[Breast and Advanced Ovarian Double Cancer with a BRCA2 Pathogenic Variant-A Case Report].

A 49-year-old woman presented with abdominal pain. A computed tomography scan revealed a left breast mass with suspected peritoneal dissemination. She had no notable family history of the disease. Following a detailed examination, she was diagnosed with ovarian cancer(Stage ⅢC)and left breast cancer(Stage Ⅰ). After confirming the diagnosis of ovarian cancer with a laparoscopic biopsy, neoadjuvant chemotherapy was scheduled. Due to its efficiency in reducing tumor burden, debulking surgery was also performed. While receiving adjuvant chemotherapy for ovarian cancer, concomitant anastrozole was administered for breast cancer. A pathogenic variant of BRCA2 was subsequently identified. Once adjuvant chemotherapy for ovarian cancer had been completed, a left mastectomy and sentinel lymph node biopsy were performed as management for breast cancer. The patient will continue treatment with anastrozole for breast cancer and olaparib for ovarian cancer and will be followed up appropriately.

Ruptured Abdominal Aortic Aneurysm with a Duplicated Inferior Vena Cava.

We report a very rare case of a ruptured abdominal aortic aneurysm (AAA) with an anomaly of the inferior vena cava (IVC). The AAA was covered with a large hematoma and an expanded vein was on its left side. It was not until we could not locate the IVC on the right side of AAA that we recognized the anomaly during the operation. Although we reviewed the findings on enhanced computed tomography, we were confused whether the case was a duplicated or left-sided IVC. Subsequently, a bifurcated vascular prosthesis was implanted without ligation of the left renal vein to join the left-sided IVC.

Ruptured Deep Femoral Artery Aneurysm Confused with an Incarcerated Inguinal Hernia: a Case of an Elderly Patient.

Deep femoral artery (DFA) aneurysms are rare. DFA is protected by the adductor canal, which may delay the diagnosis. Then, its early diagnosis may be difficult and it is possible to be misdiagnosis with incarcerated inguinal hernia, which occurs more often in elderly people. We report a very rare case of a treatment of an advanced elderly patient with an isolated ruptured DFA aneurysm that was preoperatively confused with an incarcerated inguinal hernia. A 97-year-old man was admitted to a neighboring hospital due to a painful mass of the right groin after transient consciousness loss and the patient was diagnosed with right incarcerated inguinal hernia by a nonenhanced computed tomography (CT). Although he was observed for 3 days, he suddenly lost consciousness again with a decrease in blood pressure. Thus, he was referred to our hospital due to the painful pulsatile inguinal mass after resuscitation from shock. As we diagnosed a ruptured DFA aneurysm by an enhanced CT, we emergently performed an excision of the aneurysm with revascularization of the right DFA. The postoperative course was uneventful without ischemic change of the lower leg.

A Case of Heparin-Induced Thrombocytopenia Type 2 after Repair of Juxtarenal Abdominal Aortic Aneurysm.

Heparin-induced thrombocytopenia (HIT) is still a relatively uncommon condition and it is not well known how to administer argatroban during continuous hemodiafiltration (CHDF). A 72-year-old man required CHDF with heparin because of the oliguria and hyperpotassemia directly after the open repair of a juxtarenal abdominal aortic aneurysm. As the postoperative blood platelet count dropped and there was a thrombus in the CHDF circuit, HIT was suspected and nafamostat mesilate, but not heparin, was immediately administered for CHDF. As heparin-platelet factor 4 complex was positive, we diagnosed him with HIT and started argatroban while monitoring the activated clotting time (ACT), resulting in no further obstruction of the CHDF and an increase in the platelets. There was no disadvantage for administering nafamostat mesilate which we have commonly used instead of heparin, we should have used argatroban once we suspected HIT. It may be important to consider the history of heparin especially in administering heparin and it may be useful to monitor the ACT when initially starting argatroban for patients with HIT.

A Case of True Brachial Artery Aneurysm with Severe Left Upper Limb Ischemia.

Brachial artery (BA) aneurysms are rare, and most are false aneurysms. Although true BA aneurysms have been reported, most have been reported without symptoms. A 65-year-old man was referred due to a left upper limb mass with rest pain and slight ulceration of the left second and third fingers. As enhanced computed tomography revealed the patency of only the left proximal and distal BA as well as the thrombosed mass, excision of the aneurysm and BA replacement were performed with a great saphenous vein graft. The postoperative course was uneventful, and the rest pain and ulceration were resolved.

Revascularization for acute blunt popliteal artery injury.

Case: A 45-year-old man was brought to our hospital in pre-shock after falling from a motorcycle. As we diagnosed him with open fracture of the right femur with leg ischemia, we performed revascularization of injured popliteal artery and treated the leg. The pathological findings showed fragmentation and decrease of elastic fibers and fragmentation of collagen fibers, but no inflammatory cells or intimal hyperplasia, and no dissection. Outcome: Unfortunately, amputation had to be carried out on the 29th postoperative day due to infection and leg dysfunction. The postoperative course was uneventful. The patient could walk with an artificial leg and was discharged approximately 5 months after popliteal artery replacement. Conclusions: We report a case of revascularization involving a patient with open fracture of the right femur due to acute blunt popliteal artery injury.

[Lung Cancer Treated with Wedge Resection of the Lower Lobe of the Left Lung with the Assistance of Extracorporeal Membrane Oxygenation(ECMO) after Right Pneumonectomy].

