Since 1993, 21 patients with unresectable or non-curatively resectable gastric carcinoma have received FLP neoadjuvant chemotherapy (NAC), consisting of 5-fluorouracil (333 mg/m²continuous intravenous infusion for 8 days) and cisplatin (50mg/m²as a 2-hour intravenous infusion on day 1 and 8). Patlents recelved at least 2 cycles of FLP. Nineteen out of 21 patients underwent surqical treatment. and stomach resection was performed in 18 (85.7%). There were no deaths and no major morbidity following operation. Clinical response, toxicity, and survival were assessed. Results: There was no complete response (CR), but 12 patients (57.1%) had partial response (PR). The response rate was 64.7% for positive abdominal para-aortic lymph nodes (No.16), 47.6% for primary regional involvement. 40.0% for liver meatastasis and 11 -1% for peritoneal dissemination, respectively. One vear survival for all Datients was 40.5% and median survival time (MST) was 322 days. MST for responders was 471 days and that for non-responders was 209 days. MST was 835 days for patients who underwent curative resection and 310 days for those who underwent non-curative surgery. there was no treatment related death (TRD) or grade 4 toxicities. Grade 3 leukopenia occurred in 4 patients (19.0%), grade 3 anemia occurred in 3 patients (14.3%), and grade 3 stomatitis in 2 patients (9.5%). We concluded that neoadjuvant chemotherapy with FLP was feasible and useful for tumor reduction, especially for para-aortic lymph node metastases. A little survival benefit was seen for patients whose primary tumor had a PR or who had undergone curative resection.

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This study has been carried out rate of Epstein-Barr virus (EBV) positive gastric carcinomas, these have been known frequency of EBV infection in gastric carcinoma with lymphoid stroma (GCLS) that has marked lymphocytic infiltration around the tumor and stroma in the medullary poorly differentiated adenocarcinoma. And has been undertaken significance of EBV infection and carcinogenesis of EBV for latent gene protein EBNA2 and LMP1 expression and characterized clinicopathological findings in EBV positive gastric carcinomas, and classified EBV positive gastric carcinoma in EBV related neoplasma. Additionally, relationship between EBV infection and lymphcytic infiltration of gastric carcinomas. The subjects consisted of three groups, 10 cases were GCLS, 14 cases were marked lymphocytic infiltration except for GCLS, and 300 cases were none or few lymphocytic infiltration. EBV positive cases were 8 to 10 (80.0%) in GCLS, 8 of 14 (57.1%) in lymphocytic infiltration group, and 23 of 300 (7.7%) in nonlymphocytic infiltration group. GCLS and lymphocytic infiltration group were frequent related of EBV positive gastric carcinomas that were lower lymph nodes involvement than non-lymphocytic infiltration group. EBV expression was early gastric carcinoma and positive reaction was observed in the nucli of almost all neoplastic cells, and these infection were monoclonal multiplication, but EBNA2 and LMP1 were not detect in all EBV positive cases. EBV positive gastric carcinomas were in Burkitt's lymphoma group (EBNA2-, LMP1-) or nasopharyngeal carcinoma group (EBNA2-, LMP1+/-). Our result suggest that EBV has inactivity and unability of permanent multiply in cancerous cells, but EBV infection occurred early oncogenesis and EBV infected cancerous cells include a faciling for escaping immunoreaction, for example the lymphocystic immunoreaction, and has been kept long term the latent infection and these phenomenon may be add to carcinogenesis of gastric carcinoma.

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The operative outcome after hepatic resection for hepatocellular carcinoma (HCC) was examined in 91 patients, according to whether the underlying hepatitis type is B or C. Twenty-four patients positive for hepatitis B antigen (HBs Ag)-(Group B), and 67 patients positive for hepatitis C antibody (HCVAb)(Group C) were compared. Group B patients were younger and had a larger tumor than the patients in Group C. Because of the higher incidence of portal vein involvement or intrahepatic metastasis in patients with tumors more than 5 cm in diameter, operative procedures and operative outcomes were examined in patients with a tumor smaller than 5 cm in diamter (n=81). Recurrence was observed in 4 out of 18 patients (22.2%) in Group B, and in 36 out of 63 patients (57.1%) in Group C. The patterns of recurrence were not similar in the two groups. Multiple recurrence in the residual liver was observed in 2 cases (50%) in Group B, while in Group C there were only five multiple recurrent cases (13.9%), and significant differences were not observed in the prevalence of recurrent sites in the liver. In conclusion, as Group B revealed a smaller decrease in liver funciton, and often recurrence from the primary tumor, systemic resection should be offered as far as possible in the initial operation. In contrast, in Group C, as synchronous or metachron or us multicentric occurrence is dominant, limited resection according to Glisson structure should be performed.

