Endoscopic Factors that Can Predict Histological Ulcerations in Early Gastric Cancers

Background/Aims@#Predicting histological ulceration in early gastric cancer (EGC) during endoscopic examination is crucial for endoscopists deciding on the treatment modality. The aim of this study was to investigate the endoscopic factors that can predict histological ulcerations in EGCs. @*Methods@#We retrospectively analyzed patients who underwent endoscopic submucosal dissection (ESD) for EGC. Clinical features and endoscopic characteristics of EGC such as location, histological differentiation, longest diameter, tumor morphology, mucosal break, converging fold, color change, and surface irregularity were reviewed. Histological ulceration was defined based on ESD specimens. @*Results@#A total of 633 EGC lesions from 613 patients were included and histological ulcerations were found in 90 lesions (14.2%). Presence of converging folds, tumor morphology, and color changes on endoscopic examination were related to histological ulceration in the univariate analysis and converging folds along with color changes were statistically significant factors in the multivariate analysis. Kaplan–Meier analysis showed that patients with histological ulcerations in EGCs tended to have higher marginal recurrence rates. @*Conclusions@#Mucosal breaks are not equivalent to histological ulcerations. Rather, the existence of converging folds and color changes during endoscopic examination suggest histological ulcerations. Endoscopists should consider these factors when they decide the treatment modality for EGCs.

A Case of Proton Pump Inhibitor-responsive Esophageal Eosinophilia

No abstract available.

A Case of Pediatric Menetrier's Disease Associated with Helicobacter pylori Infection

Menetrier's disease in childhood is a rare form of gastropathy characterized by hypoalbuminemia, endoscopic and/or radiologic findings of hypertrophic gastric folds, and histologic findings of foveolar hyperplasia in the stomach. It tends to have a self-limited course compared to the chronic and complicated course in adult Menetrier's disease. A 7-year-old boy was referred to Incheon St. Mary's Hospital for facial edema. Physical examination on admission showed periorbital swelling, pitting edema in both legs, and epigastric tenderness. Laboratory tests on admission indicated hypoproteinemia (3.0 g/dL) with hypoalbuminemia (2.1 g/dL) and hypogammaglobulinemia. Urinalysis showed no abnormalities. The test results for anti-cytomegalovirus immunoglobulin M and cytomegalovirus PCR were negative. Stool Helicobacter pylori antigen was positive and fecal alpha1-antitrypsin clearance was 40.1 mL/day, consistent with protein-losing gastroenteropathy. Gastroduodenoscopy showed hypertrophic edematous gastric folds, erythema, and superficial erosion in the body of the stomach. The duodenum was normal. Histologic findings showed foveolar hyperplasia. His symptoms improved with conservative treatment including proton pump inhibitor from day 9 of hospitalization and resolved completely. Here we reported a case of pediatric protein-losing hypertrophic gastropathy associated with Helicobacter pylori infection.

Survival of hypoxic human mesenchymal stem cells is enhanced by a positive feedback loop involving miR-210 and hypoxia-inducible factor 1

The use of mesenchymal stem cells (MSCs) has emerged as a potential new treatment for myocardial infarction. However, the poor viability of MSCs after transplantation critically limits the efficacy of this new strategy. The expression of microRNA-210 (miR-210) is induced by hypoxia and is important for cell survival under hypoxic conditions. Hypoxia increases the levels of hypoxia inducible factor-1 (HIF-1) protein and miR-210 in human MSCs (hMSCs). miR-210 positively regulates HIF-1alpha activity. Furthermore, miR-210 expression is also induced by hypoxia through the regulation of HIF-1alpha. To investigate the effect of miR-210 on hMSC survival under hypoxic conditions, survival rates along with signaling related to cell survival were evaluated in hMSCs over-expressing miR-210 or ones that lacked HIF-1alpha expression. Elevated miR-210 expression increased survival rates along with Akt and ERK activity in hMSCs with hypoxia. These data demonstrated that a positive feedback loop involving miR-210 and HIF-1alpha was important for MSC survival under hypoxic conditions.

