Chronic contained rupture of an abdominal aortic aneurysm mimicking a retroperitoneal tumor

Chronic contained rupture of an abdominal aortic aneurysm (AAA) is a rare event that is difficult to diagnose due to the atypical and chronic symptoms. We report a case of chronic contained rupture of AAA mimicking a retroperitoneal tumor in a 36-year-old man. The patient presented with weight loss and chronic lower abdominal pain, and was referred to our clinic with a suspected retroperitoneal tumor. Abdominal computed tomography (CT) revealed a distinct mass measuring 15 x 10 x 10 cm in the left retroperitoneal space, involving the abdominal aorta. One week later he experienced sudden abdominal pain radiating to the back. He was subsequently diagnosed with ruptured AAA and aortic dissection. The patient received implantations of both common iliac arteries to the abdominal aorta using Y-grafts and an ascending-to-descending aortic graft in a two-stage operation. His recovery from surgery was uneventful.     

Apocrine carcinoma of the vulva in a band-like arrangement with inflammatory and telangiectatic metastasis via local lymphatic channels

BACKGROUND: Primary adenocarcinomas of the vulva have been classified as sweat gland carcinomas, extramammary Paget's disease, and primary breast carcinomas of the vulva. They share some common histopathologic features. METHODS: We describe a 72-year-old Japanese woman with apocrine carcinoma of the vulva and local lymphatic metastasis. RESULTS: The patient presented with a bruise on her inguinal area. Physical examination revealed a 4 cm x 7 cm, dark-red, irregularly elevated tumor on the left labium majora. Dome-shaped, flesh-colored, small papulovesicles were scattered on the abdomen, accompanied by erythema and induration. The lesion showed a band-like arrangement. General examination revealed multiple bone metastases, particularly in the spine. Microscopic examination revealed a moderately differentiated adenocarcinoma with signet ring cells. A few pagetoid clear cells were present in the hypertrophic epidermis. The peripheral papulovesicles demonstrated the same histopathologic view as in inflammatory and telangiectatic, metastatic breast carcinoma. Tumor cells were positive for various ductal and glandular markers. Estrogen and progesterone receptors were not expressed. Ultrastructural findings suggested differentiation towards apocrine or mammary glands because of the presence of an apocrine process and electron-dense mucous granules. The patient died in spite of combination chemotherapy and irradiation therapy. CONCLUSIONS: We report a rare case of apocrine carcinoma of the vulva in a band-like arrangement with local lymphatic metastasis which showed the clinical and histopathologic characteristics of inflammatory and telangiectatic carcinoma.     

Clinical effectiveness of the Prostar XL suture-mediated percutaneous vascular closure device following PCI: results of the Perclose AcceleRated Ambulation and DISchargE (PARADISE) Trial

BACKGROUND: The Prostar XL is a hemostasis device designed to percutaneously close the arterial puncture site with two nonabsorbable sutures. The Early Discharge and Economical effectiveness study for New hemostasis device (EDEN) trial, which was performed in Japan, showed that the Prostar XL device shortened time to hemostasis, time to ambulation and the average length of hospital stay, and decreased local vascular complications. However, the ooze of blood from the puncture site incision requires relatively longer time to ambulation. OBJECTIVES: The Perclose AcceleRated Ambulation and DISchargE (PARADISE) trial was performed to assess the effectiveness of the Prostar XL device on patient comfort, shortened time to ambulation and discharge from hospital by minimizing the oozing problem. METHODS: This multicenter, non-randomized registry was designed to compare times to hemostasis, ambulation and discharge, as well as the incidence of peripheral vascular complications in Prostar XL patients with the conventional manual compression group in the EDEN trial. Hydrochloride lidocaine containing 1% epinephrine was used as local anesthesia to reduce blood oozing. RESULTS: Between September 1999 and March 2000, a total of 109 patients were enrolled in this study. The closure device was successfully placed in 108 of 109 attempts. Time to hemostasis was significantly less than with the conventional manual compression group in the EDEN trial. Times to ambulation and discharge were significantly less than with the Prostar XL and conventional manual compression groups in the EDEN trial. CONCLUSION: We conclude that the Prostar XL device plus hydrochloride lidocaine containing 1% epinephrine as local anesthesia appears to be a safe and effective method to achieve hemostasis, and to improve times to ambulation and discharge after interventional procedures.     

