Background : Recently, therapies targeting the biological characteristics of individual cancers have become available based on markers indicating its molecular biological mechanism. Coreneedle biopsy (CNB) is widely conducted not only to diagnose, but also to determine a therapeutic strategy for breast cancer. Although its diagnostic accuracy has already reached an acceptably high level, false-negative results have occasionally been encountered.
Methods : The results of adjunctive imprint cytology (AIC) that coincided with CNB results in 1,114 patients who were suspected to have breast cancer was retrospectively reviewed. The feasibility and clinical usefulness of SIC assisted diagnosis was then analyzed.
Results : By CNB alone 567 cases were diagnosed as not malignant. Twenty of the 567 cases (1.8%) were suspected as malignant by cytological review of AIC, and 18 of them were confirmed to have breast cancer by additional biopsy. The combination of CNB with AIC accomplished a sensitivity of 100% (567/567) and a specificity of 99.6% (545/547). Small lesions, and large noninvasive- or scirrhous-type carcinomas were the common features of the CNB-negative/ AIC-positive cases.
Conclusions : Adjunctive imprint cytology is a simple and easy procedure to assist in the pathological diagnosis of breast cancer by CNB and therefore, a possible novel standard method.

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Background : Sentinel lymph node biopsy (SNB) more accurately detects micrometastases (N1mi) and isolated tumor cells (N0(i+)) than conventional axillary dissection. However, their prognostic values, as well as the necessity of follow-up axillary surgery in such cases, are still uncertain. This study was done to answer these clinical questions ; patients with N1mi and N0(i+) were enrolled.
Methods : 1,177 breast cancer patients who were clinically node-negative received SNB between January 2001 and March 2011. Among these patients, a total of 81 patients with N1mi and N0(i+) was retrospectively assigned to either SNB alone (SNB group : 28 patients) or SNB followed by axillary dissection (ALND group : 53 patients). Clinicopathological features and long-term outcomes of these groups were compared.
Results : At a median follow-up of 5.6 years, there were no instances of axillary recurrence in either group. The five-year disease-free survival (DFS) rates were 86.8% and 82.8% in the ALND group and the SNB group, respectively ; the overall survival (OS) rates were 94.7% and 100% in the ALND group and the SNB group, respectively. There were no significant differences in DFS and OS between the two groups.
Conclusion : Our present study suggests that axillary dissection might be avoided in the carefully selected patients with micrometastases.

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The proportion of bilateral primary breast cancer among all breast cancer patients has been increasing because new diagnostic imaging and treatments for breast cancer have been developed. We analyzed the clinicopathological features of bilateral primary breast cancer patients in our hospital. There were 1,250 primary breast cancer patients who underwent surgery at our hospital between 1997 to 2009. Of these patients, 32 patients had bilateral primary breast cancer ; and of those, 21 patients had synchronous bilateral primary breast cancer and 11 patients had metacchronous. The average age at diagnosis of breast cancer was 47.5 years for first metachronous cancer, which is significantly younger than that of synchronous cancer which was, 61 years (P=0.004).
Although second metachronous primary cancer involved human epidermal growth factor receptor type 2 (HER-2) positive lesion in 45% of them, metachronous breast cancer had a better prognosis than that of synchronous cancer. Both early detection by diagnostic imaging and adjuvant therapy with Trastuzumab for HER-2 positive breast cancer might be expected to improve the prognosis of metachronous primary breast cancer.

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We report our hospital's treatment strategy for left-sided, obstructive colorectal cancer, which involves preoperative metallic stent placement followed by single-stage elective surgery. Subjects : A total of 49 patients was treated between July 2006 and October 2011. The subjects included 24 men and 25 women, with an age range of 51 to 86 years. Results : Stent placement was performed due to ileus in 41 patients and detection of severe stenosis on endoscopy in 6 patients. The placement site was the transverse colon (n=3), descending colon (n=9), sigmoid colon (n=27), or rectum (n=10). Stent placement was successful in 45 of 49 patients (91.8%). In three of the patients for whom stent placement was successful, emergency surgery was performed due to poor stent location (n=1), perforation following stent placement (n=1), or stent occlusion (n=1). Excluding these patients, stent placement was effective for 42 of the 49 patients (85.7%). Patients with successful stent placement were able to resume eating. In addition, the proximal end of the stenosed area was preoperatively located using an enema or endoscopy. The mean number of days to surgery was 11.7 days in cases of ileus and 8.5 days in cases of severe stenosis. The depth of cancer invasion was A/SS (n=26), SE (n=14), or S1 (n=9), while the stage of progression was stage II (n=17), IIIa or IIIb (n=13), or IV (n=19). Single-stage elective surgery was performed for 39 of the 42 patients for whom stent decompression was effective (92.9%). Conclusion : Metallic stent placement was associated with a favorable quality of life in patients following decompression or placement.

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Hyperparathyroidism during pregnancy is very rare but is associated with high rates of miscarriage, stillbirth, premature birth and neonatal tetany. A 38-year-old woman developed a slight fever and felt unwell ; hypercalcemia with an elevated intact PTH was detected. She was diagnosed as having primary hyperparathyroidism induced by parathyroid hyperplasia ; tumor involving both lower parathyroid glands was detected on ultrasonography and ^99mTc-MIBI scintigraphy. The patient refused immediate surgery. Then, 21 months later, in the 24th week of pregnancy, she underwent total parathyroidectomy with intramuscular autotransplantation of parathyroid tissue and safely gave birth to a baby girl 4 months later ; currently, the patient and her daughter are both healthy with normal serum calcium levels 16 months postoperatively. In pregnant women the serum calcium level is usually at the lower limit. Therefore primary hyperparathyroidism should be considered in pregnant women with hypercalcemia. Surgery is safe to do in the second trimester of pregnancy.

