Informative value of Hemoccult test according to the number of positive slides in mass screening of colorectal cancer]

Desmoid tumors develop in the muscle or aponeurosis, but rarely in the chest wall. We report a patient with desmoid tumor in the chest wall. A 30-year-old female visited our hospital due to an abnormal shadow in the chest detected at a health examination. No definite diagnosis could be made by chest CT, MRI, or Ga scintigraphy, and finally a biopsy demonstrated desmoid tumor. The left anterior chest and posterolateral chest (lung apex) were opened, and tumors were resected together with the chest wall. No radiotherapy was performed. No recurrence has been observed for 1.5 years after operation. This tumor does not yield distant metastasis, but its recurrence rate is very high. Therefore, we intend to follow this patient for a long period.     

High-resolution CT of the lung: determination of the usefulness of CT scans obtained with the patient prone based on plain radiographic findings

OBJECTIVE: We assessed the usefulness of chest radiographs for predicting whether high-resolution CT scans obtained with the patient prone would be valuable in assessing suspected diffuse lung disease. MATERIALS AND METHODS: In 100 consecutive patients undergoing high-resolution CT, findings on plain chest radiographs were classified as normal, possibly abnormal, or abnormal. CT scans obtained with the patient supine were assessed for the presence and distribution of lung abnormalities without knowledge of the plain radiographic classification. A second review of the CT scans was done with equal numbers of scans obtained with the patient prone and with the patient supine. The usefulness of the CT scans obtained with the patient prone for detecting lung disease was determined and related to the plain radiographic classifications. RESULTS: High-resolution CT scans obtained with patients prone were helpful in excluding or confirming posterior lung abnormalities in 10 (28%) of 36 patients who had normal findings on chest radiographs, five (28%) of 18 patients who had possibly abnormal findings on chest radiographs, and only two (4%) of 46 patients who had abnormal findings on chest radiographs. The proportion of patients who benefited from high-resolution CT scans obtained with the patient prone was significantly lower among the patients with abnormal findings on chest radiographs than among the patients with normal (p = .008) or possibly abnormal (p = .02) findings on chest radiographs. The two patients with abnormal findings on radiographs in whom CT scans obtained with the patient prone were helpful had minimal radiographic abnormalities. CONCLUSION: In patients with suspected diffuse lung disease, obtaining high-resolution CT scans with the patient prone may be useful when chest radiographs show normal findings, possibly abnormal findings, or minimal abnormalities indicative of diffuse lung disease. However, such scans are of little value in patients whose radiographs show abnormalities indicative of diffuse lung disease.     

Guidelines for the selective ordering of admission chest radiography in adult obstructive airway disease

STUDY OBJECTIVE: To validate previously developed guidelines for the selective use of chest radiography in adults admitted for exacerbation of obstructive airway disease. DESIGN: Prospective, observational cohort study using criteria developed in a previous retrospective study. PARTICIPANTS: Unselected convenience sample of 128 adults with obstructive airway disease who did not respond to standard emergency department treatment and required admission. SETTING: Municipal hospital ED and inpatient medical service. INTERVENTIONS: Patients were categorized as "complicated" or "uncomplicated" according to previously developed criteria. Management was recorded as altered if the patient's physician answered the question, "Did the chest radiography alter your management of this patient?" affirmatively. RESULTS: Of 27 patients whose management was altered by the chest radiography, 26 were classified as complicated, for a sensitivity of 96% (95% confidence interval [CI], 81, 100). One of 44 admissions classified as uncomplicated had management altered by the chest radiography (negative predictive value, 98%, 95% CI, 88, 100). This chest radiography was later reread as normal. Classification as an uncomplicated patient with obstructive airway disease was strongly associated with either a normal chest radiography or a radiographic finding that was clinically unimportant (P = .0002). CONCLUSION: Patients with acute exacerbation of obstructive airway disease who are otherwise uncomplicated do not benefit from routine admission chest radiography. The use of this simple clinical strategy would safely reduce the number of chest radiographs by about one-third in this and similar patient populations, decreasing both health care costs and exposure to ionizing radiation.     

