Small Satellite Lesions Research Articles

Ultrasmall Metal TPZ Complexes with Deep Tumor Penetration for Enhancing Radiofrequency Ablation Therapy and Inducing Antitumor Immune Responses.

Radiofrequency ablation (RFA) is one of the most common minimally invasive techniques for the treatment of solid tumors, but residual malignant tissues or small satellite lesions after insufficient RFA (iRFA) are difficult to remove, often leading to metastasis and recurrence. Here, Fe-TPZ nanoparticles are designed by metal ion and (TPZ) ligand complexation for synergistic enhancement of RFA residual tumor therapy. Fe-TPZ nanoparticles are cleaved in the acidic microenvironment of the tumor to generate Fe2+ and TPZ. TPZ, an anoxia-dependent drug, is activated in residual tumors and generates free radicals to cause tumor cell death. Elevated Fe2+ undergoes a redox reaction with glutathione (GSH), inducing a strong Fenton effect and promoting the production of the highly toxic hydroxyl radical (•OH). In addition, the ROS/GSH imbalance induced by this treatment promotes immunogenic cell death (ICD), which triggers the release of damage-associated molecular patterns, macrophage polarization, and lymphocyte infiltration, thus triggering a systemic antitumor immune response and noteworthy prevention of tumor metastasis. Overall, this integrated treatment program driven by multiple microenvironment-dependent pathways overcomes the limitations of the RFA monotherapy approach and thus improves tumor prognosis. Furthermore, these findings aim to provide new research ideas for regulating the tumor immune microenvironment.

Intraoperative Resection Guidance and Rapid Pathological Diagnosis of Osteosarcoma using B7H3 Targeted Probe under NIR-II Fluorescence Imaging.

Complete removal of all tumor tissue with a wide surgical margin is essential for the treatment of osteosarcoma (OS). However, it's difficult, sometimes impossible, to achieve due to the invisible small satellite lesions and blurry tumor boundaries. Besides, intraoperative frozen-section analysis of resection margins of OS is often restricted by the hard tissues around OS, which makes it impossible to know whether a negative margin is achieved. Any unresected small tumor residuals will lead to local recurrence and worse prognosis. Herein, based on the high expression of B7H3 in OS, a targeted probe B7H3-IRDye800CW is synthesized by conjugating anti-B7H3 antibody and IRDye800CW. B7H3-IRDye800CW can accurately label OS areas after intravenous administration, thereby helping surgeons identify and resect residual OS lesions (<2mm) and lung metastatic lesions. The tumor-background ratio reaches 4.42± 1.77 at day 3. After incubating fresh human OS specimen with B7H3-IRDye800CW, it can specifically label the OS area and even the microinvasion area (confirmed by hematoxylin-eosin [HE] staining). The probe labeled area is consistent with the tumor area shown by magnetic resonance imaging and complete HE staining of the specimen. In summary, B7H3-IRDye800CW has translational potential in intraoperative resection guidance and rapid pathological diagnosis of OS.

Choroidal amelanotic mass with vermiform margins, vision loss, and extreme fatigue.

To describe a case of a previously healthy middle-aged male with an atypical choroidal mass and fatigue. Case report. A 56-year-old Caucasian male presented with decreased vision in the right eye (OD) and a choroidal amelanotic mass OD with subretinal fluid. He received bevacizumab (1.25 mg/0.05 mL) injections by multiple providers without improvement in vision and with tumor progression. Visual acuity was 20/400 OD and 20/25 left eye (OS). The anterior segment was unremarkable in both eyes (OU). He was referred with suspected diagnosis of choroidal melanoma, metastasis, or osteoma. On examination, a choroidal amelanotic tumor with vermiform margins measuring 12 mm in base and 1.8 mm in thickness was seen OD. Smaller satellite lesions were noted inferiorly. Fundus OS was normal. Infectious evaluation was unrevealing and angiotensin-converting enzyme, lysozyme, and chest x-ray were normal. Fine-needle aspiration biopsy was declined by the patient. Given the clinical suspicion of choroidal sarcoidosis with characteristic tumor color, vermiform margins, and presence of satellite lesions, oral corticosteroids 60 mg/day for 2 months were started, followed by sub-Tenons triamcinolone acetonide (40mg/1 mL) injection three months later and urgent rheumatologic evaluation. He self-discontinued the oral corticosteroids and the tumor progressed by the next follow-up. Oral corticosteroids were restarted at 80mg/day. 16 months after his presentation to us, he experienced fatigue with electrocardiogram findings of third-degree heart block from sarcoidosis. He received an intracardiac defibrillator and 80 mg/day of corticosteroids with plans to initiate methotrexate for stronger immunosuppression. Understanding the numerous manifestations of ocular and systemic sarcoidosis is crucial. Choroidal sarcoidosis characteristically exhibits vermiform margins. Close follow-up and systemic monitoring is necessary in patients presenting with ocular signs of sarcoidosis. The diagnosis of choroidal sarcoidosis can be challenging. Features including vermiform tumor margins, satellite lesions, and choroidal infiltration on OCT are suggestive of choroidal sarcoidosis. All patients with ocular sarcoidosis should be monitored for systemic involvement. In this case, the ocular manifestation guided the diagnosis and eventually the treatment of cardiac sarcoidosis.

