Background:We experienced a very rare case of breast cancer in which ossification became apparent during neoadjuvant chemotherapy（NAC）. 　Case: A 74-year-old female. Mammography revealed a lobulated, high-density mass in the left U/O region that was diagnosed as category 4. Ultrasound revealed two irregular, poorly defined hypoechoic masses measuring 28 mm and 25 mm in the left C and EA regions, respectively. MRI also revealed two masses with contrast enhancement in the same region. Core needle biopsy revealed invasive micropapillary carcinoma, ER-, PgR-, HER2 3+. As NAC, 4 cycles of pertuzumab + trastuzumab +docetaxel were administered, followed by 4 cycles of AC. On the mammogram after NAC, a decrease in density and the appearance of large coarse calcification were observed. On ultrasound, the posterior echo disappeared in the same area as the tumor. On contrast-enhanced ultrasound, enhancement was seen around the tumor. On MRI, a gradual contrast enhancement effect was seen around the tumor.The RECIST assessment was cPR. Bt+Ax（II）surgery was then performed. The histopathological diagnosis was invasive ductal carcinoma, 0.6cm, n0, ER0, PgR0, HER2 3+, Grade 2b.
　Conclusion:Though ossification is often involved in breast cancer, in this case calcification increased during preoperative chemotherapy along with tumor shrinkage. This phenomenon is extremely rare.

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　When multiple fine strong echoes are observed diffusely in the thyroid, diffuse sclerosing subtype or intraglandular dissemination of papillary carcinoma should be suspected. However, such echoes can also be found in benign conditions, including Graves' disease. A case of Graves' disease with multiple fine strong echoes observed diffusely in the thyroid is presented in this case report. The patient was a man in his 40s. Six months before his first visit to our hospital, he was diagnosed as having Graves' disease and was treated with potassium iodide. Ultrasonography revealed mild diffuse enlargement of the thyroid gland and multiple fine strong echoes in the left lobe of the thyroid without any nodules. Fine-needle aspiration cytology revealed a benign cytological appearance. Pathological examination of the excised specimen revealed a papillary carcinoma with a maximum diameter of 8mm in the left lobe and a papillary carcinoma with a diameter of 2mm in the right one. Numerous disseminated papillary carcinomas were observed in the left lobe and the pyramidal lobe, but most of the dissemination consisted of psammoma bodies with few cancerous cells. Since no tumor embolization was observed in the dilated lymph vessels, the diffuse sclerosing subtype of papillary thyroid carcinoma was denied. The multiple fine strong echoes observed in this patient were considered to represent psammoma bodies. It is generally difficult to determine by ultrasonography whether multiple fine strong echoes observed diffusely in the thyroid are due to papillary carcinoma or to benign conditions such as calcium oxalate crystals. Careful observation is required since fine-needle aspiration cytology may not prove papillary carcinoma.

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　Annual breast Dynamic contrast-enhanced MRI（DCE-MRI）screening is recommended for women with hereditary breast and ovarian cancer（HBOC）.The term “MRI-targeted US”is used when US follows the DCE-MRI examination, particularly if previous US has not always been performed. We report a case of a female in her forties diagnosed with breast cancer by MRI-targeted US during surveillance in a BRCA2 mutation carrier. She had a family history of breast cancer with her father and paternal aunt affected. Her genetic test result revealed the same BRCA2 pathogenic mutation that her paternal aunt carried. We performed annual mammogram, ultrasound, and DCE-MRI examinations for surveillance. DCE-MRI showed a round, circumscribed mass with rim enhancement in the left breast in the posterior position 3 years after initial surveillance. A graph of the kinetic curve from the mass confirmed a “fast”initial and delayed“washout”enhancement pattern. The assessment was suspicious（BIRADS^®category 4）.MRI-targeted US revealed an oval, circumscribed, hypoechoic mass, measuring 1.0×0.9×0.4cm, in the left breast at 4:00. The depth-width ratio was 0.82. The assessment was probably benign（JABTS diagnostic US category 3a）.MRI-targeted US showed probably benign features; however, the mass was newly detected on surveillance DCE-MRI and therefore it was decided to proceed with US-guided vacuum assisted biopsy. The histopathology revealed invasive carcinoma of no special type, ER/PR positive, HER-2 negative. Several papers have reported that hereditary breast cancers appear atypical and benign in nature in US mammography. We found that DCE-MRI played an important role for surveillance a woman with HBOC. Such a benign appearance in MRI-targeted US reminds us that, in any new-onset breast lesion in DCE-MRI in women with HBOC, the suspicion of breast cancer should be raised.

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　A fibrotic focus（FF）is a scar or radial fibrosis located in the center of a tumor that is composed mainly of collagen fibers and fibroblasts. The presence of FFs has long been reported to reflect the grade of invasive ductal carcinoma of the breast and is a useful clinicopathological parameter for predicting the prognosis of patients with breast cancer. We reviewed breast ultrasound（US）images and postoperative histopathology specimens of two patients with invasive ductal carcinoma of the breast with FFs located in the center of the mass.
　Analysis of US images and postoperative histopathological specimens showed that the echo level was higher than that of the marginal area on US images in both patients, consistent with the FF forming in the central part of the mass. The histopathology specimens showed collagen fibers, numerous fibroblasts, tumor cells, inflammatory cells, and stromal mucus in the FF.
　We conclude that the presence of scatterers of a different nature along with collagen fibers inside the FF causes backscatter in US images, increasing the internal echo level.
　Reports indicate that breast cancer with FF shows high tumor aggressiveness and proliferative activity that is accompanied by high tumor angiogenesis. Furthermore, it has been shown that the number of microvessels in a tumor forming an FF increases significantly from the tumor center to the periphery, and that tumor angiogenesis in this peripheral region is associated with the prognosis. The difference in the echo level between the center and edge of the mass observed in this case may reflect the number of microvessels in the tumor as well as the presence or absence of FF due to backscatter.
　The higher echo level in the center of a hypoechoic mass compared to that of the margins on US imaging may be associated with FF,indicating high malignancy and poor prognosis. This may also signify fewer microvessels in the center of the mass and tumor angiogenesis at the tumor margins.

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[in Japanese]

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　Ultrasound-guided fine-needle aspiration biopsy（UG-FNAB）is an essential diagnostic modality for thyroid nodules. Although it is minimally invasive and generally safe, rare but serious complications have been reported. 　We present the case of a woman in her 50s with Graves’disease who was receiving medical treatment. Neck ultrasonography revealed two hypoechoic nodules with irregular margins, measuring 9mm and 5mm, located in the thyroid isthmus, and UG-FNAB was performed. At the time of the procedure, thyroid function tests showed subclinical hypothyroidism, and the patient was not on anticoagulant therapy. 　Approximately two hours after the procedure, she noticed neck swelling and returned to the hospital. Physical examination revealed diffuse cervical swelling, and ultrasonography demonstrated isoto hyperechoic changes around the nodules, suggestive of hematoma formation. She was admitted for close observation. The swelling gradually worsened, and six hours after FNAB, she developed progressive dyspnea and hoarseness. Fiberoptic laryngoscopy revealed marked bilateral arytenoid edema, necessitating emergent nasotracheal intubation. On the following day, surgical evacuation of the hematoma, total thyroidectomy, and tracheostomy were performed.

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[in Japanese]

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[in Japanese]

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[in Japanese]

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