Kishiwada Tokushukai Hospital

Abstract Background The progression rate of aortic stenosis (AS) varies among individuals, and myocardial fibrosis—detectable as late gadolinium enhancement (LGE) on cardiac MRI—may reflect a more advanced disease phenotype. Prior studies have suggested that rapid AS progression is associated with worse clinical outcomes and increased mortality, but the mechanisms driving this acceleration remain incompletely understood. This study aimed to evaluate the association between LGE positivity and the hemodynamic progression of AS. Methods We retrospectively analyzed 61 patients (mean age: 81.9 years; 43 females) with severe AS who underwent contrast-enhanced cardiac MRI prior to transcatheter aortic valve implantation (TAVI). Patients were stratified by the presence or absence of myocardial LGE. The progression rate of AS was defined as the annualized change in aortic valve area (AVA, cm²/year) based on echocardiographic measurements taken over a mean follow-up duration of 28.5 months. Differences between groups were assessed using the Mann-Whitney U test. Results Among 61 patients, 14 (23%) were LGE-positive. The LGE-positive group showed a significantly faster AVA progression rate than the LGE-negative group (mean 0.165 vs. 0.062 cm²/year; p = 0.0029). Boxplot analysis confirmed a distinct separation between the groups. Conclusion LGE positivity on cardiac MRI is associated with a significantly accelerated decline in AVA among patients with aortic stenosis. Myocardial fibrosis may serve as an imaging biomarker for identifying individuals at risk of rapid disease progression.Accelerated Progression of AS and LGE

We report a rare case of myxofibrosarcoma characterized by extremely low internal echoes on ultrasonography, a feature that may serve as an important diagnostic clue. The patient was a 54-year-old woman with a medical history of treatment for primary breast cancer as well as axillary recurrence treatment. After a prolonged disease-free interval of 15 years, the patient detected an ipsilateral axillary mass and was referred to our hospital. Ultrasound revealed a well-circumscribed axillary mass, measuring 21 mm, with extremely low internal echoes. MRI of the axillary mass showed faintly high signals on fat-suppressed T1-weighted images, predominantly high signals on T2-weighted images, and persistent enhancement accompanied by small non-enhanced areas on dynamic studies. Positron emission tomography (PET) showed a maximal standardized uptake value (SUVmax) of 3.1. With a working diagnosis of either axillary re-recurrence or a form of axillary sarcoma, we successfully resected the axillary mass for both diagnostic confirmation and potential curative intent. Postoperative pathological evaluation demonstrated atypical stellate cells with abundant chromatin growing in sparse and focally dense patterns against a mucus-rich background. Immunostaining showed AE1/AE3 negativity and a Ki-67 labeling index of 40%, leading to a final diagnosis of myxofibrosarcoma. Given the patient's preferences and prior exposure to chemotherapy and radiotherapy for breast cancer, she did not receive any adjuvant therapy and has been followed without recurrence on an outpatient basis for 11 months. Diagnostic physicians should be aware that myxofibrosarcomas may exhibit extremely low internal echoes, weak high signals on fat-suppressed T1-weighted images, and low SUVmax values on PET, findings that are attributable to the mucus-rich background.

Breast hamartomas are benign disorders and are generally composed of breast-constituting pathological components, mainly fat components. A 68-year-old woman was found to have a left breast mass on computed tomography (CT) for coronary artery evaluation due to suspected angina pectoris. Mammography showed a well-defined oval mass, 2.7 cm in size, without obvious fat findings in the upper and outer quadrant of her left breast. Ultrasound showed a well-circumscribed mass with predominant low internal echoes, high internal echoes in very small areas, weakly enhanced posterior echoes, and no blood flow into and around the mass. Magnetic resonance imaging (MRI) of the breast mass showed low signals on T1-weighted images, predominant low signals on fat-suppressed T2-weighted images, and no enhancement through early-to-late-phase images on dynamic studies. The patient, therefore, underwent a core needle biopsy, which unfortunately only showed abundant fibrous components and no malignant cells, leading to no definitive pathological diagnosis. We, therefore, treated the breast mass with a lumpectomy to get both a pathological diagnosis and a cure of the presumed benign breast mass. The bisected mass had whitish cut surfaces except for the core needle biopsy-induced hemorrhage areas. Postoperative pathological study showed predominant fibrous components, a small amount of adipocytes, and sparse mammary duct-lobular structures in the fibrous components, leading to the diagnosis of fibrous breast hamartoma. The patient recovered uneventfully and is scheduled to receive annual mammography follow-ups. Diagnostic physicians should note that breast hamartomas can have predominant fibrous components.

A 78-year-old man was referred to our institution with bloody stools. Colonoscopy revealed advanced rectal cancer with stenosis at the lower rectum(anal verge 4-12 cm). Biopsy findings revealed highly differentiated adenocarcinoma. Magnetic resonance imaging(MRI)/computed tomography(CT)/positron emission tomography(PET)showed the tumor on the rectal wall, mesenteric lymph nodes, and an enlarged left lateral lymph nod(e No. 283), but no metastasis was detected. The patient was diagnosed with rectal cancer(cT4aN3M0, cStgae Ⅲc)and received neoadjuvant chemoradiotherapy(CRT) (50.4 Gy irradiation of the primary tumor and small pelvis, including the lateral lymph nodes, and oral capecitabine). After CRT, the diagnosis was revised to ycT2N3M0, ycStage Ⅲb. He subsequently underwent robot-assisted abdominoperineal resection and D3+ltLD2 dissection. Lymph node metastasis was detected in No. 283-lt and No. 241, and the pathological diagnosis was ypT2N3M0, ypStage Ⅲb. Histological evaluation of response to treatment was Grade 2. He showed a favorable postoperative course and was discharged on postoperative day 18. He received 8 courses of adjuvant chemotherapy with CAPOX from postoperative day 32 and is alive with recurrence-free 9 months after surgery. This case suggests that CRT is a viable option for treating locally advanced rectal cancer.

