A Case of Myocardial Infarction with Non-obstructive Coronary Arteries Complicated by a Ventricular Septal Rupture: The Challenge of Achieving Hemodynamic Stability Using Impella Devices

The prognosis of myocardial infarction with non-obstructive coronary arteries (MINOCA) is reported to be as worse as myocardial infarction with obstructive coronary arteries. However, its mechanical complications are still poorly understood. A 71-year-old woman developed MINOCA after ascending aortic replacement surgery. During treatment, the patient experienced cardiogenic shock due to a ventricular septal rupture (VSR). The introduction of Impella devices reduced the left-to-right shunt and improved the patient's hemodynamics. Finally, a scheduled surgical repair was performed under stable conditions. In this report, we focused on the pathophysiology of MINOCA-related VSR and discussed the effectiveness of Impella devices as a bridge to surgical repair and circulatory backup during the perioperative period.

P-027 which is the best method of testicular sperm retrieval for NOA? an answer from 1071 TESE cases in my clinics over 25 years

Study question

Which improves sperm recovery rate (SRR) for men with non-obstructive azoospermia (NOA), microdissection TESE (m-TESE) or conventional TESE (c-TESE)?

Summary answer

SRR of c-TESE vs. m-TESE for NOA was not significant. We need to develop a safer, less-invasive technique with fewer complications and higher SRR.

What is known already

m-TESE has been performed for men with NOA since Schlegel P’s report (Hum Reprod, 1999). Seminiferous tubules containing many developing germ cells were likely to be larger and more opaque and the ability to find spermatozoa increased from 45% (10/22) to 63% (17/27) after introduction of the microdissection technique. However, Jarvis S et al. (Turek PG group, 2019) reported that at least one site revealed mature sperm in 24 (29.3%) of 82 men with prior failed micro TESE procedures, and sperm were more likely to be found in the testis periphery rather than centrally with FNA mapping.

Study design, size, duration

TESE was performed in 1071 azoospermic patients in my clinics; c-TESE was performed for all azoospermic patients between 1996 and 2005 in Sendai; c-TESE for OA and m-TESE for NOA was performed from 2006 in Sendai, and from 2012 in Takanawa. The patients were divided into four groups; 1) FSH≦9.2mIU/ml, Testicular volume(TV)≧15/ml (OA), 2) FSH≦9.2mIU/ml, TV < 15ml, 3) FSH>9.2mIU/ml, TV≧15ml, 4) FSH>9.2mIU/ml, TV < 15ml (NOA).

Participants/materials, setting, methods

c-TESE was performed in 178 azoospermic men (50, 12, 7, 109, respectively) in 1996-2005. c-TESE was performed in 181 patients (131, 26, 15, 9, respectively) and m-TESE was performed in 541 patients (56, 33, 35, 416, respectively) in 2006 -2020. SRR, pregnancy rate (PR), and birth rate (BR) in 1996-2005 were compared with those in 2006-2020.

Main results and the role of chance

Statistical analysis was performed by chi-square analysis. SRR in c-TESE was 96.0% (48/50) in group 1 (OA) vs. 36.7% (40/109) in group 4 (NOA) in Sendai between 1996 and 2005 (P < 0.001).

SRR of c-TESE was 36.7% (40/109) in group 4 (NOA, in Sendai, 1996-2006), whereas SRR of m-TESE was 31.3% (130/416) in group 4 (NOA, in Sendai and Takanawa, 2006-2020). There was no significant difference (np).

Total SRR of conventional TESE for all azoospermic patients between 1996 and 2005 was 54.9% (96/175), whereas total SRR of c-TESE for OA and m-TESE for NOA between 2006 and 2020 was 51.7% (373/721). NOA rate 4) of azoospermic patients of 1996-2005 and that of 2006-2020 was 61.2% (109/178) and 58.9% (425/721), respectively. There was no significant difference (np).

PR was 37.4% (61/163) and BR was 31.9% (52/263) in c-TESE (1996-2005), PR was 39.6% (388/980), and BR was 27.6% (270//980) in both c-TESE and m-TESE (2006–2020). There was a significant difference in birth rate (P < 0.05).

