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The aim of this study was to assess clinical outcomes using linac-based, fractionated, stereotactic radiotherapy (fSRT) with a micro-multileaf collimator for large brain metastasis (LBM) unsuitable for surgical resection. Between January 2009 and October 2018 we treated 21 patients with LBM using linac-based fSRT. LBM was defined as a tumor with ≥30 mm maximal diameter in gadolinium-enhanced magnetic resonance images. LBMs originated from the lung (n = 17, 81%), ovary (n = 2, 9.5%), rectum (n = 1, 4.8%) and esophagus (n = 1, 4.8%). The median pretreatment Karnofsky performance status was 50 (range: 50–80). Recursive partition analysis (RPA) was as follows: Classes 2 and 3 were 7 and 14 patients, respectively. The median follow-up was 5 months (range: 1–86 months). The range of tumor volume was 8.7–26.5 cm3 (median: 17.1 cm3). All patients were basically treated with 35Gy in 5 fractions, except in three cases. The progression-free survival was 3.0 months. The median survival time was 7.0 months. There was no permanent radiation injury in any of the patients. Radiation-caused central nervous system necrosis, according to the Common Terminology Criteria for Adverse Events version 4.0, occurred in one patient (grade 3). One patients received bevacizumab for radiation necrosis. Two patients underwent additional surgical resection due to local progression and cyst formation. For patients with LBM unsuitable for surgical resection, linac-based fSRT is a promising therapeutic alternative.

It is controversial whether universal screening for bacterial vaginosis (BV) should be done in the early stages of pregnancy in order to prevent preterm birth. In particular, whether the intermediate vaginal flora type should be included in the group to be treated for BV. This vaginal smear type is a mixture of Lactobacillus and Gardnerella or Bacteroides spp. We examined three vaginal flora types, excluding the mixed-type, with a Nugent Score of 4 and evaluated their significance in achieving term delivery. The subjects were pregnant women who were examined at our Hospital between June 2009 and December 2010. Their vaginal swabs were taken at their first prenatal visit and were studied by Gram staining. The resulting Nugent Score 4 organisms were further classified into the following four types: mixed-type, gram-positive cocci type, Bifidobacterium type, and non-bacterial type. The clinical courses for all the types except “mixed-type” were followed-up. Among the 566 pregnant women, 58 (10.2%) had a Nugent Score of 4. There were 38 cases of mixed-type (65.5%), 3 cases of gram-positive cocci type (5.2%), 10 cases of Bifidobacterium type (17.2%), and 7 cases of non-bacterial type (12.1%). The three women with the gram-positive cocci type attained successful term delivery despite two of them experiencing GBS infection and requiring treatment with penicillin and tocolytics. Among the 10 cases of Bifidobacterium type, 5 cases were term delivery with no therapy, 3 cases were term delivery with metronidazole treatment and 2 cases were preterm birth with maternal complications. Among the 7 cases of non-bacterial type, 6 cases were diagnosed with preterm PROM, and 5 of them resulted in preterm birth despite prophylactic antibiotic therapy. Classification of smears with a Nugent score of 4 into four bacterial morphotypes may be effective, for required treatment may vary depending on the morphotype.

Background To assess the neuroimaging and clinical outcomes in patients with brainstem metastasis (BSM) treated with linac-based fractionated stereotactic radiotherapy (fSRT) with a micro-multileaf collimator. Methods Between May 2007 and January 2017, 24 patients (15 male and 9 female) with BSM (25 lesions: midbrain, 10; pons, 13; and medulla oblongata, 2) were consecutively treated with linac-based fSRT. BSM originated from the lung (n = 18, 75.0%), colon (n = 3, 12.5%), and breast (n = 3, 12.5%). The median patient age was 67.0 (range: 42–80) years. Recursive partition analysis classified 2 patients as class I, 17 as class II, and 5 as class III. Overall survival was calculated using the Kaplan–Meier method. Results Tumor volume ranged from 0.01 to 7.49 cm3 (median: 0.233 cm3), and patients were treated with a dose of 24–40 Gy in 7–13 fractions. The median OS was 9 months after fSRT (95% confidence interval 4.104–13.896). Large tumor volume, presence of brainstem-related symptoms, poor pretreatment Karnofsky performance status, and recursive partition analysis class III were significantly associated with low overall survival. Tumor volume decreased in 18 metastatic lesions, remained stable in 6, and increased in 1. No patient exhibited permanent radiation injury. Grade 2 nausea and vomiting according to the Common Terminology Criteria for Adverse Events 4.0 occurred in 1 patient who received corticosteroids. Conclusions Linac-based fSRT with a micro-multileaf collimator delivered in the doses of 24–40 Gy in 7–13 fractions is a safe and effective local therapy for patients with BSM.

