We studied 53 cases of upper GI GIST (gastrointestinal stromal tumor) who underwent surgical resection from 1980 to 2004. The diagnosis of GIST was defined by positive immunohistochemical staining wih KIT or CD34.RESULTS: We found 33 GISTs in the stomach, 5 in the duodenum, 11 in the jejunum, and 4 in the ileum. We classified GISTs in the duodenum, jejunum, and ileum as small intestinal GISTs in this study. Mean patient age was 59.7 years, with 21 men and 32 women. The mean tumor size of 53 GISTs was 7.8cm and that of gastric GISTs 7.2cm and small intestinal GISTs 8.9cm (p=0.25). The population of MI (Mitotic Index)>50/HPF was 12 of 53 GISTs, 7 of 33 (21.2%) in gastric GISTs, and 5 of 20 (25%) in small intestinal GISTs. According to the risk classification evaluated with the combination of tumor size and MI, 27.3%(9/33) of gastric GISTs and 45.0%(9/20) of small intestinal GISTs were classified as highrisk malignancy. Twelve patients suffered tumor recurrence, 3 of which were gastric GISTs and 9 were intestinal GISTs. Ten-3 of the stomach and 7 of the small intestine-died of disease in 8 months to 11 years. Median observation was 38.1 months, with overall 5year survival of the 53 patients 77.1% and 10-year survival 70.7%. Lowrisk GISTs caused no recurrence or metastasis, and 10year diseasefree survival of intermediaterisk GISTs was 95.2% and that of highrisk GISTs 36.1%(p=0.01). The prognosis of small intestinal GISTs was significantly inferior to gastric GISTs; 10-year disease-free survival of gastric GIST was 84.7%, whereas intestinal GIST was 45.4%(p=0.02).Conclusions: The predicting indicators of upper GI GIST are tumor size, MI, and tumor location. Strict followup is mandatory for these highrisk patients even after complete resection.

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Purpose: We studied the incidence of variance and outcome of a clinical pathway (CP) for hepatectomy. Patients and Methods: From January 2003, a CP was introduced in management of hepatectomy without reconstruction of the bile duct. From January to December 2004, a CP was implemented for 115 patients undergoing hepatectomy without reconstruction of the bile duct. Results: Patients completing the CP were 80%. Mean postoperative hospitalization stay was 9.0 days. Clinical factors correlated with the incidence of variance were the type of disease (primary liver cancer or metastatic liver tumor), surgical procedure, operating time, blood loss, blood transfusion, and the amount of diet on postoperative day (POD) 2. Conclusions: We evaluated indications of a CP for hepatectomy. The most useful clinical factor was operating time. The frequency of incidence of variance will be probably high if we cannot conduct hepatectomy within a 5-hour operation.

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Introduction: Signet-ring cell carcinoma of the colon and rectum, although rare, bodes a dismal diagnosis, yet precise characteristics remain to be clarified.Methods: Among 3, 169 patients we treated for colorectal carcinoma excluding patients with m disease, signet-ring cell carcinoma was found in 7 (0.2%). We compared clinicopathological characteristics and prognoses of different histological types of cancer-differentiated, poorly differentiated, mucinous, and signet-ring cell types.Results: In the 2 men and 5 women with signet-ring cell carcinoma, mean age was 45.7 years old and 4 tumors were located in the rectum, and 1 each in the cecum, sigmoid colon, and transverse colon. Three were Type 3 and 2 Type 1 tumors, with the depth of invasion ss (a1) or more in all. Lymph node metastasis was found in 5 of the 6 cases and peritoneal dissemination in 3 of the 7 cases, but no liver metastasis. Recurrent patterns in the 4 undergoing curative surgery (Cur A and B) were 2 local, 1 nodal, and 1 bone marrow recurrence. Mean survival was 319.9 days, with no 3-year survival, giving signet-ring cell carcinoma the worst prognosis of all histological types. Microsatellite instability was examined in 6 cases, with 3 showing positive results.Conclusion: To improve the prognosis of signet-ring cell carcinoma, early diagnosis and multimodal therapy, including the most up-date chemotherapy are vital

