Successful resection of cardiac metastatic liposarcoma extending into the SVC, right atrium, and right ventricle

Cardiac metastatic liposarcoma is a rare tumor. We report a case of successful resection of a cardiac metastatic liposarcoma extending into the superior vena cava (SVC), right atrium, and right ventricle. Using cardiopulmonary bypass (CPB) by venous cannulation of the upper portion of the SVC and inferior vena cava (IVC), the intracardiac tumor was completely resected. Surgical resection with the addition of radiotherapy prolonged the patient's life.     

Case of autosomal dominant polycystic kidney disease associated with congenital hepatic fibrosis

A 31-year-old man was admitted to the hospital because of a low-grade fever, general malaise, nausea, vomiting, and a poor appetite. On admission his renal function was severely deteriorated (serum creatinine 16.12 mg/dl, BUN 163 mg/dl), and he had severe anemia (Hb 7.5 g/dl) and thrombocytopenia (67,000/microl). A radiological examination revealed the presence of multiple cysts in his kidneys bilaterally. The patient was diagnosed as having end-stage renal disease due to polycystic kidney disease, and hemodialysis was started on the day of admission. After the initiation of hemodialysis, his symptoms and laboratory tests improved, except for anemia and thrombocytopenia. He was noted to have marked splenomegaly and dilation of the portal vein, raising the suspicion of portal hypertension as the cause of the splenomegaly and pancytopenia. To treat his pancytopenia (anemia and thrombocytopenia) and to determine the reason for his portal hypertension, a splenectomy and open-wedge biopsy of the liver were performed. Histological findings in the liver included extensive fibrosis of the portal areas with an excess of moderately dilated bile ducts, compatible with a diagnosis of congenital hepatic fibrosis. After splenectomy, his red blood cell and platelet counts returned to normal, and he was discharged on maintenance dialysis. Congenital hepatic fibrosis is often associated with autosomal recessive polycystic kidney disease (ARPKD), but not with autosomal dominant polycystic kidney disease (ADPKD). However, both his mother and older brother had multiple renal cysts, indicating that this was an unusual case of ADPKD complicated by congenital hepatic fibrosis.     

Airway compression by the ascending aorta due to a thin thoracic cage

An 89-year-old woman with dyspnea and disturbed consciousness due to hypoventilation was admitted to our hospital. Chest radiography showed no abnormal shadow, but she was intubated for deteriorated hypoventilation. Bronchoscopy demonstrated obstruction of the left main bronchus at the carina. Computed tomography (CT) showed neither a mass lesion in the mediastinum nor an aortic aneurysm, but compression of the airway by the ascending aorta was observed. It was thought that the patient’s thin thoracic cage was unable to support the weight of the ascending aorta, which consequently compressed the left main bronchus. After inserting stents into both main bronchi, the patient’s consciousness improved, and respirator support was withdrawn. In aged, bedridden, thin patients with hypopnea or recurrent airway infection, CT and bronchoscopy should be performed to investigate airway patency.     

Successful video-thoracoscopic drainage for descending necrotizing mediastinitis

Descending necrotizing mediastinitis (DNM) is a rare but severe disease with a high mortality rate. We report a case of a 77-year-old woman with DNM who was treated using video-thoracoscopic drainage and a Blake drain. She was admitted to our hospital with a 3-day history of a sore throat. Computed tomography (CT) revealed a peritonsillar abscess descending into the anterior and posterior mediastinum below the carina. She was diagnosed with DNM, and emergency surgery was performed. The mediastinal abscess was drained via video-thoracoscopy, and a 24F Blake drain was inserted into the mediastinum. Following mediastinal drainage, cervical drainage was performed for treatment of the retropharyngeal abscess. The outcome of videothoracoscopic mediastinal drainage was satisfactory, and no further invasive treatment was required. We believe that video-thoracoscopic mediastinal drainage is an effective, minimally invasive treatment for DNM with subcarinal spread. Blake drains are useful for mediastinal drainage.     

Apparent diffusion coefficients of breast tumors: clinical application.

