A case of idiopathic myointimal hyperplasia of the mesenteric veins presenting with small bowel obstruction.

BACKGROUND: Idiopathic myointimal hyperplasia of the mesenteric veins (IMHMV) is a rare ischemic bowel disease with venous occlusion resulting from the proliferation of smooth muscles in the venous intima. In most patients, the disease affects rectosigmoid colon and causes persistent abdominal pain and hematochezia, which is similar to inflammatory bowel disease (IBD). In addition, it is difficult to make a precise diagnosis of IMHMV without surgery. CASE PRESENTATION: An 81-year-old woman was admitted to our hospital with mild abdominal pain, nausea and vomiting. Repeated adhesive ileus was suspected due to the previous open and laparoscopic surgeries. Surgery was planned to treat small bowel obstruction. Intraoperatively no adhesive lesions were observed. However, a mass lesion was seen at the terminal ileum, which was suspected to have caused her bowel obstruction. Partial resection of the small intestine was performed. Macroscopic and histopathological examinations of the excised specimen showed circumferential ulceration with scarring, a thickened venous wall with active inflammation, and fibrotic changes that consequently produced stenosis and obstruction of the venous lumen in the subserosa. Additionally, Elastica van Gieson staining demonstrated thickening of the venous intima. The final diagnosis was IMHMV. At two years and 8 months after the operation, the patient was well without any additional medication. CONCLUSION: IMHMV of the small intestine is rare. We described a case of IMHMV that was associated with ileus.

Short-term outcomes of preoperative chemoradiotherapy with S-1 for locally advanced rectal cancer.

The purpose of the present study was to evaluate the short-term results of preoperative chemoradiation therapy with S-1 for locally advanced rectal cancer. A total of 32 patients with advanced rectal cancer who had been treated with preoperative chemoradiotherapy with S-1 and underwent surgical resection between May 2012 and December 2019 were analyzed. Advanced rectal cancer of clinical stage II and III was diagnosed in 13 (41%) and 19 (59%) patients, respectively. Therapeutic toxicities of anemia (24 patients; 75%), anal pain (22 patients; 69%) and skin and subcutaneous tissue disorders (19 patients; 59%) were frequently observed in all grades. Grade ≥3 leukopenia, anemia, neutrophil count reduction, platelet count reduction and diarrhea were identified in 2 (6%), 1 (3%), 1 (3%), 1 (3%) and 1 (3%) patients, respectively. A total of 29 patients (91%) completed this therapy without any change to the protocol or dosage. R0 resection was performed in 100% of the patients, and no postoperative mortality was observed. Pathological complete response was observed in 9 cases (28.1%). This therapy can be considered for cases of locally advanced rectal cancer due to its acceptable toxicity and relatively high antitumor effect.

[Combination Therapy of Bevacizumab plus Paclitaxel Was Effective for a Metastatic Choroidal Tumor Secondary to Breast Cancer in a Patient with Ocular Symptoms].

A 44-year-old woman experienced loss of vision and distorted vision in the right eye. After she visited our hospital, she was diagnosed with a right metastatic choroidal tumor. At the age of 35 years, she had undergone surgery for left breast cancer; as recurrence of the breast cancer was suspected, the patient was referred to our department. A CT scan revealed left axillary lymph node swelling, liver metastasis, and lung metastasis. Lymph node needle biopsy was performed under ultrasound guidance, and the pathological findings revealed recurrence of breast cancer. Combination chemotherapy of bevacizumab( BV)plus paclitaxel(PTX)was administered. After chemotherapy, the metastatic lesion had remarkably shrunk, as observed on a CT scan. Optical coherence tomography(OCT)revealed that the tumor was flattened in her right eye. Choroidal metastasis of breast cancer is rare. BV plus PTX therapy was effective for treating choroidal metastasis of breast cancer, and it should be followed by ophthalmological examination over time.

Time-Enhancement Curve of Four-Dimensional Computed Tomography Predicts Aneurysm Enlargement with Type-II Endoleak after Endovascular Aneurysm Repair.

