Surveillance CT Scans Research Articles

Robotic hand port assisted resection of liver and peritoneal metastases in patient with high-grade myxoid liposarcoma

Presenter: Karolin Ginting MD | The Jewish Hospital Background: Extremity soft tissue sarcomas, especially with the myxoid subtype, have a propensity to metastasize to extrapulmonary sites. Among these patients, metastasis to the liver is relatively rare and usually presents in a single site. Methods: We presented a 41-year-old severely obese woman (BMI: 40) with a history of high-grade myxoid liposarcoma of the left thigh presents with liver and peritoneal masses found on surveillance CT scan. Core biopsy showed evidence of metastatic poorly differentiated myxoid liposarcoma. After further discussion during interdisciplinary tumor board conference, surgical resection and adjuvant chemotherapy were recommended. Results: Adequate intraoperative examination and mobilization of these masses was expected to be challenging due to patient habitus, prompting a decision to proceed surgery with robotic and hand-port assisted technique. During diagnostic laparoscopy and intraoperative ultrasound study, two small liver masses in segment IVa and the right liver, and a peritoneal nodule were noted. Complete excisions of these masses were done under ultrasonography guidance. The postoperative course was unremarkable, and the patient was discharged home on day five without complication. Final pathology of both the peritoneal nodule and the largest liver mass showed R0 resection of metastatic myxoid liposarcoma and confirm benignancy of the two smaller number masses. Conclusion: Successful resection and outcome were achieved through a multidisciplinary approach including medical oncology, surgical oncology, radiology and pathology. Further research into survival benefits of resection, as well as the use of radiation or chemotherapy as an adjuvant treatment, would be beneficial in enabling physicians to better understand the available choices further patients, and to generate more valuable decision-making discussions.

Evaluation of routine CT scans in the follow-up of diffuse large B-cell lymphomas

ABSTRACT Objective Our aim was to retrospectively assess the role of routine CT scans within the first year of follow-up with a limited surveillance policy prior to Lugano recommendations in diffuse large B-cell lymphomas (DLBCL) achieving complete metabolic remission (CMR). We also evaluated the type of relapse detection and exposure to CT scans within the first five years. Methods Patients diagnosed with DLBCL who achieved CMR after first-line immunochemotherapy were included. Imaging studies and medical records were thoroughly reviewed. Results Among 101 DLBCL patients in the first CMR, a total of 19 relapses were identified in the study period (18.8% of DLBCL patients included). Nine patients relapsed within the first year (47.4% of all relapses) but only 3 of them were detected by the 202 surveillance CT scans performed during this first year of follow-up. Conclusions Our real-world data provide clinically applicable results which are in agreement with the Lugano recommendations based on trial data, highlighting the lack of utility of routine CTs in DLBCL patients achieving CMR.

Robotic completion pancreatectomy for recurrent pancreatic duct adenocarcinoma four years after open pancreatoduodenectomy

Presenter: Karolin Ginting MD | The Jewish Hospital Background: Second primary tumor in remnant pancreas is rare given poor prognosis with pancreatic ductal adenocarcinoma (PDAC). We are seeing long term survivors given recent advances in surgical technique and chemotherapy. Previous studies have shown the potential benefit of competition total pancreatectomy in improving survival rate in patients with isolated cancer in remnant pancreas. However, this poses technical challenges due to adhesions and complex anatomy. Robotic techniques offer potential technical advantage in oncologic resection of remnant pancreas. Methods: We described an isolated recurrence of pancreatic ductal adenocarcinoma in a 60-year-old female who underwent pancreaticoduodenectomy (PD) four years ago for pancreatic ductal adenocarcinoma. Interestingly, this patient also had synchronous hepatic cholangiocarcinoma that was resected at the time of initial PD. Results: Robotic en-bloc resection of the pancreatic remnant with splenectomy and left adrenalectomy was completed without complication and was discharged on post-operative day 4. Final pathology showed ductal adenocarcinoma with 1 of 15 positive lymph nodes. She completed adjuvant gemcitabine and capecitabine post operatively. Surveillance CT scan of the chest, abdomen and pelvis a year later was negative for recurrence. Conclusion: Robotic en-bloc resection and completion pancreatectomy in a patient with isolated recurrent PDAC is feasible and safe. In addition, minimally invasive surgery in this case allowed the patient to recovered more expeditiously and with less pain compared to her initial surgery.

Diagnostic Accuracy of Surveillance of FDG-PET/CT in Detection of Early Relapse in Malignant Lymphoma.

