The use of primary systemic chemotherapy (PSC) for breast cancer is effective as postoperative adjuvant therapy. Although pathological response is the strongest prognostic factor, response rates very according to various parameters. The purpose of this study is to evaluate what clinical factors affect the efficacy, pathological response with breast cancer patients following PSC. Between March 2005 and July 2007, consecutive 254 patients with primary breast cancer received PSC. We classified them according to histological types, nuclear grade, the immunohistochemical expression of several markers, as estrogen receptor (ER), progesterone receptors (PR) and human epidermal growth factor receptor 2 (HER2). Eighty-five patients (33.5%) demonstrated pathologic response more than grade 2. The lowest rate of pathologic response was seen in papillo-tubular carcinoma (19.2%). Hormone receptor positive patients demonstrated significantly less response (22.5%) to PSC than that (59.2%) in the negative patients. Molecular classification with immunohistochemistry and nuclear grade behaves as a predictor of pathological response to PST for primary breast cancer.

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Purpose : The purpose of this study was to identify characteristics and risk factors for bile leakage after hepatectomies for hepatocellular carcinoma (HCC). Methods : We analyzed risk factors for bile leakage in consecutive 359 patients who underwent hepatectomy for HCC in our hospital between 2001 to 2010. The causes, management and outcomes of bile leakage were also investigated. Results : Anatomic hepatectomy was performed in 296 patients (82.5%) and repeat hepatectomy in 59 patients (16.4%). The prevalence of bile leakage was 12.8% (46 patients) and intractable bile leakage that required endoscopic therapy or percutaneous transhepatic biliary drainage occurred in eight patients. The operative time >= 300 minutes was an independent risk factor for bile leakage. The main causes of intractable bile leakage were latent stricture of the biliary anatomy caused by previous treatments for HCC and intra-operative injury of the hepatic duct associated with repeat hepatectomy. Conclusions : Preoperative assessment of the biliary anatomy should be considered for patients who had previous multiple treatments for HCC including hepatectomy, to reduce intractable bile leakage requiring invasive treatments.

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Granulomatous mastitis (GM) is a rare disease that should be well understood as a benign breast disease, because there are reported cases of a mastectomy being performed based on misdiagnosis of breast cancer. We experienced eight cases of GM, and we considered them along with 63 reported cases in Japan.
All cases presented breast tumors on one side, and skin redness was found in 22 cases (31%), the pain and/or tenderness were found in 46 cases (65%). Eighteen cases were diagnosed as suspicion of clinical breast cancer, and mastectomy was performed in seven cases. The treatments for GM included drainage, surgical operation, and steroid therapy. This was effective in 18 of 19 cases who had administered prednisolone (PSL), and the tumors of six cases disappeared. In the other four cases extirpation was performed, because of relapsed after PSL ended. In seven cases there was spontaneous recovery.
We propose the treatment after GM is diagnosed, should be passage observation or drainage is tried first, and steroid therapy can be selected when conditions worsen. The surgical therapy is only selected at the end.

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We studied twelve cases of acute empyema operated on under thoracoscopy in our hospital from January 2009 to December 2010. We defined that the development of the disease was triphasic, infiltrative phase, fibrinopurulent phase and organizing phase. There were ten males and two females, ranged from 52 to 79 years old, with a mean of 64. The disease affected the right side in eight patients and did the left side in four patients. The duration from the onset of the symptoms to the operation ranged from 7 to 67 days, with a mean of 27 days. Postoperative drainage was performed for from 3 to 12 days, with a mean of 5.5 days. Ten patients were operated on in fibrinopurulent phase, and two in organizing phase. Underlying disease included diabetes mellitus in three patients and rheumatoid arthritis in one patient who had been on steroid therapy. Improvement of lung expansion was obtained in eleven patients except the remaining one whose disease was in organizing phase. Thoracoscopic surgery for acute empyema is desirable to perform in fibrinopurulent phase, but it may be effective even in organizing phase if it is in an early time of the phase.

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BACKGROUND : Patients with renal or adrenal cancer accompanied by direct invasion to the inferior vena cava (IVC) with tumor thrombus generally have poor prognosis. En bloc resection may avoid sudden death from heart failure or acute pulmonary emboli. METHODS : We enrolled five patients with renal (three) or adrenal (two) cancer invading the liver and the IVC with tumor thrombus who underwent en bloc extirpation using techniques of combined urologic and hepatic surgeries. Results : Three patients underwent total hepatic vascular exclusion (THVE). In one patient, femoro-femoro bypass was required in addition to THVE. The remaining one patient who had direct invasion to the liver underwent posterior segmentectomy. Curative resection with no residual tumor was performed in all cases. Two patients died from liver failure due to metastatic liver tumors. A mean postoperative survival period was 30.6 months. Conclusions : Our surgical strategies combining urologic, hepatic, and cardiovascular surgeons may play an essential role in achieving successful operation with less mortality and morbidity for such large urological cancer invading the liver and the IVC.

