Shizuoka Red Cross Hospital

Abstract Background : Invasive lobular carcinoma (ILC) is often difficult to diagnose because of subtle imaging findings and occasional false-negative biopsy results. Case presentation : A woman was initially referred for further evaluation because of marked breast asymmetry detected during screening. At the initial presentation, ultrasonography revealed an indistinct hypoechoic area, and core needle biopsy demonstrated mastopathy. Twelve years after the initial presentation, screening again prompted evaluation, and repeat core needle biopsy also showed mastopathy; therefore, the patient was returned to routine screening. Fourteen years after the initial presentation, follow-up ultrasonography demonstrated an increased depth–width ratio and newly detected internal vascularity. Vacuum-assisted biopsy was subsequently performed, leading to the diagnosis of pleomorphic invasive lobular carcinoma with loss of E-cadherin expression. Conclusion : Longitudinal imaging assessment, including subtle ultrasonographic changes such as depth–width ratio, may facilitate earlier detection of ILC.

A thrombus in the sinus of Valsalva (SOV) with a native aortic valve is a rare aetiology of type 2 myocardial infarction. To the best of our knowledge, no previous report has evaluated blood flow dynamics in the SOV of a patient who experienced an SOV thrombus. A 72-year-old woman presented to our hospital with chest pain. Based on electrocardiogram and echocardiography findings, she was diagnosed with ST-elevation acute coronary syndrome (ACS) due to left main trunk (LMT) occlusion. Emergency coronary angiography revealed embolization in the distal left anterior descending artery. Her symptoms improved after catheter engagement in the LMT. Echocardiography revealed an abnormal mass (20 × 20 mm) in the left coronary cusp, which appeared to intermittently occlude the LMT. Emergency surgical removal revealed that the thrombus was adherent to the aortic wall at the left SOV. Histopathological examination confirmed a fresh red thrombus. The patient was discharged on warfarin 13 days postoperatively. Time-resolved three-dimensional cine phase-contrast magnetic resonance imaging (4D-flow MRI) was performed to assess blood flow. She was subsequently diagnosed with antiphospholipid syndrome. 4D-flow MRI showed reduced blood flow velocity in the left SOV compared with the other sinuses, without evidence of excessive wall shear stress. These findings may represent a 'second hit' of antiphospholipid syndrome. Further investigation is warranted to elucidate the mechanisms underlying SOV thrombosis. It is important to consider SOV thrombus as an aetiology of ACS, even in patients without history of thrombosis or prior aortic valve surgery.

Introduction: The paucity of research concerning the conservative management of spinal cord and cauda equina schwannomas and meningiomas complicates the determination of surgical necessity and its optimal timing. This study aimed to elucidate the clinical and imaging characteristics of schwannomas and meningiomas in the thoracolumbar and lumbar spine that support long-term conservative management strategies.

This retrospective cohort study aimed to emulate the ADVANCE trial population and directly compare the Endurant and Excluder using propensity score matching. Patients were included if endovascular aneurysm repair was performed for abdominal aortic aneurysm using either Endurant or Excluder at 10 hospitals in Japan between January 2012 and July 2022. Cases were selected according to the modified ADVANCE trial inclusion and exclusion criteria. To minimize selection bias and simulate a randomized controlled trial setting, propensity score matching was performed using patient and anatomical characteristics. The primary outcome measure was the proportion of patients with sac regression ≥ 5mm at 1year. The secondary outcome measures were rates of freedom from late complications, T1aEL, sac enlargement ≥ 5mm, and overall survival. Outcomes were first analyzed in patients within the instructions for use (IFU) and then in all matched patients including outside IFU patients. After matching, the within-IFU group included 124 pairs and the total cohort of 266 pairs. The primary outcome measures for Endurant and Excluder were met in 38.9% and 36.6% (p = 0.74) in the within-IFU group and 33.5% and 35.0% (p = 0.74) in the total cohort, respectively. No significant differences were observed in any secondary outcome measures. However, T2EL and use of additional proximal cuff were significantly more frequent for Excluder in both the within-IFU and total cohort. Furthermore, T1b and T5ELs occurred significantly more for Endurant in the total cohort. There were no significant differences in all clinical outcome measures between Endurant and Excluder. Level IV, multicenter retrospective cohort study.

