To evaluate the indications for modified radical mastectomy, preoperative clinical TNM classification, histopathological examination of dissected lymph nodes and consequent 5-year disease-free surivival rates were compared between 42 patients treated by modified radical mastectomy (group 1) and 114 patients treated by standard or extended radical mastectomy (group 2). The mean tumor size in the patients treated by modified mastectomy was less in patients who were disease-free for 5 years than in those with recurrence, but no significant difference was observed. Although the preoperative evaluation of the axillar lymph nodes (N), which is the only preoperative indicator of the degree of lymph node metastasis, did not accurately represent the prognosis of the disease the increase in the number of metastatic lymph nodes evidenced by histology (n) was significantly correlated with the decrease in 5-year disease-free survival rates in both group 1 and group 2. Then the correlation between N and n in group 2 was examined. No significant difference in either the percentage of patients with positive nodes or the number of metastatic nodes was found between the patients classified as N0 and N1a. These results suggest that modified radical mastectomy can be applied to the patients with breast cancer assigned to grades of less than T2 N1a.

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In the present study, we compared patients with gastric carcinoid who were preoperatively positive or negative for serum AFP in order to clarify the characteristic features of AFP-positive gastric carcinoid. The prognosis of AFP-positive gastric carcinoid and the location of AFP in the cancerous focus were also studied. The subjects were 143 patients who underwent surgery for gastric cancer. They were composed of nine with serum AFP levels of 21ng/ml or more (positive cases) and 134 with corresponding levels of 20ng/ml or less (negative cases), and these two groups were compared clinicopathologically. The AFP-positive patients were further divided into those with relatively high AFP levels of 100ng/ml or more and those with relatively low AFP levels of 99ng/ml or less, and the two groups were compared with regard to the prognosis and the location of AFP in cancer cells. Most AFP-positive cancers were located in the A area and were markedly advanced macroscopic types 2 or 3, with a high frequency of hepatic metastasis. The high-level group showed a high probability of hepatic metastasis and a high risk of recurrence of hepatic metastasis. Two cases without hepatic metastasis in the high-level group were found to be AFP-producing cancers. We believe that determination of serum AFP is useful not only for detecting AFP-producing cancer but also for judging the likelihood of recurrence of heptic metastasis.

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The serum concentrations of CEA, AFP and hCG were extensively studied. Levels of CEA, AFP and hCG were positive in 18%, 15% and 10% of patients, respectively. The positive rate examined by a combination assay using the three tumor markers was about twice as great as that obtained by single assay. The patients' sera positive to tumor markers showed many metastases to lymph nodes, deep invasion in the gastric wall and a high incidence of vessel invasion. Five year survival rate was 73% for cases negative for CEA, AFP and hCG, but the rate were 8%, 19% and 0% for CEA, AFP or hCG positive cases, respectively. Patients with CEA, AFP or hCG positive serum had a poorer prognosis than those with negative carcinomas. Liver metastases were frequently seen in AFP positive patients and the rate of bone metastases was high in cases positive for hCG. These results demonstrated that staging, curability and recurrence may be more easily diagnosed by a combination assay than assaying each macker. In patients showing high serum concentrations of CEA, AFP or hCG, it is necessary to perform extensive resection and multimodal therapy.

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Thirty-five patients who had been operated on because of elevated-type early gastric cancer during the period between 1966 and 1985 were analysed from both clinical and pathologic viewpoints. As they included 2 patients with double carcinoma of the stomach, the number of lesions studied was 37. Most patients were over 40 years of age, and the frequency of patients over 60 years old was 57.1%. The male to female ratio was 6 to 1. The purely elevated-type was observed most frequently, and elevated types with depressed or flat surfaces were less frequent. The lesions were distributed at the antrum (59.7%), body (29.7%), and cardia (10.8%). The purely elevated type was found more frequently in the intramucosal carcinoma (m) group than in the submucosal invasion (sm) group. The types combined with depressed or flat forms were found frequently in the sm group. As regards the histologic types of carcinoma, differentiated type was found in 83.3% of all lesions examined. Blood vessel and lymphatic invasion were observed in 13.8% and 37.9% of cases, respectively. INF classification revealed that 90% of the m group belonged to INFα and 80% of the sm group to INFγ. Five-year survival rate was 94.7%, and only one patient died of recurrence of the carcinoma.

