The purpose of this study is to provide extensive up-to-date information on carcinoid tumors to investigators actively engaged particularly in the research field of carcinoids and their variant endocrinocarcinomas. A total of 11, 842 cases of endocrinocarcinomas maintained in the Niigata Registry were analyzed. These cases were divided into two main groups: the carcinoid group (n=10, 804) and the variant group (n=1, 038), the former further into the Japanese series (n=4, 549) and the foreign series (n=6, 255). Evaluation of cases in the various categories was performed by the Niigata Registry analyzing system (NUS). The largest number of cases was recorded in the rectum (n=1, 132) followed by the respiratory system, stomach, duodenum and appendix in the Japanese series, and in the respiratory system (n=1, 319) followed by the jejunoileum, appendix, stomach and rectum in the foreign series. The malignant characteristics of carcinoids were evident by an unexpectedly high rate of metastasis in cases with small submucosal lesions of 10 mm or less in diameter, exhibiting 10.0% of 1, 045 cases. An overall significant statistical difference (P<0.01) between the Japanese series and the foreign series was evident in a male/female ratio, age, tumor-size, rate of metastases, and incidence of the carcinoid syndrome. However, such a difference was variably demonstrated when calculated in cases at different sites. Postoperative 5-year survival rates in overall cases after curative resection (Kaplan-Meier) were completely identical with the same curve patterns in both groups showing an average rate of 82.0%.

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We introduced the vacuum-assisted breast biopsy sistem (Memmotome^®) in 2000 to diagnose nonpalpable breast cancer detected by microcalcification on mammography, and have used it in consecutive 95 patients between March 2000 and December 2002. The mean age of all patients was 46.9 years (range, 28-77 years). Calcification was confirmed by specimen mammography in 100% of the patients and 13 (14%) of the patients were diagnosed as having atypical ductal hyperplasia (ADH) or breast cancer. Of these 13 patients, seven (53.8%) had DCIS and two (15.4%) had invasive ductal carcinoma, and four (30.8%) had ADH. The mammography findings were classified according to the guidelines. Patients classified into categories 3, 4, and 5 accounted for 89.4%, 9.5% and 1.1%, respectively. Moreover seven (18%) patients and five (56%) and, one (100%) had cancer in categories 3, 4, and 5, respectively.
Therefore these results suggest that Mammotome is useful to detect DCIS or invasive ductal carcinoma.

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In this study, we elucidated the usefulness of anti-infection percutaneous endoscopic gastrostomy (PEG) kit (Kangaroo kit pull type 20Fr. produced by Japan Sherwood Co.) with flexible overtube to protect bacterial infections from the oral cavity, especially the pharynx. A total of 94 patients received the pull-PEG were enrolled the study. Of the 94 patients, 54 patients received the conventional method without overtube were assigned to the group A. The frequency of wound infection in the Group A was 24.1% (13/54). The remained 40 patients received anti-infection method were assigned to group B. The frequency of wound infection in the group B was 0.0% (0/40). In contrast to the group A, wound infection was completely reduced in the group B. The result has suggested that this eradication method is very useful for prevention of wound infection after pull-PEG treatment.

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It is essential to secure a visual field for safety under laparoscopic surgeries. Pneumoperitoneum enables surgeons to secure a sufficient workspace but high-pressure pneumoperitoneum may burden the cardiovascular system. Meanwhile, an insufficient visual field is the demerit of the abdominal wall lifting method. In order to overcome the demerits of these methods, we have created the combination method of 4mmHg low-pressure pneumoperitoneum and abdominal wall lifting to secure the visual field since 1993. In this study, intraperitoneal capacity was comparatively assessed based on the CO₂ volume needed as the parameter for objectively assessing the workspace. The study enrolled 20 patients who underwent a laparoscopic cholecystectomy from January to December of 2001. There were seven men and 13 women, aged 35 to 80 with a mean of 59. The CO₂ volume needed in the lifting procedure was 1.93±0.56L, and the pneumoperitoneal pressure to obtain the equivalent capacity was 7.98±1.39mmHg. On the other hand, the CO₂ volumes needed under 4mmHg and 8mmHg pneumoperitoneum in the pneumoperitoneum alone versus in the combined procedure were 0.57±0.38L versus 2.62±0.74L and 1.98±0.59L versus 3.40±0.87L, respectively.
It has been objectively demonstrated that a largerer intraperitoneal capacity is obtainable in the combination of pneumoperitoneum and lifting procedure than in the pneumoperitoneum or lifting procedure.

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A 79-year-old man was brought into the hospital by ambulance because of dysphonia, dyspnea and swelling of the neck, which appeared at 8 p. m. He had fallen to the ground at a motorcycle accident at 2 p. m., hoarseness and impaired phonation developed 4 p. m. and 6 p. m., respectively. When he arrived, the respirations were of effort type and shallow, and impaired phonation was confirmed. Mild anemia and increased inflammatory reaction were noted. Gas analysis of arterial blood revealed PaO2 of 79.6 mmHg and PaCO2 of 36.2 mmHg, showing hypoxia. Lateral x-ray examination of the neck visualized the anteriorly oppressed pharynx and trachea, narrowing of the airway, and the opened retropharyngeal interstice. CT scan of the neck disclosed a huge hematoma in the retropharyngeal interstice behind the esophagus, extending from the lower pharynx and reaching to the mediastinum; the esophagus and trachea were oppressed. After admission endotracheal intubation was carried out to maintain the airway. On the 7^th hospital day, a tracheostomy was performed because no significant change in the size of hematoma was observed. On the 18^th hospital day when an endotracheal tube was exchanged, dyspnea was not noted. On the 26^th hospital day, the endotracheal tube was withdrawn and the patient was discharged from the hospital. In the treatment of patients with injury of the neck or head, the disease must be kept in mind regardless of causative injuries.