Introduction: Integrated PET/CT has been shown to be more accurate for lesion localization and characterization in lymphoma than PET and CT alone. Addition of CECT to PET/CT changed management of lymphoma in only about 10% of patients, while FDG/PET resulted in a management change in almost 50 % of HL patients compared with CECT alone. The majority of patients with high-grade non-Hodgkin’s lymphomas (NHL) are cured with combination treatments. However, acute and long-term toxicities impair survival. Patients with poor-risk, progressive, or relapsed disease; the goal is to improve survival with a strategy using more intensive therapy. Hence, the focus of management has now shifted towards reducing the treatment toxicity and long-term side effects while maintaining favorable outcomes especially in low-risk patients. The successful application of this tailored approach is dependent on an accurate and non-invasive diagnostic test that would reflect the true extent of disease as well as its viability early during the course of treatment. Metabolic parameters in malignant lymphoma: An imaging task force was created to update the relevance of existing imaging for staging, assessing bulk, and bone marrow involvement (BMI); the role of interim PET; standardization of PET reporting; and role for quantitative evaluation using PET and CT. A clinical task force assessed the current relevance of Ann Arbor and how best to incorporate PET/CT into staging lymphoma, the relevance of B symptoms and bone marrow biopsy (BMB), as well as to create recommendations relevant to both FDG-avid and non-avid lymphomas. The revised IWG response criteria (rIWG) incorporated FDG PET to accurately assess end-therapy persistent masses in both NHL and HL. PET/CT in surveillance assessment: Surveillance CT or PET-CT scans are widely used because of the impression that treatment at relapse is more likely to be effective when the disease is in a preclinical stage with a small tumor burden: the earlier the detection of disease the higher the treatment efficacy. The authors concluded that the routine use of surveillance PET in HL patients entering complete remission after first-line treatment should be reserved for high-risk patients. Current guidelines warrant that, once the first clinical remission is obtained, surveillance should be grounded on frequent physical examination and routine blood tests. By contrast, a significant proportion of these patients undergo follow-up CT radiological studies and fluorodeoxyglucose (FDG) positron emission tomography (PET)/CT, especially in the first 2 years after therapy. FDG-PET/CT follow up exams may be associated with false positive results. These confounding findings add up to the already significant FDG-PET/CT expense, which in turn is significantly more resource-consuming when compared to clinical and biochemical evaluation. CONCLUSION: PET/CT imaging for surveillance in malignant lymphoma may be useful in special subtypes of both Hodgkin and non-Hodgkin lymphoma.

Preliminary Results of a Response-Adapted Study of Ibrutinib and Isavuconazole with Temozolomide, Etoposide, Liposomal Doxorubicin, Dexamethasone, Rituximab (TEDDI-R) for Secondary CNS Lymphoma

