Introduction:We evaluated the effectiveness of D2-40 immunohistochemistry for detecting lymphatic invasion, in colonic adenocarcinoma with submucosal invasion removed under colonoscopy. Materials and Methods: Subjects were 30 cases of invasive colonic adenocarcinoma removed endoscopically and proven to have submucosal invasion. Serial paraffin sections were stained with hematoxylin-eosin (HE) or immunostained with D2-40, and the degree of lymphatic invasion was evaluated based on staining. Results: The number of lymphatic invasions was 2 lesions in 2 cases or 6 lesions in 5 cases by HE-stained or D2-40-immunostained sections. One lesion was detected by both HE and D2-40 antibody. The discrepancy in the degree of lymphatic invasion evaluated by HE or D2-40 was noted in 6 lesions in 5 cases. Underestimation in HE-stain-based evaluation compared to that in D2-40 was seen in 5 lesions among 4 cases. These were caused by obscure separation artifact, characteristic of lymphatic invasion, and the small size of lymphatic invasion. Overevaluation in HE-stained sections was noted in one lesion in 1 case, where D2-40 was unstained. Nonspecific D2-40 staining was often observed in tumor parenchyma, including structures just around the edge of tumor cell nests: this should not be confused with true lymphatic invasion. Conclusions: D2-40 is useful for accurately evaluating lymphatic invasion in colonic cancer with submucosal invasion undergoing colonoscopic resection.

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A 89-year-old woman undergoing fibroptic esophagoscopy elsewhere for dysphagia was found to have an esophageal tumor and was referred to our hospital. Upper gastrointestinal endoscopy showed a type 1 esophageal tumor about 3cm in diameter in the lower thoracic esophagus pathologically diagnosed as moderately differentiated squamous cell carcinoma from the biopsy specimen. CT and MRI showed metastasis in the right lymph node of cardia. Although we advised an esophagectomy, she did not agree to it due to her high age, so we treated her with radiochemotherapy. She underwent radiotherapy (54Gy) and chemotherapy (cisplatin and 5-FU) concurrently. It was effective and the tumor almost disappeared and the biopsy specimen showed few viable cells. After 12 months, the tumor recurred and the pathological diagnosis was so-called carcinosarcoma.She died 14 months after treatment and pathological autopsy showed the tumor of the esophagus to be so-called carcinosarcoma, but metastasized tissue consisted of squamous cell carcinoma and did not have a sarcoma component. We concluded that metaplastic change of squamous carcinoma cells into spindle cells, occurred due to radiochemotherapy and the tumor recurred as so-called carcinosarcoma.

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We report a rare case of primary nasal gastric Natural Killer/T-cell (NK/T-cell) lymphoma. A 46-year-old man having an aberration in gastric fluoroscopy screening. Gastroscopy had two erosive gastric lesions pathologically diagnosed as lymphoma. Immunohistochemical studies showed lymphoma cells to be positive for CD56 and TIA-1 and negative for CD8, CD79α and EBER-1, indicating NK/T-cell lymphoma. Systemic examinations with positron-emission tomography and compouted tomography (CT) showed no other lesions and no association with human T-cell lymphotropic virus type.I Under a definitive diagnosis of primary gastric NK/T-cell lymphoma, nasal type, stage I, he underwent total gastrectomy with D2 lymph node dissection. Since no lymph node metastasis nor invasion to muscularis propria were observed, no additional chemotherapy was added. He remains alive without recurrence 6 months after surgery.

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We experienced four cases of perforated duodenal diverticulum between January 1999 and December 2005. We reviewed 38 cases of perforated duodenal diverticulum reported in Japanese medical literature, including our own cases reported here, and then assessed the pathophysiology and treatment policies for perforation, which is a rare complication of duodenal diverticulum. The mean age of the patients with perforated duodenal diverticulum was 68.6 years, and the patients comprised 9 men and 29 women. Most of the chief complaints were abdominal pain, but the location was variable. Many cases were not associated with leukocytosis or muscular defense. The preoperative established diagnosis was low, 26.3%, and this condition was often difficult to diagnose. CT findings were the most useful results, enabling a definite diagnosis in 96.6% of the cases; retroperitoneal emphysema was also a characteristic feature. Surgery was the most common treatment. Most of the patients successfully underwent appropriate decompression and drainage in addition to a diverticulectomy. Nevertheless, the variable findings often make a definite diagnosis difficult, possibly leading to a deterioration in the patient. s condition.