A Booster for Radiofrequency Ablation: Advanced Adjuvant Therapy via In Situ Nanovaccine Synergized with Anti-programmed Death Ligand 1 Immunotherapy for Systemically Constraining Hepatocellular Carcinoma.

Radiofrequency ablation (RFA) is one of the most common minimally invasive techniques for treating hepatocellular carcinoma (HCC), which could destroy tumors through hyperthermia and generate massive tumor-associated antigens (TAAs). However, residual malignant tissues or small satellite lesions are hard to eliminate, generally resulting in metastases and recurrence. Herein, an advanced in situ nanovaccine formed by layered double hydroxides carrying cGAMP (STING agonist) (LDHs-cGAMP) and adsorbed TAAs was designed to potentiate the RFA-induced antitumor immune response. As-prepared LDHs-cGAMP could effectively enter cancerous or immune cells, inducing a stronger type I interferon (IFN-I) response. After further adsorption of TAAs, nanovaccine generated sustained immune stimulation and efficiently promoted activation of dendritic cells (DCs). Notably, infiltrations of cytotoxic lymphocytes (CTLs) and activated DCs in tumor and lymph nodes were significantly enhanced after nanovaccine treatment, which distinctly inhibited primary, distant, and metastasis of liver cancer. Furthermore, such a nanovaccine strategy greatly changed the tumor immune microenvironment and promoted the response efficiency of anti-programmed death ligand 1 (αPD-L1) immunotherapy, significantly arresting the poorly immunogenic hepa1-6 liver cancer progression. These findings demonstrate the potential of nanovaccine as a booster for RFA in liver cancer therapy and provide a promising in situ cancer vaccination strategy.

Persistent Diaper Rash in a 5-month-old Girl

1. Joana Matos, MD* 2. Joao Tavares, MD† 3. Susana Machado, MD‡ 4. Manuela Selores, MD‡ 1. *Servico de Pediatria do Centro Hospitalar do Tâmega e Sousa, Penafiel, Portugal 2. †Hospital Pediatrico, Centro Hospitalar da Universidade de Coimbra, Coimbra, Portugal 3. ‡Servico de Dermatologia do Centro Hospitalar do Porto, Porto, Portugal A previously healthy 5-month-old girl is referred to pediatric dermatology for a diaper rash persisting for more than 2 months despite antifungal treatment and several barrier creams. She is otherwise asymptomatic and has no relevant medical history. The family history is significant for her father with episodic erythematous lesions over the forearms and legs. Physical examination reveals a well-defined, bright, erythematous plaque affecting the perineal area, including the groins and upper thigh, with minimal peripheral scaling (Fig 1). She also has 2 smaller satellite lesions in the left thigh. There are no other abnormal findings on physical examination. The clinical features and family history suggest the diagnosis. Figure 1. Erythematous plaque in the diaper area at presentation. Many dermatoses affect the diaper region, including the most common irritant, contact dermatitis. More diffuse skin diseases and systemic disorders that can manifest with specific diaper region symptoms may include inflammatory dermatoses such as seborrheic dermatitis or psoriasis, infections (eg, Candida albicans infection, perianal streptococcal and staphylococcal dermatitis), and metabolic disorders such as acrodermatitis enteropathica or neoplasia (eg, Langerhans cell histiocytosis). Immersion burns resulting from either inadvertent or intentional immersion in hot water or other liquid may also appear with a well-delimited erythematous diaper area rash. Based on the clinical features and suggestive family history, the patient was diagnosed as having psoriasis and was prescribed an antifungal and corticosteroid combination cream plus a zinc oxide–based repair ointment. Psoriasis is …