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We report a case of a patient with intrathoracic goiter, removed through a cervical approach, extending to the tracheal bifurcation in the posterior mediastinum and discuss the surgical approach for 15 patients at the Osaka Medical Center for Cancer and Cardiovascular Diseases.
A 51-year-old woman reporting a left anterior cervical mass was observed over about 10 years, but dyspnea was present and the chest computed tomographic image showed a tumor in the left lobe of the thyroid gland extending to the retrotracheal bifurcation, although no invasion of surrounding vessels was detected and fine-needle cytology was negative. The tumor was successfully removed through a cervical approach without complications.
Between 1980 and 2002, we operated on 15 patients with intrathoracic goiter. Twelve were benign, e. g., adenoma or adenomatous goiter, and three were malignant. All eight benign lesions after 1984 were removed through a cervical incision. In two of the three malignant cases, median sternotomy was combined with a cervical incision because of invasion of vessels and nerves.
Our results suggest that intrathoracic goiter can frequently be removed through a cervical approach without median sternotomy if the lesion is benign.

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We report a case of subareolar abscess of the breast in a 67-year-old man, who presented with a painless 2 cm mass in the left subareolar region.
Fine-needle aspiration cytology showed the presence of numerous neutrophils and squamous cells.
After total excision of the mass, histological examination showed subareolar abscess, such abscess of the female breast are comparatively common, but those in the male breast are rare.
Smoking is recognized as an aggravation factor, and this case was complicated by untreated diabetes.

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We report two cases of juvenile fibroadenoma in two 12-year-old girls who reported rapidly enlarging breast masses. Results of mammography, echography, magnetic resonance imaging and aspiration biopsy cytology suggested fibroadenoma. We excised the tumors under general anesthesias, one was 6.6×4.5×4.0 cm and the other 11×9.5×6.0 cm. The histopathological diagnosis was juvenile fibroadenoma in both cases. Estrogen and progesteron receptors of one tumor were negative and those of other tumor positive. Our cases were the 19th and 20th of juvenile fibroadenoma in girls aged 10 to 15 years reported this decade in Japan.

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We report a case of a granular cell tumor (GCT) of the breast in a 68-year-old woman. The patient presented with a mass in the upper-outer quadrant of her left breast. On physical examination, an elastic hard, indiscrete mass 1×0.8cm in diameter was palpated. Mammography, ultrasonography, and magnetic resonance mammography suggested the presence of breast carcinoma. An aspiration biopsy cytology specimen was evaluated as class II. Excisional biopsy including a portion of the greater pectoral muscle infiltrated was performed. Frozen section diagnosis was benign tumor though histological type was unknown, and so we ended the operation. Histological examination revealed that large eosinophilic cells had formed nests and infiltrated into the major pectoral muscle and fat tissue, and the tumor was positive for S100 protein. The tumor was diagnosed as GCT. GCT mimics carcinoma of the breast on physical and radiological examinations, and its diagnosis is difficult on aspiration biopsy cytology and frozen section. We should be aware of this tumor on decision of treatment policy for the breast tumors.

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A 40-year-old woman who had noticed skin change at the left axilla but let it alone considered as accessory breast was seen at the hospital because the change became to form a mass since one year earlier and to enlarge since one month earlier. On palpation an 8×7.5 cm hard tumor in the left axilla was palpable Mammography, ultrasonography and chest CT scan revealed a large solid tumor in the left axilla. Needle aspiration cytology resulted in class IIIb. With a suspicion of ectopic breast cancer, a removal of the tumor and axillary lymph node dissection were performed. The tumor was well-defined, yellowish white, solid and segmental. Histpathological study revealed that the tumor was mainly composed of dermatofibrosarcoma protuberans showing storiform pattern, associated with an area of fibrosarcoma in which the dense of cells increased and spindle shaped cells showed herringbone pattern. On immunohistochemical tests, CD34 was positive in the dermatofibrosarcoma area and partially positive in the fibrosarcoma area. The patient has been free form recurrence for 3.5 years, but would require further strict follow-up because the disease has a high rate of recurrence.

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We report a case of secretory carcinoma of the breast together with some biblographical comments.
A 75-year-old woman was seen at the hospital because of a tumor in the Barea of the right breast. On physical examination, the tumor, 2cm in diameter, was elastic hard and movable. There were no dermal infiltration and nipple discharge. A needle aspirasion biopsy cytology resulted in PC-II, but breast cancer suspected from findings of palpation, echography and CT of the breast. An excision biopsy was thus performed. On the excised specimen, secretory carcinoma including discharge which was positive for PAS and Alcian blue was diagnosed. So a segmental mastectomy and axillary lymph node dissection were added. Histopathologically the axillary lymph nodes were positive and hormone receptor assay resulted in negative response.
Secretory carcinoma of the breast demands the standard operation with lymph node dissection, because it metastasizes to the axillary lymph nodes in the almost same rate as that of other invasive ductal carcinomas of the breast. Chemotherapy is thought to be often employed as adjuvant therapy, because the positive rate of hormone receptor is low.

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A case of breast cancer metastasized to the brain 28 years after mastectomy in a 74-year-old woman is reported. The patient had undergone a mastectomy because of right breast cancer at the age of 46. Histopathological diagnosis of the tumor was invasive ductal carcinoma papillo-tubular type, nl (2/16).
This time, she was seen at the hospital because of vertigo and headache. Brain CT and magnetic resonance imaging scans revealed a tumor (5×3 cm) in the cerebellar hemisphere and another tumor (7 mm) in the caudate nucleus. Systemic exploration to detect primary foci resulted in no abnormal findings.
On August 21, 2001, an extirpation of the tumor in the cerebellar hemisphere was performed with a suspicion of brain metastasis of breast cancer. Histologically, the tumor was invasive ductal carcinoma papillo-tubular type which was compatible with primary breast cancer. The tumor was considered breast cancer metastasized to the brain. She is still alive 20 months after the second operation.

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A 28-year-old unmarried woman was admitted to the hospital for the treatment of funnel chest. The patient was surgically treated not with conventional surgical procedure, but with Nuss procedure under full informed concent. After making incomplete fracture of the 3rd and 5th ribs, Nuss procedure was carrid out using two pectus bars. Chest wall deformity was corrected properly with this operation. The patient recoverd uneventfully except for postoperative pain. Good cosmetic result was confirmed with chest computed tomography 6 months after the operation. Nuss procedure may be a good treatment option for funnel chest in adults.

