Asymptomatic Isolated Calf Deep Vein Thrombosis: Does It Worsen after Varicose Vein Surgery?

In our varicose vein center, on a trial basis, among the patients with asymptomatic calf deep vein thrombosis (CDVT) we carefully selected the patients for varicose vein surgery using the requirements as follows; 1) the patients had varicose veins with incompetent saphenous veins, 2) sequential examination including DUS confirmed stability and clinical insignificance of asymptomatic CDVT, 3) the patients do not have any risk factors for DVT such as a coagulation profile disorder (antithrombin deficiency, protein C deficiency, protein S deficiency, or antiphospholipid syndrome) or malignancies, 4) surgery is possible under local anesthesia alone, and 5) the patients can understand the concept of asymptomatic CDVT and undergo the surgery on their own will and informed consent. The patients who fulfilled these conditions underwent the varicose vein surgery. Twenty-eight patients with 30 limbs with varicose veins had asymptomatic CDVT, found by preoperative duplex ultrasonography (DUS). Among CDVT, 91% of CDVT existed in the soleal veins. After the diagnosis of the asymptomatic CDVT, serial DUS was performed and showed no changes in the status of the thrombus. Then varicose vein surgery (high ligation of the saphenous junctions either with or without stripping of the saphenous veins) was performed. After the surgery, the CDVT was re-evaluated by DUS. In 27 limbs, CDVT did not show any changes in the status of the thrombus, and in 3 limbs the CDVT was partially resolved. These data suggest that, at least, as far as the patients fulfilled these conditions, varicose vein surgery did not worsen the asymptomatic CDVT. (This is a translation of Jpn J Phlebol 2016; 27: 405-412.).

Clinical implications of the cortical hyperintensity belt sign in fluid-attenuated inversion recovery images after bypass surgery for moyamoya disease.

OBJECTIVE Transient neurological symptoms are frequently observed during the early postoperative period after direct bypass surgery for moyamoya disease. Abnormal signal changes in the cerebral cortex can be seen in postoperative MR images. The purpose of this study was to reveal the radiological features of the "cortical hyperintensity belt (CHB) sign" in postoperative FLAIR images and to verify its relationship to transient neurological events (TNEs) and regional cerebral blood flow (rCBF). METHODS A total of 141 hemispheres in 107 consecutive patients with moyamoya disease who had undergone direct bypass surgery were analyzed. In all cases, FLAIR images were obtained during postoperative days (PODs) 1-3 and during the chronic period (3.2 ± 1.13 months after surgery). The CHB sign was defined as an intraparenchymal high-intensity signal within the cortex of the surgically treated hemisphere with no infarction or hemorrhage present. The territory of the middle cerebral artery was divided into anterior and posterior parts, with the extent of the CHB sign in each part scored as 0 for none; 1 for presence in less than half of the part; and 2 for presence in more than half of the part. The sum of these scores provided the CHB score (0-4). TNEs were defined as reversible neurological deficits detected both objectively and subjectively. The rCBF was measured with SPECT using N-isopropyl-p-[123I]iodoamphetamine before surgery and during PODs 1-3. The rCBF increase ratio was calculated by comparing the pre- and postoperative count activity. RESULTS Cortical hyperintensity belt signs were detected in 112 cases (79.4%) and all disappeared during the chronic period. Although all bypass grafts were anastomosed to the anterior part of the middle cerebral artery territory, CHB signs were much more pronounced in the posterior part (p < 0.0001). TNEs were observed in 86 cases (61.0%). Patients with TNEs showed significantly higher CHB scores than those without (2.31 ± 0.13 vs 1.24 ± 0.16, p < 0.0001). The CHB score, on the other hand, showed no relationship with the rCBF increase ratio (p = 0.775). In addition, the rCBF increase ratio did not differ between those patients with TNEs and those without (1.15 ± 0.033 vs 1.16 ± 0.037, p = 0.978). CONCLUSIONS The findings strongly suggest that the presence of the CHB sign during PODs 1-3 can be a predictor of TNEs after bypass surgery for moyamoya disease. On the other hand, presence of this sign appears to have no direct relationship with the postoperative local hyperperfusion phenomenon. Vasogenic edema can be hypothesized as the pathophysiology of the CHB sign, because the sign was transient and never accompanied by infarction in the present series.

