PIVKA-II is a highly specific tumor marker for hepatocellular carcinoma (HCC) and is used to detect HCCearly in cirrhosis patients and to assess response to therapy and prognosis in HCC patients. The usefulness ofPIVKA-II in liver transplant recipients with end-stage cirrhosis or with HCC has yet to be clarified. Materialsand Methods: Subjects were 24 cirrhosis patients without HCC and 123 HCC patients undergoing liver transplantation between 1999 and 2005. Subjects were examined for the PIVKA-II distribution and its correlationwith histopathological findings of HCC and prognosis. Results: We found 58% of cirrhosis patients withoutHCC were positive for PIVKA-II. The mean Child-Pugh and MELD scores in the PIVKA-II positive group (10.8 and 20.9 points) were significantly higher than in the negative group (p<0.05). Of patients with HCC, cumulative recurrence at 5 years was significantly higher in the group with PIVKA-II≤400mAU/ml than inthose with PIVKA-II≤400mAU/ml (60% vs. 13%, p<0.01). Multivariate analysis showed that PIVKA-II exceeding 400mAU/ml was an independent predisposing factor for HCC recurrence (risk ratio, 5.984; p<0.01).Median PIVKA-II in patients with positive microscopic portal venous invasion was significantly higher thanthat in negative patients (p<0.01). Conclusions: High positive ratio of PIVKA-II in patients with cirrhosismay be due to severe liver damage. PIVKA-II is thus a highly useful tumor marker as a predisposing factorfor HCC recurrence of after liver transplantation, which is closely correlated with histopathological features ofHCC.

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The aim of this study was to evaluate clinical implication of the presence of other primary cancer (OPC) incases of colorectal cancer patients. A total 2, 141 cases were enrolled in this study. Of the total 387 (18.1%) hadOPC. There were 108 cases with synchronous and 288 cases with metachronous multiple cancers. The colorectal cancer cases with OPC had a significantly poorer prognosis as compared with those without OPC. Andthe rate of death for OPC was higher in patients with postoperative metachronous OPC than in those without.The major sites of OPC were the stomach (43.8%) and lung (15.3%) in males and breast (32.4%) and uterus (25.5%) in females. Multiple colorectal cancers appeared to be a risk factor for OPC. Postoperative metachronous gastric cancer was frequently found five to ten years after the operation and lung cancer within fiveyears after the operation. We must carefully monitor patients for the development of OPC, in particular, gastric cancer and lung cancer, especially in patients with multiple colorectal cancers.

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We report a case of reconstructive gastric tube necrosis 6 months after subtotal esophagectomy. A 62-year-old man underwent posterior mediastinal reconstruction with half a gastric tube following subtotal esophagectomy and partial gastrectomy for advanced thoracic esophageal cancer and early gastric cancer. Postoperative chemoradiotherapy was added for residual cancer on the aortic wall. Six months after surgery, he was admitted for fever and general fatigue. Computed tomography and gastrointestinal endoscopy showed a reconstructive gastric tube ulcer. This was complicated during conservative therapy by a gastric tube tracheal. Despite mediastinal drainage, partial gastric tube resection, pericardium patch for the tracheal fistula and esophagostomy, he died due to multiple organ failure. The possibility of reconstructive gastric tube necrosis should thus be considered in symptoms associated with mediastinitis even several months after esophagectomy.

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We report surgical management of radiation-induced massive pericardial effusion. A 55-year-old man undergoing definitive chemoradiotherapy (CRT) for esophageal squamous cell carcinoma in the middle thorax was treated with megavoltage equipment using anterior-posterior opposed fields up to 45Gy, including the primary tumor and regional lymphnodes. A booster dose of 25Gy was given to the primary tumor for a total dose of 70Gy, using bilateral oblique fields. Three years and 6 months later, he was treated with an additional 30Gy for mediastinal lymphnode metastasis, followed by percutaneous pericardiocentesis for cardiac tamponade with massive pericardial effusion 4 times in 5 months. Because medical intervention was inadequate, he underwent pericardial effusion via video-assisted thoracoscopic pericardial window placement 4 years and 6 months after definitive CRT. Histopathological examination of the pericardial tissue specimen showed marked fibrosis but no cancer recurrence, compatible with radiation pericarditis. The postoperative course was uneventful, and pericardial effusion completely disappeared.

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We report an extremely rare case of gastric submucosal adenocarcinoma arising from the ectopic pancreas. A 64-year-old man followed up for pleural disease was found in chest computerized tomography (CT) to have an enhanced 3cm tumor on the prepyloric greater curvature. Gastrointestinal endoscopy showed a smoothsurfaced solid tumor covered with intact mucosa in the prepylorus, and endoscopic ultrasonography showed a hypoechoic mass mainly located in the proper muscle layer. Retrospective reconfirmation of the previous CT showed that the 2-year-old tumor had remained almost unchanged in size. Since pyloric obstruction occurred just before operation, we conducted laparoscopic pylotectmy on a preoperative diagnosis of gastrointestinal stromal tumor of the stomach. Intraoperative pathological examination showed distributed tubular structures and a suspected ectopic pancreas. Postoperative histological examination diagnosed adenocarcinoma arising from the ectopic pancreas, because this tumor, occupying the submucosal layer to subserosa, consisted of transition between normal ductal epithelium and epithelial cancer cells. It is thus important to consider the coexistence of malignancy in submucosal tumor.

