In order to determine the indications for modified radical mastectomy, 65 patients with primary breast cancers who underwent radical mastectomies or extended radical mastectomies were studied. The authors determined the size and depth of the tumors, metastasis to lymph nodes, and stage microscopically and investigated the indication for modified radical mastectomy. Initially, cases with metastasis to Rotter's lymph nodes, subculavicular lymph nodes and internal mammary lymph nodes were excluded from the indications for modified radical mastectomy. From the viewpoint of lymph node metastasis, it was concluded that the indication for modified radical mastectomies was confined to T1n1α (axillary lymph node involvement less than 3) when the tumor was located laterally, and Tis when it was located medially. However, when it was examined from the viewpoint of the depth of the tumor, it was found that 12% of the patients had infiltration to the pectoralis major muscle, and 14% had infiltration to the retromammary space. It was revealed that even in the case of T1n0 (no lymph node involvement), the infiltration of the cancer reached very close to the pectoral fascia. Therefore, it was concluded that the indication for modified radical mastectomy must be limited to Tis.

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For diagnosis and differentiation of breast lesions, we performed breast echography by a manual contact scanning method with 5-Hz frequency linear electroscan sound.
Twenty-two out of 183 outpatients examined between January 1983 and March 1984 were diagnosed histologically as having breast cancer.
The echographies of the 22 breast cancers were evaluated according to “The Criteria for Classification of Localized Pathological Processes” by Kossoff and divided into four patterns on the basis of three points (texture, overall distribution and internal structure) of the internal echoes: Type I: fine and uniform solid mass (8 patients), Type II: coarse and uniform solid mass (5 patients), Type III: coarse and complex solid mass (7 patients) and Type IV: intracystic tumor (2 patients). Of the boundary echo, five of the eight type I masses had a smooth spherical shape and a thick halo. All five type II masses had a smooth lobular shape and a halo. All seven type III masses had a irregular shape and posterior shadowing.
Manual contact scanning is an easy method of breast echography and the four ultrasonographic patterns of breast cancer are useful for differentiation of breast diseases.

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It is highly possible that Borrmann type 4 gastric cancer has a biological behavior which is different from that of gastric cancer of other types, from the facts that early diagnosis of Borrmann type 4 gastric cancer (scirrhous carcinoma) is difficult and that some cases of gastric cancer of this type show rapid progression. In order to investigate this possibility, 95 patients with Borrmann type 4 gastric cancer were roughly divided into Type G (69 patients) and Type P (26 patients) according to the mucosal properties of the excised specimens and were compared clinicopathologically and histochemically. Type G was mostly observed in female patients. The incidence of serosal (s) and of peritoneal (p) factors was high. The incidence of lymph (ly) factor was higher than that of the other factors, 58.0% in Type G and 65.4% in Type P, although most of the cases were advanced and the prognoses were poor. The prognosis of Type G in particular was poor, and there were no 5-year survivors. Histochemical examination revealed that cases of both Types G and P showed a large quantity of acidic mucopolysaccharides in the interstitial tissues of the tumor. However, the enzyme digestion test revealed that the quantity of hyaluronic acid and sialic acid in the interstitial tissues of Type G tumor tended to be greater than that in Type P. These facts were considered to contribute to the rapid progression of gastric cancer of Type G and to be one of the causes of the poor prognosis.

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Fifteen burned patients (nine men and six women, average age 36.2 years) with adult respiratory distress syndrome (ARDS), were evaluated comprehensively by means of clinical findings, chest roentgenographical findings and immunopathological findings of the autopsied lungs. The average extent of the trauma was 63.4% of the body surface area. The average period to death was 27.4 days after being burned and seven patients died of respiratory failure. A damage of peripheral vasculatures was suggested because prominent opaqueness of peripheral vascular markings appeared in chest roentgenograms of early periods. Pneumonia-like shadows in five cases and irregular abnormal shadows in three cases were found, histologically corresponding to proteinogenous edema, necrosis, hyaline membrane and so on. Fibrotic changes in the alveolar walls were increasingly conspicuous according to the progression of respiratory distress, being covered by Type II epithelial cells or basal cells derived from the airways. Fibrin thrombus showing disseminated intravascular coagulation was found in most cases and fibrinogen or fresh fibrin was found in the outer layer of the thrombus. Changes suggesting septicemia was found in five cases and these, combined with the results of bacteriological culture, led to a consideration of infection by gram-negative bacteria. These results suggest that ARDS associated with burns is caused by a combination of various factors.

