Radiological features of screening-detected and interval breast cancers and subsequent survival in Eastern Finnish women

Interval breast cancers are diagnosed between scheduled screenings and differ in many respects from screening-detected cancers. Studies comparing the survival of patients with interval and screening-detected cancers have reported differing results. The aim of this study was to investigate the radiological and histopathological features and growth rates of screening-detected and interval breast cancers and subsequent survival. This retrospective study included 942 female patients aged 50-69 years with breast cancers treated and followed-up at Kuopio University Hospital between January 2010 and December 2016. The screening-detected and interval cancers were classified as true, minimal-signs, missed, or occult. The radiological features were assessed on mammograms by one of two specialist breast radiologists with over 15 years of experience. A χ2 test was used to examine the association between radiological and pathological variables; an unpaired t test was used to compare the growth rates of missed and minimal-signs cancers; and the Kaplan-Meier estimator was used to examine survival after screening-detected and interval cancers. Sixty occult cancers were excluded, so a total of 882 women (mean age 60.4 ± 5.5 years) were included, in whom 581 had screening-detected cancers and 301 interval cancers. Disease-specific survival, overall survival and disease-free survival were all worse after interval cancer than after screening-detected cancer (p < 0.001), with a mean follow-up period of 8.2 years. There were no statistically significant differences in survival between the subgroups of screening-detected or interval cancers. Missed interval cancers had faster growth rates (0.47% ± 0.77%/day) than missed screening-detected cancers (0.21% ± 0.11%/day). Most cancers (77.2%) occurred in low-density breasts (< 25%). The most common lesion types were masses (73.9%) and calcifications (13.4%), whereas distortions (1.8%) and asymmetries (1.7%) were the least common. Survival was worse after interval cancers than after screening-detected cancers, attributed to their more-aggressive histopathological characteristics, more nodal and distant metastases, and faster growth rates.

Specimen tomosynthesis provides no additional value to specimen ultrasound in ultrasound-visible malignant breast lesions

BACKGROUND

The aim of this study was to evaluate the accuracy and added value of specimen tomosynthesis (ST) to specimen ultrasound (SUS) in margin assessment of excised breast specimens in breast-conserving therapy for non-palpable US-visible breast lesions.

MATERIALS

Between January 2018 and August 2019, all consecutive patients diagnosed with non-palpable breast cancer visible by ultrasound (US), treated with breast-conserving surgery (BCS) and requiring radiological intraoperative breast specimen assessment, were included in this study. Excised breast specimens were examined with SUS by radiologists blinded to the ST results, and margins smaller than 10 mm were recorded. STs were evaluated retrospectively by experienced radiologists.

RESULTS

A total of 120 specimens were included. SUS showed a statistically significant correlation with pathological margin measurements, while ST did not and provided no additional information. The odds ratios (ORs) for SUS to predict a positive margin was 3.429 (confidence interval (CI) = 0.548-21.432) using a 10-mm cut-off point and 14.182 (CI = 2.134-94.254) using a 5-mm cut-off point, while the OR for ST were 2.528 (CI = 0.400-15.994) and 3.188 (CI = 0.318-31.998), respectively.

CONCLUSIONS

SUS was superior in evaluating intraoperative resection margins of US-visible breast resection specimens when compared to ST. Therefore, ST could be considered redundant in applicable situations.

Association between breast cancer's prognostic factors and 3D textural features of non-contrast-enhanced T1 weighted breast MRI

OBJECTIVES

The aim of this exploratory study was to evaluate whether three-dimensional texture analysis (3D-TA) features of non-contrast-enhanced T₁ weighted MRI associate with traditional prognostic factors and disease-free survival (DFS) of breast cancer.

METHODS

3D-T₁ weighted images from 78 patients with 81 malignant histopathologically verified breast lesions were retrospectively analysed using standard-size volumes of interest. Grey-level co-occurrence matrix (GLCM)-based features were selected for statistical analysis. In statistics the Mann-Whitney U and the Kruskal-Wallis tests, the Cox proportional hazards model and the Kaplan-Meier method were used.

RESULTS

Tumours with higher histological grade were significantly associated with higher contrast (1 voxel: p = 0.033, 2 voxels: p = 0.036). All the entropy parameters showed significant correlation with tumour grade (p = 0.015-0.050) but there were no statistically significant associations between other TA parameters and tumour grade. The Nottingham Prognostic Index (NPI) was correlated with contrast and sum entropy parameters. A higher sum variance TA parameter was a significant predictor of shorter DFS.

CONCLUSION

Texture parameters, assessed by 3D-TA from non-enhanced T₁ weighted images, indicate tumour heterogeneity but have limited independent prognostic value. However, they are associated with tumour grade, NPI, and DFS. These parameters could be used as an adjunct to contrast-enhanced TA parameters.

ADVANCES IN KNOWLEDGE

3D-TA of non-contrast enhanced T₁ weighted breast MRI associates with tumour grade, NPI, and DFS. The use of non-contrast 3D-TA parameters in adjunct with contrast-enhanced 3D-TA parameters warrants further research.

