Wedge Biopsy Research Articles

Glomus cell tumour on the head of a cat

Case summaryA solitary, sessile, non-ulcerated, freely mobile cutaneous mass approximately 1 cm in diameter on the left temporal region of a 7-year-old neutered female cat was examined. A fine-needle aspirate and wedge biopsy were performed by the referring veterinary surgeon and indicated a neoplasm of uncertain cell lineage. On histopathological examination, the deep dermis contained a discrete, non-encapsulated and vascular neoplasm with morphological and immunophenotypical features typical of a glomus cell tumour. Neoplastic cells were immunopositive for vimentin, muscle actin and smooth muscle actin, and immunonegative for cytokeratin, S100, desmin and von Willebrand factor (factor VIII-related antigen).Relevance and novel informationGlomus cell tumours arise from modified smooth muscle cells and are rare in animals, particularly cats. Specific immunohistochemistry is of fundamental importance in the correct diagnosis of these tumours and should be considered for masses when cytology and histology results are inconclusive or uncertain.

Effectivity of Hypothermic Machine Perfusion Preservation for Non-Heart-Beating Donor Kidney Transplantation in Japan

Background In Japan, brain-dead donors have been increased by revised Act of Organ Transplantation, however, insufficiency of deceased donors is still serious problem. In kidney transplantation, it is important to use marginal donors such as non-heart-beating donors for solving this problem. Static cold storage (SCS) is the most widely used organ preservation method for deceased donor, and in Japan it is now the only technique for kidney preservation, however, hypothermic machine perfusion preservation (HMP) technique may improve better outcomes than SCS. HMP technology has had a major impact in circumventing ischemic injury in kidney transplantation in western countries. In this presentation, we report efficiency of HMP method for preservation of long ischemic kidney grafts in beagle and case reports of clinical usage to kidney transplantation of non-heat-beating donor in Japan. Methods Young beagles were used as autonomic HMP transplantation model. After general anesthesia of beagles, left renal artery and vein were made ligation, after 30 min warm ischemia time (WIT) in situ, the left kidney was harvested. Each harvested kidney was assigned to one of two preservation treatment groups; SCS group (storage in UW solution at 2-4°C for 24h, n=5); HMP group (storage on LifePort® (Organ Recovery Systems), at 4-6°C on 30 mmHg pressure for 24h with KPS-1 solution, n=5). After the storage, wedge biopsies were taken for histological evaluation. The preserved graft was transplanted to the same beagle in left iliac fossa and removed right kidney. After the operation, recipient survival and graft qualities (urine output, serum creatinine, sodium and potassium) were checked as the clinical outcomes. Results All recipients of HMP group survived, however, three recipients of SCS group were dead with uremia. Serum creatinine level of HMP group was under 4mg/dL in all post-operation period and reduced under 1.5mg/dL after 11days of post-operation. The other hands, those of SCS group went up over 5mg/dL and did not reduce under 3mg/dL. In histological findings, HE staining revealed that a little bit interstitial edema was exist with HMP groups, and remarkable interstitial edema and vaculolation were exist with SCS group. Clinical Cases We performed three cases of renal transplant with HMP graft from non-heart-beating donor. The all three recipients were discharged hospital without any complications with achieved withdrawal of hemodialysis. HMP reduced the duration of delayed graft function and graft function with HMP was same as that with SCS. Conclusion In this experiment, we indicate that HMP would be better for long term WIT kidney model compared with SCS method in beagles. We experienced three clinical cases of non-heart-beating donor kidney transplantation with LifePort® preserved graft in Japan. It suggests that with marginal donor that is non-heart-beating and is with long agony, HMP should be paid more tribute to than SCS technique.

Prevalence of High Risk Human Papillomavirus (type-16 and 18) in High-Grade Cervical Intraepithelial Neoplasia (CIN) and Cervical Cancer in a Tertiary Hospital of Bangladesh

