Endometriosis, a common but enigmatic disease with many faces: current concept of pathophysiology, and diagnostic strategy.

Endometriosis is a benign, common, but controversial disease due to its enigmatic etiopathogenesis and biological behavior. Recent studies suggest multiple genetic, and environmental factors may affect its onset and development. Genomic analysis revealed the presence of cancer-associated gene mutations, which may reflect the neoplastic aspect of endometriosis. The management has changed dramatically with the development of fertility-preserving, minimally invasive therapies. Diagnostic strategies based on these recent basic and clinical findings are reviewed. With a focus on the presentation of clinical cases, we discuss the imaging manifestations of endometriomas, deep endometriosis, less common site and rare site endometriosis, various complications, endometriosis-associated tumor-like lesions, and malignant transformation, with pathophysiologic conditions.

MR Imaging Findings of Uterine Adenomatoid Tumors.

PURPOSE: Adenomatoid tumor is a rare benign genital tract neoplasm of mesothelial origin. Uterine adenomatoid tumors occur in the outer myometrium and may mimic leiomyomas. Because hormonal treatment is not applicable to adenomatoid tumors and laparoscopic enucleation is not easy as myomectomy, it is important to differentiate adenomatoid tumors from leiomyomas for the adequate treatment. The purpose of this study is to evaluate the MRI findings of adenomatoid tumor for the differentiation from leiomyoma. METHODS: MRI findings of surgically proven 10 uterine adenomatoid tumors in 9 women were retrospectively evaluated with correlation to histopathological findings. RESULTS: All 10 tumors appeared as solid myometrial masses and showed heterogeneous signal intensity with admixture of partially ill-defined slight high-intensity areas containing abundant tubular tumor cells and well-defined myoma-like low-intensity areas reflecting smooth muscle hypertrophy on T2WI including 4 lesions with peripheral ring-like high intensity. High-intensity areas on T2WI tended to show high intensity on diffusion-weighted imaging (DWI) with relatively high apparent diffusion coefficient (ADC), suggesting T2 shine-through effect due to abundant tubules. Intra-tumoral hemorrhage revealed on MRI was rare. Early intense contrast-enhanced areas on dynamic contrast-enhanced study were observed dominantly within the high-intensity areas but rarely within the low-intensity areas on T2WI. CONCLUSION: The outer myometrial mass with the admixture of well-defined low- and ill-defined high-intensity areas on T2WI may be suggestive of adenomatoid tumor. Peripheral ring-like high intensity on T2WI and DWI may also be suggestive. Dynamic contrast-enhanced MR study may be helpful for the differentiation from leiomyoma.

Dynamic contrast-enhanced MR imaging of uterine endometrial carcinoma with/without squamous differentiation.

PURPOSE: Endometrial carcinoma with strong enhancement on dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) is suggestive of high-grade type II endometrial carcinoma. However, low-grade type I endometrial carcinoma may also sometimes show strong enhancement. We hypothesized that squamous differentiation would contribute to the strong enhancement at the early phase on DCE-MRI-like uterine cervical squamous cell carcinoma and compared the DCE-MRI findings of endometrial carcinoma with and without squamous differentiation. METHODS: DCE-MRI of endometrial carcinoma including 41 low-grade type I endometrial carcinomas without squamous differentiation (LG), 39 low-grade type I endometrial carcinomas with squamous differentiation (LGSD), and 20 high-grade type II endometrial carcinomas (HG) was retrospectively evaluated. RESULTS: Significant difference in the time-intensity curves was found between LG and HG and LG and LGSD, whereas no significant difference was seen between HG and LGSD. Curve type 3 (initial signal rise which is steeper than that of the myometrium) was more frequent in HG (60%) and LGSD (77%) than in LG (34%). CONCLUSION: It should be recognized as a pitfall that high-grade type II endometrial carcinoma and low-grade type I endometrial carcinoma with squamous differentiation may show similar early strong enhancement on DCE-MRI.

Middle Pleistocene re-organization of Australian Monsoon.

The sensitivity of the Australian Monsoon to changing climate boundary conditions remains controversial due to limited understanding of forcing processes and past variability. Here, we reconstruct austral summer monsoonal discharge and wind-driven winter productivity across the Middle Pleistocene Transition (MPT) in a sediment sequence drilled off NW Australia. We show that monsoonal precipitation and runoff primarily responded to precessional insolation forcing until ~0.95 Ma, but exhibited heightened sensitivity to ice volume and pCO2 related feedbacks following intensification of glacial-interglacial cycles. Our records further suggest that summer monsoon variability at the precessional band was closely tied to the thermal evolution of the Indo-Pacific Warm Pool and strength of the Walker circulation over the past ~1.6 Myr. By contrast, productivity proxy records consistently tracked glacial-interglacial variability, reflecting changing rhythms in polar ice fluctuations and Hadley circulation strength. We conclude that the Australian Monsoon underwent a major re-organization across the MPT and that extratropical feedbacks were instrumental in driving short- and long-term variability.