Papillary Meningioma Presenting as Rapidly Progressive Dementia and Parkinsonism

There are a variety of different causes of parkinsonism including PD, secondary parkinsonism, and the parkinsonism plus syndromes. Secondary parkinsonism is caused by structural, toxic, metabolic, or infectious mechanisms. Among structural causes, intracranial neoplasms are a rare cause of secondary parkinsonism. Moreover, there are almost never case reports with intracranial space-occupying lesions resulting in parkinsonism associated with rapid cognitive impairment. Therefore, we report herein a 37-year-old woman diagnosed with papillary meningioma who presented with parkinsonism associated with rapidly progressive cognitive impairment mimicking diffuse Lewy body disease.

Sequential Changes in Aberrant Crypt Foci and Lectin Expression in the Early and Late Stages of DMH-Induced Colon Carcinogenesis in Rats

BACKGROUND/AIMS: The purpose of this study was to investigate the malignant potential of aberrant crypt foci (ACF) by measuring the multiplicity of crypts and lectin expression in the early and late stages of 1,2-dimethylhydrazine (DMH)-induced colon carcinogenesis. METHODS: Six-week-old Wistar rats were injected subcutaneously with DMH for 27 weeks. We classified ACF according to the number of crypts per ACF as a few crypts ( or =4 crypts, NC ACF). Immunohistochemistry was used to evaluate lectin expression. RESULTS: In the early stage, FC ACF (590/1,902, 31.0%) occurred more frequently than NC ACF (35/449, 7.8%); whereas in the late stage, NC ACF (176/449, 39.2%) occurred more frequently than FC ACF (324/1,902, 17.0%). The number of ACF peaked at 15 to 20 weeks. The ratio of NC/FC ACF increased gradually during carcinogenesis. The expression of both UEA1 and PNA was higher in NC ACF than FC ACF. Lectin expression increased in the late stage compared with the early stage. CONCLUSIONS: The expression of lectin was higher in NC ACF and ACF in the late stage. Therefore, ACF with higher multiplicities in the late stage may have more malignant potential in DMH-induced colon carcinogenesis.

The Relationship between Gastric Juice Nitrate/Nitrite Concentrations and Gastric Mucosal Surface pH

PURPOSE: To investigate gastric juice nitrate/nitrite concentration according to mucosal surface pH extent (area) of gastric corpus intimately contacting the gastric juice. MATERIALS AND METHODS: We included ninety-nine patients with dyspepsia. To evaluate gastric mucosal surface pH and its extent, gastric chromosocpy was performed by spraying phenol red dye on the corpus mucosa and estimating the extent of area with color changed. Nitrate/nitrite concentrations and pH of gastric juice were measured by ELISA and pH meter, respectively. Silver staining was done to histologically confirm the presence of Helicobacter pylori. RESULTS: Intragastric nitrate/nitrite concentrations in patients, showing phenol red staining mucosa were higher than those of unstaining mucosa (p=0.001): the more extensive in the area of phenol red staining area of corpus, the higher gastric juice pH found (r=0.692, p<0.001). Furthermore, the intragastric nitrate/nitrite concentrations correlated positively with gastric juice pH (r=0.481, p<0.001). CONCLUSION: The changes of mucosal surface pH and its extent in gastric corpus might affect either pH or nitrate/nitrite level of gastric juice.

Severe steatohepatitis with hepatic decompensation resulting from malnutrition after pancreaticoduodenectomy

The most common finding related to nonalcoholic steatohepatitis is obesity, but a status of severe malnutrition can also induce the steatohepatitis. The authors report a rare case of steatohepatitis leading to hepatic decompensation caused by malnutrition after pancreaticoduodenectomy. A 68-year-old female patient who had been previously diagnosed with pancreatic cancer and had undergone pancreaticoduodenectomy 5 months previously presented with abdominal distension. Routine CT performed 3 months after the surgery revealed severe fatty liver without evidence of tumor recurrence. After undergoing pancreaticoduodenectomy her food intake had reduced, and as a result she had lost 7 kg of body weight over 2 months. At this admission, CT revealed moderate amounts of ascites without tumor recurrence. Furthermore, her albumin and lipid profile levels were markedly decreased, and she had a flapping tremor and slurred speech suggestive of hepatic encephalopathy. Her liver biopsy findings were consistent with steatohepatitis and disclosed macrovesicular steatosis without definite fibrosis. After careful nutritional control, her symptoms disappeared and her laboratory findings improved.