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The patient 1, a 46-year-old female who had noticed a lump in her right breast more than one year earlier visited our clinic in May 2010. On physical examination, a 10 × 7.0 cm firm irregular mass in the upper outer quadrant of the right breast and a lymph node 2.0 cm in size in the right axilla were palpable. The tumor was diagnosed as solid-tubular carcinoma by a core needle biopsy. After neoadjuvant chemotherapy (FEC and gemcitabine + paclitaxel), the patient underwent modified radical mastectomy with axillary lymph node dissection in November 2010. The patient 2, a 67-year-old female who had noticed a lump in her right breast about one year earlier visited our clinic in June 2010. On physical examination, a 1.8 × 1.7 cm firm irregular mass in the upper inner quadrant of the right breast was palpable. The tumor was diagnosed as solid-tubular carcinoma by a core needle biopsy. The patient underwent breast conserving surgery and sentinel lymph node biopsy in July 2010. In histopathological examinations of the resected specimens from both cases, the tumor cells proliferated with rosette formation in a solid nest. Grimelius silver stain demonstrated numerous argyrophillic granules in the tumor cells. Immunohistochemically, the tumor cells were positive for chromogranin A, synaptophysin and CEA. Electron microscopy revealed numerous neurosecretory granules. Eventually, the tumor was diagnosed as atypical carcinoid of the breast by the tumor cell pattern and the characteristics of the nuclei. To our knowledge, 33 cases of carcinoid of the breast including our cases have been reported in Japan since 1982. These are the seventh and eighth cases of atypical carcinoid o the breast.

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A 53-year-old woman visited our hospital with a chief complaint of a mass in her left breast. A relatively well-defined mass shadow, 15 mm in size, was detected in the upper outer quadrant of the left breast on mammography and breast ultrasonography, and findings on color Doppler imaging, contrast-enhanced computed tomography, and contrast-enhanced magnetic resonance imaging indicated a very large amount of blood flow within the tumor. On cytology, no assessment could be made because the mass consisted primarily of blood components, with few epithelial components. Based on the above findings, the patient was considered likely to have a vascular tumor of the breast, and lumpectomy was performed. Based on the postoperative pathological findings, the tumor was diagnosed as a capillary hemangioma of the breast. Capillary hemangioma of the breast lacks characteristic findings on mammography and ultrasonography, and tests that enable assessment of intratumoral blood flow are considered useful for differentiating it from breast cancer. Moreover, differential diagnosis between breast hemangioma and angiosarcoma cannot be definitively made with percutaneous needle biopsy or incisional biopsy. Therefore, in cases in which vascular tumors are suspected on preoperative imaging, it is important to aggressively perform tumor resection and carefully examine the entire tumor.

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We have experienced a case of a giant solitary metastatic mediastinal tumor after surgery for breast cancer which required differentiation from primary thymic cancer and responded well to therapies, with resultant long-term remission. The case involved a 65-year-old woman who had undergone surgery for left breast cancer at the age of 54. She only complained of swelling of the neck. On imaging findings, a giant solitary tumor with the maximum diameter of 9.8 cm and the longer axis of 19.6 cm, extending from the neck to the middle mediastinum was identified, but no infiltration into the surroundings and lymph node metastases were seen. There was no recurrent laryngeal or phrenic nerve palsy as well as stenosis of the large vessels or esophagus. Biopsy resulted in HER-2 positive poorly differentiated epithelial tumor. At first, primary tumor of the mediastinum was suspected, but thereafter metastatic mediastinal tumor was diagnosed based on a histologic comparison with the breast cancer. Radiation therapy followed by chemotherapy with ADDC achieved a partial remission (PR), and further change to trastuzumab from ADOC resulted in complete remission (CR). CR has been maintained as of 3 years after the initiation of the therapy.

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An 86-year-old man with a nontuberculous mycobacterial infection was re-admitted on an emergency basis to his former hospital due to a tension pneumothorax. Chest drainage was performed, but air leakage from the drainage tube continued. The patient was transferred to our hospital 5 days later. Since his general condition on admission was poor, pleurodesis was initially performed. Though pleurodesis was done four times, the air leakage from the drainage tube continued. Both sputum and pleural fluid cultures grew Mycobacterium intracellulare ; perforation of the middle lobe that had nontuberculous mycobacterial disease was suspected on CT. It was concluded that the pulmonary fistula was located at the middle lobe, and an operation was performed on the 30^th day of hospitalization. A lung fistula was seen from an incision on thoracoscopy and was closed using fibrin glue and polyglycolic acid felt. Although pneumothorax complicated by a nontuberculous mycobacterial infection is intractable, surgery should be considered in cases with a fistula detected on imaging.

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A 54-year-old man presented with an asymptomatic pulmonary nodule first detected by chest X-ray. Chest computed tomography (CT) showed a solitary mass in the S10 segment of the right lung and chest dynamic magnetic resonance imaging (MRI) showed homogeneous enhancement intensity in T2-weighted images. Examinations including bronchofiberscopy revealed no clear diagnosis. Because of the strong positive detection by [18F] fluorodeoxyglucose-positron emission tomography (FDG-PET), the tumor was removed surgically. The final diagnosis was inflammatory myofibroblastic tumor of the lung. We report this case and review the literature.

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A 78-year-old woman was seen at the hospital because of an abnormal shadow on a chest x-ray film. The chest x-ray film which was taken for a purpose of preoperative examination for early gastric cancer disclosed an abnormal shadow in the left lung. Following close exploration, adenocarcinoma of the left lower lobe of lung (cT1bN0M0, stage IA) was diagnosed and complete video-assisted left lower lobectomy (ND2a-1) was performed. During the surgery, we identified an abnormal branching of the left pulmonary artery which descended between the superior pulmonary vein and the upper bronchus to the lower lobe. We cut it after double ligature. Postoperative imaging examination confirmed that the basal pulmonary artery (A⁹) branched from the left main pulmonary artery as the first branch. It is a very rare abnormal from of branching that the left basal pulmonary artery has branched from the left main pulmonary artery, and this is the fourth case report in Japan as far as we could review.

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We report an extremely rare case of malignant peripheral nerve sheath tumor (MPNST) of the esophagus. A 64-year-old woman was found to have enlargement of the ascending aorta on a chest X-ray film taken during an annual checkup. A chest computed tomography (CT) showed a posterior mediastinal tumor, 80×75×40 mm in size and suspected to be a neurogenic tumor based on an endoscopic ultrasound-guided fine-needle aspiration biopsy. Thoracoscopic esophagectomy was performed, and reconstructed by a gastric-tube using the posterior mediastinal route. The tumor was composed of spindle cells with palisaded and steriform patterns. The tumor cells were diffusely positive for S-100 protein, but negative for c-kit, desmin, CD34, and αSMA. We diagnosed low grade esophageal MPNST because the Ki-67 index was 8%. Metastasis was not detected in the regional lymph nodes. The patient has survived for two years with no sign of recurrence. Long term prognosis of esophageal MPNST is unknown, so careful follow-up is needed in the future.

