Left Anterior Chest Research Articles

GASTRIC CANCER METASTASIZED TO THE BREAST AND SKIN -CASE REPORT-

A case of gastric cancer metastasized to the breast and skin in a 37-year-old female is reported.Two months after total gastrectomy for a poorly differentiated adenocarcinoma of the stomach, a subcutaneous nodule appeared on the left anterior chest wall. Multiple nodules appeared on the anterior chest wall including the right breast and abdominal wall, successively. Though total mastectomy was carried out because of marked enlargement of the right breast mass, she died four weeks after the operation. The histological examination of the resected mass revealed metastasis of the gastric cancer.From the findings that no metastatic lesion was detected in the liver nor the lung, multiple lymph nodes were swollen around the abdominal aorta, cancer cells were observed in the lymphatic vessel of the resected breast, and skin metastasis appeared only on the anterior chest and abdominal wall, lymphatic metastatic route was speculated in this case.As the metastases to the breast and skin are the extensive progress of the gastric cancer, chemotherapy should be selected firstly, and then a plan of the later treatment should be decided in consideration of the effect of the chemotherapy.

A CASE OF MEDIASTINAL HODGKIN'S DISEASE

A 16-year-old female visited our hospital because of a mass on the neck. On physical examination, masses were palpated in the left supraclavicular fossa and on the left anterior chest wall. Biopsy studies provided no definitive diagnosis, and exploratory operation was carried out. The masses on the chest wall and in the supraclavicular fossa could be resected, but a third mass in the thymus was tightly adhered to the pericardium and could only be partially resected. Pathologic examination of the resected specimens indicated Hodgkin's disease, nodular sclerosis. The patient has been managed postoperatively by alternating COPA-ABVD therapy.Although Hodgkin's disease can be successfully treated by chemotherapy and radiation therapy, the frequency of local recurrence is considered to be high in cases with very large masses in the mediastinum even after combination chemotherapy and radiation therapy. In adition the diagnosis of Hodgkin's disease, nodular sclerosis is often difficult. For these reasons, surgical resection is considered to be important both for the diagnostic purpose and as a part of the adjuvant therapy in anterior mediastinal tumors showing chest wall infiltration.

Body surface distribution of abnormally low QRST areas in patients with left ventricular hypertrophy. An index of repolarization abnormalities.

QRST isointegral maps (I-maps) have been useful in detecting repolarization abnormalities. We investigated the body surface distribution of abnormally low QRST areas in patients with left ventricular hypertrophy (LVH) and the relation of the abnormalities in I-map to the severity of LVH as assessed by echocardiography. QRST area departure maps were constructed from electrocardiographic (ECG) data recorded in patients with LVH and precordial negative T waves resulting from aortic stenosis (AS) (10 patients), aortic regurgitation (AR) (12 patients), or hypertrophic cardiomyopathy (HCM) with asymmetric septal hypertrophy (22 patients). Fifty normal subjects served as controls. The I-map was constructed from 87 body surface electrocardiograms recorded simultaneously at a sampling interval of 1 msec. The area where the QRST area was smaller than normal limits (mean -2 SD) was designated the "-2 SD area." The echocardiographic left ventricular (LV) mass was calculated by Devereux's method. Patients with large LV masses due to AS or AR had 2 SD areas located over the left anterior chest or the midanterior chest, respectively. The 2 SD area was located over the left shoulder and left anterior chest and had a lingual shape in patients with HCM. The sum of QRST area values less than the normal range (sigma QRST) was significantly correlated with LV mass in patients with AS or AR (r = 0.83 and r = 0.69, p less than 0.01 and p less than 0.05). However, there was no significant correlation between sigma QRST and the severity of LVH in patients with HCM. sigma QRST divided by the number of electrodes in the 2 SD area was significantly greater in patients with HCM than in those with AS or AR. These findings suggest that abnormalities in patients with HCM are manifest even in mild LVH and that there is a greater disparity of repolarization in hypertrophied left ventricles due to HCM than in LVH due to aortic valve disease. QRST isointegral departure maps may provide ECG evidence of LV mass of patients with AS or AR and of susceptibility to malignant arrhythmias in patients with HCM.