The Taskforce 2000 survey on medical education in sleep and sleep disorders

A 71-year-old woman underwent radical resection in May 1994 for a mediastinal mass invading the anterior chest wall. Histopathological examination revealed adenosquamous cell carcinoma. She was treated with postoperative chemotherapy including 5-fluorouracil (5-FU) and 4'-D-tetrahydropyrayl-doxorubicin (THP), based on in vitro chemosensitivity testing (CST), by MTT assay, using a surgical specimen. In December 1994, a recurrent tumor was detected on the left anterior chest wall and the patient received two courses of 5-FU, THP and methotrexate (MTX). The size of the chest-wall tumor decreased 25%. In July 1995, the patient had involvement of the left axillary lymph node and brain metastases in addition to the mass on the chest wall. Therefore, cisplatin, 5-FU and MTX were selected as treatment agents, based on CST using a metastatic axillary lymph node. After two courses of these agents, chest computed tomography showed a 91% reduction in the size of the chest wall tumor. Radiation was administered for the brain metastasis. In March 1997, the patient died of thymic carcinoma.     

Nitrogen fixation by microbial cultures with sodium salt of organic acids as carbon source

Precordial and posterior chest wall ST-mapping has been utilized in a patient with high anterolateral and true posterior myocardial infarction. In this patient evolution of the anterolateral component of the infarct was accurately delineated by changes in the precordial map which were not detected in the standard precordial leads. The true posterior component of the infarct was clearly diagnosed by detection of pathological Q waves and ST elevations in posterior chest wall maps, whereas right precordial standard leads had shown only suggestive reciprocal changes. The study illustrates the superiority of localized chest wall mapping over conventional 12-lead electrocardiography in detecting transmural infarction in high anterolateral and posterior regions of the left ventricle.     

Functional neuroanatomy of the basal ganglia as studied by dual-probe microdialysis

This is a report of two cases of mature mediastinal teratoma associated with elevated serum SCC levels. The first patient was a 17-year-old female admitted to our hospital for severe left chest pain. Chest x-ray film and CT scan showed a mediastinal tumor. The preoperative serum SCC level was elevated. Resection was performed and the pathological diagnosis was mature teratoma. The second patient was a 32-year-old male admitted to our hospital for severe anterior chest pain. A chest CT scan showed a mediastinal tumor. The preoperative serum SCC level was high. Surgery was performed and the pathological diagnosis was mature teratoma. The cause of the high serum SCC levels was unclear, but we suspect that the pulmonary atelectasis may have caused it.     

Ethanol sclerosis: one of the best treatments for thymic cyst in very elderly patients?

An 83-year-old female patient with a giant thymic cyst that was successfully treated by percutaneous aspiration and ethanol injection. The patient had complained of coughing and chest discomfort for several years. A chest X-ray film revealed the shadow of a large abnormal mass in the anterior mediastinum. We diagnosed it as a thymic cyst. The patient refused surgery because of her age. We chose a less invasive therapy, namely, ethanol sclerosis of the cyst. The cyst was successfully treated without any complications, and no recurrence was found at the one-year follow-up. This therapy may be one of the best treatments for thymic cysts, especially in very elderly patients.     

A case of spontaneous hemopneumothorax occurred after thoracic drainage

A 21-year-old man; complaining of left chest pain and dyspnea, was admitted to our hospital with a diagnosis of spontaneous pneumothorax. Though chest X-ray on admission did not show hemothorax, chest drainage revealed intrapleural bleeding. As chest X-ray on the following day showed evident fluid level, emergency operation was carried out with a diagnosis of spontaneous hemopneumothorax. Bleeding point was a ruptured vessel between parietal pleura and bulla in apex of lung. The bulla was resected following hemostasis. After improvement of complicating postoperative re-expansive pulmonary edema, the patient was discharged on the 18th postoperative day. On treatment of spontaneous hemopneumothorax, existence of such a case as ours should be taken into account.     