Background: Secondary CNS B-cell lymphomas (SCNSL) are aggressive lymphomas with a very poor prognosis. Genetic subtypes of DLBCL with CNS tropism are enriched for chronic active B-cell receptor signaling and may respond to BTK inhibition (BTKi). CLL, MCL, and transformed lymphomas can also involve the CNS and are BTKi responsive. TEDDI-R achieves durable remissions in relapsed/refractory primary DLBCL of the CNS (PCNSL) but the profile of SCNSL tumors that are ibrutinib-responsive is unknown. We present preliminary results from a response-adapted trial of ibrutinib with TEDD-R in SCNSL. Methods: Pts with aggressive B-cell lymphomas with secondary CNS involvement are eligible if age ≥18 and adequate organ function. Pts must have relapsed after frontline therapy or can be untreated if brain parenchyma involved. Prior BTKi is allowed, but HIVinfection and EBV+ lymphomas are excluded. Baseline tests include brain MRI, FDG-PET brain and body, CSF with flow cytometry, Ommaya, and eye exam. Pts receive isavuconazole starting at 200mg BID x 3d prior to ibrutinib to prevent fungal infections associated with TEDDI-R and then 200mg daily unless ibrutinib stopped. Pts first receive ibrutinib 560mg daily x 14d in a window. If ≥20% reduction after ibrutinib, pts receive TEDDI-R for 4 cycles every 21d with IT cytarabine. Pts with <20% reduction after ibrutinib receive TEDD-R without ibrutinib for 4 cycles every 21d with IT cytarabine. No consolidation or maintenance is permitted. Surveillance for fungal infections includes chest CT after each cycle along with Beta-D glucan and aspergillus galactomannan in blood and CSF. Brain MRI and CT scans are performed after cycles 1, 2, and 4 to determine response. All remissions by MRI are confirmed with FDG-PET and CSF analysis. Surveillance brain MRI and CT scans are q3m for 1y, q4m x 1y, q6m x 1y, then annually. Results: 16 pts with a median age 67 (range 40-79) enrolled between June 2019 and July 2020. 15 (94%) pts had DLBCL comprising 9 (60%) non-GCB, 5 (33%) GCB, and 1 (7%) transformed from MZL. One pt had plasmablastic lymphoma. Eight (50%) pts had a MYC-rearrangement including 4 (25%) with both MYC and BCL2 or BCL6 rearrangements. Eight (50%) pts had isolated CNS disease and 8 (50%) had synchronous CNS and peripheral disease. All pts relapsed after a median of 2 (range 1-4) prior therapies and all (100%) pts received prior anthracycline. Seven pts (44%) had prior CNS prophylaxis and 8 pts (50%) had prior HD-MTX based salvage therapy. Toxicity was evaluated across 35 cycles. G3 and G4 neutropenia occurred in 49% and 29% of cycles, respectively, while febrile neutropenia occurred in 9% of cycles. The median (range) duration of neutropenia was 6 (1-13) days. Five (14%) cycles were complicated by ≥G3 infection, but no opportunistic infections (including Aspergillus) were observed. One pt developed a bacterial infection during cycle 1 and died. G3 and G4 thrombocytopenia occurred in 34% and 23% of cycles, respectively, and 1 pt developed G3 hematuria. G3 mucositis occurred in 9% of cycles and palmar-plantar-erythrodysesthesia led to dose reductions of liposomal doxorubicin in 5 (36%) pts. Of 15 pts who completed the 14d ibrutinib window and were evaluable, 8 (53%) were ibrutinib-responsive and 7 (47%) were ibrutinib-resistant (Figure 1). Clinical responses were concordant across anatomic compartments; of 8 pts with both CNS and peripheral disease, 5 (63%) responded to ibrutinib in both compartments while 3 (37%) did not respond in either compartment. All 8 ibrutinib responders had a non-GCB phenotype and six (75%) achieved CR. One died of treatment-related toxicity after a PR and 1 is still on therapy. Only two (29%) pts with ibrutinib-resistant tumors achieved PR and none have achieved CR. After a median follow-up of 5.1m, a landmark analysis starting after the ibrutinib window demonstrated the PFS for pts with ibrutinib-responsive compared to ibrutinib-resistant tumors was not reached vs. 0.9m (95% CI: 0.1-2m)(p=0.002)(Figure 2). Conclusions: Patients with SCNSL tumors that are ibrutinib-responsive achieve a high rate of complete response to TEDDI-R in both CNS and peripheral disease. Patients with tumors that are ibrutinib-resistant also respond poorly to TEDD-R. Toxicity is mainly hematologic, and no Aspergillus infections have occurred with the use of isavuconazole prophylaxis. Updated clinical results from this ongoing study (NCT03964090) and will be presented at the meeting. Disclosures No relevant conflicts of interest to declare. OffLabel Disclosure: ibrutinib for use in secondary cns lymphoma as part of a clinical trial

S1621 Bladder in the Colon: A Rare Case of Hematochezia

INTRODUCTION: Colorectal cancer is the most common malignancy in the GI tract. Metastatic lesion to the colon are uncommon, accounting for only 1% of all colorectal neoplasms. The most common form of metastatic spread to the bowel is through peritoneal spreading. Hematogenous and lymphatic spread to the colon is reported in breast carcinoma, lung carcinoma, and melanoma. We present a rare cause of colorectal neoplasm. CASE DESCRIPTION/METHODS: A 65yo male with a history of ESRD and urothelial carcinoma presenting with hematochezia for 2 day. Symptoms began abruptly and were painless. He reported dizziness. He denied prior history of similar episodes. Patient denied melena, constipation, or any other GI symptoms. He is not on blood thinners. Of note, patient has chronic hematuria related to his malignancy, requiring blood transfusions. His most recent outpatient labs 1 week prior revealed a hemoglobin of 8.6g/dL. Patient is on neoadjuvant pembrolizumab. Surgical history included a prior bladder biopsy. He had no reported of prior colonoscopy. He is a former smoker with no other toxic habits and no pertinent family history. On admission, HR 110, BP 85/50, and was afebrile, saturating 100% on room air. Exam was remarkable for conjunctival pallor. Rectal exam revealed red blood without notable masses or lesions. Labs were significant for a hemoglobin of 7.1g/dL, creatinine of 3.5 and BUN of 42. The remainder of his CBC and CMP were unremarkable. He was transfused 1unit packed red blood cells and given IV fluids with improvement in his BP. He underwent a colonoscopy which revealed a 4 × 3 cm cecal mass with an adherent clot. The mass was injected with epinephrine, clot was successfully removed, and the mass was biopsied. Additionally, there was blood throughout the colon, and non-bleeding diverticuli in the transverse and sigmoid colon. Pathology revealed high grade carcinoma consistent with metastatic urothelial carcinoma, morphologically similar to his prior TURP specimens. Patient had a follow-up CT C/A/P that showed no other notable metastatic disease with stable bladder mass noted on a surveillance CT scan 3 months prior. Patient went for a right hemicolectomy for further management. Patient had oncologic followup for treatment. DISCUSSION: Although colon malignancy is common, metastatic urothelial cancer isolated in the colon is rare. Managing such cases is difficult as literature is unavailable. Further research is needed to understand methods of metastasis, predicting outcomes, and managing patients.Figure 1.: Cecal mass with notable adherent clot.Figure 2.: Cecal mass status post epinephrine injection and clot removal.

