A case of ovarian carcinosarcoma with a germline pathogenic variant of BRCA2 involving a perforated appendix with an abscess.

We report a case of rare and aggressive ovarian carcinosarcoma with a germline pathogenic BRCA2 variant. A patient with a history of breast cancer who developed an inflammatory ovarian tumor with peritonitis carcinomatosis involving the appendix suffered from cachexia. Following three cycles of weekly paclitaxel and carboplatin chemotherapy, emergency surgery was required owing to sepsis. Bilateral salpingo-oophorectomy, total hysterectomy, appendectomy, and small intestine adhesiolysis were performed. Histologically, the tumor comprised an admixture of carcinomatous and sarcomatous components, with involvement of the appendix, which had caused perforation and abscess formation. The final diagnosis was ovarian carcinosarcoma with a germline pathogenic BRCA2 variant, c.658_659del (p.Val220fs). The patient responded completely to adjuvant chemotherapy. A combination of chemotherapy and surgery might be beneficial to patients with ovarian carcinosarcoma and germline pathogenic BRCA2 variants with a poor general condition. This is the first report of ovarian carcinosarcoma with a germline pathogenic BRCA2 variant that responded favorably to chemotherapy.

Evaluating the efficacy of a low-cost cognitive MRI-targeted prostate biopsy protocol: is there still a role for lower volume centers in the Prostate Imaging Reporting and Data System (PI-RADS) version 2 era?

PURPOSE: MRI-targeted biopsy has improved prostate biopsy yield. However, cost constraints have made it difficult for many institutions to implement the newer methods. We evaluated the performance of a low-cost cognitive-targeting biopsy protocol based on 1.5 T multiparametric MRI graded with Prostate Imaging Reporting and Data System (PI-RADS) version 2 to examine the role for these institutions moving forward. METHODS: Retrospective analysis of 251 consecutive patients with prostate-specific antigen (PSA) under 50 who underwent MRI and subsequent prostate biopsy at a single facility. In addition to systematic biopsy, targeted cores were obtained with cognitive recognition under ultrasound. A control group of 267 consecutive patients with PSA under 50 biopsied without prior MRI was analyzed. RESULTS: Prostate biopsy preceded by MRI had a significantly higher probability of detecting both prostate cancer (68.1% vs. 51.3%) and clinically significant prostate cancer (57.4% vs. 39.7%) (p values < 0.01). Combination of systematic and targeted biopsy outperformed either regimen alone. PSA density and PI-RADS score were identified as independent risk factors, and a proposed diagnostic model (PSA density ≥ 0.25 or PI-RADS score ≥ 4) showed sensitivity of 88.6%, specificity of 55%, PPV of 81.2%, NPV of 68.8%, and accuracy of 78.0%. CONCLUSIONS: Both pre-biopsy MRI and cognitive-targeted biopsy contributed to improvement of cancer yield. Future alterations of possible benefit included increasing target cores per lesion, and combining PI-RADS score and PSA density as indicators for biopsy. Similar protocols may represent an on-going role for lower volume centers in the diagnosis of prostate cancer.

[Retroperitoneal mixed-type liposarcoma detected by health examination].

A 68-year-old man was referred to our hospital with a retroperitoneal tumor, which was incidentally found by abdominal ultrasonography in a health examination. Computed tomography (CT) and magnetic resonance imaging (MRI) showed retroperitoneal liposarcoma in the right retroperitoneal space. He underwent surgical excision of the tumor with Gerota fascia and perinephrium. The resected tissue was a pale yellow solid and white mucous mass, weighing 1,100 g. Histopathological examination of excised tumors revealed mixed-type liposarcoma (well-differentiated and myxoid types). He received no adjuvant therapy.

[Angioimmunoblastic T-cell lymphoma complicated by recurrent drug-induced agranulocytosis].

