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INTRODUCTION The pathophysiology and mechanism of in-stent restenosis (ISR) after implantation of second-generation drug-eluting stents (DESs) are not fully clear. We compared the morphological characteristics of ISR between first- and second-generation DESs using frequency domain optical coherence tomography (OCT). METHODS Patients who underwent follow-up coronary angiography (CAG) after first-generation (CYPHER™ and TAXUS™) and second-generation (Nobori®, PROMUS Element™, Resolute Integrity and XIENCE) DES implantations were examined. ISR was defined as lesions of over 50% diameter stenosis at follow-up CAG. Frequency domain OCT was performed at the time of revascularisation of ISR. Tissue morphology was assessed at minimum lumen area. OCT images of DESs at both early (≤ 1 year) and late (> 1 year) phase follow-up were compared. RESULTS On qualitative OCT assessment, the ratios of homogeneous, layered, heterogeneous without-attenuation and heterogeneous with-attenuation morphologies were 57.1%, 17.1%, 20.0% and 5.7%, respectively, for second-generation DES ISR (n = 35), and 16.7%, 25.0%, 25.0% and 33.3%, respectively, for first-generation DES ISR (n = 36). At late phase follow-up, homogeneous morphology was significantly more common for second-generation DES ISR compared to first-generation DES ISR (first-generation: 8.0% vs. second-generation: 50.0%; p < 0.01) while heterogeneous with-attenuation morphology was significantly more common for first-generation DES ISR (first-generation: 44.0% vs. second-generation: 5.6%; p < 0.01). CONCLUSION Homogeneous tissue morphology was more frequently found for second-generation than first-generation DES ISR, especially in the late phase. This suggested that neointimal hyperplasia was the main mechanism in second-generation DES ISR, and that the neointima was stabilised, much like in bare metal stent implantation.

Nephrotic syndrome can be caused by various diseases, from primary kidney diseases to systemic diseases. A kidney biopsy is useful for confirming the causes of nephrotic syndrome and in its management. We herein describe a case of nephrotic syndrome with thrombocytopenia, lymphadenopathy, systemic inflammation, splenomegaly, kidney enlargement, and progressive renal insufficiency. A kidney biopsy showed endothelial swelling with mild interstitial fibrosis and tubular atrophy. This case met the diagnostic criteria for TAFRO syndrome. Little is known about TAFRO syndrome, especially in relation to the associated kidney pathophysiology. The accumulation of a greater number of cases in which the kidney biopsy findings are investigated is needed to clarify the pathogenesis of kidney involvement in this condition.

A 72-year-old Japanese male with acute abdomen underwent emergency surgery for a preoperative diagnosis of stercoral colonic perforation of the sigmoid colon. A pathological examination revealed a proliferating spindle cell lesion that surrounded the perforation and replaced the muscularis propria without any mass formation. The spindle cells were positive for KIT and CD34 by immunohistochemistry, and somatic mutation of the c-kit gene was found using genomic DNA extracted from the lesion. We diagnosed the spindle cell lesion as a planar gastrointestinal stromal tumor (GIST). We speculate that perforation of the sigmoid colon in this case may be caused by the stasis of stool resulting from abnormal peristalsis of the lesional site. Two other similar cases have been reported in the literature, and showed good prognoses. Although their pathogenesis is unclear, planar GISTs should be considered as a possible cause of idiopathic or stercoral colonic perforation.

We report 3 patients with non-germinomatous malignant germ cell tumor (NGMGCT) who developed therapy-associated secondary tumors. They were diagnosed as having NGMGCT by elevated serum levels of β-fetoprotein (AFP), human chorionic gonadotropin (HCG), or β-HCG. Preoperatively, all patients received a combination of etoposide and platinum-based chemotherapy and radiotherapy; neo-adjuvant therapy (NAT) was followed by complete excision of the residual tumor. Postoperatively, all underwent maintenance chemotherapy and all remained free of NGMGCT without recurrence. However, they developed therapy-associated secondary tumors, i.e. glioblastoma, meningioma, or cavernous angioma after an interval of 10.1-, 9.8-, and 8.2 years, respectively. The patient with gliobastoma died 1 year after its detection. The other 2 patients are currently alive; the meningioma was completely removed and the cavernous angioma is being monitored without additional treatment. To our knowledge, therapy-associated secondary tumors in patients treated for NGMGCT are rare.

