The purpose of the study was to inverstigate whether cyclin dependent kinase inhibitor p21 (p21) and lung resistance protein (LRP) could be predicting factors for recurrence after surgery for breast cancer. Immunostainings of p53, p21, and LRP were carried out to breast tissues which had been curatively resected. Prognostic factors were searched by means of multivariate anylysis. In a Cox proportional hazard model, p21 and LRP were factors affecting the recurrence. Patients with p21(-) and LRP(+) developed postoperative recurrence in a high frequency. Of patients administered anticancer drugs, the desease-free suvical rate in those with p21(-) was significantly low and all patients with p21(-) and LRP(+) developed recurrence. Of patients having received postoperative irradiation, a significant difference was seen in the disease-free survical rate between groups with p21(+) and p21(-). In conclusion, expression of p21(+) and LRP can each be an independent prognostic factor. And a combination of p21(+) and LRP(-) predict the best prognosis along with favourable response to chemoradiotherapy following surgery. On the centary a combination of p21(-) and LRP(+) meet disappointing response to chemoradiotherapy.

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We examined the immunohistochemical expression of matrix metalloproteinases (MMPs: MMP-2, -7, and-9) and tissue inhibitors of metalloproteinases (TIMPs: TIMP-1, and-2) in 66 cases of submucosal carcinoma of the stomach (SM-GC) as well as in 50 cases of advanced cancer (AD-GC), and compared them with clinicopathological characteristics of the cases. In SM-GC cases, positive rates for MMP-2, MMP-7, MMP-9, TIMP-1 and TIMP-2 were 42.4%, 33.3%, 9.1%, 0% and 48.5%, respectively. There was a significant correlation between MMP-7 immunoreaction and the degree of invasion (p<0.05). Moreover, only MMP-7 positive rate was significantly higher in cases with vascular, lymphatic or lymph nodes involvement than in cases without them (85.7% vs 27.1%, 76.9% vs 5.0% and 73.7% vs 17.0%, respectively: p<0.01).
In comparison with SM-GC and AD-GC, only TIMP-1 positive rate was significantly higher in AD-GC (0% vs 18.0%: p<0.01) and there were no differences in immunoreaction for MMP-2, MMP-7, MMP-9 and TIMP-2. These data suggest that MMP-7 is an important factor implicated in invasion and metastasis and is a useful marker for predicting aggressive behavior of SM-GC.

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The purpose of this study was to estimate the number of bowel movements after low anterior resection. Fifty-five patients after anterior resection were interviewed to find out about bowel movements. The male-to-female rate was 38:17. Mean bowel movement was 2.6 times per day after high anterior resection (n=12) and 3.5 times after low anterior resection (n=43), without significant difference. As for the 43 patients after low anterior resection, there were no differences in gender and age. Patients who had anastomosis within 1cm from the anal canal experienced 4.9 times of bowel movements, whereas 3.0_??_3.4 times in average in patients whose anastomoses were located longer than 1cm to the anal canal. There was a significant difference between both groups. Anastomotic leakage occurred in six patients and their mean bowel movements were 5.8 times. It was significantly more than 3.2 times in non-leakage patients. From these results, colonic J-pouch indicated for the patients undergone low anterior resection with anastomosis within lcm from the anal canal.

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Of 909 patients with malignant neoplasms admitted to the department for initial treatment in a 14 year period from 1986 to 1999. 120 (13.3%) had multiple primary cancers, and nine had three cancers. These 909 patients were divided into single and multiple cancer groups, and compared for the gender, age, family histoly of cancer, and smoking habits. The combinations of tumors in the multiple cancer group were also examined.
Patients with multiple cancer were older than those with single cancer. There were no differences in gender between the two groups. Many of men from the multiple cancer group were smokers. The family history of cancer did not differ between the two groups.
The most common tumor combinations were cancers of the urinary bladder and prostate in 15 patients, followed by prostate and stomach cancers in 14 patients and bladder and stomach cancers in 13 patients.
Consideration should be given to the possible presence of malignancy in the other organs during the diagnosis and treatment of cancer.

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Although primary hyperparathyroidism during pregnancy is rare, it can carry a considerable morbidity not only for the mother but also for the fetus. This time we have successfully performed an operation for such patient during pregnancy, with uneventful postoperative course.
A 33-year-old woman at the 14-week gestation was diagnosed as having primary hyperparathyroidism. After she was treated medically for hyperparathyroidism, she underwent a resection of adenoma of the parathyroid at the 22-week gestation. Postoperatively, she had tetany but it was relieved by oral administration and i. v. infusion of Ca preparation. After discharge, the conditions of both the mother and fetus were very well. At the 39-week gestation, a healthy child was born. The serum calcium level in the mother was slightly low, but that in the child was normal. No neonatal tetany had developed.
Generally, clinical symptoms associated with primary hyperparathyroidism progress during pregnancy. Therefore, operation for hyperparathyroidism should be carried out during the second trimester, because it is difficult to maintain serum calcium level during pregnancy and to prevent maternal hypercalcemic crisis and neonatal tetany after delivary.

