Altered white matter microstructure and neurocognitive function of HIV-infected patients with low nadir CD4.

Altered white matter microstructure has been reported repeatedly using diffusion tensor imaging (DTI) in HIV-associated neurocognitive disorders. However, the associations between neurocognitive deficits and impaired white matter remains obscure due to frequent physical and psychiatric comorbidities in the patients. Severe immune suppression, reflected by low nadir CD4 T-cell counts, is reported to be associated with the neurocognitive deficits in the patients. In the present study, we examined white matter integrity using DTI and tract-based spatial statistics (TBSS), and neurocognitive functions using a battery of tests, in 15 HIV-infected patients with low nadir CD4, 16 HIV-infected patients with high nadir CD4, and 33 age- and sex-matched healthy controls. As DTI measures, we analyzed fractional anisotropy (FA) and mean diffusivity (MD). In addition, we investigated the correlation between white matter impairments and neurocognitive deficits. Among the three participant groups, the patients with low nadir CD4 showed significantly lower performance in processing speed and motor skills, and had significantly increased MD in widespread regions of white matter in both hemispheres. In the patients with low nadir CD4, there was a significant negative correlation between motor skills and MD in the right motor tracts, as well as in the corpus callosum. In summary, this study may provide white matter correlates of neurocognitive deficits in HIV-infected patients with past severe immune suppression as legacy effects.

Neurocognitive impairment and gray matter volume reduction in HIV-infected patients.

Although neuropsychological studies of human immunodeficiency virus (HIV)-infected patients have demonstrated heterogeneity in neurocognitive impairment and neuroimaging studies have reported diverse brain regions affected by HIV, it remains unclear whether individual differences in neurocognitive impairment are underpinned by their neural bases. Here, we investigated spatial distribution patterns of correlation between neurocognitive function and regional gray matter (GM) volume across patients with HIV. Thirty-one combination antiretroviral therapy-treated HIV-infected Japanese male patients and 33 age- and sex-matched healthy controls were included in the analysis after strict exclusion criteria, especially for substance use. Fifteen neurocognitive tests were used, and volumetric magnetic resonance imaging was performed. We used voxel-based morphometry to compare GM volume between groups and identify regional GM volumes that correlated with neurocognitive tests across patients. Using the Frascati criteria, 10 patients were diagnosed with asymptomatic neurocognitive impairment, while the others were not diagnosed with HIV-associated neurocognitive disorders. Patients showed a significantly lower performance in five neurocognitive tests as well as significantly reduced GM volume relative to controls, with volume-reduced regions spread diffusely across the whole brain. Different aspects of neurocognitive impairment (i.e., figural copy, finger tapping, and Pegboard) were associated with different GM regions. Our findings suggest a biological background constituting heterogeneity of neurocognitive impairment in HIV infection and support the clinical importance of considering individual differences for tailor-made medicine for people living with HIV.

Comparison of HASTE with multiple signal averaging versus conventional turbo spin echo sequence: a new option for T2-weighted MRI of the female pelvis.

OBJECTIVES: This study was conducted in order to evaluate the feasibility of a newly developed half-Fourier acquisition single-shot turbo spin echo (HASTE) sequence for T2-weighted MRI of the female pelvis, in which scanning and post-processing filtering techniques were optimized to minimize blurring and the resultant reduction in signal-to-noise ratio (SNR) was compensated by signal averaging of multiple excitations (multi-NEX), and to compare its image quality with that of a conventional turbo spin echo (TSE) sequence. METHODS: Fifty females with gynecological disease were prospectively enrolled. They underwent pelvic MRI including sagittal T2-weighted imaging obtained with multi-NEX HASTE (mHASTE) and TSE with acquisition times of 1 m 9 s and 3 m 26 s, respectively. At the prospective reading, mHASTE was reviewed first, and any changes in the image interpretation detected during the subsequent TSE reading were recorded. The SNR and tissue contrast were quantitatively measured. Two radiologists independently assessed tissue conspicuity and overall image quality considering noise, artifacts, and blurring, and visual grading characteristics (VGC) analysis was performed to compare the two sequences. RESULTS: Adding TSE to mHASTE did not change image interpretations in any case. mHASTE produced an equivalent SNR and significantly higher contrast between the myometrium and junctional zone (p < 0.05) compared with TSE. The area under the VGC curve (AUCVGC) showed that the conspicuity of the uterus, ovaries, and lesions and the overall image quality were significantly higher on mHASTE than on TSE for both readers (AUCVGC, 0.740-0.880; p < 0.01). CONCLUSION: mHASTE is a feasible option for T2-weighted MRI of the female pelvis, as it allows faster and higher-quality image acquisition than conventional TSE. KEY POINTS: • High-quality T2-weighted imaging is essential for magnetic resonance imaging of the female pelvis. • A new HASTE sequence was developed, in which a parallel imaging technique, a wide bandwidth, and a post-processing filter were used to minimize blurring, and the resultant reduction in the signal-to-noise ratio was compensated using signal averaging of multiple excitations (multi-NEX). • Multi-NEX HASTE allows fast and high-quality T2-weighted image acquisition.

