A series of 56 cases of thoracoscopic resection for pulmonary periphreal tumors which had not been diagnosed preoperatively were subjected to a study of the usefulness of marking due to wire indwelling by comparing the tumor diameter and distance from the pleura to tumor.
Of 40 no-marking cases, 31 cases in which the tumor location was easily diagnosed predominantly had lesions beneath the pleura. The localization of the tumor was confirmed by pleural indentation of the tumor. Even with far distant tumors from the pleura, clearly demarkated and solid tumors such as hamartomas and metastatic lung tumors were easily confirmed. On the contrary, almost all nine cases, in which the localization of the tumor was made with difficulty, had lesions more than 5mm distant from the pleura which were minute tumors or irregular in morphology. For that, maneuver palpative diagnosis via a small thoracotomy could confirm the lesion as only a slight induration, that presented great difficulty in diagnosis. On the other hand, in 16 cases which were indewelt a marking wire under CT guide, resection of the tumor was easily performed regardless of the distance from the pleura and characters of the tumor, except a case in which a wire had withdrown.
It is thought that the marking should be employed for minute and irregular peripheral tumors of the lung distant from the pleura.

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One handred and twenty six patients with esophageal cancer underwent esophagectomy with more than R2 lymph node dissection at the Nara medical universty hospital, were studied on the effects on prognoses of the n-number and number of metastatic lymph nodes, and a multivariate analysis including other prognostic factors was made.
Concerning the n-number, a statistically significant difference was noted in survival rate between n2 (+) and n3 (+). As to the number of metastatic lymph nodes, the patients were classified into four groups, i.e. none (group a), one to three (group B), four to seven (group C) and more than eight positive lymph nodes (group D). There were significant differences in the survival rate between group A and group B, and group B and group C. Furthermore, limiting the cases of n1 (+) or n2 (+), group C obtained a significantly longer survival time than group D. It means that the patients with many positive lymph nodes have poor prognoses, even though these metastases are confined to relatively near the original tumors. In a multivariate analysis of seven factors including age, sex, macroscopical type, location, depth of cancer invasion, the n-number, and number of metastatic lymph nodes, the last factor has turned out to be the most connected with the prognosis. It is concluded that the number of metastatic lymph nodes is the most important prognostic factor in patients with esophageal cancer.

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A total of 22 patients with leiomyosarcoma of the stomach who were operated on in the hospital from January 1973 to December 1995 were examined clinicopathologically. The following findings were observed in this study. 1) Endoscopically, ulcer formation on the gastric mucosa over the submucosal tumor might provide an important clue for diagnosis of malignant potential. 2) If mitotic index (M. I.) exceeded 11/200 High Power Field (=HPF) in the tumor, the gastric leiomyosarcoma was most apt to have large diameter and to recurrence. 3) No metastases of the dissected lymph nodes were noted in all of the cases, and no therapeutic improvement with changes of operative procedure was observed. 4) All three deaths due to recurrence had the common factors that the tumor grew extraluminally with large diameter of more than 100mm, and that M.I. was more than 11/200 HPF. At present, there are no effective chemotherapies for recurred leiomyosarcomas. It is suggested that curative operation for the primary tumor as wall as for recurred lesion without dissection of regional lymph nodes may be important therapy.

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Of 552 patients with gastric cancer who underwent operation what is considered to be a noncurative resection (curability C resection), 35 (6.3%) survived for more than 5 years. In this paper, characteristics of these long-time survivors are evaluated and discussed, along with the problems encountered in the intraoperative assessment of the residual tumor. Among various factors that render the resection noncurative, residual tumor at the oral or anal surgical margin resulted in the best 5-year survival rate. 7.5% (n=268), followed by residual tumor at the adjacent structures (7.1%, n=28), liver metastasis (4.4%, n=91), distant lymph node metastasis (3.7%, n=190), and peritoneal metastasis (1.2%, n=249). The 5-year survival rate for the patients in whom the noncurativity of the resection was attributable to only one of these factors was 9.7% (n=329 patients), and was significantly better than for those in whom two factors (5-year survival rate, 1.8%, n=168) or three or more factors (0%, n=55) are involved. The 5-year survival was attributable to effective chemotherapy in 40.3% of the patients, false-positive macroscopic diagnoses of residual tumor in 22.6%, slow growing tumor in 14.5%, false-positive his-tological diagnoses due to inadequate materials in 14.5%, successful resection of residual tumor in 1.6%, and others in 6.5%.
As a conclusion, we postulate that an effort to reduce the number of factors that render the operation noncurative is essential to improve the survival of patients with advanced cancer. At the same time, histopathologic diagnosis with adequate surgical materials should be incorporated where possible in addition to the macroscopic observation for accurate assessment of these factors.

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Prognoses of 38 patients with gastric cancer over 80 years old, who were treated with surgical (n=16) or non-surgical (n=22) therapy between 1989 and 1996 was evaluated in order to elucidate the propriety of the operation. There was no significant difference in the 3-year survival rate between early gastric cancer patients with surgical therapy (100%) and those with non-surgical therapy (EMR: 75.0%, conservative case: 51.4%). On the other hand, there was a significant difference in the 3-year survival rate between advanced gastric cancer patients with surgical therapy (57.8%) and those with non-surgical therapy (11.1%) (p<0.05). As to 3-year survival rates by curabilities, the rates were 100% in curability A and B and 26.8% in curability C (p<0.05). There was no difference in prognosis between patients with curability C and those with advanced gastric cancer with non-surgical therapy. But, the 50% survival times of patients with curability C and non-surgically treated patients with advanced gastric cancer were 19 months and 4 months, respectively. These results suggest that aged patients with early gastric cancer can be expected to have a good prognosis by non-surgical therapy, and that non-curative operation only provides a short-term prolongation of survival time for patients with advanced gastric cancer, for whom operation should be carefully indicated.

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A series of 44 cases of perforation of the large intestine which were operated on at the hospital in a recent 12-year period were studied. There were 23 men and 21 women with a mean age of 69 years old. Abdominal pain was the common complaint seen in the all patients, and otherwise bloating, nausea and vomiting were observed. As to abdominal findings, tenderness was noted in almost all patients and Blumberg signs and muscular defense were seen in 36 patients. The mean time from the onset of the disease to admission was 39 hours, and the mean duration of hospital stay was 62.1 days. Patients in shock state preoperatively or with decreased total protein had poor prognosis. Intraabdominal free air occurred in 26 patients that represented 59.1% of all patients. The most common site of perforation was the sigmoid colon (30 cases), followed by the rectum, cecum, and transverse colon, in this order. Causative diseases included iatrogenic in 17 cases, diverticulitis in 11 cases, colorectal cancer, and idiopatic diseases. There were five deaths. All five patients died of septecemia and multi-organ failure. Our recent attempt of endotoxin adsorption due to blood filtration for septicemia successfully saved a patient.

