Objective : To investigate the prognosis of breast cancer by differentiating according to the presentation of estrogen receptor and HER2.
Material and Method : 218 cases of breast cancer in which immunohistochemical staining were performed in regard to ER and HER2 were studied. HER2 was divided into score : 0 (HER2-) and score : 3+ (HER2+) according to Hercept Test (Dako) presentation. Using these scores the subject was differentiated into 4 subtypes.
1) luminal A…ER : +, HER2 : -
2) luminal B…ER : +, HER2 : +
3) HER2 subtype…ER : -, HER2 : +
4) basal-like breast cancer (BBC)…ER : -, HER2 : -
According to these 4 subtypes the background and prognosis of each group were studied.
Results : The numbers of cases of each group were as follows. Luminal A : 121, luminal B : 25, HER2 subtype : 34, and BBC : 38. There were no differences among the groups regarding to the age, menopausal state, size of tumors, and axillary metastasis. BBC had higher incidence of solid adenoductal carcinoma compared with luminal type. Luminal A had higher survival rate without cancer compared with 3 other groups. BBC especially showed high early recurrence and lowest total survival rate compared with luminal A and HER2 subtype. Luminal B and HER2 subtype revealed same total survival rate as luminal A.
Conclusion : BBC had worse prognosis than other groups. Luminal B and HER2 subtype had tendency of early recurrence compared with luminal A, however, total survival rate was not different.

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Purpose : A study was undertaken to analyze pulmonary nodules diagnosed by thoracoscopic lung biopsy. Methods : Between April 2001 and September 2006, 98 adult patients (103 lung biopsy cases) with clinical diagnosis of pulmonary nodules by preoperative chest computed tomographic (CT) scanning were included in this study. Results : The mean size of the tumor was 1.5cm. The motive of consultation was medical checkup in 40 patients, follow up for other diseases in 40 patients. Indications for VATS were malignant findings on chest CT scanning in 42 patients, the ruling out of malignancy in 26 patients without malignant findings on chest CT scanning. 77 patients (75%) had malignant disease. 56 patients (55%) had primary lung cancer. For tumor sizes equal to or less than 2cm, the rate of malignancy was 77%. Among primary lung cancer, most patients had primary adenocarcinoma (46 cases) (82%). Pathologic staging showed stage IA in 35 cases. Conclusion : We propose that thoracoscopic lung biopsy shoud be performed for peripheral lung nodules on the basis of these results.

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A series of 35 patients with gastroesophageal reflux disease (GERD) were divided into two groups with regard to the age, and compared for sex, symptoms, ailing time, the presence of hiatal hernia (type I-III), short esophagus, and Barrett esophagus, 24hr-pH test, short- and long-term results. Females were dominant in the elder group (65 years or older ; n=18) in contrast to the male dominance in the non-elder group (under 64 ; n=17). Patients in the elder group presented with a variety of symptoms including respiratory symptoms (4 patients), vomiting (5) and body weight loss (3). All 35 patients underwent laparoscopic Nissen procedure with no conversion to the open procedure. Short term results were excellent in the both groups except for the 2 slipped wraps in elderly patients who presented with short esophagus preoperatively. Respiratory symptoms in the elderly group improved/diminished in all cases. Laparoscopic Nissen procedure is an option of choice even for the elderly when reflux itself is a concern. In the presence of short esophagus often seen in the elderly, Collis gastroplasty should be considered.

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An extremely rare case of breast carcinoma with metastasis to the tongue is reported. A 35-year-old female had been aware of her left breast tumor, and she had a surgical dissection by a plastic surgeon. Since microscopic examination of the resected tumor showed invasive ductal carcinoma, she underwent additional lumpectomy and axillary lymphnodes dissection (T1N0M0 Stage I A, pathology : invasive ductal carcinoma, solid tubular carcinoma, ER (+), PgR (+), HER2 (1+), Histological grade 3), following the previous operation. She received hormone therapy and chemotherapy after the operation, but one year later she was diagnosed as having metastatic breast cancer in skin and lung. When she suffered from discomfort in her oral cavity, an otolaryngologist found a lesion protruding from the posterior part of her tongue. Pathological appearance of the biopsy specimen of her tongue was essentially identical to those in the primary breast tumor. Despite the additional chemotherapy, she developed metastases to the brain and liver, and died from intercurrent carinii pneumonia. Metastatic breast carcinoma to the tongue is so rare that it has never been reported so far.

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An 84-year-old female was admitted to our hospital with cough and pigmentation of face and bilateral arms. She had received silicone augmentation mammoplasty about 20 years earlier. Chest CT revealed that the silicon had leaked out on the right side and that granulomas had formed around it. Anti-nuclear antibody and rheumatoid factor were positive on laboratory tests. Therefore, she was diagnosed as human adjuvant disease, and the silicon implants were removed under general anesthesia. However, the granulomas were hard and connected to the minor pectoralis muscle and chest wall, so the right silicone implant was not completely removed. After operation her symptoms slightly improved.

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A 32-year-old woman visited our hospital, complaining of an enlargement of the right breast during the last period of her second pregnancy. When she visited our hospital 9 days after her childbirth, her right breast was enlarged but no tumor was recognized. The first aspiration cytology performed after delivery revealed a lactating adenoma. The tumor was observed after she stopped breast-feeding. Nine months later, her breast had decreased in size and a 12×9-cm palpable mass was recognized in the right C area. A fibroadenoma was suspected based on the findings of a second aspiration cytology. Since she strongly felt that something was wrong with her right breast, a tumor extirpation was performed. The tumor was diagnosed to be sclerosing lobular hyperplasia (SLH). SLH is characterized by prominent hyperplasia of the lobules and sclerosis of the intralobular stroma, and its occurrence is rare. SLH has nonspecific imaging findings and cytologic features, So it is difficult to make a diagnosis without performing an excisional biopsy. In this case, the tumor showed rapid growth during the last period of the patient's pregnancy, thus suggesting that an estrogenic hormone was involved in the development of SLH.