S1745 Not All Colonic Masses Are Adenocarcinoma

INTRODUCTION: Acute lymphoblastic leukemia (ALL) is a hematologic malignancy primarily affecting bone marrow, but with potential for blast cell to infiltrate extramedullary structures, most commonly the central nervous system. The gastrointestinal tract is not considered a primary site of disease involvement unless disease relapses. CASE DESCRIPTION/METHODS: A 20 year old man with celiac disease and Philadelphia negative, CD20+ B-cell ALL presented with abdominal pain. ALL was diagnosed 10 months prior and followed by treatment with AYA protocol of CALGB 10403 chemotherapy regimen, which consisted of vincristine, daunorubicin, pegaspargase, and prednisone. Rituximab was added due to CD20 + status. Regimen adjustment was required due to adverse effects of hepatitis and pancreatitis related to pegaspargase. After receiving 2 cycles of blinatumomab, a bone marrow biopsy supported clinical remission. Four weeks thereafter, the patient presented with severe abdominal pain, worse in the right lower quadrant. Exam revealed diffuse abdominal tenderness. Labs noted a mild normocytic anemia of 11.9 g/dL and thrombocytopenia of 119 K/MM3. Abdominal computed tomography measured 1.8 cm wall thickening in the appendix and cecum. Colonoscopy demonstrated multiple large, smooth, and firm polypoid masses in the cecum, with smaller satellite lesions in the ascending colon, an additional fungating mass in the distal ascending colon. Colonic mass biopsies demonstrated extensive leukemic infiltrate, consistent with B-ALL, which stained positive for PAX5, CD10, CD34, TdT, and negative for CD20. Chemotherapy and immunotherapy was reinitiated, with future plans for stem cell transplant. DISCUSSION: Although ALL with GI involvement is rarely reported, leukemic GI infiltration is identified in up to 25% of autopsies. As immune therapy has been theorized to leave extramedullary compartments vulnerable to incomplete disease eradiation, there is a potential for disease to exist undetected. Support for early endoscopy in patients undergoing immunotherapy and presenting with GI complaints may help to exclude GI involvement prior to declaring remission. A future prospective trial to identify risk factors for patients with ALL at high risk for GI infiltration would be valuable to determine those more likely to benefit from early endoscopic evaluation, and thus avoid unnecessary procedures in a population already at elevated procedural risk due to immunocompromised state and common presence of cytopenias.Figure 1.: Picture 1: CT abdomen/pelvis depicting cecal thickening of 18.47 mm.Figure 2.: Picture 2: A & B Colonoscopic findings of cecal masses, C. Colonoscopic findings of distal ascending colon mass.Figure 3.: Picture 3: A. Histology of leukemic infiltration in the colon, B. PAX5 positive immunohistochemistry staining, C. CD34 positive immunohistochemistry staining, D. TdT positive immunohistochemistry staining.

PRIMARY LUNG ADENOCARCINOMA PRESENTING AS INGUINAL MASS

SESSION TITLE: Medical Student/Resident Lung Cancer Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Metastases to inguinal lymph nodes are common from malignant lesions arising on or in the lower extremity, lower one-half of the trunk, perineum, and male and female reproductive tracts. Inguinal lymph nodes are an unusual site for distant metastasis of adenocarcinoma of the lung. We report a rare case of primary adenocarcinoma of the lung presenting as inguinal mass. CASE PRESENTATION: A 73-year-old Caucasian female with a past medical history significant for hypertension, Chronic obstructive pulmonary disease (COPD), everyday smoker was seen in the primary care clinic for ongoing shortness of breath, worsening cough, and wheezing. She was prescribed a short course of steroids and antibiotics for possible COPD exacerbation. Despite these measures, the patient had worsening pulmonary symptoms and got evaluated in the emergency room. A CAT scan of the chest was done that showed right upper lobe bilobed masses and smaller satellite lesions seen measuring 3.4 and 2.8 cm in the greatest dimension. She got admitted to the hospital for further evaluation, and pulmonary service was consulted for possible endobronchial ultrasound-guided biopsy (EBUS) of the mediastinal nodes. During the physical exam, she was found to have a large fungating mass in the right groin. Upon further questioning, she reported that the mass began as small swelling in the groin three months ago and was evaluated by the primary care and received antibiotics for two weeks. During this time, she did not have any worsening pulmonary symptoms. She underwent bedside excisional biopsy of the lymph node, and the pathology came back positive for metastatic adenocarcinoma of pulmonary origin. A CAT scan of the abdomen revealed Hypoattenuating mass posterior aspect right lobe of the liver and second lesion in the spleen. Unfortunately, the patient had a significant worsening of her respiratory distress and was transitioned to comfort measures and passed away after three days. DISCUSSION: Extra thoracic nodal metastasis to the brain, bone, liver, and adrenal glands were the most common sites from adenocarcinoma of the lung at presentation1. Inguinal lymph nodes are an unusual site for distant metastasis. There have been only two other case reports of the Inguinal lymph node metastasis in adenocarcinoma and both were a sign of disease relapse2. we present the first case of inguinal metastasis from lung adenocarcinoma at presentation. In a retrospective study of 1486 cases of surgically removed NSCLC by Riquet et al., extrathoracic nodal metastases to inguinal lymph node was seen in one case3. Groin metastases are exceptional and no lymphatic vessel continuity can explain their incidence. Therefore, these metastases are systemic in origin. CONCLUSIONS: In conclusion, although extremely rare, metastatic disease to the inguinal region from lung cancer should be considered in the differential diagnosis of any lesion in the groin. Reference #1: Quint LE, Tummala S, Brisson LJ, Francis IR, Krup- nick AS, Kazerooni EA, et al. Distribution of distant metastases from newly diagnosed non-small cell lung cancer. Ann Thorac Surg 1996; 62:246-50. Reference #2: Tasci, Canturk & Dogan, Deniz & çiçek, Ali & Uçar, Ergün & özkan, Metin & Bilgic, Hayati. (2011). A case of lung cancer which presented with saphenous vein thrombosis and inguinal lymph node metastasis. Anatolian Journal of Clinical Investigation. Reference #3: Riquet M, Le Pimpec-Barthes F, Danel C. Axillary lymph node metastases from bronchogenic carcinoma. Ann Thorac Surg 1998; 66:920-2. DISCLOSURES: No relevant relationships by Venkatkiran Kanchustambham, source=Web Response No relevant relationships by Swetha Saladi, source=Web Response