Rock and sediment dataset of petit-spots in the northwestern Pacific.

Rock and sediment samples were collected from petit-spots in the northwestern Pacific. The sampling was conducted using deep-submergence vehicle (DSV) Shinkai 6500 and its mother ship, research vessel (RV) Yokosuka during YK20-14S and YK21-07S cruises. The collected rock samples are basalt and peperite. Some of the basalts include small mantle xenoliths (∼3 cm in diameter). The dataset of rock and sediment samples from the petit-spots located on >130 Ma northwestern Pacific plate are presented herein. The peperites are a reaction product between petit-spot magma and wet sediment, and the mantle xenoliths are fragmented mantle materials transported by the petit-spot magmas. Therefore, the petit-spot samples are of significant importance to elucidate modification process of the surface condition by petit-spot magma and to characterize the deep lithospheric mantle. The dataset presented herein provides in a sense a unique insight into the whole Pacific plate just before its subduction beneath the Japan arc.

[An Anastomotic Aneurysm Thirty Years After Open Surgery of the Descending Thoracic Aorta:Report of a Case].

An 86-year-old man was hospitalized urgently to our department because of his worsening hemoptysis. He had undergone open thoracic aortic grafting for the Stanford type B chronic aortic dissecting aneurysm 30 years earlier. Contrast enhanced computed tomography (CT) revealed the distal anastomotic aneurysm, leakage of the contrast medium around the distal anastomotic site. We urgently performed thoracic endovascular aneurysm repair( TEVAR) for the distal anastomotic aneurysm. TEVAR was done under local anesthesia because of his poor respiratory condition due to hemoptysis. He recovered well without hemoptysis. Patients after open aortic surgery are expected to survive longer. Thus, special attention should be paid to the occurrence of anastomotic aneurysms.

Weakened pacific overturning circulation, winter monsoon dominance and tectonism re-organized Japan Sea paleoceanography during the Late Miocene global cooling.

The Late Miocene global cooling (LMGC; approximately 7.9-5.8 Ma) was associated with remarkable changes in monsoon dynamics, biogenic bloom in the global oceans, and the rise of modern ecosystems at the expense of old biota. However, the possible linkage between the environmental changes and ecosystem shifts during the LMGC is still debated. In this paper, we show the high-resolution changes in the fluxes of selected radiolarian species, suggesting a drastic reorganization in the paleoceanography and ecosystem in the Japan Sea during the LMGC. The endemic radiolarian Cycladophora nakasekoi dominated the Japan Sea until 7.4 Ma when the Japan Sea sediment changed from dark radiolarian-rich sediment to organic-poor diatom ooze. Changes in the fluxes of C. nakasekoi and Tricolocapsa papillosa, the latter related to changes in the Pacific central water (PCW), show 100, 200, and ~ 500 ka cycles with their high flux mostly within the darker sediment intervals during the low-eccentricity period until 7.4 Ma, suggesting that orbitally paced PCW inflow might have been the major nutrient source into the Japan Sea. At about 7.4 Ma, these species decreased at the expense of increased Larcopyle weddellium, a radiolarian related to the North Pacific intermediate water (NPIW), and Cycladophora sphaeris, a subarctic radiolarian species, implying a decrease in PCW inflow and an increase in the inflow of NPIW and subarctic shallow water. Such a change would have been related to the LMGC-induced weakening in the Pacific Meridional overturning circulation and the southward shift of the subarctic front due to intensified East Asian winter monsoon. Such a drastic reorganization in the hydrography in the Japan Sea probably caused changes in nutrient provenance from the PCW to the NPIW and resulted in faunal turnover, marked by the disappearance of the old regional and endemic faunal components, such as C. nakasekoi.

Magnetic resonance imaging characteristics of polypoid endometriosis and review of the literature.