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Most gastrinoma occurs in the so-called gastrinoma triangle, and ectopic gastrinoma is rare. We report a case of possible primary gastrinoma of the lesser omentum. A 74-year-old woman who previously suffered twice from the duodenal ulcer perforation and underwent distal gastrectomy was referred for high serum gastrin. Intravenous glucagon injection caused a paradoxical increase in serum gastrin. Computed tomography and magnetic resonance imaging showed a tumor in the lesser omentum close to the gastric remnant. An intraarterial glucagon injection test showed the tumor to be a gastrinoma fed by the left gastric artery. We resected the gastric remnant with the tumor, which was diagnosed histologically as an endocrine tumor secreting gastrin. No increase in serum gastrin was observed in intraoperative or postoperative intravenous glucagon in jection tests. The woman shows no signs of recurrence and her serum gastrin is within the normal range in the 2 years since surgery. The glucagon provocative test was thus useful in diagnosis and treatment of possible primary gastrinoma in the lesser gastric curvature.

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A 81-year-old man with 2 days of nausea, vomiting, and mild abdominal pain and a medical history of an abdominal aortic aneurysm (AAA) diagnosed 5 years earlier was admitted as an emergency patient because of these symptoms. Computed tomography showed duodenal compression and a markedly dilated stomach and oral duodenum with an intact 7.5cm infrarenal AAA. The patient was diagnosed with a duodenal obstruction caused by the aneurysm. Elective graft replacement of the aneurysm was conducted successfully after gastric decompression. He made an uneventful recovery and remains well in follow-up. AAA is a rare cause of duodenal obstruction. We report the unique cause of duodenal obstruction secondary to expansion of an infrarenal AAA.

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Hepatocellular Carcinoma associated with Budd-Chiari Syndrome (BCS) is a relatively rare disease. A 52 year old woman was admitted to the hospital complaining of a bronchial asthma, and liver tumor, splenomegaly, and the dilatation of the azygos vein, and ascending lumbar vein were incidentally found. She was referred to our hospital for further examination and treatment. Hepatocellular carcinoma, 5cm in size, was detected in the segment 5 of the liver. The chest enhanced CT demonstrated the membranous obstruction of the inferior vena cava at the level of the diaphragm. A cavography additionally showed the development of collateral vein, ascending lumbar vein and azygos vein, that communicated with the superior vena cava. BCS associated with hepatocellular carcinoma was evident. Partial resection of the liver was carried out. No treatment was applied to the membranous stricture of the caval vein because of little pressure defference between the inferior vena cava and superior vena cava and of the absence of portal hypertension. We herein report a case of hepatocellular carcinoma associated with BCS and discuss the treatment strategy.

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A 67-year-old man admitted for sudden severe upper abdominal pain was found in abdominal computed tomography to have ruptured hepatocellular carcinoma (HCC) in the left caudate (Spiegel) lobe protruding caudally with hematoma into the lesser omentum. After hemostasis, stabilization of his general condition, and liver function evaluation, we conducted T2-weighted imaging that showed a low-intensity mass occupying the entire Spiegel lobe and involving the proper hepatic artery and portal vein. We conducted partial hepatectomy after his general condition improved. Macroscopically, the tumor was attached by a stalk to the surface of the Spiegel lobe. Histological examination showed moderately differenciated hepatocellular carcinoma and hemorrhagic change in the stalk. The postoperative course was uneventful. Twelve case reports of HCC rupture of HCC of the caudate lobe have been made, to the best of our knowledge, and a case of spontaneous HCC rupture of the Spiegel's lobe with a stalk is very rare.

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Cholesterol crystal embolization (CCE) is caused by micro showers of cholesterol crystals and has recently been recognized as a serious complication after vascular procedures. An 86-year-old Japanese woman underwent percutaneous coronary artery angioplasty via the right femoral artery. Ten days later, she developed acalculous cholecystitis and was treated by cholecystectomy. Histological exploration of the resected specimen revealed the diagnosis of cholecystitis caused by CCE. Although she could discharge our hospital once after the operation, her renal function began to worsen gradually with eosinophilia and the patient died due to heart failure 6 months after the operation. Although cholesystitis caused by CCE has only rarely been reported, the possible complication of acalculous cholecystitis caused by cholesterol crystal embolization must be borne in mind. The diagnosis of cholesterol crystal embolization after routine cholecystectomy suggests severe systemic involvement and a poor prognosis.

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A 77-years-old man admitted for jaundice and white stool was diagnosed with a middle and lower bile duct or pancreas head cancer, necessitating subgastric preserving pancreaticoduodenectomy with lymph node dissection. Resected material showed two tumors in the middle and lower bile duct and pancreas head. Histopathologically, signet ring cell carcinoma of the middle and lower bile duct had infiltrated the pancreas severely, and well-differentiated tubular adenocarcinoma was found in the pancreas head. We diagnosed this as a collision of two cancers because no cell transference was found between the two tumors. The patient underwent adjuvant chemotherapy using gemcitabine and remains alive with no evidence of reccurrence 14 months after surgery. Collision cancer of the pancreas showed features of both middle-lower bile duct and pancreas head cancer in preoperative imaging, making the diagnosis very difficult.

