Intracranial Involvement in Takayasu’s Arteritis

Takayasu’s arteritis (TAK) is a large-vessel vasculitis that targets the aorta and its major branches. Although extracranial vascular involvement is uniformly present in this disease, the frequency of intracranial involvement in TAK has not been well studied. We retrospectively reviewed the clinical and imaging records of patients diagnosed with TAK at a single Canadian university medical centre to determine the prevalence of intracranial vascular involvement. Intracranial vascular and non-vascular findings were described, and a review of the literature was performed. Of 20 patients with TAK, 12 had vascular neuroimaging completed. Intracranial vascular lesions were identified in 4 patients (33.3% of those with imaging available, 20% of all patients). The frequency of intracranial vessel involvement in TAK may be more common than appreciated. Imaging of both the intra- and extra-cranial vessels should be considered in these young patients.

Utility of CT to Differentiate Pancreatic Parenchymal Metastasis from Pancreatic Ductal Adenocarcinoma

Purpose: To report the computed tomography (CT) features of pancreatic parenchymal metastasis (PPM) and identify CT features that may help discriminate between PPM and pancreatic ductal adenocarcinoma (PDAC). Materials and methods: Thirty-four patients (24 men, 12 women; mean age, 63.3 ± 10.2 [SD] years) with CT and histopathologically proven PPM were analyzed by two independent readers and compared to 34 patients with PDAC. Diagnosis performances of each variable for the diagnosis of PPM against PDAC were calculated. Univariable and multivariable analyses were performed. A nomogram was developed to diagnose PPM against PDAC. Results: PPM mostly presented as single (34/34; 100%), enhancing (34/34; 100%), solid (27/34; 79%) pancreatic lesion without visible associated lymph nodes (24/34; 71%) and no Wirsung duct enlargement (29/34; 85%). At multivariable analysis, well-defined margins (OR, 6.64; 95% CI: 1.47–29.93; p = 0.014), maximal enhancement during arterial phase (OR, 6.15; 95% CI: 1.13–33.51; p = 0.036), no vessel involvement (OR, 7.19; 95% CI: 1.512–34.14) and no Wirsung duct dilatation (OR, 10.63; 95% CI: 2.27–49.91) were independently associated with PPM. The nomogram yielded an AUC of 0.92 (95% CI: 0.85–0.98) for the diagnosis of PPM vs. PDAC. Conclusion: CT findings may help discriminate between PPM and PDAC.

Is the Concurrent Use of Sorafenib and External Radiotherapy Feasible for Advanced Hepatocellular Carcinoma? A Meta-Analysis

We evaluate the feasibility of a concurrent application of sorafenib and external beam radiation therapy (EBRT) for advanced hepatocellular carcinoma (HCC). PubMed, Embase, Medline, and Cochrane Library were searched up to 9 April 2021. The primary endpoint was grade ≥3 complications, and the secondary endpoint was overall survival (OS). Subgroup analyses were performed for studies with the EBRT targets, intrahepatic vs. non-intrahepatic lesions (e.g., extrahepatic metastases or malignant vessel involvement only). Eleven studies involving 512 patients were included in this meta-analysis. Pooled rates of gastrointestinal, hepatologic, hematologic, and dermatologic grade ≥3 toxicities were 8.1% (95% confidence interval (CI): 4.8–13.5, I2 = ~0%), 12.9% (95% CI: 7.1–22.1, I2 = 22.4%), 9.1% (95% CI: 3.8–20.3, I2 = 51.3%), and 6.8% (95% CI: 3.8–11.7, I2 = ~0%), respectively. Pooled grade ≥3 hepatologic and hematologic toxicity rates were lower in studies targeting non-intrahepatic lesions than those targeting intrahepatic lesions (hepatologic: 3.3% vs. 17.1%, p = 0.041; hematologic: 3.3% vs. 16.0%, p = 0.078). Gastrointestinal and dermatologic grade ≥3 complications were not significantly different between the subgroups. Regarding OS, concurrent treatment was more beneficial than non-concurrent treatment (odds ratio: 3.3, 95% CI: 1.3–8.59, p = 0.015). One study reported a case of lethal toxicity due to tumor rupture and gastrointestinal bleeding. Concurrent treatment can be considered and applied to target metastatic lesions or local vessel involvement. Intrahepatic lesions should be treated cautiously by considering the target size and hepatic reserve.

