In our therapeutic guidelines for anaplastic carcinoma of the thyroid, we first conduct either excision of the tumor (surgery) or open biopsy with radiation as local control to avoid asphyxy due to the increasing tumor, followed by chemotherapy. This study was designed to compare the therapeutic results retrospectively between the surgery group and open biopsy with radiation group. Subjects were 21 (3.1%) evaluable patients with anaplastic carcinoma from a series of 668 cases of primary thyroid carcinoma treated at the hospital in a recent 16-years from January 1980 to December 1995. Of these 21 cases, 10 cases underwent surgery (Group S) and 11 cases open biopsy with radiation (Group B). There was no significant difference between Group S and Group B in clinical factors such as age, tumor size, tumor extent, distant metastases, and treatments except for surgery. One year survival rate was 10.0% in Group S and 27.3% in Group B. Although there was no significant difference in the survival rate, Group B outnumbered Group S4 to 2 in long survival patients who survived more than one year. Moreover, though no significant difference was noted in local recurrence, a better influence on the patients' quality of life in Group B was evident. Therefore, the most effective strategy for anaplastic carcinoma of the thyroid at present is to perform open biopsy with radiotherapy followed by chemotherapy as soon as possible after diagnosis. Surgery should be permitted in only operable cases without resecting the surrounding organs.

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To evaluate the clinical significance of matrix metalloproteinases (MMPs) and tissue inhibitor of metalloproteinases (TIMPs). we analyzed plasma concentrations of MMP-1, 2, 3, 9 and TIMP-1, 2 in patients with breast cancer (patient group) using the enzyme immuno-assay technique. The average levels in 32 patients were compared with the levels of 50 healthy women (control group).
The average levels of all MMPs were no higher in the patient group than in the control group. On the contrary, the average level of TIMP-1 was significantly lower in the patient group than in the control group.
Thus, the total concentration of MMPs divided by the total concentration of TIMPs (MMPs/TIMPs ratio) was elevated in the patient group. Furthermore, the MMPs/TIMPs ratio correlated with the lymphatic permeation. These results suggest that the TIMP-1 and the MMPs/TIMPs ratio correlate with lymphatic permeation of breast cancer.

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Breast cancer is a malignant tumor that commonly metastasizes to bones, but not a few long survivors can be seen after bone metastasis occurs. Appropriate selection of therapies would afford an improvement in the patient's quality of life and an effect of life-prolongation, and hence we should be careful to deal with such patients. Of 540 patients with primary breast cancer treated at the hospital in a recant 26-year period since 1971, 60 patients experienced bone metastasis were subjected to study of clinicopathological prognostic factors.
As a result, patients with breast cancer who were liable to have bone metastasis had: (1) small tumor with solid-tubular carcinoma or scirrhous carcinoma, (2) papillotubular carcinoma with tumor lenge, and (3) n0 and negative vascular invasion with solid-tubular carcinoma. The patients with solid-tubular carcinoma had easily bone metastasis, but they were found the foci in an early stage and lived for a long time after bone metastasis occurred. It is necessary to examine carefully about bone metastasis for the patients with above mentioned, especially within 5 years after operation.

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Although the presence of axillary lymph node (Ax) metastasis is currently the most important prognostic factor of breast cancer, the significance of parasternal lymph node (Ps) involvement as the prognostic factor has been still unknown. The paper deals with the significance of Ps metastasis as prognostic factor. Subjects were 267 cases of breast cancer undergone lymph node dissection including Ps. Methods of the investigation included a comparison of survival rates by numbers of positive Ps and a multivariate analysis (Cox model) using Ax metastasis, tumor diameter, histological differentiation lymphatic invasion, ER and protein expression of p53 or c-erbB2 as descriptive variables to speculate the contribution of Ps metastasis to the prognosis. When the survival rates were compared by dividing the subjects into three groups by the number of positive Ps, none, one, and more than two, there was a significant difference (p<0.01) among these three groups in an order of Ps_??_2, Ps=1 and Ps=0. Another study of comparing the survival rates by the number of positive Ps (Ps=0 versus Ps_??_1) after the subjects were divided into three groups by the number of positive Ax, none, 1 to 3, and more than 4, resulted in a significantly higher survival rate in Ps=0 group than Ps_??_1 group. In the multivariate analysis, Ps metastasis was the most prominent prognostic factor.
It is concluded that to know the presence of Ps metastasis in breast cancer is useful in estimating the prognosis and determining therapeutic plan for adjuvant chemotherapy.

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Simultaneous surgery was performed in 8 patients with malignant neoplasms complicated by cardiovascular diseases. The malignant neoplasms were lung cancer in 3 patients, colon cancer in 2, stomach cancer in 2, and liver cancer in 1. The complicating cardiovascular diseases were ischemic heart disease in 3, valvular heart disease in 2, abdominal aortic aneurysm in 2, and thoracic aortic aneurysm in 1. In the simultaneous operation, the first objective was improvement and maintenance of hemodynamics, and the radicality of the treatment for malignant neoplasms was pursued secondarily. However, operations for malignant neoplasms were performed first depending on the stage of the disease and the state of the surgical field. The approaches were obtained separately for prevention of infections except when both operations could be performed in the same operative field, and efforts were made to minimize the surgical insult especially in patients managed with an artificial heart-lung support. The surgical insult of simultaneous operation is considered to have been tolerable with the absence of prolonged operations, massive hemorrhage, or postoperative complications. All patients have been adequately rehabilitated, and all have been observed for a maximum of 54 months (mean 24 months) without signs of recurrence. From these results, simultaneous operation for malignant neoplasms and cardiovascular diseases is considered to be preferable if the neoplasms can be treated radically, and the patient is expected to tolerate the surgical insult.