S1718 An Unusual Presentation of a Rare Disease: Eosinophilic Colitis Presenting as Cecal Mass

INTRODUCTION: Eosinophilic colitis (EC) is a rare condition which most commonly presents with abdominal pain and diarrhea. We present a unique case of EC which was associated with an ulcerated cecal mass and sigmoid thickening. CASE DESCRIPTION/METHODS: An 89 year-old-male with a history of asthma, partial gastrectomy, and vagotomy presented with fever, abdominal pain, and diarrhea for 6 weeks. A colonoscopy performed 3 years prior to presentation was unremarkable. Physical examination was unremarkable. Lab work revealed leukocytosis with eosinophilia (800 /μL). Computed Tomography (CT) of the abdomen showed splenic flexure colitis. He was empirically treated with antibiotics and intravenous hydration with symptomatic improvement. Stool analysis for infection was negative. Follow-up CT of the abdomen demonstrated resolution of colitis. Persistence of diarrhea several months later prompted a colonoscopy that revealed a small, non-obstructing, friable, infiltrative, ulcerated mass in the caecum and a similar small satellite lesion. There were signs of patchy colitis, and an edematous thickened fold in the sigmoid colon. Histopathological analysis of biopsy samples revealed Intense eosinophilic infiltration involving the mucosa, muscularis mucosa, and submucosa, with variably sized clear spaces, suggestive of pneumatosis intestinale. Repeat lab work, including complete blood count, antinuclear antibodies (ANA), anti-neutrophil cytoplasmic antibodies (ANCA), immunoglobulin E, and stool analysis was unremarkable; notably, there was no eosinophilia. The diagnosis of primary EC was made by elimination. First-line treatment with an elimination diet was instituted. DISCUSSION: EC is characterized by chronic diarrhea and/or abdominal pain with eosinophilic infiltrate in the colonic wall. Although EC usually presents in a bimodal distribution (neonates, young adults), our patient was considerably older. The diagnosis is largely one of exclusion due to a lack of clear diagnostic criteria. Unlike eosinophilic esophagitis, there is no specific threshold of eosinophilic density. Secondary causes of eosinophil infiltration such as parasitic infection and malignancy should be ruled out. Treatment consists of elimination diet, tapering course of corticosteroids, and immunomodulatory agents. Due to a lack of specific diagnostic criteria, it is imperative to have a high clinical suspicion and avoid disregarding differentials based on age. Of note, EC presenting as a mass has only been described once previously to our knowledge.

