CLINICAL SIGNIFICANCE OF SERUM FERRITIN IN PATIENTS WITH SYSTEMIC SCLEROSIS

BackgroundThe main systemic sclerosis (SSc) manifestations are skin thickening, microangiopathy and ischemic changes in tissues, fibrotic damage to the lungs, heart, kidneys, and digestive system, arthritis, and myopathy. Acute phase reactants (APR) like erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) reflect inflammation activity in various inflammatory conditions. Ferritin is a protein bound to iron;low serum ferritin indicates iron deficiency and/or anemia. Instead, high ferritin levels are associated with inflammatory and non-inflammatory conditions such as dermatomyositis, pulmonary fibrosis, lupus, systemic COVID-19, vasculitis, tissue damage, thromboembolic complications, and metastatic cancer. The possible role of ferritin in SSc as APR is unclear.ObjectivesWe aimed to assess whether ferritin levels can reflect the severity of SSc and predict the outcome.Methods241 files of SSc patients with information on serum ferritin level (ferritin over 300 mg/dL is considered elevated) who visited the Rambam Rheumatology Institute in the years 2004-2021were used for retrospective analysis. Patients' demographic, clinical, laboratory, imaging, and respiratory function data were collected from electronic hospital files. Statistics included Student's T-test, Pearson's chi-squared test, and Kaplan-Meier curve;statistical significance was determined as p<0.05.Results36 patients (FerEl-SSc) had elevated ferritin values;the rest (n=205) represented the second group (FerNor-SSc). Significant differences were seen in gender (male 44.4% - 15.6%), disease duration (4.56 - 7.7 years), modified Rodnan skin score (12.3 - 6.9), as well as in incidence of lung (65.7% - 38.7%), heart (51.4% - 21.1%), and renal (28.6% - 5.9%) involvement. Increased ferritin correlated with elevated ESR, CRP, creatinine, creatine kinase, troponin, and reduced hemoglobin, impaired pulmonary function tests and reduced left ventricular ejection fraction on echocardiography. Patients with elevated ferritin had a significant increase in mortality rates (52.8% and 35.1%) and non-significant reduction in survival.ConclusionOur study demonstrated that ferritin has a potential as a sensitive marker for SSc severity in term of skin thickening, vital organ complications, and mortality. The ferritin test is simple and inexpensive, it can add to the complex SSc assessment and contribute to treatment decision-making in complicated SSc.REFERENCES:NIL.Acknowledgements:NIL.Disclosure of InterestsNone Declared.

A rare radiological presentation of pulmonary metastases from malignant melanoma.

Malignant melanoma is a highly aggressive cancer with metastatic potential to various locations such as the lymph nodes, lungs, liver, brain, and bone. After the lymph nodes, the lungs are the most common site of malignant melanoma metastases. Pulmonary metastases from malignant melanoma commonly presents as solitary or multiple solid nodules, sub-solid nodules or miliary opacities on CT chest. We present a case of pulmonary metastases from malignant melanoma in a 74-year-old man which presented unusually on CT chest as a combination of patterns like "crazy paving," upper lobe predominance with subpleural sparing, and centrilobular micronodules. Video-assisted thoracoscopic surgery, wedge resection and tissue analysis were performed, which confirmed the diagnosis of malignant melanoma metastases, and the patient further underwent PET-CT for staging and surveillance. Patients with pulmonary metastases from malignant melanoma can have atypical imaging findings, therefore radiologists should be aware of these unconventional presentations to avoid any misdiagnoses.

Optimizing the dynamics of bone turnover with genetic algorithm.

Control systems and the modeling strategies are not only limited to engineering problems. These approaches can be used in the field of bio-mathematics as well and modern studies have promoted this approach to a great extent. The computational modeling and simulation of bone metastasis is painful yet critical after cancer invades the body. This vicious cycle is complex, and several research centers worldwide are devoted to understanding the dynamics and setting up a treatment strategy for this life-threatening behavior of cancer. Cancerous cells activation and the corresponding process of metastasis is reported to boost during the periodic waves of COVID-19, due to the inflammatory nature of the infection associated with SARS-2 and its variants. The bone cells are comprised of two types of cells responsible for bone formation and resorption. The computational framework of such cells, in spatial form, can help the researchers forecast the bone dynamics in a robust manner where the impact of cancer is incorporated into the computational model as a source of perturbation. A series of computational models are presented to explore the complex behavior of bone metastasis with COVID-19 induced infection. The finite difference algorithm is used to simulate the nonlinear computational model. The results obtained are in close agreement with the experimental findings. The computational results can help explore the vicious cycle's fate and help set up control strategies through drug therapies.