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A 78-year-old man was admitted for stress fracture of the thoracic vertebrae. After admission, he began to have general rigidity and spasms with pain, and dysphagia appeared. Two years ago he was operated for rt. breast cancer (T1 N0 M0 stage I), and received aromatase inhibitor for adjuvant therapy but there was no evidence of recurrence. In this admission there was no abnormality including autoimmune antibodies in his serum. While diazepam therapy was effective, his symptoms were considered to be stiff-man syndrome.
Stiff-man syndrome is a rare disease of the central nervous system characterized by progressive rigidity of the body muscles. Cancer is known to coexist in some subgroups of this disease.
Until now 5 cases of stiff-man syndrome with breast cancer have been reported. All of these patients were female. Ours was the first case of a man with breast cancer and stiff-man syndrome.

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A 79-year-old woman had excisional biopsy of the breast tumor. The pathological diagnosis showed breast cancer and cancer cells were present on the incisional margin. In microscopic study, the tumor was composed of nests of small neoplastic cells, and had a solid proliferation. Similar to small cell carcinoma of the lung, the tumor cells had round to fusiform shape, scant of cytoplasm and comtained finely granular nuclear chromatin. As a curative operation, quadrantectomy with axillary node dissection was performed. In the histological findings, lymph node metastasis from primary tumor was found. In the mammary gland, minute invasion from primary tumor and DCIS different from primary tumor with clear nucleoli and eosinophilic cytoplasm, was found. In immunohistochemistry, the part derived from the primary tumor was positive for NCAM, but negative for synaptophisin and Chromogranin A. On the other hand, the part of DCIS was positive for NCAM and synaptophisin, but negative for Chromogranin A. We report this rare case of primary small cell carcinoma of the breast, together with a review of literatures.

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A 62-year-old female visited our department because a mammography check-up revealed an abnormality. Physical examination showed nipple discharge in the left breast alone. Neither additional mammography nor ultrasonography of the breast revealed any abnormalities. After 4 months, she visited our department again for bloody nipple discharge in the left breast. Ductography showed ductal dilatation and a shadow defect in the left CD lesion. Ultrasonography revealed a mass 4.2 × 3.3 mm in the left A lesion, although there were no abnormalities in the left CD lesion. On breast MRI, a linear enhancement area and a nodule were detected in the left CD lesion. In addition, a nodule was also detected in the left A lesion. Microdochectomy for left CD lesion and vacuum-assisted breast biopsy for left A lesion were carried out.
Histopathological examination showed invasive cancer in the A lesion and DCIS in the CD lesion. Although total mastectomy should be indicated for double breast cancer in the ipsilateral breast, we performed two breast-conserving surgeries in this case, whereby endoscopic quadrantectomy in the left CD lesion was combined with CAL, in which cryoablation facilitates minimum resection of minimal breast cancer left A lesion.

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A 58-year-old man who had fallen down the window on the 3^rd floor was brought into the hospital by ambulance. On his arrival at the hospital, a chest X-ray film and a chest CT scan showed multiple fractures of the left ribs, lower transparence of the left lung field, and raised left diaphragmatic line. Blood analysis showed elevated levels of transaminase and amylase, however, there were no unusual physical findings of the abdomen. Abdominal CT scan showed no abnormal signs. We were able to rule out the possibility of injury of the abdominal organs after follow-up blood tests and CT scans, and diagnosed the patient as having traumatic diaphragmatic hernia. Surgery via a transthoracic route was thus performed on the 3^rd hospital day. We found that the left diaphragm was lacerated and the stomach, spleen and greater ementum were herniating through the laceration of the diaphragm. A left pericardial rupture was also found during the operation. The herniated organs were reduced and the diaphragmatic rupture was closed by direct sutures. The patient left the hospital on the 23rd day after the operation.
Traumatic diaphragmatic rupture is often associated with another organ injuries, so that we should select an appropriate procedure considering the possible complication.

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A 43-year-old man visited our hospital due to epigastric discomfort. Cancer on the gastric cardia showing slight invasion of the esophagus was detected by upper GI series and endoscopic examination. Total gastrectomy with resection of the lower esophagus trough, left thoracotomy, and celiotomy were performed in August 2001. Postoperative pathology showed poorly-differentiated adenocarcinoma of Stage III. Following surgery, the patient improved and was discharged on postoperative day 41. FDG-PET in June 2002 showed accumulation of FDG in the middle mediastinum. Enlarged lymph nodes, suspected to be metastatic lesions derived from the gastric cancer, were found by CT scan. In July 2002, the patient underwent tumor resection via left thoracotomy. The postoperative pathology suggested lymph node metastasis with poorly-differentiated adenocarcinoma. The patient has been well without recurrence for four years after resection of the metastatic tumors. This is a rare case of gastric cancer with middle mediastinum lymph node metastasis. In Japan, FDG-PET is not covered by health insurance. However, the present case indicated that it is a potentially beneficial method for postoperative evaluation.

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We report a case who underwent laparoscopic splenectomy for locally recurrent gastric gastrointestinal stromal tumor (GIST) after treatment with imatinib mesylate (IM). A 56-year-old woman underwent total gastrectomy with hepatic lateral segmentectomy and partial resection of diaphragm for gastric GIST. Ten months after operation, abdominal computed tomography (CT) revealed a local recurrence of GIST at hilus of spleen, and treatment of IM was started. The effect of IM was observed for two months.
Laparoscopic splenectomy was then performed six months after IM treatment. Pathological examination of the specimen revealed hyaline degeneration of GIST cells, and no viable tumor cells were detected. An abdominal CT after second operation revealed thrombosis involving the splenic vein to the portal vein, so anticoagulant therapy was immediately initiated. The patient has been free of disease for twelve months since the second operation.
Surgical intervention should be considered for imatinib-responsive recurrent GIST, since complete resection is rarely achieved once tumor progression occurs. Laparoscopic resection for recurrent GIST is a safe and effective procedure when performed carefully without tumor rupture.