Background: Persistent infection with high-risk Human Papilloma Virus (HPV) causes development of cervical cancer. Among the high risk group, HPV-16 accounts for 50% & HPV-18 accounts for 12% of cervical cancer.Objective: The current sudy aimed to evaluate the prevalence of HPV genotype 16 and 18 in high grade cervical intraepithelial neoplasia (CINII&III) and cervical cancer.Methods: This descriptive type of cross-sectional observational study was carried out in colposcopy clinic of Mymensingh Medical College Hospital (MMCH), Bangladesh, from July 2012 to June 2013. Women with colposcopically diagnosed high-grade CIN and clinically diagnosed cervical carcinoma were enrolled. Pregnant & menstruating women were excluded from this study. Colposcopy guided cervical biopsy were taken from high grade CIN with loop electrosugical excision procedure (LEEP) and wedge biopsy were taken from cervical cancer. All the specimen were reviewed by histopathologist to confirm the diagnosis. Extra sample of specimen were sent to the Department of Microbiology and Hygiene of Bangladesh Agriculture University, Mymensingh for the detection of HPV-16 & 18 DNA by Polymerase Chain Reaction (PCR).Result: Out of 71 samples, histopathologically 4.2% was diagnosed as chronic cervicitis, 8.5% CIN I, 26.8% CIN II, 16.9% CIN III, 40.8% squamous cell carcinoma and 2.8% adenocarcinoma of cervix. The results revealed that 30 cases were positive for HPV-16, 06 cases for HPV-18 and 04 cases for both. In this study, the prevalence of HPV- 16 & 18 infection was 56.3%. Infection found to be higher in women aged between 45 and 54 (P<0.01). Most of them were from low socioeconomic status (P<0.01) and married at an early age ranging from 11 to 15 (P<0.01). It was found that multiparity correlated higher rate of HPV positivity than only one or two pregnancy, but statistically it was not significant (P>0.05).Conclusion: The high prevalence of HPV-16 and 18 in high grade CIN and cervical cancer samples suggests that vaccination against HPV-16 and 18 may be effective in bringing down the cervical cancer incidence in Bangladesh.J Bangladesh Coll Phys Surg 2018; 36(3): 112-117

Evolving biopsy techniques for the diagnosis of neuroblastoma in children

Background/PurposeTo compare the adequacy and safety of percutaneous core needle biopsy and surgical wedge biopsy of neuroblastoma in children. MethodsA retrospective review of patients who underwent biopsy for intermediate- or high-risk neuroblastoma at our institution between 2011 and 2015 was performed (recent cohort). Procedure details and outcomes were collected and analyzed using descriptive statistics and Wilcoxon rank tests; P < 0.05 was considered significant. Published data from 2002 to 2010 were compared (historic cohort). ResultsSince 2011, percutaneous, ultrasound-guided, core needle biopsy has been more commonly utilized (47% (16/34) recent vs. 25% (7/28) historic; P = 0.07), and the number of core needle samples increased from median 7 (historic) to 25 (recent). Complications decreased (21% (7/34) recent vs. 64% (18/28) historic; P < 0.01). Biopsy adequacy in the recent cohort was similar (94% percutaneous vs. 89% surgical; P = 1.00), which is improved from the historic cohort (71% percutaneous vs. 100% surgical; P = 0.06). Larger tumors were more likely to have a percutaneous biopsy (82 ± 37 cm percutaneous vs. 47 ± 29 cm surgical; P = 0.04). ConclusionsWhen multiple cores are obtained, percutaneous core needle biopsy is adequate for complete tissue diagnosis of neuroblastoma and can be safely performed. This can be considered as an alternative to open surgical biopsy. Type of studyTreatment Study. Level of evidenceIII.

Comparison of diagnostic accuracy of laparoscopic 3 mm and 5 mm cup biopsies to wedge biopsies of canine livers.

BackgroundDiagnostic accuracy of the 3 mm laparoscopic cup biopsy forceps for collection of tissue samples from canine livers is unproven.Hypotheses/ObjectivesCompare sample surface area and portal triad count between 3 mm and 5 mm laparoscopic cup biopsies and compare the histologic diagnosis obtained by each instrument to a standard necropsy wedge. The hypothesis was that more portal triads and greater sample surface area would be found with the 5 mm samples and the laparoscopic instruments would not have significantly different levels of agreement with necropsy wedge diagnosis.AnimalsTwenty‐one client‐owned dogs undergoing necropsy.MethodsProspective ex vivo study. Three samples (3 mm, 5 mm, and wedge) were taken of 2 different hepatic divisions within 24 hours of death. Morphologic diagnosis, World Small Animal Veterinary Association histologic features, surface area, and portal triad numbers were compared among the 3 samples.ResultsThere were significantly more portal triads (mean 21.4 versus 13.8; P < .0001) and a higher surface area (20.3 mm2 versus 11.5 mm2; P < .0001) in the 5 mm samples compared to 3 mm samples. Kappa coefficients and percent agreement for histologic diagnosis as compared to the wedge biopsy were not significantly different between the 2 instrument sizes (κ = 0.383 and 0.436, respectively; 67% and 69%, respectively).Conclusions and Clinical ImportanceDespite yielding smaller sample sizes, the 3 mm laparoscopic cup biopsy has a similar level of histologic diagnostic accuracy to the 5 mm instrument.

Association between Subclinical Low Serum 25(OH)D in Donors and Fatty Liver Disease in Recipients after Living Donor Liver Transplantation.