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Clinicopathological features of 23 cases (4.3%) of poorly differentiated adenocarcinoma of the large intestine were compared with those of 473 cases of well or moderately differentiated adenocarcinoma. Poorly differentiated adenocarcinoma was more common in women and in the right side of the large intestine than the others. The microscopic invasion of the poorly differentiated adenocarcinoma was deeper or equal to subserosa in all cases. The incidences of lymph node metastasis and peritoneal dissemination of poorly differentiated adenocarcinomas were significantly higher than the control. Stroma in poorly differentiated adenocarcinoma was almost intermediate or scirrhous type. the 5-year survival rate of cases of poorly differentiated adenocarcinoma was 32.6% versus 50.0% in curative resection cases. The patients with poorly differentiated adenocarcinoma had a poorer prognosis than that of the control group. The immunohistochemical staining of p53 was not related with the prognosis of poorly differentiated adenocarcinoma. The prognosis of scirrhous type was poorer than that of intermediate or medullary type in poorly differentiated adenocarcinoma.

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A case of local recurrence of parathyroid carcinoma 11 years after the initial surgical operation is reported, together with some bibliographical comments. A 70-year-old man was admited to the hospital because of a mass in the neck. At the age of 59, he underwent an extirpation of a parathyroid carcinoma with combined resection of the right lobe of the thyroid gland and modified radical neck dissection. On admission, a well movable mass was 3 cm in diameter. The level of calcium in serum was 13.4 mg/dl, and the level of C-PTH in serum was 1.8 ng/ml. CT scan and MRI of the neck demonstrated a sharply demarcated mass beneath the skin. Aspiration biopsy revealed the presence of tumor cells (class V). The tumor was extirpated, and was diagnosed as recurrence of the initial parathyroid carcinoma in the soft tissue of the anterior neck. The prognosis of the disease is relatively poor, the 5-year survival rate being 50-67%. This is a rare case with late local recurrence of parathyroid carcinoma.

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Apocrine carcinoma is an uncommon, poorly characterized type of breast tumor. We experienced a case of apocrine carcinoma without infiltration that did not belong to the general rules.
A 57-year-old woman was seen at the hospital because of an abnormal echoic shadow in her left breast pointed out at a medical checkup for breast cancer. The tumor was palpated as a hard mass (0.8×0.7cm) with ill-defined margin under the areola. An irregular hypoechoic lesion under the areola was observed by ultrasonography. Mammography did not reveal a tumor shadow. Diagnosis of aspiration biopsy cytology was breast cancer for class V. Breast conserving surgery (Bp (2.0cm)+Ax) with radiation therapy was performed. Histopathological examination revealed intraductal carcinoma with fully apocrine metaplasia.
Apocrine carcinoma is classified as invasive carcinoma according to histological classification of breast tumor by the Japanese Breast Cancer Society. Fundamentally, the name of “noninvasive apocrine carcinoma” is proper for this case. But, following the general rules, it should be classified as noninvasive ductal carcinoma, apocrine type.

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Spontaneous hemopneumothorax complicated with massive bleeding is rare. A 26-year-old man was admitted to the hospital because of severe right chest pain. Chest X-ray film revealed complete collapse of the right lung with a little pleural effusion. This lung collapse dissapeared by the chest-tube drainage. Only small amount of blood drained through the chest tube. However, six hours later after the drainage, he suddenly fell into a shock status with massive bleeding through the chest tube. An emegency thoracotomy was carried out. We recognized arterial bleeding from the stump of the aberrant vessel at the apex of the pleural cavity. We performed the ligation of this aberrant vessel. Early thoracotomy should be indicated for treatment of spontaneous hemopneumothorax complicated with massive bleeding as in this case.

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Traumatic intrapericardial diaphragmatic hernia with rupture of the diaphragm localized at the pericardial side is very uncommon.
A 51-year-old man was referred to the hospital because of an abnormal sound of the left anterior chest after meals. He had been involved in a serious traffic accident 5 years before and drained left hemothorax for several days. After admission chest CT showed the gastrointestinal tract existed above the diaphragm. Thoracoscopy was tried with a diagnosis of traumatic diaphragmatic hernia, but no diaphragmatic hernia in the left thoracic cavity was seen. It was traumatic intrapericardial diaphragmatic hernia, in which ruptured portion in the diaphragm was localized at the pericardial side. Since the repair of hte hernia was impossible by thoracotomy, he underwent a small left side thoracotomy and the pericardial space was opened. The stomach, omentum and a part of colon were found there and reduced gently. The laceration of the diaphragm was closed directly using interrupted sutures.
CT scan is helpful to confirm the diagnosis of traumatic intrapericardial diaphragmatic hernia, but the correct preoperative diagnosis is very difficult unless pneumopericardium exists in the pericardial space.

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A 50-year-old man was transferred to the hospital because of an abrupt onset of pain covering the entire abdomen on April 8, 1996. There was a previous history of gastroduodenal ulcer. On admission, muscle guarding was present throughout the abdomen. So an emergency operation was carried out with a diagnosis of generalized peritonitis due to upper gastrointestinal perforation. During operation, a huge ulcer extending from the upper body to cardiac part of the stomach and a perforated site were confirmed. Closure of the perforation, gastrostomy, and intraabdominal drainage were performed. Postoperative course was uneventful. The patient, however, abruptly developed hematemesis and hemorrhagic shock on April 18, and a partial gastrectomy was conducted with a diagnosis of hemorrhagic gastric ulcer. Since a diagnosis of squamous cell carcinoma was made on a histopathological study of the resected material, an upper gastrointestinal endoscopy was conducted, when a concave tumor was noted at the middle intrathoracic esophagus that was diagnosed as esophageal cancer. Considering a radical operation, another laparotomy was performed on June 11, but no excision was added because peritoneal dissemination was present. No such case of esophageal cancer which was detected by perforation of metastatic foci on the gastric wall has been reported so far as possible as we could review. This rare case is presented, together with a review of the literature.