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In this study, our aim was to identify factors associated with the failure of sonography to diagnose acute appendicitis. During the last five years 245 patients were diagnosed pathologically with acute appendicitis at our institution. Fifteen diagnoses were missed by abdominal sonography (False Negative, FN group). We compared the FN group with the remaining 230 patients (True Positive, TP group), who were correctly diagnosed by sonography. The diameter of the appendix was significantly thicker in the FN group than in the TP group (14.5mm vs. 9.4mm, p=0.0045). The proportion of patients with severe appendicitis was significantly higher in the FN group than in the TP group (47% vs. 20%, p=0.017). Preoperatively, however, there were no significant differences in age, sex, body mass index, white blood cell count, C-reactive protein or body temperature. We conclude that intestinal tract gas and the severely disrupted appendix may lead to false negative sonographic diagnoses of acute appendicitis. CT scanning would be valuable when sonography fails to demonstrate the inflamed appendix.

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A 73-year-old man underwent pharyngolaryngoesophagectomy for hypopharyngeal carcinoma after 60 Gy irradiation at the age of 55. A skin tube which was made of a delto-pectoral skin flap was used for reconstruction of the alimentary tract. Also he underwent colectomy because of colonic carcinoma at the age of 67. Eighteen years after the first operation, squamous cell carcinoma that developed in the skin tube circumferentialy caused dysphagia. Then the skin tube was resected and a free jejunal graft was transplanted for reconstruction between the pharynx and the thoracic esophagus. The tumor showed multiple polypoid lesions as the other reports represent papillomas. The cause of such of the carcinogenesisis chronic inflammation caused by chemical and mechanical irritation of the skin tube by passage of food and saliva. Patients with alimentary reconstruction by skin tubes should be observed carefully for decades.

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A very rare case of esophageal schwannoma is reported. A 59-year-old man was referred to our institution because of an abnormal shadow on a chest roentgenogram and chest CT scan. The chest X-ray showed a faint mass in the mediastinum, and a chest CT scan demonstrated a well-demarcated homogeneous mass in the subcarinal region of the mediastinum. Thoracoscopic surgery was performed, the esophageal muscular layer was divided, and the tumor was enucleated by gentle blunt dissection. Intraoperatively, an esophagoscope was used to confirm the absence of esophageal mucosal damage. The resected tumor was large (5.0×3.5×2.5 cm). Histopathological examination showed a schwannoma. The patient recovered uneventfully and was discharged 15 days after surgery. He is well 12 months following treatment, with no evidence of recurrence of disease.

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We report a case of O-Isep esophageal adenosquamous carcinoma originating from the esophageal proper gland duct. A 61-year-old man with a protruding lesion of the esophagus was admitted to Tochigi Cancer Center. He had no symptoms. By endoscopic examination, a nodular lesion was revealed in the lower esophagus. This lesion was O-I type according to endoscopic gross classification. Esophagectomy was performed. The tumor was 16×10 mm in size and completely covered with normal esophageal epithelium, and therefore was of O-Isep type according to histological gross classification. Microscopically, the majority of tumor cells were tubular in structure and contained mucin, similar to the esophageal proper gland duct, while some showed a keratinizing tendency. Moreover immunohistological findings and electron microscopic examination clearly demonstrated the tumor to be an adenocarcinoma. From the histological findings, we concluded that the tumor was an adenosquamous carcinoma originating from the esophageal proper gland duct.

