The status of patients with recurrent gastric cancer is diverse, and prognostic factor after recurrence had not been clarified yet. To evaluate the benefit of recurrent tumor removal of gastric cancer, we analyzed data on 202 patients with relapsed gastric cancer. In our series, 18 (8.9%) of the 202 underwent extirpation of recurrent tumor. The purpose of re-operation was for cure (n=9), differential diagnosis (n=5), and improvement of quality of life (QOL)(n=4). Resected tumors were located in the ovarium (n=4), colorectum (n=3), liver (n=3), lymph node (n=2), loco-regional (n=2) and peritoneum, adrenal gland, brain, and lung (n=1 each). No surgery-related mortality occurred. Disease free intervals after curative gastrectomy were 111 to 2, 228 days with a mean of 934 days in the patients treated for cure, 1, 038 days for diagnosis, and 1, 001 days for the QOL. There was no difference in survival time among three groups. Performance status (PS) at recurrence was PS0 in 11 and PS1 in 7 patients. Six cases were presented with high serum CEA or CA19-9 levels. Locations of the recurrent tumor after re-extirpation were the recurrent sites (n=11) and multiple sites (n=6). One patient remains alive more than 5 years after hepatectomy without recurrence, while 17 died within 3 years, in which 4 after oophorectomy survived more than 2 years. Median survival after recurrence (MSTAR) or the patients treated for cure was 15.6 months, that for diagnosis was 14.4 months, and that for the QOL was 11.6 months. Significant differences in survival existed between the patients for cure and the QOL (p=0.0399), for diagnosis and the QOL (p=0.0351);whereas no difference between for cure and diagnosis (p=0.8467). In the postoperative follow-up of gastric cancer, approximately 1/10 may have a chance for reextirpation of the tumor, those patients may benefit by early detection and radical surgery in terms of survival.

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Background: To clarify the beneficial candidates of hepatectomy for colorectal liver metastasis based on the analysis of survival predictors. Patients and Methods: Clinical, pathological, and outcome parameters were determined for 92 patients undergoing liver resection for colorectal liver metastases. Prognostic variables are (1) factors of the primary lesion, including site, dominant histological type, tumor depth, lymph node involvement and tumor budding;(2) factors of the metastatic lesion, including time to diagnosis, number, distribution, and size; and (3) factors of treatment, including resection type and hepatic arterial chemotherapy. Results: Univariate analysis showed that 6 variables were statistically significant risk factors influencing survival, namely tumor budding, tumor depth, nodal state, time to diagnosis, number of metastases and prophylactic hepatic arterial infusion chemotherapy. Of these, marked tumor budding (moderate or severe degree), deeper tumor depth serosa or invasion to other organs and time to diagnosis (synchronous metastasis) proved to worsen survival independently by stepwise regression analysis using Cox's proportional hazards model. Based on the results of this multivariate analysis, we classified patients into 3 groups. Group A included 39 patients without 3 prognostic factors or with 1 unfavorable factor (tumor depth or time to diagnosis). Group B included 21 patients with budding or 2 unfavorable factors other than budding. Group C included 32 patients with budding and 1 other unfavorable factor or all unfavorable factors. Cumulative 5-year survival was 55.5% in group A, 17.5% in group B, and 0% in group C, Extrahepatic recurrence was higher in groups B and C than in group A. Recurrence of remnant liver occurred more often in group C than in groups A or B. Group C, especially those with unfavorable 3 prognostic factors, had no advantege in survival. Conclusion: Patients without the 3 variables or with 1 unfavorable variable other than budding had a highly favorable outcome, and surgical resection is undoubtedly indicated for such patients. Patients with 3 positive variables had very poor prognosis, and resection without additional effective adjuvant therapy is highly questionable.