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Clionicopathological studies were conducted in 176 cases with simultaneous multiple gastric cancer (MGC) for comparison with solitary gastric cancer (SGC) cases operated on during the 1967 to 1994 period. The prevalence of MGC was 6.3% of resected gastric cancers. MGC was found more frequently in older and male patients than SGC. Both main and second lesions were located in the gastric body and antrum in 112 cases (61.9%) with MGC, and 32 cases had tumors located in the cardia and the antrum. Multiple early gastric cancer was found in 107 MGC cases. In multiple early cancer (MEC), macroscopically elevated lesion (31/105 cases: 29.5%) and histologically differentiated type (128/176 cases: 77.1%) were found more frequently than in solitary early cancer (SEC). Second lesions macroscopically similar to the main lesion were revealed in 64.8% of the patients. Lymph node metastasis was significantly less evident in MGC cases. Although the survival rate of patients with MGC was almost identical to that of patients with SGC, that of MEC patients was significantly lower than that of SEC patients. Since the relative survival rate of MEC patients was almost the same as that of SEC patients, age and sex were considered to influence the prognosis of MEC. This study suggests that careful decisions regarding surgical indications for gastric cancer and meticulous follow-up of the remnant stomach should be carried out with consideration of MGC.

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In total, 573 lesions were resected from 518 patients with primary gastric mucosal cancer in Hiroshima City Hospital over the last 20 years, and the patients with ly(+) or v(+) lesions were analyzed from the clinicopathological point of view. The results were as follows. 1) 17 patients (3.0%) had ly(+) lesions, 3 (0.6%) had v(+) lesions. 2) In all but one case the lesions were located in the M or A area. 3) In all cases except two the lesions were depressed or mixed type. 4) Although one lesion was pap, the others were sig or tub 1, 2. However, there were no significant differences between the differentiated and undifferentiated types. 5) The maximal tumor diameter ranged from 1.5cm in the n(+) cases, but in the ly(+) cases from 0.7cm less than those cases. 6) 12 patients had n(+). Although 7 of the latter had ly(+), there were 3 n(+) cases even among the ly(-) cases. Furthermore, the 10 cases had depressive compartment. 7) Two patients died of another disease and one died of bone metastasis. The other patients are all alive. These results indicate that gastrectomy with node dissection should be done for the depressed or mixed type of lesion which has the possibility of being not only n(+) but also ly(+), v(+) even in the case of mucosal cancer.

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In order to identify an adeqauate surgical treatment for elderly gastric and colorectal cancer patients, clinicopathological features and surgical results of the patients over 80 years of age were compared with those of patients between 75 and 79.
Although more invasive procedures were performed for patients between 75 and 79, postoperative complications were higher in gastric cancer patients over 80 (94.7%) than in those between 75 and 79 (64.9%) (p<0.05). The incidence of postoperative pulmonary complications was higher in gastric cancer patients over 80 (73.7%) than in those between 75 and 79 (37.8%) (p<0.05). In colorectal cancer, complications which were not directly related to operative methods, i.e., pulmonary complications, occurred frequently in patients over 80.
The cumulative survival rate was lower in patietns over 80. In particular, the prognosis of the patients over 80 with postoperative pulmonary complications was poor.
The number of dissected lymph nodes and the incidence of combined resection of other organs were higher in the gastric cancer patients with postoperative pulmonary complications, and multiple proce-dures extending to the upper abdomen were frequently performed for colorectal cancer patients with pulmonary complications.
These results suggest that radical lymph node dissection and combined resection of other organs in the treatment of aged patients with gastric cancer, and multiple procedures extending to the upper abdomen in aged colorectal cancer patients, should be minimized to prevent postoperative complications and improve the prognosis.

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Thirty seven patients with resectable peritoneal dissemination that were curability B in colorectal cancer were analyzed clinically and assessed factors which influence the survival. The 5-year survival rate was 31.4% and according to the multivariate analysis, there were two prognosis regulating factors included the number of disseminations of 3 and fewer and lymph node metastasis of n2 and under. Patients possess above two factors have good prognosis (survival at 5 years=56.8%). Based on prior statistical analysis. P1 and P2 divided into two groups according to the number of disseminations of 3 and fewer or 4 and over respectively. There were no statistical difference in two groups in P1. But in P2, three and fewer group had a statistically superior survival than 4 and over. And there were no statistical difference between 3 and fewer group of P2 and all of P1. These results suggest that it is appropriate that disseminations to the remole peritoneum of 3 and fewer are included P1 and 4 and over are included P2.

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In order to obtain better accuracy of lymph node (LN) metastasis from lower rectal cancer by preoperative imaging, we investigated the incidence of pararectal LN by each size of surgically resected specimens. We also determined the metastatic rates by each size and tried to apply this method to clinical use. Forty-four patients who underwent curative A or B procedure were divided into two groups; 23 patients with negative lymph nodes were assigned to group N(-), and 21 patients with positive lymph nodes, to group N(+). In group N(-) negative LNs gradually decreased in the size of more than 5mm and no LNs in the size of 10mm or over were apparant. In group N(+) LNs significantly increased in the size of 6mm in comparison with group N(-) and the rate of metastasis to LN in the size of more than 10mm was 92.9%. If the detection of LN in the size of 5mm or more in each patient is regarded as metastasis, the accuracy of detection of the patients with positive nodes was 72.7% (32/44). If the largest size is designated as more than 6mm, the accuracy was 79.5% (35/44), and if more than 7mm, 72.7% (32/44). The accuracy, sensitivity and specificity of imaging diagnosis by CT were 61.3%, 59.1% and 63.6%, respectively. LNs more than 5mm in size on imaging have been diagnosed as metastasis in accordance with the conventional criteria. But, if LN more than 6mm in size is regarded as metastasis, the accuracy is 72.7% by CT. In conclusion, we would recomend to alter the clinical criteria for metastatic pararectal lymph node size to more than 6mm from more than 5mm in lower rectal cancers in order to obtain better accuracy by imaging.