In conclusion, SRR, PR, and BR were not improved even after m-TESE was performed. Considering the fact that m-TESE cannot find sperm thoroughly, adopting other techniques such as sperm fine-needle aspiration may be required.

Limitations, reasons for caution

Not applicable.

Wider implications of the findings

We could not show the effectiveness of m-TESE compared with c-TESE. However, the total volume of seminiferous tubules collected by c-TESE was the higher. The new one-step fine-needle aspiration has the potential to achieve higher sperm yield with fewer complications. Further advanced technology will hopefully improve the SRR in NOA.

Trial registration number

none

P-763 effect of duration of cryo-storage of vitrified embryos on obstetric and perinatal outcomes

Study question

Does the duration of cryo-storage of vitrified embryos affect obstetric and perinatal outcomes?

Summary answer

Duration of cryo-storage with an open vitrification system did not affect obstetric and perinatal outcomes.

What is known already

Frozen-thawed blastocyst transfer has been performed widely with improvement of embryo culture conditions and cryopreservation techniques. Although blastocyst vitrification has become an essential method to improve clinical outcomes of IVF, there has been little study into the relationship between a long duration of cryo-storage in liquid nitrogen and obstetric and perinatal outcomes.

Study design, size, duration

This retrospective study was conducted at Kyono ART Clinic from January 2007 to December 2020. This study includes a total of 1053 singletons derived from 2461 frozen-thawed blastocyst transfers in 2461 patients. Steel’s multiple comparison test was performed for clinical and perinatal outcomes with cases of cryo-storage of less than 3 months as a control group. P < 0.05 was considered statistically significant.

Participants/materials, setting, methods

The subjects are patients who underwent their first single frozen-thawed blastocyst transfer (FBT) with an open vitrification system. Females >40 years old at cryopreservation and those who underwent preimplantation genetic testing were excluded. According to cryo-storage duration, patients were grouped as follows: group A, 0-3 months (1255 cycles); group B, 3-6 months (1008 cycles); group C, 6-12 months (162 cycles), group D, 12-24 months (36 cycles).

Main results and the role of chance

Both the mean maternal age at blastocyst cryopreservation (A: 33.7±3.6, B: 34.1±3.5, C: 34.8±3.2, D: 35.1±3.3) and the mean maternal age at FBT (A: 33.8±3.6, B: 34.4±3.5, C: 35.5±3.1, D: 36.4±3.3) in groups B, C, and D were significantly higher compared to those in group A.. There was no significant difference in the survival rate after blastocyst thawing [A: 97.4% (1256/1290), B: 98.3% (1010/1027), C: 99.4% (163/164), D: 97.2% (35/36)]. The pregnancy rate in group C was significantly lower compared to group A [A: 60.0% (752/1254), B: 61.4% (619/1008), C: 48.1% (78/162), D: 63.9% (23/36)] The gestational age of group C was significantly lower compared to group A (A: 39.5±1.8, B: 39.4±1.8, C: 38.4±3.1, D: 39.8±1.6), but there were no significant differences in live birth weight or height. There were no significant differences in congenital abnormality rate [A: 1.3% (7/541), B: 2.5% (11/440), C: 1.8% (1/56), D: 0.0% (0/16)], placental abnormalities such as placenta previa [A: 1.3% (7/541), B: 1.6% (7/440), C: 1.8% (1/56), D: 0.0% (0/16)], perinatal abnormalities such as hypertensive disorders of pregnancy or gestational diabetes [A: 6.1% (33/541), B: 8.6% (38/440), C: 1.8% (1/56), D: 6.3% (1/16)] among the four groups.

Limitations, reasons for caution

We could not provide sufficient information on confounding factors such as smoking habits, and the sample size was too small for multivariate analysis. The safety of longer storage will need to be verified as this has not been clarified in this study.

Wider implications of the findings

The pregnancy rate in group C was significantly lower than that in group A, but the effect was small: 0.065, power of 0.78. Our data suggested that the duration of cryopreservation with an open vitrification system in liquid nitrogen did not affect obstetric or perinatal outcomes.

