Cystic Necrosis Research Articles

NIMG-29. EARLY REDUCTION IN MRI DIFFUSION APPARENT DIFFUSION COEFFICIENT (ADC) STRONGLY PREDICTS LONG TERM RESPONSE TO ONC201 THERAPY IN PATIENTS WITH H3K27M-DMG

Abstract ONC201 is the first monotherapy to improve outcomes in H3K27M- diffuse midline glioma (DMG) beyond radiation. Despite impressive early efficacy in H3K27M-DMG, individual response to ONC201 is variable and no radiographic biomarkers predict long term response. Previous studies demonstrated baseline MRI diffusion apparent diffusion coefficient (ADC) is lower in DMG with H3K27M compared to wildtype but change after radiation therapy was not correlated with improved OS or PFS. We hypothesize ADC will enable stratification of patients more likely to respond to ONC201. Imaging and clinical data were abstracted from chart review of patients treated with ONC201 at University of Michigan. Two neuroradiologists performed centralized review for RAPNO measurements and mean ADC was assessed using ROI measured in consistent anatomic locations, with areas of cystic degeneration or necrosis excluded. Sixty-one patients were identified for review. Preliminary analysis was performed on twenty-three patients, with upfront ONC201 therapy, median age 14.8 years old (5-25yo), primary site includes pontine (n=15), thalamic (n=7). Baseline characteristics of age, ADC and size at diagnosis or follow-up RAPNO scored size were not statistically significant. Patients with longer than median survival (334 days) demonstrated increased ADC (+58.25x10-6mm2/s) from baseline to cycle 2 whereas patients with shorter than median survival demonstrated decreased ADC (-174.8x10-6mm2/s) (p = 0.0076). Further, patients with decreased ADC demonstrated mean OS of 302.8 days and patients with increased ADC had mean OS of 588.0 (p = 0.0054). In H3K27M-DMG patients treated with ONC201, increased ADC after two cycles of ONC201 was strongly predictive of longer overall survival. Our recent work demonstrated that ONC201 disrupts metabolic and epigenetic pathways to restore pathognomonic H3K27me3 reduction, which may underline greater change in ADC. Ongoing work will validate these findings in an independent external cohort and integrate histogram analysis, parametric assessments, MRI perfusion and liquid biopsy biomarkers (cf-tDNA and metabolomics).

CT and MRI features of adrenal hemangioma: A study of 21 cases from two centers

PurposeTo retrospectively analyze the CT and MR imaging presentations of adrenal hemangioma (AH) and to strengthen the recognition for such tumors. Materials and methodsThis retrospective study enrolled 21 patients with 22 lesions histologically proven AH from two centers between October 2010 and November 2023. The clinical presentation and preoperative diagnosis were recorded. Two radiologists reviewed the CT and MR imaging features in consensus, including number, size, shape, boundary, attenuation, signal intensity, and dynamic enhancement pattern. ResultsThe study included nine men and twelve women (mean age 55.6 ± 12.5 years, range, 35–77 years) without hormone production. AH was unilateral in 19 cases, bilateral in 2 cases. The maximum diameter was more than 3 cm in 19/22(86 %). AHs had oval (10/22,45 %), round (5/22, 23 %), or (7/22, 32 %) multilocular shape, and well-defined boundary (18/22,82 %). On unenhanced CT, 11/20 (55 %) displayed peripheral iso-density and central hypo-intensity, 3/20 (15 %) heterogeneously hyper-density, 6/20 (30 %) hypodensity, and 14/20 (70 %) contained speckled calcification. On T2-weighted images, 7/12 (58 %) exhibited nodular hyper-intensity peripherally, markedly hyper-intensity centrally, and hypo-intense fibrotic scar in between, 5/12 (42 %) hyperintensity. On T1-weighted images, 6/12 (50 %) displayed center hyper-intensity surrounded by peripheral hypo-intensity,5/12 hypo-intensity, 1/11 (9 %) hyperintensity. On DWI, 7/12 (58 %) demonstrated peripheral hyper-intensity and central hypo-intensity, 5/12 (42 %) hyper-intensity. CT and MR imaging findings were suggestive of cystic change and necrosis (19/22,86 %, 4 cystic tumors), hemorrhage (15/22,68 %), fat (7/22, 33 %) within the tumors. CT and MR enhanced images showed peripheral nodular enhancement with (3/22,14 %) or without (13/22, 59 %) delayed central filling, nodular peripheral and center enhancement with progressive partial fill-in (2/22,9%), capsular and/or septal mild enhancement (4/22, 18 %), and capsule (16/22,73 %). The solid part was significantly enhanced, similar to the abdominal aorta (AA) with no statistical difference between the two (P > 0.05). ConclusionsSmall AHs (<3cm) have the typical imaging features of hemangioma. The imaging findings of large AHs were various, the combination of T2-hyperintense signal with inner hypo-intense fibrotic scar, speckled calcification, central extensive necrosis and hemorrhage, and nodular peripheral enhancement with persistently slight further contrast accumulation may contribute to suggest the possibility. Cystic AH should be considered as a differential diagnosis for cystic adrenal masses.

