Characterization of breast changes in the early gestational period on automated breast ultrasound.

PURPOSE: This study was conducted to determine the characteristics of milk duct development in early pregnancy on ultrasound images. METHODS: Automated breast ultrasound (ABUS) images used for breast cancer screening in 332 pregnant women were evaluated retrospectively to determine when and how ductal development becomes evident on ultrasonography. The diagnostic criteria used for mammary gland changes during the gestational period were extension of the ducts to the margins of the breast where little or no echogenic fibroglandular tissue is seen on sonograms and/or the appearance of ductal structures running along the ascending Cooper's ligament tapering off or ending in a blind end at the superficial layer of the superficial fascia. The correlations between gestational stage and the prevalence of these criteria were verified by Spearman's rank correlation coefficient (ρ). Assessments were performed by a single radiologist with experience reading ABUS images. RESULTS: With a few exceptions, the prevalence of the above findings increased sharply beginning at 10 weeks, and then increased with progression of gestation, reaching a plateau after 20 weeks (ρ = 0.766, P < 0.00001). CONCLUSION: The findings in this study suggested that development of the milk ducts in early pregnancy can be observed using ABUS. These findings will be useful to gain a better understanding of breast ultrasound imaging characteristics during pregnancy.

False-positive diagnoses of damaged breast implants on imaging: a report of two cases.

Background: Silicone breast implants (SBIs), used in breast reconstruction, are durable and resistant to breakage and internal gel leakage. However, regular imaging examinations are crucial, as symptoms may not be apparent even if the implant ruptures. There are several known imaging findings that suggest SBI failure. Although artifacts such as moisture and air bubbles or substances similar to the gel extending outside the shell may appear on imaging, no reports have demonstrated false-positive diagnoses of damaged SBIs in detail. Hence, we present two cases in which failure was suspected based on the imaging results but not confirmed. Case Description: In case 1, at the 4-year follow-up after implant-based breast reconstruction, ultrasonography revealed a stepladder sign, and magnetic resonance imaging (MRI) revealed the salad oil sign. Although SBI failure was suggested, intraoperative examination revealed only a small amount of fluid retention within the capsule and no SBI fractures. Consequently, the imaging results were proved to be artifacts. In case 2, at the 7-year follow-up after implant-based breast reconstruction, ultrasonography revealed a subcapsular line sign, and MRI confirmed a keyhole sign. Although SBI failure was suggested, intraoperative examination revealed no implant fractures. Hematogenous serous effusion was found within the capsule, and blood clots and a large amount of fibrinous mass were found deposited at the bottom of the capsule. These findings caused false-positive diagnoses on imaging. Conclusions: In cases of suspected fractures, patients may opt for either observation or surgical removal, or replacement of the implant. When choosing the latter, it is important to inform patients of the possibility of an unbroken implant.

Diagnosed corrected transposition of great arteries after cesarean section: A case report.

BACKGROUND: Corrected transposition of the great arteries (cTGA) is a cardiac malformation in which the ventricular and arterial-ventricular positions in the heart are doubly reversed. In general, this defect puts a load on the systemic circulation and causes heart failure, resulting in a poor prognosis. This article reports a case of cTGA detected in a patient with post-caesarean pregnancy who had undergone elective caesarean section and was experiencing an episode of acute heart failure. CASE SUMMARY: This was the case of a 36-year-old gravida 3 para 1 woman. No problems were noted in the puerperal course following the previous pregnancy. The current pregnancy was also uneventful. An elective caesarean section was performed and the patient was discharged from the hospital 7 d after the operation. On postoperative day 18, the patient became aware of breathing difficulty and presented at a nearby clinic, where she was referred to our institution after bilateral pleural effusions were detected. She was then diagnosed with acute heart failure after noting the presence of a prominent pedal oedema and SpO2 91% (supine position and room air); the patient was promptly hospitalised for close examination and treatment. Although chest computed tomography revealed the presence of cTGA, no other cardiac malformations were observed. Owing to improvements in both the pedal oedema and pleural effusions, the patient was discharged on day 9. CONCLUSION: Close examination should be performed on the premise of congenital cardiac malformation when heart failure symptoms are noted during perinatal control.