S1707 Heart to Believe: Right Atrial Mass and New Onset Heart Failure Due to Metastatic Colon Adenocarcinoma

INTRODUCTION: A 58 year old male with history of early stage colon cancer diagnosed six years ago status post right hemi-colectomy without chemotherapy and apparently in remission presented with symptoms of heart failure and found to have a right atrial mass. CASE DESCRIPTION/METHODS: On admission, labs with mildly elevated liver enzymes. A transthoracic echo showed a pedunculated right atrial mass. Cardiac CT with contrast confirmed the presence of an 8 cm × 6 cm right atrial mass with extension into the hepatic vein and inferior vena cava. (Figure A, arrows). Biopsy of mass showed moderately differentiated colonic adenocarcinoma with cribriform glandular growth pattern (Figure B) staining positive for CDX1 and cytokeratin 20 (Figure C, D respectively), and negative for cytokeratin 7 (Figure E). Recent abdominal surveillance CT scans did not show any evidence of recurrent disease and tumor markers were normal. Subsequent colonoscopy showed a healthy appearing anastomosis without evidence primary colon tumor recurrence (Figure F). DISCUSSION: While colon cancer is the third most common cause of cancer in the United States, known metastasis to the cardia is extremely rare. To our knowledge there are only ten such cases, with all of them affecting the right atrium or ventricle.1–2 Given the clinically silent nature of metastatic cardiac malignancies, many are undiagnosed until autopsy, which estimates the presence of such metastasis ranging 2–7%.3 Spread is typically hematogenous given the intra-cardiac location of these tumors. Treatment is palliative FOLFOX based chemotherapy, although emergent surgical resection is considered in cases of hemodynamic compromise. Overall prognosis is poor with 5-year survival rates of 10-14%2.Although metastatic cardiac disease is rare, our case illustrates the need for an extensive diagnostic workup in any patient with a history of colorectal cancer presenting with new onset heart failure symptoms.Figure 1.: Figure A: Cardiac CT illustrating right atrial tumor (Arrows).Figure 2.: Figure B-E: Pathology images showing adenocarcinoma staining positive for CDX1/Cytokeratin 20 and negative for Cytokeratin 7.Figure 3.: Figure F: Colonoscopy with healthy appearing anastomosis.

Post Esophagectomy Diaphragmatic Hernia (PEDH): An Experience of a Dedicated Cancer Center of Pakistan

Objective: To study the outcomes of post esophagectomy diaphragmatic hernia managed at our institute. Methodology: We conducted a retrospective case series among patients who underwent surgical resection for esophageal cancer in the last 10 years from Jan 2010 to Dec 2019. Patient’s charts were reviewed and postoperative surveillance CT scans were reviewed for the development of post-operative diaphragmatic hernias. Demographic and variables related to diaphragmatic hernia and its management were recorded and analysed. Results: Out of 590 patients, 10 patients developed post esophagectomy diaphragmatic hernia. All patients received neo adjuvant chemo-radiotherapy. 8 patients underwent three stage esophagectomy, one had Ivor Lewis esophagectomy and one had transhiatal esophagectomy. CT scan was used as a modality of choice for the diagnosis. Two patients developed hernia during their hospital stay and 8 patients presented late. 7 patients were diagnosed due to complications of the hernia. One patient presented with acute abdomen and ischaemic gut. 2 presented with severe epigastric pain. 4 presented with shortness of breath. 3 patients were diagnosed on surveillance CT scans. All patients underwent surgery for closure of the hernia defect. Laparoscopic surgical management was performed in 5 patients. Five patients had primary tension free closure while five patients had mesh repair. Two patients had recurrence. Both were re-operated and mesh repair was done. There was no 30 days mortality. Conclusion: Diaphragmatic hernia is a serious complication. Early surgical intervention is needed for the treatment. With minimally invasive techniques, incidence has increased. For standardization of management and quality of care, randomized control trials are needed.

External validation of a convolutional neural network artificial intelligence tool to predict malignancy in pulmonary nodules

BackgroundEstimation of the risk of malignancy in pulmonary nodules detected by CT is central in clinical management. The use of artificial intelligence (AI) offers an opportunity to improve risk prediction....

Adrenal Tumors Found During Staging and Surveillance for Colorectal Cancer: Benign Incidentalomas or Metastatic Disease?