The Korean Society for Neuro-Oncology (KSNO) Guideline for the Management of Brain Tumor Patients During the Crisis Period: A Consensus Survey About Specific Clinical Scenarios (Version 2023.1).

BACKGROUND: During the coronavirus disease 2019 (COVID-19) pandemic, there was a shortage of medical resources and the need for proper treatment guidelines for brain tumor patients became more pressing. Thus, the Korean Society for Neuro-Oncology (KSNO), a multidisciplinary academic society, has undertaken efforts to develop a guideline that is tailored to the domestic situation and that can be used in similar crisis situations in the future. As part II of the guideline, this consensus survey is to suggest management options in specific clinical scenarios during the crisis period. METHODS: The KSNO Guideline Working Group consisted of 22 multidisciplinary experts on neuro-oncology in Korea. In order to confirm a consensus reached by the experts, opinions on 5 specific clinical scenarios about the management of brain tumor patients during the crisis period were devised and asked. To build-up the consensus process, Delphi method was employed. RESULTS: The summary of the final consensus from each scenario are as follows. For patients with newly diagnosed astrocytoma with isocitrate dehydrogenase (IDH)-mutant and oligodendroglioma with IDH-mutant/1p19q codeleted, observation was preferred for patients with low-risk, World Health Organization (WHO) grade 2, and Karnofsky Performance Scale (KPS) ≥60, while adjuvant radiotherapy alone was preferred for patients with high-risk, WHO grade 2, and KPS ≥60. For newly diagnosed patients with glioblastoma, the most preferred adjuvant treatment strategy after surgery was radiotherapy plus temozolomide except for patients aged ≥70 years with KPS of 60 and unmethylated MGMT promoters. In patients with symptomatic brain metastasis, the preferred treatment differed according to the number of brain metastasis and performance status. For patients with newly diagnosed atypical meningioma, adjuvant radiation was deferred in patients with older age, poor performance status, complete resection, or low mitotic count. CONCLUSION: It is imperative that proper medical care for brain tumor patients be sustained and provided, even during the crisis period. The findings of this consensus survey will be a useful reference in determining appropriate treatment options for brain tumor patients in the specific clinical scenarios covered by the survey during the future crisis.

Use of Contrast Media During CT-guided Thermal Ablation of Colorectal Liver Metastasis for Procedure Planning is Associated with Improved Immediate Outcomes.

PURPOSE: The aim of this study was to analyze the impact of using intra-procedural pre-ablation contrast-enhanced CT prior to percutaneous thermal ablation (pre-ablation CECT) of colorectal liver metastases (CLM) on local outcomes. MATERIALS AND METHODS: This retrospective analysis of a prospectively collected liver ablation registry included 144 consecutive patients (median age 57 years IQR [49, 65], 60% men) who underwent 173 CT-guided ablation sessions for 250 CLM between October 2015 and March 2020. In addition to oncologic outcomes, technical success was retrospectively evaluated using a biomechanical deformable image registration software for 3D-minimal ablative margin (3D-MAM) quantification. Bayesian regression was used to estimate effects of pre-ablation CECT on residual unablated tumor, 3D-MAM, and local tumor progression-free survival (LTPFS). RESULTS: Pre-ablation CECT was acquired in 71/173 (41%) sessions. Residual unablated tumor was present in one (0.9%) versus nine tumors (6.6%) ablated with versus without using pre-ablation CECT, respectively (p = 0.024). Pre-ablation CECT use decreased the odds of residual disease on first follow-up by 78% (CI95% [5, 86]) and incomplete ablation (3D-MAM ≤ 0 mm) by 58% (CI95% [13, 122]). The odds ratio for residual unablated tumor for larger CLM was lower when pre-ablation CECT was used (odds ratio 1.0 with pre-ablation CECT vs. 2.52 without). Pre-ablation CECT use was not associated with improvements on LTPFS. CONCLUSIONS: Pre-ablation CECT is associated with improved immediate outcomes by significantly reducing the incidence of residual unablated tumor and by mitigating the risk of incomplete ablation for larger CLM. We recommend performing baseline intra-procedural pre-ablation CECT as a standard imaging protocol. LEVEL OF EVIDENCE: Level 3 (retrospective cohort study).