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A 64-year-old man was admitted to his local hospital because of an anterior chest pain. A chest computed tomography examination revealed a 7×5 cm tunor in the upper field of his right lung. The patient underwent a percutaneous fine needle biopsy and was diagnosed as having poorly differentiated adenocarcinoma of the lung. He was referred to our hospital for further treatment after the lung cancer began to invade his chest wall. After undergoing preoperative radiotherapy, the patient received a right upper lobectomy with chest wall resection. Histologically, the tumor was diagnosed as an unclassifiable sarcoma. Tumor recurrence in his right anterior chest and right thigh subsequently occurred, the tumors were surgically removed. The resected specimens were histologically diagnosed as malignant fibrous histiocytomas (MFH). MFH frequently recurs locally and has a poor prognosis. An accurate preoperative diagnosis and an initial curative resection are vital for improving the prognosis.

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We performed stent grafting for diffuse thoracic aortic aneurysm on a two-step approach which lessened surgical stress to a patient, with successful avoidance of postoperative complications.
A 71-year-old woman who was under observation for diffuse thoracic aortic aneurysm was admitted to the hospital for operation because the aneurysm became large. There was previous history of undergoing graft replacement for abdominal aortic aneurysm. After admission, the patient precedently underwent graft replacement for the ascending aortic and arch aneurysms by the elephant trunk technique. Fifty-six days later, the patient underwent endovascular stent grafting for the descending thoracic aortic aneurysm under motor evoked potential (MEP) monitoring. The postoperative course was uneventful, and no endoleak or stent graft migration occurred. Follow-up chest computed tomography carried 3 months after the surgery showed the aneurysm to be reduced in size; there was no endoleak or stent graft migration. Replacement of the ascending aorta and arch by the elephant trunk technique followed by endovascular stent grafting of the descending thoracic aorta is less invasive for patients with diffuse thoracic aortic aneurysm. This operation mode is a potential therapeutic option for high-risk patients with diffuse aneurysmal disease of the thoracic aorta.

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Fistula between an aneurysm and the intestine is an extremely rare entity, and often follows a fatal course after manifestation. This paper presents a case of a fistula between a common iliac arterial aneurysm and small bowel presented with anal bleeding, in which hemostasis was carried out by using trans-catheter stent graft.
A 97-year-old man who had been followed in the outpatient clinic for abdominal aortic aneurysm was admitted to the hospital because of vomiting and a loss of consciousness, followed by anal bleeding. Based on findings of CT and angiography, right iliac arterial aneurysm-small intestine fistula was diagnosed, and trans-catheter placement of a covered metallic stent for the bile duct into the right common iliac artery was performed. After the operation, anal bleeding disappeared and the patient was able to eat.
Hemostatic method using stent graft is beneficial as emergency hemostasis and must be consider its use, especially for cases with poor risk like this case.

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Bronchial embolization using the endobronchial Watanabe spigot (EWS), a bronchial embolizing device made from silicone, was performed in ten patients, including six intractable pneumothorax, two pyothorax with bronchial fistula, one bronchobiliary fistula and one post-operative gastrobronchial fistula. Successful outcome was acquired in eight cases, two cases of which needed radical operation after bronchial embolization, and in the remaining two cases bronchial embolization could not be performed due to the unability to detect any responsible bronchus of fistula. No complications occurred in any of the cases.
Bronchial embolization using the EWS is easy to perform technically with full expectation of a good outcome, therefore we think that the EWS should be taken into consideration as first device of choice in the treatment of conduction such as intractable pneumothorax and bronchopleural fistule.

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A 52-year-old woman with a cough and fever had been taking tamoxifen 20 mg/daily for 8 months after breast-conserving surgery.
Chest radiograpy and computed tomography showed consolidation with air bronchography in the middle and lower fields of the left lung and was diagnosed with bronchiolitis obliterans organizing pneumonia (BOOP). Symptoms and radiographic findings improved with oral administration of prednisolone. When tamoxifen was resumed because it could not be ascertained whether this medication was the cause of the problem, chest radiography showed a frosted glass appearance in the upper fields of the right lung. The case was diagnosed as drug-induced pneumonia due to tamoxifen.

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A case of chylothorax after esophagectomy treated conservatively following the findings of lymphoscintigraphy is reported.
A 71-year-old man was referred to the hospital for close exploration for dysphagia. He underwent a radical esophagectomy and posterior mediastinal reconstruction with a diagnosis of carcinoma in the lower third of the thoracic esophagus on 4^th December 2000. The histological diagnosis was undifferentiated carcinoma and pT4 (lung and pericardium), pN4, pStage IV. The postoperative course was uneventful except drug-induced hepatitis till 7^th day after the operation. The discharge from the right thoracic tube increased to 500ml/day and became chylous on 8^th postoperative day, when oral ingestion was started. The diagnosis of chylothorax was established by Sudann staining of the thoracic effusion. Because of the liver damage, surgery was not indicated and about 500ml of discharge per day persisted. A lymphoscintigraphy, performed on 50^th postoperative day, revealed that chylo leaked from the thoracic duct at the level of tracheal bifurcation. Then 50% glucose solution was injected into the right thoracic cavity twice aiming at stopping the chylous leakage because the lymphoscintigraphy also demonstrated that the chylo leaked through the side hole of the main duct. The whole thoracic duct was demonstrated to be patent by another lymphoscintigraphy, performed after the effusion stopped completely on 93^rd postoperative day. The patient is free from disease and any complications 26 months after the esophagectomy.