Solitary cerebral metastasis from undiagnosed prostate cancer. Potential role of multiparametric MRI prostate in pre-treatment diagnostic protocols

A 73-year-old man presented with a three-week history of weakness and loss of co-ordination of the left-hand side and weakness of left-hand grip. MRI brain revealed an enhancing lesion in the right parietal lobe, adjacent to the central sulcus, with surrounding oedema and a small satellite lesion in motor cortex. Body CT and FDGPET CT revealed no obvious primary neoplasm. The patient underwent craniotomy with resection of the lesion, subsequent histopathology confirmed a metastatic carcinoma of likely prostate cancer primary origin. The patient was on 5-ARI (Finasteride) for lower urinary tract symptoms that decrease serum PSA levels to half and had benign feeling prostate on digital rectal examination (DRE). Subsequent MRI prostate confirmed presence of a lesion with very high probability of prostate cancer. The patient’s serum Prostate Specific Antigen (PSA) level was 6.8 (13.6 corrected for Finastride) which is relatively low in the context of metastatic disease. Given the recent NICE guidelines of using pre-biopsy multiparametric MRI (mpMRI) for diagnosis of prostate cancer, we suggest that in patients with cerebral metastases of unknown primary, with negative body CT, FDG PET-CT, low PSA and negative DRE, mpMRI prostate should be included in diagnostic protocol in the selected group of men, to enable early diagnosis and performing more suitable and targeted treatment. Keywords: Brain metastasis; prostate cancer; multiparametric MRI; metastasis of unknown origin

Abstract P3-13-04: 18F-FDG micro-PET/CT for intraoperative margin assessment in breast conserving surgery using: A proof-of-concept study

Abstract Positive surgical margins represent a high risk for adverse clinical outcome in breast conserving surgery (BCS). Therefore, the goal of BCS is to avoid positive margins and hence avoid reoperation. Unfortunately, most studies currently assess the rate of positive resection margins at 20%. This is in part due to the lack of a time- and cost-effective method for intraoperative margin assessment, which would enable the prediction of positive margins during the initial surgery. We propose to address this problem by performing intraoperative high-resolution 18F-fluoro-deoxyglucose (FDG) positron emission tomography (PET) with X-ray computed tomography (CT). This method relies on the high sensitivity of FDG-PET for detecting metabolically active tumor tissue, and the delineation of the anatomical margins of the specimen using CT. In this proof-of-concept study we assess the feasibility of this technique. Twenty patients with breast cancer that were eligible to undergo BCS were enrolled in the study after providing informed consent. The study was approved by the Ethics Committee of Ghent University Hospital. Prior to surgery each patient was administered 4 MBq/kg of FDG. Surgery was performed 2-4 hours after tracer administration. Following surgical excision the breast specimen was oriented with sutures and micro-PET/CT images were obtained using the MOLECUBES β-CUBE (PET) and X-CUBE (CT). The scan time was 10 minutes on PET and 3 minutes on CT. The specimen was then sent for histopathological assessment. Micro-PET/CT images were analyzed using an automated algorithm. Briefly, this algorithm defined the contour of the tumor as the region with high FDG uptake and the contour of the specimen based on the CT image. The margin status of a specimen was positive if the distance between the contour of the tumor and specimen was 0 mm. Images were also analyzed postoperatively by two surgeons blinded to the histopathological and algorithm analysis results. The sensitivity and specificity of the proposed method were then calculated by comparing to the histopathological results, which is the gold standard for margin status assessment. In all samples a region with high FDG uptake was visualized, which corresponded to the tumor on histopathological. In one specific case a small satellite lesion with high FDG uptake, 3 mm in diameter, was detected on the micro-PET images at a distance from the main tumor. Histopathological confirmed that this previously undetected lesion was a second invasive carcinoma. For margin status, a sensitivity of 75% and specificity of 75% were obtained using automated algorithm analysis. Sensitivity and specificity obtained based on surgeons' analysis was 62,5% and 75% for surgeon A and 87,5% and 91,7% for surgeon B respectively. Taking into account the intra-operative micro-PET results could theoretically have reduced the reoperation rate by 75%. This proof-of-concept study demonstrates that high-resolution intraoperative FDG-PET/CT is a promising technique for intraoperative margin assessment in BCS that could allow to reduce re-excision rate. This technique achieves both sufficient sensitivity and specificity with minimal disruption of intraoperative workflow. Citation Format: Marcinkowski R, Keereman V, Van Holen R, Vandenberghe S, Van Bockstal M, Van Dorpe J, Brans B, Goker M, Depypere H, Van den Broecke R. 18F-FDG micro-PET/CT for intraoperative margin assessment in breast conserving surgery using: A proof-of-concept study [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P3-13-04.

