Mucinous breast carcinoma is an invasive neoplasm with clusters of tumor cells floating in pools of extracellular mucin. Pure mucinous breast carcinoma needs to be differentiated from mixed mucinous breast carcinoma, also known as invasive ductal carcinoma with a mucinous component. Pure mucinous breast carcinoma can be subclassified into a hypocellular variant (type-A) and a hypercellular variant (type-B). In this study, we classified 42 cases of mucinous breast carcinoma identified in a sample of 1,041 breast carcinomas and examined the significance of the mucinous breast carcinoma subclassification. Mucinous breast carcinoma patients were more frequently hormone receptor-positive (p=0.001) and HER2 expression-negative (p=0.002) compared to non- mucinous breast carcinoma patients. The disease-free interval of mixed mucinous breast carcinoma patients was shorter than that of pure mucinous breast carcinoma patients. A multivariate logistic regression analysis showed that high nuclear grade was significantly correlated with disease-free survival (p=0.003). In this study, the mucinous breast carcinoma subclassification was found to be useful for determining appropriate treatment.

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Tubular carcinoma of the breast is a specific type of infiltrating ductal carcinoma. Our objective was to assess our experience in diagnosing tubular carcinoma of the breast and to correlate its radiologic and histopathologic features. Between 1997 and 2011, we examined 8 patients with tubular carcinoma in our department. The mean age at diagnosis was 62 years (range, 50-85 years). Mammography revealed tubular carcinoma in 7 patients (88%) as a spiculated mass or distortion. Sonography also revealed tubular carcinoma as irregularly shaped hypoechoic lesions in 7 patients (88%). One patient underwent mastectomy, and the others underwent breast-conserving therapy. Pathological analysis showed that the mean gross tumor size was 1.1 cm (range, 0.4-1.5 cm). Sentinel node biopsy was performed in 4 patients, and negative results were obtained for malignancy in all cases. ER (estrogen receptor) results were positive for all patients. All patients except one, who died of another cause, were alive and disease-free at the time of writing this report. In conclusion, most cases of tubular carcinoma can be detected by mammography, and the malignant potential of tubular carcinoma is suspected to be low.

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Despite the introduction of thoracoscopic surgery, tachyarrhythmia after esophagectomy is a common complication that cannot be neglected due to the high frequency of incidence and the severity of the impact on postoperative course. We report a study on the usefulness of a short-acting β1 selective blocker, landiolol hydrochloride, for tachyarrhythmia after thoracoscopic esophagectomy. Of the 127 patients who underwent thoracoscopic esophagectomy in the period between January 2003 to December 2011, 28 patients were treated with landiolol against postoperative tachyarrhythmia. Vital signs, the incidence of postoperative complications, and the length of postoperative hospital stay were examined retrospectively. A significant decrease in pulse rate was rapidly shown 1 hour after administration (at onset : 143.1 beats/min, 1 hour after : 117.5 beats/min, P<0.01). Pulse immediately returned to sinus rhythm in an average of 9.1±14.0 hours after administration. Neither deterioration of respiratory status nor reduction in blood pressure were observed. There were no significant differences in postoperative complications without tachyarrhythmia and the length of postoperative hospital stay compared with patients who did not develop postoperative tachyarrhythmia. In the postoperative tachyarrhythmia after thoracoscopic esophagectomy, landiolol hydrochloride is considered to be a useful drug due to its safety and ease of administration and adjustment.

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Gastric neuroendocrine carcinoma is a comparatively rare entity and accounts for 0,6% of all gastric malignancies. The classification, pathology, and treatment of the malignancy are still incompletely understood. Of a total of 2,094 cases operated on in our center from January 1994 to December 2011, eighteen cases of histopathological neuroendocrine neoplasms were reviewed. Based on the WHO classification in 2010, histopathological types of these eighteen cases were classified into neuroendocrine tumor G1 in one case, neuroendocrine tumor G2 in three cases, neuroendocrine adenocarcinoma in thirteen cases, and mixed adenoendocrine carcinoma in the remaining case. The prognosis of neuroendocrine carcinoma is poor. However, we consider that early operation can increases prolong the survival time. Even an unresectable patient survived for fifteen months by chemotherapy. Therefore we can expect the effectiveness of chemotherapy as well.

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A 59-year-old male noticed a slow growing, right breast mass. An incisional biopsy was performed and a malignancy was suspected. The patient had a total mastectomy and axillary lymph node dissection. Based on immunohistochemical staining with neuron-specific enolase, the tumor was diagnosed as a neuroendocrine carcinoma. Estrogen and progesterone receptors were positive, and HER2 was negative. Lymph node metastases were found, and vessel invasion was positive. The patient subsequently received adjuvant chemotherapy (FEC followed by docetaxel). Tamoxifen administration is ongoing.
Male breast carcinoma accounts for approximately 0.5-1.0% of all breast carcinomas ; primary breast neuroendocrine carcinomas are very rare. Furthe research based on the compilation of the data from such cases is necessary to guide treatment.

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A 47-year-old woman presented to our hospital with an acute abdomen. She had muscular guarding and tenderness throughout her abdomen, and computed tomography (CT) showed massive ascites. Diffuse peritonitis was suspected, and emergency laparotomy was performed. Laparotomy showed no gastrointestinal perforation, but yellow ascitic fluid and white, hard nodules disseminated throughout the abdominal cavity were seen. The laparotomy was only exploratory. Poorly differentiated adenocarcinoma was detected in the nodules and ascitic fluid removed during surgery, and the patient was diagnosed with carcinomatous peritonitis of unknown origin. Based on immunostaining of the peritoneal nodules, the tissue was pathologically diagnosed as being of breast cancer origin. Although no tumors were palpable in either breast, CT showed a faint shadow in the left mammary gland, and core needle biopsy of the site revealed a poorly differentiated adenocarcinoma that was pathologically similar to the peritoneal dissemination. The primary tumor was therefore identified as breast cancer.

