[in Japanese]

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[Methogs & Subjects] A total of 225 cases of advanced lower rectal cancer with the pathologic depth of tumor invasion of A or deeper treated by curative resection from 1990 to 2007 were enrolloed in this study examining correlations between clinicopathological features and therapeutic outcomes. [Results] The enrolled patients were 183 who underwent lateral lymph node dissection {LLD (+) group} and the remaining 42 who did not {LLD (-) group}. There were no significant differences in background factors between both groups. The rate of recurrence to the lateral lymph nodes in the LLD (+) group was 9.8% versus 14.3% in the LLD (-) group, without significant difference. A multivariate analysis of overall survivals resulted in that an independent poor prognostic factor was to omit LLD. The postoperative recurrence rate in patients with lateral lymph node metastasis was as high as 70.7% and the hematogenic metastatic rate in them was also high, 43.9%, with a significant difference. The five-year survival rate in those with lateral lymph node metastasis was as low as 29.0% versus 69.2% in those without lateral lymph node metastasis, and the overall survival rate in the former group was also significantly poor compared with the other. [Considerations] This study suggests a possibility that LLD for advanced lower rectal cancer patients can improve the prognosis compared with those without LLD. However, patients with lateral lymph node metastasis experienced postoperative metastasis in a high rate and had extremely poor prognosis, so that postoperative multi-modal therapy including radiochemotherapy should be considered to improve the therapeutic outcomes.

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A 62-year-old male underwent resection of multiple colorectal tumors. The surgical findings and pathology confirmed the final diagnosis of Stage IIIa colon cancer. Capecitabine was chosen for adjuvant chemotherapy after the operation. Day 4 after the initiation of capecitabine, the patient presented with severe physical and neurological disorders including inability to walk, confusion and general fatigue. Brain MRI revealed leukoencephalopathy. After cessation of capecitabine, the neurological symptoms gradually diminished over several days. At the same time, the abnormal MRI findings disappeared. Drug-induced leukoencephalopathy is known to be caused by various anti-neoplastic agents. However, capecitabine-induced leukoencephalopathy has not previously been reported in Japan. Considering our case and overseas reports, capecitabine induced leukoencephalopathy tends to develop within a short time. It is advisable to observe carefully whether patients present with neurological disorders for the first time upon starting capecitabine therapy.

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An 83-year-old woman who had a tumor of the left breast was introduced to the department of internal medicine, respiratory division, in our hospital because the core needle biopsy of the breast lesion revealed granulomatous findings in December 2008. Bacteriological examinations were performed to detect tubercle bacillus for treatment using antituberculous agents, however, they could not identify any causative pathogens from sputum, fine needle aspiration specimer and discharge from the breast lesion. She was referred to our department for further treatment such as tumor excision or open-biopsy. Grossly the tumor 6 cm in diameter had occupied the entire left breast and fixed to the major pectoral muscle and the anterior serratus muscle. The mobility of the tumor was poor. There was a fistula with continuous discharge from the breast lesion. US showed that its shape was irregular and indistinct. We performed core-needle biopsy for cytological screening and PCR to detect tubercle bacillus, and got no positive findings. At last we decided to start antituberculous therapy combining with isoniazid, rifampicin and ethambutol after positive results were obtained from the culture sample of sputum. Nine months after the treatment, the breast lesion was reduced obviously and its mobility became better.

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The patient was a 50-year-old woman. Screening mammography (MMG) had indicated an abnormal shadow in the right breast. A repeat MMG revealed no abnormality, but ultrasonography (US) showed a tumor in the C-region of the contralateral left breast, which was suspected to be a malignancy based on the results of fine needle aspiration cytology (FNAC). The patient was therefore referred to our hospital for complete evaluation and treatment.
She was confirmed to have breast cancer by repeat FNAC, and an enlarged lymph node was palpable in the axilla and over the collar bone. The presence of a metastatic lymph node seemed somewhat unlikely, judging from the size of the primary tumor on US. Thus, FNAC of the axillary lymph node was performed, but no metastasis was detected. After admission, left-breast-conserving surgery (lt-Bp+Ax) was performed. Histopathology revealed a glycogen-rich clear cell carcinoma, and the lymph node showed subacute necrotizing lymphadenitis.

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We experienced two cases in which breast cancer had recurred 25 or more years after the operation of breast cancer.
(Case 1) The patient is a female aged 73 years. She underwent Auchincloss operation for right breast cancer at age 47 years, and went on without recurrence, but an induration was found in her anterior chest wall 26 years after the operation. Fine-needle aspiration cytology of the induration was performed, and its malignancy was suspected. Thus, the tumor mass was surgically removed, and diagnosed as a local recurrence.
(Case 2) The patient is a female aged 65 years. She underwent Auchincloss operation for right breast cancer at age 40 years, and went on without recurrence, but lumbar pain appeared at age 65 years. Thus, she visited our Department. Bone metastasis, pleural membrane metastasis and right pleural effusion were observed on CT and bone scintigraphy, and no abnormal finding was found in other organs. Thus, this was diagnosed as the recurrence 25 years after the operation.
The recurrence 25 or more years after the operation of breast cancer is unusual. We survey them with reference to the previous reports.

