For telling the truth at the request of patients with gastroenterological cancer, we have the basic guidelines; namely, the truth telling is made at the request of the patient based on a questionnaire survey, and we talk with the patient's family to get their understanding if their requests are different each other. For that, we tried to take the following measures since the second half of 1998.
1) To post up posters explaining informed consent in the hospital.
2) To explain the benefits of truth telling to patient's family.
3) To learn the communication skills using ‘How to break bad news’ and ‘Dealing with patients after truth telling’.
4) To offer mental support with psychooncologist's cooperation and symptom management to patients after truth telling.
In consequence, proportion of the ratio of truth telling patients at their requests was increased (64.1% in 1998, 78.7% in 1999 and 85.0% in 2000).
These measures are useful for truth telling at the request of the gastroenterological cancer patient.

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Introduction: In Japan, many patients with hepatocellular carcinoma (HCC) have liver cirrhosis, and large amounts of fresh frozen plasma (FFP) are administered during and after hepatectomy. It is unclear, however, whether such administration is really necessary to correct coagulopathy associated with bleeding. Objectives and Results: From January 1997 to May 2001, 46 hepatectomies were conducted in HCC patients at the Second Department of Surgery, Tohoku University Hospital. Average FFP administration decreased annually, with administration after July 1999 significantly less than before June 1999. Conclusion: Excessive FFP is not necessary to be administrered routinely during and after hepatectomy.

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We evaluated hMSH2 and hMLH1 immunohistochemistry (IHC) in 60 colorectal cancer (CRC) patients with a family history involving a first-degree relative. hMSH2 or hMLH1 expression was lost in 5 (8.3%). Of these 2 showed the absence of hMSH2 and 3 of hMLH1 protein expression in IHC. Four of the 5 met Japanese criteria for hereditary non-polyposis clorectal cancer (HNPCC), which averaging 42.7 years of age at onset, 3 had onset when less than 40 years old. A 36-year-old patient suffered from metachronous CRC and underwent third-degree subtotal colectomy. We also detected 2 patients meeting Amsterdam criteria in IHC. IHC is thus useful for effectively identifying hMSH2 and hMLH1 mismatch repair-deficient CRC economically and technically and for post operative treatment, in the general hospital setting.

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We studied the causes of delayed hemorrhage after hemorrhoidectomy, evaluating fibrinolytic activity, coagulation and wound healing in post-hemorrhoidectomy patients with or without delayed hemorrhage, and healthy volunteers.
Among 2, 354 patients undergoing hemorrhoidectomy, 59 developed delayed hemorrhage between the dentate and the proximal cut end of the mucosa and around the resection lines. Although RBC, Hb, and Ht values decreased postoperatively at delayed hemorrhage, platelets, plasmin-α2-plasmin inhibitor and factor XIII remained unchanged. Titers of fibrinogen and platelet-derived growth factor increased postoperatively, including in cases of delayed hemorrhage, but these did not differ significantly between patients with or without delayed hemorrhage.
We concluded that delayed hemorrhage after hemorrhoidectomy was not caused by increased plasmin activity nor impaired coagulation and subsequent wound healing.

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An 80-year-old woman was seen at the hospital because of epigastralgia. Ultrasound examination and computed tomography (CT) of the abdomen demonstrated a solid tumor 3.0_??_4.0cm in size in the right lower abdominal region. Barium enema revealed narrowings of the terminal ileum. She noticed her own breast tumor, and she had a palpable tumor 1.5×1.5cm in diameter in the BE region of the right breast. Excisional biopsy was performed. Histologically, it was revealed to be solid-tubular carcinoma. Preoperative diagnosis was right breast cancer and an ileocecal tumor. Because of high age, a simple mastectomy and an ileocecal resection were performed simultaneously. Histological findings showed metastatic ileal carcinoma, which closely resembled breast cancer in the morphologic features. The small intestine is the very rare site of metastasis from breast cancer. Reports on resected metastatic cancer of the small intestine from breast cancer are rare, and there have been only eight operated cases in the Japanese literature. Above all, it is quite rare that small bowel metastasis and breast cancer were simultaneously detected like in our case and this is the second case report in Japan.

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A case of breast cancer with metastasis to the brain 16 years after a mastectomy in a 79-year-old woman is reported. At the age of 64 years, she received a Patey's operation for right breast cancer (T1, N0, M0, Stage I, ER+). She had no evidence of recurrence and metastasis of breast cancer for 7 years after the operation, and thereafter she had not visited our hospital until this event. Sixteen years after the operation, she was seen at the department of neurosurgery in our hospital because of headache and general fatigue. CT scan and magnetic resonance imaging scan revealed a cystic mass 2cm in diameter in the cerebellum. She underwent a resection of the tumor. The pathological findings of the tumor showed papillo-tubular adenocarcinoma which was the same as that of the breast cancer. There has been no evidence of recurrence or brain metastasis, as of 3 years after the operation. The brain is an infrequent site of metastasis of breast cancer, and it is rare that such brain metastasis occurs over 15 years after a mastectomy like in this case.