PURPOSE: To evaluate the usefulness of apparent diffusion coefficient (ADC) for the differential diagnosis of breast tumors and to determine the relation between ADC and tumor cellularity. MATERIALS AND METHODS: One hundred and thirty-six female patients (age range, 17-83 years; average age, 51.7 years) with 140 histologically proven breast tumors underwent diffusion-weighted magnetic resonance (MR) imaging (DWI) using the spin-echo echo-planar technique, and the ADCs of the tumors were calculated using 3 different b values, 0, 500, and 1000 s/mm(2). The diagnoses consisted of fibroadenoma (FA, n=16), invasive ductal carcinoma, not otherwise specified (IDC, n=117), medullary carcinoma (ME, n=3) and mucinous carcinoma (MU, n=4). Tumor cellularity was calculated from surgical specimens. The ADCs of breast tumors and cellularity were compared between different histological types by analysis of variance and Scheffe's post hoc test. The correlation between tumor cellularity and ADC was analyzed by Pearson correlation test. RESULTS: Significant differences were observed in ADCs between FA and all types of cancers (P<0.05) and between MU and other types of cancers (P<0.01) and in cellularity between FA and cancers except MU (P<0.01) and between MU and other types of cancers (P<0.01). There was an inverse correlation between ADC and tumor cellularity (P<0.01, r(2)=0.451). CONCLUSIONS: The ADC may potentially help in differentiating benign and malignant breast tumors. Tumor ADC correlates inversely with tumor cellularity.     

Stent Fracture and Reocclusion After Placement of a Single Self-Expanding Stent in the Common Iliac Artery and Endovascular Treatment

We present a case of fracture of a single self-expanding stent placed in the common iliac artery (CIA). An 80-year-old woman underwent placement of a self-expanding stent for CIA occlusion. Stent fracture and reocclusion were detected after 18 months. Successful revascularization was achieved using a stent-in-stent maneuver. The possibility of stent fracture with reocclusion should be considered following treatment with a single self-expanding stent for CIA occlusion.     

Transarterial Chemoembolization Using Cisplatin Powder in a Rabbit Model of Liver Cancer

The purpose of this study was to investigate the pharmacological advantages of transarterial chemoembolization (TACE) with cisplatin powder for hypervascular hepatic tumors in animal experiments. VX2 tumors were transplanted to the livers of nine rabbits. Cisplatin (1 mg/kg) was infused into the proper hepatic artery. In the cisplatin-HAI group, cisplatin solution was infused. In the cisplatin-GS-TACE group, after infusion of cisplatin solution, gelatin sponge particles were used for embolization. In the cisplatin-Lp-TACE group, after infusion of a cisplatin powder and lipiodol (10 mg/ml) suspension, gelatin sponge particles were used for embolization. Before and after administration, platinum concentrations in plasma were measured. Using liver specimens that were excised 60 min after infusion, platinum concentrations in tumorous and nontumorous liver tissues were measured. The mean platinum concentration in tumorous tissue was 0.88 μg/ml for the cisplatin-HAI group, 1.23 μg/ml for the cisplatin-GS-TACE group, and 12.65 μg/ml for the cisplatin-Lp-TACE group. The platinum concentration for the cisplatin-Lp-TACE group was significantly higher than that for the cisplatin-HAI group (p = 0.004) and the cisplatin-GS-TAE group (p = 0.004). The mean platinum concentration in nontumorous liver tissue was 0.98 μg/ml for the cisplatin-HAI group, 1.13 μg/ml for the cisplatin-GS-TACE group, and 1.09 μg/ml for the cisplatin-Lp-TACE group; no significant differences were seen. At both 5 and 10 min after infusion, the platinum concentrations for the cisplatin-Lp-TACE group were lower than those for the other two groups. The present results suggest that TACE using cisplatin powder/lipiodol suspension and gelatin sponge for hypervascular hepatic tumors has a number of pharmacological advantages. This material was presented at 2007 CIRSE.     

