Presence Of Emboli Research Articles

Risk factors for embolism in children with refractory Mycoplasmapneumoniae pneumonia and construction of a nomogram model for prediction of embolism

To study the risk factors for embolism in children with refractory Mycoplasma pneumoniae pneumonia (RMPP) and to construct a nomogram model for prediction of embolism. This retrospective study included 175 children diagnosed with RMPP at Children's Hospital Affiliated toZhengzhou University from January 2019 to October 2023. They were divided into two groups based on the presence of embolism: the embolism group (n=62) and the non-embolism group (n=113). Multivariate logistic regression analysis was used to screen for risk factors of embolism in children with RMPP, and the R software was applied to construct the nomogram model for prediction of embolism. Multivariate logistic regression analysis indicated that higher levels of D-dimer, interleukin-6 (IL-6) and neutrophil to lymphocyte ratio (NLR), lung necrosis, and pleural effusion were risk factors for embolism in children with RMPP (P<0.05). The area under the curve of the nomogram model for prediction of embolism constructed based on the aforementioned risk factors was 0.912 (95%CI: 0.871-0.952, P<0.05). The Hosmer-Lemeshow goodness-of-fit test showed that the model had a good fit with the actual situation (P<0.05). Calibration and decision curve analysis indicated that the model had high predictive efficacy and clinical applicability. Higher levels of D-dimer, IL-6 and NLR, lung necrosis, and pleural effusion are risk factors for embolism in children with RMPP. The nomogram model based on these risk factors has high clinical value for predicting embolism in children with RMPP.

Microemboli on Transcranial Doppler in Patients with Sickle Cell Disease: A Single Center Case Series

Background: Stroke remains a major cause of morbidity in patients with sickle cell disease (SCD). Current guidelines recommend that patients with Hemoglobin SS and Hemoglobin S beta zero thalassemia have annual transcranial doppler (TCD) screening and that patients with abnormal velocities should have regular blood transfusions to maintain a maximum HbS level &amp;lt;30% and maintain a hemoglobin level &amp;gt;9 g/dL for at least one year to decrease risk of stroke (DeBaun et al., 2020). While research has shown that patients with velocities &amp;gt;200cm/sec are at increased risk of cerebral infarct, there is no literature to discuss the follow up and management of patients with microemboli on TCD. In the past microemoli were unable to be detected, however TCD is now able to detect such findings (Wan et al., 2022). Studies have been completed on patients with ischemic stroke without SCD and have shown that the presence of microemboli on TCD is associated with a higher rate of recurrence (Das et al., 2020). The presence of emboli has also been shown to recognize patients with asymptomatic carotid stenosis and increased risk for stroke (Markus et al., 2010). Although noted in the general population, the significance of such a finding on an annual TCD screening in patients with sickle cell disease is unknown. Methods:At the Medical University of South Carolina, we performed a retrospective review of all patients with SCD who have had TCDs from 2017 to February 2023 and were found to have microemboli to evaluate management and outcome. Results: We have had 5 patients with an incidental finding of microemboli on their annual TCD since 2017. Three were male with median age of 3 (range 2 to 15 years). Four individuals are HbSS genotype. Mean hemoglobin at the time of TCD was 8.26 ± 1.4 g/dL. TCD velocity was normal in four patients at the time of the TCD, while the remaining individual had a low conditional TCD. Two have a previous history of conditional or abnormal TCDs. The location of the microemboli was variable among patients (Table 1). At the time of microemboli findings on TCD, discussions were held with family regarding options for treatment including chronic partial exchange transfusions and optimization of other disease modifying therapies. Management of all patients included MRI at the time of microemboli, which was normal in only two patients. Three patients were started on chronic manual exchange transfusions for 10 months to 3 years. One out of the 3 continued home HU while receiving transfusions while the remainder were transitioned to HU once chronic transfusions were complete. One patient was not started on chronic transfusions but monitored closely with TCDs due to family choice. On follow up, 4 have had repeat TCDs and all have normalized without any subsequent episodes of microemboli. One patient was found to have silent infarct on MRI at time of TCD and 1 has had follow up MRI 4 years after original TCD with a new silent infarct. Of note, this patient had inconsistent follow up with chronic transfusions after initial abnormal TCD. Importantly, none of our 5 patients had an acute symptomatic ischemic event since the microemboli were noted. Overall, among these patients, 2 have had concern for silent infarct and 3 of 5 started on chronic transfusions (Table 1). Conclusion: This is the first report within the literature of microemboli on annual TCD screening in patients with SCD. As this is a new phenomenon, the significance within the disease course is not known for those with sickle cell disease. Identifying patients with microemboli has been used to help navigate the need for early intervention to prevent stroke. Given that individuals with SCD are already at an increased risk for cerebrovascular events, these findings of microemboli could indicate further risk in these individuals as well and deserve further investigation. Further research is warranted as the significance of such a finding is unknown and further understanding could impact the standard of care of this patient population.

