Objective....The value of fine needle aspiration biopsy cytology (FNAC) in the diagnosis of breast pathology is great as a non-invasive method. However, occasionally there are cases in which differentiation of malignancy from benignancy is difficult. We discussed the pitfalls and efficacies of FNAC in diagnosing breast pathology. Material.....506 cases (malignant : 463, benign : 43) of FNAC were the subject of the study. A comparative study of permanent specimens and FNAC's was performed. Result......Among 463 malignant cases, 341 cases (73.7%) were diagnosed as malignant by FNAC. Including 23 cases (5.0%) with suspicious malignancy, the total number was 364 cases (78.7%). 17 cases (3.7%) were difficult to make definite diagnosis and 39 cases (8.4%) were benign. 43 cases (9.3%) were insufficient specimens. Insufficient specimens were more often seen in non-infiltrating ductal breast cancer (37.5%) and non-palpable cancer (26.3%) and usually smaller in size or frequently in grade 1 cases. Among “difficult to make diagnosis" cases, were several rare cases with grade 3 atypia. Among benign “difficult to make diagnosis" cases were papillary lesions and phyllodes tumors. For a case of ductal adenoma and for a case of granulomatous mastitis, which were benign lesions, oversurgeries were performed by overdiagnosis. Conclusion....FNAC is a useful diagnostic method, but possible similar misleading histologies should be kept in mind and excisional biopsies should be used in case of confusing diagnosis.

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Non-surgical cryoablation was used as local treatment for seven localized breast cancers 1 cm or less in diameter. The antitumor effect, as well as imaging and histopathological findings were reviewed. Under local anesthesia every case underwent US-guided treatment using the Visica^TM Treatment System (Sanarus^® Medical, Pleasanton, USA). Freezing zone showed characteristic imaging findings on US and MRI. Thus, it was possible to confirm that the cancer lesion was included in the freezing zone by comparing the precryo-imaging findings with postcryo-imaging findings. In 1 case, histopathology revealed scar-like fibrous tissue with hemosiderin deposition ; however, there were no clear viable tumor cells in the center of the freezing zone. Average observation period was 9.7 months (range, 3 to 21 months). There have been no recurrences in any of the cases.
Cryoablation for localized minimal breast cancer may become one of the preferred local treatments for breast cancer.

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Purpose : The most common postoperative complication of the Nuss procedure for the treatment of pectus excavatum is bar displacement. In order to prevent this complication, we performed the Nuss procedure with three points fixation of the metal plate bar beginning from April 2004. The aim of this report is to analyze the efficacy of this technique for preventing bar displacement.
Methods : The third point fixation of the bar, fixed directly to the right rib using absorbable suture material through a 3-mm skin incision on the right anterior thoracic wall, added to the standard Nuss procedure.
Material : From April 2004 to May 2006, this technique was applied to 25 patients who underwent the Nuss procedure for the treatment of pectus excavatum. Among the 25 patients, 17 were male and 8 were female. The age of the patients ranged from 5 to 16 years with the mean age of 9 years at the time of operation.
Result : The mean operative time was 102 min, which was a little longer than the conventional procedures. However, this is not statistically significant. Postoperative complications consisted of pneumonia in four patients and hemothorax in one patient. However, bar displacement did not occur and in all these patients the metal plate bars were removed with satisfactory results.
Conclusion : Three points fixation seems to be effective in preventing bar displacement following the Nuss procedure.

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This multi-institutional study examined whether the early detection or the prediction of postoperative complications after gastrectomy is possible through variance analysis based on deviations from the critical pathway values. The 90^th percentile values of the daily vital signs were calculated based on the data obtained from 190 cases seen at the JA Sapporo Kosei Hospital who did not develop postoperative complications after gastrectomy, these served as the standard values. Next, in each of the 11 participating institutions, the vital signs and postoperative complications of 10 consecutive gastrectomy cases were compared to the standard values. In 52.7% (58/110) of cases, there were abnormal vital signs. However, postoperative complications actually occurred in only 32.7% (19/58) of these cases. Of the cases with postoperative complications and abnormal vital signs, 73.7% (14/19) developed abnormal vital signs prior to postoperative complications becoming manifest, and 26.3% (5/19) developed abnormal vital signs on the same day that postoperative complications became manifest. Postoperative complications occurred in 5.8% (3/52) of cases for whom data did not show abnormal vital sign ; these complications were not serious. It appears possible to predict and detect postoperative complications post gastrectomy based on the 90^th percentile value of the daily vital signs.

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To clarify the clinical utility of infliximab treatment in Crohn's disease patients, a retrospective analysis was conducted with special reference to the number of reoperation. Furthermore, a questionnaire study was performed to clarify the patients' satisfaction in everyday life before and after the introduction of infliximab treatment. Cost-benefit analysis was also attempted. Clinical effect was graded as good or fairy good in 91% of the patients. As compared with the average number of operation before the introduction of infliximab treatment, the number was significantly reduced after the treatment (3.4+/-0.8 vs 0.8+/-0.4 ; p=0.013). No severe adverse event was encountered in our patients. Patients' satisfaction in everyday life, school life, and occupation status were greatly improved in about 70% of patients, and it was thought to be significantly associated with the introduction of infliximab treatment from the patients' point of view. After the introduction of infliximab treatment, the total cost increased by 463,000 to 1,295,000 Yen per person-year. These results suggested that infliximab treatment was very effective clinically, and contributed to improve the patients' everyday life in all aspects examined. However, the cost of infliximab was very high, and a cost-utility analysis will be mandatory in our country in the near future.