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Introduction: Hepatocyte growth factor receptor (c-MET) has been suggested to play a role in the progression and metastasis of colorectal carcinoma. In this study we investigated the relationship between expression of c-MET and the malignant potential of pT3 colon carcinoma. Methods: Curatively resected specimens of 88 well or moderately differentiated of the colon adenocarcinomas were studied. The median postoperative fol-low-up time was 70.2 months. Serial sections were prepared from formalin-fixed paraffin-embedded blocks, and they were stained with HE and immunohistochemically stained for cMET. Expression of c-MET at the invasive front of the tumor was evaluated as positive (+) or negative (-). Results: Expression of c-MET was positive in 37 lesions (42.0%), and it was significantly correlated with lymphatic invasion (p=0.0006) and lymph node metastasis (p<0.0001). Recurrence was detected in 27 patients (30.6%). Patients with c-METpositive lesions had a significantly higher incidence of pulmonary metastatic recurrence than patients with c-METnegative lesions (p=0.0098). Postoperative survival was significantly shorter in patients with c-METpositive lesions than in patients with c-MET-negative lesions (p=0.0028, logrank test). The multivariate proportional hazard model revealed that expression of c-MET was the only significant co-factor of postoperative survival in pT3 colon carcinoma [hazard ratio (95% confidence interval): 3.031 (1.272-7.225), p=0.0123]. Conclusion: Thus, testing pT3 colon carcinoma for expression of c-MET is useful for predicting recurrence and outcome.

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We report a case of amelanotic malignant melanoma of the esophagus, preceded by metastatic lesions of the small bowel. A 74-year-old man came to our hospital complaining of abdominal pain and general fatigue. UGI series revealed two jejunal tumors, and the jejunum was partially resected. The tumors were histologically diagnosed as undifferentiated carcinoma. The patient returned to our hospital 17 months later complaining of difficulty swallowing. A tumor in the mid-portion of the thoracic esophagus was diagnosed as undifferentiated carcinoma by biopsy of the tumor exposed on the mucosal surface. A CT scan demonstrated a large, 8cm×5cm, metastatic lymph node in the posterior mediastinum, that had shifted the left atrium anteriorly and the esophagus to the right. We abandoned tumor resection because of the far advanced infiltration and treated the patient with chemotherapy based on a low-dose FP regimen. The chemotherapy resulted in a temporary partial response, but the patient died of tumor recurrence 25 months after the primary operation (7 months after the start of chemotherapy). At autopsy the esophageal tumor was HMB-45-positive, and the final diagnosis was amelanotic malignant melanoma with mediastinal lymph node metastasis and asynchronous metastatic lesions of the jejunum.

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The patient was a 59-year-old man with advanced gastric cancer and multiple lymph node metastases, including to a para-aortic lymph node. We concluded that curative resection would be difficult, and selected TS-1/ CDDP combined chemotherapy instead. Each course consisted of TS-1 (100mg/day) for 4 weeks and CDDP (60mg/body) on days 7, 14, and 21. After the first course, the size of the primary lesion and enlarged lymph nodes decreased markedly, but the patient developed grade 3 thrombocytopenia. Later, as an outpatient, TS-1 (100mg/day) was administered for 4 weeks with CDDP (10mg/body) on days 1and 15 for a total of 8 courses without toxicity. Upper GI endoscopy revealed the primary lesion to have formed a scar-like lesion, and a biopsy showed no cancer cells. CT revealed the maintenance of complete response (CR) for 13 months, but TS-1 administration was finally stopped because of grade 1neuropathy. Five months after stopping chemotherapy, CR had been maintained, but because of the deformity of the stomach on an upper GI series the possibility of cancer cell survival could not be ruled out. We performed a distal gastrectomy, and the microscopic findings revealed marked fibrous change and no cancer cells in the gastric wall or lymph nodes, which werejudged to be Grade 3. TS-1/CDDP combined chemotherapy is capable of curing advanced gastric cancer with severe lymph node metastasis without surgical resection.

