Effectiveness of PET/CT and VATS for detecting and treating internal mammary lymph node metastasis: a case series.

OBJECTIVE: We occasionally observed internal mammary lymph node metastases of breast cancer in a clinical setting. However, unlike a standard treatment in axillary metastasis, surgical resection for internal mammary lymph node metastasis is not prevalent because of unclear safety and benefits. Thus, we aimed to evaluate the diagnostic ability and clinical outcomes of positron emission tomography/computed tomography and video-assisted thoracoscopic surgery. METHODS: We retrospectively investigated 34 patients with breast cancer with abnormal 18F-fluorodeoxyglucose uptake in internal mammary lymph nodes, at a single centre, between January 2015 and June 2022 and identified 11 female patients (mean age ± SD, 51.5 ± 12.9 years) who underwent video-assisted thoracoscopic surgery resection. Positron emission tomography/computed tomography was used to determine the clinical stage. We reviewed the surgical pathology of eleven and two patients who underwent direct-view internal mammary lymph node resection to calculate the positive predictive value of positron emission tomography/computed tomography. RESULTS: Ipsilateral fluorodeoxyglucose accumulation was observed, with an average maximum standardized uptake value of 8.9 (range, 3.1-24.0). No perioperative complications occurred, and all patients who underwent video-assisted thoracoscopic surgery alone were discharged from the hospital on post-operative day 2 or 3. The estimated positive predictive value was 80%. All patients were alive, and seven of nine patients with metastasis were relapse-free, at a mean follow-up period of 17.9 months (range, 1-51). However, two patients had recurrence at 16 and 14 months after surgery for internal mammary lymph node relapse. CONCLUSIONS: Radiotherapy is the standard treatment for suspected internal mammary lymph node metastasis detected using positron emission tomography/computed tomography; however, we could safely perform minimally invasive video-assisted thoracoscopic surgery resection, leading to a definite pathological diagnosis.

Insights into the Proton Transfer Mechanism of a Bilin Reductase PcyA Following Neutron Crystallography.

Phycocyanobilin, a light-harvesting and photoreceptor pigment in higher plants, algae, and cyanobacteria, is synthesized from biliverdin IXα (BV) by phycocyanobilin:ferredoxin oxidoreductase (PcyA) via two steps of two-proton-coupled two-electron reduction. We determined the neutron structure of PcyA from cyanobacteria complexed with BV, revealing the exact location of the hydrogen atoms involved in catalysis. Notably, approximately half of the BV bound to PcyA was BVH(+), a state in which all four pyrrole nitrogen atoms were protonated. The protonation states of BV complemented the protonation of adjacent Asp105. The "axial" water molecule that interacts with the neutral pyrrole nitrogen of the A-ring was identified. His88 Nδ was protonated to form a hydrogen bond with the lactam O atom of the BV A-ring. His88 and His74 were linked by hydrogen bonds via H3O(+). These results imply that Asp105, His88, and the axial water molecule contribute to proton transfer during PcyA catalysis.

[Evaluation of mycobacterial infections using 18F-fluorodeoxyglucose-positron emission tomography: results of nine cases].

18F-fluorodeoxyglucose-positron emission tomography (FDG-PET/CT) is a useful technique for distinguishing malignant and benign lesions, although the occurrence of false-positive results in cases involving benign lesions is possible. We evaluated nine patients with mycobacterial infections who underwent FDG-PET/CT from April 2008 to July 2010. FDG-PET/CT was performed 1-2h (during the early and late phases) after administration of FDG at a dose of 185 MBq/individual after fasting for at least 5h. Out of the nine patients, four were diagnosed with pulmonary nonmycobacterium tuberculosis, two with pulmonary tuberculosis, two with tuberculous lymphadenopathy, and one with pleural tuberculoma. All patients had a maximum standardized uptake value (SUV(max)) of > 2.5, and the SUV(max) increased from the early to the late phase. One lesion that occurred due to tuberculous pleurisy after treatment demonstrated high FDG uptake, similar to the other cases. It is difficult to distinguish mycobacterial infections from malignant diseases using FGD-PET alone; hence, the use of high-resolution CT and bacteriological tests is required for diagnosis and distinction.