Trial registration number

not applicable

Synchronous chondroblastomas in the knee joint: A case report

Introduction

A chondroblastoma (CB) is a benign chondroid bone tumor that typically arises in growing children. It frequently occurs in the proximal tibia, femur, and humerus. However, the biological behavior of CBs remains unclear because of their rarity. Herein, we report a rare case of synchronous CBs arising on the bilateral sides of the knee joint, suggesting the etiology of chronological tumorigenesis.

Presentation of case

An 18-year-old Japanese man with a complaint of right knee pain was referred to our hospital. Radiography revealed an expanding osteolytic lesion in the right proximal tibia. A small lesion in the distal femur was detected on magnetic resonance imaging. A biopsy of the tibial lesion revealed a pathological diagnosis of CB. Two-stage curettages were performed in the tibia and femur, and the pathological diagnosis of the femoral lesion was CB. No recurrence had occurred for 5 years in the tibia and a year in the femur with stable ambulation and a full range of motion.

Discussion

In our case, the CBs in the proximal tibia and distal femur co-occurred, suggesting that the seed of the CB emerged before the separation of these two bones. The key point to the generation of CB is that its origin could be initiated during mesenchymal condensation before the separation and differentiation of bones as if continental drifts.

Conclusion

We experienced a rare and suggestive case in CB etiology. An experience of synchronous CBs in the consecutive bones was suggestive of CB etiology and careful management.

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Report of a rare type of chondroblastomas in two consecutive long bones.

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Tumorigenesis of chondroblastoma is suggested at mesenchymal condensation.

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Chondroblastoma separation to different bones, resembling plate tectonics.

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Multiple chondroblastomas should be carefully treated or monitored.

Hemoptysis after coil embolization for pulmonary arteriovenous malformation: Histopathological confirmation of bronchial epithelium extension

Coil embolization is widely performed for pulmonary arteriovenous malformations (PAVMs). We describe herein 2 cases of hemoptysis during long-term follow-up after coil embolization for PAVMs. For both cases, lobectomy was performed and histopathological examinations revealed chronic inflammation and bronchial epithelium extension into the sac of the PAVM. In addition, we performed a systematic review of previous reports of hemoptysis after embolization for PAVMs.

Anticoagulant Use as an Independent Risk Factor and Higher In-Hospital Mortality in Patients Showing Alveolar Hemorrhage in Diffuse Lung Disease

Background and objectives: Bronchoalveolar lavage (BAL) is commonly performed to evaluate diffuse lung disease and occasionally to identify alveolar hemorrhage. However, the clinical impact of alveolar hemorrhage and its risk factors in patients with diffuse lung disease have not been clarified. Materials and Methods: We retrospectively analyzed the medical records of all patients who underwent BAL to evaluate diffuse lung disease from January 2017 to December 2020. Alveolar hemorrhage was defined as progressive hemorrhagic BAL fluid or the presence of ≥20% hemosiderin-laden macrophages in the BAL fluid. Logistic regression analysis was performed to assess the association between alveolar hemorrhage and other factors. Results: Sixty subjects were enrolled in this study. Alveolar hemorrhage was observed in 19 subjects (31.7%) with idiopathic interstitial pneumonia, acute respiratory distress syndrome, interstitial pneumonia with autoimmune features, drug-induced lung injury, eosinophilic pneumonia, adenocarcinoma, and systemic lupus erythematosus. The use of anticoagulants was a significant risk factor for alveolar hemorrhage (odds ratio 7.57, p = 0.049). Patients with alveolar hemorrhage required intubated mechanical ventilation more frequently (63.2% vs. 24.4%, p = 0.005) and had higher in-hospital mortality rates (26.3% vs. 4.9%, p = 0.028) than those without alveolar hemorrhage. Conclusions: Alveolar hemorrhage was observed in various etiologies. The use of anticoagulants was a significant risk factor for alveolar hemorrhage. Patients with alveolar hemorrhage showed more severe respiratory failure and had higher in-hospital mortality than those without alveolar hemorrhage.

