Balloon catheter-assisted endoscopic resection for papillary adenoma of non-exposed protruded type (with video).

Papillary adenomas, known precursors to papillary adenocarcinoma, warrant close monitoring due to their malignant potential. Historically, surgical resection represented the mainstay of treatment for papillary adenomas with intraductal extension. However, recent advancements in endoscopic techniques have facilitated the adoption of endoscopic papillectomy as a minimally invasive alternative in carefully selected cases. We report a case of an 82-year-old woman with a diagnosis of papillary adenoma exhibiting intraductal extension. This was managed with a novel endoscopic technique, balloon catheter-assisted endoscopic resection. Due to the obscured intraductal component of the papillary mass, a balloon occlusion catheter was deployed within the common bile duct and used as traction to facilitate endoscopic visualization of the mass. Endoscopic resection via papillectomy was subsequently performed. Histopathological examination of the resected specimen revealed a villous adenoma with high-grade dysplasia. Serial endoscopic ultrasound examinations with targeted papillary biopsies were performed to monitor for disease recurrence.

Is annual screening by fecal immunochemical test necessary after a recent colonoscopy?

Objective: The population-based colorectal cancer screening guidelines in Japan recommend an annual fecal immunochemical test (FIT). However, there is no consensus on the need for annual FIT screening for patients who recently performed a total colonoscopy (TCS). Therefore, we evaluated the repeated TCS results for patients with positive FIT after a recent TCS to assess the necessity of an annual FIT. Methods: We reviewed patients with positive FIT in opportunistic screening from April 2017 to March 2022. The patients were divided into two groups: those who had undergone TCS within the previous 5 years (previous TCS group) and those who had not (non-previous TCS group). We compared the detection rates of advanced neoplasia and colorectal cancer between the two groups. Results: Of 671 patients, 151 had received TCS within 5 years and 520 had not. The detection rates of advanced neoplasia in the previous TCS and non-previous TCS groups were 4.6% and 12.1%, respectively (p < 0.01), and the colorectal cancer detection rates were 0.7% and 1.5%, respectively (no significant difference). The adenoma detection rates were 33.8% in the previous TCS group and 40.0% in the non-previous TCS group (no significant difference). Conclusions: Only a few patients were diagnosed with advanced neoplasia among the patients with FIT positive after a recent TCS. For patients with adenomatous lesions on previous TCS, repeated TCS should be performed according to the surveillance program without an annual FIT. The need for an annual FIT for patients without adenomatous lesions on previous TCS should be prospectively assessed in the future.

Distinct gut microbiomes in Thai patients with colorectal polyps.

BACKGROUND: Colorectal polyps that develop via the conventional adenoma-carcinoma sequence [e.g., tubular adenoma (TA)] often progress to malignancy and are closely associated with changes in the composition of the gut microbiome. There is limited research concerning the microbial functions and gut microbiomes associated with colorectal polyps that arise through the serrated polyp pathway, such as hyperplastic polyps (HP). Exploration of microbiome alterations associated with HP and TA would improve the understanding of mechanisms by which specific microbes and their metabolic pathways contribute to colorectal carcinogenesis. AIM: To investigate gut microbiome signatures, microbial associations, and microbial functions in HP and TA patients. METHODS: Full-length 16S rRNA sequencing was used to characterize the gut microbiome in stool samples from control participants without polyps [control group (CT), n = 40], patients with HP (n = 52), and patients with TA (n = 60). Significant differences in gut microbiome composition and functional mechanisms were identified between the CT group and patients with HP or TA. Analytical techniques in this study included differential abundance analysis, co-occurrence network analysis, and differential pathway analysis. RESULTS: Colorectal cancer (CRC)-associated bacteria, including Streptococcus gallolyticus (S. gallolyticus), Bacteroides fragilis, and Clostridium symbiosum, were identified as characteristic microbial species in TA patients. Mediterraneibacter gnavus, associated with dysbiosis and gastrointestinal diseases, was significantly differentially abundant in the HP and TA groups. Functional pathway analysis revealed that HP patients exhibited enrichment in the sulfur oxidation pathway exclusively, whereas TA patients showed dominance in pathways related to secondary metabolite biosynthesis (e.g., mevalonate); S. gallolyticus was a major contributor. Co-occurrence network and dynamic network analyses revealed co-occurrence of dysbiosis-associated bacteria in HP patients, whereas TA patients exhibited co-occurrence of CRC-associated bacteria. Furthermore, the co-occurrence of SCFA-producing bacteria was lower in TA patients than HP patients. CONCLUSION: This study revealed distinct gut microbiome signatures associated with pathways of colorectal polyp development, providing insights concerning the roles of microbial species, functional pathways, and microbial interactions in colorectal carcinogenesis.