Detection of intracranial aneurysms using deep learning-based CAD system: usefulness of the scores of CNN's final layer for distinguishing between aneurysm and infundibular dilatation.

PURPOSE: We evaluated the diagnostic performance of a clinically available deep learning-based computer-assisted diagnosis software for detecting unruptured aneurysms (UANs) using magnetic resonance angiography and assessed the functionality of the convolutional neural network (CNN) final layer score for distinguishing between UAN and infundibular dilatation (ID). MATERIALS AND METHODS: EIRL brain aneurysm (EIRL_BA) was used in this study. The subjects were 117 UAN and/or ID cases including 100 UAN lesions (average sizes of 2.56 ± 1.45 mm) and 40 ID lesions (average sizes of 1.75 ± 0.41 mm) in any of internal carotid artery, middle cerebral artery, and anterior communicating artery, and 123 normal controls. The sensitivity, specificity, and accuracy of EIRL_BA were determined for UAN and ID or UAN only. Furthermore, the relationship between the lesion category and score was examined using a linear regression analysis model, and the receiver operating characteristic (ROC) analysis was used to assess whether the scores represent UAN-like characteristics. RESULTS: EIRL_BA showed a total of 203 candidates (an average of 1.73/case) in UAN and/or ID cases and 98 candidates (an average of 0.80/case) in normal controls. For diagnosing either UAN/ID, EIRL_BA showed an overall sensitivity of 80%, specificity of 84.2%, and accuracy of 83.7%, resulting in the positive likelihood ratio of 5.0. For diagnosing UAN only, the overall sensitivity of 89.0, specificity of 82.6%, and accuracy of 83.2% resulting in the positive likelihood ratio of 5.1. In a linear regression analysis, the scores significantly increased in the candidates' first and second ranks in UAN (p < 0.05) but not in ID. An ROC analysis using the score for diagnosing UAN showed an area under the curve of 0.836. CONCLUSION: EIRL_BA is applicable for detecting small UAN, and the CNN's final layer scores may be an effective index for discriminating UAN and ID and representing the likelihood of UAN.

Crystallization and preliminary X-ray crystallographic analysis of human peptidylarginine deiminase type III.

In the presence of calcium ions, human peptidylarginine deiminase (PAD) converts arginine residues in proteins to citrulline. Of the five known human PAD enzymes, the type III isozyme (PAD3) exhibits the highest specificity for synthetic and natural substrates. This study aimed to determine the structure of PAD3 in order to elucidate its selective citrullination mechanism. Crystals of PAD3 obtained using polyethylene glycol 400 as a precipitant diffracted to 2.95 Å resolution using synchrotron radiation. They belonged to space group R3, with unit-cell parameters a = b = 114.97, c = 332.49 Å (hexagonal axes). Assuming two molecules were contained in an asymmetric unit, the calculated Matthews coefficient was 2.83 Å(3) Da(-1), corresponding to a solvent content of 56.6%. Initial phases were determined using PAD4 as a molecular-replacement model.

Phosphoglyceride crystal deposition disease requiring differential diagnosis from malignant tumors and confirmed by Raman spectroscopy: A case report.

BACKGROUND: Phosphoglyceride crystal deposition disease (PCDD) is a rare acquired disease in which phospholipid crystals deposit in bone and soft tissue long after surgery, trauma, or repeated injections. CASE SUMMARY: A 60-year-old-woman was referred to our department because of multiple abdominal masses after open splenectomy for idiopathic thrombocytopenic purpura 29 years earlier. All the masses showed marked fluorodeoxyglucose (FDG) uptake on 18F-fluorodeoxyglucose positron emission tomography (18F-FDG-PET) and were strongly suspected to be malignant tumors. Surgical biopsies were performed, and the abdominal masses were found to be aligned vertically, three in a row, along the tissue layers cut in the patient's previous surgery. Pathological finding of the specimens showed foreign body granuloma consisting of histiocytes and multinucleated giant cells accumulating around needle-like crystals. The crystals were confirmed as phosphoglyceride by Raman spectroscopy, and PCDD was diagnosed. To our knowledge, this is the first report of PCDD diagnosed by Raman spectroscopy. CONCLUSION: We made a definitive diagnosis of PCDD in a patient with multiple tumors showing marked FDG uptake on 18F-FDG-PET by incisional biopsy and compo- sition analysis using Raman spectroscopy, a method that has not previously been reported for the diagnosis of PCDD.

