Perforation of a Peptic Ulcer in a Hiatal Hernia Into the Left Ventricle With Systemic Air and Food Embolism.

Perforation of a peptic ulcer into the ventricle is uncommon, and the definitive diagnosis is difficult in living patients. We herein report a case of perforation of a peptic ulcer in a hiatal hernia into the left ventricle with systemic air and food embolism. This is the first case report of the perforation diagnosed by computed tomography and confirmed by autopsy. Computed tomography was useful for the diagnosis of perforation into the ventricle.

CT-Guided Intranodal Lymphangiography for Postoperative Chylous Ascites.

The utility and minimal invasiveness of ultrasound-guided intranodal lymphangiography have already been reported by several researchers. Although ultrasound-guided intranodal lymphangiography is known to be not technically difficult in general, a patient's edematous groin due to hypoalbuminemia resulting from chylous ascites made it too challenging to detect and prick the lymph nodes precisely. This report describes a 71-year-old female with refractory chylous ascites due to an operation for an extrahepatic bile duct cancer, who was successfully treated by computed tomography (CT)-guided intranodal lymphangiography. After switching from ultrasound- to CT-guided lymphangiography, the procedure was successfully performed, and the refractory chylous ascites was treated.

[Noticeable clinical response to S-1/CDDP combination therapy for Virchow node recurrence after surgery for advanced gastric carcinoma with marked involvement of the esophagus - report of a case].

We have recently experienced a case in which S-1/CDDP combination therapy proved remarkably efficacious for a rapid, extensive lymph node recurrence with metastasis into a Virchow node that had developed after resection of advanced gastric carcinoma accompanied with a marked invasion of the esophagus. The patient, a woman aged 73, underwent a total gastrectomy upon left thoracolaparotomy for a gastric carcinoma at the cardia with a 5-cm involvement of the esophagus. On day 65 post-operation, a diagnosis of Virchow node and para-aortic lymph node recurrence was made on the basis of CT scan findings. Of tumor markers checked, CEA and CA19-9 were noted to be increased to as high as 37.55 ng/mL and 3,235 U/mL, respectively. The patient received three courses of S-1/CDDP combination therapy, with a consequent noticeable contraction of the Virchow node and enlarged para-aortic lymph node. Further, she was given two courses of S-1 therapy, which resulted in normalization of tumor markers. The patient has since been on continued chemotherapy without any sign of recurrence.

Tagged cine magnetic resonance imaging with a finite element model can predict the severity of retrosternal adhesions prior to redo cardiac surgery.

OBJECTIVE: Reoperative median sternotomy entails a risk of damaging the heart or great vessels. If the severity of retrosternal adhesion is accurately assessed before sternal re-entry, resternotomy-related complications can be prevented. The purpose of this investigation was to evaluate whether the severity of retrosternal adhesions can be accurately predicted by tagged cine magnetic resonance imaging. METHODS: Thirteen patients who were scheduled to undergo cardiac reoperation were investigated by electrocardiography-gated tagged cine magnetic resonance imaging before sternal re-entry. With the imaging data, the severity of retrosternal adhesion was scored visually on the basis of abnormality in regional myocardial motion and discordance in the tagged signals of the sternum and the myocardium. Also, with the aid of a finite element model, strain at the surface of the right ventricle was calculated on the basis of displacement of the tags on the heart over the cardiac cycle. For comparison, the adhesion severity was scored visually at the time of redo surgery by surgeons who were blinded to the preoperative assessment. RESULTS: The preoperative adhesion severity score, as determined visually by tagged cine magnetic resonance imaging, was correlated with the intraoperative severity score (correlation coefficient: r = 0.76, P < .01). Mean strain at the surface of the heart, as calculated preoperatively by finite element model analysis, was inversely correlated with the intraoperative adhesion severity score (r = -0.78, P < .01). CONCLUSION: Tagged cine magnetic resonance imaging with a finite element model can provide an accurate quantitative assessment of retrosternal adhesions before redo cardiac surgery.

