Giant aneurysm of the abdominal aorta

A giant aneurysm of the abdominal aorta presented with a 2-3 h history of right loin pain radiating to the groin and was associated with microscopic haematuria. The pain settled and a urogram was performed 2 days later. Considerable calcification in its wall outlined a very large aneurysm of the abdominal aorta with a maximum transverse diameter of 13.5cm. The patient underwent successful emergency surgery, at which time a right-sided posterolateral rupture of the aneurysm was present. The patient remains alive and well 4 years later.     

Helical computed tomography in the assessment of abdominal aortic pathology

A pilot study was undertaken to evaluate the role of helical computed tomography in the assessment of abdominal aortic pathology. A total of 17 patients underwent intra-arterial digital subtraction angiography (IADSA) and helical computed tomography, with eight patients undergoing subsequent operative intervention. A comparison of radiological findings between IADSA and helical computed tomography (CT) was made and, where applicable, a comparison was made with operative findings. Pathology included abdominal aortic aneurysm (AAA) (n=12), thoracoabdominal aneurysm (n=2) and dissection (n=1), graft distension following AAA repair (n=1) and plaque haemorrhage in the distal aorta following percutaneous transluminal angioplasty (PTA) of the iliac artery (n=1). Planned operative management as based on pre-operative helical CT imaging findings, in particular with reference to the type of graft used (straight or bifurcated) was not changed at operation. Our findings on helical CT in regards to AAA, thoroco-abdominal aneurysm and dissection correlated well with angiography and surgery findings.     

Giant right coronary artery aneurysm – A rare presentation

Coronary artery aneurysm (CAA) is focal dilatation of a coronary artery 1.5 times or more its normal size (Res Cardiovasc Med, 2016; 5: e32086). Coronary artery aneurysm is found in 1.2–4.9% of diagnostic coronary angiography and 1.4% at post‐mortem (Heart Views, 2014; 15: 13; Clin Cardiol, 2015; 29: 439). The proximal and middle segments of the right coronary artery (RCA) are most commonly involved, followed by the proximal left anterior descending (LAD) and the left circumflex arteries. The left main stem rarely develops aneurysms (Clin Cardiol, 2015; 29: 439). A giant aneurysm is a CAA> 2 cm. Giant coronary artery aneurysms (GCAA) are rare (incidence 0.02%) although cause serious complications. [4] Given the rarity of this disease, there is limited information in the literature on its presentation and there is no consensus on its optimal management option. We report a case of a GCAA with an atypical presentation and describe its management. This will add to the current small database on CAA to provide clinicians a better insight on the disease.     

肾神经内分泌肿瘤1例并文献复习

目的:探讨肾神经内分泌肿瘤的临床特征和治疗方法。方法:本文报道了1例38岁的男性患者，2004年因右肾占位行“右侧根治性肾切除术”，术后病理显示右肾神经内分泌肿瘤。手术后患者未接受任何抗肿瘤治疗。2015年1月，患者出现腹部和腹膜后转移，然后在全身麻醉下于2015年3月4日进行腹部肿瘤切除，肿瘤的大小约为20 cm×8 cm×5 cm，位于下腔静脉及腹主动脉之间，后方达脊柱前缘。术后病理显示神经内分泌肿瘤G2（非典型类癌），该患者被诊断为复发性右肾神经内分泌肿瘤。奥沙利铂加卡培他滨方案于2015年5月27日开始。经过2个疗程评估后，腹膜后肿瘤再次出现。结果:因患者生长抑素受体显像结果呈阳性，因此我们将治疗方案改为醋酸奥曲肽20 mg肌肉注射，每4周一次，目前已接受29次注射，患者目前一般状况可，多次复查结果评为病情稳定（SD）。结论:肾神经内分泌肿瘤罕见，对于术后或化疗后复发的患者，可从生长抑素类似物治疗中获益。     

Sinus valsalva aneurysm on cardiac CT angiography: Assessment and detection

After the advent of ECG gated cardiac CT angiography (CCTA) there has been significant improvement in image quality of the ascending aorta. As a result the sinuses of valsalva are readily assessable. Sinuses of valsalva aneurysm can cause significant dysfunction of the aortic root and annulus and can be congenital or acquired. The aneurysm most commonly originates from the right coronary sinus. Complications related to sinuses of valsalva aneurysm can cause chest pain and can be life threatening. The cardiac imager should actively assess the sinuses of valsalva in every CCTA study.     

