Purpose: To clarify intraductal proliferative precursor–lesion features and significance in the background of ductal carcinoma in situ (DCIS) of the breast.
Subjects and Methods: Subjects were 118 women treated for DCIS five years or longer ago. DCIS and intraductal proliferative lesions with DCIS were examined pathologically based on the concept of DIN according to WHO classification 2003.
Results: Of the 118, 26 had flat epithelial atypia (FEA) (DIN IA), atypical ductal hyperplasia (ADH) (DIN IB), or peripheral papilloma with DCIS. Low–grade DCIS (DIN 1C) spread less than intermediate (DIN 2) or high–grade DCIS (DIN 3) and thought to involve earlier cancerous lesions.
Conclusion: Our results suggested that intraductal proliferative lesions with DCIS should be considered precursors of breast cancer. The concept of DIN is thus useful in understanding the change from atypical intraductal proliferative lesions (DIN 1) to high–grade DCIS (DIN 3).

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Purpose. We aimed to examine the usefulness of the 3D–CT for gastric cancer in terms of the ability of detecting lesions by Virtual endoscopy (VE), and the diagnosis of depth of invasion by Multiple Planar Reconstructions (MPR).
Methods. We evaluated 60 consecutive patients with gastric cancer (22 early–stage, 38 advanced–stage) diagnosed with endoscopy and biopsy. Patients underwent surgery after evaluations by VE and MPR in 3D–CT for gastric cancer.
Results. Gastric cancer lesions were detected in 11 of 22 early–stage (50%), and in 33 of 37 advanced–stage (87%) by VE. The depth of tumor invasion was true to the pathological diagnosis in 43 of 60(72%). The sensitivity and specificity of T factors to the pathological diagnosis of tumor invasion were each 77% and 89% in T1 (n=22), 63% and 81% in T2 (n=24), 79% and 87% in T3 (n=13).
Conclusion. The evaluation by MPR in 3D–CT for gastric cancer may be useful for predicting the depth and width of cancer invasion, but it is difficult to detect early gastric cancer by VE.

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Purpose In the present study, we evaluated the relationship between the career as surgeons and perioperative clinical course of laparoscopic cholecystectomy (LC) which was related as the standard operation for gallstones. Material and Methods The subject of this study was 267 patients (male; 112 cases, female; 155 cases) who were performed LC from April 2005 to March 2009. Patients were classified into three groups: those with the career of surgeon under 5years (group A; 108 cases), from 6 to 10 years (group B; 106 cases) and over 11 years (group C; 53cases). The results were compared in preoperative assessment for feasibility of LC, blood loss, the rate of conversion to open cholecystectomy, operating time, postoperative early complications and postoperative hospital stay among three groups. Results There were no significant differences in backgrounds and preoperative assessment for feasibility of LC. In perioperative factors, we had the only significant difference in average operating time (p<0.0001). Conclusion It is reasonable to experience LC under the mentorship of advisory doctors in early stages of training for laparoscopic surgery. Our education and training system of LC for gallstones have been beneficial for trainee doctors.

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We report the cases of two professional boxers with confirmed old orbital bone fractures detected during mandibular body and angle fracture treatment. Old fractures were in the left medial wall and due to a bout or sparring years earlier. Neither boxer had double vision or oculomotor disorder, so we simply repaired the latest fractures. We have found that 85.7% of mandibular fractures due to blows or sports involve fractures at two sites. When treating boxing–induced mandibular fractures, the mandibular body and angle should be obserued. Boxers with orbital bone fracture detected in computed tomography (CT) but without double vision or abnormal ocular movement should be followed up regularly to monitor the possibility of these two symptoms occurring.

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Gastric cancer surgery training is difficult in Okinawa Prefecture due to the low number of gastric cancer cases, so we proposed that laparoscopy–assisted gastrectomy (LAG) be added to the surgical repertoire of hospitals in such areas. We thus under took a preliminary LAG study at our hospital.
From 2006 to 2008, a surgeon studied at a center with a large number of LAG operations, then LAG was introduced in April 2008 at our hospital. By March 2009, laparoscopy–assisted distal gastrectomy (LADG) had been done in 11 cases and laparoscopy–assisted total gastrectomy (LATG) in 7. Operation time, blood loss, postoperative hospitalization, complications, and lymph node dissection number were then compared to 20 cases of open distal gastrectomy (ODG) and 9 of open total gastrectomy (OTG) done from 2002 to 2008.
We found that LADG cases showed lower blood loss, shorter postoperative hospitalization, and fewer complications than ODG eases. LATG cases showed longer operation time than OTG cases but shorter postoperative hospitalization.
Our experience suggests that LAG be considered for addition to hospitaly repertoires in geographical areas with few gastric cancer patients.

