[Complete Remission of Metastatic Renal Cell Carcinoma with Invasion of the Duodenum and Pancreas after Treatment with Nivolumab Plus Ipilimumab Followed by Axitinib and Surgery : A Case Report].

A man in his 60s was diagnosed with clear cell carcinoma of the right kidney with multiple lung metastases, tumor thrombus of the inferior vena cava (IVC), and invasion of the duodenum and pancreas. Ipilimumab plus nivolumab was administered as first-line therapy. After 3 treatment courses, computed tomography (CT) demonstrated a slight decrease in the size of the primary tumor and lung metastases. However, the patient became hemodynamically unstable due to persistent duodenal bleeding during treatment despite frequent blood transfusions. Axitinib was then initiated as second-line therapy. The duodenal bleeding ceased 10 days after starting axitinib and his anemia remissed. Subsequent CT showed further decrease in the size of the primary tumor and lung metastases. The patient underwent right nephrectomy after improvement of nutrition. IVC thrombectomy, and pancreaticoduodenectomy. The lung metastases disappeared on postoperative imaging and no additional treatment was provided. Twelve months after surgery, he was in good health and showed no signs of recurrence.

Real-time surveillance of left atrial appendage thrombus during contrast computed tomography imaging for catheter ablation: THe Reliability of cOMputed tomography Beyond UltraSound in THROMBUS detection (THROMBUS) study.

Left atrial contrast computed tomography (LA-CT) as well as transesophageal echocardiography (TEE) can exclude left atrial appendage (LAA) thrombus, but is sometimes unable to evaluate LAA due to incomplete LAA filling. The aim of the current study was to validate the utility of real-time approach of LA-CT with real-time surveillance of LAA-filling defect (FD). We enrolled consecutive 894 patients with LA-CT studies acquired for catheter ablation and compared the diagnostic accuracy in demonstrating LAA-FD between conventional protocol (N = 474) and novel protocol with real-time surveillance of LAA-FD immediately after the initial scanning and, when necessary, adding delayed scanning in the supine or prone position (N = 420). Primary endpoint was severity of LAA-FD classified into the 3 groups: "Grade-0" for complete filling of contrast, "Grade-1" for incomplete filling of contrast, and "Grade-2" for complete FD of contrast. The prevalence of Grade-1 and Grade-2 FD was 17.3% and 11.2% in conventional protocol, whereas there was no patient with Grade-2 FD, and only 1 patient with Grade-1 FD after the additional scanning in novel protocol. In 5 patients with suspected LAA thrombus both by TEE and Grade-2 FD in LA-CT by the conventional protocol, ablation procedure was canceled due to diagnosis of LAA thrombus. Conversely, 4 patients with suspected LAA thrombus by TEE in novel protocol group was proved to have intact LAA by LA-CT with and without additional scanning. This novel approach with real-time surveillance improved the diagnostic accuracy of LA-CT in detecting LAA-FD, suggesting potential superiority of LA-CT over TEE in excluding LAA thrombus.