To explore subclinical fatty liver disease (FLD) in donors as a possible mechanism leading to FLD in recipients of living donor liver transplantation (LDLT), we extracted thirty donor-recipient pairs' serum DNA and explored the presence of CYP2R1 single nucleotide polymorphism (SNP) rs10741657 and vitamin D receptor (VDR) SNP rs2228530 A/G alleles using real-time polymerase chain reaction. We measured the serum 25(OH)D concentrations and investigated the CYP2R1 and VDR genotypes of the donors and recipients before and after LDLT for comparison with the histological findings from the donors on wedge biopsy, the recipients' removed native liver, and selective liver biopsy after LDLT. There was a significant difference in low serum 25(OH)D concentration between the donors and recipients before LDLT and in the recipients before versus after LDLT (13.90 ± 8.85 versus 47.9 ± 14.88 versus 11.82 ± 10.36, P < 0.001), and significant difference in FLD was detected on wedge biopsy from the donors and the native liver from the recipients as well as the native liver and follow-up biopsy from the recipients (P < 0.001). CYP2R1 and VDR genotype were predominant, both for the AG and for the GG alleles. For the donor VDR SNP rs2228570, low serum 25(OH)D was significantly different between genotypes AA and AG (P = 0.024) as well as between genotypes AA and AG plus GG (P = 0.042). Our data suggest that donors' VDR rs2228570 AA alleles may play a major role in low serum 25(OH)D regarding pathological FLD in recipients after LDLT.

Effects of Right Hepatic Artery Ligation

Background: Injury to right hepatic artery (RHA) may occur during hepatobiliary operative procedures. Although it may not be detected and is clinically silent in most of the cases, liver abscess, bleeding, hemobilia, and right hepatic lobe ischemia needing surgical excision have been reported. The aim of this study was a more detailed evaluation of hepatic consequences following RHA injury in an animal model. Methods: This study was conducted on 20 New Zealand rabbits 6 months of age. Blood samples for the measurement of hepatic enzymes was obtained from the rabbits before ligation of the hepatic artery. After 10 days, blood sampling was repeated and the animals were killed and 0.5 × 2 cm liver wedge biopsy was prepared from right lateral lobe, the distribution area of RHA. P values of < 0.05 were considered significant. Results: Laboratory data before and after surgical intervention showed serum bilirubin of 0.133 ± 0.044 and 0.135 ± 0.042, respectively (P value = 0.47). Serum alkaline phosphatase (ALP) was 122.4 ± 44.12 and 122.8 ± 44.43, (P value = 0.36) respectively. Serum glutamic-pyruvic transaminase (SGPT) was 31.2 ± 5.34 and 86.2 ± 33.9, (P value = 0.001) respectively. Serum glutamic oxaloacetic transaminase (SGOT) was 30.13±8.46 and 69.4±47.7, respectively (P value = 0.001). Laparotomy showed no considerable change in median lobe of livers, except mild necrosis in one (5%) rabbit. Severe necrosis was found in the right lateral lobe of 15 rabbits (75%), moderate necrosis in 3 (15%), and mild necrosis in 2 (10%) cases. No abscess or gangrene was found. The Gall bladder was intact in all animals. Conclusions: The RHA obliteration causes an increase in liver enzymes and considerable right lateral hepatic lobe necrosis (75%) but no liver abscess, gangrene or gall bladder abnormality

Video-Assisted Thoracoscopic Thymectomy Langerhans Cell Histiocytosis

Introduction: Langerhans cell histiocytosis (LCH) is an exceedingly rare proliferative disorder in which pathologic histiocytic cells accumulate in nearly every organ. Although the deposited cells share morphology and antigens with the skin Langerhans cell, the cell of origin is actually a myeloid dendritic cell. LCH is most common in the pediatric population from ages 1 to 3 effecting ~1–2 patients per million. The most common manifestation of the disease is lytic bone lesions accounting for 77% of those diagnosed. Lymph nodes and the lung are involved in 19% and 10% of cases, respectively. Methods: Our patient, a 5-month-old, 6-kg female with mild pulmonary valve stenosis, had both thymic and lung tissue involvement. To date, there has never been a report of a thymic LCH with lung metastases in an infant. Results: She underwent an echocardiogram to assess the degree of her pulmonary stenosis, which incidentally showed a large thymic cyst. That cyst was further characterized with CT scan as a heterogenous mass with multiple lung nodules. The patient was meeting all milestones appropriately and asymptomatic without cardiac symptoms, respiratory difficulty, or feeding issues. To rule out a thymoma, the patient underwent right video-assisted thoracoscopic thymectomy with wedge biopsy of the right lower lobe of the lung. Conclusion: Final pathology report showed LCH in both tissue samples. The patient did well without complications and was discharged home expeditiously. She is now under the care of the medical oncologists for continued management. No competing financial interests exist. Runtime of video: 4 mins 30 secs

Combined laparoscopic cholecystectomy and deroofing of a large liver cyst with a two trocar technique and use of a needle grasper

