Subsequent CT Research Articles

Exploratory models comparing ethiodized oil-glue and gold fiducials for bladder radiotherapy image-guidance.

Image-guidance with fiducials has been shown to improve pelvic radiotherapy outcome. However, bladder fiducials using ethiodized oil (EO) alone can disperse widely, and gold causes Computed Tomography scan (CT) metal artifacts. The study's purpose was to investigate the ability to deliver EO-tissue glue fiducials and compare them to gold for bladder radiotherapy image guidance. A fluid-filled porcine bladder model was used to assess the ability to cystoscopically inject visible EO glue fiducials into the submucosa. We then transferred the bladders into a porcine pelvis for imaging and compared them to gold fiducials using CT, Cone Beam CT (CBCT), and kilovoltage (KV) planar views. A tissue-equivalent phantom was utilized to analyze the CT number Hounsfield Unit (HU) characteristics and artifacts of the glue and gold fiducials. Percentile ranges and normal tissue voxel percentages of the subsequent CT number voxel histogram from a 2cm sphere surrounding the fiducial was used to characterize the artifact. We successfully delivered all EO glue fiducials into the porcine bladders as discrete fiducials. They were well seen on CT, CBCT, and KV imaging. The glue fiducials had lower CT number values, but less CT number spread of the voxel percentile ranges consistent with the diminished contrast and less artifact than gold. The glue fiducial types had similar CT number characteristics. This study has shown that EO glue fiducials can be delivered with online visualization qualities comparable to gold fiducials without metal-related artifacts.

Performance of dual layer dual energy CT virtual monoenergetic images to identify early ischemic changes in patients with anterior circulation large vessel occlusion

Background and purposeDual energy CT is increasingly available and used in the standard diagnostic setting of ischemic stroke patients. We aimed to evaluate how different dual energy CT virtual monoenergetic energy levels impact identification of early ischemic changes, compared to conventional polyenergetic CT images. Materials and methodsThis retrospective single-center study included patients presenting with acute ischemic stroke caused by an occlusion of the intracranial internal carotid artery or proximal middle cerebral artery. Data was gathered on consecutive patients admitted to our institution who underwent initial diagnostic stroke imaging with dual layer dual energy CT and a subsequent follow-up CT one to three days after admission. Automated ASPECTS results from conventional polyenergetic and different virtual monoenergetic energy level reconstructions at admission were generated and compared to reference standard ASPECTS. Confidence intervals (CI) for sensitivity, specificity, negative and positive predictive value were calculated. ResultsA total of 24 patients were included. Virtual monoenergetic reconstructions of 70 keV had the highest region-based ASPECTS accuracy, 0.90 (sensitivity 0.82 (95% CI 0.72–0.93), specificity 0.92 (0.88–0.97), negative predictive value 0.94 (0.90–0.96)), whereas virtual monoenergetic reconstructions of 40 keV had the lowest, 0.77 (sensitivity 0.34 (0.26–0.42), specificity 0.90 (0.89–0.96), negative predictive value 0.80 (0.77–0.83)). ConclusionsAutomated 70 keV ASPECTS had the highest diagnostic accuracy, sensitivity and negative predictive value overall. Our results indicate that virtual monoenergetic energy levels impact the identification of early ischemic changes on CT.

COVD-29. CONTINUATION OF TEMOZOLOMIDE CHEMOTHERAPY IN A GLIOBLASTOMA PATIENT AFTER RESOLUTION OF COVID-19 PNEUMONIA

We present a case of a 33 year-old patient with glioblastoma (IDH wild type, MGMT unmethylated) who was diagnosed with COVID-19 pneumonia while undergoing chemotherapy. The patient did not have any medical comorbidities. He was clinically asymptomatic following surgery, completed concurrent phase of combined chemotherapy and radiation and was undergoing treatment with adjuvant temozolomide. He had radiographic improvement of the brain tumor (decreased size, contrast enhancement and T2 flair) after three cycles of adjuvant temozolomide. However, after cycle three the patient developed fever and abdominal pain. Evaluation in the emergency room revealed low absolute lymphocyte count (0.7 K/MM3), positive COVID-19 point of care test and CT chest revealed patchy peripheral bibasilar ground glass and consolidative opacities compatible with pulmonary infection, with viral etiology such as COVID. Symptoms resolved after 2 weeks. Due to active infection and leucopenia temozolomide was on hold for 1 month. He was considered cleared of infection after resolution of symptoms. Temozolomide was initiated after resolution of leucopenia. Patient continued to do well after administration of subsequent temozolomide cycles and repeat CT chest after 2 months revealed resolution of consolidation and no new areas of consolidation. Temozolomide was safely administered in this patient without reactivation of COVID-19 infection. He did not have any thrombotic events.

Spontaneous regression of Markel cell carcinoma in anterior mediastinum without cutaneous involvement

AbstractBackground:Merkel cell carcinoma (MCC) is a rare and highly aggressive neuroendocrine malignancy typically involving the skin. The majority of MCC involves the head/neck region and the extremities. Despite the aggressive nature of the disease, there have been several case studies that report spontaneous regression. We report a unique case of spontaneous regression of an MCC in a peculiar region in the anterior mediastinum with no cutaneous involvement.Methods:A 50-year-old man who presented with a mobile low anterior neck mass, proven by biopsy, to be MCC. Subsequent PET/CT confirmed an FDG (Flurodeoxyglucose)-avid upper mediastinal mass. The mass gradually regressed over the course of 1 month subsequent to biopsy and was no longer palpable on exam or visible on subsequent CT scans. The patient was treated with intensity modulated radiation therapy with a total dose of 6,160 cGy in 28 fractions to the site of previously visible primary disease. At-risk nodal basins were also treated. On subsequent follow-up, the patient continued to have no clinical or radiographic signs of disease.Discussion:Spontaneous regression of an MCC is rare but has been reported mostly in the head/neck region following biopsy. It is unknown why spontaneous regression occurs. There is a possibility that biopsy may stimulate T-lymphocytes resulting in spontaneous regression.Conclusion:This is the first case to our knowledge of spontaneous regression of an MCC in the anterior mediastinum with no cutaneous involvement. Most MCC are seen clinically due to skin changes with a majority of cases occurring in the head/neck region.

