Total Body CT Research Articles

Are invasive postmortem examinations still the ‘gold standard’ in diagnosing the cause of death?

For many years, the foundations of both its art and science in medicine grew from the observations made at the autopsy table. The observations of the pathologists formed the pathologic basis and manifestations of disease, which further advanced the development of therapeutics. For most of the 18th and 19th centuries, morbid anatomy (autopsy pathology) was considered the science of medicine. Today, the autopsy and the knowledge that derives from it do not hold the position they once did in the profession’s history. There is a belief among the medical community a complete autopsy is necessary to find out the answers when someone dies. In some jurisdictions, the forensic pathology community is reluctant to follow the targeted or minimally invasive approach in postmortem examinations due to a lack of understanding of the process. With a complete external examination, trace evidence collection, total body computed tomography (CT) scan, and minimally invasive/targeted dissection with a collection of samples for further analysis, almost all answers can be provided in hospital and medicolegal autopsy settings. We must collaborate with sister disciplines, such as experts in radiology and the legal community, to educate them on the importance of this new approach using advanced technology.Continuously evolving modern radiological imaging has remarkably increased the accuracy of clinical diagnosis. Conventionally, when you hear the word postmortem examination, people think it includes an external examination and dissection of all body cavities. In the 21st century, most questions raised by the family, clinicians, the coroner (medical examiner), courts, and law enforcement agencies can be answered with a complete external examination of the body, total body CT scan +/- magnetic resonance imaging, and targeted dissection or minimally invasive approach incorporated with sample collection for further testing. This is cost-effective and can produce reviewable data.

LYME AND DENGUE FEVER: FROM BANGLADESH TO ITALY

Abstract Background Dengue fever (Flavivirus) and Lyme disease (Borrelia burgdorferi) are rare tropical infectious diseases transmitted by hematophagous vectors (Aedes mosquitoes and ticks, respectively), and they are extremely uncommon in Italy. In European countries, both represent a public health concern as they manifest as imported diseases. Case Report A 54–year–old man from Bangladesh was admitted with symptoms of fever, dyspnea, and pericarditic chest pain. Laboratory and imaging examinations revealed severe acute respiratory failure secondary to left lower lobe pneumonia and pleuropericardial effusion. Broad–spectrum antibiotic therapy and anti–inflammatory treatment were initiated, suspecting para–pneumonic pleuropericarditis. During hospitalization, there was a gradual improvement with a reduction in inflammatory indices and resolution of lung consolidation. The patient was discharged after 14 days with anti–inflammatory therapy (ibuprofen and colchicine). Approximately 7 days later, the patient returned to the emergency department complaining of a recurrence of symptoms and fatigue. The EKG showed phases of 2:1 AV block, EAS and EPS, complete de novo left bundle branch block (LBBB), alternating with an escape atrial rhythm, not evident in previous EKG. During hospitalization, complete AV block emerged with prolonged asystolic phases, requiring urgent placement of a temporary pacemaker. Concurrently, blood tests revealed anemia and increased levels of inflammatory markers, troponin, creatinine, transaminases, cholestatic indices, LDH, and lipase, indicative of multiple organ failure (MOF). Acute pathologies or active bleeding were ruled out by total body CT with contrast. Blood cultures and serological tests were performed to exclude infections by Trichinella, Mycoplasma, Borrelia, Dengue, and other rare infectious diseases. Due to progressive deterioration, the patient was transferred to a tertiary care hospital. In the following days, laboratory results showed positive IgG and IgM for Dengue (without serological evidence of viral RNA) and positive IgG and IgM antibodies for Borrelia burgdorferi. Conclusion In Italy, the incidence of these diseases is low, and their coexistence in the same host is even rarer (if not anecdotal). However, coinfection cannot be excluded in patients from areas where these diseases are endemic, such as Bangladesh.

HALF DOSE THROMBOLYSIS IN INTERMEDIATE – HIGH RISK PULMONARY EMBOLISM WITH TRICUSPID VALVE MOBILE MASS: A BAIL OUT STRATEGY

Abstract A 82–year–old previously healthy male was referred to the emergency department complaining sudden onset dyspnea and witnessed syncope complicated by head trauma. Recurrent dizziness occurred previously. No history or drug consumption noted. On admission: heart rate 90 beats/min, blood pressure 110/60 mmHg, respiratory rate 25 breaths/min, oxygen saturation 87% in room air, normal body temperature. No lower extremities tenderness or swelling reported. Consistent with peripheral blood oxygen saturation levels, arterial blood gas analysis showed hypoxemia and respiratory alkalosis. Laboratory exams were significant for thrombocytopenia (89.000 cells/L), elevated cardiac troponin T levels (222 ng/L) and natriuretic peptide (NT pro–BNP 3944 pg/mL). Head CT excluded acute cerebral hemorrhage. At the electrocardiogram, signs of RV strain were present (biphasic T–waves in V1–V3 leads, S1–Q3–T3). Transthoracic echocardiography (TTE) showed dilated RV with hypokinetic free wall, “D–shaped” LV, “60/60” sign and a mobile filiform mass crossing the tricuspid valve plan in the right atrium (fig. 1). The patient did not present structural valvular abnormalities or endocarditis–related risk factors. CT pulmonary angiography detected a “saddle” PE and extensive thrombosis in inferior vena cava. After unfractioned heparin (UFH) bolus, the patient was transferred to our intensive care unit and balancing risks and benefits the chosen treatment option consisted in half dose systemic thrombolysis (50 mg rtPA in 60’’; 10 mg as loading dose in 2’). Because of potential harmful effects in thrombocytopenia and recent head trauma, UFH was temporarily withheld and started again after 1 hour. The day after, a beside TTE showed complete tricuspid thrombus resolution, a significant decrease in RV/LV ratio and systolic pulmonary artery pressure (fig. 2). Apart from small hematomas, no bleedings were reported. The patient was shifted to the ward on the next day and following course was uneventful. On day 4 a direct oral anticoagulant (Dabigatran 110 mg) was started. Abdominal and inferior limb–deep–venous ultrasound were both negative for pathological reports. A total body CT was scheduled to exclude silent malignancies at discharge. Take home message: in intermediate–high risk PE, half dose systemic fibrinolysis strategy is controversial since its potential benefit is counterbalanced by concerns about major bleedings, but increasing data suggest its efficacy with low risk profile.

