A series of 686 women with breast cancer who underwent mammographic examination were subjected. The subjects were divided into five groups {T(+), C(+), TC(+), A(+) and TCA(-)} according to the presence or absence of mass density (T), microcalcification (C) or architectual distortion (A) on mammogram. Diagnostic accuracy rate (DAR) and unimaged rate (UIR) of mammography were investigated and the following results were obtained.
(1) DRA of mammography between different mammographic apparatus was no significant difference, but UIR was significantly difference among them.
(2) DAR according to mammographic findings was the highest in TC(+) group, follwed by C(+), T(+) and A(+) group.
(3) UIR under 40's was significantly higher and DAR was significantly lower than those over 50's
(4) UIR under 2.0cm in tumor size was significantly higher and DAR was significantly lower than those over 2.1cm.
(5) UIR of unclassified type was the highest in all types. DAR of unclassified type and circumscribed type were signifiacantly lower than those of infiltrative type and intermediate type.
(6) DAR of noninvasive carcinomas were significantly lower than those of invasive ductal carcinomas.
(7) UIR of the group of negative lymph node metastasis was significantly higher and DAR was significantly lower than those of the positive group.
(8) To raize DAR of mammography was needed to decrease UIR.

View full abstract

To clarify prognostic factors for metastatic colorectal cancer to the lung after pulmonary reseciton, we heve reviewed the clinical courses of 58 patients who underwent surgery in Kurume University hospital between 1978 and 2000. The cumalative 5-year survival rate was 34%. Multivariate analysis indicated that the presence of hilar and/or mediastinal lymph node metastases, the presence of extrapul-monary metastases before or at the thoracotomy, and tumor size larger than or equal to 30mm were independent prognostic factars. Especially, the former two of the three factors described above were determinant. Eleven patients underwent repeated pulmonary resection for isolated lung recurrence. Five patients are still alive, including a patient surviving for the longest of 120 months. The survival rates in these 11 patients were 63% at 3 years and 24% at 5 years after the second pulmonary operation, comparing favorably with the survival rate in those who underwent primary pulmonary resection. The median survival was 37 months. Repeated pulmonary operation for recurrent colorectal metastases to the lung yields comparable results to the first pulmonary operation.

View full abstract

We examined the influence of clinical findings on the enhancement with ferumoxides (FMX) for liver tumors on magnetic resonace imaging (MRI). Twelve patients with metastatic liver tumor (Meta) and 21 with hepatocellular carcinoma (HCC) were enrolled in this study. We examined the FMX-enhancement effect in the Meta and HCC groups, using liver signal intensity (SI) suppression rate (% suppression), tumor SI augmentation rate (% augmentation) and tumor-liver contrast noise ratio (CNR). The CNR was increased significantly after the injection of FMX in both Meta and HCC groups. We did see differences in neither % suppression of liver nor % augmentation of tumor SI between the Meta and HCC groups. In the HCC group, the liver function had little effect on the increase in CNR or liver SI suppression. However it was noticeable that the tumor SI and CNR were decreased in two of three patients with well-differentiated HCC.

View full abstract

In order to select the best treatment for the patients with small hepatocellular carcinoma (HCC), histopathological progression of the small HCC (less than 3cm in diameter and within 3 lesions) was examined on 49 patients (56 nodules) who underwent hepatectomy. These 56 nodules were classified by the tumor diameters (less than 15mm, 12 nodules ; 16-20mm, 20 ; 21-25mm, 16; and 26-30mm, 8). Since extracapsular progression (extracapsular invasion, intrahepatic metastasis, or invasion to the blood vessels) was noted in only one nodule (8.3%) in HCC of less than 15mm in diameter. Percutaneous ethanol injection therapy (PEIT) seemed to be the first choice of the treatment. However, moderately or poorly differentiated HCC, or no formation of HCC capsular was observed in six nodules (50%), or five nodules (41.7%), respectively. This results seemed to be a risk factor which might cause the local recurrence after PEIT. In HCC over 16mm in diameter, capsular invasion and extracapsular progression within lcm from the tumor edge were observed in high rates (59.1% and 45.5%, respectively). Moreover, one nodule (22mm in diameter) in four nodules of resected HCC after PEIT showed the viable cancer cells of intrahepatic metastasis pathologically. In HCC over 16mm in diameter, the therapy which insure the local control including the tumor circumference such as hepatectomy or microwave coagulation therapy, should be selected.

View full abstract

A case of polyarteritis nodosa localized to the bilateral breasts is described. A 72-year-old woman was seen at the hospital because of tender lumps and erythema in the bilateral breasts and fever which lasted for 2 weeks. The lumps were multiple and elastic hard with tender. Although an ultrasonography showed low echoic masses which were match up to the lumps, a mammography and a magnetic resonance imaging did not demonstrate any abnormal findings. At first inflammatory breast cancer was suspected, but there was no evidence of cancer of the breast, and so an excisional biopsy was performed under local anesthesia. Histologic examination showed polyarteritis nodosa with fibrinoid necrosis and fragmentation of the internal elastic lamina of the walls of small-sized arteries. There was no findings of angitis in other organs. This case was diagnosed as polyarteritis nodosa localized to the bilateral breasts. Adrenal corticosteroid therapy was begun and fever elevation and local inflammatory findings disappeared rapidly. She has been asymptomatic as of 2 years and 6months after the definite diagnosis was made. Further careful observation of clinical course would be required.

