MR vessel-encoded arterial spin labeling with the placement of metallic items to visualize the territorial blood flow after extracranial-intracranial bypass surgery: a proof-of-concept study.

BACKGROUND: Depiction of bypass blood flow in patients who received extracranial-intracranial (EC-IC) bypass surgery is important for patient care. PURPOSE: To develop a vessel-encoded arterial spin labeling (VE-ASL) method using surgical staples as a magnetic resonance (MR)-conditional product in patients who received EC-IC bypass surgery. MATERIAL AND METHODS: Pseudo-continuous labeling was used for VE-ASL acquisition with a 3-T MR unit. First, an experimental study was conducted to determine the appropriate number of surgical staples to obtain a spatially sufficient saturation effect. Thereafter, four healthy normal volunteers underwent a VE-ASL study to confirm the sufficiency of the saturation effect to the right or left common carotid artery. Finally, VE-ASL scanning was performed in seven patients after EC-IC bypass surgery to confirm the ability of VE-ASL to visualize the territorial bypass perfusion. All qualitative evaluation was performed by two neuroradiologists using a 3-point grading system (2 = good, 1 = moderate, 0 = poor). RESULTS: A quantity of 200 staples was found to be appropriate for VE-ASL scanning. In healthy volunteers, one neuroradiologist rated the images of all four cases as good, while the other rated three cases as good and one case as moderate. For the seven patients after EC-IC bypass surgery, one neuroradiologist rated all seven cases as good, and the other rated six cases as good and one case as moderate. CONCLUSION: VE-ASL using surgical staples might be useful for the evaluation of territorial bypass perfusion in patients after EC-IC bypass surgery.

[Total Remnant Pancreatectomy for Remnant Pancreatic Carcinoma after Pancreaticoduodenectomy-A Report of Two Cases].

We report 2 cases of total remnant pancreatectomy for remnant pancreatic carcinoma after pancreaticoduodenectomy (PD). Case 1 pertained to a 51-year-old man who underwent PD for pancreatic carcinoma(pT3N0, R0). Twenty-seven months later, he developed a remnant pancreatic cancer. Total remnant pancreatectomy was performed, but he died due to liver and lung metastases 27 months after the second surgery. Case 2 pertained to a 58-year-old women who underwent PD for papilla of Vater cancer(pT1N0, R0). Eight-four months later, she developed remnant pancreatic cancer, for which total remnant pancreatectomy was performed. She died due to liver metastasis 8 months after the second surgery. Pathological findings revealed recurrent carcinoma in both cases and carcinoma in situ with extensive intraductal growth to the branch in case 2. Both cases had no complications after total remnant pancreatectomy and achieved good quality of life(QOL). Longterm follow up after pancreatectomy is necessary for early diagnosis of remnant pancreatic carcinoma.

[A Case of Cavitary Lung Metastasis of Rectal Cancer].

We report a rare case of cavitary lung metastasis of rectal cancer, diagnosed initially as septic pulmonary embolism. A 55- year-old woman underwent emergency Hartmann's operation for perforation of the rectal cancer with multiple liver metastases. A 2 cm-sized thin-walled cavitary lesion was seen in the left upperlobe of the lung by CT, and septic pulmonary embolism was suspected. She recoverd from sepsis after intensive care treatment. Pathological diagnosis is adenocarcinoma (tub2), T3N1M1, Stage Ⅳ, she underwent chemotherapy. Serum CEA level was high preoperatively but gradually decreased to normal 4 months after the operation. Multiple liver metastases showed calcification, and the lung lesions remained unchanged on CT. She continued chemotherapy while changing the anticancer drug due to side effects. One year and 5 months after operation, lung CT showed thickened wall and spicula around the cavitary lesion. Serum CEA level was normal, SLX and NSE slightly increased and serum aspergillus antigen was positive. Bronchial lavage cytology was Class Ⅰ and scrape cytology was Class Ⅲ in bronchoscopy. Lung metastasis, primary lung cancer or aspergilloma were suspected and we performed partial lung resection. The pathological diagnosis was rectal cancer lung metastasis.

[A Case of Peritoneal Lymphomatosis Diagnosed by Laparoscopic Biopsy].