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The treatment of brain abscess and subdural empyema in regard to the changes in operative procedure and the indication of conservative treatment after the introduction of CT was investigated by examining the records of 34 patients treated in the past 22 years. Fifteen cases were in the pre-CT era and 19 were after the introduction of CT. There was no significant difference in age, sex, and cause between the two groups.
As for the treatment, all of the patients who were treated conservatively without CT died. But with CT monitoring, some patients could be treated by only chemotherapy and its clinical results were excellent. The mean diameter of the abscess cavity in patients treated by chemotherapy only was 2.6cm.
As for the operative cases without CT, total removal of the abscess was performed in almost all of the patients and their clinical course was poor.
However by detecting the exact location of the abscess with CT, aspiration or drainage of the abscess was performed and the clinical course was improved.
The mean diameter of the abscess cavity in the patients treated surgically was 4.8cm. It was concluded that it is possible to treat patients with abscesses by only chemotherapy when the diameter of the abscess cavity is samller than 3cm, and that when the lesions are larger than 3cm, it is advisable to aspirate or drain the abscess cavity instead of totally removing the abscess.

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Many surgeons have little interest in tumors of the salivary glands so that such tumors are on the borderline between the interest of otorhinolaryngologists and that of surgeons. Moreover, there are many surgeons who hesitate to perform surgical excision for a tumor that is associated with Bell's palsy or inveterate sialosyrinx. In the present study, a recurrent parotid cancer (14×10×7cm) with pulmonary metastasis was detected in a 57-year-old woman. This malignant mass and the involved gnathic windgall, the mandibular periosteum and the facial nerves were excised as extensively as possible. The extensive excision improved the patient's condition and the postoperative course was uneventful. The trismus due to facial nerve excision was not so severe as to disturb her daily life. As for prognosis of recurrent parotid cancer with distant metastasis, an approximately 20-percent five-year survival rate has been reported in the recent literature. On the basis of our experience and the literature, extensive surgical excision for the tumor is considered to be important.

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We have operated on four patients with traumatic bronchial rupture. The location of the traumatic rupture was the main bronchus in all four cases. Diagnostic clues were bloody sputum, dyspnea, mediastinal emphysema on chest XP and subcutaneous emphysema in the neck. Accurate diagnosis was made by either bronchoscopy or urgent thoracotomy. Delay in diagnosis was experienced in one patient in whom fibrous tissues at the separated edge of the ruptured bronchus had developed well enough to maintain the airway, but subsequently followed by bronchial stenosis. It is obvious that delay in diagnosis results in parenchymal damage to the lung such as atelectasis, fibrosis or inflammation, and the longer the delay in therapy, the greater the damage to the lung. Our patients included a 5-year-old boy in whom both the main and the middle bronchi on the right were ruptured. This experience showed that even a 5-year-old boy could become a candidate for bronchoplastic surgery, if he is given special care including an indwelling catheter to remove the bronchial secretion during the first or second postoperative day.

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Traumatic diaphragmatic hernia (TDH) is a rather rare disease, but with the increase in the number of traffic accidents and with development of a diagnostic technique many more reports have appeared. We have experienced two such cases with rare associated complications. One patient fell into shock because of pleuritis secondary to a perforated gastric ulcer, and the other developed a pericardial hematoma followed by cardiac tamponade. Both patients were saved by repairing the hernia along with gastrectomy or pericardiotomy.
The incidence of diaphragmatic injury by itself is low (13-30 percent). It is usually associated with other injuries such as ruptured spleen, hemo-pneumothorax, fractured pelvis, limb fracture and rib fracture. The complications presented here are rare with very few reported cases. Diaphragmatic injury consists of either an open or a closed injury. In Japan closed injuries are much more frequent, at a ratio of 5.5:1. TDH arises more frequently in males than in females by about 5:1, and is seen most often in persons in the age group between 20's and 50's.

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Hemangiopericytoma is a rare tumor which is derived from pericytes of capillary vessels. It was first reported by Stout and Murray in 1942. It was considered a benign tumor in the beginning, but recurrent metastasis has increasingly been noted along with an increase in the number of case reports. Hemangiopericytoma has thus come to be treated as a malignant tumor.
In a 37-year-old female patient with chief complaints of bloody sputum and cough, a chest roentgenogram revealed an abnormal shadow in the left lower lung field, and a pathological diagnosis of nonepithelial malignant tumor was made at biopsy. Since she had undergone excision of a hemangiopericytoma in the soft tissues of her left ankle joint six years earlier, left lower lobectomy was performed under the diagnosis of metastasis of the tumor to the left lung.
There are few reports in Japan on cases like this, in which hemangiopericytoma recurred 6 years after the initial treatment. It is necessary to observe the course for a long time considering its potential malignancy. Surgical excision for recurrent metastatic pericytoma should also be recommended wherever possible.