A retrospective multicenter study. To analyze symptom-specific surgical outcomes in patients with mild degenerative cervical myelopathy (DCM) and identify predictors of postoperative residual symptoms. DCM is the most common cause of spinal cord impairment in adults. While surgical intervention is recommended for moderate to severe DCM, optimal treatment strategies for mild DCM remain unclear. Previous studies have focused on total Japanese Orthopaedic Association (JOA)/modified JOA (mJOA) score without detailed symptom-specific analyses. We reviewed 679 consecutive patients who underwent surgical decompression with or without fusion for DCM across three institutions in Japan. Among them, 104 patients with mild DCM (JOA score 14.5-16.5) were included. We assessed demographic data, radiographic factors, magnetic resonance imaging parameters, and clinical scores. Symptom-specific analyses were conducted using preoperative and 2-year postoperative JOA scores, and the predictors of persistent symptoms were analyzed using multivariable logistic regression. The mean maximum canal compromise was 49.7%, and maximum spinal cord compression was 37.2%. The most common factors leading to surgery was symptom deterioration (94.2%). In symptom-specific analysis, 60.9% of patients exhibited persistent upper extremity sensory impairment, significantly higher than other domains. Multivariable analysis identified angular-edged deformity of the spinal cord on axial MRI as an independent predictor of persistent upper extremity sensory impairment (odds ratio: 4.264, 95% CI: 1.312-13.854, P =0.016). The majority of mild DCM patients who underwent surgery had severe spinal cord compression, with symptom progression serving as the trigger for surgical intervention. While surgical intervention improves overall function, upper extremity sensory impairments frequently persisted postoperatively, even in mild cases. Angular-edged deformity was a significant predictor for postoperative upper extremity sensory deficits, emphasizing the need for careful preoperative evaluation of spinal cord morphology to better inform prognosis and guide treatment decisions in patients with mild DCM. Level 4.

Study DesignRetrospective multi-institutional study.ObjectivesAlthough previous studies have evaluated the surgical outcomes of laminoplasty in patients with cervical ossification of the posterior longitudinal ligament (OPLL), the long-term results remain unclear. The purpose of this study is to assess outcomes more than 10 years post-surgery and identify to identify factors that affect the long-term prognosis.MethodsEighty-four OPLL patients with more than a minimum of 10-year follow-up after surgery were divided into a good group with more than 50% improvement of the recovery rate of the cervical Japanese Orthopaedic Association (JOA) score, and a poor group with less than 50% improvement. The demographic data and radiographic parameters of cervical spinal alignment were compared, and significant poor prognostic factors were evaluated by multivariate logistic regression.ResultsFour preoperative factors showed significant differences between 2 groups: the presence of type 2 diabetes (P = 0.012), the baseline JOA scores (P = 0.001), the narrowest segment in the cervical (P < 0.001) and the presence of T2-weighted high signal on MRI (P = 0.030). Logistic regression analysis identified 3 of 4 factors were significantly associated with postoperative poor outcomes: the presence of type 2 diabetes (P = 0.011), the baseline JOA scores (P = 0.022), and the presence of T2-weighted high signal on MRI (P = 0.035).ConclusionThis study identified three risk factors associated with poor long-term surgical outcomes following laminoplasty for cervical OPLL. These findings could be significant indicators for predicting long-term outcomes in cervical OPLL patients.

