surgery.

Features and diagnostic accuracy of fine needle aspiration cytology of thyroid nodules: retrospective study from Oman.

BACKGROUND: Fine needle aspiration cytology (FNAC) of the thyroid has been a reliable and cost-effective method for diagnosing thyroid disorders. Since FNAC results are usually operator dependent, there is a compelling need to explore FNAC accuracy among Omanis.OBJECTIVE: Describe cytological features of FNAC and assess FNAC accuracy compared to the postsurgical histopathology report.DESIGN: Retrospective diagnostic accuracy studySETTING: Tertiary care center.PATIENTS AND METHODS: Our study included adult Omani adult patients with thyroid nodules who underwent FNAC from 2014 to 2017 and had final pathology results for patients who underwent thyroid surgery. The results were classified according to the UK Royal college of Pathologists ‘Thy’ categories. Accuracy of FNAC was calculated by determining false and true positive and negative results based on histopathology findings.MAIN OUTCOME MEASURES: FNAC accuracy (sensitivity and specificity) compared to the postsurgical histopathology.SAMPLE SIZE: 867 patients with 1359 ultrasound guided FNACs of thyroid nodule; 137 underwent surgery.RESULTS: The mean age of the 867 patients was 43.7 (13.3) years, with a median of 42 years, and 87.8% were females. Out of 1359 FNACs, 1001 (73.7%) were benign (Thy2), 119 (8.8%) were atypia of undetermined significance or follicular lesion of undetermined significance (Thy3a), 31 (2.3%) were follicular neoplasm or suspicious for a follicular neoplasm (Thy3f), 52 (3.8%) were suspicious for malignancy (Thy4), 55 (4%) were malignant (Thy5), 101 (7.4%) as Unsatisfactory (Thy1). Only 137 patients underwent thyroid surgery, and the FNAC reports were compared with their final histopathology reports. The sensitivity, specificity and total accuracy of FNAC were 80.2%, 98.9% and 89.9%, respectively. The positive and negative predictive values of FNAC were 98.6% and 84.3%, respectively.CONCLUSION: Our study findings confirmed that FNAC of the thyroid is a sensitive, specific, and accurate initial tool for the diagnosis of thyroid lesions. Most of the FNACs were benign with a very low malignancy rate. Due to the minimal chance of false negative results and the slow-growing nature of thyroid malignancy, it is important that patients with benign FNAC should have periodic clinical and radiological follow-up.LIMITATIONS: Retrospective design and single-center study, and thyroid nodule size unavailable.CONFLICT OF INTEREST: None.

Clinical impact of primary tumour 123ImIBG response to induction chemotherapy in children with high-risk neuroblastoma.

More than 50% children with high-risk neuroblastoma (HR-NBL) experience disease progression, which we hypothesise is due to non-response of primary tumour to treatment. Current imaging techniques are unable to characterise response in primary tumour (necrotic versus viable tissue) at diagnosis or follow-up. Compare clinico-histological characteristics between primary 123ImIBG-avid tumours that became entirely 123ImIBG-non-avid (responders) after induction chemotherapy (IC) versus primary 123ImIBG-avid tumour that remained 123ImIBG-avid (non-responders). Retrospective review of clinico-radiological data of children diagnosed with 123ImIBG-avid HR-NBL at our centre (2005-2016). Patients received Rapid COJEC IC and two additional courses of TVD if metastatic response was inadequate. Primary tumour 123ImIBG response was assessed qualitatively as positive, negative or intermediate at diagnosis and after IC. Post-surgical histopathology slices were marked considering percentage of viable tissue. Sixteen of 61 patients showed complete primary tumour 123ImIBG response, 20 partial response, while 25 no response. There was no statistically significant difference between clinical demographics of complete responders and group of non- or partial responders. Mean percentage of viable tumour cells was higher in non-responders than in complete responders (44.6% vs 20.6%; p = 0.05). Five-year EFS was significantly higher in complete responders than non-responders (43 ± 15% vs 7 ± 6%; p < 0.005). 123ImIBG response in primary HR-NBL correlates with amount of necrotic tissue, skeletal metastatic 123ImIBG response and outcome. An entirely 123ImIBG non-avid tumour can still harbour viable tumour cells. Therefore, our findings do not support utility of primary tumour 123ImIBG response in decision making regarding residual tumour surgery. Combining both, primary and metastatic 123ImIBG response will improve interpretability of clinical trial results.

