Recurrent Effusion Research Articles

Expression of Wnt pathway molecules is associated with disease outcome in metastatic high-grade serous carcinoma

The objective of this study was to analyze the expression and clinical role of Wnt pathway molecules in metastatic high-grade serous carcinoma (HGSC). mRNA expression by qPCR of 20 molecules related to Wnt signaling (WNT1, WNT2, WNT3, WNT4, WNT5A, WNT6, WNT7, WNT11, FZD1, FZD4, FZD5, FZD6, FZD7, FZD8, FZD10, LRP5, LRP6, DKK, CCND, RUNX2) was analyzed in 87 HGSC effusions. Thirty-nine surgical specimens (19 ovarian, 20 from otherintra-abdominal sites) were analyzed for comparative purposes. Protein expression of YAP and LRP and their phosphorylated forms by western blotting were analyzed in 52 tumors. Significant differences in mRNA expression as a function of the anatomic site were observed for WNT3 (p = 0.005), WNT5A (p = 0.008), WNT7 (p < 0.001), FRZ5 (p = 0.04), and FRZ6 (p < 0.001). YAP and LRP and their phosphorylated forms were detected in HGSC specimens. FZD10 was overexpressed in effusions from patients who had complete response to chemotherapy compared with those with less favorable response (p = 0.037). WNT4 (p = 0.005), WNT7 (p = 0.047), RUNX2 (p = 0.038), LRP5 (p = 0.022), LRP6 (p = 0.011), FZD6 (p = 0.036), FZD7 (p = 0.004), and FZD10 (p = 0.015) levels were inversely related to primary chemoresistance. High FZD5 levels in pre-chemotherapy effusions tapped at diagnosis and high WNT2 levels in post-chemotherapy disease recurrence effusions were related to shorter overall survival (p = 0.018 and p = 0.011, respectively), whereas high RUNX2 (p = 0.031) and FZD1 (p = 0.029) in post-chemotherapy effusions were associated with longer overall survival. In multivariate analysis of post-chemotherapy cases, WNT2 (p = 0.002), RUNX2 (p = 0.017), FZD1 (p = 0.036), and FZD4 (p = 0.013) were independent prognosticators. In conclusion, expression of Wnt pathway molecules is anatomic site dependent. In HGSC effusions, it is informative of chemoresponse and survival.

Pleurodesis and Immunotherapy in NSCLC; Medical Thoracoscopy or VATS?

Introduction: Immunotherapy is a treatment option for non-small cell lung cancer advanced disease. However; immunotherapy in several patients induces orogonitis and effusion in different cavities. It is up to the treating physician to understand whether there is effusion due to adverse effect or disease progression. Pleurodesis in both cases might be a solution for recurrent pleura effusion.Patients and Methods: Three hundred and thirty seven non-small cell lung cancer patients with adenocarcinoma and pleura effusion during first line immunotherapy treatment underwent medical thoracoscopy or Video assisted thoracic surgery (VATS) for pleurodesis with talk poudrage. Uniportal medical thoracoscopy was performed under general with dual channel endotracheal tube in one hundred and eleven patients. Video assisted thoracic surgery was performed in one hundred and eighty seven patients and conversion from medical to VATS procedure was done to thirty nine patients. All patients had stage IV disease with pleura involvement and were under first line pembrolizumab treatment with 200mg (PD-L1 ≥ 50%).Results: The quantitative parameters of the study (expression, PY and cycle) were converted to an ordinal scale to facilitate the performance of statistical analysis. All parameters were examined as dependent against the parameter technique acting as independent to detect potential relationships. The results of multi Y versus X relationship revealed no statistically significant effect (p>0.05) of the three levels of technique against any response considered. Thus we can infer, quite safely, that the innovative operation (level 0) does not differ from the other two conventional methods (levels 2 and 3) through all parameters entered in the model. There was no significant difference between the different pleurodesis techniques.Discussion: Immunotherapy is known to induce in a number of patients pleura effusion and pericarditis. However; pleurodesis is efficient when the appropriate method is performed to every patient. Careful assessment in a case by case manner has to be performed for each patient before any procedure is performed.

Comparison of intra-articular steroid injection and hyaluronic acid in mono-articular synovitis knee

Introduction: Mono articular presentation of rheumatoid arthritis is infrequent and has been previously reported to involve the hip and knee joints. Rheumatoid arthritis is a common symmetrical chronic inflammatory arthritis with the prevalence of 1% worldwide. Mono- articular rheumatoid arthritis is a rare entity reported to initially affect large joints such as hips and knees, progressing to a poly articular presentation within 3 to 5 years. Synovitis is an important component of rheumatoid arthritis, so we conducted a study to include all the recurrent effusion of knee cases, and we have compared the functional outcome of intra-articular steroid injection and hyaluronic acid in the treatment of such cases. Material and Methods: 40 cases of recurrent effusion of knee joint attending the OPD or emergency services at Government Medical College and Rajindra hospital, Patiala between July 2016 to July 2019 were evaluated with the clinical examination, haematological investigations and radiological investigations. In all the cases, the joint was aspirated with a 16 G Needle and aspirated fluid was sent for pus cultural sensitivity in a microbiology Department of our hospital and was sent for CBNAAT to chest and TB hospital of our hospital. In Group 1, following the aspiration, injection of local corticosteroid (methylprednisolone acetate 80 mg) was given and in group 2, injection of hyaluronic acid was given, followed by a short course of antibiotics for 5 days and short course of non-steroidal anti-inflammatory drugs was given for 10 days and a crêpe bandage was applied for 2 days. The results were assessed by VAS for pain and KOOS (Knee Injury and Osteoarthritis Outcome Score) scores. Results: In all 40 patients, the pus cultural sensitivity was negative for any microorganism and CBNAAT was negative in all the 40 patients. By comparing the results obtained in KOOS scale it was seen that symptoms improved after six months in both steroid (P = 0.017) and HA groups (P = 0.004). Besides, daily activity improved in both steroid (P = 0.027) and HA groups (P = 0.047). On the contrary, pain did not decrease 6 months after intervention in both steroid (P = 0.096) and HA groups (P = 0.17) Conclusion: Mono articular synovitis in an otherwise seronegative patient is due to recurrent inflammatory response due to recurrent stress or any other intra articular pathology. Patients are advised rest, and a short course of steroidal anti-inflammatory drugs, which also helped to relieve the inflammation. This was markedly improved by intra-articular HA injection as shown by the recovery in intra-articular HA injection group as compared to the steroid group.

