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BACKGROUND Thickening of Achilles tendon (≥9 mm on radiography) is one of the diagnostic criteria for familial hypercholesterolemia (FH). Since FH is associated with premature coronary artery disease (CAD) including acute coronary syndrome (ACS), measurement of Achilles tendon thickness (ATT) is important for early diagnosis of FH. However, clinical significance of mild thickening of Achilles tendon in non-FH patients with CAD is unclear. The present study investigated the association of ATT with coronary lesion severity in early-onset ACS without clinically diagnosed FH. METHODS From outpatients who had a history of ACS under 60 years old, 76 clinically non-FH subjects (71 men and 5 women; mean age at the onset of ACS, 50.5 years) with maximum ATT of

We report a novel application of targeted sclerotherapy to eradicate high-output chylothorax. The patient underwent thoracic duct embolization; however, cannulation of the thoracic duct failed, and thoracic duct disruption was performed. Leakage continued; therefore, the leakage site in the mediastinum was punctured directly under fluoroscopic guidance and a drainage catheter was inserted, followed by sclerotherapy using OK-432. Finally, leakage stopped and chylothorax improved. This technique may be useful for refractory chylothorax in patients where thoracic duct embolization fails.

Protective effects of tolvaptan against worsening renal function in acute heart failure have been shown. However, long-term effects of its agent on renal function remain to be elucidated. The present study investigated retrospectively whether long-term treatment with tolvaptan exerts renoprotective effects in patients with chronic heart failure, by comparing serial changes in estimated glomerular filtration rate (eGFR) for years before and after tolvaptan administration. From 63 outpatients with chronic heart failure taking diuretics including tolvaptan, 34 patients whose eGFR levels were continuously measured for more than 6 months both before and after administration of tolvaptan (average dose, 7.8 mg/day at the end of the follow-up period) were selected as eligible for the present analyses. All eGFR values were separately plotted before and after the initiation of treatment with tolvaptan (except hospitalization periods) along the time course axis and the slope of the linear regression curve was calculated as an annual change in eGFR. The mean follow-up periods before and after tolvaptan administration were 1197 and 784 days (3.3 and 2.1 years), respectively. Changing rates of eGFR per year were significantly ameliorated after treatment with tolvaptan (mean ± SD, − 8.02 ± 9.35 to − 1.62 ± 5.09 mL/min/1.73m2 /year, P = 0.001). In echocardiographic parameters, inferior vena cava (IVC) diameter significantly decreased after tolvaptan administration, and the decrease in IVC diameter was correlated with the improvement of eGFR decline slope after administration of tolvaptan (P = 0.0075). This longitudinal observational study indicated that long-term treatment with tolvaptan ameliorated annual decline in eGFR in outpatients with chronic heart failure. Our findings suggest that tolvaptan has a protective effect against chronically worsening renal function in heart failure patients.

Obesity is a risk factor of postoperative complications. We experienced 2 extremely obese patients:a 32-year-old male with coronary artery disease and a 75-year-old female with aortic valve stenosis. Their initial body weights were 133 kg and 88.5 kg, respectively, and their initial body mass indexes (BMIs) were both 41. Their BMIs were reduced to 35.5 and 35, respectively, after preoperative weight reduction. Off-pump coronary artery bypass grafting and aortic valve replacement were performed, respectively. After surgery, the non-invasive positive pressure ventilation( NPPV) support was effective, and their postoperative courses were uneventful. Preoperative weight reduction and NPPV are useful for extremely obese patients who undergo cardiac surgery.

An 86-year-old male underwent pancreatoduodenectomy with resection and reconstruction of portal vein for pancreatic cancer. He was admitted to our hospital because of severe anemia and dyspnea ten months later. Computed tomography showed varices at the biliary-enteric anastomosis in the elevated jejunum caused by portal venous stenosis, which was suspected as the cause of anemia. Therefore, the patient underwent balloon dilatation of the portal vein followed by stent placement and coil embolization of the collaterals using a transileocolic portal vein approach. After the procedure, portal venous flow was improved, and the collaterals disappeared. The patient has been asymptomatic with no recurrence for three years and four months.