Signal-averaged body surface mapping for the assessment of low-amplitude potentials: Detailed maps during early ventricular activation in normal subjects

Body surface isopotential maps around early ventricular activation were investigated in 30 normal subjects by the use of the authors' signal-averaged body surface mapping system. The number of beats averaged was 96–154 (mean, 127). Two distinct patterns were recognized in the appearance of a maximum at the onset of ventricular activation: the maximum in the first type (n = 16) was located on the right anterior chest; the maximum in the second type (n = 14) was on the central or left anterior chest. The site of the earliest ventricular activation was considered to be different in each of these types. During early ventricular activation, 25 subjects (83%) had two minima: one was on the left lateral chest and the other was on the left back. The two minima probably reflect two different receding activation fronts in the ventricles. The data in the present study are important to the understanding of the early ventricular activation process, as well as the diagnosis of heart diseases in which this process is disturbed.

Acquired cystic kidney disease

A 34-year-old black sales manager was referred for evaluation of azotemia of undetermined duration. He claimed to be in good health except for borderline hypertension since age 25. He had no history of urinary tract signs or symptoms. A tumor of unspecified type had been removed from the left anterior chest wall 8 years previously; there had been no recurrence. A younger sister was a hemodialysis patient in another city; the cause of her renal failure was unknown to the patient. The family history included no deafness, hematuria, proteinuria, or renal cysts. The supine blood pressure was 160/100 mm Hg in both arms. The fundi were normal. His hearing acuity was judged to be intact. The left pectoralis major muscle had been removed surgically. Cardiovascular examination was normal. The abdomen was soft and nontender, and no masses were detected by palpation. Genital and rectal examinations were normal. The urine was negative for protein by dipstick examination. The urine sediment revealed 5 to 10 erythrocytes/high-power field and contained no casts or lipid bodies. The hemoglobin level was 13.4 g/dl and the hematocrit was 37.6%. The white blood cell and platelet counts were normal. Serum electrolyte levels were within normal limits. The serum creatinine concentration was 3.4 mg/dl; serum urea nitrogen, 45 mg/dl; serum calcium, 9,0 mg/dl; phosphate, 3.3 mg/dl; serum urate, 11.6 mg/dl; and alkaline phosphatase, 95 lU/liter. Total urinary protein excretion was 48 mg/24 hours. The creatinine clearance was 35 mI/mm. A renal scan with mTcDPTA showed prompt and symmetric flow to both kidneys; the excretion of '311-Hippuran was symmetric and slightly delayed; a furosemide washout test disclosed no evidence of obstruction. Ultrasound examination revealed kidneys of normal size

Signal-averaged body surface mapping for the assessment of low-amplitude potentials. Relation between ventricular depolarization and repolarization in normal subjects.

To examine the relation between ventricular depolarization and repolarization, body surface isopotential maps at the end of the QRS complex were studied in 32 normal subjects using a signal-averaged body surface mapping system. The number of beats averaged was 96-154 (mean 126.2). In this study, there were 8 types of isopotential map patterns at the end of the QRS complex. Mean +/- SD of QRS duration, appearance time of repolarization, and disappearance time of depolarization were 82.0 +/- 8.7 msec, 71.8 +/- 10.5 msec, and 79.7 +/- 9.4 msec, respectively. Time duration of overlapping depolarization and repolarization was 8.6 +/- 6.4 msec. The early repolarization was widely distributed on the left anterior chest and the upper sternal region. These results demonstrated the difference between the appearance time of repolarization and the disappearance time of depolarization for each lead. We concluded that it is difficult to evaluate ECG waves in the terminal portion of the QRS complex with the dipolar theory only.

Body surface mapping of high-frequency components in the terminal portion during QRS complex for the prediction of ventricular tachycardia in patients with previous myocardial infarction.