Laparoscopic cholecystectomy (LC) is usually done using four trocars; techniques to further reduce surgical trauma have been developed. Nonparasitic hepatic cysts (HC) are only treated if symptomatic or malignancy is suspected with laparoscopy becoming the preferred approach. A 41-year-old African American male presented with recurrent right (R) upper quadrant (UQ) pain. He was found to have cholecystolithiasis and multiple HCs with the largest located dorsally to segments 4, 5, 8 being >10 cm in diameter. A 5 mm trocar in the left (L) UQ, a 10–12 mm umbilical trocar, and a Teleflex needle grasper between the two trocars were placed. The gallbladder (GB) was removed using a modified dome down technique due to difficult access to the hilum due to the bulging large HC. Following LC, the HC was dissected off the duodenum, gerota fascia, right adrenal gland and inferior vena cava (IVC) and thereafter, the roof was resected using a harmonic scalpel. Resection was incomplete medially due to close proximity with the hilar structures and the IVC. Also a liver wedge biopsy was done. The intra- and postoperative course were uneventful and the patient was discharged after a 23 h observation period. Pathology confirmed chronic cholecystitis, mild hepatic steatosis and inflammation and benign HC wall with chronic inflammation. The patient was asymptomatic for more than 2 years when he developed RUQ pain. On the computed tomography scan, a small recurrent HC close to the liver hilum was identified; however the cause of his pain was a kidney stone. Combined LC and HC deroofing is a rare procedure. A minimally invasive technique should be the preferred approach. In our case only two trocars were required and the Teleflex minigrasper completely replaced a trocar-based instrument.

Can zero-hour cortical biopsy predict early graft outcomes after living donor renal transplantation?

The aim of this study was to identify relevance of subclinical pathological findings in the kidneys of living donors and correlate these with early graft renal function. This was a prospective study on 84 living donor kidney transplant recipients over a period of two years. In all the donors, cortical wedge biopsy was taken and sent for assessment of glomerular, mesangial, and tubule status. The graft function of patients with normal histology was compared with those of abnormal histological findings at one, three, and six months, and one year post-surgery. Most abnormal histological findings were of mild degree. Glomerulosclerosis (GS, 25%), interstitial fibrosis (IF, 13%), acute tubular necrosis (ATN 5%), and focal tubal atrophy (FTA, 5%) were the commonly observed pathological findings in zero-hour biopsies. Only those donors who had histological changes of IF and ATN showed progressive deterioration of renal function at one month, three months, six months, and one year post-transplantation. In donors with other histological changes, no significant effect on graft function was observed. Zero-hour cortical biopsy gave us an idea of the general status of the donor kidney and presence or absence of subclinical pathological lesions. A mild degree of subclinical and pathological findings on zero-hour biopsy did not affect early graft renal function in living donor kidney transplantation. Zero-hour cortical biopsy could also help in discriminating donor-derived lesions from de novo alterations in the kidney that could happen subsequently.

Metastatic Angiosarcoma: A Rare Cause of Chylothorax

SESSION TITLE: Pulmonary Manifestations of Systemic Disease 3 SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Metastatic angiosarcoma (MA) is a rare malignancy originating from soft tissue, and chylothorax is an even rarer manifestation of this disease. We present a unique case of MA with pulmonary and pleural involvement which presented with unilateral chylothorax and ascites. CASE PRESENTATION: A 49 year old female with a history of latent tuberculosis infection (LTBI) presented with a 2 week history of abdominal pain and dyspnea. Physical examination was significant for an ill appearance with decreased right sided breath sounds and moderate ascities. Laboratory analysis was significant for hypoalbuminemia, hyponatremia, and elevated CA 125. CT imaging revealed a large right sided pleural effusion, moderate ascities with peritoneal enhancement, and hypodense liver lesions. Paracentesis was significant for a serum ascites albumin gradient of 1.3 with negative cytology. Thoracentesis was consistent with a chylous effusion with lymphocytic predominance and a pleural adenosine deaminase of 23.7. A chest tube was placed and drained 3 liters of fluid daily. All Infectious work up was negative. Repeat CT imaging revealed right lung interstitial opacities and a wedge biopsy was consistent with angiosarcoma with pleural infiltration. The patient passed away shortly after diagnosis. DISCUSSION: Angiosarcomas are rare neoplasms originating from soft tissues, commonly heart, breast, and skin. Pulmonary involvement indicates metastatic disease, usally presenting with pulmonary nodules or diffuse alveolar hemorrhage. In these cases, the disease is aggressive with 5 year survival rates less than 20%. Only 1 case of MA presenting as a chylothorax has been reported. The rarity of these tumors makes diagnosis exceptionally difficult and requires a multidisciplinary approach. CONCLUSIONS: While this patient had risk factors for other process which can cause ascities and chylothorax (LTBI), ultimately her symptoms were related to a more rare disease process - MA. Angiosarcoma should be included in the differential of chylothorax, especially when other more common diagnoses have been excluded. Reference #1: Abraham, V. A Rare Find-Primary Pulmonary Angiosarcoma. CHEST Journal. October 2011; 140(4). Reference #2: Pan, Z et al. Diffuse alveolar hemorrhage due to metastatic angiosarcoma of the lung: a case report. Oncology Letters. December 2015; 10(6). 3853-3855. Reference #3: Vavilis, D et al. Primary ovarian angiosarcoma—review of the literature and report of a case with coexisting chylothorax. European Journal of Gynaecologic Oncology. 2007; 28(4): 287-9. DISCLOSURE: The following authors have nothing to disclose: Rishi Mehta, Jessica Johnson, Katherine Young No Product/Research Disclosure Information