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We report a case of stage IV gastric cancer resected after successful treatment with docetaxel as chemotherapy. A 70-year-old man was admitted to hospital because of progressive appetite loss. Endoscopic examination revealed type 3 advanced gastric cancer at the upper body of the stomach. Computed tomography (CT) showed pancreas and lymph node invasion at the splenic hilum. The preoperative diagnosis was stageIV gastric cancer. Since a curative operation was deemed impossible, we started the chemotherapy using TS-1 for downstaging. TS-1 (100mg/day) was orally administered for 4 weeks followed by a drug-free 2-week periodas 1 course. At the completion of 1 course, the tumors were assessed, showing disease progression (DP). Therefore, for the second regimen, CPT-11 was administered at a dose of 100mg /body intravenous infusion once a week for three weeks followed by a drug-free 2-week period as 1 course. After 2 courses, the primary lesion was assessed, showing DP. Next Docetaxel was administered at an intravenous dose of 80mg with dose free intervals of 3 weeks. After 4 courses, the primary lesion was reduced in size, so this therapy had induced a partial response (PR). Subsequently, the patient underwent curative total gastrectomy with pancreatectomy and splenectomy and cholecystectomy together with D3 lymph node dissection. Histological examination of the primary lesion revealed a small amount of residual cancer cells. This case suggests that docetaxel therapy is effective against advanced gastric cancer.

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A 67-year-old man undergoing a routine physical examination, In November, 1997 was found in a gastroscopic examination to have stomach cancer when a Borrmann type II tumor was found at the major curvature of the lower gastric corpus, for which the man underwent distal partial gastrectomy D2 dissection, and Billroth II reconstruction on January, 1998. The lesion was classified as mp, n2, H0, P0, stage IIIA. Following surgery, he was treated with 300mg/day of UFT via the oral route. CT conducted one year after surgery revealed hypertrophic paraaortic lymph nodes 30×25mm. CEA had risen to 207.2ng/dl. Under a diagnosis of recurrent gastric cancer, he was admitted on February, 1999, for radiochemotherapy. A total radiation dosage of 30Gy was applied simultaneously with the administration of low-dose CDDP+UFT. CT after one and a half month on admission showed that PR had been achieved. On June, 1999, CEA was negative and his lymph nodes were not evident on CT, leading us to conclude that CR had been achieved, a condition that has been maintained for the 6 years up to the present. Radiochemotherapy using CDDP was indicated because of local recurrence in this case.

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We report a case of perforation of the diverticulum of the third duodenal part due to insertion of an ileus tube. A 79-year-old woman who had undergone laparotomy 3 times was admitted with a diagnosis of ileus. Abdominal CT showed enlargement of the small bowel and a tumor in the ascending colon. On hospital day 1, a long tube was inserted to release ileus, but could not be inserted to the jejunum. On hospital day 2, fluoroscopy via the tube showed leaks of contrast medium from the 2nd portion of the duodenum, necessitating emergency surgery under a diagnosis of duodenal perforation due to ileus tube. In operative findings, the long tube was pushed out extraluminally into the retroperitoneal space from the diverticulum in the proximal of 3rd portion. The diverticulm was resected and a drainage tube inserted together with right hemicolectomy for the colictumor. This is, to our knowledge, the first report of perforation of the duodenal diverticulum due to insertion of an ileus tube.

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We report a case of small-cell carcinoma (endocrine cell carcinoma) of the ampulla of Vater. A 73-year-old woman admitted for appetite loss, jaundice, and high fever was found to have an elevated tumor with ulceration in the ampulla of Vater. Histological examination of a biopsied specimen showed poorly differentiated adenocarcinoma. We conducted pancreatoduodenectomy with regional lymph node dissection. Immunohistochemical analysis showed positive staining for NSE, CD-5 synaptophysin, and chromogranin A. The definitivediagnosis was small-cell carcinoma (endocrine cell carcinoma) of the ampulla of Vater. The postoperative course was uneventful, but the patient died from recurrence at the hepatic hilum 10 months after surgery. To the best of our knowledge, this is the 34th case of small-cell carcinoma (endocrine cell carcinoma) of the ampulla of Vater reported in the Japanese literature. The prognosis in surgical treatment of such cases is dismal, mainly due to early liver metastasis. Adjuvant chemotherapy in addition to surgery may thus be necessary.