Enlargement of a metastatic lymph node from differentiated thyroid cancer after COVID-19 vaccination.

BACKGROUND: The massive vaccination campaign against COVID-19 has granted a high level of protection against the severe forms of the disease at the price of some mild adverse events. OBJECTIVE: To underline that COVID-19 vaccination can induce a transient enlargement of lymph-node metastases in differentiated thyroid cancer patients. CASE PRESENTATION: We describe the clinical, laboratory, and imaging features of a 60-year-old woman affected by paratracheal lymph-node relapse of Hurtle Cell Carcinoma who came to our attention after full COVID-19 vaccination because of neck swelling and pain. In April 2021, after 5 years of stable structural disease, the patient presented an enlargement of the metastatic lymph node, associated with a rise of serum thyroglobulin (from 4.6 to 14.7 pg/mL). Anti-inflammatory treatment was started and pain and swelling remitted after 15 days. At the subsequent evaluation, at neck ultrasound, the right paratracheal lesion was smaller and thyroglobulin dropped to 3.9 pg/mL. CONCLUSIONS: We report the case of an enlargement of metastatic lymph node from differentiated thyroid cancer after COVID-19 vaccination. We warn clinicians to identify features of inflammatory response due to COVID-19 vaccination in order to prevent unwarranted surgical treatment.

A review of the results from a patient experience survey of the palliative radiotherapy bone metastases service

Introduction:A patient experience survey was undertaken as part of the role of the Macmillan Consultant Therapy Radiographer for the bone and brain metastases patients to inform future development of the service.Method:A questionnaire was developed and approved by the Trust's local Questionnaire, Interview and Survey Group to survey the experiences and satisfaction of the service including the informed consent process, radiotherapy appointments and overall experience and satisfaction. The survey used qualitative and quantitative methods, including Likert Scales and free comment boxes. The responses were analysed by counting the frequency of each response and identifying any themes in free text responses.Results:Most patients were satisfied with the consent process with 1/36 patients reporting a lack of understandable information and 4/36 wanting more side effect information. The option of plan and treat was a preference of 53% of patients due to travelling back and forth to the centre;however, only 6% stated that they wanted two separate appointments. Ninety-four percent of patients felt that they had complete confidence and trust in the professional who consented them and 86% did not feel fully involved in the decision-making process. Overall, the service was rated as 10/10 by 61% of patients (n = 36).Conclusions:The patients surveyed were satisfied with their experience of the Palliative Radiotherapy Service;however, it needs to be developed further to meet the needs and expectations of the service users.

Case report: A case of delayed cutaneous metastases from signet-ring cell mixed-type gastric cancer.

Background: Signet-ring cell gastric carcinoma is a highly malignant tumor, with the characteristics of strong invasiveness, rapid progression, a high degree of malignancy, and generally poor prognosis. The most common site of metastases is the abdominal organs, especially the liver, while delayed cutaneous metastases are rare. Case presentation: We report a case of cutaneous metastases on the head, groin, and thigh, which recurred 7 years after signet-ring cell gastric carcinoma surgery. The patient was diagnosed with a 2.0×1.5×1.0cm tumor at the angle of stomach, and treated with Billroth II distal gastrectomy accompanied with D2 lymph node dissection. According the pathology, the stage was pT1N3M0. Then the patient received two cycles of oxaliplatin and tegafur chemotherapy, which was discontinued due to the inability to tolerate the side effects of chemotherapy. Seven years after the surgery, the patient initially presented with a fleshy mass on the head and beaded nodules in the groin; then, the mass gradually became larger, along with the thighs turning red, swollen, and crusty. Firstly, the patient was diagnosed with "lower extremity lymphangitis" and treated mostly with anti-inflammatory, promote lymphatic return, detumescence and elastic force cannula in vascular surgery department. However, the symptoms relieved insufficient. Finally, the skin biopsy indicates a signet-ring cell gastric carcinoma cutaneous metastasis. The whole-body PET-CT examination showed multiple nodules with increased metabolism. Then the patient was transferred to The Department of Oncology for further chemotherapy. Conclusion: Our case highlights that gastric tumor recurrence and metastasis should be highly suspected when skin lesions appear in patients with signet-ring cell gastric carcinoma. At the same time, multidisciplinary consultation and close cooperation between surgeons, oncologists, and dermatologists are of great significance to the diagnosis and treatment of this disease.