Literature on the effects of renal failure on breast imaging in breast cancer patients on dialysis is scarce. A 73-year-old woman on dialysis noticed a mass in her left breast. In the left breast, which consisted entirely of fat tissue, mammography revealed two spiculated masses. Ultrasound also showed two irregular masses with internal low echoes, slightly attenuated posterior echoes, obscured margins, high depth-to-width ratios, no halos, and widespread peritumoral high echoes. In addition to axillary lymphadenopathy, MRI of the masses showed low signals on T1-weighted images and weakly high signals on fat-suppressed T2-weighted images. Core needle biopsy of the mass pathologically revealed atypical cells growing in trabecular and tubular patterns, with interstitial connective tissue proliferation and fat invasion, leading to a diagnosis of invasive ductal carcinoma. Due to impaired renal function, the patient underwent primary surgery, including a partial mastectomy and axillary lymph node dissection. Postoperative pathological examination showed scirrhous-type invasive ductal carcinomas infiltrating the surrounding fat tissue, nine metastatic lymph nodes, and abundant fat tissue with very scant mammary gland around the tumors. The patient had higher-than-usual postoperative drainage volumes, which varied from day to day, presumably due to the effects of dialysis. Despite a large 100 mL drainage volume on the fifth postoperative day, the patient was discharged on day six per her preference. Diagnostic physicians should note that breast cancer patients on dialysis can present with atypical breast imaging compared with patients without renal failure and should be treated with optimal surgical procedures based on thorough image evaluation.

It is well known that breast squamous cell carcinomas (SCCs) have highly cystic components. It, however, is not yet known whether the location of cystic areas contributes to the diagnosis of breast SCCs. A 62-year-old woman with a right breast mass was referred to our hospital. Mammography showed an oval mass just under the right nipple and distortion of the adjacent mammary gland with pleomorphic calcifications. Ultrasound showed a subnipple large oval cystic lesion with solid parts, microcalcifications, and an adjacent polygonal mass, both with a high depth/width ratio and internal punctuate high echoes. Magnetic resonance imaging (MRI) of the masses clarified the connection between the two masses at their deep borders and showed low signals on T1-weighted images and high and slightly high signals at the cyst and mass parts on T2-weighted images, respectively. Core needle biopsy of the solid mass pathologically showed atypical cells growing in tubular and cord-like fashions with connective tissue proliferation, leading to the diagnosis of scirrhous type invasive ductal carcinoma (IDC). The patient, therefore, underwent mastectomy and sentinel node biopsy, showing pathological node negativity on frozen section. Postoperative pathological study showed that the scirrhous type IDC cells were connected to pleomorphic spindle cells and further tied up to SCC cells with central cystic structures. In addition to estrogen and progesterone receptor negativity, immunostaining showed human epidermal growth factor receptor type 2 (HER2) negativity in the IDC components and equivocality in the SCC components. Thereafter, fluorescence in situ hybridization clarified no amplification of human epidermal growth factor receptor type 2 (HER2) genes in the SCC components. The patient recovered uneventfully, received dose-dense chemotherapy, and is scheduled for long-term follow-up on an outpatient basis. Diagnostic physicians should consider mixed-type breast SCCs when breast tumors have cystic structures just under the nipple and an adjacent solid mass.

We aimed to assess the association between base excess (BE) levels and neurological outcomes in patients with out-of-hospital cardiac arrest (OHCA), accounting for the time from cardiac arrest onset to blood sampling. This multicentre study was conducted in Osaka, Japan, and enrolled consecutive patients with OHCA who were transported to 16 medical centres between 2012 and 2021. Patients aged≥18years with witnessed OHCA and available BE measurements upon hospital arrival were examined. Patients were stratified into Q1 (BE≤-21.1mmol/L), Q2 (-21.1<BE≤-15.7mmol/L), Q3 (-15.7<BE≤-10.4mmol/L) and Q4 (BE>-10.4mmol/L) groups based on BE levels. The primary outcome was 1-month survival with a favourable neurological outcome (Cerebral Performance Category scale score: 1 or 2). Among the 23,854 patients with OHCA, only 6066 were included in the final analysis. Approximately 3.2%, 4.7%, 9.9% and 23.7% of patients in the Q1, Q2, Q3 and Q4 groups, respectively, achieved favourable neurological outcomes at 1month. Compared with Q4, the adjusted odds ratio for a favourable neurological outcome in Q1 was 0.13. Subgroup analysis revealed a significant interaction between prehospital return of spontaneous circulation (ROSC) and neurological outcomes; neurological outcomes worsened as BE decreased in patients with ROSC but not in those without ROSC. Lower BE levels upon hospital arrival are associated with poorer neurological outcomes and may serve as prognostic indicators in patients with OHCA who achieved prehospital ROSC.