English

BACKGROUND Endometrial cancer (EC) is also the second most common gynaecologic malignancy in developing countries, with an incidence of 5.9 per 100,000 women. Due to the multiple modifiable factors, a better understanding of the prognostic indicators can lead to early detection and treatment. The purpose of this study was to evaluate the frequency and the distribution of various risk factors, epidemiological factors, and histological patterns of patients diagnosed with endometrial carcinoma in a tertiary teaching hospital in south India and compare them with similar studies. The compiled findings of 60 consecutive cases that presented to our tertiary care teaching hospital in Kerala, south India, over oneand-a-half-year period were studied. METHODS This study was essentially an ex post facto retrospective study done on 60 patients for one and half years. Retrospective data collection and compilation were done with previously prepared structured questionnaires in patients with histologically proven endometrial carcinoma. All cases were subjected to hysterectomy with post-surgical histopathology correlation. A study of the risk factors, general epidemiological characteristics, endometrial biopsy findings, and post-surgical histopathology was done. RESULTS The mean age at presentation was 59.83 years. The mean age of menarche was 13.72 years, and menopause was 49.42 years. The majority of patients were married, multiparous, and presented with bleeding per vaginum (77 %). 61.7 % of the patients had a history of hypertension, 31.7 % had a history of hypothyroidism, and 43.3 % had a history of diabetes mellitus in the study population. The most common histopathological type by endometrial biopsy and histopathological correlation was endometrioid adenocarcinoma (88.3 %). CONCLUSIONS Postmenopausal age group, with early menarche and late menopause, high body mass index (BMI), thickened endometrium on ultrasound, and atrophic uterus were some of the features associated with endometrial carcinoma. The most common histological subtype was found to be endometrioid carcinoma KEYWORDS Endometrial Carcinoma, Risk Factors, Prognostic Indicators

Carney Complex With Endocrine Involvement Isolated to the Thyroid Gland

Abstract Introduction: Carney complex is a rare autosomal dominant disorder characterized by pigmented lesions of skin and mucosae, endocrine neoplasms or overactivity, and myxomas of the heart, skin, and other organs. Most patients have at least two affected endocrine organs at time of diagnosis. We present a case of Carney complex with endocrine involvement limited to the thyroid gland. Case: A 48-year-old female was referred for evaluation of thyroid nodules incidentally discovered on imaging for submandibular salivary gland swelling. Ultrasound evaluation of the thyroid revealed numerous, bilateral nodules that were mostly cystic or spongiform, though some had irregular borders and microcalcifications. A brother with Carney complex had been diagnosed with papillary carcinoma, and the patient decided to undergo thyroidectomy. Fortunately, no thyroid carcinoma was found on postsurgical histopathology. Initial biochemical evaluation showed no evidence of hypercortisolemia (8 AM cortisol 1.7 mcg/dL on 1 mg dexamethasone suppression test; 24-h urine cortisol 26.1 mcg [reference: 4-50]), growth hormone excess (IGF-1 190 ng/mL [reference: 52-328]), or hyperprolactinemia (prolactin 10 ng/mL [reference: 2.74-26.72]). Imaging showed no pituitary or adrenal masses. The patient underwent total hysterectomy with bilateral salpingo-oophorectomy for endometrial cancer prior to referral. She was diagnosed with Carney complex at age 19 years, and her manifestations included atrial and ventricular myxomas, intraductal adenoma of the breast, multiple skin lesions (lentigines, blue nevi, and cutaneous myxomas), and myxomas of the external auditory canals. She is in a Carney complex kindred that includes her mother, two brothers, and a niece. Discussion: Carney complex is usually caused by inactivating mutations or large deletions in the protein kinase A type I alpha regulatory subunit (PRKAR1A) gene located on chromosome 17q22-24. Most mutations are inherited in an autosomal dominant manner, though approximately 30% of cases are due to de novo mutations. In a review of 365 cases, the median age at diagnosis was 20 years. Growth hormone adenomas or somatomammotroph hyperplasia occurs in approximately 75% of patients, and most have at least one additional endocrine abnormality including multinodular goiter, primary pigmented nodular adrenocortical hyperplasia, and testicular or ovarian masses. There is an approximately 10% chance of developing well differentiated thyroid carcinoma. Treatment for Carney complex is individualized depending on the patient’s presentation and includes excision or surgical removal of myxomas, neoplasms, and skin lesions, as well as regular evaluation for cardiac myxomas and endocrine overactivity. This case of Carney complex is unusual because the only endocrinopathy is multinodular goiter.