Optimal timing of surgery for active infective endocarditis with cerebral complications: a Japanese multicentre study.

OBJECTIVES: The aim of this study was to investigate the effect of the timing of valve surgery on the clinical outcomes of patients with active infective endocarditis (IE) accompanied by cerebral complications. METHODS: We retrospectively analysed a cohort of 568 patients, comprising 118 with non-haemorrhagic cerebral infarction (CI), 54 with intracranial haemorrhage (ICH) and 396 without cerebral events (C; control), who underwent surgery for left-sided active IE in 15 Japanese institutes from 2000 to 2011. The mean age was 58.4 ± 16.9 years in the CI group; 54.5 ± 17.4 years in the ICH group and 56.9 ± 16.0 years in the C group. Clinical outcomes were analysed according to the timing of surgery after the diagnosis of CI or ICH was made. RESULTS: In the CI group, there were 9 (7.6%) hospital deaths, 13 (11%) new cerebral events and 1 (0.8%) redo valve surgery. In the ICH group, there were 3 (5.6%) hospital deaths, 8 (14.8%) new cerebral events and 2 (3.7%) redo valve surgeries. In the C group, there were 36 (9.1%) hospital deaths, 23 (5.8%) new cerebral events and 9 (2.3%) redo valve surgeries. Risk factors for hospital death were prosthetic valve endocarditis (P = 0.045), high C-reactive protein (CRP; P < 0.001) and the elderly (P < 0.001) in the CI group. Delayed surgery (2 weeks after CI) seemed result in a higher incidence of hospital death in the CI group. Patients who had surgery between 15 and 28 days or after 29 days from the onset of CI had higher incidences of hospital death [odds ratio 5.90 (P = 0.107) and 4.92 (P = 0.137), respectively] compared with those who had surgery within 7 days. In the ICH group, risk factors for hospital death were high CRP (P = 0.002) and elderly (P < 0.001). Contrary to CI patients, patients who had surgery between 8 and 21 days or after 22 days after the onset of ICH had lower incidences of hospital death [odds ratio 0.79 (P = 0.843) and 0.12 (P = 0.200), respectively] compared with those who had surgery within 7 days. CONCLUSIONS: Although statistically insignificant, early surgery in active IE patients with CI is safe, but very early surgery (within 7 days) should be avoided in patients with ICH.

Determination of the Clostridium perfringens-binding site on fibronectin.

The extracellular matrix protein fibronectin (Fn) is known to bind to the surface of Clostridium perfringens cells. Fn is a disulfide-linked homodimer protein, with each Fn polypeptide consisting of three types of repeating modules: 12 type I, 2 type II, and 15-17 type III modules. To determine the epitope on Fn recognized by C. perfringens cells, anti-Fn monoclonal antibodies (mAbs) and various Fn fragments (III2-10, rIII2-4, rIII5-7, rIII8, rIII9, rIII10) were employed. Although two C. perfringens-derived Fn-binding proteins, FbpA and FbpB, have been reported, they appear not to be the bacterium's surface Fn receptor. Moreover, both FbpA and FbpB were found to bind to C. perfringens cells. To avoid confusion, a mutant C. perfringens lacking both the fbpA and fbpB genes (MW5) was prepared using an in-frame deletion system. MW5 cells bound Fn on their surface, suggesting the presence of a putative Fn receptor(s) on C. perfringens cells. Of several anti-Fn mAbs, both HB39 and MO inhibited the binding of Fn to MW5 cells. HB39 reacted strongly with III2-10 and rIII9, and weakly with rIII2-4, rIII10 and rIII5-7 in Western blotting analysis. Binding of HB39 to Fn was inhibited in the presence of either rIII9 or rIII10, but not in the presence of rIII2-4, rIII5-7, or rIII8. Binding of Fn to MW5 cells was strongly inhibited by both III2-10 and rIII9, marginally inhibited by rIII2-4, but not affected by rIII5-7, rIII8, or rIII10. Significant binding of MW5 cells to immobilized rIII9 and rIII10 as well as immobilized III2-10 was observed. The region of Fn recognized by C. perfringens was thus mapped to the region encompassed by III9 and III10.

Diffusion tensor imaging of the corticospinal tract in patients with brain neoplasms.