Endoscope-assisted treatment for delayed cystic radiation necrosis after stereotactic radiosurgery for metastatic brain tumors: illustrative cases.

Cystic formation due to radiation necrosis in metastatic brain tumors is a rare condition. Surgical intervention is necessary if symptoms develop. Additionally, excising radiation necrosis lesions within the cyst is essential to prevent recurrence. Neuroendoscopic surgery is a minimally invasive method suitable for treating cystic diseases and accessing deep lesions in the brain. The authors herein present a method for removing radiation necrotic tissue from deep lesions of cystic radiation necrosis using neuroendoscopy. Endoscopic surgery was performed in two patients with symptomatic cystic radiation necrosis. Both cases involved multilocular cysts, with radiation necrosis located deep within the cyst. The authors performed a small craniotomy of approximately 3 cm and opened the cyst. After removing its contents, an endoscope was used to closely observe the interior of the cyst. Removal of the septum within the cyst allowed the endoscope to be inserted deeply. The authors identified and excised the nodular lesion diagnosed as radiation necrosis in the deep tissue. Following the surgery, the cyst shrank rapidly, and symptoms disappeared. Both patients showed no recurrence of the lesions. The authors performed minimally invasive surgery and achieved good outcomes. Endoscopic surgery was considered beneficial for treating cystic radiation necrosis. https://thejns.org/doi/10.3171/CASE24250.

8097 A Rare Case of a Renal Cell Carcinoma and Pheochromocytoma Collision Tumor

Abstract Disclosure: R. Daas: None. S. Logan: None. W. Sexton: None. V. Chumbalkar: None. M. McGettigan: None. C. Veloski: None. Background: Collision tumors are neoplasms comprised of two or more distinct tumors. A collision tumor consisting of a renal cell carcinoma and pheochromocytoma is extremely rare with less than five cases reported in the literature. Clinical Case: A 64-year-old male with a history of hypertension and type 2 diabetes presented with hematuria. The patient was on 4 anti-hypertensive medications at the time. He noted increased road rage, anxiety, tremors, and insomnia. A CT abdomen/pelvis revealed an exophytic 8.6 x 7.9 cm left upper pole renal mass and a 7.5 x 6.2 cm left adrenal mass. Contrast-enhanced MRI abdomen showed a left upper/interpolar renal mass with heterogenous peripheral enhancement, restricted diffusion, and areas of central necrosis along with a heterogenous, enhancing left adrenal mass with associated restricted diffusion and areas of cystic necrosis. Both masses had associated areas of hyperintense signal on T1 fat-suppressed MRI suggestive of hemorrhage. Lab work revealed ACTH 26.6 pg/mL (7.2-63.3), cortisol 13 ug/dL (3.7-19.4), aldosterone 23.1 ng/dL (4-31), renin 4 ng/mL/hr (0.5-4), dopamine 136 pmol/L (&amp;lt;240), epinephrine 121 pmol/L (&amp;lt;330), norepinephrine 23,666 pmol/L (1050-4800), plasma normetanephrines 12.3 nmol/L (0-0.89), plasma metanephrines &amp;lt;0.10 nmol/L (0-0.49), 24-hour urine normetanephrines 4,178 mcg (122-676) and 24-hour urine metanephrines 4,233mcg (224-832). The patient was treated with alpha blockade prior to left radical nephrectomy, left adrenalectomy and infrahilar paraaortic lymph node dissection. Despite aggressive preoperative alpha blockade with maximal doses of doxazosin, addition of metyrosine and other anti-hypertensives, he developed acute hypertension with adrenal mass manipulation during the procedure and then hypotension following removal. He was admitted to the ICU for management of hypotension with pressors and fluid resuscitation and did well. Post-operative labs showed plasma normetanephrines 0.98 nmol/L (0.00-0.89) and plasma metanephrines 0.11 nmol/L (0.00-0.49). Pathology revealed clear cell renal cell carcinoma (RCC) of the kidney. The adrenal gland showed 2 tumors; one consistent with pheochromocytoma and another intimately associated with the former consistent with metastatic RCC, morphology diagnostic of a collision tumor. Following surgical resection, the patient was referred for genetic testing, surveillance imaging and lab testing, and treated with pembrolizumab adjuvant therapy for stage IV RCC. Conclusion: Although collision tumors are rare, biochemical testing to rule out a pheochromocytoma must be performed for all indeterminate adrenal masses and presumed adrenal metastases of active malignancies. Presentation: 6/2/2024

A giant solitary fibrous tumor of the abdominal pelvic cavity: A case report and literature review.