Medical Image of the Month: Buffalo Chest Identified at the Time of Lung Nodule Biopsy

No abstract available. Manuscript truncated after 150 words. A gentleman in his late 50s with a past medical history of squamous cell carcinoma at the base of the tongue had numerous slowly-growing pneumocyst-like lesions despite clinical remission status post surgery and chemoradiation. Biopsy of one of these lesions was recommended by a multidisciplinary tumor board. An outpatient pre-procedural supine chest CT revealed a right pneumothorax above the lesion targeted for biopsy. A subsequent pre-procedural right lateral decubitus chest CT three weeks later demonstrated a left-sided pneumothorax, raising concern for buffalo chest. (A less likely possibility would be spontaneous resolution of the right pneumothorax and development of a new left pneumothorax in the less than 4-week interval.) Intraprocedural imaging continued to demonstrate the left-sided pneumothorax. A biopsy touch preparation of the first sample obtained did not demonstrate malignancy. Therefore, an attempt was made at obtaining another sample. However, the patient developed a brief but forceful coughing fit, resulting in …

Cranioplasty as the treatment for contralateral subdural effusion secondary to decompressive craniectomy: a case report and review of the relevant literature

Subdural effusion (SDE) is a common complication secondary to decompressive craniectomy (DC). This current case report describes a patient with contralateral SDE with a typical clinical course. Initially, he made a good recovery following a head trauma that caused a loss of consciousness and was treated with decompressive craniectomy. However, he only achieved temporary relief after each percutaneous fluid aspiration from an Ommaya reservoir implanted into the cavity of the SDE. He was eventually transferred to the authors’ hospital where he underwent cranioplasty, which finally lead to the reduction and disappearance of his contralateral SDE. Unexpectedly, his clinical condition deteriorated again 2 weeks after the cranioplasty with symptoms of an uncontrolled bladder. A subsequent CT scan found the apparent expansion of the whole cerebral ventricular system, indicating symptomatic communicating hydrocephalus. He then underwent a ventriculoperitoneal shunt procedure, which resulted in a favourable outcome and he was discharged 2 weeks later. A review of the current literature identified only 14 cases of contralateral SDE that were cured by cranioplasty alone. The mechanism of contralateral SDE has been widely discussed. Although the exact mechanism of contralateral SDE and why cranioplasty is effective remain unclear, cranioplasty could be an alternative treatment option for contralateral SDE.

Accuracy of plain radiography in detecting fractures in older individuals after low-energy falls: current evidence.

BackgroundOlder individuals sustaining low-energy falls (LEF) and presenting to the emergency department (ED) demand straightforward diagnostic measures for injury detection. Plain radiography (XR) series for diagnosis of fall-related injuries are standard of care, but frequently subsequent CT examination is required for diagnostic assurance. A systematic database search of diagnostic accuracy of XR for detection of fractures in older LEF patients was performed.MethodsWe searched PubMed, Embase, Cochrane Library, WHO International Clinical Trial Platform, and Clinical trials.gov databases from inception to January 2020 for studies including older patients (≥65 years) with LEF and obtaining CT examination and XR of the skeleton in an ED setting.ResultsFrom 8944 references screened, 11 studies met the criteria for inclusion. Performance of XR for detection of fractures of the pelvic ring and hip was analyzed in nine studies, two studies investigated XR performance to detect rib fractures, and two studies compared diagnostic accuracy of thoracolumbar spine XR. Sensitivity estimates ranged from 10% to 58% and specificity estimates from 55% to 100%. Clinical and statistical heterogeneity was significant among included studies, with an overall considerable risk of bias.DiscussionHigh-quality evidence on accurate imaging strategies in older patients with LEF is lacking to date. XR is missing a reasonable amount of fractures of the pelvic ring, rib cage, and thoracic and lumbar spine. However, the utility of first-line CT imaging and the benefit of diagnosing every fracture is unknown, demanding high-quality prospective trials considering patient-oriented outcome as well.