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We report an extremely rare case of hepatocellular carcinoma accompanied by sarcoid reaction in regional lymph nodes. A 67-year-old man with chronic hepatitis C admitted for back pain had serum α-fetoprotein elevated to 60ng/ml. Abdominal ultrasonography showed a hyperechoic tumor about 4cm in diameter in segment 5 of the liver. Dynamic bolus computed tomography (CT) showed peripheral enhancement of the tumor, accompanied by enlarged lymph nodes around the common hepatic artery and the inferior vena cava. Hepatic arteriography showed tumor staining, and CT during arterioportography showed a perfusion defect, yielding a diagnosis of hepatocellular carcinoma. Transcatheter arterial embolization (TAE) of the right hepatic artery was conducted, followed by microwave coagulation therapy to the liver tumor with lymph node dissection under laparotomy. Microscopically, biopsy specimens of the liver tumor showed poorly differentiated hepatocellular carcinoma, and dissected lymph nodes involved tumor metastasis including marked epithelioid granulomas.

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We report two cases of resected hepatocellular carcinoma (HCC) with nonviral autoimmune hepatitis (AIH). Case 1: A 36-year-old woman treated for AIH for 23 years with predonisolone underwent partial hepatectomy for HCC. The tumor was 4.8 cm in diameter, and involved moderate to poorly differentiated HCC surrounded by well differentiated HCC. The non cancerous lesion showed chronic hepatitis. HBV-DNA and HCVRNA were negative in serum. Case 2: A 68-year-old woman treated for AIH for 20 years with PSL underwent systematic hepatectomy for HCC. The tumor was 2.5 cm in diameter, and histologically involved moderately differentiated HCC. The non cancerous lesion showed chronic hepatitis. HBV-DNA and HCV-RNA were negative in liver tissue and serum. It is supposed that HCC in AIH is caused by liver cirrhosis, long-term administration of steroids, or association of chronic viral hepatitis. It is necessary to check them. The non cancerous lesions in both cases showed chronic hepatitis. Both women had been treated for AIH with PSL for long periods, and had little relation to HBV or HCV.

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A 73-year-old woman with hepatocellular carcinoma (HCC) reported the sudden onset of abdominal pain and Dynamic computed tomography (CT) showed a tumor in the liver (S4), a high-density mass in the common bile duct, and dilation of the peripheral bile duct. Gastrointestinal endoscopy showed bleeding from the papilla of Vater. Based on a diagnosis of HCC with hemobilia from the intraductal tumor thrombus, we conducted extended left hepatectomy and complete removal of the intraductal tumor thrombus. Histological findings showed combined hepatocellular and cholangiocellular carcinoma. Although recurrent lesions were detected, she remains alive and well 24 months after surgery. There has been one case of combined hepatocellular and cholangiocellular carcinoma with hemobilia from intraductal tumor thrombus reported in Japan to date. The prognosis of a patient suffering from HCC with hemobilia from intraductal tumor thrombus is dismal, but several cases reported indicate the possibility that surgical resection may improve prognosis. Adequate hepatic resection with complete removal of the intraductal tumor may thus improve the prognosis patients with combined hepatocellular and cholangiocellular carcinoma with hemobilia from intraductal tumor thrombus.

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A 58 year-old woman with a gallbladder polyp was eventually diagnosed after hospital admission with having a congenital choledochal cyst with a bile duct tumor, although no pancreaticobiliary maljunction was detected. We resected the bile duct with the choledochal cyst and undertook Roux-en-Y reconstruction. The bile duct formed a diverticulum 6cm at the greatest dimension from the hepatic duct, and fibrosis and inflammatory cell invasion were found histologically. The tumor was found to be papillary carcinoma limited to mucosa without lymph node metastasis. Such type II choledochal cyst with early bile duct carcinoma is extremely rare. Exposure to pancreatic juice is thought to be a cause of bile duct cancer, but this was hard to conclude in this case.

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A 52-year-old man admitted for nausea, fever, and right hypochondrial pain was found in abdominal ultrasonography to have a swollen stone-free gallbladder with thickened walls. He was diagnosed as having acute acalculous cholecystitis and immediately treated with percutaneous transhepatic gallbladder aspiration (PTGBA), yielding suppurative bile. His fever and abdominal pain did not disappear, however, necessitating emergency cholecystectomy 48 hours after symptom onset. Laparotomy showed necrotic change in the gallbladder wall. Despite acute septic shock, his general condition immediately improved with hemoperfusion with polymyxin B-immobilized fiber. He was discharged on hospital day 36. Bile culture test showed Aeromonas hydrophila and Clostridium perfringens. Some reports state that these bacteriae infections are highly progressive, causing sepsis followed by multiple organ failure and death. Aeromonas and Clostridium infection accompanied by acute acalculous cholecystitis thus requires particularly vigilant monitoring.