To study the clinical significance of terminal QRS high-frequency components for the prediction of ventricular tachycardia, an 87-lead body surface signal-averaged mapping was performed in 21 healthy subjects (control) and in 41 patients with previous myocardial infarction (anterior, 20; inferior, 21). Mapping data were analyzed and averaged (129.7 +/- 26.5 beats) for 160 seconds, and the signal-averaged beat was filtered with a bidirectional bandwidth (80-250 Hz) digital filter. J-point was determined from the 87-lead RMS voltage of nonfiltered QRS. For each lead, we calculated the sum of the absolute value of filtered QRS from 20 msec ahead of the J-point to the J-point (A-20). The body surface distribution of A-20 was expressed as A-20 map. The maxima in A-20 maps were mainly located on the upper sternal region in healthy subjects, on the left anterior chest in patients with previous anterior myocardial infarction, and on the central anterior chest in patients with previous inferior myocardial infarction. In the patients in both the group with anterior myocardial infarction and the group with inferior myocardial infarction, the value of maximum was significantly greater than in the subjects in the control group (0.181 +/- 0.086 and 0.138 +/- 0.048, respectively, vs. 0.075 +/- 0.031 mV.msec; p less than 0.01). In patients with myocardial infarction (n = 41), the value of maximum was significantly greater with ventricular tachycardia (n = 11) than without ventricular tachycardia (n = 30) (0.240 +/- 0.076 vs. 0.130 +/- 0.043 mV.msec; p less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Relation between localization of coronary artery disease and local abnormalities in ventricular activation during exercise tests.

To examine whether or not the location of local abnormalities on body surface isochrone maps reflects the site of myocardial ischemia, 48 coronary artery disease patients without myocardial infarction were studied. Eighty-seven unipolar electrocardiograms distributed over the anterior chest and the back were recorded simultaneously before and after the submaximal treadmill exercise. For each lead, the duration from the QRS onset to the time of the most rapid decrease in QRS voltage was measured (index of ventricular activation [IVA]). Based o the data provided by these 87 leads, IVA isochrone maps (IVA map) in preexercise and in postexercise, as well as IVA maps showing the difference between preexercise and postexercise, were constructed. The IVA was defined as abnormal when it exceeded (mean + 2 SD) the normal range. We called the area with the abnormal IVA, the "+2SD area." In patients having a stenosis in the left anterior descending artery, the +2SD area in each map was located mainly on the left anterior chest, whereas in patients having a stenosis in the right coronary artery, the +2SD area in each map was located mainly on the right lower thoracic surface. Moreover, the +2SD area of patients with both left anterior descending and right coronary artery disease appeared on both the left anterior chest and the right lower thoracic surface. In patients with left circumflex artery disease, however, the location of the +2SD area did not suggest a stenotic site because of its small population. On the other hand, it was difficult to determine the ischemic site from the body surface distribution of ST segment depression.(ABSTRACT TRUNCATED AT 250 WORDS)

Body surface electrocardiographic mapping to assess left ventricular diastolic overload in valvular heart disease.

In order to assess diastolic overload by electrocardiogram (ECG), we performed body surface ECG mapping (MAP), and then compared the results with echocardiographic, roentgenographic and cardiac catheterization findings. Eighty-seven unipolar electrocardiograms were simultaneously recorded for the following groups: 1) 40 normal subjects, 2) 46 patients with diastolic overload [32 patients with aortic regurgitation (AR) and 14 patients with mitral regurgitation (MR)]. QRS isopotential maps were constructed at 10, 20, 30, 40, 50 and 60 msec from the QRS onset. On the potential departure map, the area where the QRS voltage was greater than the normal limits (mean + 2SD of normal control) was designated as "+2SD area". In patients with diastolic overload, +2SD area was found on the left anterior chest and back at 40, 50 and 60 msec from QRS onset. Subjects were classified into the following 3 groups according to the location of their +2SD area: 1) group A (n = 23) in which the +2SD area was found on the left anterior chest and back, 2) group B (n = 17) in which the +2SD area was found only on the back, and 3) group N (n = 6) in which no +2SD area was found. Group A had a markedly greater left ventricular end-diastolic internal dimension than the other groups (A 63.6 +/- 6.8 mm, B 53.9 +/- 5.5 mm, N 50.7 +/- 6.0 mm, A vs. B, N p less than 0.01), and a greater cardiothoracic ratio than the other groups (A 58.5 +/- 5.6%, B 52.5 +/- 7.0%, N 52.3 +/- 4.7%, A vs. B, N p less than 0.01). There was no significant difference in wall thickness among the 3 groups. The regurgitation severity assessed by cardiac catheterization was greater in group A than in the other groups. Among AR patients, the +2SD area was located on the upper back and the upper anterior chest, whereas among MR patients, it tended to be located on the lower portions. The potential departure map is a useful noninvasive analytic method for determining the extent and grade of diastolic overload. Furthermore, the location of the +2SD area may be used to discriminate between AR and MR.