Incidental Anaplastic Lymphoma in a Case of Herpetic Hepatitis

Abstract Introduction/Objective The role of Herpes Simplex Virus (HSV) virus in the development of lymphomas is unclear and poses a diagnostic challenge along with limited literature explaining the relationship between HSV and Anaplastic large-cell lymphoma (ALCL). Methods A 26-year-old female admitted for intractable fever (103.7 F), chills, and dysuria; her urine analysis was suggestive of a mild urinary tract infection. During the admission, she developed abdominal pain with subsequent CT- scan showing thickening of the gallbladder and possible cholecystic fluid. Her liver function tests were: albumin 2.8 g/dL, AST 394 U/L, ALT 303 U/L, ALP 156 U/L, total bilirubin 0.3 INR 1. A subsequent Magnetic Resonance Cholangiopancreatography (MRCP) showed heterogeneous enhancement pattern of the liver without any masses following which she underwent cholecystectomy, during which her liver was abnormal along with an enlarged peri- cholic lymph node. Intraoperative biopsy of the liver showed patchy hepatocyte necrosis and occasional hepatocytes with ground-glass nuclei. The morphologic features were suggestive for Herpes Simplex Virus (HSV) hepatitis, and an HSV immunohistochemical stain confirmed this diagnosis. Removal of the lymph node showed a sinusoidal infiltrate of atypical lymphohistiocytic cells with abundant pale cytoplasm and large moderately irregular nuclei and occasional prominent amphophilic nucleoli. A few “hallmark”-like cells with curved nuclei were noted with rare mitosis. A panel of adequately controlled immunohistochemical stains showed positivity for CD4, CD30 (variable), and CD45. CD2, CD3, CD5, CD7, CD8, CD10, CD15, CD20, CD68 (positive in adjacent macrophages), BCL2, ALK1 were negative. Results Flow cytometry was negative for a neoplastic leukocyte population with a polytypic B-cell population. Taken together, a diagnosis of ALK1 negative, ALCL was made. A subsequent CT scan revealed borderline enlarged para- aortic lymph nodes along with an increased number of non-enlarged lymph nodes in the bilateral axillary, mediastinal, lower neck, and subpectoral regions. A bone marrow biopsy performed was negative for lymphoma. Conclusion Off note, her hepatitis serology panel, CMV, and HIV screens were negative. Thus, with her unusual presenting symptoms and no signs of malignancy led to numerous workups, which further led to an infectious cause, however, the patient was ultimately discovered to have an occult ALCL.

A Case of Enteropathy Associated T-Cell Lymphoma (EATL) with Aberrant Phenotype, CD8+, CD56+: From Diagnosis to Death

Abstract Introduction/Objective Enteropathy Associated T-Cell Lymphoma (EATL) is a rare and aggressive subtype of primary intestinal T cell lymphoma which occurs in patients with Celiac Disease (CD), most prevalent in the western world with an incidence rate of 0.22-1.9 cases per 100,000. The classic immophenotype of these neoplastic intestinal T cells show loss of CD8 and CD56. The adherence to gluten-free diet, markedly decreases the incidence of this complication. Methods The patient’s previous and current biopsies, autopsy and EMR were reviewed. The patient is 66-year female that was diagnosed with Celiac Disease in 2003 after duodenal biopsy showed features suggestive of CD with positive anti-endomysial IgA antibody serology. She presents currently with burning abdominal pain, with subsequent CT scan showing a mass in the small bowel with mid gut rotation and lesions in the lungs, liver and bladder. Endoscopy showed multiple lesions extending from the hypopharynx to the large bowel, which on biopsy showed CD3+ lymphocytes expanding the lamina propria and infiltrating the crypt epithelium. Given the patient’s clinical history a diagnosis of EATL was made. The patient passed 5 days after diagnosis due to small bowel perforation. Results The initial duodenal biopsy showed villous blunting and increased intraepithelial lymphocytes. The biopsies of the gastrointestinal lesions show abnormal infiltrate of pleomorphic, intermediate in size lymphocytes with round to irregular and occasionally cleaved nuclei with pale to clear cytoplasm. These cells infiltrate the crypt epithelium. The immophenotype of these neoplastic cells are positive for CD3, CD7, CD8, CD56, TIA-1 and BF1, while negative for CD4, CD5 and CD30. T cell clonality was also positive. In addition to the above lesions, autopsy revealed involvement of an area of small bowel perforation with full-thickness mucosal wall involvement by the neoplastic cells. In addition, there is widely dissemenated disease involving the lung, liver, bone marrow, spleen, mesenteric lymph nodes, omentum, bladder, ovaries and myometrium (first report of uterine involvement). Conclusion CD8 positive EATL may occur in 19-30% of cases, and increases up to 50% in refractory CD. The differential diagnosis of MEITL, which is typically CD8 positive, is important and most be distinguished on the basis of clinical setting in the presence of Celiac Disease.

Management of a Utero-Paravaginal Fistula: A Case Report

Study Objective We present the case of a utero-paravaginal fistula noted in a patient with primary infertility and a history of a bicornuate uterus who had previously undergone multiple gynecologic surgical procedures. Design Case report. Setting A tertiary care center. Patients or Participants N/A Interventions N/A Measurements and Main Results A 28 y/o G0 with primary infertility associated with a bicornuate uterus presented to our office for evaluation after obtaining an ultrasound and MRI which showed a normal left hemiuterus but a right cystic pelvic mass consistent with a distended uterine horn with extensive blood within it. She had previously undergone several surgical procedures in Brazil, one of which was labeled a Strassman procedure. She was taken to the OR for hysteroscopy and laparoscopy where hysteroscopy revealed a small uterine septum but otherwise normal appearing endometrial cavity and laparoscopy revealed a normal appearing uterus and endometriosis that was resected. She subsequently developed a pelvic abscess in what appeared to be the lower uterine segment suggestive of an isthmocele. Pelvic abscess was drained, and subsequent CT hysterosalpingogram was performed which revealed a utero-paravaginal fistula. Three months after her infection, she returned to the OR for utero-paravaginal fistula repair. Postoperatively she did well and sonohystogram performed 3 months post-operatively has shown no residual defect. Conclusion This is the only case in the literature we could find where this type of utero-paravaginal fistula is described. Given her extensive surgical history, it is likely this is a result of previous surgical intervention. We highlight the use of CT hysterosalpingogram to document the nature of the fistula and aid us in subsequent repair.

