Twelve patients with gastrointestinal stromal tumors (GIST), in a broad sense, were analyzed to elucidate the clinical significance and problems of immunohistochemical study. Malignant potentials were classified into three degrees by tumor size and mitotic rate. Three patients with the normal cellular type, grade I, showed the same staining as the proper muscle. The other 9 patients had increased staining of vimentin and CD34 in comparison with the proper muscle. Two patients with the uncommitted type, grade I, were judged to have immature tumors considering the low malignant potential. Two patients with the combined type and one with the smooth muscle type with α-SMA 3 (+) and desmin 3 (+), grade II or III, were judged to have mature tumors. However, malignant potential could not be judged from immunohistochemical findings alone. The above results indicate that clinical evaluation of immunohistochemical findings of GIST can initially be clarified by making an assessment with definite grading of malignant potential.

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To define the prognostic factors after surgical resection and evaluate the effectiveness of Post Operative Radiotherapy (PORT) in cases with cholangiocarcinoma, 44 cases with proximal cholangiocarcinoma were examined. The mean observation period was 20.6 months, and the survival rates 1, 3 and 5 years after the resection were 79.9%, 59.8% and 39.3%, respectively. Univariate analysis revealed that the presence of lymph node metastasis and absence of PORT were significant poor prognostic factors. Multivariate analysis revealed that the absence of PORT was a significant poor prognostic factor. The survival rates for 1 and 3 years after the resection were 80.0% and 40.0% in the curable A/B and PORT (-) group, and 100% and 53.3% in curable C and PORT (+) group. There were no local reccurences in the pathologically classified hm2 and em2 patients who underwent PORT. Even when the surgical margin is positive for the carcinoma pathologically, it is possible to avoid local recurrence with PORT.

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In 92 colon cancer patients, point mutation of the p53 gene and expression of the p21 gene were determined to discuss about appearance of apoptosis. Point mutation of the p53 gene was determined by PCR-SSCP. p21 expression was determined positive upon immunostaining when more than 20% of the nucleus in cancer cells were stained. Apoptosis was detected by DNA ladder sequencing. No correlation was noted between the presence of p53 gene mutation, expression of p21 gene and pathological factors, nor was correlation noted between p53 gene mutation and p21 gene staining rate, by apperance of DNA ladder. However a certain trend was observed in those cells with p21 positive staining showing the least appearance of DNA ladder (p<0.0115). Among those without p53 gene mutation, DNA ladder did not appear when those p21 staining was positive, and it was noted much when p21 staining was negative (p<0.0015). From the above findings, it is known that in the presence of the p21 gene DNA in repaired and induces no apoptosis, and that when the p53 gene functions normally, such a trend is further accelerated by the p21 gene.

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To clarify the cause of rectocele, the anorectal functions in patients with rectocele were inventigated. Anorectal manometric studies were performed in 38 patients with symptomatic rectocele (A group; all women, aged 22-79 years with a mean age of 52.8 years), 16 patients with asymptomatic rectocele (B group; all women, aged 37-74 years with a mean age of 50.6 years), and control subjects (C group; all women, aged 16-69 years with a mean age of 48.6 years). There were no differences in the results between the A and B groups. Anorectal manometric studies revealed a higher incidence of anal sphincter dysfunction (lower resting and voluntary contraction pressure), rectal capacity dysfunction (decrease of compliance). and rectal sensory dysfunction (increase of sensory threshold volume and minimum tolerated volume) in group A and B patients as compared with group C patients. These results, namely, the decrease of rectal compliance and high rectal pressure, could cause symptomatic and asymptomatic rectocele.

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A 55-year-old man came to our hospital because of a mass in the left upper quadrant of the abdomen. Gastroscopy showed a huge submucosal tumor with two ulcers in the posterior wall of the middle of the stomach. A preoperative diagnosis of type 5'gastric cancer in the middle of the gastric body was made, and total gastrectomy with combined resection of the gallbladder, spleen, and transverse colon was performed. Histopathological examination showed small cells with round or short spindle-shaped nuclei, aligned in a cord arrangement to form a pseudo-rosette. NSE staining, Grimelius staining and chromogranin A staining were positive. The tumor was diagnosed as gastric endocrine cell carcinoma. Gastric endocrine cell carcinoma is very rare and reported to account for 0.06% to 0.08% of gastric carcinomas.