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A 56-year-old woman was seen at the hospital because of a rapid swelling of the left breast on November Ist, 1999. There was a tumor 7cm in diameter in the A area of the left breast. Needle biopsy suggested malignant lymphoma. Because of the large size of the tumor, one course of systemic chemotherapy with CHOP was performed before a modified radical mastectomy. Histological diagnosis was diffuse, medium sized cell type, Bcell lymphoma.. After post-operative chemotherapy with CHOP two courses, she had discharged from the hospital. Thereafter the signs of relapse occurred in the right submandibular lymph nodes and on the skin of left chest, abdomen in mid-May. Therefore additional CHOP 5 courses were carried out. In mid-Octover, furafura feeling and vertigo started. Magnetic resonance imaging of the Brain showed involvement of the central nervous system (CNS). CNS involvement of malignant lymphoma is found in 9% of all non-Hodgkin lymphomas. It is a disease with very poor prognosis. We report the case together with a review of the relevant literature.

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We report a rare case of synchronous bilateral male breast cancer (MBC). A 65-year-old man with a right breast lump was referred to the hospital. Bilateral MBC was diagnosed with palpation, mammography, ultrasonography, and fine needle aspiration cytology. Bilateral modified radical mastectomies were performed, and a histological examination confirmed synchronous bilateral MBC. Adjuvant chemotherapy, hormone therapy and radiation were added. The patient is doing well for 17 months following the surgery, while he is followed in the clinic. Synchronous bilateral MBC is extremely rare, and the characteristics of MBC are also discussed.

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A case of intraductal apocrine carcinoma of the breast in a 78-year-old woman is reported herein. Our patient presented with a small, elastic and hard mass with ill-defined margin, measuring 0.8cm, in the upper outer quadrant (C area) of the right breast. Since mammography and ultsanonography suggested mastopathy, the patient was scheduled for follow-up. A follow-up routine check did not show any changes until 8 years had elapsed after the first visiting, when aspiration biopsy cytology offered a suspicion of breast carcinoma. Excisional biopsy was carried out. Almost of the tumor cells showed apocrine metaplasia without invasion into the stroma. And the tumor was diagnosed as intraductal apocrine carcinoma. Modified radical mastectomy was performed due to intraductal spreading.
Apocrine carcinoma accounts for about 0.2%, of all breast cancers. It is histopathological classified only into invasive carcinoma, and no description on intraductal apocrine carcinoma exist is found in the General Rules for Clinical and Pathological Recording of Breast Cancer, the Japanese Breast Cancer Society. This case is a rare case that was diagnosed as intraductal apocrine carcinoma, and so far 15 cases of intraductal apocrine of the breast, including this case, have been reported in the Japanese literature. Therefore, the general rules of clinicopathology of the disease should be classified as noninvasive ductal carcinoma, apocrine type “intraductal apocrine carcinoma” in the near future.

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A 21-year-old man was admitted to the hospital, because of an abnormal shadow on his chest roentgenogram. A chest CT scan showed an anterior mediastinal mass. The serum α-fetoprotein level was as high as 144.7ng/ml. No abnormalities were found in his laboratory testes. Mediastinal nonseminomatous germ cell tumor was diagnosed and one course of PEB therapy was performed. Although the serum α-fetoprotein level was slightly reduced to 52.1ng/ml after the chemotherapy, the tumor became slightly larger on imagings. We believed in components which were resistant against the chemotherapy and surgical treatment was selected. Complete resection was successfully performed and the pathological diagnosis was α-fetoprotein producing mediastinal immature teratoma with a few atypical cells. An immunohistochemical staning of the immature gland cells were positive for α-fetoprotein, but the atypical cells were negative. This is a rare case of mediastinal immature teratoma in which α-fetoprotein was detected immunohistochemically in the immature gland cells. No therapy was added after the operation. There was no evidence of recurrence on the chest roentogenograms and CT scans. The serum α-fetoprotein level became normal after the operation and no elevation of this serum marker level has been noted for 5 years after the operation.

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We successfully treated a case of immature teratoma combined with yolk sac tumor infiltrating into the pericardium and lung by operation with preoperative chemotherapy and postoperative irradiation.
A 35-year-old man was clinically diagnosed as having a anterior mediastinal teratoma or a germ cell tumor, because a 12×8cm mass lesion was detected in the anterior mediastinum and elevations of serum AFP, HCG and ACTH were noted. After 2 courses oof chemotherapy with CDDP, VP-16 and VLB for the treatment of probable germ cell tumor, the levels of serum AFP, HCG and ACTH decreased within normal ranges. Then an operation was performed. The tumor was completely removed together with a part of upper lobe of the right lung and pericardium. A postoperative microscopic examination of the tumor revealed immature teratoma combined with yolk sac tumor and syncytiotrophoblastic giant cell.
A postoperative irradiation therapy was performed (Total 4Gy). Eighty-seven months after the operation, the patient is doing well and his levels of serum AFP, HCG and ACTH are within normal ranges.