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A case of hepatocelluar carcinoma with sarcomatous change that rapidly recurred in the abdominal wall and caused carcinomatous peritonitis after the operation is reported. A 64-year-old man was referred to our hospital because of a liver mass with epigastralgia. The tumor was similar to cholangiocellular carcinoma, metastatic liver tumor, liver abscess and hepatic cyst-adenoma (or adenocarcinoma) at the point of avascularity shown by contrast enhanced computed tomography and abdominal angiography. Under the intra-operative frozen pathological diagnosis of hepatocellular carcinoma, lateral segmentectomy of the liver with lymph node dissection was performed. The specimen revealed hepatocellular carcinoma with sarcomatous change and retropyloric lymph node metastasis. On post-operation day 41, recurrence in the abdominal wall was revealed, and peritoneal dissemination was revealed at resection of the recurrent abdominal wall tumor. The patient died 87 days after the first operation. Hepatocellular carcinoma with sarcomatous change has invasive growth, a high incidence of extrahepatic metastasis and a rapid clinical course. If hepatocellular carcinoma with sarcomatous change is suspected, hepatectomy with a sufficient surgical margin and wide lymph node dissection in the early stage are necessary. This is the eighth operative case of hepatocellular carcinoma with sarcomatous change in Japan.

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A 59-year-old woman was admitted complaining of jaundice. She had undedrgone left lobectomy of the liver because of hepatocellular carcinoma fifteen months before. Laboratory examination showed elevation of serum bilirubin and α-fetoprotein levels. Ultrasonography and CT scan revealed a tumor in the common bile duct, about 2cm in diameter, protruding into the markedly dilated common bile duct.T o reduce jaundice, choledochotomy was done, resulting in the removal of a large portion of brown and soft choledochal tumor. This was identified as metastatic hepatoecellular carcinoma histologically, b ecause it was microscopically similar to previously resected hepatoma. Postoperative cholangiography revealed that a small part of the tumor remained. About one month later, pancreatoduodenectomy was performed for radical resection of the remnant tumor, which was histologically diagnosed as metastatic hepatocellular carcinoma. No other metastases were found in other parts of the common bile duct or in the head of the pancreas. Serum bilirubin and α-fetoprotein levels normalized, and she was discharged two months after surgery. According to previous reports, obstructive jaundice in patients with hepatoma was caused by direct invasion of the biliary tract or obstruction by degenerated tissues or blood coagula from the tumor. In the present case, however, choledocal obstruction was caused by metastatic tumor apart from the original tumor. This type of recurrence of hepatoma has been considered to be very rare.I t can be speculated that hepatoma cells separated from the original tumor, floated in bile and werei mplanted on mucosa of the common bile duct.

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Endocrine cell tumors occur in the rectum, stomach, and appendix, but primary endocrine cell carcinoma of the gallbladder is rare. We encountered a rare case of adeno-endocrine cell carcinoma of the gallbladder in a 72-year-old man. The nodular protruded tumor (252×20×20mm) was found in the fundus. Direct invasion of the liver bed, lymph node metastasis, and liver metastasis were seen. Histologically, the tumor consisted of two components, well-differentiated adenocarcinoma and endocrine cell carcinoma. The tumor cells in the area of the endocrine cell carcinoma were small and round-shaped. The nuclei were irregular in size and exhibited severe atypia and hyperchromatism. The tumor cells were arranged in irregular nests and a trabecular structure, and almost all of them showed a positive argyrophil reaction in the cytoplasm. A diagnosis of adeno-endocrine cell carcinoma was made. A transition between both histological features was seen histologically. It was suggested that the histogenesis of endocrine cell carcinoma of the gallbladder is closely related to that of adenocarcinoma.

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A 48-year-old man was admitted to our hospital with complaints of abdominal pain and vomiting. Endoscopic findings included marked stenosis and an edematous and reddish mucosa in the second portion of the duodenum. Ultrasonography revealed a mass measuring about 30 mm in diameter at the haed of the pancreas. Pancreatic carcinoma with duodenum involvement was suspected, but an abdominal CT scan did not show a mass at the pancreatic head and ERCP showed no abnormality of the main pancreatic duct. The patient improved conservative treatment but he was readmitted for vomiting. There was no progression of the size of the mass. Angiography showed a central avascular area and a slight increase in vascularity in the venous phase at the same site. MRI revealed a mixed solid and cystic tumor with unclear margins and hypovascularity. We suspected groove pancreatitis rather than pancreatic cancer, and performed a pancreatoduodenostomy. Histological examination showed marked fibrosis between the duodenal wall and the head of the pancreas. Segmental groove pancreatitis was diagnosed. The postoperative course was uneventful. We found reports of only 25 similar cases in Japan.

