Purpose: We clarified the prognostic significance of lymphatic and venous invasion judged by slides with double staining combining CD34 immunostaining and elastica staining.Methods: Subjects were 125 patients with pT3 colorectal carcinoma who underwent curative surgery between 1989 and 1993. Each representative pathological section including the deepest area of tumor penetration was stained with elastica staining after immunostaining for CD34. Cancer was classified based on the number of lymphatic invasions per section (ly (-), 0; ly (+), 1 or more) and on venous invasions (v (-), 0; v (+), 1 or more). We then looked at the relationship between invasion grade and patient prognosis.Results: Microscopically, we clearly identified lymph vessels with immunostained endothelium and venous vessels with round elastic fibers on slides with double staining. V (+) was strongly associated with lymph node metastasis (p=0.01). Univariate analysis showed that the ly (-) group (5-year survival of 88.9%) and v (-) group (90.0%) showed more favorable survival than the ly (+) group (75.6%, p=0.06) and v (+) group (78.9%, p=0.09). Lymph node metastasis (HR 3.6, p=0.008) was found by multivariate analysis to be independent prognostic factors, but not ly (+) and v (+).Conclusions: To diagnose the grade of vessel invasion objectively, additional staining was useful. Lymphatic and venous invasion were not found to be independent prognostic factors in patients with pT3 colorectal carcinoma.

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Parahiatal hernia is an extremely rare abnormality that occurs from muscular diaphragmatic defects separate from the esophageal hiatus. A 70-year-old woman was admitted to the hospital because of the symptom of dysphagia in eating solid meal and vomiting. Chest X-ray film revealed a gastrointestinal gas image in the posterior mediastinal space. A barium esophagram showed a herniated stomach. Initially, we diagnosed this case as paraesophageal hernia, and performed laparoscopic surgery. We found the hernia orifice separately from esophageal hiatus after removal of the cardia of the stomach from the posterior mediastinal space and there was the crus of the diaphragm between the hiatus and the orifice. Hernia orifice was closed with a mesh and the Toupet technique was performed. The patient was discharged without complication at the day after 11. Parahiatal hernia is extremely rare and it is difficult to preoperatively diagnose this. We report this case, Because laparoscopic repair of this entity can be safely and successfully accomplished.

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A 33-year-old woman admitted for abdominal discomfort, had undergone cystectomy of the omentum when 1 year old. Ultrasonography and computed tomography showed a cystic tumor in the upper right abdominal cavity. Surgery was conducted and a tumor found in the omentum. The polycystic tumor had serous contents, but no continuity with adjoining internal organs. Histopathologically it was diagnosed as lymphangioma. Lymphangioma originating from the omentum is very rare in adults. We surmised that neoplasm recurrence and the new neoplasm were related. No case has, to our knowledge, been reported of such recurrence, especially of an omental cyst 30 years after the first operation. Careful management to prevent recurrence is thus important in operation.

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In February 2004, a 60-year-old man noticing abdominal distension was admitted for difficulty in oral intake. He was found to have an abdominal tumor with massive bloody ascites. Computed tomography showed a mass about 12cm in diameter in the upper abdomen with massive ascites, which was removed by abdominal puncture. Distal partial gastrectomy was conducted after his general condition improved. Macroscopically, the tumor originated from the greater gastric curvature and was growing extraluminally. Pathologically, the tumor was stained weakly for KIT, but CD34 was negative. The tumor was diagnosed as epithelioid GIST, and a point mutation of PDGFRα was detected in exon 18.After surgery, ascites disappeared and he shows no evidence of recurrence.

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We report 10-year survival after four hepatectomies for liver metastases in gastrointestinal stromal tumor (GIST). A 69-year-old man who had undergone total gastrectomy, splenectomy, and distal pancreatectomy for GIST in 1990, was found to have a metastatic liver tumor in 1995, necessitating partial hepatectomy. Two additional hepatectomies were conducted for metastatic liver tumors. In 2003 and 2004, the man underwent radiofrequency ablation (RFA) for metastatic liver tumors in hepatic segment VIII after declining further surgery. In 2005, metastatic liver tumors appeared in segments II and IV, necessitating partial resection of corresponding segments and a previously ablated liver segment. A metastatic tumor was also present in resected segment VIII, where RFA had been previously done. Histological diagnosis for the primary tumor had been leiomyosarcoma, and immunohistochemical staining in 2001 showed all specimens to be positive for KIT and CD34, confirming the diagnosis of GIST. Long-term survival is thus possible in repeated hepatectomies in a patient with hepatic metastases from GIST.