Wavelet Scattering Transform based Doppler signal classification

Normal blood supply to the human brain may be marred by the presence of a clot inside the blood vessels. This clot structure called emboli inhibits normal blood flow to the brain. It is considered as one of the main sources of stroke. Presence of emboli in human’s can be determined by the analysis of transcranial Doppler signal. Different signal processing and machine learning algorithms have been used for classifying the detected signal as an emboli, Doppler speckle, and an artifact. In this paper, we sought to make use of the wavelet transform based algorithm called Wavelet Scattering Transform, which is translation invariant and stable to deformations for classifying different Doppler signals. With its architectural resemblance to Convolutional Neural Network, Wavelet Scattering Transform works well on small datasets and subsequently was trained on a dataset consisting of 300 Doppler signals.To check the effectiveness of extracted Scattering transform based features for Doppler signal classification, learning algorithms that included multi-class Support vector machine, k-nearest neighbor and Naive Bayes algorithms were trained. Comparative analysis was done with respect to the handcrafted Continuous wavelet transform features extracted from samples and Wavelet scattering with Support vector machine achieved an accuracy of 98.89%. Also, with set of extracted scattering coefficients, Gaussian process regression was performed and a regression model was trained on three different sets of scattering coefficients with zero order scattering coefficients providing least prediction loss of 34.95%.

CHARACTERISTICS OF THE IMMUNE MICROENVIRONMENT OF THE NORMAL MUCOUS MEMBRANE OF THE PERITUMORAL AREA IS AN ADDITIONAL INDEPENDENT PROGNOSTIC FACTOR IN GASTRIC CANCER

The aim of the study was to study and evaluate the predictive value of the immune microenvironment of gastric cancer and morphologically normal mucous membrane of the peritumoral area using an automatic morphometric analysis system on the example of CD 8+ cells.Material and Methods. Surgical samples from 130 patients with a verified diagnosis of gastric cancer were used. After immunohistochemical staining with antibodies to CD 8, a morphological assessment was performed according to the original method. We assessed the average area of CD 8+ cells in three fields of view (lens magn. ×20) using the automatic system of morphometric analysis LAS X (Leica) in the central part of the tumor and areas of morphologically normal mucous membrane of the peritumoral region directly adjacent to the tumor tissue. The results were compared with the main clinical and morphological characteristics of the tumor as well as with the overall five-year survival of patients.Results and Discussion. A high density of CD 8+ infiltration of normal mucous membrane of the peritumoral area was observed in groups T4a and T4b by the depth of invasion (n=96, p=0.0089) and was associated with the presence of emboli in the lymphatic vessels (n=96, p=0.0102) and with the more advanced stage of gastric cancer (n=96, p=0.0107). The studied cases were divided into two groups: less than 3300 square micrometers (better patient survival; n=79, p=0.01) and more than 3300 square micrometers according to the average area of CD 8+ cells in normal mucous membrane of the peritumoral area. According to multivariate survival analysis using the Cox regression model, it was found that the average area of CD 8+ cells in normal mucous membrane of the peritumoral area was a significant negative prognostic factor (RR=1.537; CI : 0.761–3.105; p&lt;0.01) comparable in degree covariance with the stage of the tumor A similar indicator assessed in central part of the tumor was not significantly associated with patient survival (RR=0.803; CI : 0.574–1.122; p&gt;0.05).Conclusion. The possibility of using an automatic analysis system to evaluate the immune microenvironment in gastric cancer was demonstrated for the first time. It was found that a high level of CD 8+ lymphocyte infiltration of morphologically normal mucous membrane of the peritumoral area was an independent negative prognostic factor. Therefore, we recommend the mandatory preoperative biopsy sampling from the mucous membrane of the peritumoral region for morphometric assessment of CD 8+ lymphocyte infiltration.