Clinical prediction model based on 18F-FDG PET/CT plus contrast-enhanced MRI for axillary lymph node macrometastasis.

Purpose: Positron emission tomography/computed tomography (PET/CT) and magnetic resonance imaging (MRI) are useful for detecting axillary lymph node (ALN) metastasis in invasive ductal breast cancer (IDC); however, there is limited clinical evidence to demonstrate the effectiveness of the combination of PET/CT plus MRI. Further axillary surgery is not recommended against ALN micrometastasis (lesion ≤2 mm) seen in sentinel lymph nodes, especially for patients who received proper adjuvant therapy. We aimed to evaluate the efficacy of a prediction model based on PET/CT plus MRI for ALN macrometastasis (lesion >2 mm) and explore the possibility of risk stratification of patients using the preoperative PET/CT plus MRI and biopsy findings. Materials and methods: We retrospectively investigated 361 female patients (370 axillae; mean age, 56 years ± 12 [standard deviation]) who underwent surgery for primary IDC at a single center between April 2017 and March 2020. We constructed a prediction model with logistic regression. Patients were divided into low-risk and high-risk groups using a simple integer risk score, and the false negative rate for ALN macrometastasis was calculated to assess the validity. Internal validation was also achieved using a 5-fold cross-validation. Results: The PET/CT plus MRI model included five predictor variables: maximum standardized uptake value of primary tumor and ALN, primary tumor size, ALN cortical thickness, and histological grade. In the derivation (296 axillae) and validation (74 axillae) cohorts, 54% and 61% of patients, respectively, were classified as low-risk, with a false-negative rate of 11%. Five-fold cross-validation yielded an accuracy of 0.875. Conclusions: Our findings demonstrate the validity of the PET/CT plus MRI prediction model for ALN macrometastases. This model may aid the preoperative identification of low-risk patients for ALN macrometastasis and provide helpful information for PET/MRI interpretation.

[A case of caseous pneumonia demonstrating intense uptake on FDG-PET].

A 79-year-old man was hospitalized because of a chest X-ray abnormality. The chest X-ray film revealed infiltration in the left middle lung field. Chest CT scan showed mediastinal lymphadenopathy, and consolidated opacities with ground-glass opacities in the S3 and a part of the S3 segments of the left upper lobe. CT-guided needle biopsy demonstrated caseating epithelioid granuloma with multinucleated giant cells. 18F-fluorodeoxyglucosepositron emission tomography (FDG-PET) showed intense uptake (standardized uptake value (SUV) max 1 hour/2 hours 18.0/21.8) in the left upper lobe. Bronchial lavage fluid culture revealed Mycobacterium tuberculosis. From these findings, we made a diagnosis of caseous pneumonia with intense uptake on FDG-PET. After antituberculosis therapy, chest X-ray images and a CT scan showed improvement of the consolidation, the ground-glass opacities and mediastinal lymphadenopathy. Intense FDG uptake in caseous pneumonia may represent its high activity. This is the first reported case of caseous pneumonia examined by FDG-PET in Japan.

Two cases of subacute combined degeneration: magnetic resonance findings.