View full abstract

Male breast carcinoma accounts for 0.5-1% of all breast cancers and it is estimated that 3% of female cases of breast carcinama are Paget's disease. Then male Paget's disease is very rare.
We experienced a case of Paget's disease of the breast in an 83-year-old man, presenting right nipple pigmentation and bloody discharge. Simple mastectomy was performed because no axillary lymph node was palpated and detected by ultrasound. The epidermis showed only a few scattered Paget's cells in the microscopic studies. In the histochemical stainings for the Paget's cells, CEA, PAS, Cyto-keratin, EMA, ER, PGR were positive. Malignant melanoma and Bowen's disease must be excluded in the differential diagnosis. The differences can be seen in CEA staining. Its prognosis is considered comparatively good, but observation of the clinical course is needed after surgical resection, because male case reports are not enough to draw out some therareutic guidelines.

View full abstract

The patient was a 69-year-old woman, who had undergone a modified radical mastectomy for left breast cancer in April, 1999. The tumor was non-invasive ductal carcinoma, and tnm classification was t1n0m0 in stage I. About ten months later, a right breast tumor, 2.4×1.8cm in diameter, was detected and diagnosed as breast cancer with an aspiration biopsy cytology. Modified radical mastectomy was perfomed. Histopathological diagnosis was histiocytoid breast carcinoma and t1n0m0 in stage I on the tnm classification.
Histiocytoid breast carcinoma is very rare and this type of tumor has not been mentioned in the WHO classification of breast cancer or in the General Rules for Clinical and Pathological Recording of Breast Cancer in Japan. So far, only about 40 cases have been reported in the English literature. We present the case of this rare tumor type with some bibliographical comments.

View full abstract

A 71-year-old man was seen at the hospital because of a rapidly enlarging right breast mass. It was soft, 7cm in diameter, in the E area of the right breast. Ultrasonography, CT and magnetic resonance imaging demonstrated a solid lesion in the cystic tumor with a clear border. The preoperative pathological diagnosis by aspiration biopsy cytology was class III. Simple mastectomy with sampling of the axillary lymph nodes, which had swellen, was performed. Histological diagnosis was papillally intracys-tic carcinoma with metastases to the axillary lymph nodes. So far only one case of male intracystic carcinoma of the breast with lymphatic metastases has been reported in Japan. Although operation whithout lymph node dissection has been suggested for male intracystic breast carcinoma, we propose that its indication has to be discussed more.

View full abstract

Squamous cell carcinoma of the breast is a rare tumor and there have been few reports describing its preoperative diagnosing measures. This paper deals with nine patients with squamous cell carcinoma of the breast in the center and their preoperative diagnosing measures. They were 63.3 years old on an average and had a mean tumor diameter of 3.9cm. In the other words, aged patients with large tumors in an advanced stage were involved in the cancer patient group compared with usual breast cancer patient groups. Preoperative diagnosing rates as cancer were 100% (8/8 cases) on palpation, 75% (6/8) on mammography (MMG), 88% (7/8) on ultrasonography, and 100% (6/6) on fine needle aspiration biopsy cytology (FNA). Although no characteristic findings were revealed on MMG, cystic part in the tumor was confirmed on US in four out of eight patients, two of whom had a rapidly enlarging tumor. Of six patients on FNA, three patients were diagnosed as having squamous cell carcinoma, which were able to be differentiated from adenocarcinoma based on findings including polymorphic cell, stratified cyto-plasm, polychromatophilia, irregular nucleus, central, and rough conglobate chromatin. In the cases of breast tumors with a cystic part on US which indicates a possibility of squamous cell carcinoma, the making diagnosis by FNA would become helpful.

View full abstract

A 75-year-old man underwent a simultaneous mitral valve replacement procedure for severe endocarditis and the resection of a rectal cancer, with massive bleeding. The patient was admitted to the hospital because of a reoccurring spiked fever, cough, sputum, dyspnea, lumbar pain and hemorrhea. Mitral valve regurgitation as a result of infectious endocarditis associated with rectal cancer (Rb) was diagnosed after a detailed examination. The anterior resection for the rectal cancer was performed after the complete closure of the chest wall during the mitral valve replacement procedure to prevent bacterial contamination. In the present case, great cares was required to control the patient's hemodynamic status, included respiratory function, and fluid-balance. Five days were required before the patient was taken off the respirator. Although a one-step approach for combined open heart surgeries and laparotomies is ideal, a preoperative risk assessment must be performed for each patient. Furthermore, great care must be taken with regard to perioperative management.

View full abstract

This paper deals with a case of thymic carcinoid with metastasis treated by multiple operations over 9 years. The case involved a 69-year-old man. When he was 60 years old, he underwent a tumorectomy and lymph node dissection in the mediastinal and bilateral supraclavicular regions under a preoperative diagnosis of thymic carcinoid with supraclavicular lymph node metastases. Because the lymph node swelling in the mediastinum was revealed on a CT scan 3 weeks after the operation, he received chemotheraphy (cisplatin 80mg/m² and etoposide 100mg/m²), resulting in no regression of the lymph nodes. Radiotheraphy (50.4Gy), however, brought about a complete regression of the lymph nodes. He developed lymph node recurrences in the neck, left axilla, right axilla with left lung metastases and submaxilla 4 years and 3 months, 7 years and 7 months, 9 years and 3 months, and 9 years and 8 months after the operation, respectively. These recurrences were managed with lymph node dissection in each time and video-assisted partial resection for the lung metastases. This case which could be followed for morethan 9 years appears to be very informative one in its metastatic mode and clinical outcomes after the salvage operations.

View full abstract

Congenital cysts of the esophagus are relatively rare. A 19-year-old man was admitted to the hospital because of epigastralgia and nausea, and an ultrasonography of the abdomen revealed a tumor shadow behind the lateral lobe of the liver. Magnetic resonance imaging (MRI) revealed a homogenous tumor adjacent to the lateral lobe of the liver and the abdominal esophagus, and disclosed a iso-signal intensity on Tl-weight images and a high signal intensity on T2-weight images, no enhancement being seen on a dynamic study. Under the preoperative clinical diagnosis of esophageal cyst, a laparoscopic enucleation was performed. The cystic wall consisted of double layers of smooth muscle without cartilage and was lined with ciliated columnar epithelium. Based on Arbona's criteria, the cyst was diagnosed as duplication cyst.
A laparoscopic approach is less invasive than conventional laparotomy, and the patient's recovery is more rapid. Laparoscopic surgery is considered to be beneficial for patients with benign esophageal tumors such as esophageal cyst and leiomyoma in the abdomen, that have been diagnosed before operation.