Clinical significance of 12 lead ECG changes in patients undergoing pericardiocentesis for cardiac tamponade

Introduction The electrocardiogram (ECG) is one of the initial tests done in patients suspected of having a cardiac Tamponade. Historically the emphasis has been on low QRS voltage and electrical alternans, which lacks specificity and sensitivity respectively. Majority of these studies included patients with pericardial effusions without tamponade. Moreover, the influence of different therapeutic interventions such as pericardiocentesis on ECG variables has not been elucidated. Objective To determine the clinical significance of 12 lead ECG changes in patients undergoing pericardiocentesis for cardiac tamponade. Methods 144 patients underwent Echo guided pericardiocentesis for cardiac tamponade at a tertiary care hospital over a period of 7 years. We compared 19 EKG variables pre and post procedure. Results Low voltage was detected in only 31 patients (29%) with 19 (18%) patients having persistent low voltage (p value = 0.0047) after the pericardiocentesis. Electrical alternans was only observed in 25 patients (23%), and persisted in 10 patients (10%) following pericardiocentesis. None of the other EKG variables measured changed reliably post procedure. Conclusion We found that although electrical alternans and low voltage were associated with cardiac tamponade, none of the ECG variables were highly sensitive or specific for the diagnosis, reproducibly changed after drainage or predicted recurrent effusion post-pericardiocentesis.

An Unusual Cause of Recurrent Pleural Effusion

Abstract Cryptococcus neoformans is a yeast that can cause severe infection in the immunocompromised. It is commonly associated with meningitis in patients with underlying HIV infection; however, infections can occur in other immunosuppressed hosts as well as the immunocompetent. Pulmonary disease is well described, but recurrent pleural effusion and empyema are rare. We describe a case in a non–HIV-infected, nontransplant cirrhotic patient presenting with recurrent pleural effusions and cryptococcal empyema. The patient is a 66-year-old man with cirrhosis, diabetes, and kidney disease who presented with 3 months of dyspnea complicated by recurrent pleural effusion and low protein ascites after treatment of hepatitis C virus. Routine cultures from multiple thoracenteses were unrevealing. Fungal culture ultimately grew C. neoformans/gattii. His serum cryptococcal antigen titer was 1:40, and chest imaging revealed several pulmonary nodules. He was admitted for evaluation of disseminated disease and central nervous system involvement, which was unremarkable. He was started on oral fluconazole 200 mg daily dosed for his renal function and was doing well in outpatient follow-up. Patients with cirrhosis tend to have a higher incidence of cryptococcal disease and are more likely to have disseminated infection with higher mortality. It is possible that deficiencies in complement and cytokine levels as well as leukocyte function may contribute to this increased risk. Effusions are an uncommon manifestation of pulmonary cryptococcosis and, as with the case in our patient, may resemble hepatic hydrothorax, leading to a delay in antifungal therapy. In conclusion, patients with liver disease have an increased risk of cryptococcosis. A high index of suspicion must be maintained for infection and should be considered in patients with recurrent effusions.

Update on Management of Pleural Disease

The goal of this paper is to review and summarize the most recent updates in the management of both benign and malignant pleural diseases. Multiple trials evaluating the use of non-surgical techniques for the management of pleural infection have been published in the last 5 years. Additionally, the use of tunneled pleural catheter (TPC) placement in the management of non-infectious recurrent pleural effusions is being increasingly studied. Finally, the separate use of TPC placement or talc pleurodesis as well as a combined rapid pleurodesis protocol involving both talc poudrage and TPC placement has been published in the area of symptomatic recurrent malignant pleural effusion. Exciting advances have been made in the field of pleural disease management. In this paper, we summarize the most relevant trials, provide a list of pertinent references for review, and discuss future research directions.

A Case of Mitral Valve Metastasis From Breast Carcinoma Mimicking as a Mitral Valve Regurgitation

Abstract- Metastatic involvement of cardiac valve and pericardium mimicking a cardiac valve pathology accompanied with cardiac tamponade is a rare phenomenon. These metastases commonly arise from the lymphoreticular system, the pulmonary system, and breast. Metastatic spread of breast carcinoma to the cardiac valve is exceedingly rare, and only two case reports have been detected in English literature so far. We report a rare case of a patient with adenocarcinoma of the breast, which presented with severe mitral valve regurgitation and pericardial effusion which was managed urgently with mitral valve replacement. Our case shows the probability of combined metastatic pericardial and valve involvement in patients with breast adenocarcinoma. The patient was treated with mitral valve replacement and intrapericardial infusion of cisplatinum drug to control possible recurrent effusion.

Early Mechanical Failure of a Tumoral Endoprosthesic Rotating Hinge in the Knee: Does Bumper Wear Contribute to Hyperextension Failure?