<Emphasis Type="Italic">Pseudomyxoma peritonei</Emphasis> secondary to epithelial appendicular neoplasms. Experience in a non-specialised centre

Introduction Pseudomyxoma peritonei is an infrequent entity, defined by collections of gelatinous material in the abdomen and pelvis and mucinous implants on peritoneum, secondary to the rupture of a mucinous lesion, usually of ovarian or appendiceal origin. Materials and methods We present our experience of 11 cases (6 males and 5 females) diagnosed with pseudomyxoma peritonei secondary to epithelial appendicular neoplasms over 27 years. The mean age of the patients was 68 years. Clinical manifestations were abdominal distension (55%), right lower quadrant pain (45%) suggesting acute appendicitis and constitutional syndrome (36%). An abdominal mass was detected at physical examination in 4 patients. CT scan revealed a tumour in right iliac fossa in 4 patients, peritoneal enlargement in 1 and a liquid collection in 1. Preoperative diagnosis was acute abdomen in 5 patients, peritoneal carcinomatosis in 3 and undetermined abdominal mass in 3. Results Surgical findings suggested pseudomyxoma peritonei in 8 patients and peritoneal carcinomatosis in 3. Appendicectomy was performed in 9 patients, and in 3 of them bilateral anexectomy was also performed. One patient underwent ileocaecal resection and another a right hemicolectomy. In all the cases, mucinous material was eliminated as much as possible. Pathology revealed mucinous cystoadenoma in 6 cases, mucinous cystoadenocarcinoma in 3 and epithelial hyperplasia in 2 patients. Median survival was 54 months, with a 5-year survival rate of 40%. The last case we treated was sent to a reference centre for the treatment of pseudomyxoma peritonei. Conclusions There is no consensus on the best treatment for pseudomyxoma peritonei. We recommend avoiding incomplete surgical resections in non-reference centres and submitting patients to a reference centre to undergo adequate treatment.     

Takayasu's Arteritis in Thailand

Takayasu's arteritis is a disease of protean manifestations and worldwide distribution. Geographic difference of the sex incidence, anatomical distribution and the type of lesion is observed. Hypertension is very common in the present series. A combination of absent or deficient peripheral pulses and hypertension is also commonly encountered. These symptoms correlate well with arteriographic findings of brachiocephalic and renal artery obstructive lesions. While aneurysm and stenotic lesions have a predilection for the abdominal aorta, the ascending aorta is commonly dilated and stenosis of the thoracic aorta occurs more often than aneurysm. However aneurysm of the aorta as well as of the brachiocephalic arteries is frequently more developed than in those reports of others. The presence of “funnel-shaped” or triangular configuration resulting from renal artery obstuctive lesions, prestenotic dilatation and/or contiguous aortic aneurysm is emphasized as the most likely characteristic of Takayasu's arteritis occurring in this part of the world. Extensive arterial involvement with evidence of lumbar and intercostal occlusion indicates the seventy of the disease. Total aortography is of value not only for the diagnosis of Takayasu's arteritis, but also for demonstration of the anatomical distribution, severity and type of the lesions.     