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A 68-year-old man admitted for right upper abdominal and back pain had undergone cholecystectomy in 1966 and congenital biliary dilation excision with hepaticojejunostomy by Roux-Y anastomosis in December 1998. Abdominal computed tomography (CT) and magnetic resonance imaging (MRI) showed a 45mm tumor in the pancreas head but no pancreatic duct dilation. ERCP showed a cystic lesion communicating with the remnant bile duct. Abdominal angiography showed hypervascular tumor staining. We conducted pancreaticoduodenectomy based on a diagnosis of cholangiocarcinoma arising in the intrapancreatic remnant bile duct. Histopathologically, adenosquamous carcinoma originated from the intrapancreatic remnant bile duct, with synchronous carcinoma of the papilla of Vater and the duodenum. None of the three carcinomas were connected. This is, to our knowledge, the first report of adenosquamous carcinoma arising in the intrapancreatic remnant bile duct after congenital biliary dilation excision accompanied by synchronous triple carcinomas consisting of intrapancreatic cholangiocarcinoma, carcinoma of the papilla of Vater, and duodenal carcinoma.

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We report a rare case of pancreaticobiliary maljunction without bile duct dilation associated with lower bile duct cancer after operation of gallbladder cancer. A 57-year-old woman admitted for suspected gallbladder cancer, was found in magnetic resonance imaging to have a hypertrophied heterogeneous gallbladder wall and pancreaticobiliary maljunction without bile duct dilation. Under a diagnosis of gallbladder cancer with pancreaticobiliary maljunction without bile duct dilation, she underwent surgery and was pathologically diagnosed postoperatively with gallbladder cancer, SS, N0 Stage II sCurA. Twelve months later, her DUPAN-2 elevated and continued to increased. PET computed tomography showed accumulation in the pancreas head and MRI a mass 20mm in diameter in the intrapancreatic bile duct. Eighteen months later, a malignant tumor of the bile duct necessitated pylorus-preserving pancreaticoduodenectomy. Pathological findings indicated that tumor cells had expanded flatly to the bile duct epithelium, leading to a diagnosis of primary adenocarcinoma of the bile duct. Many reports have mentioned pancreaticobiliary maljunction without bile duct dilation was frequently accompanied by gallbladder cancer, but bile duct cancer is rare.

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We report a case of endometriosis of the appendix and ileum with intestinal obstruction and acute appendicitis.A 42-year-old woman seen for right lower abdominal pain and vomiting was found in the physical examination to have tenderness and rebound tenderness in the right lower abdomen. Abdominal X-ray showed an intestinal obstruction. In emergency surgery based on a preoperation diagnosis of ileus with acute appendicitis, we found that the appendix had adhered to the ileomesenterium. After adhesiolysis, we observed wall thickening and some bleeding of the ileum and intussusception of the appendix into the cecum about 2cm in diameter.We then resected the appendix. Endometriosis tissue found in the submucosa and muscle layer of the appendix yielded a pathological diagnosis of endometriosis of the appendix. Postoperative hormone therapy was not effective, and the patient suffered abdominal pain and appetite loss. Magnetic resonance imaging showed left ovarian cyst suggesting endometriosis. We conducted ileocecal resection, total hysterectomy, and bilateral salpingoophorectomy 2 months after the first surgery. Pathological examination showed endometriosis affecting the uterus, bilateral ovary, and ileum. The patient has shown no recurrence in the 3 years and 9 months since her last surgery.

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We report a case of asymptomatic pulmonary embolism (PE) and deep vein thrombosis (DVT) detected before surgery for sigmoid colon cancer. A-73-year-old man diagnosed with pulmonary embolism by chestcomputed tomography (CT) was found in pulmonary perfusion scintigraphy to have multiple defects in both lungs and in venograpry of the lower extremities to have DVT in both legs. Anticoagulant therapy was started immediately. After 14 days, no apparent thrombus was seen in the pulmonary artery by pulmonary angiography. After implantation of a vena cava filter to prevent PE, We conducted sigmoidectomy with postoperative anticoagulant therapy and the use of elastic stockings. Our results suggests that the possibility of asymptomatic PE can be recognized perioperatively.

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A 25-year-old man admitted for abdominal pain and fever was found in blood tests to have inflammation and high AFP tumor markers. Abdominal computed tomography (CT) showed a 5cm tumor above the inferior mesenteric artery (IMA) with one swollen lymph node para aorta. We conducted surgery under a diagnosis of retroperitoneal abscess. The tumor was located around the IMA, and resected. The definitive pathological diagnosis was retroperitoneal yolk sac tumor (YST). One month after surgery, he was found by CT to have recurrence. We started chemotherapy. The patient had no evidence of recurrence in the 6 months after chemotherapy. The key in treating this disease is early diagnosis followed by early chemotherapy.

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