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A 53-year-old man presented at our hospital with a 3.0-cm elastic hard tumor of the left breast. Mammography revealed a round, indistinct tumor shadow and ultrasonography showed a 30.6×12-mm low echoic lesion in the CD region of the left breast.
Histological examination of a core needle biopsy specimen revealed massive necrosis and suspected invasive ductal carcinoma that was later confirmed by immunohistochemical assessment.
The patient was treated by left mastectomy with dissection of the left axillary lymph nodes. Postoperative histological assessment of the resected material revealed massive infarction in the center of the tumor. A few invasive ductal carcinoma cells were viable around the area of infracted necrosis. The nuclear grade was 1 and lymph node metastasis was absent. Estrogen and progesterone receptors were positive, and the HER-2 score was 0. The patient was discharged on postoperative day 10 and has since shown no signs of recurrence.

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A 20-year-old man who had no previous history was seen at our emergency clinic because of the sudden onset of left chest pain at rest. A chest x-ray showed mild left pulmonary collapse and pneumopericardium. A chest CT scan showed left pneumothorax, pneumopericardium, and a partial defect of the left pericardium at the left hilus of the lung. The diagnosis of left partial defect of the pericardium and left spontaneous pneumothorax was made and thoracoscopic-assisted operation was performed. Intraoperatively, a 4×3cm partial defect and bullae were noted. Bullae were resected without performing any treatment such as repair for the pericardial defect. The postoperative course was uneventful and the patient was discharged seven days after the operation. In the treatment of pneumothorax associated with pneumopericardium, congenital pericardial defect must be kept in mind as a differential diagnosis, though it is rare. Some treatments including repair are required in a patient at a high risk of developing cardiac hernia, but observation of the clinical course can be the treatment of choice according to the degree of symptoms or the size of the defect.

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The patient was a 74-year-old man who underwent surgery for esophageal cancer. He developed bilateral pneumothorax, mediastinal emphysema, subcutaneous emphysema and severe pneumoperitoneum, as revealed by examination, and was hospitalized. The peritoneal irritation sign was not present and there was no inflammation. We judged indications for emergency surgery to be absent. We conducted chest drainage and administered antibiotics, together with follow up. Lung expansion was good. However, two weeks passed and air leakage persisted, with CT showing a bulla in the middle lobe. Thus, surgery was indicated. The bulla seen on CT was resected. In the diaphragm vicinity, we were able to confirm a gastric tube without adhesion to the circumference. It was thought that these findings had resulted from the air which came from the right spontaneous pneumothorax via the gastric tube circumference, which then entered the abdominal cavity, mediastinum and contralateral pleural cavity. We discussion this case herein.

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The patient was a man in 50s. He complained of weight loss, and consulted a doctor. An endoscopic examination revealed advanced gastric cancer which invaded the esophagus. The patient was referred to our hospital. Abdominal computed tomography revealed multiple swollen regional lymph nodes, including para-aortic lymph nodes. This findings suggested metastases. We performed a total gastrectomy with para-aortic lymph node dissection. The number of dissected lymph nodes was 91, and metastases were identified in 22 including 11 positive lymph nodes out of 36 dissected para-aortic lymph nodes. This patient has been doing well for 7 year since D3 dissection with no signs of reccurence, though he refused adjuvant chemotherapy. We report herein a rare case of multiple para-aortic lymph node metastases who achieved 7 year survival after D3 dissection, with a review of the literature.

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A 66-year-old man was being treated for bronchial asthma since May, 2001. In September, 2008 he developed numbness of his limbs, muscular fatigue and a decrease in appetite. He was found to have an eosinophilia and was diagnosed as having Churg-Strauss syndrome (CSS) in November. He developed abdominal pain in April, 2009 while on maintenance steroid therapy. X-ray and computed tomography showed intraperitoneal free air, necessitating emergency surgery for perforation of the GI tract. At surgery a small intestinal perforation was noted 90 cm to the terminal ileum ; a partial intestinal resection was done. We report a CSS patient who developed a small intestinal perforation.