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It is known that blood transfusion at the time of kidney transfplantation induces immune tolerance, leading to an increased rate of fixation of the transplanted kidney. A corollary of this phenomenon is the possibility that blood transfusion combined with surgical removal of a malignant tumor will promote recurrence and growth of the tumor. The prognoses of 51 patients after radical surgery for colon cancer of stage II or more (36 with blood transfusion and 15 without) and 51 patients after radical surgery for breast cancer (24 with blood transfusion and 27 without) were analyzed by the Kaplan-Meier method in relation to the presence or absence of combined blood transfusion. Among the patients with colon cancer, the survival rate for those given blood transfusion was obviously lower than that for those who were not (p<0.0001). Similarly, the recurrence rate of breast cancer was significantly higher in patients with blood transfusion than in those without. The prognosis was also clearly worse in colon cancer patients given blood transfusion than in corresponding patients who were not. A study of the possible relationship between the quantity of transfused blood and the prognosis revealed no correlation. These findings led us to speculate that blood transfusion before and after surgery serves as a factor for worsening the prognosis of cases of colon cancer and breast cancer, and that the presence of transfusion itself is important, regardless of the quantity of transfused blood.

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The causes of upper digestive tract bleeding after hepatic abscission were analyzed in this study by dividing subjects into 2 groups (cirrhosis and cirrhosis-free) and taking liver function, blood coagulation surgical stress, and the kinetics of gastric acid secretion into account. The results were as follows.
Upper digestive tract bleeding occured in 1 case of 15 (6.7%) in the cirrhosis-free group and in 5 cases of 19 (26.3%) in the cirrhosis group. One case was fatal. Postoperative upper digestive tract bleeding was found to have no clear relationship to the extent of the hepatic abscission or to the volume of bleeding during surgery. When compared with the cirrhosis-free controls patients with cirrhosis showed significantly worse values of GPT, TTT, ICGK, ΔIRI/ΔBS, IRI max, and hepaplastin. In the cirrhosis group the preoperative MAO value was ortho-acid (5_??_20 mEq/h) in 10 cases and hypo-acid (below 5 mEq/h) in 8 cases. All of the 5 cases which developed bleeding after surgery were in the orthoacid condition. These results indicate that patients showing a preoperative MAO value of over 5 mEq/h need to be given cimetidine positively, starting immediately after surgery.

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A 51-year-old woman was admitted because of a thyroid tumor and development of paralysis of the lower half of the body. Physical examination and a ²⁰¹T1-chloride whole-body scan disclosed a metastatic lesion in the 11th thoracic vertebra. Four days after admission, the patient underwent a laminectomy which relieved the symptoms of lower-half paralysis. One month later, a total thyroidectomy was carried out and after one further month, radioiodine treatment was carried out. The spinal lesion decreased in size after two sessions of ¹³¹I treatment and the serum thyroglobulin level markedly decreased from 5, 500ng/ml to 950ng/ml.

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The direct surgical treatment of vertebral arteriovenous fistula (AVF) presents serious difficulty and risk. A 5-year-old girl was seen with a complaint of loud bruit in the left neck since birth. Selective angiography of the vertebral artery showed multiple AVF. A combined procedure involving proximal ligation of the vertebral artery and Fogarty balloon occlusion of the distal portion of the AVF was used in our case without complication and with complete cure of AVF.

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During the 10-year period from January 1976 to December 1985, reconstructive surgery was performed on 90 patients with arteriosclerosis obliterans of the abdominal aorta or iliac arteries, including anatomical bypass surgery on 121 limbs (72 patients).
Four of the limbs (3 patients) had graft occlusions and another five (4 other patients) had anastomotic stenoses.
These seven cases were reviewed with special emphasis on the causes and the prevention of the problems.
These patients were all males, and their ages ranged from 43 to 62 years. The operations performed were four Y-graftings and three single graftings. Re-operations were performed on five patients and the other two refused.
From the arteriographic and operative findings, the main causes were found to be an improper anastomotic site or procedure, progression of distal lesions, poor run-off, and anastomotic pannus formation (anastomotic neointimal hyperplasia).
For its prevention, proximal anastomosis should be preformed at a higher point of the abdominal arota with end-to-end anastomosis as far as possible and distal anastomosis at the profunda femoris artery, and an antiplatelet drug should be given after surgery.

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The patient was a 54-year-old female. She had frequently suffered from common colds since infancy and had had coughing attacks during meals since the age of 12. A bronchoesophageal fistula was discovered accidentally by esophagography. In the operative findings, the fistula was easily freed from the neighboring tissue, and there were no inflammatory signs were found around the fistula. The lumen of the fistula was covered with striated squamous epithelium and surrounded by the proper muscle layer. There was no infiltration of inflammatory cells.
This disease is relatively rare. We reviewed 85 cases in Japanese literature in the context of our own case.