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A case of HER2-overexpressing StageIIIA breast cancer successfully achieving a pathologic complete response favored by preoperative chemotherapy combined with trastuzumab following non-responded standard neoadjuvant chemotherapy is reported.
A 71-year-old woman with StageIIIA left breast cancer (D, T₂N₂M₀, scirrhous carcinoma, ER (-), PgR (-), HER2 (+)) underwent neoadjuvant chemotherapy with triweekly concurrent epirubicin and docetaxel, providing informed consent. Disease progression, despite two courses of neoadjuvant chemotherapy, led to preoperative use of trastuzumab plus paclitaxel (1 course composed of 8 weekly trastuzumab+6 weekly paclitaxel), in consideration of primary tumor adverse prognostic factors; HER2-overexpression, positive axillary lymph nodes and resistance to active standard chemotherapeutic regimen. The primary left breast tumor and the swollen left axillary lymph nodes turned out to be nonpalpable after one and two courses of this primary combined immunochemotherapy respectively, and upon completion of two courses of preoperative weekly administration of two agents without any adverse events, a breast conserving operation (Bq+Ax) was undertaken, based on preoperative evaluation for a clinically complete response. Histologically the resected specimen was proven to achieve a pathologic complete response, with negative axillary lymph node and absent invasive component in the primary tumor site.

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We report a case of low mediastinal posterior ganglioneuroma showing no clinical manifestation and detected accidentally at a routine health examination in an 18-year-old woman. She was admitted to the institute to evaluate a mass detected by a chest X-ray film. A computed tomographic scan and a magnetic resonance imaging scan revealed a mediastinal posterior mass located in the lowest position of the thorax. The mass was adjacent to the liver and diaphragm but did not have a dumb-bell shape. We suspected a neurogenic tumor of the posterior mediastinum. Preoperative examinations of the mass revealed ¹³¹I-MIBG uptake and no secretory activities of catecholamines and steroids. We chose the transdiaphragmatic approach to resect this posterior mediastinal tumor. With this approach to the tumor, we had a wide view during the operation and were able to resect the tumor completely and safely. The pathological findings showed a ganglioneuroma mass without malignant findings. Her postoperative course was uneventful and she was discharged from the institute 19 days after the operation.

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A case of retained fragment of clothes in the pericardial cavity is described in a woman who suffered from impalement injury by a cultivator. Neither chest X-rays nor computed tomography showed specific findings suggesting foreign body other than pulmonary contusion and blurred mediastinal outline. During emergent thoracotomy, a fragment of upper garment was removed from pericardial space adjacent to right auricle. Impalement injury without impaling objects was considered at the time of arrival, and involved clothes could be found to be the sole intracorporeal foreign body.
Careful observation for the depth and extent of the injury should be required to avoid grave results following chest injury which seems in itself insignificant.

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We report here a 16-year-old boy with cerebral palsy complicated with hiatus hernia and superior mesenteric artery syndrome. The patient was noticed, soon after his normal birth, to have cerebral palsy. Laryngotracheal separation at 13 years of age, a gastrostomy and an enterostomy at 14, were performed, respectively. At age 16 years, the patient was hospitalized because of his persistent vomiting. An upper GI series revealed the presence of hiatus hernia of sliding type associated with gastroesophageal reflux, as well as that of superior mesenteric artery syndrome involving the third part of the duodenum. The hiatus hernia was repaired by the Nissen fundoplication, and the superior mesenteric artery syndrome by division of the Treitz ligament followed by the clock-wise derotation of the midgut around the superior mesenteric artery. The patients post-operative course was uneventful, and he started gaining his body weight by enteral nutrition via a gastrostomy.

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We report a case of giant gastric hyperplastic polyp. A 69-year-old woman was admitted to the hospital because of hematemesis, nausea, and tarry stool. Laboratory data showed severe anemia.
An endoscopic examination showed a Y-IV type polyp which had a stalk in the anterior wall in fornix, and the polyp head was impacted in the duodenum.
Attempts of endoscopical reduction were in vain, because the polyp head was huge. Upper gastrointestinal series showed a tumor shadow 60×30mm in diameter in the descending portion of duodenum.
Since repeated endoscopical reduction was unsuccessful, an operation was performed. At surgery, the anterior wall of the stomach was incised, the polyp was reduced in the stomach, and stalk was ligated and resected. The polyp was 80×70×30mm in size, with a surface like a mulberry, and the maximum thickness of the stalk was 30mm. On a histopathological study, it was hyperplastic polyp without malignant changes. It is thought that giant hyperplastic polyp of the stomach with clinical manifestation should be treated by minimal invasive operation as far as we can.

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A 50-year-old woman seen at another hospitl because of epigastralgia and melena and found to have an easily bleeding tumor of the stomach by an upper gastrointestinal endoscopic study was admitted to the hospital for further examinations and treatment. An upper gastrointestinal series and an endoscopic examination revealed a tumor arising from the upper part of stomach prolapsing into the duodenum and the tumor was moved back through the pylorus ring easily. And another like-O-II c type tumor on the antrum was visualized. Their biopsy specimens were histologically hyperplastic polyp and poorly differentiated adenocarcinoma, respectively. A distal gastrectomy and tumor excision were performed.
Tumors of the stomach prolapsed into the duodenum are not so uncommon but the tumnor arising from the upper part of the stomach prolapsed into the duodenum like our case is relatively rare.