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Purpose: The surgical strategy for treatment of synchronous colorectal liver metastasis remains controversial. The aim of this retrospective study was to evaluate feasibility of staged laparoscopic colectomy and heptectomy for primary colorectal cancer with synchronous hepatic metastases.
Patients and Methods: Between April 2007 and March 2009, five patients were performed laparoscopic resection for primary colorectal cancer with synchronous liver metastases at Saitama Medical University International Medical Center, and thirteen patients were performed simultaneous resection of colorectal primary tumour and synchronous liver metastases at Kurashiki Central Hospital.
Results: In the staged laparoscopic colectomy and hepatectomy group, all five patients underwent D3 dissection at laparoscopic colectomy. The overall postoperative morbidity was null and the postoperative hospital stay was 7.2 days. In this group, all five patients were performed curability B surgery, and the hospital stay was 7.6 days. On the other hand, the postoperative morbidity was 61.5%, the mortality was 7.7%, and the hospital stay was 17.2days in the open simultaneous resection group.
Conclusion: This study suggests that staged laparoscopic colectomy and hepatectomy has possibility that the prior minimally invasive surgical procedure, laparoscopic colectomy, is able to lead to the safe and accurate subsequent liver surgery.

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We present a diagnosis and laparoscopic treatment strategy for obturator hernia with incarceration. Our 5 subjects, all women, had a mean age of 82.2 years. Mean time from symptom onset to hospital admission was 6.0 days. Diagnosed with incarcerated obturator hernia by computed tomography (CT), all 5 underwent immediate surgery. Three had laparoscopic small–intestine reduction and hernia repair and mesh plug insertion without complications. Two had laparoreduction, gangrenous small–intestine resection, and direct suture repair. Complicated by postoperative pneumonia causing 1 woman′s death. All were discharged a mean 11.3 days postoperatively. CT is useful in preoperatively diagnosing obturator hernia. Minimally invasive laparoscopy appears optimal for treating such cases.

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Simultaneous occurrence of multiple intracerebral hemorrhages is a rare condition. Here we report a case of simultaneous bilateral putaminal hemorrhage. A 74–year–old woman suddenly collapsed on the street. She had been medicated for hypertension for thirty years. She was receiving an angiotensin receptor blocker, a long–acting calcium antagonist and aspirin. On admission, she was comatose (Glasgow Coma Scale E1V1M2). The size of her right pupil was 4.0 mm, the left pupil was 5.0 mm. Computed tomography of her brain identfied hematomas in bilateral putamen. The right putaminal hemorrhage was 7×4×7cm, and the left hemorrhage was 5×2×4cm. As the hematomas were large and her neurological condition was severe, no surgical intervention was attempted. She died on the sixth day after admission. An autopsy of her brain was performed with the permission of her family. However, her brain was severely autolytic; therefore, pathological findings were difficult to detect.
We identified 27 cases of simultaneous bilateral putaminal hemorrhage in the literature. We summarized these cases and ours. The mean age was 56.75 years old. Nineteen cases had a history of hypertension. Twenty–five cases were comatose or semi–comatose at onset. Fifteen cases (55.6%) died. Many of surviving cases were severely disability. Multiple intracerebral hemorrhages occur in patients with hypertension, coagulation defects, neoplasm, multiple small aneurysms, or angiopathies. However, the underlying mechanism for simultaneous bilateral putaminal hemorrhages is not clear.

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A 70–year–old woman with a right–side 25×25 mm soft palate defect due to pleomorophic adenoma resection reported water and food leakage into the nasal cavity 1 month postoperatively. We conducted primary soft palate reconstruction with bilateral palatal flaps 6 months after resection, but observed a small soft palate fistula and liquid leakage through the fistula into the nasal cavity in fluorographic video images. We then conducted secondary soft palate reconstruction using a unilateral buccal mucosal flap 1 year after primary reconstruction, closing the fistula. No findings of nasal cavity leakage were seen in fluorographic video images after secondary reconstruction. We closed the soft palate defect after the second reconstruction. The defect actually should have been closed without failure on both the nasal and oral cavity sides in primary reconstruction.

