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Ultrasound-guided fine-needle aspiration cytology (FNAC) is a commonly performed procedure and often the first line of diagnostic testing for patients presenting with a head and neck swelling. This technique yields a high accuracy rate and is recommended by NICE guidance. The head and neck ultrasound waiting list, consequently, has always highlighted capacity issues and this became more pronounced during Covid-19 due to the temporary cancellation of clinics. The aim of training a sonographer was to reduce the ultrasound waiting list and allow the radiologists more time in other areas, such as reporting cross-sectional imaging. The aim of this study was to document how training was undertaken, and whether FNAC success rates were comparable to those performed by radiologists. In-house training was undertaken over a 12-month period by three consultants in an acute and outpatient setting. A retrospective audit was performed of FNAC outcomes, comparing sonographer and radiologist non-diagnostic rates over an 18-month period. Statistics of the ultrasound waiting list were also analysed over this period. 250 FNAs performed by a sonographer were analysed. Results showed a 71% conclusive rate. This was compared to a previous 4-year audit, undertaken by radiologists within the department. The comparison study analysed 1222 FNAC samples and demonstrated a non-diagnostic sample of 27.2%. This was compared with the RCR live audit, which expects a 70% diagnostic rate for FNAC samples of the thyroid. This study demonstrated comparable FNAC results between a sonographer and consultant radiologist. Statistics also showed a decrease in the ultrasound waiting list, from 310 patients to 114 patients in the past 18 months. It is possible to train a sonographer to become proficient in head and neck scanning with FNAC and for cytology rates to be comparable to that of a radiologist. The study showed a positive impact on the ultrasound waiting list.
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Lymphangitis carcinomatosa refers to pulmonary interstitial involvement by cancer and is a dreaded clinical finding in oncology because it is a late manifestation indicative of metastatic malignancy, from either a lung or a nonlung primary cancer, and is associated with poor prognosis. Its presentation is nonspecific, often with subacute dyspnoea and a nonproductive cough in a person with a known history of malignancy, but in some cases is the first manifestation of cancer. CT imaging can be suggestive, typically demonstrating thickening of the peribronchovascular interstitium, interlobular septa and fissures. However, a biopsy may be required to confirm the pathological diagnosis as these changes can also be due to concurrent disease such as heart failure, ILD, infection, radiation pneumonitis and drug reactions. Diagnosis allows symptomatic treatment, with personalised treatment directed towards the primary cancer most likely to provide a meaningful benefit. Future research should focus on prospective clinical trials to identify new interventions to improve both diagnosis and treatment of lymphangitis carcinomatosa.Copyright © ERS 2021.
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Introduction: Primary Pancreatic Lymphoma (PPL) is the exceedingly rare instance of extranodal Non-Hodgkin's Lymphoma developing mainly in the pancreas.We report a diagnostically challenging case of a patient presenting with a rapidly growing pancreatic mass, found to have PPL. Case Description/Methods: A 48-year-old female with past history of tobacco use presented with several months of cramping abdominal pain following COVID-19 infection. She denied weight loss, fevers, or night sweats. Her physical exam, CBC, CMP, lipase, LDH, and CA 19-9 were unremarkable. An abdominal ultrasound revealed a 2.8 x 1.9 x 3 cm cystic mass of the pancreatic head, most congruent with a pseudocyst. Worsening abdominal pain prompted repeat ultrasound one month later, which showed a doubling in size. Endoscopic ultrasound (EUS) with fine needle aspiration of the cystic mass and surrounding lymph nodes yielded cystic contents and reactive lymphadenopathy. Two months later, her abdominal pain worsened and repeat imaging showed further doubling in size with encasement of the celiac plexus. A second FNA performed via EUS redemonstrated cystic contents. An ultrasound-guided core needle biopsy of the mass revealed necrotic CD301 diffuse large B cell lymphoma (DLBCL). PET scan was suggestive of stage IV PPL (Figure). Imaging also identified an inguinal lymph node that returned as CD101 BCL61 high grade follicular lymphoma, which was thought to be a distinct lesion. She was started on R-CHOP. Her clinical course was complicated by the formation and subsequent rupture of a splenic artery pseudoaneurysm, gastrointestinal bleeding, anuric kidney injury, and intestinal ischemia. She ultimately transitioned to comfort care. Discussion(s): Primary pancreatic lymphoma comprises 0.6% of extranodal lymphomas and 0.2% of primary pancreatic tumors. The clinical presentation is often vague and includes abdominal pain, B symptoms, jaundice, or bowel obstruction. The diagnostic criteria according to the WHO requires that the (1) majority of tumor burden be localized to the pancreas and (2) existing nearby and distant lymph node involvement should be secondary to pancreatic presentation. A biopsy is required to diagnose PPL, which is histologically most often DLBCL. Our case highlights the challenges associated with diagnosing PPL despite two EUS with FNA. Although rare, one should proceed with a high index of suspicion for PPL in any patient presenting with a rapidly enlarging pancreatic mass.