S3401 Solitary Cystic Psoas Muscle Metastasis From Rectosigmoid Adenocarcinoma

INTRODUCTION: Colorectal adenocarcinoma is the most common subtype of colon cancer and has lower rates of metastasis when compared to other subtypes (signet-ring and mucinous). 20% of Colorectal Cancer (CRC) cases have metastatic disease at the time of presentation. Metastasis are most frequently found in the liver, lung, peritoneum, bone and extra-regional lymph nodes. Reports involving metastatic disease to skeletal muscle are rare. CASE DESCRIPTION/METHODS: A routine screening colonoscopy of a 52-year-old female revealed an 8mm flat, umbilicated, and ulcerated polyp in the rectum. Subsequent staging CT scans showed a cystic fluid-filled cavity in the left psoas muscle. This cystic iliopsoas muscle lesion, initially diagnosed as an infected fluid collection, was subsequently identified as a metastasis from rectosigmoid adenocarcinoma. Following this diagnosis the patient underwent primary surgical resection for rectosigmoid carcinoma and received chemotherapy. DISCUSSION: This patient presented with a rare metastasis of rectosigmoid adenocarcinoma. This type of metastasis is significant not only for its rarity, but also in its negative prognostic features.

S1626 A Case of Colorectal Cancer and Serrated Polyposis Syndrome in Hodgkin Lymphoma Survivor

INTRODUCTION: The risk of colorectal cancer (CRC) is increased in survivors of numerous cancers including bone cancer, testicular cancer, and Hodgkin Lymphoma (HL).1 In HL cancer survivors, the relative risk (RR) of CRC is estimated at 2 to 7 as compared to that of general population.1 In the U.S., cancer survivorship guideline provided by the Children’s Oncology Group recommends initiation of CRC beginning 5 years after radiation or at age 30 years (whichever that occurs last) with either multitarget stool DNA every 3 years or colonoscopy every 5 years.2 CASE DESCRIPTION/METHODS: A 46-year-old female with history of childhood HL and presented to PCP with 4-month history of lower abdominal pain with bloating and loose stool. Family history was notable for colon cancer in maternal grandfather but otherwise noncontributory. Subsequent work up with CT abdomen revealed 3 cm diffuse wall thickening at the proximal transverse colon. Colonoscopy revealed ulcerated non-obstructing mass involving 1/3 of luminal circumference at the transverse colon at 55 cm from anal verge. In addition, numerous sessile polyps were found throughout the GI tract from rectum to ascending colon. Pathology of biopsy specimen revealed moderately differentiated adenocarcinoma with multiple sessile serrated adenoma confirming serrated polyposis syndrome (SPS). Genetic panel was negative for pathogenic variant of MLH1, MSH2, MSH6, and PMS2. Subsequent PET CT showed confirmed intense FDG avidity at suspected proximal colon and mesenteric lymph node compatible with regional metastatic disease. Patient underwent extended right hemicolectomy with subsequent referral to medical oncology. DISCUSSION: A recent population-based study reported increased risk of colorectal neoplasia, especially advanced serrated lesions and SPS, in HL survivors as compared to general population.1 The risk is generally associated with exposure to abdominal radiotherapy and/or receipt of alkylating agent particularly procarbazine. Our patient reported receiving combination chemotherapy including doxorubicin, bleomycin, and cytosine arabinoside for treatment of HL and AML but had no exposure to procarbazine or abdominal radiation therapy. Currently, colonoscopy is recommended yearly in patients with SPS with the goal of performing resection of polyps greater than 5 mm in size.3 Given increased risk of CRC and higher prevalence of SPS, there is a need for a longitudinal multidisciplinary care to ensure appropriate colonoscopy surveillance program among HL survivors.Figure 1.: Polyp in ascending colon.Figure 2.: Mass at transverse colon.

Patient motivations for non-adherence to lung cancer screening in a military population.

BackgroundLung cancer remains the leading cause of cancer deaths in the United States, and lung cancer screening has been shown to decrease this mortality. Adherence to lung cancer screening is paramount to realize the mortality benefit, and reported adherence rates vary widely. Few reports address non-adherence to screening, and our study sought to understand the non-compliant patients in our military population.MethodsThis Institutional Review Board approved retrospective review of patients enrolled in our screening program from 2013–2019 identified patients who failed to obtain a subsequent Low Dose CT scan (LDCT) within 15 months of their prior scan. Attempts were made to contact these patients and elucidate motivations for non-adherence via telephone.ResultsOf the 242 patients enrolled, 183 (76%) patients were adherent to the protocol. Significant predictors of non-adherence versus adherence were younger age (P=0.008), female sex (P=0.005), and enlisted officer rank (P=0.03). There was no difference with regards to race, smoking status, pack-years, negative screens, lung-RADS level, or nodule size. 31 (52%) non-adherent patients were contacted, and 24 (77%) reported their reason for non-adherence was lack of follow-up for a LDCT. Twenty (64%) were interested in re-enrollment. Of the total screening cohort, 15 interventions were performed, with lung cancer identified in 5 (2%)—a 67% false positive rate. One stage IV lung cancer was found in a non-adherent patient who re-enrolled.ConclusionsLack of perceived contact for follow-up was expressed as the primary reason for non-compliance in our screening program. Compliance is critical to the efficacy of any screening modality, and adherence rates to lung cancer screening may be increased through improved contact with patients via multiple avenues (i.e., phone, email, and letter). There is benefit in contacting non-adherent patients as high rates of re-enrollment are possible.