CAVITARY PULMONARY COCCIDIOIDOMYCOSIS IN A PATIENT WITH A REMOTE HISTORY OF LIVING IN CALIFORNIA

SESSION TITLE: Infections SESSION TYPE: Fellow Case Reports PRESENTED ON: 10/08/2018 03:15 PM - 04:15 PM INTRODUCTION: Lower lobe pulmonary cavitation is a rare presentation of coccidioidomycosis. Coccidioidomycosis is endemic to the southwestern United States, but incidence in other areas has increased due to travel, and the ability of an infection to become latent and then later reactivate. We present a case of lower lobe cavitary pulmonary coccidioidomycosis (PC) in a patient living in the West Texas Panhandle who moved from California eight years ago. CASE PRESENTATION: A 64 year old African American female with uncontrolled diabetes and hypertension presented with a three-week history of fatigue, malaise, non-productive cough, subjective fevers, occasional night sweats, loss of appetite, and several days of left-sided chest pain. Computed tomography (CT) of the chest showed a low-density collection within the posterior and lateral left lung base measuring 2.1 cm x 1.4 cm and reactive lymph nodes. Given the absence of exposure risk factors, negative tuberculosis (TB) test and blood cultures, the initial diagnosis was anaerobic lung abscess due to poor dentition. The patient was discharged on oral clindamycin and then lost to follow-up. One year later, she returned with similar symptoms and hemoptysis. CT of the chest revealed an enlarged 3.9 cm x 4 cm left lower lobe cavitary mass, with a second cavitary lesion and small satellite lesions. Bronchoalveolar lavage was inconclusive. TB test and all cultures were negative. Left lower lobe wedge resection was performed. Microscopic examination of the specimen found variably sized PAS-positive and silver stain-positive structures suggestive of PC. The patient is being treated with long-term oral fluconazole and is improving. DISCUSSION: Approximately 95% of symptomatic coccidioidomycosis patients develop pulmonary manifestations. Up to 15% of patients with PC will develop a pulmonary cavity. Risk factors for cavitation include smoking-related pulmonary fibrosis and uncontrolled diabetes mellitus. Cavitary PC is one of the most challenging presentations of coccidioidomycosis to diagnose. Serological testing has low sensitivity and sputum cultures are often negative. Tissue pathology is not always diagnostic, since cavitary PC can have varied histological presentations. PC cavities occur most frequently in the upper lobes and can be either thin-walled, if developing in an area of prior consolidation (more common), or thick-walled, if developing from the excavation of a nodule. Pulmonary resection is recommended for patients with hemoptysis, mycetoma, or a peripherally enlarging cavity at risk for rupture. CONCLUSIONS: Cavitary PC can mimic other illnesses such as bacterial pneumonia, TB, abscess, and malignancy. Clinicians should be aware that cavitary PC can develop in patients with uncontrolled diabetes who have moved from an endemic area, even many years after the initial exposure. Reference #1: Brown J, Benedict K, Park BJ, Thompson III GR. Coccidioidomycosis: epidemiology. Clin Epidemiol. 2013; 5:185-97. Reference #2: Sobonya RE, Yanes J, Klotz SA. Cavitary pulmonary coccidioidomycosis: pathologic and clinical correlates of disease. Hum Pathol. 2014; 45(1): 153-9. Reference #3: Jude CM, Nayak NB, Patel MK et al. Pulmonary coccidioidomycosis: pictoral review of chest radiographic and CT findings. Radiographics. 2014; 34(4): 912-25. DISCLOSURES: No relevant relationships by Joshua Crane, source=Web Response No relevant relationships by Manish Patel, source=Web Response No relevant relationships by Thien Vo, source=Web Response No relevant relationships by Grace Wang, source=Web Response

P-05-015 Penile primary melanoma. Case report.

To present a case of an uncommon penile cancer. The primary melanoma of the glans or male urethra is rare and it is associated with a poor prognosis. It accounts <0.1% of all melanomas and represents less than 1.4% of all malignant lesions of the penis. A 37-year-old man was referred to dermatologist for evaluation of a pigmented lesion of the penis. It appeared 2 years ago, increasing in size in the last months. The physical examination showed a macular lesion on the glans, that was hyperpigmented and crusty, with irregular borders, 2x1.5cm in size, and affected the balanopreputial fold and frenulum. In addition, he had 2 small proximal satellite lesions and bilateral pathological palpable lymphadenopathy. A punch biopsy was performed to confirm the suspected diagnosis of melanoma. In a multidisciplinary assessment with urologists, dermatologists and oncologists, the patient was considered candidate for an organ-preserving surgical procedure. Then, with a radical intention, a partial penectomy (with a wide security margin of 3cm) and bilateral inguinal lymphadenectomy was performed.

Anaemia due to gastric haemorrhage by a metastatic Merkel cell carcinoma.

Anaemia due to gastric haemorrhage by a metastatic Merkel cell carcinoma.

CO2 laser treatment for regional cutaneous malignant melanoma metastases.