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We report a case of resected carcinoma of the pancreas head with papillary extension into the common bile duct. The patient was a 78-year-old man with a chief complaint of obstructive jaundice. Percutaneous transhepatic cholangiography and endoscopic retrograde cholangiography disclosed a filling defect, 2 cm in size, in the distal common bile duct. Percutaneous transhepatic cholangioscopy revealed a papillary tumor with irregular vessels on its surface in the common bile duct. Computed tomography showed a low density tumor at the pancreas head, and dilatation of the main pancreatic duct. Endoscopic ultrasonography disclosed a low echoic tumor, 3 cm in diameter, in the common bile duct. Preoperative differential diagnosis between distal bile duct carcinoma and carcinoma of the pancreas head was difficult. The patient underwent subtotalstomach-preserving pancreatoduodenectomy on July 9, 1996. Macroscopical examination of the resected specimen revealed a whitish tumor, 3.5×3.0cm in size, at the upper part of the pancreas head. The tumor directly invaded the common bile duct and formed a polypoid mass. Simultaneously, it extended into Wirsung's duct and showed intraductal growth. Pathological examination of the main tumor at the pancreas head revealed moderately differentiated adenocarcinoma, and the intraductal parts, both the common bile duct and Wirsung's duct, showed papillary adenocarcinoma. Polypoid growth of the pancreatic carcinoma into the common bile duct is an extremely rare mode of cancerous spread.

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We report a case of Peutz-Jeghers Syndrome associated with advanced jejunal cancer. A 43-year-old man was diagnosed as having Peutz-Jeghers Syndrome. He was referred to the hospital because of ileus which was pointed out at a nearby clinic. Further gastrointestinal examinations revealed multiple polyps in the stomach, small intestine, and colon. An operation was performed because there were repeated episodes of ileus symptoms. At laparotomy, a jejunal cancer which caused narrowing of the entire circumference with peritoneal dissemination was found, and histopathologically the tumor was mucinous adenocarcinoma. Possible association of the polypoid lesions with cancer could not be speculated on in this case, because the cancer was far advanced. The number of reports that have suggested a malignant change in polyps of this syndrome has recently increased. Further studies would be required to clarify the mechanism of malignant formation in the polypoid lesions. In addition, careful clinical follow-up is recommended considering an association with cancer whenever we encounter patients with this sydrome.

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Intra-abdominal desmoid tumors mainly occur in cases of familial polyposis of the colon (FPC) or in the postoperative state of digestive surgery, and cases without such a history are very rare. Only 13 cases have been reported in Japan, including our case. Our case was in a 59-year-old male. The patient came to our hospital complaining of a right lower abdominal tumor, and an elastic hard tumor with good mobility was palpable. The intestinal barium examination revealed compression of the jejunum, but no evidence of polyposis in the colon. CT and MRI revealed a solid, homogeneous tumor. We therefore performed laparotomy with a preoperative diagnosis of intra-abdominal tumor. A 17×12×9cm tumor was found in the mesentery of the jejunum. It had a smooth surface, and was globular, grey-whitish, and solid. We resected it with approximately 0.5-1.0cm of normal mesentery. Pathological examination revealed it to be a desmoid tumor. Desmoid tumors generally have a high recurrence rate because of their infiltrating growth pattern, but our patient has survived in good health with no recurrence for 2 years 3 months after surgery.

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A 67-year-old male underwent sigmoidectomy for sigmoid colon cancer. Macroscopic examination of the resected specimen showed type 2, advanced colon cancer, 22×16mm in diameter, SE, P₀, H₀, M (-). Histological examination disclosed poorly differentiated adenocarcinoma, se, ly₂, v₁, n₄ (+), Stage IV, Cur B. Sixteen months later, computed tomography disclosed an abnormal low density mass, 5cm in diameter, in the right adrenal gland, suggestive of adrenal metastasis. Since no other metastases in the lung, liver or bone could be identified, right adrenalectomy was performed. Resected specimen showed hard tumor, 65×45×30mm in diameter, with a yellowish-white and solid cut surface. Histological findings were the same as that of the sigmoid colon cancer. Thirteen months after adrenalectomy, the recurrances of paraaortic lymph nodes and bone metastases of the thoracic vertebras were revealed by abdominal computed tomography and bone scintigraphy. Although 7 months later descending colon cancer was detected and resected, he was died with postoperative pneumonia. Patients with adrenal metastasis from colon and rectal cancer often have multiple organ metastases. However, if the adrenal metastasis is solitary or the other metastatic lesions are well-controlled, the adrenal metastasis should be excised completely.