The Multifaceted Biology of PCSK9.

This article reviews the discovery of PCSK9, its structure-function characteristics, and its presently known and proposed novel biological functions. The major critical function of PCSK9 deduced from human and mouse studies, as well as cellular and structural analyses, is its role in increasing the levels of circulating low-density lipoprotein (LDL)-cholesterol (LDLc), via its ability to enhance the sorting and escort of the cell surface LDL receptor (LDLR) to lysosomes. This implicates the binding of the catalytic domain of PCSK9 to the EGF-A domain of the LDLR. This also requires the presence of the C-terminal Cys/His-rich domain, its binding to the secreted cytosolic cyclase associated protein 1, and possibly another membrane-bound "protein X". Curiously, in PCSK9-deficient mice, an alternative to the downregulation of the surface levels of the LDLR by PCSK9 is taking place in the liver of female mice in a 17ß-estradiol-dependent manner by still an unknown mechanism. Recent studies have extended our understanding of the biological functions of PCSK9, namely its implication in septic shock, vascular inflammation, viral infections (Dengue; SARS-CoV-2) or immune checkpoint modulation in cancer via the regulation of the cell surface levels of the T-cell receptor and MHC-I, which govern the antitumoral activity of CD8+ T cells. Because PCSK9 inhibition may be advantageous in these processes, the availability of injectable safe PCSK9 inhibitors that reduces by 50% to 60% LDLc above the effect of statins is highly valuable. Indeed, injectable PCSK9 monoclonal antibody or small interfering RNA could be added to current immunotherapies in cancer/metastasis.

Comprehensive conservative treatment for multiple metastases of skull osteosarcoma: A case report.

Background: Skull osteosarcoma is relatively rare, and it is difficult to be diagnosed according to medical history and imaging examination due to the complex structure and diverse components of the brain. Consequently, there is only a limited number of patients who can undergo neoadjuvant chemotherapy before the operation. Although neoadjuvant chemotherapy plays an important role in the treatment of osteosarcoma, there is still a "bottleneck" in the current treatment method which when pulmonary metastasis occurs, or surgical treatment is not Enneking appropriate. Under such circumstances, the choice of treatment can be an issue. Case: A 16-year-old male patient with multiple metastases of skull osteosarcoma was reported. The patient suffered not only tinnitus and hearing loss in the right ear but also right facial paralysis and headache. The preoperative brain MRI showed a tumor in the right cerebellopontine angle (CPA) area. He underwent skull tumor resection at another hospital in November 2018, during which process the biopsy revealed epithelioid osteoblastoma-like osteosarcoma. The patient had supplemental radiotherapy 1 month after surgery because of tumor recurrence. 32 months afterward, pulmonary metastases and multiple bone metastases were found. Then the patient underwent multiple conservative treatments which include Denosumab, Anlotinib, and DIA (cisplatin + ifosfamide + doxorubicin) chemotherapy at our hospital. After a series of 6 cycles of treatment, the patient can walk without aid. Lactate dehydrogenase (LDH) and Alkaline phosphatase (AKP) returned to a normal level. Fluorodeoxyglucose (FDG) metabolism in all bone metastases decreased to normal except for the ones in the proximal left femur, and the FDG metabolism in the left femur is significantly lower than that before treatment. Multiple bone metastases showed different extents of high-density calcification, and the volume of the local bone metastases has been reduced significantly. The patient's condition stayed stable at latest follow-up. Conclusion: We found that multiple conservative treatments, which include Denosumab, Anlotinib and DIA chemotherapy, can improve patients' life quality, and help avoid further osteolytic destruction for patients with skull osteosarcoma and multiple metastases. Its specific mechanism and scope of the application still need to be further studied.