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We report a case of gastric leiomyosarcoma showing a pedunculated extragastric development that is very rare. A 75-year-old woman was admitted to the hospital because of an abdominal tumor and epigastralgia. gastric transillumination, gastric camera and abdominal CT offered a suspicion of extramucosal tumor of the stomach. Endoscopic ultrasonography was performed and extragastric leiomyosarcoma was diagnosed.
Upon laparotomy a tumor with the size of 17×12×9cm and pedunculated from the posterior wall of the body of the stomach was present and it was excised by a wedge resection. Cross section showed yellowish white solid tumor with necrosis. The pathological diagnosis of the excised tumor was extragastric leiomyosarcoma. There was no distant metastasis and direct invasion of adjacent structure, but microscopically mitosis was found 8/10 High Power Field, and the tumor was 17cm in diameter, so that her prognosis might be very poor. There have been no signs of recurrence, and the patient is in good health to date.

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Leiomyoblastoma is relatively rare neoplasm of the stomach and more than 300 cases have been reported in the Japanse literature. Among them, however, cases revealing an exragastric growth are uncommon that numbered 32 cases including ours, and cases presented intraperitoneal bleeding, 19 cases including ours.
This paper describes a rare case of extragastric growth of leiomyoblastoma of the stomach with a narrow stalk which presented intraperitoneal bleeding.
A 39-year-old man was admitted to the hospital because of severe abdominal pain. The entire abdomen was distended, board-like, and rigid, and there were remarkable tenderness and rebound tenderness. Abdominal CT examination revealed intraperitoneal fluid collection and a high density mass lesion adjacent to the anterior wall of the stomach. Emergency operation was performed under a diagnosis of generalized peritonitis. Upon laparotomy, about 500ml of blood collection was present in the abdominal cavity. Exploration disclosed that the bleeding was originated from a part of a tumor arising in the anterior wall of the stomach which was 14×11×2cm in size, dark red in color and had a narrow stork. The tumor was excised by a wedge resection of gastric wall. Histopathological diagnosis was leiomyoblastoma of the stomach. The aptient was discharged from the hospital on the 11th postoperative day in good condition.

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Three cases of carcinoma originated in the remnant stomach after gastrectomy associated with gastritis cystica polypose (GCP) are reported. Case 1 involved a 67-year-old man who had had a distal gastrectomy for gastric ulcer 30 years before admission. The patient underwent an endoscopy for occult GI bleeding, and a carcinoma at the greater curvature side of the stoma of gastrojujunostomy was revealed. He was also found to have GCP along with the anastomotic line by histological examination. Case 2 involved a 60-year-old man who was initially operated on for duodenal ulcer 33 years prior to this admission. A cancerous lesion was found at the lesser curvature side of the stoma which was surrounded by hyperemic mucosal elevation recognized as GCP by subsequent histological examination. Case 3 involved a 36-year-old man who was found to have a carcinoma at the lessor curvature side of the stoma 24 years after the preceded surgery for gastric ulcer. GCP was also found along with the anastomosis. Histopathologically, all GCPs were characterized by hyperplasia of glandular epithelia, cystic dilatation of false pyloric glands, and submucosal infiltration of mucous gland. In immunohistochemical staining for p53 protein, cancerous lesions in all cases showed positive reaction, and non-cancerous and non-GCP mucosa showed negative reaction in all cases. Whereas a few positively stained cells which localized in the proliferative zone of the tubules present in the GCP mucosa that was thought a finding suggestive of participation in the carcinogenesis.

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Leiomyosarcoma of the small intestine presents difficulties in preoperative diagnosis, decision-making of operative procedure and eilimation of the grade of malignancy. We report a case of leiomyosarcoma of the jejunum with metastasis to lymph nodes and omentum.
A 68-year-old woman was seen at the hospital because of anal bleeding. Abdominal ultrasonography, computed tomography and magnetic resonance image showed three abdominal masses. Abdominal angiography showed three hypervascular tumors, one was fed by the first jejunal branch of superior mesenteric artery and the other two by the right gastroepiploic artery. Radiograph with contrast medium of the small intestine showed ulceration of the jejunum, so she was diagnosed as having a leiomyosarcoma of the jejunum with metastasis to omentum and operated on. Intraoperatively, the tumor of the jejunum, swelling of lymph nodes along with the first jejunal branch of superior mesenteric artery, and metastasis to the omentum were seen. We performed a partial jejunectomy with dissection of lymph nodes and a partial omentectomy. Histologically, it was revealed that the leiomyosarcoma of the jejunum metastas-ized to lymph nodes and omentum. Mitotic indexes of these tumors were 2 cells, 1.6 cells and 1.7 cells on high power view field, and proliferative cell nuclear antigen labeling indexes were 50%, 75% and 65%, respectively.

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A 68-year-old woman was admitted to the hospital because of repeated abdominal pain and vomiting starting in August, 1995. There was a previous history of undergoing a total hysterectomy for a uterocervical cancer followed by radiation therapy in 1968. The patient was diagnosed as having intestinal obstruction due to radiation enteritis and underwent a laparotomy. During surgery, a stenosis involving about 1m oral side from the ileocecal region which was probably caused by radiation enteritis was confirmed, and the portion was excised. In the oral side of the resected intestine, an impacted piece of press through pack (PTP) was foung out. The diagnosis of intestinal obstruction due to the mistakenly swallowed piece of PTP associated with radiation enteritis was made.
With an improvement of therapeutic result of irradiation for uterocervical cancer, enteritis as a complication has been increased. And cases of intestinal impairment due to mistakenly swallowed PTP have been increasingly reported with a recent wide use of PTP. Since the PTP has sharp edges that can cause severe intestinal impairment if a piece of PTP is mistakenly swallowed, some reforms of the PTP would be necessary.

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We report here two cases of intestinal Behget disease with perforation.
A 42-year-old man was admitted to the hospital because of abdominal distension and abdominal pain. There was a history of undergoing an ileocecal resection for idiopathic colon ulcer 7 years before admission, when he was diagnosed as Behcet disease. We performed a surgery under a diagnosis of ileal perforation.
Another patient, a 54-year-old woman was transferred to the hospital because of severe abdominal pain. She had been diagnosed as having Behcet disease a few years before admission.
Abdominal XP examination confirmed perforation of the intestine. Emergency operation revealed some perforations in a portion from the ascending to descending colon. Extended right hemicolectomy was performed. It is demonstrated in these cases that intestinal Behcet disease easily causes perforation and often demands emergency operation, with resultant postoperative recurrence or complication in a high frequency. So if the diagnosis of intestinal Behcet disease is made, and if downhill course is observed after periodical medical checks, some prophylactic operation would be necessary.