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Granulomatous mastitis is rare disorder that often mimicks breast carcinoma. A 47-year-old woman presented at our hospital with a 1-month history of a right breast lump. She had a 3-cm elastic hard mass located in the median upper area of her right breast. Clinical and radiological examinations suggested right breast cancer. Coreneedle biopsy was performed, and no malignant tissue was recognized. Incisional biopsy was performed. Histological examination revealed granulomas composed of epithelioid histiocytes, giant cells and neutrophilic infiltrations. Bacillus examination identified Corynebacterium kroppensedtii. Granulomatous mastitis associated with Corynebacterium kroppenstedtii infection was diagnosed and successfully treated with minomycin. Corynebacterium kroppenstedtii infection must be considered in the treatment of patients with granulomatous mastitis.

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A 70-year-old woman developed a tumor measuring 7.5×6.5 cm in the AC area of the left breast. On mammography, a lobulated, high density mass with a microlobulated margin, which was classified as belonging to category 4 was detected. On ultrasound, an irregular, low echoic mass with ill-defined borders and heterogeneous contents was found. On fine needle aspiration cytology, the mass was diagnosed as an adenomyoepithelioma. Concurrent ductal carcinoma of the breast was also identified. A modified radical mastectomy with an axillary dissection was done. On histopathology, the adenomyoepithelioma was seen in the center of the tumor, and it was surrounded by both scirrhous carcinoma and ductal carcinoma in situ. Adenomyoepithelioma is a breast tumor in which two layers of cells proliferate, it is usually considered to be a benign tumor. This is the fourth case in Japan in which invasive ductal carcinoma of the breast coexisted with adenomyoepithelioma in the same breast. At present, the patient is alive without recurrence or metastasis 2 years postoperatively.

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The patient was a 53-year-old woman who noticed a mass in her right breast in January 2005 but did not immediately seek medical attention. Because the mass subsequently enlarged rapidly, became painful, and eventually became so large that it caused deformation of the right breast, the patient visited our department in October 2005. An elastic, hard tumor with a maximum diameter of 15 cm and redness of the skin were observed. Right mastectomy was performed, and postoperative pathological diagnosis was stromal sarcoma of the breast. No lymph node metastasis or vascular invasion was observed. The patient followed a favorable postoperative course without complications and was discharged in good condition on postoperative day 10. She retumed three weeks postoperatively with a chief complaint of respiratory discomfort. Massive right pleural effusion was detected on chest X-ray, and a recurrent lesion 3 cm in size was observed in the right anterior chest wall on chest CT. Atypical cells were detected on pleural fluid cytology, and the patient was diagnosed with malignant pleural effusion caused by pleural dissemination. Drainage of the right thoracic cavity was performed after readmission. Although drainage of pleural effusion was subsequently continued, the recurrent lesion rapidly enlarged, and the patient died on postoperative day 67.

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The patient was a 59-year-old woman who had been given bisphosphonate for bone metasteses of breast cancer. Twelve months after initiation of bisphosphonate regimen, she became to feel pain of the left inferior molar tooth, swelling of gum, and jaw bone exposure. She was diagnosed as having bisphosphonate associated osteonecrosis of the jaw. There was a possibility that not-cured dental disease might cause the disease. Bisphosphonate has been demonstrated to provide improvement of quality of life of the patients who have bone metastases. In using bisphosphonate, however, it is important to consider the risk of causing osteonecrosis of the Jaw.

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The patient was a 43-year-old woman, who came to our hospital complaining a painful nodule of right breast after an infertility treatment. On palpation, there was a nodule 4.0 cm in diameter with a slight dimple in the right E area. The mass had a low echoic areas in an ultrasonography study, and was diagnosed as a breast cancer. Diagnosed as category 4 by a mammography. Fine-needle aspiration cytology showed numerous scattered small cells with bare nuclei containing pyknotic nucleoli. So, we perfomed an excisional biopsy. Histologically, massive necrosis was observed in the tumor mass. A few viable carcinoma cells were identified around the area of necrosis, and the tumor was diagnosed as an invasive ductal papillotubular carcinoma with massive infarction. This is a very rare case and important, because a breast cancer with almost entirely infarcted necrosis has practically never been reported.

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A 58-year-old woman visited our hospital for closer examination of a left breast tumor detected by ultrasonography in mass screening. The tumor was not palpable, mammography showed a high-density lesion with microlobulated margin, and ultrasonography showed hypoechoic oval shape tumor with an irregular border. Aspiration biopsy cytology indicated ClassII, but adenoid cystic carcinoma of the breast was diagnosed with core-needle biopsy. The patient underwent quadrantectomy of the breast and sentinel lymph node dissection. In the histopathology, the tumor had a gland-like structure and solid component. It was constituted of epithelioglandular and myoepithelial cells, and diagnosed as a adenoid cystic carcinoma of the breast. Adenoid cystic carcinoma was characterized as a structural variant, the so-called cribriform pattern, with poorly atypical small cells. Therefore, core-needle biopsy, with can diagnose a structural variant, is more useful than aspiration biopsy cytology which only diagnoses the atypical cells.

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We report a case of invasive lobular carcinoma (ILC) of the breast in a 52-year-old woman, which was detected by a preceding resection of metastatic uterine carcinoma. She was hospitalized complaining of abdominal fullness. A solid tumor in the pelvic space was discovered by examinations, and she underwent a hysterectomy under the diagnosis of uterine myoma. Histological examination revealed that small cells proliferated in the characteristic “Indian-file” pattern. The histological diagnosis was metastatic uterine carcinoma, and the existence of ILC of the breast was strongly suspected. Subsequently, ILC of the left breast was detected by imaging diagnosis and was confirmed by aspiration biopsy. A modified mastectomy was then performed. It is rare for an original ILC of the breast to be discovered by histological examination of a metastatic site. If the distinctive histological findings of ILC are encountered in the specimen of any other organs, the breasts should be examined immediately.