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A 61-year-old woman was admitted to the hospital because of a rapidly enlarging tumor in the right submandibular region. The tumor resection was performed under a diagnosis of malignant tumor in the submandibular gland by clinical findings, CT, magnetic resoname imaging (MRI) and angiography. But a part of the tumor could not removed because it invaded the carotid artery and jugular vein. Resected tumor was 17.6×10.7×9.5cm in size and 960g in weight. Histopathological examination revealed carcinoma in plemorphic adenoma. Postoperatively, the remnant tumor was slightly decreased in size by irradiation at 53 Gy. However, a cardiac mass was detected by ultrasonography (US) on the 74th postoperative day. A diagnosis of cardiac metastasis of the carcinoma in pleomorphic adenoma was made because malignant cells were detected by cytology of pericardial fluid. The patient did not respond to adjuvant chemotherapy and died on 221st postoperative day because the remnant submandibular tumor enlarged and the general condition deteriorated. This case so rare that a carcinoma in pleomorphic adenoma metastasized to the heart.

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Extraskeletal mesenchymal chondrosarcoma (EMCS) shows undifferentiated mesenchymal cells and cartilage tissue histologically. A case of radiosensitive EMCS of a 71-year-old woman is reported. In July, 1996, she noticed a tumor in her neck. She was admitted to a local hospital and surgical excision was performed under a diagnosis of malignant tumor of the neck on July 15. histological examination of the resected specimen revealed EMCS. However, had a local recurrence one month after the operation. the tumor grew rapidly. She was referred to our hospital. There was a large, elastic hard tumor on the left side of the neck. Ct and MRI showed that the tumor invaded surrounding tissue such as the left carotid artery, jugular vein and trachea. We judged that radical operation could not be achieved. Thus, she underwent radiation therapy (total 64Gy) which was very effective, and the tumor diminished in size remarkably. On November 19, the second operation was performed. The tumor was completely resected with the jugular vein and the right lobe of the thyroid grand. The pathological specimen showed cartilage tissue without undifferentiated mesenchymal cells. She remains well 4 months after this surgery.

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A 62-year-old man with a history of chronic hemodialysis for 13 years was admitted for secondary hyperparathyroidism. Preoperative imaging studies demonstrated an enlarged parathyroid gland. During the survey, two additional enlarged glands were identified and removed. Extensive surgery including thymic tongues failed to find the left inferior gland. The left thyroid lobe was resected. Histological examination revealed an ectopic intrathyroidal parathyroid gland. The numbers and locations of parathyroid glands vary among cases. If parathyroid glands are left in situ, hyperparathyroidism will persist or recur. If extensive survey of the neck including thymic tongues fails to identify at least two parathyroid glands on either side, an ipsilateral thyroid lobectomy is recomended because of a possible ectopic intrathyroidal gland.

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The case of a 73-year-old woman with multiple lumps in both breasts due to polyarteritis nodosa is reported. Fever up to 38°C and multiple tender lumps were present in both breasts. Cefaclor 500mg/day and mefenamic acid 250mg/day were not effective.
About one month later, she visited our hospital. Multiple lumps were palpable in the both breasts. The diameters of the lumps were 5-8mm. Echography revealed echogenic tumors localized to the subcutaneous fat tissue in both breasts. Biopsy of a subcutaneous breast lump was performed. Pathological findings were panarteritis involving medium-small-sized arteries and a surrounding inflammatory reaction. Polyarteritis nodosa (PN) was suggested. No dysfunction of other major organs was found. Five cases with localized-PN of the breasts have been reported in japan, suggesting that this case is cutaneous PN. We can not, however, rule out that the present case may develop systemic PN. Close follow up is necessary.

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We report a case of recurrent breast cancer with bone metastases, which were negative on skeletal bone survey or bone scintigram, and positive for whole body positron emission tomography (PET). A 48-year-old woman was admitted to our hospital because of left cervical lymphb node metastases. She had undergone modified radical mastectomy for left breast cancer 17 months previously. Chest X-ray, routine head CT scan, abdominal ultrasound, GI tract examinations, skeletal bone survery, and bone sctintigra-phy were performed, but there were no abnormal findings except left cervical lymph node swelling. Whole body PET was performed. It revealed abnormal accumulation not only in the left supraclavicular area but also in the cervical spine, Th-spine and L-spine. MRI revealed typical bone metastases of the spine. Whole body PET was useful for detecting bone metastases in this case.

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This paper describes our experience with a case of inflammatory breast carcinoma with psoas muscle metastasis. The patient was a 56-year-old woman. She underwent standard radical mastectomy for a right inflammatory breast carcinoma on Feburary 27, 1995. After chemotherapy, she was followed on an ambulant basis. In August, 1995, she complained of lumbago and was found to have a tumor by ultrasound. She was admitted to the hospital for examination and treatment. The tumor was diagnosed as neurinoma or sarcoma by ultrasound, computed tomography, magnetic resonance image and angiography. She was operated on October 9, 1995. There was hematoma rather than a tumor of the left psoas muscle and we resected it with psoas muscle. Pathologically, cancer cells infiltrated the psoas muscle and resembled the breast carcinoma cells. The pathological diagnosis was inflammatory breast carcinoma with psoas muscle metastasis.
Inflammatory breast carcinoma with psoas muscle metastasis is rare. Only two cases have been reported, to date.
Though the diagnosis of retroperitoneal tumor should be made comprehensively with a variety of imagingmodalities, definitive diagnosis relies upon pathological examination. The tumor occasionally has a malignant potential, such that surgical resection is recommended.

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We experienced an extremely rare case of invasive breast cancer localized at the nipple. A 47-year-old woman was seen at the hospital because of a swelling and eczematoid change of the right nipple. We found a 3.5cm tumor of the nipple but no mass at the subareolar area. This lesion was diagnosed as invasive breast cancer localized at the nipple. Breast conservative surgery (Bp (2cm)+Ax) with nipple-areolar-complex involved, so-called central quadrantectomy, was performed. Microscopically the tumor showed the finding of papillotubular carcinoma and occupied her nipple completely with a little intraductal component spreading into the underlying mammary gland. One of five axillary lymph nodes dissected showed metastasis. Postoperatively she was treated with radiation therapy to the intact breast to at a dose of 55Gy. In future a nipple-areolar plastical surgery will be expected.
There are only three case reports about invasice ductal carcinoma of the nipple, of which modified radical mastectomy in two and partial mastectomy in one were performed. In this paper we discuss the indication of breast conservative surgery for the breast cancer located in the central area.