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A patient who had been treated by artificial vessel grafting for perforation of the aorta of unknown origin developed fistula between the aorta and duodenum after elapsing for about 2 years. This paper presents the case. A 40-year-old man was seen at the hospital because of abrupt onset of lumber and back pain. Cystic aneurysm was found in the abdominal aorta beneath the renal artery, and an emergency operation was carried out. During operation, a pseudoaneurysm was present on the left side of abdominal aorta, with a perforation about 1mm in diameter in the aorta. Replacement using a I shaped graft was made. Thereafter no symptoms nor findings suggestive of Behçet disease were seen and a bacterial culture of the aortic wall revealed negative. Idiopathic perforation of the aorta was diagnosed. About 2 years later, the patient had fever and anal bleeding. Upper gastrointestinal series revealed exposure of the artificial vessel at the horizontal part of duodenum. An operation was performed with a diagnosis of fistula between the aorta and duodenum. No pseudoaneurysms nor abscess were found in the vicinity of anastomosed site of the aorta. It is etiologically thought that the fistula might be made by mechanical stimuli derived from along-term contact between the artificial vessel and duodenum.

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A 69-year-old woman was admitted to the hospital because of refractory intermittent cough. On chest CT scan and bronchoscopy, broncholithiasis was detected in the left lower lobe. Bronchoscopic removal was attempted without success. Preoperative angiography (AG) revealed occlusion of the lower branch of pulmonary artery and marked development of the bronchial artery. Left lower lobectomy was performed. During operation, the lung adhered to the pleura and the bronchial artery was developed, which was prone to bleed and difficult to control. The left lower lobe was atrophic, possibly due to the occlusion of the lower branch of pulmonary artery. We conclude that preoperative AG is crucial for the safe treatment of broncholithiasis and is definite for pneumonectomy.

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We report a case of pulmonary metastasis from breast cancer in a 61-year-old woman with a 21-year-disease-free interval. The patient had undergone a radical mastectomy for right breast cancer 21 years before admission, when its pathological diagnosis was scirrhous carcinoma combined with solid tubular pattern, t1n0m0, stage I. Periodic chest x-ray films revealed no abnormal shadow in the right upper lung field. At a recent medical checkup, a chest x-ray film revealed an abnormal shadow, further examinations including bronchoscopic lung biopsy and sputum biopsy revealed no malignany, but a chest CT scan suggested primary cancer of the lung. A right upper lobectomy was performed. The histological diagnosis of resected specimen was adenocarcinoma, it was thought that the cancer was pulmonary metastasis from breast cancer with a 21-year disease-free interval. We report the case because it is so rare that have elapsed distant metastasis of breast cancer occurs after as long as 21 years.

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A 49-year-old woman was admitted to the hospital because of chest pain. A chest X-ray film showed a post-cardial mass shadow and a chest CT scan and magnetic resonance imaging revealed a 14.5×8cm fatty mass of the posterior mediastinum. Because the tumor was large and the patient had complained of chest symptoms, we performed an operation under a diagnosis as lipoma of the posterior madiastinum. At the operation, it was revealed that the fatty mass was the herniated greater omentum through an esophageal hiatus. We put the omentum back to the peritoneal cavity and repaired the esophageal hiatus.
Postoperative course was uneventful. The patient was discharged from the hospital on the 7th hospital day. As of eight months after the operation, there have been no relapse of the disease. Esophageal hiatal hernia with the greater omentum has been rarely reported. In case of the fatty mass of the inferior posterior mediastinum, it is necessary to take this condition into consideration.

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A 56-pear-old man was found to have cancer of the thoracic esophagus while he was treated for carcinoma in the oral cavity. Endoscopic mucosal resection (EMR) was performed. Pathological examination of the resected specimen revealed that the cancer was 6mm in diameter but invaded the proper muscular layer. Therefore additional external radiotherapy was given for esophageal cancer after the operation for carcinoma in the oral cavity. Thereafter local control was favorable. Nine months after the radiotherapy, he was urgently admitted to the hospital because of bleeding from a tracheoesophageal fistula. Once he recovered from serious state in the ICU, but unfortunately he died of massive bleeding from the esophagus. At autopsy a deep ulcer perforated to the trachea was present and there was no cancer remnant. It was etiologically thought that the perforation might be caused by impaired tissue after EMR and late radiation disturbance as well.
This case suggests that we have to take caution of possible esophageal perforation after EMR and radiotherapy for esophageal cancer.

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We experienced a case of acute rapture of the stomach which is thought to be rare as a complication of cardiopulmonary resuscitation.
A 70 year old woman was brought into the hospital by ambulance. On arrival, cardioplumonaly resuscitation was performed because her cardiopulmonaly function ceased. Respirations and cardiac pulsations resumed. CT scan of the head indicated subarachnoid hemorrhage. Thereafter, bleeding from a gastric tube and prominent free air were confirmed on an abdominal CT scan. Acute gastric rapture due to cardiopulmonary resuscitation was diagnosed and an emergency operation was performed. Upon lapalotomy, about 5cm sized perforation running in the upper body of the stomach a little to the posterior wall was confirmed. Suture of the perforated portion and massive lavage drainage were performed, followed by clipping of the aneurysm of the right middle cerebral artery. The postoperative course was univentful and the patient was discharged from the hospital on 58th hospital day.
At present when cardiopulmonary resuscitation is coming into relatively general use, we have to understand its complications in that this case is thought to be valuable. We report this case together with some bibliographical comments.