To evaluate the incidence of adrenal metastases in patient with colorectal cancer (CRC) and determine the clinical and radiographic features associated metastatic CRC to the adrenal glands. The review of consecutive adults with newly diagnosed CRC found to have adrenal tumors > 1cm in size on staging or surveillance CT scans with at least two scans to evaluate progression or stability of disease. Fifty-eight of 856 (6.8%) CRC patients had an adrenal tumor. Forty-three patients (74%) with 46 adrenal tumors had benign adrenal tumors, and 15 (26%) patients with 17 adrenal tumors had metastatic disease. On univariate analysis, patients with metastatic CRC had larger adrenal tumors (26.7mm vs 12.4mm, p < 0.01), a higher mean CEA (239ng/mL vs 14.2ng/mL, p = 0.03), and were more likely to have other sites of metastatic disease seen on imaging 8/43 (19%) vs 14/15 (93%), p < 0.01. On multivariable analysis, adrenal tumor size > 1.8cm (OR 49.6 CI 8-306), CEA > 2.5ng/mL (OR 15.8 CI 1.7-144) and other metastatic disease seen on imaging (OR 68.1 CI 7-661) were independently associated with adrenal metastases. CRC patients with small adrenal tumors, normal CEA levels and no evidence of other metastatic disease are unlikely to have spread to the adrenal glands. Adrenal tumors found during staging and surveillance of CRC patients should be evaluated with appropriate imaging and biochemical analysis.

Aggressive case of early onset gastric cancer; identifying the knowledge gap

A woman aged 30 years was referred for endoscopy for iron deficiency anaemia. Colonoscopy was normal. Upper endoscopy demonstrated multiple small, carpet-like, sessile polyps in the gastric fundus and a...

Differences in optimal timing of post-surgical surveillance for limited stage lung cancer patients and associations with outcomes

Background: Guidelines for post-operative surveillance for non-small cell lung cancer (NSCLC) are variable. Historically, providers have used a one-size fits all approach, such that surveillance guidelines incorporated few important prognostic indicators for recurrence and survival. The goal of this study was to determine optimal timing for detection of recurrence by CT scan and the association between surveillance CT and overall survival. Methods: This was a retrospective, single institution series of patients undergoing surgical resection [2008– 2012] with stage I or II disease (AJCC 7th edition) with at least 6 months of follow-up. Results: Recurrence occurred in 27.2% of patients at a median of 29.5 months following surgery. Recurrences peaked at 2–3 years following surgery for the entire cohort. For those detected on CT scan surveillance, stage I the peak timing for recurrence was at 25–36 months (year 3) whereas stage II peak timing was at 19–24 months (year 2) following resection. Timing of recurrences detected by any means differed significantly based on cancer stage with 81% (n=27) of recurrences occurring more than 24 months following surgery for stage I patients compared to 41% (n=17) of stage II patients (P Conclusions: The timing of recurrence differs significantly based on stage such that few stage I patients have recurrences within 2 years following surgical resection. Additionally, rates of recurrence detected by surveillance CT scans performed less than 24 months following surgery is significantly lower for stage I patients compared to stage 2 which would favor delaying routine surveillance in this select group. Optimal timing of CT surveillance based on peak recurrence rates has the potential to eliminate unnecessary testing and expense for healthcare systems.

2683 Gastric Metastasis From Renal Cell Carcinoma: A Case Report

INTRODUCTION: Renal cell carcinoma (RCC) is the most common renal malignancy in adults and possesses extensive metastatic potential. At the time of diagnosis, over 30% of cases have metastatic lesions and a 10% risk of developing metastatic disease after 5 years. The most commonly involved sites for metastasis include regional lymph nodes and distant organs such as the lungs, liver, and brain. In very rare cases, it can spread to gastrointestinal tract. CASE DESCRIPTION/METHODS: The patient is a 74 year old male found to have a 5 cm right kidney mass while undergoing workup for uncontrolled HTN. Histology and workup after radical resection confirmed clear cell carcinoma limited to the right kidney. Follow up CT a year after diagnosis revealed bilateral adrenal gland nodules. Biopsy of which was consistent with metastatic renal cell carcinoma at which point chemotherapy was started. Restaging two years thereafter and multiple follow up surveillance CT scans revealed no evidence of disease progression. Nine years after the original diagnosis, patient was admitted for hypotension and anemia. EGD done in evaluation of anemia, revealed multiple gastric submucosal polyps, biopsy of which revealed metastatic renal cell carcinoma. Immunostaining with PAX-8 and renal tumor markers were positive further proving RCC as the primary carcinoma. At this point the patient was restarted on chemotherapy and discharged with close follow up. DISCUSSION: Within the gastrointestinal tract, metastasis of RCC to the stomach is the rarest, at a rate of &lt;0.2%. The process by which tumor cells migrate from the primary site to distant organs and the predilection to metastasize to specific organ systems is not well understood. In the rare instance that RCC metastasizes to the stomach, it most frequently presents as a polypoid submucosal protruding mass leading to gastrointestinal bleeding and symptomatic to anemia . The optimal treatment for RCC remains controversial and the utility of resection on mortality remains unclear. In our patient, the period from radical resection to detection of metastatic gastric lesions was over nine years. At the time of resection, the lesion was confined to the left kidney only as per staging imaging obtained. This raises many questions: how can metastatic lesions present after the resection of a tumor with no invasion of the kidney capsule? How can these new lesions appear almost a decade later? And finally, how effective is resection of primary RCC tumor in regards to preventing metastasis?