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A 64-year-old man with hilar cholangiocarcinoma for whom right hepatectomy and caudate lobectomy and resection of the extrahepatic bile duct we were planned was found, during surgery, to have portal vein invasion necessitating portal resection and reconstruction with an end-to-end anastomosis. Bleeding developed due to portal hypertension. Palpation and ultrasonography showed thrombotic obstruction at the anastomotic site. Despite thrombectomy and reanastomosis, a similar reobstruction occurred although neither twisting nor stricture occurred at the anastomosis. Suspecting hypercoagulation, we conducted continuous heparin injection via a catheter placed in the gastroepiploic vein after rereanastomosis. No more thrombus was formed and the postoperative course was uneventful. Postoperative examination of coagulation showed a low level of Protein C on postoperative day (POD) 19, while liver function improved. Warfarin administration replaced heparin injection for Protein C deficiency. The man was discharged on POD 49 and has been well without thrombosis for one year.

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A case of hemobilia caused by a ruptured pancreaticoduodenal artery aneurysm (PDAA) is reported. The itially admitted for acute cholecystitis with gallstones and underwent a laparoscopic cholecystectomy after case was a 56-year-old man with a habit of heavy drinking and a history of chronic pancreatitis. He was in-medical treatments. The operative procedure was uneventful. On postoperative day 3, however, he suffered from acute pancreatitis. Medical treatments seemed to be effective, but he experienced sudden hematemesis on postoperative day 8.A gastrointestinal endoscopy revealed active bleeding from the papilla of Vater. Computed tomography showed an increased density in the common bile duct and swelling of the pancreatic head. An abdominal angiography demonstrated a pseudoaneurysm of the posterior superior pancreaticoduodenal artery and extravasation of the contrast medium at the site of the aneurysm. Under a diagnosis of PDAA ruptured into the common bile duct, embolization using micro-coils was performed and the bleeding was stopped. cases of previously reported PDAA are reviewed. The patient improved after the embolization, and re-rupture did not occur thereafter. PDAA is a rare type of abdominal visceral artery aneurysm, and hemobilia caused by a ruptured PDAA is very rare. Eighty-two cases of previously reported PDAA are reviewed.

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We report a case of acinar cell carcinoma (ACC) of the pancreas head with intraductal tumor growth to the main pancreatic duct. A 46-year-old woman was admitted because of a pancreatic tumor found during a general hospital examination. On admission, the patient showed no signs of abdominal pain or jaundice. Laboratory data showed mild elevations of serum pancreatic amylase and CA19-9. An abdominal ultrasonography and CT examination showed a solid tumor, 5cm in diameter, with a distinct border and expansive growth in the head of the pancreas as well as dilation of the distal pancreatic duct. Pancreatography showed an ellipticfilling defect in the main pancreatic duct. A pylorus-preserving pancreatoduodenectomy was performed. Macroscopically, the tumor was encapsulated and had a well-circumscribed appearance without invasion to the surrounding organs. Microscopically, it was diagnosed as an acinar cell carcinoma with intraductal tumor growth to the main pancreatic duct. The patient has been well for 8 months. Among domestically reported cases of ACC over the past 10 years, 40 resections were reported; three of these cases presented with intraductal tumor growth. ACC occasionally undergoes intraductal tumor growth, probably as a result of its expansive growth characteristic.

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A 36-year-old woman admitted for abdominal pain underwent US-guided drainage and ethanol injection under a diagnosis of a huge pancreatic cyst. When the cyst failed to shrink, she was referred to our hospital for further treatment. Computed tomography (CT) showed a multilocular cyst 20cm in diameter with enhanced nodules and calcification adhering to the pancreatic body and tail. Under a diagnosis of mucinous cystic tumor of the pancreas, we surgically resected the tumor together with the pancreatic body and tail. The tumor was diagnosed histologically as minimally invasive mucinous cystadenocarcinoma with ovarian-like stroma. Muci- nous cystic tumor resection after long-term follow-up is rare.

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We present a case of a 59-year-old man with encapsulating peritoneal sclerosis (EPS) probably induced by a peritoneo-venous shunt (PVS). In February 2000, a PVS was inserted to control ascites caused by liver cirrhosis. In November 2001, the patient developed acute abdominal pain, was diagnosed with strangulation ileus, and underwent emergency abdominal surgery, during which, almost all abdominal organs were found to be covered with an opaque white hard coat. A part of the coated lesion was torn, and the intestine was exposed and strangulated by laceration with necrosis. Based on these findings, the patient was diagnosed with EPS as-sociated with strangulation ileus. Clinical EPS symptoms are ileus-like and abdominal organs are covered with an opaque white thick coat and cocooned in lumps. EPS is known to be a complication of continuous ambulatory peritoneal dialysis (CAPD), and this case suggests that an indwelling catheter other than a CAPD catheter, i. e., a foreign body in the abdominal cavity, may also be a risk factor for EPS.