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We experienced 2 rare cases of hyperammonemic encephalopathy after mFOLFOX6 therapy.
Case 1. A 52-year-old man with ileus was diagnosed with descending colon cancer and multiple liver metastases in Stage IV, and a transverse colostomy was performed. Postoperatively mFOLFOX6 was started. The fifth mFOLFOX6 therapy was performed before he was transported to our hospital because he fell into a coma on treatment day 3. His serum ammonia level was 403μg/dl and we diagnosed mFOLFOX6 induced hyperammonemia. Conservative treatment resulted in an improvement of metal status within 2 days.
Case 2. A 75-year-old man was diagnosed with rectal cancer, and a low anterior resection was performed. We diagnosed it as Stage IIIb and performed mFOLFOX6 therapy as adjuvant chemotherapy. We performed 12 cycles, but liver metastasis was seen after 6 months. We started mFOLFOX6 plus Bevacizumab therapy and he became confused on treatment day 3. His serum ammonia level was 352μg/dl and we diagnosed mFOLFOX6 induced hyperammonemia. Conservative treatment was started and his symptoms disappeared within 2 days.

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We present a rare case of child follicular carcinoma. An 11-year-old boy presented with a thyroid nodule. Ultrasonography showed a well-defined homogeneous mass with partial cystic degeneration in the left thyroid lobe. Fine needle aspiration cytology (FNAC) showed the follicular epithelial cells in small clusters with scant colloid, suggesting the possibility of follicular neoplasm and also adenomatous goiter. Left lobectomy and cervical lymph node dissection were performed. Histopathological analysis of the tumor demonstrated a follicular neoplasm and minimal capsular invasion. This confirmed a diagnosis of minimally invasive follicular carcinoma. The patient has remained under close follow-up and is currently showing no sign of recurrence after 12 months. Follicular thyroid carcinoma is extremely rare in children. The diagnosis of follicular carcinoma depends mainly on the pathological findings, and it is not always easy to make a diagnosis with preoperative FNAC. However, when a follicular neoplasm is suspected preoperatively, a follicular carcinoma should be considered in the differential diagnosis of the thyroid mass.

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The patient, a 57-year-old woman, was admitted to hospital because of a rapidly enlarging and bleeding mass in her left breast. A giant tumor with necrotic areas was observed. A left simple mastectomy was performed, and the postoperative pathological diagnosis was stromal sarcoma of the left breast. Eight months after the mastectomy, a giant tumor appeared in the abdominal cavity. Chest and abdominal CT scans revealed tumors in the abdominal cavity and right lung. Under the suspicion of metastatic tumor, we resected these tumors. Approximately 3 years later, a follow-up chest CT scan revealed a right lung small mass, which we resected. One year later, another small tumor appeared in the right lung ; again, we resected this tumor. There has been no futher sign of metastasis.

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A 48-year-old premenopausal woman was seen at the hospital because of a left breast tumor in May 1996. There were no particular medical or familial histories. On physical examination, a 4.8 × 4.0 cm elastic hard tumor was palpable in the AB area of the left breast. The breast lesion was diagnosed as a malignant tumor by ultrasound examination, mammography and fine needle aspiration cytology. We performed modified radical mastectomy in June 1996. Histopathological diagnosis was spindle cell carcinoma of the breast with axillaly lymph node metastasis. Immunohistochemistry showed that the carcinoma cells were positive for Cytokeratin and Vimentin. Six courses of FEC regimen were done after the operation. One year after mastectomy, chest computed tomography (CT) revealed metastatic nodules in the S3 and S9 areas of the left lung. We then performed partial resection of the lung for the metastases followed by treatment with 800 mg/day of doxifluridine for three years. The patient has had no abnormalities with signs of relapse for 13 years since resection of the lung metastasis. Additionally, recent follow-up CT and PET showed no findings suggestive of metastasis.

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A 76-year-old man attended our hospital with the chief complaint of a rapidly enlarging right axillary mass. The mass was 70 mm in diameter and could not definitively be diagnosed by fine needle aspiration biopsy. The mass was therefore removed for diagnosis. Immunohistochemical staining gave positive results for CK20, which led to a diagnosis of Merkel cell carcinoma. Extensive investigations revealed no other lesions. Thus, the mass was diagnosed as a primary right axillary lymph node Merkel cell carcinoma. Post-surgery, the patient was treated with X-ray radiation. Merkel cell carcinoma is an aggressive cutaneous malignancy, and has a high propensity for local recurrence and metastases. For our patient, 3 years and 3 months have passed since the treatments, but there is no evidence of recurrence or metastases.

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A 77-year-old man underwent a tracheal resection for the treatment of tracheal adenoid cystic carcinoma in 1992, and then received 60 Gy of prophylactic postoperative irradiation. Partial resection of the lung was required at 6 years and 8 years after the initial operation because of the appearance of solitary pulmonary metastases. Then, 14 years after resection of the primary tumor, he developed multiple liver metastases ; treatment included hepatectomy with radiofrequency ablation therapy. The patient was doing well without recurrence for 4 years after liver resection when metastases to a kidney were found. There are a few reports of patients with tracheal adenoid cystic carcinoma requiring metastasectomy. In addition, only 1 case with liver metastasis resection has been reported. Tracheal adenoid cystic carcinoma is characterized by recurrence to the distant sites a long time after the initial diagnosis. Metastasectomy for selected patients is one useful way to obtain long-term survival.