Cutaneous in-transit and satellite metastases are distressing presentations of melanoma progression. The purpose of this study was to analyze the efficacy of carbon dioxide (CO2) lasers in patients with melanoma with cutaneous in-transit and satellite metastases. Results of CO2 laser therapy were retrospectively evaluated in 22 patients between January 2004 and January 2008. The number of laser treatments, postoperative morbidity, regional control, and overall survival were analyzed. Twenty-two patients received a total of 42 CO2 laser treatments. The number of lesions treated per session varied from 3 to 329. The median duration of regional control in all patients was 14 weeks (range, 3-117). In 9 of 22 patients, only 1 treatment with CO2 laser was performed resulting in a mean regional control of 11 weeks. In 10 patients, an average of 4 laser treatments (range, 1-17) was necessary to achieve regional control. Three of the 22 patients underwent isolated limb perfusion after laser treatment for disease control. This study shows that (repeated) laser treatment can achieve adequate regional control with little morbidity. CO2 laser is recommended as a first-line treatment to patients with small but numerous cutaneous satellite or in-transit lesions in whom other surgery would induce substantial morbidity.

Radiofrequency Ablation is a Valuable Therapeutic Option in the Treatment of Liver Metastases From Gastrointestinal Stromal Tumors

We read with great interest the article entitled ‘‘A Role for Adjuvant RFA in Managing Hepatic Metastases from Gastrointestinal Stromal Tumors (GIST) After Treatment with Targeted Systemic Therapy Using Kinase Inhibitors’’ by Hakime et al. [1] indicating that radiofrequency ablation (RFA) in patients with GIST liver metastases, previously treated with tyrosine kinase inhibitor, has few complications and little toxicity and that the combination of RFA and imatinib seems to have improved progression-free survival rates compared with historical controls in similar patients treated with imatinib alone. These findings suggest that RFA is a potentially valuable therapeutic option in the treatment of GIST liver metastases. However, there are still some issues worthy of our deeper consideration. First, we fully agree with the author that ‘‘for primary and metastatic liver tumors of 3 cm or smaller, the rate of local control after radiofrequency ablation (RFA) has been found to be equivalent to that of resection . . . .’’ In fact, a growing number of recent studies have confirmed that RFA has been widely used for liver cancer as a rapid development of minimally invasive techniques [2–4]. Its advantages include convenient maneuvering, decreased open operation ratio, shorter hospital stays, precise curative effect, and relatively low cost. For patients with small hepatocellular carcinoma (tumors \3 cm in diameter), the long-term efficacy of RFA is similar to or even better than liver resection [2–4]. Although RFA for the treatment of GIST liver metastases has been rarely reported [1, 5], we can also learn, to some extent, from the experience of RFA in the treatment of colorectal liver metastases. Second, the essence of RFA treatment is to precisely inactivate tumor lesions entirely and minimize damage to normal liver tissue. Accurate identification of tumor-infiltrating scope and satellite lesions is the first premise. Therefore, great emphasis is placed on precise imaging before treatment. In recent years, contrast-enhanced ultrasound (CEUS) has played an important role in the RFA treatment of liver cancer and can help to confirm the actual size and shape of the tumor, the range of tumor infiltration, and the number of small tumors and satellite lesions, as well as provide a reliable reference for the development of RFA planning [6–8]. Combined with results from the existing literature [6–8] as well as our center’s experience, in addition to traditional US, computed tomography, and magnetic resonance imaging examinations, CEUS is worthy of being considered for RFA treatment of GIST liver metastases. Last, and most important, in April 2008, a National Institutes of Heath expert group re-discussed the risk stratification of primary GIST after resection and reached a new consensus: The original tumor site and tumor rupture can also serve as basic prognostic evaluation indicators [9]. Therefore, we should pay more attention to avoiding iatrogenic tumor rupture and seeding during surgery and preventing the probability of a higher postoperative recurrence and metastasis, whether in surgery or during other minimally invasive treatments, including RFA for the treatment of GIST. To achieve this goal, determining the location of tumor lesions should be especially focused. Based on our single-center experience, if the tumor is located in the liver parenchyma, the choice of RFA is feasible. However, if the tumor is located in the visceral surface of liver (especially greater than one-third of the Q.-K. Sun W. Wang (&) W.-D. Jia Department of Hepatic Surgery, Anhui Provincial Hospital, Anhui Medical University, Hefei 230001, People’s Republic of China e-mail: whouwei@sina.com

Essential role of using virtual pyeloscopy in the diagnosis of small satellite renal pelvic tumour in solitary kidney patient

Virtual pyeloscopy (VP) plays an important role in the organ-sparing nephroscopic tumour resection and traditional pole resection, especially when a fibreoptic ureteroscopic examination cannot be performed. A 67-year-old man developed macroscopic hematuria. Abdominal computed tomography (CT) and cystoscopy revealed a lower calix renal stone and a 20-mm lower pyelon mass suggesting transitional cell cancer. An additional small satellite lesion in the pelvico-ureteral junction was supposedly present. Three-phase MultiDetector CT with VP showed a solitary 3 to 4-mm renal pelvic lesion beyond the known calix stone and lower pole mass. In our case, VP played an important role in the organ-sparing nephroscopic tumour resection and traditional pole resection.