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We report a case of giant splenic hamartoma associated with thrombocytopenia. A 24-year-old man with general malaise was admitted to our hospital in March 2005 because of thrombocytopenia. Hematogenous cancer was ruled out by bone marrow biopsy, and a giant splenic tumor was found by abdominal CT. Ultrasonography revealed a heterogeneous tumor that occupied almost the entire spleen and blood-flow signals inside the tumor. Plain CT showed heterogeneous low density, whereas enhanced CT showed multiple mosaic-like low density spots in a high density area that appeared to be the parenchyma of the tumor. MRI showed spotted low intensity signals on the T1-weighted image and multiple high and low signal intensity nodules inside a high intensity area on the T2-weighted image. A diagnosis of splenic tumor with multiple thrombi was made, and we performed splenectomy. The resected specimen weighed 2, 650g and was almost completely occupied by tumor and organizing thrombus. The tumor measured 22×17×12cm, and the pathological diagnosis was hamartoma of the red pulp type. We consider that this case is the maximum size of splenic hamartoma as long as we could examine in the previous literatures.

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We report a large solitary fibrous tumor (SFT) of the retroperitoneum. A 47-year-old man was admitted to our department complaining of fullness. Physical examination revealed a large mass palpable in the whole abdomen. Abdominal computed tomography (CT) showed a large mass occupying the entire abdominal cavity. Magnetic resonance imaging showed a well-defined tumor of low intensity on T1-weighted images and of high intensity on T2-weighted images. A barium enema showed the compression of the transverse colon by the tumor. Angiography revealed a feeding artery from the left renal artery. We performed a laparotomy based on a diagnosis of a tumor arising from the retroperitoneum. During the operation, the tumor was observed to arise from the retroperitoneum and to extend around the left adrenal gland. The resected specimen was encapsuled elastic hard tumor 395×250×170mm in size and weighed 7.5kg. The cut surface of the specimen was grayish-white in color with focal hemorrhages. Histologically, the tumor consisited of spindle cells in a storiform pattern surrounded by abundant patternless collagen. Immunohistochemically, the tumor cells were diffusely positive for CD34, Bcl-2, and MIC-2. Based on these findings, the patient was diagnosed as having a solitary fibrous tumor of the retroperitoneum. This is the largest SFT to be reported. The patient is alive without recurrence 21 months after the operation.

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A 39-year-old man with abdominal pain was admitted to our hospital with a diagnosis of acute enteritis. None of the laboratory tests or imaging findings were abnormal except for marked leukocytosis of 13, 100cells/mm³. He was treated with antibiotics for few days, and the symptoms and laboratory findings improved. After oral feeding was resumed, the abdominal pain worsened and he developed signs of peritonitis. Contrast-enhanced CT scans on the 11th hospital day showed a large volume of ascitic fluid, thickened small bowel, and thrombi in the superior mesenteric vein. Laparotomy was performed for a preoperative diagnosis of acute peritonitis secondary to mesenteric vein thrombosis. Congestive necrosis of 25cm of ileum and 35cm of jejunum was observed intraoperatively, and they were resected to healthy margins. Intestinal continuity was restored by end-to-end anastomosis. Histopathological examination showed transmural hemorrhagic necrosis of the small bowel and thrombi in the superior mesenteric vein. Laboratory studies showed low levels of protein S activity (11%) and protein S antigen (24.2%). Because the patient had no underlying disease that might have caused the thrombosis, we concluded that this was a rare case of the mesenteric vein thrombosis associated with protein S deficiency.

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A 51-year-old woman was admitted to our hospital because of right lower quadrant abdominal pain. There was tenderness in the right lower quadrant without signs of peritoneal irritation, and laboratory data showed slightly inflammatory reaction. Abdominal ultrasonography showed a low echoic leision of 2.0cm in diameter with a linear high echoic leision at the right lower quadrant abdomen. We underwent an emergency operation with a diagnosis of acute appendicitis. We found a pin whole and small abscess on the wall of ascending colon near Bauhin's valve, and a penetration of the other side with small abscess in the mesenterium. In addition, we found a thin stick foreign body in that ascending colon, so we underwent an ileocecal resection and drainage with a diagnosis of perforation by swallowing foreign body accidentally. The foreign body was a toothpick. In case of an examination for patient with acute abdominal pain, we need to consider the perforation caused by the foreign body.