A 73-year-old man was hospitalized with fever, erythema, generalized superficial lymphadenopathy and marked neutropenia in July 2007. Hematologic examination demonstrated a white blood cell count of 1,400/microl with 0% neutrophils, and 18% abnormal lymphocytes. A bone marrow aspirate showed marked myeloid hypoplasia. A diagnosis of drug-induced agranulocytosis was made. Although neutrophil counts immediately returned to normal levels in response to filgrastim, fever, skin rash and systemic lymphadenopathy were all persistent. He also developed autoimmune hemolytic anemia and a second episode of agranulocytosis. The causative agent of the both episodes of agranulocytosis appeared to be acetaminophen. The histologic picture of a biopsied lymph node showed diffuse infiltration of polymorphous lymphoid cells with clear cytoplasm and proliferation of arborizing capillary vessels. Based on the histologic findings, PCR, and immunohistologic analyses, he was diagnosed with angioimmunoblastic T cell lymphoma (AILT) in leukemic state. The response of the lymphoma to conventional chemotherapy (CHOP and ESHAP) was poor. We next performed an immunomodulatory therapy using cyclosporine A to suppress cytokine production by neoplastic T cells. The treatment resulted in a partial remission of AILT including disappearance of circulating lymphoma cells. To our knowledge, this is the first published report of AILT complicated by drug-induced agranulocytosis.

[Renal insufficiency caused by leukemic cell infiltration in Sézary syndrome].

A 77-year-old woman was admitted to our hospital because of pneumonia and heart failure in July 2002. She had been diagnosed as having with Sézary syndrome in 1993, and had been treated with a combination of prednisolone, methotrexate, and cyclosporin A with subsequent stable disease but persistent generalized erythroderma. On admission, the white blood count was 23.9 X 10(9)/L with 28% Sézary cells, and serum creatinine levels were within normal limits. One month after admission, the pneumonia and heart failure improved remarkably with antibiotics and diuretics. However, at the same time, her renal function deteriorated with increasingly high serum creatinine levels. She died of anuria in September, 2002. An autopsy showed marked perivascular and peritubular infiltration of abnormal lymphocytes with degenerative nephrotubuli in the kidneys. This patient may be the first reported case of Sézary syndrome with renal failure caused by leukemic infiltration.

Re-evaluation of body weight as an indicator for contrast material dosage for indirect CT venography.

OBJECTIVE: We evaluated body weight as an accurate indicator for determining contrast load using nonionic monomeric contrast material in indirect CT venography. MATERIALS AND METHODS: One hundred and thirty-two patients (mean age 51 years) underwent indirect CT venography to exclude the possibility of DVT. We used 150 ml of isohexol (iodine, 300 mgI/ml) administered at a rate of 3.0 ml/s. Scanning delay was 180 s from the time of initiation of contrast injection. Scans were obtained in a caudal-to-cranial direction starting from the ankle. Hounsfield unit (HU) measurements were recorded at the common femoral and popliteal veins. Using linear regression analysis, we calculated the correlation the coefficient between the CT attenuation and the iodine dose per body weight of each patient. We also recorded the presence of DVT and measured the CT attenuation of the clots. RESULTS: Average contrast dosage per weight was 765.3 mgI (from 420.5 -1184.2 mgI). Average measurements of HU at the common femoral and popliteal veins were 114.4 ± 17.8 HU and 109.9 ± 21.4 HU, respectively. The regression coefficients were 0.62 and 0.41 for the common femoral and popliteal veins, respectively. DVT was detected in 33 of 132 patients. The average HU of the thrombus was 47.7 ± 13.3 HU. CONCLUSION: Indirect CT venography for detecting DVT initiated 180 s after the start of infusion of contrast material (150 ml) and a contrast injection at a rate of 3 ml/s produced high mean levels of venous enhancement. However, correlation between dose of contrast material per patient weight and CT attenuation of veins was fairly low.

Usefulness of combined PET/CT for patient with epithelial ovarian cancer showing recurrence based on tumor marker CA125.