Abstract P338: Incidence, Predictors and Impact of Infarct in New Territory in Escape Na1 Trial

Introduction: Infarct in new territory (INT) is a known complication of endovascular therapy. We assessed the prevalence, predictors and clinical relevance of INT Methods: We included patients from the ESCAPE-NA1: a multicenter, international randomized study that assessed the efficacy of intravenous nerinetide in patients with acute ischemic stroke who underwent EVT within 12 hours from onset. All imaging was re-evaluated, and INT was defined by presence of infarct in new vascular territory, outside the baseline target occlusion(s) on follow up CT and MRI. INT’s were classified by maximum diameter (&lt;2mm, 2-20mm and &gt;20mm) and location. Results: Of 1099 analyzed patients in ESCAPE NA1, 107 had INT (9.7%, mean age 67 years, 51.4% females). There were no differences at baseline in those with vs without INT. Most INTs (75.7%) were angiographically occult and 41(38.3%) were &gt; 20mm. The most common INT territory was the ACA alone or in combination with MCA/PCA (30.3%). The presence of emboli in new territory angiographically was significantly associated with INT (OR 16.39, 95%CI 8.14-33.09). Alteplase use, balloon guide catheter use, nerinetide and initial occlusion site did not predict INT. INT patients had higher final median infarct volumes compared to non-INT (44.5cc vs 23.3cc, P&lt;0.001). Large INT (diameter of &gt;20mm) were associated with poor clinical outcome compared to INT (&lt;2mm) OR (mRS 0-2) 0.17, 95%CI 0.05-0.55). Conclusion: Infarcts in new territory are common and are associated with poor outcome.

Acute Endovascular Revascularization for Patients with Common Carotid Artery Occlusion Apparent on Cervical Magnetic Resonance Angiography

ObjectivesIn the endovascular treatment of acute cerebral large-vessel occlusion, cervical magnetic resonance angiography (MRA) is a useful modality for assessing the access route. However, we sometimes encounter cases in which not only the internal carotid artery (ICA), but also the common carotid artery (CCA) is poorly visualized, leading to hesitation over which devices and techniques to choose for revascularization. We retrospectively evaluated such cases, focusing on image findings and treatment results. Materials and MethodsData from 96 patients who underwent acute endovascular revascularization from January 2016 to December 2019 were analyzed. We extracted patients with poor CCA visualization on cervical MRA from 35 cases with ICA occlusion, and examined angiographic findings, treatment methods, and outcomes. ResultsPoor visualization of the CCA in cervical MRA was observed in 8 cases. All cases displayed atrial fibrillation or sick sinus syndrome. Angiographic findings showed true CCA occlusion in 2 patients and ICA occlusion in 6 patients. Reasons for the inability to visualize the CCA on cervical MRA were speculated to be stenosis of the external carotid artery (ECA), presence of embolism in the ECA, or severe heart failure. In cases of true CCA occlusion, thrombus was aspirated using the balloon guide catheter and good recanalization was obtained. Seven of 8 patients displayed favorable recanalization, with good prognosis after 90 days in 5 patients. ConclusionsPoor CCA visualization on cervical MRA does not necessarily represent true CCA occlusion. Aspiration of thrombus from a balloon guide catheter is effective for true CCA occlusion.

P-307 Colorectal cancer in young people under 45: Experience of the medical oncology service of the Hospital Hassan II of Fez

Colorectal cancer in young people is a rare condition with a poor prognosis. Several studies have objectified the increase in its incidence as well as its aggressiveness. Family screening, genetic analysis, and early diagnosis are necessary to improve one's prognosis when risk factors exist. The aim of this work was to study the epidemiological, anatomical-clinical, therapeutic and progressive characteristics in order to assess the factors of poor prognosis in this young population. We performed a retrospective study including 40 cases aged less than 45 years with colorectal cancers diagnosed and managed within the medical oncology department of the Hassan II teaching hospital in Fez, between January 2013 and June 2017. 40 cases were included which represented 22% of all colorectal cancers during the study period. Average age was 33 years (range 19 and 45). The sex ratio was 1.7 with a clear male predominance. Colorectal cancer-predisposing history was present in 11% of patients. The tumor was located in the right colon in 37.5% of cases and in the rectum in 32.5% of cases. Over 18% of cases were discovered during a complication (13.6% during an occlusion and 5.5% continued perforation). 13% of patients had mucous (mucinous) colloid carcinoma. The cancers were poorly differentiated in 35% of the cases. Existence of vascular emboli and nerve sheaths were found in only 22 files; the presence of emboli was noted in 37.5% of cases. 41% of patients were stage III or stage II with MSS status and poor prognosis factors and received a adjuvant chemotherapy following surgical treatment. 4% of patients were stage II with MSI status, without risk factors and received no adjuvant therapy. 55% of patients were metastatic from the start and received basic chemotherapy (fluoropyrimidine). Radiation therapy was performed in 26% of patients with cancer of the middle or lower rectum. The median survival time, all stages included, was 16 months (1-60 months). According to these results, colorectal cancer in young people has a poor prognosis, mainly due to the advanced disease stage at the time of diagnosis, as well as the frequent occurrence of recurrences in the case of undifferentiated tumors. Multidisciplinary care and genetic analysis seem essential to improve the prognosis of these patients.