The role of Diffusion-weighted magnetic resonance imaging and apparent diffusion coefficient (ADC) values in the evaluation of solid breast lesions

Aim: To investigate the role of Diffusion-weighted magnetic resonance imaging and apparent diffusion coefficient (ADC) values in the differential diagnosis of solid lesions of the breast. Materials and Methods: Diffusion-weighted images and ADC values from 36 women with 37 solid lesions definitely diagnosed through breast biopsy and post-surgical histopathology were evaluated retrospectively. ADC values obtained from malignant and benign solid lesions of the breast were compared using the t-test. The optimum threshold value for use in differentiating benign and malignant lesions was determined using ROC analysis, and sensitivity and specificity values were calculated.Results: Histological analysis identified 23 lesions and 14 benign lesions. Mean age (49 ± 7.8 years) was higher in the group with malignant breast lesions than in the group with benign breast lesions (37.3 ± 8.2) (p 0.05). The mean ADC value (1.1 ± 0.2 × 10-3 mm2/s) in the patients with malignant breast lesions was significantly lower than in the group with benign breast lesions (1.49 ± 0.18 × 10-3 mm2/s) (p 0.05). When the threshold value to be used in the ROC curve was applied the differentiation of benign and malignant solid lesions, the sensitivity was 78.3% and specificity was 100%.Conclusions: Diffusion-weighted MRI and ADC values have the potential to contribute to the diagnosis of solid lesions in the breast at conventional MR examination by differentiating between benign and malignant tumors.

Ultrasound and Colour Doppler Evaluation of Nodular Thyroid Masses

Introduction: Ultrasonography (USG) of thyroid nodules is a safe, non-invasive and effective method for evaluation of nodular thyroid masses. They give a clear cut characteristic of the thyroid nodule besides their site, shape, size and number. However, its efficacy and role in differentiating nodules as benign and malignant is not well documented. Aim: To investigate the diagnostic accuracy of USG and colour doppler in differentiating a malignant thyroid nodule from a benign lesion. Materials and Methods: The present cross-sectional study was carried out among 52 patients clinically diagnosed with thyroid, from January 2018 to June 2019. After obtaining ethical approval and informed consent, USG and colour doppler were performed on these participants. The findings were evaluated based on hypoechogenicity, microcalcification, vascularity. The diagnostic accuracy of USG and colour doppler was evaluated in terms of sensitivity, specificity, Positive Predictive Value (PPV) and Negative Predictive Value (NPV) in comparison with the postsurgical histopathology findings. Results: Forty two nodules were benign while 10 were malignant. It was observed that the sensitivity was 100% for detection of halo and presence of vascularity. The specificity was 97.6% for calcification and 76.2% for vascularity. Assessment of lymph node had higher sensitivity (70%) and specificity (100%) with high positive (100%) and negative (93.3%) predictive values. Conclusion: Ultrasound and colour doppler imaging features such as inhomogeniety, presence of vascularity, halo and lymph node with malignant features had excellent histopathological correlation with malignancy.

Patterns of Nodal Metastases and Predictors of Occult Disease in HPV-Associated Oropharynx Cancer.

For human papilloma virus-associated oropharynx squamous cell carcinoma (HPV+ OPSCC), we evaluated the distribution of neck-level lymph node (LN) metastasis, based on postsurgical histopathology, and the incidence of and risk factors for occult LN metastases, as these patterns need clarification for this newer cancer subset. Retrospective cohort study. National Cancer Database (NCDB). We analyzed 2358 patients in the NCDB with HPV+ OPSCC who underwent neck dissection (ND) from 2010 to 2015. Incidence and distribution of LN metastases were calculated for neck levels I to V. Variables associated with occult LN metastasis were assessed by multivariate logistic regression. In therapeutic NDs (n = 1935), the following proportions of positive LNs were found: level I, 9.0% (n = 175); level II, 81.0% (n = 1568); level III, 29.6% (n = 573); level IV, 11.9% (n = 230); and level V, 4.9% (n = 95). In elective NDs (n = 423), occult-positive LNs were found in 35.8% (n = 152), with the following proportions by level: level I, 3.3% (n = 14); level II, 26.9% (n = 114); level III, 8.7% (n = 37); level IV, 4.0% (n = 17); and level V, 0.2% (n = 1). The presence of occult LNs was independently associated with a Charlson-Deyo score of 1 (odds ratio, 2.26; 95% CI, 1.18-4.31; P = .014) and lymphovascular invasion (odds ratio, 5.91; 95% CI, 3.21-11.18; P < .001). Occult LN metastases were not significantly associated with pT classification, primary site, or number of LNs resected. For HPV+ OPSCC, occult nodal disease is common. Therapeutic NDs should encompass at least levels II, III, and IV and possibly I, whereas elective NDs could possibly encompass levels II and III. 4.