Abdominal wall infiltration by small bowel adenocarcinoma in a patient with Crohn's disease--a case report

A 46-year-old man with Crohn's disease was referred to our hospital. In 2007, abdominal pain accompanied by redness and swelling of the right lower quadrant developed. A small bowel series and computed tomography of the abdomen revealed a stricture in the terminal ileum, suggesting a penetration of the abdominal wall. He was transferred to the department of surgery, and the affected portion of the bowel was resected to eliminate the stricture. At laparotomy, the ileum 35 cm proximal to the ileocecal valve adhered to the abdominal wall in the right lower quadrant. The involved site of the ileal wall and a portion of the abdominal wall were resected. Postoperative microscopic examination revealed an invasion of the abdominal wall by an ileal adenocarcinoma; reoperation was therefore performed. Histopathological examination revealed an adenocarcinoma at the previously sutured site of the ileal wall, against a backdrop of Crohn's disease. The postoperative recovery was good, and the patient received chemotherapy. During follow-up, computed tomography and positron emission tomography demonstrated abnormal changes of the abdominal wall, suggesting a recurrence. He received radiotherapy of the abdominal wall. Although he had tentative regression, the patient died 1 year and 9 months after the first operation.     

Appendicitis: An unusual cause of infected abdominal aortic aneurysm

An unusual case of appendicitis, which presented as an infected aortic aneurysm is described. Gas was noted in the wall of the aneurysm on abdominal radiographs and computed tomography, due to the formation of an appendico-aortic fistula. Computed tomography also demonstrated a contained rupture of the aneurysm.     

Fatal Clostridium septicum myonecrosis

A 20 year old leukaemic patient with neutropaenia secondary to chemotherapy, who developed overwhelming sepsis, myonecrosis, vascular occlusion and necrotizing enterocolitis due to Clostridium septicum infection is described. Plain abdominal radiographs and a computed tomography scan of the abdomen and pelvis showed gas in the retroperitoneal soft tissues. Clostridium septicum septicaemia has a recognized association with malignancy and neutropaenia and has a high mortality if not diagnosed and treated early. Computed tomography scanning of the abdomen, pelvis and head is advised in any patient with a positive C. septicum blood culture.     

Secondary Malignant Peritoneal Mesothelioma of the Greater Omentum after Therapy for Primary Pleural Mesothelioma

Mesothelioma is the most common malignant primary tumor of the pleura and usually associated with inhalation of asbestos fibers. In contrast, peritoneal mesothelioma is a rare entity whose pathomechanism is not yet fully understood. The coexistence of pleural mesothelioma with secondary involvement of the abdominal cavity has not been addressed in the literature. In this case report, we describe secondary malignant mesothelioma of the greater omentum. A 69-year-old man with histologically proven pleural mesothelioma on the right side and no past medical history of asbestos exposure received palliative treatment consisting of a talc pleurodesis. After a 6-month interval of stable disease, a local progressive tumor of the right pleura was seen on a CT scan. Eleven months later, during follow-up, the patient presented at our emergency department with a sudden onset of diffuse abdominal pain. Abdominal ultrasound revealed a mass within the greater omentum and the coexistence of free fluid. Subsequent abdominal CT scans demonstrated tumor infiltration from the right pleura by a transdiaphragmatic route into the abdomen, where diffuse infiltration of the greater omentum was observed. Aspiration of the ascites and the biopsy of the greater omentum confirmed the diagnosis of secondary malignant mesothelioma of the peritoneum. In conclusion, we present the extremely rare diagnosis of secondary malignant mesothelioma of the abdomen, which arose as a result of local progression from the right pleura into the abdomen.Key words: Secondary malignant mesothelioma, Pleural mesothelioma, Greater omentum     

Right iliac fossa abscess as first manifestation of perforated adenocarcinoma of sigmoid: a rare case report