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A 48-year-old man was admitted to our hospital with the chief complaint of left epigastralgia. Computed tomography (CT) images revealed a renal artery aneurysm (diameter, 2.8 cm) at the bifurcation of the left renal artery. Open repair was performed using median laparotomy by renal mobilization as far as possible to the center of the operative field. Both topical cooling by ice slush and cold perfusion were performed for renal protection. After clamping the renal artery and vein, the cold perfusate was irrigated with effluent from the orifice of the renal vein venotomy every 30 min. Two anterior branches and a posterior branch that were approximately 2 mm in diameter were reconstructed using 2 separate saphenous vein grafts. The renal ischemic time was 230 min because the reconstruction was complicated. His postoperative renal function decreased slightly but improved 6 months later. The renal protection method was effective. Detailed preoperative planning for reconstruction is essential in such a complex renal artery aneurysm.

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FOLFOX regimen comprised oxaliplatin, 5-FU and leucovorin has been widely used as an effective approach for treating advanced colorectal cancer. Toxicities induced by oxaliplatin have been well known and are mostly moderate and manageable. Gastrointestinal, hematological and neurosensory toxicities are the most common. However, we have only limited information concerning the pulmonary toxicity of this regimen and only few cases of severe lung toxicity associated with FOLFOX regimen have been reported. We report here a case of interstitial pneumonia which was associated with FOLFOX regimen in a patient with metastatic advanced rectal cancer. The patient was a 73-year-old man. Following high anterior resection of rectum for rectal cancer with multiple liver metastases, FOLFOX regimen was started. During the treatment, he developed dyspnea, sweating, and hypotension. Withdrawal of the regimen and administration of steroids resulted in symptomatic remission, and the patient was discharged from the hospital. On and after 4^th day after discharge, he had chill and was seen at the hospital on the 7^th day after discharge. Chest CT scan showed ground glass attenuation in the bilateral lung fields and an increase in serum KL-6 level was noted. Drug-induced interstitial pneumonia was diagnosed. Symptomatic remission was confirmed after hyperbaric oxygenation.
Although interstitial pneumonitis caused by FOLFOX regimen is infrequent, it can be a severe complication. Periodic X-ray examinations and early detection of symptoms are important.

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A 76-year-old man was admitted due to epigastralgia and right lower chest pain. He had undergone 5 sessions of percutaneous radiofrequency ablation (RFA) for hepatocellular carcinoma. Abdominal CT revealed a rupture of the right diaphragm and invagination of the transverse colon into the right thoracic cavity. The patient was found to have severe liver cirrhosis and atrophic change in the right lobe. A diaphragmatic hernia was diagnosed following percutaneous RFA. Since the pain disappeared the next day and symptoms of intestinal ischemia and ileus were not seen, elective laparoscopic surgery was scheduled. The invagination of the transverse colon was found to have been reduced by the time the operation was done. A defect of the diaphragm 6 × 3.5 cm in size that was caused by a burn due to RFA was found. It was closed by laparoscopic suturing and covered with composite mesh from the abdominal cavity side. The postoperative course was uneventful. Diaphragmatic hernia repair following RFA is rare ; only 14 cases have been reported in Japan. Laparoscopic operation appears to be a safe and useful option when the reduction of hernia contents is not difficult to accomplish.

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We report a 27-year-old patient with an esophagobronchial fistula (EBF) that developed at balloon dilatation for secondary esophageal stenosis.
The male patient, who had the 5p- syndrome and mental retardation, was referred to our institution because of difficulty in swallowing and anemia. Fluoroscopy and esophageal endoscopy revealed severe stenosis of the mid-esophagus.
Fundoplication with gastrostomy was successfully performed. Dilation for the stenosis was performed using a balloon dilator 4 weeks after the operation, followed by transient improvement. Biopsy specimens from the lower esophagus histologically demonstrated Barrett esophagus. A 24-hour pH-monitoring test demonstrated no pathologic gastroesophageal reflux.
After a fourth bougienage, his coughs deteriorated and EBF was diagnosed by esophagraphy. Stent placement to the esophageal stenosis was undertaken, followed by conservative therapy, which improved his respiratory symptoms temporarily.
However, 6 months later, we elected to perform total gastroesophageal dissociation because the fistula had recurred. After resection of the mid-lower esophagus with closure of the EBF by the use of the surrounding esophageal wall, the esophago gastric junction was dissected and an esophago jejunostomy was carried out in Roux-en-Y fashion in the thoracic cavity.
His postoperative course was uneventful except for minor anastomotic leakage, which recovered spontaneously with conservative treatment.
Five years after the operation, he is doing well.

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An 81-year-old man was admitted with a diagnosis of esophageal cancer with left bronchial invasion. He was treated with combination chemotherapy (5-FU + CDDP) on March 14, 2012. Sudden onset abdominal pain and nausea appeared on June 13, 2012. Abdominal CT showed wall thickening of the descending colon with free air and ascites. He underwent emergency surgery under a diagnosis of panperitonitis due to descending colon perforation. Intraoperatively, a 25-mm-diameter perforation was found in the descending colon. The patient required a partial resection of the descending colon and a transverse colostomy. On pathology, spontaneous perforation without specific inflammation or metastasis was diagnosed. The postoperative course was uneventful, and he was discharged on day 23 after surgery.

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A 56-year-old man, suffering from alcohol dependence and depression, ingested some strong acid detergent in a suicide attempt. He was diagnosed with gastric perforation, While he got through the acute period with conservative treatment, he recovered and was discharged on the 56^th day after the incident. But he was re-admitted on the 120^th day after the incident because of corrosive stricture in the middle part and the pylorus of the stomach. Although balloon dilation was performed 13 times, the gastric stricture was not improved. He had surgical treatment on the 306^th day after the incident. Because it was impossible to perform a gastrectomy due to severe adhesion, gastro-jejunostomy in the upper part of gastric body was performed. The postoperative course was uneventful and he was discharged on the 14^th postoperative day. Surgical treatment should be used for gastric corrosive stricture due to acid detergent.