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A 59-year-old man undergone laparoscopic-assisted abdominoperineal resection of rectum for rectal cancer developed respiratory and circulatory impairment several hours after the operation. Chest and abdominal CT scans revealed herniated right lobe of the liver and small intestine into the right thoracic cavity. The herniated small intestine had dilated and showed thickening of the wall. The middle lower lobe of the right lung had been oppressed to show atelectasis and mild degree of pneumothorax was associated. From these findings, right incarcerated diaphragmatic hernia was diagnosed and emergency thoracotomy was performed. During the surgery a hernia orifice was identified at the posterolateral aspect of the right diaphragm. Right-sided Bochdalek hernia was thus diagnosed. Although the herniated small intestine dilated and was slightly edematous, no ischemic changes were seen. Without performing any resection and reconstruction, both the herniated small intestine and right hepatic lobe were returned to the abdomen and the defect at the diaphragm was reinforced by using polypropylene mesh.
Right-sided Bochdalek hernia has rarely been reported in adults, but it has been reported that there might latently be a few patients with the disease who have been asymptomatic. In this case the disease might be caused by long-sustained operations under pneumoperitoneum, and so the disease must be kept in mind as a probable postoperative complication.

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A 61-year-old woman developed lower-abdominal swelling and leg edema. On blood examination tests an iron deficiency anemia and hypoproteinemia were found. Gastrointestinal endoscopic examination showed multiple polyps throughout the stomach, and a giant tumor of clustered polyps was observed in the anterior wall of the antrum. On histopathological examination of biopsy specimens, a polyp in the lesser curvature of the stomach was diagnosed as demonstrated groupIV ; 99mTc-HAS protein-losing scintigraphy demonstrated leakage of HAS into the stomach. Gastric polyposis associated with iron deficiency anemia, protein-losing gastroenteropathy, and gastric cancer was diagnosed. Since gastric cancer was strongly suspected and it was difficult to improve the patient's anemia and hypoproteinemia with conservative management a total gastrectomy was performed. The histological diagnosis was gastric hyperplastic polyposis and gastric cancer. The patient's anemia and hypoproteinemia improved postoperatively.

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The patient, a 42-year-old woman, was admitted to our hospital because of a palpable abdominal tumor. She had no past or family history, but presented with mild anemia and a mobile child-head-sized tumor. MRI and gastrointestinal fiberscopy suggested a large submucosal tumor on the greater curvature of the upper body of the stomach. At laparotomy, the tumor was free peripherally from other organs and had no lymph-node swelling. Partial gastrectomy, including resection of the tumor, was carried out. Histological findings showed a dedifferentiated liposarcoma of the stomach. Gastric liposarcomas are very rare, and only 26 cases have been reported worldwide. Here, we describe the case history of a large abdominal tumor proven to be a gastric liposarcoma.

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A 68-year-old man was admitted to our hospital with a diagnosis of poorly differentiated adenocarcinoma of the stomach. On the 6th day after admission, he developed bleeding tendency and blood examinations showed disseminated intravascular coagulation (DIC). Tumor markers and serum alkaline phosphatase level were remarkably elevated, so we considered the most likely diagnosis to be disseminated carcinomatosis of bone marrow due to bone metastasis. Systemic bone scan could not detect any bone metastasis, but lumber MRI revealed cancer invasion to the vertebula. We diagnosed the case as bone metastases of intertravecular vertebural type. We performed chemotherapy with combination of 5-FU and MTX, followed by S-1 and paclitaxel after DIC was successfully controlled. He was discharged temporarily, but died about five months and a half after his first visit. Autopsy revealed diffuse bone marrow infiltration and metastases to the lymph nodes, liver, and spleen. MRI was more useful for diagnosis of intertrabecular vertebural metastases than bone scintigraphy in this case.

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A 28-year-old man attended our emergency department with abdominal pain and anemia. Abdominal-enhanced CT suggested gastric cancer and peritoneal bleeding, following rupture of the metastatic lymph nodes, and the patient was emergently admitted. Gastrointestinal endoscopy revealed a type 2 tumor at the posterior wall of the gastric angle. A biopsy specimen showed poorly differenciated adenocarcinoma, while immunohistochemical staining was positive for alpha-fetoprotein (AFP). The serum AFP level was 133.7ng/ml. Abdominal-enhanced CT performed as a preoperative assessment showed a defect in the superior mesenteric vein (SMV), indicating portal tumor thrombus. Total gastrectomy, splenectomy, D2 lympadenectomy, and removal of the tumor thrombus were performed. AFP-producing gastric cancer, T2(MP)N3aM1(OTH)H0 P0, stageIV, was pathologically diagnosed. The patient underwent adjuvant chemotherapy with S-1. After 1 year, there was no evidence of recurrence. Here, we present the case history and definitive surgery of this rare case of AFP-producing gastric cancer with portal tumor thrombus, which was accompanied by rupture of the metastatic lymph nodes.