High Ki-67 expression is a marker of poor survival in apocrine breast carcinoma.

Apocrine carcinoma is avery rare type ofbreast cancer, which represents 0.5-4% ofall breast cancers. Theaim ofthestudy was to analyze biological and clinical features ofapocrine carcinoma and their influence on patients survival. The studied group consists of57 patients, who underwent treatment between 1987 and 2010. Expression ofER, PgR, HER2, AR, GCDFP-15, EGFR, CK 5/6, CK 8/18 and Ki-67 was assessed immunohistochemically on formalin-fixed paraffin-embedded tissue sections. Presence ofemboli and extent oflymphocyte infiltration were assessed on haematoxylin-eosin-stained slides. In the investigated group, 16 cases were ER/PgR positive and 49 were AR-positive. ER/PgR-negative tumours were often characterised by CK5/6 and EGFR positivity. The presence ofAR was related to HER-2 and GCDFP-15 expression and tumours with expression ofCK5/6 were more likely be EGFR positive and had higher Ki-67 LI. Higher probability of10-years OS and DFS was observed in patients with tumours characterized by Ki-67 LI<20% (p=0.036 and p=0.009, respectively). Favourable trend in OS was noted for patients with smaller tumours (p=0.053), without lymph node metastases (p=0.074) and without EGFR expression (p=0.060). In apocrine breast carcinoma expression ofKi-67 is one ofthemost important factors influencing patients' survival.

Metastatic Peripheral Neuroblastoma in a Dog

Background: Peripheral neuroblast neoplasms are considered as a group of tumors derived from primitive cells of the neural crest that are progenitors of the sympathetic ganglia and adrenal medulla. Reports of neuroblastoma in dogs are scarce in English literature, and there are no reports from Brazil due to its rare occurrence or missed diagnosis, because modern techniques are often not accessible in Brazil. The aim of the present study was reported a case of metastatic peripheral neuroblastoma in a 10-month-old bitch of Canadian Shepherd breed, attended at the Small Animal Veterinary Hospital of the Federal Rural University of Rio de Janeiro (HVPA-UFRRJ).Case: A 10-month-old female dog, Canadian Shepherd breed, presenting prostration, inappetence, emesis, progressive weight loss, and difficulties in the locomotion of the pelvic limbs was brought to the Small Animal Veterinary Hospital of the Federal Rural University of Rio de Janeiro (HVPA / UFRRJ) for treatment. Palpation of the abdominal cavity revealed a mass of approximately 14.0 cm diameter in the thoracolumbar region. After the second visit to HVPA/ UFRRJ, there was worsening of the clinical condition and onset of pain and dyspnea; hence, euthanasia was performed. The dog was referred for necropsy; the examination revealed a mass measuring 40.0 × 35.0 cm in the abdominal cavity that caused displacement of the intestines and compressed the liver against the diaphragm, as well as another mass that traversed the diaphragm through the esophageal hiatus and surrounded the esophagus, aorta, and caudal vena cava. The right adrenal gland was compressed and adhered to the mass, and the left adrenal gland was not visualized. Specimens of various organs were collected, fixed in 10% buffered formalin, and processed according to routine histological technique. Immunohistochemical examination performed on mass specimens revealed positivity for the anti-CD56, anti-synaptophysin, anti-GFAP, and anti-NSE markers and negativity for the anti-chromogranin and anti-Olig2 markers. Based on pathology and immunohistochemistry findings, a diagnosis of poorly differentiated peripheral neuroblastoma was made; in addition, presence of emboli of neoplastic cells in the hepatic sinusoids and branches of the portal vein and metastasis in the spleen, lymph nodes, lung, and meninges were confirmed.Discussion: Positive results for neural markers associated with negative results for those of other small round cell tumors was considered to indicate the presence of neuroblast tumors; glioblastoma and oligodendroglioma were ruled out based on the absence of anti-Olig2 labeling, and, especially, the possibility of occurrence of pheochromocytoma was excluded based on the absence of anti-chromogranin. During necropsy, the location of the mass at the retroperitoneal space near the thoracolumbar junction, craniomedially in relation to the left kidney, was confirmed, which is compatible with the location of the adrenal gland. Metastasis in the dura mater was determined to be present based on necropsy findings alone, and neoplastic invasion through the esophageal hiatus of the diaphragm of a large part of the thoracic cavity was observed, which, to the best of our knowledge, have not been described in reports of veterinary medicine. The high rate of tumor growth and compression and invasion of adjacent tissues and organs may be considered as potential factors for unfavorable prognosis of peripheral neuroblastoma.