Highlights • We describe a rare case with a clitoral metastasis from uterine cervical cancer. • The patient was treated by concurrent chemoradiotherapy and clitoridectomy. • Clitoral metastasis should be considered in patients with clitorodynia., A 81-year-old woman vaginal bleeding and vulvar pain. Pretreatment work-up revealed a 4.5 cm cervical cancer extended to the lower-third of the vagina and an isolated clitoral metastasis. The patient was treated with a multimodal treatment consisting with radiotherapy followed by clitoridectomy. She recovered uneventfully following the multimodal treatment, and is currently free of disease. Clitoral metastasis is extremely rare, however, this condition should be considered in cervical cancer patients during the pretreatment work-up or follow-up period, especially when patients complain of clitoral pain or enlargement.

Pulmonary wedge resection is an option for lung cancer patients with limited cardiopulmonary preservation. As the impact of underlying lung status on the prognosis of such patients remains unclear, we assessed this issue. A total of 149 borderline surgical candidates with localized lung cancer who had undergone wedge resection were retrospectively investigated. Clinical variables related to perioperative morbidity, local control rate, and oncological outcomes based on underlying lung disease were analyzed. According to the risk analysis of postoperative complications, underlying lung disease did not influence the surgical morbidity. Postoperative recurrence occurred in 65 patients (locoregional recurrence in 36, distant metastasis in 12, and both simultaneously in 17). Multivariate analysis revealed that emphysema on computed tomography (CT) [hazard ratio (HR) 0.45; 95% confidence interval (CI) 0.21–0.99] was an independent indicator of locoregional recurrence. Forty-four patients died of lung cancer and 29 of other causes. Multivariate analysis demonstrated that interstitial lung disease on CT (HR 1.98; 95% CI 1.01–3.89) was a predictor of poor prognosis. Pulmonary wedge resection can be safely undergone by lung cancer patients regardless of pulmonary comorbidity, although underlying lung disease may influence the prognosis after wedge resection.

Background Intrapulmonary lymph nodes (IPLNs) are often recognized as sub-centimeter solid pulmonary nodules (SCPNs). The present study investigated their clinical and pathological characteristics to allow clinicians to distinguish them from malignant nodules. Methods Among 194 SCPNs surgically resected between 2006 and 2016, 26 IPLNs were investigated histopathologically. In addition, 145 resected malignant SCPNs were compared radiographically with the 26 IPLNs. Results Radiographically, most IPLNs were in a middle or lower lobe, and all lesions were within 20 mm of the visceral pleura. Enlargement was seen in one lesion. Three lesions demonstrated linear density contiguous to pleura (LD), and 13 lesions were adjacent to the peripheral pulmonary vein (APV). Microscopically, all IPLNs showed adjacency to pulmonary veins, 23 showed interlobular septa extending from the IPLN, and 18 were surrounded by a dilatated lymphoid channel. Radiographical findings of LD and APV were also seen in malignant SCPNs (LD, 12/145; APV, 25/145). Comparative analysis revealed that enlargement and APV were significant predictors differentiating IPLNs from malignant SCPNs. The sensitivity/specificity of enlargement and APV were 92%/92% and 17%/50%, respectively. Conclusions IPLNs show typical high-resolution computed tomography findings that reflect their histopathological characteristics. Such findings help identify IPLNs prior to surgery. Specifically, enlargement and APV may differentiate IPLNs from malignant SCPNs. However, atypical cases are also possible, and radiological findings are not specific for differentiating IPLNs from malignant lesions. Thus, clinicians should consider surgical exploration when diagnosing SCPNs.