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The number of spontaneous ruptures of the esophagus reported in Japan is still smaller than in Western countries. Delay in diagnosis and inadequate treatment often cause an unfavorable outcome. We present a case of true spontaneous rupture of the esophagus that was repaired surgically.
The patient is a 65-year-old man without a drinking habit. He complained of sudden, severe chest and back pain, followed by dyspnea. Under the diagnosis of spontaneous rupture of the esophagus, direct esophageal repair and pleural drainage were performed 15 hours after the onset. Although there was complicating empyema due to the rupture, repeat irrigation, antibiotics and intravenous hyperalimentation cured the abscess in the pleural cavity. The patient recovered after 63 days of hospitalization.
The diagnostic accuracy is as low as 35.9%, and it is usual to misdiagnose the condition as perforated peptic ulcer. Gastrografin swallow is the most common diagnostic method, but advances in the esophageal fiberscope have drastically improved the diagnostic accuracy.
Surgery is the most important treatment and the timing of surgery is fundamental for a favorable outcome. Therefore, prompt diagnosis and immediate surgery lead to recover of the patient, considering the recent progress in pre- and postoperative management.

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A 36-year-old man visited our hospital with a complaint of dysphoria of the epigastrium. A torous lesion was observed in the cardia by esophagogastric fluoroscopy. The patient was diagnosed as having submucosal tumor by endoscopic and biopsy examinations, and transgastric excision of the tumor nucleus was undertaken. The tumor was oval-shaped (ca. 5.5cm in a long diameter), white and solid. The histopathological findings indicated benign leiomyoma. The course was favorable two years after operation. Only 28 cases of leiomyoma in the esophagocardiac junction have been reported in Japan. Cases of leiomyoma in the esophagocardiac junction were compared with those in the esophagus and stomach. The most common age of occurrence for leiomyoma in the esophagocardiac junction was relatively young, 30s to 40s, similar to that of lesiomyoma in the esophagus. Chief complaints on admission to hospital also resembled those in esophageal leiomyoma: disturbed deglutition, epigastralgia and subclinical condition. These chief complaints were clearly different from those in gastric leiomyoma, i.e., hemorrhagic symptoms, unidentified clinical epigastric condition and abdominal mass. Leiomyoma in the esophagocardiac junction, esophageal leiomyoma and gastric leiomyoma showed different patterns of tumor development, and preoperative diagnosis is difficult in all cases. Unless specific circumstances (a markedly large tumor suspected of being malignant, full peripheral development of a tumor, or the presence of a serious complication) are present, excision of the tumor nucleus should be carried out as the first choice treatment.

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Arteriovenous fistula is a rare complication after gastrectomy. A 66-year-old man was admitted because of upper abdominal pain and discomfort. He had a history of partial gastrectomy 35 years previously. Continuous murmur was heard in the epigastrium. A coeliacogram demonstrated a large venous branch of the portal vein. The arteriovenous fistula was excised and the afferent vessels were ligated. The patient showed an uneventful recovery and satisfactory postoperative course.

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The incidence of multiple primary cancers has been increasing year by year due to advances in diagnosis and treatment. Multiple primary cancers were most frequently present in the digestive system, especially in the stomach and other organs. During the 20 years from 1966 to 1985, 2106 patients with gastric cancers were admitted to our hospital and, of these, 53 patients 41 males and 12 females (2.5%) had cancer in other organs.
Thirty-one patients had synchronous multiple primary cancers in the stomach and other organs and 21 had metachronous cancers.
The majority of synchronous cancers were seen in the esophagus and the lung, these are known to have a poor prognosis. On the other hand, metachronous cancers were seen mainly in the colon, breast and uterus, they are known to have a good prognosis.

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Two patients who developed gastric cancer after gastrojejunostomy for benign lesions are reported.
Case 1. A 73-year-old male who had undergone gastrojejunostomy for bleeding of duodenal diverticulitis 10 years earlier; X-ray and endoscopic examination showed early gastric cancer, type IIa, in the antrum.
Case 2. A 61-year-old male who had undergone gastrojejunostomy for cholecystitis 21 years earlier; X-ray and endoscopic examination showed scirrhous gastric cancer.
Both patients underwent curative resection in our clinic.
Histological examination revealed tubular adenocarcinoma in the former patient and signet ring cell carcinoma in the latter.
We also discuss 18 cases of gastric cancer after gastrojejunostomy which have been reported in the Japanese literature.