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Although laparoscopic gastropexy has recently been established as a minimally invasive technique for gastric volvulus, it is technically difficult. We report two cases of gastric volvulus that were repaired laparoscopically with two different techniques. First case was an organoaxial rotation of the stomach in a thin elderly man whose body mass index was 16. His abdominal wall was so thin that three proper locations of the abdominal skin were incised and the gastric anterior wall was sewn from outside of the abdomen through the incisions in the pneumoperitomeum condition. Threads were tied outside the abdomen and knots were buried in the incisions. The second case was an elderly woman who presented with a mesenteroaxial rotation of the stomach. The gastric anterior wall was sutured laparoscopically. The ends of threads were pulled out the abdomen using an Endoclose ^TM needle through the small skin incisions. Threads were tied outside the abdomen and knots were buried in the incisions. These techniques were superior in the following points. First, it is easier than laparoscopic suturing. Second, it provides a clear field of vision and the special relationship between the stomach, the abdominal wall and the threads can be confirmed when the threads are tied.

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A 79-year-old male who had been treated for organic mental disorder and cognitive impairment was referred because of acute epigastric pain, abdominal distention and reduction in blood pressure. He had remarkable abdominal distention, tenderness, rebound tenderness, and muscular defense all around his abdomen. Computed tomography (CT) revealed a remarkable amount of intraperitoneal free air, gastric dilatation, retention of food debris and gas in the anterior wall of the stomach. He was diagnosed with acute peritonitis due to gastric perforation caused by gastric dilatation, and therefore underwent an emergency laparotomy. The stomach was dilated and perforated. The anterior wall of the stomach was necrotic, except for part of the cardia and antrum. Total gastrectomy was performed, and he was discharged without any major trouble. Gastric necrosis and perforation due to overeating-induced gastric dilatation is uncommon.

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A 61-year-old man admitted to our hospital because of anorexia showed marked leukocytosis (54,300/μl) on laboratory data. Gastrointestinal endoscopy showed type 1 gastric cancer in the upper gastric body, and biopsy revealed poorly differentiated adenocarcinoma. Preoperative laboratory data revealed a high serum level of granulocyte-colony stimulating factor (G-CSF) (229.0pg/ml). Because of persisting bleeding from gastric cancer, the patient underwent total gastrectomy plus distal pancreatectomy with splenectomy. Local recurrence, multiple liver metastases and multiple lung metastases were detected three months after the surgery. Despite chemotherapy, the patient died on the postoperative day 177. We present this case of G-CSF-producing gastric cancer which is relatively rare, together with a review of the Japanese literature.

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An 83-year-old man, who had been treated with a proton pump inhibitor (PPI) for gastroesophageal reflux disease, was diagnosed with early gastric cancer. He received laparoscopy-assisted distal gastrectomy. The postoperative course was uneventful until he developed dysphagia on the 15th pastoperative day. Upper gastrointestinal endoscopy revealed confluent, linear and nodular elevated plaques with hyperemia and frank ulceration in the lower esophagus, and the condition was diagnosed as Grade III candida esophagitis according to the Kodsi's classification. A biopsy confirmed the diagnosis of candida esophagitis. He was treated with oral administration of miconazole, but he suddenly developed high fever with septic shock. Blood culture revealed the presence of Candida albicans. Following systemic administration of fosfluconazole for 14 days, he clinically improved and was discharged from our hospital. Suppressed cellular immunity, malignancy, diabetes mellitus and history of antibiotic usage are significant predisposing factors for the development of esophageal candidiasis. Furthermore, decrease of gastric acid secretion is also one of such predisposing factors. In this case, the decrease of gastric acid secretion and the immunocompromized state which might be created by the long-term administration of PPI and/or by the gastrectomy appear to be related to the development of esophageal candidiasis and subsequent Candida septicemia.

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The patient, a 65-year-old male, underwent total gastrectomy and Roux-en-Y (abbreviated as R-Y in the following) reconstruction for gastric cancer at the beginning of October 2010. On visiting our hospital in late November upon an onset of right upper quadrant pain after breakfast, dilatation of the afferent loop was found by abdominal CT scan. Afferent loop syndrome due to R-Y anastomotic stenosis was suspected, and in performing endoscopy it was not possible to guide to the R-Y anastomotic site. Therefore, an endoscopist was notified in advance in order to enable the performance of an intraoperative endoscopic balloon dilation, a method of treatment that was minimally invasive for the patient, and relaparotomy was conducted.
As firm adhesions, with tortuosities, of the jejunal loop and the transverse colon to the abdominal wall were found, synechiotomy was performed during which the surgeon manually advanced an oral endoscope to the R-Y anastomotic site to perform endoscopic balloon dilation for the R-Y anastomotic stenosis. No restenosis has occurred to the present, one year and six months after the operation.

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A 70-year-old man was admitted to our hospital because of anemia. Esophagogastroduodenoscopy revealed a type 2 tumor on the anterior side of the greater curvature of the gastric prepylorus. Biopsy findings suggested well differentiated tubular adenocarcinoma or papillary adenocarcinoma. Distal gastrectomy with D2 lymph node dissection was performed. The tumor of the stomach demonstrated proliferation of hyperchromatic cells in a large irregular acinous formation with rosette and pseudo-rosette structures from the mucosa to the muscularis propria, which indicated that the tumor was poorly differentiated endocrine carcinoma. On the surface of the tumor, papillary adenocarcinoma and well differentiated tubular adenocarcinoma were intermingled. Five lymph node metastases were also detected. The histopathological findings were pT2 (MP) pN2 pM0 pStage IIB (Japanese Classification of Gastric Carcinoma, the 14th Edition). Adjuvant chemotherapy was not performed. He had been doing well without any recurrence until he died of aspiration pneumonia 7 years and 3 months after the surgery. Gastric endocrine carcinoma is a rare disease that rapidly metastasizes to other organs and carries a poor prognosis. We report a patient who survived for more than 7 years after surgery for gastric endocrine carcinoma together with a review of the literature.