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Among 56 cases of segmental arterial mediolysis (SAM), 20(35.7%) cases which were associated with multiple aneurysms were enrolled in this study examining the treatment and prognosis. Their average age was 57.8 years, and the male-to-female ratio was 14 : 6. Eighteen out of the 20 patients presented with intra-abdominal bleeding, one patient with peritonitis, and the remaining one was asymptomatic. The numbers of aneurysms were two in 13 cases, three in two, more than four in four, and 20 in one. The most commonly affected artery was the middle colic artery in nine, followed by the gastroepiploic in three among 20 ruptured aneurysms. Sixteen patients underwent emergency laparotomy and all patients survived except one who died of underlying disease. Transverse colectomy in five, right hemicolectomy in one, gastrectomy in two, and resection of the jejunum and pancreatoduodenectomy in each one were performed. Excision of seven aneurysms was performed in six patients. Unruptured aneurysms were embolized in four cases, while they were left intact in 11 cases, but the prognosis was good in all cases. A patient who had two aneurysms, one ruptured and one nonruptured, and was operated on in two stages was described.
The first choice of the treatment for SAM is interventional approach although emergency laparotomy provides good therapeutic outcomes.

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The patient was a 69-year-old man in whom an abdominal aortic aneurysm (5.2 × 5.0 cm) located below the renal artery and aneurysms of both femoral arteries (right, 9.0 × 7.5 cm ; left, 4.3 × 4.0 cm) as well as the right popliteal artery (3.5 × 2.5 cm) were detected on CT and MRI in December 2005. Blood tests revealed complication by disseminated intravascular coagulation (DIC), which was diagnosed as being caused by one of the above aneurysms. The patient was hospitalized for management of DIC. Because he developed cerebral infarction on the second day of hospitalization, DIC management using low-molecular-weight heparin was avoided due to the risk of hemorrhagic infarction. Blood vessel prosthesis implantation was performed for the right femoral artery aneurysm, which was thought to be the cause of DIC based on CT findings. DIC subsequently improved, and the patient was discharged on postoperative day 11. However, the patient required emergency admission approximately three months postoperatively due to recurrence of DIC. Following administration of low-molecular-weight heparin, DIC improved by the ninth day of hospitalization, and blood vessel prosthesis implantation was performed simultaneously for the abdominal artery aneurysm and the left femoral artery aneurysm. The patient followed a favorable postoperative course and was discharged on postoperative day 11. We report a case of multiple aneurysms that were twice complicated by DIC.

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The patient was a 16-year-old girl in whom an abnormal shadow in the left lung was initially detected on chest X-ray during a health checkup at school. During detailed examination of the pulmonary shadow, the patient developed abdominal pain, and gastroscopy revealed a submucosal tumor in the lesser curvature of stomach. FDG-PET showed significant FDG accumulation in both the pulmonary and gastric lesions. Partial gastrectomy and left lower lobectomy were performed. The gastric submucosal tumor and lung tumor were diagnosed as gastrointestinal stromal tumor (GIST) and pulmonary chondromatous hamartoma, respectively. Carney et al classified the concomitant manifestation of at least two of the following three conditions as a single syndrome called Carney's triad : gastric leiomyosarcoma, functioning extra-adrenal paraganglioma, and pulmonary chondroma. Gastric lesions have recently been reported to include GIST as well as gastric leiomyosarcoma. We present our patient, who was thought to have Carney's triad without functioning extra-adrenal paraganglioma, in other words an incomplete Carney's triad, with reference to literature.

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Sternoclavicular joint septic arthritis secondary to an indwelling central venous access device (CV port) is rarely reported. A 51-year-old woman with advanced colon cancer had a CV port implantated to allow adjuvant chemotherapy to be given. After 3 treatment courses of a modified FOLFOX-6 regimen, extended redness followed by subcutaneous swelling with tenderness was noted around the CV-insertion site. After removal of the CV and port, the severity of the pain on the right side of the neck and shoulder increased, and marked swelling around the right sternoclavicular joint was noted. Sternoclavicular joint septic arthritis was diagnosed ; a subcutaneous abscess was seen on CT and MRI. The patient recovered completely once the device was removed, adequate antibiotic treatment was given, and incisional drainage was instituted. Pseudomonous aeruginosa grew on bacterial culture. Advanced cancer patients receive intensive chemotherapy via a CV port. Generally, there is a major risk of CV port-related infection due to their immunosuppression. When a CV port-related infection is suspected, it is very important in cancer patients to promptly remove the CV port.

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An 80-year-old woman had been pointed out a mass of the right chest wall since December 2005. The mass was found to be enlarged by a follow-up chest CT in May 2007. The chest CT revealed an intrathoracic soft-tissue mass with a well-defined border, heterogeneous enhancement, and erosion of the adjacent seventh rib. MRI showed the mass to have signal intensity equal to that of muscle on T1-weighted image, high intensity on T2-weighted image, and marked enhancement by gadolinium. FDG-PET demonstrated slightly abnormal accumulation in the mass. Because malignancy was suspected from these findings, resection with the chest wall was performed in July 2007. The resected specimen was pathologically diagnosed as desmoid tumor. Because desmoid tumor is a locally aggressive tumor with the high rate of local recurrence, a tight follow-up should be needed.

