Objective: In the differential diagnosis between uterine fibroids and uterine sarcomas, realworld magnetic resonance imaging (MRI) diagnostic information is scarce; furthermore, high diagnostic sensitivity is important in clinical practice. We previously developed a diagnostic algorithm to detect uterine sarcoma with high sensitivity using simple MRI images and serum lactate dehydrogenase (LDH) levels. In this multicenter study, we investigated the preoperative diagnosis of sarcoma in the real world and further validated the usefulness of our diagnostic algorithm. Methods: Of 154 uterine sarcomas and 154 uterine fibroids treated at 15 centers between January 2006 and December 2020, 139 sarcomas (16 smooth muscle tumors of uncertain malignant potential) and 141 fibroids with diffusion-weighted imaging information were included in the analysis. The diagnostic algorithm was validated by 3 radiologists who were blinded to the clinical information and pathologic diagnoses and who read the MRIs. Results: The sensitivity/specificity of preoperative diagnosis was 77.7%/92.9% for the preoperative report; 92.1%/72.3% for algorithm A; and 82.0%/85.8% for algorithm B (McNemar’s test p<0.05). Comparison of overall survival rates among 3 groups (Group 1: negative A, Group 2: positive A and negative B; Group 3: positive B) using algorithms A and B showed p=0.012. On multivariate analysis, stage, and serum LDH level were independent prognostic factors. Conclusion MRI is useful for preoperative diagnosis of uterine sarcoma, and the sarcoma diagnostic algorithm presented in this study is an option for diagnosing sarcoma with greater sensitivity. This information should be shared with patients.

Objective: We have established 4 histopathologic subtyping of high-grade serous ovarian cancer (HGSOC) and reported that the mesenchymal transition (MT) type has a worse prognosis than the other subtypes. In this study, we modified the histopathologic subtyping algorithm to achieve high interobserver agreement in whole slide imaging (WSI) and to characterize the tumor biology of MT type for treatment individualization. Methods: Four observers performed histopathological subtyping using WSI of HGSOC in The Cancer Genome Atlas data. As a validation set, cases from Kindai and Kyoto Universities were independently evaluated by the 4 observers to determine concordance rates. In addition, genes highly expressed in MT type were examined by gene ontology term analysis. Immunohistochemistry was also performed to validate the pathway analysis. Results: After algorithm modification, the kappa coefficient, which indicates interobserver agreement, was greater than 0.5 (moderate agreement) for the 4 classifications and greater than 0.7 (substantial agreement) for the 2 classifications (MT vs. non-MT). Gene expression analysis showed that gene ontology terms related to angiogenesis and immune response were enriched in the genes highly expressed in the MT type. CD31 positive microvessel density was higher in the MT type compared to the non-MT type, and tumor groups with high infiltration of CD8/CD103 positive immune cells were observed in the MT type. Conclusion We developed an algorithm for reproducible histopathologic subtyping classification of HGSOC using WSI. The results of this study may be useful for treatment individualization of HGSOC, including angiogenesis inhibitors and immunotherapy.

Background: In the end stage of malignant bone and soft tissue tumors with lung metastasis, it is often necessary to relieve symptoms of dyspnea due to tumor enlargement and carcinomatous lymphangitis. We report a case in which nasal continuous positive airway pressure (nasal CPAP) was effective as a palliative treatment. Case: A 66-year-old male underwent wide resection with a diagnosis soft tissue sarcoma of right femur. Four years after surgery, he was hospitalized for hilar lymph node metastasis, multiple bone metastases, and carcinomatous lymphangitis. He was treated with nasal CPAP for dyspnea, and communication was possible until the day before his death. Discussion: For end-stage respiratory symptoms, medication therapy such as morphine or steroids is often used for palliation, but often symptoms are not sufficiently improved. Nasal CPAP might be a useful treatment for palliation for rapidly progressing respiratory failure.

Low-profile fixation devices for medial opening wedge high tibial osteotomy (OWHTO) were developed in order to avoid skin irritation and additional invasion. However, the low-profile system is associated with additional risks. We report three cases of locking pin back out with the low-profile locking plate system for medial OWHTO.
Knee ; Osteotomy ; Skin

This is a report on a case of delirium due to a small amount of ketamine with voriconazole. A 58 year old male was treated for multiple myeloma and hip pain due to an extramedullary tumor following the administration of oxycodone, and voriconazole was administrated for his suspected mycotic pneumonia. His pain was refractory, so we started the administration of a small dose of ketamine (4 mg/hr) for analgesia, added to oxycodone. About 30 hours later, the delirium appeared but he complained of worsening hip pain, so we added 2 mg of ketamine rapidly. Immediately after the additional administration of ketamine, his delirium became more serious. We think the reason why a small amount of ketamine induced delirium is an interaction of ketamine and voriconazole. Ketamine is metabolized to norketamine, which is thought to be more harmless than ketamine, by cytochrome P 450 (CYP) (a part of by CYP3A4) and voriconazole is an inhibitor of CYP3A4. In cases of patients treated with voriconazole, ketamine should be more carefully administrated.