ObjectivesThe aim of this study was to determine whether 64-slice multidetector computed tomography (MDCT) can differentiate coronary reperfusion with Thrombolysis In Myocardial Infarction (TIMI) flow grade 3 from TIMI flow grade ≤2 after ST-segment elevation myocardial infarction (STEMI).BackgroundMultidetector computed tomography has become a popular modality for noninvasive coronary artery imaging. Recently, 64-slice MDCT has been applied to evaluate coronary arteries in acute coronary artery disease.MethodsThe presence or absence of distal reperfusion in infarct-related arteries (IRA) was visualized with 64-slice MDCT during the acute phase in 87 non–high-risk patients after STEMI. To differentiate TIMI flow grade 3 from TIMI flow grade 2, we calculated the computed tomography (CT) number ratio by dividing the CT number of the contrast-enhanced coronary lumen at the most distal IRA by that at the proximal site to the culprit lesion in patients with reperfusion on MDCT. The MDCT findings were compared with TIMI flow grade with invasive coronary angiography (ICA) performed 20 ± 5 min later.ResultsAccording to ICA, 58 patients had TIMI flow grade 0 or 1, 17 had TIMI flow grade 2, and 12 had TIMI flow grade 3, whereas distal reperfusion was evident on MDCT in 28 of the 29 patients with TIMI flow grade ≥2 and absent in 55 of the 58 with TIMI flow grade ≤1. The CT number ratio was significantly higher in TIMI flow grade 3 than in TIMI flow grade ≤2 (0.64 ± 0.11 vs. 0.37 ± 0.12; p < 0.0001). The sensitivity, specificity, and accuracy of a diagnosis of TIMI flow grade 3 on the basis of a CT number ratio of ≥0.54 that was an optimal cutoff value determined by receiver-operator characteristic curve analysis were 92%, 97%, and 97%, respectively.ConclusionsVisualization of the IRA by 64-slice MDCT enables noninvasive differentiation of angiographic TIMI flow grade 3 from TIMI flow grade ≤2 coronary reperfusion during the acute phase in patients with STEMI.

症例は44歳，男性．腹痛にて発症し，急性腹症として救急搬送された．腹部造影CTにて上腸間膜静脈血栓症と小腸の著明な浮腫状変化を認め，限局性腹膜炎の診断に緊急開腹術を行い，約30cmの壊死部分を含む小腸部分切除術を行った．術翌日から，ヘパリンによる抗凝固療法を施行したところ，DIC徴候等認めないにも関わらず術後11日より血小板数4.4万/μlと突然の血小板減少を認め，ヘパリン起因性血小板減少症と診断した．直ちにヘパリン投与を中止し，アルガトロバン投与を開始した．同時に抗ヘパリン-PF4複合体抗体も検出された．血小板数回復後，ワルファリンによる抗凝固療法へと移行し術後30日に軽快退院となった．

患者は69歳,男性. 34歳時より35年間にわたり痔瘻に対して9回手術を受けており,約半年の周期で瘻孔の開存と閉鎖を繰り返していた.瘻孔からの粘液分泌を認め,近医にて痔瘻癌を疑われ当科紹介となる.臀部,肛門部は変形しており,瘻孔を2カ所認めコロイド状の粘液が漏出していた.腹部CTおよびMRI検査では肛門から骨盤内にかけて最大径7cm大の多房性の嚢胞性病変が存在した.瘻孔壁の生検にて腺癌が疑われたため,痔瘻癌の診断にて腹会陰式直腸切断術を施行した.嚢胞は直腸周囲の坐骨直腸窩,骨盤直腸窩の大半を占めるように存在した.直腸,瘻孔,嚢胞を一塊として摘出した後,臀部欠損部は大殿筋皮弁にて閉鎖した.瘻孔は一次孔から嚢胞内に入り,二次孔へと連続しており,明らかな腫瘤を形成していなかった.病理組織診では,粘液癌と診断された.リンパ節転移は認められなかった.骨盤内に術後放射線療法(50Gy)を追加した後.退院した.