Computed tomography-guided preoperative localization of small lung nodules with indocyanine green.

Background Small, deep-seated lung nodules and sub-solid nodules are often difficult to locate without marking. Purpose To evaluate the success and complication rates associated with the use of indocyanine green (ICG) to localize pulmonary nodules before resection. Material and Methods This retrospective study was approved by our institutional review board. Informed consent for performing preoperative localization using ICG marking was obtained from all patients. Thirty-seven patients (14 men, 23 women; mean age = 63.1 years; age range = 10-82 years) with small peripheral pulmonary nodules underwent computed tomography (CT)-guided ICG marking immediately before surgery between March 2007 and June 2016. The procedural details and complication rates associated with ICG marking are described. Results The average nodule size and depth were 9.1 mm (range = 2-22 mm) and 9.9 mm (range = 0-33 mm), respectively. Marking was detected at the pleural surface in 35 patients (95%). Three cases of mild pneumothorax (8%), five cases of cough (14%), and one case of mild bloody sputum (3%) with no clinical significance were noted. There were no severe complications. The average duration required to perform the marking was 19.4 min (range = 12-41 min). Conclusion Our results indicate that CT-guided ICG marking is safe and useful for detecting the location of small pulmonary nodules preoperatively.

[Pulmonary metastasis of an ovarian granulosa cell tumor resected 11 years before].

A 69-year-old female, who had undergone oophorectomy for a left ovarian granulosa cell tumor (OGCT) in November 1999, was referred to our hospital due to rectal infiltration of the tumor detected during the initial surgery. The patient underwent low anterior resection, omentectomy and adnexectomy for the residual lesion at 1 month after the initial operation, and was followed up without postoperative adjuvant chemotherapy. In November 2010, abdominal computed tomography( CT) showed a soft tissue tumor on the surface of the liver. Meanwhile, a solitary nodule in S3 of the left lung was detected on chest CT. Laparotomy was done under suspicion of liver metastasis, but the lesion was revealed to be peritoneal dissemination at surgery. After subsequent 1-year follow-up, the enlargement of the pulmonary nodule was noted, and partial resection of the left lung was performed. The tumor was pathologically diagnosed as a metastasis of the OGCT.

Radiologic implications of the 2011 classification of adenocarcinoma of the lung.

Now the leading subtype of lung cancer, adenocarcinoma received a new classification in 2011. For tumors categorized previously as bronchioloalveolar carcinoma (BAC), criteria and terminology had not been uniform, so the 2011 classification provided four new terms: (a) adenocarcinoma in situ (AIS), representing histopathologically a small (≤3-cm), noninvasive lepidic growth, which at computed tomography (CT) is usually nonsolid; (b) minimally invasive adenocarcinoma, representing histopathologically a small (≤3-cm) and predominantly lepidic growth that has 5-mm or smaller invasion, which at CT is mainly nonsolid but may have a central solid component of up to approximately 5 mm; (c) lepidic predominant nonmucinous adenocarcinoma, representing histopathologically invasive adenocarcinoma that shows predominantly lepidic nonmucinous growth, which at CT is usually part solid but may be nonsolid or occasionally have cystic components; and (d) invasive mucinous adenocarcinoma, histopathologically showing lepidic growth as its predominant component, which at CT varies widely from solid to mostly solid to part solid to nonsolid and may be single or multiple (when multifocal, it was formerly called multicentric BAC). In addition, new histopathologic subcategories of acinar, papillary, micropapillary, and solid predominant adenocarcinoma are now described, all as nonmucinous, predominantly invasive, may include a small lepidic component, and at CT are usually solid but may include a small nonsolid component. The micropapillary subtype has a poorer prognosis than the other subtypes. In addition, molecular genetic correlations for the subcategories of adenocarcinoma of the lung are now a topic of increasing interest. As the new classification enters common use, further descriptions of related correlations can be anticipated.