1387 Late Recurrence of Metastatic Pancreatic Angiomyolipoma in Tuberous Sclerosis Following Bilateral Nephrectomy and Transplant

INTRODUCTION: Angiomyolipomas are typically benign tumors often associated with tuberous sclerosis, most commonly occurring in the kidneys. Some variants have malignant potential. Surgical resection remains the most effective form of treatment; however, recurrence after nephrectomy is rare, especially in the pancreas. CASE DESCRIPTION/METHODS: We report a unique case of a 59-year-old female with tuberous sclerosis who underwent bilateral nephrectomy for malignant, hemorrhagic angiomyolipomas with subsequent renal transplant. Almost 10 years after initial discovery of renal angiomyolipoma, patient presented to gastroenterology clinic with elevated liver function tests and was subsequently referred for endoscopic ultrasound (EUS) to evaluate for biliary obstruction as the etiology. If no obstruction was found, an EUS guided liver biopsy was requested. The EUS showed a normal non-dilated common bile duct (CBD) with no evidence of obstruction. EUS guided liver biopsy was then performed using a 19G core biopsy needle. Incidentally, she was found to have pancreatic tail mass lesion which measured 13 mm in diameter. This was not visualized on her previous surveillance CT scans. EUS fine needle aspiration was performed on the pancreatic tail mass with a 25G needle. The liver biopsy showed mild iron overload and minimal macrovesicular steatosis. The cytology from the pancreatic lesion was reported as an angiomyolipoma. The patient was subsequently referred to surgical oncology for evaluation of distal pancreatectomy. DISCUSSION: This is the second reported case of a pancreatic angiomyolipoma in a tuberous sclerosis patient, however guidelines on surveillance are lacking. Radiological imaging has not been an effective form of detecting pancreatic angiomyolipomas. This case highlights the importance of continued surveillance, and the possible role of EUS in that surveillance, for recurrent angiomyolipoma following nephrectomy in patients with tuberous sclerosis.

The impact of method of recurrence detection on esophageal/gastroesophageal junction (EGJ) cancer outcomes.

e15580 Background: Trimodality treatment (tx) with neoadjuvant chemoradiation (CRT) followed by esophagectomy is standard tx for locally advanced EGJ cancer. Post-operatively, there is no strong consensus about role of routine surveillance imaging. At the University of Rochester, patients (pts) have surveillance CT scans every 4-6 months (mos) for the first 2 years post-esophagectomy and every 6-12 mos for the next 3 years. Methods: Pts were identified who underwent esophagectomy for T1-T3 EGJ cancer between January 2011 and December 2015 at our institution. Objectives were to describe the impact of timing and methods of recurrence detection (MoRD) on patient outcomes. Recurrence-free (RFS) and overall survival (OS) were graphed via the Kaplan-Meier method. Results: 138 pts underwent esophagectomy for EGJ cancer: 107 (77.5%) were male, median age was 64, and 116 patients (84.1%) had adenocarcinoma. 112 pts (81.2%) had neoadjuvant CRT. The entire cohort’s median OS was 38.4 mos. 68 pts (49.3%) relapsed with a median RFS of 20.0 mos. Recurrence was detected by routine imaging in 36 pts (52.9%), imaging triggered by symptoms in 27 pts (39.7%), and symptoms alone in 5 pts (7.4%). Post-relapse median OS was 2.3 mos when detected based on symptoms alone, 5.0 mos when detected by imaging triggered by symptoms, and 13.7 mos when detected by routine scans (log-rank p = 0.041). There was no significant association between baseline patient/tumor characteristics or pathologic response and MoRD . 53 patients (77.9%) received salvage/palliative tx with a median of 2 tx (IQR = 1). There was no significant association between MoRD and number of salvage/palliative tx. Conclusions: 49.3% of pts relapsed after esophagectomy for EGJ cancer, consistent with current literature. Almost half of relapses were detected based on symptoms despite routine imaging. Increased OS for pts with relapse detected by routine scans is likely related to lead time bias, but may also be related to increased tx intensity or less aggressive tumors. MoRD did not have a measurable impact on number of lines of post-relapse tx. Prospective randomized trials are needed to determine real benefit of regular surveillance scans among EGJ cancer survivors.