Quantitative Three-Dimensional Assessment of the Pharmacokinetic Parameters of Intra- and Peri-tumoural Tissues on Breast Dynamic Contrast-Enhanced Magnetic Resonance Imaging

We aimed to assess the feasibility of three-dimensional (3D) segmentation and to investigate whether semi-quantitative dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) parameters are associated with traditional prognostic factors for breast cancer. In addition, we evaluated whether both intra-tumoural and peri-tumoural DCE parameters can differentiate the breast cancers that are more aggressive from those that are less aggressive. Consecutive patients with newly diagnosed invasive breast cancer and structural breast MRI (3.0 T) were included after informed consent. Fifty-six patients (mean age, 57 years) with mass lesions of > 7 mm in diameter were included. A semi-automatic image post-processing algorithm was developed to measure 3D pharmacokinetic information from the DCE-MRI images. The kinetic parameters were extracted from time-signal curves, and the absolute tissue contrast agent concentrations were calculated with a reference tissue model. Markedly, higher intra-tumoural and peri-tumoural tissue concentrations of contrast agent were found in high-grade tumours (n = 44) compared to low-grade tumours (n = 12) at every time point (P = 0.006-0.040), providing positive predictive values of 90.6-92.6% in the classification of high-grade tumours. The intra-tumoural and peri-tumoural signal enhancement ratios correlated with tumour grade, size, and Ki67 activity. The intra-observer reproducibility was excellent. We developed a model to measure the 3D intensity data of breast cancers. Low- and high-grade tumours differed in their intra-tumoural and peri-tumoural enhancement characteristics. We anticipate that pharmacokinetic parameters will be increasingly used as imaging biomarkers to model and predict tumour behavior, prognoses, and responses to treatment.

Multi-level dilated residual network for biomedical image segmentation

We propose a novel multi-level dilated residual neural network, an extension of the classical U-Net architecture, for biomedical image segmentation. U-Net is the most popular deep neural architecture for biomedical image segmentation, however, despite being state-of-the-art, the model has a few limitations. In this study, we suggest replacing convolutional blocks of the classical U-Net with multi-level dilated residual blocks, resulting in enhanced learning capability. We also propose to incorporate a non-linear multi-level residual blocks into skip connections to reduce the semantic gap and to restore the information lost when concatenating features from encoder to decoder units. We evaluate the proposed approach on five publicly available biomedical datasets with different imaging modalities, including electron microscopy, magnetic resonance imaging, histopathology, and dermoscopy, each with its own segmentation challenges. The proposed approach consistently outperforms the classical U-Net by 2%, 3%, 6%, 8%, and 14% relative improvements in dice coefficient, respectively for magnetic resonance imaging, dermoscopy, histopathology, cell nuclei microscopy, and electron microscopy modalities. The visual assessments of the segmentation results further show that the proposed approach is robust against outliers and preserves better continuity in boundaries compared to the classical U-Net and its variant, MultiResUNet.

Diagnostic performance of the Kaiser score for characterizing lesions on breast MRI with comparison to a multiparametric classification system

PURPOSE

To determine the diagnostic performance of the Kaiser score and to compare it with the BI-RADS-based multiparametric classification system (MCS).

METHOD

Two breast radiologists, blinded to the clinical and pathological information, separately evaluated a database of 499 consecutive patients with structural 3.0 T breast MRI and 697 histopathologically verified lesions. The Kaiser scores and corresponding MCS categories were recorded. The sensitivity and specificity of the Kaiser score and the MCS categories to differentiate benign from malignant lesions were calculated. The interobserver reproducibility and receiver operating characteristic (ROC) parameters were analysed.

RESULTS

The sensitivity and specificity of the MCS were 100 % and 12 %, respectively, and those of the Kaiser score were 98.5 % and 34.8 % for reader 1 and 98.7 % and 47.5 % for reader 2. The area under the ROC-curve was 85.9 and 87.6 for readers 1 and 2. The interobserver intraclass correlation coefficient was excellent at 0.882. Reader 1 upgraded six lesions from BI-RADS 3 to a Kaiser score of >4, and reader 2 upgraded seven lesions. When applying the Kaiser score to 158 benign lesions readers 1 and 2 would have reduced the biopsy rate by 22.8 % and 35.4 %, respectively.

CONCLUSIONS

The Kaiser score showed high diagnostic accuracy with excellent interobserver reproducibility. The MCS had perfect sensitivity but low specificity. Although the Kaiser score had slightly lower sensitivity, its specificity was 3-4 times greater than that of the MCS. Thus, the Kaiser score has the potential to considerably reduce the biopsy rate for true negative lesions.

The mammographic breast density distribution of Finnish women with breast cancer and comparison of breast density reporting using the 4th and 5th editions of the Breast Imaging-Reporting and Data System

PURPOSE

To examine the breast density distribution in patients diagnosed with breast cancer in an eastern Finnish population and to examine the changes in breast density reporting patterns between the 4^th and 5^th editions of the Breast Imaging-Reporting and Data System (BI-RADS).

METHOD

821 women (mean age 62.8 ± 12.2 years, range 28-94 years) with breast cancer were included in this retrospective study and their digital mammographic examinations were assessed semi-automatically and then visually by two radiologists in accordance with the 4^th and 5^th editions of the BI-RADS. Intraclass correlation coefficients (ICCs) were used to evaluate interobserver reproducibility. Chi-square tests were used to examine the associations between the breast density distribution and age or body mass index (BMI).

RESULTS

Interobserver reproducibility of the visual assessment was excellent, with an ICCr = 0.93. The majority of breast cancers occurred in fatty breasts (93.8 %) when density was assessed according to the 4^th edition of the BI-RADS. The distributions remained constant after correction for age and BMI. Using the 5^th edition, there was an overall 50.2 % decrease in almost entirely fatty (p <  0.001), 19.4 % increase in scattered fibroglandular (p <  0.001), 28.7 % increase in heterogeneously dense (p <  0.001), and 2.1 % increase in extremely dense (p <  0.001) categories.

CONCLUSIONS

Most breast cancers in eastern Finland occur in fatty breasts with an area density of < 50 %. Assessing breast density using the 5^th edition of the BI-RADS greatly increased denser assessments.