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Introduction: Wolman disease is a rare genetic disorder with an autosomal recessive inheritance. A mutation in the LIPA gene causes lysosomal acid lipase (LAL) deficiency results in lipid storage and adrenal insufficiency. Death in early infancy is due to liver failure. Patients and methods: We describe the clinical course of a three-month-old infant diagnosed with Wolman disease. A rapid mutational analysis confirmed a LIPA gene defect. Results: He underwent matched unrelated donor peripheral blood stem cell hematopoietic stem cell transplantation (HSCT) at 3 months of age, with a treosulfan-based conditioning, which resulted in engraftment with donor-derived hematopoietic cells. He required supportive care for sinusoidal obstruction syndrome and mucositis. He was administered low dose prednisolone for grade I skin graft versus host disease, and a complete donor chimerism was documented on several occasions. At one year post HSCT, his growth and development were optimal, and there was no hepatosplenomegaly. He is maintained on glucocorticoid and mineralocorticoid supplements for primary hypoaldosteronism. Conclusion: The case emphasizes the timely diagnosis and the potential for successful treatment of Wolman disease by HSCT. © 2022 Pediatric Hematology Oncology Chapter of Indian Academy of Pediatrics
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Background Development of immunotherapy/molecular targeted therapy has significantly increased survival/QoL in advanced stages of NSCLC. Aim(s): to analyze outcome predictors, surrogate outcomes, and PROMs after neoadjuvant immunotherapy for initially unresectable NSCLC. Methods Initially unresectable NSCLC (2014-2021) patients who received immunotherapy +/- platinum-based chemo and/or radiotherapy evaluated after response (reduction of primary tumor and/or mediastinal lymphadenopathy/control of distant metastatic disease underwent surgical resection). PROMs were recorded using EORTC QLQ-29. Results 19 underwent salvage surgery after ICI. 14 had partial response (73.6%), 5 stable disease. Diagnosis was achieved by endobronchial ultrasound (EBUS) in 8 (42.1%), fine-needle aspiration biopsy (FNAB) in 7 (36.8%), metastasis biopsy in 4 (21.0%). 11 (57.9%) were treated with neoadjuvant platinum-based chemo before or with ICI, 1 (5.2%) pemetrexed before ICI, 5 (26.3%) radiotherapy for metastatic control. 3 (15.7%) had ICI adverse effects. Radiotherapy was never used preoperatively for pulmonary/mediastinal disease. 7 (36.8%) received adjuvant therapy (5 [26.3%] pembrolizumab, 1 [5.2%] pemetrexed, 1 [5.2%] pemetrexed + pembrolizumab). 4 (21.0%) had local relapse (no systemic relapse). Median OS was 19 months (range: 2-57.4). At 2 months, 94.7% were alive (6 months: 89.5%;31 months: 79.5%). 2 (10.5%) had local recurrence. 2 (10.5%) died due to recurrence, 1 (5.2%) to COVID. 4 (21.0%) relapsed (median DFS: 5.3 months [range: 2.2-13.0]). PROMs were reviewed retrospectively at 30 days/1 year with significant decrease in coughing, side effects of treatment, surgery-related problems. [Formula presented] Conclusions Radical surgical resections following definitive immunotherapy/immune-chemotherapy in selected initially unresectable NSCLC are feasible and safe (low surgical-related mortality and morbidity). Symptoms and surgery-related outcomes were lower with higher QoL due to a selected group of highly motivated patients. Legal entity responsible for the study The authors. Funding Ministero della Salute. Disclosure All authors have declared no conflicts of interest.Copyright © 2023 International Association for the Study of Lung Cancer. Published by Elsevier Inc.