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A 77-year-old woman admitted for upper right abdominal pain was found in a barium enema and colonoscopy to have an ulcerative tumor of the ascending colon and moderately differentiated adenocarcinoma diagnosed from a biopsy. A hepatic left-lobe tumor concurrently found in abdominal ultrasonography, computed tomography, and magnetic resonance imaging suggested liver metastasis by its appearance. Right hemicolectomy and partial hepatectomy were done. On histopathological examination, lymphoid follicles with germinal centers were seen in the tumor-like hepatic lesion, and remarkable lymphoid infiltration with germinal centers was seen in the portal area around the nodule. Immunohistochemical studies showed polyclonality of the infiltrating lymphocytes, suggesting that this lymphoid lesion was reactive rather than neoplastic. The nodular lesion was thus diagnosed as reactive lymphoid hyperplasia of the liver (RLH). Such a diagnosis is possible from histological, immunohistochemical, and/or genetic studies, but it remains very difficult to completely rule out malignancies such as HCC, metastatic liver tumors, or malignant lymphomas based solely on diagnostic imaging findings. Preoperative biopsy is ultimately essential for diagnosis.

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A 30-year-old woman was referred to our surgical department because of a rectal tumor found by her gynecologist during delivery. Digital examination showed an unmovable, 4-cm elastic-hard tumor in the posterior to right wall of the lower rectum, just above the dentate line. Colono-fiberscopic findings showed an elevated submucosal tumor that had partially extended into the anal canal at the tumor. s deepest region. A CT scan revealed a solid 5-cm tumor involving the anal sphincter muscle. A core needle biopsy was performed under spinal anesthesia because the conventional colono-fiberscopic biopsy was unsuccessful. A histological diagnosis of the biopsy specimen indicated a gastrointestinal stromal tumor (GIST). Microscopic examination demonstrated spindle-shaped tumor cells with frequent mitotic figures and immunohistochemical positivity for c-kit and CD-34. The patient was treated with imatinib mesylate at a daily dose of 400mg. One month later, the size of the tumor had decreased to a diameter of 2.5-cm. Trans-anal local excision was performed, with anus sphincter preservation. This case showed that imatinib chemotherapy was significantly effective against GIST, making an abdominoperineal resection unnecessary. Although the primary treatment for GIST remains surgical resection, the present case suggests that imatinib may be useful as a neoadjuvant chemotherapy.

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We report a case of postoperative anaphylactic shock induced by a cross-reaction between gabexate mesilate (=FOY) and nafamostat mesilate (=FUT). A 64 year old man underwent pancreatoduodenectomy under a diagnosis of cancer of the papilla of Vater. He underwent postoperative infusion of FUT, 20mg. Immediately following the infusion, he suffered a whole-body rash and shock with edema. He recovered consciousness after oxygen therapy and steroid infusion. One hour later, respiration and circulation had returned to normal, despite increased eosinophilic leukocytes and abnormally high IgE antibody for FUT and FOY. Also, he had underwent infusion of FOY, second times, when he had got at the operation of laparoscopic cholecystectomy, which took place one year previously, and when he taken ERCP before the operation of pancreatoduodenectomy. We concluded that there were some possibility of a cross-reaction between FUT and FOY based on the similarity of an antigenic determinant, i. e., FOY sensitization and anaphylactic response to FUT

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We report a case of dedifferentiated liposarcoma of the spermatic cord that produced a widely infiltrative local recurrence. A 44-year-old man was referred to Tokyo Medical University Hospital with a diagnosis of inguinal hernia. Preoperative computed tomography and an echogram revealed a tumor in the groin. Postoperativly, the patient was followed on an outpatient basis. However, the patient did not return to the clinic for approximately fours years. Upon re-examination a recurrent, tumor was recognized in the left groin. Computed tomography revealed a tumor in the periphery of the external iliac artery. During surgery, the tumor was found to have infiltrated a wide area. Invasion to the sigmoid colon, left ureter, external iliac artery and vein, and to the bladder wall was noticed. The initial and recurrent tumor consisted partially of well differentiated liposarcoma and mostly of spindle cells with various degrees of atypia. Accordingly, a diagnosis of dedifferentiated liposarcoma was made. The patient.s condition improved after surgery, and he has been free of recurrence for 3 years since the operation.

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