Solitary fibrous tumor (SFT) is a rare mesenchymal tumor, especially the giant one from the abdominal pelvic cavity. We report on a rare case of a giant SFT of the abdominal pelvic cavity to review the existing literature in detail to improve the diagnosis and treatment of SFT. The patient is a 52-year-old female who presented with 2 weeks of abdominal distension. Abdominal magnetic resonance imaging showed a giant mass (>20 cm) in the abdominal pelvic cavity, considered a mesenchymal tumor. She denies a history of tumor disease. A whole abdomen bulge and a mass of about 18 cm × 10 cm on the right side and middle side were found in the physical examination after admission. Abdominal enhanced computed tomography revealed a giant cystic-solid mass located on the middle and right side of the abdominal pelvic cavity, measuring approximately 20.4 cm × 11.7 cm, with multiple cystic changes and necrosis and compression of adjacent organs and tissues, and marked inhomogeneous enhancement. The patient underwent an open abdominal pelvic cavity giant tumor operation to achieve a radical resection, and did not undergo chemotherapy or radiotherapy. The patient underwent open complete resection of a giant abdominal pelvic tumor with no complications and was diagnosed as SFT according to the pathology, immunohistochemistry showed that the tumor tested positive for CD34(+), STAT-6(+), and Ki-67 (10%). Abdominal computed tomography scans were performed 6 months after resection, and no signs of recurrence or metastasis were found. The clinical symptoms and imaging features of giant abdominal pelvic cavity SFT are not typical. Preoperative diagnosis is difficult and has the potential for malignancy. Based on the results of the current study, there is no standard treatment strategy around the world and the therapeutic effect of radiation therapy and chemotherapy is relatively limited. Thus, complete surgical resection and close clinical follow-up are advocated.

Analysis of imaging features of rare tumors in nasal cavity and paranasal sinus

Objective:To explore the imaging features of rare tumors of nasal cavity and sinuses, and to improve the understanding of these diseases, thereby aiding clinical diagnosis and treatment. Methods:The CT and MRI findings of 79 cases of rare neoplasm of nasal cavity and sinuses confirmed by pathology were retrospectively analyzed, and the imaging features were summarized. Results:Among the 79 cases, there were 16 cases of neuroendocrine carcinoma, most showing expansive and infiltrative bone destruction without hyperosteogeny and sclerosis. The sphenoid sinus exhibited a "pigeon" shape. In 28 cases of malignant melanoma, MRI signals were diverse, typical signals were rare, but mixed signals were more common. In 12 cases of rhabdomyosarcoma, MRI enhancement mostly showed "grape-like" enhancement and partial ring enhancement; There were 10 cases of olfactory neuroblastoma, the lesions were consistent with the distribution area of olfactory mucosa, most of them were lobulated, marginal nodules, and "flower ring" enhancement, and 2 cases grew across intracranial and external, with multiple cystic lesions and surrounding flaky edema bands. In 5 cases of solitary fibrous tumor, Benign tumors had regular shape and uniform density, while malignant tumors had irregular shape and uneven density, The enhancement was obviously uneven and showed a "pattern" change. There were 2 cases of sarcomatoid carcinoma, both with lobed appearance, uneven density, lamellar low-density shadow, and osteolytic bone destruction. In 4 cases of schwannoma, the enhancement showed obvious inhomogeneous enhancement. One case showed cystic necrosis, one case showed calcification, and the surrounding structure was compressed without damage. There was 1 case of neurofibroma, with many cystic components, low signal separation and compartmentalized enhancement. One case of paraganglioma showed moderate enhancement in the arterial phase and progressive enhancement in the venous phase, accompanied by significant swelling bone destruction. Conclusion:Rare tumors of nasal cavity and paranasal sinuses have distinctive imaging features. CT and MRI can effectively show the extent of the lesions and the degree of infiltration into adjacent tissues and organs, which is helpful for early clinical diagnosis and staging. However, definitive diagnosis still depends on pathology and immunohistochemistry.