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A 63-year-old man complaining of recent epigastralgia consulted a gastroenterologist and the gastroduodenal endoscopy revealed an extensive and circumferential, flat-type villous adenomatous lesion in the upper half of the duodenum ; from the pylorus down to 2 cm above the Papilla Vateri. The biopsy result was adenoma. A concurrent small retrobulbar ulcer soon healed by medication. He came to us in November 2010.
Duodenal adenoma should optimally be resected surgically or totally biopsied endoscopically, because it has malignant potential like colorectal adenoma. The adenoma of this patient was very large but had no apparent malignant signs. So we resected the involved upper part of the duodenum above the Papilla Vateri, with careful dissection of the duodenum from the pancreas. This operation coincides with “pancreas-sparing duodenectomy (Nagai Ia type)” ; rarely performed on extensive benign duodenal lesions. The reconstruction was by jejunal interposition.
The exceptionally large size of this adenoma was 9.6 cm longitudinally and 5.6 cm wide. Histologically it was a tubullovillous adenoma and had no carcinomatous focus.

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A 39-year-old woman diagnosed as having familial adenomatous polyposis had a total colectomy for ascending rectal cancer (Ra, stage III) in August 2003. Based on the upper gastrointestinal endoscopy before that surgery, multiple duodenal polyps were found ; these were subsequently followed. She was transferred to our hospital in October 2007 and had an upper gastrointestinal endoscopy. Some polyps from among the multiple duodenal polyps were diagnosed as adenocarcinoma based on endoscopic and pathlogy findings. No jejunal lesions were found on intestinal endoscopy. A pancreaticoduodenectomy was performed along with a D2 lymph node dissection. Currently, 23 months after surgery, the patient is relapse-free. It is well known that familial adenomatous polyposis is often complicated by duodenal cancer, but multiple early stage, duodenal cancer lesions in a patient with familial adnomatous polyposis is rare. It is very important to do proper duodenal screenings in familial adenomatous polyposis patients.

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A 74-year-old man, who had undergone gastrectomy for a duodenal ulcer 30 years previously, was admitted to hospital with the complaint of abdominal pain. He was found to have invagination of the small intestine, and laparotomy was performed. The previous operation had been subtotal gastrectomy with retrocolic BillrothII reconstruction and a Braun's anastomosis. The Braun's anastomosis was substantially dilated, and the efferent loop jejunm was invaginated into the afferent loop jejunum through the anastomosis. We reintegrated the invagination of the jejunum, returned the dilated jejunum to a normal diameter, and created a new Braun's anastomosis. Retrograde intussusception at Braun's anastomosis is rare, but should be considered for differential diagnosis of abdominal pain in patients with a history of gastrectomy.

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A case of a 16-year-old boy, transferred to our hospital for further evaluation and therapy of recurrent right lower quadrant abdominal pain one day after discharge from another hospital. He had been conservatively treated under a diagnosis of appendicitis. A diagnosis of intussusception was made by an abdominal computed tomography with a target sign. A laparotomy demonstrated ileocolic intussusception, and an elastic mass was palpated at the invaginated cecum, so an ileocecal resection was conducted. A histologic examination demonstrated multiple small gas-filled cysts with giant cells at the submucosa and a diagnosis of pneumatosis cystoids intestinalis (PCI) was made. PCI complicated with intussusception is rare and only nine cases have been reported so far in Japan.

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We report a patient with fulminant Clostridium difficile colitis who was successfully treated by emergency total colectomy. A 78-year-old woman, who underwent a partial colectomy for colon cancer two weeks prior, developed abdominal distension without diarrhea. Abdominal CT showed diffuse thickening and dilatation of the entire colon, which is the typical in toxic megacolon. A colonoscopy revealed severe pseudo-membranous formation of the entire colon ; a positive assay for Clostridium difficile toxin in her stool was reported. A diagnosis of fulminant Clostridium difficile colitis was made, and intravenous metronidazole treatment was initiated. However as the patient's general condition was deteriorating rapidly despite antibacterial therapy, an emergency total colectomy with ileostomy was done on the 4^th hospital day. The patient quickly recovered after the operation and was discharged on the 28^th postoperative day. It is important to know that surgical treatment is the only effective modality for some fulminant Clostridium difficile colitis patients.

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A 53-year-old man presented with constipation and low abdominal pain. Abdominal computed tomography (CT) scan revealed a huge pelvic tumor 92 mm in diameter. The diagnosis of the tumor was a gastrointestinal stromal tumor (GIST) of rectum invading the prostate. First, we proposed total pelvic exenteration, but to preserve organ function, we decided to treat with neoadjuvant therapy using imatinib mesylate at a day dose of 400 mg. After 8 months, the tumor was reduced and an abdominoperineal resection with prostatectomy was performed enabling us to reconstruct the urinary tract. Although imatinib mesylate is an effective treatment against GIST, complete cure is impossible usually. We consider that neoadjuvant therapy with imatinib mesylate, which is still undergoing clinical trials, is a more effective strategy against local advanced GIST to preserve organ function and to perform a surgical resection safely.