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We report a case of gastrointestinal stromal tumor (GIST) of the small intestine presented with shock due to massive hemoperitoneum. A 70-year-old man was in a shock state when he arrived at our hospital. He went to another clinic because of sudden abdominal pain and syncope, and was moved to this hospital. Abdominal CT showed a 10-cm-sized tumor with extravasation in the lower abdomen and fluid in the abdominal cavity. We diagnosed the massive hemoperitoneum due to the rupture of an intrapelvic tumor, and performed an emergency operation. Laparotomy revealed a hemispherical mass of the small intestine (10 cm in diameter), and an outgrowing mass in the ileum at about 120 cm distant form the Treitz's ligament. We performed a partial resection of the small intestine. The size was 10×9×5 cm. H-E staining showed proliferation with spindle shaped cells. Immunohistochemical stainings showed positive responses to c-kit and CD34. Mitotic Index was 39/50HPF. So we made the definite diagnosis of GIST of small intestine, high risk group. Now the patient is in good condition without metastasis or recurrence.

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We describe our experience with a case of intestinal metastasis of breast cancer. A 71-year-old woman who had undergone wide tumor excision and sentinel lymph node biopsy for left breast cancer in August 2002 was admitted to our hospital because of abdominal pain and vomiting. Abdominal computed tomography (CT) revealed intestinal stasis only. The patient was treated with non-surgical management, but did not respond. On day 9, abdominal multidetector-row CT (MDCT) was performed, showing intestinal stasis and stenosis. On day 10, a partial resection of the intestine was performed, revealing a diagnosis of primary intestinal carcinoma or intestinal metastasis of breast cancer. The pathological diagnosis was an intestinal metastasis of the breast cancer. Her postoperative course was uneventful.

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We report a patient with solitary small intestinal metastasis of rectal cancer at six years after rectosigmoidectomy. The patient was a 74-year-old man who received laparoscopy-assisted low anterior resection with grade 3 lymphadectomy in September 2003. In September 2009, follow-up computed tomography (CT) revealed a small mass lesion in the pelvic cavity near the anastomosis. In January 2010, PET-CT showed the mass was enlarged 20 mm in size and detected another lesion in front of the sacrum. CEA increased up to 16.1 ng/ml. He was diagnosed with pelvic lymph node metastasis and recived chemo-radiation therapy. CT revealed that the masses got smaller, and no metastasis of other organs was detected. CEA decreased to 4.0 ng/ml. In April 2010, ileo-cecal resection and Halltoman's operation were performed. Pathological examination revealed well-moderately differentiated adenocarcinoma mainly in the sub-mucosal layer, which was similar to the prior rectal adenocarcinoma specimen. Finally, this small intestinal lesion was diagnosed as metastasis of the rectal carcinoma. No recurrent lesion was detected on the anastomosis by laparoscopy-assisted low anteriol resection.

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Case 1 : A 77-year-old woman with right lower abdominal pain was found to have acute appendicitis with an abscess. An ileocecal resection was performed. Histopathological examination revealed a goblet cell carcinoid with adenocarcinoma of the appendix and lymph node metastasis of the carcinoid. Case 2 : A 59-year-old woman with lower abdominal pain came to the hospital. An appendectomy was performed based on a diagnosis of acute appendicitis. Histopathological examination revealed a goblet cell carcinoid of the appendix. Because of serosal invasion, a right hemicolectomy with D3 dissection was added. We present these two cases together with a review of the literature.

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We report a rare case of metachronous mucinous cystadenoma of the appendix that occured after the resection of an inguinal canal mucinous tumor. A 67-year-old male was found to have a mucinous tumor in the right inguinal canal. On histopathology, the tumor was suspected to be a pseudomyxoma or a mesothelioma, but an exact diagnosis could not be made. Seven months later, he was found to have a cystic tumor of the appendix ; it was successfully resected. The tumor was diagnosed as a mucinous cystadenoma. Mucinous cystadenoma of the appendix can cause pseudomyxoma peritonei ; therefore, it should be resected as soon as possible. Patients with a mucinous tumor involving any of the tissues derived from the peritoneum should be followed postoperatively so as not to miss the development of other mucinous cystic tumors.

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Gastrointestinal perforation is a possible, though rare, serious adverse effect of bevacizumab. We report a case in which multiple colonic perforations occurred four months after cessation of bevacizumab administration. A 62-year-old man underwent right hemi-colectomy for ascending colon cancer with multiple lung metastases and para-aortic lymph node metastases. Chemotherapy was started after the operation. Bevacizumab/FOLFIRI was given as second-line therapy, after FOLFOX4 as first-line therapy. The chemotherapy regimen was changed to cetuximab/CPT-11 after progression of the cancer. Multiple colonic perforations occurred on the 133rd day after cessation of bevacizumab administration, resulting in subtotal resection of the remaining colon. In the resected specimen, histopathological findings included vasculitis and thrombi in arterioles, venules and capillaries. Bevacizumab was highly suspected to have caused the colonic perforations seen in this case. This case highlights the possibility of colonic perforation occurring long after cessation of bevacizumab administration.