Consequences of Discontinuing a 4/6 Cyclin D-Dependent Kinase Inhibitor During Endocrine Treatment in Hormone-Sensitive Metastatic Breast Cancer Patients in the Context of the COVID-19 Outbreak.

BACKGROUND: The impact of some hasty medical decision made during the first wave of the Coronavirus Disease 2019 (COVID-19) remains unknown. We have evaluated the consequences of one of these precautionary measures: the withdrawal of the cyclin D-dependent kinases 4/6 inhibitor (CDK4/6i) in patients whose metastatic disease was controlled by a combination of endocrine treatment and CDK 4/6i. METHOD: This study was noninterventional, retrospective, multicentric, and included 60 patients with HR+ HER2- metastatic disease. Their disease was controlled with the combination of endocrine treatment and CDK 4/6i. The CDK 4/6i was stopped for two months during the first COVID-19 outbreak. A univariate analysis was performed to assess the risk factors associated with disease progression. RESULTS: During this therapeutic break, 22 (37 %) patients had a radiological and/or clinical disease progression. Among them, the CDK 4/6i was re-introduced to 16 patients (n = 16/22; 73 %). A new line of treatment (chemotherapy or targeted therapy) was initiated due to the rapid symptomatic tumor progression in four patients (n = 4/22; 18 %). Two patients (n = 2/22) died in visceral crisis before another anti-tumoral treatment was introduced. In univariate analysis, the presence of liver metastases increased the risk of metastatic disease progression during the withdrawal of the CDK 4/6 (OR = 6.6; 95 % CI 1.87-23.22; P= .0033). CONCLUSION: Progression was observed in 37% of patients during the two-month treatment interruption of the CDK 4/6i. A prolonged CDK 4/6i treatment interruption in patients with clinical benefit on endocrine treatment does not seem to be a reasonable option in light of these results.

Pituitary metastasis as the first manifestation of lung carcinoma.

Pituitary metastases are rare. Clinical presentation could range from asymptomatic to panhypopituitarism or local symptoms. We present a case report of a 43-year-old male patient with a new onset headache, visual disturbances, and panhypopituitarism. The investigation led to the diagnosis of pituitary metastasis as the first manifestation of underlying lung cancer.

Jugular Paraganglioma Presenting with a Tumor Thrombus Extending from Posterior Fossa to Right Atrium and Multiple Skeletal Metastases.

INTRODUCTION: Paragangliomas are tumors of neuroendocrine origin, may appear in different localizations, and are related to the autonomic nervous system. Paragangliomas are generally asymptomatic and may rarely appear with adrenergic symptoms, and clinical findings depend on the catecholamines they secrete. Extra-adrenal paragangliomas are mostly benign, like all paragangliomas. Malignancy criteria consist of local recurrence, metastasis after total resection, and presence of distant metastasis during primary diagnosis. CASE PRESENTATION: This report presents the case of a 31-year-old man with jugular paraganglioma, multiple skeletal metastases, and a long-segment tumor thrombus. Imaging procedures showed a continuous tumor thrombus extending from the posterior fossa to the right atrium and metastases in C2, T1, T6, T8, L5, and right humerus. Histopathological assessment of the metastasis in C2 identified malignant paraganglioma. Curative surgery was not an option for this patient, hence combined chemotherapy was given. CONCLUSION: In cases of malignant paraganglioma with multiple distant metastases, chemotherapy and radiotherapy are feasible treatment methods.

Simulation-Free Radiation Therapy: An Emerging Form of Treatment Planning to Expedite Plan Generation for Patients Receiving Palliative Radiation Therapy