We evaluated sequential dynamic contrast-enhanced CT (DCE-CT) scans to assess the possibility of early prediction of treatment responses by quantifying the tumor size reduction and the change in tumor enhancement during and after a course of radiotherapy (RT). Thirty-nine patients with non-small-cell lung cancer were treated with RT for initial treatment. DCE-CT scan was performed within one week before the beginning of treatment, after 17 or 18 fractions (34 or 36 Gy), and 1 week and 1 month after the end of RT. The correlation between the relative decrease in tumor diameter and that in the attenuation value was evaluated. Nineteen patients were evaluated in this study. The median tumor size was 39.5 mm at the start of treatment, 30.8 mm at 34-36 Gy, and 16.1 mm 1 month after the end of RT. The relative decrease in tumor diameter at 34-36 Gy well correlated with that 1 month after treatment (r = 0.85, r: Pearson's correlation coefficient, p < 0.001). Relative change in the attenuation value at the rim of the tumor at 34-36 Gy did not significantly correlate with the change in tumor diameter 1 month after the completion of RT, but in the center of the tumor, the change of the attenuation value in the delayed phase correlated with the change in tumor diameter. The decrease of tumor diameter during RT may be predictive of treatment response. The relative change of tumor enhancement in the center of the tumor in the delayed phase correlated with tumor shrinkage 1 month after the completion of RT.

Our purpose was to produce a prototype of a foot-controlled image-scrolling device that will prevent work-related upper extremity complaints by radiologists. After foot-controlled image-scrolling devices were added to a picture archiving and communication system, 15 (83%) of 18 radiologists indicated that fatigue and pain in their upper extremities were diminished. Upon further production and implementation of this image-scrolling device in radiology clinics, the new interface may help to prevent work-related injuries in radiologists.

Background Regional iodine distribution assessment on dual-energy computed tomography (DECT) has been suggested as useful for management of acute pulmonary thromboembolism (APTE) patients. However, no reported studies have made a direct comparison between quantitatively assessed DECT and right-to-left ventricular (RV/LV) ratio on CT for differentiation of right heart dysfunction (RHD) from non-right heart dysfunction (NRHD) in APTE patients. Purpose To determine the capability of DECT for differentiation of RHD from NRHD in APTE patients. Material and Methods Thirteen APTE patients underwent DECT and echocardiography at onset of APTE. Patients were divided into RHD ( n = 7) and NRHD ( n = 6) groups based on echocardiography. A normalized lung perfused blood volume map was generated, and two kinds of overall perfusion (OP) index were determined, one placed over each lung field (OP index A) and as the average from six regions of interest (ROIs) placed over each lung field (OP index B). The heterogeneity index was also determined as the standard deviation for the six ROIs. RV/LV ratio evaluations were also performed. To assess differences between the two groups, each index was statistically compared with the Mann-Whitney U test. The receiver-operating curve-based positive test was then performed to determine the feasible threshold value for dividing patients into the two groups. Finally, differentiation capabilities of the indexes were compared using McNemar’s test. Results Significant differences between the two groups were found for both OP indexes and RV/LV ratio ( P Conclusion Quantitative DECT has good potential for differentiation of APTE patients with and without right heart dysfunction.

OBJECTIVE. The purpose of this article is to review advanced imaging of pulmonary nodules, including pathologic and pharmacokinetic background, conventional contrast-enhanced CT and MRI assessment, dynamic contrast-enhanced CT and MRI techniques, and dual-source and area-detector CT systems for pulmonary nodule evaluation. CONCLUSION. Clinicians need to understand the underlying principles and pathologic and pharmacokinetic backgrounds of contrast-enhanced CT and MRI to further improve diagnostic performance. With adjustments in image acquisition and postprocessing, contrast-enhanced CT and MRI, especially the dynamic versions, can have enhanced clinical application for pulmonary nodules and expanded clinical relevance for other thoracic diseases.