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This paper deals with a case of metastasis of a renal cell carcinoma to the ascending colon. The patient was a 66-year-old man who had undergone a left nephrectomy for renal cell carcinoma 3 years prior. He was admitted due to hematochezia and dizziness. The CT scan revealed a mass lesion with enhancement located at the ascending colon, enlargement of the right adrenal gland, and tiny tubercl shadows in the lungs. On colonoscopy, a soft and elevated hemicircular lesion was found in the ascending colon. The differential diagnosis included renal cancer metastasis or a mesenchymal tumor ; a definitive diagnosis could not be made based on the biopsy specimen. The patient developed hematochezia related to the tumor ; a laparoscopic-assisted right hemicolectomy was done. A renal cancer colonic metastasis was diagnosed based on pathology. Four months after the operation, multiple lung metastases, and metastasis to the right adrenal gland and pancreatic tail were found. The patient was given interferon-α and sunitinib and survived for four years. Renal cancer colonic metastasis of is relatively rare. We report this case and review the relevant literature.

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A 19-year-old male was admitted due to an abdominal tumor with tenderness. Abdominal CT showed a thickened wall of the ascending colon. Abdominal US showed findings like a Target sign. He underwent an emergency operation under a diagnosis of intestinal intussusception. He received a right hemicolorectomy because the abdominal tumor was diagnosed as ascending colon cancer based upon the intraoperative findings.
The histopathological findings revealed the tumor as signet ring cell carcinoma of the colon.
Ahthough he received postoperative adjuvant chemotherapy, an abdominal CT showed lymph node recurrence ten months after the operation.
We found only 15 cases of signet ring cell carcinoma of colon in young patients in the Japanese literature, and that they had a high frequency of lymph node metastasis and peritoneal dissemination, while they had a low frequency of liver metastasis.
To improve the prognosis of such patients, more effective and well-established treatment is now expected.

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A 66-year-old woman was found to have sigmoid colon cancer by colonoscopy at a periodic medical checkup, and was admitted to the hospital for surgery. A biopsy resulted in well to moderately differentiated adenocarcinoma. Because local submucosa invasion was likely, laparoscopic-assisted sigmoidectomy was performed. Blood analysis performed immediately after the operation showed high serum amylase and lipase levels, 824 mg/dl and 2179 mg/dl, respectively. However, she had no back pain and an abdominal CT scan also showed no abnormal findings of the pancreas and the surroundings. Pancreatitis was unlikely. Conservative therapy by administering a protease inhibitor normalized both serum amylase and lipase levels on the second postoperative day. The histopathological diagnosis was well to moderately differentiated adenocarcinoma, tumor invasion depth of sm2, ly1, v0 and pN0. The lesion was positive for amylase staining and the tumor was thus diagnosed as amylase-producing tumor.
Although amylase-producing tumors associating with lung cancer have sometimes been reported in this country, such tumors associating with colonic cancer have not been reported so far. We present this very rare case of amylase-producing sigmoid colon cancer which was surgically resected.

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We report a patient with undifferentiated colon cancer who followed a rapidly progressing course after development of intestinal obstruction due to the cancer followed by gastrointestinal perforation.
A 90-year-old woman complaining of abdominal pain and vomiting was referred to the hospital with a suspected diagnosis of gastrointestinal perforation. An abdominal CT scan showed massive intra-abdominal free air and a tumor lesion at the ascending colon. Emergency surgery was performed ; a hard tumor was palpable in the ascending colon and an area of the colon proximal to the tumor was obstructed. An ischemic change was seen from a portion about 120 cm apart from the Treitz ligament to the ileum end, and a perforation 1 cm in diameter was identified in the cecum 5 cm proximal to the tumor. Right hemicolectomy including the ischemic small intestine and lavage with drainage were performed. The removed specimen included a 4×6 cm tumor of type 4 encircling the lumen of the ascending colon. On histopathological examinations, tumor cells comprising arypical ones dominantly proliferated in solid and honeycomb arrangement which partly exposed on the serosa, showing remarkable vascular invasion. Histologically no tubule formation and mucus production were noted, and the findings were of undifferentiated colon cancer. The patient developed general peritonitis and septicemia and died of multiple organ failure.
Undifferentiated colon cancer is extremely rare and hence this case is reported here with a review of the literature.