Prognostic impact of heart mate risk score among elderly heart failure patients with non-responder for cardiac resynchronization therapy

Background

For patients with severe heart failure (HF) who are not eligible for transplantation, there is destination therapy (DT) that uses a continuous flow left ventricular assist device (LVAD). Implantation of LVAD improves HF and can be expected to improve the prognosis of life. Elderly refractory HF patients with non-responders for cardiac resynchronization therapy (CRT) may benefit from LVAD as DT. In considering indications of LVAD as DT for the elderly in Japan, conditions such as a low risk of Heart Mate Risk Score (HMRS) have been raised. HMRS has been shown to correlate with mortality in the cohort of LVAD patients enrolled in the Heartmate II trials.

Purpose

Because elderly CRT non-responder refractory HF patients are not indicated for transplantation and may benefit from LVAD as DT in Japan, we aimed to investigate the HMRS and prognosis among elderly CRT non-responders.

Methods

Of 467 patients underwent CRT implantation between 2000 and 2015, 157 were aged 65–75 years old. Of which 59 patients who could be determined to be non-responders based on echocardiographic data were included in this study. The primary endpoint was all-cause mortality, the secondary was readmission for HF and appropriate implantable cardioverter defibrillator (ICD) therapy.

Results

The patients' mean age was 68 years, males were 71%. The mean serum creatinine value was 1.1 mg/dl, albumin was 3.8 mg/dl, and BNP was 383 pg/ml. The mean left ventricular ejection fraction (LVEF) was 26%. The subjects were divided into 3 groups according to HMRS. The average of HMRS was 2.2, the low-risk group included 17 (29%) patients, the medium was 22 (37%), and the high was 20 (34%). There was no significant difference in age, LVEF, BNP, and NYHA functional classification at the time of CRT implantation between three groups. In the low-risk group, creatinine and INR were significantly lower, and albumin was significantly higher compared to the high-risk group. BNP tended to be lower in the low-risk group, but there was no significant difference. The mortality rate by HMRS was 12% in the low-risk group, 36% in the medium-risk group, and 50% in the high-risk group. On the Kaplan-Meier analysis, the low-risk group had a significantly lower mortality rate than the high-risk group (Figure). Furthermore, focusing on HF readmission, the rate of readmission was 59% in the low-risk group, 86% in the medium -risk group, and 65% in the high-risk group, and there was no significant difference between three groups. There was also no significant difference in appropriate ICD therapy between three groups.

Conclusion

Approximately 30% of elderly non-responders of CRT are in the low-risk group by HMRS and their mortality was lower than that of the other two groups. These elderly CRT non-responder patients might be considered a candidate for DT in Japan.

Funding Acknowledgement

Type of funding sources: None.

Examination on the necessity of pericardial fat tissue resection in extended thymectomy for myasthenia gravis

Background

Extended thymectomy with pericardial fat tissue resection has been a mainstay in the treatment for myasthenia gravies (MG), but few studies have examined the necessity of the pericardial fat tissue resection in extended thymectomy.

Methods

We pathologically examined the distribution of germinal centers in the resected thymus including the thymus-surrounding fat tissue. Patients who underwent extended thymectomy using subxiphoid thoracoscopy for generalized MG or thymoma with anti-acetylcholine receptor antibody (anti-AchR Ab) positivity from March 2015 to January 2021 were included in this study.

Results

A total of 20 patients underwent extended thymectomy (generalized nonthymomatous MG, n=5; generalized MG with thymoma, n=6; thymoma with anti-AchR Ab positivity, n=9). The resected specimens were divided to 6 parts and were pathologically examined to investigate the distribution of the geminal centers in all lesions. The number and distribution of germinal centers in the thymus varied depending on the patient, and no germinal centers were identified in the right or left pericardial fat tissues.

Conclusions

It is necessary to resect the pericardial fat tissue in patients whose preoperative images show the presence of pericardial fat tissue hyperplasia or ectopic thymoma. However, extensive pericardial fat tissue resection might not be necessary for all MG patients who undergo extended thymectomy with opening of the bilateral pleural by video-assisted or robot-assisted thoracoscopic surgery (RATS) via a subxiphoid approach.