Bisphosphonate-Induced Orbital Cellulitis in a Patient With Suspected Parathyroid Carcinoma: A Case Report.

Bisphosphonates are widely used for a number of metabolic bone conditions. Orbital inflammation is a very rare side effect of bisphosphonate therapy that can risk permanent visual loss. We describe the complex case and successful treatment of a 79-year-old man who developed orbital cellulitis following the use of intravenous pamidronate disodium for severe hypercalcaemia. The challenges regarding the diagnosis of parathyroid carcinoma are also discussed.

Beneath HMGA2 alterations in Pleomorphic Adenomas: Pathological, Immunohistochemical, and Molecular Insights.

AIMS: Most salivary gland neoplasms are distinguished by specific recurrent gene fusions. Recently, a subset of pleomorphic adenomas (PAs) originated from the parotid gland harboring the HMGA2::WIF1 fusion was described with a canalicular adenoma-like morphology and a greater propensity for recurrence and carcinomatous transformation. METHODS AND RESULTS: This study delineates the clinicopathological attributes of 54 cases of PAs exhibiting HMGA2 alterations, predominantly characterized by the HMGA2::WIF1 fusion, alongside a comparative analysis of their morphological and immunohistochemical profiles. The cohort consisted of 23 females and 31 males (n=54), mean age was 56.7 (25-84), tumors predominantly originated from the parotid gland (94.4%, 51/54), with 3 cases from seromucous glands (5.6%). Mean tumor size was 2.6 cm (0.8-7.5). No clinical difference (demographic, follow-up) was observed among histological subsets (conventional, hybrid, and pure). Complete excision was performed in all cases, with follow-up data available for 41% (22/54) of patients, showing 13.6% of recurrence (3/22) between 5 and 8 months. Various histological growth patterns were identified, with the pure hypercellular monomorphic subset being the most prevalent. The HMGA2::WIF1 gene was identified in all subsets without any particular predominance. Novel gene partners of HMGA2 were identified, comprising NRXN1, INPP4B, MSRB3, PHLDA1, and FLJ41278. CONCLUSIONS: The present study reports that the HMGA2::WIF1 gene fusion was present in all subsets of PAs without significant predominance. However, further investigations are warranted to explore the relationship between histological subsets of PAs and the molecular alterations underlying them.

Diagnostic, therapeutic, and prognostic characteristics of patients with acromegaly according to tumor size at diagnosis.

PURPOSE: To evaluate clinical, laboratory, radiological, therapeutic, and prognostic characteristics of patients with acromegaly according to the size of the growth hormone (GH)-secreting pituitary adenoma at diagnosis. METHODS: Observational, retrospective, single-center study of patients with acromegaly followed at a tertiary center. Data were collected regarding clinical presentation, characteristics of the adenoma in the magnetic resonance imaging, GH and IGF-1 levels, and disease control after surgery or adjuvant treatment (normal IGF-1 levels). Patients were divided according to the adenoma size at diagnosis in: group I < 10 mm; II 10-19 mm; III 20-29 mm; IV 30-39 mm; and V ≥ 40 mm. Comparisons were made between the groups, and correlations of tumor size with disease parameters, ROC curves, and logistic regression analyses were performed to investigate tumor size and confounding factors that could impact the outcomes. RESULTS: 117 patients were studied [59 women, age at diagnosis 43 ± 13 years; group I = 11 patients (9%); group II 54 (46%); group III 34 (29%); group IV 10 (9%); group V 8 (7%)]. Hypopituitarism, cavernous sinus invasion, GH levels, and use of somatostatin receptor ligands had their prevalence increased according to the adenoma size. Age showed a negative correlation with tumor size. A tumor diameter around 20 mm was the best predictor for the presence of hypopituitarism, invasiveness, need of adjuvant therapies, and poorer disease control. CONCLUSION: Adenomas < 20 mm showed lower morbidity and better therapeutic response in acromegaly, while those ≥ 20 mm had similar clinical, therapeutic, and prognostic behavior.