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A 57-year-old woman came to our hospital because of an upper abdominal mass that she had first noticed around January 2001. A smooth, mobile mass about 15 cm in diameter was palpable on admission. Abdominal computed tomography (CT) suggested that a gigantic tumor was compressing the stomach, pancreas, and spleen, and that there was a high degree of vascularization around the tumor. Endoscopy did not disclose any abnormal findings in the gastrointestinal mucosa. Endoscopic ultrasonography revealed well-regulated wall structures of the tract. The angiographic findings indicated that the left and right gastroepiploic arteries supplied the tumor. Since these findings suggested that the tumor had originated in the greater omentum, stomach, or pancreas, the tumor was resected. On laparotomy the tumor was found to have originated near the junction of the left and right gastroepiploic arteries. The tumor was partially attached to the anterior wall of the stomach and appeared to have arisen from the greater omentum. Only the tumor was removed. The gigantic tumor was cystic with tumor-like margins and weighed 3 kg. Histopathological examination indicated that the tumor may have originated in the stomach. The diagnosis of gastrointestinal stromal tumor (GIST) was established by immunohistochemical staining.

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A 78-year-pld woman complaining of heart burn was referred to the hospital with a diagnosis of type IIc early gastric cancer in March, 2001. After admission an aneurysm of the splenic artery was confirmed by a CT scan. No metastatic lesions were found.
Total gastrectomy with lymph node dissection (D1+α) and, a splenectomy were performed on May 11, 2001. Abdominal exploration revealed a white nodule on the anterior surface in the gastric upper body, and an induration in the duodenum side of pyloric ring. IIc lesion in the upper gastric body was not palpable. No metastases and lymph node swelling were observed. Resected specimen disclosed three kinds of tumors. Histopathologically, the IIc lesion was diagnosed as well to moderately differentiated adenocarcinoma. Since the nodule in the serosal surface was positive for CD34 and vimentin immunohistochemically, gastrointestinal stromal tumor (GIST, uncommitted type) of the stomach was definitely diagnosed. And the induration in the pyloric ring was definitely diagnosed as carcinoid. Synchronous occurrence of gastric cancer, GIST and carcinoid is extremely rare. We report this rare case together with some bibliographical comments.

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We report a case of concomitant malignant primary gastric lymphoma and primary gastric adenocarcinoma. A 68-year-old man seen for epigastralgia was found in an upper gastrointestinal series and endoscopy to have a large ulcerative lesion from the upper body to the angle of the stomach. Endoscopic biopsy showed malignant lymphoma. He was admitted and underwent chemotherapy, which shrank the ulcerative lesion and localized it at the angle of the stomach. He then underwent total gastrectomy and combined lymphnode dissection.
Histopathologically, the gastric lymphoma lesion disappeared and papillary adenocarcinoma limited to the mucosal layer was found at the angle of the lesser curvature. His postoperative course was uneventful and he remains diseasefree as of this writing.

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An 86-year-old woman complained of appetite loss and tarry stool and pointed out anemia and a significant increase in CEA level on a hematological study at another hospital was admitted to the hospital for close exploration of the gastrointestinal organs. Gastric endoscopy disclosed type 2 advanced gastric cancer on the lesser curvature of antrum of the stomach. Abdominal CT scan showed a deep stained tumor at the gastric antrum and thickened wall of the gallbladder. A distal gastrectomy (D1) was performed with a diagnosis of gastric cancer. During surgery, the gallbladder was felt to be very hard and a cholecystectomy was added. Operative findings suggested Stage IV gastric cancer, H0P1T3N1. Although the gallbladder had a hard wall, its mucosa surface was macroscopically normal. Histopathologically the gastric cancer was 85×70mm in diameter, type 2, adenosquamous cell carcinoma, and se, ly3 and v2. The resected gallbladder was adenocarcinoma proliferating mainly in the interstitial structure, which had the same histological features as the adenocarcinoma part of gastric cancer showed. From these findings, gallbladder metastasis from gastric cancer was diagnosed. Gastric cancer rarely metastasizes to the gallbladder and only four such cases have been reported so far. Abobe all, there have been no cases of gallbladder metastasis of adenosquamous cell carcinoma of the stomach, as far as we could review.

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A 55-year-old woman was seen at the hospital because her therapy for gastric ulcer was unsuccessful at other hospital. Upper gastrointestinal endoscopy showed ulcer with fur occupying a three-forth of the circumference of the duodenum covering from the superior angle to descending part. The patient was admitted to the hospital. Abdominal ultrasonography and an enhanced CT scan disclosed a tumor of the uncus of pancreas, and swelling of the extrahepatic bile duct and lymph node No16. In addition, obstructive jaundice and abnormalities in the hepatic function appeared. There was a possibility of pancreatic cancer or duodenal cancer and the patient was operated on. At surgery, the descending part of the duodenum and pancreatic head had formed a mass which was thought impossible to be radically resected, and so a division of the duodenum at the bulb was performed, followed by a duodenojejunostomy and a biliary bypass operation. The postoperative course was uneventful and a shrinkage of the tumor was observed. However, tarry stool and anemia developed 4 months after the operation which demanded another operation. When the descending part of the duodenum was incised, a 4cm ulcer with exposed vessels in its center was present on the pancreatic side, and a pancreatoduodenectomy was performed. The patient's postoperative course was uneventful.