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We have performed emergency operations on 5 patients with perforated gastric cancer.
Three cases were pathologically diagnosed from frozen sections during the operation. Two of these three patients underwent radical surgery (R₂), but one was inevitably subjected to non-curative gastrectomy because of a poor general condition.
In the remaining two cases, malignancy was proved postoperatively. One of these 2 patients underwent a reoperation for lymph node dissection.
These experiences suggest that at the operation for a perforated stomach one has to make a careful observation of the perforated lesion and, if the condition requires, pathological diagnosis with frozen section is recommended.
Although the operative procedure should be selected according to intraperitoneal findings and general condition, a curative operation including lymph node dissection is desirable.

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Although duodenal neoplasms are rarely encountered, we experienced a case of giant duodenal leiomyoma. A 71-year-old female was admitted to the gynecologic ward under the diagnosis of an ovarian tumor. She had complained of a huge abdominal mass and chronic anemia of more than 2 years' duration. She was operated on two days after hospitalization, at which time a large tumor involving the duodenum, pancreas head and the transverse mesocolon was found. Both ovaries were intact. We then performed a pancreaticoduodenectomy with right hemicolectomy. This tumor aorse from the second portion of the duodenum, compressing the pancreas head and bile tract and firmly adhering to the transverse mesocolon. Microscopically it consisted of interlacing sheets of smooth muscle cells without mitotic figures or cellular atypias. The postoperative course was uneventful and the patient is now pursuing her regular activities without any trouble.

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The patient was a 59-year-old man without any particular complaint. Upon examination, he was found to have a high serum CEA level, and a subsequent detailed examination revealed a hepatic tumor in the medial segment of the left hepatic lobe (S₄). The tumor was suspected of being metastatic because his serum AFP level was within normal range. Detailed examination of other intra-abdominal organs, however, revealed no abnormalities. Therefore, after diagnosis of a primary hepatic carcinoma producing CEA, the S₄ subsegment was excised using the microwave coagulator. The tumor size was 2.6×1.8cm. Histopathologically, it was found to be a hepatocellular carcinoma of Edmondson type II with a capsule. The postoperative course has been favorable; the serum CEA level returned to normal, thereby confirming the production of CEA by the tumor.
Increased CEA levels are rare in primary hepatocellular carcinomas, but very common in metastatic liver cancers. Therefore, detailed examination of other intra-adbominal organs is necessary in the diagnosis of such cases.

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The number of cases of benign tumors of the gallbladder which are diagnosed preoperatively has recently increased, and their recognition with problems regarding their malignancy are increasing.
Eleven patients with benign tumors of the gallbladder, 5.9% of the patients who underwent surgery for gallbladder diseases in the same period, were experienced in our clinic during the past 3 and a half years. The rate of definite diagnosis by ultrasonography was high, and furthermore, ultrasonography combined with conventional roentgenography enabled a preoperative diagnosis rate of more than 80%.
Becase of the reported high incidence of malignancy originating from adenoma, cholecystectomy and intraoperative rapid pathological diagnosis should be undertaken in patients with benign tumors.

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The patient was a 58-year-old man who visited our hospital because a round calcified picture in the left epigastric region was found during a health examination. Abdominal CT and selective splenic arteriography led to a diagnosis of calcifying splenic cyst, and splenectomy was performed. Histopathololgical examination revealed a pseudocyst showing no endothelial cells on the cystic inner wall. Splenic cyst is a relatively rate disease. To our knowledge, only 207 cases have been found in Japan to date. The number of patients with true cyst and pseudocyst was almost the same, while true cyst tended to be more common in women. True cyst was more often encountered in younger age groups, whereas pseudocyst occurred relatively evenly in all age groups. As characteristic symptoms, true cyst was often associated with palpation of a painless mass, and pseudocyst with palpation of a painful mass. Etiological consideration disclosed a past history of bruise on the pleuroperitoneal region in 31% of the patients with pseudocyst. Calcification was found more often in cases of pseudocyst; particularly, severe calicification was common. For treatment, splenectomy was performed in 96.5% of patients.