Outcomes of endoscopic sub-mucosal dissection in laterally spreading colorectal polyps: A tertiary care centre experience from India.

BACKGROUND: Endoscopic sub-mucosal dissection (ESD) is an established endoscopic modality for the management of colorectal polyps. However, there are no studies regarding the outcomes of ESD from India. In this study, we aimed at evaluating the outcomes of ESD in patients with adenomatous polyps in the colon and rectum. METHODS: Data of consecutive patients who underwent ESD for colorectal polyps from 2018 to 2021 were analyzed, retrospectively. The primary outcome of the study was the technical success of ESD. The secondary outcomes included the rate of histologically complete resection (R0), adverse events and recurrence. RESULTS: Seventy patients (63.5 years, 60% males) underwent ESD for polyps in colon and rectum. A majority were located in rectum (80%) and sigmoid colon (15.7%). Narrow band classification of the polyps was Japanese Narrow Band Imaging Expert Team (JNET)-2a in 50 (71.4%) and JNET-2b in 13 (18.6%) patients. ESD was technically successful in 64 (91.4%) patients using conventional technique (72.8%) and pocket or tunnelling technique (18.6%). There were no major adverse events. Histologically RO was achieved in 58 (82.8%) patients and deep sub-mucosal invasion was noted in 12 patients. At a median follow-up of 19 (interquartile range [IQR] 15-27) months, recurrence was noticed in four (5.7%) patients all of which could be managed endoscopically. CONCLUSION: ESD, performed at a tertiary care centre in India, yields high rates of technical success and histologically R0, with a relatively low incidence of adverse events and recurrences.

Hypopituitarism after gamma knife radiosurgery for pituitary adenomas: long-term results from a single-center experience.

OBJECTIVE: The aim of this study was to investigate the incidence and risk factors of new-onset hypopituitarism after gamma knife radiosurgery (GKRS) for pituitary adenomas in a single center. METHODS: In this retrospective study, 241 pituitary adenoma patients who underwent GKRS from 1993 to 2016 were enrolled. These patients had complete endocrine, imaging, and clinical data before and after GKRS. The median follow-up time was 56.0 (range, 12.7-297.6) months. RESULTS: Fifty patients (20.7%) developed new-onset hypopituitarism after GKRS, including hypogonadism (n = 22), hypothyroidism (n = 29), hypocortisolism (n = 20), and growth hormone deficiency (n = 4). The median time to new-onset hypopituitarism was 44.1 (range, 13.5-141.4) months. The rates of new-onset hypopituitarism were 7%, 16%, 20%, 39%, and 45% at 1, 3, 5, 10, and 15 years, respectively. For those patients treated with a single GKRS, sex (p = 0.012), suprasellar extension (p = 0.048), tumor volume (≥ 5 cm3) (p < 0.001), tumor progression (p = 0.001), pre-existing hypopituitarism (p = 0.011), and previous surgery (p = 0.009) were significantly associated with new-onset hypopituitarism in univariate analysis. In the multivariate analysis, tumor volume (≥ 5 cm3) and tumor progression were associated with new-onset hypopituitarism (hazard ratio [HR] = 3.401, 95% confidence interval [CI] = 1.708-6.773, p < 0.001 and HR = 3.594, 95% CI = 1.032-12.516, p = 0.045, respectively). For patients who received 2 or more times GKRS, no risk factors associated with new-onset hypopituitarism were found. CONCLUSION: New-onset hypopituitarism was not uncommon after GKRS for pituitary adenomas. In this study, large tumor volume (≥ 5 cm3) and tumor progression were associated with new-onset hypopituitarism after a single GKRS.