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A 69-year-old man visited a clinic because of severe peri-umbilical pain, which had developed suddenly while he was on his way to work. He was brought into the hospital with a suspicion of gastrointestinal perforation. On admission, the blood pressure was only 60mmHg and he was in shock. Mild anemia and symptoms of severe peritoneal irritation were also noted. Abdominal CT scans revealed intraperitoneal bleeding and a protruding mass on the posterior wall of the gastric body. An emergency operation was performed, because the possibility of superior mesenteric artery obstruction or strangulated ileus could not be ruled out. At laparotomy, about 800g of blood was found within the peritoneal cavity, but the source of the bleeding could not be identified. During intraperitoneal exploration after a removal of the hematoma by washing, a mass was palpated on the posterior wall of the stomach, and then the epiploic foramen was opened. A submucosal mass about 6cm in diameter was revealed, which was suspected of being a GIST, ruptured into the peritoneal cavity. Therefore, full-thickness partial wedge gastrectomy was done to remove the tumor. Examination of the surgical specimen revealed no obvious communication between the tumor and mucosa. Histopathologically, the walls of the tumor were formed by fibrous scar tissue with sclerosis and thickening, and the lesion was filled with hematoma. It is thought that old aneurysm in the gastric wall might present. These features were compatible with idiopathic abdominal apoplexy.

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We report a case of Cronkhite-Canada syndrome (CCS) which was diagnosed after detection of alpha-fetoprotein (AFP)-producing gastric cancer during surgery for appendicitis. A 68-year-old man was admitted to the hospital because of right lower abdominal pain. He was diagnosed as having peritonitis due to acute appendicitis. Ileocecal resection was performed because of severe inflammation in the ileocecal region. Intraabdominal palpation during operation revealed a tumor of the stomach. Evaluation after the operation revealed AFP-producing gastric cancer and multiple colonic polyps about 10mm in diameter. From his skin pigmentation, diarrhea, and nail atrophy, he was diagnosed as having CCS. Distal gastrectomy was performed for gastric cancer. Pathological examination showed poorly differentiated adenocarcinoma, AFP positive staining. The background mucosae of the stomach and colon were compatible with CCS. Steroid was administered to control diarrhea due to CCS. Malignant tumors often develop in patients with CCS. However, there have been no previous reports of AFP-producing gastric cancer in patients with CCS.

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We report a case of gastrointestinal stromal tumor (GIST) of the stomach diagnosed by fine needle aspiration biopsy under endoscopic ultrasonography (EUS-FNAB). A 37-year-old woman visited a clinic for epigastralgia was found having a 15-mm sized submucosal tumor in the mid-stomach by gastric X-ray studies. She was introduced to the hospital. EUS showed a hypoechoic mass, which was regarded as gastric leiomyoma, and then she was followed in the outpatient clinic. Thirty-four months later, this tumor enlarged to 50mm in diameter. Microscopy of EUS-FNAB specimen revealed the tumor as GIST. It was removed through a wedge resection of the stomach. Hematoxylin-Eosin staining showed spindleshaped tumor cells densely populated in the fascicular bundles and one or two mitoses were found in every high power microscopic view fields. Immunohistochemical studies showed that the tumor cells were positive for c-kit protein and CD34, but negative for SMA and S-100 protein. This tumor was determined as a borderline case concerning malignant grade of GIST. Surgical resection must be selected as at first most effective treatment for GIST, but we are apt to carry out excessive resection or dissection without knowledge of the definite diagnosis. EUS-FNAB, which enables taking specimen from submucosal tumors, is very useful to ensure the histological diagnosis of submucosal tumors including GIST.

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Calcified gastric cancer is a very specific type of cancer and 20 cases have been reported during the last decade in Japan. We experienced two cases of calcified gastric cancer. The first patient was a 71-year-old woman who was diagnosed as having mucinous carcinoma of the stomach. The second patient was an 80-year-old man who was diagnosed as having signet-ring cell carcinoma in the remnant stomach undergone a distal gastrectomy for gastric cancer 30-years earlier. Preoperative enhanced CT scan of the abdomen in them showed punctate calcification in the gastric wall and at the anastomosis of the remnant stomach in the first and second patients, respectively. Both patients underwent a total gastrectomy but died of pertnitis carcinomatosa 4 months and 7 months after diagnosis, respectively.
The prognosis of calcified gastric cancer is extremely poor, and demands urgent treatment as soon as possible is after making diagnosis.

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We report a patient with α-fetoprotein (AFP) producing advanced gastric cancer surviving for 8.5 years after curative total gastrectomy with resection of the pancreatic tail and spleen, following by prophylactic hepatic arterial infusion of 5-FU+mitomycin C+epirubicin for 13 months. The patient was a 65-year-old man with elevated serum AFP titer of 1, 070ng/ml. Pathologic and operative findings were tub2, se, n1, P0, H0, and stage IIIa. The number of metastatic lymph nodes was 15. The serum AFP titer decreased within normal level of 2.3 ng/ml on the 55th postoperative day and the normal level has been kept up to now. It is well known that AFP producing gastric cancer metastasizes to the liver in a high incidence rate. This case suggests that the prophylactic hepatic arterial infusion may prevent hepatic metastasis from AFP producing gastric cancer.

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We report a case of recurred gastric cancer in a 70-year-old woman to whom weekly paclitaxel administration was useful.
The patient had undergone a distal gastrectomy for gastric cancer in April 2001, which was pathologically evaluated as tub2, T2 (SS), ly3, v0, N1, CY1, Stage IV, and CurC. After discharge, the patient had been given UFT (400mg/day) orally but tumor markers became increase since July, 2001. Oral administration of TS-1 (100mg/day) was started in September. The tumor makers once decreased, but increased again and adverse side effects appeared. The TS-1 regimen was withdrawn after three courses. Thereafter obstructive jaundice, paraaortic lymph node swelling, bilateral hydronephrosis, and retention of ascites appeared, and weekly administration of paclitaxel at a dose of 170mg/m2 was started in January 2003. After completion of one course of the regimen, a PTCD tube inserted for obstructive jaundice could be removed, and after three courses a diminishing of swollen lymph nodes, improvement of bilateral hydronephrosis, and disappearance of ascites were identified, resulting in remarkable improvement of the patient's QOL.
It is thought that weekly administration of paclitaxel can be an expectable option for recurred gastric cancer.