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We report a case of successful truncal vagotomy and pyloroplasty for a stenosis due to pediatric duodenal ulcer. The patient was a 14-year-old male who repeatedly had episodes of abdominal pain since at age 10. Postprandial vomiting appeared at age 13 and lost 10 kg of body weight in 10 months. At the age of 14 it became difficult to ingest fluid and because of development of dehydration and electrolytes imbalance he was admitted to our hospital on an emergent basis. The body weight at the time of admission was 28 kg (-2.4SD). An endoscopic study of upper gastrointestinal tract revealed stenosis at the duodenal bulb with an ulcer on the anterior wall. With administration of PPI the patient could only take liquid. Upper gastrointestinal tract study revealed duodenal stenosis, and a flat plate of abdomen 2 hours later revealed residual contrast material in the stomach. Because of no improvement of obstruction with conservative treatment, truncal vagotomy and pyloroplasty were performed. The patient began to take regular diet and was discharge 11 days after the operation. The body weight became 38 kg and the course after discharge was uneventful without recurrence of ulcer.

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A 67-year-old healthy male who suddenly presented with massive melena was admitted to our hospital. An upper gastrointestinal endoscopy revealed profuse bleeding from an ulcer at the tip of a submucosal tumor in the second portion of the duodenum opposite the ampulla of Vater. The neoplasm was pedunculated with a thick stalk measuring 5 cm long. Blood transfusion was given to stabilize the patient's vital signs and maintain his general condition. A preoperative diagnosis of lipoma was highly suspected after computed tomography (CT) scan showed the homogenous low-density lesion at the duodenum. Partial resection of the duodenum was done to prevent further bleeding and for histopathological confirmation. The pathological finding was duodenal lipoma located in the submucosal layer. The postoperative course was uneventful, and he was discharged 13 days after the surgery. This case was reviewed and compared with similar case reports of duodenal lipoma.

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The patient is a 60-year-old female with the chief complaint of anemia. She was found to have a submucosal tumor in the duodenum by upper gastrointestinal endoscopy and was referred to our hospital. Enhanced CT showed a 6-cm mass in the second portion of the duodenum. Angiography showed a hypervascular tumor with feeding arteries from the anterior and posterior superior pancreaticoduodenal artery. Both barium enema and CT showed deviation of the colon to the left, which led to the diagnosis of mesenterium commune. Operation was performed on July 28, 2003 under the diagnosis of duodenal GIST. The tumor was located on the opposite side of the pancreas, approximately 15 cm from the pyloric ring. Partial duodenectomy and simple closure were performed because the duodenum was not fixed to the peritoneum due to mesenterium commune. Pathologically, proliferation of spindle cells was found with little cell atypia and mitosis. Immunohistological staining was positive for c-kit, α-SMA and partially for CD34. This led to the final diagnosis of GIST. It is often difficult to select the operative procedure due to its anatomical distribution. We report a case of duodenal GIST that was surgically resectable due to its accompanying mesenterium commune.

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A 76-year-old male was admitted to our hospital, because of detection of asymptomatic anemia. Upper gastrointestinal endoscopy revealed a submucosal tumor in the posterior wall of descending duodenum. Enhanced computed tomography (CT) of the abdomen showed a centrally necrotic tumor of 55×52mm that was suspected to have invaded the head of the pancreas. The diagnosis was a duodenal Gastrointestinal Stromal Tumor for which radical resection might lead to marked loss of organ function (e.g.pancreaticoduodenectomy) and therefore we started neoadjuvant chemotherapy with imatinib 400mg/day in an attempt to achieve organ preservation. CT study revealed reduction of tumor diameter to 34×32mm with clear margin to the head of pancreas after 90 days of the treatment. Complete surgical resection was performed with partial duodenectomy and the postoperative course was uneventful for 23 months after partinal duodenectomy.

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A case of adenosquamous cell carcinoma of the papilla major is very rare. A 79-year-old woman was admitted with complaints of general fatigue and jaundice. We performed percutaneous transhepatic biliary drainage to improve the liver dysfunction, and duodenoscopy showed a tumor from the papilla major. Then we performed a pancreato-duodenectomy and the pathological finding was adenosquamous cell carcionama of the papilla major. Only 23 cases of adenosquamous cell carcinoma of papilla major have been reported in Japan.

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A case of small bowel obstruction due to a fecalith with history of amelioration and deterioration of symptoms of ileus throughout the disease course is herein described. A 77-year-old male with diagnosis of small bowel obstruction was admitted to our hospital. He had undergone a radical distal gastrectomy for early gastric cancer 1 year earlier. He was managed conservatively for a month, but thereafter suffered a recurrence of bowel obstruction. During the course of admission abdominal computed tomography scans and contrast studies with Gastrografin administered through a long tube could not identify the cause. As a result, we eventually had to perform a laparotomy. At surgery, no adhesion of the small intestine was observed. However, a foreign body, which measured 4 centimeters in diameter, was found to be impacted at the beginning of the ileum. We therefore performed an enterotomy to remove it. The analysis of the foreign body demonstrated it to be a fecalith. An intestinal obstruction caused by enterolith, such as fecalith, is considered to be a rare event.

