Paz‐Fumagalli, Ricardo

ABSTRACT A previously healthy 29-year-old man presented with abdominal pain and was found to have a liver mass with periductal infiltration and a stricture of the common bile duct, concerning for cholangiocarcinoma. Hepatic function panel disclosed alanine transaminase 293 U/L, aspartate aminotransferase 122 U/L, γ-glutamyl transferase 2019 U/L, normal total bilirubin, carcinoembryonic antigen, and carbohydrate antigen 19-9. Biopsy established the diagnosis of diffuse large B-cell lymphoma, with no underlying hepatic disease. He was started on polatuzumab-rituximab-cyclophosphamide-doxorubicin-prednisone chemotherapy and achieved complete tumor response. This case highlights the importance of a thorough evaluation of liver tumors and the critical role of tissue diagnosis.

PIK3CA-related overgrowth spectrum (PROS) encompasses rare disorders characterized by vascular malformations and predisposition to thrombotic complications. COVID-19 has been associated with diverse cutaneous manifestations through endothelial dysfunction and microvascular thrombosis. We present a 33-year-old female with PROS and extensive capillary malformations who developed multiple cutaneous ulcerations on her affected right leg exclusively during COVID-19 infection in 2020, with complete resolution following recovery. Preexisting endothelial abnormalities and thrombotic predisposition in PROS may create heightened vulnerability to COVID-19-induced vascular injury, explaining why cutaneous manifestations occurred exclusively in zones of capillary malformation. This susceptibility may be mediated by the Phosphoinositide 3-kinase/ Protein kinase B/ mechanistic target of Rapamycin (PI3K/AKT/mTOR) pathway, which regulates cell growth and vascular homeostasis, is constitutively activated in PROS, and is exploited by SARS-CoV-2 during infection. Clinicians managing patients with vascular malformations should be aware of this potential interaction.

Introduction Endovascular abdominal aortic aneurysm repair (EVAR) is the primary treatment for abdominal aortic aneurysm (AAA). Despite favorable early outcomes, lifelong surveillance is essential as endoleaks remain a major cause of reintervention. Among these, type II endoleaks (T2E) remain controversial regarding optimal management. This study aimed to identify factors associated with intervention for T2E using time-to-event analysis and predefined anatomic thresholds. Secondary objectives included comparing outcomes between T2E patients with (intT2E) and without (nointT2E) intervention. Methods A retrospective review of EVAR procedures from 2011-2024 was performed. Patients with newly diagnosed or persistent T2E were identified on completion and follow-up CT angiography. Patients were categorized as intT2E or nointT2E. Multivariable Cox regression evaluated time to first intervention, and logistic regression served as sensitivity analysis. Kaplan-Meier curves assessed freedom from intervention by inferior mesenteric artery (IMA) size. Results Among 207 EVAR patients, 78 (37.6%) developed T2E over a mean 3.4 ± 2.4 years. Nineteen (24.3%) required intervention. IntT2E patients were younger (74.9 ± 6.8 vs 78.3 ± 7.9 years, P = 0.02), had more frequent anticoagulation use (47.4% vs 20.3%, P = 0.02), larger IMAs (4.2 ± 0.6 vs 3.3 ± 0.7 mm, P < 0.01), and more lumbar arteries (6.0 ± 1.2 vs 5.0 ± 1.3, P = 0.02). IMAs >4 mm occurred in 68.4% of intT2E vs 8.5% of nointT2E ( P < 0.01). Mean sac growth was greater in intT2E (9.7 ± 5.3 mm vs −1.9 ± 6.5 mm, P < 0.01). Thirty-day complications following the index EVAR procedure, mid-term reinterventions, and overall mortality were similar between groups. Post-embolization, T2E resolved in 36.9%, with sac regression in 63.1%. Among embolized patients, 26.3% required a second embolization and one patient required 3 attempts without achieving resolution. IMA >4 mm independently predicted intervention (HR 7.18, 95% CI 1.97-26.16, P < 0.01). Logistic regression confirmed IMA >4 mm (OR 23.4, 95% CI 6.17-88.6, P < 0.01), >6 lumbar arteries (OR 4.2, 95% CI 1.10-15.98, P = 0.02), and anticoagulation (OR 3.4, 95% CI 1.17-10.6, P = 0.02) as predictors. Conclusions Approximately one-quarter of T2E patients required embolization. IMA >4 mm was the strongest predictor of intervention, while anticoagulation and increased lumbar artery number also increased risk. Management should prioritize risk-stratified surveillance and selective intervention.