The feasibility of ultrasound-guided vacuum-assisted evacuation of large breast hematomas

Background Breast hematoma is an often underrated and disregarded post-procedural complication in the literature. Current treatment modalities are comprised of either surgical or expectant therapy, while percutaneous procedures play a smaller role in their treatment. We aimed to examine the efficacy of vacuum-assisted evacuation (VAE) in the treatment of clinically significant large breast hematomas as an alternative to surgery. Patients and methods We retrospectively analysed patients that underwent breast interventions (surgical and percutaneous), who later developed clinically significant large hematomas and underwent a trial of VAE of hematoma in our hospital within the period of four years. Patient and procedure characteristics were acquired before and after VAE. Success of intervention was based on ≥ 50% clearance of hematoma volume and patients' subjective resolution of symptoms. All patients were followed clinically and by ultrasound if needed at different intervals depending on the severity of presenting symptoms. Results Eleven patients were included in the study. The mean largest diameter of hematomas was 7.9 cm and mean surface area was 32.4 cm2. The mean duration of the procedure was 40.5 min. In all patients VAE of hematoma was implemented successfully with no complications. Control visits showed no major residual hematoma or seroma formation. Conclusions Our results show that VAE of hematoma can be implemented as a safe alternative to surgery in large, clinically significant hematomas, regardless of aetiology or duration. The procedure carries less risk, stress and cost with the added benefit of outpatient treatment when compared to surgical treatment.

Peritumor to tumor apparent diffusion coefficient ratio is associated with biologically more aggressive breast cancer features and correlates with the prognostication tools

PURPOSE

The apparent diffusion coefficient (ADC) is increasingly used to characterize breast cancer. The peritumor/tumor ADC ratio is suggested to be a reliable and generally applicable index. However, its overall prognostication value remains unclear. We aimed to evaluate the associations between the peritumor/tumor ADC ratio and histopathological biomarkers and published prognostic tools in patients with invasive breast cancer.

MATERIALS AND METHODS

This prospective study included 88 lesions (five bilateral) in 83 patients with primary invasive breast cancer who underwent preoperative 3.0-T magnetic resonance imaging. The lowest intratumoral mean ADC value on the slice with the largest tumor cross-sectional area was designated the tumor ADC, and the highest mean ADC value on the peritumoral breast parenchymal tissue adjacent to the tumor border was designated the peritumor ADC. The peritumor/tumor ADC ratio was then calculated. The tumor and peritumor ADC values and peritumor/tumor ADC ratios were compared with histopathological parameters using an unpaired t test, and their correlations with published prognostic tools were evaluated with Pearson's correlation coefficient.

RESULTS

The peritumor/tumor ADC ratio was significantly associated with tumor size (p<0.001), histological grade (p = 0.005), Ki-67 index (p = 0.006), axillary-lymph-node metastasis (p = 0.001), and lymphovascular invasion (p = 0.006), but was not associated with estrogen receptor status (p = 0.931), progesterone receptor status (p = 0.160), or human epidermal growth factor receptor 2 status (p = 0.259). The peritumor/tumor ADC ratio showed moderate positive correlations with the Nottingham Prognostic Index (r = 0.498, p<0.001) and mortality predicted using PREDICT (r = 0.436, p<0.001).

CONCLUSION

The peritumor/tumor ADC ratio was correlated with histopathological biomarkers in patients with invasive breast cancer, showed significant correlations with published prognostic indexes, and may provide an easily applicable imaging index for the preoperative prognostic evaluation of breast cancer.

Pulmonary postmortem computed tomography of bacterial pneumonia and pulmonary edema in patients following non-traumatic in-hospital death

In this study, we compared the postmortem computed tomography (PMCT) findings among nonpathological lungs, lungs with bacterial pneumonia, and lungs with pulmonary edema in patients following non-traumatic in-hospital death. We studied 104 consecutive adult patients (208 lungs) who died in our tertiary care hospital and underwent PMCT and pathological autopsy (both within 2.5 days after death), and were pathologically diagnosed with nonpathological lungs, bacterial pneumonia, and pulmonary edema. Thirteen pulmonary features were assessed on the CT scans. We also examined the association between the time elapsed since death and the pulmonary findings. We observed increased lung opacities with horizontal plane formation, diffuse opacities, diffuse bronchovascular bundle thickening, symmetric opacities to the contralateral lung, and decreased segmental opacities with time elapsed since death (Cochran-Armitage test for trend). Multiple logistic regression revealed that the presence of opacities without horizontal plane formation or centrilobular opacities, and the absence of diffuse bronchovascular bundle thickening were associated with histopathological pneumonia, whereas the presence of opacities with horizontal plane formation, diffuse opacities, and interlobular septal thickening were associated with histopathological pulmonary edema. In conclusion, specific pulmonary PMCT findings increased with time elapsed since death, and some lung findings may facilitate the diagnosis of bacterial pneumonia and pulmonary edema.

Development of pancreatic cancer during observation for hepatocellular carcinoma: A retrospective cohort study

BACKGROUND/AIMS

We aimed to investigate incidence, characteristics, and possible risk factors of pancreatic cancer in patients under observation for hepatocellular carcinoma (HCC) because the association of hepatitis virus B infection and pancreatic cancer has been reported.

PATIENTS AND METHODS

We performed a retrospective cohort study in the Gastroenterology Department of a University Hospital in Japan between 2004 and 2012. A total of 1848 patients who underwent treatment for HCC were included at the initiation of treatment for HCC (mean follow-up period, 33.6 months). The patients received trimonthly radiological follow-ups. Newly developed cases of pancreatic cancer during follow-up for HCC were compared with that of an age- and sex-matched theoretical cohort from national statistics. Possible predisposing factors for pancreatic cancer related to HCC were assessed. Cumulative probabilities of developing a pancreatic cancer were compared using log-rank test.

RESULTS

About 13 of 1848 patients developed pancreatic cancer (mean follow-up period, 45.2 months). The risk ratio for all patients was 3.02 (log-rank test: P =0.01). Statistical analyses showed no effects of the following factors on the development of pancreatic cancer: age, sex, follow-up period, alcohol intake, laboratory data, presence of hepatitis virus, characteristics of HCC, type of treatment, number of radiological examinations, and cumulative effective dose.