PURPOSE: To maximize the extent of tumor resection and minimize postoperative neurological deficits in patients with brain neoplasms, it is very important to evaluate the integrity of the corticospinal tract (CST) before surgery. We attempted to determine whether CST abnormality in these patients correlates with clinical motor weakness. METHODS: We retrospectively evaluated 19 patients (16 men, 3 women, aged 39 to 70 years) with pathologically proven brain neoplasms with lesions adjacent to the posterior limb of the internal capsule and categorized their motor function as normal or abnormal based on clinical assessment. After correcting raw diffusion tensor image (DTI) data for motion and eddy-current artifacts, we computed fractional anisotropy (FA) and apparent diffusion coefficient (ADC) maps. We manually segmented the CST from the level of the cerebral peduncle to the internal capsule, used the segmented CST as the mask for FA and ADC measurements, and compared normalized FA (nFA) and ADC (nADC) values relative to the contralateral normal side using a 2-tailed, unpaired t-test. RESULTS: Compared with the normalized values for patients with normal motor function, patients with abnormal motor function demonstrated significantly decreased FA (P<0.001, 0.65±0.09 versus 0.85±0.08) and significantly increased ADC (P<0.01, 1.49±0.17 versus 1.23±0.22). CONCLUSION: DTI metrics can be used for preoperative evaluation of the integrity of the CST microstructure.

Reversibility of ischemic findings on 3-T T2*-weighted imaging after emergency superficial temporal artery-middle cerebral artery anastomosis in patients with progressive ischemic stroke.

Vascular ischemic signs, i.e. multiple hypointense vessels in the ischemic territory, were identified by gradient echo-type 3-T T(2)*-weighted magnetic resonance (MR) imaging in 3 patients with acute ischemia due to major vessel occlusion. Emergency superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis was performed in 2 patients with progressive stroke caused by bleeding-type moyamoya disease or severe MCA stenosis. Both patients were initially treated conservatively, but their neurological signs deteriorated. 3-T T(2)*-weighted MR imaging detected funicular low signals in both patients indicating enhancement of cortical vessels or medullary veins. The area of the vascular ischemic signs was almost the same or smaller than the hypoperfusion area on perfusion-weighted MR imaging or single-photon emission computed tomography. Postoperatively, the vascular ischemic signs disappeared in both patients, suggesting a relationship with severe ischemia due to high-risk misery perfusion. Their postoperative course was uneventful, and MR imaging revealed no new cerebral ischemic lesions or cerebral hyperperfusion. The patient without surgery developed cerebral infarction in the area of the vascular ischemic signs. Vascular ischemic signs detected by 3-T T(2)*-weighted MR imaging may represent a new predictor of high-risk misery perfusion, and may disappear after STA-MCA anastomosis performed in the subacute stage.

Clinical Application of MR Spectroscopy and Imaging of Brain Tumor.

Advanced imaging techniques, including diffusion tensor imaging (DTI), perfusion-weighted imaging (PWI), and magnetic resonance spectroscopy (MRS) can provide more information than that regarding anatomy. These techniques have been commonly used in the clinical field and recently been shown useful in diagnosing brain tumors, especially in cases difficult to specify using conventional imaging. Differentiation requires more than attention to each advanced image. Diagnostic accuracy improves by combining information from MRS with that from other sequences, such as maps of apparent diffusion coefficient (ADC) and fractional anisotropy (FA) generated from DTI and of cerebral blood volume (CBV) generated from PWI. We show clinical applications of advanced imaging techniques, combined MRS, for brain tumor.

Dynamic susceptibility contrast perfusion weighted imaging in grading of nonenhancing astrocytomas.

PURPOSE: To evaluate if the relative tumor blood volume (rTBV) using dynamic susceptibility contrast magnetic resonance imaging (DSC-MRI) can aid in distinguishing low- from high-grade nonenhancing astrocytomas. MATERIALS AND METHODS: Seventeen patients with histologically proven astrocytomas underwent MRI including DSC-MRI. Maximum TBV regions of interest were recorded from each neoplasm and normalized to contralateral normal white matter. Demographic features, diagnostic MRI findings including tumor volumes, and the normalized rTBV ratios were compared between low-grade (I and II, LGA, n = 6) and high-grade (III) astrocytomas (HGA, n = 11) using Mann-Whitney's U-test and receiver operating characteristic (ROC) analysis. RESULTS: Maximum rTBV ratios were statistically higher for HGA (1.11 ± 0.13) than LGA (0.66 ± 0.17, P < 0.005) with the best cutoff threshold at 0.94 (sensitivity of 90.9%, specificity of 100%). Differences in mean age and tumor volume on fluid-attenuated inversion recovery (FLAIR) imaging between the two groups did not reach statistical difference (P = 0.22, 0.36). CONCLUSION: The addition of DSC-MRI can aid in accurate grading of nonenhancing astrocytomas with high sensitivity and specificity.