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A 55-year-old man was admitted to our department because of bilateral solitary pulmonary nodules. There were previous histories of undergoing total gastrectomy for gastric cancer 7 years before admission, in 2004, upper lobe segmentectomy and lower lobe wedge resection for left pulmonary metastases from gastric cancer in 2007, and the resection of right adrenal gland metastasis in 2008. The patient had been followed after one-year chemotherapy with oral TS-1 until these bilateral solitary pulmonary nodules developed in the right (S5) and in the left lung (S9) in 2010. The chemotherapy was resumed and the bilateral solitary pulmonary nodules had been observed for further one year. No apparent new metastatic nodules developed during the observation, though both nodules increased in size. Thus, we performed sequential wedge resections for these pulmonary nodules, and diagnosed as metastases from gastric cancer. No further evidence of recurrence or metastatic disease was found at his latest follow-up examinations.

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The case involved a 62-year-old woman who underwent distal gastrectomy for gastric cancer at the age of 52. She had been free from recurrence until December 2009, when she noticed right shoulder pain and general fatigue. Then, she was referred to our hospital by a nearby doctor because laboratory data showed marked elevation of serum alkaline phosphatase and coagulopathy. Bone scintigraphy showed “super bone scan”. Blood examination showed findings of DIC. We diagnosed the case with disseminated carcinomatosis of the bone marrow (DCBM) as postoperative recurrence of gastric cancer. MTX/5-FU sequential therapy was unsuccessful. She developed acute subdural hemorrhage and died at the 31st hospital day. An autopsy revealed DCBM of gastric cancer. The autopsy cases of DCBM after long postoperative survival period are rare. We report an autopsy case of DCBM, together with a review of the previous autopsy cases in the literature.

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A 74-year-old man had surgery one year prior to resect a duodenal polyp at another hospital. Follow-up upper gastrointestinal endoscopy revealed an irregular elevated lesion in the second portion of the duodenum. On pathology of a biopsy specimen a diagnosis of well differentiated adenocarcinoma was made, and the patient was admitted to our hospital. Duodenal cancer was diagnosed, and a pylorus-preserving pancreaticoduodenectomy was performed. On histopathology of the resected specimen, a well differentiated adenocarcinoma primary located in the minor duodenal papilla was diagnosed. Therefore, a primary adenocarcinoma of the minor duodenal papilla was diagnosed. Currently, the patient is alive without recurrence for 3 months since surgery. Primary adenocarcinoma of the minor duodenal papilla is rare. Thus, we report this case with a review of the literature.

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A 66-year-old Japanese woman required endoscopic removal of a sharp foreign body from the duodenum while in Indonesia. However, she continued to have a dull abdominal pain. After a month, she returned to Japan and was admitted to our hospital. On physical examination abdominal tenderness in the right lower quadrant without peritoneal irritation and a movable mass were found. A relationship between the abdominal pain and the patient's past history was considered. Abdominal plain computed tomography showed a high-density, linear object in the ileum ; the top part of the object penetrated the ileal wall and reached the mesentery. A gastrointestinal perforation and an inflammatory tumor caused by the linear foreign body were diagnosed. Based on the location and the form of the object, endoscopic removal was impossible, and a partial ileal resection was performed. The foreign body was found to be a toothpick. To diagnose gastrointestinal perforation caused by a foreign body, it is important to consider this as a possibility in the differential diagnosis of patients presenting a similar history. We report a case of gastrointestinal perforation caused by a toothpick which was diagnosed early based on the past history.

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A malnourished 78-year-old male was admitted to our hospital with a diagnosis of advanced gastric and lung cancers.
Gastroduodenoscopy also revealed a superficial esophageal cancer. Radical treatment for the malignancies was planned. However, the patient's condition worsened because of repeat episodes of aspiration pneumonia and poor nutritional intake.
Nutritional support was administered, and Stamm jejunostomy was performed. Insertion of the jejunostomy tube was uneventful ; the bowel wall was very thin, and no palpable tumor or adhesions were found in his intestine.
After the operation, he developed vomiting and abdominal pain. Ten days after surgery, abdominal contrast-enhanced CT was performed ; bowel wall thickening around the inserted jejunostomy tube was noted. A diagnosis of intussusception was made and treated non-operatively. The patient's symptoms were relieved immediately, but he subsequently developed vomiting and abdominal pain.
Radiological examination showed intussusception in the same portion of his abdomen, and an emergency operation was performed.
During surgery, a 20-cm-long intussusception distal from the tube insertion was found. It was impossible to relieve the intussusception via the Hutchinson maneuver because of the presence of a firm adhesion between the diseased bowels ; blunt dissection was needed. There were no signs of bowel injury, ischemia, or necrosis. The patient's postoperative course was uneventfull.

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A 60-year-old man visited our hospital after suddenly developing vomiting and abdominal pain that gradually worsened. He was immediately admitted after marked intestinal dilatation was seen on a plain X-ray film. The patient had no history of surgery, and a whirl sign was observed around the superior mesenteric artery on computed tomography. Since volvulus of the small intestine was suspected, emergency surgery was performed. On laparotomy, a small amount of serous ascites was observed, and the small intestine was markedly dilated throughout. Volvulus of the small intestine with a 270° anti-clockwise rotation of the mesentery was observed around the superior mesenteric artery, and ischemia was also seen. No necrosis was observed. Upon untwisting the volvulus and examining the entire small intestine, a foreign object, 4×2 cm in size, was found in the intestinal tract, approximately 10 cm proximal to the terminal ileum. The object was extracted by making an incision in the intestine and identified as a mass of seaweed. The patient was diagnosed with volvulus of the small intestine caused by obstruction due to food. The patient indicated at a later date that he had consumed a dish containing kelp two days before onset. While cases of volvulus of the small intestine are occasionally reported, there are no other reports of cases caused by obstruction due to food. We therefore report the present case, which appears to be extremely rare, with reference to the literature.

