As of the most recent WHO classification of immunodeficiency diseases, lymphoproliferative disorders that occur during treatment with immunosuppressive drugs are classified as \"other iatrogenic immunodeficiency-associated lymphoproliferative disorders (OIIA-LPDs)\" other than post-transplant lymphoproliferative disorders. Most patients with OIIA-LPD have rheumatoid arthritis as the underlying disease. Research indicates that approximately half of people diagnosed with OIIA-LPD see a remission of their lesion after stopping treatment with methotrexate (MTX), a drug used in rheumatoid arthritis treatment. Hereby, we present the case of an 81-year-old woman with rheumatoid arthritis who developed OIIA-LPD at the bilateral lingual margins. The patient had been receiving MTX for the preceding 10 years. After determining that OIIA-LPD was MTX-related, the patient underwent MTX withdrawal and was treated conservatively. The lesion resolved one month after MTX withdrawal. This case report confirms immunosuppressive drug withdrawal as a potentially effective treatment for multiple OIIA-LPDs of the oral mucosa.

Stafne bone defect (SBD) is a rare developmental bone defect characterized by an asymptomatic focal concavity of the cortical bone, typically on the lingual aspect of the mandibular body, which generally contains salivary gland tissue. It can be detected during routine dental examinations and typically appears as an ovoid, well-defined, well-corticated, radiolucent depression in the posterior mandibular region below the inferior alveolar nerve (IAN) (in: Neville et al, Oral and maxillofacial pathology, Elsevier, Inc, St. Louis, MO, 2016).An 80-year-old male presented to our clinic for a routine dental examination. Panoramic radiography and cone-beam computed tomography (CBCT) displayed two well-defined, well-corticated, ovoid radiolucencies inferior to the IAN canal on the left mandibular molar region. The working diagnosis was SBD, and the patient was informed of the findings. Irregular margins on the superior aspect of the anterior defect were noted on CBCT imaging; therefore, follow-up with panoramic images at 6 months, 1 and 5 years was recommended.

OBJECTIVE: To propose an efficient collimator angle optimization method by combining island blocking (IB) and parked gap (PG) problem to reduce the radiotherapy dose for normal tissue. The reduction will be done with single-isocenter multi-lesion volumetric modulated arc therapy (VMAT) for the stereotactic body radiation therapy (SBRT) of liver cancer.
METHODS: A novel collimator angle optimization algorithm was developed based on the two-dimensional projection of targets on a beam\'s eye view (BEV) plane as a function of gantry and collimator angle. This optimization algorithm minimized the sum of the combined IB and PG (IB & PG) areas from all gantry angles for each arc. For comparison, two SBRT plans were respectively generated for each of the 20 retrospective liver cancer cases with multiple lesions. One plan was optimized using the IB & PG algorithm, and the other plan was optimized with a previously reported optimization algorithm that only considered the IB area. Plans were then evaluated and compared using typical dosimetric metrics.
RESULTS: With the comparable target coverage, IB & PG plans had significantly lower D500cc, D700cc, mean dose (Dmean), and V15 of normal liver tissues when compared to IB plans. The median percent reductions were 3.32% to 5.36%. The D1cc, D5cc, and Dmean for duodenum and small intestine in IB & PG plans were significantly reduced in a range from 7.60% up to 16.03%. Similarly, the median integral dose was reduced by 3.73%. Furthermore, the percentage of normal liver Dmean sparing when IB & PG plans compared to IB plans, was found to be positively correlated (ρ = 0.669, P = 0.001) with the inter-target distance.
CONCLUSIONS: The proposed IB & PG algorithm has been demonstrated to outperform the IB algorithm in almost all normal tissue sparing, and the magnitude of liver sparing was positively correlated with inter-target distance.

A 20-year-old woman presented to our hospital with abdominal pain. Abdominal computed tomography revealed multiple masses in the upper jejunum, which were suspected as lipomas. Partial resection of the small intestine, including the masses, was performed on the same day due to intussusception secondary to the masses. Pathological examination revealed that the masses consisted of mucosa and edematous submucosa with multiple dilated blood vessels and lymphatic ducts without muscularis propria. The masses were diagnosed as multiple muco-submucosal elongated polyps (MSEP), a type of non-neoplastic polyp. MSEP was originally named colonic MSEP, but with the development of endoscopic techniques and imaging tests, similar polyps have been reported to occur not only in the colon but also in the entire intestinal tract. In this case, multiple MSEPs in the upper jejunum caused intussusception. As reported cases of multiple lesions causing intussusception are few, our case may help to clarify the pathogenesis of this disease.

Tumor-infiltrating lymphocytes (TILs), especially CD8+ TILs, represent a favorable prognostic factor in high-grade serous ovarian cancer (HGSOC) and other tumor lineages. Here, we analyze the spatial heterogeneity of different TIL subtypes in HGSOC. We integrated RNA sequencing, whole-genome sequencing, bulk T cell receptor (TCR) sequencing, as well as single-cell RNA/TCR sequencing to investigate the characteristics and differential composition of TILs across different HGSOC sites. Two immune \"cold\" patterns in ovarian cancer are identified: (1) ovarian lesions with low infiltration of mainly dysfunctional T cells and immunosuppressive Treg cells and (2) omental lesions infiltrated with non-tumor-specific bystander cells. Exhausted CD8 T cells that are preferentially enriched in ovarian tumors exhibit evidence for expansion and cytotoxic activity. Inherent tumor immune microenvironment characteristics appear to be the main contributor to the spatial differences in TIL status. The landscape of spatial heterogeneity of TILs may inform potential strategies for therapeutic manipulation in HGSOC.