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Lateral lymph node dissection (LLD) is widely accepted for treating advanced lower rectal cancer in Japan. To clarify the effectiveness of LLD, we retrospectively analyzed the relationship of clinicopathological features to lateral lymph node metastasis and postoperative prognosis with or without LLD in 76 patients with advanced lower rectal cancer. Significantly improved survival was associated with decreased local recurrence in tumors of pT3-4 (5-year 86.1% vs 58.5%, p<0.05), 3cm or more in maximum diameter (5-year 86.7% vs 64.9%, p<0.05), and well or moderately differentiated adenocarcinoma (5-year 88.1% vs 69.8%, p<0.05) with LLD. Frequency of lateral lymph node metastasis increased in patients with positive upward lymph node metastasis (5/16 cases vs 0/18 cases, p<0.05) while LLD did not affect their survival and prognosis of patients in Dukes C was poor. Thus, it is recommended to apply LLD to advanced lower rectal cancer patients with tumors of pT3-4, 3cm or more in maximum diameter, well or moderately differentiated adenocarcinoma, and positive upward lymph node metastasis. However, prognosis of patients in Dukes C, even received operation with LLD, is still poor.

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A 71-year-old man diagnosed with gastric cancer was admitted for surgery. Chest X-ray on admission showed a large tumor shadow in the left upper lung field. Enhanced computed tomography scan and histological examination of the biopsied specimen showed squamous cell lung carcinoma. Upper gastrointestinal radiography showed an elevated lesion with shallow central ulceration on the anterior wall in the upper stomach, and gastrofiberscopy showed a submucosal tumor with central ulceration. Histologically, it was difficult to diagnose as metastatic gastric cancer. The man developed bleeding from the stomach tumor and underwent total gastrectomy. Histologically, the resected specimen showed metastatic gastric cancer. Clinically, apparent metastasis from primary lung cancer to the stomach is rare. We reviewed 80 cases of metastasis from primary lung cancer to the stomach in the Japanese literature.

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In a case of gastric cancer associated with gastric tuberculosis, a 74-year-old woman was admitted to our hospital for dysphagia. Gastrointestinal fiberscopy revealed gastric cancer in the cardiac region with stenosis of the lower esophagus. Plain chest X-ray and chest computed tomography (CT) showed a linear high-density area in the lower left lung field. Esophageal stenting and chemotherapy were conducted preceding surgery. Lower esophagectomy and total gastrectomy with distal pancreatectomy and splenectomy were then done. Histological examination revealed tubercular lesions such as Langhans' giant cells and epithelioid granuloma in a gastric cancer lesion and regional lymph nodes. Although tubercle bacillus was not detected, the lesion was diagnosed as gastric tuberculosis basad on histopathogical findings. Pulmonary tuberculosis was inactive, so chemotherapy was not undertaken for tuberculosis. The patient is doing well without evidence of gastric cancer recurrence or of tubercular recrudescence in the 18 months since surgery. Coexistence of gastric cancer associated with gastric tuberculosis is rare, and this is only the 18th case reported in Japan to our knowledge.

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A 61-year-old man underwent distal gastrectomy and partial hepatectomy September 30, 1998, for alphafetoprotein (AFP)-producing gastric cancer with liver metastasis (S4c+S8). Preoperative serum AFP was abnormally elevated at 5715 ng/ml. A catheter was placed in the common hepatic artery following the operation for continuous arterial chemotherapy to prevent residual liver recurrence. Epirubicin hydrochloride (20 mg on POD 20) and Fluorouracil (250mg/day, total of 40, 500mg) were infused. Nine months after the operation, an arborecent necrotic lesion resembling aseptic biloma due to tumor thrombi appeared in the right lobe, for which right hepatectomy was done July 8, 1999. Histlogical study showed liver necrosis caused by bile duct necrosis and bile leakage around Glisson's capsule. In this case, the inflammation due to bile leakage around Glisson's capsule because of continuous arterial infusion with 5-FU causes an arborecent liver necrosis and an occlusion of portal vein. He survived 2 year and 7 months without recurrence after the second operation.