It Ain't Called Crypto for Nothing

SESSION TITLE: Fungal Infections 2 SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: In the age of Chest CTs, pulmonary nodules are a common finding and determining the etiology and need for treatment can be challenging. The differential for pulmonary nodules includes infection, rheumatologic manifestations, malignancy, and inflammatory lung diseases. In the work up of these findings, patient characteristics, risk factors, and clinical history help to narrow the potential causes. However, in medicine, things are often not as simple, and a simplistic approach to pulmonary nodules may lead to missed diagnoses. In this case series, we present two cases of biopsy-proven Cryptococcal pneumonia in immune competent pts. CASE PRESENTATION: In both cases, our patients were M in their 60s, without any known immune dysfunction, malignancy, HIV, or history of chronic steroid use. The first patient (pt A) presented to the ED, with c/o SOB, chest pain, subacute dry cough, and fatigue. CTA of the chest was performed which revealed multiple large pulmonary nodules and adenopathy. The second patient (pt B) presented for a second opinion given progressive SOB, fatigue, and weight loss with pulmonary nodules refractory to antibiotic therapy. In both cases, an infectious work-up was completed and included fungal testing and rheumatologic screening which were all negative. PET CTs were obtained and in both cases the lesions were highly PET avid. Biospies were subsequently performed (Pt A CT guided biopsy, Pt B VATs wedge biopsy) and revealed Crytoccoccus neoformans. Pts LPs' were negative for CNS involvement. Both pts were started on Fluconazole with clinical and radiographic improvement. DISCUSSION: Cryptococcal pneumonia is a relatively rare diagnosis, even more rare in immune competent patients. Findings on chest imaging often include nodular opacities with or without cavitation, adenopathy, and pleural effusions. These findings however, are non-specific and are associated with multiple disease states. Despite a low pre-test probability, biopsy-proven Cryptococcal pneumonia was identified and subsequently treated in these immune competent patients. CONCLUSIONS: Although a rare entity in immune competent hosts, Cryptococcal pneumonia should remain on the differential in the work-up of pulmonary nodules in the immune competent host. Reference #1: Cryptococcal pneumonia: the great mimicker, Lasya Thambidurai MD, et al. British Journal of Radiology. Published Online: January 05, 2017 Reference #2: Lindell RM, Hartman TE, Nadrous HF, Ryu JH. Pulmonary cryptococcosis: CT findings in immunocompetent patients. Radiology 2005; 236: 326-31 DISCLOSURE: The following authors have nothing to disclose: Amit Bharara, Rebecca Potfay, George Kallingal No Product/Research Disclosure Information