Peritoneal lymphomatosis is an extremely rare presentation of lymphoma. We report a case of peritoneal lymphomatosis diagnosed by laparoscopic biopsy. A 56-year-old female presented to our hospital with a 2-week history of increasing abdominal distension associated with anorexia and generalized weakness. Abdominal CT findings demonstrated extensive disseminated peritoneal disease with marked thickening of the peritoneal surfaces and a large omental cake with large volume ascites. The examination of blood data and cytology of ascites indicated to the diagnosis of malignant lymphoma. She was proceeded to an urgent laparoscopic biopsy for diagnosis and observed the thickening of the peritoneal surfaces and large volume ascites. Pathological and immunohistochemical examination of the omentum revealed that it was diffuse large B-cell lymphoma presented by peritoneal lymphomatosis. The patient started an immediate course of combination chemotherapy consisting of rituximab, cyclophosphamide, doxorubicin vincristine and prednisolone(R-CHOP)and no recurrence has been noted for 5 years and 10 months from first visit. The differential diagnosis for disseminated peritoneal disease is vast. Laparoscopic biopsy was minimally invasive, and useful for an urgent and accurate the diagnosis and the treatment strategy of disseminated peritoneal disease.

Delivering the diluted contrast agent with saline via a spiral flow tube improves arterial enhancement for contrast enhancement of magnetic resonance angiography of the neck: A retrospective study.

A contrast agent can be pushed by a saline solution more effectively through a spiral flow tube than through a conventional T-shaped tube in contrast-enhanced magnetic resonance angiography (CEMRA). To compare the degree of contrast enhancement and signal stability in the carotid artery by using CEMRA between a spiral flow tube and a T-shaped tube.A total of 100 patients were analyzed in this retrospective study. The first 50 patients underwent CEMRA of the carotid artery with the T-shaped tube, while the last 50 patients used the spiral flow tube. Gadoterate meglumine was diluted with saline to make a total volume of 20 mL. Injection was performed with a bolus rate of 2.5 mL/s for 8 seconds. Five regions of interest (ROIs) were placed on the contrast-enhanced area in each carotid artery and the signal intensity (SI) in the ROI was used for the analysis. The ROIs on the brain stem were also placed and the average SI in this ROI was used as a reference signal. The enhancement of the artery (Eartery) was calculated as a normalized signal using the following equation: Eartery = SI in the ROI of the carotid bifurcation/SI in the ROI of the brain stem. Signal homogeneity in the contrast-enhanced area (SHenhance) was assessed by calculating the coefficient of variation from the SI in the 5 ROIs. The value of SHenhance and Eartery between the data obtained from the spiral flow tube and the T-shaped tube were compared. P-values <.05 were considered significant.We found a significant difference in SHenhance between the data obtained from the spiral flow tube (0.20 ±â€Š0.060) and the T-shaped tube (0.24 ±â€Š0.056) (P = .001). The Eartery values significantly increased by 15% (spiral flow tube, median 14.1 with interquartile range [IQR] 11.8-15.4 vs T-shaped tube, median 12.3 IQR 11.3-14.0, P = .02) using the spiral flow tube.These findings suggest that, by using the Spiral flow tube, the homogeneity of the contrast-enhanced signal intensity in the carotid artery was significantly improved without decreasing the signal intensity in CEMRA.

[Implantation Cyst at Anastomosis after Anterior Resection of the Rectum-A Report of Five Cases].

We report 5 cases of implantation cysts at anastomosis after rectal surgery. All patients underwent resection of the rectum usingthe double staplingtechnique (DST). Implantation cysts were recognized within a period of 3 months to 6 years after surgery. Abdominal CT showed cystic masses with calcification in all cases. Colonoscopy revealed submucosal tumor-like lesions in 3 cases, and serum CEA level was increased in 2 cases. In one patient with anal pain, transanal aspiration was performed; the other 4 patients are free from symptoms and are beingobserved without treatment.

[A Resected Case of Long-Term Survival of Pancreatic Cancer with Simultaneous Multiple Lung Metastasis with Systemic Chemotherapy].

The patient was a 78-year-old man with resection of distal pancreatectomy for pancreatic cancer with simultaneous multiple lung metastasis. They were papillary and tubular adenocarcinoma, Pt, TS3, infiltrative type, ly0, v0, pT3, CH0, DU0, S1, RP1, PV0, A1(Asp), PL0, OO0 and pN0, M1(PUL), pStage IV. He was received gemcitabine after the surgery. S-1 was added because of lung metastasis progression. Chemotherapy was continued for about 10 years from resection, and intra-abdominal recurrence was not observed and good performance status was maintained. 5-year survival rate of pancreatic cancer is as low as about 6.5%in Stage IV. There are cases where lung resection to isolated lung metastasis are performed after resection of pancreas and long-term-survival are obtained. A resected case of long-term-survival of pancreatic cancer with simultaneous multiple lung metastasis is rare, so we will report with a few literature considerations.