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A patient who died of rupture of a bacterial abdominal aortic aneurysm which was obstructed with thrombi is presented. A 63-year-old male patient had major complaints of abdominal pain, hyperthermia and diarrhea. By CT, ultrasonography and angiography the patient was diagnosed as having an abdominal aortic aneurysm originating from the area directly below the bifurcation of the superior measenteric artery, which was obstructed with thrombi. Although emergency laparotomy was undertaken because of the suspicion of a ruptured aneurysm, the lesion could not be excised and the patient died 3 days after the operation. The lesion was found to be a bacterial abdominal aortic aneurysm due to infection of Escherichia coli.
The possibility of a usual aneurysm being ruptured decreases markedly if the aneurysm is obstructed with thrombi. In contrast, a microbial aneurysm rarely heals spontaneously even if it is obstructed with thrombi. Under this condition the infection continues in the thrombi, resulting in rupture of the aneurysm. The histopathological examination of this patient also revealed findings showing that thrombi cannot prevent the rupture of an aneurysm in the case of a microbial aneurysm.

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Primary malignant lymphoma in the intestinal tract is a rare disease, with an incidence which is believed to be 1-1.7% that of intestinal cancer. The site where it commonly develops is the ileocoecum, and it occurs solitary in most cases.
Its differential diagnosis from cancer prior to surgery is very difficult even using radiography or endoscopy. Although surgical therapy is, as a rule, applied as treatment, as in the case of cancer, postoperative combined therapy is important in that the lesions have already advanced before surgery in many cases and that they are highly sensitive to drug therapy and radiotherapy.
In our patient, a 49-year-old man, with double primay malignant lymphomas in the jejunum and cecum, the lesions in the cecum were preoperatively diagnosed on biopsy by endoscopy of the large intestine. Remission was induced by internal treatment. However, because symptoms of ileus appeared, palliative resection was undertaken.
The lesion was histologically diagnosed to be the diffuse, large-cell type according to the LSG classification, and to be considerably malignant. However, re-resection for relapse of the lesion in the intestinal tract and combined treatment involving drug therapy and radiotherapy for relapse of the lesion in the lymph nodes were very effective, resulting in a long-term survival of more than three years.

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This report deals with a case a tumor in 60-year-old male who was admitted to our hospital with a complaint of an abdominal tumor. The tumor, 17×16×11cm arising from the wall of the jejunum at a distance of 10cm from Treitz ligamentum, weighted 1, 850g and contained about 1, 000cc of necrotic substance. The tumor was diagnosed as leiomyosarcoma of the jejunum.
According to the literature, leiomyosarcomas of the small intestine are mostly found in the upper jejunum, especially from Treitz ligamentum to a distance of 60cm. The size of the tumor was 15cm or less in 73% of the cases, and tumors over 15cm were found in 25 cases. We found it difficult to diagnosis leiomyosarcoma of jejunum and to distinguish it from leiomyoma preoperatively. The effective therapy is to excise the tumor completely, and longterm follow-up is necessary because of recurrence in both the early period and after 5 years postoperatively.

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A rather rare case of omental torsion which was secondary to inguinal herniation of the omentum was reported. The patient, a 60-year-old male, was admitted to our hospital because of right lower abdominal pain. Laparotomy for the preoperative diagnosis of right inguinal hernia with incarceration disclosed that the greater omentum was fully rotated in a clockwise direction and moderate amount of bloody ascites in the peritoneal cavity was present. The rotated portion of the omentum was totally resected and histologically it was extensively necrotic with focal hemorrhage and inflammatory cell infiltration but free of any neoplastic change.
We reviewed 57 cases of omental torsion reported in Japan, of which 13 (23%) were of primary idiopathic type, 40 (70%) were secondary type and four were not specified. The preoperative diagnosis of omental torsion seems extremely difficult and none of the 57 cases was diagnosed correctly; the majority (74%) were diagnosed as acute appendicitis. It seems to be justifiable as the generally accepted treatment of this disease that invaded portions of the omentum should be resected completely regardless of the extent of the involved areas.

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Renal angiomyolipoma is a relatively rare mesodermal mixed tumor. In Japan, 124 cases have been reported. This paper describes our recent experience with a case of renal angiomyolipoma without accompanying nodular sclerosis.
The patient was a 48-year-old woman who was admitted under the condition of acute heart failure and was unexpectedly found by abdominal echography to have a mass at the upper pole of the left kidney. Because detailed examination suggested a malignant tumor in the left kidney, the kidney was excised. Histopathological examination of the excised specimen showed a mixture of abundant fatty, muscular and vascular tissues, leading to a diagnosis of renal angiomyolipoma.
Preoperative diagnosis of this condition is relatively easy in patients with a complication of nodular sclerosis, who show the triad of epilepsy, mental disturbance and facial sebaceous adenoma. In contrast, cases without that complication are difficult to differentiate from renal carcinoma. The number of cases diagnosed preoperatively has increased recently with the use of CT, because the CT value of the fatty tissue in this tumor is low.

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