Fibulins: a new biomarker for pulmonary thromboembolism?

Objectives Fibulin-1, -2, -4, and -5 have important role in several vascular diseases. We aimed to investigate if fibulin-4 and -5 can be used as a biomarker for pulmonary thromboembolism (PTE). Methods This is a prospective case control study. Thirthy patients diagnosed with PTE and 31 in the control group. Data on demographic characteristics, length of hospital stay, blood cell counts, troponin and BNP levels, arterial blood gases, radiological reports, indication for thromboembolitic treatment, intensive care unit (ICU) requirement, and loss of life were recorded for the patients group. Serum Fibulin-4 and Fibulin-5 levels were measured. Results Fibulin 4 levels correlated positively with female gender (p < .01, r = 0.433). Positive results were found in 14 (46.7%) patients for PESI.0.1; in 7 (23.3%) patients for D-dimer; in 7 (23.3%) patients for troponin-I; in 7(23.3%) patients for BNP. Median values for Fibulin 4 level were significantly higher in patients positive for BNP. Fibulin-5 level was found to be correlated with the presence of embolism (p = .041, r = 0.263). Conclusions Fibulin-4 and -5 have been shown to be relevant to cardiovascular biology and diseases. Experimental studies and observations in humans show that they may play a role in several cardiovascular diseases particularly pulmonary embolism.

Diagnostic performance of contrast-enhanced and unenhanced combined pulmonary artery MRI and magnetic resonance venography techniques in the diagnosis of venous thromboembolism.

We aimed to determine the diagnostic performance of the contrast-enhanced and unenhanced combined pulmonary arterial MRI and magnetic resonance venography techniques in the diagnosis of venous thromboembolism (VTE). 44 patients who underwent CT pulmonary angiography (CTPA) for suspected PE constituted the study population. Patients underwent combined pulmonary and lower extremity MRI, and Doppler ultrasonography within 72 h after CTPA. Combined MRI included two sequences: unenhanced steady-state free precession (SSFP) and contrast-enhanced three-dimensional (3D) gradient echo (GRE). The presence of emboli in pulmonary arteries and thrombi in lower extremity veins on 3D-GRE and SSFP sequences was recorded. CTPA showed a total of 244 emboli in 33 (75%) patients whereas contrast-enhanced 3D-GRE MRI showed deep vein thrombosis (DVT) in 34 (77%) subjects. Sensitivities for SSFP vs 3D-GRE MRI respectively in PE detection were 87.9 vs 100% on a per-patient basis, and 53.7 vs 73% on a per-embolus basis. Of 34 patients with established DVT, 31 (91%) were detected by Doppler ultrasound and 29 (85%) were detected by SSFP technique respectively. Both contrast-enhanced and unenhanced combined MRI of acute PE and DVT are feasible one-stop-shopping techniques in patients with suspected thromboembolism. Pulmonary VTE is a common disease with high mortality. Non-invasive techniques withhigh accuracy are required for the assessment of VTE. CT-related radiation and contrast material risks cause concerns. MRI is a radiation-free technique evaluating the vessels with and without contrast. Combined contrast enhancedor unenhanced pulmonary and lower extremity MRI is feasible in patients with suspected thromboembolism.

Circulating Tumor Cell Phenotype Indicates Poor Survival and Recurrence After Surgery for Hepatocellular Carcinoma.

Circulating tumors cells (CTCs) may be a promising prognostic marker for patients with malignant tumors. However, there are few reports regarding its value for hepatocellular carcinoma (HCC) patients. To investigate CTCs with epithelial and mesenchymal phenotypes as a potential prognostic biomarker for HCC patients. Peripheral blood samples were obtained from 165 HCC patients before radical surgery. CTCs were isolated via the CanPatrol CTC enrichment technique and classified using epithelial-mesenchymal transition (EMT) markers. The relationship of CTC phenotype with clinicopathological factors and HCC recurrence in patients was analyzed. CTC-positive status (count ≥ 2/5mL) was found in 70.9% of the 165 HCC patients. Increased CTC number was more common in patients with higher AFP levels, multiple tumors, advanced TNM and BCLC staging, and presence of embolus or microembolus (P < 0.05). CTCs heterogeneity was noted using EMT markers. Mesenchymal CTCs were significantly correlated with high AFP levels, multiple tumors, advanced TNM and BCLC stage, presence of embolus or microembolus, and earlier recurrence (P < 0.05). The presence of mesenchymal CTCs predicted the shortest relapse-free survival, followed by mixed phenotypic CTCs, and then epithelial CTCs (P < 0.001). CTC phenotype may serve as a prognostic indicator for HCC patients. CTCs assessment should include phenotypic identification tailored to characterize cells based on epithelial and mesenchymal markers.