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We have successfully treated two cases of so-called descending necrotizing mediastinitis resulting from acute laryngopharyngitis or phlegmon of the floor of oral cavity, with aggressive drainage and irrigation.
A 59-year-old man had an abscess which surrounded the tracheobronchial bifurcation, appeared as a mass-like abscess formation in the right upper anterior mediastinum, and descended to the posterior mediastinum. He was also associated with bilateral pyothorax. Another 23-year-old man had characteristic remarkable pneumomediastinum and pyothorax as well as cardiac tamponade due to pyopericarditis. Both patients were successfully cured by aggressive combination therapy including administration of antibiotics, mediastinal drainage and pericardiac drainage via median sternotomy, intercostal thoracic drainage, and irrigation of the abscess cavity.
We think that sufficient draiange of descending routes of the abscess may lead to a favorable therapeutic result for cases of descending necrotizing mediastinitis which resist antibiotics regimen and become worse.

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Acute mediastinitis after cardiovascular surgery is the most common cause of acute mediastinitis. Descending necrotizing mediastinitis (DNM) causing deep neck infection is a life threatening disease with a reported mortality of 40%. In this paper we present two cases of DNM which were successfully treated by transcervical drainage with or without mediastinal drainage with video assisted thoracotomy. A 65-year-old man was admitted to the hospital because of dental infection associated with acute medias-tinitis. Transcervical draiange was successful. The patient was discharged in good condition. Another patient, a 46-year-old man was admitted to the hospital because of tonsillitis associated with acute mediastinitis. Transcervical drainage was not enough. Mediastinal drainage and debridement with video assisted thoracotomy were successful in this case. CT of the chest was essential in the diagnosis of mediastinitis. In the treatment of DNM, cervical drainage as well as debridement and drainage with video assisted thoracotomy is advocated to salvage the patient.

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We report a case of bronchial artery-pulmonary artery communication. A 36-year-old man was seenat our hospital because of a chief complaint of hemoptysis. CT scanning revealed cylindrical brow chiectasis, but bronchoscopic and cytologic examination presented neither endoscopic nor cytologic abnormalities. He was followed-up, but then admitted to our hospital because of massive hemoptysis. Bronchial angiography revealed a communication between the bronchial and pulmonary arteries. Bron-chial artery-pulmonary artery communication was considered to be derived from bronchiectasis. There-fore, right middle lobectomy was performed. He is now leading a normal social life two years after the surgery without hemoptysis. Communications between the bronchial and pulmonary arteries due to bronchiectasis are very rare, and only 14 cases including ours have been reported in the Japanese literature.

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A patient with esophagogastric phlegmon who presented with symptoms seemed like myocardial infarction and had an acute clinical course was successfully treated by peritoneal drainage and incision drainage.
A 49-year-old man was seen at the department of internal medicine in our hospital because of pain in the aterior thoracic region. Myocardial infarction was suspected, but no abnormal findings were revealed on an angiography. The pain abruptly extended to the upper abdomen and peritoneal sign developed. So the patient was referred to the department for operation. Preoperative CT revealed diffuse and whole-circumferential thickening of the wall ranging from the thoracic esophagus to entire stomach, especially a large volume of gas in he wall of the stomach. Based on these findings, a diagnosis of peritonitis due to esophagogastric phlegmon was made and the patient was operated on. During operation, a thickenin gof the gastric wall and draiange of sticky pus from the incision for drainage were confirmed. Postoperative course was uneventful and the patient was discharged from the hospital on 70th postoperative day.
This disease is often fatal and early diagnosis and early treatment are essential. Upon operation, it is important to select appropriate operative proceudre case by case, and CT is a useful tool in preoperative diagnosis. and we have realized keenly the significance of taking into account the possible presence of the disease for acute abdomen.

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We present three cases of esophageal leiomyoma (2 females and one male) treated by endoscopic lumpectomy, which were estimated arising from muscularis mucosae by ultrasonography (EUS). The location of these tumors were the upper thoracic esophagus in two cases and middle thoracic esophagus in one case. Endoscopically, all lesions were covered with normal epithelium with smooth surface. The tumors were visualized as a low echoic shadow continued from the second layer and the internal echo was homogenous by EUS. The tumors were diagnosed as esophageal leiomyoma arised from the muscularis mucosae. Two out of three tumors were easily resected with 2-channel endoscopy and the remaining tumor with over-tube. The resected esophagus showed a well demarcated nodular lesion composed of smooth muscles with interlacing-like pattern. Mitosis were rarely seen. Histologically, those three tumors were leiomyoma.
Endoscopic lumpectomy is a very useful method for esophageal leiomyomas of intramural or intraluminal type which arise from the muscularis mucosae.

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Carcinosarcoma of the esophagus is a rare malignant neoplasm composed of both carcinomatous and sarcomatous elements. The patient, a 71-year-old male, presented with swalling difficulties. A large tumor was found on radiologic imagings in the upper thoracic esophagus, and sarcoma was diagnosed by endoscopic biopsy. Thoracic esophagectomy was followed by cervical, mediastinal and abdominal lymph node dissection. The polypoid tumor, 8 × 4 × 2 cm in size, was composed of carcinomatous and sarcomatous elements histologically. Additional immunohistochemical examinations disclosed EMA (epithelial membrane antigen) and Vimentine-positive cells in the sarcoma-like element. According to the Guide Lines for Clinical and Pathological Studies on Carcinoma of the Esophagus, this case was diagnosed as so called carcinosarcoma. Cervical para-esophageal lymph node metastasis was histologically confirmed. Radical esophagectomy with lymph node dissection may be recommended for carcinosarcoma of the esophagus if permited by the general condition of the patient.