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We have experienced a case of gastric tube cancer which was diagnosed during treatment for gastric tube ulcer after an esophageal cancer.
The patient was a 68-year-old man who had undergone a subtotal esophagectomy with reconstruction by subcutaneous gastric tube substitution for an esophageal cancer 5 years earlier.
Ulcer was discovered in the anterior wall of the gastric tube 10 months after the operation. The ulcer has been treated by proton pump inhibitor (PPI) for 3 months, when the ulcer was improved to S₁ stage. PPI was changed to H₂-blocker, but 7 months later the ulcer recurred.
Continuous 24-hour pH monitoring in the gastric tube showed a remarkable low pH value through out the night, and Helicobacter pylori was detected by histological examination. So the ulcer was treated medically by PPI again, but it was intractable. Biopsy specimens revealed no malignancy during this medical treatment and eventually negative conversion of Helicobacter pylori was attained.
Examination of the resected spesimen revealed moderately differentiated adenocarcinoma in November 1999, so a partial gastrectomy was performed. The depth of the lesion was diagnosed histologically as sm₂ (tumor invaded the second submucosa) with an ulcer of Ul-IV about 2.0cm in diameter. Since it is said that the survival time of patients with double cancer of the esophagus and gastric tube depends on the stage of gastric tube cancer, it is important to go through periodic endoscopic examinations after surgery to detect and cure the disease in an early stage.

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We experienced a very rare case of microcarcinoma of the stomach with left side gallbladder, preduodenal portal vein, intestinal malrotation, and polyspleen in an adult. A 43-year-old woman was admitted to the hospital for the purpose of operation for gastric cancer, which was detected while she was followed up for gastric cancer. During the operation, the gallbladder was found to be located in the liver bed at the lateral segment of the liver, the duodenum was located at the back of the portal vein with intestinal malrotation, and polyspleen was detected. A distal gastrectomy with reconstraction by B-I method was performed. We conclude that left side gallbladder is rare in adults, and it is often combined with abdominal organ anomalies and is incidentally found during operation in most cases. We surgeons should be aware of possible variables or abnormal anatomy and attention should be paid to avoid complications.

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A case of left paraduodenal hernia diagnosed preoperatively with computed tomography (CT) is reported. A 72-year-old woman was admitted to the department of internal medicine in our hospital because of left upper abdominal pain. She was referred to the department because no symptomatic remission was attaired by conservative therapy. Physical examination demonstrated an elastic soft mass with tenderness in the left upper abdomen. Abdominal CT scan showed the low density mass with clear border and the mass contained a loop of the small bowel. So an emergency operation was performed with a diagnosis of left paraduodenal hernia and incarceration of the small bowel. Laparotomy revealed a moderate amount of bloody ascites and a necrotic jejunum herniated lateral to the ligament of Treitz and bulging against the left mesocolic fossa. Hilus was approximately 6cm in diameter. The necrotic bowel was resected with end-to-end anastomosis, and the hilus was closed. Abdominal CT scan is very useful for diagnosis of left paraduodenal hernia. Early treatment of the hernia requires sufficient understanding of the CT findings.

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A 76-year-old man who had been followed up for duodenal ulcer in this hospital since. An irregular depressed lesion (type IIc), measuring 0.5×0.5cm in diameter, at the second portion of the duodenum by Gastrointestinal endoscopy was incidentally found having. Histological examination of the biopsied specimen revealed well differentiated tubular adenocarcinoma. In the first place, an extirpation of the lymph node (No.6, 13a, 13b) was perfomed. Because of no metastasis to these lymph nodes with frozen section diagnosis, a partial resection of the duodenum was performed. The resected specimen showed type IIc early duodenal carcinoma of depressed type, measuring 0.5×0.5mm insize. Histologically, well differentiated tubular adenocarcinoma was limited to the mucosa without lymph node (No.6, 13a, 13b) metastasis. This case is the 29th case of early duodenal carcinoma with depressed type reported in the Japanese literature.

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A 73-year-old man was admitted to the hospital because of melena. Radiographic and endoscopic examinations of the upper gastrointestinal tract showed a polypoid lesion of the duodenal bulb and cholecystlithiasis. Endoscopic biopsy of the duodenal polypoid lesion gave a histological diagnosis of group IV. Endoscopic excision was thought to be difficult, and a distal gastrectomy with a partial resection of the duodenum and a cholecystectomy was performed. Histological examination revealed tubular adenocarcinoma localized within the mucosal layer of tubular adenoma.
We reviewed 19 cases of cancer in adenoma of the duodenal bulb in the Japanese literature.
Most cases of them had adenocarcinoma localized within the mucosal layer as carcinoma in adenoma. No lymph node metastasis was reported in these cases.
As the definite diagnosis of cancer in adenoma of the doudenal bulb is not necessarily made by endoscopic biopsy preoperatively, endoscopic polypectomy or surgical polypectomy would be needed for duodenal polypoid lesions.