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A 50-year-old woman was diagnosed as having scirrhous carcinoma of the stomach. Since laparoscopy, severe peritoneal dissemination was present, the patient was thought not to be a candidate for surgery. Therefore combination chemotherapy with S-I, CDDP and paclitaxel was started.
S-1 (80mg/body) was administer orally twice a day for 21 consecutive days, CDDP (60mg/m²) was infused on day 8 and paclitaxel was infused intraperitoneally (120mg/body) weekly. Since down-staging was observed after two courses, operation was performed. Significant reduction of peritoneal disseminations was confirmed, and we could perform a curability B operation. Histologically, only a few remnant neoplasm cells were identified in the peritoneum. The effect was accepted also in the main tumor (grade Ib). S-1 and paclitaxel regimen is continued on anambulant basis. No signs of recurrence have been observed for ten months after the operation.

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We report a resected case of jejunal angiodysplasia.
A 66-year-old woman was admitted to the hospital for close examination for anemia. After admission she had repeated episode of tarry stool, but upper gastrointestinal scopy and barium enema showed no prominent bleeding site. With a suspicion of small bowel disorder, an abdominal angiography was conducted and a vascular lesion was found at the periphery of a branch of the jejunal artery. After a microcoil was placed at periphery of the influx artery, an operation was initiated. We confirmed the microcoil by intraoperative fluoroscopy and performed a partial resection of the small intestin including the lesion. On the resected material, a 6×6cm, dark red Isp type tumor with smooth surface was noted. Histopathological study revealed growth of small arteries and veins as well as capillary vessels and growth of smooth muscle fibers in the vascular wall. Angiodysplasia was definiterly diagnosed.

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A 57-year-old man, who had been followed after laparotomy for an abdominal tumor which was unresectable at another hospital, was brought into the hospital by ambulance because of abrupt onset of severe cough 10 months after the laparotomy. Abdominal CT scan revealed a well-defined encapsulated tumor 15 cm in diameter in the lower abdomen, which contained liquid and air concomitantly forming an abscess. Because the patient went into sepsis, an emergency operation was performed and 1, 600 ml of pus was drained. Once the patient went into multi-organ failure, but recovered from the condition by administration of antibiotics and hemocatharsis. Thereafter abscess due to fistulization of a submucosal tumor arising in the ileum was diagnosed based on abdominal CT and magnetic resonance imaging scans, and was removed. Immunological studies showed that the ileal tumor was positive for c-kit, CD34, smooth muscle actin, while negative for S100 and desmin. It was GIST of the ileum, smooth muscle type.
Since GIST of the ileum formed an abscess causing sepsis is extremely rare, this case is presented here.

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We report a case of gastrointestinal stromal tumor (GIST) of the ileum with intraabdominal hemorrhage. A 37-year-old man admitted with lower abdominal pain, was found in laboratory studies to have leukocytes. Computed tomography (CT) showed an intraabdominal tumor in contact with the small intestine and fluid collection in the lower abdomen. Under a diagnosis of intraabdominal hemorrhage from the small intestinal tumor, we conducted emergency surgery, finding 800 ml of bloody fluid in the abdominal cavity and a small intestinal tumor 4 cm in diameter that was 130 cm oral to the ileocecal valve. The tumor was extraluminal and growing with coagula, so we determined that intraperitoneal bleeding was caused by rupture of the tumor. We partially resected the small intestine. Histopathological diagnosis was smooth muscle GIST. The patient remains free of tumor recurrence in the 18 months since surgery.

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A rare case is reported of lipoma of the sigmoid colon which prolapsed through the anus.
A 63-year-old woman was admitted for abdominal pain, constipation, and anal bleeding. Colonoscopy detected a large submucosal tumor of the sigmoid colon. The tumor presented characteristic fatty densitometric values on CT and a bright signal on a T1-weighted image. The tumor prolapsed through the anus during hospitalization. Resection was performed via a mini-laparotomy. The resected tumor was 7cm in diameter. Pathological findings confirmed increased mature fatty tissue.

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Parastomal hernia is a relatively frequent complication of intestinal stoma but strangulation of it is rare. We report a case of incarcerated parastomal hernia required an emergency operation. A 72-year-old woman, undergone an abdominoperineal excision of the rectum with end sigmoidostomy for rectal cancer five years earlier, was admitted to the hospital because of left-sided abdominal pain and vomiting. Abdominal CT scan showed peristomal intestinal dilatation in the subcutaneous area. We diagnosed the case as strangulated ileus due to incarcerated parastomal hernia and performed an emergency operation. During surgery, the stoma was situated at the edge of the rectus sheath and the strangulated small intestine was seen beside it. The orifice of the hernia was dilated and repaired locally. It is etiologically thought that the patient's obesity and poor siting of the stoma might cause parastomal hernia in this case. Enterostomy should be constructed by an adequate procedure through the center of the rectus sheath in order to prevent parastomal hernia.

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Gastrointestinal stromal tumor (GIST) rarely arises from the colon. We report a case of GIST of the colon.
A 70-year-old man seen at the hospital because of abdominal distention and diarrhea was found to have a ridge like a submucosal tumor in the descending colon on colonoscopicfiber. CT scan revealed an about 9-cm tumor in the descending colon, pleural effusion, ascites and a left renal tumor. After admission, right lower abdominal pain developed and peritoneal signs became apparent, so that an emergency operation was performed. Upon laparotomy, couded ascites, a tumor about 10cm in diameter adherent to the spleen at the splenic flexure of the colon, and perforation of the cecum were identified. Excision from a part of the ileum to a part of the descending colon was performed, and an artificial anus was created by using the ileum. On the excised specimen, the tumor wihch formed ulcer on the mucosa surface of the colon and had grown extramurally was identified, and perforation of the cecum was associated. Histopathological study showed growth of spindle-shaped cells. On immunostainings, the specimen was negative for smooth muscle actin, desmin, s-100 protein, NSE, CD34, and c-kit, and was positive for vimentin.