View full abstract

We clinically studied recent five cases of gastrointestinal stromal tumor of the stomach (GIST in the narrow sense). An average age of them was 66 years, and the male-to-female ratio was 3:2. Three and each one lesion were present in the U, M, and L area, respectively. These lesions were 0.5-30cm in size and there were one intramural and four extramural lesions. Contrast enhanced CT scan revealed heterogeneous enhancement, extrinsic pressure to the surrounding tissues and expansive growth in three cases with lesions more than 5cm in size. No cases had been definitely diagnosed as GIST in the narrow sense before surgery. Gastric cancer was associated in three cases. In the treatment, total gastrectomy was performed in three cases of the disease with gastric cancer and a partial gastrectomy in the remaining two cases. Histopathologically, three cases with lesion of more than 5cm disclosed to be malignant. Immunohistologically all cases were CD34 and c-kit positive.
Of GISTs, GIST in the narrow sense which shows no differentiation into smooth muscle and nerve tissue is immunohistologically CD34 and c-kit positive, and is derived from Cajal interstitial cells. So it may be called c-kitoma. These five cases involved three cases associated with gastric cancer. It is thought that further accumulation of clinical cases of GIST is needed to elucidate the mechanisms of simultaneous occurrence of gastric cancer and GIST of the stomach.

View full abstract

The patient was a 53-year-old man who had a history of undergoing a surgical hypophysectomy for the treatment of acromegaly at the age of 32 and radiation therapy for an elevation of GH level at the age of 51. Because he complained of epigastric discomfot and tarry stool, an upper gastrointestinal endoscopy was performed. He was found to have early gastric cancer, and was admitted to the institute for surgical intervention. On laboratory finding, the level of GH was higher than normal level, and an upper gastrointestinal endoscopy revealed two IIc type gastric cancers on the angle and greater curvature of the antrum. He underwent a distal gastrectomy with D2 lymph node dissection. Pathologycally both lesions were moderately differentiated adenocarcinoma without lymph node metastasis, the angle lesion being limited to the mucosal layer and the antrum lesion to the submucosal layer. In the previous reports, the persisting high level of GH might influence the carcinogenesis in acromegalic patients, and the assosiation of malignancy is an important factor for the prognosis in them. It should be kept in mind in the long term observation of patients with acromegaly.

View full abstract

A 73-year-old man visited a hospital because of rapidly worsening numerous warts on the extrem-ities and was diagnosed as having gastric cancer by a photogastroscopic test. And multiple esophageal papillomas were associated. The patient was admitted to the hospital with a diagnosis of gastric cancer with Leser-Trélat sign and multiple esophageal papillomas. Distal gastrectomy and a biopsy of the skin were performed. Histopathological study of gastric cancer revealed a part of squamous cell carcinoma in adenocarcinoma. The skin biopsy revealed seborrheic keratose. This case is very interesting in that warts and esophageal multiple papillomas as well as squamous cell carcinoma in parts of gastric cancer and lymph nodes were seen. The mechanisms of Leser-Trélat sign have been reported that epidermal growth factor might participate in it, however, it was obscure in this case. In this study, immunostainings for EGF, KGF, and IL12 were conducted in every lesion and production of proliferating factor from gastric cancer foci was investigated, however, no humoral mediator has been demonstrated.

View full abstract

This paper presents a case of perforated duodenal diverticulum. A 67-year-old man was admitted to the department of internal medicine division of gastroenterology in our hospital because of epiastric pain. Endoscopy of the upper gastrointestinal tract revealed diverticula, and a computed tomography (CT) of the abdomen showed emphysema in the anterior region of the kidney and retroperitoneum near the second part of the duodenum. With a diagnosis of retroperitoneal perforation of the duodenal diverticulum, we conducted a laparotomy that revealed a retroperitoneal abscess in the second part of the duodenum and dorsum of the pancreas head and phlegmonous changes around the abscess. Due to marked inflammation at the duodenal wall, we did not conduct sutural closure of the perforation. Instead a drainage of the abscess cavity and a gastrojejunostomy were performed which resulted in a satisfactory postoperative course. In this paper, we also reviewed 56 cases of perforated duodenal diverticulum including fistulation cases reported in Japan.

View full abstract

We have experienced a case of duodenal stenosis probably due to acute cholecystitis which was successfully traeted by conservative therapy.
An 84-year-old man complaining of fever and mild upper abdominal pain was admitted to the hospital with a diagnosis of cold-induced gastroenteritis. Symptomatic remission had been achieving by infusion therapy with antibiotics, however, massive vomiting occurred on the seventh hospital day. Upper gastrointestinal series and an endoscopy revealed a stenosis at the descending part of the duodenum. Ultrasonographic study and a CT scan visualized the swollen gallbladder adjacent to the duodenal stenosis. Duodenal stenosis which might be caused by cholecystitis was diagnosed. The patient did not hope to undergo any operation for his advanced age. Conservative therapies including fasting, IVH, and administratiton of antibiotics were selected which yieled a release of the stenosis in about 10 days.
Although operation is employed in almost all patients with duodenal stenosis, there are some patients whose stenoses are successfully released by conservative therapy like this patient. We must carefully select candidates for operation from patients with duodenal stenosis.