CONCURRENT PULMONARY AND JEJUNAL SARCOMATOID CARCINOMA WITH BRAIN METASTASES

SESSION TITLE: Medical Student/Resident Lung Cancer Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Pulmonary sarcomatoid carcinoma (SCA) is a poorly differentiated, aggressive type of non-small cell lung cancer accounting for 0.1-0.3% of all lung cancers1-3. It is commonly seen in male smokers in their sixties. We present a rare case of concurrent pulmonary and jejunal SCA with brain metastases. CASE PRESENTATION: 75-year-old male with 40-pack year smoking history presents to the hospital with two weeks of nausea, vomiting, weight loss and dyspnea. CXR revealed a 10.1 x 7.4 cm right perihilar mass. Subsequent chest CT showed a 7.8 x 6.6 x 8.7 cm mass involving the posterior segment of right upper lobe, right middle lobe, and right lower lobe. PET scan showed avid lesions involving jejunum, brain, and adrenal glands. Endobronchial biopsy of the lung mass obstructing the lumen of posterior segment of right upper lobe revealed SCA with focal pleomorphism. Immunohistochemical staining was positive for Keratin AE1/AE3 and vimentin. A subsequent jejunal mass biopsy was also consistent with SCA with staining positive for keratin CAM5.2 and ß-hCG. Patient underwent whole brain radiotherapy as well as palliative pembrolizumab therapy. DISCUSSION: SCA is an aggressive cancer with average survival of 8.8 months and 13 months when involving small intestine and lung respectively. 5,7 Immunohistochemical staining is crucial in differentiating metastases versus primary SCA. In our case, TTF-1, Napsin-A, and CK7 staining of the jejunal mass were negative, which contradicts lung derivation. 4 This is a rare case of primary pulmonary SCA and concurrent primary jejunal SCA with brain metastases. Most SCA tumors involving small intestine are polypoid with central ulceration and frequently necrotic and hemorrhagic. 6,7 In contrast, pulmonary SCA usually arises as a solitary central airway mass with an average size of 7 cm.3 Symptoms in pulmonary SCA are non-specific such as chest pain, dyspnea and weight loss.1,4 This makes early diagnosis challenging. Patients often present in advanced stages with extra-thoracic metastases.4 Findings of brain metastasis is rare due to aggressive course of disease with low survival time.3 Both pulmonary and jejunal SCA are resistant to traditional therapeutic methods. Novel therapies like immunotherapy appears promising. CONCLUSIONS: This case is unique as it has two concurrent primaries for SCA, lung and jejunum. It is imperative to perform a complete oncological evaluation to assess for metastases. Early diagnosis and proper adjuvant therapy could prolong survival and improve quality of life. Reference #1: Arshad, H., Dudekula, R., Niazi, M., Malik, S., and Khaja, M. (2017). A Rare Case of Sarcomatoid Carcinoma of the Lung with Spine Metastasis, Including a Literature Review. Am J Case Rep. 2017; 18: 760-765. Beasley, M., Brambilla, E., and Travis, W. (2005). The 2004 World Health Organization classification of lung tumors. Semin Roentgenol. 2005 Apr, 40 (2): 90-7. Reference #2: Oliveira MF, Watanabe SC, Andrade MP, Rotta JM, Pinto FC. Sarcomatoid carcinoma of the lung with brain metastases. J Bras Pneumol. 2013;39(6):753-756. doi:10.1590/S1806-37132013000600016 Jia J, Ren J, Gu J, Di L, Song G. Predominant sarcomatoid carcinoma of the lung concurrent with jejunal metastasis and leukocytosis. Rare Tumors. 2010;2(3):e44. Published 2010 Sep 30. doi:10.4081/rt.2010.e44 Reference #3: Huang, S., Shen, S., and Li, X. (2013). Pulmonary sarcomatoid carcinoma: a clinicopathologic study and prognostic analysis of 51 cases. World J Surg Oncol 2013; 11: 252. Kwok CM. Sarcomatoid carcinoma of the jejunum with gastric metastases: A case report and review of the literature. Int J Surg Case Rep. 2016;28:161-164. doi:10.1016/j.ijscr.2016.09.046 Zhang B, Cheng BO, Wang L, Zhao KE, Zhuo GZ, Ding JH. Primary sarcomatoid carcinoma of the jejunum with massive intra-abdominal hemorrhage: A case report and review of the literature. Mol Clin Oncol. 2016;4(5):811-816. doi:10.3892/mco.2016.809 DISCLOSURES: No relevant relationships by Kushagra Gupta, source=Web Response No relevant relationships by Anthony Loschner, source=Web Response No relevant relationships by Elizabeth McCaskey, source=Web Response No relevant relationships by Toribiong Uchel, source=Web Response

S2007 Aorto-Esophageal Fistula Presenting with Acute Upper Gastro-Intestinal Bleeding!

INTRODUCTION: Aorto-enteric fistula (AEF) is an abnormal connection between the aorta and the gastrointestinal (GI) tract. Two types are described and consist of primary and secondary AEF. Primary AEF is rare and is due to mechanical factors and native aortic inflammation or infection. Secondary AEF occur after aortic reconstruction. AEF commonly involve small and large bowel. In addition to that AEF remains a challenging entity with elevated morbidity and mortality, esophageal involvement is rare and often misdiagnosed. Thus we report a patient presenting with hematemesis that was attributed to AEF based on endoscopic suspicion. CASE DESCRIPTION/METHODS: An 84 y.o. woman with history of ischemic stroke and hypertension presented with acute hematemesis. Vitals showed sinus tachycardia. Physical exam disclosed generalized weakness and pallor. Hemoglobin was 9.0 g/dL (baseline 12.5 g/dL). Urgent upper endoscopy showed a 1cm necrotic area in the posterior wall of the lower esophagus with active oozing suspicious for an AEF (Figure 1). After epinephrine 1:10,000 injection, a 10 mm Over-The-Scope clip was applied. To achieve hemostasis, two covered stents of 20 mm × 8 cm and 18 mm × 8 cm size were applied in the lower esophagus. A subsequent abdominal CT scan showed a 6.5 × 4 cm pseudoaneurysm at the descending thoracic aorta and confirmed the presence of an AEF (Figure 2-A, B). Patient then underwent an endovascular graft placement and repair of the descending aortic pseudoaneurysm. Intra-procedural contrast injection delineated the AEF connecting the aortic pseudoaneurysm and the distal esophagus. However patient’s course was further complicated by multi-organ failure and patient’s family decided on withdrawal of care. DISCUSSION: AEF is an uncommon but potentially life-threatening condition. It mostly presents with GI bleeding. Diagnosis is difficult thus the frequency of delayed and missed diagnoses. Diagnostic tools include ultrasound, CT angiography and arteriography. Endoscopy can be helpful but some cases are only diagnosed during laparotomy or postmortem. Treatment is controversial due to limited literature. Patients with a relatively lower procedural risk are offered an open surgical repair and high risk patients usually undergo less invasive endovascular approach. Prognosis remains poor despite advances in endovascular and surgical techniques. Heightened awareness of AEF is required in view of its rare occurrence, challenging diagnosis and limited therapeutic options.Figure 1.: Upper endoscopy image showing a 1 cm area of necrosis in the posterior wall of the lower esophagus with active oozing noted suspicious for a possible aorto-esophageal fistula.Figure 2A.: Contrast abdominal computer tomography scan image, coronal view showing a 6.5 × 4 cm pseudoaneurysm at the descending thoracic aorta at 7 cm above celiac axis.Figure 2B.: Contrast abdominal computer tomography scan image, sagittal view showing a 6.5 × 4 cm pseudoaneurysm at the descending thoracic aorta at 7 cm above celiac axis.