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Background: In India, less than 5% of women get routine screening for breast cancer due to lack of awareness and the absence of a coordinated national breast cancer screening programme. A community health initiative was launched by Niramai in collaboration with City Health officials in Bangalore as a pilot to increase awareness and make breast health screening available to all. Free breast cancer screening using AI powered Thermalytix test is being offered to all the underprivileged women walking into Bruhat Bengaluru Mahanagara Palike (BBMP) government hospitals from November 14, 2017 till today (after a break for 15 months during COVID). Material(s) and Method(s): This observational study was conducted in 22 BBMP-affiliated primary health centers where outpatient women over the age of 18 years and not pregnant were enrolled. The procedure included a briefing on camp procedures, taking patient consent, identification of eligible candidates, general health education, and conducting the Thermalytix test by a healthcare worker who was trained to use the Thermalytix software tool. Women were triaged using the output generated by Thermalytix 180. Those triaged as red were referred for further detailed imaging investigation in a district hospital using mammography, ultrasound and FNAC/biopsy. Result(s): A total of 6935 women underwent Thermalytix screening in 22 BBMP hospitals during Nov 2017 to July 2022. A total of 1687 participants were excluded from the analysis as they did not meet the eligibility criteria. The median age of the 5248 eligible participants was 42 years (range 18-86). Among them, 90 women (1.71%) had previously noticed a lump in their breast, 431 women (8.12%) had breast pain, 16 women had complained of nipple discharge, and 5 women had noticed skin discoloration. When screened, 62 (1.2%) women were detected with abnormalities and triaged positive by Thermalytix. Among them 11 women have so far gone through diagnostic investigations, of which 8 were radiologically positive and were recommended for histopathology correlation. The overall test positivity rate of Thermalytix in this cohort was 1.2% and positive predictive value with radiological positivity as reference was found to be 9/11 = 81.81%. Furhter histological analysis reported 1 DCIS and 8 benign fibroadenoma. The tests were conducted in screening camps and the average cost of conducting the test in the field came to around 6.5 USD per person. Conclusion(s): Thermalytix could be a potential automated screening tool for population-level screening in resource constrained settings. The portable equipment enabled easy movement across different PHCs. Since it is a privacy-aware test, there was less refusal to participate in the test. Community mobilization with the help of the local government health officials was crucial to ensure walk-ins. Conflict of interest: Ownership: yes Board of Directors: yes Corporate-sponsored Research: yesCopyright © 2022 Elsevier Ltd. All rights reserved
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Circulating tumor DNA is a liquid biomarker that offers a highly specific method to assess HPV-associated tumor burden via a blood draw. It has the potential for many clinical applications in cancer care, including prognostication, monitoring treatment response, and surveillance for disease recurrence. In this case report, we present a case of recurrent HPV-associated hypopharyngeal squamous cell carcinoma first detected by circulating tumor HPV DNA that demonstrates the role of circulating tumor HPV DNA tests in posttreatment surveillance and the utility of HPV testing in all HPV-mediated tumors, regardless of subsite.Copyright © 2023 Elsevier Inc.
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Introduction: The percentage of pathology trainees who are underrepresented minorities is low. The DEI committee established a Science, Medicine, and Cytology summer pilot program to improve exposure to cytopathology focusing on DEI. Material(s) and Method(s): An online course was developed during the Covid-19 pandemic targeting underrepresented minorities at the high school and college level, and consisted of several didactic sessions, presenting the most common procedures involving cytologists, including fine-needle aspiration, rapid onsite evaluation, and smearing techniques. Interviews of cytopathologists were also included. Participants were surveyed for their demographic information and for an evaluation of the course. Result(s): 23 participants completed the survey (Table 1). The highest level of education was high school 16 (70%), college 6 (26%), and other 1 (4%). Self-identified demographics included 2 (9%) Hispanic, 9 (36%) Asian/Asian American, 2 (8%) Black / Black American, 6 (24%) White/Caucasian, 2 (8%) African, 1 (4%) Muslim American and 1 (4%) Sudanese. Household highest level of education was high school 2 (9%), some college 1 (4%), completed college 9 (39%), completed graduate program 9 (39%), 2 (9%) preferred not to answer. 14 (61%) participants have a family member in healthcare. The program met expectations for 20 (87%). The program format was effective and appropriate for their level of education for 23 (100%). The content helpful for 22 (96%). 13 (57%) considered healthcare as a potential career. 5 (22%) considered cytology as a career (Table 2). Conclusion(s): Evaluations were excellent, generating awareness of medicine and cytopathology. Individuals with families in healthcare were overrepresented, as there were barriers in reaching underrepresented minorities. The population that signed up was influenced by our ability offer the course online. Expansion to a wider audience would increase the number of attendees. (Table Presented).