Response Evaluation Criteria in Gastrointestinal and Abdominal Cancers: Which to Use and How to Measure.

As the management of gastrointestinal malignancy has evolved, tumor response assessment has expanded from size-based assessments to those that include tumor enhancement, in addition to functional data such as those derived from PET and diffusion-weighted imaging. Accurate interpretation of tumor response therefore requires knowledge of imaging modalities used in gastrointestinal malignancy, anticancer therapies, and tumor biology. Targeted therapies such as immunotherapy pose additional considerations due to unique imaging response patterns and drug toxicity; as a consequence, immunotherapy response criteria have been developed. Some gastrointestinal malignancies require assessment with tumor-specific criteria when assessing response, often to guide clinical management (such as watchful waiting in rectal cancer or suitability for surgery in pancreatic cancer). Moreover, anatomic measurements can underestimate therapeutic response when applied to molecular-targeted therapies or locoregional therapies in hypervascular malignancies such as hepatocellular carcinoma. In these cases, responding tumors may exhibit morphologic changes including cystic degeneration, necrosis, and hemorrhage, often without significant reduction in size. Awareness of pitfalls when interpreting gastrointestinal tumor response is required to correctly interpret response assessment imaging and guide appropriate oncologic management. Data-driven image analyses such as radiomics have been investigated in a variety of gastrointestinal tumors, such as identifying those more likely to respond to therapy or recur, with the aim of delivering precision medicine. Multimedia-enhanced radiology reports can facilitate communication of gastrointestinal tumor response by automatically embedding response categories, key data, and representative images. ©RSNA, 2024 Test Your Knowledge questions for this article are available in the supplemental material.

Clinical and multiparametric MRI features for differentiating uterine carcinosarcoma from endometrioid adenocarcinoma

IntroductionThe purpose of our study was to differentiate uterine carcinosarcoma (UCS) from endometrioid adenocarcinoma (EAC) by the multiparametric magnetic resonance imaging (MRI) features.MethodsWe retrospectively evaluated clinical and MRI findings in 17 patients with UCS and 34 patients with EAC proven by histologically. The following clinical and pathological features were evaluated: post- or pre-menopausal, clinical presentation, invasion depth, FIGO stage, lymphaticmetastasis. The following MRI features were evaluated: tumor dimension, cystic degeneration or necrosis, hemorrhage, signal intensity (SI) on T2-weighted images (T2WI), relative SI of lesion to myometrium on T2WI, T1WI, DWI, ADCmax, ADCmin, ADCmean (RSI-T2, RSI-T1, RSI-DWI, RSI-ADCmax, RSI-ADCmin, RSI-ADCmean), ADCmax, ADCmin, ADCmean, the maximum, minimum and mean relative enhancement (RE) of lesion to myometrium on the arterial and venous phases (REAmax, REAmin, REAmean, REVmax, REVmin, REVmean). Receiver operating characteristic (ROC) analysis and the area under the curve (AUC) were used to evaluate prediction ability.ResultsThe mean age of UCS was higher than EAC. UCS occurred more often in the postmenopausal patients. UCS and EAC did not significantly differ in depth of myometrial invasion, FIGO stage and lymphatic metastasis. The anterior-posterior and transverse dimensions were significantly larger in UCS than EAC. Cystic degeneration or necrosis and hemorrhage were more likely occurred in UCS. The SI of tumor on T2WI was more heterogeneous in UCS. The RSI-T2, ADCmax, ADCmean, RSI-ADCmax and RSI-ADCmean of UCS were significantly higher than EAC. The REAmax, REAmin, REAmean, REVmax, REVmin and REVmean of UCS were all higher than EAC. The AUCs were 0.72, 0.71, 0.86, 0.96, 0.89, 0.84, 0.73, 0.97, 0.88, 0.94, 0.91, 0.69 and 0.80 for the anterior-posterior dimension, transverse dimension, RSI-T2, ADCmax, ADCmean, RSI-ADCmax, RSI-ADCmean, REAmax, REAmin, REAmean, REVmax, REVmin and REVmean, respectively. The AUC was 0.997 of the combined of ADCmax, REAmax and REVmax. Our study showed that ADCmax threshold value of 789.05 (10–3mm2/s) can differentiate UCS from EAC with 100% sensitivity, 76.5% specificity, and 0.76 AUC, REAmax threshold value of 0.45 can differentiate UCS from EAC with 88.2% sensitivity, 100% specificity, and 0.88 AUC.ConclusionMultiparametric MRI features may be utilized as a biomarker to distinguish UCS from EAC.