SUN-571 Thymic Hyperplasia: An Unusual Manifestation of Graves’ Disease

Background: The association of Graves’ Disease with thymic hyperplasia is often underrecognized, even though it was first described more than 100 years ago. We hereby present a case of a hyperthyroidism and thymic hyperplasia where surgery could have been avoided. Clinical Case: A 43-year-old female presented with complaints of palpitations, increased sweating, tremors and fatigue for 6 months. Labs showed undetectable TSH with elevated free T4 of 2.3 ng/dl (reference range 0.82-1.77 ng/dl) and free T3 7.7 pg/ml (reference range 2 - 4.4 pg/ml). TSI antibodies were elevated at 617 (Normal <150 %). Due to a previous history of lung nodules, the patient underwent a surveillance CT scan of the chest concurrently. This CT chest showed an anterior mediastinal mass measuring 5 cm×3 cm. The mass was highly suspicious for being thymic in origin. This mass was not noticed on the CT chest done a year ago. PET scan revealed hypermetabolic activity in the thymic and thyroid regions. It was recommended to the patient that this mass likely was thymic hyperplasia in the setting of Graves’ Disease which was amenable to conservative management. However, the patient chose to undergo trans-sternal thymectomy instead of active surveillance. Pathology showed true thymic hyperplasia and no evidence of malignancy. Conclusion: This case illustrates the benign nature of thymic enlargement in Graves’ Disease. The presence of thyrotropin receptors on the thymic epithelial cells which participate in the autoimmune response, leading to hyperplasia in Graves’ disease has been implicated in the pathogenesis of thymic enlargement (1). Pathologically, two distinct features are seen in the thymus in Graves’ disease: lymphoid hyperplasia and true thymic hyperplasia (2). In both these conditions, the thymus gland appears diffusely enlarged. The treatment of thymic enlargement in this condition is the treatment of Graves’ disease, thereby avoiding the need for surgical interventions.

Robotic-assisted ipsilateral adrenalectomy after robotic-assisted partial nephrectomy: a case report

Robotic-assisted adrenalectomy (RA) was established since 2001 as an alternative to open and laparoscopic adrenalectomy, although re-operative RA after upper pole partial nephrectomy is uncommon. Here, we describe RA for presumed renal cell carcinoma (RCC) recurrence after ipsilateral upper pole robotic-assisted partial nephrectomy (RPN), using the da Vinci Xi. A 43-year-old male underwent left RPN in November 2017 for a 3.3 cm upper pole enhancing solid renal mass. Pathology revealed clear cell, RCC, FG 2, pT1a, negative margins. Seven months later, routine surveillance CT scan demonstrated a 2.09 cm enhancing left adrenal nodule, suspicious for recurrent RCC. MRI was performed and confirmed the presence of enhancing adrenal nodularity suspicious for tumor recurrence. Percutaneous biopsy of the adrenal lesion was performed and it was inconclusive. The multidisciplinary tumor board recommended excision, and a robotic approach was selected. The RA was performed using three 8 mm robotic Xi trocars, one midline 12 mm blunt tip Hasson trocar, and one 5 mm AirSeal trocar for assistant ports. The 8 mm robotic Xi instruments (fenestrated bipolar forceps, monopolar curved scissors and permanent cautery hook) were used during the procedure. Total operation time was 249 minutes. Total console time was 134 minutes. Blood loss was 250 mL and there were no complications. He was discharged on post-operative day one. Pathology showed adrenal gland without significant histopathological changes. The gland measured 8.3 cm × 7.6 cm × 2.8 cm and weighed 63.2 grams. The final pathology report showed that there was no evidence of involvement by RCC. The post-operative course was unremarkable. The da Vinci Xi RA is a safe and feasible procedure for adrenal masses after ipsilateral RPN. Surgeons attempting the procedure should be comfortable with the inflammation and adhesions encountered in re-operative surgery and should work with an experienced team to avoid damage to surrounding organs (such as the spleen, pancreas, colon and stomach) and major vessels (such as the aorta, renal artery and vein). For masses of unclear etiology proceeding with adrenal mass biopsy prior to re-operative surgery should be considered as false-positive imaging results are possible.

Surveillance for locally advanced esophageal and gastroesophageal junction (GEJ) cancers: Patterns of recurrence and methods of detection.