CONCLUSIONS

Increased incidence of pancreatic cancer was found in patients under observation for HCC in a relatively small cohort. HCC or other common underlying conditions might be a risk factor for development of pancreatic cancer.

Peritumoral ADC values in breast cancer: region of interest selection, associations with hyaluronan intensity, and prognostic significance

Objectives

We aimed to evaluate the differences in peritumoral apparent diffusion coefficient (ADC) values by four different ROI selection methods and to validate the optimal method. Furthermore, we aimed to evaluate if the peritumor-tumor ADC ratios are correlated with axillary lymph node positivity and hyaluronan accumulation.

Methods

Altogether, 22 breast cancer patients underwent 3.0-T breast MRI, histopathological evaluation, and hyaluronan assay. Paired t and Friedman tests were used to compare minimum, mean, and maximum values of tumoral and peritumoral ADC by four methods: (M1) band ROI, (M2) whole tumor surrounding ROI, (M3) clockwise multiple ROI, and (M4) visual assessment of ROI selection. Subsequently, peritumor/tumor ADC ratios were compared with hyaluronan levels and axillary lymph node status by the Mann-Whitney U test.

Results

No statistically significant differences were found among the four ROI selection methods regarding minimum, mean, or maximum values of tumoral and peritumoral ADC. Visual assessment ROI measurements represented the less time-consuming evaluation method for the peritumoral area, and with sufficient accuracy. Peritumor/tumor ADC ratios obtained by all methods except the clockwise ROI (M3) showed a positive correlation with hyaluronan content (M1, p = 0.004; M2, p = 0.012; M3, p = 0.20; M4, p = 0.025) and lymph node metastasis (M1, p = 0.001; M2, p = 0.007; M3, p = 0.22; M4, p = 0.015), which are established factors for unfavorable prognosis.

Conclusions

Our results suggest that the peritumor/tumor ADC ratio could be a readily applicable imaging index associated with axillary lymph node metastasis and extensive hyaluronan accumulation. It could be related to the biological aggressiveness of breast cancer and therefore might serve as an additional prognostic factor.

Key Points

• Out of four different ROI selection methods for peritumoral ADC evaluation, measurements based on visual assessment provided sufficient accuracy and were the less time-consuming method.

• The peritumor/tumor ADC ratio can provide an easily applicable supplementary imaging index for breast cancer assessment.

• A higher peritumor/tumor ADC ratio was associated with axillary lymph node metastasis and extensive hyaluronan accumulation and might serve as an additional prognostic factor.

Shear Wave Speed of the Lesion in Preoperative Breast Ultrasonography: Association with Disease-free Survival of Patients with Primary Operable Invasive Breast Cancer

RATIONALE AND OBJECTIVES

We aimed to investigate the relationship between shear wave speed (SWS) of the lesion on preoperative breast ultrasonography (US) and disease-free survival of patients with primary operable invasive breast cancer.

MATERIALS AND METHODS

This retrospective study was approved by our Institutional Review Board. The requirement for informed consent was waived. A total of 195 consecutive newly diagnosed invasive breast cancer patients (age 33-83 years; mean 54.0 years) with preoperative breast US with SWS measurement of the lesion were identified. They underwent surgery between May 2012 and May 2013. SWS was measured at the center and three marginal zones in the main tumors, and the maximum value was used for analyses. For 35 patients who underwent primary systemic therapy (PST), the maximum SWS before PST was used. Cox proportional hazards modeling was used to identify the relationship between clinical-pathologic factors and disease-free survival.

RESULTS

Fourteen recurrences occurred at 6-47 months (mean 22.3 months) after surgery. On multivariate analysis, a positive history of PST (hazard ratio [HR] = 4.93; 95% confidence interval [CI]: 1.66, 14.70; P = .004), adjuvant chemotherapy (HR = 3.67; 95% CI: 1.11, 12.1; P = .033), and higher maximum SWS (HR = 1.55; 95% CI: 1.07, 2.23; P = .020) were associated with poorer disease-free survival.

CONCLUSION

Higher maximum SWS on preoperative US, in addition to a positive history of PST and adjuvant chemotherapy, was significantly associated with poorer disease-free survival of patients with invasive breast cancer.

Development of pancreatic cancer is predictable well in advance using contrast-enhanced CT: a case-cohort study

OBJECTIVES

To investigate the radiological findings prognostic for the development of pancreatic adenocarcinoma in a cohort of patients with hepatocellular carcinoma, using multiphasic computed tomography (CT).

METHODS

A case-cohort study performed in a single university hospital. A database of patients who received hepatocellular carcinoma (HCC) treatment and trimonthly follow-up with four-phase dynamic CT was used (n = 1848). The cohort group was randomly extracted from the database (n = 103). The case group comprised nine patients from the database who developed pancreatic adenocarcinoma. The radiological findings were assessed during follow-up (average, 32 months).

RESULTS

The incidence of pancreatic mass, inhomogeneous parenchyma, loss of fatty marbling and main pancreatic duct dilatation gradually increased from 4 to 13 months before the diagnosis of pancreatic adenocarcinoma. There was a significantly higher incidence of pancreatic mass, inhomogeneous parenchyma and loss of fatty marbling on CT at baseline (average, 34 months before diagnosis) in the case group compared with the cohort group (P values < 0.01) and those findings at baseline were revealed as prognostic factors for pancreatic carcinogenesis, respectively (log-rank test, P values < 0.001).

CONCLUSIONS

Several radiological findings observed on multiphasic CT can assist in predicting pancreatic carcinogenesis well in advance.

KEY POINTS

• Pancreatic findings in multiphasic CT help predict development of pancreatic adenocarcinoma. • Key findings are mass, inhomogeneous parenchyma and loss of fatty marbling. • Those findings were observed 34 months before confirmed diagnosis of adenocarcinoma. • Those findings were prognostic factors for pancreatic carcinogenesis.