[Micronodular thymoma with lymphoid stroma（MNT）].

We report a surgical case of MNT, which is a rare type of thymoma. A 56-year-old man was referred to our hospital for examination of a mass in the anterior mediastinum. The computed tomography (CT) scan showed a lobulated mass with relatively smooth margins. Also, contrast study indicated homogeneous enhancement. Since these findings suggested the possibility of thymoma, the patient underwent thymothymomectomy. Histological findings showed short spindleshaped tumor cells forming nests of various sizes, and lymphoid stroma with lymphoid follicles. The pathological diagnosis was MNT. The long-term outcome after resection of MNT currently remains unclear, and accumulation of further cases is required.

Semi-quantitative evaluation of chest computed tomography for coronavirus disease 2019 in a critical care unit: A case-control study.

The spread of abnormal opacity on chest computed tomography (CT) has been reported as a predictor of coronavirus disease 2019 (COVID-19) severity; however, the relationship between CT findings and prognosis in patients with severe COVID-19 remains unclear. The objective of this study was to evaluate the extent of abnormal opacity on chest CT and its association with prognosis in patients with COVID-19 in a critical care medical center, using a simple semi-quantitative method. This single-center case-control study included patients diagnosed with severe COVID-19 pneumonia who were admitted to a critical care center. The diagnosis of COVID-19 was based on positive results of a reverse transcription polymerase chain reaction test. All patients underwent non-contrast whole-body CT upon admission. Six representative axial chest CT images were selected for each patient to evaluate the extent of lung lesions. The percentage of the area involved in the representative CT images was visually assessed by 2 radiologists and scored on 4-point scale to obtain the bedside CT score, which was compared between patients who survived and those who died using the Mann-Whitney U test. A total of 63 patients were included in this study: 51 survived and 12 died after intensive treatment. The inter-rater reliability of bedside scores between the 2 radiologists was acceptable. The median bedside CT score of the survival group was 12.5 and that of the mortality group was 16.5; the difference between the 2 groups was statistically significant. The degree of opacity can be easily scored using representative CT images in patients with severe COVID-19 pneumonia, without sophisticated software. A greater extent of abnormal opacity is associated with poorer prognosis. Predicting the prognosis of patients with severe COVID-19 could facilitate prompt and appropriate treatment.

Objective assessment of dermatitis following post-operative radiotherapy in patients with breast cancer treated with breast-conserving treatment.

PURPOSE: To evaluate radiation dermatitis objectively in patients with breast cancer who had undergone post-operative radiotherapy after breast-conserving surgery. PATIENTS AND METHODS: Skin color (L*, a*, and b* values) and moisture analyses were performed for both breasts (before, after, 1 month, 6 months, and 1 year after radiotherapy) to examine irradiated and non-irradiated skin divided into four quadrants in 118 patients. These patients underwent breast conservative surgery followed by 50 Gy/25 fractions (median) of radiotherapy with or without boost irradiation (10 Gy/5 fractions). RESULTS: L*, a*, and moisture values were changed by irradiation and maximized at completion or 1 month after radiotherapy. One year after radiotherapy, the skin color had returned to the range observed prior to radiotherapy. However, moisture did not return to previous values even 1 year after treatment. The lateral upper side (quadrant C) showed greater changes than other quadrants in the L* value (darker) at the end of radiotherapy. The Common Toxicity Criteria version 3 scores were found to correlate well with a* and L* values at the completion and 1 month after radiotherapy. Boost radiotherapy intensified reddish and darker color changes at the completion of radiotherapy, while chemotherapy did not intensify the skin reaction caused by radiotherapy. CONCLUSION: Moisture impairment as a result of irradiation lasts longer than color alterations. Objective assessments are useful for analyzing radiation dermatitis.