Pituitary lymphoma appearing 9 years after pituitary adenoma resection.

Background: Pituitary lymphomas (PLs) are very rare, accounting for <0.1% of all intracranial tumors. Of which, PL that is associated with PL is even rarer. Here, we describe a case of PL of a 51-year-old woman that appeared 9 years after pituitary adenoma resection. Case Description: A 51-year-old woman presented with visual disturbance. She had a history of pituitary adenoma resected through endoscopic trans-sphenoidal surgery (eTSS) 9 years before. Although her previous annual follow-up did not show any signs of recurrence, she noticed visual disturbance. One month later, her visual acuity rapidly worsened with headache and fatigue, being referred to our hospital. On examination, she had bilateral quadrantanopia. Her laboratory data showed slightly increased prolactin levels. Magnetic resonance images showed a mass in the sella with suprasellar extension, so she underwent eTSS. The tumor had a fibrous, hard part and a soft gray part, and it was mostly resected. Visual symptoms improved transiently, but ophthalmoplegia appeared 2 weeks after surgery, indicating intrathecal dissemination. Histological analysis confirmed the diagnosis of T-lymphoblastic lymphoma. Positron emission tomography showed tracer accumulation at the pancreas, confirmed as lymphoma through biopsy. However, we could not determine which site of lymphoma was the primary site. She underwent chemotherapy, including cyclophosphamide, vincristine sulfate, doxorubicin hydrochloride, dexamethasone, and methotrexate. The patient died despite several months of treatment. Conclusion: Recurrence of pituitary adenoma cannot be carelessly assumed from a pituitary growing mass after pituitary adenoma resection. PLs have poor prognosis due to their aggressive character. Immediate biopsy and confirmation of the diagnosis are necessary for the treatment of pituitary masses with aggressive features.

Hepatocellular Adenoma With Hepatocyte Nuclear Factor-1 Alpha (HNF-1α) Mutation: A Case Report.

Hepatocellular adenoma (HCA) is an uncommon benign liver tumor that exhibits a variety of subtypes, each distinguished by unique molecular alterations. This case report describes a 43-year-old man with a history of alcoholism who presented with stomach pain. Imaging revealed multiple hepatic lesions and sigmoid colon inflammation, while laboratory tests showed mild neutrophilic leukocytosis and elevated liver enzymes. Tumor markers were normal. A liver biopsy confirmed HCA with hepatocyte nuclear factor-1 alpha (HNF-1α) inactivation, characterized by negative immunostaining for glutamine synthetase, nuclear beta-catenin, serum amyloid A, C-reactive protein, and liver fatty acid-binding protein (L-FABP). This case is unique due to the patient's gender and the absence of typical risk factors such as abnormal hormone levels. HCAs in males, particularly with HNF-1α inactivation, are rare and pose diagnostic challenges. Comprehensive diagnostic approaches, including biopsy and immunohistochemical analysis, are crucial for accurate subtype identification. The potential for malignant transformation, particularly in male patients, underscores the need for vigilant monitoring and appropriate management. This case highlights the importance of considering HCA in differential diagnoses regardless of gender and typical risk factors, contributing valuable insights into the diverse presentations and risks associated with HCA, and emphasizing the need for awareness and further research to improve diagnosis and management of this rare condition.

Unveiling the hidden culprit: Parathyroid adenoma induced recurrent renal calculus and pancreatitis-A case report.