Incidental Finding to Diagnostic Dilemma

SESSION TITLE: Pulmonary Manifestations of Systemic Disease 2 SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Lymphocytic Interstitial Pneumonitis (LIP) is a common manifestation of lung disease associated with Sjogren’s disease. We present a case fraught with diagnostic challenges. CASE PRESENTATION: A 59 year old man with history of Sjogren’s syndrome and asthma was referred to pulmonology after incidental X-ray finding of right lower lobe infiltrate. Review of systems revealed dry eyes, dry cough and dyspnea on exertion. He had a 25 pack-year smoking history. Medications were notable for saline eye drops and Albuterol inhaler. Physical examination revealed temperature 37 degrees Celsius; blood pressure 145/77; pulse 61; oxygen saturation 96% on room air. He was obese, with no lymphadenopathy and chest clear to auscultation. Initial Lab work was unremarkable. Serology was positive for antinuclear antibodies (ANA), anti Anti-Sjögren’s- syndrome-related antigen A and antigen B (SSa/SSb) antibodies. Pulmonary function tests revealed a mildly restrictive pattern. Initial CT scan showed right upper lobe infiltrate which worsened on 3 month follow up CT. Bronchoscopy with bronchoalveolar lavage (BAL) showed normal cell count and cytology, cultures grew beta streptococcus group B. After 2 weeks of antibiotics he developed night sweats and dyspnea on mild exertion. A third CT scan demonstrated dense right lower lobe consolidation, bilateral ground-glass opacities and enlarged sub-pleural nodules. Repeat BAL grew Cryptococcus. He received 7 weeks of fluconazole without improvement. Needle biopsy for sub-pleural nodule revealed multiple dense lymphoplasmacytic infiltrates. Ultimately, wedge biopsy confirmed dense lymphoplasmacytic infiltrate, lymphoid follicles, intra-alveolar macrophages and histiocytes. B-cell polyclonality was confirmed by PCR. He was diagnosed with focal lymphoid hyperplasia and lymphocytic interstitial pneumonia. Treatment with corticosteroids yielded transient resolution. Dramatic resolution was achieved with Rituximab (with azathioprine for maintenance). DISCUSSION: The pathogenesis of LIP is thought to be abnormal proliferation of indigenous cell lines and lung parenchymal infiltration with lymphoid cells. It may be a focal or diffuse, benign (monoclonal) or potentially malignant (polyclonal). It is most commonly seen in women in their 50s and is associated with autoimmune disease. Frequently, LIP presents with cough, chest pain and hemoptysis. There may be a restrictive ventilatory defect on PFTs. Imaging is variable and a lung biopsy required for diagnosis. CONCLUSIONS: Timely recognition of LIP prevents misdiagnosis. Treatment usually is with high dose corticosteroids. Alternative to steroid use may be immunosuppressant agents such as rituximab and azathioprine, however literature to support use of such agents is limited to case reports. Reference #1: Lymphocytic Interstitial Pneumonia, Tanmay S. Panchabhai MD, Carol Farver MD, Kristin B. Highland MD, MSCR Clinics in Chest Medicine, 2016-09-01 DISCLOSURE: The following authors have nothing to disclose: Reema Qureshi, Saira Imran No Product/Research Disclosure Information

Toxic Epidermal Necrolysis vs Lupus Flare?

SESSION TITLE: Critical Care 2 SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Toxic epidermal necrolysis (TEN) and Stevens Johnson syndrome (SJS) are severe mucocutaneous reactions characterized by extensive necrosis and detachment of epidermis. Systemic lupus erythematosus (SLE) patients are at increased risk of SJS/TEN. Here we discuss a patient with SLE who developed TEN. CASE PRESENTATION: A 45 year old female with discoid and systemic lupus erythematosus presented to dermatology with bullous skin lesions 2 days after starting gabapentin, naproxen, and duloxetine. Despite stopping her new medications, she developed a facial rash which spread to her trunk and extremities, affecting 30% body surface area. She had denuded oral mucosa and conjunctival hyperemia with no photosensitivity or eosinophilia. Complements were normal. Wedge biopsy showed acute on chronic vacuolar interface dermatitis with epidermal ulceration and partial to full-thickness epidermal necrosis, suggestive of chronic discoid lupus with superimposed bullous eruption. The patient was admitted to the ICU and treated with intravenous immunoglobulin for three days. Home medications were held. Supportive care included intravenous hydration, reverse isolation in heated environment, specialized wound care, oral and eye care. Methicillin resistant staphylococcus aureus bacteremia was treated. The patient clinically improved and was in reepithelialization phase at time of discharge. DISCUSSION: The incidence of TEN is 0.4-1.2% per million. In patients with SJS/TEN, the prevalence of SLE is estimated to be 1.2% (compared to 0.02-0.05% in the general population). It is unclear if the predisposition for TEN in SLE patients is because of the underlying inflammatory state or because of medications SLE patients often require, such as NSAIDs. Differentiating SLE from TEN is complicated by clinical and histologic similarities. Pathology often demonstrates subepidermal vacuoles, necrotic keratinocytes, and confluent epidermal necrosis, which is found in SLE and TEN. Bullous eruptions and erosive mucosal involvement are typical features in TEN, but can also be found in SLE. This patient developed skin and mucosal lesions after starting new medications and had improvement without steroids, which makes active SLE less likely. Normal complement and serology also supports the clinical diagnosis of TEN over active SLE. CONCLUSIONS: Mortality in patients with SJS and TEN exceeds 10 and 30% respectively. Because the management of active SLE lesions and TEN differ greatly, early recognition of TEN can be life saving. High index of suspicion, early biopsy, and serology can be helpful in differentiating such cases. Reference #1: M. Ziemer, et al, “Stevens-Johnson syndrome and toxic epidermal necrolysis in patients with lupus erythematosus: a descriptive study of 17 cases from a national registry and review of the literature,” Brit J Dermatol 2012; 166 (3), 575-600. Reference #2: Ranario JS, et al. Bullous lesions in a patient with systemic lupus erythematosus. J Clin Aesthet Dermatol 2014; 7:44-49 DISCLOSURE: The following authors have nothing to disclose: Gauri Behari, Sukhdeep Malhi, Bradley Tymchuk, Ronnie Self II, Suman Lata, Ibrahim El-Abbassi No Product/Research Disclosure Information

Diagnostic utility of core needle biopsy versus open wedge biopsy for pediatric intraabdominal solid tumors: Results of a prospective clinical study