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A 22-year-old man was seen at our hospital because of the abrupt onset of lower abdominal pain. Perforation of the lower digestive organ was diagnosed from abdominal CT findings and emergency operation was performed. At surgery sigmoid colon perforation was identified and Hartmann operation was done. He had no family history, but the most likely diagnosis was the vascular type of Ehlers-Danlos syndrome (EDS), because he had had percutaneous hemorrhage, hyper-flexible joints, and translucent skin from his childhood and tissue fragility was confirmed during the operation. On the 34^th postoperative day, he suddenly developed abdominal pain and re-operation was performed on an emergency basis with a diagnosis of recurrent perforation. During surgery, a perforated site was found at the oral side of the stoma, and resection of the perforated site and transverse colostomy were done. The patient required intensive treatment after the operation but eventually recovered conservatively. Following a skin biopsy, the definite diagnosis of EDS was made by DNA studies.
EDS is an inherited disorder causing connective tissue fragility. The vascular type is a most serious type of EDS that presents dissection and/or rupture of the arteries and gastrointestinal perforation. When we encounter juvenile patients with lower gastrointestinal perforation, particular attention should be paid to physical findings by keeping a possibility of the disease in mind. Further we should not perform intestinal anastomosis because it entails a risk of inducing re-perforation.

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A 65-year-old woman, complaining of abdominal fullness, was found to have an abdominal tumor by a nearby clinic, and was referred to our hospital for further examination. Ultrasonography and magnetic resonance imaging revealed a pelvic mass, 7×5 cm in diameter, which was diagnosed as an ovarian tumor as it was adjacent to the uterus. A laparotomy demonstrated that the tumor was not arising from the ovary but from the small intestine, and was growing extraluminally with a narrow peduncle, with no invasion to the surrounding organs. We resected the tumor by partial resection of the small intestine. The tumor was immunohistochemicallly positive for KIT and was diagnosed as gastrointestinal stromal tumor of the small intestine. Although extraluminal pedunculated gastrointestinal stromal tumors of the small intestine are rare and difficult to diagnose before surgery, they remain one possible differential diagnosis for pelvic tumors.

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A 51-year-old man with a past history of cecal tuberculosis presented with abdominal pain. Computed tomography demonstrated a cystic tumor, 2 cm in diameter, beside the cecum ; blood tests showed leukocytosis. On colonoscopy done two months prior, no cystic tumors or submucosal tumors were detected. Given the differential diagnosis of cystic tumor, an ilio-cecal resection was done. The cut surface of the cecum showed an intraluminal stricture between the vermiform appendix and Bauhin's valve, mimicking a cystic tumor, although the surface of the cecum had a normal shape ; no cystic mass was seen. On microscopy, the cecal wall was found to have fibrous thickening and chronic inflammation without caseous necrosis or tubercle bacillus, suggesting old tuberculous cicatrization. In a patient with a cecal cystic tumor a pseudotumor caused by cecal tuberculosis, though rare, should be considered.

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A 67-year-old man transferred to our hospital with abdominal pain was diagnosed as having colon ileus caused by sigmoid colon cancer. After reducing the colon pressure with an ileus tube, he received a laparoscopic-assisted sigmoidectomy. On and after the eighth day after the surgery, unusual bleeding (melena, hemoperitoneum, muscle hemorrhage, and subcutaneous hemorrhage) was noted. Coagulation tests revealed exclusively prolonged APTT, normal PT, a decrease in the factor VIII, and a high titer of factor VIII inhibitor. Acquired hemophilia A was thus diagnosed. We started the therapy with factor VIII concentrates and predonizoron. On the next day, he was transferred to another hospital for hematological treatments. Thereafter administration of steroids alone and cyclosporine alone were unsuccessful and the combined therapy with cyclophosphamide and steroids achieved a partial remission. The patient was saved. Acquired hemophilia A is a rare and fatal condition of coagulopathy. When we surgens encounter a sudden onset of severe hemorrhagic tendency of unknown origin, we should consider a possibility of acquired hemophilia A.

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A 44-year-old man presented with melena and having an anal fistula associated with a 5 × 3 cm peri-anal tumor with a history of peri-anal abscess drainage three times previously. Sigmoid colon cancer was found in the colonoscopy and he was transferred to our hospital. After sigmoidectomy with lymph node dissection and local resection for the anal fistula with tumor, the sigmoid cancer was classified as stage IIIb. Histologically, both the sigmoid and anal tumors showed two virtually-identical, moderately-differentiated adenocarcinomas. We surmise that malignant sigmoid colon cells were implanted within the anal fistula, developing a metastatic focus. After systemic adjuvant chemotherapy and radiation for the anal lesion, no recurrence has been seen in 4 years 9 months of follow-up. Colorectal cancer implantation in an anal fistula is rare, so far as we know, with just 33 cases including Japanese cases reports, recorded since 1954. It should be not forgotten, however, that this is a potential complication of primary malignancy since metastatic cancer occurs in chronic/recurrent anal abscesses and peri-anal fistula.

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A 75-year-old man was admitted to our hospital for acute onset of fever and upper abdominal pain. Abdominal computed tomography (CT) revealed the presence of intraperitoneal free air and a 3 cm gas-containing lesion in segment S6 of the liver. He was diagnosed with acute peritonitis due to a ruptured liver abscess, necessitating emergency drainage under laparotomy. Clostridium perfringens (C. perfringes) were detected in the ascites. The postoperative course of the patient was uneventful without recurrence of liver abscess. The patient was discharged from hospital on the 27^th day. Although gas-containing liver abscess caused by C. perfringens is rare, it is necessary to consider the possibility of infection by this organism in cases of gas-containing lesions in the liver, because the clinical course can be fulminant and fatal. This patient was saved because he was treated shortly after the occurrence, before the involvement of coexisting hemolysis.

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A 90-year-old woman presented with high fever and appetite loss in September 2011. CT performed for the purpose of close exploration at another hospital disclosed a distended gallbladder and a tumor showing an extrahepatic extension, and then she was referred to our hospital. Abdominal contrast-enhanced CT scan and MRI showed an about 6-cm diameter tumor growing from the posterior inferior segment of the liver to extrahepatic area. The tumor had oppressed the gallbladder and the duodenum. Extrahepatic type non-B and non-C hepatocellular carcinoma was diagnosed and the tumor was resected together with a part of the liver. The histopathological diagnosis was moderately differentiated hepatocellular carcinoma with a simple nodular type. The background liver showed no cirrhosis findings. The postoperative course was uneventful and she was discharged from the hospital on independent gait on the 18^th postoperative day.
The degree of surgical invasion must thoroughly be evaluated when we indicate hepatic resection for the extremely elderly patient. If the patient's general physical condition is favorable and the indication is strictly considered, we can select surgical resection actively even for the extremely elderly patient.

