Computed tomography (CT) venography using a multidetector CT prior to the percutaneous external jugular vein approach for an implantable venous-access port.

BACKGROUND AND PURPOSE: The objective of this study was to determine the success rate and complications of using the percutaneous approach of the external jugular vein (EJV) for placement of a totally implantable venous-access port (TIVAP) with a preoperative estimate of the detailed anatomical orientation of the cervical venous plexus using computed tomography venography (CT-V). METHODS: A prospective cohort study of 45 patients in whom placement of a TIVAP was attempted via the right EJV was conducted. The preoperative anatomical estimation of the cervical venous plexus was performed with CT-V using a Multidetector Helical 16-section CT. The angulation between the right EJV and the right subclavian vein, anterior jugular vein, transverse cervical vein, and suprascapular vein was estimated. RESULTS: CT-V success was achieved in 45 of 45 patients (100 %). A plexus of veins under the clavicle was most commonly responsible for the insertion of the central venous catheter. The EJV approach resulted in a successful cannulation rate of 93 %. No initial complications of pneumothorax or carotid artery puncture occurred during insertion procedures. Late complications occurred in three patients. These included one port erosion (2 %), one catheter occlusion (2 %), and one wound hematoma (2 %). Catheter-related infections were observed in one patient (2 %). CONCLUSIONS: The percutaneous EJV approach with CT-V guidance is an optional method for patients with multiple central venous cannulations, those in hemodialysis, or those with long catheter indwelling periods.

[Expression of bone morphogenetic protein 2 in lung adenocarcinoma with ossification].

We report a case of primary lung cancer with ossification. A 69-year-old woman was referred to our hospital due to an abnormal shadow on a chest roentgenogram. Chest computed tomography demonstrated an irregular mass with scattered high-density areas in the left lower lung. Excisional biopsy of the mass revealed lung adenocarcinoma, and we performed left lower lobectomy. Histologic examination revealed the tumor to be a papillary adenocarcinoma with ossification. We confirmed that bone morphogenetic protein(BMP)-2 developed from the tumor by a western blot analysis.

[Solitary fibrous tumor of the bronchus; report of a case].

A 69-year-old woman was referred to our hospital due to an abnormal shadow on a chest roentgenogram. Computed tomographic scanning revealed a complete atelectasis of the left lower lobe. Though the definitive diagnosis was not obtained preoperatively, we performed a left lower lobe excision because atelectasis existed for more than one year. Immunohistochemical staining showed that tumor cells were positive for vimentin, CD34, bcl-2, CD99, and negative for S-100, α-smooth muscle actin. The tumor was diagnosed as a solitary fibrous tumor of the bronchus, which has been rarely reported to date.

[Pulmonary actinomycosis that was difficult to make an accurate diagnosis].

A 35-year-old man was referred to our hospital, because of recurrent pneumonia. His chest X-ray film and computed tomography showed mass-like consolidation with a cavity in the right upper lobe. He underwent a bronchoscopic examination, but no diagnosis was established. Therefore a surgical biopsy was performed, but the pathological findings revealed that it was only an inflammatory change without any malignant component. For a while, antibiotic and the steroid treatment was continued resulting in the aggravation of clinical findings. Finally, an upper lobe excision was performed for the complete excision of the lesion. As a result of pathology, pulmonary actinomycosis was diagnosed.

[Re-operation for relapsed thymic carcinoid; report of a case].

A 68-year-old male patient underwent extended thymectomy via median sternotomy, 4 years ago. The pathological diagnosis was thymic atypical carcinoid having invaded the pleura and vessel. During follow-up, the new nodular shadows in the anterior mediastinum were pointed out by a chest computed tomography (CT) scan, 40×38 mm and 11×10 mm in size. We performed again tumor resection and resection of pleural disseminations. The patient was free of clinically evident recurrence 3 years after treatment.

Comparison of 1-h with 3-h planar 99mTc-pyrophosphate scintigraphy in patients with suspected transthyretin cardiac amyloidosis using SPECT as a reference standard.