A 63-year-old man was hospitalized with an increased serum prostate specific antigen (PSA) level (72 ng/ml). A prostate biopsy was performed, and histological examinations indicated moderately and poorly differentiated adenocarcinoma with positive staining for carcinoembryonic antigen (CEA). The patient was diagnosed as having prostate cancer (clinical stage : T3bN0M0) and received radiotherapy and hormonal therapy. Five years after the diagnosis, the serum CEA level increased to 153.8 ng/dl, and the patient complained of abdominal pain. His serum PSA level remained normal (0.1 ng/dl). Computed topography indicated multiple bone metastasis and the involvement of multiple lymph glands. A biopsy of a cervical lymph gland revealed poorly differentiated adenocarcinoma with positive staining for CEA. Gastrointestinal examination showed no evidence of abnormality. The diagnosis of metastatic prostate cancer was made, and docetaxel (60-70 mg/m2) was administered. Eight courses of docetaxel therapy led to an approximately 20% reduction in lymph volume, and the serum CEA level decreased. However, liver metastases developed 12 months later, and the patient died at 18 months after the diagnosis of metastatic prostate cancer with a high serum CEA level. We encountered a case of recrudescence of prostate cancer positive for CEA with a low serum PSA level and report the effect of docetaxel therapy for atypical prostatic carcinoma.

The aim of this study was to establish the relation between observed ultrasonographic (US) images produced with a galactose-based contrast agent and histologic characteristics of small hepatocellular carcinomas (HCCs). A total of 64 nodules in 64 patients, 22 well differentiated and 42 moderately differentiated with a histologically proven HCC, smaller than 3.0 cm in diameter and who had undergone hepatectomy were consecutively examined by contrast-enhanced US using a galactose-based contrast agent. Perfusion images were acquired by intermittent high-intensity, harmonic power Doppler sonography using a high pulse-repetition frequency and high-pass filter setting. Perfusion images of the arterial and late phases were classified into several patterns and compared with the histologic findings obtained from resected specimens. Most of the well- and moderately differentiated resected HCCs showed hyperechoic change during the arterial phase. However, 13 (59%) of the well-differentiated HCCs showed isoechoic change and 27 (64%) of the moderately differentiated HCCs showed hypoechoic change during the late phase. The difference is statistically significant (P < 0.0001). In a comparison of microscopic portal invasion (vp) of HCCs using enhanced US patterns, both vp(−) and vp(+) groups showed a high incidence of the hypervascular pattern during the arterial phase; in contrast, during the late phase 11 (73%) of 15 vp(+) nodules showed hypoechoic change with spotty signals. This difference is statistically significant (P < 0.0001) when compared with a high incidence (52%) of signal defect in the vp(−) group. The existence of well-differentiated components associated with the periphery of moderately differentiated HCCs also correlated closely with patterns during the late phase (P < 0.01). Late-phase contrast-enhanced US images of small HCCs with a galactose-based contrast agent are useful for predicting specific histologic characteristics.

Background. Malignant struma ovarii is a rare tumor, consisting of a struma ovarii with malignant change. Because of the rarity of the tumor, only a few reports with detailed data of thyroid function of the patient have been published. Case. Medical and surgical treatments were performed in a case of malignant struma ovarii with Graves' disease and data from thyroid function tests were analyzed. After removal of the tumor, rapid improvement of thyroid function was observed and thyroglobulin level decreased. Conclusion. This case demonstrates the possible, if not dominant, contribution from the malignant struma ovarii to the hyperthyroidism of the patient.

Thromboembolism has been shown to play a role in the pathogenesis of inflammatory bowel disease (IBD). A possibility exists that lipoprotein (a) [Lp(a)], a newly-discovered prothrombotic factor, also participates in the development of at least some cases of IBD. Marked elevation of serum Lp(a) levels was observed in a young patient with ulcerative colitis. A biopsy specimen of the rectal mucosa showed findings compatible with ulcerative colitis, as well as small vessel thrombus occurring within the muscularis mucosa in the rectum. Serum Lp(a) levels were markedly elevated on admission (71 mg/dl), with a gradual decrease to 46 mg/dl on discharge. Moreover, serum Lp(a) levels decreased in parallel with clinical improvement. In the quiescent clinical stage, no small vessel thrombus was observed in the mucosa on follow-up colonoscopy. The association between IBD and hyper-Lp(a)-emia would be presumable but it has been, to our knowledge, previously unreported. The case reported here would be the first young patient, suggesting the presence of hyper-Lp(a)-emia and small vessel thrombus formation occurring in association with the development of ulcerative colitis.