Colorectal cancer usually present with known symptoms while there are less common manifestation including abscess formation which can be intra or extra peritoneal. A 60-year-old Caucasian male with a history of RLQ abdominal pain, nausea, vomiting and anorexia from 15 days ago referred to surgery ward. Ultrasound showed a hypoachoic lesion with diameters 50 mm × 70 mm in RLQ of abdomen and a round echogenic area in right lobe of liver with diameter 15 mm. The findings were revealed an abscess located in right iliac fossa then local drainage of abscess was performed. Four days later the patient was re-admitted because of severe abdominal distention and lack of bowel movement. Laparoscopy was performed before proceeding with further examinations, due to the poor general condition of the patient. The sigmoid was adherent into the abdominal wall and mild intestinal loop distention and apple-core view was observed during operation. Cancer of sigmoid complicated by a right iliac fossa abscess was diagnosed and Hartman colestomy was undertaken. At the last follow-up examination 3 months after operation, the patient was in good health with no clinical evidence of recurrence.     

Identification of somatic APC mutations in recurrent desmoid tumors in a patient with familial adenomatous polyposis to determine actual recurrence of the original tumor or de novo occurrence

A 25-year-old female with familial adenomatous polyposis (FAP) presented with an abdominal tumor just below the scar due to a colectomy performed 15 months previously. This tumor (tumor A) measured 7 cm in diameter, was diagnosed as a desmoid tumor of the abdominal wall, and was excised. Despite the subsequent administration of sulindac (300 mg daily for 1 year), a desmoid tumor recurred at the same site. Excision was performed again when the tumor was 8 cm in diameter, and examination revealed it to consist of a large tumor (B) and a small tumor (C) that bulged out from tumor B. Germ-line APC analysis showed a C deletion at codon 1460 resulting in a stop codon. Two somatic mutations were observed in tumor A: a TCAA deletion at codon 1068 and a deletion of a codon at bp 1192–2097. In tumor B, a somatic mutation was found at codon 1041 changing CAA to TAA. We could not detect any somatic mutations in tumor C. We conclude that somatic mutation analysis of the APC gene can be used to identify whether a recurrent desmoid tumor in a patient with FAP is a new primary tumor or a recurrence from microscopic remnants of the original tumor.     

A case of adrenal myelolipoma with colonic cancer and gallstones

A 47-year-old female, referred to Kushiro Rohsai Hospital because of upper abdominal pain on January 10, 1986, was found to have a gallbladder stone on X-ray examination of her abdomen. On admission, the occult blood found in her stool was strongly positive and a barium enema and a colonoscopy showed an elevated lesion in the caecum. Subsequently, a diagnosis of a colonic cancer was made after a biopsy. Sonography and CT scans revealed a gallbladder stone and a right suprarenal mass 4 cm in diameter. At surgery, this gallbladder stone was found, as was a Borrman II type tumor in the caecum. The surface of an adrenal mass was hard and smooth and a cut of this surface showed a yellowish gray color. Microscopic examination revealed adrenal cortical tissue beneath the capsule with a mixture of hematopoietic and adipose tissue. These findings were compatible with myelolipoma. Postoperatively, a bone marrow aspiration was performed, but no definite abnormality was detected.     

Assessment of a single-pass venous phase CT chest,abdomen and pelvis and dual-energy CT in general oncology outpatients

Introduction

This study assessed replacing traditional protocol CT-arterial chest and venous abdomen and pelvis, with a single-pass, single-bolus, venous phase CT chest, abdomen and pelvis (CAP) protocol in general oncology outpatients at a single centre.

Methods

A traditional protocol is an arterial phase chest followed by venous phase abdomen and pelvis. A venous CAP (vCAP) protocol is a single acquisition 60 s after contrast injection, with optional arterial phase upper abdomen based on the primary tumour. Consecutive eligible patients were assessed, using each patient's prior study as a comparator. Attenuation for various structures, lesion conspicuity and dose were compared. Subset analysis of dual-energy (DE) CT scans in the vCAP protocol performed for lesion conspicuity on 50 keV virtual monoenergetic (VME) images.