Relationship between FDG uptake and the pathological risk category in gastrointestinal stromal tumors.

PURPOSE: To evaluate (18)F-fluorodeoxyglucose (FDG) uptake and the pathological risk category of gastrointestinal stromal tumors (GISTs), and to investigate the possibility of determining the pathological risk category by positron emission tomography/computed tomography (PET/CT). PATIENTS AND METHODS: We undertook 29 PET/CT studies in 20 patients with GISTs. Eleven of the 20 patients underwent PET/CT prior to therapy, with three of these also undergoing follow-up PET/CT after operation or imatinib therapy. RESULTS: All eleven lesions imaged before treatment were FDG-positive on PET/CT. Seven of these eleven primary lesions were categorized as high risk and the other four primary lesions were categorized as low or intermediate risk. There was a significant difference between the maximum standardized uptake value (SUVmax) of the primary lesions categorized as high risk (11.8±3.15) and that of the primary lesions categorized as low and intermediate risk (2.88±0.47) (p<0.001). Recurrent tumors were also shown as FDG-positive. CONCLUSION: Primary GISTs and recurrent tumors can be detected by PET/CT. Our study suggests that the degree of FDG uptake is a useful indicator of risk category. In addition, PET/CT is probably useful for follow-up examinations of GIST after operation or imatinib therapy. J. Med. Invest. 57: 270-274, August, 2010.

Discovery and characterization of a novel potent, selective and orally active inhibitor for mammalian ELOVL6.

The elongase of long chain fatty acids family 6 (ELOVL6) is a rate-limiting enzyme for the elongation of saturated and monounsaturated long chain fatty acids. ELOVL6 is abundantly expressed in lipogenic tissues such as liver, and its mRNA expression is up-regulated in obese model animals. ELOVL6 deficient mice are protected from high-fat-diet-induced insulin resistance, suggesting that ELOVL6 might be a new therapeutic target for diabetes. We previously identified an indoledione compound, Compound A, as the first inhibitor for mammalian ELOVL6. In this study, we discovered a novel compound, Compound B, and characterized its biochemical and pharmacological properties. Compound B has a more appropriate profile for use as a pharmacological tool compared to Compound A. Chronic treatment with Compound B in model animals, diet-induced obesity (DIO) and KKAy mice, showed significant reduction in hepatic fatty acid composition, suggesting that it effectively inhibits ELOVL6 activity in the liver. However, no improvement in insulin resistance by ELOVL6 inhibition was found in these model animals. Further studies need to address the impact of ELOVL6 inhibition on pharmacological abnormalities in several model animals. This is the first report on pharmacology data from chronic studies using a selective ELOVL6 inhibitor. Compound B appears to be a useful tool to further understand the physiological roles of ELOVL6 and to evaluate the therapeutic potential of ELOVL6 inhibitors.

How to manage RI venography in pre-orthopedic surgery patients.