A 72-year-old man with general fatigue was referred, and CT and MRI revealed a pancreatic mass with necrosis that was suspected of invading the stomach, splenic artery, celiac artery, liver, and portal vein. Upper gastrointestinal endoscopy showed an extrinsic mass with ulcer formation in the posterior wall of the upper gastric corpus and irregular mucosa in the lower esophagus incidentally. Biopsy showed squamous cell carcinoma from both lesions, leading to the diagnosis of pancreatic adenosquamous carcinoma and early esophageal cancer. We performed distal pancreatectomy with splenectomy, total gastrectomy, partial hepatectomy, superior mesenteric-portal vein resection, and reconstruction. The pathological results revealed pancreatic adenosquamous carcinoma and infiltration of cancer cells at the dissected peripancreatic margin. Therefore, we administered radiotherapy(50.4 Gy to the retroperitoneal region)in postoperative month 2. Endoscopic mucosal resection was performed for the early stage esophageal cancer lesion in postoperative month 5. Three courses of S-1 were administered as adjuvant therapy since postoperative month 7, and he is currently alive without recurrence 1 year and 8 months after surgery. Multidisciplinary treatment can be effective for locally advanced pancreatic adenosquamous carcinoma.

Double cancer of intrahepatic cholangiocarcinoma and gastric cancer is rare. A 62-year-old man underwent gastrectomy for gastric cancer. The pathological findings were tub1tub2, m, ly0, v0, n0, Stage I A. Two years and a month later, a liver tumor(diameter of 3 cm)and a pelvic mass(diameter of 2.5 cm)were observed. Metastasis from gastric cancer was suspected and chemotherapy(SOX)was administered. However, after 5 courses, CT revealed worseningof the liver tumor (diameter of 12 cm)and pelvic mass(diameter of 3 cm). Intrahepatic cholangiocarcinoma and its peritoneal metastasis were also suspected. There was a limit to treatment with chemotherapy, and it was difficult to judge whether to target gastric cancer or intrahepatic cholangiocarcinoma for chemotherapy. In addition, the lesions were localized in the right lobe of the liver and the pelvis. Therefore, we decided to perform resection. As a second-stage operation, pelvic mass extraction and portal vein embolization were performed first. The pathological result of the pelvic mass assessment was mucinous carcinoma. Subsequently, expansive right hepatectomy was performed. The pathological findings were also suggestive of mucinous carcinoma, which was finally diagnosed as intrahepatic cholangiocarcinoma and peritoneal dissemination. Six months after the surgery, several recurrent nodules were observed in the pelvis and GEM plus CDDP was initiated. Currently, 1 year after surgery, there are no restrictions in the activities of daily life of the patient and he is treated on an outpatient basis.

In the treatment of hepatocellular carcinoma, atypical, off guideline multidisciplinary approaches are sometimes effective. A 70-year-old man was diagnosed with multiple hepatocellular carcinomas, multiple bone metastases, and a right adrenal metastasis. Sunitinib was started and the primary hepatic lesions and bone metastases disappeared. However, his adrenal metastasis worsened. Sorafenib, radiotherapy, and some investigational agents were administered, but the adrenal metastasis did not respond. There were no other new lesions except the adrenal lesion 4 years after the initial treatment, so we decided to perform a resection. In the left half lateral decubitus position, the adrenal mass was removed with right thoracolaparotomy. After the surgery, his tumor markers quickly returned to normal. Seven years after the initial treatment(2 years and 4 months after the last surgery), he is alive without any recurrence. Multidisciplinary treatment with chemotherapy, radiotherapy, and surgery may result in long term survival even for patients with advanced hepatocellular carcinoma with multiple extra-hepatic lesions.

A 67-year-old man with elevated hepatobiliary enzymes was referred to our hospital for further examination. Computed tomography indicated hilar cholangiocarcinoma of Bismuth type Ⅳ and revealed invasion of the right hepatic artery and the left portal vein. We diagnosed locally advanced unresectable hilar cholangiocarcinoma, and performed 5 courses of chemotherapy with gemcitabine plus S-1. After chemotherapy, the tumor was significantly reduced in size and vascular invasions were alleviated, so we decided to perform surgical resection. An extended left hepatectomy with caudate lobe and extrahepatic bile duct resection was performed. Although the intraoperative pathological examination was positive for cancer at the hepatic margins, we did not perform further bile duct resection because of the difficulty. After the surgery, we administered adjuvant chemotherapy with gemcitabine for 5 courses. Another 8 courses of gemcitabine plus S-1 therapy were given because of elevation of CA19-9. The tumor marker levels normalized, and the patient is still alive without findings of recurrence 4 years after the first treatment. Multidisciplinary treatment with chemotherapy and surgery may suggest the possibility of increasing long term survival even for patients with locally advanced unresectable cholangiocarcinoma.