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A case of early small cell carcinoma of the esophagus which was detected during treatment for Wernicke-Korsakoff syndrome due to vitamin B1 deficiency and was treated by operation with adjuvant chemotherapy, is reported.
A 53-year-old man, who had been receiving therapy for Wernicke-Korsakoff syndrome at the department of internal medicine in our hospital, was point out having 2+O-IIc type of esophageal cancer on upper gastrointestinal series for screening purpose. His previous medical history was unknown. The patient was transferred to the department, and underwent a right thoracolaparotomic subtotal esophagectomy, retrosternal gastric tube reconstruction, and R-II. Histopathologically, the 0-Ilc type lesion was moderately differentiated squamous cell carcinoma with the invasion depth of mm3, and the 2 type lesion was composed of small cell type of poorly differentiated carcinoma with ythe invasion depth of sm3. Otherwise, n (-), lyl, and v2 were rated. After the operation adjuvant chemotherapy with CDDP and 5 FU was conducted. There has been no sign of recurrence, as of 11 months after the operation.

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A 65-year-old man hospitalized for treatment of diabetes and renal failure was found to have a submucosal tumor in the posterior wall of the stomach angle by endoscopic examination. Histological examination of biopsy specimens showed no evidence of malignant change, EUS and submucosography revealed a submucosal tumor in the posterior wall of the stomach angle, the margin of which was slightly irregular and the internal echo pattern was slightly heterogeneous. As this tumor was not suspected to be malignant, he was followed up by endoscopic examination. In the 3rd GIF, a type IIa+IIc lesion was detected near the submucosal tumor and biopsy indicated Group V. He was thus referred to our department for surgery. Both lesions were resected by distal gastrectomy with D2 lymph node dissection.
The lesions were histologically diagnosed as leiomyoblastoma and cancer limited to the mucosal layer, such that a favorable prognosis is expected.

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We experineced two rare cases of neonatal duodenal ulcer perforation. Both patients were female in-fants, 2 days of age who presented with complaints of vomiting and abdominal distension. They underwent an emergency operations based on the diagnosis of upper gastrointestinal perforation. Both operations revealed the presence of duodenal ulcer perforation with a circular punched-out lesion in the anterior wall of the duodenal 1st portion, with similar pathological characteristics in the two cases.
The operations performed were direct closure of the perforation area, omental patch and intraabdominal drainage and both postoperative courses were uneventful. Although 4 and 7 years have passed since the respective surgeries, significant problems in growth have not yet been seen on long-term follow-up observations of the two cases.

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An 18-year-old male patient was admitted to a hospital complaining of fever and abdominal pain in mid-May, 1993. On June 25, sudden abdominal pain occurred, and the abdominal X-ray examination revealed free air. We performed emergency surgery with a diagnosis of panperitonitis. At operation, many indurations which were thought to be ulcers and four perforations were found in the ileum. After deciding the incision line of the intestine under intraoperative endoscopy, two meters of ileum and ascending colon were resected, and an ileostomy was then constructed. After the operation this case was diagnosed as Crohn's disease, because multiple acute deep ulcers with granulomas were observed microscopically. The ileostomy was closed and an anastomosis between the ileum and the ascending colon was made under administration of salazosulfapyridine for six months. Reports of Crohn's disease with multiple free perforations of the small intestine are rare in the Japanese literature. Here, we present this case with a review of 7 other case reports.

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A 38-year-old man was admitted to the hospital because of recurrent abdominal pain and distension. The patient had repeated vomiting caused by intestinal obstruction with high fever. Although antituberculosis medication was effective for the high fever, intestinal obstruction worsened. Ileo-colectomy was performed because of complete obstruction of the ileum with multiple ulcers in the terminal ileum. Pathological examination demonstrated characteristic tuberculosis. Although antituberculosis medications are usually effective for intestinal tuberculosis, sometimes they cause intestinal obstruction by inducing ulcer scars. The importance of careful observation is emphasized.

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We present a case of primary malignant lymphoma of the ileum with intussusception diagnosed by abdominal ultrasonography, CT and Ba enema studies preoperatively. A 53-year-old man visited our hospital because of abdominal pain. Blood laboratory data indicated anemia (Hb 10.7g/dl), but CEA and CA19-9 as tumor markers were in normal range. Abdominal ultrasonography revealed the Target sign and Hay forksign of intussusception. Abdominal CT revealed an intussusception ranging 12cm from the ileocecal region to the ascending colon. We suspected a tumor leading the intussusception. Ba enema studies revealed a defect like a cancer nail, with ileo-colic type intussusception. We suspected submucosal tumor of the ileum due to a smooth surface defect in the lead by Ba enema studies. Under a diagnosis of intussusception caused by ileal tumor, an operation was performed. Ileo-cecectomy and lymph node dissection were done due to supra-mesentric lymph node swelling. A tumor 5.1×3.5×1.8cm in diameter existed in the ileum about 40cm oral from the Bauhin valve. We diagnosed it as diffuse medium-sized type B cell non-Hodgkin's lymphoma pathologically. Chemotherapy with CHOP 4 times was given. He is doing well with no recurrence to date.

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Perforation of a diverticulum of the colon is extremely rare in juvenile people, and it commonly appears in the sigmoid colon and in patients who have multiple diverticula if it occurs. This time we have experienced a case of perforation of solitary diverticulum in the ascending colon in a juvenile patient. In this patient a barium enema study and abdominal computed tomography scan presented difficulty in differential diagnosis from acute appendicitis. This case which is thought to be rare as well as to be suggestive in terms of the differential diagnosis is reported here, together with a review of the literature.

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We experienced two cases of endometriosis of the sigmoid colon with completely different morphology. Case 1: A 47-year-old woman was seen at the hospital because of shortness of breath. Barium enema study showed an elevated lesion of the sigmoid colon. Colonoscopy revealed an elavated lesion like a submucosal tumor. So we suspected a submucosal tumor and operated on. Intraoperative frozen section diagnosis was made as endometriosis of the sigmoid colon and a low anterior resection was carried out. case 2: A 39-year-old woman was seen at the hospital because of narrow stool and constipation. Barium enema study showed severe whole-circumferential stenosis of the sigmoid colon. Colonoscopy also showed the severe stenosis, but the mucosa was intact. So we suspected a diffuse cancer or endometriosis and operated on. After endometrial tissue in the region was confirmed by an intraoperative histopathologic study, a sigmoidectomy was carried out. Both two patients has good postoperative recovery, and have been followed up by gynecologists. For undiagnosed patients with such submucosal tumor or colonic stenosis, the intraoperative frozen section should be done to make the definite diagnosis by entertaining the disease as a probable differential diagnosis, and we have to minimize the resection area.

