Sentinel node navigation surgery (SNNS) is based on the sentinel node (SN) concept. The lymphatic channel is complicated in gastric cancer, so we must be prudent in attempting SNNS. We studied the propriety of intraoperative subserosal dye injection for detecting SNs and ideal SNNS avoiding radical operation. Subjects and Methods: 1) We conducted intraoperative subserosal dye injection in 78 patients with gastric cancer (pathological depth M-SE). The blue node (BN) was confirmed in each case, providing 100.0% detection rate, 98.7% accuracy and 93.3% sensitivity. 2) Of these cases, 53 cases had pathological depth of M-SM and no lymph node metastasis histologically, we conducted immunostaining for all 1, 329 dissected lymph nodes. We detected micrometastasis in 10 of the 53. All micrometastasis was in the dye-stained lymphatic channel. We then studied micrometastasis in 5 cases of pathological depth of SM (162 dissected nodes) with nodal metastasis-positive cases. Two cases had extra-channel nodal micrometastasis in this advanced cancer group.
Conclusion: From our result of BN detection by intraoperative subserosal dye injection, SN was included in BN. And from the results of micrometastasis detection, in early gastric cancer, although no metastasis is seen in HE staining, lymph nodes should be dissected along with the lymphatic channel stained by intraoperative subserosal dye injection.

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Background: We evaluated the prognostic nutritional index (PNI), reported by Onodera, in patients un- dergoing gastrointestinal surgery for the gastric and colon cancer, and compared criteria for risk evaluation between younger and older patients. Methods: Subjects were 65 patients, 38 with gastric cancer, 18 with co-lon cancer, and 9 with rectal cancer, rated as Stage I or II. We evaluated the relationship between patient age and preoperative PNI, dividing by postoperative course into those with and without complications. We com- pared PNI was compared between groups. Patients were further assigned by age into an older group (≥75) or younger group. PNI was also compared between these groups. Results: The correlation between patient PNI and age was negative. The PNI in patients without complications was 42.9±5.7, while that in those with complications was 37.8±4.3, statistically significant (P=0.003). PNI in older patients was 39.8±5.0, while that in younger patients was 44.5±5.7, again statistically significant (P=0.001). In older and younger patients with complications, PNI was significantly lower in the older group at 35.5±4.8, versus 40.0±3.0 in the younger group (P=0.045). In the relationship between PNI and age relative to the postoperative course, a demarcation (PNI=46.2-0.071×Age) was observed between patients without and with complications. Conclusion: PNI decreased concomitantly with aging. In originally reported risk assessment criteria, most older patients were evaluated as risky or contraindicated for surgery. The demarcation line decreased concomitantly with age, in- dicating that preoperative risk assessment of older patients should take into account the decrease in PNI with aging.

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A 67-year-old woman was brought to the hospital by ambulance because of recurrent vomiting and emaciation.Parenteral nutrition immediately was instituted to treat dehydration and hyponutrition. A plain posteroanteriorfilm and CT scan of the chest revealed bowel gas in the posterior mediastinum. Subsequentcolonoscopy demonstrated the bowel in the posterior mediastinum to be the transverse colon. When she consumeda meal, symptoms of intestinal obstruction occurred and led to a diagnosis of diaphragmatic herniawith incarcerated transverse colon. An approximately 30 cm segment of the transverse colon had herniatedsuperiorly into a sac that passed through an abnormally wide esophageal hiatus. The gastroesophageal junctionremained fixed below the diaphragm, and the stomach remained in its proper position. The portion of thetransverse colon in the sac was easily reduced into the abdominal cavity, leaving a 5 cm hiatal orifice that extendedto the right. Since the edge of the orifice was hard and unyielding, approximation of the defect with sutureswas abandoned. Instead, omentopexy was performed to fill the hiatal sac with a portion of the greateromentum and to fix it with sutures to the edge of the orifice. Recovery was uneventful except for postoperativepneumonia. A thin barium meal demonstrated the stomach and transverse colon in their proper position.The patient was discharged on the 34th postoperative day. This is the first report of omentopexy as a meansof repairing esophageal hiatal hernia.