This case report describes a 52-year-old patient presenting with recurrent episodes of pancreatitis and renal stones. Further investigation revealed hypocalcemia and elevated parathyroid hormone (PTH) levels, leading to diagnosis of a parathyroid adenoma. This case highlights the importance of considering primary hyperparathyroidism in patients with recurrent pancreatitis and renal stones, as early diagnosis and surgical intervention can prevent recurrence and reduce morbidity. Abstract: Primary Hyperparathyroidism secondary to Parathyroid adenoma, rarely presents as acute pancreatitis. A 38-year-young male with a history of recurrent renal stones referred from a local center, presented to the emergency services, with a diagnosis of acute pancreatitis and bilateral renal stones. Laboratory evaluation showed an elevated calcium level, elevated PTH levels, low vitamin D, and low phosphorus levels. CT scan done outside was suggestive of acute pancreatitis along with bilateral renal calculi. USG neck and MIBI scan done as a part of hypercalcemia evaluation showed presence of a right parathyroid adenoma. Parathyroid adenoma was later removed, and calcium and parathyroid levels were normal on subsequent follow ups.

Unveiling a Nasal Enigma: Pleomorphic Adenoma of Nasal Septum Causing Chronic Obstruction and Epistaxis.

Tumors in the nasal septum originating from salivary glands are uncommon, and among them, pleomorphic adenomas represent a distinctive manifestation.This case study explores a female in her early thirties with a right-sided nasal mass, nasal obstruction, and intermittent bleeding. CT imaging revealed a lesion arising from the nasal septum with bony erosion. Histopathology confirmed pleomorphic adenoma,emphasizing the importance of thorough clinical evaluation, imaging, and biopsy for accurate diagnosis. Pleomorphic adenomas, typically found in major salivary glands, can occur in the respiratory tract, presenting challenges in distinguishing them from malignant tumors. Treatment involves wide local resection, and postoperative recurrence may necessitate radiotherapy. While intranasal pleomorphic adenomas generally have a favorable prognosis, those arising from the nasal septum have an elevated likelihood of malignancy. Vigilant monitoring is crucial due to the potential for recurrence, malignant transformation, and metastasis.

"Unraveling the Tapestry": A Retrospective Exploration of Recurrent Parotid Pleomorphic Adenoma Cases.

The standard surgical procedure for treating the parotid gland's recurrent pleomorphic adenoma (RPA) is parotidectomy with facial nerve preservation (FN). Treatment of RPA remains challenging since controversies occur regarding recurrence, degree of revision surgery, postoperative radiation, and difficulty in conserving the FN. A retrospective review of patient's medical records treated for benign parotid neoplasms was conducted between 2017 and 2022 to identify individuals who underwent surgery for RPA. Demographic information, surgical intervention details, pre-and postoperative facial nerve function, histopathological analysis, and recurrence rates were collected. These variables were compared in patients with single recurrent tumors versus patients with multiple recurrent tumors. Twenty-one patients met the criteria, including 13 with a first recurrence, 7 with a second recurrence, and 1 with a third recurrence. Following surgery for multiple RPA, long-term FN outcomes were significantly worse (P = 0.005). There were no observable risk factors for tumor recurrence. The interval between the initial revision surgery and subsequent ones was drastically shortened. Our study suggests that the risk of permanent facial paralysis is greater with subsequent surgical procedures. Early detection of recurrence can aid in early re-operation.

Novel Detection of Pleomorphic Adenomas via Analysis of 68Ga-DOTATOC PET/CT Imaging.

INTRODUCTION: Currently, the diagnosis of salivary gland tumors using imaging techniques is unreliable. METHODS: In this monocentric retrospective study, we examined patients who received a 68Ga-DOTATOC PET/CT and subsequently underwent a salivary gland tumor resection between 1 January 2010 and 31 December 2021. PET/CT image assessment was compared with somatostatin receptor (SSTR) expression and histology. RESULTS: Thirteen patients (five pleomorphic adenoma (PA) and eight other parotid lesions (OPL)) received a 68Ga-DOTATOC PET/CT. Imaging displayed strong focal tracer uptake in all PA except for one with strong tumor to background discrimination. PA revealed higher SUVmax, SUVmean, liver and blood pool quotients than those of Warthin tumors (WT) and of OPL. In comparison to the contralateral parotid, SUVmax (p = 0.02), SUVmean (p = 0.02), liver quotient (p = 0.03) and blood pool quotient (p = 0.03) were all significantly higher. In contrast, WT and OPL showed in relation to the contralateral parotid no significant differences of SUVmax (WT p = 0.79; OPL p = 0.11), SUVmean (WT p = 1.0; OPL p = 0.08), liver quotient (WT p = 0.5; OPL p = 0.08) and blood pool quotient (WT p = 0.8; OPL p = 0.19). Two PA and one granuloma were not available for examination. In the immunohistochemal analysis, all PA demonstrated the highest intensity of SSTR2 expression (grade 3). Furthermore, PA had a high percentage of cells expressing SSTR2 (20%, 80% and 55%). CONCLUSIONS: A strong tracer uptake in PA was shown in 68Ga-DOTATOC PET/CT. This may allow physicians to utilize radioligated somatostatin analogue PET CT/MR imaging to accurately diagnose PA. Additionally, it may be possible in the future to treat the PA with a noninvasive peptide receptor radionuclide therapy or with somatostatin analogues.