Effect of uterine position and intrapelvic motions on the image quality of 3D T2-weighted MRI of the uterus: Can short prescans predict the non-diagnostic image quality?

PURPOSE: To evaluate prescan findings of uterine position and intrapelvic motions that predict the non-diagnostic image quality of three-dimensional T2-weighted MRI (3D-T2WI) of the uterus. METHODS: This retrospective study included 287 women who underwent pelvic MRI including 3D-T2WI and short prescans consisting of 2D-T2WI and cine imaging. One radiologist classified 3D-T2WI of the uterus as being of diagnostic or non-diagnostic image quality and evaluated the prescans regarding uterine position and intrapelvic motions. Multivariate logistic regression analysis was performed to identify predictors of non-diagnostic 3D-T2WI. The predictive ability of the prescans was verified by two independent MRI technologists. RESULTS: Non-diagnostic 3D T2WI was found in 42 patients (14.6 %) and was significantly associated with severe motions of urinary flow in the bladder (p < 0.001), small bowel (p = 0.039), and respiration (p < 0.001). In the multivariate analysis of uterine position and intrapelvic motions, risk factors for the non-diagnostic image quality were prominent urinary flow when the uterus contacted the bladder (p < 0.001, adjusted odds ratio = 35.1) and severe respiratory and small bowel motions when the uterus was surrounded by the bowel (p < 0.001, adjusted odds ratio = 68.4). No risk factors were found for the uterus contacting the vertebrae. With these predictors, the prescans demonstrated a sensitivity of 82.9 and 68.3 %, and specificity of 88.2 and 93.9 % for the non-diagnostic 3D-T2WI by the two technologists, respectively. CONCLUSION: Intrapelvic motions have a different effect on the image quality of 3D-T2WI depending on the uterine position, and short prescans may be useful in predicting time-consuming non-diagnostic 3D-T2WI of the uterus.

Evaluation of suspicious nipple discharge by magnetic resonance mammography based on breast imaging reporting and data system magnetic resonance imaging descriptors.

PURPOSE: To evaluate the findings of magnetic resonance mammography for suspicious nipple discharge based on breast imaging-reporting and data system magnetic resonance imaging (MRI) descriptors and establish any correlations with the histopathologic diagnoses. METHODS: Forty-seven patients with suspicious nipple discharge underwent MRI using a 1.5-T system. Images were evaluated for a signal of abnormal discharge, related abnormal enhancement according to the breast imaging-reporting and data system MRI descriptors, and the presence of clustered ring enhancement and were compared with the histopathologic diagnoses established in 39 lesions. RESULTS: The most common finding in patients with suspicious nipple discharge was non-masslike enhancement. Seventeen malignant and 22 benign lesions were detected. The most frequent findings in the malignant lesions were "segmental" (59%), "heterogeneous" (57%), and plateau pattern (40%). Clustered ring enhancement was found in 60% of the enhanced malignant lesions (P = 0.002). The combination of segmental distribution and clustered ring enhancement showed a significant association with malignant lesions (P = 0.004). CONCLUSIONS: Magnetic resonance imaging provides clinically useful information in patients with suspicious nipple discharge.

Performance evaluation of 4 measuring methods of ground-glass opacities for predicting the 5-year relapse-free survival of patients with peripheral nonsmall cell lung cancer: a multicenter study.

OBJECTIVE: To evaluate the performance of 4 methods of measuring the extent of ground-glass opacities as a means of predicting the 5-year relapse-free survival of patients with peripheral nonsmall cell lung cancer (NSLC). METHODS: Ground-glass opacities on thin-section computed tomographic images of 120 peripheral NSLCs were measured at 7 medical institutions by the length, area, modified length, and vanishing ratio (VR) methods. The performance (Az) of each method in predicting the 5-year relapse-free survival was evaluated using receiver operating characteristic analysis. RESULTS: The mean Az value obtained by the length, area, modified length, and VR methods in the receiver operating characteristic analyses was 0.683, 0.702, 0.728, and 0.784, respectively. The differences between the mean Az value obtained by the VR method and by the other 3 methods were significant. CONCLUSIONS: Vanishing ratio method was the most accurate predictor of the 5-year relapse-free survival of patients with peripheral NSLC.