Efficacy of dual use of Tc-99m-pertechnetate and Tc-99m-tetrofosmin scintigraphy for the assessment of thyroid nodules.

Radioisotope methods have shown to be useful in the non-invasive diagnosis of thyroid nodules over the past years. The present prospective study aims to evaluate the efficacy of gamma imaging using single and dual tracer using Tc-99m pertechnetate and Tc-99m tetrofosmin for evaluation and management of thyroid nodules. Dynamic (perfusion) imaging was performed after injecting 148-185MBq (4-5mCi) of Tc-99m pertechnetate followed by static imaging. A second, dynamic (perfusion) imaging study within same week was performed with 296-370MBq (8-10mCi) of Tc-99m tetrofosmin on same group of patients followed by early and delayed images. Results of radionuclide perfusion scan from both studies were compared qualitatively with postsurgical histopathology or fine needle aspiration cytology (FNAC). Total 65 nodules in 50 patients were included in the study. With single tracer, the specificity and accuracy of Tc-99m pertechnetate was 23% and 45% and for Tc-99m tetrofosmin scan was 40% and 49%. When dual tracers were evaluated for the same group of patients, the specificity was 56% and accuracy was 55%. Dual Tracer technique with Tc-99m pertechnetate and Tc-99m tetrofosmin could be helpful in selecting nodules need surgical intervention. This technique can be used for convenient and rapid diagnostic evaluation of thyroid nodules non-invasively. We suggest a combination of fine needle aspiration biopsy and dual use of Tc-99m-pertechnetate and Tc-99m-tetrofosmin as a routine diagnostic approach to thyroid nodules.

Use of Diffusion-Weighted Magnetic Resonance Imaging and Apparent Diffusion Coefficient in Gastric Cancer Staging.

The apparent diffusion coefficient (ADC), the quantitative parameter of diffusion-weighted magnetic resonance imaging (DW-MRI), is a measure for this restricted diffusion, and its role in gastric cancer (GC) including distinguishing malignant segments from healthy gastric wall, metastatic perigastric lymph nodes from benign nodes and evaluating response of GC to neoadjuvant chemotherapy has been investigated in previous studies. Evidence suggests that ADC may also be of help in assessment of aggressiveness and preoperative staging of gastric cancer, which needs to be explored in further studies. To investigate the role of DW-MRI and its quantitative parameter, ADC in staging of gastric cancer. Forty-six patients (28 male, 18 female, mean age 62 years) with non-metastatic biopsy- proven GC who underwent abdominal DW-MRI before surgery were included in this retrospective study. Tumor invasion depth (T-stage) and nodal involvement (N-stage) were evaluated using signal increase on DW-MRI, and tumor ADC was measured. Diagnostic performance of these results was assessed by comparing them with postsurgical histopathology based on 8th TNM classification. Sensitivity, specificity, and accuracy of DW-MRI in T-staging were 92.1%, 75%, 89.1% for ≤T2 vs. ≥T3; and 75%, 88.5%, 82.6% for ≤T3 vs. T4. However, sensitivity, specificity, and accuracy of DW-MRI in N-staging were 89.3%, 88.9%, 89.1% for ≤N1 vs. ≥N2; and 73.7%, 96.3%, 86.9% for ≤N2 vs. N3, respectively. Relative preoperative ADC values correlated with pT staging (r=-0.397, p=0.006). There was also a statistically significant difference of relative ADC values between ≤T3 and T4 stages, and a cut-off of 0.64 s/mm2 could differentiate these stages with an odds ratio of 7.714 (95% confidence interval, 1.479-40.243). The area under the receiver operating characteristic curve for differentiating ≤T3 and T4 stages was 0.725. DW-MRI may contribute to the clinical staging of non-metastatic GC. In particular, relative ADC of DW-MRI can distinguish T4 gastric cancer from less advanced T-stages.