The pseudo-SAH sign: an imaging pitfall in postmortem computed tomography

Postmortem computed tomography (PMCT) of the brain has an important role in detection of subarachnoid hemorrhage (SAH), which has a high mortality rate. However, a phenomenon known as "pseudo-SAH," or high-attenuation areas along the cisterns mimicking SAH, may be seen on CT. The aim of this study was to evaluate the diagnostic accuracy of brain PMCT for SAH and to identify the characteristics of pseudo-SAH. Findings on PMCT (sulcal effacement, asymmetry, maximum thickness of SAH signs, presence of acute/subacute intraventricular/intraparenchymal hemorrhage) and clinical history (left ventricular assist device [LVAD] implantation, anticoagulation therapy/coagulation disorder, global ischemia) were compared between subjects with true SAH and those with pseudo-SAH. Twenty eight of 128 enrolled subjects had positive signs of SAH on PMCT, 20 (71.4%) had SAH on autopsy, and 8 (28.6%) did not. The sensitivity, specificity, positive predictive value, and negative predictive value of SAH signs seen on PMCT were 95.2, 94.6, 71.4, and 99.3%, respectively. Asymmetry of SAH signs and acute/subacute intraventricular and intraparenchymal hemorrhage were significantly more common in true SAH cases than in pseudo-SAH cases. The maximum thickness of SAH signs was significantly greater in true SAH cases. A history of LVAD implantation, anticoagulation therapy, and/or a coagulation disorder were more common in true SAH cases but not significantly so. A history of global ischemia was significantly more common in pseudo-SAH cases. If signs of SAH are observed on PMCT, it is important to look for other signs on PMCT and carefully review the clinical history to avoid a diagnostic error.

Laminar crystal deposition in large vessels in a patient with crystalglobulinemia

Crystalglobulinemia is an extremely rare complication of monoclonal gammopathy and is characterized by crystal thrombi within systemic organs. We herein report the first described case of crystalglobulinemia accompanied by laminar crystal deposition in the large vessels. A 44-year-old man presented with a history of numbness, pain, and swelling of the left leg in addition to visual impairment. Renal and skin biopsies revealed crystal thrombi within the capillary lumens. The patient was finally diagnosed with crystalglobulinemia associated with multiple myeloma. He was treated with hemodialysis and chemotherapy but died of the disease 15 months after admission. Autopsy demonstrated a huge amount of crystal deposition in the subintimal layer of the vascular wall throughout the thoracic to abdominal aorta. The characteristic deposition extended to the iliac arteries, common carotid arteries, and subclavian arteries but did not affect the bilateral renal arteries. Antemortem computed tomography demonstrated higher intensity in the wall of the abdominal aorta but not in the walls of the renal arteries, suggesting that a finding of high intensity on computed tomography could be a clinical marker of systemic crystal deposition.

Comparison of the cardiothoracic ratio between postmortem and antemortem computed tomography

As postmortem imaging has gained prominence as a supplement to traditional autopsy, it is important to understand the normal postmortem changes to enable the accurate evaluation of postmortem imaging. No studies have evaluated the postmortem changes in cardiothoracic ratio (CTR) compared with antemortem images in the same subjects. We studied 147 consecutive subjects who underwent antemortem and postmortem CT, and autopsy. Postmortem CT was performed <23h after death and was followed by autopsy. The subjects were divided into three groups: normal heart, old myocardial infarction, and CPR-treated hearts. CTR was compared between antemortem and postmortem CT using paired t tests, which revealed that the CTR was greater on postmortem CT than on antemortem CT in all groups (mean CTR: 0.53±0.06vs. 0.50±0.06, respectively; P<0.01). Sex, age, time elapsed since death, and the causes of death were examined as potential confounding factors for the postmortem changes in CTR, but no significant associations were found. Receiver-operating characteristic (ROC) curves were used to determine CTR values for cardiomegaly, which was defined according to the autopsy weight of the heart. The area under the ROC curve was 0.71 (95% confidence interval 0.63-0.79). The CTR threshold of 0.54 identified cardiomegaly with the greatest accuracy, compared with the general threshold of 0.50. In conclusion, the CT-determined CTR increases after death, irrespective of the heart's condition. We should be cautious of overdiagnosis of cardiomegaly on postmortem CT, and new criteria for interpreting cardiomegaly on postmortem CTR are needed.

Cerebral embolism through hematogenous dissemination of pulmonary mucormycosis complicating relapsed leukemia

Invasive mucormycosis in patients with hematological diseases mostly occurs in the lungs. Invasive mucormycosis of other anatomical sites is relatively infrequent and its pathogenesis has not so far been well elucidated. Here, we describe an autopsy case of pulmonary invasive mucormycosis complicated by cerebral embolism with infarct. A 77-year-old Japanese woman with relapsed acute myeloid leukemia complained of left visual disturbance and weakness of the lower limbs. The diagnosis of leukemic infiltration to the central nervous system was made. Repeated intrathecal injection of methotrexate plus cytarabine resulted in partial amelioration of the neurologic symptoms. However, the patient then developed fever, dyspnea, and subsequent right hemiparesis. A computed tomography (CT) scan showed a consolidative shadow with halo sign in the left lung field, which was compatible with either invasive pulmonary aspergillosis or mucormycosis. These findings accounted for fever and dyspnea, but not hemiparesis. Despite antifungal therapy, the patient succumbed to death after two weeks. Autopsy revealed pulmonary invasive mucormycosis with a fungal ball in the lumina of the adjacent ascending aorta. Intriguingly, autopsy and postmortem CT scan identified left cerebral infarct due to mucormycosis, which accounted for the right hemiparesis. It is likely that the fungal ball caused the cerebral embolism through hematogenous dissemination. We should suspect hematogenous dissemination when we see a patient with pulmonary invasive mucormycosis developing neurologic symptoms.