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Pneumomediastinum in COVID-19 critically ill patients Introduction: Pneumomedisatinum(PM) is an uncommon potentially life-threatening complication of COVID-19 and can be an aggravating factor. This study aimed to determine the incidence and outcomes of PM in critically ill COVI19 patients. Method(s): A retrospective study carried out in a 9-bed intensive care unit from October 1st, 2020 to February 28, 2021 including patients with confirmed COVID19 related acute respiratory distress syndrome (ARDS) with confirmed PM on Chest computed tomography (CT). Were recorded patients characteristics, management and outcomes. Result(s): 7 cases of PM were reported : 5 men, 2 women, aged between 47 and 70 years-old. None of them had underlying lung disease. 4 patients were under invasive mechanical ventilation (IMV), 2 under non-invasive ventilation (NIV) and one had a spontaneous PM at the time of the event. Chest CT scan showed : pulmonary involvement, moderate (n=4/7) to severe (n=3/7), PM (n=7/7), subcutaneous emphysema (n=5/7) and pneumothorax (n=2/7). The highest positive end-expiratory pressure (PEEP) for patients receiving IMV and NIV were respectively 10cmH2O and 6cmH2O. Urgent mediastinal decompression wasn't immediately indicated, conservative therapy with reduced airway pressure was adopted. Patients with NIV were intubated after NIV failure. Despite protective ventilation with lower pressure, needle aspiration and chest drainage, all patients expired during their hospital stay. Conclusion(s): Our findings suggest that PM is secondary to inflammatory response due to COVID-19 and mostly triggered by the use of positive pressure ventilation and it is associated with poor outcome in critically ill COVID-19 patients.
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The proceedings contain 158 papers. The topics discussed include: use of cumulative sum in the assessment of diagnostic competency of cytopathology fellows;what's up in Whatsapp - telecytopathology experience connecting rural districts of Punjab to a tertiary care center in India;ballistic gel model for ultrasound-guided fine needle aspiration: a cost-effective method for simulation training;science, medicine, and cytology: a pilot program of the ASC diversity equity and inclusion (DEI) committee;comparison of low-cost phantoms for ultrasound guided fine needle aspiration biopsy teaching;deep learning algorithm for malignant pleural fluids cytology;application of international system for reporting serous fluid cytology (ISRSFC) in effusion samples - a prospective study;evaluation of 'crowd wisdom' in biliary brush cytology;characterization of the cellular composition of malignant pleural effusion specimens for clinical applications: preliminary study;and diagnostic criteria for COVID-19 pneumonia in broncho-alveolar lavage specimens.
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Introduction: The telemedicine center of our hospital provides expert consultation services to two rural districts of Punjab. The aim of this study was to assess its utility in Fine needle aspiration Cytology (FNAC) diagnostic service. Material(s) and Method(s): A 2-year retrospective audit from April 2020-2022 covering the COVID pandemic time was carried out on all cases of telecytopathology consultation files of the E-sanjeevani platform. A total of 75 cases whose FNAC smear images clicked by android smartphones with 48MP cameras and sent by Whatsapp to the E-Sanjeevani administrator were included. The images along with brief case clinical details were e-mailed for expert opinion to the cytopathologist (RS). The image quality, ability to provide a diagnosis, site-wise differences and comparison of the referral and expert review diagnosis was made. Result(s): The ages of the patients ranged from 4-80 years (2 children, 73 adults), with 25 males and 50 females. The sites of FNA performed at the district hospital were lymph nodes (22), breast (21), thyroid (15), soft tissue (8), salivary gland (2), skin (4), lip (2) and glans penis (1). The number of Whatsapp images evaluated ranged from 3-20 with median of 11 per case. They were in JPEG file format with size ranging from 40-163kb. Image quality was rated visually as good, medium, and poor in 46 (61%), 21m (28%) and 8(11%) cases respectively. There was no distortion of images upon enlarging them for better visualization on a large monitor. Best accuracy was obtained in breast and lymph nodes FNA. Soft tissue FNA was difficult to interpret and was inconclusive in 3/8 cases. Conclusion(s): Telecytopathology by Whatsapp is simple, quick, feasible and very useful to provide expert opinion in FNAC of various sites thereby enabling the pathologist in the district hospital setting. (Figure Presented).