[Cystic fibrosis with focal biliary cirrhosis and portal hypertension in Japan: a case report]

A 9-year-old Japanese girl was found to have persistently elevated hepatic enzymes, chronic bronchitis, chronic sinusitis, and poor weight gain beginning at 5 months of age. Chest computed tomography (CT) revealed diffuse bronchial wall thickening and peripheral bronchiectasis. Abdominal CT showed pancreatic atrophy, liver cirrhosis, a dilated splenic vein, and splenomegaly. Her sweat chloride concentration was 117mmol/l (normal, <60mmol/l). CFTR gene analysis revealed the presence of the Y517H variant on one allele and the 1540del10 variant one the other allele. These findings established a definitive diagnosis of cystic fibrosis (CF). While CF is the most common autosomal recessive genetic disorder among Europeans, it is quite rare in Southeast Asia including Japan. It is important that CF be considered in the work-up of children with chronic hepatic and respiratory disorders even if it is uncommon among children of a similar background.

Myelolipoma mimicking osteosarcoma in the distal femur

Introduction and importance

Periosteal reactions indicate malignant bone tumors, including osteosarcoma; establishing an accurate diagnosis is key to determining the most appropriate treatment strategy. We describe a rare case of myelolipoma in the distal femur metaphysis with massive extraskeletal lesions and periosteal reactions.

Case presentation

A 25-year-old woman was referred to our hospital to treat a gradually expanding mass around her knee that grew to the size of a baby's head. She had a history of hydrocephalus caused by congenital cytomegalovirus infection and was bedridden for life. Radiography showed a prominent osteoblastic rim and osteolytic lesion with a moth-eaten appearance. Osteosarcoma was suspected due to excessive extraskeletal invasion and periosteal reactions. T1- and T2-weighted magnetic resonance images showed a high-signal-intensity homologous lesion. Biopsy specimens contained adipose and hematopoietic tissues. A myelolipoma was diagnosed. Due to her fragility, surgical intervention was suspended. Two years after diagnosis, the tumor size did not change.

Clinical discussion

Myelolipomas are benign tumors that typically arise from the adrenal gland and rarely develop in the extremities. This type of tumor typically does not cause any tumor-related symptoms or endocrine disturbances and has been reported as a type of incidentaloma. To effectively manage myelolipoma patients, differential diagnosis of tumors mimicking malignant bone tumors is important.

Conclusion

We successfully managed a destructive ectopic myelolipoma in the distal femoral metaphysis, with massive extraskeletal lesions and periosteal reactions. Clinicians should appropriately differentiate myelolipoma from tumors mimicking malignant bone tumors.

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Report discusses a rare case of ectopic extra-adrenal myelolipoma in the femur.

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The extraskeletal invasion and periosteal reactions resemble malignant bone tumors.

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Clinicians should properly differentiate it from mimics of malignant bone tumors.

Type A thymoma with simultaneous solitary intrapulmonary metastasis: A case report

A 79‐year‐old woman was referred to our facility because of an abnormal chest shadow. Chest computed tomography (CT) showed a solitary right middle lung nodule with a maximum diameter of 3 mm and anterior mediastinal nodule with a maximum diameter of 21 mm. The lung nodule was suspected of being a primary lung cancer rather than a metastatic tumor because there were no primary malignant tumors, apart from an anterior mediastinal tumor visible on diagnostic imaging, including F¹⁸ fluorodeoxyglucose‐positron emission tomography, and a solitary lung nodule. Partial lung resection by video‐assisted thoracoscopic surgery (VATS) was performed, and the intraoperative frozen section of the tumor tissue resulted in a diagnosis of carcinoid tumor. As a result, right middle lobectomy by VATS was performed. The final histological diagnosis of the permanent specimen was intrapulmonary type A thymoma. VATS thymectomy was performed three months later. The histological diagnosis was type A thymoma with intrapulmonary metastasis (Masaoka stage IVb). Additional therapy was not performed because complete resection was achieved. Follow‐up CT was performed once every six months after the operation. The patient has been followed up for one year without any further recurrence.

Ependymoma of the broad ligament mimicking an ovarian surface epithelial tumor

We report a case of ependymoma of the broad ligament occurring in a 21-year-old woman. CT and MRI findings showed a 40-mm-diameter, well-demarcated cystic mass with a lobulated solid component in the right pelvis. The solid component showed heterogeneous intermediate signal intensity on T2-weighted image and prolonged mild contrast enhancement. The tumor was resected and confirmed as ependymoma based on the histologic findings along with its immunohistochemical profile. To our knowledge, this is the first report of an adnexal ependymoma describing the precise radiological characteristics that resembled those of borderline or malignant epithelial ovarian tumors.