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This paper deals with a 67-year-old woman with rectal metastasis of breast cancer. The patient underwent a pectoral muscle preserving mastectomy for right breast cancer on September 21, 1994, which was papillo-tubular and scirrhous carcinoma, T2aN0M0, and stage II. In April 1997, bone metastasis was detected and she had received 6 courses of chemotherapy (CMF) until May 2001, resulting in PR which was maintained for a long time. However, hepatic metastasis was found and 18 courses of docetaxel divided into small doses given from May 2001 to December 2002 resulted in CR. The patient became to complain of anal and severe constipation since October 2002 and was found an encircling narrowing of the lower rectum on barium enema study. Lower gastrointestinal endoscopy revealed type 4 whole-cirfumferential stenosis with erosion on mucosa 2 cm proximal to the dentate line. Histopathological study of biopsied specimen revealed poorly differentiated adenocarcinoma. On December 14, 2002, an abdominoperineal excision of the rectum was performed. Histopathologically, the excised material showed specific staining GCDFP (15) (+), HMFG2 (-), lactoferrin (+), ALA (+), ER (3+), and PgR (+), and rectal metastasis of breast cancer was thus diagnosed. Because of HER-2 (2+), chemotherapy with paclitaxel and trastuzumab was started in January 2003.
There have been few reports on gastrointestinal metastasis of advanced breast cancer, especially those on resected metastasis of the lower rectum from breast cancer. This rare case is reported together with some bibliographical comments.

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A 59-year-old woman presented with diarrhea, abdominal distention and nausea. Abdominal CT scan showed a 65×45mm solitary nodule in the posterior segment of the right lobe of the liver. Transarterial portography showed absence of the portal bifurcation. With a preoperative diagnosis of intrahepatic cholangiocellular carcinoma, the patient was operated on. Operative portography visualized absence of the portal bifurcation and a large aberrant vessel that ran transversely from the right anterior segment to the left lateral segment. The patient required a right posterior segmentectomy with a partial resection of the inferior vena cava and diaphragm to remove the lesion. The pathological diagnosis was intrahepatic cholangiocellular carcinoma. Absence of the portal bifurcation is a rare anomaly. Failure to recognize this anomaly would lead to inadvertent ligation of the main trunk which might result in disruption of portal blood stream to the entire liver. Surgeons need to recognize this anomaly for performing safe liver surgery.

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A 71-year-old man complaining of right hypochondralgia was referred to the hospital because gallbladder stone was pointed out at another hospital. There was slight tenderness in the right upper quadrant of the abdomen. Hematological studies showed increases in hepatic and billiary enzymes. Abdominal ultrasonography and CT scan revealed a stone in the gallbladder. Magnetic resonance cholangio-pancreatography (MRCP) showed a mild dilatation of the common bile duct and a filling defect in the lower bile duct probably due to a stone. With a diagnosis of gallbladder and common bile duct stones, a laparoscopic cholecystectomy, incision and lithotomy of the common bile duct, and C-tube drainage were performed. During surgery, when dissecting the cystic duct up to the common bile duct, the bile duct which runs toward the porta hepatis had been confluent and was thought to be the accessory hepatic duct. However, this uncommon bile duct had again joined with the right hepatic duct.
Although there are many variations in unnatural run of the biliary duct, this unnatural run of the bile duct which had arisen from the cystic duct to the right hepatic duct is rare. In this paper a case of gallbladder and common bile duct stones associated with this rare unnatural run of the bile duct is reported.

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This paper presents a case of intracystic ectopic pancreatic tissue which was found after cholecystectomy with a diagnosis of cholelithiasis, together with some bibliographical comments.
A 67-year-old woman seen at the hospital because of epigastric pain was diagnosed as having cholelithiasis on various examinations. A cholecystectomy was performed. On a histopathological study of the resected specimen, a part of ectopic pancreatic tissue was present which involved acini and excretory ducts. Heinrich II type was consequently diagnosed.
Ectopic pancreatic tissue is often accidentally detected at endoscopic study or during surgery, and hence it is not a rare entity. However, there are few cases of ectopic pancreatic tissue in the gallbladder. Only 18 cases including our case have been reported in the Japanese literature as far as we could review.

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A 73-year-old man was referred to the hospital because of recurrent bouts of abdominal pain and anal bleeding. On abdominal ultrasonography and abdominal CT scan, hepatic infiltration of gallbladder cancer was suspected. Upper gastrointestinal endoscopy identified biliary bleeding. No remission was attained by blood transfusion. With angiography, a diagnosis of a pseudoaneurysm of the right hepatic artery due to direct invation of gallbladder cancer to the liver was made. For the purpose of hemostasis, vascular embolization was carried out. Thereafter when his condition became stable, an extended right lobectomy of the liver, an excision of the bile duct, and biliary reconstruction were performed. On the removed material, gallstones and clots were present in the gallbladder; the tumor was nodular infiltrating type involving the entire gallbladder; directly invaded the liver; also invaded the right hepatic artery with ulcer formation; and exposed to the gallbladder. Histological diagnosis was well differentiated tubular adenocarcinoma.
Gallbladder cancer causing biliary bleeding is rare, especially gallbladder cancer with direct invasion into the liver to form a pseudoaneurysm of the right hepatic artery. This rare case is presented here, together with some bibliographical comments.

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We report two cases of undifferentiated carcinoma of the gallbladder which is rare. Patient 1, a 78-year-old man, presented with acute cholecystitis. Abdominal CT scan and ultrasonography showed a small nodule 1.0cm in diameter at the neck of the gallbladder. Endoscopic retrograde cholangiopancreatography showed obstruction of the cystic duct. He underwent a laparoscopic cholecystectomy under the diagnosis of gallbladder tumor. Histopathological findings revealed undifferentiated carcinoma of the gallbladder. Because surgical margin was positive, a choledochotomy with lymph node dissection was additionally performed. No evidence of recurrence has appeared 8 month after the surgery. Patient 2, an 85-year-old woman, was admitted to the hospital for the treatment of acute cholecystitis. Abdominal CT scan and ultrasonography showed cholecystocholedocho-lithiasis with a liver abscess. She underwent surgery after percutaneous transhepatic gallbladder drainage. We judged that the liver abscess was due to tumor necrosis during the operation. However, a cholecystectomy and a choledocholithotomy without tumor resection were performed because of her poor risk with the aged. Histopathological findings also revealed undifferentiated carcinoma of the gallbladder. She died of rapid growth of metastatic liver tumor and lymph nodes 75 days after the surgery.