Pseudoinfarction pattern in an infant

A child affected by exertional chest pain secondary to gastroesophageal reflux (GER) disease is reported. Family history revealed the presence of rumination in two members. In our patient, heart diseases as well as other causes of chest pain were excluded. An ultrasound examination of the gastro-esophageal junction, performed in the first 15 minute of the post-prandial period, showed a pathological number of GER episodes. The patient was treated with cisapride (0.2 mg/kg t.i.d. per os). At follow-up, after three months, he was symptom-free. We repeated an ultrasound examination, which resulted normal. Ours is the first paediatric case characterized by exertional chest pain secondary to GER disease.     

Decreased serum apolipoprotein AII/AI ratio in systemic amyloidosis

BACKGROUND: Intrapericardial teratomas are rare and usually present early in infancy or childhood. PROCEDURE: We describe herein a rare case of an adult patient with an intrapericardial teratoma who presented with fever, cardiac arrhythmias, and oppressive substernal chest pain. Preoperative diagnosis was suggested by echocardiography and computerized tomography of the chest. The tumor weighed 530 g and its histologic features were those of a mature cystic teratoma. It was excised totally and 10 years' follow-up revealed no evidence of residual disease. DISCUSSION: Our patient is one of the very few adult patients with intrapericardial teratomas who was treated successfully with surgery. Both echocardiography and tomography of the chest suggested the diagnosis and delineated the relationship of the tumor to the great vessels. CONCLUSION: The diagnosis of Intrapericardial teratomas is suspected by echocardiography and/or tomography of the chest and confirmed by specific histologic features. These tumors should be excised whenever detected.     

Horner's syndrome associated with a solitary bone plasmacytoma of the first rib

A case of solitary plasmacytoma originated in the left first rib in a 45-year-male is presented. The initial symptomatology was a Horner's syndrome. A chest X-ray, gammagraphy, TAC and arteriography showed a tumor shadow in the left chest wall; no evidence of plasmacytoma after clinical study found use where. The treatment was surgical excision and postsurgical radiotherapy. The histological investigation revealed a plasmacytoma of the rib. The patient have been followed for two years. The patient is asymptomatic, without evidence of local recurrence and systemic spread of the disease two years after treatment.     

Idiopathic pulmonary artery aneurysm

The purpose of this article is to report two cases of pulmonary artery (PA) aneurysm in patients who had no evidence of left-to-right intracardiac shunting or other known relevant etiologies. One patient, a 52-year-old woman, was admitted to the hospital due to exertional palpitation, while the other patient, a 73-year-old woman, came to the hospital because of fever and cough. In both women, chest radiographic findings of a hugely dilated PA were confirmed by computed tomography (CT). In both cases, a ventriculogram showed fusiform dilatation of the main PA without evidence of pulmonary valve stenosis. The results of chest radiography, two-dimensional echocardiography, CT of the thorax, including pulmonary angiography in one patient, were compatible with the diagnosis of PA aneurysm. No specific drug regimen was administered nor was any surgical intervention performed in either patient. Both patients were asymptomatic as of the last telephone follow-up. Idiopathic PA aneurysm is a benign condition with better survival than PA aneurysms of other etiologies, because of the absence of left-to-right intracardiac shunting and significant pulmonary hypertension. PA aneurysm must be considered as part of the differential diagnosis in an enlarged pulmonary trunk seen on chest radiogram, and two-dimensional echocardiography should be performed initially.     