Tumor surgeons use a variety of endoprosthetic designs for reconstruction after bone tumor resection. However, functional results and implant survival have not been evaluated for each design. Because the outcomes and failure modes (for example, implant breakage, loosening) may differ between prosthetic design types, it is important to examine the problems associated with different designs. Because of experiences in our practice, we became concerned about a surprisingly high frequency of device breakage with one particular design, and we wished to report on that experience. QUESTION/PURPOSES: (1) In a small series of patients, what proportion of a particular design (Zimmer® Segmental [Zimmer Inc, Warsaw, IN, USA]) of rotating-hinge endoprosthesis experienced implant breakage at short-term follow-up? (2) What patient symptoms were associated with this finding? (3) What is the function as assessed by Musculoskeletal Tumor Society (MSTS) score with the use of this implant before and after revision? We treated 87 patients in our tertiary center from 1987 to 2014 who had sarcomas around the knee with wide resection and reconstruction with tumoral endoprosthesis; five patients were lost to follow-up. In all, 33 of the remanining 82 prostheses, treated from 1987 to 2006, were reconstructed with fixed-hinge designs. From 2006 to 2014, 49 patients were reconstructed with a knee endoprosthesis, and 48 of them had a rotating-hinge prosthesis. In our center, we mostly used four designs: 16 of 49 patients were reconstructed with GMRS (Stryker Howmedica, Kalamazoo, MI, USA), seven received the LPS™ (DePuy Synthes, Warsaw, IN, USA), 20 of 49 had the METS (Stanmore, Hertfordshire, UK), and six of 49 received the Zimmer Segmental. The focus of this report is on the six patients with the Segmental. We retrospectively gathered clinical and radiologic data from these six patients' records and we assessed radiographic images. We evaluated function with the MSTS score of the 49 patients. The median follow-up duration of the Segmental prosthesis reconstruction was 65 months (range 24 to 85). Three of the six patients had posterior instability and recurrent joint effusion on physical examination. Three patients who did not have hyperextension presented with restricted knee ROM. Six revision procedures were performed in three patients. The median MSTS score at 6 months for the Segmental® prosthesis was 15 of 30 (range 6 to 24). The score in the three patients who had posterior instability was 9 of 30 (range 6 to 15) and it improved to median 25 of 30 (range 19 to 30) 6 months after revision. The patients with the Segmental® prosthesis who did not undergo revision had a median MSTS score of 20 (range 16 to 24). The Zimmer Segmental rotating-hinge tumoral prosthesis underwent revision for implant breakage at short term in three of six patients after tumor resection and reconstruction of the knee. Bumper breakage was associated with posterior instability that was related to wear of the bushing blocking system. We are unaware of reports of these issues by other observers or in other prosthetic designs, but we feel larger registries should be created to see if this failure mechanism has been observed by others. If so, this design needs to be improved or the blocking system should be avoided.Level of Evidence Level IV, therapeutic study.

A CURIOUS MANIFESTATION OF SARCOIDOSIS

SESSION TITLE: Pulmonary Manifestations of Systemic Disease SESSION TYPE: Fellow Case Reports PRESENTED ON: 10/21/2019 3:15 PM - 4:15 PM INTRODUCTION: Patients with sarcoidosis have pulmonary involvement greater than 90% of the time, however that typically involves intra-thoracic lymph nodes and lung parenchyma, with pleural involvement being exceedingly rare.[1,2,3] We present a case of a new onset unilateral pleural effusion in a patient with sarcoidosis. CASE PRESENTATION: A 68 year old female with a biopsy proven diagnosis of pulmonary sarcoidosis presented to the pulmonary clinic with complaints of a non-productive cough and worsening dyspnea on exertion. She noted that over the previous four months she had a decreased exercise capacity when running on the treadmill. She trialed discontinuing her beta-blocker, however, her exertional dyspnea symptoms persisted. Chest radiography revealed a new right-sided moderate sized effusion. Pleural fluid analysis showed a lymphocyte predominant exudative effusion while cytology and cytometry were negative for malignancy. Due to her recurrent effusion she underwent pleuroscopy for pleural biopsy with indwelling pleural catheter placement. Parietal pleura biopsies showed mesothelial cell proliferation concerning for mesothelioma, however BAP-1 immunostaining was negative along with no evidence of homozygous p16 deletion on fluorescence in situ hybridization. As the histologic workup was non-conclusive the patient underwent video-assisted thoracoscopic surgery. Right middle and lower lobe wedge resection showed non-caseating granulomas and were negative for acid-fast bacilli and fungal stains. Subsequently due to her symptomatic recurrent pleural effusion she was started on steroid therapy with improvement of parenchymal lesions, lymphadenopathy, and pleural effusion noted on imaging within three weeks of initiation. DISCUSSION: Pleural effusions related to sarcoidosis have been described in the medical literature predominantly as case reports/series. A recent prospective study using pleural ultrasound to identify pleural effusions in patients with known sarcoidosis noted an incidence of only 1.1%.[2] Pleural effusions are typically noted to be lymphocyte predominant exudates, however, transudates, chylothorax, and hemothorax have all been described. The pleural fluid to serum protein ratio, compared to the LDH criteria, is typically noted to be in the exudative range.[2] Due to the variability and non-specific findings on pleural fluid analysis, diagnosis should be guided by biopsy confirmation. Treatment should be reserved for patients with recurrent effusions, which are typically responsive to steroid therapy. CONCLUSIONS: As a result of the relative rare nature of pleural effusions in patients with sarcoidosis, it is imperative to confirm the true etiology of the effusion. Although pleural fluid analysis is useful, pleural biopsy remains the gold standard diagnostic test in the workup of an undiagnosed pleural effusion and should be utilized in the workup of such in patients with sarcoidosis. Reference #1: Sharma OP, Gordonoson J. Pleural effusion in sarcoidosis: a report of six cases. Thorax. 1975; 30:95–101 Reference #2: Huggins JT, Doelken P, Sahn SA, King L, Judson MA. Pleural effusion in a series of 181 outpatients with sarcoidosis. Chest. 2006; 129:1599–1604 Reference #3: Baughman RP, Teirstein AS, Judson MA, et al. Clinical characteristics of patients in a case control study of sarcoidosis. Am J Respir Crit Care Med. 2001; 164:1885–1889 DISCLOSURES: No relevant relationships by Sara Shadchehr, source=Web Response No relevant relationships by Dhaval Thakkar, source=Web Response