Common Postmortem Computed Tomography Findings Following Atraumatic Death: Differentiation between Normal Postmortem Changes and Pathologic Lesions

Computed tomography (CT) is widely used in postmortem investigations as an adjunct to the traditional autopsy in forensic medicine. To date, several studies have described postmortem CT findings as being caused by normal postmortem changes. However, on interpretation, postmortem CT findings that are seemingly due to normal postmortem changes initially, may not have been mere postmortem artifacts. In this pictorial essay, we describe the common postmortem CT findings in cases of atraumatic in-hospital death and describe the diagnostic pitfalls of normal postmortem changes that can mimic real pathologic lesions.

Comparison of attenuation of striated muscle between postmortem and antemortem computed tomography: results of a longitudinal study

Objective

We evaluated the postmortem changes of striated muscle by comparing computed tomography (CT) images obtained postmortem and antemortem in the same patients.

Materials and Methods

We studied 33 consecutive patients who underwent antemortem CT, postmortem CT, and pathological autopsy in our tertiary care hospital between April 2009 and December 2010. Postmortem CT was performed within 20 h after death and was followed by pathological autopsy. Pathological autopsy confirmed the absence of muscular diseases such as amyotrophic lateral sclerosis, muscular dystrophy, myositis, and myasthenia, in all of the patients. The CT attenuation values of four cardiac muscle sites (anterior wall of the left ventricle, left ventricular free wall, posterior wall of the left ventricle, and the ventricular septum) and two skeletal muscle sites (the pectoralis major muscle and the erector spinae muscle) were compared between antemortem and postmortem CT using paired t test.

Results

Striated muscle had significantly greater attenuation on postmortem CT than on antemortem CT (P<0.001) in all six tissue sites. No significant association was found between postmortem change in the CT attenuation of striated muscle and gender, age, or elapsed time since death.

Conclusion

This is the first longitudinal study to show hyperattenuation of striated muscle on postmortem CT images compared with antemortem CT images in the same patients.

Sudden onset of sleep due to hypothalamic lesions in neuromyelitis optica spectrum disorder positive for anti-aquaporin-4 antibody

We report a patient with neuromyelitis optica spectrum disorders who presented with sudden onset of sleep as the sole manifestation. Magnetic resonance imaging investigation revealed lesions in the hypothalamus bilaterally, which vanished completely after methylprednisolone pulse therapy.

Early postmortem volume reduction of adrenal gland: initial longitudinal computed tomographic study

We aimed to confirm whether postmortem adrenal volumetric changes occur by measuring adrenal volumes on computed tomography (CT). Fifty-five adrenal glands from 28 subjects who died were included. All subjects underwent antemortem CT (AMCT) and postmortem CT (PMCT) within 94-1,191 min after death, followed by conventional autopsy. CT volumetry was performed using freely-available software. Differences between AMCT and PMCT adrenal volumes were evaluated statistically along with differences in the degree of volume change, elapsed time to PMCT, and presence of underlying malignant disease. The mean volume of the right adrenal gland decreased from 3.8 cm(3) on AMCT to 2.6 cm(3) on PMCT (P < 0.001); the left adrenal gland decreased from 4.2 cm(3) on AMCT to 3.1 cm(3) on PMCT (P < 0.001). Conventional autopsy revealed decreased intracellular lipid components in portions of the adrenal glands. No correlation between the adrenal gland reduction rate and the elapsed time from AMCT to death or from death to PMCT was observed (P = 0.99 and 0.79; P = 0.28 and 0.59 for the right and left adrenal glands, respectively). Significant differences in both the bilateral adrenal gland reduction rates and underlying malignant disease were found for the left adrenal gland (P = 0.015), but not for the right (P = 0.74). Adrenal volume reduction was observed on PMCT compared to AMCT. This highlights the need to further elucidate the mechanism of adrenal shrinkage during the agonal stage and after death. This may be explained by pathological findings of intracellular lipid depletion.

Greater thickness of the aortic wall on postmortem computed tomography compared with antemortem computed tomography: the first longitudinal study

OBJECTIVES

To evaluate postmortem changes of the aorta on postmortem computed tomography (CT) in comparison with those on antemortem CT obtained in the same patients.

MATERIALS AND METHODS

We studied 57 consecutive patients who had undergone antemortem CT, postmortem CT, and pathological autopsy in our tertiary care hospital between April 2009 and December 2010. Postmortem CT was performed within 20 h after death, followed by pathological autopsy. Pathological autopsy confirmed the absence of cardiovascular disease such as aortic aneurysm, aortic dissection, or Marfan syndrome in all patients. Aortic wall thickness and aortic cross-sectional areas were measured on both antemortem CT and postmortem CT. Difference in aortic wall thickness between antemortem CT with and without contrast medium, and between antemortem CT and postmortem CT, and in cross-sectional area of the aortic wall between antemortem CT and postmortem CT was evaluated statistically.

RESULTS

No significant difference in aortic wall thickness was observed on antemortem CT in comparison of contrasted and non-contrasted images. The aortic wall was significantly thicker on postmortem CT than on antemortem CT (p < 0.0001). No significant difference in cross-sectional area of the aortic wall was observed between antemortem CT and postmortem CT measurements.

CONCLUSION

This is the first longitudinal study to confirm greater thickness of the aortic wall on postmortem images compared with antemortem images in the same patients and to show no change in cross-sectional area of the aortic wall between before and after death.

Heart wall is thicker on postmortem computed tomography than on antemortem [corrected] computed tomography: the first longitudinal study

Objective

To evaluate the postmortem changes of the heart wall on postmortem (PM) computed tomography (CT) in comparison with those on ante mortem CT (AMCT), and in comparison with the pathological findings, obtained in the same patients.