AIM: Polypoid endometriosis is a rare variant of endometriosis and may mimic malignancy. The purpose of this study is to evaluate magnetic resonance (MR) imaging characteristics of polypoid endometriosis for the differential diagnosis with malignancy. METHODS: MR imaging findings of four histologically proven polypoid endometriosis were retrospectively evaluated with the review of the literature. RESULTS: All polypoid endometriosis exhibited high signal intensity on T2-weighted images reflecting abundant dilated endometrial glands. Peritoneal lesions were surrounded by low signal intensity rim represented the "black rim sign" reflecting endometriotic fibrous adhesion. Two cases arising from endometriotic cysts showed transmural extension (peritoneal extension and myometrial infiltration). Endometriotic hemorrhagic foci were demonstrated in four lesions as high signal intensity on T1-weighted images and/or susceptibility-induced signal voids on susceptibility-weighted MR sequence. Diffusion-weighted images showed high signal intensity with relatively high apparent diffusion coefficient (ADC) due to T2 shine-through effect but no diffusion restriction, and dynamic contrast-enhanced (DCE) MR imaging showed gradually increasing contrast-enhancement pattern like benign pathologies. CONCLUSIONS: Polypoid endometriosis may mimic malignancy; however, black rim sign may be a characteristic MR imaging finding for the peritoneal lesions, and no diffusion restriction and gradually increasing contrast-enhancement pattern may reflect its benign nature.

The feasibility of reduced field-of-view diffusion-weighted imaging in evaluating bladder invasion of uterine cervical cancer.

OBJECTIVES: Uterine cervical cancer with bladder mucosal invasion is classified as FIGO stage IVA with poor prognosis. MRI can rule out the bladder invasion and skipping cystoscopy may be possible; however, high false-positive rate may be problematic. The purpose of this study is to evaluate the diagnostic performance of reduced field-of-view (FOV) diffusion-weighted imaging (DWI) in evaluating bladder mucosal invasion of cervical cancer. METHODS: 3T MRI including T2WI and reduced FOV DWI in 15 women with histologically proven cervical cancer (two stage IIIB, six stage IVA, seven stage IVB) were retrospectively evaluated compared with cystoscopic findings. RESULTS: Cystoscopy revealed mucosal invasion in 13 of 15 cases. The border between the tumor and the bladder wall was unclear on T2WI and clear on reduced FOV DWI in all 15 cases. The diagnosis of mucosal invasion on reduced FOV DWI had a sensitivity of 100%, specificity of 50%, accuracy of 93%, PPV of 93%, and NPV of 100%. CONCLUSIONS: Addition of reduced FOV DWI may improve the staging accuracy of MRI for cervical cancer in assessing the bladder mucosal invasion. ADVANCES IN KNOWLEDGE: Reduced FOV DWI may improve the staging accuracy of cervical cancer in assessing bladder mucosal invasion with high NPV and PPV, which may be helpful for avoiding unnecessary cystoscopy.

Clinical value of N-acetyl mucinous compounds and lipid peaks in differentiating benign and malignant ovarian mucinous tumors by MR spectroscopy.

PURPOSE: To retrospectively evaluate the clinical significance of the peaks of N-acetyl mucinous compounds (NAMC) at 2 ppm and lipid at 1.3 ppm in in-vivo proton magnetic resonance (MR) spectroscopy for distinguishing benign and malignant mucinous tumors in patients with ovarian masses. METHODS: MR spectroscopy was performed in patients with pathologically diagnosed mucinous ovarian tumors at 3 T MRI system. The peaks of NAMC, lipid, and total choline compounds (tCho) were classified into three classes in comparison with the noise level by visual estimation. The NAMC concentration was quantified relative to unsuppressed water by using LCModel analysis. RESULTS: A total of 27 ovarian mucinous tumors in 27 patients were included in this study. The NAMC peak was observed in all 27 mucinous tumors, and the lipid peak was observed in 14 of 27 tumors: 1 of 9 benign tumors (11%), and 13 of 18 malignant tumors (11 borderline malignancies and 7 carcinomas) (72%). The presence of the lipid peak for the diagnosis of malignant mucinous tumor showed generally better diagnostic ability than MR imaging, with a sensitivity of 72%, specificity of 89%, accuracy of 78%, PPV of 93%, and NPV of 62%. The concentration of the NAMC in malignant mucinous tumors tended to be higher than that in benign mucinous tumors, but there was no statistically significant difference. CONCLUSIONS: The bimodal peaks of NAMC and lipid are suggestive of malignant mucinous tumors, and the presence of the lipid peak may be useful in distinguishing benign from malignant ovarian mucinous tumors.

Performance of real-scale anaerobic baffled reactor-swim bed tank system in treating fishmeal wastewater.