Characterization of K-ras gene mutations in association with mucinous hypersecretion in intraductal papillary-mucinous neoplasms

Background/Purpose Intraductal papillary-mucinous neoplasms (IPMNs) of the pancreas have a favorable prognosis. However, invasive ductal carcinomas of the pancreas show a rapid progression. The aim of this study was to investigate gene mutations in pure pancreatic juice from IPMN patients and to define these genetic mutations in relation to the histopathological and clinical features of IPMNs. Methods Twenty-two patients with IPMN, 21 patients with ductal carcinoma, and 20 patients with normal pancreas or chronic pancreatitis were recruited for this study. We measured the main pancreatic duct’s largest diameter and the maximum size of a dilated branch was assessed by ultrasonography or endoscopic ultrasonography. Pure pancreatic juice was collected and was investigated for K-ras, p16, and p53 mutations. Results Mutant K-ras gene was detected in 13 of the 22 patients (59.1%) with IPMNs. Different kinds of mutations were detected in the same patient in 4 cases. In the 13 patients with mutant K-ras gene, the diameter of the most dilated part of the main pancreatic duct was 2–8 mm (average, 4.5 mm) and in 7 patients with wild-type K-ras gene, the diameter was 2–5 mm (average, 2.7 mm). There was a significant difference in the diameter of the main pancreatic duct between patients with and without the mutant K-ras gene (P = 0.0323). Conclusions The incidence of K-ras mutation may be associated with the hypersecretion of mucin.     

Distribution of an explanatory note concerning the risks of anesthesia prior to preanesthetic evaluation

To make the public aware of the risks of anesthesia, we prepared an explanatory note composed of 634 Japanese characters or of 248 English words. The incidences of fatal anesthetic complications over a five-year period in 2,358,642 anesthetics in 741 Certified Training Hospital belonging to the Japanese Society of Anesthesiologists were cited in the explanatory note. Patients were asked to read and sign the explanatory note prior to agreeing to surgery. After patients having received this general information about surgical and anesthesia risks, surgeons then apply to the Department of Anesthesiology for their anesthetic management. Thereafter, responsible anesthesiologists visit and evaluate patients, and explain common as well as specific anesthesia risks to each patient. A survey by mailing questionnaires regarding this explanatory note and anesthesia risks sent to patients, who had read and signed the explanatory note, revealed that the patients were generally satisfied with the content of the explanatory note. This system may help patients, surgeons and anesthesiologists to recognize anesthesia risks on the same basis.     

Clinicopathological prognostic factors and impact of surgical treatment of mass-forming intrahepatic cholangiocarcinoma

The clinicopathological characteristics relevant to prognosis after surgical treatment of intrahepatic cholangiocarcinoma (ICC) remain unclear. In this study, the clinicopathological features of 19 patients with mass-forming ICC, the most common form of the disease, were reviewed to analyze prognostic determinants. Two or more segmentectomies of the liver with systematic lymphadenectomy were performed in 18 patients. Resection of the extrahepatic bile duct was performed in 14 patients, and reconstruction of the portal vein was accomplished in 5 patients. Stage IVA or IVB tumors were seen in 13 patients, and lymph node (LN) metastasis was present in 14 patients. The estimated 5-year survival rate after surgery for mass-forming ICC was 28%, with median survival time of 18 months. In univariate analysis, five variables were determined to be significantly correlated with poor survival of patients with mass-forming ICC after surgery. These variables include mass-forming ICC with periductal infiltration, perineural invasion, portal vein invasion, presence of intrahepatic metastasis, and two or more LN metastases. Survival rates of 5 patients without LN metastasis and 6 patients with a single LN metastasis were 80% and 33% at 5 years, respectively, while 8 patients with two or more LN metastasis failed to survive beyond 2 years. Multivariate analysis revealed the presence of intrahepatic metastasis to be an independent prognostic factor of poor survival. Hepatectomy with resection of the extrahepatic bile duct and systematic lymphadenectomy yields a good chance for prolonged survival for patients with mass-forming ICC when the lesion is singular and LN metastasis is limited to a regional LN. Because the presence of intrahepatic metastasis was closely related to a poor prognosis in patients with mass-forming ICC, efficacious chemotherapy would be needed to control development of the lesion.