32 Background: Trimodality treatment with neoadjuvant chemoradiation (CRT) followed by surgery is a standard treatment for esophageal/GEJ (E/GJ) cancers. Following esophagectomy, there is no strong consensus about optimal surveillance and routine imaging. At our institution, patients have surveillance CT scans every 4-6 months for the first 2 years post-surgery and every 6-12 months for the next 3 years. Methods: An IRB-approved chart review was performed identifying patients who underwent surgical resection for locally advanced E/GJ cancer between January 2011 and December 2015 at the University of Rochester. Study objectives were to describe timing of and methods used to detect recurrence as well as their impact on patient outcomes. Recurrence-free (RFS) and overall survival (OS) were graphed via the Kaplan-Meier method. Results: 138 patients underwent surgical resection for E/GJ cancer during the study period: 107 (77.5%) were male, median age was 64, and 116 patients (84.1%) had adenocarcinoma. 111 patients (80.4%) received neoadjuvant CRT. Median OS for entire cohort was 43.4 months. 65 patients (47.1%) relapsed with a median RFS of 19.8 months. Recurrence was detected by routine imaging in 34 patients (52.3%), imaging triggered by symptoms in 25 patients (38.5%), and symptoms alone in 6 patients (9.2%). Median OS post-relapse was 1.5 months when detected based on symptoms alone, 5.0 months when detected by imaging triggered by symptoms, and 13.5 months when detected by routine scans (Log-rank p = 0.046). There were no significant associations between baseline patient /tumor characteristics and subsequent method of recurrence detection. Conclusions: 47.1% of patients suffered relapse after trimodality therapy for E/GJ cancer, consistent with published literature. Almost half of these were detected based on symptoms despite routine imaging. Increased OS for patients with relapse detected by routine scans is likely related to lead time bias, but may be related to increased treatment intensity, or due to less aggressive tumors. Prospective randomized trials are needed to determine the true benefit of regular surveillance scans among esophageal cancer survivors.

Clinical evaluation and surveillance imaging of children with myelomeningocele and shunted hydrocephalus: a follow-up study.

OBJECTIVEThe majority of children with myelomeningocele undergo implantation of CSF shunts. The efficacy of adding surveillance imaging to clinical evaluation during routine follow-up as a means to minimize the hazard associated with future shunt failure has not been thoroughly studied.METHODSA total of 300 spina bifida clinic visits during the calendar years between 2012 and 2016 were selected for this study (defined as the index clinic visit). Each index visit was preceded by a 6-month period during which no shunt evaluation of any kind was performed. At the index clinic visit, all patients were evaluated by a neurosurgeon. Seventy-four patients underwent previously scheduled surveillance CT or shunt series scans in addition to clinical evaluation (surveillance imaging group), and 226 patients did not undergo surveillance imaging (clinical evaluation group). Subsequent unexpected events, defined as emergency department visits, caregiver-requested clinic visits, and shunt revision surgeries were reviewed. The timing and likelihood of an unexpected event in each of the 2 groups were compared using Cox proportional hazard survival analysis. The rate of shunt revision surgery in the follow-up period as well as the associated outcomes and rate of complications were analyzed.RESULTSThe clinical characteristics of the 2 groups were similar. In the clinical evaluation group, 4 of 226 (1.8%) patients underwent shunt revision based on clinical findings during the index visit, compared to 8 of 74 (10.8%) patients in the surveillance imaging group who underwent shunt revision based on clinical and imaging findings at that visit (p < 0.05). In the subsequent follow-up period, there were 74 unexpected events resulting in 10 shunt revisions in the clinical evaluation group, for an event rate of 33% and operation rate of 13.5%. In the surveillance imaging group there were 23 unexpected events resulting in 2 shunt revisions, for an event rate of 34.8% and an operation rate of 8.7%; neither difference was statistically significant. The complication rate for shunt revision surgery was also not different between the groups.CONCLUSIONSObtaining predecided, routine surveillance imaging in children with myelomeningocele and shunted hydrocephalus resulted in more shunt revisions in asymptomatic patients. For patients who had negative results on surveillance imaging, the rate of shunt revision in the follow-up period was not significantly decreased compared to patients who underwent clinical examination only at the index visit.

“A Case of Leiomyosarcoma causing Ileo-caecal Intussusception: The wrong tumor at the wrong site”

Intussusception remains a very rare presentation in adults where the cause is usually a pathological lead point. A common consensus that appears in the literature dictates that most cases of large bowel and ileo-caecal intussusception are secondary to a malignant lesion compared to small bowel intussusception. Pre-operatively determining the nature of the lead point is not always possible but intussusception itself can be readily diagnosed with the use of CT scanning. Surgical resection with or without initial attempts at reduction of the intussusception remains the treatment of choice. A leiomyosarcoma reported only a handful of times in the past, is a rare cause of the same. We present a case of a patient with known metastatic leiomyosarcoma who was incidentally found to have ileo-caecal intussusception during a surveillance CT scan which was subsequently treated with surgical resection and was found to have a metastatic LMS as the lead point.