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A 33-year-old woman seen at another hospital because of epigastric pain and right lower abdominal pain was referred to the hospital because palliative therapies for her symptoms were unsuccessful. On admission, fever, accelerated inflammatory reaction, and right lower abdominal pain with tenderness were noted, but there were no peritoneal signs. Although symptomatic remission was gained by palliative therapy, aggravation of symptoms occurred again and the patient required surgery. During surgery, we found that the small intestine in the pelvis had been extensively and interruptedly necrotized, and performed a resection of the small intestine. Pathological diagnosis was small intestinal necrosis due to polyarteritis nodosa.
Polyarteritis nodosa causes a variety of general symptoms, but it is rare that the disease presents with acute abdomen demanding a laparotomy. We report this case of polyarteritis nodosa which presented with acute abdomen and caused small intestinal necrosis.

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A 66-year-old man had undergone a total gastrectomy in 1991 was admitted to our hospital for a bowel obstruction in 1988. No findings suggesting a mesenteric pseudocyst were observed at that time. He was refered to our hospital because of a sudden abdominal pain and vomiting after breakfast on July 9, 2000. Ultrasonography and a CT scan demonstrated a cystic lesion 55 mm in diameter in the mesenterium and a dilatation of the jejunum and duodenum as well as a swollen gallbladder.
An upper gastrointestinal series showed bowel stenosis at the Roux-en-Y anastomosis as a result of the tumor. A laparotomy was performed, and a cyst with chylous fluid was identified near the Roux-en-Y anastomosis. The patient has been well without recurrence after the resection of the cystic lesion and the jejunum. No signs of recurrence have been noticed to date. A pathological examination revealed that the cystic lesion was a pseudocyst.

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An 86-year-old man examined at another hospital for general fatigue showed severe anemia (Hb 6.5/dl) and was referred to our hospital. He was diagnosed as bowel obstruction and a right obturator hernia. The ileum was partially resected for the mass with invagination, about 8.5cm in diameter, located at the ileum about 70cm proximal to the ileocecal valve. A 4×4.5×3cm submucosal tumor was found in the resected ileum. Histological examination revealed T-cell malignant lymphoma classified as diffuse large cell lymphoma. Primary T-cell malignant lymphoma of the small intestine is very rare, and its prognosis is much poorer than that of B-cell malignant lymphoma.

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A 71-year-old man was seen at the hospital because of abdominal pain. On a hematological study, anemia was noted and he was admitted to the hospital. Small bowel fluoroscopy showed a narrowing over the entire circumference of the jejunum. A tumor of the small intestine was diagnosed and an operation was scheduled, but abrupt anal bleeding occurred and the patient went into shock, demanding an emergency operation. At surgery, two tumors of type 3 about 20cm and 50cm distal from the Treitz' ligament were found. There was no communication between the two tumors which were thought to be simulataneously occurred multiple tumors. We interpreted that radical operation was impossible due to associated peritoneal dissemination, and palliatively performed a partial resection of the jejunum. Histologically the tumor was comprised of dense proliferation of short spindle cells with a high N/C ratio. On immunostains, the tumor was strongly positive for NSE, and positive for CD56 and EMA. Consequently neuroendocrine cell carcinoma was diagnosed.
An analysis of nine cases seen in the Japanese Literature disclosed that the disease has extremely high malignancy and poor prognosis. In order to establish effective diagnosing methods and therapy for the disease, further accumulation of cases would be demanded.

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A 48-year-old woman was admitted to our hospital because of sudden severe abdominal pain.
She had been treated with prednisolone for rheumatoid arthritis (RA). Computed tomography suggested the existence of thrombus in the celiac artery and the superior mesenteric artery (SMA). Abdominal angiography showed the occlusion of celiac artery and superior mesenteric artery. So a continuous intraarterial infusion of urokinase and heparin was administered. After 9 days, abdominal angiography showed no improvement, so operation was performed. During the operation, a necrotic area was found in an intestinal region 70cm distal from the Treitz ligament to the terminal ileum. The necrotic portion of the intestine was resected, and ileostomy was performed.
After operation, laboratory findings revealed anti-cardiolipin antibody. We considered that superior mesenteric artery occlusion was triggered as a complication of antiphospholipid antibody syndrome.

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In adult, most patients with intestinal malrotation are asymptomatic and their abnormal condition found incidentally during examination for another digestive disease or at laparotomy. We report a case of acute appendicitis accompanied by intestinal malrotation diagnosed preoperatively and treated by laparoscopic appendectomy.
A 24-year-old man reporting left lower quadrant pain underwent laparoscopic appendectomy due to suspected acute appendicitis accompanied by intestinal malrotation. This rare condition should thus be considered in diagnosing acute abdomen. Laparoscopic appendectomy is minimally invasive and recommended for diagnosing and treating this condition.