Abstract Liver metastases from well-differentiated thyroid carcinomas are rare. We report 3 patients, 1 with follicular and 2 with oncocytic thyroid cancers, treated for liver metastases with yttrium-90 radioembolization. The 2 patients with oligometastatic disease received ablative radiation doses, while 1 patient with diffuse metastatic liver disease was treated palliatively with 2 sessions of reduced nonablative radiation dose due to a large hepatopulmonary shunt fraction diagnosed at work-up. The 2 cases of oligometastatic disease had a complete local response by imaging criteria, while the third case had a pronounced local partial response, without adverse events. Future guidelines should include radioembolization as a viable option for locoregional therapy of liver metastases of differentiated thyroid cancer not responsive to radioiodine in patients that do not qualify for or refuse hepatic surgery.

Objective To evaluate outcomes in patients with type 2 endoleak (T2E) and the impact of treatment outside the device instructions for use (IFU). Methods This retrospective single-center study included abdominal aortic aneurysms (AAA) patients who underwent EVAR (2011- 2024). Primary outcomes were 30-day and mid-term complications, reintervention, and mortality by T2E status. Propensity score matching was applied and secondary analysis stratified outcomes by IFU compliance, comparing within ( in IFU) or outside( out IFU) IFU in each T2E group. Results Among 154 EVAR patients (137 men (89.1%) and 17 women (11.0%); mean age 77.5 ± 7.6 years), 77 were T2E(−), and 77 were T2E(+). Baseline characteristics were similar. Thirty-day complications were comparable (T2E(−): 5, 6.4% vs T2E(+): 2, 2.56%, P = 0.72). The mean follow-up duration was 2.7 ± 2.4 years. Sac diameter change (Δ) decreased in the T2E(−) (7.7 ± 8.4 mm) and enlarged in the T2E(+) (1.79 ± 12.5 mm; P < 0.01). Mid-term graft-related complications (T2E(−): 3, 3.8% vs T2E(+): 49, 62.8%, P < 0.01) and reinterventions (T2E(−): 3, 3.8%, vs T2E(+): 20, 25.6% P < 0.01) were higher in the T2E(+) with no difference in mortality ( P = 1.00). These findings remained after excluding type 1 endoleaks. Among the T2E(+), those treated out IFU had longer hospital stays ( out IFU: 3.0 ± 2.8 days vs in IFU: 1.8 ± 2.0 days, P = 0.03), higher T1E ( out IFU: 3, 33.3% vs in IFU: 1, 4.34%, P < 0.01), higher rates of reintervention ( out IFU: 9, 100.0% vs in IFU:17; 24.6%, P < 0.01) and higher all-cause mortality than those within IFU criteria ( out IFU: 5, 55.0% vs in IFU: 13, 18.8%, P < 0.01). IFU status did not significantly affect outcomes in T2E(−) patients. Conclusions T2E is associated with sac growth and increased reinterventions, but not higher mortality. On subgroup analysis, those T2E(+) treated out IFU had longer hospitalizations, higher T1E rates, more reinterventions, and higher all-cause; but not aneurysmal-related mortality.