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Esophageal carcinoma of the diverticulum is very rare, and we report only the 35th case of intraesophagodiverticular carcinoma in the Japanease literature. A 75-year-old man with chest pain was found to have esophageal carcinoma of the diverticulum and hospitalized. Upper gastrointestinal series showed protruding lesions in the diverticulum 2.5×2.0cm in the right wall of the middle thoracic esophagus. Esophagoscopy also showed irregular protruding lesions not dyed by lugol solution in the diverticulum 33 cm from the incisor. Thoracic CT and MRI showed dilation of the esophageal wall in the middle thoracic esophagus but no swelling of the lymph nodes. Blunt digital finger dissection of the esophagus with mediastinoscopy was done due to the patient's age, pulmonary dysfunction, a history of 3 cerebral infarctions and dysphasia. The pathological diagnosis was moderately differentiated squamous cell carcinoma, sm in invasion depth. About the therapy of the intraesophagodiverticular carcinoma we have to think of the difficulty to diagnose of the invasion depth and the easiness to invade due to the thin wall.

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We report a case of advanced squamous cell carcinoma of the esophagus with extremely high serum CEA reflecting the period of recurrence and therapeutic effect. A 70-year-old man examined by upper gastro-intestinal endoscopy due to dysphagia was found in endoscopic examination to have a tumor at the upper thoracic esophagus. Histological biopsy findings indicated squamous cell carcinoma. On admission, laboratory data showed serum CEA elevated to 19 ng/ml. Neoadjuvant chemoradiotherapy and right transthoracic esophagectomy with extended lymph node dissection were done. Serum CEA decreased to normal, 2.0ng/ml, after surgery. After the first admission, he was admitted 4 more times for recurrence in lymph nodes and its invasion to an anastomosis. On each admission, serum CEA was extremely high. After chemoradiotherapy or chemotherapy, serum CEA decreased along with recurrent tumor size. He died of the disease 24 months after surgery.

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A 64-year-old Japanese man diagnosed with midesophageal cancer and a concomitant right aortic arch had an aberrant left subclavian artery originating from a diverticulum at the descending aorta. Ductus arteriosus (DA) between the diverticulum and left pulmonary artery oppressed the esophagus, an anomaly known as vascular ring. Left thoracotomy was applied in esophageal resection, starting with division of DA. In our experience, DA encirclement is dangerous because the aortic diverticulum wall is thin, whereas blood flow is detected at the pulmonary DA. It should be stressed that following the left recurrent laryngeal nerve ensures safe indication and division of DA.

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We report 2 cases of transient peroneal nerve palsy and brachial plexus palsy after surgical resection for gastric cancer. Case 1: A 50-year-old man undergoing pancreatoduodenectomy for advanced gastric cancer of the spine reported numbness and weakness in both feet on the day after surgery. The administration of Vitamin B12 and physical rehabilitation were successful and he was discharged a month after surgery without any neurological deficits. Case 2: A 46-year-old man undergoing distal gastrectomy for gastric cancer of the spine with both arms abducted at 90° reported weakness in both arms on the day after surgery. The admini-stration of steroids and vitamin B12, nerve block of the stellate ganglion, and physical rehabilitation were conducted and, 3 months after the surgery, he returned to work free of any deficits. The peroneal nerve palsy and brachial plexus palsy after abdominal surgery are very rare and few reports have been published. Intra operative overstretching and suppression of the nerves is assumed to be the main cause of palsy, suggesting the need to pay greater attention to the surgical position of patients during surgery.

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We report a rare case of early gastric cancer with duodenal extension. A 56-year-old woman found to have epigastric discomfort in February, 1998, was further found in gastrointestinal endoscopic examination to have a wide, continuous, granulous polypoid lesion from the prepyloric area to the duodenal bulbus. Then, she admitted our hospital. Reexamination via gastrointestinal endoscopy and biopsy upon admission showed adenocarcinoma in biopsy specimens. We then conducted gastrectomy with partial duodenectomy. Macroscopically, the resected specimen showed a I+IIa+IIc lesion which is 4cm long in the stomach and a I+IIa lesion 3.8cm long in the duodenal bulbus. The lesion consisted of well-differentiated adenocarcinoma partially mixed with moderately differentiated adenocarcinoma. Duodenal extension was almostly to the mucosa. Lymph node metastasis was not found. It is thought to be important to decide the safty resected line and sufficient area of the lymph nodes dissection.