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Primary carcinoma of the ileum is very rare and lacks in specific clinical symptoms and physical findings.
In instances in which this disease is suspected by some imaging studies, we have difficulty in making diagnosis before operation by endoscopic biopsy.
And generally speaking, abdominal ultrasonography is easy and non-invasive examination, but it is unsuitable for examination of the disease of the digestive organs because of intestinal gas.
We have experienced one case of primary carcisnoma of the terminal ileum which was suspected by abdominal ultrasonography and diagnosed by endoscopic biopsy before operation.
The patient, an asymptomatic 69-year-old woman, received a medical checking, while she had been treated for chronic hepatitis C.
Abdominal ultrasonography showed the wall thickening of terminal ileum and swelling of lymph nodes around it.
As a result of colonfiberscopy, endoscopic biopsy and X-ray examination of the small intestines, we diagnosed this case as primary carcinoma of the ileum before operation and performed a right hemicolectomy.

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A 59-year-old man underwent three operations for hepatic and pulmonary metastases from carcinoma of the rectum. After absolute curative low anterior resection of the rectum for rectal carcinoma on March 18 1992, CT revealed a hepatic metastasis in October of the year. Partial resection of the liver was performed. In May, 1995, he underwent a partial resection of the right lund for pulmonary metasasis which was revealed by CT. Furthermore, he underwent a right upper lobectomy of the lung for multiple pulmonary metastases in Augast, 1997. Follow-up CT has revealed no metastatic lesions after the last surgery. Repeated surgeries for heterochronous metastases to the liver and lung will improve the prognosis of the patient after succesful surgical resection of carcinoma of the rectum.

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Multiple aneurysms in the celiac artery region were surgically treated in a patient with idiopathic portal hypertension. A 49-year-old woman with the chief complaint of abdominal distension was diagnosed with having liver cirrhosis, esophageal varices and hypersplenism and was referred to the hospital. She seldom drinks alcohol and hepatitis virus infection was negative. An angiography revealed a 3cm aneurysm at the proximal portion of common hepatic artery, and multiple splenic aneurysms with the maximum diameter of 2cm. We treated the patient with Hassab's procedure and an excision of the hepatic artery aneurysm. During the operation, we judged that reconstruction of the hepatic artery was unnecessary, because the preoperative angiography showed the major bypass blood flow to the liver through the pancreatoduodenal artery, and good beats of the hepatic artery were palpable after the removal of the aneurysm. The status of the liver was pathologically diagnosed as idiopathic portal hypertension on account of the presence of preserved basic construction of the liver tissue. Arteriosclerosis of the intima of the hepatic aneurysm was not recognized. This reason seemed to be generated by an increase in intraluminal pressure with a hypertrophic change of the media.

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A 75-year-old woman was found to have rectal cancer covering the entire circumference of the rectum (RsS) on a barium enema study. Four days after the enema study, abdominal pain abruptly developed and it was diagnosed as barium peritonitis by an abdominal CT scan. Intraabdominal lavage and drainage and an artificial anus were made. And a high anterior resection of the rectum was performed on the 39th postoperative day. Enhanced CT scan to follow the clinical course revealed a tumorous lesion in the liver S6, which showed a tendency to increase in size on CT-AP and CT-A. We diagnosed the case as hepatic metastasis of rectal cancer and performed a hepatectomy. The tumorous lesion in the S6 was pathologically diagnosed as foreign body inflammatory granulation. It was inferred that barium had infiltrated into the liver to cause inflammatory granulation of the liver in this case.
It is thought that patients with a tumorous lesion of the liver after barium peritonitis require serious consideration including a possible diagnosis of barium granulation.

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Hepatocellular carcinoma (HCC) is thought to be a rare complication of autoimmune hepatitis (AIH). We report a case of HCC associated with AIH in a 67-year-old woman.
The patient in whom liver disfunction had been pointed out since 1989 was diagnosed as having liver cirrhosis due to AIH in 1996. Considering the poor prognosis of cirrhosis, immunosuppressive therapy was not adopted. In October 1999, a liver tumor was detected by abdominal computed tomography and was diagnosed as HCC. A hepatectomy was performed. The resected specimen from the non-tumorous lesion showed type B cirrhosis, and the tumorous lesion 8cm in diameter was moderately differentiated HCC. HBV-DNA and HCV-RNA were not detected in the tissue specimen from the non-tumorous lesion. In this case, there was a history of neither alcohol abuse, blood transfusion nor immunosuppressive therapy and hepatitis virus relation markers were negative. It was an interesting case about the carcinogenesis of liver cancer in AIH and we reviewed the literature on this disease in Japan.

