Purpose: We clinicopathologically evaluated multiple carcinoma of the esophagus. Methods: Among 574 patients with esophageal cancer undergoing esophagectomy or endoscopic mucosal resection (EMR) with-out preoperative treatment at Keiyuukai Sapporo Hospital between 1995 and 2001, 116 (19.7%) had multiple carcinoma of the esophagus. All such patients underwent esophagectomy with 3 field lymph node resection.
Results: Multiple carcinoma of the esophagus is characterized by (1) an incidence of pharyngeal malignancy significantly higher in patients with multiple carcinoma (P<0.001);(2) a statistically significant difference in overall 5-year survival rate;(3) no significant difference between groups in the extent of lymph node metas-tasis or alcohol and smoking index or male-to-female ratio. Secondary lesions were characterized by (1) Mu-cosal cancer in 83.6%;(2) Endoscopic type 0-IIb or 0-IIc lesions in 89.7%;(3) a maximum lesion length of <1cm in 58.8%;(4) a distance between the main tumor and the secondary lesion of <3cm in 73.3%.
Conclu-sions: Multiple and multifocal tumors should be considered in the diagnosis, treatment, and follow-up of can-cer of the esophagus.

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Purpose: The incidence of primary esophageal cancer complicated by carcinoma in other organs has in-creased in Japan, particularly that of esophageal cancer associated with head and neck cancer and gastric can-cer. Materials and Methods: We analysis 241 cases (23%) of synchronous or metachronous other primary malignancies of 1, 050 of esophageal cancer treated at the Department of Surgery, Kurume University School of Medicine, from 1982 to 2001. Results: The incidence of combined cancers increased 12%, 19%, 26%, and 31% at 5-year intervals. The site of combined malignancies was the head and neck in 40% and the stomach in 29%. The incidence ratio of combined head and neck cancer from 1982 to 1991 was 33% and that from 1992 to 2001 was 42%. The incidence of combined gastric cancer (29%) remained unchanged. Death related to other primary malignancies occurred in 5.5% of all patients. Death not related to esophageal cancer was due to malignancies in the head and neck (40%), lung (17%), liver (16%), stomach (9%), and other organs (19%). Although the incidence of multiple primary cancer has increased, the incidence of death related to other pri-mary malignancies decreased each 5 years. This may be due to measures taken to find other primary malig-nancies in patients with esophageal cancer. Conclusions: It is important to follow up patients primarily treated for esophageal cancer, focusing on synchronous or metechronous malignancies and recurrence.

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Endoscopic mucosal resection (EMR) is now widely used to treat early gastric cancer, and good results have been obtained. Frequent subsequent remnant lesions, however, complicate the decision of treatment. We evaluated remnant gastric cancer surgically resected after EMR and considered additional treatment for lesions. We also discuss the problem of extending indication of EMR. Patients and Methods: Subjects were 27 patients with 29 lesions undergoing surgical resection between January 1993 and February 2003 for rem-nant gastric cancer after EMR. We divided lesions into 3 groups based on reasons for EMR, i.e., 1) cases with absolute indication for EMR, 2) cases which EMR was tried for diagnosis, and 3) cases with relative indication for EMR. Results: 1) One case with an absolute indication of EMR advanced to MP invasion, and involved lymph node metastasis. This patient underwent gastrectomy 26 months later after EMR. 2) Most cases for which EMR was tried for diagnosis involved piecemeal resection. 3) One patient with poorly differentiated adenocarcinoma died of peritoneal recurrence after surgery. Summary: 1) In cases with an absolute indica-tion for EMR, post-EMR remnant cancer should be resected by partial resection of the stomach. If long peri-ods pass between EMR and surgery, gastrectomy with lymph node dissection is required. 2) Even if EMR is tried for diagnosis, it should involve a resection if possible. 3) Extending indication of EMR for undifferentiated carcinoma needs further investigation.

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Aim: We evaluated the effects of postgastrectomy dietary training on postoperative BMI change. Pa-tients and methods: Subjects were 63 patients who had undergone curative gastric cancer surgery and had been instructed in dietary procedures postoperatively. After consulting an experienced clinical dietitian about the recommended diet after gastrectomy, we identified 20 foods not recommended early after gastrectomy. For each of the 20 foods, patients made selections from the following 4 questions: 1. not eaten since before surgery, 2. not eaten at all postoperatively, 3. eaten selectively, and 4. eaten as usual. We classified patients into 3 groups as follows: Group A: excluding foods in “1” foods in “2” lated BMI change 3 months after surgery. Results: Among subjects, 30 were in Group A, 20 in Group B, and 13 in Group C. Group A lost 2.46kg/m² compared to preoperative BMI, Group B lost 2.77kg/m², and Group C lost 1.65kg/m². Group C's BMI loss was significantly less than that of Group A or B. Conclusion: Overrestric-tive dietary instruction may reduce postoperative quality of life (QOL), whereas more natural dietary habits may improve QOL.