淡明細胞性軟骨肉腫 (以下CCS) は, 淡明細胞の出現を特徴とするまれな軟骨性腫瘍で, 画像上も組織学的にも良性腫瘍や骨肉腫などと誤りやすい. CCSの1例について捺印細胞像の特徴を把握し, 軟骨芽細胞腫, 巨細胞腫, 骨肉腫などとの鑑別を試みた. 症例は43歳男性. 主訴は左大腿部の運動時痛. 他院で骨巨細胞腫と診断されたが, 当院ではCCSと診断し, 切除術および人工骨頭置換術が施行された. 病変部の捺印標本にPap. 染色他, 特殊染色, 免疫染色を施行した. 細胞は孤立散在性で数が多く, 類円形または短紡錘形の細胞が主体で一部集塊傾向があり, この部分は軟骨基質を伴っていた. 核は類円形, まれに2核, わずかに大小不同をみるが異型に乏しく, 核小体は微小で, N/Cは低い. 細胞質は概して淡明であった. その他, 破骨細胞様巨細胞を散在性, 集籏状に認めた. Pap. 染色で緑色, 不整形の類骨基質が観察され, 免疫染色では2型コラーゲンが腫瘍細胞および軟骨基質に陽性となった. 以上から, 軟骨芽細胞腫や骨巨細胞腫の細胞像とは区別し得ると思われたが, 通常型の軟骨肉腫や異型の少ない軟骨形成型骨肉腫との鑑別は注意を必要とした. また免疫染色は, 鑑別上参考になると思われた.

深部病変でもガイド下に行われるようになった骨・軟部腫瘍の吸引生検細胞診と一部捺印細胞診について) 代表的な腫瘍における細胞学的特徴について要点を述べた. 出現する腫瘍細胞やマトリックスの特徴から, 1) 類骨マトリックス形成性腫瘍, 2) 軟骨マトリックス形成性腫瘍, 3) 多核巨細胞の出現の目立つ腫瘍, 4) 小円形細胞を主体とする腫瘍, 5) 紡錘形細胞を主体とする腫瘍, 6) 多形性を特徴とする腫瘍) 7) 脱分化型肉腫などを便宜的に分類して細胞学的鑑別診断を試みた.加えて, 補助診断としての免疫組織化学の応用上の問題点についても触れた.これらの細胞学的特徴の解析と鑑別が基本ではあるが, 組織型の正しい推定に際しては, 臨床情報 (年齢, 部位, 検査成績など) と画像を十分評価してなされるべきことを強調した.

normalized. The presence of pyloric wall stratifi cation can be used as a criterion for cure; the absence of wall stratifi ca- tion can be added to ultrasound diagnostic criteria for IHPS. Abstract Purpose. During conservative therapy of infantile hypertro- phic pyloric stenosis (IHPS) with atropine sulfate, there are many patients who do not achieve normal values of pyloric wall thickness and canal length even though they are clini- cally cured (vomiting has ceased); an objective criterion for cure has not yet been established. The aim of this study was to examine whether the appearance of pyloric wall stratifi - cation can be used as a criterion for cure. Methods. Twenty infants with IHPS who were treated con- servatively were enrolled. Two of them ultimately required surgery. Ultrasound examinations were done serially and the pyloric wall thickness and canal length were measured. The echogenicity of the pyloric wall and the presence of wall stratifi cation were noted. Results. On admission, all infants satisfi ed the ultrasound criteria for IHPS and had a heterogeneous pyloric wall without stratifi cation. With conservative therapy, symptoms disappeared, the pyloric wall thickness and the canal length gradually decreased, the echogenicity gradually became homogeneous and hypoechoic, and wall stratifi cation appeared (in most cases before the pyloric wall thickness and the canal length had normalized). The absence of wall stratifi cation suggests that cellular interstitial changes, such as edema or infl ammation, are present in the pyloric wall in the acute stage. Conclusion. Pyloric wall stratifi cation was absent during the acute stage, but it appeared after initiation of treatment but before the pyloric wall thickness and the canal length had