OBJECTIVE: The preoperative evaluation of venous thromboembolism (VTE) is important to avoid complications, because VTE is often induced by orthopedic surgery. We focused on radioisotope venography (RIV) using 99mTc-macroaggregated human serum albumin, examining orthopedic patients. METHODS: We conducted 34 examinations in 33 patients who were referred for RIV and lung perfusion scintigraphy for the pre-orthopedic operative evaluation of VTE. Two board-certified (one nuclear medicine board-certified) radiologists interpreted the images based on the following: (1) flow defect of the lower extremities; (2) interruption of flow; (3) irregular or asymmetric filling of the deep vein (low flow); (4) presence of collateral vessels; and (5) abnormal RI retention on delayed-phase images. Scoring was based on a 5-point scale, and more than 2 points was considered VTE positive. RESULTS: Abnormal findings were noted in 27 of the 34 examinations performed in the 33 patients and normal findings in the other 7 examinations. According to the RI score, 21 patients were classified into the VTE-positive group and 12 into the VTE-negative group. Surgery was canceled because of advanced age and respiratory dysfunction in 2 of the 21 patients in the VTE-positive group. Of the 19 patients who underwent surgery, an IVH filter was placed before surgery in 2 and anticoagulant treatment with heparin and warfarin was initiated on the day of surgery in 12 to prevent postoperative VTE, and only one of the patients receiving anticoagulant treatment developed PTE after surgery. Surgery was canceled due to advanced age and at patient's request in 2 of 12 patients in the VTE-negative group. Anticoagulant treatment with heparin/ warfarin was performed to prevent postoperative VTE in only 3 patients: one with a past medical history of pulmonary infarction, one with atrial fibrillation, and one suspected of having antiphospholipid antibody syndrome. No patient in the VTE-negative group developed VTE after surgery. CONCLUSION: The preoperative identification of patients with VTE by RIV might be useful for perioperative management and the evaluation of preventive measures against postoperative VTE.

Thallium-201 chloride scintigraphy in soft tissue tumors.

OBJECTIVE: We report the findings of Thallium-201 chloride ((201)TlCl) scintigraphy and consider how to use this technique to evaluate the character of soft tissue lesions. PATIENTS AND METHODS: We enrolled 91 consecutive patients (45 males and 46 females, age range 8-91-years-old). Nineteen patients were malignant and 72 were benign. Patients were scanned 15 minutes (early phase) and 3 hours (delayed phase) after (201)TlCl injection. More intense uptake in the lesion compared to the normal side was considered as 'high', the same degree of uptake was considered 'iso', and decreased uptake was 'low'. The retention index (RI) was calculated in 9 patients in the malignant group and in 16 patients in the benign group. RESULTS: In malignant tumors, 15 of 19 patients showed high uptake in both the early and delayed phases. One malignant fibrous histiocytoma patient was high only in the delayed phase and 1 liposarcoma patient was high only in the early phase. Two liposarcoma patients showed an iso uptake in both phases. One of these patients was pathologically diagnosed as a myxoid type. In benign lesions, no lipoma showed increased uptake. All neurogenic tumors except for 2 demonstrated high uptake. All 3 ganglions of the lower extremities showed iso uptake. Most inflammatory diseases showed increased uptake. Clinically-considered benign patients consisted of tumorous lesions or inflammatory disease. Only 2 patients were considered 'low', and these were diagnosed as intramuscular hematoma and cyst. RI was variable in both malignant and benign lesions and no statistically significant difference was seen between malignant and benign lesions by t-test (p=0.72). CONCLUSIONS: A high (201)TlCl uptake lesion is more frequently seen in malignant tumors, but regardless of whether the tumor is benign or malignant, according to the histopathological variety, the (201)TlCl uptake pattern can not be the only indicator to differentiate malignant from benign tumors. We ultimately need to evaluate the nature of tumors by a combination of several imaging techniques.

[Comparison with bone scintigraphy and MDCT findings in patients with round focal accumulation on bone scintigraphy].

PURPOSE: This study aimed to compare with bone scintigraphy showed round focal accumulation and Multidetector Row CT (MDCT) findings. METHODS: We obtained 101 patients (mean age 69.2 years; 75 men, 26 women) and 186 diseases. They were examined both MDCT and bone scintigraphy within a month of each other. We classified into two groups (with metastasis and spondylosis) according to their MDCT findings. Bone scintigraphy was estimated on planar image, MDCT was evaluated in three directions with 1 x 1 x 1 mm thickness. RESULTS: We determined 20 metastases cases and 81 of spondylosis. We could not judge abnormal findings on MDCT in 4 patients (1 metastasis, 3 spondylosis); thus, detectability by MDCT was 93.5%. In the spondylosis group, the accumulation lesions were localized on the lower vertebral body in 76 patients (59%), with most showing as osteophytes. In the metastasis group, 11 patients showed more than 1 accumulations, 9 were osteoblastic changes and 10 were lytic. There was a tendency that patients who accumulated more than 1 vertebral bodies (64%) had osteoblastic and irregular distribution and those who accumulated just one body (78%) were lytic and their locations were focused on the lateral side. CONCLUSION: For evaluating bone scintigraphy, MDCT finding was helpful to increase the detectability in bone metastasis. Therefore, we should refer to MDCT finding positively in reading bone scintigraphy.