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A 59-year-old woman was admitted to the hospital because of fever. During close inspection for fever, a barium enema study and a colonoscopy showed a pedunculate elevated lesion with the diameter of 3cm in the transverse colon. Besides the lesion, no abnormalities probably causing fever were detected, and a transverse colectomy was performed. Fever and inflammatory findings disappeared immediately after the operation. On the resected material, an about 1cm pyogenic abscess was present in the head of the polyp like lesion. Histological diagnosis was inflammatory fibroid polyp (IFP), because infiltration of inflammatory cells mainly in the submucosa and concentric arrangement of fibrous connevtive tissue in the vicinity of microarteries were observed.
It is suggested that acute inflammation might participate in IFP, and this case is thought to be valuable in the consideration of causes and pathogenesis of IFP.

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We report two cases with free perforations of the sigmoid colonic diverticulum those were successfully treated by primary suture closure. The first case was a 66-year-old man who presented with a sudden-onset lower abdominal pain. A physical examination showed signs of peritonitis in the lower abdomen. The second case was a 79-year-old man who presented with a severe abdominal pain of sudden onset. A physical examination showed signs of pan-peritonitis. In both cases, emergent operations were performed between 5 and 7 hours after onset. Multiple diverticulum of the sigmoid colon were observed, one of which exhibited a free perforation to the abdominal cavity. The perforations were closed using sutures because the size of the perforations was less than 5mm in diameter and little edematous change was observed around the wall of the sigmoid colon. Free perforation of the colon diverticulum is generally associated with severe fecal peritonitis, and a two-stage operation is usually performed. Recently, one-stage procedures for free perforations have been reported to have low morbidity and mortality rates similar to those of two-stage procedures. Some selective cases of free perforations of colon diverticulum may be treatable using primary suture closure.

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A 75-year-old woman who had had a weak long constipation, was seen at the hospital because of lower abdominal pain. She had no signs of retroperitoneal inflammation at that time, but then she had anal bleeding and the abdominal pain gradually increased. An abdominal X-ray film showed a linear air track along the descending aorta, and an abdominal computed tomography revealed a retroperitoneal air space behind the third portion of the duodenum coming down to the bifurcation of the aorta. These findings suggested rectal perforation, and a detailed interview disclosed that she had tried to take feces out by herself with chopsticks. Therefore, the diagnosis of rectal perforation due to extraction of feces with chopsticks was made finally. A colostomy at the sigmoid colon and open drainage and debridment of the retroperitoneal space were performed. The post-operative course was uneventful, and reconstruction of the colostomy was performed on the 30th postoperative day, and the patient was discharged home on foot.

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We report a case of tailgut cyst which was suspected preoperatively by clinical manifestation and diagnostic images. A 59-year-old woman was seen at the hospital because of rectal fullness due to a mass effect. She had undergone multiple surgical procedures to the anorectal region with the diagnosis of a pygal abscess. Digital examination of the rectum revealed an extramural mass at the posterior wall of the rectum. CT scan and magnetic resonance imaging scan showed a multilocularcystic mass in the retrorectal space. With a strong suspicion of tailgut cyst, a complete excision through a transsacral approach was performed. Resected specimen was a smooth-walled, multiloculated cyst measuring 8.5×8.0cm, and containing yellowish green fluid. Histologically, the cyst was lined with squamous, transitional, and mucin-producing columnar, goblet epithelia with bundles of smooth muscle conforming to the periphery of the cyst. Consequently, the mass was diagnosed as tailgut cyst. In Japan, less than 20 cases of tailgut cyst have been reported. However, it may be a more frequent entity in the retrorectal cystic tumors, with the spread of the term tailgut cyst.

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A 79-year-old woman consulted a urologist in our hospital because of hematuria and lower abdominal pain. After several examinations, a tumor in the pelvis was revealed, and she was admitted to the hospital. Physical signs of peritoneal irritation appeared on the 4^th hospital day, and a sub-emergency operation was performed. Upon laparotomy, a tumor of the transverse colon was adherent to the bladder and peritoneum to form an abscess and numberless disseminated lesions were observed around it. Resection of the transverse colon was performed. The tumor was found growing outside the colon wall. Histologically, the tumor was composed of spindle-shaped cells on HE staining, and immunostaining for c-Kit was positive. As a result, the tumor was diagnosed as GIST. We think this paper is valuable because there have been few cases of GIST of the colon investigated immunologically.