The Contribution of 18F FDG PET-CT for the Investigation of Fever of Unknown Origin and Inflammation of Unknown Origin

BackgroundFever of unknown origin and inflammation of unknown origin are highly challenging diagnostic conditions. The current practice for evaluating patients is to conduct a positron emission tomography-computed tomography (PET-CT) scan as either a first- or a second-line modality. We aimed to assess the contributory effect of PET-CT to the diagnosis and compare it with the contributory effect of CT alone. MethodsWe performed a systematic review and meta-analysis. We included all cohorts that examined the contribution of PET-CT to the investigation of classical fever of unknown origin and inflammation of unknown origin. The primary outcome was the contribution of PET-CT to the final diagnosis. Secondary outcomes were sensitivity and specificity of PET-CT and CT scans, and contribution of a CT scan. We pooled the results of all studies and calculated the pooled contributory effect of PET-CT. ResultThirty-six studies (3516 patients) were included in the systematic review. The pooled contribution of PET-CT was 75.4%. The compiled sensitivity and specificity values for all studies were 85.9% and 59.5%, respectively. Five studies (405 patients) compared between the PET-CT component and the total body CT component. The pooled contribution of a CT scan was 68%. The summed sensitivity and specificity values of a CT scan for all studies were 63.1% and 84.4%, respectively. ConclusionsPET-CT has a contributory effect of 75% for the diagnosis of fever of unknown origin and inflammation of unknown origin. PET-CT had superior sensitivity and inferior specificity vs the CT scan.

A cross-staged gantry for total-body PET and CT imaging

Total-body Positron Emission Tomography (PET) scanning is a promising new method for rapidly acquiring comprehensive wide-volume metabolic data with a lower radiation dosage compared to discrete whole-body PET imaging. PET scanners are generally used with Computed Tomography (CT) scanners to precisely understand tumor location and composition with the help of anatomical images. However, PET/CT sequential imaging methods for simultaneous total-body imaging are impractical for claustrophobic patients due to the enclosed gantry design and require large examination rooms because of the need for an exceptionally long patient table. To address this challenge, the Jagiellonian- -PET Tomography (J-PET) Total-body scanner employs an innovative approach: utilizing both PET and CT devices on the same patient table but from different axes. The motion system of the J-PET Total Body scanner requires custom linear stages to move both PET and CT gantries. In this study, a novel cross-staged linear guiding solution is proposed by combining scanners on intersecting separable stages. The proposed sliding system is a combination of different machine elements and will be produced for the J-PET Total-body PET/CT Scanner. Concept designs are shown, and the proposed system is described. The application of the system for the J-PET total-body PET/CT scanner is discussed. The proposed solution is still in the development phase. The system holds the potential to achieve combining CT and PET scanners from different axes and enables motion artifact-free imaging for total-body imaging.

Delayed diagnosed injuries in trauma patients after initial trauma assessment with a total-body computed tomography scan

IntroductionEven when using the Advanced Trauma Life Support (ATLS) guidelines and other diagnostic protocols for the initial assessment of trauma patients, not all injuries will be diagnosed in this early stage of care. The aim of this study was to quantify how many, and assess which type of injuries were diagnosed with delay during the initial assessment of trauma patients including a total-body computed tomography (TBCT) scan in a Level 1 Trauma Center in the Netherlands. MethodsWe conducted a retrospective cohort study of 697 trauma patients who were assessed in the trauma bay of the Amsterdam University Medical Center (AUMC), using a TBCT. A delayed diagnosed injury was defined as an injury sustained during the initial trauma and not discovered nor suspected upon admission to the Intensive Care Unit (ICU) or surgical ward following the initial assessment, diagnostic studies, or during immediate surgery. A clinically significant delayed diagnosis of injury was defined as an injury requiring follow-up or further medical treatment. We aimed to identify variables associated with delayed diagnosed injuries. ResultsIn total, 697 trauma patients with a median age of 46 years (IQR 30–61) and a median Injury Severity Score (ISS) of 16 (IQR 9–25) were included. Delayed diagnosed injuries were found in 97 patients (13.9 %), of whom 79 injuries were clinically significant (81.4 %). Forty-eight of the delayed diagnosed injuries (49.5 %) were within the TBCT field. Ten delayed diagnosed injuries had an Abbreviated Injury Scale (AIS) of ≥3. Most injuries were diagnosed before or during the tertiary survey (60.8 %). The median time of delay was 34.5 h (IQR 17.5–157.3). Variables associated with delayed diagnosed injuries were primary ICU admission (OR 1.8, p = 0.014), an ISS ≥ 16 (OR 1.6, p = 0.042), and prolonged hospitalization (40+ days) (OR 8.5, p < 0.001). ConclusionWith the inclusion of the TBCT during the primary assessment of trauma patients, delayed diagnosed injuries still occurs in a significant number of patients (13.9 %). Factors associated with delayed diagnosed injuries were direct admission to ICU and an ISS ≥ 16.