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The patient was 49-year-old male, who was repeatedly admitted with diagnosis of bowel obstruction, 6 times in the past one year. Bowel obstruction was relieved each time with conservative management. However, he was admitted to our hospital this time with recurrence of vomiting and abdominal pain. He did not have history of previous laparotomy. Diagnosis of bowel obstruction was made by a plain X-ray of abdomen and abdominal CT study. An ileus tube was inserted but it did not go beyond proximal jejunum. A gastrografin study revealed two spots of dilatation in proximal jejunum, however the contrast medium did not go well further down to anal side. With suspicion of presence of multiple diverticulosis of jejunum, a laparotomy was performed and multiple diverticulae were found 50 to 105cm distally from Treitz ligament on the jejunal wall opposite to mesenterium. A segmental resection of jejunum was carried out. No mechanical obstruction, nor any abnormal pathology was found distally. A total of 6 diverticulae were present in the resected segment. The pathological diagnosis was pseudodiverticulosis of jejunum. Recurrent torsion and its reduction of jejunal segment around the dilated diverticulae was thought to be causing bowel obstruction.

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A 34-year-old man was admitted to our hospital complaining of massive anal bleeding. He denied history of nausea, vomiting, abdominal pain, use of nonsteroidal anti-inflammatory drugs or anticoagulant drugs or a history of peptic ulcer disease. Examination such as ultra sonography and computed tomography showed no evidence of abdominal inflammation or tumor. Subsequent colonoscopic examination revealed an entirely normal appearance of colonic mucosa. In the cecum, active bleeding from the appendiceal orifice was identified. Since no ulcerative or vascular lesion could be identified either within or adjacent to the appendiceal orifice, endoscopic therapy was not attempted, and emergency operation was performed immediately. The appendix looked normal and no signs of adhesion or inflammation or tumor were seen. Since no lymph node swelling was recognized, a simple appendectomy was performed in the usual manner, and the patient got well after the surgery, and has not experienced further evidence of bleeding since then. Histopathological study of the appendix showed hyperplasia of the lymphoid follicles in the submucasa, mucosal erosion and hemorrhage. Although there was no evidence of specialized pathognostic changes, no infection, no granuloma or no vasculitis, the specimen contained shallow ulceration and disrupted artery, suggesting the possibility of Dieulafoy's lesion. Relatively common sources of bleeding of lower intestine are colonic vascular ectasis, diverticulosis, neoplasms, and colitis. However, the appendix is a rare source of bleeding, and previous reports are extremity limited.

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A 56-year-old man complaining of abdominal pain and diarrhea initially and then the abdominal pain localizing to the right lower quadrant was referred to our hospital with diagnosis of acute appendicitis. Conservative treatment was carried out at home, however, he had to be admitted to the hospital because of the right lower abdominal pain got worse and developed high fever. The patient was diagnosed as having diverticulitis of appendix by abdominal ultrasonography and CT. Appendectomy and intraperitoneal drainage were performed. The histopathological diagnosis was diverticulitis of appendix accompanied with appendicitis. To make preoperative diagnosis of diverticulitis of appendix was rather difficult in this case. We report a case of diverticulitis of appendix successfully diagnosed by preoperative abdominal ultrasonography and CT.

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We report a case of mucinous cystadenocarcinoma of appendix with intussusception, which was resected by laparoscope-assisted surgery. A 43-year-old woman complaining of sudden lower abdominal pain and vomiting was referred to our hospital. An abdominal computed tomography showed a cecoappendical mass in the transverse colon. Laparoscope-assisted ileocecal resection was performed under a diagnosis of cystic tumor of the appendix with intussusception. Histopathological examination showed mucinous cystadenocarcinoma of appendix. During the laparoscopic surgery, a great attention should be paid to avoid intraperitoneal dissemination of tumor cells, because of possible complication of pseudomyxoma peritonei.

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A 77-year-old woman who tended to be constipated was referred to our department because of abdominal distention. Abdominal plain radiography and computed tomography indicated intraperitoneal free air. So, we diagnosed her panperitonitis to be due to perforation of the GI tract, and an emergency operation was carried out. Laparotomy findings revealed a pinhole perforation of the transverse colon, there were little ascites, and peritonitis was localized. Partial resection of the transverse colon and end-to-end reconstruction were performed. Histologic examination showed features of idiopathic perforation of colon. Interestingly, there were fissuring ulcerations like obstructive colitis.
Idiopathic perforation of the transverse colon is a rare disease, so we must keep in mind a probable differential diagnosis.

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Laparoscopic-assisted right hemicolectomy was undertaken for Crohn's disease with a duodeno-colic fistula. It was difficult to dissect the extremely thickened tissue around the ascending colon. Using all approaching techniques, such as medial, lateral, retroperitoneal and superior approaches to the fistula, made it possible to encircle the fistula without causing damage to the surrounding tissues or organs and finally to divide it laparoscopically. It is important to learn and obtain the all approaching techniques for laparoscopic surgery for inflammatory bowel diseases.

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The patient was a 76-year-old man who underwent endoscopic mucosal resection for a laterally spreading tumor (LST) of the sigmoid colon in 1997. The pathological diagnosis was well-differentiated adenocarcinoma with invasion to submucosa (SM), slight venous invasion (v1) and mild lymphatic invasion (ly2) in the colonic wall. Nevertheless, the depth of the submucosal invasion was 3800 μm and the vertical margin was positive (VM1). So, in the same year, the patient underwent laparoscopic sigmoidectomy with D2 lymph node dissection, which was categorized in curative A resection. In 2005, an abdominal CT scan detected tumorous lesions in the S7 and S5 regions of the liver. Right hepatic lobectomy was performed with a preoperative diagnosis of metastatic hepatic cancer or intrahepatic bile duct carcinoma. As pathological examinations demonstrated the same pathological image as the primary sigmoid colon cancerdid, it was diagnosed as hepatic metastasis. This case is of hepatic metastasis of submucosal colonic cancer which occurred after 8 years had elapsed following surgery for the primary lesion that was considered rare. We thus report the case, together with a review of the literature.