Measurement of heterogeneous distribution on Technegas SPECT images by three-dimensional fractal analysis

This review article describes a method for quantifying heterogeneous distribution on Technegas (99mTc-carbon particle radioaerosol) SPECT images by three-dimensional fractal analysis (3D-FA). Technegas SPECT was performed to quantify the severity of pulmonary emphysema. We delineated the SPECT images by using five cut-offs (15, 20, 25, 30 and 35% of the maximal voxel radioactivity), and measured the total number of voxels in the areas surrounded by the contours obtained with each cut-off level. We calculated fractal dimensions from the relationship between the total number of voxels and the cut-off levels transformed into natural logarithms. The fractal dimension derived from 3D-FA is the relative and objective measurement, which can assess the heterogeneous distribution on Technegas SPECT images. The fractal dimension strongly correlate pulmonary function in patients with emphysema and well documented the overall and regional severity of emphysema.     

Appearance of rectal varices in extrahepatic portal obstruction after treatment for esophago-gastric varices: a case report

We report a case of rectal varices that developed after endoscopic injection sclerotherapy (EIS) and Hassab's operation for esophageal varices with extrahepatic portal obstruction. A 54-year-old woman was admitted to our hospital in September 1997 for treatment of hematochezia. Emergent colonoscopy revealed tortuous rectal varices with a white plug. Angiography revealed that rectal varices were provided with backward blood flow by the inferior mesenteric vein due to extrahepatic portal obstruction. In this case, previous treatment, EIS and Hassab's operation, for esophago-gastric varices might have inhibited the development of collaterals apart from surface of gastrointestinal tract, such as para-esophageal collateral veins or spleno-renal shunt. Since the thrombus in the extrahepatic portal vein causes strong pressure on inferior mesenteric vein which is connected to the inferior vena cava via the inferior rectal vein, rectal varices might be developed. In this case, it was considered that rectal varices were not treated enough by endoscopic therapy because of regurgitant hyper blood flow against portal venous pressure. Therefore, rectal transection was performed. After the treatment, the patient suffered no further episodes of bleeding from rectal varices.     

Receiver operating characteristic (ROC) analysis of images reconstructed with iterative expectation maximization algorithms

PURPOSE: The quality of images reconstructed by means of the maximum likelihood-expectation maximization (ML-EM) and ordered subset (OS)-EM algorithms, was examined with parameters such as the number of iterations and subsets, then compared with the quality of images reconstructed by the filtered back projection method. METHODS: Phantoms showing signals inside signals, which mimicked single-photon emission computed tomography (SPECT) images of cerebral blood flow and myocardial perfusion, and phantoms showing signals around the signals obtained by SPECT of bone and tumor were used for experiments. To determine signals for recognition, SPECT images in which the signals could be appropriately recognized with a combination of fewer iterations and subsets of different sizes and densities were evaluated by receiver operating characteristic (ROC) analysis. The results of ROC analysis were applied to myocardial phantom experiments and scintigraphy of myocardial perfusion. RESULTS: Taking the image processing time into consideration, good SPECT images were obtained by OS-EM at iteration No. 10 and subset 5. CONCLULSION: This study will be helpful for selection of parameters such as the number of iterations and subsets when using the ML-EM or OS-EM algorithms.     

Value of renal biopsy in the prognosis of liver transplantation in familial amyloid polyneuropathy ATTR Val30Met patients.

Liver transplantation for familial amyloid polyneuropathy (FAP) patients has been carried out worldwide and the outcomes seem to be promising. To clarify the severity of amyloid deposits on visceral organs, we evaluated the histopathological findings of biopsied renal and sural nerve specimens in 13 FAP patients with ATTR Val30Met by quantitative analysis, and compared them with the outcome of transplantation. Renal dysfunction with proteinuria seemed to correlate with the degree of amyloid deposits in glomeruli, not with that in medullary tissues. The severity of renal amyloid deposition did not consistently parallel that of myelinated nerve fiber loss in sural nerve. Three patients with proteinuria and severe amyloid deposits in glomeruli were considered to be unsuitable for transplantation. Ten patients underwent living donor liver transplantation and three resulted in unfavorable outcomes. These three had heavy amyloid deposits on renal tissues, especially in glomerular areas, but the severity of myelinated nerve fiber loss in their sural nerves was very similar to that in patients who made a good recovery. The prognosis after operation might be closely related to the severity of amyloid deposits in renal glomeruli. Renal biopsy is, therefore, recommended when determining the indications and contraindications for liver transplantation in FAP patients, although this biopsy is not routinely required.