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An 82-year-old woman with HBV-related hepatitis was diagnosed with extrahepatically growing hepatocellular carcinoma in the lateral segment of the liver. At the time of diagnosis, she refused medical treatment because she experienced no symptoms. However, she progressively began to exhibit fatigue and loss of appetite. A computed tomography (CT) scan showed that the tumor had increased in size and was directly invading the spleen. In addition, tumor thrombosis of the left main portal branch and intrahepatic metastases to the Spiegel lobe were seen. Although the patient's liver function was defined as ‘liver damage B’, and occupied a large part of the left hepatic lobe, we determined that the tumor, was operable. We performed an extended left lobe hepatectomy and a splenectomy. Post-operatively, we administered adjuvant hepatic intra-arterial chemotherapy for close to one year. Approximately two years after the operation, the patient is still alive and well. Only two cases of hepatocellular carcinoma with direct invasion into the spleen have been previously reported in the literature. Therefore, the current case is considered to be rare, and we report this case while also reviewing the pertinent literature.

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An 83-year-old woman seen at the hospital because of epigastralgia showed no inflammatory reaction and increases in hepatobiliary enzymes on blood examinations. Abdominal CT scan revealed a distended gallbladder and remarkable edema at the submucosal structure of the body of the gallbladder, as well as a feature in which tissues appeared to focus on the neck. Torsion of the gallbladder was diagnosed and emergency laparoscoic cholecystectomy was performed. The gallbladder was a Gross type I floating gallbladder and it was twisted counterclockwise by 180 degrees. As the neck and the Calot triangle were almost normal, we determined that an easy operation should be promised and employed single incision laparoscopic cholecystectomy by using a needle forceps to the right hypochondriac region. The operating time was 60 minutes and the patient was discharged from the hospital on the 7^th postoperative day following a satisfactory postoperative course.
There have been many reports describing that torsion of the gallbladder which affects a floating gallbladder and has a mild degree of inflammation at the neck is a good candidate for laparoscopic cholecystectomy. This paper deals with a safe and successful performance of single incision laparoscopic cholecystectomy for a case of torsion of the gallbladder in an early stage after the onset of the disease.

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We report two cases of biliary complication after percutanous transhepatic gallbladder drainage (PTGBD) followed by laparoscopic cholecystectomy (LC) for acute cholecystitis. First case : A 75-year-old woman who complained of right upper abdominal pain presented with icterus and increased transaminases. Abdominal computed tomography (CT) showed gallstones and gallbladder wall thickness and swelling. Therefore, she was diagnosed as acute moderate cholecystitis, and then PTGBD was performed. The inflammation of the gallbladder was reduced, and LC was performed 18 days after PTGBD. Second case : A 66-year-old woman presented with acute abdominal pain in her right upper lesion. She was diagnosed as acute moderate cholecystitis by abdominal CT and ultrasonography (US) which showed gallstones and gallbladder wall thickness and swelling, and then PTGBD was performed. The inflammation of the gallbladder was reduced, and LC was performed 8 days after PTGBD. In both cases, bile leakage from the drain was recognized one day after surgery. Endoscopic nasobiliary drainage (ENBD) followed by cholangiography showed bile duct injury during the PTGBD procedure. The discharge of bile juice from the drain disappeared seueral days after ENBD. After the removal of the drain, both patients were able to be discharged from hospital. We consider that, in cases where PTGBD is followed by LC, unexpected bile duct injury during PTGBD requires a greater awareness of the risk.

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The case involved a 79-year-old man who underwent laparoscopic cholecystectomy for acute cholecystitis in October 2009 and was discharged from our hospital on the seventh postoperative day after uneventful postoperative course. After discharge, he had been treated for diabetes mellitus in the department of internal medicine in our hospital until March 2011, when the patient was seen at our department because of right lateral abdominal pain. An abdominal CT scan showed an about 11-cm diameter abscess in the right lateral abdominal wall which involved a piece of metal. The metallic piece was considered to be a clip used for ligation at the previous operation from its shape. The abscess disappeared by percutaneous abscess drainage, but there was a risk of recurrence of the abscess due to the remnant clip and we determined to remove the clip. We confirmed the location of the clip by abdominal ultrasonography and removed the clip from the abdominal wall muscle layer under fluoroscopy.
We rarely encounter the abscess formation in the abdominal cavity due to a remnant clip, but no cases of abdominal wall abscess formation due to a remnant clip have been reported so far. Clips which are left after laparoscopic-assisted surgeries can cause abscess formation. It would be important to recover unnecessary escaped clips completely.

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Adenosquamous cancer originating from the liver is rare ; it constitutes only 2%-3% of all intrahepatic bile duct cancers. In this study, we report a case of adenosquamous cancer originating from the liver that was coexisted with gastric cancer.
The patient was a 71-year-old male whose chief complaint was upper abdominal pain ; he was diagnosed with early gastric cancer based on upper gastrointestinal endoscopy findings. Furthermore, a space-occupying, 6-cm tumor lesion was found in the S4 region of the liver on abdominal computed tomography (CT). As well, upper gastrointestinal endoscopy revealed three neoplastic lesions in the gastric body, all of which were diagnosed as well-differentiated adenocarcinomas based on biopsy results. Given all of these findings, the patient was diagnosed as having two cancers : early gastric cancer and intrahepatic bile duct cancer. The intrahepatic bile duct cancer was considered to be a prognostic factor and therefore it was resected first before the gastric cancer was treated when there was no postoperative recurrence of the intrahepatic bile duct cancer. A large excision of the hepatic left lobe together with the postcaval veins was done. On histopathology, an adenosquamous cancer was diagnosed.