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A 53-year-old woman was treated conservatively under a diagnosis of ileus. However, abdominal pain, anemia and leukocytosis took a sudden turn for the worse until admission to our hospital. The abdominal distension, tenderness and rebound soreness over the entire abdomen were becoming worse. Plain X-ray and CT of the abdomen revealed a small-intestinal gas image and an air-fluid level. Under a diagnosis of strangulated ileus, an emergency operation was performed. Laparotomy revealed an oval defect 2.5 cm in diameter in the sigmoidmesocolon. About 150 cm of the small intestine was strangulated by the defect. The strangulated intestine was resected and the oval defect was closed. The post-operative course was uneventful and on the 14th post-operative day the patient was discharged. Transmesosigmoid hernia is very rare. The Japanese literature was reviewed.

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A 70-year-old female who complained of anal pain and rectal bleeding was told that she had an anal tumor by a local Physician and was referred to our hospital. Endoscopy revealed a tumor located above the dentate line on the right upper side. Abdominoperineal resection and wedge resection of the posterior wall of the vagina were performed. The tumor was expophytic, growing between the internal and external sphincter muscle, and histologically diagnosed as mucinous carcinoma originating from anal gland. The carcinoma was 27×15×18 mm in size, and a₁n₀H₀P₀M (-) stage II. Inguinal lymph node dissection was performed 5 months later because of metastasis to the right inguinal lymph nodes. Mucinous carcinoma of an anal gland is rare, and distant metastasis including inguinal lymph node metastasis and local recurrence is likely to occur. The initial symptoms of this lesion are so similar to those of perianal benign disease, such as hemorrhoids, that accurate diagnosis in the early stage is very important.

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A 62-year-old Japanese man was referred to our hospital because of a giant bulge in the right inguinal region and pollakiuria. By computed tomography a bladder hernia was found. At surgery, a tumor, 10×10cm in size, was found in the right inguinal region and this was suspected to be a bladder. When watee was poured into the bladder, the tumor was expanded. Therefore this tumor was diagnosed as a bladder and inguinal herniorrhaphy was performed safely without resection of the bladder. At treatment of an inguinal hernia, bladder hernia must be considered. Taking a history about a patient's urinary habit before an operation is important. And during the operation, pouring water into the bladder is useful for diagnosis of bladder hernia.

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Diagnosis of the peritoneal recurrence at an early stage is difficult in gastric cancer. Here we report a case of peritoneal recurrence detected early by diagnostic laparoscopy. In September, 1992, curative resection was performed for gastric cancer. Epigastralgia was appeared in February, 1998, 65 months after surgery. Abdominal ultrasonography and computed tomography indicated no abnormal findings except gall stones. The serum concentration of carcinoembryonic antigen was 4.5ng/ml being slightly elevated. Diagnostic laparoscopy revealed three nodules with the diameter of approximately 2mm in the Douglas pouch. Macroscopically, an irregular surface and margin and neovascularization were found in two of these nodules, indicating peritoneal dissemination. These nodules were endoscopically resected. Pathological examination of the nodules confirmed the peritoneal dissemination of gastric cancer. Diagnostic laparoscopy has a great advantage in the diagnosis of the peritoneal recurrence at an early stage, because it is easy and allows detailed inspection with minimal invasion.

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We evaluated the usefulness of endoscopic nasobiliary drainage (ENBD) for bile leakage after biliary surgery. Twenty-five (1.8%) of 1, 389 patients undergoing surgery for gall stone disease developed postoperative bile leakage between 1975 and 1995, and the four most recent patients were managed by ENBD. Regarding treatment methods, further surgery and ENBD were performed on six and four patients, respectively. The other 15 cases were managed conservatively. Regarding the hospitalization period after development of bile leakage, that of patients receiving ENBD was shorter than that required by patients treated by other methods. All four patients receiving ENBD had bile leakage from the cystic duct. In one patient, bile leakage was recognized soon after surgery, and in the other three, bile leakage developed on the 7th or 8th postoperative day. Bile leakage disappeared soon after ENBD was initiated, and inflammatory findings also disappeared promptly in all four cases. The leakage of contrast medium on cholangiography disappeared 6-13 days after ENBD was performed. These patients were discharged without further surgey following removal of the ENBD tube 6, 8, 13 and 13 days (average 10 days) after its insertion. ENBD is useful as a safe, effective and noninvasive treatment for postoperative bile leakage.

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