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We report a case of adenocarcinoma of aberrant pancreas in the stomach. A 58-year-old woman consulted our hospital for repetitive vomiting after meals. Endoscopic examination revealed pyloric stenosis, but there was no evidence of malignancy. Endoscopic ultrasonography of the pylorus showed preservation of its layered structure and no evidence of a tumor. When balloon dilatation of the pyloric ring on two occasions failed to improve the symptoms, laparotomy was performed. Since preoperative pathological examination of the mucosa in the pylorus revealed no evidence of malignancy, pylorectomy was performed. Histopathological examination revealed adenocarcinoma cells adjacent to aberrant pancreas with acinar cells and pancreatic ducts present between the muscular layer of the mucosa and the subserosa, and a diagnosis of adenocarcinoma of aberrant pancreas in the stomach was made. Distal gastrectomy was performed later, and histopathological examination of the surgical specimen revealed No.5 lymph node metasasis. The final pathological findings were pT2, pN1, sH0, sP0, cM0, fStage II.

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We report a case of preoperatively diagnosed right paraduodenal hernia. A 71-year-old man with malignant lymphoma undergoing chemotherapy reported sudden right mid-abdominal pain. Small bowel series showed a jejunal loop with stenosis of inlet and outlet in the right mid-abdomen. CT scan of the upper abdomen showed an encapsulated and dilated small bowel loop in the right mid-abdomen, diagnosed as right paraduodenal hernia. In surgery, the hernial orifice was located in the intermesocolic fossa of Broesike. The incarcerated small intestine was repositioned and defect of transverse mesocolon was closed by suture. The superior mesenteric artery and vein were not located in the anterior wall of the hernial sac. This finding differed from the common type of right paraduodenal hernia in the mesentericoparietal fossa of Waldeyer.

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We report a rare case of signet-ring cell carcinoma of the ampulla of Vater. A 59-year-old man admitted for further examination of liver function disorder in a blood chemistry test done due to a fever and appetite loss was found in abdominal ultrasonography (US) and computed tomography (CT) to have a dilated intrahepatic bile duct, common bile duct, and main pancreatic duct. At duodenoscopy, the papilla of Vater was reddish and enlarged with a small ulcer, and biopsy specimens from the papilla demonstrated signet-ring cell carcinoma. We conducted pylorus-preserving pancreatoduodenectomy based on a diagnosis of signet-ring cell carcinoma of the ampulla of Vater. The tumor was 2×3cm, ulcerated, and protruding. Histopathological findings showed signet-ring cell carcinoma occupied the ampulla of Vater and lymph node metastasis was found within group 1 nodes. The patient is doing well and has no recurrence 1 year and 8 months after surgery. Signet-ring cell carcinoma of the ampulla of Vater is rare, with our case being only the 16th reported in the literature.

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We report a case in which a patient with hepatic portal venous gas accompanying pneumatosis cystoides intestinalis survived with conservative treatment. A 75-year-old woman reporting abdominal pain and vomiting and admitted was found in biochemical examination of the blood to have no increase in hepatic or biliary enzymes but an increase in WBC count and serum CRP. Computed tomography showed hepatic portal gas in the left and caudate lobes of the liver and pneumatosis cystoides intestinalis in the wall of the ascending colon. A nasogastric tube was placed to collect gastric content, with NPO under IVH control. During preparation for emergency surgery, the patient's abdominal pain decreased rapidly, her abdomen became flat and soft, and neither tenderness nor muscular defense was noted. Seven days later, computed tomography showed that both hepatic portal gas and the pneumatosis cystoides intestinalis had disappeared. The prognosis of disease complicated by portal venous gas is usually poor, and an emergency surgery is often necessary. Several cases of hepatic portal venous gas treated successfully with conservative therapy have been reported recently. We review the literature concerning such therapy and discuss factors important to conservative therapy for he- patic portal gas.