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A 67-year-old woman who was found having a tumor in the right liver by abdominal ultrasonography at another hospital was admitted to our hospital for close exploration. Calcification was recognized in the tumor by a CT scan of the abdomen. The operation was performed for the purpose of diagnosis and treatment of the liver tumor. During surgery it was diagnosed as benign tumor and the tumor was removed. Histopathological studies showed hyaline change and remaining of degenerated blood vessel and the tumor was diagnosed as sclerosing hemangioma of the liver. Although sclerosing hemangioma of the liver is a comparatively rare disease, we must keep this disease in mind when a liver tumor with calcification is encountered.

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The patients was a 73-year-old female who had undergone sigmoidectomy for sigmoid colon cancer in October 1998, and pulmonary resections for lung metastases in both February 2000 and 2001. She was referred to our department with the elevated levels of ALP and CA19-9 and dilatation of the bile duct. Both DIC-CT and ERCP revealed a cylindrical filling defect in the common bile duct, although no tumorous lesion was detected in the liver parenchyma by either US or CT. Thus we conducted a laparotomy in February 2002. We recognized mucin in the common bile duct, and an intraductal tumor in the right intrahepatic bile duct by intraoperative cholangioscopy. We performed a biopsy of the tumor and T-tube drainage. The histological examination of the biopsy specimen revealed adenocarcinoma, and then right hepatectomy was performed in March 2002. Histological examinations of the resected specimen showed the same high columnar cancer cells with papillary growth as both resected primary colon cancer and lung metastases did. Furthermore, because of immunohistological findings regarding CEA and cytokeratin, we diagnosed the liver tumor as metastasis from the colon cancer. We herein present the extremely rare case of liver metastasis from colon cancer mimicking mucin-producing cholangiocarcinoma.

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The patient was a 53-year-old male. A mass 6cm in diameter in the right hepatic lobe was found on abdominal US in May 1988. Hepatocellular carcinoma was diagnosed and TACE was performed in July. Right lobectomy was planned after TACE, however, considering the preoperatively estimated liver resection rate (64.2%) and poor preoperative liver function, residual liver volume was not sufficient. Therefore, the therapeutic plan determined was (1) right portal branch ligation, and (2) right lobectomy secondary to the ligation after achieving hypertrophy of the left lobe. The right portal branch ligation and the cholecystectomy were performed in October. Left lobe hypertrophy was observed after the operation and the liver resection rate reached 50% the following year, so we judged that operation was possible and performed the right lobectomy. No postoperative complication was found. The patient is still alive without relapse 12 years and 7 months after the surgery. In cases where lobectomy is required in spite of insufficient residual hepatic volume, hepatectomy after portal branch ligation can be an effective way of extending an indication of hepatectomy for the treatment of hepatocellular carcinomas.

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A 55-year-old man suffering from hepatocellular carcinoma (HCC) with sarcomatous change without preoperative treatment is reported. His complaints were low-grade fever and sudden right abdominal pain. A tumor about 15 cm in diameter was shown in the right lobe of the liver by US and CT. This tumor was hardly enhanced by CT ; only the periphery of the tumor was enhanced at the arterial phase. MRI demonstrated Iow signal intensity of the entire tumor on the T1-weighted images (T1WI), high signal intensity on the T2-weighted images (T2WI), and the center of the tumor evidenced very high signal intensity on T2WI. Under the Preoperative diagnosis of HCC with bleeding and necrosis, right lobectomy was performed. The pathological diagnosis was HCC with sarcomatous change. The tumor consisted of spindle cells which had high-grade nuclear malformation and acidophilia body (sarcomatoid pattern). He was discharged on the 24 postoperative day and received chemotherapy with UFT-E and 5-FU out patients clinically. Ten months later, he died due to metastasis of the right adrenal gland and lymph node at 5 months and lung metastasis at 8 months.

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A 73-year-old woman was refered to our hospital with a gallbladder tumor. CT showed a papillary tumor in the gallbladder, a 7cm liver tumor and a 3cm retropancreatic lymphnode. Both gallbladder tumor and liver tumor were enhanced at early phase through late phase. Laboratory studies showed elevated serum levels of alpha-fetoprotein (AFP), carcinoembryonic antigen (CEA) and protein induced by Vitamin K antagonist (PIVKA-II). She was diagnosed as having AFP producing gallbladder carcinoma. Right hemi-hepatectomy with lymphnode dissection was performed. The histopathological finding was hepatoid adenocarcinoma of the gallbladder. Immunohistlogical stain showed tumor cells were positive for AFP and CEA. After operation, concentration of the serum AFP returned to the normal level. The patient has been doing well with no evidence of recurrence for 10 months.

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A 67-year-old man with gallstone and chronic cholecystitis underwent laparoscopic cholecystectomy (LC). Two years and 4 months later, he revisited the hospital complaining of painful swelling of the port site of his right upper abdominal wall. The histological examination after surgical exploration revealed that he had port-site metastasis and peritoneal dissemination of cancer. The pre-and intra-operative examinations failed to identify the primary lesion of the cancer. However, histological re-examination of the entire gallbladder revealed a gallbladder carcinoma in situ 2 mm in size. Thus, the bile spillage during LC for unsuspected gallbladder carcinoma might have resulted in port-site metastasis and peritoneal dissemination. The origin, features, prevention, and management of port-site metastasis after LC for unsuspected gallbladder carcinoma are discussed in this report.

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A 71-year-old woman was admitted to the hospital in order to examine an elvated lesion of the gallbladder. Abdominal CT scan demonstrated a hemispheric and diverticular lesion of the gallbladder. DIC-CT showed a filling defect of the fundus of gallbladder. We carried out laparoscopic cholecystectomy with a suspicion of gallbladder cancer with macroscopic mucous lake. The resected specimen revealed a ulcer type tumor with the size of 17mm at the fundus of anterior wall of gallbladder. There were mucous deposits in the ulcer of the tumor. Pathologic diagnosis was well differentiated mucinous cancer of the gallbladder with mucous lake.
Mucinous cancer is a cancer in which mucous lake and mucous nodules are formed outside the cancer cells. It is subclassified into well differentiated type and poorly differentiated type. Mucinous carcinomas of the gallbladder are very uncommon. Their radiological findings have not been described previously. We present a case report of well differentiated mucinous carcinoma of the gallbladder with mucous lake and mucous nodules together with a review of reported cases in Japan.