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The patient was a man in his twenties who had been diagnosed as having choriocarcinoma in 2005. He had multiple hepatic metastases, multiple lung metastases, and retroperitoneal lymph node swelling, and received chemotherapy. Following the chemotherapy multiple hepatic metastases disappeared, but multiple lung metastases and retroperitoneal lymph node swelling were left, for which partial lung resection followed by pleurodesis and closure of a right pulmonary fistula were performed in April 2006. In June 2006 retroperitoneal lymph node dissection was done. Thereafter he had been free from recurrence, however, chest x-ray examination and chest CT scan disclosed a tumor of the right chest wall in February 2008. A metastatic chest well tumor was suggested and the tumor was removed in May 2008. The removed material which was a white solid tumor showed no histological findings suggestive of metastasis of choriocarcinoma, and thus chest wall desmoids tumor was diagnosed. A part of the surgical margin was positive.
Desmoid tumors predominantly affect the abdomen and rarely the chest wall. The tumors recur locally in a high frequency, so that irradiation therapy for prevention of the recurrence is scheduled for the patient.

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We present a case of thymic carcinoid with MEN type I. A man in his 20s was diagnosed as having MEN type I ; an anterior mediastinal tumor was noted on chest CT and MRI. A diagnosis of hyperparathyroidism was made. The patient required an extended thymectomy, excision of the parathyroids, and lymphnode dissection in the supraclavicular area. On histology, atypical carcinoid was diagnosed ; no lymphnode metastases were noted. 25% of thymic carcinoid patients have lymphnode meatstases. Therefore, it is important to do an adequate dissection of the supraclavicular lymphnodes. Since many MEN type I patients have hyperparathyroidism, surgery can be done simultaneously to deal with the thymic carcinoid and the hyperparathyroidism.

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A 75-year-old woman with an about 6-year history of a left upper abdominal tumor was seen at the hospital because of epigastric pain and nausea. Close exploration demonstrated chondrosarcoma about 10cm in diameter invading the thoracic and abdominal wall. At operation the chondrosarcoma was removed with the chest and abdominal wall. A defect on the chest and abdominal wall was repaired using a Composix Kugel Patch^®. The size of the patch used was 18cm wide and 14cm long. The patient's postoperative course was uneventful and the patient has been followed for 3 years postoperatively with no evidence of recurrence in the outpatient clinic. We consider that the present method using a Composix Kugel Patch^® is very useful for repairing a large defect of the thoracic and abdominal wall.

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A 90-year-old woman with advanced gastric cancer (T4N3M0, stage IV) was admitted to our hospital because of body weight loss and anorexia after chemotherapy with S-1. She underwent central venous catheter and port implantation with local anesthesia. On the sixth day after minor operation, she complained of general fatigue and taste disorder. On the 14th day postoperatively, her plasma sodium concentration was 112mEq/l, serum and urine osmolarity were 233mOsm/kg and 525mOsm/kg, respectively. Urine sodium concentration was 76mEq/l. Clinically, there were no symptoms related to dehydration, so she was diagnosed with inappropriate secretion of antidiuretic hormone (SIADH). The patient was then treated with water limitation and hypertonic saline infusion. Subsequently, the anorexia disappeared. The serum sodium concentration increased gradually to 143mEq/l. In conclusion, when an elderly patient with cancer undergoes a relatively minor operation, periodic measurement of the serum sodium concentration is important in the postoperative period.

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A 76-year-old man complained of abdominal discomfort. On upper gastirointestinal endoscopy, a type 2 tumor was found in the mid-portion of the gastric body. On tumor biopsy, a poorly differentiated adenocarcinoma was noted. On abdominal CT, no lymph node metastasis nor gallbladder abnormality was found. Distal partial gastrectomy (D2+12b/p, 13, 8p) with prophylactic cholecystectomy was performed. Operative findings were suggestive of stageIB (T2N0H0CY0P0) gastric cancer ; no macroscopic abnormalities in the gallbladder or of the mucosal surface were identified. On histopathology, the type 2 gastric cancer was diagnosed, as a poorly differentiated adenocarcinoma (mp, ly2, and v2). On microscopic examination of the gallbladder, a gastric cancer metastasis (T2N1H0M1 StageIV) was found. Gallbladder metastasis is rare in gastric cancer patients.

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A 73-year-old man who had been aware of right hypochondoralgia since March 2006 was seen at another hospital, when abdominal echography revealed a 7cm-sized pancreatic tumor. Abdominal CT scan performed in our hospital showed a cystic tumor with solid mass formation in the pancreatic head. Malignant potential on mucocele of the pancreas was considered, and pyrolus preserving pancreatoduodenectomy was performed. Histlogically the tumor showed spindle cells arranged in whorls with storiform pattern. Immunohistologically the tumor was positive for c-kit and CD34, but negative for α-SMA and S-100.
Thus duodenal gastrointestinal stromal tumor (GIST) was diagnosed. He has had no signs of recurrence for approximately one year after the operation.

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A case of food-induced ileus due to ginger is presented. A 69-year-old man developed severe abdominal pain. A diagnosis of ileus due to strangulation of the intestine was made, and surgery was performed.
The ileus involved 120 cm of small bowel, and there was an area of intestinal necrosis located 20 cm from the end of the ileum that was removed surgically. The patient had injested three pieces of ginger about 5 cm long ; these were found in the necrotic bowel. Thus, a diagnosis of food-induced ileus was made. Postoperatively, the patient required intensive care, including endotoxin adsorption treatment due to respiratory failure caused by endotoxic shock, renal insufficiency, and DIC. With treatment the patient improved and could eat. Unfortunately, he subsequently developed pneumonia and died on the 36^th postoperative day.