OBJECTIVE: We investigated the hemodynamic features of Type-II endoleaks after endovascular aneurysm repair (EVAR) using four-dimensional (4D) computed tomography (CT) to identify patients with aneurysm enlargement. METHODS: During a 13-month period (January 2017-January 2018) at our institution, we performed 4D-CT examinations in 13 patients after EVAR because of suspected Type-II endoleaks. Three patients were excluded from the study because of other endoleaks or absence of detectable endoleaks. The ramaining 10 patients were divided into two groups: enlargement group (n = 4), in which the aneurysm volume increased, and stable group (n = 6), in which the aneurysm remained stable or shrank. A CT scanner and three-dimensional workstation were used. All images were obtained using a consistent protocol (22 phase scans using the test bolus tracking method). We analyzed the hemodynamics of the endoleak cavity (EC) relative to those of the aorta and evaluated the time-enhancement curves (TECs) using measurement protocols. The strengths of correlations between these factors in the two groups were analyzed statistically. RESULTS: TECs in the enlargement group showed a more gradual curve, and the upslope, the gradient of TEC in the ascending phase and the upslope index were significantly more gradual than those in the stable group (p = 0.0247, 0.0243). The EC washout and the EC washout index were also more gradual than in the stable group's (p = 0.019, 0.019). The enhancement duration was longer in the former than in the latter (80%, p = 0.0195; 70%, p = 0.0159; 60%, p = 0.0159). The CT number in the equilibrium phase was larger in the enlargement group than in the stable group (p = 0.019). CONCLUSION: The 4D-CT is useful for predicting aneurysm enlargement with Type-II endoleaks after EVAR.

A long-term survivor of undifferentiated carcinoma of the liver successfully treated with surgical treatments: A case report and literature review.

INTRODUCTION: Undifferentiated carcinoma of the liver is extremely rare. The biological characteristics and standard strategy for its treatment have not been established yet. PRESENTATION OF CASE: A 45-year-old man was admitted because of fever elevation and shivering. Abdominal computed tomography revealed a hypovascular cystic mass in segments 6 and 7 of the liver measuring 11.5 × 9.0 cm with ring enhancement and partial solid component. A diagnosis of liver abscess was made, and percutaneous transhepatic abscess drainage was performed. Reddish brown-colored pus showed no bacteria or amoebas. However, cytology demonstrated malignant cells. After additional examinations of magnetic resonance imaging and the positron emission tomography, extended posterior sectionectomy with cholecystectomy was performed. The excised specimen showed a solid and irregular tumor with extensive central necrosis. A pathological examination revealed diffuse proliferation of oval- and spindle-shaped malignant cells. Immunohistochemically, the malignant cells were diffusely positive for AE1/AE3 and vimentin and focally positive for granulocyte colony-stimulating factor and cytokeratin 19; however, hepatocyte-specific antigen, glypican 3, cytokeratin 7, and CD56 were negative. Therefore, a diagnosis of undifferentiated carcinoma of the liver was made. He has remained well without any recurrence for three years since the operation. DISCUSSION: Undifferentiated carcinoma of the liver might grow rapidly, resulting in necrosis with a cystic component. Therefore, it can be difficult to distinguish from liver abscess. CONCLUSION: This disease has markedly different clinical and biological features from common primary malignant tumor of the liver. However, if the tumor is a solitary mass, surgical resection might lead to a good prognosis.

Malignant lymphoma incidentally diagnosed due to the perforation of the small intestine caused by a fish bone: A case report.

INTRODUCTION: The ingestion of a foreign body is relatively common. However, it rarely results in the perforation of gastrointestinal tract. We herein report an unusual case of malignant lymphoma incidentally diagnosed after the perforation of the small intestine by a fish bone. PRESENTATION OF CASE: A 90-year-old woman was admitted to our hospital because of abdominal pain and vomiting. Abdominal computed tomography demonstrated free air and ascites in the abdominal cavity. In the pelvic cavity, a radiopaque linear shadow about 35mm in diameter was shown in the small intestine, and the stricture was exposed to the abdominal cavity. Therefore, a diagnosis of perforation of the small intestine due to ingestion of a foreign body and panperitonitis was made. Emergent laparotomy was performed. The intraoperative findings revealed perforation of the small intestine with a fish bone in the jejunum. Local inflammation at the perforation site was seen, and circulated wall thickness was observed at the distal side of the jejunum. Partial resection of the jejunum and anastomosis of jejuno-jejunostomy was performed. A pathological examination and immunohistochemical study of the resected specimen resulted in a diagnosis of malignant lymphoma of follicular lymphoma Grade 1. DISCUSSION: It is very difficult to identify the existence malignancy accompanied with gastrointestinal perforation with ingestion of a foreign body. CONCLUSION: In cases suspected of involving malignancy, careful observation during surgery is needed in order to avoid missing the accompanying malignancy.