OBJECTIVES: The purpose of this study was to examine the diagnostic value of planar 99mTc-pyrophosphate (PYP) imaging at 1 and 3 h after tracer administration in patients with suspected transthyretin cardiac amyloidosis (ATTR-CA) using SPECT as a reference standard. We also tested whether blood pool activity of PYP is associated with renal dysfunction. METHODS: PYP images of 109 consecutive patients with suspected ATTR-CA were retrospectively reviewed. The myocardial PYP uptake was visually graded on a scale of 0 to 3 and quantified with the heart-to-contralateral (H/CL) ratio in accordance with the current expert consensus recommendations. The diagnostic value of planar images for identifying positive PYP SPECT was assessed by a receiver-operating characteristic curve analysis with the area under the curve (AUC). The uptake ratios of the ascending and descending aorta, left atrium, and trapezius muscle divided by the liver uptake were measured on SPECT images and compared to the renal function. RESULTS: A total of 41 patients (38%) had myocardial PYP uptake on SPECT images. In comparison with the visual scores on 1-h anterior planar images, those on 3-h anterior planar images had lower sensitivity (80.5% vs. 97.6%) and higher specificity (86.8% vs. 55.9%) for identifying positive PYP SPECT. The ROC analysis showed that the combination of visual scores on both 1-h and 3-h anterior planar images had significantly higher AUC values in comparison with 1-h anterior planar images alone (0.90 [95% CI 0.83-0.94] vs. 0.83 [95% CI 0.75-0.88]; P < 0.001), which was comparable to the AUC values on 3-h anterior planar images alone (0.88 [95% CI 0.80-0.92]; P = 0.071). In comparison with visual scores on 1-h or 3-h anterior planar images alone, the combination of visual scores and H/CL ratio did not significantly improve the diagnostic value for identifying positive PYP SPECT (P = 0.73 and P = 0.50, respectively). The uptake ratios of ascending aorta/liver, descending aorta/liver, left atrium/liver, and trapezius muscle/liver were not significantly associated with the serum creatinine level or estimated glomerular filtration rate (P > 0.05 for all). CONCLUSIONS: In the assessment of ATTR-CA using PYP imaging, visual scores on 3-h anterior planar images for identifying positive PYP SPECT had lower sensitivity and higher specificity in comparison with those on 1-h anterior planar images. The diagnostic value of the visual scores on 1-h and 3-h anterior planar images was not improved by adding the H/CL ratio. Blood pool activity of PYP was not significantly associated with renal dysfunction.

Computed tomography-gastro-colonography for percutaneous endoscopic gastrostomy using a helical computed tomography.

BACKGROUND: Despite the widespread use of percutaneous endoscopic gastrostomy (PEG) tubes, their placement may be associated with a variety of complications, including gastrocolic fistula. METHODS: In total, 48 individuals underwent computed tomography-gastro-colonography (CT-GC)-guided PEG placement. Study end points included success of CT-GC, inability to thread the PEG tube, the eventual tube location, tube adjustments needed, adverse events, operating time, and PEG tube-related infection. RESULTS: A successful CT-GC was achieved in all 48 patients (100%), and we successfully used a standard PEG technique to place the gastrostomy tube in 44 patients (92%). In 4 patients (8%), the laparoscopic-assisted PEG technique was used because the transverse colon became interposed between the abdominal wall and the anterior wall of the stomach. The overall procedure-related minor complication rate was 8%. CONCLUSION: CT-GC is an optional method for the estimation of intra-abdominal, anatomical orientations that may minimize the risk of complications before PEG placement.

Central venous access via external jugular vein with CT-venography using a multidetector helical 16-section CT.

OBJECTIVE: To determine the success rate and complications of using the external jugular vein (EJV) for central venous access with a preoperative estimate of the detailed anatomical orientation of the cervical venous plexus using computed tomography venography (CT-V). DESIGN: Prospective, observational human study. SETTING: Surgical intensive care unit. PATIENTS: Fifty-two patients who were undergoing EJV cannulations with CT-V using a Multidetector Helical 16-section CT (MDCT). INTERVENTION: The preoperative anatomical estimation of the cervical venous plexus was performed with CT-V using an MDCT. In particular, the angulation between the EJV and the right subclavian vein (SCV) was measured. The anatomical abnormalities and the angulation between the EJV and the anterior jugular vein (AJV), transverse cervical vein (TCV), and suprascapular vein (SSV) were estimated. MEASUREMENTS AND MAIN RESULTS: The success of CT-V was achieved in 52 of 52 patients (100%). The mean angulation between the right EJV and the right SCV was 144 ± 36 degrees in the obtuse-angle cases (88%) and 72 ± 28 degrees in the sharp-angle cases (12%). A plexus of veins under the clavicle was most commonly responsible for insertion of the central venous catheter (CVC). The EJV approach resulted in a 93% rate of successful cannulations. No complications of pneumothorax or carotid artery puncture occurred during insertion procedures. CONCLUSIONS: The EJV route is associated with comparable technical success and lower major procedural complication. The EJV approach with CT-V guidance is an option as the initial method when central venous cannulation must be performed under suboptimal conditions.

Feasibility of adjuvant chemotherapy with S-1 consisting of a 4-week administration and a two-week rest period in patients with completely resected non-small cell lung cancer.