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A 54-year-old man, who four months previously had undergone a total gastrectomy with Roux-en-Y reconstruction, developed abdominal distension and pain in the upper abdomen. Blood tests revealed elevated levels of hepatobiliary and pancreatic enzymes. Abdominal X-ray films were unremarkable. Abdominal CT scan showed a markedly dilated intestine with fluid accumulation and a small amount of ascites. The pancreas was quitet swollen. The dilated intestine was thought to be the afferent loop ; a strangulating ileus of the afferent loop of the small intestine was diagnosed. On laparotomy, a strangulation of a segment of the afferent loop was identified ; the anastomotic site was rotated 180 degrees clockwise. Manual release of the rotation quickly restored a pink tint to the strangulated intestine. Perioperative management was centered on the treatment of the patient's acute pancreatitis ; the patient was discharged having had an uneventful post operative course. Since afferent loop ileus may present without vomiting and show a gasless ileus, prompt diagnosis using CT is mandatory.

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A 78-year-old woman developed vomiting and abdominal pain. Abdominal CT scans showed an esophageal hiatal hernia with an ‘upside down stomach’. Gastrofiberscopy showed type 0-IIc gastric cancer at the esophagogastric junction. Based on these findings, the patient was diagnosed as having early gastric cancer and an esophageal hiatal hernia. She underwent a laparoscopy-assisted total gastrectomy and an esophageal hiatal hernia repair. The final diagnosis was type 0-IIc, T1bN0M0, stage IA, with residual tumor of R0. The postoperative course was uneventful. We report this case of gastric cancer and esophageal hiatal hernia complicated by an ‘upsidedown stomach’ requiring laparoscopic surgery. This is the first time such surgery was done in Japan.

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A 39-year-old woman developed anemia and tarry stools. She was diagnosed as having gastrointestinal bleeding and an intussusception along with a duodenal tumor based on abdominal CT scans, a small bowel series, and small bowel endoscopy. The patient had no abdominal pain or symptoms of intestinal obstruction. She underwent elective laparotomy. Intraoperative endoscopy revealed that the tumor (7 cm in diameter) was pedunculated and located on the opposite side of the papilla of Vater in the duodenal bulb. The tumor was diagnosed as an inflammatory fibroid polyp (IFP) on the intra-operative pathology of an open biopsy. Consequently, a duodenectomy was performed. On postoperative pathology, a proliferation of spindle-shaped cells which lacked atypia and chronic inflammation were noted. Therefore, the tumor was diagnosed as a duodenal IFP. The characteristics reported in the literature of patients with this rare duodenal IFP are also presented in this paper.

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A 42-year-old man with neurofibromatosis type 1 (NF1) who visited a hospital because of tarry stool in March 2010 was referred to our hospital because a duodenal tumor was detected by upper gastrointestinal endoscopy. Abdominal CT scan revealed a 50 × 50 × 25 mm tumor from the second to the third part of duodenum. Upper gastrointestinal endoscopy and EUS showed a 21 × 16 mm submucosal tumor with a central depression in the vicinity of the papilla of Vater at the second part of duodenum, and it was proved to be neuroendocrine tumor (NET) by a biopsy. Another submucosal tumor 51 × 31 mm in diameter was present in the third part of duodenum. Pancreaticoduodenectomy was performed in May. The histopathology resulted in NET and gastrointestinal stromal tumor (GIST). The postoperative course was uneventful. The patient was discharged from our hospital on the 19^th postoperative day and has been free from recurrence as of 2 years and 8 months after the operation.
Recently clinical cases of NF1 associated with either NET or GIST have sometimes been reported, however, there are few cases of NF1 associated with the both diseases concomitantly. We thus report this case of NF1 with NET and GIST of the duodenum, together with some bibliographic comments.

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Intussusception is a rare form of bowel obstruction in adults. However adult intussusception mostly arises from tumors of the intestine. Interstitial sarcoma is also a rare type of tumor of the breast. It mainly metastasizes hematogenously to areas such as the lung, liver, and bone. We encountered a rare case of breast interstitial sarcoma that had metastasized to the intestine and caused intussusception. The patient was a 55-year-old woman. She had undergone a mastectomy because of a rapidly growing tumor of the right breast. The pathological diagnosis of the tumor was interstitial sarcoma. Six months after the surgery, she suddenly presented with abdominal pain, nausea, and vomiting, and was brought to our hospital. CT revealed intussusception of the intestine with a jejunal tumor. On performing a laparotomy, we found that the anal side of the jejunum was invaginated into the oral side with an intestinal tumor at 30 cm from the ligament of Trietz. We first manipulated the intussusception by Hutchinson's technique, and then resected more than 15 cm of the jejunum including the tumor. Last, a jejunojejunostomy was performed. The pathological diagnosis was similar to that of the primary breast tumor, that is, interstitial sarcoma.

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A 23-year-old woman was admitted to our hospital for tumorous lesions in the abdomen. Enhanced abdominal CT scan revealed tumors with calcification at hepatoduodenal ligament and the mesentery of the jejunum. The QuantiFERON-TB Gold In-Tube test results were positive. She underwent an incisional biopsy for the mass lesion in the mesentery to confirm the diagnosis of tuberculosis by single-port laparoscopic surgery (SPLS). After adhesiolysis was performed between the tumor and the surrounding intestine, the incisional biopsy was conducted under direct vision at the umbilicus site. Then, the tumor wall was sutured laparoscopically. The biological and histopathological findings indicated mesenteric lymph node tuberculosis (MLNT) that had a score of 1 on the Gaffky scale, was PCR-positive, and was accompanied by caseous granulomas. MLNT presents a clinical dilemma for diagnosis. It generally appears to form a mass lesion that may require open surgery to confirm the diagnosis. Here we report a case in which a confirmed diagnosis of MLNT was made by SPLS. In view of the difficulty involved in total excisional biopsy of the lymph nodes, wedge resection of the cold abscess wall and suturing of the open wall should be performed to prevent Mycobacterium tuberculosis infection from disseminating to the intra-abdominal cavity.