We report the case of a 41-year-old patient with epithelial ovarian cancer of stage IIIc. One year and nine months after completion of chemotherapy performed after surgery, the level of the tumor marker CA125 began to increase gradually. Conventional computed tomography (CT) and magnetic resonance imaging (MRI) were performed, but the recurrence site could not be determined clearly. However, combined positron emission tomography/computed tomography (PET/CT) revealed a metastasis in the right external iliac lymph node. This allowed commencement of chemotherapy at an early recurrent stage and subsequently the level of CA125 showed a significant decrease.

A resectable case of gastrointestinal stromal tumor derived from the rectal wall after oral targeted molecular therapy with imatinib mesylate.

We performed targeted molecular therapy in a patient with a non-resectable pelvic gastrointestinal stromal tumor (GIST). Imatinib mesylate was administered at 400-600 mg/day for 6 months, and the tumor became resectable. The patient was a 58-year-old female who visited a gynecologic hospital with the chief complaint of a swollen feeling in the lower abdomen. A pelvic tumor was found by imaging, and the patient was referred to our hospital. Laparotomy was performed, but it was found that the tumor arose from the intestinal serous membrane, rather than from the uterus, and complete excision was difficult. A portion of the tumor tissue was excised, and the abdomen was closed. GIST was diagnosed on postoperative pathological examination, and the tissue was positive for c-kit protein on immunostaining. The tumor had markedly shrunk after oral administration of imatinib mesylate for 6 months, and excision by laparotomy became possible.

Progression of 189 women diagnosed with uterine cervical dysplasia based on abnormal results in mass screening.

During the five-year period from January 1997 to December 2001, cytological abnormalities in the uterine cervix were confirmed in 189 women (class IIIa: 172, class IIIb: 9, class IV: 7, and class V: 1) who underwent cytology screening of the uterine cervix at the Tokai University Health Evaluation and Promotion Center. Biopsy samples from the uterine cervix showed that the 172 women categorized into class IIIa based on cytology included 28 with no atypical lesions, 53 with mild dysplasia, 24 with moderate dysplasia, 3 with severe dysplasia; and the 9 women in class IIIb included 2 with mild dysplasia, 5 with moderate dysplasia, 1 with carcinoma in situ, and 1 with invasive carcinoma. The conformity rates between the cytology data and the biopsy samples were 71.3% and 11.1% in class IIIa and class IIIb, respectively. A three-year followup survey of the class IIIa and class IIIb subjects confirmed progression (PRO) in 8 (4.7%), continuous (CON) symptoms in 48 (27.9%), and regression (REG) in 116 (67.4%) in class IIIa, and PRO, CON and REG in 3 (33.3%), 4 (44.4%), and 2 (22.2%), respectively, in class IIIb; the percentage of subjects in the CON+REG group was significantly higher than in the PRO group (p = 0.0052). Twelve subjects underwent resection because uterine carcinoma was suspected in the punch biopsy; these subjects have remained under observation and have now made a complete recovery. Our results suggest that patients with uterine abnormal cells should undergo regular cytology and colposcopy for detection of high-risk patients and to allow treatment at an early stage.

[Continuous speech recognition system for radiological reporting: comparison with experience of dictation].

PURPOSE: To compare rates of accuracy of recognition between experienced dictators and inexperienced ones in using an enrollment-less continuous speech recognition (CSR) system of radiological reporting, and to evaluate the usefulness of the system. MATERIALS AND METHODS: Twenty board-certified radiologists were classified into 2 groups: a group of 10 members with more than 6 years' experience of conventional dictation by transcriptionist (group A) and a group of 10 members with no experience of dictation (group B). All radiologists created fresh radiological reports on sets of images using free-style dictation in the reports. We counted errors and total words in the reports individually, and compared the rates of accuracy of word recognition in the two groups. We used a CSR system AmiVoice (Advanced Media, Inc., Tokyo, Japan). RESULTS: The average rate of accuracy of word recognition was 96.42 +/- 1.68% in group A and 95.92 +/- 1.15% in group B. There was no significant difference in accuracy rate between the two groups. CONCLUSION: The accuracy of word recognition was independent of the experience of dictation, and the enrollment-less CSR system of radiological reporting was considered convenient and useful.