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A 46-year-old man was admitted to the hospital because of a right lower abdominal mass. Abdominal CT scan showed multiple liver metastases, and colonoscopy examination revealed a type 2 cancer in the ascending colon. Right hemicolectomy with lymph node dissection (D₃), partial hepatectomy and partial resection of the duodenum were performed because the tumor invated the duodenum. Histopathologically the resected tumor was endocrine cell carcinoma because it showed strongly positive reactions in chromogramin stain. Histological diagnosis was se, n4(+), P₁, H₂, ly₃, v₃ and stage IV. After the surgery he complained of appetite loss and received intravenous hyperalimentation without vitamin supplementation. On the 20th post operative day, he developed ocular abnormalities, ataxia and disturbance of consciousness. Cranial MRI showed symmetrical high intensity lesions in periaqueductal area of the midbrain on T2-weighed images. It was typically characterized by Wernicke's encephalopathy. The patient was immediately treated with vitamin B1 IV therapy and recovered from encephalopathy soon. On the 88th post operative day, the patient died of rapidly progressed liver metastases and peritonitis carcinomatosa. Endocrine cell carcinomas of the ascending colon are quite rare in Japan. Wernicke's encephalopathy after colectomy is also very rare, and this case report indicates that patients with some degree of malnutrion are at risk for Wernicke's encephalopathy.

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We experienced a case of lipoma of the sigmoid colon associated with a carcinoma of the sigmoid colon. A 76-year-old woman was admitted to our hospital because of general fatigue. Endoscopic examination demonstrated an ulcer in the stomach. Since then she was recovering from this ulcer but Hemooccult tests of stool had been positive. Colonoscopy demonstrated a Borrmann 2 type tumor and an yellowish elevated lesion with smooth surface about 30cm from the anal verge. Resection of the sigmoid colon was performed under a diagnosis of carcinoma and submucosal tumor of the sigmoid colon. Histopathologically the Borrmann 2 type tumor was well differentiated adenocarcinoma and the elevated lesion was submucosal lipoma. Lipoma of the colon has been reported that is associated with carcinoma, especially carcinoma of the colon in a high frequency. Accordingly, when we point out a lipoma of the colon at colorectal examination, we should examine the whole body in detail.

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It is designated that carcinoids of the rectum with the diameter of more than 1cm and less than 2cm without invasion into muscularis are candidates for local resection. We have, however, experienced 2 such cases in which lymph node metastasis was detected after radical operation. In Case 1, a 51-year-old woman had a Isp type carcinoid of Rb and 17mm in diameter with a central depression (histologicaly, sm, ly1, and v1), as well as a rectovaginal tumor (which eventually lymph node metastasis). Both tumors were locally excised. Thereafter, abdominoperineal excision of the rectum and associated resection of the uterus and vaginal posterior wall were added, when another metastasis to internal iliac lymph node was found. There have been no signs of recurrence, 8 years after the operation. In Case 2, a 37-year-old man had a Isp type carcinoid of Rs and 13mm in diameter, and underwent a low anterior resection of the rectum. Histologically, the resected material showed sm, ly1 and v0, and a metastasis in the pararectal lymph node of group I was detected. There have been no signs of recurrence, 2 years after the operation.
From our experience with these cases, we may have a useful indication for the treatment of rectal carcinoids with the diameter of more than 1cm and less than 2cm without muscularis invasion: It seems likely that both a thorough preoperative exploration with EUS for pararectal lymph node metastasis and a consideration of resected material for vascular invasion are very important to select more appropriate treatment predicting possible lymph node metastasis.

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Leiomyosarcoma of the rectum is a rare entity. A case report of the disease is presented here. An 81-year-old woman was seen at the hospital because of anal hemorrhage. Digital rectal examination showed a mass in the anterior wall of the rectum. Proctosigmoidoscopy revealed an ulcerated tumor with the diameter of 2cm on the anterior wall of the rectum which was located 1cm from the anal verge. A biopsy was taken and histological examination confirmed leiomyosarcoma. MRI was performed to delineate the extent of the tumor, which suggested some invasion into the vagina. On September 3, 1996, an abdominoperineal resection of the rectum with lymph node dissection was carried out. The tumor invaded the vagina and a local resection of the vagina was performed. Histological examination showed leiomyosarcoma with a mitotic rate being three or more per 10 high power fileds on average. Some lymph nodes were positive for metastasis. Review of the literatur shows disagreement over the therapeutic approach, most likely due to a lack of large series of patients with this disease in each institute. Lesions less than 2.5cm in size located within the bowel wall can be treated by wide local excision. In our case, although the ulcerated tumor was 2cm in diameter, it extended outside the bowel wall. Therefore, we has to choose the abdominoperineal resection of the rectum with lymph node dissection that provided a good prognosis.

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A relatively rare case of hepatocellular carcinoma orignating from an ectopic liver is reported. A 68-year-old woman was admitted to the hospital because of an abnormal abdominal mass. Blood tests revealed high serum level of α-fetoprotein, CA19-9 and Dupan-2. HCV antibody was positive. Though CT, MRI, angiography and ERCP were performed, only the CT suggested that an abdominal tumor had arisen due to ectopic hepatocellular carcinoma. Upon operation the tumor was found to be attached to the liver by only connective tissue. The tumor was so closely adhered to branches of the celiac artery that we had difficulty to separate it from the arteries. The tumor was removed, however the patient died of excessive blood loss during the surgery. Pathologically it was moderately to poorly differenciated hepatocellular carcinoma which appeared to have arisen from an ectopic liver. We should entertain a possibility of hepatocellular carcinoma arising in an ectopic liver, like this case, if an abdominal tumor is associated with a high serum level of α-fetoprotein and positive HCV antibody.