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A 68-year-old man underwent pancreaticoduodenectomy for middle and lower extrahepatic cholangiocarcinoma in September, 2004. The histopathological diagnosis using an intraoperative frozen section revealed that cancer cells were present at the cut end of the right hepatic duct, although two additional resections of the hepatic duct were performed. Concomitant right hepatectomy was not performed because of concerns about postoperative coronary insufficiency. On pathology, cancer cells were confirmed at the epithelium of the hepatic duct on the hepatic side. A total of 50 Gy irradiation was applied around the anastomosis of the bile duct and the jejunum as adjuvant therapy. Six years later, the patient died due to sepsis caused by MRSA cholangitis and liver failure ; until that time, he had had an uneventful course without any evidence of recurrence. At autopsy, a recurrence at the anastomotic site was found. This case suggests that a patient with a positive surgical margin at the cut end of the hepatic duct can survive for a considerably long period of time when the finding is limited to the epithelial layer of the bile duct. At the same time, it is also important to note that careful long-term follow-up is necessary even in these types of patients because of the possibility of late recurrence.

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A 61-year-old man visited our hospital because of upper abdominal discomfort and refractory diabetes mellitus. Computed tomography (CT) and magnetic resonance imaging (MRI) revealed a pancreatic tumor showing a unique intraductal growth pattern through the whole pancreas and pancreatic parenchymal atrophy. Endoscopic retrograde pancreaticography showed dilatation of the main pancreatic duct filled with tumor thrombi or intraductal tumor growth. Total pancreatectomy was perfomed to achieve a radical resection. Histopathologically, atypical malignant tumor cells showed tubular and papillary growth, and slightly invaded to the pancreatic parenchyma, but were not exposed to the serosa. However, invasion to lymphatic or blood vessels was scarcely seen, and metastases to lymph nodes were not observed. The final diagnosis was pancreatic cancer T3N0M0 stage III. The tumor was immunohistochemically proven to be intraductal tubulopapillary neoplasm (ITPN) based on positive staining of mucin core protein (MUC) 1 and cytokeratin (CK)-7 and negative staining for MUC2, MUC5AC, MUC6, chromograninA, synaptophysin, and trypsin. ITPN is a relatively new concept of pancreatic neoplasms, distinct from other intraductal neoplasms of the pancreas ; pancreatic intraepithelial neoplasia (PanIN), intraductal tubular neoplasm (ITN), and intraductal papillary mucinous neoplasm (IPMN). Here we report this rare case with references to relevant literature.

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Extragenital malignant tumors rarely metastasize to the uterus, of these in Japan, metastasis from stomach cancer to the uterus is relatively common. This paper deals with our experience with metastasis of pancreatic cancer to the uterus, with some bibliographic comments. The case involved a 68-year-old woman who, in the course of cytodiagnosis of the uterine mucosa, was found to have a class V probability of cancer. She was due to undergo hysterectomy, but a blood sample revealed a high value of the tumor marker CA19-9. The gynecologist referred her to us. Upon performance of an abdominal CT scan, a low density tumor about 3cm in diameter was found in the pancreas tail and a MRI (sagittal section) revealed an about 3-cm diameter hypointense tumor in the muscle layer of the uterine tail on T2-weighted images. Suspecting pancreatic and uterine cancer, we performed excisions of the pancreatic body and tail, spleen, transverse colon, and left adrenal gland, as well as total hysterectomy. The histopathology revealed that the pancreatic tumor was invasive pancreatic ductal carcinoma (including differentiated tubular adenocarcinoma) and was neuroinvasive. The uterine tumor presented the same lesion as the pancreatic cancer, indicating that tubular adenocarcinoma had invaded extensively from the uterine mucosa to the serous membrane. Accordingly, we diagnosed the case as metastasis of the pancreatic cancer to the uterus. For adjuvant chemotherapy, gemcitabine was administered intravenously, but on the 259^th day of illness the patient passed away from lymphangiosis carcinomatosa.

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A 72-year-old woman was seen at another hospital because of abdominal distension. She was admitted to our hospital for the examination of splenomegaly and liver tumors. Abdominal computed tomography (CT) showed a heterogeneously enhanced spleen and ring-enhanced multiple liver tumors. 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) showed uptake in the spleen and liver tumors. We diagnosed a primary malignant splenic tumor with liver metastasis, and performed a splenectomy and biopsy for the liver tumor. Histopathological examination indicated hemangiosarcoma. We performed transcatheter arterial embolization (TAE) for multiple liver metastasis, and she was alive for one year with quality of life. Primary splenic hemangiosarcoma carries a poor prognosis and is rare, so that effective therapies for the disease have not been established as yet. TAE for liver matastasis may improve the prognosis.

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A 30-year-old man was admitted to our hospital because of left upper abdominal pain and left shoulder pain. One month prior, he had hurt his left lateral chest and abdomen when he fell on the ground ; however, he had not visited a hospital. Abdominal computed tomography (CT) scan on admission showed ascites throughout the abdomen, but neither injuries nor tumors of any abdominal organs were observed. Fresh blood was aspirated by abdominal paracentesis. Two days after admission, diagnostic laparotomy was performed because the abdominal pain had increased and spread. Laparoscopic findings indicated bleeding from the spleen ; therefore, a splenectomy was performed by opening the abdomen. Two parenchymal injuries were macroscopically observed on the spleen. Pathological findings did not show malignancies but only congestion and edema of the spleen ; neither malignant lymphoma nor leukemia were found on hematological examination. On the basis of these findings and the history of injury, the patient was diagnosed as having delayed splenic rupture. We report a rare case of delayed splenic rupture 1 month after injury. Despite the difficulty in making the preoperative diagnosis, diagnostic laparoscopy was very useful in this case.

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A 46-year-old woman was admitted to our hospital because of a left breast tumor. She had received adjuvant chemotherapy for advanced ovarian cancer. No obvious tumor was palpated on physical examination. Ultrasonography of the breast revealed a 10×7mm low echoic mass with heterogeneous center and microlobulated boundary. Fine needle aspiration cytology showed a suspicion of ductal carcinoma. Lumpectomy and sentinel lymph node biopsy were performed. The pathological diagnosis was mammary and axillally lymph node metastases from ovarian cancer.
Mammary metastases from ovarian cancer are rare. We report this rare case of breast metastasis from ovarian cancer, together with a brief review of the literature.