Comprehensive study of ancient schwannoma: Exploring histomorphological diversity and diagnostic challenges.

Background: Ancient schwannoma is a rare subtype of schwannoma characterized by an extended duration of development and distinctive degenerative changes. These changes encompass relative loss of Antoni type A areas, perivascular hyalinization, hemorrhage, cystic necrosis, calcification, and the presence of atypical nuclei that can mimic sarcomatous pleomorphism. These histologic features often lead to diagnostic challenges, with ancient schwannomas frequently being misdiagnosed as malignant tumors. Objectives: This study aims to provide a comprehensive evaluation of the histomorphological spectrum observed in ancient schwannoma. Methods: A retrospective analysis was conducted on 248 schwannoma cases received at our tertiary health centre, spanning the years 2017 to 2023. Among these cases, 25 were identified as ancient schwannoma. Extensive examination of degenerative changes was performed using hematoxylin and eosin-stained paraffin-embedded tissue sections under light microscopy. Results: Patient ages ranged from 22 to 82years, with a nearly equal distribution between genders (12 females and 13 males). Tumors were located in various anatomical sites including the forearm, brain, abdomen, retroperitoneum, intradural space, lumbar region, and pelvis. Tumor dimensions varied from 1.5 to 11cm. Histologically, most cases exhibited nuclear atypia, cystic changes, hemorrhage, and siderophages, along with perivascular hyalinization, myxoid change, calcification, and xanthomatous change. Immunohistochemistry confirmed the neural origin of these tumors. Conclusion: Recognition of the diverse spectrum of secondary changes, coupled with the presence of focal areas showing paucicellular and cellular spindle cell arrangements, is crucial for the accurate diagnosis of ancient schwannoma. This study underscores the importance of histomorphological evaluation in distinguishing these benign tumors from malignant counterparts, thereby guiding appropriate clinical management strategies.

P-05 Malignant pheochromocytoma with a negative biomarker hormonal assay: A case report

Abstract Description Malignant pheochromocytoma is a rare, predominantly sporadic, but also familial disease, with a malignancy frequency of about 10%. Clinical Case A 25-year-old male was referred to us by the general surgeon after he had a hypertensive crisis during the appendectomy surgery and then accidentally discovered a left adrenal gland mass by CT scan. Assessment of the patient done by physical examination, the height 168cm, weight 53 kg and the BMI 19 kg/m2 and the vital sign was Bp 200/110, and PR 87 b/min. Investigations: normal renal function test and negative metanephrines, normetanephrine and aldosterone, renin and aldosterone renin ratio also normal serum electrolytes. Imaging abdomen CT shows a mass measuring 4.8 X3.7X6.2 cm in its (AP, TS&amp;CC dimension) in the left adrenal gland (encircle), density 40-50 HU. with central hypo density represented cystic necrosis. Right adrenal is normal limbs following intravenous contrast, the left adrenal mass enhances brightly (130-140HU) with central cystic necrosis … consisting with typical features of pheochromocytoma. The patient referred to expert surgeon and there was some preoperative preparation inform of the patient received phenoxybenzamine (alpha blocker) the receive propranolol to control reflux tachycardia and normalized the blood pressure, resection of left adrenal mass was done and the gross tissue biopsy was sent to histopathologist, and the result revealed a diagnosis of malignant pheochromocytoma, after two weeks from operation CT images post operatively after total resection of left adrenal mass revealed clear bed no residual SOL with surgical clips seen. Conclusion Marker-negative Pheochromocytomas are an uncommon form of the illness. Even more dangerous forms, malignant pheochromocytomas typically release metabolites. However, a doctor must be alert to patients with negative markers who exhibit typical symptoms and must make a diagnosis using a combination of clinical, radiologic, and biochemical testing. When choosing patients for presurgical alpha blockade, this is extremely important. Table 1