We report two cases of subacute combined degeneration. Both patients had undergone total gastrectomy. The chief complaints were numbness in both upper extremities in case 1 and numbness in both the upper and lower extremities and gait disturbance in case 2. The pain, temperature, and vibration senses of both patients were decreased. Laboratory examinations showed macrocytic anemia and a decreased serum vitamin B12 level in both cases. In both cases T2-weighted magnetic resonance images showed an area of hyperintensity in the dorsal columns of the cervical spinal cord. The patients were treated with vitamin B12. The abnormal signals had disappeared on follow-up magnetic resonance examination 1 year later in case 1 and 3 months later in case 2. These patients showed neurological improvement, but the numbness in the upper extremities persisted even after the area of abnormal signal intensity had disappeared in case 1.

Prevalence and distribution of coronary calcium in asymptomatic Japanese subjects in lung cancer screening computed tomography.

BACKGROUND: Coronary artery calcium (CAC) is associated with a risk of coronary heart disease. The prevalence and distribution of the CAC score have been examined in Western countries, but few studies have been performed in Asia, and especially in Japan. The goal of this study was to investigate CAC scores in an asymptomatic Japanese population. METHODS: CAC score and risk factors were analyzed in 1834 asymptomatic subjects who underwent lung cancer screening computed tomography. RESULTS: CAC was present in 26.9% of all the subjects, 29.8% of the males, and 17.1% of the females. In all age groups, the CAC score was higher in males. In multivariate analysis, male gender [odds ratio (OR) 2.461, 95% confidence interval (CI) 1.361-4.452, p=0.002], aging (OR 1.102, 95% CI 1.081-1.123, p<0.001), dyslipidemia (OR 1.740, 95% CI 1.216-2.490, p=0.002), and fasting glucose (OR 1.008, 95% CI 1.002-1.015, p=0.012) were significantly associated with a CAC score >100. CONCLUSION: The results of this study provide a pattern of CAC distribution based on age and gender in asymptomatic Japanese subjects. This pattern was similar to that in Western countries, although the absolute CAC scores were lower. High CAC scores were associated with male gender, aging, dyslipidemia, and fasting glucose.

Relationship between Alcohol Intake and Risk Factors for Metabolic Syndrome in Men.

OBJECTIVE: The precise relationship between alcohol intake and metabolic syndrome (MetS) is still unclear, and the results from previous studies have been inconclusive. Thus, we examined the effect of alcohol intake on the risk of MetS in men in order to gain more information on a potential relationship. METHODS: This study included 22,349 men who were divided into four groups according to their average alcohol intake [non-, light (less than 20 g ethanol/day), heavy (equal or more than 20 g and less than 60 g ethanol/day) and very heavy (equal and greater than 60 g ethanol/day) drinkers]. We measured each subject's body mass index (BMI), waist circumference and blood pressure (BP) and conducted a blood test to obtain a complete blood count and biochemical panel. These results were used to obtain the MetS prevalence. Additionally, fatty liver was diagnosed using abdominal ultrasonography. RESULTS: Light drinkers had smaller waist circumferences. Heavy and very heavy drinkers had larger waist circumferences, a higher BMI, a higher BP, higher fasting plasma glucose levels, higher triglycerides (TG) levels and higher high-density lipoprotein (HDL) cholesterol levels while they had lower low-density lipoprotein cholesterol levels than nondrinkers. The prevalence of high BP, hyperglycemia and high TG was significantly higher in heavy and very heavy drinkers than in nondrinkers. The prevalence of low HDL cholesterol levels decreased with an increase in alcohol consumption. The prevalence of MetS was significantly lower in light drinkers and higher in very heavy drinkers compared with nondrinkers. CONCLUSION: Alcohol intake significantly influences the risk of MetS in men. A significant association was seen between an alcohol intake of 60 g/day or higher and the prevalence of MetS.

Development of quantitative analysis method for stereotactic brain image: assessment of reduced accumulation in extent and severity using anatomical segmentation.