腎盂原発と考えられた癌肉腫の1例

The first case of carcinosarcoma originating from the renal pelvis in Japan is reported. A fifty-five year old woman was admitted to the hospital on July 13, 1987, complaining of a one-year history of lumbago. On physical examination, a mass of child's head size was palpable in the right loin. There were other palpable masses in the posterior head (8 x 8 cm), left anterior chest (3 x 3 cm) and sacral region (3 x 3 cm). A chest X-ray showed multiple pulmonary metastases and an excretory urogram revealed a non-visualizing right kidney. Computed tomogram and renal angiogram suggested right renal tumor. Right renal arterial embolization with ethanol sclerosing was performed. She had previously undergone biopsy of the sacral lesion at another hospital, histological examinations of which pointed to suspected carcinosarcoma. She was treated by a combination chemotherapy with vincristine, adriamycin and cyclophosphamide. Despite one course of chemotherapy, her general condition deteriorated with progression of metastatic lesions in the regions other than the lungs. She died of the disease on december 9, 1987. Autopsy was performed. Sections of the right kidney showed a transitional cell carcinoma in-situ with squamous and glandular differentiation in addition to the chondrosarcoma. The metastases were found in the liver, lung and bone, all of which consisted of chondrosarcoma. On the other hand skin metastases consisted of both carcinomatous and sarcomatous elements. The pathological specimens were reviewed at the Armed Forces Institute of Pathology, Washington, D.C.

Skin involvement in Hodgkin's disease: A case report.

Skin involvement of Hodgkin's disease, which typically occurs in the advanced stage, is rare and is associated with a poor prognosis. We report a case of Hodgkin's disease which recurred solely in the skin and followed a favorable clinical course. A 44-year-old Japanese man was diagnosed as having a mediastinal Hodgkin's disease in January 1983. After a complete remission, recurrent skin tumors appeared in the left supraclavicular and anterior chest regions in March 1988. No evidence of lymph nodes or visceral organ involvement was detected. The tumors regressed after chemotherapy. There is no evidence of the disease 7 months after discharge.

Use of body surface electrocardiographic mapping to localize the asynergic site in previous myocardial infarction

Body surface electrocardiographic (ECG) maps of myocardial infarction were analyzed using the departure mapping technique, which represents the abnormal potential distribution out of normal ranges. Body surface ECG mapping using 87 leads was performed on 65 patients with previous myocardial infarction and on 40 normal volunteers. Potential departure maps at 10, 20, 30, 40, and 50 msec after the onset of QRS were constructed; each map indicated, if present, the area of abnormal decreased potential that is more than 2 standard deviations from the normal range (-2 SD area). In patients with myocardial infarction, the appearance time and the location of the -2 SD area were specific for the sites of left ventricular asynergy; the sensitivity and specificity were 86% and 100% for the asynergy of segment 2 (20 msec, on the upper left anterior chest), 87% and 97% for segment 3 (30 msec, on the middle anterior chest), 86% and 80% for segment 4 (20 or 30 msec, on the lower right anterior chest), and 88% and 90% for segment 5 (30, 40, or 50 msec, on the middle back), respectively. The sensitivity of these criteria was better than that of 12-lead ECG, while the specificity was comparable. In the analysis of body surface ECG mapping data, departure maps aid in depicting abnormalities and in making an accurate assessment. Body surface ECG mapping can be used to improve the diagnostic ability of ECG to detect myocardial infarction.

A CASE REPORT OF SPINAL HOURGLASS TUMOR

A 51 year old woman was admitted with the chief complaints of left upper arm and left anterior chest pains. The clinical X-rays revealed a mediastinal tumor. The computed tomography of the chest showed an hourglassshaped tumor developing in the vertebral canal and the vertebral foramen of Th3. The patient was operated on with transthoracicapproach. By enlarging the vertebral foramen of Th3, the Th3, the tumor was dissected totally. The pathological diagnosis was neurinoma. It is clinically important to select the apropriate approach for treatment of spinal hourglass tumor. The computed tomography of the spine provided the exact location and the mode of development of the tumor, and was the mot useful diagnostic tool.