Gastric Fundic Gland Polyps and Their Relationship to Colorectal Neoplasia in Koreans: A 16-year Retrospective Study / 대한소화기학회지

BACKGROUND/AIMS: There is an ongoing debate on the relationship between gastric fundic gland polyps and increased incidence of colorectal neoplasia in Caucasians. However, there was no report on the relationship between gastric fundic gland polyp and colorectal neoplasia in Korea. The aim of this study was to identify the characteristics of gastric fundic gland polyps and whether a relationship exists between fundic gland polyps and colorectal neoplasia in Korean population. METHODS: Persons who underwent an esophagogastroduodenoscopy and colonoscopy from 1992 to 2007 at the Health Promotion Center of Incheon St. Mary's Hospital, The Catholic University of Korea were reviewed retrospectively. The relationship between gastric fundic gland polyps and colorectal neoplasia were analyzed. RESULTS: Among 22,451 subjects, fundic gland polyps were found in 328 subjects (1.5%). Fundic gland polyps were more common in women than in men (odds ratio of 6.25; 95% CI of 4.68-8.34). The odds ratios for colorectal neoplasia in all subjects with gastric fundic gland polyps were 0.56 (95% CI of 0.33-0.95) and men who were 50 years of age or older had an odds ratio of 2.81 (95% CI of 1.03-7.66) as compared to the control group. However, age and sex-adjusted odds ratios for all gastric fundic gland polyps were 0.73 (95% CI of 0.42-1.26), for men 1.78 (95% CI of 0.80-3.98), and for women 0.37 (95% CI of 0.16-0.87). CONCLUSIONS: Surveillance colonoscopy in patients with fundic gland polyps can be performed in the same manner as general population in Korea.

Fine Needle Aspiration Biopsy of a Myxoid Leiomyosarcoma with Epithelioid Features and It Metastasized to the Abdominal Wall: A Case Report

We present the cytologic findings observed in a fine needle aspiration biopsy specimen of a rare myxoid variant of leiomyosarcoma with epithelioid features and the tumor had metastasized to the abdominal wall. The aspirate showed hypercellularity in a hemorrhagic background. Some large 3-dimensional aggregates of spindle cells were observed. Each cell had a solitary ovoid-to-elongated nucleus with finely granulated chromatin, one or two small distinct nucleoli and an irregular nuclear membrane. There were irregular fascicles of spindle cells with cigar-shaped, blunt-ended nuclei admixed with inflammatory cells. Epithelioid cells with a rather narrow, dense cytoplasmic rim and a well-defined cell border were embedded in a myxoid matrix in a cord-like and cluster arrangement. The matrix appeared as a pale green substance with sharply defined edges. There were very few mitoses. These cytologic features were the same as those of a uterine myxoid leiomyosarcoma that was surgically excised 7 years ago, and immunohistochemical staining revealed the smooth muscle origin of the tumor.

Comparison between FDG Uptake and Pathologic or Immunohistochemical Parametersin Pre-operative PET/CT Scan of Patient with Primary Colorectal Cancer / 핵의학분자영상

PURPOSE: To evaluate the relationship between F-18 FDG uptake of tumor in PET/CT scan and pathological or immunohistochemial parameters of colorectal cancer. MATERIALS AND METHODS: 147 colorectal cancer patients who underwent both pre-operative F-18 FDG PET/CT scan and surgery were included. In cases with perceptible FDG uptake in primary tumor, the maximum standardized uptake value (SUVmax) was calculated. The pathologic results such as site, size, depth of invasion (T stage), growth pattern, differentiation of primary tumor, lymph node metastasis and Dukes-Astler & Coller stage and immunohistochemical markers such as expression of EGFR, MLH1, MSH2 and Ki-67 index were reviewed. RESULTS: 146 out of 147 PET/CT scans with colorectal cancer showed perceptible focal FDG uptake. SUVmax showed mild positive linear correlation with size of primary tumor (r=0.277, p=0.001) and Ki-67 index (r=0.226, p=0.019). No significant difference in F-18 FDG uptake was found according to site, depth of invasion (T stage), growth pattern, differentiation of primary tumor, presence of lymph node metastasis, Dukes-Astler & Coller stage and expression of EGFR. CONCLUSION: The degree of F-18 FDG uptake in colorectal cancer was associated with the size and the degree of Ki-67 index of primary tumor. It could be thought that FDG uptake of primary tumor has a correlation with macroscopic and microscopic tumor growth.