Through visual assessment by three-dimensional (3D) brain image analysis methods using stereotactic brain coordinates system, such as three-dimensional stereotactic surface projections and statistical parametric mapping, it is difficult to quantitatively assess anatomical information and the range of extent of an abnormal region. In this study, we devised a method to quantitatively assess local abnormal findings by segmenting a brain map according to anatomical structure. Through quantitative local abnormality assessment using this method, we studied the characteristics of distribution of reduced blood flow in cases with dementia of the Alzheimer type (DAT). Using twenty-five cases with DAT (mean age, 68.9 years old), all of whom were diagnosed as probable Alzheimer's disease based on NINCDS-ADRDA, we collected I-123 iodoamphetamine SPECT data. A 3D brain map using the 3D-SSP program was compared with the data of 20 cases in the control group, who age-matched the subject cases. To study local abnormalities on the 3D images, we divided the whole brain into 24 segments based on anatomical classification. We assessed the extent of an abnormal region in each segment (rate of the coordinates with a Z-value that exceeds the threshold value, in all coordinates within a segment), and severity (average Z-value of the coordinates with a Z-value that exceeds the threshold value). This method clarified orientation and expansion of reduced accumulation, through classifying stereotactic brain coordinates according to the anatomical structure. This method was considered useful for quantitatively grasping distribution abnormalities in the brain and changes in abnormality distribution.

[Cardiac pool scintigraphy using the solid-state Digirad 2020tc Imager--comparison with the conventional anger-type gamma camera using moving cardiac phantom].

UNLABELLED: Movable gamma camera, 2020tc Imager, was light miniaturized using Si photodiode as a semiconductor sensor instead of photomultiplier tubes. To validate performance of this new camera in cardiac pool scintigraphy, multigated equilibrium radionuclide ventriculography using the moving cardiac phantom was performed with 2020tc Imager and a conventional Agner-type gamma camera (PRISM 3000). METHOD: Both measured cardiac functional values were compared with the set-up ones for the phantom. Five-, 7.5-, and 10-minute-multigated data were acquired using both cameras under constant contractile condition. Constant 5-minute-multigated data acquisitions using 2020tc Imager were also carried out with varied contractile conditions. RESULTS: Measured ejection fraction (EF) derived from 2020tc Imager and an Anger-type camera were 68.5 +/- 0.6 and 70.3 +/- 1.4%, respectively. Both of these values were absolutely close to the set-up EF value of 70%. Both of end-diastolic volume and EF showed excellent correlation between set-up and measured values with the correlation coefficient of 0.97 and 0.99, respectively. CONCLUSION: This new movable camera could provide comparative cardiac functional values with an Anger-type camera and it can be useful to evaluate acute cardiac function in a coronary care unit.

Early detection of intravascular large B-cell lymphoma by (18)FDG-PET/CT with diffuse FDG uptake in the lung without respiratory symptoms or chest CT abnormalities.

Intravascular large B-cell lymphoma (IVLBCL) is a rare and aggressive subtype of systemic extranodal non-Hodgkin diffuse large B-cell lymphoma (DLBCL). We report a rare case of IVLBCL who showed diffuse 18F-fluorodeoxyglucose (FDG) uptake in the lung in FDG-positron emission tomography/computed tomography (PET/CT) without respiratory symptoms or chest CT abnormalities. Serum biochemical studies showed a raised level of lactate dehydrogenase (LDH) and serum soluble interleukin-2 receptor (sIL-2R), which suggested the presence of malignant lymphoma strongly. A non-contrast CT showed no abnormalities in the lung fields, no lymphadenopathy was found. FDG-PET/CT revealed diffuse FDG uptake in the both lungs and in spleen as well as multiple hot spots in the liver. Under the suspicion of IVLBCL especially by the diffuse FDG uptake in the lung, a random skin biopsy was performed from three regions, the left forearm, right abdomen and left thigh in which there had been no evidence of FDG uptake. The definite diagnosis of IVLBCL was made based on the pathological analysis of the specimen from the left thigh. She achieved complete remission (CR) after combined chemoimmunotherapy. FDG-PET/CT was useful for the early detection of IVLBCL even without respiratory symptoms or any abnormal findings by chest CT.

Prognostic factors for regression from impaired glucose tolerance to normal glucose regulation in Japanese patients with nonalcoholic fatty liver disease.