UNASSIGNED: Primary ALK-positive histiocytosis of the breast is rare. Here, we report a case of ALK-positive histiocytosis with multiple unilateral breast lesions.
METHODS: Our patient was a 38-year-old female with primary ALK-positive histiocytosis of the breast with multiple lesions. There were no lesions in other organs, and the patient was considered surgically resectable and underwent a left total mastectomy and sentinel lymph node biopsy. Histopathologically, there were at least three lesions in the left breast in upper inner quadrant (UIQ), upper quadrant (UQ), and upper outer quadrant (UOQ). All lesions showed spindle-shaped tumor cells that were positive for CD163 and ALK and negative for AE1/AE3. Fluorescence in situ hybridization (FISH) showed ALK and KIF5B rearrangements, suggesting the presence of the KIF5B-ALK fusion gene. In conclusion, this case was confirmed to be ALK-positive histiocytosis with multiple lesions in the unilateral breast. The patient underwent surgery and was discharged without complications.
UNASSIGNED: Reports of ALK-positive histiocytosis are very rare, and reports of primary cases in the breast are even rarer. The basic treatment for ALK-positive histiocytosis is surgical resection; however, ALK inhibitors may be effective in unresectable or disseminated cases. Accurate diagnosis at the time of initial treatment is necessary to expand the treatment options.
CONCLUSIONS: This is the first case of ALK-positive histiocytosis with multiple lesions in the unilateral breast.

Cranial fasciitis (CF) is a rare, rapidly growing, benign fibroproliferative lesion of the skull in the pediatric population. It is characterized by benign mesenchymal proliferation of spindle cells arranged as short, intersecting loose fascicles within a fibromyxoid stroma, and mostly appears as a single mass. A surgical excision with clear surgical margins is definitively curative for CF. Up to date only two cases with multiple CF have been reported in the literature. In this report, we describe a 1-year-old girl with multiple locations of CF, as the first case to be reported in the Turkish population. The radiological and morphological findings of our case were comparable with the observations of the two previous reports in the literature. Histopathological examination remains to be the gold-standard for differential diagnosis of CF, as the treatment of this lesion differs from other malignancies of the skull in the pediatric population.

Paroxysmal sympathetic hyperactivity (PSH) is a neurological emergency mostly secondary to traumatic brain injury (TBI). Acute large vessel occlusion (LVO) in the posterior circulation with PSH as the initial manifestation is uncommon. It may lead to catastrophic consequences for patients if not detected and treated timely. Here, we present three patients with acute LVO in the posterior circulation with PSH as the initial symptom. All patients were male and averaged 63 years old. The PSH Assessment Measure (PSH-AM) scores of all cases were > 17. Brain imaging showed that multiple lesions in posterior circulation were involved in three patients. Although the prognosis of all patients was poor, PSH symptoms disappeared in all patients after endovascular treatment. These cases suggests that acute posterior circulation-related ischemic stroke should be considered with PSH occurring as the first symptom. Extensive disconnection due to multiple lesions in posterior circulation may play an important role in the occurrence and development of PSH. Endovascular treatment may be effective for PSH caused by acute posterior circulation-related ischemic stroke. This is worthy of further study in the future.

The encoder-decoder-based deep convolutional neural networks (CNNs) have made great improvements in medical image segmentation tasks. However, due to the inherent locality of convolution, CNNs generally are demonstrated to have limitations in obtaining features across layers and long-range features from the medical image. In this study, we develop a local-long range hybrid features network (LLRHNet), which inherits the merits of the iterative aggregation mechanism and the transformer technology, as a medical image segmentation model. LLRHNet adopts encoder-decoder architecture as the backbone which iteratively aggregates the projection and up-sampling to fuse local low-high resolution features across isolated layers. The transformer adopts the multi-head self-attention mechanism to extract long-range features from the tokenized image patches and fuses these features with the local-range features extracted by down-sampling operation in the backbone network. These hybrid features are used to assist the cascaded up-sampling operations to local the position of the target tissues. LLRHNet is evaluated on two multiple lesions medical image data sets, including a public liver-related segmentation data set (3DIRCADb) and an in-house stroke and white matter hyperintensity (SWMH) segmentation data set. Experimental results denote that LLRHNet achieves state-of-the-art performance on both data sets.

UNASSIGNED: Arterial deterioration is mostly caused by atherosclerosis, which progresses with age. However, we have observed serious backgrounds or etiologies in younger patients with non-atherosclerotic diseases and deterioration of small-to-medium-sized arterial lesions. Therefore, we aimed to identify the specific features of patients aged <40 years with deterioration of small-to-medium-sized arteries.
UNASSIGNED: We selected patients who were admitted to our department from 1995 to 2019 with deterioration of small-to-medium-sized arteries (aneurysms, dissection, rupture, or arterial injury/damage) and focused on the cohort aged <40 years. We examined the backgrounds or etiologies of the patients including genetic and inflammatory diseases, which might have caused the arterial deterioration.
UNASSIGNED: Consequently, more than half (54.1%) of the patients aged <40 years had non-atherosclerotic comorbid diseases. However, the number of deteriorated arterial lesions was higher in patients aged <40 years than in patients aged ≥40 years (3.13 vs. 1.33 lesion/patient; P = 0.011). Furthermore, the data analysis of patients with multiple arterial lesions (≥3) revealed that the younger population tended to have more specific backgrounds or etiologies, notably Ehlers-Danlos syndrome and Behçet\'s disease. There were no differences in the all-cause mortality and cardiovascular disease-related mortality between patients aged <40 and ≥40 years (P = 0.89 and 0.29, respectively).
UNASSIGNED: Over 50% of patients aged <40 years with deterioration of small-to-medium-sized arteries had non-atherosclerotic, specific clinical backgrounds or etiologies, including genetic and inflammatory diseases. In addition, they exhibited more arterial lesions than older patients.