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A 13-year-old boy visited a hospital because of vomiting and abdominal pain, but no symptomatic remission could be gained. Thereafter the patient had stools with massive fresh blood. He was seen at the department of pediatrics in our hospital and had been conservatively treated with the diagnosis of hemorrhagic enteritis. However, his tenderness came to extend to the entire abdomen and he was referred to our surgical department. On the same day we diagnosed the case as acute abdomen and performed laparoscopy that revealed a hemorrhagic lesion in the upper portion of the jejunum. We made a small laparotomy and performed partial resection of the small intestine. The resected specimen included multiple ulcers. The histopathological diagnosis was small bowel ulcer secondary to allergic purpura.
It is believed that the disease generally carries good prognosis, but sometimes it can cause massive hemorrhage when it is complicated by small bowel ulcer. Early diagnosis of the hemorrhagic site and early treatment are thus mandatory.

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The patient was a 53-year-old woman who underwent laparoscopic-assisted distal gastrectomy for a submucosal tumor of the stomach and was diagnosed as having ectopic pancreas of the stomach. Three months later dull pain developed in the entire abdomen and an abdominal CT scan revealed a tumor like abscess in the abdominal cavity. The patient's clinical course was observed while she was on oral antimicrobial therapy. The tumor became smaller and the abdominal pain subsided. The tumor was movable so that mesenteric lesion was suspected. The tumor was still decreasing in size even after discontinuation of the antimicrobial therapy. However, abdominal CT scan performed in the sixth month after the initial CT scan showed new appearance of para-aortic lymph node swelling. We performed laparotomic biopsy by bearing a possible diagnosis of malignant lymphoma in mind. The movable lesion was clarified to be the swollen mesenteric lymph node. Histopathology disclosed both mesenteric and para-aotic lymph nodes to be diffuse large B-cell lymphoma. As of 10 months after the operation when eight courses of R-CHOP therapy had completed, complete cure has been kept. This is a case of malignant lymphoma in which we had difficulties in differentiating from postoperative abscess remnant from CT findings and clinical course.

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An 80-year-old man was admitted with rectal cancer. Abdominal CT scan and MRI examination revealed an approximately 12-cm cystic tumor with calcification and a solid enhanced region. We operated on him based on the diagnosis of rectal cancer and mesenteric carcinoma or duplication of the intestine or gastrointestinal stromal tumor. The operative findings showed expansive growth of an approximately 13 cm × 6 cm × 5 cm tumor that was 40 or 50 cm into the intestinal mesenterium from the ileum end. It was enucleated without resection of the intestine. On the basis of pathological analysis, the tumor was diagnosed as adenocarcinoma of a small intestinal mesenteric cyst.
Adenocarcinoma of a mesenteric cyst is rare ; to our knowledge this is the second case of adenocarcinoma of a mesenteric cyst in Japan.

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We report a case of laparoscopic sigmoidectomy for a vesicosigmoidal fistula caused by diverticulitis of the sigmoid colon. The disease is rare ; however, it appears to be on an increasing trend in Japan.
A 44-year-old man with pneumaturia and fecaluria came to our hospital. A barium enema revealed inflammatory stenosis of the sigmoid colon around the diverticula. CT and MRI showed a fistula and also showed that a diverticulum had adhered to the bladder, which contained air. No malignancy was found and vesicosigmoidal fistula caused by diverticulitis of the sigmoid colon was diagnosed. Laparoscopic sigmoidectomy was performed. The firm adhesion of the sigmoid colon and the bladder around the fistula was divided with sufficient recognition and preservation of important organs such as the ureter. After adhesiolysis, the bladder was filled with saline solution containing indigo carmine to ensure that there was no leakage, and no treatment was performed for the bladder except an intravesical catheter for 6 days. The postoperative course was uneventful.
Patients benefit greatly from treatment by less invasive surgery, which allows them to make an early return to society.

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A 39-year-old woman who had abdominal pain and was found to have an approximately 8-cm cystic lesion on the mesenteric side of the ascending colon extending to the intra- and extraluminal sides on CT examination at the previous hospital was admitted to our hospital. Barium enema revealed a diverticular structure on the wall of the mesenteric side of the ascending colon. Due to the lack of symptoms and the decrease in the size of the lesion, she underwent follow-up with imaging examinations at our outpatient department. Two years later, she felt abdominal pain again and underwent examination at our hospital. CT examination revealed that the lesion had become larger, extending to the intraluminal side and causing stenosis of the ascending colon. As we could rule out the possibility of a malignant tumor, we performed ileocecal resection for histological diagnosis and relief from symptoms. Histological examination revealed that the cystic lesion was overlaid by the mucosal epithelium, had a smooth muscular layer and had no lumen connecting it to the ascending colon. We finally diagnosed the patient with colonic duplication with a round and non-continuous pattern. The characteristics and impressive imaging findings may be useful for the diagnosis of non-continuous colonic duplication.

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A 68-year-old man experienced diarrhea more than 10 times a day and appetite loss for a week. He had severe dehydration, hypokalemia, hyponatremia and hypochloremia with renal dysfunction and elevation of the creatine phosphokinase level at admission. Despite rapid infusion for recovery from dehydration, his symptoms became more severe, necessitating hemodialysis because of acute renal failure, leading to seizure and disturbed unconsciousness. After remission of his general status, mucous diarrhea persisted 6-8 times a day. Colonoscopy revealed an encircling tumor with a villous structure 1 cm above the dentate line and extending 10 cm upward. McKittrick Wheelock syndrome (MWS) is a rare pathological condition leading to electrolyte disturbance and dehydration by large-volume mucous secretion from villous tumor of the colon. This patient was also diagnosed with MWS and an operation was performed. The postoperative course was uneventful and MWS has not recurred for 1 year and 3 months. We report this rare case of MWS accompanied with electrolyte disturbance and elevation of the creatine phosphokinase level, necessitating hemodialysis.