Imaging diagnosis and differential diagnosis of extraskeletal osteosarcoma

ObjectiveThe aim of this study was to investigate the clinical, imaging and pathological features of extraskeletal osteosarcoma (EOS) and to improve the understanding of this disease and other similar lesions.MethodsThe data for 11 patients with pathologically confirmed extraosseous osteosarcoma, including tumour site and size and imaging and clinical manifestations, were analysed retrospectively.ResultsSix patients were male (60%), and 5 were female (40%); patient age ranged from 23 to 76 years (average age 47.1 years). Among the 11 patients, 7 had clear calcifications or ossification with different morphologies, and 2 patients showed a massive mature bone tumour. MRI showed a mixed-signal mass with slightly longer T1 and T2 signals in the tumour parenchyma. Enhanced CT and MRI scans showed enhancement in the parenchyma. Ten patients had different degrees of necrosis and cystic degeneration in the mass, 2 of whom were complicated with haemorrhage, and MRI showed “fluid‒fluid level” signs. Of the 11 patients, five patients survived after surgery, and no obvious recurrence or metastasis was found on imaging examination. One patient died of lung metastasis after surgery, and 2 patients with open biopsy died of disease progression. One patient died of respiratory failure 2 months after operation. 2 patients had positive surgical margins, and 1 had lung metastasis 6 months after operation and died 19 months after operation. Another patient had recurrence 2 months after surgery.ConclusionThe diagnosis of EOS requires a combination of clinical, imaging and histological examinations. Cystic degeneration and necrosis; mineralization is common, especially thick and lumpy mineralization. Extended resection is still the first choice for localized lesions. For patients with positive surgical margins or metastases, adjuvant chemoradiotherapy is needed.

Magnetic resonance imaging analysis of embryonal rhabdomyosarcoma of the prostate.

Rhabdomyosarcoma (RMS) is a highly malignant tumor that originates from myogenic progenitor cells. To investigate the magnetic resonance imaging (MRI) characteristics of prostate embryonal rhabdomyosarcoma (ERMS). We retrospectively analyzed the clinical and MRI imaging data of 9 cases of prostate ERMS that were confirmed pathologically. The patients were aged between 14∼49 years with a median age of 27 years, and they all underwent MRI, diffusion-weighted imaging (DWI), and dynamic contrast-enhanced MRI (DCE-MRI). The MRI scan of the lesions showed an irregular shape, mixed signals, uneven equal/long T1 signal and an equal/long T2 signal, cystic necrosis in 9 cases and hemorrhage in 6 cases; DWI and ADC images showed a mixed high/low signal, and the tumor parenchyma showed ADC low signal, with an average ADC value of 0.666 × 10-3 mm2/s. There were 5 cases of DCE-MRI TIC type II and 4 cases of DCE-MRI TIC type I. The average value of Tpeak was 120 s and the average value of MCER was 172.3%. After the enhancement, the signal of tumor enhancement was uneven, and showed patchy and reticular enhancement, however, the cyst degeneration, necrosis area, and hemorrhage focus were not enhanced. There were 3 cases with multiple pelvic lymph nodes and 1 case with multiple bone metastases. The MRI manifestations of prostate ERMS have certain characteristics, and the combination of DWI and DCE-MRI are helpful in the diagnosis.

Acute Emphysematous Cholecystitis Rarely Accompanied by Necrotized Cystic Duct: A Case Report

Emphysematous cholecystitis is an acute abdominal disease characterized by gas in the gallbladder lumen and wall. Emphysematous cholecystitis and related cystic duct necrosis are rare, but if not noticed, they can cause a mortal picture up to perforation and sepsis. In this article, we present a case of emphysematous cholecystitis involving gangrenous gallbladder and necrotizing cystic duct, which developed suddenly in an immunosuppressive patient who presented to the emergency department with abdominal pain and was treated with rapid emergency successful surgery.

Pretreatment synthetic MRI features for triple-negative breast cancer

To evaluate the quantitative parameters derived from synthetic magnetic resonance imaging (SyMRI) for predicting triple-negative breast cancer (TNBC). This prospective study enrolled participants with invasive ductal breast carcinoma (IDBC) and separated them into a TNBC group and a Non-TNBC group. Preoperative breast MRI included both the SyMRI and conventional MRI sequences. The quantitative parameters derived from the SyMRI included T1 and T2 relaxation times, proton density (PD), and their standard deviations (SD). Clinicopathological characteristics, conventional MRI findings, and quantitative synthetic parameters were assessed for all participants. Multivariable logistic regression analysis was performed to determine the potential independent imaging predictors for TNBC preoperatively. Receiver operating characteristic (ROC) curve analysis was used to evaluate the performance of these parameters. A total of 231 participants with histopathological proven IDBC were included in this study (n=46 in the TNBC group and n=185 in the Non-TNBC group). The TNBC group had significantly larger tumour size (p=0.011) and more frequent intratumoural cystic or necrotic lesions (p<0.001) as compared to the Non-TNBC group. The univariate analysis showed that the TNBC tumours had significantly higher T1 (p=0.006) and T2 (p<0.001) values than Non-TNBC tumours. Subsequent multivariable analysis indicated that T2 values and the presence of cystic or necrotic lesions were the independent predictors for TNBC. The T2 from synthetic imaging and the presence of cystic degeneration or necrosis within the breast cancer may serve as potential imaging biomarkers for preoperative differentiation of TNBC from Non-TNBC.