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A 58-year-old man admitted for jaundice was found in computed tomography (CT) to have a circumfer-entially enhanced tumor in the medial segment of the liver (S4) and a homogeneously enhanced tumor in the dilated left hepatic duct to the common hepatic duct. Cholangiography using an endoscopic nasal biliary drainage (ENBD) tube showed a smooth, soft filling defect in the common hepatic duct, yielding a diagnosis of cholangiocellular carcinoma, necessitating left hepatectomy with extra-hepatic bile duct resection and removal of the bile duct tumor. Postoperative histopathological examination showed the tumor to be moderately differen- tiated hepatocellular carcinoma invading the biliary tract. PIVKA-II has been pointed out in the literature as a valuable marker of this disease. To improved the disease prognosis, early differential diagnosis of obstructive jaundice with bearing this disease in mind and radical hepatectomy with extra-hepatic bile duct resection are considered to important.

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A 67-year-old woman admitted for a liver tumor detected incidentally by computed tomography (CT) was found in further CT to have a 4×2.5cm mass at segment 7 of the liver, whose margin was enhanced in the early phase. Magnetic resonance imaging showed a low-intensity mass in T1-weighted imaging and a partially high-intensity mass in T2-weighted imaging. Angiography showed pale tumor staining with hypervascularity in the margin of the tumor. We suspected atypical cholangial cell carcinoma, and conducted right hepatic lobectomy. The tumor was white, clear, and elastically soft, with spiculation. Histopathologically, it showed invasion to the glison sheath with marked hyalinized stroma. The final diagnosis was epithelioid hemangioendothelioma of the liver. We review 63 cases of epithelioid hemangioendothelioma of the liver reported in the Japanese literature. Of these, only 13 were resectable. Preoperative diagnosis of this tumor is generally difficult.

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A primary hepatic carcinoid tumor originating in the liver is rare. We report a resected case of primary hepatic carcinoid tumor difficult to diagnose preoperatively. A 53-year-old woman seen for anemia and a stool test positive for occult blood from April 1999 underwent gastrointestinal and colon fiberscopy, but we could not detect the origin of anemia. Abdominal computed tomography (CT) showed a cystic lesion about 25 mm in diameter in the right hepatic lobe. She was admitted for surgery in January 2003 because the tumor began to grow during follow-up. We conducted right anterior subsegmentectomy (S5) with lymph node cleaning and cholecystectomy because ultrasonography, computed tomography, and angiography suggested cystic adenocarcinoma or atypical hepatocellular carcinoma. The resected specimen was a cystic tumor demarcated by the milk-white fibrous membrene with a hemorrhaging lesion. It had a clear margin from the surrounding parenchyma of the liver. Immunohistologically the tumors were positive for synaptophysin staining and negative for other antigens, leading to a diagnosis of carcinoid in microscopic findings of HE staining. She discharged uneventful 12th postoperative day and was followed carefuly during 10 months after surgery.

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Biliary papillomatosis is a very rare, usually benign biliary tumor. We report a case of biliary papillomatosis with carcinomatous change in the lesion. An asymptomatic 71-year-old woman found to have liver disfunction in a medical examination was admitted and operated on based on a diagnosis of cholangiocarcinoma of the left hepatic lobe by abdominal CT and ERCP. Interoperative cholangioscopy showed that the papillary tumor had occluded the left hepatic duct. It also showed multiple small lesions in the bifurcation of the anterior and posterior hepatic duct and the lower common bile duct. We conducted left hepatic lobectomy and resected the extrahepatic bile duct. Histopathologically the resected specimen showed papillary proliferation ofthe bile duct epithelium in all multiple lesions from the intra-to the extra-hepatic bile duct. Carcinomatous change was recognized in part of the main left hepatic duct lesion, leading to a diagnosis of cholangiocarcinoma arising in biliary papillomatosis. Diagnosis and the selection of surgical procedures must take into account that carcinomatous change is reported in about 30% of all case reports.

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A 91-year-old man admitted for progressive upper right quadrant pain and vomiting, and tenderness without muscular defense of the right hypochondrium was found in laboratory test to have marked inflammation and slight jaundice. CT showed swelling and wall-thickening of the entire gallbladder, but it was not enhanced. Characteristic low-density phyma was confirmed in the cervix. Suspecting necrotizing cholecystitis caused by gallbladder torsion, we immediately undertook laparoscopic cholecystectomy (LC). The Grosstype-I floating gallbladder was twisted clockwise 360 degrees at the axis in the cystic duct (CD). Dilation ofthe common bile duct (CBD) and choledocholithiasis were observed in intraoperative cholangiography. As general condition of the patient got worse, we only inserted c-tube into the CBD. Histopathological findingsshowed acute bleeding infarction of the gallbladder followed by torsion in the CD. Severe inflammation was negligible in the gallbladder cervix, and LC is regarded as the most useful way to treat this condition.