[A case of incipient pancreatic ductal adenocarcinoma concomitant with intraductal papillary mucinous neoplasm, confirmed by multiregion sequencing analysis].

Concomitant pancreatic ductal adenocarcinoma (PDA) is observed in a subset of patients with intraductal papillary mucinous neoplasm (IPMN) of the pancreas, and early detection of those progressing lesions is difficult. We present a case with a de novo carcinoma in situ (CIS) discovered incidentally around the resection margin of IPMNs. A man in his 70s with a history of acute pancreatitis at the age of 50 years and no family history of PDA had a pancreatoduodenectomy for three isolated branch duct IPMNs that caused recurrent pancreatitis. During the 2-year follow-up period, the index lesion in the pancreatic head grew significantly, whereas the other cysts remained small and without mural nodules. The majority of the cysts are histologically composed of low-grade dysplasia and are classified as gastric-type IPMN. CIS with nuclear overexpression of p53 was located in the main pancreatic duct and adjacent brunch duct, which involved the pancreatic resection margin. The precise pathological analysis combined with multiregion sequencing revealed the CIS harbored KRAS G12V and TP53 R248W. Conversely, IPMNs contained GNAS mutant cells as well as components containing additional KRAS mutations. These findings suggested that the CIS formed independently of the multiple IPMNs and appeared to be an early manifestation of concomitant PDA with coexisting IPMNs. Despite widespread agreement on the resection of the radiographically significant IPMN lesion (s), the latent invasive cancer was not eradicated. A detailed pathological and molecular assessment of the resected materials may aid in a better management strategy for concurrent lesions.

A Case Report of a Patient with Spontaneously Resolving Unruptured Uterine Artery Pseudoaneurysm after Surgery for Miscarriage during the Early Stages of Pregnancy Using Manual Vacuum Aspiration.

Uterine artery pseudoaneurysms are caused by damage to blood vessel walls from iatrogenic changes including cesarean section or cervical dilatation and uterine curettage. Manual vacuum aspiration (MVA) is becoming increasingly popular from the perspective of reducing the risk of endometrial injury. This is a case report of a 33-year-old primigravida female patient diagnosed with an unruptured uterine artery pseudoaneurysm that spontaneously resolved after surgery for miscarriage using MVA. The patient experienced a miscarriage at 10 weeks and 0 days of gestation and underwent surgery using MVA. Fourteen days after surgery, the patient was diagnosed with a uterine artery pseudoaneurysm by transvaginal ultrasound tomography and contrast computed tomography of the pelvic region. The patient received elective follow-up and was found to be completely thrombosed 2 months after surgery. MVA for miscarriage may cause uterine artery pseudoaneurysms. Elective therapy may be an option for unruptured uterine artery pseudoaneurysms.

In vitro Demonstration of Melanoma Metastasis in Lymph Nodes of Prepared Specimens Using a Light-emitting Diode-based Multispectral Photoacoustic Ultrasound Imaging System.

Although an excellent photoacoustic (PA) ultrasound method has been reported for the evaluation of lymph node melanoma metastasis in animal experiments, it remains to be evaluated in clinical trials. Recently, we performed PA ultrasound assessment using light-emitting diodes to detect metastatic melanoma in the lymph nodes of specimens prepared for microscopic examination. The PA effect was not obvious in amelanotic melanoma, but was seen in melanotic melanoma by PA imaging (PAI) and histopathological correlation in cases of primary melanotic melanoma accompanied by metastatic lymph nodes, including the coexistence of amelanotic melanoma and melanotic melanoma. Clinical workup should be performed with not only PAI but also conventional ultrasonography in cases with metastasis related to amelanotic transformation, which would likely be missed by PAI alone.

[Upper Gastric Poorly Differentiated Adenocarcinoma with a Giant Ulcer That Regressed Due to the Malignant Cycle-A Case Report].