UTILITY OF IMMUNOHISTOCHEMISTRY IN PLEURA-BASED LUNG CANCERS: A DIAGNOSTIC DILEMMA

SESSION TITLE: Monday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Lung cancer screening guidelines do not target patients likely to develop cancers of the pleura, resulting in delayed diagnosis. Pleural lung cancers with clinicopathologic and histologic similarities such malignant melanomas (MM), sarcomatoid mesothelioma (SM) and synovial sarcoma (SS) further compound diagnostic uncertainty, resulting in increased morbidity and mortality, with 5-year survival rates as low as 9%. We present a case highlighting this diagnostic conundrum as well as the limitations of immunohistochemistry (IHC). CASE PRESENTATION: A 79-year-old male with history of atrial fibrillation on Eliquis, prostate cancer post brachytherapy and melanoma to the mid back post resection without sentinel lymph node biopsy presents to the ER with a 1 week history of progressive dyspnea on exertion and wheezing. He denied chest pain, palpitations, orthopnea, fever, constitutional symptoms or recent falls. He denied a history of radiation or asbestos exposure. On presentation vitals were normal with decreased breath sounds in the left middle to lower lung fields. Lab results were normal except mild anemia. Initial chest x-ray showed new large left pleural effusion. CT chest showed large left pleural effusion with multiple pleural-based nodules in the left upper lobe. Eliquis was held and two thoracenteses done days apart drained 2400cc of dark red exudative fluid, negative for malignant cells. A week later, video-assisted thoracoscopic surgery (VATS) was performed due to recurrent effusion. VATS revealed extensive lung pleura and pericardial studding; 1500cc of serosanguinous fluid was drained. Histology showed a malignant tumor composed of hyperchromatic spindle cells. Differentials included SS, MM and SM. IHC was positive for one of two melanoma markers (S100+, Melan-A-), one of two mesothelioma markers (WT1+, calretinin-), and also for TLE1 (synovial sarcoma marker). Repeat IHC at a large referral institution showed nonspecific staining for TLE1 and a final diagnosis of MM was rendered after comparison with previously resected MM. DISCUSSION: MM, SM and SS were considered in this case of recurrent bloody pleural effusions, multiple pleural-based plaques and spindle cell histology. MM and SM both carry poor prognosis compared with SS, necessitating definitive diagnosis. TLE1 was used as a specific marker for SS, but has been found in 69% of SM cases and 57% of spindle-cell melanomas. Molecular analysis for SYT-SSX can confirm SS, but is not always readily available. A definitive diagnosis was only made after comparison of previously resected melanoma, further illustrating the diagnostic dilemma. CONCLUSIONS: Lung cancer is the leading cause of cancer deaths in the USA with melanomas having the 6th highest incidence of cancers. Pleural lung cancers have the potential for high mortality with significant clinical and pathological overlap, for which IHC may not provide a definitive diagnosis. Reference #1: Matsuyama A, Hisaoka M, Iwasaki M, Iwashita M, Hisanaga S, Hashimoto H. TLE1 expression in malignant mesothelioma. Virchows Archiv. 2010;457(5):577-583. Reference #2: Morrell TJ, Xiong Y, Deng A, Dresser K, O’Donnell P, Cornejo KM. Expression of TLE1 in Malignant Melanoma with Spindle Cell Morphology: A Potential Diagnostic Pitfall. International Journal of Surgical Pathology. In press. https://doi.org/10.1177/1066896918805137. Reference #3: Lao I, Chen Q, Yu L, Wang J. Sarcomatoid malignant mesothelioma: a clinicopathologic and immunohistochemical analysis of 22 cases. Chinese Journal of Pathology. 2014;43(6):364-369. DISCLOSURES: No relevant relationships by Sahai Donaldson, source=Web Response No relevant relationships by Gene Otuonye, source=Web Response No relevant relationships by Dan Ran-Castillo, source=Web Response No relevant relationships by David Shiu, source=Web Response No relevant relationships by Matthew Tavares, source=Web Response No relevant relationships by Mikhail Tismenetsky, source=Web Response

1318 Pancreaticopleural Fistula in a Patient With Recurrent Alcoholic Pancreatitis: Combined Endoscopic and Medical Management

INTRODUCTION: Pancreaticopleural fistula (PPF) is a rare complication of pancreatitis, resulting from disruption of the pancreatic duct. This injury may be secondary to acute/chronic pancreatitis, trauma, or surgery. Here we describe a patient with a PPF, and our workup and treatment for this rare condition. CASE DESCRIPTION/METHODS: A 61-year-old male with COPD, alcohol misuse, and history of recurrent acute alcoholic pancreatitis complicated by pseudocysts was admitted with one month of worsening shortness of breath from a large left pleural effusion, which reaccumulated within four days after a 1.6 L thoracentesis. On examination he had mild abdominal tenderness in the RUQ and epigastrium. Labs were notable for serum amylase 1105 U/L, lipase &gt;1000 U/L, and WBC 10.8. He underwent another thoracentesis, removing 1.5 L of fluid which was an exudate with amylase greater than 2000 U/L. CT of the chest and abdomen showed a subdiaphragmatic LUQ fluid collection with communication to the pancreatic body and duct. A chest tube was then placed to prevent fluid re-accumulation. MRCP confirmed a PPF from the proximal pancreatic body duct to the left pleura. He was started on octreotide. ERCP confirmed a fistula originating from the distal pancreatic duct but attempts to pass a wire into the dorsal pancreatic duct were unsuccessful, and a ventral pancreatic sphincterotomy was performed. His chest tube was removed after one day, and he was discharged to continue octreotide at home. Unfortunately, he returned the following day with complaints of dyspnea. Pancrelipase was then added in an attempt to minimize pancreatic exocrine secretions. On follow-up 1 and 2 months later, the pleural fluid is much smaller, and the patient's dyspnea has resolved. DISCUSSION: Here we present a novel management of PPF without pancreatic duct stent placement and instead with pancreatic sphincterotomy to divert pancreatic secretions away from the fistula tract and medical therapy (octreotide and pancrelipase) to reduce the pancreatic secretion. The diagnosis was reached through a combination of clinical history, lab studies (particularly, the elevated amylase in the pleural fluid), and CT and MR imaging. This was further confirmed with ERCP, which is useful especially if a stent can be placed to divert secretions away from fistula tract. Ultimately, this diagnosis requires a high index of suspicion, particularly in patients who present with recurrent effusions in the setting of pancreatitis.

METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS-INDUCED PERICARDITIS AND PERICARDIAL TAMPONADE IN AIDS PATIENT: PRESENTATION, PROGRESSION, AND MANAGEMENT

SESSION TITLE: Monday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: We report a case of 46-year old woman with untreated AIDS (CD4 count 12), and recurrent neck abscesses, who presented with a neck abscess, and developed acute pericarditis, which resulted in pericardial effusion and tamponade. Blood, purulent drainage from the abscess, and pericardial fluid cultures were positive for methicillin resistant staphylococcus aureus (MRSA). The patient was successfully treated with 6 weeks of IV Vancomycin, and pericardial drainage. CASE PRESENTATION: The patient is a 46 year old woman with past medical history of AIDS (Most recent CD4 count 12) who was not on anti-retroviral therapy due to social reasons with recurrent skin/soft tissue infections, who presented with fever and chest pain of 1 week duration. She also reported a recurrent anterior neck mass. On hospital admission, her chest pain was constant for the past week, and is worse with movement and deep inspiration. She states the pain is under her left breast and radiates towards her left shoulder. She denies shortness of breath, or lower extremity edema. DISCUSSION: MRSA Pericarditis is a very rare life-threatening infection, with only a few cases reported in literature [1] [2] [3]. Mortality rates for purulent pericarditis were reported to be as high as 40% in the treated population. In immunosuppressed patients or following thoracic surgery, Staphylococcus aureus (30%) and fungi (20%) are more common [10]. CONCLUSIONS: Management of MRSA pericarditis was done through pericardial drain, with some cases treated with pericardial window (Class I recommendation for pericardial window, and Class IIa for subxiphoid pericardiotomy by 2015 ESC Guidelines for the diagnosis and management of pericardial diseases: The Task Force for the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology). Our case was managed by pericardial drainage alone, and although she had recurrence of pericardial effusion, pericardiotomy was felt to be very risky given her AIDS with CD4 count Reference #1: 1) Kurahara, Y. and Kawaguchi, T. Cardiac Tamponade with Community-acquired Methicillin-resistant Staphylococcus aureus Pericarditis. Intern Med. 2013;52(15):1753. Reference #2: 2)Hussam, M., Ragai, M., Iman, M. and Zakaria, A. Community-acquired methicillin-resistant Staphylococcus aureus pericarditis presenting as cardiac tamponade. South Med J. 2010 Aug;103(8):834-6 Reference #3: 3)Oizumi, H., Ichinokawa, H., Hoshino, H., Shitara, J. and Suzuki, K. Pericardial Window for Methicillin-Resistant Staphylococcus aureus Pericarditis. Ann Thorac Surg. 2019 Jan;107(1):e27-e29. DISCLOSURES: No relevant relationships by Laith Ali, source=Web Response No relevant relationships by Brian Cuneo, source=Web Response No relevant relationships by Amre Ghazzal, source=Web Response No relevant relationships by Tariq Sallam, source=Web Response

A RARE CASE OF DASATINIB-INDUCED CHYLOTHORAX

SESSION TITLE: Tuesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM INTRODUCTION: Dasatinib is a tyrosine-kinase inhibitor approved for treatment of BCR-ABL positive chronic myelogenous leukemia and Philadelphia chromosome positive acute lymphoblastic leukemia. Dasatinib induced chlyothorax is rare. Here we describe one such case. CASE PRESENTATION: 65-year-old gentleman with chronic myeloid leukemia status post stem cell transplantation currently on tyrosine kinase inhibitor, Dasatinib, was referred to our clinic for further evaluation of left sided pleural effusion. The effusion was noted incidentally on a follow-up echocardiogram to monitor the progression of aortic stenosis. Patient denied shortness of breath, chest plain, dizziness, fevers, or chills. He has been a nonsmoker throughout his life. On examination patient’s vitals were within normal limits. He was saturating well on room air. Physical exam was remarkable for decreased air entry on the left base with stony dull note to percussion. Chest x-ray showed moderate sized left pleural effusion. Routine labs were unremarkable. Patient was suspected to have exudative pleural effusion. Prime differentials were: Non-Hodgkin lymphoma, lung cancer and dasatinib induced pleural effusion. Dasatinib was held. Thoracentesis was performed and 1.5 L of coffee-colored fluid was removed, and sent for analysis. Post-procedure chest x-ray showed improved aeration and small apical left pneumothorax. Follow-up chest x-ray, 3 days later, showed resolution of the pneumothorax with recurrence of left-sided pleural effusion. Patient remained asymptomatic. One week later, patient continued to have bilateral pleural effusions, left more than right, on CT chest. On repeat thoracentesis, 1.5 L of fluid was drained again. Pleural fluid analysis revealed exudative fluid with elevated triglyceride levels of 500 and an elevated cholesterol level of 51, consistent with chylothorax. Patient was started on prednisone 40 mg daily. Dasatinib was stopped and patient’s pleural effusion stabilized on steroids. DISCUSSION: Pleural effusion is a known side effect of dasatinib seen in 5-28% of patients. Dasatinib induced chylothorax is rare with unknown patho-physiology. Proposed mechanisms include inhibition of platelet derived growth factor receptor beta, or block in T lymphocyte function. Management includes withholding dasatinib or in some cases reducing the dose, treating with diuretics and a short course of prednisone. CONCLUSIONS: In patients treated with dasatinib who develop pleural effusion, dasatinib induced chylothorax should be considered as a differential diagnosis. Dasatinib should be discontinued and an alternate tyrosine kinase inhibitor should be considered. Further investigation to define the pathogenesis of dasatinib related chylothorax is warranted given the widespread use of the drug. Reference #1: Z. Baloch et al. 'Dasatinib induced chylothorax in chronic myeloid leukemia.' https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5242121/# Reference #2: Y. Huang et al. 'Dasatinib related chylothorax.'Turkish Journal of Hematology.2015 Mar;32(1):68-72. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4439910/# DISCLOSURES: No relevant relationships by Paramesh Dakshinesh, source=Web Response No relevant relationships by Sana Grover, source=Web Response No relevant relationships by Rajamurugan Meenakshisundaram, source=Web Response