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The pancreatic injury is classified into, 1-type (contusion), 2-type (laceration), 3a-type (distal ductal injury), and 3b-type (proximal ductal injury) by The Japanese Association for The Surgery of Trauma. Reconstruction of the pancreatic duct and resection of the pancreas are generally needed for the 3-type pancreatic injury. We report a case of 3b-type pancreatic injury in which second operation could be avoided due to the patent accessory pancreatic duct after pancreatic juice drainage by a retroperitoneal approach. The case involved a 54-year-old man who had been kicked in the epigastrium bu a horse. At first, we diagnosed the case as 2-type pancreatic injury and performed conservative management. On hospital day 6, magnetic resonance cholangiopancreatography (MRCP) disclosed an injury to the main pancreatic duct at pancreas head. And we recognized a pancreatic fisutula in the retroperitoneal cavity. We performed necrosectomy and pancreatic juice drainage by a retroperitoneal approach. We planned second operation, but the pancreatic fisutula cured because pancreatic juice was discharged into the duodenum through a papilla of Vater from the patent accessory pancreatic duct. It seemed that pancreatic juice drainage by a retroperitoneal approach was effective for 3b-type pancreatic injury without merger abdominal injuries.

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We report two cases of ruptured pseudocyst of the pancreas caused by alcohol induced chronic pancreatitis, in which we were able to follow the enlargement of a pseudocyst with time until its rupture in both cases. Case 1 : A pancreatic pseudocyst enlarged and ruptured that reguired an emergency operation for immediately developed pan-peritonitis despite under medication. The remnant wall of the pseudocyst and surrounding peritoneum were anastomosed with the jejunum, which followed a good clinical course. The amylase value of the discharge from a decompression tube placed in the anastomosis was not high, so that the pseudocyst and main pancreatic duct might not connect with each other. Case 2 : While a pancreatic pseudocyst became larger under medical treatment, no peritoneal irritation sign emerged immediately after rupture. A few days later, however, Percutaneous drainage was needed to treat peritonitis. The pancreatic pseudocyst was confirmed to connect to the main pancreatic duct by fistelography using a drainage tube.
The clinical results of pancreatic pseudocysts vary depending on whether they have arisen with or without infection, and with or without communication with the main pancreatic duct. In the case of an enlarging pseudocyst with infection, prompt drainage of the cyst should be most important.

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A 72-year-old woman was referred to the hospital for the purpose of close exploration and treatment of acute pancreatitis. Abdominal CT and magnetic resonance imaging scans revealed a cystic lesion at the pancreatic body and tail. Endoscopic retrograde pancreatography (ERP) demonstrated communication between the lesion and the main pancreatic duct via a branching pancreatic duct. The resection of the body and tail of the pancreas was performed with a diagnosis of mucinous cystic neoplasm (MCN) or branch type intraductal papillary mucinous neoplasm (IPMN). A fluoroscopic study of the preparation disclosed communication between the lesion and main pancreatic duct via a branching pancreatic duct. Pathological studies showed that the cyst was composed of one or two layered columnar epithelium and that remarkably proliferated ovarian-type stroma was involved. Accordingly MCN was diagnosed.
MCN is a relatively uncommon entity and commonly affects the pancreatic body and tail of middle aged or older woman. So far MCN had been believed to have a unilocular or multilocular structure with a capsule without communication with the pancreatic duct, but it has become apparent that there is communication between the lesion and the pancreatic duct in some cases. Here we report a case of MCN which had communication between the lesion and pancreatic duct and showed prominent proliferation of ovarian-type stroma.

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Hiatal hernia of the broad ligament of the uterus is a very rare internal hernia. We report a patient who had been diagnosed by preoperative CT scan and treated under laparoscopy. A 53-year-old woman was referred to our hospital because of a left lower abdominal pain. At first, there were no specific findings on ileus. The subsequent abdominal CT scan revealed displacement of the uterus toward the right side, and a dilated small bowel loop on the left dorsal aspect of the uterus. Diagnosis of intestinal obstruction due to a hiatal hernia of the left broad ligament of the uterus or something was made, and laparoscopic surgery was finally carried out. About a 15-cm portion of the small intestine was incarcerated into a hiatus about 3 cm in diameter as a hernia opening. The ileum was carefully reduced and the hernia opening was closed. Besides several serosal injury happened to be made, the color of the incarcerated portion was slightly poor, we made about a 3.5 cm incision to repair and observe. Enterectomy was avoided. This rare disease should be kept in mind as a probable diagnosis in a female patient with ileus. In cases in which the cause may not be wide adhesion and internal herniation is suggested, laparoscopic surgery with or without conversion to laparotomy may be indicated.

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A 45-year-old woman who had a repair of volvulus and cecopexy for cecal volvulus came to our hospital one month after the operation with abdominal pain and frequent vomiting started in the morning. Abdominal CT showed that the second portion of duodenum was markedly dilated and the third portion of it was compressed by superior mesenteric artery (SMA). The SMA-Ao angle was measured 15 degrees by 3D-CT. Upper gasto-intestional series showed straight line obstruction of the third portion of the duodenum by SMA. The symptom had been improved with an indwelling ileus tube, but 1month after the improvement the same symptom, recurred. Under a diagnosis of SMA syndrome, we performed side-to-side duodeno-jejunostomy. The post operative course was uneventful and recurrence of the symptom has not been seen up to this time. We suspected SMA-Ao angle was sharpened because of the traction of SMA to caudal side due to cecopexy or body weight loss in postoperative term, causing this pathological obstruction.