This case is that of an 84‒year‒old woman in whom upper gastrointestinal endoscopy revealed a giant ulcerative lesion with irregular margins on the upper curvature of the stomach. Abdominal contrast computed tomography(CT)showed marked thickening of the stomach wall in contact with the pancreatic body and enlargement of the regional lymph nodes, suggesting a tumor metastasis to the lymph nodes. At the patient's request, she was followed‒up without surgery, and 8 months later, upper gastrointestinal endoscopy revealed that the ulcerative lesion was scarred and covered with a non‒ tumor mucosa. Contrast CT showed an improvement in the thickening of the stomach wall and shrinking the enlarged lymph nodes. She is currently being followed‒up in an outpatient clinic with no progression since 1 year 8 months. Total gastrectomy for the elderly is associated with perioperative complications and postoperative loss of appetite, which may lead to a decreased QOL. For gastric cancer cases with giant ulcers, it is necessary to carefully consider the surgical indications, bearing in mind the malignant cycle and perforation complications.

Genetic Tracing of Clonal Expansion and Progression of Pancreatic Ductal Adenocarcinoma: A Case Report and Multi-Region Sequencing Analysis.

Pancreatobiliary tumors frequently contain multiple malignant and precancerous lesions; however, the origin of the driver mutations and the mechanisms that underlie the generation of distinct clones within an organ field remain unclear. Herein, we describe a 76-year-old male suffering from moderately differentiated adenocarcinomas of the pancreas that primarily involved the distal bile duct and multiple "dispersing" invasive lesions in the pancreatic head. The patient underwent pylorus-preserving pancreaticoduodenectomy with superior mesenteric vein resection, and targeted sequencing of 18 genes associated with pancreatic tumorigenesis and immunohistochemical analysis of RNF43 and ARID1A were performed on each tumor compartment, including the invasive and non-invasive areas. Multi-region sequencing revealed shared KRAS and TGFBR1 mutations in all invasive foci, including those involving the distal bile duct. Distinct KRAS variants were found to be present in other non-continuous and non-invasive lesions in the pancreas. Intraductal lesions with KRAS G12D and RNF43 V50R mutations were evident in the main pancreatic duct. This appeared to be a founder clone, given that the mutation profile was common to the invasive foci as well as the additional high-grade dysplasia harboring ARID1A mutations, thereby suggesting a clonal branch-off during tumor evolution. In addition, we also observed independent intraductal papillary mucinous neoplasms with KRAS G12V and GNAS R201H mutations. Our theory, learned from this patient, was that lesions skipped dissemination and wide-spread movement potentially through the pancreatic ductal system as a process of pancreatic cancer development.

[Gastrectomy of a GIST with Diaphragmatic Repair Utilizing the Fascia Lata-A Case Report].

A 73-year-old man was admitted with the chief complaint of upper abdominal discomfort.After close examination, he was diagnosed with a huge stomach gastrointestinal stromal tumor(GIST)that occupied the upper left abdomen with a maximum diameter of 150 mm.The patient was referred to our department for surgery.The border between the tumor and spleen was unclear on CT images.As the diaphragm was thinned due to compression by the tumor, gastrectomy with splenectomy and partial resection of the diaphragm was planned.For the diaphragmatic defects, a simple closure was considered at first. However, artifacts have a high risk of infection when the defect holes are too large.Therefore, in this case, we attempted to repair the diaphragm hole with the autologous fascia lata.Intraoperatively, while the tumor was resected with 1 more layer of the diaphragm, the diaphragm itself was thinned, resulting in a defect hole of about 60×80 mm.Therefore, an 80×110mm fascia lata was harvested, and the diaphragm was repaired.Fascia lata can be conveniently harvested as a free graft.In addition, the fascia of the thigh has the advantage of being more resistant to infection than artificial materials.In addition, there was no functional failure due to collection, and special plastic surgery techniques and tools were unnecessary.Thus, it is a useful reconstruction material for general surgeons.Here we report the details of the surgery along with a review of the literature.

Evacuatory Dysfunction after Stapled Hemorrhoidopexy: A Case Report of Rectal Pocket Syndrome.