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The worldwide rollout of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccinations in the last 2 years has produced a multitude of studies investigating T-cell responses in the peripheral blood and a limited number in secondary lymphoid tissues. As a key component to an effective immune response, vaccine-specific T follicular helper (Tfh) cells are localized in the draining lymph node (LN) and assist in the selection of highly specific B-cell clones for the production of neutralizing antibodies. While these cells have been noted in the blood as circulating Tfh (cTfh) cells, they are not often taken into consideration when examining effective CD4+ T-cell responses, particularly in immunocompromised groups. Furthermore, site-specific analyses in locations such as the LN have recently become an attractive area of investigation. This is mainly a result of improved sampling methods via ultrasound-guided fine-needle biopsy (FNB)/fine-needle aspiration (FNA), which are less invasive than LN excision and able to be performed longitudinally. While these studies have been undertaken in healthy individuals, data from immunocompromised groups are lacking. This review will focus on both Tfh and cTfh responses after SARS-CoV-2 vaccination in healthy and immunocompromised individuals. This area of investigation could identify key characteristics of a successful LN response required for the prevention of infection and viral clearance. This furthermore may highlight responses that could be fine-tuned to improve vaccine efficacy within immunocompromised groups that are at a risk of more severe disease.
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COVID-19 , T-Lymphocytes, Helper-Inducer , Humans , Adult , COVID-19 Vaccines , SARS-CoV-2 , T Follicular Helper Cells , COVID-19/prevention & control , VaccinationABSTRACT
COVID-19 vaccine-associated clinical lymphadenopathy (C19-LAP) and subclinical lymphadenopathy (SLDI), which are mainly detected by 18F-FDG PET-CT, have been observed after the introduction of RNA-based vaccines during the pandemic. Lymph node (LN) fine needle aspiration cytology (FNAC) has been used to diagnose single cases or small series of SLDI and C19-LAP. In this review, clinical and LN-FNAC features of SLDI and C19-LAP are reported and compared to non-Covid (NC)-LAP. A search for studies on C19-LAP and SLDI histopathology and cytopathology was performed on PubMed and Google Scholar, on 11 January 2023. Reports on LN-FNAC of C19-LAP were retrieved. A total of 14 reports, plus one unpublished case of C19-LAP observed in our institution, diagnosed by LN-FNAC were included in a pooled analysis and compared to the corresponding histopathological reports. In total, 26 cases were included in this review, with a mean age of 50.5 years. Twenty-one lymphadenopathies assessed by LN-FNAC were diagnosed as benign, and three cases as atypical lymphoid hyperplasia; the latter were subsequently confirmed as benign (one by repetition of LN-FNAC, two by histological control). One case of mediastinal lymphadenopathy in a patient suffering from melanoma was reported as reactive granulomatous inflammation, while one unsuspected case was diagnosed as metastasis from melanoma. In all cases, the cytological diagnoses were confirmed by follow-up or excisional biopsy. The high diagnostic value of LN-FNAC in excluding malignant processes was extremely useful in this context and may be particularly valuable when CNB or histological excisions are difficult to perform, as was the case during Covid lockdowns.
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BACKGROUND AND AIMS: Rapid On-Site-Evaluation (ROSE) with an in-room pathologist (ROSE-P) has been shown to improve the diagnostic yield of specimens obtained from patients undergoing Endoscopic Ultrasound fine needle aspiration or biopsy (EUS-FNAB) of pancreatic lesions. Recently, there has been an increased interest and utilization of Telecytology (ROSE-T) to optimize clinical workflows, and to address social distancing mandates created during the COVID-19 pandemic. The purpose of this study is to compare diagnostic outcomes of ROSE-P and ROSE-T. METHODS: A single center cohort study of patients who underwent EUS-FNAB of solid pancreatic lesions with ROSE was conducted. The primary outcome was overall diagnostic yield of cancer. All patients who underwent EUS-FNA were entered into a prospectively maintained database. Statistical analyses were performed using descriptive statistics and univariate analysis. RESULTS: There were 165 patients in each arm. There was no difference in diagnostic yield between ROSE-P and ROSE-T (96.4% vs 94.5%, p=.428). ROSE-T was associated with increased use of 22-gauge needles (p=.006) and more needle passes (p<.001). There was no significant difference in age, gender, lesion size, needle type, procedure times, or adverse events between the two groups (p<.05 for all). There were more pancreatic tail lesions sampled in the ROSE-P group (p<.001). CONCLUSION: Rapid on-site evaluation using Telecytology was not associated with any difference in final histologic diagnosis for EUS-FNAB of solid pancreatic masses. This has important implications for optimizing clinical workflows.