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We report on a case of a hepatic eosinophilic granuloma due to visceral larva migrans. A 51-year-old man underwent a medical checkup in August 2009 and was found to have a liver tumor on abdominal ultrasonography. The ill-defined tumor was approximately 10 mm in diameter and was located in S2 of the liver. He was a hepatitis B carrier and a possibility of carcinoma could not be ruled out. We therefore performed laparoscopy assisted lateral segmentectomy for total biopsy after informed consent was obtained from the patient. On pathology, no carcinoma cells were seen, and a palisading granuloma was shown in the tumor. Eosinophilic granuloma due to visceral larva migrans was diagnosed, because IgE was high, 479IU/ml, and the Ascaris serum antibody level was 3+.

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A 64-year-woman was admitted due to an 8-day history of fever and right hypochondralgia. Abdominal ultrasonography and computed tomography showed a liver abscess, 12 cm in diameter, at the posterior-inferior segment of the liver. Percutaneous transhepatic abscess drainage (PTAD) was performed, and the patient's symptoms quickly improved. Subsequently, however, it was noted that the liver cyst had been identified on routine screening 3 years prior. Therefore an infected liver cyst was suspected. After PTAD the volume of discharge through the drainage catheter was 50-100 ml every day. Thus, the patient had a posterior-inferior segmentectomy of the liver 20 days after PTAD. The patient was discharged 13 days after the operation and has since been free from recurrence. PTAD is very effective in the treatment of an infected liver cyst. However, in cases such as ours PTAD alone is not always effective ; in these types of cases liver resection should be considered to achieve complete recovery.

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A 60-year-old man visited our hospital with abdominal pain. Computed tomography (CT) revealed a tumor of the caudate lobe. We performed more examinations, but could not confirm a diagnosis. We operated for the purpose of diagnosis and therapy. By resecting a portion of the tumor and performing an intraoperative frozen section examination, it became clear that the tumor was associated with the infiltration of lymphocytes and not a carcinoma. Perfoming a partial caudate lebectomy and frozen section examination again, we diagnosed malignant lymphoma. Because the tumor infiltrated the surrounding solid tissue, we considered the need for a partial resection of the inferior vena cava. Although the tumor partially remained, we finished the operation at that point because complete resection was too invasive and chemotherapy for malignant lymphoma was effective universally. Postoperative course was good and we referred the patient to the Department of Internal Medicine. Based on the diagnosis of primary malignant lymphoma of the liver, the patient was given eight courses of R-CHOP chemotherapy and had a complete remission. He was still alive with no recurrence at 24 months after the operation. We report this case with a survey of the literature.

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A 68-year-old man with hepatocellular carcinoma (HCC) was treated by laparotomy radiofrequency ablation (RFA) and taranscatheter arterial chemoembolization (TACE) repeatedly. He was admitted to our hospital complaining of a painful mass at the upper quadrant of the abdomen after TACE. The mass ruptured and discharge of pus was observed. Fistulography revealed communication between the subcutaneous abscess and the gallbladder through the fistula. There was a stone in the neck of the gallbladder. Enhanced CT showed the wall thickness and enhancement of the fundus of the gallbladder, and a soft tissue density area in the peritoneal wall adjacent to the gallbladder before TACE. Therefore we thought that in this case cholecystolithiasis caused the perforation in the gallbladder and formed a localized abscess, and ultimately the penetration into the abdominal wall. Cholecystitis worsened after TACE and formed a cholecystocutaneous fistula. We performed drainage and it healed conservatively. A cholecystocutaneous fistula is very rare and should be treated by fistulectomy and cholecysttectomy. In our case, however we could heal it conservatively by only performing drainage.

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We report a case of carcinosarcoma of the gallbladder. A 70-year-old man developed melena. A 12-cm tumor of the gallbladder which appeared to involve the transverse colon was seen under the liver bed on abdominal CT scan and lower endoscopy. The tumor was noted to be rapidly growing. With a suspected diagnosis of carcinoma of the gallbladder invading the transverse colon, an extended cholecystectomy and right hemicolectomy were performed. The tumor filled the gallbladder and expanded into the transverse colon. A definite diagnosis of true carcinosarcoma of the gallbladder was made on histology. The patient died due to a local recurrence on postoperative day 56 ; he had left the hospital postoperative day on 23. This condition is extremely rare ; only 48 cases have been reported in Japan. In this paper, we present the clinical and pathological features of carcinosarcoma of the gallbladder.