Therapeutic Effect of Allogenic Bone Marrow Transplantation in Acute TNBS-induced Colitis / 대한소화기학회지

BACKGROUND/AIMS: Bone marrow-derived cells (BMDC) contribute to tissue maintenance under many kinds of pathologic conditions. We carried out a study to see how BMDC play a role in the treatment of experimental murine colitis. METHODS: We divided the animals into 3 groups and treated them with 50% ethanol (control group), 2,4,6-trinitrobenzene sulfinic acid colitis (TNBS group), and TNBS+bone marrow transplant (BMT group). To induce colitis, TNBS (5.0 mg/mouse) dissolved in 50% ethanol was injected into anus weekly for two weeks. Bone marrow transplantations were performed using bone marrow of male transgenic mouse (donor) with green fluoresence protein (GFP) into female wild type mouse (recipient) three weeks before TNBS instillation. All animals were sacrificed, and colons were extracted one week after the last TNBS instillation. We measured microscopic scores of mucosal injury and investigated the GFP expression for bone marrow engraftment. The immunostaining of vimentin and alpha-smooth muscle actin (alpha-SMA) for myofibroblasts was performed. RESULTS: The score of mucosal injury in the TNBS group was much more severe than those in control, and reduced significantly by BMT (p<0.05). GFP-positive cells were almost deposited in pericryptal niche of BMT group but not at all in both control and TNBS group. Most of myofibroblasts stained with both vimentin and SMA also infiltrated into pericryptal niche. But, the number of myofibroblasts stained with vimentin and SMA in both control and TNBS group was smaller than that in BMT group. CONCLUSIONS: BMDC deposited on pericryptal niche might have a significant role in repairing acute experimental murine colitis.

Pineal Parenchymal Tumor of Intermediate Differentiation with Gangliocytic Differentiation: A Case Report

A 49-year-old man presented with an extremely rare case of pineal parenchymal tumor with gangliocytic cells, manifesting as progressive gait disturbance and urinary incontinence lasting for one year. Brain MRI revealed a homogenously enhancing mass, measuring 3.5x2.7 x1.7 cm, in the pineal body. The mass compressed the deep cerebral vein with superior displacement, which caused mild obstructive hydrocephalus. Histological examination revealed lobular structures consisting of isomorphic small round cells with stippled chromatin and clear cytoplasm, and less cellular areas having large pleomorphic cells and ganglioid cells. Mitotic figures and tumor necrosis were not evident. Immunohistochemically, the neoplastic cells were positive for neuronal markers (neuron-specific enolase, neurofilament, NeuN and synaptophysin), but not for glial fibrillary acidic protein or S-100. Especially, neurofilament showed diffuse interstitial immunoreactivity with accentuation in a few gangliocytic cells and Ki-67 labeling index (2.5%) was low. Therefore, this case was diagnosed as pineal parenchymal tumor of intermediate differentiation with gangliocytic differentiation.

Comparison between FDG Uptake and Clinicopathologic and Immunohistochemical Parameters in Pre-operative PET/CT Scan of Primary Gastric Carcinoma / 핵의학분자영상

PURPOSE: The purpose of this study was to find out what clinicopathologic or immunohistochemical parameter that may affect FDG uptake of primary tumor in PET/CT scan of the gastric carcinoma patient. MATERIALS AND METHODS: Eighty-nine patients with stomach cancer who underwent pre-operative FDG PET/CT scans were included. In cases with perceptible FDG uptake in primary tumor, the maximum standardized uptake value (SUVmax) was calculated. The clinicopathologic results such as depth of invasion (T stage), tumor size, lymph node metastasis, tumor differentiation and Lauren's classification and immunohistochemical markers such as Ki-67 index, expression of p53, EGFR, Cathepsin D, c-erb-B2 and COX-2 were reviewed. RESULTS: Nineteen out of 89 gastric carcinomas showed imperceptible FDG uptake on PET/CT images. In cases with perceptible FDG uptake in primary tumor, SUVmax was significantly higher in T2, T3 and T4 tumors than T1 tumors (5.8+/-3.1 vs. 3.7+/-2.1, p=0.002). SUVmax of large tumors (above or equal to 3 cm) was also significantly higher than SUVmax of small ones (less than 3 cm) (5.7+/-3.2 vs. 3.7+/-2.0, p=0.002). The intestinal types of gastric carcinomas according to Lauren showed higher FDG uptake compared to the non-intestinal types (5.4+/-2.8 vs. 3.7+/-1.3, p=0.003). SUVmax between p53 positive group and negative group was significantly different (6.0+/-2.8 vs. 4.4+/-3.0, p=0.035). No significant difference was found in presence of LN metastasis, tumor differentiation, Ki-67 index, and expression of EGFR, Cathepsin D, c-erb-B2 and COX-2. CONCLUSION: T stage of gastric carcinoma influenced the detectability of gastric cancer on FDG PET/CT scan. When gastric carcinoma was perceptible on PET/CT scan, T stage, size of primary tumor, Lauren's classification and p53 expression were related to degree of FDG uptake in primary tumor.