Carbon Flux as a Measure of Prostate Cancer Aggressiveness: [11C]-Acetate PET/CT

Purpose: Dynamic [11C]-acetate positron emission tomography (PET) can be used to study tissue perfusion and carbon flux simultaneously. In this study, the feasibility of the quantification of prostate cancer aggressiveness using parametric methods assessing [11C]-acetate kinetics was investigated in prostate cancer subjects. The underlying uptake mechanism correlated with [11C]-acetate influx and efflux measured in real-time in vitro in cell culture.Methods: Twenty-one patients with newly diagnosed low-to-moderate risk prostate cancer underwent magnetic resonance imaging (MRI) and dynamic [11C]-acetate PET/CT examinations of the pelvis. Parametric images of K1 (extraction × perfusion), k2 (oxidative metabolism) and VT (=K1/k2, anabolic metabolism defined as carbon retention) were constructed using a one-tissue compartment model with an arterial input function derived from pelvic arteries. Regions of interest (ROIs) of the largest cancer lesion in each patient and normal prostate tissue were drawn using information from MRI (T2 and DWI images), biopsy results, and post-surgical histopathology of whole prostate sections (n=7). In vitro kinetics of [11C]-acetate were studied on DU145 and PC3 cell lines using LigandTracer® White equipment for the measurement of the radioactivity uptake in real-time at 37°C.Results: Mean prostate specific antigen (PSA) was 8.33±3.92 ng/mL and median Gleason Sum 6 (range 5-7). K1, VT and standardized uptake values (SUVs) were significantly higher in cancerous prostate tissues compared to normal ones for all patients (p<0.001), while k2 was not (p=0.26). PSA values correlated to early SUVs (r=0.50, p=0.02) and K1 (r=0.48, p=0.03). Early and late SUVs correlated to VT (r>0.76, p<0.001) and K1 (r>0.64, p<0.005). In vitro studies demonstrated higher extraction and retention (p<0.01) of [11C]-acetate in the more aggressive PC3 cells.Conclusion: Parametric images could be used to visualize the [11C]-acetate kinetics of the prostate cancer exhibiting elevated extraction associated with the cancer aggressiveness. The influx rate of [11C]-acetate studied in cell culture also showed dependence on the cancer aggressiveness associated with elevated lipogenesis. Dynamic [11C]-acetate/PET demonstrated potential for prostate cancer aggressiveness estimation using parametric-based K1 and VT values.

Head and Neck Schwannomas: A Tertiary Referral Single-Center Experience

Objective: The aim is to share our experience of the clinical features and important issues encountered in diagnosing and treating multiple head and neck schwannoma cases seen at our centre, all of which went on to have surgical treatment. Methods: This was a retrospective review of the medical records of cases over an 11-year period (2007–2018) diagnosed with schwannoma by post-surgical histopathology. The demographic characteristics of these cases, along with their clinical characteristics, namely, tumour location, preoperative diagnostic tests undertaken, surgical approach used, and any postoperative complications, including the management of such complications, were reviewed. Results: A total of 31 patients (18 male, and 13 female) were included in the study. Contrast-enhanced magnetic resonance imaging was the most commonly used pre-operative diagnostic method (77%). 58% of the cases were extra- and 42% intra-cranial. Extracranial schwannomas were noted to arise from several different areas of the head and neck region. The most common neurological deficit post-operatively was facial paralysis. Conclusion: Since head and neck schwannomas can develop from any area where the nerve sheath is present, they may present with a wide variety of non-specific symptoms. The treatment plan should be made with the anticipated preoperative and postoperative neurological deficit firmly in mind.

Ultra-High-Field Targeted Imaging of Focal Cortical Dysplasia: The Intracortical Black Line Sign in Type IIb.