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We report a case of early SM colon cancer with synchronous hepatic metastases. A 71-year-old man had undergone endoscopic resection for a Type 0-I sp polyp of the sigmoid colon. The pathological diagnosis was a poorly differentiated adenocarcinoma invaded to the submucosal layer accompanied with lymphatic and venous infiltration. The vertical cut margin was positive. Abdominal CT showed a 4.0 cm tumor at the S7 segment and another 1.6 cm at S5 of the liver. Needle biopsy indicated colonic adenocarcinoma metastasis. He had a sigmoid colon resection, hepatic posterior segmentectomy and partial hepatectomy of the S5 segment. The histological examination found lymph node metastasis but no residual cancer in the sigmoid colon, and histological diagnosis of the liver was two lesions of moderately differentiated tubular adenocarcinoma. He has remained tumor-free in the 97 months after hepatic resection. We consider this case to be rare and report the case together with a review of the literature.

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We report a case of carcinoid tumor in the lower rectum of a patient with neurofibromatosis type 1. A 53-year-old man with neurofibromatosis type 1 was diagnosed with a submucosal tumor in the lower rectum at another hospital. Biopsy specimen showed a rectal carcinoid tumor. He was admitted to our hospital and had a laparoscopy assisted low anterior resection. Histopathological examination of the surgical specimen resulted in a final diagnosis of carcinoid tumor of the rectum. Periodic surveillance would be required, because neurofibromatosis type 1 frequently accompanies malignant tumors. Although it is a rare disease, it should be considered that a rectal carcinoid tumor might be complicated in a patient with neurofibromatosis type 1.

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A 42-year-old male complained of bloody stool. A colonoscopy revealed a type 2 tumor, 30 mm in diameter, 15 mm from the dentate line of the lower rectum. The biopsy showed a well differentiated adenocarcinoma. A partial intersphincteric resection with a transverse coloplasty and a transverse colostomy was performed. On pathology, a well differentiated adenocarcinoma invading into the propria muscle layer with no lymph node metastasis was diagnosed. He was discharged 21 days after surgery. A gastrographin enema performed a month after the operation showed intrapelvic leakage at a transverse coloplasty site. Although conservative therapies were administered, a gastrographin enema performed 11 months after surgery continued to show an intrapelvic fistula. Thus, surgical repair using a gluteus maximus musculocutaneous flap was performed 15 months after the first surgery. Gastrographin enema showed no intrapelvic fistula and the transverse colostomy was closed. Four years and four months after the closure of the colostomy, the patient recovered well, without any evidence of recurrence ; fecal continence was well preserved. Surgical repair using a gluteus maximus musculocutaneous flap was effective in our case.

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A 71-year-old female was admitted to our hospital for evaluation of a hepatic lesion. She had a history of chronic type C viral hepataitis and chronic myeloid lymphoma which was treated by chemotherapy without relapse for 10 years. The ultrasonography finding showed a low echoic, solid, 23×25 mm mass in segment 5 of the liver. The tumor markers associated with liver malignancy were all negative. A slight elevation of liver function enzyme and soluble serum interleukin-2 receptor levels (753U/ml) were found. On computed tomography, magnetic resonance imaging, and angiography, the tumor had well-enhanced features similar to the hepatocellular carcinoma ; an anatomical resection of the liver was performed. The tumor specimen was a yellowish, clear-bordered, and uniformly solid mass. A diagnosis of reactive lymphoid hyperplasia of the liver was made based on immunohistochemistry. Thus,the patient was appropriately treated ; she has had no recurrence for 4 years.

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A 74-year-old woman who visited a doctor regularly for hypertension, underwent abdominal ultrasonography (US) that revealed a liver tumor ; she was referred to our hospital for further evaluation. US showed a homogenous well-demarcated tumor (size, 17 mm) with low echnogenicity in the hepatic segment 2. Abdominal computed tomography (CT) showed that the marginal area of the tumor was mainly enhanced in the arterial phase, and the central area was heterogeneously enhanced in the equilibrium phase. Gadolinium ethoxybenzyl magnetic resonance imaging (Gd-EOB-MRI) revealed a tumor with low intensity in the T1-weighted image and high intensity in the fat-saturated T2-weighted image. The strong enhancement in the marginal area and slight enhancement in the central area of the tumor in the arterial phase was also revealed by MRI. 18-Fluorodeoxyglucose positron emission tomography (FDG-PET) showed no abnormal FDG uptake. The patient underwent lateral segmentectomy for possible malignant liver tumor. Intraoperative examination revealed a relatively soft grayish-white tumor. Histological findings revealed significant elastic and collagen fiber proliferation with hyalinization around sclerosed small blood vessels ; the condition was diagnosed as sclerosed hemangioma of the liver. We report this case and discuss the treatment for lesions mimicking hepatic cancer.