Materials and Methods

We studied 57 consecutive patients who had undergone AMCT, PMCT, and pathological autopsy in our tertiary care hospital between April 2009 and December 2010. PMCT was performed within 20 hours after death, followed by pathological autopsy. The cardiac chambers were measured at five sites on both AMCT and PMCT by two board-certified radiologists who were not provided with clinical information. The differences in heart wall thickness between AMCT with and without contrast medium, between AMCT and PMCT, and between PMCT and pathological anatomy were evaluated statistically. Confounding factors of postmortem change such as gender, presence of arteriosclerosis, the organ related to cause of death, age, and elapsed time since death were examined statistically.

Results

No significant differences were observed on AMCT in comparison of contrasted and non-contrasted images. The heart wall was significantly thicker on PMCT than on AMCT (p < 0.0001) at all five measurement sites. The heart wall was significantly thicker on PMCT than on pathology specimens when measured in accordance with pathological standard mensuration. However, no significant difference was observed between PMCT measurements and those of pathology specimens at any site when the papillary muscles and epicardial fat were included. No significant association was found between postmortem change in heart wall thickness and gender, presence of arteriosclerosis, the organ related to cause of death, age, or elapsed time since death.

Conclusion

This is the first longitudinal study to confirm greater thickness of heart wall on postmortem images compared with ante mortem images, in the same patients. Furthermore, the postmortem changes on CT were supported by the pathological findings.

Muscle metabolism in patients with polymyositis simultaneously evaluated by using 31P-magnetic resonance spectroscopy and near-infrared spectroscopy

Simultaneous measurements of muscle energy metabolism using (31)P-magnetic resonance spectroscopy ((31)P-MRS) and the kinetics of muscular oxygen metabolism using near-infrared spectroscopy (NIRS) were conducted in polymyositis (PM) patients. The subjects were 12 PM patients (age 45 +/- 12 years) and 12 normal controls (age 41 +/- 12 years). The muscle phosphocreatine (PCr) index and intracellular pH (pHi) were determined with (31)P-MRS and the changes in intramuscular oxygenated (oxy-Hb), deoxygenated (deoxy-Hb), and total haemoglobin (total Hb) were evaluated with NIRS . The pHi and PCr index before steroid therapy in PM patients were significantly lower during exercise than in normal controls, and their recovery was statistically significantly delayed compared with the controls. The pattern of changes in NIRS over time before steroid therapy in PM patients differed from that in normal controls. There were smaller changes in deoxy-Hb and oxy-Hb during exercise, and total Hb decreased during exercise. In contrast, the kinetics of muscular metabolism after steroid therapy showed changes similar to those seen in normal controls. Simultaneous (31)P-MRS and NIRS measurements to determine the kinetics of muscular metabolism are expected to be useful as a noninvasive approach for the evaluation of treatment effects in PM patients.

Salivary bisphenol-A levels detected by ELISA after restoration with composite resin

Bisphenol-A diglycidylether methacrylate (Bis-GMA), which is synthesized from bisphenol-A (BPA), a compound with exogenous endocrine disrupter action, is widely used as a dental material. During clinical filling with sealants and composite resins, the compounds are solidified by polymerization and then used. However, it has been noted that unpolymerized monomers may become dissolved in saliva. In this study using a competitive ELISA system, we investigated the changes in the BPA concentration in saliva after restoration with composite resins. Commercial composite resins from nine companies were tested. Mixed saliva was collected from 21 subjects. Based on the dynamics of salivary BPA detected by this ELISA system, we concluded that several tens to 100 ng/ml of BPA were contained in saliva after filling teeth with composite resin but that sufficient gargling can remove it from the oral cavity. Our data suggest that sufficient gargling after treatment is important for risk management.

[Experimental retinal branch vein occlusion. 4. Pathological changes in the middle and late stage]

Retinal branch vein occlusion in macaca monkeys (Macaca irus) was produced by dye laser photocoagulation, and observed histopathologically from five days to one year after photocoagulation. Ten days later, retinal edema and hemorrhage observed at an early stage gradually decreased. Two weeks later, capillary bed closure areas were observed in fluorescein angiography. The capillary closure was not reversible when disturbance of the retinal circulation continued for more than three or four days after photocoagulation. Three months later, dry retina was observed in the capillary bed closure areas. One year later, the retina was severely degenerated and thinned. In these retinal areas, capillary lumens observed microscopically were occluded by cellular components. Sheathing of large veins was observed in these retinal areas. The walls of these large veins were thick and fell into hyaline degeneration. Their lumens were narrowed or obstructed. During the period of observation, retinal neovascularization was not observed.

[Recanalization of venule following experimental retinal branch vein occlusion]

Retinal branch vein occlusion was experimentally produced in monkey (macaca irus) by dye laser photocoagulation. Venous dilatation, retinal edema and punctate hemorrhages were the ophthalmoscopic changes immediately after the occurrence of venous occlusion by photocoagulation. Fluorescein angiography revealed delay of retinal circulation and dye leakage from these venules. Fluorescein angiography on the 2nd day revealed caliber irregularities in the venules distal to the photocoagulated points. Histopathologically, thrombus formation and partial defect of the endothelial cells were observed in the venules in the areas which showed recovery with immature endothelial cells on the 4th day. Young endothelial cells proliferating along the endothelial basement membrane, which remained around the thrombi, and recanalization were observed on the 7th day. These results reveals a process of recanalization in the thrombogenous retinal venous occlusion.

[Experimental retinal branch vein occlusion]

Experimental retinal branch vein occlusion in monkeys (macaca irus) were produced by yellow wavelength (577nm) dye laser photocoagulation. The clinical sequence was observed in terms of the structural and ultrastructural findings occurring during the natural history of experimental branch vein occlusion, particularly in the early stage. Immediately after the occlusion, venous dilatation and retinal edema and hemorrhage appeared. Extravascular leakage of dye in fluorescein angiography and hemorrhage appeared from small venules at an early stage. Leakage from the larger vessels was observed later. Opening of the intercellular junctional complexes, which signifies breakdown of the blood-retinal barrier was detected by electron microscopy. Subsequently degenerative or necrotic changes in endothelial cells appeared with the formation of intravascular thrombi and extravascular leakage of blood components appeared from these vessels.