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We have experienced a case of stricture type ischemic colitis causing intestinal obstruction in an early stage after onset of the disease.
A 56-year-old woman was admitted to the hospital because of anal bleeding and lower abdominal pain. Imaging methods revealed a severe stricture about 6cm in length in the lower part of the descending colon. Barium enema study was followed by aggravation of ileus symptoms. Transanal decompression was tried, but no symptomatic remission was achieved. So a colectomy was performed on the 4th day after the onset. Resected material revealed that necrosis on the mucosa extended whole-circumferentially, and histologically, severe hemorrhagic necrosis was observed in the mucosa and submucosal layer. This case was diagnosed as stricture type ischemic colitis in that this ischemic change might extend to the full thickness of the intestine partially. Postoperative course was uneventful.
Usually, stricture type ischemic colitis in which cicatrical change of ulcer gradually develops is often operated on one to three months after the onset of the disease when intstinal obstruction occurs. In this case, the whole-circumferential ischemic change extended to the full thickeness of a part of the intestine and the stricture had rapidly progressed so that the early operation was needed. Accordingly, in the diagnosis of stricture of the colon, we must entertain the presence of such ischemic colitis as causes intestinal obstruction in an early stage, though it is rare.

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Ischemic change of the colon often occurs in an early period after operation for abdominal aortic aneurysm. It is very uncommon that ischemic colitis occurs after elapsing for a long time. a 65-year-old woman who had undergone repair for a subrenal abdominal aortic aneurysm was diagnosed as shock due to acute cholecystitis nine months after the operation. The patient was recovered from shock by conservative treatment, but 2 weeks later, she had bloody diarrhea and abdominal pain. Colonoscopy and barium enema study revealed a whole-circumferential stricture and thumb printing image covering from the descending colon to upper portion of the rectum, and a diagnosis of ischemic colitis was made. She was treated conservatively for 3 months, but the stenosis did not disappear. Therefore, a resection of the left colon and transverse colostomy were performed. On histological examination, the almost resected specimens showed ulceration on mucosa, and edema, bleeding, inflammation, fibrosis of the subserosa. Perforation was also seen in a part of the resected material. It consisted with ganggrenous ischemic colitis.

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A case of transverse megacolon with non-fixation of the descending colon is reported. A 28-year-old woman was seen at the hospital because of abdominal pain, nausea, constipation, and diarrhea. Barium enema study showed the dilated transverse colon, measuring 20cm in diameter. No causes of gastrointestinal symptoms were identified other than transverse megacolon. Conservative therapies were ineffective. At laparotomy, a dilated segment of the transverse colon measured 50 cm in length and the descending colon unfixed to the retroperitoneum were seen. Resection of the dilated colon (left hemicolectomy) was performed with end-to-end anastomosis. Histological examination revealed that the ganglion cells of the colon were normal. We consider that non-fixation of the descending colon with acquired factors such as torsion might cause the transverse megacolon.

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A case of afferent loop obstruction due to invasion of carcinoma of the transverse colon is reported. A 69-year-old man was admitted to the hospital because of fever, abdominal pain and nausea. There was a previous history of undergoing a Billroth II antecolic gastrectomy for gastric ulcer 25 years before admission. He was diagnosed as having an advanced carcinoma of the transverse colon by a total colonoscopy and Ba-enema study. The temperature rose to 39°C suddenly, and the laboratory studies revealed leukocytosis and an elevation in CRP level. Ultrasonography and computed tomography revealed a large cystic mass adjacent to the pancreas head and a diagnosis of obstruction of the afferent loop was made. Endoscopic drainage of the afferent loop was attempted but failed. Therefore, an emergency operation was performed on the same day and the obstructed afferent loop was drainaged. Thirteen days after the drainage, he underwent a radical operation for the transverse colon carcinoma. However, he died of carcinomatous peritonitis and multiple lung metastasis 2 months after the operation.
Afferent loop obstruction is a complication following gastrectomy, though it is rare. The most common causes of obstruction are internal hernia, adhesion, and flexion. According to the literature, only 2 cases of obstruction of afferent loop due to invasion of colonic carcinoma including our case have been reported in Japan.

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Invasion into the abdominal wall of a carcinoma of the colon may produce an abscess of the abdominal wall and on rare occasions this may be the presenting sign of the carcinoma. A 48-year-old man was admitted to the hospital because of a tumor in the left upper quadrant of the abdomen. Colonoscopy showed a type 3 tumor and a whole-circumferential stenosis in the desescending colon. Abdominal ultrasonogram revealed an echogenic mass about 5 cm in size in the left upper quadrant. Computed tomogram demonstrated a low density area about 5 cm in size with air in the mass. Lower gastrointestinal fluoroscopy revealed apple core sign in the descending colon, and defluxion and collection of barium from the anal side of the tumor to the left lateral wall. From these findings, the case was diagnosed as abscess formation due to invasion into the abdominal wall of cancer of the descending colon, and a transverse colostomy and drainage of the abscess cavity were performed. After 26 days after the operation when his general condition improved, a left hemicolectomy was performed. The resected tumor was 70×60mm in size and perforated portion was obscure. Histological diagnosis was mucinous adenocarcinoma.

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Retroperitonitis due to perforation of the sigmoid colon develops unusual manifestations. We experienced a patient with diverticular perforation of the sigmoid colon that caused subcutaneous emphysema of the cervicothoracic part. An 85-year-old woman was admitted to the hospital because of lower abdominal pain. Physical examination revealed crepitation from the neck to chest and distention of the entire abdomen. X-ray studies demonstrated subcutaneous emphysema from the neck to chest and intraperitoneal free air. Abdominal CT revealed pneumoretroperitoneum extending from the vena cava to perirenal fat tissue. On emergency laparotomy, the sigmoid colon was fixed to the retroperitoneum. When the sigmoid colon was mobilized anteriorly, a perforated diverticulum of the sigmoid colon surrounded by abscess was found. The diverticular perforation of the sigmoid colon causing subcutaneous emphysema of the cervicothoracic part would be unusual.

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Among of all colorectal carcinomas, squamous cell carcinomas are rare, especially those arising in the colon. To our knowledge, only 42 cases have been reported since the first case was described by Schmidtmann in 1919. We experienced such a case of primary squamous cell carcinoma of the sigmoid colon.
A 67-year-old man complaining of severe constipation underwent examinations of the total colon, and was dignosed as having a squamous cell carcinoma by colonoscopy with biopsy. The serum level of SCC antigen was found to be high. General exploration revealed no evidence of another malignancy. Preoperative diagnosis was primary squamous cell carcinoma of the sigmoid colon palliative sigmoidectomy was performed. Resected material revealed an 85×86mm, elevated type, and infiltrated carcinoma. Histopathologically it was moderately differentiated squamous cell carcinoma with slight keratinization and no components of tubular structures nor secretion of mucus were seen. The case is presented with a review of the literature.