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We encountered two patients with gastric cancer who suffered from postoperative CMV pneumonia. Case 1: A 63-year-old man, who received intra-abdominal CDDP administration before gastrectomy. On the 10th postoperative day, interstitial pneumonia was diagnosed. He was suspected as having CMV pneumonia and antiviral drugs were administered. He needed ECMO due to severe pulmonary insufficiency. A definitive diagnosis was established 10 days after the commencement of drug administration. He eventually recovered from the pneumonia. Case 2: A 66-year-old man with early gastric cancer underwent distal gastrectomy. He had received postoperative radiation therapy for the treatment of lung cancer. Postoperatively, interstitial pneumonia was diagnosed. He was also suspected as having CMV pneumonia and antiviral drugs were administrated empirically. The postoperative lymphocyte counts in both patients showed immunosuppression associated with radiation or chemotherapy may predispose to postoperative viral pneumonia. CMV pneumonia is a critical condition and early administration of antiviral agents is necessary even before a definite diagnosis can be made. Postoperative CMV pneumonia in patients with gastric cancer is rare. We should however be aware of the risk of its development and promptly administer antiviral drugs should it occur.

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A 64-year-old male was admitted to our hospital complaning of epigastralgia. An endoscopic biopsy revealed a malignant duodenal lymphoma. Two courses of combbined chemotherapy (CHOP regimen) were performed, but the chemotherapy was discontinued because of duodenal stenosis. A pancreaticoduodenectomy was thus performed. Histological examination of the duodenal lesion did not reveal the presence of any lymphomas. A complete remission was attained after the chemotherapy. The lesion was classified as a stage I lymphoma according to the staging system of Naqvi et al. Surgical treatment has been the standard procedure for the treatment of early stage gastrointestinal lymphomas. Combined chemotherapy is usually used only in cases of advanced stage lymphomas. However, the use of chemotherapy for treating eary stage lymphomas is now being investigated. This case suggests that chemotherapy may be useful for stage-I duodenal malignant lymphomas.

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We report a case with multiple T-cell malignant lymphomas of the duodenum and small intestine, which caused perforated panperitonitis. A 75-year-old man was hospitalized because of an upper abdominal pain. An endoscopy showed a duodenal ulcer, and immunohistochemical staining of the biopsy specimens revealed the presence of T-cell malignant lymphoma. Since the patient refused to undergo an operation, CHOP combination chemotherapy was performed. After 4 months of chemotherapy, the patient was admitted for severe epigastralgia. An abdominal CT examination showed the presence of free air, so an emergency operation was performed. Multiple tumorous lesions in the jejunum were observed, one of which had been perforated, T-cell malignant lymphoma is very rare, and its prognosis is much poorer than that of B-cell lymphomas.

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In August 1997, abdominal ultrasonography during a physical examination of a 55-year-old female revealed a unilocular cyst measuring 8 cm in the medial segment. Abdominal computed tomography (CT) showed a low absorption unilocular cyst with a smooth inner wall and flat lumen. On October 27, 1998, the patient consulted our department for back pain. Abdominal ultrasonography revealed a small cyst measuring 2.5 cm within the cyst. Abdominal CT showed papillary swelling on the cystic wall, which protruded into the lumen. CT arteriography showed irregular swelling involving the cystic wall and cystic lumen as well as the small cyst. A preoperative diagnosis of hepatic cystoadenocarcinoma was made, and partial resection of the medial hepatic segment was performed. The resected specimen revealed microcysts in addition to the small cyst in the cystic wall. Histopathological examination showed that the entire cystic wall and the wall of the small cyst consisted of cancer tissue, and that the inner wall of the microcysts consisted of adenoma. Hepatic cystic adenoma may have caused the hepatic cystadenocarcinoma in this patient. In addition, the morphological chagnes in the cyst observed during follow-up were considered to be related to cancer cell proliferation.

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A 67-year-old man came to our hospital complaining of anal pain and bleeding on defecation. An anorectal tumor was detected, and transanal excision was performed. The histological findings indicated that further operation was needed, and abdominoperinineal resection of the rectum was performed. Histologically, the tumor was poorly differentiated adenocarcinoma associated with pagetoid spread and had infiltrated into the submucosal layer. The CEA values continuously increased beginning 1 year after the operation, and 6 months later, bilateral swelling of the inguinal lymph nodes and a tumor shadow in S7 of the liver were detected by CT. Partial resection of the liver and dissection of the inguinal lymph nodes were performed.
Histological analysis revealed that the tumors had metastasized from the anorectal carcinoma. No signs of recurrence have been detected during the 1 year and 6 months since the second operation.

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A 64-year-old woman admitted due to severe asthma was found to have vasculitis at muscle biopsy and eosinophilia and was diagnosed with Churg-Strauss syndrome (CSS). Despite steroid therapy, perforations of small intestine occurred 2 times a week, requiring emergency surgery. Worsening vasculitis led to gangrenous cholecystitis and gastrointestinal necrosis and bleeding, and the patient died despite emergency surgery. A 67-year-old man who had a history of asthma admitted due to lower limb listness was found in nerve biopsy to have eosinophilia and vasculitis and diagnosed with CSS. Ileac perforation following steroid pulse therapy necessitated emergency surgery. Pathological findings indicated angitis in both cases despite preoperative steroid therapy. CSS prognosis is generally not so poor, indicating the need to watch for possible reperforation in patients with complications of gastrointestinal perforation since steroid therapy does not improve angitis.

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