View full abstract

A 28-year-old man who had been operated on for small intesitinal type Crohn's disease with ilial perforation a year before, was admitted to the hospital because of nausea and vomiting. Gastrointestinal lesions of Crohn's disease was diagnosed, and the patient was once discharged from the hospital after successful conservative therapy. However, symptoms recurred and he was readmitted to the hospital. An upper Gl series and an endoscopic examination showed cobble stone like appearance and stenosis from the pylorus to bulbus. We treated him with conservative therapy and balloon dilatation therapy, but in vair. About a month later, a partial gastrectomy with a Billroth II reconstruction was perfomed. Pathologically, non caseating epithelioid cell granuloma, tranasmural inflammation and fibrosis were seen. Although minute gastroduodenal lesions of Crohn's disease have been increasingly found out such cases demanding an operetion are quite rare, and only 34 cases have been reported in Japan.

View full abstract

A 66-year-old man who had been hospitalized for schizophrenia at a mental hospital was admitted to the hospital because of a sudden onset of abdominal pain and distension. There was a previous history of undergoing an appendectomy at the age of 38. A simple X-ray film of the abdomen showed a mass shadow with dilatation of the small intestine and niveau. Abdominal CT scan revealed a shadow of a foreign body like a seed of plant in the terminal ileum with a significant dilatation of the proximal small intestine. The patient was diagnosed as having intestinal obstruction due to some seed of plant. Conservative treatment by an ileus tube was ineffective, therefore an emergency operation was done. At laparotomy, there was adhesion of the ileum owing to the previous appendectomy. A foreign body was impacted in the ileum 30cm distal from the Bauhin's valve. The ileum wall was to be fragile after adhesiotomy, and so a partial resection of the ileum including the foreign body was performed. The foreign body was a seed of peach, measured 4.5×3.5cm in size. In this case, we could not know the kind of foreign body because of difficulty in taking history due to his mental disease, but an abdominal CT scan showed the characteristic image of the seed. This imaging procedure contributes to make the diagnosis of the disease.

View full abstract

We have experiecnced a case of intussusception after removal of a long ileus tube in a postoperative adult patient. A 63-year-old man was admitted to the hospital because of recurrent adhesive ileus. Emergency operation was performed. Intestinal adhesion was prepared and a long ileus tube was left in the terminal ileum for postoperative decompression and stenting of the intestine. As the patient was going well, the tube was removed on 7 postoperative day; however immediately after the removal, the patient complained of nausea, vomiting and left lateral abdominal tenderness. Abdominal X-ray film, a CT scan and an ultrasonography indicated small intestinal intussusception. On the 50th postoperative day after conservative therapy was unsucseeful, reoperation was performed. Antegrade intussusception was found at 60cm from the Treitz ligament, which was repaired manually. There were no organic disorders causing intussusception and removal of a long tube might indure the intussusception. This case has suggested that care should be taken on removal of a long ileus tube.

View full abstract

A 25-year-old woman who had no remarkable medical and family histories presented with sudden onset of dark red watery stool without any cause and developed shock. CF revealed no obvious lesions from the terminal ileum to anus through the large intestine. Angiography visualized multiple arterial ruptures in the ileum. An operation disclosed lesions in the ileum covering from 20 to 40cm from the terminal ileum, which coincided with ruptured arteries at the angiography. This portion was resected. Macroscopically, longitudinal discontinuous ulcers with the longer diameters of 3-6cm and pavement like mucus remnant were confirmed on the mesentery side. Histologically, ulcer formation up to UL-III, ruptured arteries, and epitheloid granuloma with Langhans giant cells at the bottoms of ulcers and the surrounding tissues were present. Subsequently small bowel Crohn's disease was diagnosed.
It is very rare that Cronhn's disease present with massive anal bleeding like in this case. Since this case lacked clinical symptoms suggestive of Cronhn's disease, the preoperative diagnosis could not be made, in that angiography was very helpful in diagnosing bleeding site, and determining operative application and surgical margin to be resected.

View full abstract

A 56-year-old woman was admitted to the hospital because of right lower abdominal pain, fever and diarrhea. Three years before admission, she had occasionally suffered from right lower abdominal pain but let it alone. Tenderness and muscular defense were observed in the right lower abdomen. Abdominal CT scan showed thickening of the ileum end wall, so that an emergency operation was performed with a suspicion of peritonitis due to ulcer of the ileum. In a 10-cm section of the ileum from the terminal ileum in the oral direction, the serosa of the ileum had become reddish and swollen. No inflammatory change of the appendix was seen, so that the operation consisted of an ileocecectomy. The resected specimen was found to have a rough and eroded mucosa. A histological diagnosis of MALT lymphoma was confirmed by the results of immunochemical examinations. Because it was suspected that the resection had not resulted in a complete cure, the patient underwent chemotherapy after the surgery and has been free from the disease until now. We present this case because primary MALT lymphoma of the small intestine is relatively rare.

View full abstract

A 54-year-old man was admitted to the hospital because he was pointed out a polyp protruding from the orifice of the appendix by a screening colonoscopy. Colonofiberscopy visualized a protruding lesion with redness and granular surface near the appendix orifice. Histological findings of a biopsy from the appendix polyp demonstrated tubular adenoma. Endoscopical polypectpmy was unsuccessful, and a laparoscopically assisted appendectomy was performed. In the resected specimen, the adenoma was a pedunculated polyp with the head 10mm in diameter and the stalk 12mm in length. Histopathological diagnosis was typical tubular adenoma.
In Japan, sofar only 14 cases have been reported including our case. This case in the fourth case report of adenoma of the appendix diagnosed preoperatively.

View full abstract

A case of a giant mucinous cystadenoma of the appendix presented with ileus is reported with a review of the literature. An 82-year-old woman was admitted to the hospital because of abdominal pain and frequent vomiting. After recovery of the ileus by welling an ileus tube, abdominal computed tomography revealed a 9.3×7.6cm giant mass lesion of the cecum. A colon fiberscopy revealed a submucosal tumor-like elevated lesion of the appendix orifice, but a biopsy material taken from the epithelia of appendix orifice did not reveal any abnormal findings. With s suspicion of primary tumor of the appendix, an ileo-cecectomy was carried out. The resected tumor was 10×7×6cm in size. Microscopically it was mucinous cystadenoma. The patients postoperative course was uneventful.