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A 65-year-old man was seen at the hospital because of a 3-day history of abdominal pain and vomiting. Following abdominal CT scanning, colonic obstruction due to sigmoid colon cancer was diagnosed and a metallic stent was placed semi-urgently. Massive defecation occurred immediately after the placement and the patient started to take meals on the next day. On the 29^th day after the placement, laparoscopic-assisted anterior resection of the rectum was performed. As the sigmoid colon was found to be lifted to the abdominal wall, invasion of sigmoid colon cancer into the abdominal wall was diagnosed and associated resection of the abdominal wall was performed. Histopathology showed that the portion at where the associated resection of the abdominal wall was done had no relation with cancer and that deep ulcer had formed at the stump of the stent causing inflammatory changes on the serosal aspect which presented a morphology looked like the cancer invasion into the abdominal wall. In this case it is etiologically considered that the stent might move after the placement and the stump had touched the bending portion of the intestine for a long time, causing the condition. Periodic imaging follow-up would be mandatory after the stent placement and we must use a long stent as far as possible near the bending portion. If the stent stump touches the bending portion, early surgery would be desirable.

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A 49-year-old woman was diagnosed with advanced rectal cancer with multiple liver and lung metastases. She underwent low anterior resection and received chemotherapy with mFOLFOX6 (oxaliplatin plus 5-fluorouracil/leucovorin) together with bevacizumab. After 19 courses of chemotherapy, the patient developed thrombocytopenia due to oxaliplatin-related splenomegaly. Elective splenectomy resulted in an increase in the platelet count and facilitated the restart of chemotherapy. The oxaliplatin-based chemotherapy had led to hepatic sinusoidal dilation and obstruction, which had induced the splenomegaly and thrombocytopenia. Thus, splenectomy seems to be useful for treating thrombocytopenia with splenomegaly and facilitating the continuation of chemotherapy.

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A 57-year-old man who had been treated with chemotherapy after surgery for a left testicular tumor at the urological department in our hospital was seen at our department because of right lower abdominal pain and fever. The WBC count was 39,490/mm³ and the CRP level was 21.78mg/dl, showing increased inflammatory reaction. Abdominal CT scan revealed inflammatory findings at the right side colon. Following administration of antibiotics, his clinical course was observed but no remission was gained. Right hemicolectomy was thus performed on the fifth hospital day. Even after the operation no responses to antibiotics were noted. Abdominal CT scan performed on the forth postoperative day showed extensive multiple liver abscesses. He died on the tenth postoperative day. Histopathology of the resected specimen disclosed amoebae. Many patients with amoebic infection are asymptomatic and in about 10% of them, amoebae invade the intestine to cause enteric amebiasis. Although the mechanism of the onset has been obscure, the uses of steroids and anticancer drugs are pointed out as factors to provoke the disease on the side of the hosts. In the case of an immuno-compromised host who is on adjuvant chemotherapy and resultantly is prone to infection, like our case, a possibility that his or her amoebic infection can rapidly progress is suggested.

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We report a rare case of solitary hepatic epithelioid hemangioendothelioma (HEH). A 72-year-old man, who had undergone radiation and hormone therapy for prostatic carcinoma, had a thoracic CT scan due to the presence of common cold like symptoms. No abnormal findings were detected in the respiratory system. However, a liver tumor was incidentally found in the right lobe. The tumor showed ring enhancement on dynamic CT scans ; around the tumor the dilatation of intrahepatic bile ducts was detected. Given EOB-MRI and DSA findings, this case was clinically diagnosed as intrahepatic cholangiocarcinoma (ICC). The patient's prognosis was thought to be related not to his prostatic carcinoma status, but to the ICC. Thus, the patient consented to ICC surgery. Thus, a radical right posterior segmentectomy was performed. Histopathological and immunohistochemical examinations of the specimen revealed that small spindle tumor cells were in a matrix, which consisted of a large amount of collagen fibers in the peripheral region of the tumor, and this tumor was immunohistochemically CK-negative, CD34-positive, S100p-negative, and HMB45-negative. Based on these findings, this case was finally diagnosed as HEH. Solitary HEH is rarely reported.

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A 92-year-old man presented with abdominal pain and vomiting to our hospital in September 2011 and was admitted. Abdominal ultrasonography and CT detected gallbladder stones and common bile duct stones. The patient was treated with endoscopic sphincterotomy and endoscopic retrograde biliary drainage. He had a soft, hen's egg-like mass below the right inguinal region. The patient was treated with one-stage cholecystectomy and transabdominal preperitoneal repair via single-incision laparoscopic surgery. The operation time was 246 minutes ; the amount of bleeding was 345 mL. The patient was discharged from the hospital on the 12th day after surgery. Here, we have reported this case together with a review of the literature.

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Double cystic duct is a rare anomaly of the biliary duct systems and it may cause intraoperative injury of the bile duct. This was detected by abdominal ultrasonography upon medical examination in a 67-year-old woman initially admitted to the hospital because of a gall bladder stone. The double cystic duct was suspected preoperatively upon MR cholangiopancreatography, and single incisional laparoscopic cholecystectomy (SILC) was performed. Intraoperative cholangiography through the main cystic duct revealed another cystic duct originating from the right hepatic duct, thus double cystic duct was diagnosed. In recent years, SILC has become increasingly widely selected as an operative procedure. Although double cystic duct was suspected before the surgery, intraoperative cholangiography, ensured that we could perform the SILC safely with no injury to the bile duct. There are no reports about SILC being performed for a case of double bile duct. We present our case with a review of the literature.