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Carcinoma of the duodenal ampulla of Varter is rare with only four cases reported in Japan. A 58-year-old-man admitted for obstructive jaundice underwent pylorus-preserving pancreatoduodenectomy based on a diagnosis of carcinoma of the duodenal ampulla of Varter (biopsy showing adenocarcinoma) with multiple liver metastasis and lymphnode meastasis confirmed by abdominal enhanced CT, cholangiography, and upper gastrotastestinal endoscopy examination for control of bleeding. The resected speciemen showed undifferentiated carcinoma, an ulcerative mass, t4 (45×35mm), panc3, du3, pn1, n4, A0, PV0, P0, H3, M (-), stage IVb. He died indays after surgery for carcinomatosa. This disease has a poor prognosis in a case like ours because of exceeding stage IIIa on diagnosis for rapid progression and delayed appearance of symptoms. This disease must be detected early and effective chemotherapy implemented to improve prognosis. Our case suggested the tumor originated from intestinal pluripotential stem cells because tumor cells showed epithelial membrane antigen and endocrine granular constitution.

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We reported a rare case of adult hepatoblastoma in a 54-year-old man with hepatitis C who was found to have a liver tumor in segment 6 during a medical checkup. AFP was elevated to 301ng/ml and the AFP-L3 ratio was 72.5%. Abdominal ultrasound showed a mixed-echo tumor. Abdominal CT showed a low-density area with unclear border. After administration of contrast medium, the tumor was partially enhanced in the early phase without washout in late phase. Systematic posterior segmentectomy was successful. The tumor was 3 cm in diameter and was the smallest adult hepatoblastoma known, to the best of our knowledge. HE staining showed a fibrous capsule and septum, with some foci of hemorrhage, necrosis, and fibrosis in the tumor. Embryonal epithelial cells with hyperchromatic nuclei had proliferated irregularly. Osteoid-like and cartilaginous foci, myxomatous stroma, and tumor cells multiplied in a trabecular pattern similar to hepatocellular carcinoma were observed. Pathological examination showed mixed epithelial and mesenchymal hepatoblastoma. The background liver was assessed as F3-F4 instaging of fibrosis and A2 in grading of inflammation. The patient was definitively diagnosed with Stage III based on staging criteria of primary liver cancer in Japan. Adjuvant hepatic arterial chemotherapy with cisplatin and farmorubicin was done, and the patient has been well and free of recurrence for about two years, with tumor markers remaining normal.

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We report a case of pancreatic tail cancer associated with autoimmune pancreatitis. A 72-year-old male referred for detailed examination and radical therapy against suspected pancreatic tumor was found to have a high rheumatoid factor in blood tests and diffuse enlargement of the pancreas without extension of its main duct observed by computed tomography. Endoscopic retrograde cholangiopancreatography showed diffuse irregular narrowing of the main pancreatic duct and stenosis of the intrapancreatic common bile duct. Under a diagnosis of autoimmune pancreatitis, we conducted medicinal therapy with steroids. After steroid therapy, enlargement of the pancreas head and body was reduced and constriction of the common bile duct and main pancreatic duct improved. The tumor in the tail of the pancreas was enhanced, however, and pathological examination showed moderately differentiated tubular adenocarcinoma, necessitating distal pancreatectomy. To our knowledge, few reports exist of pancreatic cancer associated with autoimmune pancreatitis.

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An asymptomatic 77-year-old woman was admitted to our hospital for evaluation of an intraabdominal tumor which was incidentally found during a CT examination. The physical examination indicated a fist-sized abdominal mass in the lower abdomen. CT also revealed a well circumscribed heterogeneously enhanced tumor, measuring 5.6cm in diameter, within the mid lower abdominal cavity. T2-weighted MRI showed a heterogeneous high intensity tumor with flow voids in a branch of the superior mesenteric artery around the tumor. Under the diagnosis of a mesenteric tumor, surgical resection was performed. The tumor had a smooth and well capsularized surface, and was located in the mesentery of the ileum. The resected specimen was an elastic hard tumor, 7×5.5cm in diameter, 72g in weight. No change in blood pressure was recorded during the surgery. The tumor was confirmed to be a paraganglioma by histological examination.