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A 55-year-old woman was admitted to our hospital because of right abdominal pain. Abdominal CT scan showed an inflammatory mass about 10 cm in diameter near the transverse colon. Laparotomy was performed under a preoperative diagnosis of perforation of transverse colon diverticulum. At surgery, a mass about 10 cm in diameter in the mesentery of the transverse colon was detected, and the transverse colon including the mass was resected. The histological diagnosis was mesenteric panniculitis of the transverse colon.
Nine months postoperatively, she was admitted to our hospital again complaining of left lower quadrant pain. Abdominal CT scan and MRI demonstrated an inflammatory mass about 6 cm in diameter close to the sigmoid colon and uterus. From these findings, mesenteric panniculitis of the sigmoid colon was suspected. However, the possibility of malignant tumor of the uterus or sigmoid colon could not be ruled out. Therefore, laparotomy was performed. The sigmoid colon was resected together with the mass, uterus and ileum. Histological examination showed mesenteric panniculitis of the sigmoid colon.
Mesenteric panniculitis is a nonspecific inflammatory disease of unknown cause. This case is thought to be very rare, because there have been no previous reports of mesenteric panniculitis recurring in a different area.

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A mesenteric pseudocyst is defined as a mesenteric cyst without epithelium. It is very rare, and only 20 cases including ours have been reported in the Japanese literature. In the present report, we present the case of a mesenteric pseudocyst that might be caused by foreign body reaction. As an abdominal CT scan and US showed a 6.0 cm tumor composed of the cystic and solid part, it was suspected to be GIST with cyst. A Whirl sign connecting to the tumor was identified which suggested an intestinal volvulus. After resection, pathological examination revealed a mesenteric pseudocyst.
We compared 17 cases of GIST with 9 cases of mesenteric pseudocyst of the small intestine in the cystic region. Our study revealed that if an intraabdominal tumor with cystic region includes chylous fluid, does not have a thick wall, or does not have a complicated abnormal intestinal mucosa, it should be diagnosed as a mesenteric pseudocyst rather than GIST.

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Omental torsion is a relatively rare disease. We report two cases of sequential omental torsion due to inguinal hernia. Case 1 was a 40-year-old male. His main complaints were right lower abdominal pain and fever. By abdominal CT examination, a tumor that had a spiral layer structure was identified in his right lower abdomen, and right inguinal hernia was found. An operation was performed under diagnosis of omental torsion combined with right inguinal hernia. The greater omentum was excised at proximal tortional portion, and the inguinal hernia was repaired using Bassini method. Case 2 was a 55-year-old male. He was admitted with left lower abdominal pain and a tumor in the left inguinal region. By means of abdominal CT examination, a tumor consisting of a spiral layer structure was identified in the left lower abdomen, and left inguinal hernia was found. We diagnosed as omental torsion due to left inguinal hernia and performed surgery similar to that for case 1 mentioned above. For the diagnosis of omental torsion, CT examination was effective, and it may probably improve diagnostic capability by using CT examination with this disease in mind.

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A 75-year-old man visited another hospital complaining of abdominal distension. Close examinations revealed cholecystolithiasis and ascites, and he was referred to our hospital for a more detailed examination and treatment of the increasing ascites. We suspected malignant disease, but cytological examination of the ascites and other examinations could not show malignancy. However, FDG-PET revealed abdominal lesions suspected to be malignant tumors. So we performed a laparoscopic biopsy of the lesions for pathological diagnosis and selection of appropriate treatment protocols. The pathological diagnosis was peritoneal malignant mesothelioma. FDG-PET was useful for detecting peritoneal malignant mesothelioma.

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A 72-year-old woman, who had been followed by periodic echography for a retroperitoneal cyst which had been found at close exploration after she had tested HCV positive, was referred to the hospital for the purpose of operation because an enlarging tendency of the cyst was noted at the 3^rd year's examination. The cyst was clearly demarcated from the surroundings so that a laparoscopy-assisted removal of the cyst was performed. Dissection was easily done and there were no invasions into the surrounding organs. The tumor was 4.5×5.5cm in diameter and oval in shape with smooth surface, and the lumen was occupied with mucous fluid and blackish brown muddy substance. Pathological studies disclosed moderately differentiated tubular adenocarcinoma in an elevated portion of the internal wall, and thus retroperitoneal mucinous cystadenocarcinoma was diagnosed. No invasion of cancer tissue to the cystic wall was seen, and we decided to follow the patient's clinical course. However, an abdominal CT scan performed 3 months after the operation revealed recurrence of a giant tumor at the retroperitoneum and metastasis to the periaortic lymph nodes. Chemotherapy with paclitaxel+CBDCA resulted in a remarkable shrinkage of the tumor and disappearance of the periaortic lymph node metastasis, however, further chemotherapy was withdrawn according to her denial due to adverse episodes. Thereafter the tumor started to enlarge again. Resumption of the chemotherapy was ineffective and the patient died 2 years after the initial operation.

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A 27-year-old man was referred to our division by a local practitioner to undergo examinations for an omphalic tumor in July, 2005. Although no abnormality was recognized in the omphalos, CT revealed a multiple cystic tumor located in the retrorectal space, which measured 5.0×6.5 cm in size. On subsequent barium enema, colonoscopy, endoscopic US and MRI, we considered it to be a congenital cystic tumor which did not invade the colon and rectum. The tumor was removed by the trans-sacral approach in December and diagnosed as a mature cystic teratoma. At present, 21 months after the surgery, there has been no sign of sequela.
Sacrococcygeal teratoma in an adult is rare, and our case is thought to be the 34th reported case in Japan. Sacrococcygeal tumors are often found in a physical checkup, because the patient frequently has no complaint. As it is difficult to deny malignancy, a complete resection should be recommended. Although the trans-sacral approach is most frequently used, the choice of the approach should be decided in terms of its size, its location and relation with the organs around the tumor.