The Clinical Features and Pathophysiology of Acute Radiation Dermatitis in Patients Receiving Tomotherapy

BACKGROUND: Radiation therapy (RT) including tomotherapy has been widely used to treat primary tumors, as well as to alleviate the symptoms of metastatic cancers. OBJECTIVE: The primary purpose of this study was to examine the characteristics of the clinical features and pathophysiological mechanisms associated with acute radiation dermatitis in cancer patients that received tomotherapy, and compare the results to patients treated by conventional radiation therapy. METHODS: The study population consisted of 11 patients that were referred to the dermatology department because of radiation dermatitis after receiving tomotherapy; all patients were evaluated for clinical severity. The patients were assessed and identified using the National Cancer Institute Common Toxicity Criteria version (CTC) 3.0. We performed biopsies of the skin lesions that were examined for apoptosis using the terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate nick end-labelling (TUNEL) assay and stained immunohistochemically with monoclonal antibodies to CD8, CD4 and TGF-beta. As a positive control, patients with radiation dermatitis treated with conventional radiation therapy were also studied. RESULTS: The results of the clinical features of the skin of tomotherapy patients were the following: grade 1 (36%), grade 2 (55%) and other changes (9%). Among the population that had skin lesions due to acute radiation dermatitis, the mean number of positive cells per high power field (HPF) was the following: there were 30.50+/-.50 TUNEL- positive cells, 34.60+/-12.50 CD8+ T cells, 5.19+/-3.17 CD4+T cells and 9.95+/-1.33 TGF-beta positive cells measured per HPF. The mean number of positive cells per HPF for the patients that received conventional radiation therapy was: TUNLEL-positive cells in 7.5+/-1.64, CD8-, CD4- and TGF-beta-positive cells in 12.50+/-3.73, 3.16+/- 1.47, 6.50+/-1.97. CONCLUSION: We found that the number of TUNEL-positive cells and CD8+ T cells were higher in the lesions of patients receiving tomotherapy compared to the lesions of the patients receiving conventional radiation therapy. These findings suggest that tomotherapy without dose modification may cause significantly more severe forms of radiation dermatitis by apoptosis and cytotoxic immune responses than conventional radiation therapy.

Traction with using a Rubber Band and Clips for Effective Endoscopic Submucosal Dissection / 대한소화기내시경학회지

BACKGROUND/AIMS: Traction with using a rubber band and clips may be helpful for performing endoscopic submucosal dissection (ESD) by keeping adequate tissue tension and satisfactory submucosal exposure. METHODS: 17 patients with noninvasive neoplasias or intramucosal cancers (16 gastric lesions and 1 colonic lesion) were included to evaluate this technique's feasibility (3), because of a difficult location for dissection (11), unsatisfactory mucosal elevation despite adequate submucosal injection (2), and a high risk of perforation from the thin colonic wall (1). Submucosal dissection was performed after traction was applied, with a using a rubber band and clips, to a precut margin of the lesion. RESULTS: The mean sizes of the 16 gastric neoplasias and the corresponding resected specimens were 16+/-9 mm (6~40) and 37+/-9 mm (18~50), respectively, and the sizes of the colonic intramucosal cancers and the resected specimens were 41 mm and 51 mm), respectively. Both the en-bloc resection rate and the complete resection rate were 77%. Complete ESD without snaring was preformed in 10 cases (59%). The traction was assessed as useful in eleven cases (65%), not useful in two (12%), and annoying in four (23%). CONCLUSIONS: Traction with using a rubber band and clips can be useful for performing ESD.