View full abstract

A 73-year-old woman was referred to the hospital because of right lower abdominal pain, and she was diagnosed as having carcinoma of the cecum. Right hemicolectomy was conducted. Histopathological examination revealed poorly differentiated adenocarcinoma. A metastatic tumor of the hilus of the spleen and paraaortic lymph node which had been confirmed before operation enlarged rapidly. Furthermore, hyperleukocytosis recognized preoperatively progressed after the operation and the leukocyte count reached to 101, 200/mm³. The general condition worsened rapidly, and she died 2 months after her first consultation.
An immunohistochemical study showed negative staining for granulocyte-colony stimulating factor (G-CSF) in the tumor cells, but the serum G-CSF level was markedly high, 430pg/ml. The tumor in this case is strongly suspected to be G-CSF pruducing tumor

View full abstract

A nine-month-old male infant was taken to the hospital because of vomiting and sullenness. He was delivered normally. A mass was palpable at the right side of the abdomen and an ultrasonography (US) revealed target sign and a cystic mass. Then he was admitted with a suspicion of intussusception. Gastrographin enema revealed a filling defect characteristic of intussusception in the colon, which could not be reduced. Abdominal computed tomography (CT) showed multiple concentric ring and the cystic mass in the ascending colon. An emergency operation was carreid out with a diagnosis of intussusception caused by duplication of th intestine or the mesenteric cyst. The intussusception had been reduced. The mass was identified in the terminal ileum. It could not be resected by itself, and required an ileocecal resection. The mass was round in shape and identified near the terminal ileum on the mesenteric side. Histopathologically the tumor had common muscular wall and its own mucosal lining. So duplication cyst was diagnosed. It is difficult to diagnose the duplication preoperativery due to its atypical type of location, size, form, age, and symptoms. In case in which nonoperative reduction leads to failure in the child intussusception, it is necessary to explore the leading point carefully with the radiographic appear-ance.

View full abstract

A 35-year-old man, who had no paticular history except occasional symptoms of troublesome defecation, was sdmitted to the hospital because of sudden onsets of bloody stool. The appetite was fair and bowel movements were good. No tumor was palpable by a digital examination. Colonoscopy revealed a transeverse colon ulcer with bleeding from a visible vessel, and endoscopic clipping was successful. A biopsy specimen showed hemmorrage into the interstitial tissue, and infiltration of inflam-matry cells and granulation tissue were histologically noted. No specific findings suggestive of inflamma-tory bowel disease, nor infectious colitis were demonstrated. Probable causes in this case are thought to be an impact on the faecal materials, troublesome defecation and a mechanical pressure effect on the mucosa. Simple stercoral ulcer of the transverse colon was definitely diagnosed.

View full abstract

We present a surgically treated case of periaortic lymph node recurrence one year after an operation for cancer of the sigmoid colon.
The patient was a 71-year-old woman. She had undergone a sigmoidectomy with D3 lymph node dissection for cancer of the sigmoid colon in January 1997, when pathological diagnosis was moderately differentiated adenocarcinoma with the invasion depth of tumor of ss, n2(+), and stage IIIb. Abdominal CT scan performed one year later revealed successive tumors covering from the inferior margin of left renal vein to common iliac artery. Metastasis to the periaortic lymph nodes was strongly suspected. Since close exploration revealed no other metastases, paraaortic lymph node dissection was made. There have been no signs of recurrence, as of 3 years one month after the reoperation. This case which is thought to be precise in gaining a relatively long-term survival is described here.

View full abstract

It is relatively uncommon that colon cancer metastasizes to the ovary. We have experienced a case of early colon cancer with ovarian metastasis. A 38-year-old woman was seen at the hospital because of a lower abdominal tumor. She had a previous history of undergoing a resection of sigmoid colon cancer. At that time the tumor was moderately differentiated adenocarcinoma and the depth of invasion was sm. Further histological examination revealed ly3, v0 and n2. This time, 6 months after the operation, the lower abdominal tumor was found. Abdominal CT scan showed cystic tumors in the bilateral ovaries. Bilateral oophorectomy and a hysterectomy were performed. Histologically, these ovarian tumors were similar to the resected sigmoid colon cancer, and were diagnosed as ovarian metastasis of colon cancer. There have been no signs of recurrence for five years. However, as of 5 years and 4 months after the oophorectomy, she died of multiple hepatic and lung metastases.
Ovarian metastases of colorectal cancer are comparatively rare, and are usually synchronous with advanced colorectal cancer. The prognosis of these patients is very poor. This case is thought to be valuable in terms of metachronous ovarian metastases of early colon cancer and long survival for 5 years of more after oophorectomy.

View full abstract

An 80-year-old woman had been diagnosed as having hemorrhoids with anal bleeding and prolapse, and had been treated conservatively for 3 months by her local practitioner. After that, she was referred to the hospital because of an anorectal tumor. An elastic soft blackish-red protruding mass was detected in the anal canal by digital and endoscopic rectal examination. It was diagnosed as anorectal malignant melanoma by histological examinations of a biopsy specimen which stained by hematoxylin and eosin and stained positive for HMB-45 monoclonal antibody. An abdominoperineal resection of the rectum with regional lymph node dissection (D₂) was conducted. The resected specimen showed two grayish white tumors, one 3.9×3.2cm and the other 3.7×1.7cm in size, just on the dentate line. Microscopical features were a₁, ly₁, v₁, n₀, in stage II. A metachronous metastatic liver tumor occurred 8 months after the surgery and the tumor soon occupyed most of the liver. She died 17 months after the surgery. No effective multidisciplinary treatment for this disease has been established. We emphasize the importance of earlier proper treatment for this disease because it is highly malignant with a rapid growth of the tumor.