This study evaluates the process performance of a real-scale anaerobic baffled reactor (ABR) coupled with swim bed tank (SBT) as an aerobic post-treatment process in treating fishmeal wastewater discharged from an actual fishmeal processing factory in Bali, Indonesia. The industrial wastewater released from the aforementioned factory contains high concentrations of organic COD (more than 10 g COD·L-1) and ammonia (100 to 200 mg-N·L-1). During the study period, ABR demonstrated a high organic removal of 95.7 ± 2.9%, with an organic loading rate of 2.1 ± 1.3 kg COD·m-3·day-1. Furthermore, the average total COD influent and effluent of the proposed system were 37,800 ± 15,000 mg COD·L-1 and 435 ± 113 mg COD·L-1, respectively, during the entire experimental period. Based on the determination of volatile fatty acids (VFAs) and microbial community analysis of the ABR-retained sludge, the first and second columns of the ABR were utilized as hydrolysis zones and the third column functioned as an acidification zone. The remaining columns were used for methane production and as final removal zones. The results concluded that this system has the potential to treat fishmeal wastewater under onsite industrial conditions.

Susceptibility-weighted MR sequence for the evaluation of ovarian masses with torsion.

OBJECTIVE: Adnexal torsion is a rare gynecologic emergency caused by twisting of an adnexal mass. Twisted vascular pedicle is the most specific imaging finding for adnexal torsion, however, identification of twisted vascular pedicle can be challenging. The purpose of this study is to evaluate the feasibility of susceptibility-weighted MR sequence (SWS) for the diagnosis of adnexal torsion. METHODS: MR imaging including SWS (SWAN: susceptibility-weighted angiography) of surgically proven four benign ovarian masses with torsion (one acute and three subacute to chronic torsions) were retrospectively evaluated. Three cystic masses and one solid mass were included in this study. RESULTS: High signal intensity venous thrombus within the twisted vascular pedicle on T1-weighted imaging (T1WI) was detected in three lesions with subacute to chronic torsion (75%) but not in one lesion with acute torsion, whereas susceptibility-induced signal voids within the twisted vascular pedicle on SWAN were detected in all four lesions (100%). CONCLUSION: The demonstration of venous thrombus in the twisted vascular pedicle by SWS may be diagnostic for adnexal torsion. ADVANCES IN KNOWLEDGE: SWS can detect blood products sensitively and can reveal venous thrombus in the twisted vascular pedicle, which may be helpful for the diagnosis of adnexal torsion.

Clinical utility of susceptibility-weighted MR sequence for the evaluation of uterine sarcomas.

PURPOSE: High intensity intra-tumoral hemorrhagic necrosis on T1-weighted images is a suggestive finding for uterine sarcomas, however, the reported prevalence varies. The purpose of this study is to evaluate the capability of susceptibility-weighted MR sequences (SWS) for the diagnosis of uterine sarcomas. MATERIALS AND METHODS: MR imaging of surgically proven 10 uterine sarcomas and 24 benign leiomyomas were retrospectively evaluated for the presence of high intensity areas on T1-weighted images and signal voids on SWS (T2 star-weighted angiography: SWAN). RESULTS: High intensity areas on T1-weighted images and signal voids on SWS were observed in 40% and 100% of sarcomas, whereas 0% and 4% of leiomyomas, respectively. The accuracy, sensitivity, and specificity for T1-weighted images were 82%, 40%, and 100%, and for SWS were 97%, 100%, and 96%, respectively. CONCLUSION: The demonstration of intra-tumoral hemorrhage in patients suspected with uterine sarcomas by SWS may provide valuable diagnostic findings.

Evaluation of Red Degeneration of Uterine Leiomyoma with Susceptibility-weighted MR Imaging.

PURPOSE: Red degeneration of uterine leiomyoma (RDL) is a hemorrhagic infarction caused by peripheral venous thrombosis. The peripheral high-intensity rim on T1-weighted MRI is characteristic for RDL; however, it may not be observed at all the phases of RDL. Susceptibility-weighted MR sequences (SWS) have exquisite sensitivity to blood products, and we hypothesized that the low-intensity rim due to the T2* shortening effects of blood products may be more clearly demonstrated on SWS. The purpose of this study is to evaluate the capability of SWS for the diagnosis of RDL. METHODS: Surgically proven 15 RDL, which showed suggestive MRI findings (high-intensity rim or entirely high signal intensity on T1-weighted imaging) were retrospectively evaluated. MRI was qualitatively evaluated for the presence of high-intensity rim around a mass on fat-saturated T1-weighted images, and low-intensity rim on T2-weighted images and on SWS (susceptibility-weighted imaging [SWI] or T2-star-weighted angiography [SWAN]). RESULTS: The high-intensity rim on T1-weighted images, low-intensity rim on T2-weighted images and on SWS were observed in 47%, 47%, and 100% of RDL, respectively. The other 53% of lesions showed entirely high signal intensity on T1-weighted images. Pathological examination revealed coagulative necrosis in all 15 lesions. CONCLUSION: SWS may be helpful for the diagnosis of RDL by revealing characteristic peripheral low-intensity rim.