An unusual case of corpse concealment driven by emotional distress

Corpse concealment involves hiding a body for criminal purposes for many different reasons, such as destroy evidence of a murder or avoid the discovery of the victim. Although defendants could argue that they did not conceal the corpse with any criminal intent, but rather to spare themselves or others from emotional distress or to honor the wishes of the deceased. However, these arguments are often challenging to substantiate, and defendants may encounter significant legal obstacles when attempting to justify their actions.Herein, we report a case involving the concealment of a woman's corpse by her father. Autopsy and histological investigations were significantly limited due to the advanced decomposition of the body. Nevertheless, by integrating these data with radiological findings obtained from total body CT and micro-CT of the larynx-hyoid complex, hanging was deemed the cause of death. Additionally, the psychological evaluation of the father indicated that the act of concealment was motivated by emotions rather than criminal intent.

Extremely Rare Type of Breast Cancer-Dedifferentiated Breast Liposarcoma-Diagnosis and Treatment.

Primary liposarcoma of the breast is an uncommon soft tissue malignant tumor, comprising only 0.003% of all malignant breast tumors. The main differential diagnosis of this mass consists of malignant phyllodes tumor and metaplastic breast carcinoma. The objective of this paper is to report a case of dedifferentiated breast liposarcoma, therapeutic approach and outcome. We present a case of a 79-year-old woman complaining of a large mass in her left breast which had increased in size over the last 6 months. Physical examination revealed an enlarged left breast, and a total body CT scan showed a large tumor in contact with the musculature of the anterior thoracic wall, with no metastatic lesions. The histopathology report of a fine needle biopsy described a high-grade sarcoma. The Oncological Tumor Board recommended neoadjuvant radiotherapy sessions and reevaluation by MRI and CT scans. The patient underwent radical mastectomy with latissimus dorsi myo-cutaneous flap reconstruction. The final histopathology diagnosis was a grade 3 dedifferentiated liposarcoma (FNCLCC), with certain response to radiotherapy and positive MDM2, CDK4 markers. The postoperative period was uneventful; 12 months after surgery, the follow-up CT scan showed multiple pulmonary lesions with metastatic characteristics. Liposarcoma is a very rare type of breast cancer, and the most important treatment for breast sarcoma is surgery, the role of axillary lymph node removal, chemotherapy and radiotherapy still being controversial. Considering such cases are scarce and the development of surgical guidelines is difficult, reporting any new case is crucial.

P03.12.A PHASE III RANDOMIZED TRIAL COMPARING PREOPERATIVE HYPOFRACTIONATED RADIOSURGERY (HSRS) TO POSTOPERATIVE HYPOFRACTIONATED RADIOSURGERY (HSRS) FOR PATIENTS WITH LARGE BRAIN METASTASES SUITABLE FOR SURGICAL RESECTION SUPPORT TRIAL

Abstract BACKGROUND Standard of care for patients with large brain metastases (BMs) suitable for surgery is surgical resection followed by radiosurgery in single or multifractions (SRS/HSRS) on tumor bed. Although a satisfactory local control is obtained, an increasing rates of leptomeningeal disease (LMD) related to surgery, and symptomatic radionecrosis related to SRS/HSRS have been observed. In the last years the employ of preoperative SRS/HSRS has been investigated in retrospective studies. Advantages seem to be: better target delineation to intact lesion, reduction of normal brain irradiated considering useless of margins, potential prevention of any cells spilled during resection, greater oxygenation ratio of intact region, sterilization effect, and resection of majority of irradiated tissues. Preoperative HSRS versus postoperative ones will be investigated in multicentric randomized phase III trial. Primary endpoint is rate of leptmeningeal disease secondary endpoints, local control, symptomatic radiation necrosis, surgical morbidity, quality of life (QoL) and neurocognitive functions assessment between the two modalities; brain distant progression (BDP), and overall survival (OS) will be evaluated too. MATERIAL AND METHODS Inclusion criteria are: patients aged 18-80 years, diagnosed malignant primary tumor, KPS≥70, oligometastatic disease, limited brain metastases (up to 4), large BM suitable for surgery. Exclusion criteria are: prior WBRT, SCLC, or germinal cell tumour or Lymphoproliferative disease, prior neurosurgery, and incompatibility to perform MRI. Stratification factors will be: histology of primary tumor (Breast, NSCLC, Melanoma, Other) and BMs location (sovra-or infra-tentorial). In Arm A (experimental) patients undergo preoperative HSRS, 27 Gy in 3 fractions, followed by surgery. In Arm B (control): patients undergo surgical resection followed by postoperative HSRS at the same doses. Outcome evaluation will be assess using MRI, total body CT scan and/or CTPET, neuropsychological and Quality of life assessment before and after treatments. For distinguish RN occurrence and disease progression delayed-contrastMRI, and perfusion MRI will be employed. Considering that estimated 1 year LMD is 10% for postoperative HSRS, and ≤ 2% for preoperative enrolment of 146 patients is expected (73 per Arm). RESULTS Enrollment started at April 2023 and among first patients included the treatment has proven to be safe. CONCLUSION Preoperative HSRS in large BMs suitable for surgical resection need prospective evaluation aiming to improve outcome, and reduced treatments side effects.