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We report a case of idiopathic small bowel perforation developed in a patient on maintenance hemodialysis.
A 64-year-old female was admitted to the hospital because of abdominal pain lasting for 5 days. She had been diagnosed as having nephritic syndrome, chronic renal failure, and systemic lupus erythematosus (SLE). Since free air and ascites in the abdomen were detected by abdominal CT scan, perforation in the digestive tract was diagnosed and emergency laparotomy was performed. At laparotomy, perforation 5mm in diameter was comfirmed locating on the antimesenteric side, 200cm distal to the Treitz' ligament. Partial resection of the small intestine including the perforated lesion was performed. Histopathologically the mucosa, muscular and serous layers completely ruptured at the perforated lesion, but no special lesions suggestive of chronic inflammation were seen around the lesion. No causes of the perforation could be identified from these findings, and idiopathic small bowel perforation was diagnosed. Postoperatively, she experienced anastomotic failure which was improved by reoperation, and she was discharged from the hospital 73 days after the first operation.

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We report a case of small intestinal perforation due to allergic ganulomatous angitis (AGA) which is rare.
A 66-year-old man was admitted to the hospital because of abdominal distention and bilateral upper and lower limb numbness. He was diagnosed as having AGA. Conservative therapy with steroid was started but massive, melena occurred on the 45th day after initiation. Colonoscopy showed ulcer with bleeding at the small intestine, and steroid pulse administration therapy for that resulted in symptomatic remission. However, he suddenly comlained of severe abdominal pain on the 101th day after diagnosis. An abdominal CT scan revealed the presence of ascites and free air. We diagnosed the case as perforation of the colon requiring emergency surgery. At operation, we found the perforation of the small intestine with dirty ascites and confirmed that the location of the perforation was coincided with that of the ileal ulcer. Illeocecal resection was carried out after irrigation of the abdominal cavity. The pathological diagnosis was perforative enteritis associated with vasculitis. We must pay attension to perforation of the small intestine due to AGA.

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A 49-year-old woman treated with bevacizumab and FOLFOX for recurrence of cecal cancer was admitted for upper abdominal pain. Abdominal computed tomography scan showed intraperitoneal free air and ascites, loading to the diagnosis of perforation of the intestine. Laparotomy revealed perforation of the small bowel at 50 cm distal to the Treitz' ligament, caused by the invasion of the recurrent cancer to the lymph nodes of the mesentery. We performed a segmental jejunectomy with resection of recurrent lymph nodes, followed by primary anastomosis. The postoperative course was uneventful, and the patient was discharged on the postoperative day 30.

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We report a rare complication in a laparoscopy-assisted-colectomy. A 71-year-old woman underwent laparoscopy-assisted right colectomy for ascending colon cancer. On the 7th postoperative day, she experienced sudden abdominal pain accompanied by vomiting. Laparotomy revealed an internal hernia through the mesenteric defect at the anastomoticsite. Suturing the mesenteric defect is not commonly performed in the operative procedure of laparoscopy-assisted colectomy. However, some cases have been reported where the mesenteric defect caused internal hernia resulting in bowel obstruction. Therefore, our experience might indicate the need for closure of mesenteric opening for the prevention of post operative internal hernia.

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This paper presents a case of iliac ulcer with abscess formation presented with ileus that is very rare.
A 77-year-old man who had recurrent bouts of diarrhea and constipation from August 2006 was seen at the hospital because of vomiting, lower abdominal pain and diarrhea on October 31, 2006. Ileus was suspected, and he was admitted to the hospital. Stenosis of the ileum was detected by enterography and a tumor of the ileum was pointed out by abdominal CT scan. Symptomatic remission was attained by fasting and meal was started. He was discharged by his strong request. But he came to the hospital again because of abdominal pain after supper on November 28, 2006. He was admitted to the hospital with the diagnosis of ileus. At operation performed on December 5, the tumor was palpable about 80cm proximal to the terminal ileum and thus partial resection of the ileum was performed. Histologically, simple ulcer with abscess formation was presented.
Iliac ulcer with abscess formation presented with ileus is very rare, so that we report this case with some bibliographical comments.

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A 73-year-old woman complaining of intermittent abdominal pain was admitted to our hospital under a diagnosis of intestinal obstruction. Though we performed conservative treatment, the bowel obstruction did not improve. In surgery, we found a relatively firm tumor measuring about 6 cm in diameter in the small intestine around 220 cm from the terminal ileum complicated with incarceration and volvulus. Fibrous adhesion between the terminal ileum and the sigmoid colon caused torsion of the small intestine. The intestine did not show necrotic changes and adhesions, and was easily moved to the normal position. We resected the tumor with a part of the small intestine. Postoperative pathological diagnosis was gastrointestinal stromal tumor (GIST) of the small intestine. The tumor was 6.5 × 5.4 × 5.0 cm in size. The mitoses of the nucleus showed below 5/50 HPF. The tumor was assigned to the intermediate risk group. This rare case was reported here together with some bibliographical comments.

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A 59-year-old Japanese woman with renal carcinoma had a right nephrectomy. Two weeks later, she developed vomiting and melena. On abdominal CT, intussusception was diagnosed, and she underwent emergent surgery. During surgery, an intussusception and an intestinal tumor were found ; the involved intestine was resected. On histopathology, the tumor was noted to be a renal carcinoma metastasis. Renal carcinoma with intestinal metastasis is rarely reported. In fact, in Japan only 19 such cases, including the present case, have been reported to date.