Mediastinal abscess diagnosed after its rupture into the trachea in a patient after esophagectomy

A 52-yr-old man with esophageal cancer underwent esophagectomy and retrosternal reconstruction using stomach under general anesthesia. In the postoperative period, the patient developed mediastinal abscess which failed to be diagnosed by daily routine chest X-rays, because of surgical alterations of mediastinal anatomy. On the 11th postoperative day, the abscess ruptured into the trachea and severe hypoxemia (PaO2 73 mmHg, FIO2 1.0) developed while the patient was still on mechanical ventilation. A chest X-ray on that day showed a radiolucent cavity with defined margins in the right superior mediastinum. Thoracic CT scanning on the 15th postoperative day disclosed a capsulated cavity which indicated abscess formation in the posterior mediastinum. Although surgical drainage was not undertaken, the patient's severe hypoxemia was resolved within 4 days by the supportive therapies including chest physiotherapy, postural drainage and administration of antibiotics and corticosteroids. Although mediastinal abscess after esophagectomy is a rare complication, it may rupture into the trachea and lead to severe hypoxemia. In this case thoracic CT scanning was useful to detect the mediastinal abscess which had not been diagnosed by routine chest X-rays.     

Pulmonary actinomycosis with "balls-in-a hole" appearance diagnosed by examination of bronchial lavage fluid

A 49-year-old man was referred to our hospital because of abnormal chest X-ray findings. Chest X-ray films showed infiltrative opacities in the right lung, and histological findings of a transbronchial biopsy specimen showed non-specific inflammation. The patient was treated with Ofloxacin for one month. After the treatment, chest X-ray films showed that the infiltrative opacities in the right upper lobe had decreased, but that opacities in the right lower lobe had increased, with an air meniscus sign. A chest computed tomography scan at the same time revealed that the remaining opacities contained multiple mass-like lesions within a cavity in the right S6, appearing as "balls in a hole". One year after the first visit, the patient visited the hospital again because of cough and sputum. A chest X-ray film showed that the size of the cavity in the right lower lobe had increased. The histological findings from a fresh transbronchial biopsy specimen revealed a non-specific inflammation again; however, black clots obtained from bronchial lavage fluid after biopsy were histologically identified as sulfur granules, a classic pathological indication of actinomycosis. This confirmed the diagnosis of pulmonary actinomycosis. The patient was treated with penicillin, and the opacities in the right lower lobe subsided.     

A case of chronic necrotizing pulmonary aspergillosis successfully treated with combination therapy of antifungal drugs and ulinastatin

A 64-year-old woman with a history of old tuberculosis, had a fungus ball shadow with meniscus sign in the upper right lung field on a chest X-ray film in 1991. Based on the chest X-ray findings, pulmonary aspergilloma was suspected. Because the size of the intracavitary fungus ball increased, the patient was treated with itraconazole over one year in 1995, but there was no improvement. One month later, she was admitted because of fever, hemoptysis and productive cough, and chest X-ray showed an enlargement of intracavitary mass and infiltrative shadow in the right lung. Chronic necrotizing aspergillosis was diagnosed on the basis of her clinical and radiographic features, and positive serological test. Although itraconazol and amphotericin B were given, cavity and intracavitary fungus ball shadow kept growing. Combination therapy of antifungal drugs and ulinastatin markedly improved symptoms and resulted in complete disappearance of the fungus ball on chest CT scan.     

Rupture of the aortic arch due to bacterial aortitis--a case report of a patient undergoing successful surgical therapy

A 59-year-old man came to our hospital because of hoarseness and chest pain. On initial examination, a chest roentgenogram showed no abnormality. Three weeks later, while the patient was waiting to undergo a computed tomographic (CT) scan, shock suddenly developed. A chest roentgenogram revealed an extremely wide mediastinal shadow. A CT scan revealed rupture of the aortic arch near the base of the left subclavian artery, although there was no aneurysm. An emergency operation was performed. The ruptured aortic arch was replaced with an artificial graft during cardiopulmonary bypass with selective cerebral perfusion. A diagnosis of infectious aortitis was not made until a pathologist discovered colonies of gram-positive cocci in the resected specimen of the aortic arch. Postoperatively, antibiotics were administered for only four days. The patient is well about two years after the operation. Infectious aortitis had a very low prevalence and rarely involves the thoracic aorta. However, we should be aware of that it may cause aortic rupture even in the absence of aneurysmal dilatation.     