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A case of cancer of the sigmoid colon in which the carcinoma prolapsed from the anus due to intussusception is reported.
A 62-year-old woman was seen at the hospital because she noticed of anal bleeding and a prolapsed intestine through the anus by about 20cm after evacuation. A Borrmann type 2 type 2 tumor was noted at the head of prolapsed intestine, and was diagnosed as adenocarcinoma on biopsy. Barium enema study revealed a claw like image and a pelvic CT scan presented target sign, indicating intussusception of the intestine. An iperation was performed with a diagnosis of intussusception of the intestine headed by the sigmoid cancer. During operation, we found difficulty in repositioning the intussusception completely due to severe adhasion, and performed a sigmoydectomy with lymph node dissection (group 3) in the state of invaginated intestine. The resected material revealed a 3.5×2.5cm Borrmann type 2 tumor with the invasion depth of mp that was a moderately differentiated adenocarcinoma of n0, Ly1, V0, ow (-), aw (-), and Stage I.
So far another 20 cases of cancer of the sigmoid colon prolapsed through the anus due to intussusception have been seen in the Japanese literature. These redlatively rare 21 cases including ours are discussed in terms of clinical characteristics here.

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A 67-year-old woman was seen at the hospital because her stool was positive for occult blood at a medical checkup in December, 1995. Previous history disclosed that she underwent a subtotal gastrectomy for signet ring cell carcinoma of the stomach in April, 1992. After admission to the hospital, a total colonoscopy detected four IIa + IIc type polyps. The colonic polyps were diagnosed as metastases to mucosal and submucosal lesions from the original gastric carcinoma.
A subtotal colectomy was performed. During operation no carcinomatous peritonitis was present but only paraaortic lymph node metastasis was seen.
It is rare that colonic metastases from gastric carcinoma presented as multiple colonic polyps like in this case.

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A 68-year-old woman visited another hospital because of mucinous feces and vertigo, when laboratory data showed anemia and hyponatremia. She was referred to the hospital for surgery. A nodular surfaced tumor was palpable in the rectum just above the anal verge on digital examination. Endoscopy revealed a large tumor with a lot of mucus on the surface. Biopsy from the villous tumor offered a suspicion of adenocarcinoma. Abdominal CT showed two low attenuation areas in the liver and a large tumor occupied in the pelvis without invasion to the surrounding organs. Although a preoperative treatment did not improve her vertigo, an operation, which included abdominosacral excision of the rectum with partial resections of liver, was performed. The rectal tumor, 12cm in diameter, was located 15cm from the dentate-line actually. The cut surface of hepatic specimen was multilocular and cystic containing a lot of mucus. Histological findings of the rectal tumor revealed well differentiated adenocarcinoma mainly invading the subserosal layer, and villous adenoma or tublovillous adenoma partially. The hepatic lesions were metastases of the rectal carcinoma pathologically. After the operation the vertigo subsided gradually, and she could walk. Resected cases of hepatic metastases from villous tumor of the rectum are rare. The liver metastasis in this case was characteristic macroscopically.

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This paper presents our experience with operated case of rectal cancer associated with ulcerative colitis (UC) in a 28-year-old woman, together with a review of the Japanese literature. The patient had been suffered from relapsing symptoms of UC since she was 18 years old. She was admitted to the hospital because of anal pain, and diagnosed as having a rectal cancer. The tumor invaded the vagina, and involved regional lymph nodes invading the right internal genital vessels. Resection of the entire colon and rectum associated with neighboring involved organs with an ileostomy were carried out. The histological diagnosis was poorly differentiated adenocarcinoma partly with signet ring cells. To our knowledge, 35 young patients under 30 years old have been previously reported in Japan. Among them, only three patients were pathologically diagnosed as to have poorly differentiated adenocarcinoma. We had to treat our patient in the early stage, because she had obviously belonged to a high risk group with developing colorectal cancer.

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We report two cases of endocrine cell carcinoma of the rectum. Case 1: A 61-year-old man operated on for a carcinoma of the rectum (Ra) was found to have liver tumors during surgery. So an anterior resection of the rectum and a partial hepatectomy were performed. Postoperative histological examination revealed endocrine cell carcinoma of the rectum and metastasis to the liver. Carcinomatous cachexia progressed rapidly about two and a half months after the surgery and the patient died about four months postoperatively. The autopsy revealed multiple metastatic foci in the liver, pleura, peritoneum, left adrenal gland, and skin. Case 2: A 76-year-old woman with carcinoma of the rectum (Rb) which was found to be endocrine cell carcinoma by preoperative histological study required operation for intestinal obstruction. During operation, liver tumors were detected and an abdomino-perineal amputation of the rectum was performed. Although one-shot hepatic arterial infusion therapy with FAM was performed after surgery, a computed tomographic scan of the abdomen showed multiple masses in the liver two months after the operation. The patient remained alive for six months after the surgery. Endocrine cell carcinoma has a very poor prognosis with rapid hematogenous or lymphogenous metastasis. In the treatment of the disease, surgery combined with chemotherapy according to small cell carcinomas of the lung which is also appropriate for the stage of the disease has to be considered.

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A 58-year-old man visited another hospital at about 2 p.m. on August 31, 1996, because a piece of iron nail perforated his abdominal wall when he was driving in the nail by a hammer and then an abdominal pain gradually appeared. Simple abdominal X-ray film revealed a piece of iron in the abdomen, and so he was referred to the hospital. Abdomincal CT scan revealed the immigrated iron piece in the S3 of the liver, but no intraabdominal bleeding was noted. A mild abdominal pain still lasted but the general condition was stable. As elective surgery for removal of the foreign body was scheduled for the patient. About 8 hours later, however, severe abdominal pain as well as hypotension occurred and the patient fell into a shock state. Abdominal ultrasonography revealed a pool of liquid under the left diaphragm. With a diagnosis of intraabdominal bleeding due to hepatic injury, an emergency operation was conducted. Upon median incision of the upper abdomen, there were about 1300ml of bloody ascites and a ruptured injury about 6mm in length on the surface of the S3 of the liver that might be made by stabbed iron piece, and the ruptured was bleeding site. After the iron piece was removed, the ruptured wound was sutured. Postoperative course was uneventful and the patient was dischaged from the hospital on the 17th hospital day.