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Purpose: We studied the relationship between serum interleukin-6 (IL-6) and lymph node and hepatic metastasis from colorectal cancer, clarifying the role of IL-6 as a prognostic factor. Patients and Methods: In 65 patients with colorectal cancer and 20 healthy volunteers, we statistically assessed the correlation of preop- erative IL-6 value (pg/ml) with 1) Dukes'classification, 2) lymph node metastasis (n), 3) hepatic metasta-sis (H'), 4) IL-6-related factors (HGF, IL-1β, TNF-α, TGF-β1), 5) adhesion molecules (ICAM-1, VCAM-1, E-selectin). 6) Supposing that cutoff value of IL-6 was set at 5.81 (mean+2SD for 25 Dukes'A and B patients), we determined the association between IL-6 elevation and prognosis regarding to stage III, IV and all pa-tients. 7) We also examined the expression of IL-6 in tumor tissue. Results: 1) IL-6 in Dukes'C and D cases (7.12, 18.57) was significantly higher than in control cases (1.05)(p<0.01). 2) A significant relationship was seen between IL-6 and lymph node metastasis. IL-6 in n2 (+) and n3 (+) cases (10.20, 14.23) was significantly higher than in n (-) cases (3.27)(p<0.01). And IL-6 in H'(+) cases (18.57) was significantly higher than in H0'(4.93), showing a significant relationship between IL-6 and hepatic metastasis (p<0.01). 3) A significant relationship was seen between IL-6 and HGF (p<0.01), ICAM-1 (p<0.01), VCAM-1 (p<0.01) and E-selectin (p<0.01). 4) When the cutoff value of IL-6 was set at 5.81, overall cumulative survival for 43 patients with IL-6 exceeding 5.81 was significantly lower than for 20 patients with IL-6 of 5.81 or less (p<0.01). The significant relationship remained among patients in stage III and IV. 5) In all cases with high serum level (more than 25.0pg/ml) of IL-6, immunohistochemical staining showed positive findings for IL-6 in the cytoplasm of cancer cell. Conclusion: We suspect that IL-6, which may be released from colorectal cancer cells, is involved in the inva-sive phase during the development of lymph node and/or hepatic metastasis. Our results indicate that serum IL-6 could be used as a prognostic factor in colorectal cancer patients.

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We report 2 cases of perforation of the digestive tract caused by a mistakenly ingested press-through package (PTP). Case 1: A 97-year-old woman hospitalized for ileus was referred for surgery because conser-vative treatment did not relieve symptoms. Emergency surgery was conducted after abdominal CT indicated strangulated ileus. A PTP was found to have perforated the jejunum 130cm from the Treitz ligament, due to penetration by a PTP. The jejunum, including the perforation, was partially resected. Case 2: A 65-year-old man treated as an outpatient for cerebral infarction and arteriosclerosis obliterans developed a sore throat and retrosternal pain after mistakenly ingesting a PTP. Emergency gastrointestinal fiberscopy on admission showed that the esophagus was perforated, necessitating emergency surgery. The perforation was directly sutured closed and gastrotomy conducted to remove the PTP. Reports of perforation of the digestive tract by PTPs are increasing, necessitating better guidance to patients in proper PTP use and improved PTP design.

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A 60-year-old woman followed up for arrhythmia, hypertension, and chronic hepatitis B was found to have a mass in the left liver on abdominal ultrasonography. Further examinations showed a tumor 40×30mm in diameter at segment III of the liver, and hepatocellular carcinoma was suspected. The lateral segmentec-tomy of the liver was done. Pathological findings for the tumor showed lymphoplasmacytic lymphoma. Nole-sions other than those in the liver were seen, so she was diagnosed as having primary hepatic malignant lym-phoma, which is comparatively rare. This is the 19th resected case of primary hepatic malignant lymphoma reported in the Japanese literature, and the second resected case of hepatic lymphoplasmacytic lymphoma. If the tumor is localized in the liver, it would appear most effective to conduct both surgical resection and che-motherapy.