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We report 2 cases of hilar bile duct carcinoma with superficial spread to the duodenal side of the common bile duct. The first patient, a 46-year-old man who underwent extended left hepatic lobectomy with caudate lobectomy for hilar bile duct carcinoma, during which the distal side of the common bile duct was divided at the intrapancreatic bile duct, was found histologically to have a frozen section with superficial spread of cancer cells to the resection margin, necessitating pancreatoduodenectomy. The second patient, a 66-year-old man referred for surgical treatment of hilar bile duct carcinoma, initially underwent extended right hepatic lobectomy with caudate lobectomy and division of the distal side of the common bile duct at the intrapancreatic bile duct. Postoperative histological examination showed superficial spread of carcinoma to the resection margin, necessitating pancreatoduodenectomy as a second-stage operation. Both surgical specimens contained a nodular-infiltrating tumor, and histopathological findings showed well-differentiated tubular adenocarcinoma. Hilar bile duct carcinoma with superficial spread to the proximal margin has been described in a number of reports, but few reports exist on the superficial spread of hilar bile duct carcinoma to the distal margin.

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We report a case of parathyroid hormone related protein (PTHrP) producing islet cell carcinoma of the pancreas. An asymptomatic 48-year-old man was referred for a liver tumor found in mass screening. CT and angiographic study showed a hypervascular tumor 4cm in diameter in the pancreas head and multiple liver tumors. A needle biopsy of the liver tumor yielded a diagnosis of islet cell tumor of the pancreas and multiple liver metastases, necessitating pancreatoduodenectomy and partial liver resection. The immunohistochemical strain of PTHrP was positive in carcinoma. Weekly high-dose 5FU administration (total: 36g of 5FU) via he-patic artery catheter was done. It was initially effective but followed by multiple bone metastases 13 months after surgery. The patient experienced hypercalcemia and acute renal failure, and serum PTHrP was high at 18.1pmol/L. Hypercalcemia relapsed despite treatment, and the patient died 15 months after surgery.

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We report a case with in situ carcinoma of the pancreas (CIS) and intraductal papillary-mucinous tumors (IPMTs). A 68-year-old man was found in abdominal CT on admission to have acute pancreatitis with dilation of the main pancreatic duct at the body and tail of the pancreas and local inflammation had no recognizable mass at the head or body even after inflammation was reduced. ERP showed stenosis of the main pancreatic duct at the body of the pancreas and slight dilation at the tail, but inadequate representation of branches. Cytology of the pancreatic juice was class IV, so we conducted pancreatectomy of the body and tail and splenectomy with D1 lymph node dissection. Pathological findings showed fibrous thickening of the main pancreatic duct at the stenotic portion and atrophy of the acinus around the duct. Although the epithelium of the main pancreatic duct at the stenotic portion was CIS, the epithelium at the tail of the stenotic portion showed intraductal papillary-mucinous adenoma with moderate dysplasia. Most epithelium of branches at the tail of the stenotic portion had IPMTs with dysplasia and part of the epithelimu was CIS. The patient has been followed up for 7 months without evidence of recurrence.

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We report surgical treatment of pancreatic head cancer with nonhemophilic coagulation factor-VIII (FVIII) inhibitor.
An 80-year-old woman admitted for a pancreatic head mass and obstructive jaundice was found. In blood coagulation tests on admission to have prolonged APTT (91.6s), decreased plasma F-VIII activity (4.8%), and elevated F-VIII inhibitor titer (8.6BU/ml), yielding a clinical diagnosis of pancreatic head cancer with nonhemophilic coagulation factor-VIII inhibitor. The patient underwent pancreatoduodenectomy receiving a large quantity of F-VIII. No bleeding was observed during surgery. On postoperative day (POD) 44, 24days after withdrawal of F-VIII, she developed intermuscular bleeding associated with profoundly elevated F-VIII inhibitor titer. She was treated successfully using recombinant factor VIIa, followed by prednisolone. Plasma F-VIII inhibitor titer had normalized by the time she was discharged on POD 86.