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Ectopic liver is a rare anomaly of the liver. We have recently experienced two cases of ectopic liver on the gallbladder that were encountered incidentally during endoscopic surgery.
Both patents underwent a laparoscopic cholecystectomy with a diagnosis of gall stone, when brown nodule with a smooth surface was found out on the gallbladder in them. There was no communication between the nodule and liver and nodule with gallbladder was successfully excised in both cases. Histopathologically both resected specimen were demonstrated to be ectopic liver on the gallbladder with normal liver tissue.

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Perforation of the common bile duct can be associated with congenital biliary dilatation in childhood, but it rarely appears in adults. We experienced a case of perforation of the common bile duct with choledocholith in a 68-year-old man.
The patient complaining of fever and upper abdominal pain was emergently admitted because upper abdominal CT and ultrasonography revealed calculus of the common bile duct and fluid collection of Morison's pouch. A remission of abdominal symptom was attained by conservative therapy, but an increase in white blood cell count and fever were sustained. The patient was underwent an emergency operation with a diagnosis of choledocholithis and intraabdominal abscess. Upon laparotomy, dense adhesion due to previous gastrectomy and cholecystectomy was present. The abscess cavity was filled with infectious bile and a perforation 3 mm in diameter in the anterior wall of the common bile duct under the confluence was found. Intraoperative cholangioscopy revealed a stone 15 mm in diameter under the site of perforation. The stone was taken out and a T-tube was placed in the hole. He had an uneventful postoperative course and was discharged from the hospital. We think that stone impaction might cause the perforation in this patient.

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Perforation is a rare complication of the congenital choledochal cyst. It occurs commonly in childhood, especially in infants. We report a very rare adult case of congenital choledochal cyst presenting with perforation of the common hepatic duct. A 27-year-old woman was admitted to the hospital because of epigastric pain. Ultrasonography and computed tomography showed the dilated extrahepatic bile duct and abdominal fluid collection. Culdocentesis showed bilious ascites. Endoscopic retrograde cholan-giopanceratography revealed congenital choledochal cyst of Todani's type Ic and pancreaticobiliary maljunction. On laparotomy, a perforation, 3mm×mm in size, was found on the right posterior wall of the common hepatic duct. The amylase level in the intracystic bile juice was extremely high, showing 20, 900IU/ml. Resection of the extrahepatic bile duct, cholecystectomy, and Roux-en Y hepaticojejunostomy were performed. Histologically, a small localized transmural necrosis was seen. Not only in children but also in adults, it is postulated that the perforation of the choledochal cyst may be related to the reflux of the pancreatic juice into the common bile duct by pancreaticobiliary malijunction and the abrupt increase in intraluminal pressure caused by some mechanism.

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It has been reported a relationship between bile duct cancer and Clonorchis infections. We report a case of common bile duct cancer associated with clonorchiasis. A 74-year-old man was admitted to the hospital because of brownish urine. The increased serum ALP, LAP and r-GPT levels were noted in blood chemistry tests. Abdominal US and CT revealed the dilated intrahepatic bile duct and common bile duct and a tumor was pointed out in the common bile duct. Then PTCD was performed. Cholangiogram showed complete obstruction of the common bile duct. Cytological examination of the bile revealed infection with Clonorchis sinensis possibly associated with malignancy. Pancreaticoduodenectomy was performed on the assumption that the diagnosis was a common bile duct cancer. The pathological diagnosis was papillary adenocarcinoma. Close relationship between Clonorchis infection and intrahepatic bile duct cancer is well known. But reports of common bile duct cancer with Clonorchis infection are very rare. This parasitic disease is considered a risk factor of the common bile duct cancer, when some chemical metabolites from the parasites might contribute to the carcinogenesis rather than direct physical damage due to the parasites to the common bile duct.

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We experienced a case of bilocular gallbladder due to adenomyomatosis (ADM) with an early carcinoma of the gallbladder, which is relatively rare, in a 79-year-old woman. Abdominal ultrasonography and CT scanning revealed an uneven tumor of solid and cystic pattern with fine calcification in the fundus of the gallbladder. Contrast enhanced CT showed a 38×25mm tumor with a periphery only where slight accumulation of a contract material was seen. A carcinoma of the gallbladder associated with ADM of segmental type (type s) was suspected, and a cholecystectomy was performed. In the resected gallbladder, a great number of Rokitansky-Ashoff sinuses (RAS) of chronic cholecystitis in the fundus as well as thickening of the muscular layer were observed, indicating type s ADM. The adenocarcinoma in the fundus of the gallbladder was less than 1cm in size, and the carcinoma in mucosa was well differentiated adenocarcinoma with the invasion depth of mp and infiltrating into the muscular layer as well as extending in RAS. In addition, mucinous papillary adenoma like findings and atypical glandular epithelium were seen in the RAS glandular epithelium. A possibility that glandular epithelium had acquired various characters in the course of proliferation is suggested in this case.

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A 58-year-old woman was admitted to the hospital because of epigastralgia. The patient was diagnosed as having a cholangiocellular carcinoma (CCC) occurred in the caudate lobe based on a high serum CA19-9 value and radiological examinations. The tumor was 5cm in diameter with slight invasion into the inferior vena cava, but no lymph node swelling was observed. We performed repeated hepatic artery infusion chemotherapy with 5-FU 500mg. ADM 20mg and MMC 4mg (once two weeks, six times in total). After the chemotherapy, a marked reduction of tumor size to 2cm in diameter and a decrease in serum CA19-9 value were observed. However, it had reached the limit of the effect of chemotherapy, hepatic resection with lymph nodal dissection was performed in order to obtain complete removal of the tumor. On pathological examination, greater part of the tumor showed necrosis, which suggested the preoperative chemotherapy to be strongly effective. As to CCC, there have never been established the effective chemotherapeutic mode in drug selection and drug delivery system. The reported case herein should contribute to the following establishment of effective chemotherapy for CCC, because precise effect of preoperative repeated chemotherapy was confirmed on radiologic, laboratory and pathological examinations.

