Systemic lupus erythematosus presenting with lymphoid interstitial pneumonia as an initial manifestation

A 25-year-old woman with an extensive travel history developed chronic cough and multiple lung nodules. The lung biopsy revealed lymphoid interstitial pneumonia. The patient later developed cervical lymphadenopathy, arthritis and livedo reticularis, then systemic lupus erythematosus was diagnosed with positive double-stranded DNA and low complement. The patient’s symptoms responded to prednisolone and azathioprine.

Abstract 17160: Cardiac Sarcoidosis Mimicking Arrhythmogenic Right Ventricular Cardiomyopathy Presenting With Syncope

A 35-year-old previous healthy man presented with palpitations and nearly syncope. Electrocardiography showed first degree atrioventricular block (PR interval 316 milliseconds) and premature ventricular complex (PVC) possibly originating from right ventricle (RV). The transthoracic echocardiography disclosed dilated RV with preserved right ventricular systolic function with a RV systolic pressure of 33mmHg, and thickened interventricular septum (12.7mm) with normal left ventricular size and function. At this point, the initial diagnosis was arrhythmogenic right ventricular cardiomyopathy (ARVC) with ventricular arrhythmias. The 24-hour Holter study showed 904 monomorphic PVCs and short-run ventricular tachycardia. The chest computed tomography demonstrated dilated RV with scalloping over free wall and multiple lung nodules mainly located in both upper lung fields (Figure A&B). Radiofrequency catheter ablation and implantation of implantable cardioverter defibrillator were suggested under the impression of ARVC. Therefore, he visited our hospital for second opinion. Since the diseased conduction system was unusual in patient with ARVC, CMR imaging was performed which revealed late gadolinium enhancement over both ventricles and basal interventricular septum (Figure C), raising the suspicion of cardiac sarcoidosis. Thereafter, the 18F-fluorodeoxyglucose (FDG)-Positron Emission Tomography study was arranged and showed FDG uptake over basal septum and lateral wall of LV, and multiple lung nodules (Figure D). Endomyocardial biopsy of RV showed myocardial fibrosis without a specific diagnosis. Thoracoscopic wedge resection of the lung nodule was performed, and pathology showed non-necrotizing granulomas distributed along with broncho-vascular bundles and subpleural area. No microorganism could be demonstrated. Sarcoidosis with cardiac and pulmonary involvement was impressed. Further steroid treatment will be initiated.

Case Report: Complete Response of Recurrent and Metastatic Cystadenocarcinoma of the Parotid Gland With a Single Course of Combined Nivolumab and Ipilimumab Therapy

Although cystadenocarcinoma is classified as a low-grade histological subtype of salivary gland carcinoma (SGC), recurrence and metastases sometimes develop. However, standard treatments for advanced cases have not yet been established. Here, we present a case of unresectable local recurrence and cervical lymph node metastases of cystadenocarcinoma of the parotid gland with multiple lung nodules, all of which showed complete response with only a single course of combined nivolumab and ipilimumab therapy. The patient's medical history of metastatic melanoma roused our suspicions that the multiple lung nodules were cystadenocarcinoma metastases or malignant melanoma. Combination therapy was used based on our suspected diagnosis of lung metastases of melanoma although histological examination of the lung nodules could not be performed. While various chemotherapies are used for advanced SGCs including cystadenocarcinoma, overall, the results are unsatisfactory. In contrast, there have not yet been any reports of advanced cystadenocarcinoma of the salivary gland treated with immune checkpoint inhibitors (ICIs). Given that, in our case, a single course of combined ICI therapy induced a complete response in the unresectable and lymph node metastases from the cystadenocarcinoma and the multiple lung nodules, ICIs, including combined therapy, could be a promising treatment for advanced cystadenocarcinoma.

Pulmonary hyalinising granuloma: a rare and elusive cause of multiple lung nodules

A 72-year-old woman was referred with incidentally detected multiple lung nodules, one of which was identified as 18F-fluorodeoxyglucose (FDG)-avid on positron emission tomography. Extensive workup followed, including numerous radiographs, surveillance scans and a CT-guided biopsy which demonstrated chronic inflammation only. Following a wedge-resection, a diagnosis of pulmonary hyalinising granuloma (PHG) was made. PHG is a cause of FDG-avid single or multiple pulmonary nodules and can mimic lung cancer or metastatic disease radiologically. The diagnosis is often difficult to make with minimally invasive techniques such as needle-guided biopsies which do not tend to yield the diagnosis and requires surgical resection for definitive diagnosis and exclusion of malignancy.

Preoperative computed tomography-guided coil localization for multiple lung nodules

Background: Preoperative computed tomography (CT)-guided coil localization can increase the technical success of video-assisted thoracoscopic surgery (VATS)-guided diagnostic wedge resection of lung nodules relative to cases treated without localization. When multiple lung nodules (MLNs) are to be resected, preoperative localization for each lung nodule is required. The aim of this study was to explore the feasibility, safety, and clinical efficacy of preoperative CT-guided coil localization of MLNs. Methods: Between November 2015 and July 2019, 31 patients with MLNs were assessed via CT-guided coil localization followed by VATS-guided wedge resection. Rates of technical success for both the localization and wedge resection procedures, as well as data pertaining to patient complication rates and long-term outcomes were recorded and assessed. Results: In total, 68 nodules (average of 2.2 nodules/patient) were localized and resected using this approach. Nodules were unilateral and bilateral in 23 and 8 patients, respectively. The rate of CT-guided coil localization technical success for these nodules was 98.5% (67/68), with a technical success rate of single-stage coil localization on a per-patient basis of 96.8% (30/31). Following localization, asymptomatic pneumothorax occurred in four patients (12.9%). The wedge resection technical success rate was 100%. Mean VATS operative time was 167.3 ± 75.2 min, with a mean blood loss of 92.6 ± 61.5 ml. Patients were followed between 3 and 46 months (median: 24 months), with no evidence of new nodules, distant metastases, or postoperative complications in any patients. Conclusion: Preoperative CT-guided multiple coil localization can be easily and safely used to guide single-stage VATS diagnostic wedge resection in patients with MLNs. The reviews of this paper are available via the supplemental material section.