View full abstract

A 22-year-old man suffered from a III_B typed liver injury due to a traffic accident in September, 1999. For hemostasis, as the initial treatment, a transcatheter arterial embolization was performed at an emergency hospital. After life saving, as a fever continued, he had laparotomy twice at that hospital; a cholecystectomy on the fourth day, and a partial hepatic resection for the injured liver involving S5 and S6 on the ninth day after the accident. After the surgery, bile leakage happened, that was incurable by conservative therapy. He was transferred to the hospital for treatment in March, 2000.
Although the anterior branch of the intrahepatic duct was revealed by endoscopic retrograde cholangiography (ERC), the posterior branch was not by ERC and revealed from the drainage route. Angiography revealed blood supply to S7 and S8 lesions. We thought that the bile leakage was caused by an injury of the posterior branch. Because the left lobe of the liver has been hypertrophy, after intraoperative cholangiography, a right lobectomy was made with a good outcome. He was discharged from the hospital three weeks after the last operation.
At the surgery for liver injury, because hepatic duct injury often occurs, the anatomical hepatic resection after cholangiography should be performed as possible as we can.

View full abstract

We have experienced a case of hepatico-colonal fistula which is a rare complication after microwave coagulation therapy (MCT). A 78-year-old man was seen at the hospital because of melena. Rectal examination revealed a hard mass and pathological diagnosis was rectal cancer. Preoperative CT scan of the liver showed five metastatic lesions in segment 4, 5 and 6. Low anterior resection was performed combined with MCT irradiation to the liver metastasis under ultrasonography. The body temperature had remained consistently elevated above 38°C since postoperative day 3. A contrast enhanced CT scan showed several low-density areas with niveau formation, which were diagnosed as liver abscesses after MCT. Percutaneous transhepatic drainage to the each liver abscess was made and then the temperature dropped rapidly within normal range throughout the hospital stay. Three months after the operation, an asymptomatic hepatico-colonal fistula located between transverse colon and segment 6 was detected by colonoscopy and fistelography. Although postoperative course was uneventful except this fistulization, he died of recurrence in May 1999.

View full abstract

It is said that hepatic metastasis occurs in about 10% of postoperative patients with gastric cancer and 20% or more of those with recurred gastric cancer, and their prognoses are poor showing the 5-year survival rate of several to 10% even if they have H1 tumors. However, patients undergone hepatectomy tend to have better prognosis that is prominent in those undergone hepatectomy metachronously. Furthermore, primary hepatic cancer often has liver cirrhosis as an underlying disease, for that we have great difficulty in making diagnosis, with resultant poor prognosis.
We report here a case of hepatocellular carcinoma (HCC) occurred 7 years after an operation for gastric cancer with metachronous metastasis to the liver. The patient was a 65-year-old man, who underwent a distal gastrectomy for gastric cancer on December 18, 1990 and an enucleation of a S3 liver tumor due to metastasis on September 20, 1991. Postoperatively, he received blood transfusion and adjuvant chemotherapy with Etoposide, Adriamycin, and cisplatin (EAP) by i. a. infusion. Subsequently he underwent a wedge resection for a metastatic lung tumor on November 30, 1993, when hepatitis C virus antibody and liver cirrhosis were detected. Blood biochemical studies revealed increases in the serum AFP and PIVKA-II levels on December 1998. Abdominal CT scan revealed HCC. Laparotomy revealed severe adhesion inside the peritoneal cavity due to the previous operation. Tumor enucleation of S2 for HCC with microwave coagulation was performed. There have been no signs of recurrence of liver metastasis or HCC, as of 27 months after the last operation.

View full abstract

We experienced a case showing prolonged postoperative jaundice after an extended hepatectomy for giant metastatic liver tumors. A 48-years-old man was pointed out having anemia and positive fecal occult blood at a medical checkup, and was admitted to the hospital for close examination. The examination revealed a type 2 tumor of the transverse colon with a giant metastatic tumor occupying the entire right lobe and another metastatic tumor in the lateral segment of the liver. Right hemicolectomy combined with a right lobectomy and an enucleation of the lateral segment tumor were performed. After the operation, serum total bilirubin (T-Bil) level increased with its peak (16.8mg/dl) on 11 POD.
In our study about the courses of eight postoperative deaths due to liver failure, it was found that the serial changes of serum alkaline phosphatase (ALP) showed a significant reverse-correlation with serum T-Bil. Serum ALP decreased soon after hepatectomy, and then increased up to normal value in survival cases like this case. While in the patients with progressive liver failure, ALP decreased and kept lowered level. These findings sugges that monitoring of serum ALP is useful to predict postoperative course of T-Bil.

View full abstract

We have experienced a case of intrahepatic bile duct cancer in which a tumor marker AFP alone had increased. The patient, who had been followed with a diagnosis of hepatic hemangioma for 8 months, was suspected to have intrahepatic bile duct cancer or metastatic hepatic cancer on imagings which were made because the hepatic tumor became larger on a close exploration. As for tumor markers, CA19-9, and CEA were negative and only AFP was positive and consequently the problem of differentiation from hepatocellular carcinoma arose. Extended right lobectomy of the liver was made. Histopathological features were suggestive of moderately differentiated adenocarcinoma. Immunohistochemically, it was positive for cytokeratin 7 and 19 and AFP. AFP-producing intrahepatic bile duct cancer was diagnosed.
Of resected bile duct cancers, it is very rare that bile duct cancer is associated with an increase in AFP alone and histopathological examinations, especially cytokeratin stain, are of value to make the definite diagnosis is for such a rare entity.