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A 69-year-old man was pointed out slight impairment of liver function while he was treated for pulmonary emphysema at another hospital, and was referred to the hospital in 2000. Eight years before admission, in 1992, he had received interferon (IFN) therapy for chronic hepatitis C, with an excellent result; transaminases were continuously normalized and blood HCV-RNA showed lasting negative conversion; and histology of liver tissue was improved to F2A1 after the therapy from F3A2 before the therapy according to the new Inuyama's classification. Thereafter the patient had not been followed by his own decision. After admission, hepatocellular carcinoma 12cm in size in the right lobe was diagnosed and a right lohectomy of the liver was made. Histologically, it was moderately differentiated hepatocellular carcinoma, with a concomitant hepatic lesion of F1A0. A relatively non-curative resection was made.
In a review of domestic cases in which excellent results with INF therapy followed by hepatocellular carcinoma, about half of them were diagnosed as hepatic carcinoma within 3 years after INF therapy. And cases revealing severer hepatic fibrosis had earlier occurrence of hepatic carcinoma. There remains a possibility that precancerous lesions or minute cancer which are impossible to be detected by imaging procedures exist after successful IFN therapy, so that periodic follow-up examinations would be required for such cases by paying consideration to the occurrence of hepatic carcinoma.

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Both emphysematous cholecystitis and torsion of the gallbladder are relatively uncommon, and recently clinical cases of laparoscopic cholecystectomy have been increasingly reported. This paper presents a case of torsion of the gallbladder with emphysematous cholecystitis successfully treated by a laparoscopic cholecystectomy.
A 91-year-old woman was admitted to the hospital because of acute abdominal pain. Computed tomography on admission revealed a markedly enlarged gallbladder suggestive of floating gallbladder. Laboratory tests showed no abnormal findings except slight anemia. Abdominal pain persisted despite bed rest and fasting. CT revealed slight amount of ascites and gas shadow in the wall and lumen of the gallbladder distended reaching to the pelvic cavity on the next day. Laboratory tests showed leucocytosis. Laparoscopy revealed the brownish black gallbladder twisted clock-wise by 180 degree. The gallbladder was resected with ease due to its anatomical character and intraoperative puncture of the gallbladder. The post operative course was uneventful and the patient was discharged from the hospital 12 days after the operation.
Review of the Japanese literature disclosed six cases of emphysematous cholecystitis and 13 cases of torsion of the gallbladder treated laparoscopically. The present case was considered the first one of combined two diseases successfully treated laparoscopically.

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We have experienced a case of hinf₃ huge mucinous cancer of the gallbladder infiltrating into the greater omentum. This paper presents the case, together with a review of 16 domestic cases including ours.
A 61-year-old woman was admitted to the hospital because of epigastric pain. Gallbladder cancer infiltrating into the left medial segment of the liver was diagnosed preoperatively, and an embolization of the right portal branch was performed, followed by an extended right lobectomy of the liver, an excision of the extrahepatic bile duct, and lymph nodes dissection. The tumor was the swollen gallbladder 13cm in diameter, with necrosed tissues and large volumes of mucus in the lumen. Pathologic diagnosis was well differentiated mucinous cancer of the gallbladder with invasion into the greater omentum and findings of hinf₃, revealing stage IVa. Mucinous cancer is a cancer in which mucous lake and mucous nodules are formed outside the cancer cells. It is subclassified into well differentiated type deriving from papillary adenocarcinoma, well and moderately differentiated tubular adenocarcinoma, and poorly differentiated type deriving from signet ring cell carcinoma. In a review of the domestic 16 cases, there are more cases of relatively early cancer, and even cases of poorly differentiated type that is thought to have a poor prognosis had a favorable prognosis after resection of the foci. We have difficulty in making the definite diagnosis for the disease, but favorable prognosis can be expected by appropriated selection of operative procedure according to the progress of the cancer and active resection.

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A 68-year-old man was admitted to the hospital because of back pain in july 1999. He had past history of undergoing a cholecystecomy for gallbladder cancer in 1995 (histology: well differentiated tubularadenocarcinoma, depth: mp). At the first hospital, a high level of serum CA19-9 was pointed out. And he examined with conventional imaging methods including ultrasonography, CT, and magnetic resonance imaging, but no abnormal findings were revealed. The serum CA19-9 level continued to increase, and so he was refered to the hospital for further examination. FDG-PET revealed a high uptake near the abdominal aorta. CT imaging showed a small lymph node at the same place in the FDG-PET. To confirm the diagnosis, we made an operation and excised the hard lymph node along the common hepatic artery. Histological diagnosis was moderately differentiated tubularadenocarcinoma in the lymph node, which looked like the gallbladder cancer. FDG-PET appears to be very useful for detecting the recurrent site in the patient with elevated tumor makers after operation for gastrointestinal malignancy.

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An 8-year-old girl was admitted to the hospital because of periumbilical pain and right lower quadrant abdominal pain. On admission, a string was found to extend inferiorly from her umbilicus. Ultrasonography demonstrated a cystic tumor-like lesion. Computed tomography revealed the lesion which deviated to the right from the midline. At operation, the cystic tumor had a tobular structure which joined the internal iliac artery, suggestive of an infected umbilical artery. We report the case of infected umbilical artery which is thought rare, together with a review of the literature.