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An 84-year-old woman with chronic hepatitis C, who has undergone radiofrequency ablation for hepatocellular carcinoma (HCC) in the hepatic right posterior segment three times in the past 2 years, developed recurrent tumors. She has not wanted any treatment for 4 months, but she was referred to the department of surgery for a resection in order to control recurrent cholangitis due to bile duct tumor thrombus (BDT). Computed tomography (CT) showed a tumor of 7 cm in diameter and BDT causing dilation of intrahepatic bile ducts in the posterior segment and a tumor of 1 cm in diameter in the left lateral segment. CT also revealed the gallbladder located to the left side of the ligamentum teres hepatis and anomalous branches of the portal triad. On a diagnosis of a recurrence of HCC in the right posterior segment with a BDT and in the lateral segment of the right-sided round-ligament, we a performed right posterior segmentectomy, bile duct tumor thrombectomy, and partial hepatectomy in the lateral segment. The right-sided round-ligament is a rare entity comprising 0.1-1.2%, which frequently accompanies anomalies of the portal triad. For patients with HCC and BDT, the preoperative planning is essential with keeping in mind this anomaly.

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A 48-year-old female was referred to our hospital with a possible diagnosis of congenital choledocal cyst. MRI showed cystic dilatation of the hepatic ducts bilaterally and cylindrical dilatation of the extrahepatic duct. MRI also demonstrated many stones in the dilated bile ducts and the gallbladder, as well as an intrahepatic stone in segment VI of the liver. She was diagnosed as having type IV-A congenital dilatation of the bile duct with cholelithiasis. An excision of the extrahepatic bile ducts, a cholelithotomy, and a Roux-en-Y hepaticojejunostomy and jejunostomy were performed. Quantitative analysis showed that each stone consisted of more than 98% cholesterol. We report a case of type IV-A congenital dilatation of the bile duct with intrahepatic and extrahepatic cholesterol stones.

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We report a case of secondary hemocholecyst following percutaneous liver biopsy. Mirizzi syndrome was suspected based on imaging studies. A 64-year-old man developed right upper quadrant abdominal pain 7 days after liver biopsy done due to alchoholic liver injury. Computed tomography showed a swollen gallbladder and a high density mass measuring 3 cm in diameter on the day of pain onset. Ten days after the liver biopsy, magnetic resonance imaging demonstrated a stenosed common hepatic duct displaced by the swollen gallbladder and the heterogeneous parenchymal mass. The patient underwent a cholecystectomy under a diagnosis of acute cholecystitis and Mirrizi syndrome. Although the gallbladder was enlarged and filled with hemorrhagic fluid, there were no findings indicating inflammation. We diagnosed this case as secondary hemocholecyst following liver biopsy ; this is the first reported case of Mirizzi syndrome that was suspected based on imaging findings. Recently the number of hemobilia and secondary hemocholecyst cases have been increasing due to the increasing number of procedures such as liver biopsy and percutaneous transhepatic bile drainage being done. We discuss the etiology and appropriate treatment of hemocholecyst with respect to the present case.

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The patient was a 75-year-old man who had been diagnosed as having double gallbladder 18 years previously. He complained of worsening epigastralgia for one year. Abdominal CT showed the accessory gallbladder embedded within the hepatic hilus. The gallbladder lumen was filled with biliary sludge. ERCP revealed an accessory gallbladder communicating with the left hepatic duct. We performed cholecystectomy for both gallbladders. After resecting the main gallbladder, we found the accessory gallbladder between the left and right hepatic ducts. It was difficult to disrupt the adhesions between the accessory gallbladder and hepatic ducts. Therefore, we incised the gallbladder, and resected the gallbladder wall to the maximum extent possible. We found an abnormal node in the resected accessory gallbladder wall. Intraoperative rapid diagnosis revealed the node to be an adenocarcinoma. The hepatic ducts and common duct wall were hard, indicating direct invasion of the carcinoma from the accessory gallbladder. Double gallbladder occurs in about one per 4000 births. Thus, double gallbladder with adenocarcinoma is very rare. We report our patient with reference to the relevant literature.

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We report a case of intrahepatic cholangiocarcinoma (IHCC) concomitant with venous thromboembolism (VTE). A 65-year-old woman complaining of swelling and pain of the bilateral lower limbs visited another hospital. These symptoms originated from deep vein thrombosis (DVT). Laboratory examinations showed elevation of serum biliary enzymes, and a liver tumor 9 cm in diameter with dilated intrahepatic biliary ducts found on an abdominal CT. Upon further inspection in our hospital, the liver tumor was diagnosed as an IHCC with adjacent lymph node metastasis. The pulmonary embolism (PE) was detected by chest enhanced CT. An extended left hepatectomy with lymph nodes dissection was performed during the treatment for VTE, by heparin-based anticoagulant therapy and temporal placement of the inferior vena cava filter. VTE should be taken into consideration during the treatment of advanced-stage IHCC.