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We report a case of tumor seeding after percutaneous radiofrequency ablation (RFA) for hepatocellular carcinoma (HCC). A 56-year-old woman who had previously undergone RFA with 2 insertions of a cooled-tip electrode to 28×20mm subcapsular HCC in liver segment VII was found 9 months later in abdominal com-puted tomography to have a small, mild contrast-enhanced mass outside the hypodense area of the RFA, so partial hepatectomy was done based on a diagnosis of HCC recurrence. Macroscopically, 2 tumors measured 7×6mm and 3×3mm. Histopathologically, the 2 well-differentiated HCC tumors existed in a layer of fatty tis-sue near the completely necrosed tissue of the ablated area. The final diagnosis of tumor seeding was deter-mined because no contact was seen between the 2 tumors, consistent with 2 insertions, and the ablated area.

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A 74 year-old man admitted for jaundice was found in diagnostic imaging to have a growing papillary tu-mor occupying the lumen of the lower bile duct. We diagnosed it as lower bile duct cancer without invasion to other organs, lymph node metastasis, liver metastasis, or distant metastasis, suggesting it could be curatively resected. Though we attempted to improve jaundice before surgery with PTCD, it was persisted and his liver function gradually worsened. He died of liver failure 3 months after admission. Autopsy showed a yellowish expanded papillary tumor in the lower bile duct, 3 metastatic nodules in the liver, and one on the omentum. Histopathological specimens showed undifferentiated round cells arranged crowded or in uncertain gland pattern. In immunohistological studies, granules stained with chromogranin A, Grimelius, CD56, or CAM in the cytoplasm of the cancer cells, and the tumor was diagnosed as small cell carcinoma arising primarily in the common bile duct.

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A 62-years-old man reporting upper abdominal pain and distension was found in laboratory studies to have high serum amylase of 403U/l. Ultrasonography and CT showed dilation of the main pancreatic duct and a mass 10mm long in diameter. ERCP also showed dilation of the main pancreatic duct from the pancreas head to the body, and Vater's ampulla dilation and a filling defect near Vater's ampulla were also seen. Histo-logical examination of the biopsy specimen and cytological examination of pancreatic juice did not show malig-nant cells. He was diagnosed as intraductal papillary mucinous tumor (IPMT) of the main pancreatic duct and underwent pylorus-ring-preserving-pancreaticoduode-nectomy. Pathological findings showed intraductal pap-illary adenoma with moderate to focal severe atypia in the main pancreatic duct, and carcinoma in situ in the branching pancreatic duct.

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A 62-year-old woman underwent lower anterior resection for rectal cancer in January 2000. Her serum CEA rose in November 2000, but image diagnosis showed no metastatic lesion. Computed tomography showed a tumor of the body of the pancreas in August 2001, so we conducted distal pancreatectomy with splenectomy. The tumor was 7×4cm and pathological findings showed moderately differentiated carcinoma and metastasis from rectal cancer. She underwent postoperative chemotherapy with 5-fluorouracil and iso-vorin, and in July 2003 she remained alive and recurrence-free. Pancreatic metastasis from colorectal cancer is very rare and, only 14 cases of resectable pancreatic metastasis, including ours, have been reported in the Japanese literature. If pancreatic metastasis is solitary and no other metastasis occurs, surgical resection is recommended.

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We report a patient with mesenteric panniculitis associated with a large amount of chylous ascites recur-ring after conservative therapy. A 77-year-old woman reporting abdominal fullness was found in abdominal CT to have a large amount of ascites and a shadowy mass with calcification in the mesentery of the small in-testine. We conducted surgery to diagnose and treat her under a diagnosis of malignant lymphoma, indicated by elevated soluble IL-2 receptor. Laparoscopic findings showed chylous ascites and a sclerotic, shortened mesentery of the small intestine. The mass in the mesentery was diagnosed as mesenteric panniculitis upon biopsy. Ascites disappeared with conservative treatment. She was readmitted for abdominal fullness about 10 months later. Abdominal CT showed large amount of ascites and lt. hydronephrosis. We conducted a second operation on suspicion of malignancy, since a shadowy mass in the mesentery of the small intestine had en-larged. Laparoscopic findings showed inflammation of the abdominal cavity even severes that at the last op-eration. Biopsy of the highly sclerotic, mesentery was again diagnosed as mesenteric panniculitis. Her postop-erative course was uneventful, and she is being treated as an outpatient with steroid therapy without ascites recurrence.