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Introduction: The COVID-19 pandemic (COVID-19) affected digestive endoscopic activity worldwide. Resumption and maintenance of elective endoscopic activity are crucial to containing the impact of COVID-19 on mortality and prognosis of gastrointestinal disorders, primarily cancers. Aim: To assess the impact of COVID-19 during and after the lockdown period on endoscopic activity. Material and methods: The endoscopic activity undertaken during the COVID-19-related lockdown (March 2020-May 2020) and in the post-lockdown period (June 2020-March 2021) was compared with that in the corresponding periods of the year before COVID-19 in a gastroenterology centre in Italy. Results: During the lockdown period, there was a reduction in esophagogastroduodenoscopy (EGD), colonoscopy (CSPY), endoscopic ultrasound (EUS), and endoscopic-retrograde cholangiopancreatography (ERCP) of 75.8%, 74.8%, 60%, and 42%, respectively, compared with the corresponding period of the year before COVID-19. During the post-lockdown period to date, EGD, CSPY, EUS, and ERCP increased as compared to the lockdown period (30.6%, 50.6%, 33.6%, and 65.4%, respectively), but only ERCP showed a full recovery when compared with the corresponding period of the year before COVID-19. Conclusions: Endoscopic activity decreased significantly during the COVID-19 lockdown, and only ERCP had a full recovery in the post-lockdown period. The pandemic-related limitations and the backlog of endoscopic procedures represent important reasons for the increased risk or delayed diagnosis of GI cancers.
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In December 2019, the new coronavirus infection (COVID-19) was declared a pandemic by the World Health Organization after rapidly spreading over the world in just a few months. All elective operations and nonemergency treatments have been postponed worldwide. However, some patients require surgical therapy as well, and the time spent waiting should not have a negative impact on the surgical outcome or disease course. Following the initial onset of the COVID-19 epidemic, instructions for proper and safe surgery for healthcare staff and patients should develop. Thyroid surgeries have decreased during the COVID-19 pandemic. Most of them can be postponed for a long time. Assessment of thyroid nodules recommends clinical examination, imaging studies, fine needle aspiration (FNA) and vocal cord examination. All these procedures are necessary, and sometimes they cannot be postponed. To determine the best timing, a thorough preoperative assessment should be undertaken, taking into account both oncological and anatomical features. Furthermore, COVID-19 status must be negative prior to any intervention, and hospital infrastructure must be ready to deal with the demanding situation.
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Introduction: The COVID-19 pandemic delayed the diagnosis, treatment, and follow-up visits of patients with thyroid cancer. However, the magnitude with which these restrictions affected the Brazilian health care is still unknown. Methods: Retrospective analysis of thyroid cancer-related procedures performed in the Brazilian public health system from 2019 to 2021. Data were retrieved from the Department of Informatics of the Unified Health System (DATASUS). The following procedures were evaluated: fine-needle aspiration biopsies (FNABs), oncologic thyroidectomies, and radioiodine (RAI) therapies for thyroid cancer. The year of 2019 served as baseline control. Results: Compared with 2019, FNABs, oncologic thyroidectomies, and RAI therapies performed in 2020 decreased by 29%, 17% and 28%, respectively. In 2021, compared with 2019, FNABs increased by 2%, and oncologic thyroidectomies and RAI therapies decreased by 5% and 25%, respectively. Most pronounced reductions were observed in the first months of the pandemic. In April 2020, FNABs decreased by 67%, oncologic thyroidectomies by 45%, and RAI therapies by 75%. In 2021, RAI therapies were the only procedure with a statistically significant decrease. Conclusion: The restrictions to public health care during the COVID-19 pandemic resulted in a significant reduction in diagnostic and treatment procedures for thyroid cancer in Brazil. The effects of these transitory gaps in thyroid cancer care, due to COVID-19, are still unclear.
Subject(s)
COVID-19 , Thyroid Neoplasms , Humans , Brazil/epidemiology , COVID-19/diagnosis , COVID-19/epidemiology , COVID-19/therapy , Pandemics , Iodine Radioisotopes , Retrospective Studies , Thyroid Neoplasms/diagnosis , Thyroid Neoplasms/epidemiology , Thyroid Neoplasms/therapyABSTRACT
Introduction: Access to high-quality, comprehensive, subspecialty care is challenging in rural health care settings under ideal circumstances. In the clinically restricted environment created by the SARS-CoV-2 pandemic, this has been even more problematic. The regional distribution of a broad patient demographic across multiple tertiary care centers within a large rural health care system presents unique challenges. Here we describe our system platform for the management of a large population of thyroid patients across an expansive rural health system during the pandemic. Method(s): This retrospective review was approved by our institutional review board. Patients undergoing surgical management of thyroid and parathyroid disease were identified using a system electronic medical record via Current Procedural Terminology codes. Applications essential for management of these patients included implementation of an endocrine database, utilization of a multidisciplinary thyroid cancer tumor board, and coordination of regional patient access through the Geisinger System Program for Thyroid and Parathyroid Disorders. Result(s): We identified 930 endocrine surgical cases at our institution managed over the past 3 years. A total of 281 patients have been reviewed thus far. A total of 185 thyroid surgeries were performed on 173 patients. Final pathology was benign in 99 (53.5%) patients;77 (41.6%) were welldifferentiated thyroid carcinomas. The average elapsed days from fine needle aspiration biopsy to surgery was 54.8 (with those >100 days excluded). Average elapsed days from biopsy to surgery in patients with molecular testing was 61.5 days compared with 49.9 days for those without molecular testing. These 2 averages were significantly different from each other (P=.02) but not from the overall average. Conclusion(s): In this presentation, the effective management of a large population of thyroid patients is demonstrated through the utilization of several critical clinical applications. We propose a care delivery scheme for the evaluation and management of thyroid patients utilizing multiple clinical access points together with a multidisciplinary program for endocrine disease management.