New implant technique for separation of the seminal vesicle and rectal mucosa for high-dose-rate prostate brachytherapy.

PURPOSE: For safer treatment of seminal vesicles (SVs), we initiated a new technique using an anchor applicator for high-dose-rate interstitial brachytherapy (HDR-ISBT) of prostate cancer. METHODS AND MATERIALS: Between January 2004 and March 2005, 23 intermediate- to high-risk patients were treated with HDR-ISBT as monotherapy. Transrectal ultrasonography guided implantation of the treatment applicator in and around the prostate gland and proximal SV. We used an "anchor" applicator to prevent posterior displacement of the SV. After insertion of the anchor applicator, the actual treatment applicator was implanted at the best position for optimal SV coverage. SV coverage was analyzed using a dose-volume histogram. RESULTS: Implantation of the applicator on the posterior side of the SV was successful for 43 of 46 SVs (93%). The median percentage of the SVs receiving the prescribed dose was 41% (range 11-86%). Only one case of acute Grade 2 toxicity (3%) was seen. CONCLUSIONS: Our anchor applicator technique for HDR-ISBT can separate the SV from the rectum. This is the first report of dose-volume histogram analysis of the SV for HDR-ISBT.

CT-guided needle biopsy of lung lesions: a survey of severe complication based on 9783 biopsies in Japan.

PURPOSE: The aim of our study was to update the rate of severe complications following CT-guided needle biopsy in Japan via a mailed survey. MATERIALS AND METHODS: Postal questionnaires regarding CT-guided needle biopsy were sent out to multiple hospitals in Japan. The questions regarded: the total number and duration of CT-guided lung biopsies performed at each hospital, and the complication rates and numbers of pneumothorax, hemothorax, air embolism, tumor seeding, tension pneumothorax and other rare complications. Each severe complication was followed with additional questions. RESULTS: Data from 9783 biopsies was collected from 124 centers. Pneumothorax was the most common complication, and occurred in 2412 (35%) of 6881 cases. A total of 39 (35%) hospitals reported 74 (0.75%) cases with severe complications. There were six cases (0.061%) with air embolism, six cases (0.061%) with tumor seeding at the site of the biopsy route, 10 cases (0.10%) with tension pneumothorax, six cases (0.061%) with severe pulmonary hemorrhage or hemoptysis, nine cases (0.092%) with hemothorax, and 27 cases (0.26%) with others, including heart arrest, shock, and respiratory arrest. From a total of 62 patients with severe complications, 54 patients (0.55%) recovered without sequela, however one patient (0.01%) recovered with hemiplegia due to cerebral infarction, and the remaining seven patients (0.07%) died. CONCLUSIONS: This is the first national study documenting severe complications with respect to CT-guided needle biopsy in Japan. The complication rate in Japan is comparable to internationally published figures. We believe this data will improve both clinicians as well as patients understanding of the risk versus benefit of CT-guided needle biopsy, resulting better decisions.

Mucoepidermoid carcinoma of the thymus treated by multimodality therapy: a case report.

A case report of mucoepidermoid carcinoma of the thymus, aggressively treated by multimodality therapy including surgery, radiotherapy, chemothermotherapy, and systemic chemotherapy is presented. The patient, a 53-year-old man, underwent potentially complete resection for an anterior mediastinal tumor, histologically diagnosed as a mucoepidermoid carcinoma of the thymus with Masaoka stage II disease. However, because of local recurrences in the left chest wall and pleura, re-resection was twice performed 4 years and 5 months, and 5 years and 7 months after the initial surgery, in combination with intrathoracic chemothermotherapy and irradiation. Seven years and 1 month after the initial operation, in vitro chemosensitive test based-chemotherapy using vinorelbine for pleural disease was performed, resulting in maintenance of good quality of life (QOL) due to dramatic decrease in pleural effusion. He died of tumor progression, 7 years and 9 months after the initial treatment. Although the clinical aspects of thymic mucoepidermoid carcinoma are little known, it is assumed that such aggressive therapeutic multimodalities as repeated surgical resection, irradiation and chemothermotherapy, and chemotherapy based on in vitro chemosensitivity tests contributed to long-term survival for this unusual disease.