View full abstract

We diagnosed a case of primary carcinoma of the cystic duct based on Farrar's criteria. A 63-year-old man came to our hospital because of colicky pain caused by cholecystolithiasis. Magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography showed a defect on the cystic duct. Though a carcinoma of the cystic duct highly suspected, we could not make a certain diagnosis. We performed liver bed dissection, choledochotomy and regional lymph nodes dissection. Considering superficial expansion choledochotomy was done at the level of the hilus of the liver and intra pancreatic bile duct. The depth of the cancer invasion was limited to the subserosal layer. Cancer tissue had spread superficially to the choledochial mucosa.
Histologically moderate neural invasion was evident. When diagnosing a patient with colickey pain caused by cholecystitis, careful image examination is important.

View full abstract

A 63-year-old man was admitted to the hospital because of suspicion of a pancreatic tumor which was detected on an abdominal ultrasound (US) in a periodic medical checkout. There were no abnormal-ities in blood biochemical tests and tumor markers. Examination on pancreatic endocrine hormones revealed a mildincrease in somatostatin. Abdominal US revealed a 4.0×3.0cm hypoechoic solic tumor with relatively homogeneous inner part at the pancreatic body. The tumor was strongly enhanced by an abdominal contrast enhanced CT. And an angiography of superior mesenteric artery also showed dense accumulation of a contrast material. Pancreatic endocrine tumor was diagnosed and a resection of pancreatic body and tail associated with splenectomy was performed. Section of the tumor was light yellowish brown in color, with small cystic structure at the edge and almost solid center. Histopathologically, the solid part in the center involved colonies of microscopically small cysts composed of cuboidal cells; and it was pancreatic serous cystadenoma.
We present the case of pancreatic serous cystadenoma which was difficult to distinguish from pancreatic endocrine tumor, because imaging diagnoses and macroscopic findings suggested solid tumor.

View full abstract

A rare case of mucinous cystadenocarcinoma of the pancreas treated by a total pancreatectomy is reported. A 68-year-old man was admitted to the hospital because of weight loss. A cystic tumor spreading over the whole pancreas was observed by abdominal supersonic, CT and magnetic resonance imaging inspections. Mucinous cystadenocarcinoma of the pancreas was diagnosed, and a total pancreatectomy was performed. The pancreas was totally hard and decayed, and many cysts were observed.By pathohystological inspection, this case was diagnosed as mucinous cystadenocarcinoma with light parenchyma infiltration and lymph node metastasis. Mucinous cystadenocarcinoma is rare and it accounts for 1% of all cases of pancreatic malignant tumor. The prognosis of this disease is better than thouse of other normal pancreatic cancer, and positive surgical treatment is considered desirable. So far only eight cases of mucinous cystadenocarcinoma treated by total pancreatectomy including our case have been reported in Japan.

View full abstract

Omental panniculitis is a very rare disease characterised by unspecific inflammation. We report a case of greater omental panniculitis which was difficult to be distinguished from a malignant tumor. A 73-year-old woman was admitted to the hospital because of upper abdominal pain and was diagnosed as having gastric cancer. Abdominal CT scan showed that adipose tissue nearby the gastric cancer had a lower density, and peritoneal dissemination from the gastric cancer was suspected. At laparotomy, a tumor appeared fist-sized, yellow in color and elastic hard was present in the greater omentum concomitant with the gastric cancer and it was strongly adherent to the mesenterium of transverse colon and pancreas head. We had great difficulty to distinguish the tumor from dissemination of gastric cancer or malignant omental tumor. Therefore, a pancreaticoduodenectomy had to be performed for resection with the gastric cancer. It was diagnosed as greater omental panniculitits from pathological findings which revealed fibrosis and infiltration of many foamy macrophage cells to the tumor. Omental panniculitis itself is a benign disease, and unnecessary surgery has to be avoided under the correct diagnosis. It is the first case of greater omental panniculitis concomitant with malignant disease.

View full abstract

An 87-year-old man, on hormonal therapy for prostate cancer, was admitted to other hospital because of nausea and vomiting. He was exported to the hospital with shock state and abdominal pain. His blood pressure was stable, but Hb was as low as 7.4g/dl. Abdominal CT scan showed two enhanced tumors near the gastric wall with intraabdominal bleeding. Emergency angiography showed no extravasation. Endoscopic ultrasonography showed the two tumors on the gastric wall. We performed a laparotomy with a diagnosis of the two tumors of the extra gastric wall. Two tumors were present on the gastric wall with bloody ascites. A partial gastrectomy including the two tumors was made. The two tumors did not invade into the gastric wall. Histologically these two tumors were bloody necrosis, and were diagnosed as omental granuloma (Braun tumor). We consider that necrotic inflammatory lymph nodes changed to the granuloma. Our case is the first case of omental granuloma with intraabdominal bleeding in Japan.

View full abstract

A 70-year-old man was admitted to the hospital because of a mass in the right lower quadrant of abdomen. Abdominal CT scan visualized an irregular shaped, homogeneous-appearance mass in the lateral side of the cecum and two heterogenous mass lesions in the upper and medial side of the iliopsoas muscle. Barium enema revealed a hypotention of the cecum wall. From the above findings, he was diagnosed as having sarcoma of the cecum with lymph node metastasis or other retroperitoneal tumor. At operation, a fist sized tumor strongly fixed to the wall of the cecum and two pigeon egg sized tumors were located surrounding by the right common iliac artery. Ileocecal resection, a lymphadenectomy and a tumorectomy were performed. Histological examination of the tumors on the iliopsoas muscle showed well differentiated liposarcoma. The tumor clinically diagnosed as cecal sarcoma before operation was pleomorphic liposarcoma, which invaded the cecum extraluminally. Definite diagnosis was solitary peritoneal metastasis from well differentiated liposarcoma. Retroperitoneal liposarcoma which lacks clinical manifestations is often found after it has formed a giant mass. We report this case because of its unusual pattern of tumor extension.