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SESSION TITLE: Tales in Bronchoscopy SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: Peripheral pulmonary nodule biopsy can be challenging based on its location and size. Robotic bronchoscopy is augmenting peripheral navigation, allowing for approximation of peripheral nodules. The diagnostic yield is variable and is primarily dependent upon operator experience, selection of biopsy equipment and nodule texture. Hard pulmonary nodules are difficult to biopsy with a needle, brush and forceps. We report a case of utilizing combined disposable 1.1 mm cryoprobe and robotic bronchoscopy to diagnose a right lower lobe nodule. CASE PRESENTATION: A 83-year-old woman with a remote history of non-Hodgkin's lymphoma presented with dyspnea and fatigue. 18F-FDG PET/CT revealed a 2.7 cm hypermetabolic nodule with central photopenia in the right lower lobe (RLL) along with patchy bilateral ground-glass opacities related to COVID-19 infection. After a few weeks, robotic navigation was used for approximation of the RLL superior segment nodule. Under fluoroscopic and radial guidance with circumferential signal, 6 forcep biopsies and 5 fine needle aspirations with 21-gauge needle yielded a non-diagnostic sample. A decision was made to utilize a 1.1 mm disposable cryoprobe, which was inserted through the opening made by the forceps into the target lesion. Six cryo biopsies were obtained with 4-6 seconds freeze time. Minimal bleeding was encountered and no pneumothorax occurred. Histopathological examination revealed necrotizing granulomatous inflammation. DISCUSSION: To the best of our knowledge, this is the first reported case of combination 1.1 mm disposable cryoprobe biopsy with robotic bronchoscopy. Interventional pulmonologists are primarily using cryo probe for mechanical tumor debulking and peripheral lung biopsy for diagnosis of interstitial lung disease. The use of a 1.1 mm cryoprobe under robotic guidance allows for well-preserved tissue samples and possibly boosting diagnostic yield. The advantage of the 1.1 mm cryoprobe lies with its size and excellent flexibility. The robotic platform also corrects for any unwanted deflection. One limitation of using a flexible cryoprobe is its blunt tip, requiring an additional step in gaining access to nodules located outside the airway with either the biopsy needle or forceps. Future improvements in cryoprobe design with a sharp tip may address this limitation. CONCLUSIONS: Combining 1.1 mm disposable cryoprobe with robotic bronchoscopy is safe and can be considered as an adjunct to conventional biopsy, allowing for well-preserved tissue. Further prospective studies to evaluate its performance and safety is warranted. Reference #1: Kho SS, Chai CS, Nyanti LE, et al. Combination of 1.1 mm flexible cryoprobe with conventional guide sheath and therapeutic bronchoscope in biopsy of apical upper lobe solitary pulmonary nodule. BMC Pulm Med. 2020. 158(20). doi.org/10.1186/s12890-020-01199-3 Reference #2: Chen AC, Pastis NJ Jr, Mahajan AK, et al. Robotic Bronchoscopy for Peripheral Pulmonary Lesions: A Multicenter Pilot and Feasibility Study (BENEFIT). Chest. 2021;159(2):845-852. doi:10.1016/j.chest.2020.08.2047 Reference #3: Sahajal Dhooria, Inderpaul Singh Sehgal, Ashutosh NA Digambar Behera, Ritesh Agarwal. Diagnostic Yield and Safety of Cryoprobe Transbronchial Lung Biopsy in Diffuse Parenchymal Lung Diseases: Systematic Review and Meta-Analysis. Respiratory Care. 2016. 61(5):700-712. doi.org/10.4187/respcare.04488 DISCLOSURES: No relevant relationships by Sailendra Chundu No relevant relationships by Moiz Javed No relevant relationships by Abid Khokar No relevant relationships by Ali Saeed No relevant relationships by Andrew Talon No relevant relationships by Melinda Wang