EP20 Hypercalcaemia in sarcoidosis

Case report - IntroductionSarcoidosis often classically presents as Lofgren’s syndrome in up to 30% of cases, a triad of erythema nodosum, bilateral hilar lymphadenopathy and polyarthritis. However, the lack of identification and awareness of extrapulmonary manifestations of sarcoidosis can often lead to delayed diagnosis and treatment. In sarcoidosis, hypercalcaemia is a feature in only 10-20% of all cases. However, the manifestation of hypercalcaemia may be the first presentation of sarcoidosis in patients who do not show the classical features of acute sarcoidosis. Case report - Case descriptionA 38-year-old man presented with a 5-month history of profound fatigue, poor concentration, and non-specific joint pains. He reported earlier swelling of his ankles and feet. He had lost 1 stone in weight over the last month. There was no history of fever or night sweats. He smoked 10 cigarettes per day but was otherwise fit and well. On examination urine dipstick testing was negative. There was no evidence of lymphadenopathy. Cardio-respiratory and abdominal examinations were unremarkable. Examination of his skin and joints was also unremarkable. There was mild non-tender ankle oedema.His first blood tests showed a raised adjusted calcium of 3.25 and a raised white cell count of 11.8, with an eosinophilia of 0.75. Other preliminary blood results were unremarkable (normal Hb, U+Es, LFTs, CRP, ESR, RF, anti-CCP, ANA and TFTS). His chest X-ray was reported as clear.His PTH was appropriately suppressed and vitamin D level was adequate with normal urinary calcium and normal serum protein electrophoresis. Serum ACE level was raised at 114 (normal 8-52). PTH related peptide test was not available.A CT chest abdomen and pelvis scan carried out to rule out malignancy was normal with no notable lymphadenopathy. A subsequent PET CT scan was normal. Acutely, his hypercalcaemia was treated with IV fluids and IV pamidronate. Although his calcium rapidly normalised, he reported feeling only 10% better. He complained of ongoing ankle pain. An MRI scan of both ankles with contrast showed mild synovitis of ankle, subtalar and talonavicular joints. There was also evidence of tenosynovitis.Given the constellation of hypercalcaemia, raised serum ACE level and ankle synovitis on MRI scan, he was treated for sarcoidosis with prednisolone 20mg. This led to a rapid improvement in his symptoms and normalisation of serum ACE. He was started on azathioprine as a steroid-sparing agent. Case report - DiscussionIn cases series, hypercalcaemia due to sarcoidosis accounts for only 6% of all hypercalcaemic patients. The mechanism of hypercalcaemia in sarcoidosis is thought to be via activated pulmonary macrophages and sarcoid lymph node granulomas which upregulate the enzyme 1-alpha hydroxylase, resulting in the increased formation of calcitriol (1,25(OH)2D3). This increases calcium absorption from the gastrointestinal tract, stimulates renal calcium reabsorption and promotes calcium release from skeletal stores, causing hypercalcaemia.This case was particularly unusual as earlier literature suggests that sarcoidosis-associated hypercalcaemia is a result of activated pulmonary macrophages and sarcoid granulomas. However, this patient had significant hypercalcaemia without any radiological lung involvement or granulomata, posing the question whether there are other pathways causing hypercalcaemia in sarcoidosis. Hypercalcaemia without pulmonary involvement may be due to the presence of small amounts of sarcoid granulomata in extra-pulmonary locations such as the porta hepatis. These may not be as easily detectable on radiological investigations but may contribute to the upregulation of 1-alpha hydroxylase and subsequent hypercalcaemia. Another explanation for the significant hypercalcaemia in this patient may be due to the production of parathyroid hormone-related peptide (PTHrP) from sarcoid granulomas and bone marrow, which upregulates renal 1-alpha hydroxylase enzymes and increases the formation of calcitriol.There was no area to obtain a tissue biopsy given the normal CT and PET CT scans, resulting in a greater reliance on history, examination, and serological investigations. In addition, 30-50% of all patients with sarcoidosis have hypercalciuria, yet this patient interestingly had only an isolated hypercalcaemia with a normal urinary calcium. Case report - Key learning points Hypercalcaemia is rare in the absence of pulmonary involvement with only 10 cases reported in literature.Although non-specific, an elevated serum ACE level may be a useful pointer to the diagnosis of sarcoidosis in the absence of other classical signs.In this case, granulomatous tissue responsible to produce 1,25(OH)2D3 might be below the limits of radiological detection. Production may originate from extra-pulmonary sarcoid granulomatous tissue such as in the porta hepatis. Another possible mechanism for hypercalcaemia may be the production of PTHrP which has been reported in sarcoid tissue specimens and in the bone marrow.