Results

One hundred and eleven patients were assessed with both protocols. Forty-six patients had their vCAP scans using DECT. The vCAP protocol had no significant difference in the attenuation of abdominal structures, with reduced attenuation of mediastinal structures. There was a significant improvement in the visibility of pleural lesions (p < 0.001), a trend for improved mediastinal nodes assessment, and no significant difference for abdominal lesions. A significant increase in liver lesion conspicuity on 50 keV VME reconstructions was noted for both readers (p < 0.001). There were significant dose reductions with the vCAP protocol.

Conclusion

A single-pass vCAP protocol offered an improved thoracic assessment with no loss of abdominal diagnostic confidence and significant dose reductions compared to traditional protocol. Improved liver lesion conspicuity on 50 keV VME images across a range of cancers is promising.     

A low-grade myofibroblastic sarcoma in the abdominal cavity

Low-grade myofibroblastic sarcoma (LGMFS) is a fusiform cell tumor which develops in bone or soft tissues. This type of tumor frequently occurs in the oral cavity and extremities, while it is extremely rarely found in the abdominal cavity. This article reports a case of LGMFS exceeding 20 cm in diameter in the abdominal cavity observed in a 65-year-old male patient. The patient visited our hospital complaining of a heavy feeling of the stomach and abdominal distension. Imaging examinations revealed a giant solid tumor in the abdomen, and surgical treatment was scheduled. During the operation, a tumor about 20 cm in diameter with its anterior aspect covered with the greater omentum was found. The tumor had firm adhesions to the surrounding tissues, and it was excised with concomitant resections of the tail of the pancreas and the spleen. Histopathologically, fusiform cells were arranged in a complicated or storiform pattern, and immunohistochemical staining revealed that the tumor was positive for α-smooth muscle actin, negative for S100β, H-caldesmon and c-KIT, and a diagnosis of LGMFS was made.     

Abdominal Aortic Aneurysm with Perianeurysmal Fibrosis: Demonstration of Ureteric Obstruction by Computerized Tomography

When perianeurysmal fibrosis occurs in association with an abdominal aortic aneurysm it may produce ureteric obstruction and renal function impairment. Such a case is described and the pre-operative radiological evaluation of this condition is discussed. The role of computerized tomography is emphasized in its ability to provide accurate anatomical detail regarding the aneurysm, the extent of surrounding fibrosis and ureteric involvement within it.     

The CT Appearances of Ruptured Abdominal Aortic Aneurysms

There is no place for investigative CT scans in patients who have the classical triad of abdominal aortic aneurysm rupture, namely excruciating abdominal pain or backache, a pulsatile mass and hypotension. These patients require immediate surgery. However, in the absence of this triad, CT scans play an important role in the diagnosis of abdominal aortic aneurysm rupture. The CT scan findings will dictate whether the patient requires immediate surgery as in the case of acute rupture, or, whether the surgery can be delayed up to 24 hours to allow for stabilisation and hydration, as in the case of subacute and chronic rupture.     

球囊导管腹主动脉阻断术在骶骨肿瘤术中的并发症及其预防

目的 观察并预防骶骨肿瘤术中应用球囊导管腹主动脉阻断术的并发症。方法 对17例骶骨肿瘤患，使用双腔球囊导管，于肾动脉远端处阻断腹主动脉段。每次充盈阻断时间为45min，间歇10min。监测是否发生肾动脉阻断与急性肾功能衰竭、腹主动脉或髂总动脉损伤、再灌损伤与肾功能损害、穿刺局部巨大血肿、下肢静脉血栓形成等并发症。结果 本组病例发生穿刺局部血肿1例，未发生急性肾功能衰竭、下肢静脉血栓形成、肢体远端缺血坏死、腹主动脉及骼总动脉损伤等并发症；所有病例随访6个月～24个月，未发生腹主动脉壁血栓形成或腹主动脉瘤。结论 只要严密观察和预防并发症，球囊导管腹主动脉阻断术安全、可靠。