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A 28–year–old woman presented at our surgical outpatient department complaining of sudden swelling and pain in her left breast. Examination revealed diffuse swelling extending over the entire left breast, with no evidence of neoplasm. Findings from needle biopsy confirmed a diagnosis of granulomatous lobular mastitis (GLM). Steroid was administered orally, and the dose was very gradually tapered. Swelling abated and, 8 months later, the breast had returned to an unaffected state. Although the treatment of GLM remains controversial, the present patient with generalized inflammatory symptoms was successfully treated with steroid therapy.

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We report a rare case of noninvasive ductal carcinoma in a benign phyllodes tumor seen in a 26–year–old woman. The 4 cm right breast tumor, diagnosed in core needle biopsy as a benign phyllodes tumor. Contrast–enhanced computed tomography (CT) and magnetic resonance imaging (MRI) showed a benign pattern. Histologically, the resected specimen was diagnosed as a benign phyllodes tumor within noninvasive ductal carcinoma. The general postoperative course was satisfactory.

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Advances in supportive therapy have made high–dose chemotherapy feasible as new chemotherapeutic agents have been developed. Chemotherapy is thus worthwhile in those with unresectable multiple pulmonary soft tissue sarcoma metastases such as malignant fibrous histiocytoma (MFH).
A 71–year–old man with a 20×20 cm soft–tissue left–thigh tumor was found in histological postbiopsy diagnosis to have MFH necessitating hip disarticulation, which was followed by detection of over 10 metastatic lesions in both lungs three months later. The lesions were unresectable, necessitating five chemotherapy courses, which shrank lower left–lung lobe lesions, with other lesions disappearing. The lower left lobe was excised. Metastatic lesions appeared in the mid right lung lobe 20 months and 55 months (roughly 4.5 years) and in the omentum 65 months (roughly 5.5 years) after disarticulation. Both lesions were excised. No evidence of distant metastasis has been seen in the 68 months (5.6 years) since disarticulation.

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A 68–year–old woman undergoing low anterior rectal cancer resection with adjuvant chemotherapy was diagnosed with multiple lung metastases. She underwent mFOLFOX6 and FOLFIRI, but extensive presumably malignant pleural effusion was found in the right thoracic cavity. Bevacizumab was administered third–line with FOLFIRI. Pleural effusion completely disappeared on CT three months later and she was judged to have achieved partial response (PR). This case indicates the potency of bevacizumab on malignant pleural effusion arising from colorectal cancer.

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A 77–year–old man seen for appetite loss and vomiting was found in gastrointestinal endoscopy to have a type 3 tumor on the greater upper gastric corpus curvature. Tumor biopsy showed papillary adenocarcinoma. An upper gastrointestinal series showed a fistula between the stomach and transverse colon. Abdominal CT showed gastric corpus wall thickening with a gastrocolic fistula, multiple metastatic splenic and hepatic tumors and peritoneal dissemination. Chemotherapy combined docetaxel, cisplatin, and 5–FU (DCF). Two chemotherapy courses shrank the primary and metastatic tumors and closed the gastrocolic fistula. He was able to resume oral ingestion and was discharged after an additional course of chemotherapy.

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A 50–year–old woman seen for a positive fecal occult blood test and diagnosed with gastric cancer based on gastrointestinal endoscopy results was found in chest x–ray and abdominal computed tomography (CT) to have situs inversus. In a perfect mirroring of the usual vascular arrangement, 3–dimensional (3D) CT showed the hepatomesenteric trunk divided into the common hepatic and superior mesenteric arteries and the gastrosplenic trunk divided into the splenic and left gastric arteries. Laparoscopy–assisted total gastrectomy and lymph node dissection were completed without complications. The postoperative course was uneventful and she was discharged on postoperative day 12. Laparoscopic surgery is feasible and safe in those with situs inversus.

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We report a case of laparoscopic jejunal interposition reconstruction following total gastrectomy in gastric cancer with familial adenomatous polyposis (FAP). In FAP, other organs should be observed for duodenal and gastric polyposis, so we chose jejunal interposition rather than Roux–en–Y reconstruction. We performed laparoscopic side–to–side esophagojejunostomy and jejunoduodenostomy using a linear stapler after total gastrectomy and lymphadenectomy. This procedure is technically feasible.