A 60 year-old male was referred to the authors' hospital with a persistent urge to defecate. The patient had undergone stapled hemorrhoidopexy (SH) for the treatment of prolapsed hemorrhoids approximately 10 years earlier. He started to have difficulty with defecation and a false sense of urgency shortly after the surgery. Computed tomography showed a diverticulum-like fistula along the circumference of the rectum. Colonoscopy revealed communication between the diverticular cavity and the rectal lumen. The cavity contained a thumbnail-sized fecalith. When the fecalith was removed, the patient's urge to defecate dissipated. The patient was diagnosed with rectal pocket syndrome secondary to SH. The lower rectum was transected, and the remaining rectum and the anal canal were anastomosed by manual suture. Temporary ileostomy with double orifices was performed. The ileostomy was closed 3 months later. The patient experienced no subsequent difficulty with defecation or urgency.

Clinical course of conservative management for isolated superior mesenteric arterial dissection.

OBJECTIVES: Isolated superior mesenteric arterial dissection (ISMAD) is an uncommon type of arterial dissection and treated with surgery, stenting, or conservative management. This study aimed to evaluate the criteria for conservative therapy for ISMAD patients based on imaging findings. METHODS: Eighteen consecutive ISMAD patients without peritoneal irritation at onset were retrospectively studied. The decision to perform stenting was based on the emergence of peritoneal irritation, aneurysm, or mesenteric ischemia. Clinical manifestations, follow-up contrast-enhanced computed tomography (CECT) findings, and patient outcome were evaluated. RESULTS: Most patients (16, 89%) were successfully treated conservatively; two patients (11%) required endovascular stenting because of an aneurysm or ulcer-like projection (ULP) sign. The median duration of fasting and hospital stays was 3 (range, 1-8) and 9 (range, 4-34) days, respectively. On CECT, the median distance from the superior mesenteric artery (SMA) origin to the entry site was 12 mm (range, 5-35 mm), and the median length of dissection was 87.5 mm (range, 20-150 mm). Among 16 patients treated conservatively, serial imaging was obtained in 11 patients (69%), and disappearance of the dissection within 4 months occurred in five patients. Two patients treated with endovascular stent underwent follow-up CECT 1 year after onset, and there were no complications. CONCLUSIONS: ISMAD patients without peritoneal irritation can be treated conservatively if there are no signs of an aneurysm, ULP, or mesenteric ischemia. When an aneurysm or ULP sign exists, endovascular stenting was able to preserve SMA blood flow with the improvement of the dissection.

Diagnostic value of ultrasonography and TI-201/Tc-99m dual scintigraphy in differentiating between benign and malignant thyroid nodules.

PURPOSE: To evaluate the performance of ultrasonography (US) and TI-201/Tc-99m dual (Tl/Tc) scintigraphy in differentiating between benign and malignant thyroid nodules. METHODS: Eighty-six patients diagnosed to have a thyroid tumor on postoperative histopathologic examination between June 2009 and February 2017 were included in this retrospective study. A radiologist reviewed the US and Tl/Tc scintigraphy reports along with all available clinical and histopathologic information. On Tl/Tc scintigraphy, a nodule in which uptake was higher in the delayed phase than in the surrounding parenchyma was defined as a delayed accumulation pattern and a nodule in which uptake was higher in the delayed phase than in the early phase was defined as a persistent pattern. The Tl/Tc scintigraphy images were evaluated in a blinded manner to assess reproducibility. A statistical analysis was performed to identify features associated with malignancy. Interobserver variability was calculated using the κ statistic. RESULTS: US had higher sensitivity (81.2%), specificity (88.2%), and positive (96.6%) and negative (53.6%) predictive values than Tl/Tc scintigraphy. An ill-defined margin and microcalcification were independent predictors of a malignant thyroid nodule on multivariate logistic regression (P = 0.003 and P = 0.014, respectively). The persistent pattern had high specificity (85.7%) equivalent to that of US but had lower sensitivity (34.7%). The κ values for the delayed accumulation and persistent patterns were 0.66-0.78 and 0.32-0.50, respectively. CONCLUSIONS: An ill-defined margin and microcalcification on US were independent predictors of a malignant thyroid nodule. A persistent pattern seen on Tl/Tc scintigraphy could contribute to the differential diagnosis.