Biosensor system for continuous flow determination of enzyme activities. II. Simultaneous determination of plural enzyme activities

A biosensor system for continuous flow determination of plural enzyme activities was prepared from the combination of two pyruvate sensors, a prereactor and a flow cell. This system was applied to the simultaneous determination of lactic dehydrogenase (LDH) and glutamic-pyruvic transaminase (GPT) activities in the same sample. These enzyme activities can be determined by measuring pyruvate produced by the enzyme reactions as follows. The amount of pyruvic acid can also be determined from the amount of oxygen consumed upon oxidation of pyruvic acid by pyruvate oxidase. (Formula: see text). Therefore, both of the detectors for the determination of lactic dehydrogenase and glutamic-pyruvic transaminase activities were prepared from the combination of a pyruvate oxidase membrane and an oxygen electrode. Pyruvate oxidase was covalently immobilized on a membrane prepared from cellulose triacetate. A linear relation was obtained between the output current and LDH or GPT activities in the range of 50 to 3,600 IU l-1 or 6 to 1,000 IU l-1, respectively. Each assay of these enzyme activities was completed within 15 min. The results obtained had a precision of ca. 4%. The sensor was stable for more than 25 days at 5 degrees C.

Transition of physical fitness in wheelchair marathon competitors over several years

Twenty eight stress tests for 14 wheelchair marathon competitors were performed to determine their physical fitness just before the Oita International wheelchair marathon since 1984. All the subjects were wheelchair-bound Japanese males and workers at Sun Industry. Oxygen consumption at the maximal workload was significantly larger than that of non-athletic paraplegics and the mean values were 35.0 +/- 4.8 ml/kg in competitors and 22.6 +/- 5.0 ml/min/kg in non-athletic paraplegics. Eight competitors had more than 2 stress tests and 6 of them had 3 tests from 1984 to 1987. The oxygen consumption at the maximal workload of their third test was very high (46.5 +/- 6.8 ml/min/kg) equal to highly trained paraplegics, and was larger than the result of the first test significantly. Their physical fitness was reduced significantly during the off season, however their physical fitness was maintained at a satisfactory higher level than that of non-athletes. This study demonstrated that individual training for wheelchair marathoners had improved the competitors' physical fitness over several years.

[Experimental retinal branch vein occlusion]

Experimental retinal branch vein occlusion was produced in monkeys (macaca irus) by dye laser photocoagulation (yellow wavelength 577nm The 920 ARGON/DYE Laser System, Coherent Radiation). The Clinical process was observed based on ophthalmoscopic and fluorescein angiographic alterations which occur during the natural history of experimental branch vein occlusion. Immediately after occlusion, venous dilatation, retinal edema and punctate hemorrhage, were recognized by ophthalmoscopy, and leakage of dye from postcapillary venules, followed later by additional leakage from large veins were observed frequently by fluorescein angiography. Circulatory disturbances remained over 3-4 days, and the retinal branch vein occlusion were persisted. Ten days later, a non-perfusion area was observed by fluorescein angiography. More than 1 year later, these nonperfusion area remained.

Physical fitness of paraplegics in full wheelchair marathon racing

The wheelchair marathon is one of the most difficult sports for participants with much uncertainty regarding the security of the paraplegics. The physical fitness of paraplegics has been examined regularly since The Oita International Wheelchair Marathon (half marathon) was inaugurated (1981). A full marathon (42.195 km) was adopted at The 3rd Meeting (1983). The individual equations between heart rate (HR) and oxygen consumption VO2 were drawn from the preliminary test on the subjects who were expected to be among the top finishers in these races. VO2 during these races was indirectly estimated and showed a fairly low value (35.0 +/- 3.8 ml/kg/min in the full race, 32.7 +/- 6.3 ml/kg/min in the half race respectively) in comparison with able-bodied elite runners. However, the paraplegic participants had extremely high HR (171.6 +/- 20.5 beats/min, 168.1 +/- 9.8) continuously throughout the race. Though the ratio of active muscle mass of arms to legs in paraplegic athletes may approximate to near equal, paraplegic arms seem to exert physiologically and mechanically less efficient power. There were no significant differences in physical fitness between the full and the half marathon elite finishers. The cardiovascular function of paraplegic athletes may well be ranked among those of able-bodied athletes in their fitness. Full wheelchair marathon seems to be safe if it is held in an appropriate environment.

Long-term prognosis of behavior therapy in practice

A prognosis study was carried out on 30 cases of patients treated with behavior therapy. The treatments, which took more than three years before the study, averaged four years and eight months. The results are as follows: (1) The improvement achieved by therapy was maintained or further improved in 29 cases during the post-therapeutic period of more than three years. (2) The prognosis largely depended on the grade of improvement at the end of therapy. A complete disappearance of symptoms at the end of therapy did not necessarily mean that it was a fair prognosis. (3) There was no relation between the prognosis and the length of history of illness or the situation of therapy terminated. (4) The impression is that long-term prognoses are different depending on the main symptoms.

A case of hypogonadotropic eunuchoidism associated with familiar periodic paralysis--induction of paralytic attacks by testosterone administration

A case report was made of a 24-year-old man suffering from hypogonadotropic eunuchoidism associated with a hypokalemic type of familiar periodic paralysis. The attacks were observed only during the period of continual administration of the oil solution of 115.7 mg of testosterone enanthate and 20.0 mg of testosterone propionate, intramuscularly as a depot. From the findings on this patient, it was concluded that testosterone might possibly play a role in the occurrence of attacks in the case of periodic paralysis.