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Bronchogenic cysts are congenital anomalies usually seen in the mediastinum but rarely in the abdomen. Abdominal bronchogenic cysts with malignant regeneration are extremely rare, and only 2 cases have been reported. We report a case of retroperitoneal bronchogenic cysts, one of which was diagnosed as a malignant cyst using preoperative fine-needle aspiration cytology. A 57-year-old man admitted for back pain was found in computed tomography to have a well-defined, circumscribed 8cm multilobular mass in the retroperitoneal space, attached to the left crus of the diaphragm, and was widely attached to the pancreatic body, pressing it anteriorly. Cytological examination of fluid obtained by ultrasonography-guided fine-needle aspiration revealed adenocarcinoma cells, indicating a malingnant retroperitoneal cystic tumor. Because the tumor was widely attached to the pancreatic body, it was resected with distal pancreatectomy and splenectomy. Histologically, cysts were lined with pseudostratified ciliated columnar epithelium resting on fibrous connective tissue. Some atypical cells were growing papillary, diagnosed as papillary adenocarcinoma, resulting in a definitive diagnosis of malignant retroperitoneal bronchogenic cyst with malignant regeneration.

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A 62-year-old man was referred to another hospital for evaluation of constipation and was admitted to our hospital when a pelvic tumor and right hydronephrosis were discovered. A barium enema showed that the rectum was shifted to the left side. The rectal wall was stenosed circumferentially, but the mucosal layer had a smooth surface. Contrast-enhanced computed tomography showed that the tumor was unclear around the rectum and the right side of the pelvic cavity. The rectum was shifted to the left side, and the wall of the urinary bladder on the right side was irregularly thickened. The right ureter was dilated, and right hydronephrosis was observed. Laparotomy was performed based on a diagnosis of rectal stenosis and right hydronephrosis secondary to a pelvic tumor. The histological diagnosis was intra-abdominal desmoid tumor. Postoperative treatment with Tamoxifen and Indometacin improved the abdominal findings on palpation and the other clinical findings. Treatment of the unresectable pelvic desmoid with Tamoxifen and Indometacin was successful. We discuss intra-abdominal desmoids including the problems of treatment.

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We report a case of pseudo-obstruction associated with progress systemic sclerosis (PSS) successfully managed by resection of the affected ileum. A 74-year-old-woman with PSS admitted for abdominal fullness and vomiting had a history of frequent abdominal pain and distension in the last 5years. Plain abdominal X-ray showed marked intestinal gas with air-fluid, indicating small intestinal ileus, but no significant findings were seen in colonoscopy. Small bowel examination by contrast media imaging confirmed localized absence of peristalsis at the terminal ileum and no organic abnormalities. Initially the patient was treated by medication and discharged 1month later. After abdominal symptoms reappeared soon after, we decided to operate because the pseudo-obstruction was limited to the terminal ileum, conducting partial resection of the thickened ileum. The patient was discharged 37days later with normal bowel function. A resected specimen of the ileum showed marked atrophy of the muscularis propria and deposition of collagen in the submucosal layer. Although pseudo-obstruction is intractable and usually treated by medication, patients may require long-term intravenous hyperalimentation. This particular case report presents a possible surgical indication in which the disease is limited to a small part of the bowel.

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A 65-year-old woman was admitted to our hospital because of fecal occult bleeding. She had undergone curative pylorus-preserving pancreatoduodenectomy for duodenal cancer 7 years previously (T4, tub1, ly0, v0, n0, H0, P0, M0, stage IIIA). Barium enema showed a tumor of 2cm in diameter in the transverse colon. Colonoscopy revealed an elevated lesion 1.5cm in diameter with ulceration on its top. Histological examination of biopsy specimens revealed well differentiated adenocarcinoma. Partial resection of the transverse colon was performed. Histopathological examination revealed irregular atypical ducts of various size from the serosa to the submucosa, indicating well differentiated adenocarcinoma. Lymph vessel invasion was observed, but the specimen was negative blood vessel invasion. And then No.223 lymph node metastase was detected (wel, ss, v₀, ly₁, n₃ (+)(No.223), stage IIIb). The features of the lesions were compatible with the histological findings in the previously resected duodenal cancer. Metastatic colon cancers have been reported to occur in 0.1%-1% of colon cancers, and the most common form of metastase are the tethering type. We encountered a solitary metastatic cancer in the colon. This case is a warning that metastatic colon cancers can be diagnosed more than 7 years after primary resection of duodenal cancer, and that periodic checkups for colon cancer are necessary after duodenal cancer operations. Despite the poor prognosis of metastatic colon cancer, curative operation should be attempted in the absence of other metastase.