Diagnosis and follow-up of posterior inferior cerebellar artery dissection complicated with ischemic stroke assisted by T1-VISTA: a report of two cases.

BACKGROUND: Volume isotropic turbo spin-echo acquisition (VISTA) is a new method similar to the 3D black-blood imaging method that enables visualization of a intramural hematoma. T1-VISTA has recently been applied in the diagnosis of intracranial arterial dissection. However, the identification of an intramural hematoma in posterior inferior cerebellar dissection (PICA-D) by T1-VISTA has only rarely been reported. CASE PRESENTATION: We herein report two patients who suffered from PICA-D complicated with ischemic stroke. Initial magnetic resonance arteriography was not informative, however, T1-VISTA depicted high-intensity signal areas suggesting an intramural hematoma of PICA-D in both cases. The high-intensity signal areas gradually reduced and finally disappeared at 4 months and 5 months after the onset, respectively. CONCLUSION: Our cases demonstrate that T1-VISTA was able to assist in the diagnosis and follow-up of PICA-D.

Mucoepidermoid Carcinoma of the Breast Found during Treatment of Lymphoma.

A 71-year-old woman, previously treated for malignant lymphoma, was admitted to our hospital with a tumor in the right breast. The tumor size was 2.0 cm in diameter, and the borderline was unclear. The core needle biopsy material revealed an invasive adenocarcinoma with metaplastic change. Right mastectomy and sentinel lymph node biopsy was performed. Histologically, the tumor was composed of mucus-secreting, epidermoid, and intermediate cells. These findings confirmed the diagnosis as mucoepidermoid carcinoma (MEC) of the breast. MEC is more frequently observed in the salivary glands and occurs rarely in the breast, with an incidence of approximately 0.3% of all breast cancers. Because of the rarity of the disease, the clinicopathological features and clinical outcome have not been fully investigated. The relationship between MEC of the breast and lymphoma are unclear. Here we report a rare case of MEC of the breast.

Successful treatment of an abdominal aortic aneurysm with a severely angulated and large aortic neck using a modified Zenith.

This report presents the case of an abdominal aortic aneurysm (AAA), in which the aortic neck was severely angulated. Furthermore, there was moderate stenosis and a severe angle with calcification of the suprarenal aorta. EVAR was performed with a commercial Zenith stent-graft, with a slight modification, because an open aneurysm repair was risky in general condition. No complications occurred during the follow-up period.

Rhabdomyolysis developing after transcatheter arterial chemoembolization for hepatocellular carcinoma.

A 25-year-old man with hepatocellular carcinoma developed severe muscular weakness and pain 15 days after transcatheter arterial chemoembolization (TACE). The diagnosis of rhabdomyolysis was made based on myalgia localized in the bilateral upper extremities (bilateral trapezius, deltoid, biceps brachii, and teres major muscles) on magnetic resonance imaging and increased levels of muscle-derived serum enzymes. In this case, some drugs administered during the clinical course of TACE (diclofenac, famotidine, and cefotiam dihydrochloride) were suspected to be involved in the rhabdomyolysis, but the exact cause of rhabdomyolysis was not identified. The symptoms were completely improved by right trisegmentectomy of the liver following conservative treatment.

Primary aldosteronism associated with severe rhabdomyolysis due to profound hypokalemia.

A 55-year-old Japanese man was admitted to our hospital with severe weakness. Without measurement of serum electrolyte concentrations, diuretic therapy for hypertension was started 2 weeks prior to admission. Laboratory findings showed profound hypokalemia (1.4 mEq/L), and extreme elevation of the serum creatinine phosphokinase levels (15,760 IU/L), suggesting that the patient had hypokalemic paralysis and hypokalemia-induced rhabdomyolysis. Further evaluations, including adrenal venous sampling strongly suggested that he had primary aldosteronism. He was treated successfully by laparoscopic adrenalectomy. This case provides an important lesson that serum electrolyte concentrations should be measured in hypertensive patients before the administration of antihypertensive agents.

Percutaneous osteoplasty for hypervascular bone metastasis.