A Case of Alveolar Haemorrhage Induced by Iodinated Contrast Medium Use

An 81-year-old man complaining of exertional dyspnoea underwent coronary angiography using an iodinated contrast medium. After angiography, the patient required systemic corticosteroid therapy because of respiratory failure due to alveolar haemorrhage. Percutaneous coronary intervention was performed 29 days after angiography using the same contrast medium. After the intervention, the patient required intubated mechanical ventilation and renal replacement therapy. Bronchoalveolar lavage was bloody with many haemosiderin-filled macrophages. Systemic corticosteroid therapy again improved his clinical condition. Iodinated contrast media may cause alveolar haemorrhage and re-exposure to contrast media may induce a more severe adverse reaction.

LEARNING POINTS

Iodinated contrast media may cause alveolar haemorrhage.Re-exposure to iodinated contrast media may induce a more severe adverse reaction.

Potential complications in patients undergoing an ethanol injection into the vein of Marshall

BACKGROUND

Ethanol injections into the vein of Marshall (VOM) (EIM) are considered to be a good therapeutic option for atrial tachyarrhythmias, however, the safety remains to be determined. To elucidate what would affect the safety and potential complications of an EIM, we investigated the anatomical features of the VOM and patient background.

METHODS

We performed the EIM before the conventional pulmonary vein isolation for drug-resistant atrial fibrillation in 88 patients and evaluated the anatomical features of the VOM and their background.

RESULTS

All procedures were completed, however, other than myocardial staining, trivial contrast medium leaked out of the VOM into the pericardial space, that is, extravasation of contrast medium with capillary rupture, during the EIM in 20 patients (22.7%) regardless of the features of the VOM. No pericardial effusions requiring further intervention developed after the extravasation, which resolved by the next day on echocardiography in 18 of those patients. However, two patients who had extravasation other than during the initial contrast injection required additional therapeutic intervention for nonnegligible pericardial effusions. Their body weights were significantly lower and the latter two patients were also small lean women with heart failure and a preserved ejection fraction.

CONCLUSIONS

The physical constitution, regardless of the characteristics of the VOM, could be strongly associated with adverse events during the EIM. We must take extreme care in smaller patients with poor compliant hearts during the EIM.

P3359Myocardial flow reserve using 13N ammonia PET for detection of cardiac allograft vasculopathy in heart transplant patients

Purpose

Risk stratification and early detection of cardiac allograft vasculopathy (CAV) are essential in heart transplantation patients. CAV is associated with poor outcome in the chronic phase after heart transplantation. CAV presents a diffuse vascular involvement and has been difficult to noninvasively diagnose by the lack of a sensitive method to detect developing vascular pathology in the allograft. The present study investigates the ability of 13N-ammonia PET for detection of CAV in heart transplant patients.

Methods

Data of adenosine-stress 13N-ammonia PET imaging for thirty-one patients (mean age, 39 years-old) after 11 + 7 years from transplant was analyzed. Five patients had undergone percutaneous coronary intervention (PCI), and the remaining 26 patients had no history of definite myocardial ischemia. Myocardial flow was generated from the time activity curve of left ventricle input and myocardial uptake using 3-compartment model and the first 2 minutes' dataset of list-mode acquisition. Global - myocardial flow reserve (MFR) was calculated by stress to rest flow ratio. Patient with global-MFR <2.0 was defined as significant decrease. Summed difference score (SDS) was used as an estimate for the extent of ischemia, and the patient showing SDS >2 was identified as those having significant ischemia.

Results

The mean Global-MFR of our subjects were 2.3 (1.2 to 3.9). MFR using 13N-ammonia PET significantly decreases in one third of heart transplant patients in chronic stage. Eleven patients with Global-MFR <2.0 (35%) were observed, and eight of them had no history of clinical myocardial ischemia. The proportion of patients with a history of PCI is 18% in patients with Global-MFR <2.0 (vs 5%, p=0.210). Moreover, there were eight patients with SDS >2 (26%) including three patients having a history of PCI. The proportion of patients with a history of PCI tends to be high with SDS >2 (38% vs 9%, p=0.056).