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A 50-year-old man diagnosed with a gallbladder tumor at a medical checkup. He underwent distal gasteroctomy for gastric cancer when he was 48-year-old, and treated by S-1 as adjuvant chemotherapy. Cholecystectomy with hepatic resection and extrahepatic bile duct resection was performed under the diagnosis of gallbladder cancer. Resected specimen revealed that the tumor was located under the mucosa of the gallbladder. On histopathology, the tumor was adenocarcinoma and had the same histological features as the previous gastric adenocarcinoma, so the final diagnosis was gallbladder metastasis from the previous gastric cancer. Gallbladder metastasis from gastric cancer is rare, especially unsynchronous metastasis is very rare. Herein, we report this rare case with a review of the literature.

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We report a case of gallbladder metastasis from renal cell carcinoma. A 76-year-old man had undergone right nephrectomy for right renal cell carcinoma 6 years previously. Subsequently, he had undergone resection for skin metastasis from the same renal cell carcinoma. Follow-up ultrasonography showed a gallbladder tumor that had grown to about twice its original size in 1 year 6 months. We performed open cholescystectomy, considering a diagnosis of primary gallbladder cancer. A histopathological examination disclosed clear cell carcinoma as well as renal cell carcinoma and skin metastasis. The patient was diagnosed with gallbladder metastasis of renal cell carcinoma.

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The patient was a 74-year old woman who had been followed for a cystic tumor at the pancreas tail 4cm in diameter in an outpatient basis since the age of 64. The tumor diameter gradually increased at first, but ERP performed four years after her first visit disclosed communication between the main pancreatic duct and the cyst. Four years and four months later she developed acute pancreatitis. And further three months later the tumor enlarged to the diameter of 7 cm. The patient had epigastric distress about 10 years after her first visit when the tumor further enlarged to the diameter of 11 cm. ERP showed disappearance of the communication between the main pancreatic duct and the cyst. Mucinous cystic neoplasm of the pancreas was likely and resection of the pancreas tail with splenectomy was performed. The tumor was a cystic lesion having a thick fibrous capsule with part of ovary like stroma. Mucinous cystadenoma was thus diagnosed.
Since mucinous cystic neoplasm of the pancreas has malignant potential, it carries poor prognosis in malignant cases, and we often have difficulties in differentiation between benign and malignant lesions before surgery, surgical resection is recommended. We experienced a case of mucinous cystic neoplasm of the pancreas resected after a long-term observation of the clinical course that might offer some explanation for natural course of this disease. Accordingly we present the case with a review of the literature.

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We report a rare case of intraductal papillary mucinous neoplasm (IPMN) accompanied by branch fusion between the ventral and dorsal pancreatic ducts. A 50-year-old man was admitted for evaluation of a dilated pancreatic duct in the pancreatic head. MRCP showed a dilated and winding pancreatic duct of the pancreatic head with a unique shape and dilated cystic branch, compatible with a diagnosis of branch type IPMN. After 2 years of observation, MRCP showed the dilatation of the cystic lesion of the branch duct to a diameter of 32 mm. The pancreatic cyst included a defect of signal intensity suggestive of an elevated malignant tumor, for which a pylorus-preserving pancreaticoduodenectomy was performed. Pancreatography of the resected specimen showed communication of the dorsal pancreatic duct with the ventral pancreatic duct through a corresponding lower branch. In Japan this type of incomplete fusion of the pancreatic duct is classified as “Branch fusion type II” by Hirooka. On pathology an intraductal papillary mucinous carcinoma (IPMC) with micro-invasion was diagnosed. The imaging of the branch fusion of the pancreatic duct obtained in this case is very unique.

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Although the prognosis of pancreatic metastasis is reported dismal, pancreatic resection may achieve long-term survival in some cases. We report a resected case of pancreatic metastasis from carcinoma of the colon.
A 75-year-old woman who underwent sigmoidectomy for sigmoid colon cancer was found to have a tumor in the pancreatic tail by a follow-up abdominal CT scan performed five years after the operation. The tumor had rim enhancement on portal phase and delayed phase without invasive signs. MRCP showed no dilatation and disruption of the main pancreatic duct. Metastatic pancreatic tumor was likely. The patient underwent distal pancreatectomy and splenectomy. The pancreatic tumor was diagnosed as metastasis from the sigmoid colon cancer. Ten months later, chest CT scan showed multiple pulmonary metastases. As of 25 months after the pancreatectomy, she is alive while chemotherapy is being given. Resectable pancreatic metastasis from colon cancer is rare, but some long-term survival cases have been reported. If the patient is well tolerated to pancreatectomy and has no metastasis in the other organ, he or she should be considered as a good candidate for pancreatic resection.

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A 63-year-old man who visited his local physician because of upper abdominal pain was found to have impaired liver function and jaundice and was referred to our hospital. A common bile duct stone and a solid-hypervascular tumor (11.7×10.5 cm) in the tail of the pancreas were observed, and the tumor had developed into a portal tumor thrombus via the splenic vein. Following a fine needle aspiration biopsy, a preoperative diagnosis of pancreatic endocrine tumor was made because the tumor cells were CD56 and chromogranin A positive. Distal pancreatectomy combined with resection of the portal vein was performed.
Histopathologically, cord-/ribbon-like arranged atypical cell multiplication and significant vascular invasion were observed, and tumor thrombus was seen in the splenic vein, the inferior mesenteric vein and the portal vein. According to examination by immunostaining, the Ki67 labeling index was less than 2 %, CD56 and chromogranin A were positive, and all pancreatic hormones were negative. Non-functional pancreatic endocrine carcinoma was diagnosed. No recurrence has occurred as of 13 months after the surgery, and the patient is still alive. Few cases of non-functional pancreatic endocrine carcinoma with portal tumor thrombus have been reported so far. We have present this report with some bibliographical consideration.