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A 83-year-old woman refered due to small bowel obstruction whose symptoms did not disappear after a long tube had been placed to decompress the bowel, was found in computed tomography to have an ileal loop deviating from the abdominal cavity to a right side pelvic floor hernia. Emergency laparotomy showed that the ileum had herniated into the right sciatic foramen. The herniated ileum was reduced by traction, avoiding ileal resection. The sciatic foramen defect was repaired by suturing the right mesosalpinx. The patient had an uneventful postoperative course and was discharged on postoperative day 23. Sciatic hernia is very rare, and 77 patients have been reported in the world literature. Our case is reported with a review of the literature on sciatic hernia.

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A 77-year-old woman admitted for nausea in January 2005 was found in plain abdominal radiography to have multiple air fluid levels. A nasogastric tube did not improve symptoms. A long intestinal tube inserted on hospital day 6 improved symptoms smoothly. Sudden abdominal pain onset was found in abdominal examination to involve peritoneal irritation on hospital day 10. Laboratory studies showed severe inflammation response. Intestinal radiography using a long intestinal tube showed an oval shadow in the small intestine. Abdominal computed tomography showed ascites, free air, and a sponge like mass in the small intestine. Consumption of persimmons was confirmed in a detailed medical history interview. Surgery was conducted based on a diagnosis of small bowel obstruction and perforation due to spilled diosphyrobezoar impacted at the ileum about 30 cm from the ileocecal junction had perforated the ventral wall, necessitating ileal resection. A 4.2×2.6×2.8-cm black foreign body was suspected to be a spilled diosphyrobezoar. The postoperative course was uneventful and the patient was discharged on postoperative day 19. Although small bowel obstruction due to spilled bezoar is relatively rare, early diagnosis and treatment is important so that perforation can occur.

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A 84-year-old man had nausea and stomach fullness in early January 2003.He was diagnosed as having ileus by a neighborhood clinic and was referred to our hospital. He had no history of abdominal surgery. Because his abdominal pain was not severe, we started long tube conservative therapy. After 3 days, the ileus was relieved. Radiographic small bowel examination with contrast medium revealed no obstruction of the intestine, but there was a diverticulum in the small bowel. Meckel's diverticulum was suspected. The patient developed ileus again in the middle of January, 2003 and we decided to operate. During the operation, we found an adhesion of the appendix and the apex of Meckel's diverticulum. The small bowel was obstructed by an internal hernia through the adhesion. There was no necrosis in the small bowel and we resected the appendix and the Meckel's diverticulum. The patient's post operative course was uneventful and he left our hospital 11 days after the operation.

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An 82-year-old man who had undergone distal partial gastrectomy for gastric carcinoma 4 years and 9 earlier admitted for small bowel obstruction was found in enhanced CT to have a tumor 4cm in diameter in the ileum. Swallowing of meglumine amidotrizoate (Gastrografin) showed a tumor in the ileum. The jejunum (about 60 cm), bladder, and sigmoid colon was resected because the tumor had invaded the bladder and sigmoid colon. Pathological findings showed that the tumor was mainly located between the small intestine and bladder. Pathological features strongly resembled those of the specimen from the first operation, leading to diagnose this tumor as metastatic tumor from gastric carcinoma. Few cases are reported as solitary metastatic carcinoma of the small intestine, such as in this case, because the majority of metastatic carcinoma of the small intestine involves direct invasion and peritoneal dissemination of malignant tumors in the abdomen. Solitary metastatic carcinoma of the small intestine, which is clinically presented as acute abdomen such as perforation, intussusception, ileus and intestinal bleeding, should be considered as a differential diagnosis after malignant tumor operation.