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A 66-year-old woman consulted with our hospital with continuous right lower abdominal pain. We palpated a goose egg-sized, soft mass in the right lower abdomen with rebound tenderness. On laboratory data, WBC, CRP and tumor marker CEA rose to 10500/μl, 10.72mg/dl and 8.5ng/ml, respectively. Abdominal CT and MRI showed an 80 × 50mm, cystic tumor at the right side of the pelvis. Therefore, we diagnosed as an ovarian cyst and suspected that torsion of the tumor with infection or bleeding caused severe inflammation and peritoneal irritation sign, and then performed an emergency operation. At the laparotomy, we observed the right ovary to be normal and the appendix abnormal ; a goose egg-sized cystic mass, without obvious malignancy, that twisted clockwise 720 degrees was at the terminal of the appendix. So we performed only appendectomy. Its pathological examination revealed that the tumor was a mucinous cystadenoma. Her postoperative course was uneventful without sign of recurrence for 4 years. There have been only 14 cases of the axial torsion of the mucinous cystadenoma of the appendix, all of which were not diagnosed by the preoperative images. We reports a case of axial torsion of the mucinous cystadenoma of the appendix with discussion about its clinical features reviewing the past literatures.

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A 61-year-old woman came to our hospital because of abdominal pain and vomiting. A diagnosis of intussusception induced by a cystic tumor was suspected by an abdominal computed tomography. Gastrogarafin enema established the diagnosis of intussusception. The reduction of the intussusception was impossible by a gastrogarafin enema, but it was easily reduced by colonoscopy. The tumor revealed a submucosal tumorlike appearance in the cecum under the endoscopic view. We diagnosed the tumor as a mucocele of the appendix, and an ileocecal resection was performed. The pathological diagnosis was mucinous cystadenocarcinoma of the appendix. It is important to avoid injury to the tumor, because the disseminated tumor cells will cause pseudomyxoma peritonei.

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We report a case of appendiceal mucinous cystadenocarcinoma originating from a remnant of the vermiform appendix following appendectomy. A 76-year-old man with a history of appendectomy 30 years ago visited a nearby physician because of right lower abdominal pain and infected discharge from the surgical wound after appendectomy. Abdominal CT scan revealed a tumor lesion, in which the inner part was heterogenous, with the formation of a fistula communicating with skin in the ileocecal area of the abdomen. The patient was operated on with the most likely diagnosis of intractable intestinal fistula and abdominal abscess. Laparotomy showed a tumor lesion about 6 cm in diameter in the ileocecal region and a small nodule at the nearby peritoneum. At surgery we performed ileocecal resection including the mass and removed the peritoneal nodule. Based on findings of a histological continuum between tumor cells and normal mucosa at the terminal of the remnant of the vermiform appendix, the resected lesion was diagnosed as appendiceal mucinous cystadenocarcinoma originating from a remnant of the vermiform appendix following appendectomy.

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We report a case of type 4 cecal cancer with intussusception caused by lipohyperplasia of the ileocecal valve.
A 71-year-old man presented with right lower abdominal pain. An abdominal CT scan showed strongly enhanced wall thickness of the cecum, in which a lipomatous tumor was impacted. A contrast enema using gastrographin did not visualize the oral side from the lower part of the ascending colon demonstrating a filling defect in a shape of a claw. Colonoscopy revealed a soft yellow tumor 5 cm in longer diameter which had invaginated in the ascending colon. The tumor was pushed back by air, however, the colon wall was looked erosive. We suspected ischemic change of the colon caused by intussusception led by the lipoma, and performed ileocecal resection. The pathological diagnosis was well differentiated adenocarcinoma, type 4 and lipohyperplasia of the ileocecal valve. We present this case with a review of the literature.

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A 71-year-old woman was found to have anemia and positive fecal occult blood while following her diabetes in our hospital, so she was given a thorough examination of the gastrointestinal tracts. A barium enema revealed a 30-mm upheaval lesion in the sigmoid colon. Colonoscopy demonstrated an elevated tumor with festering of muscosa in the sigmoid colon. The result of tumor biopsy was group 3. Because the tumor was suspected to be malignant ,an operation was performed. Intraoperative findings revealed that the serosa in the tumor had an irregular part, so we diagnosed the tumor malignancy and performed sigmoidectomy with lymph node dissection. Pathological examination of the resected specimen demonstrated spindle cells arrayed in a fascicular fashion. Immunohistochemical staining was positive for S-100 protein, and negative for CD34, c-kit, and α-SMA. A diagnosis of benign schwannoma in the sigmoid colon was confirmed. Schwannoma in the gastrointestinal tract, especially in the colon, is rare. We here present a rare case of schwannoma of the sigmoid colon.

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A 47-year-old female who was diagnosed as having ascending colon cancer underwent right hemicolectomy and received a chemotherapy in 1994. After 5 years, the tumor markers (CEA, CA19-9) were elevated, but obvious recurrence was not detected. In 2002, CT and MRI showed bilateral ovarian tumors, and hystero-oophorectomy was performed. The histopathological diagnosis was bilateral metastatic ovarian tumor from the colon cancer. In 2003, she felt an abdominal mass, and a CT revealed a paraaortic tumor. She was diagnosed as developed paraaortic lymph nodes recurrence of the colon cancer, and a lymph nodes, resection was performed. She received an adjuvant chemotherapy for 6 months. After 5 years from the last operation, she is surviving without any recurrence of the cancer, now. A long term survival may be achieved in a recurrence of colon cancer, if the recurrence site is surgically resectable.

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A 77-year-old man was admitted to our hospital because of perianal erythemia and anal pain. Despite Pagetoid cells with positive immunostaining for cytokeratin 20 (CK20) and negative immunostaining for gross cystic disease fluid protein 15 (GCDFP15), no rectal of anal tumors were detected. An occult malignancy was strongly suggested. So we performed wide local excision with transanal sleeve resection and reconstruction using a V-Y skin flap. The final histopathological diagnosis was primary rectal cancer with tub1, pM, ly0 and v0. Thus, the surgery resulted in anus-preserving curative operation. Perianal Paget's disease with CK20+/GCDFP15-phenotype generally suggests the presence of anorectal cancer. Transanal sleeve resection seems to be the appropriate treatment of choice, when perianal Paget's disease shows the CK20+/GCDFP15-phenotype without demonstrable evidence of rectal cancer preoperatively, like in our case.