Effect and mechanism of Zuogui Pills on neural function recovery in ischemic stroke mice based on OPN/IGF-1/mTOR

To explore the effect and mechanism of Zuogui Pills in promoting neural tissue recovery and functional recovery in mice with ischemic stroke. Male C57BL/6J mice were randomly divided into a sham group, a model group, and low-, medium, and high-dose Zuogui Pills groups(3.5, 7, and 14 g·kg~(-1)), with 15 mice in each group. The ischemic stroke model was established using photochemical embolization. Stiker remove and irregular ladder walking behavioral tests were conducted before modeling and on days 7, 14, 21, and 28 after medication. Triphenyl tetrazolium chloride(TTC) staining was performed on day 3 after modeling, and T2-weighted imaging(T2WI) and diffusion-weighted imaging(DWI) were performed on day 28 after medication to evaluate the extent of brain injury. Hematoxylin-eosin(HE) staining was performed to observe the histology of the cerebral cortex. Axonal marker proteins myelin basic protein(MBP), growth-associated protein 43(GAP43), mammalian target of rapamycin(mTOR), and its downstream phosphorylated s6 ribosomal protein(p-S6), as well as mechanism-related proteins osteopontin(OPN) and insulin-like growth factor 1(IGF-1), were detected using immunofluorescence and Western blot. Zuogui Pills had a certain restorative effect on the neural function impairment caused by ischemic stroke in mice. TTC staining showed white infarct foci in the sensory-motor cortex area, and T2WI imaging revealed cystic necrosis in the sensory-motor cortex area. The Zuogui Pills groups showed less brain tissue damage, fewer scars, and more capillaries. The number of neuronal axons in those groups was higher than that in the model group, and neuronal activity was stronger. The expression of GAP43, OPN, IGF-1, and mTOR proteins in the Zuogui Pills groups was higher than that in the model group. In summary, Zuogui Pills can promote the recovery of neural function and axonal growth in mice with ischemic stroke, and its mechanism may be related to the activation of the OPN/IGF-1/mTOR signaling pathway.

Delayed Death Due to Methanol Poisoning: An Autopsy Case Report

Methanol is a non-drinking type of alcohol used for industrial and automotive purposes. Methanol itself is not dangerous, but its harmful metabolites may cause the accumulation of acid in the blood, leading to metabolic acidosis, permanent blindness, and death. In this case report study, the case was a 28-year-old Nepalese man who was admitted in a semi-unconscious state to the emergency department. A working diagnosis of methanol poisoning was made. After more than two weeks, he succumbed to death due to a worsening cerebral infarction. At autopsy, extensive hemorrhagic infarction was observed, involving bilateral cerebral hemispheres. Well-defined subcortical hemorrhages leading to laminar necrosis were seen at the frontoparietal lobes. Cystic or lacunar necrosis was present at the basal ganglia. The brainstem showed the presence of duret hemorrhage. The man died approximately three weeks after the methanol ingestion. This case highlights the important pathological changes and accumulating effects of methanol in the brain.

Cystic lesions in the salivary gland. Pitfalls to be avoided on cytology.

Cystic lesions of the salivary glands are very uncommon entities. However, on occasion, some neoplasms of the salivary glands show a cystic component, which may be predominant or only partially cystic. Basal cell adenoma, canalicular adenoma, oncocytoma, sebaceous adenoma, intraductal papilloma, epithelial-myoepithelial carcinoma, intraductal carcinoma, and secretory carcinoma are such cystic entities. Cystic degeneration and necrosis, which can develop within solid tumours, represent another possibility. The ability to recognise this type of lesion is a challenge in diagnostic cytology because hypocellular fluid is frequently recovered. Furthermore, evaluating all of the differential diagnoses for cystic lesions of the salivary glands is helpful in obtaining the correct diagnosis. Herein, we evaluate the various types of cystic lesions within the salivary glands.