PurposeThe best method for diagnosing pediatric nonnephroblastoma solid intraabdominal tumors is unknown. We hypothesized that core needle biopsy (CNB) is noninferior to open wedge biopsy (OWB) for pathologic diagnosis. MethodsWe prospectively enrolled children aged 1day to 17years with radiographic evidence of nonnephroblastoma solid intraabdominal tumors scheduled for OWB from 5/2013 to 12/2015 at a single institution. Four 16-gauge CNBs were obtained, followed by OWB. Two pathologists independently reviewed all specimens to determine adequacy for diagnosis. ResultsFourteen patients enrolled, 57% male, with an average age of 4years (range 7days to 16years). Both pathologists agreed OWB was completely sufficient for diagnosis in 13 patients (93%), compared to 4 patients for CNB (29%: Burkitt lymphoma, adrenocortical tumor, inflammatory myofibroblastic tumor, p=0.001, δ=−0.64±0.27, 95% CI). In 6 patients (43%), CNB was incompletely diagnostic according to at least one pathologist (neuroblastoma, hepatoblastoma). In 4 patients (29%), both pathologists determined that CNB was nondiagnostic (ganglioneuroblastoma, teratoma, hepatoblastoma, and recurrent neuroblastoma). ConclusionsIn a prospective clinical study, CNB is inferior to OWB for the pathologic diagnosis of pediatric nonnephroblastoma solid intraabdominal tumors. These data suggest that OWB should generally be performed in these patients. Level of evidenceStudy of Diagnostic Test, Level I.

Kidney Transplantation from Donors Died of Organophosphate Poisoning

Background Suicide through taking poison organophosphate, the most widely used pesticide in China, is an infrequent cause of death in organ donors. The transplant colleagues may hesitate to use these organs due to concerning the quality and safety of the organs. We want to investigate the effect of kidney transplantation from donors died from suicide through taking organophosphate. Method Kidney transplantation from donors died of suicide by taking organophosphate were retrospectively reviewed. Results There were 6 donors died of poisoning of organophosphate. Pre-implant wedge biopsy of donor kidneys showed normal glomerular and tubunar morphology in 3 donors, normal glomerular morphology with mild acute tubular necrosis (ATN) in 2 donors, mild ATN and 4% glomerulosclerosis in 1 donor (Table 1). All kidneys showed favorable pump parameters in hypothermic pulsatile machine perfusion (flow: 115 ± 26 ml/min, resistance: 0.25 ± 0.09 mmHg/[ml/min]). Twelve cases of kidney transplantation were performed with cold ischemic time of 9.2 ± 3.8 h. No case of delayed graft function or acute rejection occurred. After a follow-up of 13-62 months, all recipients survived with excellent renal graft function, with 12 months eGFR of 75.8 ± 14.1 ml/min/1.73m2. Conclusion Kidneys from donors dying of poisoning of organophosphate are suitable for transplantation and can achieve excellent graft function.

An integrated segmentation and shape-based classification scheme for distinguishing adenocarcinomas from granulomas on lung CT.

Distinguishing between benign granulmoas and adenocarcinomas is confounded by their similar visual appearance on routine CT scans. Unfortunately, owing to the inability to discriminate these lesions radigraphically, many patients with benign granulomas are subjected to unnecessary surgical wedge resections and biopsies for pathologic confirmation of cancer presence or absence. This suggests the need for improved computerized characterization of these nodules in order to distinguish between these two classes of lesions on CT scans. While there has been substantial interest in the use of textural analysis for radiomic characterization of lung nodules, relatively less work has been done in shape based characterization of lung nodules, particularly with respect to granulmoas and adenocarcinomas. The primary goal of this study is to evaluate the role of 3D shape features for discrimination of benign granulomas from malignant adenocarcinomas on lung CT images. Towards this end we present an integrated framework for segmentation, feature characterization and classification of these nodules on CT. The nodule segmentation method starts with separation of lung regions from the surrounding lung anatomy. Next, the lung CT scans are projected into and represented in a three dimensional spectral embedding (SE) space, allowing for better determination of the boundaries of the nodule. This then enables the application of a gradient vector flow active contour (SEGvAC) model for nodule boundary extraction. A set of 24 shape features from both 2D slices and 3D surface of the segmented nodules are extracted, including features pertaining to the angularity, spiculation, elongation and nodule compactness. A feature selection scheme, PCA-VIP, is employed to identify the most discriminating set of features to distinguish granulmoas from adenocarcinomas within a learning set of 82 patients. The features thus identified were then combined with a support vector machine classifier and independently validated on a distinct test set comprising 67 patients. The performance of the classifier for both of the training and validation cohorts was evaluated by the area under receiver characteristic curve (ROC). We used 82 and 67 studies from two different institutions respectively for training and independent validation of the model and the shape features. The Dice coefficient between automatically segmented nodules by SEGvAC and the manual delineations by expert radiologists (readers) was 0.84± 0.04 whereas inter-reader segmentation agreement was 0.79± 0.12. We also identified a set of consistent features (Roughness, Convexity and Spherecity) that were found to be strongly correlated across both manual and automated nodule segmentations (R > 0.80, p < 0.0001) and capture the marginal smoothness and 3D compactness of the nodules. On the independent validation set of 67 studies our classifier yielded a ROC AUC of 0.72 and 0.64 for manually- and automatically segmented nodules respectively. On a subset of 20 studies, the AUCs for the two expert radiologists and 1 pulmonologist were found to be 0.82, 0.68 and 0.58 respectively. The major finding of this study was that certain shape features appear to differentially express between granulomas and adenocarcinomas and thus computer extracted shape cues could be used to distinguish these radiographically similar pathologies.