Solitary pulmonary metastases from renal cell carcinoma: comparison of high-resolution CT with pathological findings.

PURPOSE: The aim of this study was to examine the radiographic features of solitary pulmonary metastases from renal cell carcinoma by comparing high-resolution CT (HRCT) findings with histopathological observations. MATERIALS AND METHODS: Three thoracic radiologists retrospectively reviewed HRCT findings from eight patients who underwent surgery on the basis of the diagnosis of solitary pulmonary metastatic renal cell carcinoma. The histopathological diagnoses for six of these eight lesions were metastases from clear cell carcinoma of the kidney, one case was a metastasis from papillary renal cell carcinoma, and the remaining case was a metastasis from a poorly differentiated carcinoma including predominantly spindle cells, papillary cells, and clear cells. RESULTS: The HRCT findings of all cases of clear cell carcinoma showed solid nodular lesions without ground-glass attenuation (GGA). The HRCT findings for one case of papillary renal cell carcinoma showed a lobulated nodule with a small amount of GGA in an area in the periphery and an air bronchogram. The HRCT findings of the remaining case of poorly differentiated carcinoma showed an ill-defined nodule with a GGA area and pleural indentations. CONCLUSION: In brief, solitary pulmonary metastases from renal cell carcinoma may present as a smoothly marginated nodule, lobulated nodule, or a nodule with peripheral GGA.

Oncologic Outcomes of Segmentectomy Versus Lobectomy for Clinical T1a N0 M0 Non-Small Cell Lung Cancer.

BACKGROUND: We retrospectively compared the oncologic outcome after segmentectomy versus lobectomy in patients with clinical (c-) T1a N0 M0 non-small cell lung cancer (NSCLC) detected as a part-solid ground-glass nodule or purely solid nodule on thin-section computed tomography. METHODS: From 1997 to 2010, 312 patients with c-T1a N0 M0 NSCLC were determined to require a surgical approach categorized as segmentectomy or lobectomy. Preoperatively available data were collected using logistic regression analysis, and propensity matching was performed. Factors affecting local-regional recurrence were assessed by Cox proportional hazards regression analysis and Kaplan-Meier estimates. RESULTS: The 5-year and 10-year overall survival rates for the 80 patients who underwent segmentectomy were 97.5% and 83.5%, respectively, compared with 87.75% and 75.0%, respectively, for the 232 patients who underwent lobectomy (p = 0.019). Local-regional recurrence as the first relapse site was found in 3 the 80 segmentectomies (3.8%) of and in 15 of the 232 lobectomies (6.5%). The difference in local-regional recurrence-free survival in patients undergoing segmentectomy compared with lobectomy was not significant (p = 0.304). In 69 propensity score-matched pairs, there was no significant difference in the overall survival (p = 0.442) or local-regional recurrence-free survival (p = 0.717) between the two groups. Multivariate analysis using the Cox proportional hazards regression model identified lymphatic invasion as the only independent factor predicting local-regional recurrence (relative risk, 10.764; 95% confidence interval, 2.98 to 57.68). CONCLUSIONS: Our results suggest that the oncologic outcome of segmentectomy vs lobectomy is similar in this cohort of c-T1a N0 M0 NSCLC patients. These results will be validated by large-scale, prospective, randomized trials.

Pulmonary tumor thrombotic microangiopathy caused by prostate carcinoma.

Pulmonary tumor thrombotic microangiopathy (PTTM) is a fatal malignancy-related condition that involves rapidly progressing hypoxia and pulmonary hypertension. We report a case of PTTM caused by prostate carcinoma, which was diagnosed before autopsy in an 81-year-old man. Computed tomography showed diffuse ground-glass opacities, consolidation, and small nodules in the peripheral regions of the lung. Autopsy showed adenocarcinoma cells embolizing small pulmonary arteries with fibrocellular intimal proliferation, which was consistent with PTTM caused by prostate carcinoma.