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Case 1: A 55-year-old man seen at the hospital because he had noticed right hypochondralgia had a history of diabetes and hypertension. Computed tomography (CT) showed extensive gas in the lumen of the gallbladder and intrahepatic bile duct. Cholecystectomy conducted on day 1 after adomission revealed 17 bilirubin stones 1 to 3 mm in diameter in the gallbladder. Pathological examination of the gallbladder revealed gangrenous cholecystitis. With cultivation of bile juice collected during operation, a Clostridium was detected. Case 2: A 47-year-old man seen at the hospital due to right abdominal pain had a history of bronchial asthma. CT showed extensive gas in the lumen and wall of the gallbladder and intrahepatic bile duct. Cholecystectomy conducted on day 2 after admission revealed many stones 1 to 5 mm in diameter in the gallbladder. Pathological examination of the gallbladder revealed gangrenous cholecystitis. With cultivation of bile juice collected during operation, a Klebsiella, Aeromonous, Enterococcus and Citrobacter was detected. Our cases are the 21st and 22nd with emphysematous cholecystitis with pnumobilia reported in the Japanese literature.

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We report a case of resected undifferentiated carcinoma of the gallbladder with anomalous arrangement of the pancreaticobiliary duct. A 42-year old man was diagnosed with a tumor projecting into the gallbladder by ultrasonography and computed tomography. Anomalous arrangement of the pancreaticobiliary duct without dilation of the biliary duct was observed by endoscopic retrograde cholangiopancreatography. Abdominal angiography showed a hypervascular tumor, necessitating cholecstectomy with resection S4a+S5 of the liver, resection of the extrahepatic common bile duct, lympadenectomy, and hepaticojejunostomy. The tumor was 3.5×2.5 cm and presented macroscopically as a nodular. Histology showed atypical tumor cells and a diagnosisof undifferentiated gallbladder carcinoma. The clinical stage was si, hinf1a, binf0, pv0, a0, bm0, hm0, stageIVa. Immunohistologically, EMA, cytokeratin, CA19-9, and CEA stains were positive but vimentin and AFP stains were negative.

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A 53-years-old woman suffering intermittent abdominal pain for several years was admitted with bowel obstruction. Examinations showed a small intestinal tumor. Surgery showed a submucosal tumor 90 cm proximal from the terminal ileum. Bowel obstruction was caused by mural thickening due to tumor invasion. We also found enlarged lymph nodes in the mesentery near the tumor. Two submucosal lesions were also found. Histologically, all 3 tumors were carcinoid, and argentaffin-positive. Immunohistochemically, tumor cells were serotonin-positive. Lymph nodes metastasis was also seen. Small-bowel carcinoid tumor usually metastasizes, developing multicentric tumors. According to the literature, 5-year survival in patients with this malignancy in 55-58%. Our patient remains disease free for 4.5 years after resection. These tumors are reported to keep recur even after 5 years, however, and longer-term postoperative follow-up is necessary for patients with small-bowel carcinoid tumor.

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A 61-year-old woman came to our hospital because of massive ascites upon recommendation from a local clinic. Aspiration cytology showed agglomeration of atypical cells but no primary tumor. Probe laparotomy revealed a tumor resembling serous papillary adenocarcinoma of the ovary in pathological findings, but normal bilateral ovary. Reduction surgery included omentectomy and left oophorectomy. Cisplatin was administered intraperitoneally at surgery and adjuvant chemoterapy was conducted for ovarian cancer postoperatively. Ascites disappeared and serous CA125 levels dropped to normal range. No residual peritoneal tumor was seen in a second-look operation, but atypical cells were still detected in the peritoneal lavage. We added three court chemotherapy there after followed by regular outpatient treatment. No evidence has been found of tumor recurrence for the present.

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We report end-to-end anastomosis of the pancreas after segmental resection of the pancreas body due to intraductal papillary tumor. A 67-year-old symptom-free man with no complaint was referred to our hospital because of a cystic lesion 3.5 cm in diameter found in abdominal ultrasonography at mass screening. Endoscopic retrograde pancreatography and cytology of the pancreatic juice led to a diagnosis of intraductal mucin-producing papillary adenoma. The patient underwent segmental resection of the pancreas body and reconstruction by end-to-end anastomosis of the pancreas, and was discharged without complications. Endoscopic retrograde pancreatography 16 months postoperatively showed the main pancreatic duct clearly to the tail without dilation or reccurence. The patient has been alive for three years without problems. It may be difficult to survey the pancreas tail of the patient after pancreatojejunostomy. All trials of pancreatography through pancreatogastrostomy failed in our cases. End-to-end anastomosis after segmental pancreas resection is more effective requiring shorter operation time and making it easy to survey the residual pancreas tail.

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