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A 69-year-old man who had been followed for a polyp of the gallbladder detected in November 1998 at another hospital was found to have anemia, and was referred to the hospital. Abdominal CT scan visualized a tumor shadow about 3.5 cm in diameter at the fundus of gallbladder, and a tumor shadow about 2 cm in diameter in the hepatoduodenal mesentery suggestive of lymph node metastasis. Abdominal angiography showed accumulation of contrast material at the periphery of the gallbladder artery. With a diagnosis of the gallbladder cancer, an extended cholecystectomy, excision of the extrahepatic bile duct and D2 lymph node dissection were performed on January 25, 2001. On the surgical stump of the excised material, the tumor was 4.0×4.3 cm in diameter and the section was yellowish white in color and solid. Histopathologically anhistic arrangement of large tumor cells with relatively wide cytoplasm and prominent atypical nuclei was observed. On immunostainings, undifferentiated carcinoma originated from the gallbladder was diagnosed.
It is believed that undifferentiated carcinoma of the gallbladder is relatively rare, and this rare case is presented here, together with some bibliographical comments.

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We successfully saved a patient with intraabdominal bleeding caused by rupture of a pancreatic pseudocyst with resultant intracystic hemorrhage by performing hemostatic procedure under laparotomy.
A 32-year-old woman, who had abrupt onset of upper abdominal pain and clouding of consciousness and went into shock during hospitalization elsewhere, was transferred to the hospital with a diagnosis of intraabdominal bleeding of unknown origin. Emergency laparotomy disclosed pulsating bleeding from a part of the pancreatic tail and tissue debris surrounding the part which seemed like cystic wall. With four stitches of the pancreatic parenchyma around the bleeding site, hemostasis was attained so that the abdomen was closed without pancreatic resection. The operative bleeding amounted to 4800 ml. The postoperative course was uneventful and the patient was discharged from the hospital on the 15^th hospital day. No bleeding has occurred up to now.
Intraabdominal bleeding is a rare complication of pancreatic pseudocyst, and only 16 cases have been reported in Japan as far as we could review. This paper presents the case together with some bibliographical comments.

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We report a rare case of solid type of pancreatic serous cystadenoma which presented with obstructive jaundice and was suggestive of a solid tumor of the pancreatic head with portal invasion. The patient was a 71-year-old man complaining of jaundice. Percutaneus transhepatic cholangiography showed a severe stenosis of the intra-pancreatic bile duct. Abdominal ultrasonography, computed tomography and magnetic resonance imaging showed a 3.5-cm solid and hypervascular tumor in the pancreatic head and dilatation of the distal pancreatic duct. A stenosis of the main portal vein and development of collateral vessels were shown on portal angiography. Pancreaticoduodenectomy was performed with a suspicion of a malignant solid tumor of the pancreatic head infiltrating into the bile duct, pancreatic duct and portal vein. No infiltration into the pancreatic duct, bile duct and portal vein was noted. No cystic lesion was shown in the cut surface of the tumor, but histopathologically the tumor was separated into small cystic components, of which epithelial cells contained a large quantity of glycogen. The pathological diagnosis was solid type of pancreatic serous cystadenoma.

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The splenic abscess is a relatively rare entity. We report a case of a solitary splenic abscess following a perforated gastric ulcer complicated with peritonitis. A 54-year-old man was admitted to our hospital 2 weeks after his first complaint of abdominal pain. He underwent a wide resection of the stomach and drainage for peritonitis due to a perforated gastric ulcer. There was severe peritonitis and the preoperative computed tomography (CT) showed a tumor formation in the omentum. Microbiological examination of the ascites revealed contamination of the streptococcus group. On the first postoperative day he was free from fever and systemic intravenous administration of antibiotics was continued for 5 days. On the 14^th postoperative day he complained of remittent fever and upper abdominal pain. Antibiotics administration was recommenced and CT imaging revealed a solitary splenic abscess. After 3 weeks antibiotics therapy, the blood chemistry showed no evidence of inflammation and CT imaging demonstrated the reduction of the splenic abscess. Because a splenic abscess can occur after the disappearance of previous infection, diagnostic imaging for a splenic abscess should be performed in patients who have successfully recovered from a previous inflammatory condition, but who subsequently complain of abdominal pain and remittent fever.

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A 65-year-old man with a 20-year history of medical therapy for gastric ulcer had repeated episodes of remission and aggravation of the ulcer alternately. The patient was admitted to the hospital because a tumor of the pancreatic body was found on ultrasonography elsewhere in 1993. On admission serum gastrin level and BAO were high, 814.7pg/ml and 25.5mEq/l, respectively. Abdominal CT scan revealed an enhanced tumor at the pancreatic body. Angiography showed accumulation of contrast material at the location where was identical with the tumor. Zollinger-Ellison syndrome (gastrinoma) was diagnosed and resection of the pancreatic body and tail associated with pancreatectomy and dissection of lymph node group 1 was performed. Histopathological diagnosis was malignant islet cell tumor. Thereafter an increase in gastrin level occurred in 1996, 1998, and 2000, when abdominal CT scan and angiography visualized a tumor of the liver S6 in each episode. In all three occasions a partial hepatectomy was performed with the diagnosis of hepatic metastasis of the gastrinoma. Histopathologically these lesions were metastatic islet cell tumor. As of February 2003, there have been no signs of recurrence and the patient is followed strictly.

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A 65-year-old woman complaining of epigastralgia and low grade fever was found to have a splenic tumor. After further evaluation, a hand assisted laparoscopic splenectomy was performed under a suspicion of primary malignant lymphoma of the spleen. The pathological diagnosis was malignant lymphoma of the spleen. Three months prior to this admission, an abdominal CT scan taken for postoperative follow-up of her breast cancer showed no splenomegaly or splenic tumor. The large splenic tumor had grown in only 3 months. Three weeks later, this splenic tumor was decreased in size from 5 cm to 2.9 cm in diameter on ultrasonography. We report this rare case of primary malignant lymphoma of the spleen.

