From 1979 through 1992, we have conducted operations for differentiated thyroid carcinoma in 392 cases, 18 of which were under the age of 20. As in the case of adults, the same basic surgical approach was used for the young patients: 1) total thyroidectomy, 2) bilateral lymph node dissection, and 3) parathyroid autotransplantation. We attempted to determine the strengths and weaknesses of our operative approach by comparing for diameter of neoplasms, lymph node metastases and the like with adults, including the Quality of Life in the postoperative course. Tumor diameter was more than t2 in 80% of the cases, and in 60% of adults. Lymph node metastases were found in about 90% of the patients, and in 76% of the adults. Evidence of progressive carcinoma was found operatively in more young persons than adults, but there was no recurrence in all 18 cases. Postoperative complications included only a mildly lowered parathyroid function in one case and postoperative cheloid in 3 cases. No problem whatsover was noted in growth or development of the patients less than 10 years of age; 3 females who had come of age had children. Thus our surgical approach is considered appropriate, and promises sufficient radicality and favorable postoperative course.

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The possibility of performing limited surgical procedure such as simple closure or tube duodenostomy to perforated peptic ulcers was examined in 21 such patients treated by the limited procedure at the hospital in a period from 1981 to 1992. An average age of this patients group was 67.3±17.6. The male-to-female ratio was 17:4. The ratio of perforations in duodenal to gastric ulcer was 19:2. Almost of the patients (90%) had other serious disease and four cases already presented shock symptom when they arrived to the hospital. The reason why we performed the limited operation was old age, poor general condition or other serious disease. The mean time between onset of symptoms and operation was 19.1±17.9 hours. Postoperative complications were noted in 81% of them. The hospital mortality rate was 38% (8 case) and 13 patients were discharged from the hospital. MOF, renal failure and sepsis should be considered as reasons for operative mortality. The postoperative course was poor, because most patients had some high risks. However four survivors are free from any symptoms and do not need any therapy at present. If operative indication is properly considered, the limited surgical methods can be employed for perforative peptic ulcer.

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We investigated 21 cases of therapeutic methods of rectal carcinoids which had been treated in the hospital from 1961 to 1993. Looking closely into these cases, the male-to-female ratio was 12:9, and the mean age was 53-year-old. Classifying these cases, 9 cases belong to type Isp carcinoid, and the other 12 cases belong to type Is. The tumor size of these cases were between 2mm to 80mm. Endoscopic resections were operated in 14 cases, local surgeries in 5, and radical surgeries in 2. The usual therapeutic course needs the circumstance as follows; the endoscopic polypectomy should be done in the rectal carcinoids which are less than 15mm, and have no depression, no ulcer, no metatstasis, furthermore, the histological examination should be done. We reviewed our usual therapeutic course in detail.
In conclusion;
1. There was no recurrence in these 21 cases.
2. Function preserving therapy should be indicated for patient's Q. O. L., whenever possible.

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In this study our cases of hepatoma which developed after the treatment for esophagogastric varices caused by liver cirrhosis or those diagnosed as having a hepatoma and the varices simulatneously were studied, and some discussion on the therapeutic guidelines was added.
There were 25 cases of hepatoma following esophagogastric varices caused by liver cirrhosis. In 13 of the 25 cases, hepatoma was heterochronously found after the treatment of esophagogastric varices. Of the 13 cases, operation was performed in six cases as the treatment of the varices and EIS in another six cases. We were able to apply ourselves closely to treat the hepatoma in the six operated cases without worrying about bleeding from the varices. When compared for the prognosis, long-term survivors are noted in operated cases and there was no death due to hemorrhage. Operation is superior to the other in hemostasis. The remaining 12 cases were synchronuously diagnosed as having a hepatoma and varices. Of the 12 cases, two cases were operated on, in which we were able to concentrate on the treatment of hepatoma alone. It is concluded that aggresive attitude toward operation should be basically employed for the treatment of verices due to liver cirrhosis, if the hepatic functional reserve of the patient can permit it.

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In 30 patients following curative gastrectomy for gastric cancer in our institution, functional assess-ment (about (1) maximal fasting area (2) maximal contraction rate (3) presence of gallstones and debris echoes) at the gallbladder was made serially before, and 2, 4 weeks and 6 months after the operation by ultrasonography, and bile flow assessment was done 4 weeks after the operation by ^99mTc-N-pyridoxyl-5-methyltryptophan (^99mTc-PMT) hepatobiliary scintigraphy, to clarify the etiology of postoperative cholecystolithiasis.
By ultrasonography, significant enlargement and contractile dysfunction of the gallbladder was found in 29 patients except one patient who had undergone pylorus preserving gastrectomy (PPG), compared with preoperative values. However, these findings recovered gradually thereafter.
Debris echoes were visualized in 17 (58.6%) in 2 weeks, and in 14 (48.3%) in 4 weeks out of 29 patients. Transition from debris echoes to gallstones was comfirmed in only 2 (6.9%) of these 29 patients within 4 weeks. However, these findings disappeared gradually thereafter.
By hepatobiliary scintigraphy, we found a delayed tendency of bile flow of gallbladder, peak time of the common bile duct and time of RI appearance in the duodenum, and regurgitation of bile flow to intrahepatic duct after caerulein injection (0.2μg/kg i.m.) in 7 (24.1%) out of 29 patients except one patient with PPG in addition to dysfunction of gallbladder in 4 weeks.
It is concluded that denervation due to gastrectomy with lymph node dissection might cause dysfunc-tion of the sphincter of Oddi, especially failure of coordinated movement between the sphincter of Oddi and gallbladder, in addition to dysfunction of the gallbladder in an early period after gastrectomy for gastric cancer.