Ruptured ovarian mature cystic teratoma with jaw bone and teeth: A case report / 대한산부인과학회지

The mature cystic teratoma of the ovary (ovarian dermoid cyst) is the most common ovarian neoplasm in young women and comprises approximately 10~25% of all ovarian tumors. There are many complications such as torsion, rupture, infection, suppuration, and rarely malignancy change. Teratoma derives from the three embryonic cell lines and may contain skin, sebaceous tissue, hair, cartilage and bone, neuroglial tissue, gastrointestinal and respiratory tissue, teeth, and muscle. Even though the presence of dental tissue within dermoid cysts has been reported in the literature, the cysts containing jaw bone and teeth are extremely rare. We report a case of ruptured ovarian dermoid cyst containing jaw bones and eight well-formed teeth with a brief review of literature.

A case of aggressive angiomyxoma of the vulva / 대한산부인과학회지

Aggressive angiomyxoma is an uncommon soft-tissue neoplasm which affects the pelvis and genital organs of the young female predominantly. This tumor has a high tendency of local recurrence, but it usually does not develop metastasis. Although surgical excision with wide tumor-free margins may be necessary to obtain a complete cure, some of patients experience local recurrences. Many of the tumors are estrogen receptor (ER) and progesterone receptor (PR) positive and medical therapy with gonadotropin-releasing hormone (GnRH) agonists showed to be effective in a few cases. We present a case of 29-years-old women who has aggressive angiomyxoma which was misdiagnosed as bartholin duct cyst. She was treated by wide local excision with postoperative adjuvant GnRH agonist therapy for 3 months. She is now free of disease during 9 months of follow up. We have described this case with the brief of literature.

A case of adrenocortical adenoma clinically mimicking pheochromocytoma / 대한내과학회지

The coexpression of cortical and medullary features in a single adrenal cortical cell has been recognized, leading to terms such as cortico-medullary cells. Here, we reported a case of adrenocortical adenoma consisting of cortico-medullary cells that clinically mimicked pheochromocytoma. A 52-year-old woman was admitted to our hospital complaining of an 8-month history of paroxysmal palpitation with refractory hypertension. A 24-hour urine study revealed increased norepinephrine and metanephrine levels. Computed tomography of the abdomen revealed a 1.0x0.9-cm mass in the left adrenal gland. The patient subsequently underwent unilateral laparoscopic adrenalectomy for a presumptive pheochromocytoma. Light microscopic findings of the left adrenal mass indicated an adrenocortical adenoma, but electron microscopy identified lipid vacuoles and smooth endoplasmic reticulum, along with dense core neurosecretory granules, so-called cortico-medullary cells. This is the first report of the detection of cortico-medullary cells in adrenocortical adenoma presenting as pheochromocytoma in Korea.

Ultrasonographic and Mammographic Findings of Nodular Sclerosing Adenosis

PURPOSE: To evaluate the ultrasonographic and mammographic findings of cases of nodular adenosis. MATERIALS and METHODS: We evaluated 22 lesions with a pathologically proven nodular adenosis from five hospitals for three years. We excluded adenosis cases combined with other breast diseases. The findings of ultrasonography and mammography were retrospectively interpreted in consensus by two radiologists that were experienced in breast imaging according to the BI-RADS criteria. RESULTS: The age of the patients was 29-56 years with a mean age of 43.4 years. Ten lesions were biopsied with a 14-gauge core needle, seven lesions were biopsied with an 11-gauge vacuum-assisted mammotome and five lesions were removed by surgical excision. Mammography was performed in 15 patients and distinct abnormalities were seen in seven cases. These abnormalities consisted of an indistinct irregular mass, three circumscribed masses and three focal asymmetries. Calcifications were not seen in all of the masses. Ultrasonography was performed in 22 patients, revealing 13 irregular shaped lesions 8 oval shaped lesions and one round shape lesion. The margin was either circumscribed (n = 7) and not circumscribed (n = 15) in the lesions. The orientation of mass was parallel in 13 lesions and not parallel in 9 lesions. The boundary was an abrupt interface in all of the cases. The echogenecity of the mass was hypoechoic in 15 cases, isoechoic in 4 cases, hyperechoic in 2 cases and complex echogenic in one case. Nineteen of the cases showed no posterior feature and one case showed combined features. The final categories by the BI-RADS criteria were category 3 in three cases and category 4 in 19 cases (C4a 11, C4b 8). CONCLUSION: Nodular adenosis mostly presents as category 4 on ultrasonography. Therefore, a differential diagnosis with malignancy is difficult to determine. However, the findings of lesions highly suggestive of being malignant such as a spiculation or echogenic halo, are rare. On mammography, it is commonly obscured.