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Although hepatic metastasis after operation for gallbladder carcinoma occurs in a high frequency, no effective therapy has been established as yet. We experienced a case of hepatic metastasis after operation for a gallbladder carcinoma in which WHF (weekly high dose 5-FU hepatic arterial infusion) regimen was extremely effective, resulting in a complete remission (CR).
A 29-year-old man underwent a resection of the gallbladder bed and pancreatoduodenectomy for a gallbladder carcinoma and metastasis to lymph nodes of the pancreatic head on February 27, 1995. Eight months after the operation, along with an increase in CA19-9, metastasis to the S4 of the liver was found with CT and ultrasonography (US). A subcutaneous implant reservoir was indwelt in the hepatic artery from the left subclavian artery to administer WHF at a dose of 5-FU of 1000mg/body/week. It took 5 hours for one regimen. After starting the WHF regimen. CA19-9 decreased gradually, and after the 15th regimen the hepatic metastasis completely disappeared on CT and US. The effect of the regimen was rated as CR. Since then, the patient had severe diarrhea after additional third WHF regimen, so that the regimen was discontinued. There has been no recurrence of hepatic metastasis on CT as of about 9 months after CR was achieved, and the patient is alive in PSO.

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It has been known that intrahepatic cholelithiaiss is frequently associated with cholangiocarcinoma and the prognosis is very poor in that case. We have experienced such a case surviving for more than three years after operation.
A 55-year-old woman complaining of an upper abdominal pain was found having intrahepatic gallstones by endoscopic retrograde cholangiography and abdominal computed tomography. The lateral segment of the left lobe of liver was resected and histologic sections revealed associated chlangiocarcinoma whitch extended to surgical margin. Forty-three days later, the medial segment of the left lobe was resected to remove residual carcinoma, though cancerous tissue was not detected histologically. The patient has been well for more than three years after the operation.
Significance of exact clinical investigation and pertinent operation should be emphasized in the management of intrahepatic cholelithiasis with a long history of the disease, especially in a case with recurrent infections.

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A case of lymphangioma of the pancreas in a 51-year-old man is presented. In May 1994, the patient was admitted to the hospital because of impaired function that was pointd out at a medical checkup. A large cystic tumor was found in the right hypochondrial region with ultrasonography, computed tomography, and magnetic resonance imaging. Psuedomyxoma or lymphangioma arising in the retroperitoneal cavity was most probable preoperatively. Pancreatoduodenectomy was perofrmed because the tumor made firm adhesion to the duodenum and head of the pancreas on July 29, 1994. The surgical specimen mearuring 190×165mm had a sponge-like structure with milky serosal fluid in it and was diagnosed histologically as cavernous lymphangioma arising in the pancreas.

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Methotrexate-5-FU (MTX-5-FU) sequential therapy was given to 8 patients with unresectable pancreatic cancer. The regimen consisted of intravenous administration of MTX (100mg/m²) followed by 5-FU (600mg/m² 15 min drip infusion) and leucovorin rescue (15mg po or iv, 6 times in every 6 hrs) was performed 24 hrs after administration of MTX. This therapy yielded a response rate of 28.6%. The mean period of survival was 10.3 months. Adverse effects included nausea, vomiting and appetite loss (50%), stomatitis (37.5%) and thrombocytopenia and pigmentation (12.5%). They were in grade 1 or 2. These results suggest that MTX-5-FU therapy might be useful for unresectable pancreatic cancer.

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Pseudocyst of the spleen is an uncommon entity. Since it has epitheilial cells in the cystic wall, the etiology is still obscure. This paper describes a patient with splenic pseudocyst associated with acute attack of chronic pancreatitis, together with a review of the literature including some discussion on the etiology. A 44-year-old woman was admitted to the hospital because of abdominal pain. Under a diagnosis of acute pancreatitis, she underwent conservative therapy. A abdominal X-ray examination, ultrasonography, and abdominal CT demonstrated a cystic lesion of the spleen. A splenectomy was performed on August 31, 1995. Exploration of the abdominal cavity revealed a splenic cyst and no adhesion between the spleen and pancreas. On the histopathological examination, it was diagnosed as splenic pseudocyst. In postoperative course, she was readmitted for the acute attack of chronic pancreatitis twice and underwent the conservative therapy for each time. This fact would suggest that the patient experienced repeated acute aggravation of chronic pancreatitis. It is thought that there is a correlation between the pancreatic lesions and splenic pseudocyst in this case. When we encounter a pancreatic lesion, imaging diagnosis should be made by entertaining a possible association of splenic lesions.

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We report an adult patient with virilizing adrenocortical carcinoma and review of the literature reported in Japan. The patient sought medical advice for amenorrhea. A huge retroperitoneal mass was detected in the right abdomen by ultrasonography. Serum concentrations of various hormones were normal. Abdominal CT and MRI revealed that the tumor was heterogeneous, and was composed of both a solid part with massive calcification and a polycystic part. At laparotomy, there was mild fibrous adhesion but no invasion to the surrounding tissues. The resected tumor weighed 1640g and measured 20×10×7.5cm in size. Macroscopically, the tumor contained bone and fat tissue and the cystic part serous fluid. A diagnosis of adrenocortical carcinoma was made by pathological and immunohisto-chemical examinations. In all other 13 cases previously reported, the tumors consisted only of a solid component without any cystic formation. This case was unique in that the tumor showed a combination of solid and polycystic patterns.

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There is a few report of adult type of polycystic kidney disease (APKD) accompanying with cancer of different organ, such as the liver, bile duct, papilla vater, kidney, or pancreas. But no report with colonic cancer has been reported as far as we could review, so it is considered to be very rare.
A 57-year-old woman was admitted to the hospital because of melena. Abdominal CT-scan revealed many cysts in the liver and kidney, and a rectal cancer was showed by Ba-enema. The patient was operated on. APKD does not always cause renal disfunction, and the ratio of APKD patients who need hemodialysis in their sixty's is 39%. Liver disfunction does not occur generally in the case with liver cyst in APKD. So, we can select surgical therapy positively to APKD patients with cancer if indicated.