Two cases of dermatomyositis associated with neuroendocrine tumors.

Dermatomyositis is an idiopathic inflammatory myopathy with cutaneous manifestations, which is associated with several types of malignancies, yet it has been rarely linked to neuroendocrine tumors (NETs). Here we report two cases of dermatomyositis associated with NETs of differing primary sites. Case 1: A 46-year-old female presented with a facial rash and proximal muscle weakness of both extremities. Investigations revealed elevated creatine kinase (CK) and positive anti-transcriptional intermediary factor 1-γ antibody (TIF1γ). The patient had been diagnosed with dermatomyositis and underwent a total body CT scan, which revealed prominent mediastinal lymphadenopathy, which a subsequent biopsy determined to be neuroendocrine carcinoma of small cell type. Treatment with high-dose corticosteroids was initiated, in addition to chemotherapy-based oncological management. Case 2: A 54-year-old female presented with a facial rash, progressive dyspnea, and general malaise. Laboratory investigations revealed positive anti-melanoma differentiation-associated gene-5(MDA5) and positive anti-Ro antibody, with a normal level of creatine kinase (CK). A chest CT scan revealed multiple ground-glass opacities. Despite treatment with high-dose intravenous methylprednisolone, IVIG and an infusion of the anti-IL-6 sarilumab [Kevzara], the patient rapidly deteriorated and was intubated. Within days, the patient developed bowel ischemia and underwent a laparotomy which was then complicated by an invasive infection. This resulted in patient's death. Pathology results from colonic tissue demonstrated an appendiceal neuroendocrine tumor. These cases demonstrate the heterogeneity and complexity of dermatomyositis in association with neuroendocrine tumors.

Evaluation of the effects of radiation doses from computed tomography on the biochemical parameters of the hepatorenal organs of albino rats

Background Aims: Computed tomography (CT) uses X-rays which are ionizing radiation. Interaction of ionizing radiation with the body may result in harmful effects on the organism depending on the radiation dose. This study aimed to evaluate the impact of different doses of CT radiation on the hepatorenal organs of male albino rats using biochemical parameters as the pathological response of the organs to radiation. Materials and Methods: Thirty healthy male Wistar albino rats weighing 180–200 g were assigned into five groups of six rats each. Rats in groups B, C, D, and E underwent noncontrast helical total body CT irradiation and received varying doses of CT radiation while group A received sham irradiation and served as control. At 72 h postirradiation, blood was collected using conventional methods, and serum was harvested for the determination of alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase (ALP), total bilirubin (TB), total protein (TP), albumin (Alb), urea, uric acid, and creatinine. Results: The mean serum levels of TP in the control (group A) and in the irradiated groups B, C, D, and E were 8.21 ± 0.34, 6.08 ± 0.30, 5.86 ± 0.42, 5.22 ± 0.30, and 4.72 ± 0.16, respectively. The mean values of TP in the irradiated groups decreased significantly in a dose-dependent manner compared to the control. The mean serum levels of ALP in the group A and in the irradiated groups B, C, D, and E were 75.20 ± 3.14, 111.60 ± 1.60, 117.60 ± 1.12, 124.40 ± 2.48, and 133.60 ± 2.46, respectively. The mean serum levels of AST in the group A and in the irradiated groups B, C, D, and E were 33.80 ± 0.58, 54.40 ± 2.29, 52.60 ± 1.78, 58.60 ± 2.64, and 63.60 ± 0.81, respectively. The mean serum levels of ALT in the group A and in the irradiated groups B, C, D, and E were 21.20 ± 0.86, 36.00 ± 0.84, 40.40 ± 1.17, 37.40 ± 0.93, and 41.60 ± 1.03, respectively. The mean serum levels of TB in the group A and in the irradiated groups B, C, D, and E were 2.78 ± 0.28, 3.70 ± 0.18, 4.77 ± 0.40, 5.88 ± 0.11, and 6.34 ± 0.04, respectively. The mean serum levels of Alb in the group A and in the irradiated groups B, C, D, and E were 3.68 ± 0.16, 5.96 ± 0.21, 6.65 ± 0.26, 8.15 ± 0.23, and 8.91 ± 0.17, respectively. The mean serum levels of urea in the group A and in the irradiated groups B, C, D, and E were 42.40 ± 0.17, 54.40 ± 1.33, 56.00 ± 1.76, 54.60 ± 1.72, and 57.80 ± 1.39, respectively. The mean serum levels of uric acid in the group A and in the irradiated groups B, C, D, and E were 5.65 ± 0.36, 8.32 ± 0.46, 8.87 ± 1.11, 9.13 ± 0.29, and 9.91 ± 0.29, respectively. The mean serum levels of creatinine in the group A and in the irradiated groups B, C, D, and E were 2.05 ± 0.13, 4.44 ± 0.32, 5.81 ± 1.17, 6.31 ± 0.03, and 6.63 ± 0.40, respectively. The mean values of ALP, AST, ALT, TB, Alb, urea, uric acid, and creatinine increased significantly in the irradiated groups compared to the control group. Conclusion: From the lowest to the highest doses of CT irradiation in the study, alterations in the biochemical parameters were evident and significant. Moreover, this suggests a possible deleterious biological effect of CT radiation on the hepatorenal organs probably due to the effects of radiation-induced free radicals which adversely affected the hepatorenal organs.