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A 67-year-old woman who had undergone right nephrectomy for renal cell carcinoma 13 years previously and thereafter experienced systemic recurrence developed cholecystitis. She was admitted to the hospital and underwent cholecystectomy because antibiotic therapy and percutaneous transhepatic gallbladder drainage failed to control cholecystitis. On pathological examination of the gallbladder, a 3.5 × 2.5 × 1.5cm tumor was incidentally identified near the gallbladder neck with the histology of clear cell carcinoma. We diagnosed the gallbladder tumor as metastasis from renal cell carcinoma. The tumor had occupied the gallbladder lumen in the vicinity of the gallbladder neck which might obstruct the cystic duct to cause cholecystitis. Gallbladder metastasis from renal cell carcinoma is comparatively rare and only 16 such cases have been reported in Japan.

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A 48-year-old man was admitted to our hospital with the chief complaint of back pain. He had a history of chronic pancreatitis, and was diagnosed with acute exacerbation. An endoscopic pancreatic duct stent placement was performed, and the symptom was relieved within a week. One month after the stent placement, abdominal-enhanced computed tomography (CT) revealed a 30-mm ring-enhanced low density mass in the pancreas head. The symptoms of pancreatitis had recurred, and therefore pancreatoduodenectomy was performed to treat the abscess in the pancreas head. The specimen showed focal necrotizing pancreatitis in the pancreas head, with marked fibrosis in the surrounding tissue. The patient was successfully treated surgically, and showed no glucose tolerance disorder for 24 months.

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In spite of recent remarkable progress in image diagnostic technology, pancreatic cancer remains a difficult disease for early detection. We report three patients who underwent curative resection for stage I pancreatic cancer.
All patients were female, ages 68, 70 and 71 years old who were referred to our hospital for an incidental pancreatic tumor detected by ultrasonography with no symptoms. Computed tomography (CT) revealed tumor enhancement in all patients. Although two patients were diagnosed with pancreatic cancer and distal pancreatectomy were performed, the other patient underwent central pancreatectomy for a suspected pancreatic neuroendocrine tumor. In all patients, the histopathological diagnosis was stage I tubular adenocarcinoma. All three patients underwent adjuvant chemotherapy with gemcitabine and remain free of disease.
Since all three patients had stage I pancreatic cancer and exhibited tumor enhancement by enhanced CT, such a study is considered useful for the diagnosis of early pancreatic cancer.

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We report a case of locally advanced pancreatic cancer with postoperative peritoneal dissemination requiring bypass surgery and TS-1 administration. A 67-year-old male complained of epigastralgia in May, 2007. Computed tomography revealed a pancreatic body cancer involving the celiac artery and splenic artery. After a distal pancreatectomy with en bloc celiac axis resection (DP-CAR) combined with portal vein resection done at the department of surgical oncology, Hokkaido University School of Medicine, adjuvant chemotherapy using gemcitabine (GEM) was started. In July 2008, peritoneal dissemination with bowel obstruction and marked ascites developed ; an ileo-ileal bypass operation and TS-1 administration effectively improved the patient's condition. In May 2009, the patient developed a duodenal obstruction ; gastrojejunostomy improved his distressful symptoms and gave the patient two months of relative comfort. Marked ascites and bowel obstruction caused by peritoneal dissemination usually adversely affect a patient's QOL. Adequate bypass surgery and chemotherapy based on the patient's wishes sometimes alleviate the pain and prolong life. Surgeons must do their utmost to help patients during their terminal illness.

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In this report we present an extremely rare case of a splenic epidermoid pancreatic cyst in a 48-year-old Japanese male with no clinical symptoms. A cystic tumor of the pancreatic tail was detected incidentally by abdominal computed tomography. Laparoscopic distal pancreatectomy with splenectomy was performed because the possibility of malignancy could not be ruled out. The pathological diagnosis was an epidermoid cyst occurring in an intrapancreatic accessory spleen. This condition is rare, but it should be considered in the differential diagnosis of cystic lesions in the pancreatic tail.

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We report a case in which a partial splenectomy was performed to remove a splenic tumor that occurred after a distal gastrectomy. The patient was a 74-year-old woman who had undergone a laparoscopy-assisted distal gastrectomy in 2006 for gastric cancer, which was pathologically identified as poorly differentiated tubular adenocarcinoma pTSMN1M0 stage Ib. Computed tomography (CT) in 2008 showed a 5-mm hypodense area at the spleen. In 2010, this area started to increase rapidly in size, growing from 13 to 22 mm. Abdominal ultrasonography revealed a hyperechoic tumor. Magnetic resonance imaging (MRI) showed a tumor with clear margins that had a low signal on T1-weighted imaging and a high signal on T2-weighted imaging. FDG PET/CT did not reveal abnormal concentrations. Hemangioma was suspected on the basis of the imaging findings, but the sudden rapid growth meant that malignancy could not be ruled out and the decision was made to perform surgery. The posterior gastric artery could not be clearly identified by CT angiography, which suggested the possibility of necrosis of the gastric remnant if the spleen was extracted. Therefore, a partial splenectomy was performed. The spleen was transected after precoagulation of the transection line using an InLine^®. Histopathologically, no malignant signs were found, and splenic hemangioma was diagnosed.