S1441 Emphysematous Pancreatitis Complicated by Gastroduodenal Artery Pseudoaneurysm and Extra-Pancreatic Involvement

INTRODUCTION: Emphysematous pancreatitis (EP) is a rare form of necrotizing pancreatitis associated with gas-forming bacteria and a high mortality rate. Extra-pancreatic complications include pleural effusion, ascites, vascular and gastrointestinal involvement. Disruption of the pancreatic duct can cause pancreatic ascites and pleural effusion. Gastroduodenal artery (GDA) pseudoaneurysms are rare complications of EP caused by release of proteolytic enzymes leading to weakening and ballooning of the vessel wall. CASE DESCRIPTION/METHODS: We present a case of an 82-year-old male ex-smoker with a history of hyperlipidemia, peptic ulcer disease, and noninsulin-dependent diabetes mellitus, who presented with postprandial epigastric pain. During the first 24 hours of onset, he met three out of the five Ranson criteria: age greater than 55, LDH above 350, glucose of 393 mg/dl, with additional findings of AST 46 IU/L, WBC 14.64, amylase 2,378, and lipase greater than 600. CT revealed pancreatic gas, bilateral pleural effusions, and cholelithiasis, the latter of which was determined to be the cause of acute EP (Figure 1). The patient required surgical debridement and ERCP with stenting of biliary and pancreatic ducts (Figure 2). Intraoperative cultures were negative for enteric, fungal, or anaerobic organisms. One month later, the patient presented with septic shock and leukocytosis. Abdominal CT revealed sequelae of necrotizing pancreatitis with increased extent of fluid collection. Upper endoscopic ultrasound identified a 35 mm fluid-filled lesion in the pancreatic head positive for gram-negative rods and Streptococcus anginosus. The following week, the patient presented with melena and painless bleeding from his Davol drain. Abdominal CT angiography showed a pseudoaneurysm arising from the distal GDA and endovascular coil embolization was performed (Figure 3). One year later, the patient presented with weight loss. Abdominal CT identified a 7.0 cm pancreatic pseudocyst causing extrinsic compression in the gastric body and antrum leading to LA Grade C stasis esophagitis. A 15 mm cystgastrostomy metal stent was placed across the posterior gastric wall to relieve gastric outlet obstruction. DISCUSSION: Our case offers a unique sequela of EP causing GDA pseudoaneurysm with delayed formation of a pancreatic pseudocyst leading to severe esophagitis and gastric outlet obstruction. Effective diagnostic and therapeutic management helped this patient survive his multiple, life-threatening complications associated with EP.Figure 1.: Figure 1. Abdominal CTs in coronal view performed 6 hours apart. (A) Initial abdominal CT without contrast showed extensive inflammatory and air (white arrow) around the pancreatic head concerning for emphysematous pancreatitis versus duodenal perforation. (B) Subsequent same-day CT examination with oral contrast only demonstrated marked increase in pancreatic gas and inflammatory changes (white arrow) concerning for rapid progression. There was no extravasation of oral contrast (dashed white arrows) thereby ruling out perforated viscus as a cause for the air.Figure 2.: Figure 2. ERCP and sphincterotomy were performed given the known pancreatic head necrosis. The main pancreatic duct (A) and common bile duct (B) were cannulated, and temporary pancreatic and biliary stents were placed.Figure 3.: Figure 3. (A) Abdominal CT angiography showed pseudoaneurysm (white arrow) arising from a branch of the gastroduodenal artery in the region of peripancreatic inflammatory changes. (B) The gastroduodenal artery was embolized with multiple coils (dashed white arrow) endovascularly to treat the pseudoaneurysm.

S1781 Etanercept-Mediated Ischemic Colitis

INTRODUCTION: Ischemic colitis is an inflammatory condition due to a reduction in blood flow supplying the colon. It is characterized by insufficient oxygen and nutrient delivery leading to an imbalance between supply and demand. The colon is especially susceptible to hypoperfusion compared to the remainder of the gastrointestinal tract due to its significant vascular network.1 CASE DESCRIPTION/METHODS: Patient is a 54 year old female with past medical history significant for rheumatoid arthritis well-controlled on methotrexate, etanercept, and prednisone. Notably, she has a history of HTN and tobacco use with 37 pack-years. Patient initially presented with a 3-day history of bright red bleeding per rectum with no obvious inciting cause. Episodes of rectal bleeding were accompanied by dizziness, chills, nausea, and lightheadedness. Physical exam was notable for severe LLQ pain. Labs on admission showed leukocytosis of 19.2. Based on presenting symptoms, patient was initially treated for diverticulitis. Colonoscopy was performed, and biopsy pathology revealed fibrinopurulent exudate and hyalinized lamina propria, confirming the presence of ischemic colitis. Subsequent CT angiography was performed to assess for vascular etiology; however imaging was found to be normal. Upon literature review, case reports suggest a relationship between ischemic colitis and biologic use. Implicated biologics include anti-TNF agents, primarily infliximab.2 This case illustrates the potential for etanercept-mediated ischemic colitis, potentially through cytokine mediated pathogenesis.3 DISCUSSION: Although the side effect seen here is rare, literature review suggests a potential link between biologic agents and ischemic colitis. As such, it is important to recognize this potential relationship, especially as it relates to at-risk patients with vascular disease. Acknowledging ischemic colitis as a serious complication related to biologic agents can help guide clinicians in selecting appropriate medications in the management of autoimmune disorders.Figure 1.: Colonoscopy findings suggestive of ischemic colitis.Figure 2Figure 3

