Diffuse Pulmonary Meningotheliomatosis with Sarcomatous Transformation in a Shiba Dog

A 2-year-old neutered female Shiba dog exhibited laboured breathing for 1 month. Computed tomography of the thoracic cavity revealed multiple nodules (2-5 mm diameter) in the lungs. Grossly, the lungs were firm and normal in shape. The nodules were grey-white in colour. Microscopically, the nodules were non-encapsulated and exhibited an irregular shape. They were composed of polygonal or spindle cells with indistinct cell borders arranged in sheets. The cells had large, round, hyperchromatic nuclei and abundant pale eosinophilic cytoplasm with no atypia. Intrapulmonary arterial emboli and infiltration into the bronchioles were observed. Immunohistochemically, the cells were positive for vimentin and negative for cytokeratin, glial fibrillary acidic protein and α-smooth muscle actin. Ultrastructurally, the cells displayed cytoplasmic processes, desmosomes and intermediate filaments. These findings led to a diagnosis of diffuse pulmonary meningotheliomatosis with sarcomatous transformation. To the best of our knowledge, this is the first report of diffuse pulmonary meningotheliomatosis in a dog.

Prognostic significance of sarcopenia in patients undergoing esophagectomy for superficial esophageal squamous cell carcinoma

Nononcological prognostic factors in superficial esophageal squamous cell carcinoma (SESCC) patients remain unclear. The aim of this study is to evaluate the relationship between sarcopenia and surgical outcome in patients with SESCC who had undergone definitive surgery. A total of 194 SESCC patients who had undergone thoracic esophagectomy with three-field lymphadenectomy without neoadjuvant therapy at Tokai University Hospital between January 2006 and December 2015 were analyzed retrospectively. Manual tracing using CT imaging was used to measure the cross-sectional areas of the skeletal muscle mass. The cutoff values for the skeletal muscle index used to define sarcopenia were based on the results of a previous study. Twenty-eight patients (14.4%) had sarcopenia, while the remaining 166 patients (85.6%) did not. A multivariate analysis suggested that sarcopenia was an independent risk factor for postoperative pulmonary complications (OR = 3.232, P = 0.026). The overall survival rate and the disease-free survival rate were both significantly worse in the sarcopenia group than in the nonsarcopenia group (P < 0.001). In a multivariate analysis, sarcopenia was an independent prognostic factor affecting overall survival (HR = 7.121, P < 0.001) and disease-free survival (HR = 6.000, P < 0.001). Patients with sarcopenia and lymph node metastasis (n = 18) had a worse outcome than the other patients (P < 0.001). This study suggests that the alleviation of sarcopenia through nutritional support and rehabilitation in SESCC patients scheduled to undergo surgery might help to prevent postoperative pulmonary complications and to improve the long-term outcome.

Treatment of Labial Fistula Communicating with the Duodenal Stump After Gastrectomy

BACKGROUND Anastomotic failure after gastroenterological surgery is usually treated by intraperitoneal drainage and a mature ductal fistula. A ductal fistula may develop into a labial fistula. Although a ductal fistula is controllable, a labial fistula is intractable. We report a case of a labial fistula that communicated with the duodenal stump after gastrectomy. This condition was successfully treated by intraluminal drainage with continuous suction (IDCS) via a rectus abdominis musculocutaneous flap (RAMF). CASE REPORT A 70-year-old male underwent distal gastrectomy with intentional lymphadenectomy because of advanced gastric cancer. Digestive reconstruction was completed by the Billroth II method. Pancreatic leakage, intraperitoneal abscess, and anastomotic failure of gastrojejunostomy occurred after surgery. The duodenal stump was ruptured at postoperative day (POD) 26, and ductal fistula associated with the duodenum was observed. Unfortunately, this ductal fistula developed into a labial fistula at POD 90, and a high output of duodenal juice was observed. Additional surgery was proposed at POD 161. The broken stump and labial fistula were covered by a pedunculated RAMF, and a dual drainage system (a combination of a Penrose drain and a 2-way tube) travelled through the RAMF. The tip position of the drainage system was located in the duodenum, and the IDCS was effectively introduced. The secondary ductal fistula finally matured through the RAMF, and was subsequently closed at POD 231. The intractable labial fistula was successfully treated, and the patient was discharged at POD 235. CONCLUSIONS A high-output labial fistula, which communicated with the duodenal stump after gastrectomy, was refractory in our patient. Effective IDCS through an RAMF was useful for replacement of the labial fistula with a secondary ductal fistula.

Usefulness of Silent MR Angiography for Intracranial Aneurysms Treated with a Flow-Diverter Device

BACKGROUND AND PURPOSE

The flow-diverter device has been established as a treatment procedure for large unruptured intracranial aneurysms. The purpose of this study was to compare the usefulness of Silent MR angiography and time-of-flight MRA to assess the parent artery and the embolization state of the aneurysm after a flow-diverter placement.

MATERIALS AND METHODS

Seventy-eight large, unruptured internal carotid aneurysms in 78 patients were the subjects of this study. After 6 months of treatment, they underwent follow-up digital subtraction angiography, Silent MRA, and TOF-MRA, performed simultaneously. All images were independently reviewed by 2 neurosurgeons and 1 radiologist and rated on a 4-point scale from 1 (not visible) to 4 (excellent) to evaluate the parent artery. The aneurysmal embolization status was assessed with 2 ratings: complete or incomplete occlusion.

RESULTS

The mean scores of Silent MRA and TOF-MRA regarding the parent artery were 3.18 ± 0.72 and 2.31 ± 0.86, respectively, showing a significantly better score with Silent MRA (P < .01). In the assessment of the embolization of aneurysms on Silent MRA and TOF-MRA compared with DSA, the percentages of agreement were 91.0% and 80.8%, respectively.