A 59-year-old male was admitted to our hospital with an abnormal shadow on a chest X-ray. Right pneumonectomy and lymph node dissection (ND2a) were performed. A pathological examination revealed adenocarcinoma( pT3N2M0). Fourteen years later, chest computed tomography(CT) showed a tumor shadow in the lower lobe of the left lung. His pulmonary function was sufficient to allow a 2nd operation. He underwent wedge resection of the lower lobe of the left lung with the assistance of extra corporeal membrane oxygenation (ECMO). His postoperative course was uneventful. A pathological examination revealed large cell neuroendocrine carcinoma, which was 18 mm in diameter. His performance status declined slightly, but he had no problems associated with the activities of daily life. The patient is currently alive 6 months after the 2nd operation without any sign of recurrence. ECMO is a useful technique for thoracic surgery after pneumonectomy.

Endovascular Treatment of Left Subclavian Artery Pseudoaneurysm after Clavicle Fracture in an Elderly Adult with a 40-Year History of Behçet's Disease.

Behçet's disease (BD) is a rare chronic systemic vasculitis of unknown etiology that presents in young adults. We report a very rare case of a left subclavian artery pseudoaneurysm identified after a left clavicle fracture in a 70-year-old man with a 40-year history of intestinal BD. The patient received fixation by banding to treat a fracture after falling from a bed about 5 months previously, and he was referred to our hospital due to the finding of a left subclavian pulsatile mass. As enhanced computed tomography showed a left subclavian artery pseudoaneurysm, it was repaired using an endovascular stent graft.

Elective treatment of middle colic artery aneurysm.

Middle colic artery aneurysms are rare and most have been reported with rupture or symptom. We report the successful elective treatment of a middle colic artery aneurysm without symptom, which is very rare. It failed to perform transcatheter arterial embolization for anatomical reasons, and, thus, the patient, a 77-year-old man, underwent surgical resection in spite of a history of laparotomy. Although a common cause of middle colic artery aneurysms is segmental arterial mediolysis, the present pathological findings indicated that fragmented or degenerated elastic fibers may also play an important role like aortic aneurysms.

Immunoglobulin E oligomers identified in blood components activate mast cells: relevance to anaphylactic transfusion reaction.

BACKGROUND: In most cases of anaphylactic transfusion reaction, the mechanisms underlying its development are unclear. We found a donor whose transfused blood components were implicated in two cases of anaphylactic transfusion reaction, and we found that the donor plasma showed mast cell degranulation activity. STUDY DESIGN AND METHODS: The donor plasma was examined to identify the mast cell-activating factors in it. Cultured mast cells prepared from cord blood were used for in vitro degranulation assay. Serum prepared from the donor plasma was fractionated by three-step chromatography using mast cell degranulation activity as a marker. The fractions selected from the third step of chromatography were analyzed by mass spectrometry after separation by sodium dodecyl sulfate-polyacrylamide gel electrophoresis. The characteristics of the identified proteins and other plasma samples that had been donated by the donor over several years were examined. RESULTS: Two plasma proteins of high molecular weight were detected in the anion-exchange fractions and identified as human immunoglobulin (Ig)Es of 500 kDa and higher. The mast cell degranulation activity of the IgEs decreased in the presence of monomeric human IgE as well as an anti-human IgE antibody. Mast cell degranulation activity was detected in the donor plasma since January 4, 2002, when the first case was reported. CONCLUSION: We identified high-molecular-weight IgEs as the mast cell-activating factors in the donor plasma. Results of analysis suggest that these IgEs were dimeric and trimeric and that they directly activated the transfusion recipient's mast cells by triggering the crosslinking of Fcε receptor I, thereby inducing an anaphylactic transfusion reaction.

[Pulmonary leiomyosarcoma treated with surgery; report of a case].

Primary pulmonary leiomyosarcoma is a rare malignant tumor of the lungs. A 79-year-old woman showed a mass of 9 cm in diameter in a chest X-ray and computed tomography (CT) scan. A malignant tumor was suspected and left lower lobectomy was performed. From pathological findings, pulmonary leiomyosarcoma was diagnosed. The disease stage was pT2N0M0, p0d0e0pm0 (p0), pIB. From histopathological findings, the tumor appeared to be high grade, but no recurrences have occurred 2 years postoperatively and surgical treatment was considered effective.

Chronic contained rupture of an abdominal aortic aneurysm with vertebral erosion: report of a case.

A 73-year-old man had lumbago of unknown cause for several months prior to presentation. At examination prior to surgery for gastric cancer, an abdominal aortic aneurysm (AAA) of 6 cm in maximum diameter, retroperitoneal hematoma and vertebral erosion were found on abdominal computed tomography (CT). Hematological examination revealed mild anemia and stable hemodynamics. A diagnosis of chronic contained rupture of an AAA was made and knitted Dacron bifurcated graft replacement was performed. When an intraluminal thrombosis at the posterior wall was removed, a punched-out defect (3 x 2 cm) was discovered. When the old hematoma was removed, a destroyed vertebral body was found. After surgery, the lumbago was alleviated. The patient was transferred to the Department of Surgery and a gastrectomy was performed. The patient's postoperative course was uneventful.

Mitral valve repair for mitral insufficiency due to infective endocarditis in a patient with idiopathic thrombocytopenic purpura.

A 63-year-old woman with an 18-year history of idiopathic thrombocytopenic purpura (ITP) was admitted with a persistent fever of unknown cause. Blood culture was positive for alpha-Streptococcus and echocardiography revealed severe mitral regurgitation and vegetation on the mitral valve. After antimicrobial therapy for six weeks, she underwent mitral valve repair using a Cosgrove ring. The platelet count increased and remained stable by perioperative treatment with intravenous high-dose gamma-globulin and platelet transfusion without steroids therapy or splenectomy. The hospital course was uneventful. Perioperative high-dose gamma-globulin therapy and platelet transfusion for the cardiac operation were useful to increase and maintain the platelet count for an ITP patient complicated with infective endocarditis.