#5430 ANTI-PLA2R ASSOCIATED MEMBRANOUS NEPHROPATHY AND CHRONIC LYMPHOCYTIC LEUKAEMIA, IS THERE A LINK?

Abstract Background and Aims The spectrum of glomerular lesion that occurs in the context of plasma cell dyscrasias (PCD) is wide, including type I and type II membranoproliferative glomerulonephritis (MPGN), focal proliferative GN, membranous nephropathy (MN), minimal change disease and amyloidosis. A clear-cut link between hematological dyscrasias and glomerulopathy is often offered by the finding of paraproteins in the kidney or by kidney leucocytic infiltration and, in these scenarios, malignancy treatment is often found to be also effective towards the glomerulopathy. In the context of PCD in which proliferation of the B-cell clone does not lead to plasma-cell terminal differentiation such as chronic lymphocytic leukemia (LLC) the physiopathological link with glomerulonephritis is not well established and it's hard to determine whether the combination of these two disorders is fortuitous. With regarding to MN, it's now well established that this histopathological pattern must be related to the presence of circulating autoantibodies, where anti-PLA2R auto-antibodies usually been associated with primary MN. To our knowledge association between LLC and anti-PLA2R associated MN has not been described. Case report We report the case of a 76-year-old man who was admitted in February 2022 with anasarca and acute kidney injury. He had recently been evaluated by a hematologist in the context of suspected chronic lymphocytic leukemia (CLL). Laboratory findings, along with typical CLL white blood cell count, showed decreased kidney function from baseline and were compatible with nephrotic syndrome, with proteinuria progressively increasing up to 27 gr/24 h in the following weeks. CLL was confirmed by lymphocyte typing. A total body CT scan showed mediastinal, abdominal and inguinal lymphadenopathies, but no suspected neoplastic lesions. Screening for autoimmunity tested completely negative, as well as infectious screening for common hepatic viruses (HBV, HAV, HCV), EBV, CMV, HIV, Parvovirus B19. Lymph node biopsy showed no aspects of aggressive lymphoproliferative disease and hematological consultation only indicated clinical and laboratory follow-up of LLC, with no further indication to specific therapies. A kidney biopsy was performed showing diffuse thickening of the basement membrane (Fig. 1) with granular deposition of IgG (+++) and C3 (++) along the glomerular capillary walls at immunofluorescence. Electron microscopy revealed subepithelial immune deposits (Fig. 2) with initial incorporation from the glomerular basement membrane (GBM). Anti PLA2R antibodies, found negative at first determination, subsequently tested positive at high titre (ELISA 1356.4 U/ml). A diagnosis of stage two membranous nephropathy was made, and the patient was treated with Rituximab 375 mg/m2 every week for four weeks. Clinical stability was obtained with repeated intravenous administration of diuretics (furosemide 60 mg + canrenone 200 mg) along with albumin. Nevertheless, nephrotic syndrome persisted, and kidney function progressively decreased with serum creatinine up to 2.8 mg/dL. Immunophenotype, which showed reduction but no suppression of CD19+ lymphocytes, was again repeated on November 2022 and showed typical LLC findings (CD 19+, CD 20+, CD 23+, CD 5+) with repopulation of CD19+ lymphocytes. Anti PLA2R antibodies gradually decreased instead, reaching a value of ELISA 1.8 U/ml in November 2022 and persisted negative until present. The patient recovered from nephrotic syndrome in Autumn 2022 and is currently on stage G3B chronic kidney disease with persistent sub-nephrotic proteinuria in supportive treatment. Conclusion Simultaneous diagnosis of primary MN and LLC led us to ask ourselves whether this patient could benefit from LLC-specific chemotherapy, even though there were no signs of aggressive hematological disease and no clear link with the nephropathy. We think that further investigations are required to deeply understand the connection between hematological and renal disorders, in order to identify whether there are two diseases to treat separately or two sides of the same disease to treat as one.