Intra-abdominal hemorrhage caused by omental artery rupture is a rare condition. There are few reports on the treatment of omental artery rupture with only transcatheter arterial embolization (TAE). A 27-year-old man presented to our emergency room with upper abdominal pain that suddenly occurred during sleep. Abdominal computed tomography (CT) revealed fluid collection in the peritoneal cavity and a left subphrenic hematoma with extravasation. Celiac angiography revealed extravasation from the omental artery, which arose from the proximal left gastroepiploic artery. A microcatheter was advanced into the left gastroepiploic artery and around the culprit artery bifurcation, which was embolized by inserting coils. The postoperative course was uneventful without worsening of anemia or abdominal symptoms. The patient was discharged after the absence of extravasation was confirmed by contrast-enhanced CT. Although surgical therapy has often been performed for omental bleeding, TAE, which is less invasive and has the advantage of simultaneous diagnosis and treatment, should be attempted as the first-choice therapy.

A 73-year-old man underwent laparoscopy-assisted partial resection of the rectum to treat rectal cancer diagnosed in September 2011 at a previous hospital. Lymph node dissection was not performed and the vertical margin was positive. When multiple liver tumors were detected 10 months later, the patient was referred to our hospital. A computed tomography (CT) scan revealed local recurrence of the rectal cancer, lymph node metastasis, and 9 liver metastases, which had a maximum diameter of 10 cm, and where curative resection would have been difficult. The rectal cancer expressed epidermal growth factor receptor (EGFR) and wild type K-ras gene, and we initiated cetuximab/irinotecan (CPT-11) chemotherapy. After 2 courses of chemotherapy, the liver tumors had markedly decreased in size and anterior resection of the rectum with regional lymph node dissection was performed. The pathological diagnosis of the rectal tumor was mixed adenoneuroendocrine carcinoma ( MANEC). Extended right hepatectomy was performed four months later. The liver tumors were also diagnosed as metastases of MANEC of the rectum. The therapeutic efficacy of chemotherapy was assessed as Grade 1b. The patient is alive without recurrence 34 months since the initial rectal surgery and 15 months after the liver resection. Thus, an anti-EGFR antibody agent might be effective against MANEC of the colon and rectum.

Magnetic resonance imaging findings are reported for 12 pathologically proven lesions of clear cell carcinoma (CCC) of the ovary in 11 women (mean age 50 years). T1- and T2-weighted MR images were obtained in all patients, and gadolinium-enhanced MR images were obtained in 9. The mean diameter of the tumors was 13 cm. Seven patients presented with stage-I tumors. All 12 lesions consisted of cystic masses with solid protrusions occurring in 10 and solid masses in 2. The cysts were unilocular in 9 lesions and multilocular in 1. In four lesions, the cysts displayed with high intensity on T1-weighted images. Round solid protrusions were identified in 8 lesions. In 5 lesions, the number of protrusions was only a few. The solid portions of 5 masses had slightly high-intensity regions on T1-weighted images. The number of patients with ascites was three. Magnetic resonance imaging of CCC usually shows a unilocular large cyst with solid protrusions, which are often round and few in number. Such MR imaging findings suggest malignant tumor but are not specific.

A 45-year-old woman, who had had rheumatoid arthritis for 12 years, had three attacks of cerebral embolism over two months and died after the final attack. Intensive clinical laboratory investigations did not disclose any specific origins of emboli, but an autopsy revealed a nodule at the base of the aortic valve which was pathologically proved to be a rheumatoid nodule. The thrombi were present from the distal part of left internal carotid artery up to the proximal part of the left middle cerebral artery. They were rich in fiber, but poorly organized endothelial cell, raising the possibility that they originated from other parts and have recently reached there. On the top of the rheumatoid nodule, a thrombus was present. It was easily ablated and a small amount of fibrin stuck the nodule. Based on these results, we concluded that cerebral emboli were originally generated at the top of a rheumatoid nodule in the heart. In patients with RA, rheumatoid nodules are rarely seen in the heart. If present, they usually cause cardiac failure or atrioventricular block, and seldom result in cerebral infarction. This is the first case in which an autopsy proved rheumatoid nodule in the heart which had caused multiple cerebral emboli. We should consider the possibility of rheumatoid nodules in the heart as an origin of cerebral emboli in patients with rheumatoid arthritis.