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We describe the case of a 65-year-old woman with minute implantation metastasis at the percutaneous transhepatic gallbladder drainage tract done for occult early gallbladder carcinoma. The patient was diagnosed as having acute cholecystitis with lithiasis and had a laparoscopic cholecystectomy 4 days after PTGBD. Histological examinations revealed adenocarcinoma within the mucosa of the resected gallbladder. Subsequently, a liver bed dissection and excision of the abdominal PTGBD tract were performed 40 days after the first operation. Histopathological findings included a minute metastatic lesion (1 mm in diameter) in the muscle layer of the abdominal tract. She is alive and well without recurrence for more than 6 years. It is possible that seeding metastasis along the PTGBD tract occurs when PTGBD is performed in patients with occult gallbladder carcinoma, even though the lesion is an early carcinoma or the PTGBD placement is brief. Thus, the PTGBD tract should be resected as soon as possible if a PTGBD catheter is placed in a patient with occult gallbladder carcinoma.

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Pancreatic neuroendocrine tumors (PNETs) have been believed to be uncommon, but the incidence of PNETs is increasing in recent years. In typical cases of PNET, it appears as a hypervascular solid tumor with the homogeneous inner part. We have experienced a case of non-functional PNET showing atypical imaging findings which was surgically resected.
The patient was a 40-year-old man who was pointed out having a 30 mm-sized pancreatic tumor on an abdominal ultrasonography at a medical checkup. The tumor was hypovascular and was associated with cystic components and calcification. FDG-PET scan showed abnormal uptake of FDG at the tumor. The most likely diagnosis was solid-pseudopapillary neoplasm (SPN) or non-functional PNET, and spleen-preserving resection of the pancreas tail and body was performed. The histopathological diagnosis was non-functional PNET.
It is still obscure why this tumor was hypovascular, but the cystic components might be caused by hemorrhage within the tumor.

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Lymphoepithelial cysts (LEC) of the pancreas are non-neoplastic cystic lesions and are not candidates for surgery if the definite diagnosis is made preoperatively. However, these lesions are often resected because the differentiation from malignant diseases such as mucin-producing neoplasm is difficult. LEC of the pancreas, especially LEC with sebaceous differentiation, is rare.
In case 1, there was a well-circumscribed cystic tumor at the body and tail of the pancreas. We performed distal pancreatectomy without gaining definitive preoperative diagnosis.
In case 2, a well-defined cystic tumor with an inner portion comprised solid components was found at the pancreas tail. Judged from our experience with case 1, LEC was suspected during the operation. Tumor enucleation was thus performed to get the diagnosis of LEC. Histopathologically, the cyst wall was lined by squamous epithelium with sebaceous glands and surrounded by lymphoid tissue in both cases. They were subsequently diagnosed as LEC of the pancreas with sebaceous differentiation.

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The most common initial symptom of pancreatic cancer is abdominal pain followed by jaundice and back pain, in this order, and pancreatic cancer rarely presents with tumor embolism-related symptoms. This time we have experienced a case of pancreatic carcinoma presented with tumor embolism of the superior mesenteric vein. The patient was a 77-year-old man who was seen at our emergency clinic because of abdominal pain and anal bleeding. He had severe epigastralgia and an ECG showed atrial fibrillation. An abdominal contrast-enhanced CT scan mainly in the arterial phase was performed with a suspected diagnosis of thrombosis of the superior mesenteric artery. The CT scan identified no causes of the symptoms. Exploratory laparotomy performed due to the severe symptoms disclosed bloody ascites, the small intestine and mesentery which changed dark-red in color, and thrombosis of the superior mesenteric vein. Resection of the small intestine, removal of the thrombus and proctostomy were performed. Pathological examination reported that findings suggestive of a tumor were found within the wall of the vein collected during the surgery. Exploration of the primary lesion detected a tumor at the transitional portion from the pancreas head to the body. The cytodiagnosis of the pancreatic duct was adenocarcinoma. Accordingly pancreatic carcinoma with tumor embolism and thrombosis of the superior mesenteric vein was diagnosed.
There have been no cases of pancreatic carcinoma presented with tumor embolism and thrombosis of the superior mesenteric vein, like in this case. This very rare case is reported here.

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We report a case of a splenic hamartoma associated with pancytopenia. A 52-year-old man was found with thrombocytopenia and splenomegaly in a health examination in Fabruary 2008 and admitted to our hospital in August 2008. Laboratory findings showed a decrease in platelet count and a slight decrease in hemoglobin level and white blood cell count. Computed Tomography (CT) • Magnetic Resonance Image (MRI) showed a splenic tumor measuring 140×120 mm with degeneration and necrosis. Owing to thrombocytopenia, we suspected a malignant tumor because of the large size relatively, and a splenectomy was performed. The resected specimen measured 200×160×110 mm, weighed 1,460 g and was almost completely occupied by the tumor. The pathological diagnosis was hamartoma of the red pulp type. After the splenectomy, pancytopenia improved. We believe that this case is one of the biggest splenic hamartoma that we could find in the previous literature.