Outcomes following embolization in patients with cardiac myxoma

Cardiac myxomas are the most frequent primary benign intracardiac tumors. We reviewed our 27-year experience to evaluate factors associated with an embolism in patients with cardiac myxomas and their long-term outcomes. A retrospective review identified 99 patients with cardiac myxomas between 1985 and 2012. Tumors were divided into two groups based on their gross external features. Tumors with a smooth regular border and a solid consistency were classified as solid; papillary myxomas were characterized by an irregular and gelatinous exterior with friable, soft consistency. The patients were classified into embolic and non-embolic groups to focus on embolic events. Mean age at surgery was 49.8 ± 16 years. There were 92 left atrial myxomas (92.9%). Embolization was observed in 25 patients (25.3%) before surgery. Three variables were associated with an embolic event, small tumor size (odds ratio [OR] = 4.36 P = 0.037 confidence interval [CI] 95% 0.534-0.980), atrial fibrillation (OR = 10.119 P = 0.001 CI 95% 0.021-0.397), and papillary-type pathology (OR = 11.544 P = 0.001 CI 95% 0.033-0.399). Tumor pathology or the presence of embolization prior to surgery had no effect on operative mortality or long-term survival. Embolization of cardiac myxomas is more likely to occur in papillary-type tumors, that are smaller in size and in patients presenting with preoperative atrial fibrillation. However, the presence of embolization at the time of surgery does not increase operative morbidity or mortality or affect long-term survival.

Catching a floating thrombus; a case report on the treatment of a large thrombus in the ascending aorta

BackgroundThe ascending aorta is an uncommon site for non-infective thrombus. In non-aneurysmal and non-atherosclerotic vessels this condition becomes extremely rare, while it represents a source of potential cerebral and peripheral embolic events. Currently, there is no consensus in the guidelines on how to treat a free floating thrombus in ascending aorta, therefore we present our decision making process and therapeutic strategy.Case presentationA healthy 48-year-old man was hospital admitted with acute abdominal pain. CT-scan showed a right renal embolism in presence of a defect in the distal ascending aorta suggestive for thrombus. After heart team discussion the patient was scheduled for surgery and successfully underwent an emergent thrombus removal. Also, owing to multiple aortic wall insertions, the ascending aorta was replaced. The patient’s recovery was uneventful and histological examination showed no signs of connective tissue disorders of aortic wall while confirmed the thrombotic nature of the mass.ConclusionsWe present a patient with a floating thrombus in the ascending aorta who underwent an ascending aorta replacement. While angio-CT scan led to a prompt diagnosis, intraoperative epi-aortic echocardiography allowed to define precise location of thrombus, minimizing operative risk. This case demonstrates that multi-disciplinary heart team discussion is essential to define a successful strategy, that surgical treatment is feasible with specific tools such as epi-aortic echocardiography.

Serrated adenomas of the colon: Clinical, morphological, and molecular genetic characteristics

to investigate the clinical, morphological, and molecular genetic characteristics of serrated adenomas of the colon. The study included 82 colon adenomas from 63 patients aged 29 to 81 years, who underwent colonoscopy with biopsy or polypectomy. The mean age of men was 63.3 years; that of women was 56.8 years. Comprehensive clinical, morphological, immunohistochemical, and molecular genetic examinations were made. The histological examination showed that sessile serrated adenomas (SSA) of the colon were most common (46.4%), while hyperplastic polyp (HP) and traditional serrated adenoma (TSA) were found less often and with the same frequency (26.8%). The most typical location of SSA was the right colon; that of TSA was the left one. HP was detected equally on both sides of the colon. The immunohistochemical examination of the subtypes revealed no significant differences in the expression of markers. An analytical panel of antibodies against Desmin, Podoplanin (D2-40), CK20, CD34, Ki-67, Muc2, CEA, and CDX2 was used when identifying dysplasia areas, suspecting malignancy with invasion into the muscular layer of the mucous membrane and when determining the possible presence of emboli in blood and lymph vessels. BRAF gene mutation was identified in half of SSA cases; genetic BRAF mutation was observed in 41.7% of HP cases; genetic KRAS mutation was seen in 16.6%. The patients with TSA showed KRAS and BRAF mutations in 58.4 and 8.3% of cases, respectively. Mutations of these genes were absent. The study revealed that the subtypes of serrated adenomas substantially differ by sex, age, localization, and molecular genetic characteristics.