Purpose: Herein we report the clinical and dosimetric experience for patients with metastases treated with palliative simulation-free radiation therapy (SFRT) at a single institution. Methods and Materials: SFRT was performed at a single institution. Multiple fractionation regimens were used. Diagnostic imaging was used for treatment planning. Patient characteristics as well as planning and treatment time points were collected. A matched cohort of patients with conventional computed tomography simulation radiation therapy (CTRT) was acquired to evaluate for differences in planning and treatment time. SFRT dosimetry was evaluated to determine the fidelity of SFRT. Descriptive statistics were calculated on all variables and statistical significance was evaluated using the Wilcoxon signed rank test and t test methods. Results: Thirty sessions of SFRT were performed and matched with 30 sessions of CTRT. Seventy percent of SFRT and 63% of CTRT treatments were single fraction. The median time to plan generation was 0.88 days (0.19-1.47) for SFRT and 1.90 days (0.39-5.23) for CTRT (P = .02). The total treatment time was 41 minutes (28-64) for SFRT and 30 minutes (21-45) for CTRT (P = .02). In the SFRT courses, the maximum and mean deviations in the actual delivered dose from the approved plans for the maximum dose were 4.1% and 0.07%, respectively. All deliveries were within a 5% threshold and deemed clinically acceptable. Conclusions: Palliative SFRT is an emerging technique that allowed for a statistically significant lower time to plan generation and was dosimetrically acceptable. This benefit must be weighed against increased total treatment time for patients receiving SFRT compared (c) 2022 The Author(s). Published by Elsevier Inc. on behalf of American Society for Radiation Oncology. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Pathological Findings in COVID-19 and Non-COVID-19 Vaccine-Associated Lymphadenopathy: A Systematic Review.

COVID-19 vaccine-associated lymphadenopathy (C19-VAL) is increasingly encountered with the widespread use of the vaccine in controlling the outbreak. We aim to characterize the pathological findings of COVID-19 and non-COVID-19 vaccine-associated lymphadenopathy (NC19-VAL). A search for studies that reported pathological findings in vaccine-associated lymphadenopathy on PubMed and Google Scholar was performed on 11 December 2021. C19-VAL studies were pooled for analysis. These studies were split into clinical lymphadenopathy (CL) and subclinical lymphadenopathy detected on imaging (SLDI) for subgroup analysis. A total of 25 studies were related to COVID-19 vaccines, and 21 studies were included in the pooled analysis. The pooled analysis included 37 patients with a mean age of 47.8 ± 19.1 years old, and 62.2% were females. The mean duration from last vaccination to development of CL/SLDI was 14.5 ± 11.0 days. Most were diagnosed as reactive or negative for malignancy (28/37, 75.5%), followed by Kikuchi-Fujimoto disease (KFD) (3/37, 8.1%), florid lymphoid hyperplasia (2/37, 5.4%), and granulomatous inflammation (2/37, 5.4%). Metastases were reported in two patients with a history of malignancy (2/37, 5.4%). Cases with florid lymphoid hyperplasia and KFD were younger than those with reactive changes. A total of 14 studies were related to non-COVID-19 vaccines. Caseating granulomatous inflammation was reported in BCG vaccine-associated lymphadenopathy, while other vaccines were associated with reactive lymphoid hyperplasia, florid post-vaccinal reactions, and KFD. Although most C19-VAL cases were reported as reactive or negative for malignancy, other diagnoses included florid lymphoid hyperplasia, KFD, and granulomatous inflammation. Metastases were reported in lymphadenopathy of patients with a history of malignancy, who had been incidentally vaccinated. In conclusion, C19-VAL can yield different histopathological diagnoses when sampled, most of which require clinical and radiological correlation for optimal patient management.

Ambulatory Same-Day Map-and-Treat Angiography for Selective Internal Radiation Therapy Using a Transradial Approach.

Historically, selective internal radiation therapy (SIRT) with yttrium-90 (Y-90) requires a two-week interval between workup and treatment (map and treat). The intervening gap between workup and treatment is used to plan for the dose required and obtain delivery of the radioactive Y-90. During the coronavirus disease 2019 pandemic, the delivery of a robust SIRT service was challenging due to unprecedented demands on all hospital services. Emergent practice changes were required to ensure this service could still be delivered to patients while retaining sufficient inpatient hospital beds and services for acutely unwell patients. In response to this, the interventional radiology team proposed the retention of a full SIRT service by removing the historical two-week interval between map and treat, delivering both components of the SIRT procedure on the same day. A traditional approach using femoral access would require a prolonged period of immobility and potentially an overnight stay. By adopting a transradial approach without sedo-analgesia, an ambulatory day-case map and treat SIRT with no post-procedure immobilisation was performed. This case report demonstrates the technical feasibility of same-day 'map-and-treat' SIRT, highlighting a paradigm shift from the conventional femoral access method and immobilisation to an 'ambulatory' approach with immediate mobilisation post-procedure.