[Hemosuccus Pancreaticus Due to Pancreatic Head Invasive Pancreatic Duct Carcinoma].

A 51-year-old man was admitted to our hospital because of anorexia and jaundice. Abdominal CT and MRCP taken after admission revealed tumor in the pancreatic head. Upper gastrointestinal endoscopy showed bleeding from the orifice of the major papilla. In angiography, an irregular image was found in the branch of the gastroduodenal artery, and a coil embolization surgery was performed mainly on the same part. We diagnosed pancreatic cancer and pancreaticoduodenectomy was performed. Pancreatic cancer with bleeding from the orifice of major papilla is very rare. We describe our case with known reports.

[A Case of Choriocarcinoma of the Small Intestine with Multiple Lung and Liver Metastases].

A 73-year-old male presented with melena and severe anemia. An esophagogastroduodenoscopy(EGD)and colonoscopy( CS)revealed no source of hemorrhage. Multiple small intestinal tumors were observed on abdominal ultrasound(US). CT also showed mesenteric lymph node metastases and multiple lung and liver metastases. Since active bleeding was suspected, we performed an emergency surgery. The small intestine including 2 tumors and 2 mesenteric lymph node metastases were resected. On histopathological examination, choriocarcinoma was diagnosed. The blood hCG level was remarkably elevated. The primary lesion could not be detected. Chemotherapy containing cisplatin(CDDP)and irinotecan(CPT-11)was initiated; although the blood hCG level was temporally lowered, the patient died of liver failure 8 months after the surgery.

[A Case of Recurrent Gastric Cancer with No. 13 Lymph Node Metastasis Treated with SurgicalResection].

We report a rare case of a resected recurrent lymph node on the posterior surface of the pancreatic head(lymph node No. 13)4 years after total gastrectomy. The patient was a 61-year-old man diagnosed with advanced gastric cancer. We performed total gastrectomy and splenectomy, after which histopathological analysis showed duodenal invasion and lymph node (No.17)metastasis. Because the pathological stage was Stage Ⅳ, he received chemotherapy(S-1 plus CDDP plus trastuzumab) for 1 year. Four years after primary surgery, lymph node(No.13)metastasis was detected on a CT scan. After 4 courses of chemotherapy(capecitabine plus CDDP plus trastuzumab), the size of the metastatic lymph node decreased. Subsequently, we performed surgical resection of the involved lymph node. Histopathological findings showed glanuloma and fibrous tissue without any remnant cancer.

[Two Cases of Surgical Treatment for Disseminated Gastric Carcinoma].

Case 1: A 75-year-old man underwent distal gastrectomy with Billroth Ⅰ reconstruction and resection of the involved transverse mesocolon. Microscopic examination revealed adenocarcinoma(tub2, tub1), pT4b(SI)N3M0, pStageⅢc. Adjuvant chemotherapy with S-1 was performed for 6 months after the operation. One year later, CT revealed a localized dissemination in the transverse mesocolon; therefore, we performed transverse colectomy. Adjuvant chemotherapy with PTX was performed, and the patient remains free from recurrence 7 years after the initialoperation. Case 2: A 65-year-old man was diagnosed with gastric scirrhous carcinoma by esophagogastroduodenoscopy. CT and colonoscopy showed a tumorous lesion in the pelvis(Schnitzler's metastasis). Neo-adjuvant chemotherapy with S-1 plus CDDP was performed. After 6 courses, CT and endoscopy showed shrinkage of the tumors, and no other distant metastasis was detected by PET-CT. We performed totalgastrectomy(D2), splenectomy, and low anterior resection of the rectum simultaneously. Microscopic examination revealed adenocarcinoma(tub2, por2, sig), pT4a(SE)N0, and the histological response was Grade 1a. S-1 was administered, and the patient has had no recurrence in the 1 year 6 months after the operation. Dissemination of gastric cancer tends to be difficult to treat and has a poor prognosis. However, in some cases, the proper combination of chemotherapy and surgery might be beneficial for long survival.

[A Patient with Basaloid Carcinoma of the Esophagus Removed Surgically after Pre-Operative Chemotherapy Who Developed TTP during Post-Operative Chemotherapy].