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Small–bowel lipoma is relatively rare. We report a case of prolapsed irreducible lipoma of the cecal terminal ileum causing transversal intussusception.
A 59–year–old man with intermittent abdominal pain and found in colonoscopy elsewhere to have a transverse colon tumor was hospitalized for worsening pain. Computed tomography (CT) showed ascending and transversal colon intussusception with a low–density mass at its apex, diagnosed as lipoma. Despite reducing of the intussuception, pain still remained, necessitating ileocecal resection yielding a specimen containing a 45×40×78 mm pedunculated tumor histopathologically diagnosed as prolapsed irreducible lipoma of the cecal terminal ileum.

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A 63–year–old man with lower right abdominal pain and admitted for abdominal wall abscess and cecal wall thickening detected in computed tomography (CT) was diagnosed with cecal cancer on barium enema after abscess drainage. Ileocecal resection included part of the abdominal wall the tumor appeared to have invaded. Pathological findings showed moderately differentiated adenocarcinoma with mucinous adenocarcinoma (pSE, pN0, fStage II). The man remains in good health without recurrence 22 months after surgery. Colon cancer with abdominal wall abscess is relatively rare, but requires considering possible latent colon cancer when an abdominal wall abscess is found.

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A 36–year–old man was referred to our hospital after developing dull lower abdominal pain, pneumaturia, and fecaluria. He had a history of acute appendicitis treated without surgery at the age of 6, and had since experienced recurrent episodes of cystitis, pneumaturia, and fecaluria. Escherichia coli was cultured from the urine. Abdominal CT and MRI suggested an enterovesical fistula. Cystoscopy revealed a stone in the bladder, for which lithotripsy was performed. An unusual dilation of the appendix orifice was found on colonoscopy. Retrograde cystography did not show an enterovesical fistula ; however, a small bowel series using an ileus tube revealed an appendicovesical fistula. The patient therefore underwent surgery and the fistula was found between the right side of the bladder dome and the middle of the appendix. Appendectomy with partial cystectomy including the fistula was performed. We concluded that the appendicovesical fistula might have developed after appendicitis at the age of 6 and that the diagnosis could have been delayed for as long as 30 years because the fistula was well established. Appendicovesical fistula is a rare condition, generally forming after appendicitis. Direct imaging of the fistulous tract is not easy, and the fistula often takes a long time to diagnose. However, the diagnosis can be made if specific findings are present, and the disease is completely curable by operation.

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We report a resected case of both metachronous adrenal metastasis and periceliac lymph node metastasis from colon cancer. A 78–year–old woman undergoing right hemicolectomy for ascending colon cancer six months earlier was found in abdominal computed tomography (CT) to have right adrenal metastasis. She underwent chemotherapy with mFOLFOX6 + bevacizumab for 3 months but the metastatic tumor did not shrink, and lymph node swelling was found around the celiac artery, necessitating right adrenalectomy, inferior vena cava resection, and periceliac lymphadenectomy. Tumor cells positive for CK20 and negative for CK 7 yielded a diagnosis of primary–site metastasis from colon cancer. No signs of recurrence have been seen in the 12 months since surgery.

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Umbilical cancer metastasis known as Sister Mary Joseph′s nodule generally involves terminal cases. We report a case of descending colon cancer with umbilical metastasis together with a review of the literature.
A 70–year–old man with anemia detected in abdominal aortic aneurysm examination was followed by colonoscopy indicating advanced descending colon cancer involving a with festering umbilical tumor biopsy showed to be metastatic adenocarcinoma. Abdominal computed tomography (CT) showed an umbilical tumor 1.5 cm in diameter diagnosed as advanced descending colon cancer with an umbilical metastatic tumor. Partial colectomy and tumor resection at the umbilicus were followed by postoperative allopathy. The man died of peritonitis carcinomatosa 11 months postoperatively.
This condition must thus be considered in the detection of umbilical tumors.

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In Japan, lateral pelvic lymph node dissection is generally performed for the treatment of T3–4 lower rectal carcinoma, and not for T1 lower rectal carcinoma, because lateral pelvic lymph node metastasis in T1 lesion is rare. We experienced a rare case of synchronous isolated lateral pelvic lymph node metastasis from T1 lower rectal carcinoma in which preoperative diagnosis was possible. A 67–year–old woman had positive fecal occult blood test in medical examination and pointed out a lower rectal carcinoma by colonoscopy at local hospital. Preoperative pelvic computed tomography and magnetic resonance imaging examination demonstrated isolated lateral pelvic lymph node enlargement. Clinical diagnosis was early lower rectal carcinoma with synchronous isolated lateral pelvic lymph node metastasis, so we performed a total mesorectal excision with an extended left lateral pelvic lymphadenectomy in which internal iliac vessels and pelvic nerve plexus were resected. Pathologicaly, lateral pelvic lymph node metastasis was confirmed, so adjuvant chemotherapy with 5– fluorouracil was performed for six months. Three years and two months after the operation, the patient is alive and recurrence free. Even for T1 lower rectal carcinomas, preoperative evaluation of the lymph node status is essential. Lateral pelvic lymph node metastasis of early rectal carcinoma was reviewed in the present study.