Papillary fibroelastoma: clinical and echocardiographic features and initial approach in 54 cases

Papillary fibroelastoma (PFE) is a benign cardiac tumor that is currently detected more often due to the technological improvements in echocardiography. To describe the echocardiographic features of PFE and correlate them with the clinical presentation and initial treatment. A prospective analysis of patients with a diagnosis of PFE was conducted between 2000 and 2015. We assessed the clinical history, symptoms at the time of diagnosis, echocardiographic features, and initial treatment. Fifty-four patients with a diagnosis of PFE by echocardiography were included. The incidence was 0.038%. Mean age was 62±16years; 50% were male. Forty-six percent of patients had symptoms at the time of diagnosis, the most frequent of which was transient ischemic accident (TIA). Embolic episodes occurred in 31% of patients, mainly to the brain. PFEs were valvular in 70.4% of cases and multiple in 13%. Mean maximum length was 1.18±0.58cm, and 44% were mobile. PFEs >1.5cm were most often found in the heart valves (56.8% vs 10.8%; P=.045). There was no significant relation between size, mobility, location and number of tumors, and the presence of embolism or symptoms. Most frequent treatment was oral anticoagulation in 48.6%, followed by simple tumor resection in 42.8% of cases. PFE is a small tumor, predominantly valvular and benign, but entails a high incidence of cerebral embolism. The initial approach should be individualized according to clinical manifestations, comorbidities, and the experience of the surgical center.

Detection of Doppler Microembolic Signals Using High Order Statistics.

Robust detection of the smallest circulating cerebral microemboli is an efficient way of preventing strokes, which is second cause of mortality worldwide. Transcranial Doppler ultrasound is widely considered the most convenient system for the detection of microemboli. The most common standard detection is achieved through the Doppler energy signal and depends on an empirically set constant threshold. On the other hand, in the past few years, higher order statistics have been an extensive field of research as they represent descriptive statistics that can be used to detect signal outliers. In this study, we propose new types of microembolic detectors based on the windowed calculation of the third moment skewness and fourth moment kurtosis of the energy signal. During energy embolus-free periods the distribution of the energy is not altered and the skewness and kurtosis signals do not exhibit any peak values. In the presence of emboli, the energy distribution is distorted and the skewness and kurtosis signals exhibit peaks, corresponding to the latter emboli. Applied on real signals, the detection of microemboli through the skewness and kurtosis signals outperformed the detection through standard methods. The sensitivities and specificities reached 78% and 91% and 80% and 90% for the skewness and kurtosis detectors, respectively.

Blunt traumatic occlusion of the internal carotid and vertebral arteries

The stroke rate, management, and outcome after blunt cerebrovascular occlusion (Biffl Grade IV injury) is not well defined, given the rarity of the disease. Both hemodynamic failure and embolic mechanisms have been implicated in the pathophysiology of subsequent stroke after blunt cerebrovascular occlusion. In this study, the authors evaluated their center's experience with Biffl Grade IV injuries, focusing on elucidating the mechanisms of stroke and their optimal management. A retrospective review identified all internal carotid artery (ICA) or vertebral artery (VA) Biffl Grade IV injuries over a 7-year period at a single institution. Fifty-nine Biffl Grade IV injuries were diagnosed affecting 11 ICAs, 44 unilateral VAs, and 2 bilateral VAs. The stroke rates were 64%, 9%, and 50%, respectively. Of the 11 Biffl Grade IV ICA injuries, 5 presented with stroke while 2 developed delayed stroke. An ipsilateral posterior communicating artery greater than 1 mm on CT angiography was protective against stroke due to hemodynamic failure (p = 0.015). All patients with Biffl Grade IV injuries affecting the ICA who had at least 8 emboli per hour on transcranial Doppler (TCD) ultrasonography developed an embolic pattern of stroke (p = 0.006). Treatment with aspirin versus dual antiplatelet therapy had a similar effect on stroke rate in the ICA group (p = 0.5) and all patients who suffered stroke either died (n = 3) or required a decompressive hemicraniectomy with subsequent poor outcome (n = 4). All 10 strokes associated with Biffl Grade IV VA injuries were embolic and clinically asymptomatic. In VA Biffl Grade IV injury, neither the presence of emboli nor treatment with antiplatelet agents affected stroke rates. At the authors' institution, traumatic ICA occlusion is rare but associated with a high stroke rate. Robust collateral circulation may mitigate its severity. Embolic monitoring with TCD ultrasonography and prophylactic antiplatelet therapy should be used in all ICA Biffl Grade IV injuries. Unilateral VA Biffl Grade IV injury is the most common type of traumatic occlusion and is associated with significantly less morbidity. Embolic monitoring using TCD and prophylactic antiplatelet therapy do not appear to be beneficial in patients with traumatic VA occlusion.