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We report a case of a megacolon with intussusception prolapsing through the anus. A 38-year-old woman seen in an emergency for suspected rectal prolapse after defecation underwent emergency surgery after digital exploration confirmed prolapse. After manual by reducing the intussusception, we conducted a sigmoidectomy, but no tumor was found that might have cause the intussusception. This case is extremely rare, because all of the 30-some cases of such intussusception reported in Japan were caused by a tumor. We suggest that accurate diagnosis including checking for tumors and avoiding forcible manual reduction in surgery are very important considerations in such cases.

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We report 5 patients surgically treated for malignant tumors with nephrotic syndrome. The purpose of this report is to examine the post operative course with respect to the nephrotic syndrome. Only 1 patient had a malignant lymphoma, another 4 patients had colon cancer with nephrotic syndrome. Four out of five patients underwent a renal biopsy, and all of them had membranous glomerulonephritis. After surgical treatment of the tumors, remission of proteinuria and serum albumin can be expected.

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A 50-year-old man admitted for a possible recurrent carcinoid tumor involving the hypogastric nerve had undergone low anterior resection preserving the hypogastric nerve 5 years earlier due to a rectal carcinoid 11mm in diameter, initially diagnosed as an endocrine tumor of 40mm located at the bifurcation of the abdominal aorta. Regional lymph node metastasis was observed histologically and the tumor at the bifurcation was a metastatic lymph node. After about 4 years of follow-up he developed severe hypogastric pain. CT and US revealed a tumor involving the hypogastric nerve. We conducted tumor resection under the suspicion of carcinoid tumor recurrent in the anterior floor of the sacrum. Histological findings revealed a carcinoid tumor involving the hypogastric nerve. Initial surgery including resection of the hypogastric nerve may have prevented recurrence, although the patient was only 45 years old at the first surgery. He remains well without recurrence 24 months after the third surgery.

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We report a case of adenosquamous carcinoma of the rectum with synchronous multiple liver and bone metastases. A 73-year-old woman was admitted to our hospital complaining of narrow stools and lumbago. A biopsy specimen histologically revealed a poorly differentiated adenocarcinoma. She was diagnosed as having advanced rectal cancer with multiple liver metastases and bone metastasis based on imaging findings. She underwent a Hartmann operation for the relief of symptoms like bleeding and stenosis. Macroscopically, the type 3 tumor had a cross section of 3.0×3.0cm and was located in the rectum. Histological findings showed an adenosquamous carcinoma invading the subserosa with marked lymphatic and venous invasion. After the operation, she received combination chemotherapy with intrahepatic arterial infusion of 5-FU and intravenous infusion of CPT-11 and l-LV, according to the chemotherapy protocol for colon cancer. The characteristics of a large number of patients with adenosquamous cell carcinoma of the colorectum should be collected and analyzed. Furthermore, to improve the clinical outcome of patients with mu ltiple hematogeneous metastases, new adjuvant therapy using molecular and genetic approaches should be pursued.

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A 65-year-old man with gastric cancer underwent distal gastrectomy in November 2001, i. e., radical D2 resection with curability A. Histopathological findings were tub2, type2, mp, ly1, v1, and n0. In October 2003, he suffered melena. Colonoscopy showed a semicircular type2' tumor 6cm from the anal verge. Biopsy results showed moderately differentiated adenocarcinoma that developed more rapidly than expected for primary rectal cancer, suggesting metastatic rectal cancer. Specimens of resected gastric cancer and biopsied rectal cancer tissues compared using loss of heterozygosity (LOH) analysis showed patterns to be consistent between samples, yielding a diagnosis of rectal cancer metastatic after surgery for gastric cancer. In November 2003, further surgery was attempted, but resection was not possible, so colostomy was conducted. Postoperatively, he was treated with TS-1/CDDP chemotherapy and followed up, but died of hepatic failure in September 2004. LOH analysis was very useful in determining whether the cancer was primary or metastatic.

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