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Endocrine cell carcinoma (ECC) of the rectum is a rare neoplasm usually associated with a poor prognosis. No standard chemotherapeutic regimens exist for the treatment of ECC. We encountered a case of rectal ECC in which chemotherapy was administered based on the results of a chemosensitivity test, the collagen gel droplet–embedded culture drug sensitivity test (CD–DST). A 64–year–old man with anal pain was diagnosed with rectal cancer. The patient received Mile's operation and was microscopically diagnosed as having ECC with foci of differentiation to adenocarcinoma. Multiple hepatic metastases were found 1 month after surgery. The patient received TEGAFIRI (oral UFT and leucovorin with irinotecan), which was intermediately sensitive based on the CD–DST. TEGAFIRI initially reduced the extent of hepatic metastases, indicating a partial response after 3 months of administration. However, progress of the disease was confirmed and TEGAFIRI had become ineffective after 5 months of administration. Thereafter, although mFOLFOX6 with bevacizumab, which was insensitive based on the CD–DST, was administered, the progression of hepatic metastases continued, indicating progressive disease. The patient died 13 months after surgery. In conclusion, we suggest that CD–DST may be useful for identifying sensitive antitumor agents for the treatment of rectal ECC for which no standard chemotherapeutic regimens exist.

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We report a case of ileostomy carcinoma diagnosed 20 years after total colectomy for familial adenomatous polyposis (FAP). A 69–year–old woman presenting with an ileostomy–site tumor two years earlier was found in biopsy twice before resection to have inflammatory granuloma and no evidence of malignancy. The tumor, 15 mm in diameter, was hemorrhagic and disturbed pouch changing. Partial tumor resection yielded a pathological diagnosis of well–moderate differentiated adenocarcinoma. No sign of recurrence has been seen in six months of follow–up after resection. Ileostomy carcinoma after colectomy for FAP is rare. Routine follow–up after ileostomy may detect ileostomy carcinoma early, but tumor biopsy alone is insufficient for diagnosis, which requires surgical resection.

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A 73–year–old Japanese women seen in July 2009 for epigastralgia, elevated serum gamma–glutamyltransferase, and a hepatic cystic lesion detected in ultrasonography was found in abdominal dynamic computed tomography (CT) to have a cystic lesion 3 cm in maximum diameter in the left lateral hepatic segment (S3) containing. Two protruding tumors slightly enhanced in early and delayed phases. Magnetic resonance cholangiopancreatography showed the cystic lesion communicating with the intrahepatic bile duct. These findings yielded a preoperative diagnosis of intraductal papillary bile duct neoplasm with cystic bile duct dilation induced by mucin, necessitating limited laparoscopic–assisted liver resection. Grossly, the resected specimen had a markedly dilated bile duct with mucin and a papillary mass protruding into the lumen. Microscopically, tall papillary growth was present in part of the cystically dilated bile duct, with some atypical cells in papillary growth (carcinoma in situ). Tumor cells were immunoreactive for MUC1 and MUC5AC, but not for MUC2 or MUC6. Based on recent criteria, our case corresponds to intraductal papillary mucinous pancreatic neoplasm (pancreaticobiliary type).

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Amyand′s hernia is an extremely rare type of inguinal hernia that involves herniation of the appendix. Here, we report a case of Amyand′s hernia in a 77–year–old man. The patient had developed a painful swelling in the right inguinal region 3 years ago; the swelling could be manually reduced but became increasingly painful over time. The hernia was intraoperatively identified as an external inguinal hernia containing the ileocecum and an uninflamed appendix. Only weak adhesions were present between the appendix and hernial sac; therefore, the appendix could be easily separated and was replaced within the abdominal cavity. The mesoappendix was not involved, and an appendectomy was not required. The inguinal hernia was repaired in a radical operation using a direct Kugel patch. The patient′s postoperative course was favorable, and he was discharged 3 days after the surgery. Postoperative infection of the surgical site did not occur.

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