Multi-target endoscopic ultrasound EUS-M guided biopsy is superior to pet scan for staging for malignancies

BackgroundPET scan is widely used not only to diagnose malignancy and its staging, but a small proportion of patients do have false-positive results. EUS now is a well-established modality to get tissue diagnosis, and with multi-target approach can help stage disease more accurately with histopathological results. We share our experience with EUS-M cases with different variety of malignancies.MethodsA total of 25 cases underwent EUS-M from June 2020 till June 2022. Informed consent was obtained, and with Covid screen test with PCR was performed before the procedure. Procedures were done with all SOPs as per institutional guidelines. 22G FNB needle was used in 24 cases, 25G needle in 01 case;Franseen design with the capillary suction method was used to obtain visible core samples for histopathology without ROSE. All cases have confirmed the histopathological diagnosis with the same pathology from other site of Biopsy. Order of Biopsy was Nodes→ Liver metastatic lesion→ Primary Tumour. In cases of nodes mediastinal→ porta-hepatis/pancreatic→ Para-aortic. All samples were adequate for making a confirmatory diagnosis on the tissue sample.ResultsAmong total of 25 cases, Age 54 Mean (22–77) with 16 Males. Duration of procedure 38 Minutes Mean (20–85). Cases with multiple lymphadenopathy from different anatomical regions were 09, while other sites included Liver for metastasis and Primary tumour from pancreas/CBD/GB in 16 cases. Multiple site single pass was performed in 24 cases. 19 cases had malignant pathologies. Final diagnosis of the Disease was pancreatic adenocarcinoma 07, NETs 02, Lymphoma 04, GB Adenocarcinoma/Cholangiocarcinoma 06 and metastatic RCC 01, TB 01. 04 cases had benign disease. All procedures were done under Conscious sedation as day care procedure. There were no immediate or early complications in all cases.ConclusionsEUS-M is a safe and accurate modality to stage malignancy with superiority over PET Scan to obtain a histological diagnosis.

Application of endoscopic ultrasound EUS in evaluation of mediastinal lesions

BackgroundEndoscopic Ultrasound (EUS) has emerged as a useful tool to obtain tissue acquisition for diagnosis. In mediastinology, EUS plays its supportive role in certain areas in mediastinum to obtain via trans-oesophageal route safely and accurately tissue diagnosis from lesions suspected likely malignancy either lung pathologies or metastasis from other primaries. In third-world countries, tuberculosis is also commonly encountered along with it. We share our initial experience of different pathologies encountered in EUS-guided biopsy of mediastinal lesions.MethodsA total of 21 cases underwent EUS guided Biopsy from June 2020 to June 2022. Informed consent was obtained, and with Covid screen test with PCR was performed before the procedure. Procedures were done with all SOPs as per institutional guidelines. 22G FNB needle in 20 cases and 25G in one case;Franseen design with the capillary suction method was used to obtain visible core samples for histopathology without Rapid-Onsite-Evaluation (ROSE). All cases have adequate sample for histological diagnosis. The post-procedure oral antibiotic was given to all patients.ResultsAmong these cases, 13 were male, with a mean age of 55 years (range 22–87) and a mean duration of procedure 21 minutes (10–35 min). Majority of them;12 cases were malignant pathologies, while the remaining 09 were benign. The number of ‘passes’ with the needle was average 2.5 with single pass 02, two pass 10, three passes 05 and multitarget lesions were 04. There were Mediastinal lesions in 16 cases and mediastinal nodes biopsy in 05 cases. Common tissue diagnoses include Tuberculosis 06, Squamous cell Carcinoma 04, Lymphoma 03, Benign in 02, Sarcomatoid carcinoma 02 and Metastatic renal Cell Carcinoma 01, Metastatic breast 01, Sarcoidosis 01, Solitary fibrous tumour 01. There were no immediate or early complications in all cases.ConclusionsEUS-guided biopsy of lesions in different mediastinal areas is safe and provides tissue diagnosis with high diagnostic accuracy with the use of FNB needles.