AN UNCOMMON MALIGNANT PLEURAL EFFUSION

SESSION TITLE: Tuesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM INTRODUCTION: Malignant pleural effusions (MPE) are usually related to metastatic disease, most commonly from lung cancer and breast cancer. We present a case of primary pleural low-grade B-cell lymphoma, presenting with a right pleural effusion, which management defers from other etiologies of MPE. CASE PRESENTATION: An 84-year-old man with a past medical history of laryngeal cancer and atrial fibrillation, who presented to the emergency department with progressive exertional shortness of breath associated with dry cough and onset of right-sided pleuritic chest pain the past 3 days. Review of Systems was otherwise negative. Social history was non-contributory. On physical examination he was in mild-to-moderate respiratory distress, tachycardic, tachypneic and afebrile, with decreased breath sounds and dullness to percussion over the right hemithorax. Chest radiograph revealed a large right-sided pleural effusion (Fig. 1). Thoracentesis was performed and one and a half liters of cloudy exudative fluid was drained. Repeat radiograph showed adequate interval lung re-expansion (Fig. 2). Cytology analysis demonstrated low grade B cell lymphoma with CD20 positive. Staging CT/PET scan and bone marrow biopsy were normal. The patient was started on rituximab and bendamustine with no intrapleural catheter (IPC) placement after the oncologist and pulmonologist were consulted. There were no immediate complications or recurrence of pleural effusion and the patient was discharged home with outpatient follow up. DISCUSSION: Malignant pleural effusions are the second leading cause of exudative effusions. Pleural involvement by metastatic disease, including lymphoma is common, however primary pleural lymphoma remains an extremely rare condition, representing only 7% of all lymphomas (1). From all the reported cases, low-grade B-cell lymphoma representing 1.34% (2). Recent guidelines published by the American Thoracic Society regarding management of malignant pleural effusion take in consideration lung re-expansion and life expectancy before moving forward with therapeutic interventions. Outweighing benefits and risk regarding IPC, pleurodesis and combination of both should be discussed with patients and the multidisciplinary team for the benefit of the patients. As in our case, due to the high chemotherapeutic response, he will benefit from holding any unnecessary interventional procedures, avoided increased risk for infections, periprocedural complications and limitation of daily activities. Chemotherapy was initiated with close monitoring for newly developing pleural effusion. CONCLUSIONS: We submit a unique case of primary pleural low-grade B cell lymphoma presenting with large malignant pleural effusion in which management can differ from recommended guidelines. This also outlines the importance of multidisciplinary approach to avoid unnecessary procedures with better outcomes for patients with this condition. Reference #1: Mei-Lin S, Bin S, Jian-hua G & Shu-juan J. Rare case of primary lymphoma presenting with pleural effusion. Thoracic Cancer 7. 2016. 145-150 Reference #2: Vega F, Padula A, Valbuena JR et al. Lymphomas Involving the pleura. Arch Pathol Lab Med. 2006;130.1497-1502 DISCLOSURES: No relevant relationships by Israel Acosta Sanchez, source=Web Response No relevant relationships by Kathlyn Camargo Macias, source=Web Response No relevant relationships by Abed Madanieh, source=Web Response No relevant relationships by Chirin Orabi, source=Web Response No relevant relationships by jorge otoya, source=Web Response

EP1.14-01 Major Therapeutic Response to T-DM1 in Metastatic Lung Adenocarcinoma with HER2 Mutation

The HER2 exon 20 mutation is described in 1-5% of patients with Non-small cell Lung cancer, and at the moment no targeted agents are approved in Europe. However, the use of conjugated antibodies such as trastuzumab and ado-trastuzumab emtansine (T-DM1) has shown promising results. We describe the case of a major response to T-DM1 in fourth line treatment in a patient with metastatic adenocarcinoma and HER2 mutation. A 60-year-old male, former smoker (3 packs/year), presented to the emergency room in 2016 for dyspnoea. A bilateral pleural and compressive pericardial effusion with tamponade requiring pericardial drainage were discovered. A lung adenocarcinoma with HER2 mutations was diagnosed. He benefited from two successive treatment lines between September 2016 and September 2017 (carboplatin- paclitaxel and bevacizumab followed by bevacizumab maintenance until progression, then pemetrexed for two cycles). At this time, he developed a new disease progression as a recurrence of tamponade requiring surgical drainage and a third line with docetaxel and trastuzumab was started for twelve cycles. After eight months, he presented an acute respiratory failure due to the recurrence of pericardial and pleural effusions, requiring a pleural drainage (Fig.1A). After discussion at the multidisciplinary meeting, a fourth line of treatment with T-DM1 in compassionate has been proposed. After three cycles, we observed an excellent clinical response, with disappearance of dyspnoea, resumption of normal daily activity. The radiological evolution was also very favourable (Fig.1B). The patient benefited from other six months of treatment before getting a new progression. In this case T-DM1 showed a major clinical and radiological benefit despite its use in fourth line. Other clinical reports and phase II trials confirmed promising results with targeted agents already used in breast cancer. Several studies are exploring the efficacy of these agents, opening up new hopes.