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Non-functioning islet cell carcinoma lacks specific symptoms and often presents difficulty in preoperative diagnosis. We experienced a long-term surviving patient with non-functioning islet cell carcinoma which was diagnosed when the patient consulted us about a vaginal tumor, and had multiple liver metastases and peritoneal dissemination at surgery.
A 29-year-old woman underwent an incisional biopsy for a vaginal tumor. Postoperative CT scan revealed a splenic tumor 9 cm in size incidentally. She was taken to the operating room for splenectomy and found there to have a pancreatic tail tumor directly invading the spleen. Multiple liver metastases and an omental nodule appeared, too. Distal pancreatectomy and splenectomy were performed. The tumor was diagnosed histopathologically as non-functioning islet cell carcinoma with multiple liver metastases and peritoneal dissemination. The vaginal tumor was concluded to be a part of peritoneal dissemination. Mitomycin C (MMC) 30 mg and gelform pieces were injected into the hepatic artery selectively through the transcutaneous arterial catheter after the operation. She was placed on UFT 400 mg p.o. daily and PSK 3 g p.o. daily, additionally. Despite of multiple liver metastases, ascites and esophageal verices, she lives on for postoperative 10 years now.

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We present a case of serous cystadenoma of the pancreas which was highly communicated with a main pancreatic duct. A 49-year-old woman, who had been under treatment for diabetes mellitus at another hospital since the age of 34, was diagnosed as having chronic pancreatitis at the age of 45. At the same time, a cystic neoplasm in the head of the pancreas was revealed on CT. Thereafter, in 1996, a rapid growth of the cystic lesion was observed by abdominal ultrasonography and an endoscopic retrograde pancreatogram showed multiple cystic lesions in the head of the pancreas that were communicated with a main pancreatic duct. In 1997, she was admitted to the hospital. Under a diagnosis of mucinous cystadenoma, a pylorus preserving pancreatoduodenectomy reconstruction with pancreatogastrostomy was performed. Histologically, serous cystadenoma was identified. Although communication with a main pancreatic duct is common in mucinous cystic neoplasmas of the pancreas, it has been uncommon in a large series of serous cystadenomas. In cases reported previously, communication with a main pancreatic duct has never been shown by endoscopic retrograde pancreatogram. Serous cystadenoma of the pancreas is thought to have an acinic cell origin. This case offers a new insight into the histogenesis of this neoplastic lesion and complicates differential diagnosis.

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A case of malignant lymphoma of the pancreas, extremely rare, is presented here. 60-year-old man was admitted to the hospital because of an abdominal mass. Abdominal ultrasonography and computed tomography indicated a solid mass in the head of the pancreas. Endscopic retrograde cholangiopancreatography disclosed a gradual narrowing of the main pancreatic duct and a leakage of contrast medium into the tumor. Angiography failed to show encasement of the artery but did show compressive and expansive image of the vessels. The lesion was diagnosed as non-functioning islet cell tumor or solid cystic tumor, and a pylorus-preserving pancreatoduodenectomy was performed. Pathological and immunochemical study indicated diffuse lymphoma with B cells of medium size. Postoperative adjuvantchemotherapy (CHOP) was conducted in 2 courses. Multiple sclerosis subsequently became evident on the 87th postoperative day and the patient died 156 days later.

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We experienced a case of primary malignant lymphoma of the spleen which presented difficulty in diagnosis before and during operation. A 68-year-old man was accidentally diagnosed as having tumors in the hilum of the spleen by an abdominal CT conducted during a follow-up survey for cholelithiasis. As ultrasonography, EUS, abdominal MRI, angiography and other examinations failed to offer the definite diagnosis, laparotomy was carried out. Enucleation of the tumors was attemptd at first, but hemorrhage occurred and so a splenectomy inculding the tumors in the splenic hilum was performed. After the operation a tumor measuring 1.2cm in diameter in the cut surface of the resected spleen was found for the first time. Eventually, the resected splenic tumor was diagnosed s malignant lymphoma of diffuse small or medium-sized cell type (B cell type) with metastasis to regional lymphnodes by histopathologic examination.
The solitary primary splenic lesion in this case was the smallest one among those reported thus far in Japan to the authors' best knowledge.

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Adrenal metastasis of rectal cacer is often encountered, but it is rare that a case of solitary adrenal metastasis which was resectable is very rare. In this paper, we present our experience with such a case together with a review of previous seven cases in the Japanese literature.
The case involved a 63-year-old woman, who underwent an abdominoperineal excision of the rectum and associated resection of the uterus and vagina with a diagnosis of rectal cancer with vagina invasion in February, 1996. Histopathologically it was moderately differentiated adenocarcinoma in Stage IIIa. Thereafter, she was followed on an ambulant basis when a gradual increase in CEA was noted. On CT a left adrenal tumor was found in April, 1997. Endocrine examination revealed no abnormalities, and an extirpation of the tumor was conducted with a suspicion of metastatic adrenal tumor in May. Histological exploration resulted in that the tumor was adrenal metastasis of the rectal cancer. There have been no signs of recurrence, as of 7 months after the operation.
In a review of the seven cases seen in the Japanese literature, long survivors were observed among patients after extirpation of the tumor. So it is desirable to conduct operation aggressively as soon as possible after adrenal metastasis is detected.

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A 67-year-old male was admitted to our hospital for exploration of a whole-circumferential stricture of the rectum on July 24, 1997. Colon fiberscopy revealed a high degree of stricture at a portion 4cm from the anal verge, but no tumorous lesion was visualized though only redness on the mucosa was seen. Endoscopic biopsy from the strictured portion revealed no malignant findings. Abdominal CT revealed a small calcified image at the prostate, but no tumors were seen in the pelvic and abdominal cavities. For the purpose of histological biopsy, an operation was performed. Under skin incision from the right side of the sacrococcygeal joint to the 6' oclock portion of the anal verge, a part of stringy induration around the rectum was resected. As a result of histopathological study, the diagnosis of moderately differentiated adenocarcinoma arisen in the prostate was made. As the PAP level increased to 900ng/ml, a hormonal therapy was conducted at the department of urology, with a complete disappearence of the stricture.
It is uncommon that cancer of the prostste causes a stricture of the rectum, and in this case the rectal stricture was induced by the prostatic cancer that did not form any tumors.

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We experienced a patient who had a huge intraabdominal desmoid tumor growing from the mesentery of appendix. A 17-year-old women was referred to the hospital because of a rapidly growing abdominal tumor. On the day of the referral, she had a severe abdominal pain. Suspecting torsion of an ovarian tumor, an emergency operation was performed. The operative findings revealed a tumor arose in the mesentery of the appendix, measuring 20.0×15.5×13.0cm, and weighing approximately 2500g. Bilateral ovaries were intact. We resected the ileocecal region including the desmoid tumor. Histological diagnosis was intraabdominal desmoid tumor arising in the mesentery of the appendix. The patient has been well for about 24 months after the operation without any manifestation of recurrence. It is believed that desmoid tumors are naturally benign, but the local recurrence rate is high so that careful follow-up would be demanded.
This is one of the youngest cases of the intraabdominal desmoid tumors without poliposis coli which have been reported in Japan, and we examined clinical details of reported cases of intraabdominal desmoid tumor.