P318 A LETHAL SPASM

Abstract S.F.E.G., a 52–year–old woman of Filipino origin, with no previous cardiology except arterial hypertension under therapy, came to our attention for a witnessed episode of cardiac arrest at home. Rescued by the emergency medical team, who found ventricular fibrillation at presentation, and performed ACLS with ROSC obtained after 3 DC shocks. The first ECG was unremarkable (sinus rhythm, diffuse ST depression). Total body CT was negative. Admitted to the Coronary Unit, the echocardiogram was normal for cavity dimensions and kinetics, as well was coronary angiography except for “short intramyocardial course in the second segment of LAD with slight systolic "milking". In the following days, however, there was a significant rise in HsTnI (1,000 → 47,000 ng/L), with concomitant sudden ventricular bigeminy and negative anterior T waves, akinesia of the anterior apical segments of the LV at cardiac ultrasound (not present at admission), in a patient still intubated and therefore with a non–evaluable clinic. Coronary angiography was repeated, which highlighted this time significant vasospasm affecting the middle segment of the LAD, that regressed after intracoronary nitrates. She was extubated without neurological sequelae, and subjected to ICD implantation by secondary prevention. To treat the vasospastic angina she was discharged with calcium channel blockers at the maximum tolerated dosage, as per guidelines (diltiazem 120mg TID + nifedipine 60mg BID). One month later the patient returned to our attention due to worsening dyspnoea, abdominal pain and anasarca (ascites, bilateral pleural effusion, peripheral oedemas). Hospitalized in a medical setting and treated with diuretics for suspected heart failure, despite the echocardiogram showing preserved biventricular systolic function, normal diastolic function, no valve disease, no pericardial effusion. BNP was 359 pg/mL, subsequently decreasing to 148 pg/mL. After excluding every other possible causes even with total body CT, our hypothesis was that of calcium channel blocker collateral effect (vasodilatory edema). We tapered the dosage until only diltiazem 60mg TID was mainteined, obtaining a significant clinical improvement (weight loss by 10 kg), without further recurrence of coronary vasospasm. This clinical case demonstrates the potential lethality of coronary vasospasm, and a rare complication during therapy with high doses of calcium channel blockers, with very few cases described in the literature.

P196 ENDOCARDITIS MASQUERADING AS STILL‘S DISEASE: WHEN AN ECHOCARDIOGRAM SAVES YOUR LIFE

Abstract A 44–year–old man in apparent good health thus far presented with weight loss and fever preceded by shivers, profuse sweating, and arthralgias. Blood tests documented normal white blood count with slightly altered CRP and ESR. Chest X–rays did not find pleuro– parenchymal lesions with normal cardiac silhouette. Abdomen ultrasounds was regular. Due to the persistence of the symptoms, he was referred to a rheumatologist who diagnosed Adult Still’s disease (AOSD) and recommended therapy with prednisone and sulfasalazine, interleukin–1 inhibitor, with the resolution of the fever. After three months, because of the recrudescence of the fever, he was admitted to the emergency room a total–body CT–scan documented inflammatory–abscess lesions in the brain and hypodense areas in the spleen. ECG showed type 1 second–degree atrioventricular (AV) block. The patient was therefore transferred to the Cardiology Department; echocardiograms documented an endocardic mass on the aortic valve and suspected periannular abscess also infiltrating the interventricular septum. The patient underwent urgent surgery with excision of the aortic valve, opening and draining of the abscessual cavities, reconstruction of the aortic annulus with bovine pericardium patch and aortic valve replacement with bioprosthesis. The patient did not present further febrile episodes after surgery but a pacemaker implantation was necessary due to persistent AV block. Biological material sent for culture was positive for S. gallolyticus. AOSD is one of the most common conditions responsible for fevers of unknown origin. It is characterized by fever, arthritis, evanescent rash, leukocytosis, and multiorgan involvement. Yamaguchi criteria required for the diagnosis of AOSD are as follows: main criteria: Fever &amp;gt;39°C, lasting 1 week or more, Arthralgia or arthritis, lasting 2 weeks or more, Typical rash, Leukocytosis &amp;gt;10,000/mm3; Minor criteria: Sore throat, Recent development of significant lymphadenopathy, Hepatomegaly or splenomegaly, Negative tests for antinuclear antibodies and rheumatoid factor; Exclusion criteria: Infections, Malignancies, Other rheumatic diseases.

P379 A BIG MASS AROUND THE HEART: SHOULD I BE WORRIED?

Abstract Lipomas account for about 10% of all cardiac tumors and symptoms are often secondary to the compression of cardiac chambers and the consequent hemodynamic impact. We report the case of a 76–year–old woman with no cardiological history, undergoing oncological follow–up for breast cancer underwent a left radical mastectomy in 2014, not followed by radiotherapy or chemotherapy, who came to our attention due to the identification at the total–body CT scan of a mediastinal mass. A voluminous intrapericardial formation was detected, with a maximum size of 5.4 x 8.6 cm, characterized by adipose attenuation values at baseline. On examination, the patient was asymptomatic and eupneic, in good hemodynamic compensation, in functional class NYHA I. The ECG showed sinus rhythm with regular atrioventricular and intraventricular conduction without significant alterations in repolarization. On the echocardiogram, the left ventricle appeared of normal size and thickness without alterations in the global and segmental systolic function, EF 65%; the right ventricle was regular in size and contractility; a voluminous pericardial mass of about 8 x 4.5 cm was observed in the inferior, posterior and lateral site, homogeneous, not vascularized, not compressing the cardiac cavities and not determining hemodynamic impact. The patient was then submitted to cardiac MRI which confirmed the suspicion of intrapericardial lipoma. Considering the absence of symptoms, the benign nature of the lesion and the absence of compression on the cardiac structures, we decided not to remove the mass and to continue clinical and radiological follow–up, thus monitoring size and symptoms.