INTRAPULMONARY TERATOMA: A CAUSE OF SHORTNESS OF BREATH IN A YOUNG WOMAN

SESSION TITLE: Tuesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM INTRODUCTION: Intrapulmonary Teratoma (IPT) is a rare benign cystic lesion with fewer than 100 cases reported in medical literature(1). We report a case of an 18-year-old female with symptoms of shortness of breath, recurrent pulmonary effusions which, following thoracotomy, was attributed to a mature cystic teratoma containing respiratory and pancreatic tissue. CASE PRESENTATION: An 18-year-old female presented to the emergency room short of breath with right-sided chest pain. Notably, she had a month-long history of intermittent shortness of breath treated with antibiotics for presumed pneumonia only with marginal improvement in her symptoms. Initial vital signs and physical exam were unremarkable. Chest X-Ray showed a large right-sided pleural effusion, chest CT reported a large right-sided loculated pleural effusion with compressive atelectasis for which thoracentesis was done and a chest tube placed. She was given Ceftriaxone, Doxycycline along with tissue plasminogen activator (tPA) and dornase alpha (DNase), essentially managed as empyema. After clinical and radiographic improvement, she was discharged home on a 4-week course of Levofloxacin. 3 weeks from discharge, shortness of breath persisted with imaging notable for worsening right-sided pleural effusion(Figure 1). Subsequently, right thoracoscopy which was converted to right thoracotomy revealed a large complex multi-loculated cystic structure containing greenish material. Histology diagnosis was a mature cystic teratoma composed of respiratory and pancreatic tissue. Two-month follow up after removal of the teratoma in toto resulted in the patient having a complete clinical recovery. DISCUSSION: Since they were first described by Mohr, as few as 65 IPTs have been reported in literature between 1839 and 1996 (2).Patients age between 10 months and 68 years(3) with equal sex predilection and presenting complaints are often non-specific - chest pain (52%), hemoptysis (42%), cough (39%) and trichoptysis (13%), which is rare but pathognomonic. IPTs can appear as lobulated masses, cavitary lesions or as areas of consolidation on imaging. CT helps in estimating different elements that compose the teratoma (soft tissue/fluid/fat/calcification), differentiating ruptured from unruptured teratoma and, delineating degree of mediastinal invasion and/or proximity to vascular structures. Histopathologically, IPTs can demonstrate endo-, meso- or ectodermal elements like in our patient whose histology was impressive for respiratory epithelium and pancreatic tissue. There are reports of rupture of cysts containing pancreatic tissue owing to the production of proteolytic or digestive enzymes (2). For this reason and the possibility of being malignant, surgical excision is advised. CONCLUSIONS: IPTs are a rare entity and may present with non-specific symptoms. Radiographic imaging often assists in diagnosis and surgery is the mainstay of treatment. Reference #1: Ditah C, Templin T, Mandal R, Pinchot JW, Macke RA. Isolated intrapulmonary teratoma. J Thorac Cardiovasc Surg. 2016 Dec;152(6):e129–31. Reference #2: Asano S, Hoshikawa Y, Yamane Y, Ikeda M, Wakasa H. An intrapulmonary teratoma associated with bronchiectasia containing various kinds of primordium: a case report and review of the literature. Virchows Arch. 2000 Apr 10;436(4):384–8. Reference #3: Carter D, Eggleston JC. Teratoma. In: Hartmann WH, ed. Tumor of the Lower Respiratory Tract. Washington: Armed Forces Institute of Pathology, 1980: 325-6 DISCLOSURES: No relevant relationships by Rohit Aloor, source=Web Response no disclosure on file for Daniel Harley; No relevant relationships by ARJUN KANWAL, source=Web Response No relevant relationships by Vaishnavi Raman, source=Web Response No relevant relationships by Himanshu Rawal, source=Web Response

EBV-MEDIATED POSTTRANSPLANT LYMPHOPROLIFERATIVE DISORDER PRESENTING AS A PLEURAL EFFUSION AND ACUTE CELLULAR REJECTION: A CASE REPORT

SESSION TITLE: Tuesday Fellows Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM INTRODUCTION: Post-transplant lymphoproliferative disorder (PTLD) is a rare complication following adult lung transplantation, but carries a three-fold increase in the risk of death compared to non-sufferers (1). Described manifestations of PTLD include lung nodules & infiltrates, thoracic adenopathy, GI involvement and CNS mass lesions (2). CASE PRESENTATION: A 59 year-old male with a history of cystic fibrosis underwent bilateral lung transplantation for progressive hypoxic respiratory failure needing VV-ECMO; he suffered no significant complications until he developed fatigue and a 600mL drop in FEV1 two months post-transplant. A right lung opacity was found on CXR; he received antibiotics for pneumonia, but his symptoms persisted. Chest CT demonstrated mediastinal and hilar lymphadenopathy, and a large right sided effusion (Image 1). Flow cytometry on pleural fluid obtained from thoracentesis showed kappa-light-chain restricted plasmacytic cells, consistent with PTLD. An EBV PCR returned positive (584cpy/mL). He underwent bronchoscopy with transbronchial lung biopsy, endobronchial ultrasound-guided transbronchial lymph node sampling and tunneled pleural catheter placement for recurrent effusion. Pleural fluid again showed plasmacytoid cells. The transbronchial biopsy showed perivascular mononuclear cell infiltrates with endothelialitis and septal extension, concerning for grade A3 rejection. His EBV viremia worsened (2660cpy/mL). After a multidisciplinary discussion, it was decided his pathologic findings were due to PTLD; he was treated with reduction of immunosuppression and four weeks of rituximab. After the first dose, his EBV load dropped by almost half, and his FEV1 recovered. After four doses, his serum EBV was undetectable, and repeat CT showed near-resolution of the adenopathy (Image 2). DISCUSSION: Cystic fibrosis patients are at higher risk for PTLD, likely because they are younger at transplant and therefore tend to be EBV seronegative when transplanted (3). Adult EBV seropositivity is pervasive, and lung tissue is lymphoid-rich (2); transplanted lungs may carry a high load of infected B-cells to the recipient, who then receive therapies to suppress host immunity (including cytotoxic T-cells that check the infected lytic-phase B-cells which perpetuate infection) (2). While treatments differ by center, the anti-CD20 monoclonal antibody rituximab is often used to deplete B-cells, in tandem with reducing immunosuppression (2). Remission rates range from 52-66%, with better outcomes for early-onset PTLD and EBV positive patients (2). CONCLUSIONS: Our patient was unique in manifesting with a pleural effusion as a primary site of his PTLD, though he also had lymphadenopathy that regressed with therapy. While older and a cystic fibrosis patient, he had positive prognostic factors (early presentation, EBV-positivity), and ultimately had a good outcome from rituximab and reduced immunosuppresion. Reference #1: Zaffiri L, Neely M, Cherikh W, et al. Incidence and Outcomes of Post-lymphoproliferative Disorder in Lung Transplant Recipients. Analysis of the ISHLT Registry. J Heart Lung Transplant 2018; 37(4): S450. Reference #2: Green M and Michaels MG. Epstein-Barr Virus Infection and Posttransplant Lymphoproliferative Disorder. Am J Transplant 2013; 13: 41-45. Reference #3: Lowery EM, Adams W, Grim SA, et al. Increased risk of PTLD in lung transplant recipients with cystic fibrosis. J Cyst Fibrosis 2017; 16: 727-734. DISCLOSURES: No relevant relationships by Luis Angel, source=Web Response No relevant relationships by Melissa Lesko, source=Web Response No relevant relationships by Sunil Nair, source=Web Response

P1.16-18 Pleural Malignant Effusion. Is it Possible to Predict Recurrence After Palliative Pleural Procedure?