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There are few reports on surgical treatment for primary aldosteronism associated with renal failure. We present such a case in which control of blood pressure and balance of electrolytes became easy after a laparoscopic adrenalectomy.
A 49-year-old man, with past histories of hypertension and chronic failure, was referred to the hospital bacause of acute heart and respiratory failure. On admission, he displayed hypertension, heart failure, renal dysfunction (serum creatinine; 4.1mg/dl), and elevated levels of plasma aldosterone (57.1ng/ml) and rennin activity (0.13ng/ml). Hemodialysis (HD) was introduced. However, his blood pressure and electrolyte balance were not controlled well by HD and multiple antihypertensive agents. Examination revealed a right adrenal tumor. Laparoscopic adrenarectomy was performed, and the aldosteronproducing adenoma was removed. After the operation, his blood pressure and electrolyte balance was controlled easily by HD alone (three times a week), and the patient was discharged uneventfully. This case has demonstrated the efficiency of low invasive laparoscopic surgical treatment for primary aldosteronism even after introduced HD.

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This paper describes a case of right renal cell carcinoma with direct invasion into the liver and diaphragm and with distant metastasis to the lung (T4, N0, M1, V0, stage IV) in a 53-year-old woman. For the patient, percutaneous transhepatic portal embolization (PTPE) followed by associated resection of the right kidney and right lobe of liver succeeded in resection of the tumor en-block. Operation time was 5 hours 13 minutes, bleeding quantity was 801g, and excised tumor was 1800g in weight. No serious postoperative complications were encountered.
Histopathological study revealed that the liver foci comparatively differed from the original foci in cell type, histologic type, and atypia of nucleus. In other words, extremely malignant tumor tissue had destroyed the liver capsule and directly infiltrated into the liver tissues.
The kidneys are present beneath the retroperitoneum, so that, in order to invade the liver directly, renal cell carcinoma is demanded to progress destroying many physical obstacles such as renal capsule, perinephric tissue, retroperitoneum, and liver capsule. This is an explanation that direct invasion of renal cell carcinoma to the liver rarely occurs.

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A 53-year-old woman underwent an emergency surgery for ruptured ovarian clear cell carcinoma to save her life. Abdominal ultrasonogram and CT scan showed a ruptured right ovarian tumor caused massive intraabdominal hemorrhage. Grossly the tumor invaded the uterus so that the bilateral ovaries and uterus were totally removed. Although rupture of ovarian cancer is rare, it should be diagnosed preoperatively because it needs the same operation as for over stage Ic ovarian cancer which differs from benign ovarian diseases. If we kept in mind that rupture of ovarian cancer is a probable cause of intraabdominal hemorrhage, we could diagnose preoperatively by ultrasonography and CT scanning.

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We report a case of liposarcoma arising from the mesocolon required operations five times. A 53-year-old man was admitted to the center because of an abdominal tumor. We removed the tumor 20cm in diameter arising from the mesentery of sigmoid colon. During 21 months after the operation, recurrent tumors were resected four times. After four year disease free interval, a tumor in the small bowel mesentery, 4cm in diameter, was found. The fifth laparotomy was carried out to remove the tumor. Histologically, the tumors were myxoid liposarcoma without dedifferentiation. The tumor involved the adjacent organs at the second and third operations. There has been no evidence of recurrence as of 7 years after the first operation.

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We report a case of malignant peripheral nerve sheath tumor (MPNST) of the mesenterium in a patient with von Recklinghausen's disease (VRD).
Case: A 28-year-old woman•was admitted with abdominal fullness and right abdominal pain. Abdominal CT scan showed a 8×7cm in diameter irregularly enhanced tumor in the abdominal cavity, and a 3cm in diameter tumor in the left lateral segment of the liver. Angiography showed that the tumor was not well vascularised. The tumorectomy was performed by partial transverse colectomy and left lateral segmentectomy of the liver. Histological examination confirmed the diagnosis of MPNST and metastatic liver tumor. She died of the abdominal dissemination and the liver metastasis 3 months after the operation.

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We report a case of gallbladder herniation through the foramen of Winslow which required an emergency operation. An 89-year-old woman who had upper abdominal pain lasting for five days was referred to the hospital because an abnormality of the gallbladder was pointed out at another hospital. On an abdominal ultrasonography and a CT scan ascites was revealed, the gallbladder was located under the left lobe of the liver, the gallbladder swelled and its wall was remarkably hypertrophic. An emergency operation performed on the day of admission revealed that there was middle amount of ascites like bile juice and the gallbladder herniated into the lesser sac through the foramen of Winslow and twisted with a gangrenous change. We surmise that, as her gallbladder had the mesentery on only cystic duct, so-called “floating gallbladder”, it caused herniation. With greater awareness of torsion of the gallbladder, earlier recognition should lead to earlier surgery.

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This article report on a case of an extraperitoneal giant fibrolipoma which grew in a 10-year course. A 69-year-old man was seen at the hospital because of abdominal distention that was caused by a tumor in the abdominal area. The tumor had grown and it occupied almost whole abdomen. An abdominal CT scan revealed that the tumor occupied the entire abdominal area and that it had low density with septum and a cystic part. Furthermore, the tumor was pressing on the liver and gastrointestine. An abdominal MRI showed that the tumor had a high intensity.
From these findings, it was decided that the patient would undergo surgery. Intraperitoneal liposarcoma was diagnosed before operation. At laparotomy, however, the tumor existed at the extraperitoneum and the origin was around the symphysis pubica.
The excised tumor was 29.5kg in weight and covered with a smooth firm elastic type membrane. The section was segmentaland yellow in color. Histological findings showed that the tuomor was fibrolipoma and that there was no malignancy.