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A 75-year-old woman who underwent an orthopedic operation for lumbar vertebral canal stenosis was admitted to our hospital, because of abdominal distension, severe diarrhea, and developing sepsis. Colonoscopic examination showed a pseudomembrane in the colorectum, and Clostridium difficile toxin A was detected in the pseudomembrane. Vancomycin and metronidazole were administrated via a nasostmach tube and transanal tube for the pseudomembranous colitis, and intensive care for multiple organ dysfunctions were also performed. Because the patient had septic shock as well as developing multiple organ dysfunctions despite appropriate conservative therapy, an emergency laparotomy was carried out. The hugely distended colon with a highly edematous mesocolon was observed, and subtotal colectomy and ileostomy were performed. Immediately after the operation, the patient was recovering from the septic coma and respiratory dysfunction.The patient, however, died from acute respiratory dysfunction and progressive liver dysfunction on the 48 postoperative days. Surgical operation may be recommended as a therapeutic strategy for a pseudomembranous colitis with progressive multiple organ dysfunctions or septic shock.

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We report a rare case of gastric obstruction that followed sigmoid colostomy and required reoperation. An 81-year-old woman with kyphosis who had undergone abdominoperineal resection of the rectum and endsigmoid colostomy by the intraperitoneal approach for rectal cancer 5 months earlier was admitted for abdominal pain and projectile vomiting. Abdominal CT showed such marked dilatation of the stomach that it filled the abdominal cavity. There was no evidence of cancer recurrence or bowel obstruction. An upper gastrointestinal series revealed gastroptosis and that the gastric antrum was compressed by the sigmoid colostomy. Gastric obstruction secondary to sigmoid colostomy was diagnosed, and re-colostomy by the extraperitoneal pproach was performed. The postoperative course was uneventful, and the gastric obstruction was eliminated. To our knowledge, this is the first report of late gastric obstruction due to sigmoid colostomy. Colostomy by the extraperitoneal approach should be considered in patients with gastroptosis or kyphosis.

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We report a rare case of left hydronephrosis secondary to sigmoid colon diverticulitis. A 70-year-old man was admitted with left lower abdominal pain, fever, appetite loss, and a palpable mass in the left iliac fossa. Hematological examination revealed anemia and an inflammatory reaction. A gastrographin contrast enema showed colonic stenosis, approximately 12cm long, extending from the sigmoid colon to the rectum. Abdominal CT and US revealed left hydronephrosis and colonic wall thickening, with some diverticula and lymph node swelling. Colonic endoscopy showed a reddish stenotic colon and irregularities, but there no cancer cells in the biopsy tissues. Based on these findings, we conducted a surgical exploration with a preoperative diagnosis of acute diverticulitis or diffusely infiltrating carcinoma of the colon, then performed low anterior resection with ileostomy preserving the left ureter, which was involved by the inflamed tissue. Histopathologically, the resected specimen showed multiple diverticula with marked inflammation, but no evidence of malignancy. An abdominal CT scan performed 3 months after surgery showed less dilatation of the left ureter. Although hydronephrosis secondary to ureteral occlusion is usually associated with malignancy, other rare possibilities, including colonic diverticulitis, as reported in the case, must also be considered.

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A 78-year-old man consulted us for anal bleeding and pain. Digital examination of the anus and rectum revealed internal and external hemorrhoids at 3 o'clock and 7 o'clocks, respectively. The patient was treated medically by drug therapy, but complained of continuous anal pains and the left inguinal lymph node rapidly enlarged. Surgical biopsy of the anal tumor and lymph node was performed under spinal anesthesia. Pathological examination revealed poorly differentiated carcinoma of the anal canal and the lymph node metastasis. Abdominoperineal rectal excision was performed and followed by 4 cycles of chemotherapy with irinotecan, leucovorin, fluorouracil, and doxyfluridine. The patient died six months later of carcinomatosis. Undifferentiated carcinoma of the anal canal is rare. We have reported a case of undifferentiated carcinoma of the anal canal and metastatic squamous cell carcinoma to inguinal nodes in which the outcome was poor after resection.

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