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Among pancreatic carcinomas anaplastic ductal carcinoma is a relatively uncommon entity and is believed to carry extremely poor prognosis. Recently we have experienced a case of anaplastic ductal carcinoma with tumor thrombus in the main pancreatic duct.
A 63-year-old woman who visited a hospital because of epigastralgia and back pain was suspected to have acute pancreatitis and was referred to our hospital for the purpose of close exploration and treatment. Abdominal CT and MRI revealed a tumor with the longer diameter of about 8 cm located mainly in the pancreas body in a morphology as it replaced the pancreas parenchyma. The margin of the tumor was comparatively well enhanced and its central portion had extensive low density area. Both magnetic resonance cholangiopancreatography (MRCP) and endoscopic retrograde cholangiopancreatography (ERCP) showed disruption of the main pancreatic duct at the pancreas head. Cytodiagnosis performed at ERCP resulted in class V. Subtotal stomach preserving pancriaticoduodenectomy was performed. The histopathological diagnosis was anaplastic ductal carcinoma (pleomorphic type). We confirmed the extension of carcinoma as the tumor cells filled inside of the main pancreatic duct at the pancreas head. Adjuvant chemotherapy was started in our clinic from the fifth week after the operation, but abdominal CT scan performed two months after the operation revealed multiple periaortic lymph nodes metastases. The patient died about four months after the operation.

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Pancreatic carcinosarcoma is a rare neoplasm consisting of 2 malignant components : epithelial and mesenchymal cells.
An 83-year-old woman was referred for a mass in the pancreatic body that had been detected incidentally during abdominal CT for ischemic colitis. The radiologic findings and blood examination suggested pancreatic cancer, and a distal pancreatectomy was performed. Histologically, the tumor showed exhibited 3 differentiated components, namely, well-differentiated ductal adenocarcinoma, sarcoma, and neuroendocrine tumor. The results of immunohistopathological and K-ras sequence analyses suggested that these tumors could have been of monoclonal origin. The patient died 10 months after the surgery due to multiple liver metastasis, and an autopsy was performed. We believe that this case is significant in the study of pancreatic tumor origin.

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A 76-year-old woman presented to a hospital because of vomiting was found having stenosis at the descending part of duodenum by upper gastrointestinal endoscopy. The lesion was diagnosed as adenocarcinoma by a biopsy and she was referred to our hospital for the purpose of close examination and treatment. Abdominal contrast-enhanced CT scan showed wall-thickening of the descending part of duodenum and dilatation of the common bile duct. No tumors were demonstrated in the pancreas and the main pancreatic duct did not dilate. The patient was operated on with the preoperative diagnosis of primary duodenal cancer. During surgery, a 3-cm diameter tumor was seen at the descending part of duodenum. Accordingly subtotal stomach preserving pancreaticoduodenectomy was performed. The pathological diagnosis was pancreatic cancer arising in the ectopic pancreatic tissue existing from the submucosal layer of the duodenum to the proper muscular layer.
We present our experience with a case of ectopic pancreatic cancer developed in the duodenum, which is rare, together with a review of the literature.

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A solitary splenic metastasis from cecal cancer was diagnosed in a 68-year-old man who had undergone a right hemicolectomy for cecal cancer. Three years after the operation, a 2.5 cm, round, hypodense mass was detected in the spleen on CT. FDG-PET revealed strong uptake at the splenic mass ; no other lesion was discovered. A metachronous solitary splenic metastasis was suspected, and a laparoscopic-assisted splenectomy was performed. The operative time was 2 hours and 56 minutes ; the bleeding loss was 8 g. On postoperative histology, splenic metastasis from the cecal cancer was noted. The postoperative course was uneventful and the patient was discharged on the 8^th day after surgery. The patient is alive without any recurrences or metastasis after 3 years of follow up.

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We report a case of a surgically resected giant cystic pheochromocytoma. A 43-year-old female had a large abdominal mass. A computed tomography scan revealed a large, multicystic tumor with a maximum diameter of 26 cm occupying almost the entire abdominal cavity. The blood supply to the tumor suggested that its origin was the left adrenal grand ; subsequently, a diagnosis of pheochromocytoma was established based on urinalysis showing elevated catecholamine metabolite levels. A surgical resection of the left adrenal pheochromocytoma along with the left kidney was performed. The postoperative course was uneventful. The resected tumor mass weighed 5,900 g. On histopathology, the diagnosis of a well-differentiated pheochromocytoma with a relatively low risk of developing metastases was confirmed. To our knowledge, this is the first report of a patient surviving surgical resection of a giant pheochromocytoma weighing over 5,000 g.

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A 78-year-old man visited his previous physician with a chief complaint of sudden right lower quadrant abdominal pain. He was referred with suspected gastrointestinal perforation. Abdominal contrast-enhanced computed tomography (CT) showed intraperitoneal free air and ascites, as well as fluid accumulation accompanied by air adjacent to the anterior bladder wall. Since gastrointestinal perforation could not be ruled out, exploratory laparotomy was performed on the same day. No gastrointestinal abnormalities were found intraoperatively. Retrograde cystography was performed on postoperative day 3, and the patient was diagnosed as having an urinary bladder perforation. Since urinary drainage was effective after urinary catheterization, conservative treatment was given, and the patient's condition improved. Spontaneous urinary bladder rupture is rare, and because it presents with various clinical symptoms, it is difficult to accurately diagnose preoperatively, and differential diagnosis from other causes of acute abdomen is an issue. The present case and a review of the literature suggest that bladder rupture should be suspected in patients with extraperitoneal findings such as fluid accumulation and air around the bladder.