Integrative plasma and fecal metabolomics identify functional metabolites in adenoma-colorectal cancer progression and as early diagnostic biomarkers.

Changes in plasma and fecal metabolomes in colorectal cancer (CRC) progression (normal-adenoma-CRC) remain unclear. Here, plasma and fecal samples were collected from four independent cohorts of 1,251 individuals (422 CRC, 399 colorectal adenoma [CRA], and 430 normal controls [NC]). By metabolomic profiling, signature plasma and fecal metabolites with consistent shift across NC, CRA, and CRC are identified, including CRC-enriched oleic acid and CRC-depleted allocholic acid. Oleic acid exhibits pro-tumorigenic effects in CRC cells, patient-derived organoids, and two murine CRC models, whereas allocholic acid has opposing effects. By integrative analysis, we found that oleic acid or allocholic acid directly binds to α-enolase or farnesoid X receptor-1 in CRC cells, respectively, to modulate cancer-associated pathways. Clinically, we establish a panel of 17 plasma metabolites that accurately diagnoses CRC in a discovery and three validation cohorts (AUC = 0.848-0.987). Overall, we characterize metabolite signatures, mechanistic significance, and diagnostic potential of plasma and fecal metabolomes in CRC.

Adrenal Oncocytoma: A Rare Tumor with Conflicting Imaging Features.

Oncocytic adenomas are rare benign tumors that typically originate in organs such as the kidneys, thyroid, parathyroid, salivary glands, or pituitary gland. Oncocytic adenoma of the adrenal gland is extremely rare. It often shows heterogeneous, nonspecific features on anatomic imaging, as well as high 18F-FDG avidity despite its benign nature. The definitive diagnosis relies on histopathologic examination, including immunohistochemistry. We present an incidentally detected benign adrenal oncocytic adenoma with intense 18F-FDG uptake mimicking sinister pathologies.

Primary aldosteronism and hypokalemia-induced rhabdomyolysis in a patient with aldosterone-producing adenoma: A case report and literature review.

Many cases of primary aldosteronism (PA) in patients who developed hypokalemia-induced rhabdomyolysis and underwent adrenalectomy for aldosterone-producing adenoma (APA) have been reported; however, the immunohistopathological and molecular features remain unknown. We herein report the case of a 28-year-old woman with PA who presented with hypokalemia-induced rhabdomyolysis and underwent adrenalectomy for unilateral APA. An immunohistochemical analysis revealed that most adenoma cells were positive for steroidogenic enzymes, including CYP11B2. A genetic analysis revealed a somatic mutation in the KCNJ5. These findings suggest a strong aldosterone production capacity in our patient's adenoma, which was presumably related to her severe hyperaldosteronism and the resultant hypokalemia-induced rhabdomyolysis.

Circulating small extracellular vesicle RNA profiling for the detection of T1a stage colorectal cancer and precancerous advanced adenoma.