Normal inflammatory markers in giant cell arteritis with long-standing cranial and symptomatic large-vessel involvement

We report the case of a 78-year-old woman who presented with cardiovascular risk factors and a history of an atypical transient ischaemic attack. She was referred by her primary care physician to the vascular surgery department at our institution for evaluation of progressive weakness, fatigue, arm claudication and difficulty assessing the blood pressure in her right arm. She was being considered for surgical revascularisation, but a careful history and review of her imaging studies raised suspicion for vasculitis, despite her normal inflammatory markers. She was eventually diagnosed with biopsy-proven giant cell arteritis with diffuse large-vessel involvement. Her symptoms improved with high-dose glucocorticoids.

POS0811 EULAR RECOMMENDATIONS ON GIANT CELL ARTERITIS IN REAL LIFE

Background:GCA is the most frequent systemic vasculitis in patients older than 50 years involving medium-sized and large arteries. On July 2019 EULAR published its updated recommendations for the management of large vessel vasculitis, including GCA.Objectives:To analyze how the application of the updated EULAR recommendations changed clinical practice in GCA patients in our Hospital.Methods:All patients with a new diagnosis of GCA between January 1st, 2018 and December 31st, 2020 were enrolled in this study. Two cohorts were analyzed: patients who received GCA diagnosis in the eighteen months before EULAR recommendations publication (between January 1st, 2018 and June 30th, 2019: cohort A) and patients who received GCA diagnosis in the following eighteen months (between July 1st, 2019 and December 31st, 2020: cohort B). Data are expressed as median (IQR).Results:70 patients were enrolled in the study (F: 47, M: 23, age: 76 (69-79) years): 39 patients in cohort A, 31 in cohort B. Table 1 summarize main clinical features and treatment of patients. Sixteen patients of cohort A (41%) and eleven patients of cohort B (35%) presented large vessel involvement demonstrated by FDG-PET/CT. Thirty-one patients in cohort A (79%) and twenty-seven in cohort B (87%) presented cranial symptoms and were studied with temporal arteries ultrasound (US) and/or biopsy (TAB). More specifically, in cohort A US was performed in 42% of patients with cranial symptoms and TAB in 58% of them. After EULAR recommendations publication (cohort B) the percentage of patients with cranial symptoms who performed US increased to 56% and the percentage of TAB decreased to 52%.After EULAR recommendations publication, time between symptoms onset and first rheumatologic evaluation was reduced by 30% (from 61 (23-131) to 43 (22-92) days).No difference in treatment regiments were found between groups, whether in glucocorticoid initial dose or DMARDs adjunctive therapy.Conclusion:After EULAR recommendations publication, two major improvement were achieved in our cohort. EULAR suggests GCA patients should be urgently referred to a specialist team. Consistently with this recommendation, time between symptoms onset and first rheumatologic evaluation was markedly reduced. Moreover, EULAR suggests always confirming GCA diagnosis by imaging or TAB, with US as first choice. In line with these recommendations, in our cohort US became more and more frequently performed and progressively preferred over TAB. On the other hand, no differences in treatment regiments were found over time, with EULAR recommendations satisfied both before and after their publication.References:[1]Hellmich B, et al. Ann Rheum Dis 2019.ALL GCA(n: 70)Before EULAR recommendations(n: 39)After EULAR recommendations (n: 31)Time between symptoms onset and first rheumatologic evaluation (days)53 (22-110)61 (23-131)43 (22-92)Temporal artery US28/58 (48%)13/31 (42%)15/27 (56%)Temporal artery biopsy32/58 (55%)18/31 (58%)14/27 (52%)Large vessel involvement (FDG-PET/CT)27 (39%)16 (41%)11 (35%)Glucocorticoid initial dose (mg/die prednisone equivalent)50 (47-50)50 (50-50)50 (38-50)DMARDs43 (61%)24 (61%)19 (61%)Disclosure of Interests:None declared