[Infected Thoracic Aortic Aneurysm Secondary to the Purulent Pericarditis;Report of a Case].

A 69-year-old man was hospitalized urgently to the department of cardiology, with the progressive general malaise. On admission, his blood pressure was 80/42 mmHg, his white cell count 13,700/µl, and C-reactive protein 25.55 mg/dl suggesting existence of aggressive infection with impaired circulation. Massive pericardial effusion was detected in echocardiography. Pericardial drainage was undergone promptly. There was drainage of 700 ml and the property was purulent. Pneumococcus was detected by the culture test of the pericardial fluid. Antibiotic administration was started by a diagnosis of the purulent pericarditis. His general condition was improved. However, a rapidly expanding saccular aneurysm was found in a descending thoracic aorta by computed tomography( CT). As an infected thoracic aortic aneurysm secondary to the purulent pericarditis, we performed thoracic endovascular aneurysm repair (TEVAR). The intravenous administration of antibiotics was continued for 2 weeks after TEVAR, which was followed by oral antibiotic administration for 1 year. The aneurysm completely disappeared by CT, 10 months after TEVAR. In case with an infected thoracic aortic aneurysm, TEVAR can be a 1st choice of treatment, depending on a causative organism and the morphology of the aneurysm.

Surgical methods and clinical results of subfascial endoscopic perforator surgery in Japan.

OBJECTIVES: To clarify the surgical methods and the clinical results of subfascial endoscopic perforator surgery in Japan. METHODS: This study included 1287 limbs of 1091 patients who underwent subfascial endoscopic perforator surgery in 14 hospitals. Simultaneous saphenous vein treatment was performed in 1079 limbs (83.8%), and 118 limbs (9.2%) had deep venous lesions. The venous clinical severity score was calculated before and 6 to 12 months after surgery. The ulcer healing rate and ulcer recurrence rate were calculated cumulatively. RESULTS: Preoperative venous clinical severity score was significantly decreased from 10.0 ± 6.6 to 3.1 ± 3.4 ( P < .0001) postoperatively. The primary ulcer healing rate was 96.2% (332/345 C6 limbs) at an average follow-up of 47.7 months, and the ulcer recurrence rate was 12.0% (49/393 C5, C6 limbs) at the average follow-up of 46.0 months after the ulcer healed. CONCLUSION: These results indicate that subfascial endoscopic perforator surgery is an alternative to improve the long-lasting disease severity and/or clinical outcome.

Evaluating Myometrial Invasion in Endometrial Cancer: Comparison of Reduced Field-of-view Diffusion-weighted Imaging and Dynamic Contrast-enhanced MR Imaging.

PURPOSE: To compare the diagnostic ability of reduced FOV diffusion-weighted (DW) MR imaging with that of 3D dynamic contrast-enhanced (DCE) MR imaging in evaluating the depth of myometrial invasion in patients with endometrial cancer. METHODS: Three tesla MR images including T2-weighted imaging, reduced FOV DW imaging and 3D DCE MR imaging in sagittal and oblique axial (short axis) planes in 25 women with surgically proven endometrial cancer were retrospectively evaluated. The depth of myometrial invasion (stage S: < 50% vs stage D: ≥ 50%) on MR imaging was correlated with surgical pathology results. RESULTS: The 25 endometrial cancers included 16 stage S and 9 stage D tumors. The depth of myometrial invasion could be accurately evaluated in 68% of the cases for T2-weighted imaging, 92% for 3D DCE MR imaging, and 96% for reduced FOV DW imaging. In two patients with coexisting adenomyosis, both T2-weighted imaging and 3D DCE MR imaging failed to reveal the deep myometrial invasion, and reduced FOV DW imaging clearly demonstrated the tumor margin in the cases. Combination of reduced FOV DW imaging reading together with T2-weighted imaging improved the assessment of myometrial invasion with a diagnostic accuracy of up to 100%. CONCLUSIONS: Addition of reduced FOV DW imaging may improve the staging accuracy of MR imaging for endometrial cancer in assessing the depth of myometrial invasion. Especially, reduced FOV DW imaging has an advantage in assessing the depth of myometrial invasion for patients with coexisting adenomyosis. Reduced FOV DW imaging can be an alternative to 3D DCE MR imaging in evaluating myometrial invasion of endometrial cancer without the use of contrast medium.