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A 52-year-old woman was admitted to the hospital for multiple left breast tumors. There was a history of undergoing oophrectomy for a right ovarian carcinoma (T3c by TNM classification) 5 years before. Painless three tumors were palpable at the A and B regions of the left breast. Ultrasonography revealed three tumors with irregular margin, 1_??_2cm in diametar at the left breast. The another imaging examinations also demonstrated almost same findings. Aspiration biopsy cytology revealed malignant cells as noted in the past specimen of the ovarian carcinoma. From the data mentioned before, a diagnosis of metastatic breast tumor of ovarian carcinoma was made. However she refused to have any treatment for the breast tumor and passed away 8 months later because of carcinomatous peritonitis.
It is known that the breast is an organ to which other organ malignancy hardly metastasize. This paper presents a case of metastatic breast tumor of ovarian carcinoma that is rarely seen in the literature.

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A 75-year-old man was admitted to the hospital because of hypoglycemia and an abdominal mass. The patient was diagnosed as having a greater omental tumor with liver metastasis by various examinations, and was operated on. Pathologically, the tumor was poorly differentiated sarcoma originated from the greater omentum with liver metastasis. The patient died of prominent peritoneal dissemination 17 months after the operation. Sixty cases including our case of malignant tumor origniated from the greater ometum have been reported in the past 16 years in Japan. Angiography was useful examination for the diagnosis of these tumors, and peritoneal dissemination occurred in 44.1% of those 60 cases.
In our case, serum IGF-II and other endocrinological factors were all within normal limits. However, since IGF-II in the tumor cells was not measured, a possibility that IGF-II had caused hypoglycemia is not completely excluded.

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A case of malignant peritoneal mesothelioma mimicking panperitonitis is presented. A 77-year-old female was admitted to our hospital because of constipation in May, 1996. Blood laboratory tests were normal except for anemia, and elevated tires of CRP and serum CA125. CT and US exams of the abdomen revealed local ascites in extrahepatic and left lower abdominal spaces. An exploratory laparotomy showed a thickened mesentery and bands of pale fibrous tissue along the antimesenteric serosal surface, consistent with panperitonitis. Peritoneal biopsy was performed and a diagnosis of granulomatous peritonitis was reported. Her condition worsened and she died 3 months after admission. At autopsy examination, it was diagnosed as sarcomatous type is relatively rare among diffuse malignant peritoneal mesotheliomas. Based on our experience with this case, we discuss herein malignant peritoneal mesothelioma.

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Retroperitoneal malignant fibrous histiocytoma (MFH) is rarely encountered and lacks subjective symptoms. Therefore, it is often detected as a giant tumor, and the prognosis is poor. This time we report a case of MFH resected surgically under a diagnosis of undifferentiated sarcoma of the retroperitoneal space. A 68-year-old man was seen at the hospital because of an abdominal tumor. Abdominal computed tomography showed a retroperitoneal giant tumor whose inner density was heterogenous. The tumor was suspected to be undifferentiated sarcoma by a biopsy under the guide of abdominal ultrasonography. While the definite diagnosis could not be made, an operation was performed. The adhesion between the tumor and surrounding tissue was slight, and so extirpation of the tumor without associated resection of intestine was allowed. With pathological findings and special dyeing of the resected specimen, the tumor was diagnosed as MFH (storiform pleomorphic type).
No adjuvant chemotherapy nor radiotherapy was conducted after the operation, and the patient is strictly followed up on an ambulant basis.

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A 29-year-old woman was referred to the department because of an intrapelvic tumor which was found during close examinations for possible gynecological diseases. She was strictly followed up on an ambulant basis, but an increasing tendency in size of the tumor was observed and the patient was admitted for operation. Upon laparotomy, the tumor which was entirely covered with retroperitoneum existed in the median presacral region, and there was no infiltration into the sacrum. The extirpated tumor was 8.0×7.1×6.5cm in size, and the section was slightly yellowish white in color and elastic soft. Histopathologically it was benign schwannoma where spindle cells in fascicular or interlacing arrangement were seen, and was positive for S-100 protein. The postoperative course was uneventful. There has been no sign of recurrence as of 9 months after the operation.

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It seldome occurs that an isolated internal iliac artery aneurysm causes ureteral obstruction. This paper reports an operated case of isolated internal iliac artery aneurysm compressed and stretched the ureter causing hydronephrosis. A 67-year-old woman was uregently referred to the hospital because of colicky pain of the right lower abdomen. Right ureteral obstruction and hydronephrosis caused by the compression of the isolated right internal iliac artery aneurysm were revealed.
Immediate percutaneous nephrostomy was followed by elective aneurysmectomy. Right ureter was adhered to the surface of the right internal iliac artery aneurysm (4cm in diamter) and was compressed and stretched. Ureterolysis and resection of the aneurysm were performed. She took an uneventful course with restored right ureteral flow.
Although the aneurysm was atherosclerotic in origin, there supposed to be an inflammatory process between the ureter and the aneurysm. this is the fourth reported case in Japan about the internal iliac artery aneurysm associated with ureteral obstruction.

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A 56-year-old man presented with intermitted lower extremity claudication (after walking about 500 meters). On examination, his right femoral artery was palpable, while the popliteal artery and more distal peripheral arteries were not palpable. The peripheral arteries of the left lower extremity were palpable throughout. Using photoelectric plethysmography, a pulse wave was recorded in the left third toe, but not in the right. Angiography demonstrated a complete occlusion of the right femoral artery as well as a complete occlusion of the left common iliac artery with well developed colleteral blood flow in the pelvic region. We performed a right fomoro-popliteal bypass grafting with an in-situ saphenous vein. The postoperative course was uneventful. A postoperative angiogram indicated good patency of the graft. There have been no signs or symptoms of ischemia in the left lower extremity.
The finding of complete occlusion of the left common iliac artery without ischemic symptoms or signs due to well developed collateral blood flow was very interesting. Though the limb-threatening ischemia by interruption of critical collaterals during nonvascular operation is a rare occurrence, the recognition and appropriate management of this occurrence in patients with arteriosclerosis obliterans should minimize the morbidity of this unusual but serious complication.

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