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The patient was a 57-year-old man with abdominal pain and loss of appetite and was admitted to our hospital. The patient had a 12.6×11.7 cm cystic lesion in the right hepatic lobe and we recognized its partial perforation to the abdominal cavity. A blood test showed marked inflammation and Entamoeba histolytica IgG(+), and the patient was diagnosed as having an amoebic liver abscess. He had HTLV-1 and syphilis infections. With regard to the therapy, a percutaneous drainage and oral metronidazole administration (2 weeks) were performed, and the abscess decreased markedly in size and the systemic and inflammatory findings improved.

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A 67-year-old woman was pointed out dilatation of the intra-hepatic bile duct in the left lobe while she had been followed clinical course as a HBV career, and visited our hospital in April 2006. On admission, abdominal ultrasonography showed limited dilatation of the intrahepatic bile duct in the anterior lateral segment of liver and strong echo with the diameter of 5mm without acoustic shadow near the point of dilated bile duct. Abdominal CT scan revealed no calcification or mass which might have caused obstruction of the bile duct. Magnetic resonance cholangiopancreatography and endoscopic retrograde cholangio pancreatography demonstrated obstruction of the intrahepatic bile duct in the anterior lateral segment. We suspected the obstruction caused by cholangiocarcinoma, and performed left hepatic lobectomy. Intra-operative ultlasonography showed hepatolithiasis in a branch of the bile duct in the anterior lateral segment, but no mass was detected. The final pathological diagnosis was cholangiocarcinoma. Intraductal papillary growth of atypical cells was shown with interstitial microinvasion. The patient's postoperative course was uneventful. Intraductal papillary growth of neoplastic biliary epithelia (an intraductal papillary neoplasm of the bile duct [IPN-B]) resembling an intraductal papillary mucinous neoplasm of the pancreas is occasionally associated with hepatolithiasis.

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In February 2005, abdominoperineal rectal resection was performed in a 52-year-old man diagnosed with rectal cancer. The tumor was Borrman type2 and was 5 × 7 cm in size. On pathology, the tumor was found to invade the subserosal layer, and there was micro invasion of the lymphatic vessel and vein. There were no metastases to lymph nodes or other organs. The patient received oral uracil/tegafur (UFT) plus leucovorin therapy for 6 months after the initial surgery. In February 2007, 2 years after the initial surgery, laboratory evaluation was abnormal for the liver function. CT showed wide spread liver metastases to the left lobe, with massive portal vein tumor thrombi in the main left branch. Left lobectomy was performed in April 2007, and irinotecan combined with infusional 5-fluorouracil/folinic acid therapy (FOLFIRI) was given for 6 months pastoperatively. The patient did not have a recurrence in the 10 months following the second surgery.
Colorectal carcinoma hepatic metastases from with massive portal venous tumor thrombi are rare (0.6-3.5% among patients with hepatic metastases from colorectal carcinoma). It has been reported that, without surgery the mean survival time is 3.8 months. On the other hand, this case shows that a safe and effective surgical procedure may improve the patient's otherwise poor prognosis.

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The patient is a 17-year-old boy with the diagnosis of fibrolamellar hepatocellular carcinoma (FLC). He was given a diagnosis of hepatic abscess at another hospital in March 2006. He suffered from abdominal pain, and he was referred to our hospital for further examinations. Computed tomography showed a hypervascular tumor, 7 cm in diameter, in the right lobe (posterior segment) of the liver. A hyperintense tumor with a hypointense central scar within the tumor was seen on T2-weighted magnetic resonance images (MRI). A hyperintense tumor was seen on a superparamagnetic iron oxide particle MRI. No tumor biopsy was performed. He was given a diagnosis of FLC, and a segmentectomy of segment 5/6 was performed. The cut surface of the resected specimen showed a firm, lobular tumor, measuring 7 cm in diameter with a fibrous central scar. Microscopically, the tumor was typical FLC which consisted of eosinophilic tumor cells and fibrous connective tissue of lamellar pattern. In conclusion, we encountered a case of FLC in a patient who was given the diagnosis preoperatively on the basis of image studies.

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A 71-year-old man with complaint of hemosputum was referred to the department of internal medicine of our hospital. There was a previous history of left nephrectomy with the diagnosis of renal cell carcinoma about 15 years ago. Chest CT scan demonstrated a left pulmonary hilar tumor, 35 × 22 mm in size, was diagnosed as a suspicion of lung adenocarcinoma by TBLB. Abdominal CT showed two lump-shaped tumors, 55 mm in diameter, in the lateral side of the spleen, and in the left subphrenic region. Both abdominal and lung tumor demonstrated high FDG uptake on PET and their SUVmax were similar. At first left lower lobectomy of the lung was performed, and the pathological diagnosis was a metastatic lung carcinoma from the renal cell carcinoma. Subsequently, two months later after the lobectomy, resection of the abdominal tumor was performed. We did not recognize the continuity between the tumor and the hepatic left lobe macroscopically. It was a moderately differentiated hepatocellular carcinoma (HCC) by the pathological study. The tumor was completely occupied with HCC, without normal hepatic cells. Immunohistochemical stain with AFP showed positive in most of the cells. The connection of the connective tissue, blood vessels and bile ducts to the left lobe of the liver was not recognized. Therefore, we diagnosed as an ectopic HCC. This is a very rare and interesting case, in that metachronous double carcinomas consisted of ectopic HCC and renal cell carcinoma.