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We report herein a case of colonic cancer with heterochronous solitary left adrenal metastasis. A 58-year-old woman, who had undergone a right hemicolectomy for cancer of the ascending colon about ten months earlier, was admitted to the hospital because of fever and general fatigue. Abdominal CT scan revealed a mass, about 50mm in diameter, in the left suprarenal region. Left adrenectomy was performed with a diagnosis of solitary adrenal metastasis from cancer of the colon. Histologically, poorly differentiated adenocarcinoma metastatic to the adrenal medulla was seen with severe venous involvement, and the cortex was atrophic and survived very little. However, the capsule was kept intact, and no swelled lymph nodes around the adrenal gland and in the retroperitoneum were recognized. These indicate that the metastasis to the adrenal gland had occurred via venous spread. It is well known that the portal venous system communicates with the left adrenal vein through the splenic, retroperitoneal and left renal veins. In the present case, it is inferred that cancer of the ascending colon might metastize to the left adrenal gland by this retrograde venous spread.

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We report a case of a rectal villous tumor (carcinoma in adenoma) recurred as advanced rectal cancer invaded the muscle layer after trans-anal local resection. A 48-year-old woman was admitted to the hospital because of anal bleeding and anal prolapse of a rectal polyp. Rectal endoscopy revealed a soft thumb tip sized villous tumor right upper the dentate line. Trans-anal local resection was made and a microscopic examination proved tubule-villous adenoma with in situ carcinoma and the tumor-negative cut margin. After close follow up for six months, a digital examination revealed a pea sized firm nodule at the site of local resection. We performed trans-anal resection included the rectal muscle layer. The second microscopic examination showed advanced rectal cancer invaded the muscle layer, so that we had to perform a rectal amputation. This recurrence was probably due to the remnant adenoma which microscopic examination failed to notice or the operative implantation of cancer cells. Rectal tumors containing villous components such as villous tumors and nodule-aggregating lesions have a high malignant potential especially in tumor with the diameter over 4cm. Prudent determination of the operative method and strict postoperative follow up are mandatory for such tumors.

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Endocrine cell carcinoma of the rectum is a rare entity and the prognosis is thought to be very poor because of early metastasis along both lymphatic and vascular routes. In this paper, a resected case of endocrine cell carcinoma of the rectum is reported. An 86-year-old man was seen at the hospital because of a body weight loss and a tenesmus. Colonofiberscopy revealed a type 5 tumor covering the entire circumference of the rectum (Rab) with almost smooth mucosa and a partial ulceration, of which biopsy specimen was diagnosed as poorly defferentiated adenocarcinoma. A Hartmann's operation was performed.
On immunohistochemical staining of the resected specimen, the tumor cell was positive for chromogranine A and NCAM, and endocrine cell carcinoma of the rectum was definitely diagnosed.
Endocrine cell carcinoma of the rectum is thought to be biologically malignant and surgical treatment can not offer a cure of the disease. When undifferentiated carcinoma or poorly differentiated adenocarcinoma is indicated for rectal lesions at biopsy, aggressive exploration entertaining a possible existence of the disease is essential. And effective multimodal therapy including operation and chemoradiotherapy should be performed.

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Thrombotic thrombocytopenic purpura is disease caused by diffuse microthrombosis. If left untreated, its prognosis is poor, with 80-100% mortality.
A 62-year-old man reporting pyrexia, hemolytic urine, and conscious disturbance was found in computed tomography (CT) to have a liver abscess and gallbladder swelling, and necessiting percutaneous drainage. Because his serum total bilirubin increased to 13.1mg/dl and he developed hemolysis, we considered possible thrombotic thrombocytopenic purpura. After plasma exchanges, his laboratory data returned to normal. He was discharged without recurrent thrombotic thrombocytopenic purpura. Microscopic findings showed destroyed peripheral red blood cells.
When severe hemolysis occurs, thrombotic thrombocytopenic purpura should be considered even in gastrointestinal disease, with plasma exchange proving to be an effective treatment.

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We report a relatively rare case of biliary cystadenocarcinoma. A 54-year-old woman admitted for abdominal distension and pain after eating was found in abdominal ultrasonography (US) to have a cystic tumor in the lateral segment of the liver. The cystic tumor was diagnosed as biliary cystadenoma or cystadenocarcinoma by computed tomography (CT), magnetic resonance imaging (MRI), and angiography, and lateral segmentectomy was done. Macroscopically, the cystic tumor was a multiloculated cyst within serous fluid and coagulation. Pathologically, it was diagnosed as cystadenocarcinoma arising from cystadenoma because of the coexistence of adenoma, well-differenciated adenocarcinoma, and the transitional zone of these in the cystic wall.
MRI was very useful for making the different diagnosis between biliary cystadenoma and cystadenocarcinoma, because it was possible to detect the characteristic fluid in the cyst and fibrous wall of the cyst.

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We report a young patient with cholangiocellular carcinoma. A 30-year-old man with icterus was diagnosed with cholangiocellular carcinoma of the left hepatic lobe with invasion to the right hepatic duct and the right anterior branch of the portal vein. Left hepatic trisegmentectomy, caudate lobectomy, and resection and reconstruction of the bile duct and portal vein were done. His postoperative course was uneventful and he was discharged on postoperative day (POD) 19. Five months after surgery, portal hypertension due to recurrence at the portal anastomosis was noted, but he died 14 months after initial surgery despite additional treatment and follow-up. The rarity of cholangiocellular carcinoma in the young prompted us to report this case.