MRI of cardiac sarcoidosis: basal and subepicardial localization of myocardial lesions and their effect on left ventricular function.

OBJECTIVE: The objective of our study was to use MRI to analyze the topographic localization of myocardial lesions and their relationship to plasma brain natriuretic peptide (BNP) levels and several cardiac function parameters in patients with cardiac sarcoidosis. MATERIALS AND METHODS: Delayed contrast-enhanced MRI was performed in 40 patients with sarcoidosis (11 cardiac, 29 extracardiac cases). Using a 29-segment model of the left ventricle (LV), the extent of myocardial hyperenhancement was visually scored (0 = no hyperenhancement, 1 = 1-25%, 2 = 26-50%, 3 = 51-75%, 4 = 76-100% hyperenhancement) and was compared with plasma BNP level and several parameters of cardiac function. RESULTS: Ten of the 11 patients with cardiac sarcoidosis showed myocardial hyperenhancement, whereas none of the 29 patients without cardiac sarcoidosis did. In patients with cardiac sarcoidosis, hyperenhancement was significantly more extensive in basal short axis slices than in apical short axis slices (p < 0.0005). Myocardial hyperenhancement was significantly more frequent in subepicardial layers than in subendocardial layers. The global extent of myocardial hyperenhancement was significantly correlated with plasma BNP levels and the LV end-diastolic volume index and was negatively correlated with the LV ejection fraction. CONCLUSION: In patients with cardiac sarcoidosis, myocardial lesions detected on delayed contrast-enhanced MRI were predominantly localized in the basal and subepicardial myocardium. The extent of myocardial lesions may be related to LV dysfunction and plasma BNP level in patients with cardiac sarcoidosis.

The utility of 18F-fluorodeoxyglucose positron emission tomography for early diagnosis of radiation-induced myocardial damage.

PURPOSE: We evaluated the clinical significance of focal increased uptake in the basal myocardium on F-fluorodeoxyglucose positron emission tomography (FDG-PET) in patients with esophageal cancer after radiotherapy. METHODS AND MATERIALS: Between August 2004 and July 2005, a total of 64 patients who had been irradiated for thoracic esophageal cancer underwent FDG-PET at least three months after the completion of chemoradiotherapy. Some patients showed increased FDG uptake in the basal portion of the myocardium. To clarify the clinical significance of these findings, further examinations of hearts were performed. The dose distribution in the myocardium with high FDG uptake was also analyzed retrospectively. RESULTS: Thirteen (20.3%) of the 64 patients showed high FDG uptake in the basal myocardium corresponding to the irradiated fields compared with FDG uptake in the myocardium outside the irradiated fields. Eight of the 13 patients consented to undergo examinations of the heart. Five of those eight patients showed low 123I-BMIPP uptake and four showed low 201TlCl uptake in the myocardium corresponding with high FDG uptake regions. In two patients, delayed enhancement was found in some parts of the area with high FDG uptake on Gd-DTPA magnetic resonance imaging (MRI), and the delay-enhanced lesion showed hypokinesia on cine-MRI in one patient. CONCLUSIONS: FDG-PET often shows focal increased uptake in the basal myocardium after radiotherapy for esophageal cancer. This finding indicates the possibility of radiation-induced cardiac damage, and cardiac function and symptoms of such patients should be followed carefully.

[A case of high FDG-uptake into the myocardium after radiotherapy for esophageal cancer].

Radiation-induced cardiac disease has been observed in patients who have been irradiated to the mediastinum. A 68-year-old man who had been treated with chemoradiotherapy for esophageal cancer showed high FDG-uptake in his myocardium six months after the radiotherapy. The area of high FDG-uptake closely matched the irradiation field. This area also showed low 123I-BMIPP-uptake and delayed enhancement on Gd-MRI. These findings suggested the likelihood of radiation cardiomyopathy. There have been several studies on the detection of radiation cardiomyopathy by perfusion imaging, but few on detection by metabolic imaging or MRI. Early visualization and quantification of the degree of radiation cardiomyopathy might be possible by FDG-PET and 123I-BMIPP Gd-MRI.