Isolated Myelopathy in Occult Breast Carcinoma with Negative Paraneoplastic Antibodies: A Case Report of a Rare Condition

Isolated paraneoplastic myelopathy (IPM) is a rare neurological manifestation of systemic cancer and represents an intermediate-risk phenotype of disease according to the diagnostic criteria for Paraneoplastic Neurologic Syndromes (PNS). Here, we present the case of a 47-year-old woman who developed subacute cervical myelopathy and was then diagnosed with breast cancer. Through this lens, we provide a discussion of current literature on IPM. Over four months, our patient developed progressive tetraparesis, hypoesthesia with C3 level, and urinary retention. The first MRI was negative, but a four-month-control MRI showed a T2-hyperintense spinal lesion (C2–C7 and T2–T4). Cerebrospinal fluid (CSF) analysis was normal. Infective and autoimmune screening, including onconeural, anti-MOG, and aquaporin-4 antibodies, was unremarkable. The total-body CT scan was negative, but total-body PET-CT scan evidenced an enlarged axillary lymph node, with the detection of breast cancer cells at fine-needle aspiration. Despite negative mammography, a breast MRI confirmed a mammary nodule, which was removed, and a ductal infiltrating breast carcinoma diagnosis was made. Her neurological condition partially improved after steroid therapy. Our final diagnosis was probable IPM, according to PNS criteria. This rare condition affects most frequently middle-aged women and is often associated with breast and lung cancer, even if two-thirds of patients’ cancer diagnosis is subsequent to the onset of neurological deficits. Clinical presentation is often subtle, and CSF analysis, neuroimaging, and onconeural autoantibodies could be negative or non-specific. However, if the suspect of paraneoplastic disease is strong, cancer should be searched thoroughly since early diagnosis and treatment are associated with a better outcome.

Misunderstood Gastric Perforation of a Pancreatic Acinar Cell Carcinoma: A Wolf in Sheep’s Clothing

A 70-year-old man was admitted to the Emergency Department (ED) for marked asthenia and severe anemia. In addition, a high level of lipase was found. During hospitalization, a locally advanced gastric cancer was diagnosed, with endoscopic evidence of a large polyploid formation originating under the cardias that occupied most of the gastric lumen. A total body CT scan was performed before surgery; the tumor affected the posterior gastric wall, with tenacious infiltration of the pancreatic body. Therefore, we performed a total gastrectomy with esophageal jejunum anastomosis and reconstruction of intestinal continuity according to Roux, distal spleno-pancreatectomy, and cholecystectomy. At histology, a pancreatic acinar cell carcinoma (PACC) with full thickness infiltration of the gastric wall was diagnosed. Acinar cell carcinomas are highly aggressive neoplasms, and surgical resection, when feasible, is the treatment of choice regardless of size, also because the role of neoadjuvant or adjuvant chemo- or radiotherapy remains uncodified.

Total-body low-dose CT image denoising using a prior knowledge transfer technique with a contrastive regularization mechanism.

Reducing the radiation exposure experienced by patients in total-body computed tomography (CT) imaging has attracted extensive attention in the medical imaging community. A low radiation dose may result in increased noise and artifacts that greatly affect the subsequent clinical diagnosis. To obtain high-quality total-body low-dose CT (LDCT) images, previous deep learning-based research works developed various network architectures. However, most of these methods only employ normal-dose CT (NDCT) images as ground truths to guide the training process of the constructed denoising network. As a result of this simple restriction, the reconstructed images tend to lose favorable image details and easily generate oversmoothed textures. This study explores how to better utilize the information contained in the feature spaces of NDCT images to guide the LDCT image reconstruction process and achieve high-qualityresults. We propose a novel intratask knowledge transfer (KT) method that leverages the knowledge distilled from NDCT images as an auxiliary component of the LDCT image reconstruction process. Our proposed architecture is named the teacher-student consistency network (TSC-Net), which consists of teacher and student networks with identical architectures. By employing the designed KT loss, the student network is encouraged to emulate the teacher network in the representation space and gain robust prior content. In addition, to further exploit the information contained in CT scans, a contrastive regularization mechanism (CRM) built upon contrastive learning is introduced. The CRM aims to minimize and maximize the L2 distances from the predicted CT images to the NDCT samples and to the LDCT samples in the latent space, respectively. Moreover, based on attention and the deformable convolution approach, we design a dynamic enhancement module (DEM) to improve the network capability to transform input informationflows. By conducting ablation studies, we prove the effectiveness of the proposed KT loss, CRM, and DEM. Extensive experimental results demonstrate that the TSC-Net outperforms the state-of-the-art methods in both quantitative and qualitative evaluations. Additionally, the excellent results obtained for clinical readings also prove that our proposed method can reconstruct high-quality CT images for clinicalapplications. Based on the experimental results and clinical readings, the TSC-Net has better performance than other approaches. In our future work, we may explore the reconstruction of LDCT images by fusing the positron emission tomography (PET) and CT modalities to further improve the visual quality of the reconstructed CTimages.