We report three cases of percutaneous osteoplasty for the treatment of hypervascular bone metastasis. Four hypervascular bone metastases were treated in three consecutive patients by percutaneous osteoplasty under fluoroscopic or computed tomographic guidance. Primary malignant tumors included pheochromocytoma and renal cell carcinoma. Pain relief after osteoplasty was achieved in all three patients. There was no major complication. Projectile bleeding and subcutaneous hematoma were noted during or after osteoplasty but were easily controlled conservatively. Percutaneous osteoplasty for hypervascular bone metastases is not only a highly effective but also a minimally invasive technique that provides immediate pain relief without major complication.

Hepatic encephalopathy from dual splenorenal shunts treated with balloon-occluded retrograde transvenous obliteration by using a double-balloon technique.

The authors report on their experience with a 61-year-old woman with hepatic encephalopathy and two large splenorenal shunts. She was treated with dual balloon-occluded retrograde transvenous obliteration (B-RTO). Retrograde injection of the sclerosant into the shunt was performed with balloon occlusion of the two vessels draining into the left renal vein, and complete occlusion was achieved without complications. After B-RTO, the patient's clinical symptoms improved substantially and contrast-enhanced computed tomography (CT) performed 3 months later demonstrated complete thrombosis of the splenorenal shunts.

Second branchial cleft cyst with "cyst-within-cyst" appearance.

A 68-year-old female consulted our hospital, complaining of a large mass on the left side of the neck. Computed tomography and magnetic resonance imaging revealed the characteristic internal architecture of the mass, in which a small cyst was located within a cystic mass, showing a "cyst-within-cyst" appearance. A final diagnosis of second branchial cleft cyst was made pathologically. A "cyst-within-cyst" appearance is not usually seen in a second branchial cleft cyst. This appearance may be attributed to several fine-needle aspiration biopsies for diagnostic purposes.

Handlebar hernia: a case report.

A 36-year-old man fell from his bicycle and struck his lower abdomen on the end of the handlebar. Computed tomography (CT) showed a small bowel loop protruding into the subcutaneous fat layer of the abdominal wall. We present this case of handlebar hernia, a rare type of traumatic abdominal wall hernia, and the usefulness of CT in diagnosing such injuries.

MDCT of the gonadal veins in females with large pelvic masses: value in differentiating ovarian versus uterine origin.

OBJECTIVE: The objective of our study was to determine the usefulness of recognizing the continuity of the gonadal veins to the pelvic mass to differentiate ovarian versus uterine origin on MDCT in females with a large pelvic mass. MATERIALS AND METHODS: Two radiologists interpreted the MDCT images obtained on a monitor, using paging methods, in 86 female patients with a large pelvic mass (> 8 cm) and 40 patients without an abdominopelvic mass as control subjects. The following issues were recorded using a 5-point scale: visualization of gonadal veins and origin determination based on anatomic continuity. Receiver operating characteristic (ROC) curve analysis was performed, and the interobserver differences were checked with kappa statistics. The maximum diameters of the gonadal veins were also measured. With consensus interpretations, the sensitivity, specificity, and accuracy of ovarian origin determination were calculated. RESULTS: Gonadal veins were shown in more than 70% of the subjects in both the control group and the patients with a mass (hereafter referred to as the "mass group"). There was no significant difference in the diameter of the gonadal veins between the control and mass groups and between patients with an ovarian mass and those with a uterine mass. The values for the area under the ROC curve (A(z)) of the two observers for ovarian origin determination were 0.90 and 0.92. The kappa value was 0.48. The sensitivity, specificity, and accuracy were 83.3%, 87.5%, and 84.9%, respectively. CONCLUSION: Gonadal veins can be shown on MDCT with high consistency; MDCT provides useful information for determining the origin of relatively large pelvic tumors arising in females.

The incidence of hepatic pseudolesions caused by focal rib compression as seen on multidetector row CT in patients of different hepatic function.

OBJECTIVE: To determine whether the incidence of pseudolesions of the liver caused by rib compression is correlated with liver function. MATERIALS AND METHODS: Multidetector row CT images of 150 consecutive cases were evaluated for the presence of pseudolesions caused by rib compression. Liver function was categorized into two groups mainly using the Child-Pugh classification: Group I-normal liver function and Grade A; Group II-Grades B and C. The number of focal deformities of the liver caused by rib compression was also counted. The incidence of pseudolesions based on number of patients or focal deformities of liver parenchyma by rib compression were compared between the two groups. RESULTS: There were 108 and 42 patients in Groups I and II, respectively. 169 and 41 focal deformities of the liver caused by rib compression were found in Groups I and II, respectively. Patient-based and deformity-based incidences of pseudolesions were 10.7% (16/150) and 7.6% (16/210), respectively. All pseudolesions were seen in patients of Group I. Both patient-based and deformity-based incidences of pseudolesions were significantly higher in Group I as compared with those in Group II. CONCLUSION: Pseudolesions of the liver caused by focal rib compression may be seen more frequently in patients with preserved liver function than in those with impaired function.