IntroductionThe safety of discontinuing immune checkpoint inhibitors (ICIs) because of a durable response in patients with advanced NSCLC remains uncertain, and post-discontinuation survival outcomes based on the reason for cessation are not well defined.MethodsA pooled analysis was conducted using data from four prospective cohort studies involving 835 patients with advanced NSCLC who discontinued ICIs. Patients were categorized based on discontinuation reasons: durable response; immune-related adverse events (irAEs) (subcategorized by tumor response at discontinuation); non-irAE adverse events; disease progression; and other causes.ResultsDisease progression was the most common reason for ICI discontinuation (N = 528 [63.2%]), followed by irAEs (N = 187 [22.4%]) and tumor response (N = 23 [2.8%]). Regarding response status at ICI discontinuation due to irAEs, complete/partial response (CR/PR) was the most frequent (N = 85), followed by stable disease/not evaluable (SD/NE, N = 69) and disease progression (N = 33). After a median post-discontinuation follow-up of 15.8 months (interquartile range, 6.9–23.2), patients who discontinued because of a response had excellent outcomes, with no deaths and only three progression-free survival events. While post-discontinuation overall survival was comparable between the irAE-CR/PR and irAE-SD/NE groups, ICI therapy ≥12 months was associated with improved post-ICI discontinuation survival in the irAE-CR/PR group.ConclusionsDiscontinuation of ICIs because of a durable tumor response is rare in real-world settings but represents a feasible strategy for patients with advanced NSCLC. Patients in the irAE-CR/PR group had favorable post-ICI discontinuation survival if they received ICI therapy lasting ≥12 months.

Abstract Background: Patients with fibrotic interstitial lung diseases (ILDs) often experience impaired health-related quality of life (HRQoL). The King's Brief Interstitial Lung Disease Questionnaire (K-BILD) has been developed to measure disease-specific HRQoL. However, its clinical application in real-world settings has not been fully explored. Methods: This prospective longitudinal study enrolled 290 patients with fibrotic ILD who initiated antifibrotic therapy. HRQoL was assessed using K-BILD at the start of antifibrotic therapy, at 6 months, and at 1 year. Associations between K-BILD scores, pulmonary function, and mortality risk were evaluated. Results: K-BILD was assessed in 284, 159, and 154 patients at the start of antifibrotic therapy, at 6 months, and at 1 year, respectively. The median K-BILD scores were 63, 67, and 67 points at the respective time points. At 6 months and 1 year, there were increases of 10 points or more in K-BILD in 45 and 41 patients, respectively. Conversely, there were decreases of 10 points or more in 30 and 42 patients, respectively. K-BILD was moderately associated with pulmonary function tests at the start of antifibrotic therapy; however, only weak correlations were found between changes in K-BILD and %FVC over time. Patients with K-BILD scores in the lowest tertile had significantly shorter survival compared to those in higher tertiles (median survival: 27.8 vs. 40.6 months). A longitudinal decrease in K-BILD of ≥10 points was associated with shorter survival. Multivariate analyses indicated that K-BILD was associated with mortality risk independent of ILD-GAP stage at the start of antifibrotic therapy. Conclusion: Antifibrotic therapy improves HRQoL in certain patients with fibrotic ILDs. Assessing K-BILD may be useful for monitoring mortality risk independently of pulmonary function tests.

Return to work (RTW) and resumption of driving (ROD) are critical factors that influence postoperative quality of life in patients undergoing total hip arthroplasty (THA). However, few studies have focused on the minimally invasive (MIS) approach and its effect on these outcomes. To investigate RTW and ROD's timelines and influencing factors following anterior MIS-THA. A retrospective analysis was conducted on 124 patients who underwent anterior MIS-THA. Data on the demographics, occupational physical demands, and RTW/ROD timelines were also collected. Clinical outcomes were measured using standardised scoring systems. Statistical analyses were performed to evaluate the differences between the groups based on employment status and physical workload. Among employed patients, the RTW rate was 94.7%, with an average return time of five weeks. The average ROD time was 3.5 weeks across all patients. Despite similar postoperative clinical scores, RTW time was significantly influenced by occupations' physical workload, with heavier physical demands associated with delayed RTW. Anterior MIS-THA facilitates early RTW and ROD, particularly in occupations with lower physical demands. These findings highlight the importance of considering occupational and physical workload in postoperative care planning to optimize recovery outcomes.