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A 56-year-old man was admitted to the hospital because of urticaria and hoped to receive followup examinations for hepatitis. Ultrasonography showed atrophy of the gallbladder and thickening of the wall with comet-like echo. Endoscopic retrograde cholangio-pancreatography showed a segmental stricture at the gallbladder body. Abdominal CT scan showed contrast enhancement of the gallbladder wall. EUS showed a number of small cystic areas in the thickened gallbladder wall. The images were compatible with segmental type adenomyomatosis. An angiography aiming at ruling out gallbladder cancer revealed no clear evidence of the cancer. He underwent a laparoscopic cholecystectomy. Microscopic examinations revealed well differentiated adenocarcinoma in the Rokitansky-Aschoff sinus, accompanied by subserosal invasion. He underwent an additional operation including regional lymphadenectomy. There have been no signs of recurrence for 63 months after the last operation. Considering difficulties with detection of cancer and possible development of cancer in adenomyomatosis, we agree with an opinion that cholecystectomy followed by pathological examinations should be considered for patients with adenomyomatosis.

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Early bile duct carcinoma is difficult to diagnose before the appearance of jaundice. We report a jaundice-free patient with cholangiocarcinoma in the mucosal layer of the bile duct (Bs-Bi).
A 74-year-old woman was found in ultrasonographic screening to have a high level of biliary enzymes and dilation of the common bile duct. Endoscopic retrograde cholangiography showed dilation and irregular defects of the bile duct (Bs-Bi), although her total bilirubin was 0.6mg/dl on admission. Abdominal computed tomography showed mild dilation of the intrahepatic bile duct and wall thickness strongly enhanced by the contrast medium. Abdominal angiography showed no vascular abnormality around the common bile duct. From these findings we diagnosed relatively early bile duct carcinoma and conducted pylorus-preserving pancreatoduodenectomy. Pathological examination showed papillary adenocarcinoma limited to within the mucosal layer with wide mucosal dissemination. Lymph node metastasis was negative (pap, m, ly0, v0, n0, stage I).
Generally, a patient with early bile duct carcinoma has a relatively good prognosis, so it is extremely important to screen for bile duct carcinoma at an early stage.

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The subject was a 22-year-old man who was first seen at a local clinic for a complaint of increasing abdominal distention. Since abdominal computed tomography (CT) revealed multiple tumors in the right and left lobes of the liver, he was referred to our hospital for further examination and treatment. On examination at our hospital, the upper abdomen was markedly distended and firm masses were palpable. Abdominal CT revealed multiple masses in the liver and a mass approximately 60mm in diameter in the tail of the pancreas. The serum glucagon level was elevated to 610pg/mL. Immunological staining of ahepatic tumor specimen obtained by aspiration biopsy was strongly positive for glucagon. Based on these findings, a diagnosis of malignant glucagonoma and multiple liver metastases was made. Continuous hepatic artery infusion and transcatheter arterial embolization (TAE) was started for the liver metastases, and hormonal therapy with octreotide was added. The abdominal distention improved, and the serum glucagon level decreased. However, during the third month after the start of treatment, the serum glucagon level increased again, and he died of rapid emaciation after an approximately four-and-a half month course. This was a very rare case, because glucagonomas generally grow slowly with clinical manifestations occurring late, and there have been no reports of cases presenting with manifestadons of rapid growth of liver metastases as in this case.

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A case of imperforate hymen causing hematometerocolpos is presented. A 12-year-old girl complaining of abdominal pain was seen at the hospital with a suspicion of an ovarian cyst. Pelvic examination revealed a bulging and closed hymen. Trans-abdominal ultrasonography, computed tomography and magnetic resonance imaging showed distended cavity of the vagina and uterus, and no other anomalies were found in the urogenital organs. The closed hymen was excised crossly and about 600ml of bloody fluid was drained. Postoperative course was uneventful.
We collected a total of 35 cases of imperforate hymen at puberty in the Japanese literature. Imperforate hymen is a rare entity, but we must kept it in mind as a differential diagnosis of an abdominal tumor in adolescent girls who have no menarche and perform genital inspection.

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A 69-year-old man was transffered to our department because of an ileocecal mass, 9×6cm in diameter, which was accidentally detected by abdominal CT scans for preoperative evaluation of scrotal Paget's disease. Radiographic features on CT and magnetic resonance imaging examinations suggested leiomyoma or leiomyosarcoma originated from the small intestine. Laparotomy revealed a 9.5×6.5×6.0cm omental tumor in the right lower quadrant of abdomen without adhesions to the surrounding organs. The tumor was removed following a resection of the omentum with an approximately 5cm margin. Histopathological examinations revealed a solitary fibrous tumor. Solitary fibrous tumor is a rare soft tissue tumor, usually arises from the intrathoracic pleura. To our knowledge, only two cases of solitary fibrous tumor originated from the omentum have been reported previously in Japan.