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Most extragastrointestinal stromal tumors (EGISTs) develop in the mesenterium or the omentum. EGISTs located in the anterior pararenal space are uncommon. A 74-year-old woman was found to have a mass on follow-up ultrasonography done for a previous cholecystectomy. Abdominal computed tomogram showed a well-defined, inhomogeneously enhanced, 8-cm-diameter tumor behind the stomach. T2-weighted MR imaging showed that the tumor had a heterogeneous high signal intensity with some higher signal intensity. At laparotomy, the tumor was found at the dorsal aspect of the bursa omentalis. There was no continuity between the tumor and the gastrointestinal tract. The tumor was extirpated with a safety margin. Macroscopically, the tumor was dark reddish, and hemorrhagic foci were recognized on the cut surface. Histological examinations revealed palisading elongated nuclei. Immunostaining for CD117 was positive. As a result, the tumor was diagnosed as an EGIST. Although, EGISTs should be considered in the differential diagnosis of abdominal mass lesions without connection to the gastrointestinal tract.

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A 58-year-old woman was admitted to our hospital with abdominal pain and vomiting after colonofiberscopy. Abdominal computed tomography (CT) scan showed an expansion of the stomach and enlargement of the small intestine, but not an intestinal obstruction. Ten hours later, abdominal pain increased and another abdominal CT scan showed a dilated small bowel loop and ascites. An emergency operation was performed under the diagnosis of strangulated ileus due to an internal hernia. The ileum was impacted in a defect of the left broad ligament of the uterus, and a section 70cm long was necrotized so an ileocecal resection was performed. On the eleventh day after the surgery, the patient was released from hospital. Internal hernia through the broad ligament of the uterus is rare, accounting for only 1.6% of all internal hernias. We report on our experience of an internal hernia through the broad ligament of the uterus after colonofiberscopy.

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We report three cases of postoperative chylous ascites in which the use of somatostatin analogue (octreotide) was useful.
The patient 1, a 61-year-old woman, underwent laparoscopic-assisted lymph node biopsy of paraaortic lymph node with a suspicion of malignant lymphoma. Her drainage became milky-white since the 6th postoperative day and the triglyceride (TG) level in the drainage was 3,295 mg/dl. Administration of octreotide at a dose of 300μg/day was started with a diagnosis of chylorrhea. On the second day, the use of octreotide resulted in a falloff in chyle output and the TG level was restored up to 218 mg/dl. The patient 2, an 83-year-old woman, underwent emergency operation with a diagnosis of peritonitis due to perforation of the esophagogastric junction. Chylous ascites appeared on the 6th postoperative day when the TG level was 399 mg/dl. Administration of octreotide at a dose of 200μg/day was started and the TG level was restored up to 72 mg/dl. The patient 3, a 53-year-old man, underwent total pylorus-preserving pancreatoduodenectomy for cancer of the pancreas head. On the 6th postoperative day, chylorrhea was noted and the TG level of the drainage was 399 mg/dl. The TG level was restored up to 72 mg/dl after the use of octreotide.
The early use of octreotide for postoperative chylorrhea appears to be beneficial.

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A 27-year-old man was seen at the hospital because of lower abdominal pain and vomiting lasting for more than 10 days and intesnsifying gradually. An abdominal CT scan showed multilocular tumor about 10 cm in longer diameter in the pelvic cavity. On the cranial side of the tumor, whirl pool sign was identified and the oral side small intestine had dilated. Intestinal obstruction due to small bowel volvulus was diagnosed and emergency operation was carried out. Upon laparotomy, we saw that an about 10 cm-diameter multilocular tumor arising in the small bowel mesentery had impacted in the pelvic cavity that caused volvulus of the small bowel mesentery. Partial resection of the small intestine including the tumor was performed. The histopathological diagnosis was lymphangioma of the small bowel mesentery.
Lymphangiomas of the small bowel mesentery are relatively rare. Most cases of the disease have been reported in children and few cases in adults. This paper deals with a case of lymphangioma of the small bowel mesentery in an adult who presented with ileus due to small bowel volvulus which is extremely rare.

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A 68-year-old man who was horned by his cattle and bruised the left upper quadrant of abdomen in January 2010 was seen at a hospital on that day and was diagnosed with abdominal contusion. After he returned home, abdominal pain still persisted and he was seen at our hospital on the next day. When he was seen, a 12×10 cm bulge with subcutaneous hemorrhage was noted in the left upper quadrant of abdomen. An abdominal CT scan showed a herniated small intestine to the outside of the abdominal cavity from an injured portion of the rectus abdominis. The patient was admitted to our hospital to undergo emergency operation with a diagnosis of traumatic abdominal wall hernia on the same day. When the abdomen was opened by midline incision, we identified an about 5 cm-sized defect on the abdominal wall in the left upper quadrant of abdomen, just under the subcutaneous hemorrhage, through which the upper portion of the jejunum was incarcerated. No ascites and abdominal hemorrhage were seen. Hematoma due to strangulation was noted at the small intestine mesentery, but there were no findings of necrosis. Thus the small intestine was manually returned to the abdomen without intestinal resection. The peritoneum, striated muscle, and rectus abdominis were sutured respectively, and then the abdomen was closed. The postoperative course was uneventful and the patient was discharged from the hospital on the 15th postoperative day.
We describe this case of traumatic abdominal wall hernia caused by a cattle's horn in which abdominal CT was useful in diagnosis.