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The patient was 83-year-old male who came to our clinic with a complaint of growing tumor in his gluteal area. Detailed studies revealed a cystic tumor of 23 cm in its maximum diameter in the presacral area comprssing pelvic organs anteriorly. With diagnosis of presacral developmentol cyst the tumor was resected by transsacral approach. The resected specimen revealed a cystic wall of multilayer squamous epithelial cells without dermal apparatus and was diagnosed as epidermoid cyst. Postoperative course was uneventful and the patient has been free from recurrence. Sixty-three cases of presacral epidermoid cysts were reported in Japan including this case. Our case was the oldest case reported. We report this case with the literature review of 62 reported cases in regard to their nature and method of operation.

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There are two anatomically weak spaces in the lumbar area, namely superior and inferior lumbar triangle. Lumbar hernia is rare and may occur in these triangles. In this paper, a case of idiopathic superior lumbar hernia is reported with some review of previous literatures.
A 67-year-old woman was seen at the hospital because of a soft mass at the right lower lumbar area. The mass was about 6cm in diameter and its consistency was elastic soft. Computed Tomography (CT) showed a lumbar muscle defect and herniated retroperitoneal fat, therefore the patient was admitted for operation. At operation, the hernia orifice was about 2cm in diameter. Musculus obliquus internus abdominis and musculus erector spinae were sutured, covering the superior lumbar triangle with a Marlex Mesh. No recurrence has been observed.

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We have experienced a case of difficult management of ventilation after surgical treatment of a patient with giant incarcerated umbilical hernia due to malrotation of intestine. A 49-year-old woman was admitted to our hospital because of pain, distention and giant mass of her abdomen. Abdominal computed tomography revealed a mass including small intestine and colon. Emergent surgery was carried out. The torsion and necrosis of small intestine was seen. Therefore partial resections of the jejunum was performed. The torsion of small intestine due to malrotation was considered to have led to incarcerated umbilical hernia. After the surgical treatment, disorder of ventilation was seen due to high abdominal pressure. Noninvasive positive pressure respiration and tracheotomy was effective.

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A 71-year-old woman visited a hospital because of a one-week history of a right inguinal bulge and tenderness was referred to our hospital because observation of her clinical course under drip infusion therapy with antibiotics failed to provide symptomatic remission. When she was first seen, we noted prominent redness and swelling with tenderness from the right inguinal region to the pubic symphysis. Abdominal CT scan showed swelling of the appendix. The appendix had ended blindly in the vicinity of the internal inguinal fossa from where an abscess with gas continued in the subcutaneous tissue of the right inguinal region. An emergency operation was performed with a diagnosis of inguinal hernia in which the appendix was impacted. Laparotomy by lower abdominal midline incision disclosed the appendix which was incarcerated into the internal inguinal fossa ; no extension of inflammation into the abdominal cavity was demonstrated. In order to prevent intra-abdominal contamination, we did not mobilize the appendix and incised the right inguinal region for drainage. A hernia sac, which was strangulated, became necrotic, and changed black in color, was seen. A peripheral portion of the appendix from the incarceration became lytic. The appendix was reduced into the abdominal cavity ; the root of the appendix was ligated and transected ; and the surgical stump was buried. The postoperative course was uneventful and the patient was discharged from the hospital on the 28th hospital day.

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An 83-year-old woman who had felt a swelling in the right inguinal region since 40 years earlier which had been able to be reduced by her hands visited another hospital on April 26, 2006, because she could not reduce the right inguinal swelling by her hands. Then she was referred to the hospital with a diagnosis of right incarcerated inguinal hernia. An abdominal pelvic CT scan showed an about 5-cm sized tumor in the extraplacental subcutaneous structure where was identical with the right inguinal swelling. Since the tumor continued the uterine on the anterior surface of the rectum, a temporary operation was performed with a diagnosis of inguinal hernia with uterine incarceration. An about 6-cm long skin incision was made on the skin above the swelling and the inguinal duct was opened, when a tumor enveloped with a hernia sac was disclosed. Opening of the hernia sac revealed the prolapsed uterine. No ischemic change was noted so that the incarcerated uterine was reduced to the abdominal cavity, the hernia opening was closed by means of the mesh plug method, the operation being completed. The hernia sac had prolapsed from the posterior wall of inguinal canal where was inside of the inferior epigastric artery, and hence internal inguinal hernia was diagnosed.
We report this case of internal inguinal hernia in which the uterine was incarcerated, together with some bibliographical comments.

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We experienced a case of an abscess of the scrotal region which was caused by incarcerated ileocecum in an inguinal hernia.
An 88-year-old man, who had been diagnosed as having a right inguinal hernia was admitted to the hospital because of a high fever of 38°C and a right inguinal and scrotal raddish swelling. He had no abdominal pain, no peritoneal signs and no ileus symptoms. Abdominal CT scan showed a lumen structure existing in the inguinal canal toward the abdominal cavity. We performed an operation with a suspicion of right incarcerated inguinal hernia. An incision via an inguinal approach disclosed, an incarcerated ileocecum with the appendix and the abcess in the right inguinal and scrotal region. The main inflammation was seen at the appendix, spreaded to the wall of the cecum. Therefore, cecal resection was performed. Histological findings showed that the main inflammation was almost localized in the appendix and the ileocecum was comparatively kept intact. There have been some cases of incarcerated inguinal hernia in which the incarceration of the cecum might be caused by that of the appendix. It is etiologically considered that the similar manner of incarceration of the cecum might occur in this case, because the inflammation of the cecum was in a relatively minor level. Incarcerated ileocecum in an inguinal hernia is very rare in the Japanese literature.

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