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We report a case of a lymphangioma of the jejunum which was surgically resected. The case involved a 16-year-old male who had realized a sense of abdominal distension for the past 5 years. He visited a hospital because of a 2-week history of abdominal pain and ultrasound examination revealed an abdominal tumor. He was referred to our hospital. Abdominal CT scan and MRI showed a multilocular cystic mass, about 13cm in longer diameter, without enhancement effect at the midline of the abdominal cavity and the mass had fluid-fluid level formed by high and low density components. We diagnosed the mass as mesenteric lymphangioma with repeated bleeding and performed operation. On laparotomy, the 10-cm diameter mass was found in the mesentery of the jejunum near the ligament of Treitz and was resected with a part of the jejunum close to the mass. The histopathological diagnosis was lymphangioma of the jejunal mesentery. Lymphangioma of the jejunal mesentery is relatively rare. We review 30 cases reported in Japan, including this case.

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The patient was a 57-year-old male. From August 2010, he had discomfort with urination. Enhanced computed tomography (CT) showed an intrapelvic hypervascular tumor, 10 cm in diameter. Endoscopic ultrasound (EUS) and barium enema examination indicated that there was a giant tumor extrarectum, so a surgical resection was performed. Histological diagnosis was malignant hemangiopericytoma from retroperitoneum. Malignant hemangiopericytoma often recurs, therefore strict and long term follow up is necessary after the operation.

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A 28-year-old woman visited our hospital complaining of a left inguinal subcutaneous mass, which had an enlarging tendency. Computed tomography (CT) and magnetic resonance imaging (MRI) showed a cystic mass (2.6×1.3×8.0 cm) located in the pelvic cavity and lt. inguinal canal, which was parallel to a round ligament. The mass was diagnosed as a Nuck's hydrocele, and was subsequently completely resected with a round ligament by totally extraperitoneal preperitoneal repair (TEPP). During the operation, an enlarged internal inguinal ring (internal inguinal hernia I-2) was found, and the hernia was repaired with a mesh. In general, spontaneous cure for an adult Nuck's hydrocele cannot be expected, so a surgical operation is necessary. In cases where Nuck's hydrocele expands for beyond the internal inguinal canal to the abdominal side, TEPP is very useful because of its wide field of view of the preperitoneal cavity and resection.

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A 64-year-old man was hospitalized with right lower abdominal pain and a protruding abdominal mass. Abdominal CT scan and MRI showed a large tumor occupying the entire abdomen. The tumor adhered to the appendix and part of the ileum. An operation was performed to extract the tumor and deal with the intestinal tract adhesions. The tumor was 33 cm in diameter. On histology, a mesenchymal tumor which partially infiltrated the subserous layer from the serous layer of the enteric tract was diagnosed. On immunohistology, the tumor was thought to be a gastrointestinal stromal tumor (GIST) ; it was KIT protein-positive and CD-34 protein-positive. However, extragastrointestinal stromal tumor (EGIST) was the final diagnosis because on histopathology it was thought that the tumor originated from the peritoneum. The tumor was considered to be malignant, because the tumor was large and contained many mitotic figures. This EGIST case was considered to be clinically malignant based on GIST clinical practice guidelines.

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We experienced a case of aggressive retroperitoneal synovial sarcoma. A 59-year-old man who had been suffering from occasional abdominal pain for several years visited our hospital because the pain became severe. Abdominal CT scan showed a hemorrhagic polycystic tumor 15cm in size in the left subphrenic space. Laparotomy findings showed hemorrhagic ascites and a slightly fragile retroperitoneal tumor, and tumor resection was performed. Pathological and genetic findings revealed primary retroperitoneal synovial sarcoma. During the follow-up period, extensive tumor recurrence was observed and palliative reduction surgeries were done four times, however, the patient died 20 months after the first surgery.
Primary retroperitoneal synovial sarcoma is an extremely rare tumor and carries poor prognosis. Complete surgical resection is the treatment of choice, however, the retroperitoneum has a large space and allows primary tumors to grow silently before its presentation. Thus, strategies for synovial sarcoma have yet to be established, and so we need to select optimal strategies for selected cases.

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We report a case of reduction en masse of an inguinal hernia. An 85-year-old man was admitted to our hospital complaining of right inguinal swelling and pain. He had repeated incarceration and self-reduction of a right inguinal hernia for 5 years. He tried self-reduction before admission. Computed tomography revealed a spherical shaped space containing part of the small intestine and fluid closed to the right inguinal region. We suspected strangulation of the bowel and performed an emergency operation. Laparotomy revealed a section of necrotic small intestine and bloody ascites covered with spherical shape peritoneum in the preperitoneal space. We reduced the incarceration and performed an enterectomy. Hernioplasty was achieved by the McVay method. Reduction en masse is extremely rare and only twenty cases have been reported in Japan. We should consider the possibility of reduction en masse for patients with long-term repeated incarceration and self-reduction.

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Internal hernia is a herniation of a viscus into an unusually large fossa, fovea or foramen within the body cavity, and is rare. This disease often develops into strangulated bowel obstruction, requiring emergent judgement. We experienced six surgical cases of internal hernia, from 2005 to 2011. All cases complained of intestinal obstruction symptoms, such as abdominal pain, vomiting, abdominal fullness, and subsequently underwent computed tomography (CT) scans. Three cases were diagnosed as internal hernia preoperatively based on abdominal CT. Emergent operations were carried out in five cases because of a diagnosis of strangulated intestinal obstruction.
Two cases of corrected strangulated intestine managed the hernial orifice with a laparoscopic procedure. One case required intestinal resection. It is difficult to diagnose internal hernia preoperatively. However, abdominal CT scan is useful for preoperative and immediate diagnosis of internal hernia, thereby enabling us to perform minimally invasive treatments.

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A 76-year-old man developed left inguinal pain and swelling, as well as a gait disorder and a high fever. The scrotum was the size of a volleyball ; repositioning the contents by hand was impossible. A left incarcerated inguinal hernia was diagnosed. A gastrografin enema showed that the contents included the cecum. An iliopsoas abscess seen on computed tomography (CT) was suspected as the cause of the high fever. A hernia repair and the drainage of the abscess was not done at the same time that the illiopsoas abscess was dealt with due to concerns about operation site contamination. Once the patient was under general anesthesia the contents of the hernia were found in the abdominal cavity during surgery. The posterior wall was reinforced using a direct Kugel patch. CT-guided puncture of the iliopsoas abscess was performed two weeks after the hernia operation. The high fever subsided immediately after the CT-guided puncture. To date, there has been no recurrence of the hernia or the high fever.

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