Abstract P2-05-08: Combined neoadjuvant iniparib and carboplatin in locally advanced or metastatic canine mammary tumors (MT) to support human clinical studies

Abstract INTRODUCTION Among breast cancers, the triple negative subtype (negative for hormone receptors and not overexpressing HER2) has the worst prognosis and its response to Iniparib has been investigated in clinical trials. Further investigations are needed to optimize drug schedule and patient selection criteria. Iniparib antitumor mechanism is not completely understood, as well as iniparib diffusion kinetic into tumoral tissues. We address these questions in spontaneous canine invasive mammary carcinomas, which are a good model for this cancer subtype (Ibisch et al., World Veterinary Cancer Congress 2012), in a neoadjuvant setting. To our knowledge, this is the first study of iniparib administration in cancer-bearing dogs. MATERIAL AND METHODS Twenty female dogs with spontaneous MT with malignant criteria (tumor size, speed of growth, ulceration, relapse, or metastasis) were included. All tumors were described as rapidly growing. Dogs received a first infusion of iniparib at day 0 and a combination of carboplatin and iniparib at day 7. Biological materials (tumor biopsies and blood) were collected before and 5 minutes after iniparib infusion for pharmacokinetic and metabolism studies. Tumor response was evaluated by caliper measurements and histopathological analysis of mammary tumors and draining lymph nodes. A chain mastectomy was performed 3 or 4 weeks later. Histological records included the subtype of carcinoma (WHO 1999), Elston &amp; Ellis grade, presence of emboli, lymph node metastasis and IHC stainings using ER, PR, Her2 (scored according to Wolff et al.2007), CK5/6, EGF-R and Ki67. Intensity of necrosis and apoptosis was evaluated using PAS coloration and immunohistochemistry for caspase 3, at DO on tumor biopsies and at surgery. Toxicity of the protocol was evaluated and its efficiency on invasive carcinomas was compared to surgery alone (control group of 27 female dogs with invasive mammary carcinomas treated by chain mastectomy alone). RESULTS Treated and control groups shared similar features concerning animal breeds, age, neutering status and tumor location. 75% of the treated MT were malignant. Necrosis and apoptosis were significantly increased in respectively 63 and 56% of iniparib treated tumors. Clinical evidence of toxicity was minimal (15% of dogs with nausea, 60% with transient polyuria-polydipsia). Tumor stabilization was observed before surgery in all dogs but one. Median survival has not been reached. CONCLUSION Iniparib at 35mg/kg combined with carboplatin at 300 mg/m2 seemed well tolerated in this study and deserves further investigations. The degree of necrosis and apoptosis in the treated tumors can be evaluated with these techniques. Iniparib pharmacokinetic and metabolism studies in cancer-bearing dogs are ongoing. Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P2-05-08.

Digital Squamous Cell Carcinoma in Dogs

Squamous cell carcinoma represents 47.4% of all malignant canine digital lesions, but despite its frequency, there are few published studies available. Pathology submission records of 154 cases and follow-up of 49 animals were analyzed. On the 49 cases, histological evaluation was performed of the differentiation degree, mitotic index, presence of emboli, and immunohistochemical expression of vimentin and E-cadherin. The mean (SD) age of affected animals was 10.2 (2.3) years; no sex predisposition was recorded. Beauceron and Briard were 2 new overrepresented breeds. Dark-haired animals comprised 97 of 105 (92%); 94 dogs of 125 (75.2%) belonged to large and giant breeds. The forelimb was affected twice more than the hind limb. Probable metastases were observed in 4 dogs; new tumor development was recorded in 11 of 49 (22.4%). Epidemiologic factors, histological grade, mitotic index, and expression of immunohistochemical markers seemed not to be related to the clinical outcome.