OBJECTIVE: The aim of this retrospective cohort study was to assess the predictive factors for the regression from impaired glucose tolerance (IGT) to normal glucose regulation (NGR) in patients with nonalcoholic fatty liver disease (NAFLD). METHODS: A total of 164 NAFLD patients who had IGT in the first 75-g oral glucose tolerance test (OGTT) and underwent a repeated OGTT five years later were enrolled. A multivariate logistic regression analysis was carried out to identify factors predicting the regression from IGT to NGR. RESULTS: Out of the 164 patients, 29 regressed from IGT to NGR within five years after the first OGTT. The multivariate analysis by logistic regression showed that regression from IGT to NGR occurred when the patient was young (risk ratio for ten years: 0.38; 95% confidence interval [CI] 0.20-0.72; p=0.003), had a fasting plasma glucose (FPG) level of <100 mg/dL (risk ratio: 6.53; 95%CI 1.88-21.73; p=0.003), had a 2-hr post-load plasma glucose (PG) level of <160 mg/dL (risk ratio: 4.86; 95%CI 1.08-22.72; p=0.040), a body mass index (BMI) decrease of ≥1.5 (risk ratio: 5.20; 95% CI 1.41-19.24; p=0.014), physical activity of ≥2 Metabolic Equivalent of Task (MET) h/day (risk ratio: 5.57; 95%CI 1.68-18.44; p=0.005), and showed disappearance of the fatty liver by ultrasonography at five years (risk ratio: 9.92; 95%CI 2.87-34.34; p<0.001). CONCLUSION: Our results suggest that six factors: young age, FPG <100 mg/dL, 2-hr post-load PG of <160 mg/dL, BMI decrease of ≥1.5, physical activity of ≥2 MET h/day, and the disappearance of fatty liver predict the regression from IGT to NGR in NAFLD patients.

Giant coronary artery aneurysms associated with Kawasaki disease detected on whole-heart magnetic resonance coronary angiographic screening.

Kawasaki disease (KD) is one of the most important causes of coronary artery aneurysms in children and young adults. However, the natural course of the disease and the patient prognosis remain obscure. A 72-year-old asymptomatic man with undiagnosed KD underwent whole-heart magnetic resonance coronary angiography during a health checkup. The imaging disclosed giant aneurysms in the proximal portion of the right coronary artery and the left anterior descending artery. The patient was successfully treated with coronary artery bypass grafting. The present case suggests that there may be a substantial number of patients who have attained middle to old age with undiagnosed KD.

Computed tomography and magnetic resonance imaging findings in cases of dermoid cyst coexisting with surface epithelial tumors in the same ovary.

OBJECTIVE: The purpose of this work was to describe the computed tomography (CT) and magnetic resonance imaging (MRI) findings in cases of dermoid cysts coexisting with surface epithelial tumors in the same ovary. METHODS: The pathologic reports of 141 dermoid cysts, 97 mucinous and 35 serous tumors were reviewed. The CT and/or MR images in the cases with a dermoid cyst and a surface epithelial tumor coexisting in the same ovary were analyzed. RESULTS: Eleven cases of mucinous tumors (6 benign, 3 low-grade, and 2 malignant) coexisted with dermoid cysts. Mucinous tumors were found in coexistence with 11.3% of dermoid cysts, and dermoid cysts were found in coexistence with 7.8% of mucinous tumors. In 10 cases, 3 radiologic patterns were observed: small fatty foci in the septa of the cystic tumor, an adjacent fat-containing component and a septated cystic component, and a dermoid cyst with no detectable mucinous tumor component. No histopathologically specific differences were observed between these groups. Small amounts of mucinous components were difficult to detect, but small fatty foci were easily detected. In 1 case, mucinous carcinoma formed a mass lesion in the wall of the dermoid cyst. CONCLUSIONS: The coexistence of these two neoplasms was not rare. If a dermoid cyst accompanies a multiseptated cyst and if the multiseptal cyst contains fatty foci, these two components may be associated. Recognizing the potential for the coexistence of these two neoplasms in the same ovary is essential for making a correct diagnosis.