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Limy bile is a condition characterized by excessive precipitation of calcium carbonate in the gallbladder (GB). Ordinarily this condition is caused by obstruction of the cystic duct with calculi consisted of cholesterol. In this paper we report a case of limy bile which is rare from the following points of view : (1) the condition developed after dissolution therapy and (2) it was caused by black stones consisted of calcium bilirubin.
A 53-year-old woman who had a past history of dissolution therapy 30 years before admission, was admitted to our hospital because of a right upper abdominal calcified shadow pointed out by UGI at a medical check up. Abdominal X-P, US and CT scan showed calcified material sized 40 mm on the identified position of the GB. The GB was not visualized on MRCP. She underwent cholecystectomy with a diagnosis of cholelithiasis or limy bile. Laparotomic operation was performed because of a risk of intraoperative bile leakage and coexistence of GB carcinoma. Intraoperative frozen section showed no malignancy. The resected specimen showed some small stones impacted in the cystic duct and toothpaste like limy bile filled in GB. The stones consisted of 99% calcium bilirubin component, and the toothpaste like limy bile was composed of calcium carbonate, calcium bilirubin and others, in ratios of 80%, 10% and 10%, respectively, by an infrared ray analysis.

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An 81-year-old man was admitted to our hospital because of epigastralgia, nausea and abdominal distansion. Abdominal ultrasonography (US) showed gallbladder (GB) distention 18cm in diameter and wall thickening and color doppler US showed arterial blood flow in the wall. Enhanced computed tomographic (CT) scan showed distension and wall thickening of the GB, and absence of its arterial enhancement of the wall. Magnetic resonance imaging (MRI) showed winding of the common bile duct in the GB neck. These findings suggested GB torsion, except US findings. Then we performed emergency laparoscopic cholecystectomy under a suspicion of GB torsion. Intraoperative findings were compatible to GB torsion, a dark red colored, Gross type I floating GB was twisted about 180 degress counterclockwise. Using intraoperative GB aspiration and reduction of the twisted GB, we successfully completed the procedure.
GB torsion is relatively rare and is occasionally undiagnosed preoperatively, but we think that laparoscopic procedure is the treatment of first choice for the undiagnosed case.

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Xanthogranulomatous cholecystitis (XGC) is a chronic destructive form of cholecystitis, often coexisting with gallbladder carcinoma (GBC). A 73-year-old man was admitted to our hospital being pointed out to have a gallbladder tumor by an abdominal ultrasonography. Enhanced computed tomography and magnetic resonance imaging showed an irregular surfaced wall thickening of the gallbladder with low density area of adjacent liver. Positron Emission Tomography (PET) showed that there was an abnormal accumulation of maximum of 8.1 of standarized uptake value (SUV) in the gallbladder. A diagnosis of gallbladder cancer with invasion of hepatic bed was made, and we performed an extended cholecystectomy with resection of regional lymph nodes. Histological examination revealed XGC without evidence of malignancy. It is often difficult to differentiated between XGC and GBC preoperatively. Thus. an elaborate therapeutic planning based on the precise diagnostic imaging is important. Intraoperative frozen section may be a favorable tool for performing appropriate surgical procedure.

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A 75-year-old male patient saw a physician with complaint generalized ill feeling and received a CT study which revealed splenic rupture and intraperitoneal hemorrhage and was referred to our hospital with the diagnosis of hemorrhagic shock. Abdominal CT and an emergent angiogram were taken and then a splenic artery embolization therapy was performed. After improvement of the general condition of the patient a MRI study was performed and with suspicious diagnosis of splenic angiosarcoma, a splenectomy was performed. The excised specimen had a size of 16×15×8 cm, weight of 800 gm and a diagnosis of primary splenic angiosarcoma was made by pathological and immunohistological study. The patient had a liver metastasis early in the postoperative period and developed DIC and peritonitis carcinomatosa 3 months after the surgery and died. This is a case of malignant disease with poor prognosis without yet established definite strategy of treatment. A possible diagnosis of splenic angiosarcoma should be kept in mind in the differential diagnosis of splenic tumor.

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Endometriosis presenting in the groin is rare. We report a case of a patient of endometriosis located in the groin that was noted when the patient had a Nuck's hydrocele resection. A 36-year-old woman developed a right painless inguinal nodule that was elastic, soft, and oval ; it was 3 cm in length and 2 cm in width. The pre-operative diagnosis was Nuck's hydrocele. The nodule, which was located in the right inguinal tract near the external inguinal ring, was resected. A patent processus vaginalis (canal of Nuck) that was continuous with the hydrocele was found. The hydrocele was removed, and a mesh-plug hernioplasty was done. On pathology, endometriosis was noted in the hydrocele. Endometriosis located in the groin is uncommon ; it is particularly rare in Nuck's hydrocele. Findings typical of this condition include the presence of an inguinal mass and menstruation-associated pain. In 90% of cases the right groin is predominantly involved. Since our patient did not have any pain associated with the nodule, a diagnosis of inguinal endometriosis could be not made prior to surgery. Surgeons and gynecologists should bear in mind the diagnosis of endometriosis in female patients with an inguinal mass.

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A 57-year-old female was admitted because of vomiting and abdominal pain. She had undergone appendectomy and hysterectomy. A jejunal stenosis was found by a gastrographin contrast examination. An operation was carried out under the diagnosis of jejunal obstruction due to adhesion. An oval defect approximately 3 cm in diameter was found in the mesentery of the transverse colon and a part of the jejunum 70 cm distal to the Treitz ligament was invaginated into the defect. The invaginated intestine was reduced but had a severe stenosis, so the partial resection of the jejunum was performed and the defect of the mesentery was closed by suturing. Postoperative course was uneventful. Transmesocolonic hernia is rare, but should be considered in the differential diagnosis of ileus in patients with past history of surgery.

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