Conventional MR imaging has limitations in detecting focal cortical dysplasia. We assessed the added value of 7T in patients with histologically proved focal cortical dysplasia to highlight correlations between neuropathology and ultra-high-field imaging. Between 2013 and 2019, we performed a standardized 7T MR imaging protocol in patients with drug-resistant focal epilepsy. We focused on 12 patients in whom postsurgical histopathology revealed focal cortical dysplasia and explored the diagnostic yield of preoperative 7T versus 1.5/3T MR imaging and the correlations of imaging findings with histopathology. We also assessed the relationship between epilepsy surgery outcome and the completeness of surgical removal of the MR imaging-visible structural abnormality. We observed clear abnormalities in 10/12 patients using 7T versus 9/12 revealed by 1.5/3T MR imaging. In patients with focal cortical dysplasia I, 7T MR imaging did not disclose morphologic abnormalities (n = 0/2). In patients with focal cortical dysplasia II, 7T uncovered morphologic signs that were not visible on clinical imaging in 1 patient with focal cortical dysplasia IIa (n = 1/4) and in all those with focal cortical dysplasia IIb (n = 6/6). T2*WI provided the highest added value, disclosing a peculiar intracortical hypointense band (black line) in 5/6 patients with focal cortical dysplasia IIb. The complete removal of the black line was associated with good postsurgical outcome (n = 4/5), while its incomplete removal yielded unsatisfactory results (n = 1/5). The high sensitivity of 7T T2*-weighted images provides an additional tool in defining potential morphologic markers of high epileptogenicity within the dysplastic tissue of focal cortical dysplasia IIb and will likely help to more precisely plan epilepsy surgery and explain surgical failures.

SUN-378 Adrenocortical Carcinoma Diagnosed During Evaluation of an Incidentally Discovered Adrenal Mass

Background. Adrenocortical carcinoma (ACC) is a rare neoplasm with an estimated incidence of 0.5-2.0 per million per year. Most patients present with symptoms or signs of hormone excess or complaints related to tumor mass effect. We present a case of ACC discovered incidentally on computed tomography (CT) imaging of the abdomen. Case. A 59-year-old female presented to the emergency department (ED) after falling in her shower. She felt light headed before the fall, but she denied loss of consciousness or confusion after the event. The patient was noted to be hypertensive (185/105 mm Hg) and hypokalemic (2.6 mM, 3.6-5.1). A contrast enhanced abdominal CT scan revealed a 9.1 cm heterogeneous left adrenal mass. Plasma metanephrine and normetanephrine levels were unremarkable. Morning cortisol failed to suppress during a 1 mg overnight dexamethasone suppression test (10.1 μg/dL, < 1.8), and plasma midnight cortisol was unequivocally elevated at 24.3 μg/dL (< 7.5). ACTH (5 pg/mL, 6-58) and DHEA (0.159 ng/mL, 0.630-4.700) levels at 8 AM were both low. Postsurgical histopathology was notable for high grade mitoses (> 20/50 high powered fields), capsular invasion into peri-adrenal adipose tissue, and lymphovascular invasion, though surgical margins were uninvolved by tumor. No evidence of locoregional or distant metastases was observed on tumor staging, leading to a diagnosis of stage III ACC (T3N0M0). The patient elected treatment with local external beam radiation but declined mitotane. Secondary adrenal insufficiency is managed with hydrocortisone. Discussion. This patient’s case illustrates the female predominance (1.5-2.5:1) and typical time of diagnosis (fifth-to-sixth decade) reported in adult cases of ACC. It is unusual because only 20-30% of cases are diagnosed incidentally during imaging for an unrelated medical problem, and ACC accounts for only about 2-5% of incidentally diagnosed adrenal masses. The size (> 4 cm) and heterogeneity of the patient’s tumor were radiographic features indicating ACC, and the finding of adrenal hypercortisolemia is consistent with the high prevalence (45-70%) of metabolically active tumors that predominantly secrete cortisol. Hypertension and hypokalemia likely reflect saturation of renal 11-β-hydroxysteroid dehydrogenase with excess cortisol, though the patient lacked the features of rapidly progressive Cushing’s syndrome described in many cases of cortisol secreting ACC. Most cases of ACC are stage II or higher at initial diagnosis, and five-year survival for advanced stage ACC is only 10-25%. Disease stage and completeness of resection are the most important factors that influence prognosis, though high mitotic rate and hypercortisolemia in this patient’s case are negative prognostic factors. Adjuvant mitotane appears to improve recurrence-free survival, and radiation reduces the rate of local tumor recurrence.