View full abstract

This paper presents a case of retroperitoneal paraganglioma with hepatic metastasis 7 years after operation for the primary foci in a 44-year-old woman. The patient had been pointed out abnormal findings on an abdominal ultrasonography in October 1992, and had undergone an excision of a tumor with a diagnosis of retroperitoneal tumor. The tumor was present in the retroperitoneal cavity surrounded by the pancreas, liver, duodenal bulb, and gastric fundus; adhesion about 3cm with the pancreas was confirmed; and the tumor involved the left hepatic artery. Pathological diagnosis was nonfunctioning paraganglioma. Six years and 10 months after the operation, in October 1999, a hepatic tumor was found while she was followed in the clinic. A partial hepatectomy was performed. The resected tumor was diagnosed as hepatic metastasis of the paraganglioma.
Paraganglioma often metastasizes or recurs after a long silent time after the resection, even if it is diagnosed as histologically benign. Consequently, the disease may require postoperative observation of clinical course for a long time.

View full abstract

We experienced a case of retroperitoneal leiomyosarcoma with local recurrence 7 years after the first operation. The patient was an 84-year-old woman, who had a history of undergoing a resection of a retroperitoneal tumor 7 years earlier in the hospital, when the pathological diagnosis was leiomyosarcoma. First time, an abdominal CT scan revealed a cystic mass adjacent to the right kidney, approximately 9.0×5.0cm in size. The tumor was resected completely from the retroperitoneum without combined resection. The pathological diagnosis was recurrence of leiomyosarcoma.
Retroperitoneal leiomyosarcoma is relatively rare. Local recurrence frequently occurs after a resection of the primary lesion, with a resultant poor prognosis. Complete resection is mandatory to improve the prognosis even for recurrent cases, and repeated resections of the recurrent disease will bring about a good prognosis.

View full abstract

Incarcerated inguinal hernia is often indicated emergency surgery as acute abdomen, and sometimes we have to perform intestinal excision with necrosed incarcerated organ. In this paper, a rare case of panperitonitis duo to cecal perforation in incarcerated right lateral inguinal hernia is reported.
A 79-year-old man was admitted to the hospital because of abdominal pain and fever, who had a previous history of undergoing an appendectomy. From clinical findings incarceration in the right inguinal canal was susupected. A computed tomography (CT) showed free air in the abdominal cavity and a lumen structure exiting in the inguinal canal toward the abdominal cavity. Panperitonitis due to perforation of GI tract was diagnosed and an operation was carried out. Operative findings revealed a large amount of purluent ascites in the abdomen and strangulation of ileocecal joint at the internal inguinal ring. Perforation approximately 10mm in diameter was recognized at the posterior wall of the cecum, through which intestinal contents might exude into the abdominal cavity to cause peritonitis. Therefore, an ileocecal resection and drainage were performed.
The most common contents of incarceration in the inguinal canal are small intestine and omentum, and some cases of incarcerated appendix or cecum with appendix have been reported. This case is very rare, because the appendix had moved and the cecum became the top of the incarceration. Retrospective interpretation of CT findings could offer the correct diagnosis concerning the concents of impaction.

View full abstract

A case of ileus due to incarceration of a right femoral hernia in an extremely elderly woman (101-years-old) is reported. She was admitted to the hospital because of vomiting, nausea, and abdominal pain. There was no past history of surgery nor injury. An abdominal X-ray film revealed intestinal huge air. Abdominal US and CT scan revealed the edematous intestine on the right lower abdominal wall. An emergency operation was carried out under general anesthesia. There was incarceration of the small intestine that showed ischemic but no necrotic change into a right femoral canal. No intestinal resection was made. After the operation, the cardiopulmonary function was stable and the renal function improved. The patient started to drink on the second and to eat on the third postoperative day. Postoperative delirium lasted for seven days. On 14th post operative day she was discharged from the hospital, and her prognosis has remained uneventful.
Surgery has been increasingly indicated for elderly patients with a recent prolongation of average life span and a progression of medical capabilities. It is, however, rate that emergency laparotomy is indicated for elderly patients over 100 years and so far only eight cases including this case have been reported in Japan.

View full abstract

A 56-year-old woman was admitted to the hospital because of constipation and urinary retention. History revealed that she had been born with a sacrococcygeal mass, which had gradually increased in size over the years. She was diagnosed as having a sacrococcygeal teratoma on CT and MRI studies. The tumor was removed. It is believed that malignant change of sacrococcygeal teratoma increasingly occurs with aging. In this case, however, histopathological study revealed benign tumor. The sacrococcygeal area is the most common site of teratoma in infancy, although rare in adults. Sacrococcygeal teratoma should be considered in the differential diagnosis of a pelvic mass in adult, though it is extremely rare. Complete resection should be recommended for the patient in consideration of its malignant transformation.

View full abstract

We report a case of double cancer, advanced gastric cancer and intraductal papillary adenocarcinoma of the pancreas in a patient presented with hematemesis. A 61-year-old man was admitted to the hospital because of hematemesis. He was diagnosed as having a Borrmann 2 type gastric cancer and achieved temporary hemostasis by an emergency endoscopy. Computed tomography showed multilocular cytic lesion on the pancreas head and dilatation of the main pancreatic duct. Intraductal papillary adenocarcinoma of the pancreas was highly suspective by a cytology of pancreatic juice. Total gas-trectomy and a pancreaticoduodenectomy with regional lympohnode dissection were carried out. Postoperative course was uneventful, and he was discharged from the hospital on the 45th postoperative day. Double cancer of the pancreatic cancer with other organ cancer is relatively rare, especially that of intraductal papillary adenocarcinoma. this case was the second report in the Japanese literature to our knowledge.

View full abstract