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SESSION TITLE: Critical Systemic Disease Case Report Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Granulomatosis with polyangiitis(GPA) is an autoimmune small vessel vasculitis that is included in the group of anti-neutrophilic cytoplasmic antibody(ANCA)- associated small vessel vasculitides (AAVs). GPA is a systemic disease, however acronym ELK is used to describe the most common involvement of Ear, nose, throat, Lungs, and Kidneys. We report a case of GPA, highlighting its presentation. CASE PRESENTATION: 59-year old female presented with vaginal bleeding, malaise, blurry vision, non productive cough and shortness of breath few days after receiving COVID-19 vaccine. Physical exam was remarkable for bilateral conjunctival injection with right sided ptosis and inguinal lymphadenopathy. Laboratory findings were significant for acute kidney injury and anemia. Computed tomography (CT) of chest revealed bilateral bronchovascular nodules and masses with interlobular septal thickening and enlarged mediastinal lymph nodes. Fine needle aspiration of left inguinal lymph node was negative for malignancy. Bronchoscopy with bronchial brush revealed alveolar hemorrhage with capillaritis;bronchoalveolar lavage(BAL) showed hemosiderin laden macrophages. Tissue biopsy was negative for malignancy. Testing for pulmonary renal syndrome was positive for C-ANCA and proteinase-3 (PR-3) antibodies. Anti-GBM antibody and anti-MPO antibody was negative. Plasmapheresis (PLEX) and pulse dose steroids were initiated however the patient was unable to tolerate the treatment. Her clinical condition continued to decline requiring multiple pressors, broad spectrum antibiotics and continuous renal replacement therapy. She was transitioned to comfort care per family's wishes and passed away. DISCUSSION: GPA is a rare necrotizing granulomatous vasculitis of small to medium sized vessels that can affect any organ but mainly involves the upper and lower respiratory tract. Necrotizing glomerulonephritis is common. Pulmonary involvement can include consolidation, tracheal or subglottic stenosis, diffuse alveolar hemorrhage, pleural effusion and interstitial lung disease. Lymphadenopathy, as seen in our patient is a rare presentation. Tissue biopsy is crucial for the diagnosis. Association with PR-3 ANCA is seen in more than 80% of GPA patients. Cases of AAVs after administration of COVID vaccine have been reported in the literature, although it is difficult to demonstrate causal relationship. Treatment of GPA with immunosuppression, usually corticosteroids, rituximab or cyclophosphamide, is recommended. The role of PLEX continues to evolve with emerging data, but use of this therapy is reasonable for patients with severe kidney injury and DAH secondary to active vasculitis refractory to immunosuppressive therapy. CONCLUSIONS: Early diagnosis of GPA is challenging as it can mimic metastatic lung malignancy. It should be considered in a broad range of differentials when evaluating patients presenting with pulmonary nodules. Reference #1: Greco A, Marinelli C, Fusconi M, Macri GF, Gallo A, De Virgilio A, Zambetti G, de Vincentiis M. Clinic manifestations in granulomatosis with polyangiitis. Int J Immunopathol Pharmacol. 2016 Jun;29(2):151-9. doi: 10.1177/0394632015617063. Epub 2015 Dec 18. PMID: 26684637;PMCID: PMC5806708. Reference #2: Kitching, A. R., Anders, H. J., Basu, N., Brouwer, E., Gordon, J., Jayne, D. R., Kullman, J., Lyons, P. A., Merkel, P. A., Savage, C., Specks, U., & Kain, R. (2020). ANCA-associated vasculitis. Nature reviews. Disease primers, 6(1), 71. https://doi.org/10.1038/s41572-020-0204-y Reference #3: Szymanowska-Narloch, A., Gawryluk, D., Błasińska-Przerwa, K., & Siemińska, A. (2019). Atypical manifestations of granulomatosis with polyangiitis: the diagnostic challenge for pulmonologists. Advances in respiratory medicine, 87(6), 244–253. https://doi.org/10.5603/ARM.2019.0062 DISCLOSURES: No relevant relationships by Sean Davidson No relevant relationships by Eric Flenaugh No relevant relationships by Marilyn Foreman No relevant relationships by KOMAL KAUR No relevant relationships by Gabriela Oprea-Ilies