Essential role of using virtual pyeloscopy in the diagnosis of small satellite renal pelvic tumour in solitary kidney patient

Virtual pyeloscopy (VP) plays an important role in the organ-sparing nephroscopic tumour resection and traditional pole resection, especially when a fibreoptic ureteroscopic examination cannot be performed. A 67-year-old man developed macroscopic hematuria. Abdominal computed tomography (CT) and cystoscopy revealed a lower calix renal stone and a 20-mm lower pyelon mass suggesting transitional cell cancer. An additional small satellite lesion in the pelvico-ureteral junction was supposedly present. Three-phase MultiDetector CT with VP showed a solitary 3 to 4-mm renal pelvic lesion beyond the known calix stone and lower pole mass. In our case, VP played an important role in the organ-sparing nephroscopic tumour resection and traditional pole resection.

Secondary choriocapillaritis in infectious choroiretinitis

AbstractPurpose Primary choriocapillaritis is the mechanism at the origin of diseases such as MEWDS, APMPPE, multifocal choroiditis and serpiginous choroiditis. In case of severe chorioretinal inflammation as in infectious posterior uveitis, indocyanine green angiography (ICGA) shows much more widespread involvement than seen by funduscopy or fluorescein angiography (FA) in form of hypofluorescent areas. The aim of this work was to analyse this occult choroidal involvement.Methods Charts of patients with toxoplasmic retinochoroiditis (TRC), syphilitic and tuberculous posterior uveitis seen in the Centre for Opththalmic Specialised Care (COS) in Lausanne, Switzerland from 1995 to 2011 were reviewed and patients with occult choroidal ICGA lesions were analysed.Results Occult ICGA lesions were characterized by a ring of hypofluorescence around the focus as well as small hypofluorescent satellite lesions in TRC and tuberculous posterior uveitis. In syphilitic posterior uveitis the ICGA hypofluorescence was characterized by more extensive areas that could contrast with minimal FA and fundus findings. For all three entities these hypofluorescent areas responded well to treatment, completely regressing in syphilitic posterior uveitis and regressing to a size equivalent to the foci seen on funduscopy and FA.Conclusion The aspect and the quick response to therapy of occult hypofluorescent areas on ICGA seen in severely inflamed infectious posterior uveitis most probably correspond to inflammatory choriocapillaris hypo or non‐perfusion and its extent needs to be assessed by performing a global appraisal of these cases including ICGA.

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There are 2 major issues related to the treatment of large bladder tumors: the often difficult to find small size satellite or concomitant lesion (usually Stage pTa and carcinoma in situ) and the sometimes challenging endoscopic removal of the large size tumor bulk. Editorial CommentUrologyVol. 79Issue 4PreviewUrologists are interested in improving the detection and transurethral resection (TUR) of nonmuscle-invasive bladder tumors. The aim is to achieve better staging, derive rational treatments, and improve local surgical control to reduce the frequency of tumor recurrence and disease progression. Toward this end, the authors have studied narrow band imaging (NBI) cystoscopy coupled with bipolar plasma vaporization (BPV) for large bladder tumors in a randomized clinical trial. Compared with conventional TUR using white light cystoscopy, the combined surgical method reduced the residual tumor detection on repeat TUR from 17.5% to 6.7% and the 1-year tumor recurrence rate from 17.8% to 7.9%. Full-Text PDF

Primary Cutaneous CD30-Positive Large T-Cell Lymphoma in an 80-Year-Old Man: A Case Report

Primary cutaneous CD30-positive large cell lymphoma (CD30+ PCLCL) is a rare subtype of cutaneous T-cell lymphoma (CTCL) that can present in a variety of ways. We report a patient with a three-month history of an enlarging, exophytic mass with two smaller satellite lesions on the left forearm. Biopsy of the skin stained positive for CD30, and, after thorough systemic evaluation, a diagnosis of CD30+ PCLCL was made. When PCLCL is suspected, it is important to perform immunohistological studies for CD30 types and conduct a thorough workup to rule out systemic LCL. These measures will reduce the use of unnecessarily aggressive chemotherapy regimens for CD30+ PCLCL, an indolent disease with a favorable prognosis.