Replacement of a feeding tube through the gastric tube in patients after esophagectomy with retrosternal reconstruction.

INTRODUCTION: We present our technique of endoscopic replacement of the jejunostomy through the stomach conduit in patients after esophagectomy with retrosternal reconstruction. METHODS: After an upper gastrointestinal tract endoscopy was performed, the stomach conduit was sufficiently inflated with air and the site of the previously removed gastric tube was confirmed by the puncture using 23 G needle. After an approximately 6-mm incision was made under local anesthesia, a 4-mm peel-off introducer sheath was advanced into the stomach conduit under endoscopic control. A 3-mm jejunostomy tube was inserted through the sheath and placed into the jejunum using the endoscopic guidance. Using endoscopy, the jejunostomy tube was confirmed to be placed without bending. RESULTS: Between 1998 and 2006, subtotal esophagectomy with retrosternal cervical esophagogastrostomy was performed in 48 patients. All patients were inserted with at least either jejunostomy tube or decompression tube through the stomach conduit. Among them, 11 patients (23%) were performed percutaneous replacement jejunostomy through the stomach conduit. There were 9 men and 2 women whose mean age was 67 years (range: 59 to 76 y). Replacement of the jejunostomy tube was successful in all patients. The procedure required about 30 minutes. There were no deaths and no procedural complications. After 24 hours, the tube was used for enteral feeding. No late complication occurred in our cases. CONCLUSIONS: We believe that the endoscopic percutaneous approach described in this report is safe and effective in patients after esophagectomy with retrosternal reconstruction.

Is FDG-PET/CT useful for managing malignant pleural mesothelioma?

OBJECTIVE: Imaging techniques such as CT, MRI and PET/CT have essential pre- and post-treatment roles in detecting tumors and evaluating the extension of malignant pleural mesothelioma (MPM). We sough to evaluate the advantages and limitations on FDG-PET/CT findings. PATIENTS AND METHODS: We performed 13 FDG-PET/CT studies in 9 patients with MPM (8 males, 1 female, aged 51 to 84 years, 9 at the initial diagnosis, 4 follow up studies). We reviewed FDG-PET/CT findings of primary tumors, recurrent tumors, lymph nodes, metastasis. RESULTS: All primary and recurrent tumors were FDG positive. The uptake patterns at initial diagnosis were; diffuse+multi-nodular uptake pattern in 5, diffuse irregular thickened uptake pattern in 2, some focal thickened pattern in one, and a slight diffuse uptake pattern in one. Two of the 3 patients diagnosed as N0 by PET and operated on had negative lymph nodes confirmed pathologically. The other patient diagnosed as N0 by PET, who had one month of time lag between PET/CT examination and surgery, was confirmed as N2 by extrapleural pneumonectomy. In 3 patients, hilar or mediastinal lymph nodes were difficult to distinguish from irregular pleural thickening. One patient had a FDG positive lymph node in the ipsilateral supraclavicular region confirmed as metastasis (N3). One patient had a FDG positive lymph node in the para-aortic region. Lung metastasis was seen in one patient (M1). In another patient, two focal nodular uptakes in the colon were detected and confirmed as colon polyps (pathologically Group 3-4). At restaging, 3 of 4 patients showed diffuse+multi-nodular uptake and one patient showed multi-nodular uptake. CONCLUSIONS: The utility of FDG-PET/CT is limited for evaluation of primary tumor extension and nodal status. FDG-PET/CT is useful for detecting distant metastasis and for evaluating activity in supraclavicular or abdominal lymph nodes. It is also useful for identifying unsuspected diseases.

Clear-cell sarcoma of the small intestine detected by FDG-PET/CT during comprehensive examination of an inflammatory reaction.

Clear-cell sarcoma (CCS) is a rare, malignant, soft-tissue tumor, which involves the extremities, particularly the foot and foot joint tendons and aponeuroses. It is morphologically similar to but histochemically distinct from malignant melanoma. CCS arising in the gastrointestinal tract has rarely been reported. The prognosis of CCS is reportedly poor because of the high incidence of metastases at the time of initial diagnosis and the high frequency of recurrence. We report a case of early-stage CCS of the small intestine detected by (18)F-fluoro-2-deoxy D-glucose Positron Emission Tomography/Computed Tomography (FDG-PET/CT) during the comprehensive examination of an inflammatory reaction. In this case, FDG-PET/CT clearly visualized the lesion, which was difficult to detect by contrast CT.