Abstract Disclosure: P.L. castellanos: None. A.M. Chindris: None. S. Rao: None. J. Janus: None. R. Paz-Fumagalli: None. V.J. Bernet: None. Introduction: Limited information exists regarding the relationship between outcomes and decision-making based on results from Ultrasound-guided fine needle aspiration (USG-FNA) of cervical nodes/nodules suspicious for thyroid cancer metastases. Management options for positive findings include surgery, percutaneous ethanol ablation, radioactive iodine therapy, external beam radiation systemic therapy, or observation. This retrospective review is aimed at describing the management and associated outcomes of a cohort of thyroid cancer patients who underwent USG FNA for cervically metastases. Methods: Following our Clinic IRB review and approval, we performed a chart review and identified 163 patients with thyroid cancer patients who had undergone USG FNA of apparent cervical metastases at the Florida campus between 2012 and 2018. Cytology results and corresponding tumor marker washout from each sampled focus were recorded. The records review included recording anatomical and biochemical outcomes related to management decisions based on USG FNA results. Appropriate statistical plots were used to help visualize the data pattern. ResultsThe median age was 59 years 69.9% were female and 91.3% were Caucasian. Initial presentation typically consisted of the appearance of a neck nodule and thyroidectomy was the first line of therapy in 155 of 163 cases. Imaging post-thyroidectomy demonstrated evidence of cervical lymphadenopathy in 75.5% of cases with localization in the lateral neck in 65.2% and central in 19.2% respectively. Regarding USG-FNA outcomes, 46.2% yielded malignancy while 26% were benign. The most prevalent cytology was papillary thyroid cancer detected in 87.1%.Thyroglobulin washout was performed on all patients with a history of papillary variant thyroid carcinoma, with positive results reported in 8.3%. Ethanol ablation was the most used treatment for lymph node recurrence followed by neck surgery in 56.2%. During the follow-up, 14% of the patients who were TGAB+ remained so.Outcome trends were as follows: The combined anatomical and biochemical negative was 82.3%, while the combined anatomical and biochemical positive was 2.5%. The combined anatomical negative and biochemical positive was 7.6%, alongside the combined anatomical positive and biochemical negative was 7.6%. Conclusion: Of 163 thyroid cancer cases with cervical lymphadenopathy, 46% had cytology-proven presence of malignancy. These patients underwent either observation, PEA, or surgery.At follow up the majority of the patients were without anatomical and biochemical evidence of disease while about 7-8% were positive by one of the parameters and much fewer were positive for disease by both parameters. Presentation: 6/3/2024

Chronic mesenteric ischemia (CMI) can be treated with surgical revascularization or with angioplasty and stenting. As experience has been gained, endovascular treatment appears safe and effective in selected patients. Currently, surgical revascularization has better success and patency rates but also a higher short- and midterm mortality and morbidity, especially in patients at high surgical risk. A 72-year-old female with severe respiratory dysfunction presented with CMI resulting in profound malnutrition. Serial percutaneous interventions averted urgent surgery and reversed the mesenteric ischemia. Nine months later, after repeated angioplasty and stenting had failed, elective uncomplicated iliomesenteric bypass, in a medically optimized patient, resolved the ischemia. At an 18-month follow-up, the graft remained widely patent and the patient asymptomatic with a body weight corresponding to her ideal body weight. Compared to surgical revascularization, reocclusion or restenosis occurs more frequently after endovascular treatment of CMI, and reintervention may be necessary. Nevertheless, percutaneous intervention effectively provides relief from mesenteric ischemia and has lower perioperative complication rates compared to surgery in patients at high surgical risk. After initial relief of the CMI, the patient's condition may improve, allowing for more definitive secondary surgical revascularization, if needed.

Introduction: Nearly half of the adult population in the United States has been diagnosed with hypertension. Adrenal hormonal hypersecretion is a leading cause of secondary hypertension. Adrenal vein sampling (AVS) may assist in differentiating between unilateral and bilateral adrenal hormonal hypersecretion to identify patients who are candidates for adrenalectomy. We reviewed the use of AVS at our institution along with associated outcomes after adrenalectomy. Materials and Methods: A retrospective chart review was conducted of patients with a diagnosis of primary hyperaldosteronism (PA) or adrenocorticotropic hormone-independent Cushing syndrome (AICS) and who underwent adrenalectomy between January 1, 2010, and December 1, 2021. Patient data of baseline characteristics, preoperative workup, including AVS, and postoperative outcomes were collected and analyzed. Results: Seventy-one patients were identified in the study period (48 PA and 23 AICS). Computed tomography scan identified unilateral adrenal nodules in 52 patients (29 left; and 23 right), bilateral nodules in 13 patients, and no nodules in 6 patients. AVS was performed in 45 patients with PA (93%) and 5 patients with AICS (21%). After surgery, the number of PA patients with hypokalemia or requiring potassium supplementation significantly decreased after adrenalectomy (before surgery: 33 [68.7%]; and after surgery: 5 [10.4%], P < .01). The number of medications required for hypertension in AICS patients also significantly decreased. No major adverse events were noted. Conclusions : Our long-term experience demonstrates the ongoing use of AVS during workup of patients with primary hyperaldosteronism and for select patients with adrenocorticotropic hormone-independent Cushing syndrome. However, a low level of discordance between imaging and AVS findings in PA patients suggests that there may be a subset of patients in whom preoperative AVS is not necessary.