CONCLUSIONS

Silent MRA is superior for visualizing blood flow images inside flow-diverter devices compared with TOF-MRA. Furthermore, Silent MRA enables the assessment of aneurysmal embolization status. Silent MRA is useful for assessing the status of large and giant unruptured internal carotid aneurysms after flow-diverter placement.

Severely Calcified True Aneurysm: A Thought-Provoking Case of Solitary Origin and Postoperative Management

Patient: Male, 70

Final Diagnosis: Splenic artery aneurysm

Symptoms: Asymptomatic

Medication: —

Clinical Procedure: Surgery and Endoscopy

Specialty: Surgery

Inferior Pancreaticoduodenal Artery Aneurysm Related with Groove Pancreatitis Persistently Repeated Hemosuccus Pancreaticus Even After Coil Embolization

Patient: Male, 58

Final Diagnosis: Inferior pancreaticoduodenal artery aneurysm

Symptoms: Bleding

Medication: —

Clinical Procedure: Pancreaticoduodenectomy

Specialty: Surgery

A case with good response to belimumab for lupus nephritis complicated by IgG4-related disease

Immunoglobulin (Ig)G4-related disease (IgG4-RD) is an unusual complication of systemic lupus erythematosus (SLE). We report a case in which belimumab proved efficacious for not only SLE, but also IgG4-RD. A 58-year-old Japanese woman had suffered from photodermatosis and erythema on the limbs for 20 years. She presented in slight fever and fatigue since 2016. Laboratory data showed hypergammaglobulinemia, proteinuria and positive results for anti-nuclear antibody and anti-double-stranded DNA antibody. Furthermore, elevated levels of serum IgG4 were detected. Contrast-enhanced computed tomography disclosed multiple areas of poor enhancement in the kidneys. The patient was diagnosed with lupus nephritis and IgG4-RD from renal biopsy. Treatment was started with prednisolone at 40 mg/day and mycophenolate mofetil. Proteinuria and serological findings improved initially, but tapering the dose of glucocorticoid proved difficult. After treatment was started with belimumab, clinical symptoms and proteinuria resolved completely. The dose of glucocorticoid was successfully tapered and serum concentration of IgG4 fell further. This appears to represent the first report of a case in which both SLE and IgG4-RD were effectively treated using belimumab.

Changes in topographical relation between the ductus arteriosus and left subclavian artery in human embryos: a study using serial sagittal sections

BACKGROUND

At birth, the ductus arteriosus (DA) merges with the aortic arch in the slightly caudal side of the origin of the left subclavian artery (SCA). Since the SCAs (7th segmental arteries) were fixed on the level of the 7th cervical-first thoracic vertebral bodies, the confluence of DA should migrate caudally. We aimed to describe timing and sequence of the topographical change using serial sagittal sections of 36 human embryos and foetuses (CRL 8-64 mm; 5-10 weeks), Those made easy evaluation of the vertebral levels possible in a few section.

MATERIALS AND METHODS

The DA or 6th pharyngeal arch artery seemed to slide down in front of the sympathetic nerve trunk along 1.0-1.2 mm from the second cervical vertebral level at 5-6 weeks and, at 6 weeks (CRL 14-17 mm), the DA confluence with aorta reached the 7th cervical level. Because of the highly elongated common carotid artery, the sliding of DA confluence seemed to be much shorter than the cervical vertebrae growing from 1 mm to 2.4 mm.

RESULTS

At the final topographical change at 6-7 weeks, the DA confluence further descended to a site 1-vertebral length below the left SCA origin. From 6 to 9 weeks, a distance from the top of the aortic arch to the left SCA origin was almost stable: 0.3-0.5 mm at 6 weeks and 0.4-0.6 mm at 9 weeks.

CONCLUSIONS

The heart descent and the caudal extension of the trachea and bronchi, those occurred before the DA sliding, were likely to be a major driving force for the sliding.

Randomized clinical trial of adjuvant gemcitabine chemotherapy versus observation in resected bile duct cancer

BACKGROUND

Although some retrospective studies have suggested the value of adjuvant therapy, no recommended standard exists in bile duct cancer. The aim of this study was to test the hypothesis that adjuvant gemcitabine chemotherapy would improve survival probability in resected bile duct cancer.

METHODS

This was a randomized phase III trial. Patients with resected bile duct cancer were assigned randomly to gemcitabine and observation groups, which were balanced with respect to lymph node status, residual tumour status and tumour location. Gemcitabine was given intravenously at a dose of 1000 mg/m² , administered on days 1, 8 and 15 every 4 weeks for six cycles. The primary endpoint was overall survival, and secondary endpoints were relapse-free survival, subgroup analysis and toxicity.

RESULTS

Some 225 patients were included (117 gemcitabine, 108 observation). Baseline characteristics were well balanced between the gemcitabine and observation groups. There were no significant differences in overall survival (median 62·3 versus 63·8 months respectively; hazard ratio 1·01, 95 per cent c.i. 0·70 to 1·45; P = 0·964) and relapse-free survival (median 36·0 versus 39·9 months; hazard ratio 0·93, 0·66 to 1·32; P = 0·693). There were no survival differences between the two groups in subsets stratified by lymph node status and margin status. Although haematological toxicity occurred frequently in the gemcitabine group, most toxicities were transient, and grade 3/4 non-haematological toxicity was rare.

CONCLUSION

The survival probability in patients with resected bile duct cancer was not significantly different between the gemcitabine adjuvant chemotherapy group and the observation group. Registration number: UMIN 000000820 (http://www.umin.ac.jp/).