Congenital venous web causing subclavian vein obstruction: A case report

A 712-year-old black girl had exercise-induced swelling of the left arm and left anterior chest wall caused by a congenital venous web of the subclavian vein. Operative repair was accomplished by venotomy and excision of the web. A venous digital subtraction angiogram obtained on the sixth postoperative day showed unobstructed flow through the operative area. We believe that an isolated, nonthrombotic functional obstruction of the subclavian vein by a venous web has not been previously reported in the English-language literature.

Detection of diseased coronary artery by exercise ST-T maps in patients with effort angina pectoris, single-vessel disease, and normal ST-T wave on electrocardiogram at rest.

To examine the clinical significance of ST-T isopotential maps, 87-lead body surface mapping was performed after treadmill exercise in 21 patients with effort angina pectoris, single-vessel disease, and normal ST-T waves on the resting electrocardiogram. Single-vessel disease was found in the left anterior descending artery (LAD) (nine patients), in the right coronary artery (RCA) (seven patients), and in the left circumflex artery (LCx) (five patients). At 40 msec after the J point, the isopotential maps showed the site of the minimum to be in the left anterior chest in all patients. According to the changes in the position of the minimum from the ST segment to the T wave, postexercise maps were classified into four types. Type A maps (n = 8) were characterized by the persistence of the minimum in the left anterior chest until its negativity decreased and until it became less negative than another minimum that subsequently appeared in a different position. Type B maps (n = 6) were characterized by the gradual movement of the minimum toward the lower thoracic surface. Type C maps (n = 5) were characterized by the gradual movement of the minimum to the left upper direction and then to the back. Type D maps (n = 2) did not show any of the characteristics of A, B, or C. All patients with type A, type B, or type C maps had single-vessel disease of LAD, RCA, or LCx, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Plasma Nitroglycerin Levels, Blood Pressure and Apical Heart Rate Variations to Site of Application of Nitroglycerin Ointment

The purpose of this study was to observe changes in plasma nitroglycerin levels, systolic and diastolic blood pressure, and apical heart rate after the administration of nitroglycerin ointment to selected sites. The sample consisted of 15 subjects with a diagnosis of coronary artery disease. The four application sites used were the fifth intercostal space of the left anterior chest, medial aspect of the left upper arm, medial aspect of the left thigh, and medial aspect of the left lower leg. There was no statistically significant difference in plasma nitroglycerin levels and diastolic blood pressure to site of application. Mean systolic blood pressure was significantly lower (p less than 0.05) for the upper arm and anterior chest sites than for the thigh and ankle at both 75 and 90 minutes. Mean heart rate was significantly higher (p less than 0.05) for the anterior chest than for the ankle at 45 and 60 minutes.

A single fatal penetrating chest wound caused by a dagger-shaped fragment of broken door glass.

A 19-year-old woman ran against a glass door, and, breaking it, was struck in the left anterior chest by a single dagger-like fragment of broken door glass. This fragment deeply penetrated her chest and wounded the anterior wall of the left ventricle of her heart. She rapidly died from loss of blood. The majority of single fatal penetrating chest wounds seen at postmortem examinations are caused by firearms and bladed weapons. While penetrating chest wounds occasionally result from fragments of glass, most severe and fatal wounds from glass result from one's falling into or through plate glass and sustaining wounds of the head, face, abdomen, or extremities. A single fatal wound from a dagger-shaped piece of glass is distinctly uncommon. To prevent such an accident from occurring, safety glass must be used in front doors of public institutions.