Diffusion-weighted echo-planar MR imaging and ADC mapping in the differential diagnosis of ovarian cystic masses: usefulness of detecting keratinoid substances in mature cystic teratomas.

PURPOSE: To elucidate whether apparent diffusion coefficient (ADC) values calculated from echo-planar diffusion-weighted MR imaging (EPDWI) are useful in the differential diagnosis of ovarian cystic masses. MATERIALS AND METHODS: EPDWI was performed in 131 patients with ovarian cystic masses (54 mature cystic teratomas, 35 endometrial cysts, four other benign cysts, 14 benign neoplasms, and 24 malignant neoplasms). The areas of the highest signal intensity on EPDWI (b = 1000 seconds/mm(2)) and the lowest ADC values within the cystic component were evaluated. RESULTS: On qualitative and quantitative analyses, mature cystic teratomas tended to show higher signal intensity and had areas of lower ADC values than endometrial cysts and other benign and malignant neoplasms (P < .005). In vitro scanning of the cystic contents of mature cystic teratomas confirmed that high signal on DWI or low ADC value was attributable to the keratinoid substance within the tumors. The difference in ADC between malignant and benign lesions were significant when mature cystic teratomas and endometrial cysts were included, but was not significant when they were excluded. CONCLUSION: The ADC value may add useful information to the differential diagnosis of ovarian cystic masses in limited populations, such as those with mature cystic teratomas with a small amount of fat.

Detection of combined hepatocellular and cholangiocarcinomas on enhanced CT: comparison with histologic findings.

OBJECTIVE: The purpose of this study was to evaluate the performance of enhanced CT in making a diagnosis of combined hepatocellular and cholangiocarcinomas (HCC-CCs) by comparing CT findings with histologic findings. CONCLUSION: One third (nine of 27 cases) of the combined HCC-CCs were correctly diagnosed on enhanced CT by detailed analysis of the enhancing pattern around or within the mass. Various factors such as an atypical enhancing pattern, the size of each component, and the presence of a mass composed of intermediate tumor cells-that is, cells with intermediate characteristics between HCC and CC-were found to be the causes of misdiagnosis of combined HCC-CC on enhanced CT.

Percutaneous femoral catheter placement for long-term chemotherapy infusions: preliminary technical results.

OBJECTIVE: The purpose of our study was to evaluate the feasibility and usefulness of using a port-catheter system equipped with a W-spiral catheter for hepatic chemotherapy; this novel catheter does not require fixation by pericatheter embolization and can be safely withdrawn when not needed. SUBJECTS AND METHODS: Sixty-one patients (40 men and 2l women; mean age, 59 years) with advanced liver cancers (primary hepatic or biliary cancer [n = 31] and metastatic liver cancer [n = 30]) underwent percutaneous port-catheter placement with the tip of W-spiral catheter inserted into the right gastroepiploic artery and the side-hole opened at the common hepatic artery after embolization of the right gastric artery, pancreaticoduodenal arteries, or aberrant hepatic arteries. Pericatheter embolization for preventing catheter dislodgement was not performed. The technical success of port-catheter placement, clinical patency of the port-catheter system, and technical success of port-catheter removal were evaluated. RESULTS: Percutaneous port-catheter placement using this method was successfully performed in 59 (97%) of 61 patients. Subsequently, chemotherapy was successfully performed through the port in 57 (93%) of 61 patients. Complications during and after the procedure were observed in two (3%) of 61 patients and 12 (20.7%) of 58 patients. Hepatic artery thrombosis occurred in two (3.4%) of 58 patients. The port-catheter removal and the catheter replacement were performed in eight and four patients, respectively, who wanted the procedure. It was completed successfully without any complications. CONCLUSION: This method of implantation of a port-catheter system appeared to offer clinical advantages of safe catheter removal, femoral artery access, and an acceptable complication rate.