Human liver epigenetic alterations in non-alcoholic steatohepatitis are related to insulin action

ABSTRACTBoth genetic and lifestyle factors contribute to the risk of non-alcoholic steatohepatitis (NASH). Additionally, epigenetic modifications may also play a key role in the pathogenesis of NASH. We therefore investigated liver DNA methylation, as a marker for epigenetic alterations, in individuals with simple steatosis and NASH, and further tested if these alterations were associated with clinical phenotypes. Liver biopsies obtained from 95 obese individuals (age: 49.5 ± 7.7 years, BMI: 43 ± 5.7 kg/m2, type 2 diabetes [T2D]: 35) as a wedge biopsy during a Roux-en-Y gastric bypass operation were investigated. Thirty-four individuals had a normal liver phenotype, 35 had simple steatosis, and 26 had NASH. Genome-wide DNA methylation pattern was analyzed using the Infinium HumanMethylation450 BeadChip. mRNA expression was analyzed from 42 individuals using the HumanHT-12 Expression BeadChip. We identified 1,292 CpG sites representing 677 unique genes differentially methylated in liver of individuals with NASH (q < 0.001), independently of T2D, age, sex, and BMI. Focusing on the top-ranking 30 and another 37 CpG sites mapped to genes enriched in pathways of metabolism (q = 0.0036) and cancer (q = 0.0001) all together, 59 NASH-associated CpG sites correlated with fasting insulin levels independently of age, fasting glucose, or T2D. From these, we identified 30 correlations between DNA methylation and mRNA expression, for example LDHB (r = −0.45, P = 0.003). We demonstrated that NASH, more than simple steatosis, associates with differential DNA methylation in the human liver. These epigenetic alterations in NASH are linked with insulin metabolism.

Multimodality imaging findings of massive ovarian edema in children.

Massive ovarian edema is a rare benign condition that predominantly affects childbearing women as well as preadolescent girls. It is thought to result from intermittent or partial torsion of the ovary compromising the venous and lymphatic drainage but with preserved arterial supply. The clinical features of massive ovarian edema are nonspecific and can simulate tumors, leading to unnecessary oophorectomy. To demonstrate imaging features that should alert radiologists to consider the diagnosis of massive ovarian edema preoperatively so that fertility-sparing surgery may be considered. We identified five girls diagnosed with massive ovarian edema at pathology. Presenting symptoms, sidedness, imaging appearance, preoperative diagnosis, and operative and histopathological findings were reviewed. Age range was 9.6-14.3years (mean age: 12.5years). Common imaging findings included ovarian enlargement with edema of the stroma, peripherally placed follicles, isointense signal on T1-W MRI and markedly hyperintense signal on T2-W MRI, preservation of color Doppler flow by US, and CT Hounsfield units below 40. The uterus was deviated to the affected side in all patients. Two of the five patients had small to moderate amounts of free pelvic fluid. Mean ovarian volume on imaging was 560mL (range: 108-1,361mL). While the clinical presentation of massive ovarian edema is nonspecific, an enlarged ovary with stromal edema, peripherally placed follicles and preservation of blood flow may be suggestive and wedge biopsy should be considered intraoperatively to avoid unnecessary removal of the ovary.

Hepatic Calcified Tumor-like Mass Complicating Umbilical Vein Catheterization in a Neonate

Presented is a case of a hepatic calcified mass complicating umbilical vein catheterization in a neonate and diagnosed by wedge biopsy. Wedge biopsy of the hepatic mass, situated in proximity to the falciform ligament, revealed expansion of portal tracts by fibrosis and calcification. Some aggregates of calcified material appeared in ectatic vascular spaces. The biopsy findings accounted for the radiographic appearance of the mass and the constellation of features were deemed indicative of calcification secondary to umbilical vein catheterization. Umbilical vein catheterization in neonates may be complicated by a calcified mass that requires histologic evaluation for distinction from other space-occupying lesions. Such a calcified pseudotumor may develop after an umbilical catheter has been in place for only 5 days.