Qualitative and quantitative analysis of characteristic body surface potential map features in anterior and inferior myocardial infarction

Body surface potential maps were recorded from 120 electrode sites in 236 normal subjects and 258 patients with initial evidence of either anterior myocardial infarction (MI) or inferior MI to identify characteristic map patterns in both groups. After time normalization, averaged map distributions were displayed at 18 equal time intervals during both QRS and ST-T waveforms from the normal, anterior MI and inferior MI groups. At each time instant, the 120-point averaged normal map was subtracted in turn from the corresponding anterior and inferior MI maps; the resulting differences at each electrode site were divided by the pooled standard deviation and the obtained values (discriminant indexes), plotted as contour lines with 1 standard deviation increments, producing discriminant maps for each bigroup comparison. The most consistent discriminant patterns in 114 patients with anterior MI were observed in early QRS in the upper left anterior chest where abnormal negative voltages reflected loss of electric potentials while reciprocal changes were noticed in the lower back; by mid-QRS, both distributions had moved jointly and vertically, the former in the lower torso on the midsternal line, the latter in the upper back. In 144 patients with inferior Ml, abnormal positive distributions were observed in early QRS in the upper back, followed later by excessive negative voltages in the inferior right anterior chest; at mid-QRS, both distributions had migrated horizontally, the former proceeding toward the upper anterior torso, the latter to the lower left dorsal area. Abnormal negative voltages were seen in the precordial region during ST in the inferior MI group, moving toward the lower left flank where they stayed throughout T; in the anterior MI group abnormal negativities appeared in the precordial area at the beginning of T and remained there until the end of repolarization. Intragroup variability was investigated by producing scattergrams of extrema and of abnormal peak discriminant indexes (≥2 standard deviations) derived from individual patients within each population. The presence of electrocardiographic subgroups was suggested for both classes of infarction: anterior MI with or without apical involvement in the anterior group and inferior-posterior MI with or without right ventricular involvement and with or without apical extension in the inferior group. Thus, both types of infarction share a temporally common but spatially discriminating portion of the early QRS. Repolarization patterns in both infarction groups were also spatially discriminant from normal subjects, but temporally heterogeneous one from the other. Retrospective classification of patients based on the presence of one or more patterns typical in time and in location of their respective groups yielded 96% and 93% of correct assignment to the anterior MI and the inferior MI classes, respectively. The specificity was 94% for normal control subjects.

ST segment changes in exercise body surface mapping after myocardial infarction in patients with isolated left anterior descending coronary artery disease

To investigate the clinical significance of exercise-induced ST segment elevation and ST segment depression after myocardial infarction (MI), we performed 87-lead ECG mapping after previous anterior infarction in 24 patients with isolated left anterior descending coronary artery disease before and 1.5 minutes after treadmill exercise. Thirteen patients showed ST segment elevation only, seven patients showed both ST segment elevation and depression, and four patients showed ST segment depression only. ST segment elevation most frequently occurred in the left anterior chest leads corresponding to the QS area, and ST segment depression developed in the left lower chest and left lower back leads. There was good correlation between the number of lead points showing ST segment elevation (nSTe) after exercise and the number of lead points showing QS waves (nQS) before exercise ( r = 0.65). nSTe was also correlated with the asynergy index ( r = 0.43). These findings suggest that ST segment elevation is mainly the result of aggravation of wall motion abnormalities of the infarcted myocardium. Body surface distribution of ST segment depression was similar to that in effort angina pectoris without MI. We conclude that exercise-induced ST segment depression in MI mainly reflects the ischemia of the surviving myocardium of small infarcts or the peripheral area of large infarcts.

A CASE OF LEFT VENTRICULAR ANEURYSMAL CHANGE AFTER REPAIR OF A CARDIAC STAB WOUND

The patient, a 25-year-old man, had received a stab wound to the left anterior chest with a kitchen knife and was transported to our center. As plane chest roentgenography showed left hemothorax and his blood pressure was decreased, thoracotomy was urgently carried out. An approximatoly 3cm stab wound was recognized on the left side of the anterior descending branch of the left coronary artery, and hemostasis was performed by 4-acus interrupted suture using 3-0 Ticron® thread. Although the postoperative blood circulation was stable, ECG and enzymological examination showed suspicion of myocardial infarction and coronary arteriography showed occlusion of the anterior descending branch of the left coronary artery. Furthermore, left ventricular arteriography showed anteroseptal dyskinesis and ventricular aneurysmal changes. The patient is uneventfully under observation of the course. In the present case, the thrombotic occlusion and so on, which were caused by direct ligation of the coronary artery with suture thread or distortion or flexion of the coronary artery with ligature were considered to be the cause of ventricular aneurysm formation. With regard to the indication for surgery, the procedure for ventricular aneurysm after myocardial infarction is though to be applied to this case.