A 63-year-old man presented with the chief complaint of an unpleasant feeling in the chest after a meal.Esophagogastroduodenoscopy revealed interminglement of ulcer infiltration type lesions and protruding lesions in the lower esophagus.A large type 1 protruding lesion was located mainly in the esophagogastric junction(EGJ)and it progressed towards the stomach.A hypertrophic and protruding lesion on the lower esophageal wall and a 6 cm tumor in the major axis of the fornix were observed on thoracic and abdominal CT, and an endocrine cell carcinoma or basaloid carcinoma were suggested after biopsy.Finally, we diagnosed a basaloid carcinoma after immunohistochemistry analysis.We administered 4 courses of TS-1 plus CDDP as pre-operative chemotherapy.Because of a significant reduction in tumor size, approximately 5 months after first presentation, we performed esophageal resection by right thoracotomy and laparotomy, and reconstructive surgery for the thoracic gastric duct.The pathological diagnosis was basaloid carcinoma with multiple foci of squamous cell carcinoma.After surgery, we continued chemotherapy with TS-1 plus CDDP, which was previously effective, but a liver metastasis appeared 8 months later.We discontinued chemotherapy because of a prominent decline in platelets.Because of the clinical symptoms, we diagnosed secondary thrombotic thrombocytopenic purpura accompanied by a malignant tumor.We implemented plasma exchange and steroid pulse therapy, but this patient experienced no therapeutic effect and died.

[Hepatic Lateral Segmentectomy for Management of Liver and Adrenal Abscess Following a Laparoscopy-Assisted Left Hemicolectomy - A Case Report].

A 67-year-old woman underwent laparoscopy-assisted left hemicolectomy for early descending colon cancer(pTis, pN0, cH0, cM0, Stage 0).Her postoperative course was uneventful, without fever and/or tenderness at the anastomotic site.A month following discharge from the hospital, enhanced computed tomography revealed a liver abscess measuring 80mm in diameter at the lateral segment and a left adrenal abscess measuring 30mm in diameter.Although some free air and fluid collection was noted near the anastomotic site, there was no tenderness, and a gastrografin enema did not reveal leakage and/or pooling of the contrast agent near the anastomotic site.We administered antibiotics and performed percutaneous transhepatic abscess drainage following which imaging revealed shrinkage of her liver and adrenal abscesses and lowering of fever.However, enhanced computed tomography, performed a month later, revealed recurrence of the liver abscess, for which we performed a hepatic lateral segmentectomy.After undergoing the hepatectomy, she has shown no recurrence of the liver and adrenal abscesses.Several cases of liver abscess have been reported in association with colorectal cancer; however, an adrenal abscess occurring in association with colorectal cancer has not yet been reported.This case reveals that a minor leak could be associated with a liver and adrenal abscess.

[Three Cases of Long-Term Survival in Colon Cancer with Postoperative Peritoneal Recurrence].

Case 1 is a 57-year-old man with pelvic recurrence 1 year 8 months after surgery for ascending colon cancer.We performed a Hartmann's operation.He has been relapse-free for 11 years.Case 2 is a 67-year-old man with intraperitoneal small intestinal relapse 4 years after surgery for cecum cancer.We performed resection.He has brain metastases recurrence in 2 years 6 months after surgery, died after 2 years 9 months.Case 3 is a 53-year-old man with recurrence in the bladder rectal fossa 5 years after sigmoidectomy.We performed resection.He has been relapse-free survival at 1 year 2 months.

[Four Cases of Colorectal Cancer with Para-Aortic Lymph Node Metastases Successfully Resected Resulting in Long-Term Survival].

We encountered 4 cases of colorectal cancer with para-aortic lymph node(LN)metastases.Para -aortic LN dissection was performed after the diagnosis of solitary LN metastases.Case 1: A 69-year-old woman was diagnosed with ascending colon cancer.She underwent right hemicolectomy with D3 LN dissection.After 1 year and 3 months, tumor marker levels(CEA) were elevated, and para-aortic LN metastases were detected on CT.She was administered FOLFOX.After 1 year, para-aortic LN dissection was performed.She is doing well without any recurrence for 8 years and 9 months.Case 2: A 52-year-old man was diagnosed with rectal cancer.He underwent abdominoperineal resection with lateral pelvic LN dissection.After 5 months, his tumor marker levels(CEA)were elevated, and para-aortic LN metastases were detected on CT.He was administered various chemotherapies, but the LN were swollen.After 6 years and 2 months, para-aortic LN dissection was performed.He received systematic chemotherapy, and is alive with recurrent disease.Case 3: A 67-year-old man was diagnosed with obstructive sigmoid colon cancer.He underwent high-anterior resection with D3 LN and para-aortic LN dissection.He received systematic chemotherapy and is alive with recurrent disease.Case 4: A 61-year-old man was diagnosed with obstructive rectal cancer.He underwent low-anterior resection with D3 LN and para-aortic LN dissection.He is doing well without recurrences for 2 years and 1 month.Our results suggest that patients with localized para-aortic metastases of colorectal cancer may achieve good long-term survival after dissection of para-aortic LN.and surgical treatment is indicated in selected cases.

