Takaharu Miyauchi

Portal gas in a patient with acute obstructive cholangitis: report of a case with emphasis on US findings.

Portal gas is relatively rare, and its relationship to ischemic bowel diseases has been emphasized. We report the case of a 70-year-old woman with acute obstructive cholangitis in whom portal gas was detected by ultrasonography (US) but not by computed tomography (CT). The former showed multiple echo spots moving in the portal vein. Doppler signals confirmed them to be bidirectional and spiky, which immediately led to the diagnosis of portal gas. Immediate appropriate antibiotic treatment and biliary drainage yielded the disappearance of the portal gas. We stress the usefulness of US and Doppler US for detecting and diagnosing portal gas. Our observation suggests that when portal gas is detected by US, the possibility of cholangitis should be included in the differential diagnosis.

Three-dimensional computed tomography in the head and neck diseases with bony abnormalities

The purpose of this study was to define the role of three-dimensional (3D) computed tomography (CT) in the head and neck diseases with bony abnormalities. Thirty-two patients were examined with a low dose radiation technique. Three-dimensional CT clearly delineated bony lesions in 27 of 32 patients. Three-dimensional CT could not demonstrate subtle bony erosions infiltrated by tumor, a temporal bone fracture, and a blow-out fracture, although two-dimensional (2D) images obtained before the 3D reconstructions clearly depicted those lesions. These two kinds of CT technique were thought to be complimentary.

Tumor regression of multiple bone metastases from breast cancer after administration of strontium-89 chloride (Metastron)

We report a case of tumor regression of multiple bone metastases from breast carcinoma after administration of strontium-89 chloride. This case suggests that strontium-89 chloride can not only relieve bone metastases pain not responsive to analgesics, but may also have a tumoricidal effect on bone metastases.

Primary cystic germinoma originating from the midbrain

A primary intracranial germinoma that involves the midbrain is rare. We describe an unusual case of primary cystic germinoma originating from the midbrain. A 29-year-old man presented with diplopia, and his MRI showed a cystic, ring-like enhanced lesion in the thalamo-mesencephalic junction. Open biopsy was performed and the diagnosis of germinoma was based upon the histopathological findings. Following chemotherapy and radiotherapy, the symptoms improved and the tumor disappeared. We propose that primary intracranial germinoma should be included in the differential diagnosis of midbrain tumors, because early diagnosis and appropriate treatment for midbrain germinoma improves clinical outcome.

Superb microvascular imaging (SMI) findings of splenic artery pseudoaneurysm: a report of two cases

Splenic artery pseudoaneurysm (SAPA) is a relatively infrequently encountered but clinically important vascular change, because it carries a high risk of rupture that warrants prompt treatment regardless of its size. Thus, sufficient knowledge is indispensable when seeing chronic pancreatitis patients or post-traumatic patients. Here, we report two such cases. The first case was a 52-year-old woman known to have chronic pancreatitis who presented with hematemesis and hemodynamic instability in which X-ray computed tomography (CT) and color Doppler sonography (CDS) had difficulty visualizing slow blood flow in SAPA, but superb microvascular imaging (SMI) clearly demonstrated the slow blood flow in SAPA, prompting our therapeutic decision to perform rapid embolization. The second case was a 51-year-old woman with post-traumatic SAPA in which 3D SMI enabled us to understand more clearly the topographic relationship between multiple SAPAs as compared with conventional US, leading to a decision to provide immediate surgical treatment. SMI was thought to provide a new insight into the US diagnosis of SAPA. When examining patients suspected of having a SAPA, SMI is an indispensable diagnostic tool at present.

Sonographic findings in two cases of lymphangioma of the mesocolon in adults

Lymphangioma of the mesocolon is very rare. We report two cases of surgically resected and histologically proven mesocolic lymphangioma in adults. In both cases, ultrasound revealed a large cystic mass with multiple thin septa in the lower abdomen. A peculiar finding was the large craniocaudal sliding movement of the mass synchronized with the patients respiration, which was a clue to the diagnosis of mesenteric lymphangioma.

Successful treatment continuation with a single mild partial splenic embolization for thrombocytopenia caused by oxaliplatin-based chemotherapy for advanced colon cancer.

We report the case of a patient with advanced colon cancer receiving oxaliplatin-based chemotherapy that was able to continue systemic chemotherapy by performing mild partial splenic embolization (PSE) for thrombocytopenia caused by splenomegaly due to oxaliplatin. Mild PSE may be useful for thrombocytopenia due to splenomegaly in cancer patients because it provides more treatment opportunities.

Isolated hepatic metastasis with hepatic venous invasion and tumor thrombus in right atrium

A 78-year-old man was transferred to our hospital for detailed examination and treatment of sudden-onset and rapidly increasing general edema. Routine blood counts and laboratory test results were normal. His medical history included chronic heart failure over a very long period under medical treatment and a sigmoidectomy for 4-cm sigmoid colon cancer carried out 3 years previously. At that time, an isolated small (about 2 cm) liver metastasis (segment 4) was also detected. Simultaneous segmentectomy and sigmoidectomy was initially considered, but the patient’s cardiac problem prevented it, and ultrasound (US)-guided radio-frequency ablation (RFA) was selected as the most appropriate treatment for the hepatic metastasis. During the following three years, the patient visited the outpatient clinic regularly, and several whole-body computed tomography (CT) studies at intervals of 6 months showed no abnormalities. They also showed the treated hepatic metastasis to be completely necrosed (Fig. 1). The patient was symptom-free for a long time, but very recently he suddenly became edematous. Abdominal US performed in our hospital using a Toshiba Aplio XG unit (Tokyo, Japan) revealed an approximately 6 9 5-cm irregular and ill-margined slightly hypoechoic tumor in S4, which extended posteriorly and directly invaded the left, middle, and right hepatic veins. The left and middle hepatic veins were completely occluded and were not recognized on B-mode US, and the right hepatic venous lumen was partially recognized. The tumor extended towards the right atrium, and a huge tumor thrombus was found there (Fig. 2). The intrahepatic and extrahepatic portal system was normal, but a large amount of ascites was also present throughout the whole abdominal cavity. Contrast-enhanced US using Sonazoid solution (GE Health Care), performed to observe blood flow in the liver, provided more detailed information about the hemodynamics of the lesion and the surrounding hepatic veins (mechanical index *0.25). Soon R. Satoyoshi (&) H. Kotanagi Department of Surgery, Akita Red Cross Hospital, 222-1 Kamikitade Saruta, Nawashirosawa, Akita 010-1495, Japan e-mail: rika-s@alto.ocn.ne.jp