S1574 Colorectal Cancer in a Young Male With Primary Sclerosing Cholangitis Without Underlying Inflammatory Bowel Disease

INTRODUCTION: Primary Sclerosing Cholangitis (PSC) presents with hepatic duct inflammation, fibrosis and stricturing leading to biliary obstruction, recurrent cholangitis and eventually end-stage liver disease. There is a strong association between PSC and Inflammatory Bowel Disease (IBD), especially Ulcerative Colitis (UC), which itself is strongly associated with Colorectal Cancer (CRC) development. Thus, all patients diagnosed with PSC must undergo a colonoscopy to evaluate for concomitant IBD even if asymptomatic at the time of diagnosis. The cumulative absolute risk of CRC or dysplasia in patients with both PSC and UC is approximately 5 to 6 times higher than CRC in UC alone. The classic presentation of PSC is marked by abnormal liver enzymes or cholestatic symptoms. Subsequent colonoscopy identifies underlying IBD in up to 80% of cases which often progresses to CRC. We describe the case of a healthy 29-year-old male newly diagnosed with PSC. Colonoscopy revealed an extremely rare presentation of adenocarcinoma without apparent underlying IBD. CASE DESCRIPTION/METHODS: 29-year-old active-duty male presented with 6 days of nausea, vomiting, scleral icterus and abdominal discomfort. Initial total bilirubin was 11.7 mg/dL with transaminitis, elevated alkaline phosphatase and CA 19-9. IBD panel and infectious workup were negative. RUQUS and abdominal CT revealed segmental dilatation of common bile duct and mural thickening of the sigmoid colon. Follow-up MRCP / ERCP showed severely stenotic main bile duct limiting further evaluation (Figure 1). Colonoscopy found a hemicircumferential, ulcerated, friable 4 cm × 3 cm mass in the sigmoid colon, with otherwise normal colonic mucosa (Figure 2). Histologic examination demonstrated invasive poorly differentiated adenocarcinoma. His bilirubin continued to rise to 19.4 mg/dL and required biliary drain placement. Subsequent CT chest showed multiple scattered, solid nodules and the patient was transferred for further staging and potential liver transplant. DISCUSSION: This case is notable as our patient’s PSC diagnosis was immediately followed by the discovery of colon adenocarcinoma without underlying IBD. Though IBD in patients with PSC tends to be asymptomatic at the time of diagnosis, the endoscopic and histologic appearance of the colon is nearly always consistent with underlying IBD. This case exemplifies that PSC may be a direct risk factor for the development of CRC even in the absence of underlying IBD.Figure 1.: ERCP with limited contrast transmission (arrow) due to the severely stenosed main bile duct.Figure 2.: Fungating Sigmoid Colon lesion prior to biopsy.

S1879 Dysphagia and Odynophagia: Rare Initial Manifestations of Diffuse Large B-Cell Lymphoma

INTRODUCTION: Diffuse large B cell lymphoma (DLBCL) can involve extranodal sites including the gastrointestinal (GI) tract, reportedly occurring in up to 30% of patients. In the GI tract, stomach is the most commonly affected organ. CASE DESCRIPTION/METHODS: A 68-year-old non-obese, immunocompetent male with no history of tobacco and alcohol use presented with six months of progressively worsening solid food dysphagia, odynophagia, and 30 pounds unintentional weight loss. He also mentioned subjective fevers without chills or night sweats. CT imaging showed a 4.4 cm esophageal mass with hilar, mediastinal, supraclavicular, abdominal, iliac, and inguinal lymphadenopathy. Upper endoscopy visualized a circumferential, ulcerated mass from middle to distal esophagus, and a patch of erythematous mucosa in the proximal gastric body. Biopsies of the esophageal mass and abnormal gastric mucosa revealed high grade diffuse large B cell lymphoma with Ki67 proliferative index of >95%, and without evidence of Epstein-Barr Virus. Subsequent FISH studies did not report rearrangements in BCL-2, BCL-6 or MYC. He received 5 cycles of chemotherapy regimen that consisted of rituximab, etoposide, prednisone, vincristine, cyclophosphamide and doxorubicin (R-EPOCH) with excellent treatment response based on subsequent CT imaging that showed significant decrease in size of thoracic, abdominal and pelvic lymphadenopathy. DISCUSSION: With only a handful of cases reported in the literature, esophagus is an infrequent site of extranodal lymphoma. And for esophageal symptoms of dysphagia and odynophagia to be the initial manifestations leading to the diagnosis of DLBCL is rare. Given the widespread lymphadenopathy noted on imaging, we suspect that our patient’s site of origin of DLBCL was in the lymph nodes with a rare secondary spread to the esophagus and stomach, rather than primary DLBCL of the GI tract. Aside from adding to the sparse cases described in the literature, this case highlights the importance of keeping a broad differential diagnosis for esophageal mass particularly in patients who do not have the classic risk factors for esophageal adenocarcinoma and squamous cell carcinoma.Figure 1.: CT chest showed a 4.4 cm esophageal mass with bilateral hilar, mediastinal and left supraclavicular lymphadenopathy, and bilateral pulmonary nodules consistent with metastasis.Figure 2.: Upper endoscopy visualized a circumferential, ulcerated mass from middle to distal esophagus.Figure 3.: Biopsies of the esophageal mass and abnormal gastric mucosa revealed a diffuse infiltrate of large, atypical lymphoid-appearing cells surrounded by a large area of necrosis (A) with stains positive for MUM-1 (B) and BCL-6 (C), consistent with high grade diffuse large B cell lymphoma.