Use of a Convolutional Neural Network to Predict the Malignant Potential of Gastrointestinal Stromal Tumors in Transabdominal Ultrasound Images: Visualization of the Focus of the Prediction Model

We established a deep convolutional neural network (CNN) model based on ultrasound images (US-CNN) for predicting the malignant potential of gastrointestinal stromal tumors (GISTs). A total of 980 ultrasound images from 245 pathology-confirmed GIST patients after surgical operation were retrospectively collected and divided into a low (very-low-risk, low-risk) and a high (medium-risk, high-risk) malignant potential group. Eight pre-trained CNN models were used to extract the features. The CNN model with the highest accuracy in the test set was selected. The model's performance was evaluated by calculating accuracy, sensitivity, specificity, positive-predictive value (PPV), negative-predictive value (NPV) and the F1 score. Three radiologists with different experience levels also predicted the malignant potential of GISTs in the same test set. US-CNN and human assessments were compared. Subsequently, gradient-weighted class activation diagrams (Grad-CAMs) were used to visualize the model's final classification decisions. Among the eight transfer learning-based CNNs, ResNet18 performed best. The accuracy, sensitivity, specificity, PPV, NPV and F1 score were 0.88, 0.86, 0.89, 0.82, 0.92 and 0.90, respectively, which were significantly better than those achieved by radiologists (resident doctor: 0.66, 0.55, 0.79, 0.74, 0.62 and 0.69; attending doctor: 0.68, 0.59, 0.78, 0.70, 0.69 and 0.73; professor: 0.69, 0.63, 0.72, 0.51, 0.80 and 0.76). Model interpretation with Grad-CAMs revealed that the activated areas mainly focused on cystic necrosis and margins. The US-CNN model predicts GIST malignant potential well, which can assist in clinical treatment decision-making.

Dual-phase contrast-enhanced multislice computed tomography scans play a key role in the diagnosis of abdominal wall desmoid-type fibromatoses.

Abdominal wall desmoid-type fibromatoses (AWDF) are occasionally encountered in clinical work, but related CT reports are rare, and most cases were misdiagnosed as malignant tumors. We aimed to determine the diagnostic value of multislice computed tomography (MSCT) in relation to the clinical diagnosis of AWDF. The medical records of 14 patients whose pathology results provided initial confirmation of AWDF were reviewed, and data describing their clinical characteristics, tumors' MSCT characteristics, and the condition of the surrounding tissues were analyzed and summarized retrospectively. Intraobserver and interobserver reproducibilities were evaluated. AWDF tended to occur in women of childbearing age (24-32 years). They occurred more frequently during the first year following pregnancy. The mean disease duration was 5.64 ± 3.78 months. All isolated tumors were growing along the musculoaponeurotic layer, and their maximum diameters were between 32 and 76 mm. Tumors' capsules were incomplete, and although the tumors infiltrated the surrounding muscles, the surrounding fat tissue and vessels were not infiltrated. None of the patients' tumors showed cystic degeneration, calcification, necrosis, or peritumoral edema. The tumors had slightly lower densities on the pre-contrast enhancement scans and mild-to-moderate enhancement after contrast enhancement. All tumors contained ribbon-like structures, and approximately 65% of the tumors encircled vascular structures. Dual-phase contrast-enhanced MSCT scans were associated with a high level of diagnostic efficacy for AWDF. The abdominal wall masses grew along the musculoaponeurotic layer, which, together with the ribbon-like structures within the tumors, should prompt clinicians to consider the presence of AWDF.

Obliterative Endotheliitis Leading to Cystic Lung Necrosis in Severe COVID-19 during the First Wave of the Pandemic

In the early months of the outbreak (2020–2022), COVID-19 was responsible for acute respiratory distress syndrome (ARDS) and an exceptional number of intensive care unit (ICU) admissions. Weaning difficulties from invasive mechanical ventilation (IMV) and many deaths related to COVID-19 were associated with persistent pulmonary hyperinflammation leading to pulmonary fibrosis and sometimes, in the first wave of the pandemic and before the use of dexamethasone was introduced, pulmonary cystic necrosis. A 72-year-old man hospitalized with severe COVID-19 required IMV and died on day 31 of refractory ARDS. Postmortem examination of the lungs found obliterative endotheliitis proximal to pulmonary cystic necrosis. The presence of SARS-CoV-2 envelope and complement/lectin (MASP-2) deposits near the endotheliitis lesions suggested that the virus acted directly on vascular involvement by a complement-mediated mechanism. Together with classic features of ARDS (epithelial lesions and diffuse alveolar damage), endothelial involvement with endotheliitis was the hallmark of severe COVID-19. Corticosteroids and complement blockade were sometimes beneficial for treating severe COVID-19, perhaps by preventing microvascular damage.