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Although many cases of traumatic intramural hematoma in the duodenum in children have been reported, nontraumatic intramural hematoma in the large intestine is extremely rare. Recently, we experienced a case of intramural hamatoma in the sigmoid colon associated with Marfan's syndrome of the incomplete type (forme fruste). This case is described with some comments based on the literature.
The patient lacked ophthalmic symptoms and hereditary signs, but had skeletal anomalies. The complication of rupture of a dissecting aortic aneurysm due to median cystic necrosis accompanied by mucoid degeneration occurred after surgery. The patient's condition was thus considered to be Marfan's syndrome of the incomplete type. It is said that lesions in the cardiovascular system in Marfan's syndrome are attributable to abnormalities in the proteins composing the connective tissue or of the system for controlling protein production. The presence of a degenerative condition, Marfan's syndrome, may also have been involved in the formation of the intramural hematoma in the sigmoid colon of this patient.

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A 30-year-old woman had obstructive jaundice 10 days after a steering-wheel injury. Further examination revealed stenosis of the middle portion of the bile duct, intimal dissection of the distal end of the common heaptic artery, and occlusion of the gastroduodenal artery. Stenosis of the bile duct was cured only by external cholecystostomy. Dissection of the hepatic artery progressed proximally, but no treatment was necessary. The mechanism of these injuries appears to be the shearing force applied to the bile duct and heaptic artery due to cephalad movement of the liver by an external blow.
There have been 10 cases of traumatic bile duct stenosis reported in the Japanese literature, and one case was added. In most cases, jaundice appeared about two weeks after the injury, and the site of the stenosis was the middle portion of the bile duct, and the patient was cured only by external biliary drainage.
This case seems to be the first reported case of bile duct stenosis with injury to the hepatic artery due to blunt abdominal trauma.

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We recently encountered a case of cystic lymphangioma of the spleen. The patient was a 57-year-old woman who was admitted to our hospital with a chief complaint of epigastric pain. Upon laparotomy, multiple cyst of the spleen was seen and splenectomy was performed. Histology revealed a benign cystic lymphangioma of the spleen and the inner layer of the lesion was covered with a cellular lining.
This disease was first reported in 1885 and 47 cases have been reviewed up to 1982. There have been only 23 reported cases of this pathological condition, including our own case, in Japan. Many of these cases had developed in relatively young women and their initial symptom was a feeling of fullness in the upper abdomen. The preoperative diagnosis can be made by upper GI series, CT scan and/or ultrasonography from a finding of extrinsic compression of the stomach or multiple cystic images of the spleen. It is generally accepted that the treatment of choice is splenectomy to prevent such conditions as rupture or bleeding or to relieve pressure on adjacent organs.

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A 70-year-old man was admitted to the department of medicine in our hospital with a diagnosis of metastatic lung tumor on October 23, 1985.
On October 26, he consulted our department following severe hematemesis and melena. We performed immediate examinations (US, CT, angiography, etc). The examinations revealed a tumor in the right kidney, which was suspected to be renal cell carcinoma, bleeding of the second portion of the duodenum and multiple metastases of the liver.
Transcatheter arterial embolization (TAE) was performed for treatment of the tumor and control of the duodenal bleeding.
On February 9, 1986, he died and autopsy was performed. Specimens obtained at autopsy showed the clear cell type of renal cell carcinoma. Histologically most of the tumor was necrotic, suggesting that TAE had been very effective. On the other hand, there was no influence of TAE on the tumor-free duodenal wall.

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A 53-year-old female was admitted to our clinic because of a pulsating tumor at the left cubital fossa. A swollen lymph node was also palpated proximal to the tumor. The tumor was diagnosed pseudoaneurysm of the ulnar artery from angiographic findings. Both the tumor and lymph node were removed surgically.
Histology of the tumor showed the formation of lymphoid follicles with infiltration of eosinophils, which suggested the diagnosis of Kimura's disease. However, further examinations including immunohistological studies, revealed further findings such as anomalous vascular proliferation, papillary growth of the endothelium with infiltration of eosinophils and marked infiltration of lymphocytes with lymphoid follicles. On the basis of these findings, the tumor was finally diagnosed as angiolymphoid hyperplasia with eosinophilia (ALHE). Previous cases of ALHE were reviewed, paying special attention to the differentiation between ALHE and Kimura's disease.

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