Bioprosthetic tricuspid valve stenosis is extremely rare. We report the case of a 54-year-old man with a history of infectious endocarditis (IE) and two previous tricuspid valve replacements (TVRs). The first TVR at age 25 was performed secondary to IE using a Star-Edwards Ball Valve. The repeat-TVR using a St. Jude Medical Epic bioprosthesis was performed at age 51 due to severe ball valve stenosis. Repeat surgical valve replacement is an extremely high-risk procedure. Percutaneous transcatheter tricuspid balloon valvuloplasty (PTTBV) is an acceptable treatment option for symptomatic severe tricuspid valve stenosis. There have been few reports of successful PTTBV performed after bioprosthetic TVR. Successful treatment with PTTBV for bioprosthetic tricuspid valve stenosis was achieved without complications in this patient. We believe that PTTBV can be performed either as a destination therapy or as a bridge to TVR.
Almost all foreign matter in the gastrointestinal tract is excreted naturally, but in rare cases it may cause peritonitis, abscess from perforation and penetration of the gastrointestinal tract. In Japan there are many digestive tract punctures due to fish bones because of dietary habits. Three cases of fish bone aspiration experienced at our hospital are reported here because they follow different onset patterns. Case 1 was an 88-year-old man with emergency transport to our hospital with left lower abdominal pain, and as a result of examination it was diagnosed as descending colon penetration by a fish bone. Partial descending colon resection by Hartmann's operation was performed. Case 2 was an 87-year-old woman who visited our hospital with right hypochondralgia from the previous day. She was diagnosed with small intestinal penetration by a fish bone on CT. We performed laparoscopic surgery several days later and found that the fish bone had left the small intestine and fallen into the abdominal cavity. The fish bone was retrieved, and the inside of the abdominal cavity was cleaned. Case 3 was a 75-year-old man with left lower abdominal pain for more than 1 month before visiting our hospital. Abdominal pain worsened after several days, and an emergency operation was performed on a diagnosis of abdominal wall abscess caused by a fish bone. It is thought that accurate diagnosis before surgery and appropriate surgery according to the case, and especially proper retrieval of the fish bone are important.
A 32-year-old woman, gravida 1 para 0, had a history of persistent trophoblastic disease, which was treated by dilation/curettage and chemotherapy at the age of 21. She visited a previous hospital wishing for a baby, but was referred to our hospital because the right side of the uterine myometrium was found to have been replaced by numerous dilated blood vessels. The contrast-enhanced CT revealed that dilated arteries and veins occupied the right uterine wall. The lesion was diagnosed as uterine arteriovenous malformation (UAVM) since pelvic veins were enhanced at the arterial phase. To counter the risk of perinatal hemorrhage, we recommended prepregnancy transcatheter arterial embolization (TAE). Pelvic angiography revealed that the right uterine artery was the main feeding artery of the UAVM. After the twice via the bilateral uterine arteries, the size of the UAVM lesion reduced from 49 mm to 35 mm. A contrast-enhanced CT after the second TAE showed a reduced blood flow from the uterine arteries, but persistent blood flow in the right round ligament artery to the UAVM was detected. Therefore, we performed the third TAE via the right round ligament artery. The size of the UAVM was decreased to approximately 30 mm, suggesting a reduced risk of pregnancy complications. As additional TEA might also evoke ovarian insufficiency due to excessive radiation exposure, we terminated the prepregnancy treatment. Four months after the last TAE, she conceived naturally. No enlargement of the UAVM or abnormal vaginal bleeding was observed during pregnancy. At 39 weeks of gestation, she delivered alive baby by vacuum extraction due to fetal dysfunction. The total blood loss at delivery was 975 g. In conclusion, although TAE has been widely adopted as an effective treatment for UVAM, there has been no consensus on the treatment goal. Further reports should be accumulated to determine the cut-off value of UAVM size for a safe pregnancy.
A case of spindle cell carcinoma of the breast arising within a mammary cyst is reported. A 42-year-old female who had a familial history of breast cancer visited the outpatient clinic at our hospital complaining of a lump in the left breast. A tumor measuring 2 cm in diameter was palpated in the upper inner quadrant of her left breast. The ultrasonic finding showed a slightly low echo in the cystic region. Light yellow brown fluids were aspirated from the tumor by fine needle and the tumor disappeared. These aspirates were diagnossed as class I cytologically. Two months after the first visit, she visited our clinic again complaining of a 3.5 cm sized tumor in the same region. Ultrasonography showed an increased low echoic part in the cyst. Several supplemental diagnostic examinations were performed, but the exact diagnosis could not be confirmed. Therefore surgical biopsy was done. Pathohistologically the tumor was diagnosed as infiltrating ductal carcinoma containing spindle cells, while immunohistochemical evidence of both epithelial markers (Epithelial Membrane Antigen, Cytokeratin AE1/AE3) and mesenchymal marker (Vimentin) were positive. Immunohistochemically, estrogen receptor was storongly positive, while progesterone receptor and human epidermal growth factor2 were negative and the Ki67 index was 87.2 ％. Total mastectomy and axillary lymph node (Ｉ-group) dissection were performed. The remains of fine DCIS were found and one lymphnode metastasis which was stained positive by cytokeratin staining. Adjuvant chemotherapy was administerd with 4 cycles of FEC (Fluorouracil, Epirubicin hydrochloride, Cyclophosphamide) and Docetaxel, and was followed by adjuvant endocrine therapy with Tamoxifen citrate. Three years and six months after surgery no evidence of recurrence was observed in the outpatient clicic. The possibility of spindle cell carcinoma should be kept in mind in patients with a familial history of breast cancer who show cystic regions on ultrasound.