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A 52-year-old man, twice indicated as having liver nodules and admitted for abdominal pain, lower lum-bar pain, and diarrhea, was found to have rebound tenderness at the nodule in the right lower quadrant. Com-puted tomography showed multiple liver nodules, continuous wall thickening along the small intestine, and lymph node swelling in the mesentery, all hypervascular. Enteral fluoroscopy showed ileal sclerosis, wall roughness, and circular shadowless lesion. The elevated tumor in the terminal ileum was diagnosed preopera-tively by biopsy as a carcinoid tumor. Serum 5-HIAA and serotonin were high. Surgery was done due to ab-dominal pain and diarrhea upon oral intake, and 50 cm of the ischemic sclerotic intestine was resected. The specimen showed multiple yellow elastic hard tumors, diagnosed histologically as carcinoid tumors. The pecu-liar elastic vascular sclerosis in the mesenteric artery was also detected in the ischemic lesion of the ileum.

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A 78-year-old man with a history of lung cancer surgery, reporting abdominal pain was found in physical examination, abdominal X-ray, abdominal ultrasound examination, and abdominal CT to have an abscess-like lesion in the mid lower abdomen but no evidence of recurrence in the liver, lung, or brain. Exploratory laparotomy showed a tumor in the ileum 60cm proximal to Bauhin's valve, necessitating partial resection of the ileum. Histological studies showed specimens of the small bowel lesion to be squamous cell carcinoma, similar to those of the resected lung specimen. One month later, abdominal CT showed multiple liver metastases and he died 3 months after the operation because of liver failure. Surgeons should thus note whether patients with lung cancer have abdominal symptoms due to the presence of intestinal metastasis. Metastasis from primary carcinoma of the lung to the small bowel is associated with a poor prognosis, but aggressive surgery is associated with successful palliation and improved short-term survival.

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A 60-year-old woman followed up for type C chronic hepatitis and found to have an abdominal mass 3cm in diameter in the lesser omentum 9 months earlier underwent elective laparotomy in November 2001 to excise the tumor despite the absence of change in tumor size. The tumor was isolated from the stomach and well encapsulated and did not adhere to adjacent organs, allowing complete removal. The tumor was a wellcircumscribed mass with solid and partially cystic cut surface, 3.2×3.0×2.8cm. Histologically, it consisted of spindle cells and mitotic counts of less than 5 per 50 high-power fields. Immunohistochemically, it was positive for c-kit and CD34 but negative for alpha-smooth muscle actin and S-100. The pathological diagnosis was lowmalignancy gastrointestinal stromal tumor (GIST) of the lesser omentum. The patient remains free from recurrence 23 months after surgery.

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We report a unique case of “cystic” gastrointestinal stromal tumor (cystic GIST) associated with von Recklinghausen's disease. A 61-year-old woman with abdominal distension deteriorating for three months underwent laparotomy for removal of a cystic pelvic mass suspected of being an ovarian cyst. An 11cm long cystic tumor was found originating from the small intestine 100cm rostral to Bauhin's valve. The tumor and part the intestine were resected and an end-to-end anastomosis performed. The postoperative course was uneventful. Pathological examination showed a GIST with positive staining for c-kit, CD 34, Vimentin, and α-smooth muscle actin, and negative staining for S-100 and Desmin. To the best of our knowledge, this is the first case of cystic gastrointestinal stromal tumor associated with von Recklinghausen's disease to be reported in the Japanese literature.

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A 54-year-old women with a 20-year history of diabetes seen. On May 2, 2002, for abdominal pain and diarrhea was given. An antibiotic and an antidiarrheal agent, but showed no improvement. She was then treated under a tentative diagnosis of bacterial enteritis. On May 12, muscular defense appeared. Computed tomography (CT) showed penetrating edematous changes in the ascending colon, sigmoid colon, and rectum, and ascitis, necessitating emergency surgery under a diagnosis of peritonitis. A necrotic focus observed on the serous membrane of the ascending colon, was resected. No abnormalities were seen on the serous membrane of the sigmoid colon or rectum. Culture with pseudomembrane-removing solution confirmed methycillinresistant staphylococcus aureus (MRSA) but the patient was negative for CD toxin. Due to a lack of improvement, she underwent total extirpation of the rectum and anal canal, resection of the peripheral tissue for concurrent Fournier's syndrome, and other procedures, for total of 4 times, to no avail, and died on June 13. We treated a patient with extensive penetrating colorectal necrosis without underlying disease that may have been due to microangiopathy such as collagen disease. In such patients, early diagnosis and complete removal of necrotic tissues are essential but the prognosis may be poor.

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