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A 38-year-old man was admitted to the hospital because of a lower abdominal mass. He was operated on twice for Hirschsprung disease in infancy and underwent right testectomy for right undescended testis in later childhood. Serum β-HCG level was high. 3D-CT-angiography revealed the possibility that the feeding artery was the right testicular artery. But the past history denied the possibility of a testicular tumor. We operated for the abdominal tumor of unknown origin. During the operation, we found a large tumor that looked like a testis, which was covered with retroperitneum and we identified the testicular cord, the epididymis and the gubernaculums testis. The pathological examination revealed uniform pattern seminoma. He has remained in good health without recurrence 12 months after the operation. There were 10 case reports of adult abdominal seminoma, including this case, so far in Japan. However, there were no other cases after testectomy, except this case. We report this case along with an analysis of 10 other case reports.

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We report a 67-year-old female who, a year and a half prior developed epigastric pain. MRI done at the time showed multiple pelvic cystic tumors which had a low signal intensity on T1 images and a high signal intensity on T2 images. An ovarian cyst was suspected. Prior to the current hospitalization she developed epigastric pain and vomiting. Abdominal CT scan showed a stenosis of the small-intestine close to the pelvic cystic tumor. An intestinal obstruction caused by the cystic tumor was suspected, and emergency surgery was performed. On laparotomy, dark red, smooth-surfaced, elastic soft, multiple cystic tumors of the ileal mesentery were noted ; a stenosed ileum crossed the tumor. The tumor was excised along with a part of the ileum that was adherent to the tumor. On histopathology a lymphangioma of the ileal mesentery was diagnosed. Lymphangioma of the mesentery is rare in adults. We present this case with a review of the Japanese literature.

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We report a case of cystic medial necrosis with intra-abdominal bleeding due to rupture of the sigmoidal artery. Cystic medial necrosis often occurs in the great arteries and rarely involves the peripheral arteries in the abdominal cavity.
A 64-year-old woman was admitted because of sudden lower abdominal pain. Abdominal CT scan showed a hematoma about 9 cm in diameter in the mesentery of the sigmoid colon. She was diagnosed as being in shock due to intra-abdominal bleeding caused by rupture of the sigmoidal artery ; an emergency laparotomy was performed. On laparotomy, the bleeding site involving the sigmoidal artery was found, and the sigmoid colon including the mesentery was resected. On pathology cystic medial necrosis was diagnosed. The patient has since been free from recurrences.

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A 74-year-old woman was admitted to our hospital due to a retroperitoneal mass. Abdominal ultrasonography, CT and MRI demonstrated a solid tumor 8.0 cm in diameter in the dorsum of the right kidney. Since this tumor demonstrated high fluorodeoxyglucose (FDG) uptake on positron emission tomography (PET), we could not rule out the possibility of malignancy. Laparotomy was thus performed under a preoperative diagnosis of retroperitoneal tumor. The pathological diagnosis was schwannoma, with a mixed formation of Antoni types A and B. Because schwannomas are among the benign tumors showing high FDG uptake on PET, we should recognize them when making a differential diagnosis versus malignant tumors.

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An 84-year-old woman presented at our hospital with right gluteal pain and dysbasia. Abdominal computed tomography (CT) showed a pelvic abscess through the right sciatic foramen outside the pelvic cavity, and also an intestinal caucus in the pelvic floor. Emergency laparotomy showed a sciatic hernia with an abscess due to the appendix. Because of the infection, we could not repair the foramen with artificial material. A drainage tube was placed from the right lower abdomen to the foramen. The patient was discharged on foot and is doing well without evidence of recurrence. Sciatic hernia is very rare, and nobody has reported a case of sciatic hernia containing an appendix.

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Parastomal hernias are among the common late complications of colostomy. However, surgical approaches to parastomal hernia repair remain controversial. We report two cases of parastomal hernia repair with DualMesh biomaterial.
Case 1. A 67-year-old female received a Miles operation for rectal cancer and an extraperitonial sigmoid stoma was constructed. Parastomal hernia occurred and a hernia repair operation was performed. The hernia defect was present in the abdominal wall and located at the cephalad side of the stoma. We sutured the fascial defect and placed DualMash to cover the hernia defect. The distal colon and stoma were left external to the mesh.
Case 2. A 67-year-old female received a Hartmann's operation for a recto-vaginal fistula and transperitoneal colostomy was performed. The patient developed a parastomal hernia and we repaired the hernia by the same procedure as that used for the first case.
Nether case showed parastomal hernia recurrence, and we consider the parastomal hernia repair with DualMesh biomaterial to be easy and very useful.

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