307 A CARDIAC MASS IN A PATIENT WITH GORLIN-GOLTZ SYNDROME: INCIDENTAL DIAGNOSIS OR SOMETHING TO LOOK FOR?

Abstract Aims Gorlin-Goltz syndrome or nevoid basal cell carcinoma syndrome (NBCCS) is a rare autosomal dominant, multisystem, tumor-predisposing disorder. The primary manifestation of NBCCS is the development of multiple basal cell carcinomas (BCCs) but is also associated with a variety of other benign and malignant tumors. Cardiac fibromas are increased in frequency in patients with NBCCS, developing in approximately 3 percent of affected individuals. They typically present in infancy. They are benign growths, and almost all develop within the ventricular myocardium. Although usually asymptomatic, they can result in impaired left ventricular function and conduction defects, necessitating resection. Methods and results we presented a case of a 59-years-old woman with a diagnosis of Gorlin-Goltz syndrome and no history of cardiovascular diseases who underwent a right knee arthroplasty in our hospital. After the surgery the patient was admitted to rehabilitation department. Electrocardiogram that showed sinusal rhythm with inverted T waves in lateral leads and a transthoracic echocardiography examination were performed. Echocardiography showed a large mass within the basal and middle segments of left ventricle lateral wall. Left ventricular ejection fraction was preserved. Cardiac magnetic resonance (CMR) revealed an intramyocardial mass with well-defined borders and several calcifications, hypointense on T1-weighted and T2-weighted images and delayed-contrast hyper-enhancement with hypoenhancing central cores. Based on these imaging features, the mass was suggestive of cardiac fibroma with calcifications. The patients was asymptomatic. Afterwards, a total body CT was performed to exclude other tumours in other sites. This case was discussed with cardiac surgeons and since the patient was asymptomatic with no conduction abnormalities or heart failure signs, urgent surgical intervention was excluded. The patient was discharged with a 3 months follow-up. Conclusion our case highlights the importance of echocardiography evaluation before surgery in patients with genetic syndrome like Gorlin-Goltz syndrome. Last guidelines published in 2021 recommend that all patients with NBCCS should be screened with a cardiac ultrasound and if cardiac symptoms occur in a patient with NBCCS, a cardiac ultrasound should be repeated to exclude a late-onset cardiac tumour. Furthermore, CMR plays an important role in characterizing cardiac masses and determining the management.

694 DRUG INDUCED KIDNEY INFARCTION: A CASE REPORT

Abstract Isotretinoin (ISO) is a synthetic analog of vitamin A. Notwithstanding the well-known long-term efficacy in the treatment of severe resistant cystic acne, ISO induces several side effects too. Dyslipidemia, increased liver enzymes, as well as reduction of biotidinase have been already reported [1]. Homocysteine (HCY), a sulfur-containing amino acid, is recycled into methionine by a transmethylation reaction requiring folate and vitamin B12. Given that during ISO treatment elevated liver enzymes (SGOT, SGPT) are often observed, it has been hypothesized that iatrogenic liver dysfunction could affect cystathionine-b-synthase, an enzyme involved in HCY metabolism, [2]. Several studies have highlighted that elevated plasma HCY concentrations are associated with an increased risk of premature occlusive vascular disease. We hereby report a case of drug-induced kidney infarction after ISO therapy. A previously healthy 18-year-old male, on therapy with 40 mg/die isotretinoin for acne, was admitted to the Emergency Unit for abdominal pain, nausea and vomiting and dyspnea. A trans-thoracic echocardiogram showed dilated and hypocontractile left ventricle. During the hospitalization he had a total body CT that showed the presence of an ischemic lesion on left kidney without other pathological findings. He started therapy with 12 IU/kg UFH as soon as a surgical emergency was excluded. Subsequently, he underwent a coronary angiogram that resulted unremarkable. Cardiac MRI showed extensive delayed gadolinium late enhancement with intramural linear pattern. In the hypothesis of drug-induced vasculitis, an extensive serological testing was performed. Elevation of serum liver enzymes (SGOT, SGPT), CRP, LDH was found. Mutations on MTHFR gene and Leiden Factor were not detected, neither alteration in coagulation parameters. Finally the dosage of plasmatic HCY resulted over the range of normality and ISO was discontinued. The patient was discharged on optimized medical therapy for heart failure. He is currently managed as outpatient. HCY levels could be found elevated in patients with ischemic events during ISO treatment. Given the widespread use of this drug for acne, it could be reasonable to dose HCY in patients with suspected liver dysfunction. Physicians should be aware of this scenario and should act swiftly to avoid uneventful outcomes. [1] Schulpis KH et al. Elevated plasma homocysteine levels in patients on isotretinoin therapy for cystic acne. Int J Dermatol. 2001 Jan;40(1):33-6. [2] Polat M, et al. Plasma homocysteine level is elevated in patients on isotretinoin therapy for cystic acne: a prospective controlled study. J Dermatolog Treat. 2008;19(4):229-32.