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We report a case of rectal carcinoid tumor metastasis to the breast. A 54-year-old woman noticing a mass in the left breast had suffered rectal carcinoid tumor and liver metastasis 7 years earlier. The treatment she received included rectal resection, 3 liver resections, and lymph node dissection in the pelvis. Pathological examination of the rectal tumor showed mp, ly2, v2, n2 (5/7). The breast mass in the upper inner quadrant measured 4.0cm in diameter. Aspiration biopsy cytology showed Class V, suggesting carcinoid tumor. The breast mass was excised and a pathological examination demonstrated metastatic carcinoid tumor of the breast through confirmation of histological similarities to the rectal carcinoid tumor. The tumor cells in the breast showed negative immunohistochemical staining for ER/PgR.

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We present a case of a gastrointestinal stromal tumor (GIST) of the rectum in a 63-year-old man who had visited our hospital complaining of pain on voiding. Digital examination revealed a hard mass, the surface of which was smooth, fixed at the anterior wall of the rectum, 4cm oral from the anal verge. CT and MRI showed an Inhomogeneous mass 10cm in size, occuping the small pelvic cavity. A transrectal needle biopsy was performed. Immunohistochemistry findings showed the tumor cells were strongly stained with CD34, weakly with c-kit gene product, but were not stained with S-100 protein nor smooth muscle actin. From these findings, a diagnosis of a GIST (uncommitted type) was made, and an abdominoperineal excision was performed. Macroscopically the tumor was 14×10×8cm in size, showing exoluminal growth from the anterior wall of the rectum. Immunohistochemical staining of the resected specimen was the same as that of the needle biopsy specimen. Successful reduction of c-kit-positive recurrent GIST by STI571, which was produced to treat chronic myelocytic leukemia, has been reported. Immunohistochemical staining of the specimen obtained by transrectal needle biopsy is useful to determine whether neoadjuvant therapy by STI571 is effective.

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A 69-year old man was admitted to our hospital with upper abdominal pain caused by the reflux esophagitis. An abdominal CT scan showed a 4cm cystic liver tumor in segment S7/8, and colonoscopy revealed an 8mm early flat-type (IIa+IIc) cancer with central depression and fold convergence in the recto-sigmoid area. Invasive colorectal carcinoma with liver metastasis was suspected, and high anterior resection of the rectum with D2 lymphadenectomy and partial hepatectomy were performed simultaneously. Histological examination revealed the moderately differentiated adenocarcinoma with slight invasion of the submucosal layer (sm1) and venous infiltration, but no lymph node metastasis. The liver tumor with central necrosis showed histological findings similar to those of the primary colorectal carcinoma. The pathological TNM stage according to the system of the Japanese Society for Cancer of the Colon and Rectum was stage IV, and surgical curability was B. We consider this case to be rare and valuable because of its rarity.

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Pharyngoesophageal diverticulum (Zenker's diverticulum), which is a pulsion diverticulum that occurs at a weak site in the posterior wall of the pharyngoesophagus, between the inferior constrictor of pharynx and the cricopharyngeus muscle, i. e. Killian's triangle, is rare in Japan. We treated 7 patients with Zenker's di-verticulum surgically from 1988 to 2003. We reviewed clinical findings and treatments of them. All had dysphagia initially. All underwent diverticulectomy, and 4 additionally underwent cricopharyngeal myotomy (CM). Postoperatively, 6 patients experienced dramatic alleviation of symptoms. Postoperative complications occurred in 2, i. e. pneumonia in 1 and recurrent laryngeal nerve paralysis in the other. No postoperative recur-rence was seen. We suggest that diverticulectomy added to CM is effective for Zenker's diverticulum. The patients with a large diverticulum are at risk of postoperative surgical complications due to the difficulty of the surgery, so careful operation is needed for them.

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