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We report here a case of ectopic pheochromocytoma associated with von Recklinghausen's disease. A 69-year-old man with a past history of admission for hypertension was seen at the hospital because of a rapidly growing tumor in his hip. He was diagnosed as having von Recklinghausen's disease, and suspected of coexistence of pheochromocytoma because of his present and past history of hypertension. An abdominal CT-scan revealed a tumor between the aorta and left kidney. The endocrinological laboratory data showed elevations in the levels of serum and urinary noradrenaline. He was operated on, and the tumor was excised. On intraoperative and pathological findings, the tumor was diagnosed as ectopic pheochromocytoma. After the operation the blood pressure and both serum and urinary levels of noradrenaline returned within the normal ranges without hypotensive drugs.

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The recurrence rate of pheochromocytoma is said to be 6.17.1%, but only a few reports have been made on resection of local recurrence accompanied by malignant transformation and lymph node metastasis. We experienced a case of reccured malignant pheochromocytoma accompanied by extensive lymph node metastasis following a course of 8 years after an exision of the left adrenal gland for benign pheochromocytoma. The patient is a 50-year-old man who underwent an excision of the left adrenal gland for benign pheochromocytoma originating in the left adrenal gland on August 31, 1993. On May 30, 2001, a tumor in the left renal hilus was pointed out by CT and on July 5, uptake was observed at the same site by ¹³¹I-MIBG scintigraphy. Under the diagnosis of recurrence, he was admitted to our hospital on September 17. On CT, a large number of tumors 3.5×2.8cm in maximum diameter were seen in the retroperitoneum in the paraaortic region, andthe diagnosis of local recurrence accompanied by lymph node metastasis was made. On October 5, excisions of the tumors and retroperitoniel lymph node dissection were performed. Pathological findings of the resected specimens also indicated malignant pheochromocytoma accompanied by extensive lymph node metastasis. His clinical course is being followed with no signs of recurrence.

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A 54-year-old man complaining of abdominal dull pain was referred to the hospital in June 1994 for further examination and treatment of a left adrenal tumor which was accidentally found by abdominal CT scan. Either hypertension or other abnormality was not shown although elevations of urinary catecholamine (CA), homovanillic acid, and vanillylmandelic acid were observed in laboratory examinations. Abdominal CT and magnetic resonance imaging scans revealed a well-defined tumor with cystic change inside, 10 cm in diameter in the left adrenal gland, and it grew between the renal vein front and renal artery behind. 131I-MIBG scintilation scan showed the uptake of 131I-MIBG not only in the tumor but also in the pelvis, and another tumor was confirmed in the sacrum by CT scan. A diagnosis of malignant adrenal pheochromocytoma with sacral metastasis was made based on these results, and surgical resection of the left adrenal gland and kidney, where the tumor could not be separated from renal vein or artery, was performed in October 1994. The elevations of both serum CA level and blood pressure were found in the midst of the surgery. The left adrenal tumor, which weighed 145 g and measured 10×6×4.5 cm in dimension, was histologically diagnosed as pheochromocytoma containing secreting granules. After the operation, urinary dopamine, HVA and VMA were still elevated. Since any other remained tumor except one in the sacrum was not found by 131I-MIBG scintilation scan which was performed 4 months after the surgery, a partial resection of the sacrum with the tumor was performed. After the 2nd surgery, urinary CA and its metabolites were all normalized, and 131I-MIBG scintilation scan showed no abnormal uptake. He could walk after the physical rehabilitation for 4 months, and left the hospital. Up to the present, no recurrences of the tumor are found by both laboratory examinations and 131I-MIBG scintilation scan.
Various therapies such as surgery, chemotherapy, arterial embolization, and external or internal radiotherapy using 131I-MIBG have been applied for metastatic lesions of malignant pheochromocytoma. We performed surgery on the present patient having a solitary metastatic lesion in the sacrum and could get a good clinical outcome.

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A 77-year-old man admitted to explore anal bleeding and constipation was found in endoscopic study to have a stricture and ulcer formation in the rectum. Biopsy of the lesion showed poorly differentiated adenocarcinoma. Pelvic computed tomography (CT) and magnetic resonance imaging (MRI) showed diffuse thickening of the rectum and swelling of the prostate with partial involvement of the urinary bladder. Under a preoperative diagnosis of rectal cancer with invasion to the prostate and urinary bladder and metastasis to lung, liver and bilateral inguinal lymph nodes, the patient underwent total pelvic exenteration. After surgery, the histological diagnosis was adenocarcinoma of the prostate. Two months after the first operation, the testis was resected for antiandrogen and the serum PSA decreased. Four months after orchidectomy, the serum PSA increased again.
Although rectal invasion of the prostate cancer is relatively rare, it should be considered in the presence of a stricture and ulcer formation of the lower rectum.

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A 53-year-old man was admitted to the hospital because of abdominal pain, fever and general fatigue. Spiral computed tomography (CT) showed a mass with the maximum diameter of 40 mm in the left lower quadrant of the abdomen. We suspected an inflammatory pseudotumor of the greater omentum, soft tissue tumor or metastatic tumor from CT, barium enema and digital substruction angiography (DSA). We performed an emergency operation because he developed symptoms of diffuse peritonitis and ileus during close examinations.
On histopathological examination, sulfur granules of actinomycosis were observed in purulent exudates and actinomycosis of the greater omentum was diagnosed. Postoperative course was uneventful. He has been free from any symptoms and signs of recurrence, as of 12 months after the operation. Actinomycosis is relatively rare and it is not easy to diagnosis for this disease. But it is necessary to considered in the differential of the abdominal mass.

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A 26-year-old woman found to have a 50 mm mass in the left lower abdomen was found in abdominal computed tomography (CT) and magnetic resonance imaging (MRI) to have a multilocular cystic mass with a slightly enhanced lesion similar to its wall in the left retroperitoneal space. Under a diagnosis of retroperitoneal cystic tumor with a solid lesion suspected to be malignant, and we conducted laparoscopic resection. Pathological examination showed mucinous cystadenoma, with the suspicious solid lesion in preoperative imaging found to be a conglomeration of small honeycomb-like cysts. Primary retroperitoneal mucinous cystadenoma associated with a soppibly malignant solid lesion in preoperative imaging and resected successfully via laparoscopic excision is rare.

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