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We experienced two cases of liposarcoma arising in the mesenterium. Case 1: A 56-year-old man was admitted to the hospital because of abdominal distension. Computed tomography (CT) and ultrasonography showed a huge tumor in the abdominal cavity which was suspected of liposarcoma. In June, 1979, a laparotomy was performed and revealed that the tumor arose in the small intestinal mesentery and that there were some scattered nodular lesions. The neoplasm was removed with the small intestine. After the first operation, he received three surgical excisions for intraabdominal recurrences. However he died of cardia failure in August, 1989. Case 2: A 61-year-old woman was admitted to the hospital because of vague lower abdominal pain radiating to the left hypochondric region. Abdominal CT showed a high-density lesion located in the mesenterium and magnetic resonance imaging (MRI) of this lesion showed an iso-intensity mass in T1 weighting image and a highintensity mass in T2 weighting image. These findings suggested a soft tissue tumor of mesenteric origin, especially a lipoma or liposarcoma. Laparotomy revealed a yellowish tumor infiltrating into the mesenterium diffusely and this tumor involving the superior mesenteric artery and vein. We gave up radical resection and a partial resection of the tumor was performed to determine its histological diagnosis. Histologically, the tumor showed liposarcoma, well differentiated. The patient recovered uneventfully and was discharged on the 13th postoperative day.

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Peritonitis chronica fibrosa incapsulata is a relatively rare disease in which the intraperitoneal organs are enclosed in fibrous membranous sheaths. We report two cases of peritonitis chronica fibrosa incapsulata.
Case 1: A 69-year-old man was seen at the hospital because of epigastric discomfort. We suggested malignancy of gastrointestinal tract and performed laparotomy. Operative findings revealed that the entire small intestine was lumped with thick gummy sheaths. Histological diagnosis was non-specific inflammation.
Case 2: A 49-year-old man was seen at the hospital because of abdominal distension and anorexia. He had been treated for lung tuberculosis. Emergency operation was performed due to severe ileus condition. Operative findings revealed that the entire small intestine was lumped with thin fibrous sheaths. Histological diagnosis was non-specific inflammation, and no tuberculosis lesion was found.
It is difficult to make the diagnosis of peritonitis chronica fibrosa incapsulata preoperatively, but the patients who develop intestinal obstruction without previous laparotomy may have be peritonitis chronica fibrosa incapsulata.

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Retroperitoneal liposarcomas often have a delayed onset of symptoms and appear as a huge tumor when it is detected. We describe here a patient with retroperitoneal liposarcoma who underwent four resections due to recurrences and is still doing well. A 79-year-old woman was admitted to the hospital because of abdominal distension and pain in October 1992. A computed tomography revealed a large solid mass, 40cm in diameter, located in the retroperitoneal space, which was resected surgically. The resected material was 10kg in weight. Histpathologically it was diagnosed as liposarcoma.
Subsequently, follow-up studies detected local recurrences of liposarcoma in the retroperitoneum. Except the first operation, a total of three curative operations were performed in January 1996, Nobember 1996 and August 1997, respectively. Surgical materials were about 10cm in size locating in the pelvic cavity; 20cm in size and 2kg in weight; and 14cm in size and 0.4kg in weght, respectively. The patient is still alive as of 5 years after the first operation and is followed on an ambulant basis. Surgical resection is the treatment of choice for liposarcoma, and we to have to deal with recurrence of liposarcoma surgically.

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A case of metachronous double primary cancer of gallbladder and lung which is believed to have poor prognosis was successfully operated on, with an uneventful postoperative course. A 60-year-old man wad referred to department of thoracic surgery for evaluation of a nodular shadow in the right S6 on a routine chest roentgenogram and CT scan in June 1994. Transbronchial biopsy revealed adenocarcinoma and right upper lobectomy was performed. Pathological study demonstrated a well differentiated adenocarcinoma. Immunohistochemically, tumor cells showed positive reaction to CEA and negative to CA-19-9. Past history disclosed that he had cholecystectomy with wedge resection of the liver, pancreatoduodenectomy, right hemicolectomy and regional lymphadenectomy for a gallbladder cancer in July 1990 (at the age of 56). Histological diagnosis was poorly differentiated adenocarcinoma with lymph node metastasis. Result of immunohistochemistry was adverse to that of lung tumor. Postoperatively, he had adjuvant chemotherapy with mitomycin C (MMC, 10mg×2), epirubicin hydrochloride (20mg×2) and tegafur-uracil (UFT, 300mg/day) which was continued for 4 years until the present admission. After a right lower lobectomy and lymph node dissection (R2a), the patient was diagnosed as having metachronous double cancer of the gallbladder and lung.
The patient has been well without signs of recurrence for the last 42 months. We think that, even through the second cancer arises in the lung, aggressive treatment should be attempted if possible. It is obscure that whether the adjuvant chemotherapy for the first neoplasm might contributed to the development of the second neoplasm. For that, some notes are presented.

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A 75-year-old woman was admitted to the hospital because of intensifying severe abdominal pain. Physical examination at admission showed tenderness with Blumberg's sign of the right upper quadrant. Abdominal CT revealed cholecystolithiasis and swellings of the gallbladder and right kidney. Blood laboratory studies showed a leucocyte count of 14, 800/mm³ and blood sugar level of 746mg/dl. An emergency operation was carried out with the diagnosis of peritonitis. During laparotomy, there were swollen gallbladder with several stones and pyonephrosis of the right kidney. Cholecystectomy and right nephrectomy were performed. The resected material revealed a 30×35mm, irregular and elevated lesion extending from the body to fundus of the gallbladder and a change in colour to dark-red of most part of the right kidney. Histopathologically, the elevated lesion of the gallbladder was diagnosed as papillary adenocarcinoma and a transitional cell carcinoma of the ureter covering from a portion near the surgical stump to the renal pelvis was demonstrated. A diagnosis of synchronous double cancer of the ureter and gallbladder was made. In the present case, dysfunction of the ureter due to the ureteral carcinoma was considered to have caused pyonephrosis, which led to diffuse peritonitis.

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