Rapid detection of traumatic effusion using surgeon-performed ultrasonography

BACKGROUND: In the injured patient, rapid assessment of the thorax can yield critical information for patient management and triage. OBJECTIVES: The objectives of this prospective study were (1) to determine if experienced surgeon sonographers could successfully use a focused thoracic ultrasonographic examination to detect traumatic effusion, and (2) to compare the accuracy and efficiency of ultrasonography with supine portable chest radiography. METHODS: Surgeon-sonographers performed thoracic ultrasonographic examinations on patients with blunt and penetrating torso injuries during the Advanced Trauma Life Support secondary survey. All patients also underwent portable chest radiography. Performance times for ultrasonography and chest radiography were recorded. Comparisons were made of the performance times and accuracy of both tests in detecting traumatic effusion. RESULTS: In 360 patients, there were 40 effusions, 39 of which were detected by ultrasonography and 37 of which were detected by chest radiography. The 97.5% sensitivity and 99.7% specificity observed for thoracic ultrasonography were similar to the 92.5% sensitivity and 99.7% specificity for portable chest radiography. Performance time for ultrasonography was significantly faster than that for chest radiography (1.30 +/- 0.08 vs. 14.18 +/- 0.91 minutes, p < 0.0001). CONCLUSION: Surgeons can accurately perform and interpret a focused thoracic ultrasonographic examination to detect traumatic effusion. Surgeon-performed thoracic ultrasonography is as accurate but is significantly faster than supine portable chest radiography for the detection of traumatic effusion.     

A surgical case of liposarcoma in the chest wall within the thoracic cavity of a young patient

A 21-year-old man presented to our hospital on June 7, 1990, asymptomatic but with an abnormal shadow in his chest roentgenogram. A well-demarcated tumorous shadow was seen in the left hilum of the lung in the frontal view of the chest X-ray, and adjacent to the posterior chest wall in the lateral view. A percutaneous needle biopsy was performed, and since there were no malignant findings, the tumor was left untreated for future examinations. However, since the tumor was observed to be enlarging gradually in subsequent chest X-rays, it was resected surgically on June 18, 1991. The tumor was fist-sized and its surface smooth, and was protruding into the thoracic cavity. At surgery, the tumor was separated from the chest wall. The tumor, weighing 170 grams, was diagnosed pathologically as a liposarcoma (myxoid type). It was confirmed that there was no infiltration into the surrounding tissue and that total resection had been performed. There are few reports of liposarcomas within the thoracic cavity developing in the extra-mediastinal chest wall. As our case is the second in Japan occurring in a young patient, we present it here together with a review of the literature.     

Benign fibrous mesothelioma successfully treated by thoracoscope-assisted surgery: report of a case

We report herein the case of an 84-year-old man in whom a benign fibrous mesothelioma (BFM) was successfully treated by thoracoscope-assisted surgery. In September 1996, the patient underwent a sigmoidectomy for colon cancer, soon after which a followup examination disclosed a coin lesion on his chest X-ray film. The patient was readmitted to our hospital in November 1996 for further investigation of this tumor. A chest computed tomography scan revealed a 3.5 x 3.0 cm homogeneous tumor arising from the pleura. A needle biopsy was performed under ultrasonographic guidance, and the specimen was histopathologically diagnosed as a BFM. In view of his poor respiratory function, the tumor was excised by thoracoscope-assisted surgery. This case report serves to demonstrate the benefits of thoracoscope-assisted surgery for such patients.     

Pemphigus-like antibodies in dermatitis herpetiformis

Pemphigus-like antibodies were demonstrated in a patient with dermatitis herpetiformis. The patient was a 28-year-old Japanese who showed itchy tense bullae on the back, chest and shoulders. We speculate the antibodies are similar to those found in burns, drug eruptions and certain other skin diseases.