[A Case of Retroperitoneal Recurrence and Left Kidney Metastasis Occurring Four Years after Laparoscopy-Assisted Surgery for Sigmoid Colon Cancer].

A 67-year old woman underwent laparoscopy-assisted high anterior resection for sigmoid colon cancer. A histopathological examination revealed no lymph node metastasis, but extramural cancer deposits were present. Four years later, enhanced computed tomography revealed recurrence in the retroperitoneum and metastasis to the left kidney. A left nephrectomy and left hemicolectomy were performed. A year after the second operation, computed tomography revealed metastasis to the lung. Histopathological reexamination for extra-lymph nodal spread after the first operation revealed venous involvement. Generally, colon cancer with extra-lymph nodal spread has a higher risk of retroperitoneal recurrence, and venous involvement leads to a poor prognosis. We describe our case with the known report.

[A Case of Para-Aortic Lymph Node Metastases of Sigmoid Colon Cancer Treated with Complete Resection].

We present a case of sigmoid colon cancer with isolated para-aortic lymph node metastasis in a 67-year-old male patient. We treated this patient using simultaneous curative lymph node dissection with primary tumor resection. After inserting a transanal tube and decompressing the proximal colon for obstructive colitis, we performed high anterior resection with paraaortic lymph node dissection without neoadjuvant chemotherapy. The pathology results were as follows: tub2, SE, N3, H0, P0, M1(No. 216, 280), stage Ⅳ, curability B. Adjuvant chemotherapy with the XELOX regimen was administered, and the patient remains alive with no signs of recurrence 24 months after surgery. Although simultaneous dissection of para-aortic lymph node metastasis is controversial, curative dissection is advisable for localized cases.

[A Case of Long-Term Survival of a Patient with Gastric Cancer with Peritoneal Dissemination].

The patient was a 75-year-old man with a history of gastrectomy with combined resection of the transverse colon ligament for gastric cancer in July 2011. He was diagnosed with adenocarcinoma (tub2, tub1), L, Ant-Gre, type 2, pT4b (SI: transverse colon ligament) and pN3b, H0, M0, P0, CY0, Stage ⅢC. On abdominal computed tomography 7 months after surgery a peritoneal metastasis was seen near the transverse colon. The patient was treated with resection for peritoneal dissemination with part of the transverse colon. Three years after the last surgery, the patient is still alive without relapse.

[Colorectal Cancer with Macroscopic Invasion to Adjacent Organs--A Case Report].

We encountered a case of colorectal cancer with macroscopic invasion to the adjacent organs. A 61-year-old man with abdominal pain and nausea was diagnosed as having sigmoid colon cancer invading the ileum, ureter, internal iliac artery, and external iliac vein. A lower anterior resection and resection of the small bowel, ureter, external iliac vein, and internal iliac artery was performed and succeeded in an R0 resection. The patient was discharged from the hospital in 29 POD. Pathology results revealed an adenocarcinoma, pT4b, pSI, INF b, int, ly0, v, pPM0, pDM0, pN0, Type 2, Stage Ⅱ. Four courses of XELOX plus bevacizumab were administered. The patient underwent ileostomy closure, and is currently free of relapse 3 years 2 months after resection. The survival rate of patients with combined resection of the invaded organs is significantly higher than that of patients with a non-combined resection. The survival rate after curative resection is also significantly higher compared with non-curative resection. Aggressive resection of invaded organs seems to be important for a good outcome.

[A Case of Long-Term Survival after Resection of Liver and Adrenal Metastases from Rectal Cancer].

A 72-year-old man underwent Miles' operation for rectal cancer. Histological findings showed moderately differentiated adenocarcinoma, a, ly0, v1, n0, stage Ⅱ(ly0, v1). Five months later, left lateral segmentectomy and left adrenalectomy were performed owing to the metastasis of the rectal cancer to the liver and adrenal glands. Two years after these operations, left nephrectomy was performed for retroperitoneal recurrence around the left kidney. All resected specimens showed metastatic adenocarcinoma derived from the rectal cancer. No recurrence has been detected in the 4 years since the left nephrectomy. Aggressive resection of well-controlled metastatic lesions including those in the adrenal glands is recommended.