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An 86-year-old woman had a laparoscopic right colectomy. She complained of abdominal pain in the evening, of the day that the drain (an 8-mm drain had been inserted in the 5-mm port hole.) had been removed in the morning. Computed tomography showed that the jejunum had prolapsed into the hypodermis. Emergency surgery was performed. When the drain hole was extended and the hypodermis was exfoliated, the intestinal tract was found to be strangulated. By opening the fascia and releasing the strangulation, an excision of the intestine was not required. Three causative factors were considered : 1) the patient's advanced age and related abdominal wall weakness ; 2) injury to the fascia that occurred when a port fell out and was reinserted without a sheath and ; 3) the extent of damage to the fascia was extended when an 8-mm drain was inserted into the 5-mm port hole. When the diagnosis is delayed in such patients, the risk of intestinal necrosis and bowel resection increases. A hernia can also occur through the 5-mm port hole ; when examining the patient, this possibility should be borne in mind.

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A case study of woman in 70's who had chemotherapy (UFT+PSK) after the resection of rectal cancer (Ra, type2, SS, N0, H0, P0, M0, StageII). Computed tomography (CT) scans at 6 months postoperative showed several nodes up to 16 mm in mesentery. These nodes continued to grow until 1 year postoperative, and diffusion MRI, 6 months after the operation, showed a high intensity lesion in the mesentery. So the patient was suspected of having peritoneal dissemination of rectal cancer, and a laparotomy was performed. The histopathological diagnosis was mesenteric panniculitis. We describe a case report of mesenteric panniculitis that was difficult to differentiate from peritoneal dissemination.

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The case of a 67-year-old man with a 2-year history of bloating for which he had not sought treatment is reported. The patient visited our hoslital with a chief complaint of coughing. CT and MRI showed a giant tumor, 35 cm in size, in the peritoneal cavity, and retroperitoneal liposarcoma was suspected. The tumor occupied an extensive part of the peritoneal cavity and had displaced both ureters, the abdominal aorta, inferior vena cava, and the left common iliac artery and vein to the right. Abdominal angiography showed displacement to the right of the abdominal aorta and the left common iliac artery, as well as the presence of a feeding artery from the bifurcation of the left external iliac artery and the left internal iliac artery. Bilateral ureteral stents were inserted, and surgery was performed. Lapartomy showed that the tumor had ventrally displaced and adhered to the left common iliac artery and vein, as well as the left external iliac artery and vein, but it was resectable. The tumor was 40 cm × 40 cm × 27 cm and weighed 20.5kg. Based on the intraoperative findings, the tumor was thought to have originated in fat tissue around the left external iliac artery. The histopathological diagnosis was well-differentiated liposarcoma. The present case is described because of the rarity of reported cases of resected retroperitoneal liposarcomas exceeding 20kg.

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Gastrointestinal metastases of osteosarcomas, especially those metastasizing to the duodenum, are very rare. Here, we report a case of duodenal metastasis of an osteosarcoma, in which symptoms of bleeding and stenosis were treated by gastrojejunostomy and radiation therapy. The patient was a 36-year-old man who had been treated for osteosarcoma of the right femur. Wide resection for the primary tumor was performed after preoperative chemotherapy. For lung metastatic tumors, partial lung resection and radiation therapy were performed. Six years after surgery, a 6-cm duodenal metastatic tumor was detected, and the patient was anemic because of tumor bleeding and duodenal obstruction. To reduce these symptoms, irradiation with 30 Gy X-rays, and a gastrojejunostomy bypass were performed. As a result, the bleeding was controlled and the patient was able to resume oral intake ; moreover, the tumor size was reduced by 45%. These findings indicated the requirement for palliative and comprehensive tumor management of cancer patients at the terminal stage, in order to improve the quality of life.

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Neurofibromatosis type 1 (NF1) is an autosomal dominant disorder. Individuals with NF1 are acknowledged to be at increased risk of malignancy, but the complication of epithelial tumors is relatively uncommon. Here, we report a rare case of breast cancer and pheochromocytoma associated with NF1. A 48-year-old woman was brought to the hospital because of left breast pain. She had a lump in the lower outer quadrant of the left breast, and multiple café au lait spots and soft tumors in the skin of the whole body. Aspiration cytology revealed breast cancer. Preoperative abdominal computed tomography revealed a left adrenal tumor. Endocrinous laboratory data and a 131-I-MIBG scintigram offered a diagnosis of left adrenal pheochromocytoma. The patient was diagnosed as having left breast cancer and left adrenal pheochromocytoma with NF1. We performed a laparoscopic left adrenalectomy for pheochromocytoma, followed by a left radical mastectomy for breast cancer. Here, we present the case report and a review of the literature.

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