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This paper presents a case of extragonadal germ cell tumor (EGCT) arising from the retroperitoneum.
On May 8, 1997, a 29-year-old man was seen at the hospital because of left upper abdominal pain and appetite loss lasting from around February. An immovable and painful fist-sized tumor with clear border was palpated in the left upper quadrant of abdomen. Abdominal CT scan revealed a tumor about 10cm in size which occupied the left abdomen and compressed the ureter left superiorly. Disturbance of gastrointestinal passage due to the tumor appeared, and so an operation was performed on May 30. During operation, the fist-sized projecting retroperitoneal tumor was confirmed in the left abdominal cavity. The compressed ureter was not involved and was dissected bluntly. Further, the tumor invasion into parts of the greater psoas muscle and aorta was revealed and these parts were incisively dissected and resected together with lymph node (16b1). The resected material revealed a 12×8.5×5cm elastic hard tumor with smooth surface. Histologically, it was complex type in which embryonal carcinoma, choriocarcinoma, and teratoma coexisted. Postoperative course was uneventful. After postoperative high dose VIP therapy, HCG-β has been normalized up to now.

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Retroperitoneal liposarcoma lacks clinical symptoms. It presents with compressed symptoms with an increase in the size of tumor and is often detected when it grows up to be a huge mass. We report a case of retroperitoneal liposarcoma which was more than 6, 000g in weight. A 47-year-old woman complaining of abdominal distesion was referred to the hospital because a retroperitoneal tumor was pointed out at another hospital. The patient was diagnosed as having differentiated retroperitoneal liposarcoma by diagnostic imagings and underwent an operation. The tumor was located from the left subphrenic space to pelvic cavity and excised together with the distal pancreas, spleen and left adrenal gland, since those organs were fixed to the tumor. The excised tumor weighed 6, 080g and was histologically diagnosed as well differentiated liposarcoma. We are following the patient without any adjuvant therapy, because the effectiveness of chemotherapy and/or radiation therapy on liposarcoma has not been defined as yet, especially for well differentiated type.

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This paper presents a 75-year-old woman with lower abdominal linea alba hernia. She had undergone a laparoscopic cholecystectomy six years before. Abdominal CT scan revealed a defect 6cm in diameter in the abdominal wall on a lower median part of the abdomen, and a protrusion of the small intestine in the subcutaneous fat layer. A diagnosis of incisional hernia following a laparoscopic cholecystectomy was made, and an operation was performed. Under laparoscopy, the hernia port was observed not at the umbilical trocar site but at the lower median abdominal wall. It was diagnosed as lower abdominal linea alba hernia and then the hilus of the hernia was closed. Linea albs hernia is a rare condition in Japan. Especially, the hernia occurred in the lower abdomen is so rare that only five cases have been reported. Althrough abdominal wall hernia was diagnosed preoperatively by CT, it was difficult to distinguish the linea alba hernia from incisional hernia by CT, in that laparoscopy was helpful to get the definite diagnosis.

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Patient 1, an 80-year-old woman, was admitted to the hospital because of a right femoral painful mass. Pelvic CT scan showed an incarceration of the obturator hernia and a femoral abscess. Emergency operation was performed through the inguinal approach under spinal anesthesia, and a necrosed ileum was resected. The hernia hilus was closed by suturing the fascia transversalis and the transversus aponeurosis to the obturator internus fascia. The femoral abscess was drained.
Patient 2, a 90-year-old woman, was admitted to the hospital because of intestinal obstruction and pain extending down the inner surface of her thigh (Howship-Romberg sign). Pelvic CT scan showed an incarceration of the obturator hernia. Her operation was performed through the inguinal approach under spinal anesthesia like in the patient 1, a necrosed ileum was resected, and the hernia hilus was closed by direct suture.
Obturator hernia is common in lean women. In instances in which ileus or femoral pain is confirmed, CT scan of the inguinal region with a suspicion of the disease is required. It is thought that CT is a useful tool to diagnose obturator hernia preoperatively, and the inguinal approach is less invasive and beneficial method to treat obturator hernia.

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Triple cancer of the esophagus, stomach, and colorectum is rare. This paper presents such a rare case of triple cancer. A 55-year-old man was seen at the hospital because of abdominal pain and diarrhea. Colonoscopic examination revealed an advanced cancer of the upper rectum with severe stenosis over the entire circumference of the rectum. Routine preoperative endoscopic examination revealed a type 0-IIc cancer at the upper body of the stomach. Low anterior resection (LAR) and a proximal gastrectomy were performed. One year and 5 months after the LAR, an endoscopic examination showed a type 0-IIc cancer in the thoracic esophagus. Endoscopic mucosal resection (EMR) of the esophageal cancer was performed. Histologically, the resected specimen showed cancerous invasion in the submucosa (sm₂). Adjuvant radiotherapy for the esophagus was performed. The patient has been followed up carefully in the outpatient clinic for 9 months since EMR of the esophageal cancer, with no signs of recurrence.

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