Inflammatory myofibroblastic tumors of the breast with simultaneous intracranial, lung, and pancreas involvement: ultrasonographic findings and a review of the literature.

We encountered a case of inflammatory myofibroblastic tumor (IMT) of the breast with simultaneous intracranial, lung, and pancreas involvement. Here, we present the clinical imaging results and report the significance of sonographic findings of breast IMT along with a review of the literature. A 16-year-old girl with a history of subarachnoidal hemorrhage was admitted to our hospital due to tonic-clonic seizure. Computed tomography (CT) and magnetic resonance imaging (MRI) showed multiple intracranial, lung, and pancreas mass lesions and a solitary mass lesion in the right breast. Breast ultrasonography showed a circumscribed oval-shaped hypoechoic mass with a central hyperechoic region. Power Doppler sonography revealed an unusual spiral-shaped flow signal. Breast tumorectomy was performed for definitive diagnosis, and pathological analysis indicated IMT. A literature review indicated that ultrasonographic findings of IMT of the breast are nonspecific, as in other systems or organs. It would be difficult to make a diagnosis of IMT of the breast preoperatively due to its rarity and the lack of specificity of clinical imaging findings. In addition, it is better to consider the possibility of IMT of the breast especially in younger patients without an obvious family history of hereditary breast cancer.

Significance of perithyroidal lymph nodes in benign thyroid diseases.

PURPOSE: The incidences of perithyroidal lymph nodes (PTLNs) in benign thyroid diseases were investigated. METHODS: A total of 108 patients were divided into 36 with benign thyroid nodules, 33 with Hashimoto's thyroiditis, 14 with Graves' disease, 10 with hypothyroidism of undetermined etiology, nine with silent thyroiditis, and six with subacute thyroiditis. We assessed the relationships among PTLNs and these groups, thyroid volume, thyroid parenchyma echogenicity, and anti-thyroid-stimulating hormone receptor, anti-thyroglobulin, and anti-thyroid peroxidase antibodies (TRAb, TgAb, and TPOAb). RESULTS: The PTLN-positive rates in Hashimoto's thyroiditis (69.7%), subacute thyroiditis (83.8%), silent thyroiditis (77.8%), and Graves' disease (35.7%) groups were significantly higher than those in benign thyroid nodules (5.6%) and hypothyroidism of unknown etiology (0%) groups. The PTLN-positive rates were significantly higher in cases with TgAb and/or TPOAb (P < 0.01) and in those with lower parenchyma echogenicity (P < 0.01). CONCLUSION: PTLNs were seen in inflammatory thyroid diseases, but were rarely detected in other thyroid diseases. These findings indicate that PTLNs are an indicator for differentiating inflammation of the thyroid. Lower echogenicity of the thyroid, known to correspond to inflammation, showed a correlation with the positive rate of PTLNs. PTLNs in cases of Graves' disease may be due to coexisting thyroiditis related to TgAb and/or TPOAb.

Two cases of aortoenteric fistula with gastrointestinal bleeding.

Aortoenteric fistula (AEF) is a life-threatening condition that can present with gastrointestinal (GI) bleeding. AEFs have been classified into primary and secondary types. Primary AEF (PAEF) is a direct communication between the aorta and the GI tract. Secondary AEF (SAEF) is the result of a previous abdominal aortic aneurysm repair involving placement of a synthetic aortic graft. Diagnosis of AEF, especially PAEF, is difficult largely because AEF is so rarely encountered in practice. Computed tomography (CT) and endoscopic gastroduodenoscopy (EGD) are most frequently used to diagnose AEF, with abdominal contrast-enhanced CT being the preferred initial diagnostic test of choice. Although EGD can exclude other common causes of GI hemorrhage, it cannot be used to rule out AEF when another source of bleeding is identified, as the two conditions can coexist. We discuss here two patients with GI bleeding who were diagnosed as PAEF and SAEF. We tried to diagnose and treat with EGD, but failed. That bleeding was due to an AEF became evident when abdominal CT scans revealed direct extravasation of contrast media from the abdominal aorta into the GI tract. The lack of awareness of AEF, coupled with the inaccessibility to the distal duodenum via EGD, were probably responsible for initial misdiagnosis and delay of appropriate management. We suggest that the diagnosis of AEF remains dependent on the clinician's heightened suspicion.