A case of von Recklinghausen's disease with coincident malignant peripheral nerve sheath tumor and gastrointestinal stromal tumor.

(18)F-fluorodeoxyglucose positron emission tomography ((18)F-FDG PET/CT) was performed to evaluate a left femoral subcutaneous mass in a patient with von Recklinghausen's disease (vRd) that gradually enlarged, causing pain and numbness. The left femoral mass showed intense FDG uptake with the maximum standardized uptake value (SUVmax) of 9.0. Other subcutaneous masses considered benign and neurogenic in nature also showed FDG uptake (SUVmax around 3 or less), but the degree of FDG uptake differed considerably from the left femoral mass. This observation suggested that the degree of FDG uptake may be a useful indicator of malignant transformation. Incidentally, PET/CT also showed an asymptomatic large abdominal mass with intense FDG uptake (SUVmax 8.8). The abdominal mass was resected and confirmed as gastrointestinal stromal tumor (GIST) of the small intestine. Three months later, the left femoral mass was operated on and pathologically diagnosed as a malignant peripheral nerve sheath tumor (MPNST). Various malignant diseases are known to occur with high frequency in vRd. Therefore, vRd patients need to have periodical examinations including PET/CT. We present a rare case of a patient with vRd with a MPNST of the left femur and coincidental GIST of the small intestine. February, 2009.

Cervical approach by lifting the superior sternum for mediastinal parathyroid adenoma.

We report our experience with sternum lifting method in 5 patients with a retrosternal large parathyroid gland around an innominate vein. There were 2 men and 3 women aged 35 to 81 years. All patients showed a retrosternal large parathyroid gland around an innominate vein. Under general anesthesia, the patient is placed in a supine position with the neck extended. About 3 to 4 cm cervical incision is made above the sternal notch. Two hooks are placed at both sternoclavicular junctions. After the sternum is retracted upward, the anterior mediastinum can now be well visualized with the surgeon at the head of the table. When the direct vision is not clear, using the video imaging provides the physician with a clear, magnified view of the area under deep sternum. All patients underwent complete cervical excision using our method without any complications. The average operative time was 61 minutes and blood loss was minimal. Excellent postoperative outcomes were observed. The patients had no pain or other complications. All patients were discharged 4 days after the surgery. We believe that cervical excision using our method is a better alternative in those patients with anterior mediastinal parathyroid glands around an innominate vein.

Clinical significance of p53 protein expression in papillary thyroid carcinoma.

BACKGROUND: Although mutations in the p53 suppressor gene in thyroid carcinoma have usually been detected in anaplastic carcinoma, P53 protein expression has been detected immunohistochemically in papillary thyroid carcinoma (PTC). In the present study, we examined the immunohistochemical expression of P53 protein in PTC to investigate the relations between its expression and the clinicopathologic features. METHODS: The study was performed on 68 patients in whom thyroidectomy with lymph node dissection had been performed to treat PTC at Teikyo University Hospital. Expression of P53 protein was evaluated immunohistochemically in sections of paraffin-embedded tissue in 68 primary tumors and 196 lymph node metastases. RESULTS: Overexpression of P53 protein in the primary tumor was observed in 29 cases (43%). Statistical analysis revealed significant correlation between P53 protein expression in the primary tumor and large tumor size (unpaired t-test: p < 0.01), the presence of lymph node metastasis (unpaired t-test: p < 0.05), and the mean number of lymph node metastases (unpaired t-test: p < 0.05). Although 29 (43%) of the primary tumors overexpressed P53 protein, 143 (73%) of the metastatic lymph nodes overexpressed P53 protein irrespective of whether there was P53 overexpression by the primary tumor. CONCLUSIONS: The results of this study suggest that immunohistochemistry for P53 in the primary tumor could be useful in the clinical evaluation of patients with PTC. Moreover, P53 protein overexpression in lymph node metastasis may be useful as a treatment guide or target for lymph node recurrences.