The efficacy of adjuvant chemotherapy with S-1 in patients with completely resected non-small cell lung cancer (NSCLC) has yet to be clarified, and the appropriate schedule for the adjuvant chemotherapy with S-1 remains unknown. A phase II study was conducted to evaluate the feasibility and efficacy of adjuvant chemotherapy with S-1. Patients enrolled in this study were 20-75 years old, had pathological stage IB-IIIA NSCLC, and had received complete resection of NSCLC. S-1 (80 mg/m2) was administered orally to the patients for four weeks followed by a two-week rest period (conventional schedule), for a maximum of eight cycles. The primary endpoint was relative dose intensity (RDI), while the secondary endpoints were safety and 1 year of disease-free survival (1y-DFS). Between May 2007 and October 2009, 28 patients were enrolled. The RDI was 63.1% (95% CI, 48.6-77.7). No grade 3 or worse hematological toxicity was observed. Grade 3 non-hematological toxicities were observed in four patients. No grade 4 or worse hematological toxicity was detected. The probability of 1y-DFS was 85.7% (95% CI, 72.8-98.6). In the subgroup analysis, the median RDI of patients over 65 years old was lower compared to the other patients (44.8 vs. 100%; P=0.013; Mann-Whitney U test). Creatinine clearance (CCr) was lower in the older group, with more grade 2 or 3 non-hematological toxicities in the elderly patients. These results suggest that the conventional schedule of adjuvant chemotherapy with S-1 is not likely to be feasible in older patients with completely resected NSCLC.

Primary adenocarcinoma of the stomach in von Recklinghausen's disease with high serum levels of multiple tumor markers: a case report.

INTRODUCTION: Gastric tumors in patients affected by neurofibromatosis type 1 are usually carcinoids or stromal tumors, and rarely adenocarcinomas. CASE PRESENTATION: We report a case of an adenocarcinoma of the stomach in a 53-year-old Japanese man with neurofibromatosis type 1. An abdominal computed tomography scan and ultrasonography showed tumors in his liver. Gastric fibroscopy revealed a Borrmann type III tumor on his cardia that had spread to his esophagus and was highly suspicious for malignancy. Multiple biopsies showed an adenocarcinoma of the stomach, which was evaluated as gastric cancer, stage IV. Chemotherapy with TS-1 was performed. Our patient died four weeks after initial admission. Histological examination of a liver needle biopsy showed metastatic adenocarcinoma in his liver. CONCLUSION: To the best of our knowledge, high serum levels of α-fetoprotein, carcinoembryonic antigen, and carbohydrate antigen 72-4, resulting from gastric adenocarcinoma, have not been reported previously in a patient with neurofibromatosis type 1. We report this rare case along with a review of the literature.

Gastric Cancer with a Very High Serum CA 19-9 Level.

Carbohydrate antigen 19-9 (CA 19-9) is a sensitive marker for pancreatic and hepatobiliary malignancies. The highest frequency of elevated serum CA 19-9 levels is found among patients with pancreatic cancer. CA 19-9 has recently been demonstrated to be a marker of digestive tract malignancies. We report the case of a patient with a gastric cancer and a very high serum CA 19-9 level. During laparotomy, a large mass was found in the antrum. A distal gastrectomy with D2 dissection of the lymph nodes was performed. Histological examination, including immunohistochemistry, revealed an adenocarcinoma of the stomach producing CA 19-9. To the best of our knowledge, no patient with an extremely high serum CA 19-9 level resulting from a gastric adenocarcinoma has been reported previously.

The diagnostic and prognostic relevance of human telomerase reverse transcriptase mRNA expression detected in situ in patients with nonsmall cell lung carcinoma.

BACKGROUND: The objectives of this study were to evaluate the diagnostic and prognostic relevance of human telomerase reverse transcriptase (hTERT) detected in situ in patients with nonsmall cell lung carcinoma (NSCLC) and to investigate the possible correlations between hTERT mRNA in NSCLC and the patients' clinicopathologic features, including survival. METHODS: hTERT mRNA was detected by in situ hybridization in 146 samples from patients with NSCLC. The signal intensity of hTERT mRNA expression was evaluated by two independent observers. The expression level was defined subjectively as strong, moderate, or weak. RESULTS: hTERT mRNA was detected mainly in the cytoplasm of tumor cells. It was detected in the cytoplasm of 100% of samples from patients with NSCLC but was not detected in normal lung tissue, except in activated lymphocytes. There was a significant correlation between hTERT mRNA expression and pathologic tumor status, pathologic disease stage (pStage), and Ki-67 labeling index. There was no significant correlation between hTERT mRNA expression and age, gender, pathologic lymph node status (pN), histology, or tumor differentiation. The 5-year survival rates for patients with strong and moderate hTERT mRNA expression levels were 46.9% and 77.9%, respectively; the difference was statistically significant (P = 0.0001). A multivariate analysis of survival using a stepwise procedure revealed that hTERT mRNA expression, pN status, pStage, and age were statistically significant prognostic factors (P = 0.0029, P = 0.0012, P = 0.0237, and P = 0.0496, respectively). CONCLUSIONS: The findings suggested that hTERT mRNA expression may be useful for the diagnosis of NSCLC and also may be an independent prognostic factor for patients with NSCLC.