Malignant pleural effusion (MPE) accounts for several hospital admissions. MPE recurs rapidly in a considerable number of patients. Since MPE is associated with poor survival, a detailed prognosis may help to recognize patients with at higher risk of recurrence, aiming to individualize treatment strategies. However, there have been few studies that evaluated factors, including systemic therapy, associated with MPE recurrence. The aim of this study was to recognize risk factors of recurrence in symptomatic patients only, who required a pleural approach. A prospectively assembled database was analyzed to search for patients with symptomatic MPE. The obtained data included basic demographics, primary tumor site, performance status, neutrophil/lymphocyte ratio (NLR) and platelets/lymphocyte ratio. Metastatic sites were also evaluated, which was defined as presence of any numbers of metastasis at each organ. Regarding the postoperative period, we analyzed pleural effusion recurrence, the palliative approach used, in addition to the biochemical profile of pleural fluid. Pleural thickening and pulmonary infiltrate were also described. Systemic treatment was evaluated. Patients were classified into three groups at MPE diagnosis: systemic treatment-naïve patients, patients who received first-line systemic treatment and patients receiving second-line systemic treatment or further therapy. The quantitative variables without definite cutoff points were submitted to the ROC (Receiver Operating Characteristic) curve, using a sub-sample of 50% of the recorded cases. Cutoff points were defined as the ones with sensitivity and specificity values >0.80. Univariate and multiple Cox regression models were used to evaluate the risk of recurrence (HR) and their respective 95% confidence intervals (95%CI). Of the 288 analyzed patients, the most frequent main procedure was pleurodesis (43.1%). Disease recurrence occurred in 58 patients (20.1%). Recurrence-free survival was 73.3% at 12 months. Patients submitted to the pleurodesis procedure had a longer recurrence-free survival of 84.6%, with HR = 0.33 (95%CI = 0.17 - 0.63) when compared to patients who underwent the pleural drainage. Regarding the chemotherapy lines of treatment, Cox univariate analysis showed that the risk of recurrence for those submitted to the 1st line of palliative CT was HR = 3.19 (95% CI = 1.32 - 7.70) and for the 2nd line of palliative CT, HR = 7.32 (95% CI = 3.34 - 16.07) when compared to the systemic treatment-naïve patients. The independent factors for recurrence-free survival were procedure and chemotherapy lines. Patients who were submitted to pleurodesis had a protective factor for recurrence, with an HR = 0.34 (95% CI = 0.15 - 0.74, p = 0.007). On the other hand, patients submitted to the 1st and 2nd line of palliative CT had, respectively, an HR risk = 2.81 (95% CI = 1.10-7.28, p = 0.034) and HR = 3.23 (95% CI = 1.33 - 7.84, p = 0.010). Patients receiving the first or second line of systemic treatment have a higher risk of MPE recurrence when compared to patients who underwent MPE treatment before starting the systemic treatment. The definitive treatment of MPE, such as pleurodesis, was associated with a lower risk of MPE recurrence.

Survival in patients with malignant pleural effusion undergoing talc pleurodesis

ObjectivesRecent observations indicate a potential survival benefit in patients with malignant pleural effusion (MPE) who achieve successful pleurodesis in comparison to patients who experience effusion recurrence post pleurodesis. This study aimed to explore this observation using two datasets of patients with MPE undergoing talc pleurodesis. Materials and MethodsDataset 1 comprised patients who underwent talc pleurodesis at Oxford Pleural Unit for MPE. Dataset 2 comprised patients enrolled in the TIME1 clinical trial. Pleurodesis success was defined as absence of need for further therapeutic procedures for MPE in the three months following pleurodesis. Data on various clinical, laboratory and radiological parameters were collected and survival was compared according to pleurodesis outcome (success vs. failure) after adjusting for the aforementioned parameters. ResultsDataset 1 comprised 60 patients with mean age 74.1±10.3 years. The most common primary malignancies were mesothelioma, breast and lung cancer. 29 patients (48.3%) achieved pleurodesis. The adjusted odds ratio (aOR) for poor survival with pleurodesis failure was 2.85 (95% CI 1.08–7.50, =p 0.034).Dataset 2 comprised 259 patients from the TIME1 trial. The mean age was 70.8±10.3 and the most common primary malignancies were mesothelioma, lung and breast cancer. Pleurodesis was successful in 205 patients (79%). aOR for poor survival was 1.62 (95% CI 1.09–2.39, p = 0.015). ConclusionAchieving pleurodesis seems to impart a survival benefit in patients with MPE. Further studies are required to explore factors that may contribute to this phenomenon and to address the difference in survival between pleurodesis and indwelling pleural catheter interventions.

Flexion Instability After Total Knee Arthroplasty.

Flexion instability after total knee arthroplasty (TKA) is caused by an increased flexion gap compared with extension gap. Patients present with recurrent effusions, subjective instability (especially going downstairs), quadriceps weakness, and diffuse periretinacular pain. Manual testing for laxity in flexion is commonly done to confirm a diagnosis, although testing positions and laxity grades are inconsistent. Nonsurgical treatment includes quadriceps strengthening and bracing treatment. The mainstays to surgical management of femoral instability involve increasing the posterior condylar offset, decreasing the tibial slope, raising the joint line in combination with a thicker polyethylene insert, and ensuring appropriate rotation of implants. Patient outcomes after revision TKA for flexion instability show the least amount of improvement when compared with revisions for other TKA failure etiologies. Future work is needed to unify reproducible diagnostic criteria. Advancements in biomechanical analysis with motion detection, isokinetic quadriceps strength testing, and computational modeling are needed to advance the collective understanding of this underappreciated failure mechanism.