Conclusion

This modality using 13N ammonia PET is useful for easily detection of CAV before manifestation of symptomatic myocardial ischemia in heart transplant patients.

Testicular teratoma demanded in-depth pathological exploration to rule out malignancy: A pediatric case report

Introduction

Prepubertal testicular tumors can be both benign and malignant. Although most testicular teratomas are benign, some immature cases include malignant transformation or the mixed type with yolk sac tumor and, occasionally, it is challenging to rule out malignancy.

Case presentation

We present a case of immature testicular teratoma in a 7-month-old infant, whose alpha-fetoprotein level was sequentially elevated following orchidectomy. Since malignancy could not be ruled out, we performed whole body imaging and in-depth pathological exploration. GLYPICAN3, OCT3/4, and SOX2 staining revealed no evidence of malignancy. The patient was finally diagnosed with benign immature teratoma, and has been free from recurrence for 3 years.

Conclusion

Here, we describe the case report, as well as all the comprehensive diagnostic tests that we performed in order to rule out the malignant component.

Blastomatoid pulmonary carcinosarcoma: A rare case report and review of the literature

A 65‐year‐old never‐smoking woman presented to a local hospital, because an abnormal shadow was detected at the right lower lung field by annual chest X‐ray. Computed tomography (CT) revealed a 5‐cm tumor in segment 6 of her right lung and an enlarged subcarinal lymph node, suggesting metastasis. The lung tumor was diagnosed as adenocarcinoma by a CT‐guided percutaneous needle biopsy. She was referred to our hospital and underwent right lower lobectomy with lymph node dissection (ND2a‐2). A histopathological examination of the tumor showed a biphasic proliferation made of carcinomatous and sarcomatous components. The carcinomatous component consisted of glandular structures of atypical cells that possessed chromatin‐rich nuclear and clear cytoplasm, confirming high‐grade fetal adenocarcinoma. The sarcomatous component consisted of immature spindle cells that differentiated into chondrosarcoma. Immunohistochemically, the glandular structures expressed membranous beta‐catenin, and the ultimate diagnosis was blastomatoid variant of pulmonary carcinosarcoma. She received four courses of cisplatin plus vinorelbine as adjuvant chemotherapy and remained alive with neither recurrence nor distant metastasis at two and a half years after the operation. We experienced a rare case of blastomatoid pulmonary carcinoasarcoma.

The inflammatory pseudotumor presenting periodic acid-Schiff-positive inclusions with acute unilateral facial nerve palsy

Although most acute peripheral facial palsies can be attributed to Bell's palsy, other factors, such as infection, trauma, and neoplasm, can cause facial palsy as well. Among these, facial nerve tumors are rare but should be considered in the differential diagnosis of facial palsy. Palsies due to facial nerve tumors usually present with slow onset but occasionally present as acute episodes. In such cases, facial nerve decompression is the treatment of choice to allow the tumor room to grow without compressing the nerve or its blood supply. We describe a case of severe, acute facial palsy presenting with a spindle-shaped bone erosion on the mastoid portion of the facial canal. Although facial neuroma was suspected preoperatively, emergency decompression surgery revealed that an unusual inflammatory pseudotumor was responsible for the finding. Postoperative histological analysis revealed extensive destruction of the nerve fibers, with extensive infiltration of foamy macrophages containing characteristic, diastase-resistant, periodic acid-Schiff (PAS)-positive inclusions, which are hallmark of the uncommon bacterial infections. This was a case of facial palsy with an unusual etiology. The case shows the benefit of decompression surgery not only as treatment for the palsy but also as exploratory surgery in cases of facial nerve tumor.

Ethanol injection into the Marshall vein provoking a pericardial effusion resulting in a fatal complication in a patient with persistent atrial fibrillation

An EIM (ethanol infusion into the vein of Marshall [VOM]) provoked a fatal complication in a chronic hemodialysis patient. Autopsy revealed a lacerated VOM covered with thrombi as the only potential cause. The EIM caused vascular damage and clots resulting in myocardial necrosis and interstitial bleeding around the lacerated VOM.