It takes more than 20 years for normal colorectal mucosa to develop into metastatic carcinoma. The long time window provides a golden opportunity for early detection to terminate the malignant progression. Here, we aim to enable liquid biopsy of T1a stage colorectal cancer (CRC) and precancerous advanced adenoma (AA) by profiling circulating small extracellular vesicle (sEV)-derived RNAs. We exhibited a full RNA landscape for the circulating sEVs isolated from 60 participants. A total of 58,333 annotated RNAs were detected from plasma sEVs, among which 1,615 and 888 sEV-RNAs were found differentially expressed in plasma from T1a stage CRC and AA compared to normal controls (NC). Then we further categorized these sEV-RNAs into six modules by a weighted gene coexpression network analysis and constructed a 60-gene t-SNE model consisting of the top 10 RNAs of each module that could well distinguish T1a stage CRC/AA from NC samples. Some sEV-RNAs were also identified as indicators of specific endoscopic and morphological features of different colorectal lesions. The top-ranked biomarkers were further verified by RT-qPCR, proving that these candidate sEV-RNAs successfully identified T1a stage CRC/AA from NC in another cohort of 124 participants. Finally, we adopted different algorithms to improve the performance of RT-qPCR-based models and successfully constructed an optimized classifier with 79.3% specificity and 99.0% sensitivity. In conclusion, circulating sEVs of T1a stage CRC and AA patients have distinct RNA profiles, which successfully enable the detection of both T1a stage CRC and AA via liquid biopsy.

Video-based performance analysis in pituitary surgery - Part 1: Surgical outcomes.

BACKGROUND: Endoscopic pituitary adenoma surgery has a steep learning curve, with varying surgical techniques and outcomes across centers. In other surgeries, superior performance is linked with superior surgical outcomes. This study aimed to explore the prediction of patient-specific outcomes using surgical video analysis in pituitary surgery. METHODS: Endoscopic pituitary adenoma surgery videos from a single center were annotated by experts for surgical workflow (3 phases, 15 steps) and surgical skill (using modified Objective Structured Assessment of Technical Skills; mOSATS). Quantitative workflow metrics were calculated, including phase duration and step transitions. Poisson or logistic regression was used to assess the association of workflow metrics and mOSATS with common inpatient surgical outcomes. RESULTS: 100 videos from 100 patients were included. Nasal phase mean duration was 24mins and mean mOSATS was 21.2/30. Mean duration was 34mins and mean mOSATS was 20.9/30 for the sellar phase, and 11mins and 21.7/30 respectively for the closure phase. The most common adverse outcomes were new anterior pituitary hormone deficiency (n=26), dysnatremia (n=24) and cerebrospinal fluid (CSF) leak (n=5). Higher mOSATS for all three phases and shorter operation duration was associated with decreased length of stay (p=0.003 & p<0.001). Superior closure phase mOSATS were associated with reduced post-operative CSF leak (p<0.001), and superior sellar phase mOSATS were associated with reduced post-operative visual deterioration (p=0.041). CONCLUSION: Superior surgical skill and shorter surgical time were associated with superior surgical outcomes, at a generic and phase-specific level. Such video-based analysis has promise for integration into data-driven training and service improvement initiatives.

Parathyroid Adenoma Detected in 68Ga-PSMA PET/CT but Not in the Dedicated Imaging Modalities.

BACKGROUND: Primary hyperparathyroidism is a common endocrine disorder characterised by excessive parathormone secretion that results in hypercalcemia, primarily caused by parathyroid adenoma. Accurate localisation of hyperfunctioning tissue is essential for curative surgical treatment. Although conventional imaging modalities like ultrasonography and 99mTc-MIBI scintigraphy (SPECT) along with 18F-fluorocholine PET/CT are commonly employed, there are cases with false-negative imaging results. CASE PRESENTATION: This case report presents a patient with primary hyperparathyroidism and a parathyroid adenoma detected solely through 68Ga-PSMA-11 PET/CT, typically used for prostate cancer diagnosis. The lesion observed in the PET/CT was confirmed as a parathyroid adenoma through laboratory evaluation, while other imaging techniques failed to detect it. CONCLUSIONS: This finding suggests that the PSMA ligands' particular affinity for neovascularisation in focal changes may facilitate the visualisation of parathyroid adenomas. The utilisation of 68Ga-PSMA-11 PET/CT in primary hyperparathyroidism could potentially improve the preoperative localization of parathyroid adenomas when conventional imaging methods are inconclusive.