Recovery of gastric ileus following laparoscopic ventral rectopexy within an enhanced recovery protocol.

PURPOSE: The enhanced recovery after surgery (ERAS) protocol has had limited adoption in laparoscopic ventral rectopexy (LVR), and the extent of gastric ileus shortly after LVR remains unknown. This study was designed to assess the degree of gastric emptying shortly after LVR within an ERAS protocol. METHODS: From August 2012 to June 2014, 40 patients diagnosed with external or internal rectal prolapse were recruited. All patients underwent LVR within an ERAS protocol. Carbohydrate solution (CS) was administered before and 5 h after surgery on the same day. The pyloric area (PA) was measured using ultrasonography before and after each CS intake. RESULTS: The PA was measured in 34 patients. The PA measured prior to CS intake, before surgery, was not significantly different from that after surgery. The rate of increase in the PA, which was calculated by the PA measured 1 h after CS intake divided by the PA measured prior to CS intake before surgery, was not significantly different from that after surgery. The postoperative hospital stay was 1 (1-2) day, and 36 patients (90 %) were discharged on the first postoperative afternoon. CONCLUSION: Postoperative gastric ileus was resolved in most cases within 5 h after LVR under an ERAS protocol.

Optimization of Region of Interest Drawing for Quantitative Analysis: Differentiation Between Benign and Malignant Breast Lesions on Contrast-Enhanced Sonography.

OBJECTIVES: This study was performed to evaluate the diagnostic utility of quantitative analysis of benign and malignant breast lesions using contrast-enhanced sonography. METHODS: Contrast-enhanced sonography using the perflubutane-based contrast agent Sonazoid (Daiichi Sankyo, Tokyo, Japan) was performed in 94 pathologically proven palpable breast mass lesions, which could be depicted with B-mode sonography. Quantitative analyses using the time-intensity curve on contrast-enhanced sonography were performed in 5 region of interest (ROI) types (manually traced ROI and circular ROIs of 5, 10, 15, and 20 mm in diameter). The peak signal intensity, initial slope, time to peak, positive enhancement integral, and wash-out ratio were investigated in each ROI. RESULTS: There were significant differences between benign and malignant lesions in the time to peak (P < .05), initial slope (P < .001), and positive enhancement integral (P < .05) for the manual ROI. Significant differences were found between benign and malignant lesions in the time to peak (P < .05) for the 5-mm ROI; the time to peak (P < .05) and initial slope (P< .05) for the 10-mm ROI; absolute values of the peak signal intensity (P< .05), time to peak (P< .01), and initial slope (P< .005) for the 15-mm ROI; and the time to peak (P < .05) and initial slope (P < .05) for the 20-mm ROI. There were no statistically significant differences in any wash-out ratio values for the 5 ROI types. CONCLUSIONS: Kinetic analysis using contrast-enhanced sonography is useful for differentiation between benign and malignant breast lesions.

[A case of mucinous cystic neoplasm of the liver].

We present a case of resected mucinous cystic neoplasm of the liver in a 71-year-old woman admitted to our hospital with epigastric discomfort. Abdominal ultrasonography and computed tomography revealed a multi-locular cystic tumor measuring 35 mm in diameter in segment IV of the liver. Left hepatic lobectomy was performed based on the diagnosis of mucinous cystic neoplasm of the liver; subsequent histology revealed that the tumor was multi-locular, cystic, and lined with a single layer of columnar epithelium with low-grade atypia and was associated with a typical ovarian-like stroma. There was no evidence (imaging or histological) to support communication of the cyst with the intrahepatic bile duct, despite modest bile deposition being observed in the cystic wall. The definitive diagnosis was mucinous cystic neoplasm with low-grade intrahepatic epithelial neoplasia.