[Pulmonary Carcinosarcoma Presenting Hemothorax Caused by Pleural Invasion;Report of a Case]

A 71-year-old man presented with hemothorax with cough, sputa and worsening dyspnea. On chest X-ray and computed tomography(CT), a huge tumor in the right upper lobe with hematoma and small amount of gas suggesting hemopneumothorax was revealed. No apparent lymphadenopathy nor intrapulmonary metastases were observed. The tumor showed a little enhancement on the contrastenhanced CT. Then the resction of the tumor was performed, and the pathological evaluation revealed a carcionosarcoma (adenocarcinoma+osteosarcoma) pT3N0 (stage II B) G4 pl2. Sarcomatoid carcinoma such as carcinosarcoma should be considered as a possible cause of hemothorax in making a diagnosis of hemorrhagic hypovascular huge lung tumor.

Mammary analogue secretory carcinoma of salivary glands: a clinicopathologic and molecular study including 2 cases harboring ETV6-X fusion

Mammary analogue secretory carcinoma (MASC) is a recently described low-grade carcinoma with morphologic and genetic similarity, including ETV6-NTRK3 fusion, to secretory carcinoma of the breast. ETV6 is frequently involved in other epithelial and nonepithelial tumors, and many fusion partners of ETV6 have been reported. In the present study, 14 Japanese MASC cases were clinicopathologically and molecularly analyzed. The median age of the patients was 39 years, and the male:female ratio was 6:8. All cases showed histopathologic findings compatible with those previously described for MASC and harbored an ETV6 split as visualized by fluorescence in situ hybridization. Two cases showed thick fibrous septa and invasive features including vascular or perineural tumor involvement, findings that are rare in MASC. In addition, in these 2 cases, non-NTRK3 genes appeared to fuse with ETV6 (ETV6-X fusion). NTRK1 and NTRK2, both members of the NTRK family, were not involved. Of the 14 MASC cases, the ETV6-NTRK3 fusion transcript was positive in 6 cases, and the relative expression level of the ETV6-NTRK3 fusion transcript was variable, ranging from 1 to 5.8. Results of the present study of MASC suggest that (1) ETV6 occasionally fuses with unknown non-NTRK3 genes, (2) ETV6-X cases might have an invasive histology, (3) for molecular diagnosis of MASC, fluorescence in situ hybridization to detect ETV6 splits is the method of choice, and (4) the expression level of the ETV6-NTRK3 fusion transcript is considerably variable. These findings provide a novel insight into the oncogenesis, histopathology, diagnosis, treatment, and prognosis of this newly recognized carcinoma.

Anti-sympathetic action enhances statin's pleiotropic effects: the combined effect of rosuvastatin and atenolol on endothelial function

AIM

Assessment of flow-mediated dilation (FMD) and nitroglycerin-mediated dilation (NMD) in the brachial artery by a new device (UNEXEF18G) has been reported to be excellent for evaluating endothelial function, and sympathetic overdrive can accelerate the atherosclerotic process. The purpose of this study was to investigate and confirm whether anti-sympathetic beta-blocking action can enhance the pleiotropic effects of statins.

METHODS

FMD and NMD were measured using the UNEXEF18G before and after 4-week treatment of rosuvastatin (5 mg/day) with or without atenolol (25 mg/day) in 44 hypercholesterolemic patients (70±8 years old, LDL-C >140 mg/dL) with hypertension. Patients were randomly allocated to two treatment arms: rosuvastatin alone (R-group, N.=22) and rosuvastatin with atenolol (RA-group, N.=22).

RESULTS

Baseline FMD was not different between the two treatment arms, and both groups showed improvement in FMD (R-group, 3.48±1.9% to 4.65±2.41%, P<0.05; RA-group, 3.42±1.48% to 5.46±1.79%, P<0.05), while there were no differences in NMD. The effects on lipid profiles were identical in the two groups. In addition, FMD improvement was greater in the RA-group than in the R-group (Δchange 2.15±1.29% vs. 1.16±1.15%, P<0.05).

CONCLUSION

Beta-blockade enhances the pleiotropic effects of statins on endothelial function. The mechanism should be confirmed by further studies.