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We report herein a patient in whom Fournier's gangrene caused by rectal cancer was reconstructed using a rectus abdominis myocutaneous flap. The patient was a 79-year-old male. He was seen by the urology service because of scrotal pain ; Fournier's gangrene was diagnosed. After drainage of the scrotum and the construction of a sigmoidostomy, a rectal cancer was detected. An abdominoperineal resection was performed and a skin defect 6×7 cm in size was left in the perineal region. The rectus abdominis myocutaneous flap was used for the reconstruction. After the surgery, there was no sign of recurrence or infection. The rectus abdominis myocutaneous flap is an excellent choice in cases with a large perineal defect due to its vascular stability and sufficient dead space filling of the pelvic cavity.

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A 23-year-old woman developed right inguinal pain and abdominal distention. She had a bulging mass and tenderness due to abdominal distention in the right inguinal region. Pelvic CT scan showed a cystic mass in the right inguinal region. Surgery was performed with a diagnosis of a cystic mass associated with a right inguinal hernia. Intraoperative findings showed that the cyst contained a dark red liquid and that the hernial sac was connected to the cyst. A high ligation of the hernial sac was done, the cyst was extracted and the internal hernial ring was closed using Marcy's method. On pathohistology, the cysts inner cavity was covered with mesothelial cells, as part of the vaginal process of the peritoneum, and the findings of endometriosis were noted.
The vaginal process of the peritoneum that remains open in women is called Nuck's canal. A hydrocele of Nuck's canal is a cyst that stores liquid in Nuck's canal. In endometriosis, endometrial cells are present in regions other than the intrauterine cavity. Endometriosis located in Nuck's canal is rare. Therefore, we report this adult case of endometriosis located in a hydrocele of Nuck's canal.

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We report a case of femoral hernia with incarceration of the vermiform appendix diagnosed preoperatively using CT. A 70-year-old woman was admitted to the hospital because of a right groin swelling. Physical examination revealed an elastic hardened mass in the right femoral region. Abdominal CT disclosed a right femoral hernia with incarceration of the appendix ; emergency surgery was performed. The operative findings revealed that the femoral hernia had incarcerated the vermiform appendix ; ischemic changes were noted. Appendectomy and mesh plug hernioplasty were performed. The postoperative course was uneventful, and she was discharged on the fourth hospital day. Incarceration of the appendix in femoral hernia is rare. The signs and symptoms of acute appendicitis are often overshadowed by the findings of an incarcerated hernia. CT is an accurate diagnostic modality in hernia with incarceration of the appendix. We discuss the 23 cases (including this one) reported in the Japanese medical literature.

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The lumbar region has two sites of reduced abdominal wall resistance, the superior lumbar triangle and the inferior lumbar triangle. An abdominal hernia that occurs at these sites is referred to as a lumbar hernia. A case of lumbar hernia occurring after iliac crest bone harvest for which laparoscopic hernia repair was performed is reported. The patient was a 74-year-old man who, at the age of 67 years, underwent vertebroplasty for a compression fracture of the cervical spine, during which bone was harvested from the right iliac crest. He first visited our department due to a protrusion in the right lumbar region that he noticed two years earlier. The patient was diagnosed with a lumbar hernia occurring after iliac crest bone harvest in which the hernia contents were the ascending colon. Surgery was performed using three ports with the patient in the left lateral decubitus position. The ileocecum was mobilized, a 4.2-cm hernial orifice was identified, a Bard Composix Mesh^® shaped into a circle with a 10-cm diameter was placed to secure a 3-cm overlap, and the entire periphery was fixated using AbsorbaTack^TM. Fixation of the ileocecum to the abdominal wall was performed using a few tacks, and the procedure was concluded with a favorable visual field and operability. The patient was discharged on day 6 following an uneventful postoperative course and is currently, seven months postoperatively, being followed up with no recurrence.

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A 39-year-old woman who had undergone a hernia repair using mesh-plug method for a right external inguinal hernia elsewhere became to have an occasional bulge with the size of thumb at the right inguinal region since one month after the operation. She had let the bulge alone because it was painless until 1.5 years after the operation, when the bulge with a slight pain appeared in the same site. The patient visited a previous doctor who had performed the operation because she felt symptoms different from the previous symptoms. The patient was referred to our hospital with a suspicion of recurrence of inguinal hernia. Physical examinations revealed an egg-sized palpable tumor which could not be reduced by hands at the caudate side from the right inguinal ligament. CT scan showed findings of femoral hernia. The patient was considered a candidate for surgery. During surgery femoral hernia containing the Fallopian tube and tubal isthmus was diagnosed. No findings suggestive of circulatory impairment were seen. The hernia contents were reduced through the femoral ring and the femoral ring was repaired by means of UPP method. The patient has been free from recurrence as of five months after the second operation.
We present the case of femoral hernia containing the Fallopian tube and tubal isthmus after surgery for inguinal hernia, which is rare.

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This report presents a case of synchronous primary breast malignant lymphoma and cecal cancer following methotrexate therapy for rheumatoid arthritis. A 76-year-old woman developed rheumatoid arthritis, and methotrexate treatment was started in January 2012. In August 2012, she visited the hospital because of a tumor in the upper outer quadrant of the right breast. A core needle biopsy was performed for the diagnosis of the tumor, which measured 2.8×1.0 cm in size, detected by mammography and ultrasonography. Immunostaining revealed the tumor to be non-Hodgkin's lymphoma (diffuse large B-cell type). Positron emission tomography-computed tomography (PET-CT) showed masses with increased uptake in the right breast and cecum. The cecal mass lesion was diagnosed as a type 2 cecal cancer during colonoscopy, and therefore an ileocecal resection and lymphadenectomy were performed. The pathological findings showed well differentiated adenocarcinoma (3.0×1.7 cm, pT2, ly0, v0, pN0(0/9), pStage II). The Ann Arbor clinical stage was I_EA due to a lack of any other abnormal lesions identified by PET-CT or in the bone marrow. Chemoradiation therapy was initiated without surgery.

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