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An 86-year-old man was admitted to the hospital because of a right lower abdominal tumor which had gradually grown since he had first felt one year before admission. Abdominal CT scan visualized a well-defined tumor with a heterogeneous center covering from the right inguinal region to the height of the kidney and being adjacent to the right lateral abdominal wall to pelvic wall. Abdominal magnetic resonance imaging scan showed low signal intensity on T1-weighted images, and high signal intensity at the head and low signal intensity at the tail on T2-weighted images. Angiography visualized feeding vessels from the lumber, right superior gluteal, and right circumflex iliac arteries. The patient was operated on with a diagnosis of a retroperitoneal tumor. The tumor was present on the retroperitoneum from inguinal region to the height of the kidney. It was firmly adherent to the femoral nerve and lateral iliac artery and vein, but was possible to be dissected and removed with a part of retroperitoneum. The removed tumor was a 20×11×8cm encapsulated solid tumor with the weight of 980g. On the section, the head side was pail yellow and the tail side was white in color. Histopathologically, the tail side of the tumor was composed of dense proliferation of tumor cells varying from spindle to polygon in shape; and the head side was associated with a myxoma like change. Immunohistochemically the tumor was positive for α1-antichymotripsin. The definite diagnosis of retroperitoneal malignant fibrous histiocytoma was made.

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A 48-year-old man was seen at the hospital because an abnormal mass enlarged gradually on the left lower abdomen. The mass measuring 10×8cm was an elastic-soft and protuberant nodule. Abdominal CT and magnetic resonance imaging scans revealed a heterogeneous tumor, adjacent to the rectus muscle of the abdomen. The tumor was diagnosed as sarcoma from frozen section intraoperatively, an extensive resection achieving a sufficient surgical margin from the mass, with an excision of left rectus muscle of the abdomen, was conducted. Histological diagnosis was dermatofibrosarcoma protuberans. No signs of recurrence and metastasis have been found as of 3 years after the surgery. The definite diagnosis of the disease is difficult and should be considered comprehensively based on the patient's medical history and clinical/pathological findings. The tumor recurs frequently, regular follow up would be required after extensive local resection.

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There are two anatomically weakened spaces in the lumbar area, superior and inferior lumbar triangle. Lumbar hernia is rare and may occur in these triangles. In this paper, a case of idiopathic inferior lumbar hernia is reported with some discussion on previous cases in the literature. A 79-year-old woman was seen at the hospital because of a right dorsolumbar mass. Abdominal CT scanning showed the ascending colon through a right lumbar muscle defect. With the diagnosis of inferior lumbar hernia, a herniorrhaphy was performed. The defect was closed by Marlex mesh. No recurrence signs have been found, as of 4 months after the operation. In the Japanese literature, only 87 cases of lumbar hernia have been reported, and our case reported here is the 21st case as inferior lumbar hernia. Lumbar hernia demands surgical repair, because there is a report of necrosis of incarcerated intestine. For these five years, cases of the disease in elderly people have been increasingly reported, and further increase is probable. The disease must be kept in mind in daily clinical scenes.

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We report a case of heterochronously occurred bilateral inguinal lymph node metastases of unknown origin.
A 70-year-old woman was seen at the hospital because of a right inguinal tumor with the size of an egg. With ultrasonography, CT, and aspiration biopsy cytology, metastatic squamous cell carcinoma of the inguinal lymph nodes was diagnosed and the patient was admitted to the hospital. Primary lesion was obscure despite explorations of the gastrointestinal tract, urinary/genital organs, skin, and external genitalia. After the tumor was reduced by preoperative chemotherapy with CDDP+5-FU, it was surgically removed. Radiation therapy at a total dose of 60 Gy was given to the right inguinal region after the operation. The patient was strictly followed and had experienced no recurrence and appearance of primary lesion until approximately 3 years 3 months after the operation, when she felt a left inguinal tumor with the size of a quail egg. Metastatic squamous cell carcinoma of the inguinal lymph nodes was diagnosed with ultrasonography, CT, and aspiration biopsy cytology. In spite of the same systemic exploration as we conducted for the cotralateral lesion, primary lesion was still unknown. Immediately the patient underwent a removal of the tumor, followed by irradiation at a total dose of 50 Gy for the left inguinal region. There have been no emergence of primary lesion or signs of recurrence, as of about 2 years 5 months after the removal of the left inguinal lesion.

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von Recklinghausen's disease (R disease) is an autosomal dominant inheritable disease, characterized by café-aulait skin macules and multiple neurofibromas. It has a variety of symptoms such as bone lesions, ophthalmologic diseases, and benign and/or malignant tumors. This paper presents a very rare case of R disease with triple cancer, breast cancer, lung cancer, and malignant gastrointestinal stromal tumor (GIST) of the small intestine.
A 74-year-old woman was found having an intraabdominal tumor on palpation during observation after surgery for breast and lung cancer. Abdominal CT scan visualized a solid tumor, 4cm in diameter, in the small intestine. Excision of the small intestine was performed with a diagnosis of primary small bowel tumor. Histopathological diagnosis was malignant GIST of the small intestine.
R disease is reportedly associated with various malignant tumors, but it is very rare that R disease is associated with triple cancer like this case. Strict follow-up observation would mandatory for patients with R disease by keeping a possibility of associated malignancies in mind.

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