Hybrid endoscopic ultrasound in the covid-19 era for the tissue diagnosis of solid lesions;an initial experience from a tertiary care centre from Pakistan

BackgroundEndoscopic Ultrasound (EUS) is a well-established mode of intervention for tissue acquisition in solid organs with rapid on-site evaluation (ROSE). In the Covid-19 era, the implementation of infection control mechanisms has led to modified hybrid techniques to get high diagnostic yield for tissue sampling. Combination of Covid-19 SOPs and tissue acquisition method outline this hybrid technique to get a high diagnostic Yield. We share our initial experience of EUS cases performed with this approach without ROSE.MethodsAll 125 cases who underwent EUS-guided biopsy from June 2020 till June 2022 were included. The Procedure was done in a negative pressure room with all SOPs as per institutional guidelines for patient and staff safety with a minimum number of persons during the procedure.ResultsAmong these cases, 85 were male, mean age of 56 years (range 22–90), Mean duration of procedure 28 minutes mean (10–90 min). 91 cases for organs targeted for malignant pathology include pancreas 53, liver 03, lymph nodes 22, subepithelial lesions 10, mediastinal lesions 15, common-bile duct/gall bladder 07, gastric and retroperitoneal 01 case, 13 cases had a multi-targeted biopsy for the additional staging of disease. The number of ‘passes’ with the needle was average 02 with single pass 20, two pass 60, three passes 20, multitarget single pass in 25. Needle size (Franseen design) used for procedures was 22G in 115 cases and 25G in 10. Common tissue diagnoses include pancreatic adenocarcinoma 38, neuroendocrine tumours 06, tuberculosis 07, gastrointestinal stromal tumours 03, leiomyoma 05, lymphoma 06, metastatic renal cell carcinoma 05, squamous cell carcinoma 05, cholangiocarcinoma/gall bladder adenocarcinoma 13, Sarcoma 03, solid pseudopapillary epithelial neoplasm of pancreas (SPEN) 03 and one case for Schwannoma, breast metastasis, accessory spleen, ectopic pancreas, sarcoidosis There were no immediate or early complications in all cases.ConclusionsHybrid EUS in Covid 19 Era has emerged as a useful/cost-effective and safe approach to get tissue yield without the need for ROSE.

Implementing a database to track patients’ compliance in the high-risk pancreatic cancer clinic

BackgroundPancreatic cancer is projected to become the second leading cause of cancer death in the United States by 2030. Screening of high-risk individuals (HRI’s) using endoscopic ultrasound (EUS) or magnetic resonance imaging (MRI), specifically magnetic resonance cholangiopancreatography (MRCP), saves lives and reduces morbidity and mortality. Screening can detect surgically resectable lesions, which is key to survival since most lesions present as unresectable or metastatic. The specific aims of this project were to address the quality improvement process to track adherence of the patients who participate in the high-risk pancreatic cancer clinic at UMass Memorial Healthcare.MethodsPatients deemed to be high risk according to the Cancer of the Pancreas Screening (CAPS) Consortium Guidelines included having at least one first-degree relative with a diagnosis of pancreatic cancer, a genetic mutation that places them at higher risk for pancreatic cancer, or both are the cohort. The data was collected via EMR using REDCap, a secure web application to analyze high-risk patients’ adherence with yearly screening. The method utilized a quality improvement project design.ResultsResults demonstrated a majority of participants were female, 53% had a first-degree relative with pancreatic cancer, a majority of participants did not carry a genetic mutation while the highest mutation finding included 16 participants (14.4%) with a BRCA 2 gene mutation. A majority of participants, 64.9% (n=72) were non-compliant with screening while 35% (n=39) had yearly screening. Participants who were non-adherent with screening endorsed multiple factors for non-adherence including not believing surveillance was necessary, not qualifying for screening at the time of initial appointment, not receiving reminder phone calls for clinic appointments and surveillance imaging, other health concerns, high insurance deductibles, the COVID pandemic, and high anxiety.ConclusionsMitigation of the reasons for non-adherence is a crucial practice implication. Patient education regarding the importance of long-term yearly screening and teaching patients self-efficacy behaviors may improve screening adherence. Prospectively analyzing compliance will reduce missed care opportunities. Health care policies must be amended to require insurance companies to cover the screening of HRI’s.