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We experienced a family consisting of three members with familial primary hyperparathyroidism without other endocrinal tumors.
Case-1: A 48-year-old woman, who had been followed at our outpatient clinic after an operation for a breast cancer, was accidentally pointed out hypercalcemia. She was diagnosed as hyperparathyroidism, and was operated on. The pathological diagnosis was hyperplasia. Case-2: A 63-year-old woman, the aunt of case-1 patient, had been suffering from attack of renal stone several times. She was diagnosed as hyperparathyroidism, and was also operated on. The pathological diagnosis was two adenomas of the parathyroid glands. The patient experienced a recurrence of hypercalcemia 12 years after the operation. Case-3: The patient was a 38-year-old woman, the sister of case-1 patient. A familial disease was suspected, and serum calcium levels of the family members were measured. The value of this patient was above the normal range. Ulrasonography of the neck revealed a tumor lesion, which appeared like a parathyroid gland. The patient was diagnosed as early stage of hyperparathyroidism.
We conclude that familial primary hyparparathyroidism is an incomplete type of multiple endocrine neoplasia. Its pathological type and the policy of operation are discussed.

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A 63-year-old woman noted several masses in her left axilla in January 1994. They were found to be enlarged lymph nodes measuring 4 to 5cm in diameter. There was no palpable nodule in the left breast. Echography revealed several lymph nodes in the C-C' region of the left breast, and modified radical mastectomy was performed on suspicion of primary malignant lymphoma of the breast. Pathological examination showed invasive ductal carcinoma of the left breast measuring 0.9×0.5cm associated with Hodgikin's disease of the left axilla.

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The patient was a 31-year-old man. An abnormal shadow was detected on chest radiography during a medical check-up conducted at the work place, and the patient consulted our department. While the patient was waiting for surgery under the diagnosis of a mediastinal tumor, he experienced sudden chest pain and dyspnea, and was admitted on an emergency basis. Thorax computerized tomography (CT) and MRI revealed a mass with irregular inside and a capsule in the middle mediastinal right hilar region, as well as right pleural effusion. The operation was performed under a diagnosis of a mediastinal tumor and pleurisy. Pleural effusion was absent during the operation. Since the tumor adhered to the central side of the right superior lobe so intensely that it was difficult to detac, we resected the tumor together with the right superior lobe. A yellow-white pultaceous substance and pus were seen in the resected specimen, and a hair-like substance was noted in some areas. Cavity formation was observed at the site where the tumor invaded the lung, and the inside of the cavity was filled with pus. Mature teratoma, with abundant sebaceous and salivary glands, was diagnosed histopathologically. A mediastinal tumor invaded inside the lung in this surgical case.

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A case of AFP producing malignant teratoma of the anterior mediastinum which rapidly enlarged is reported.
A 30-year-old man was found having an anterior mediastinal tumor on a chest X-ray film on a regular check-up. AFP level that had increased preoperatively to 2221.0ng/ml was normalized postoperatively. Histologically, the tumor was diagnosed as malignant teratoma with yolk sac carcinomatous area, with metastasis to mediastinal lymph nodes. Immunohistochemical staining for AFP was positive in tumor cells. The tumor seemed to have originated from the thymus.
The patient postoperatively received two courses of combination chemotherapy with cisplatinum and ectoposide. Fourteen months later, pleural dissemination occurred despite a normal AFP level. After another four courses of combination chemotherapy with cisplatinum, bleomycin and vinblastine, the pleural nodules were reduced in size and number.
In a review of the Japanese literature, 18 cases of malignant teratoma with yolk sac tumor were compared with 62 cases of pure yolk sac tumor for AFP level and prognosis.

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Mesotheliomas of the pleura are relatively rare and the malignant potential of them is still obscue. This time a localized mesothelioma of the pleura was thoracoscopically resected in a 52-year-old man. The patient was pointed out having an abnormal shadow on a chest X-ray film. Preoperative possible diagnosis was benign localized mesothelioma of the pleura. A thoracoscopic resection of the tumor was planned and, if necessary, a radical operation subsequently. Thoracoscopic resection of the tumor was performed safely and the diagnosis was confirmed pathologically as benign fibrous mesothelioma of the pleura.
We believe that thoracoscopic surgery which is less invasive and enables us to diagnose pathological-ly and to perform a subsequent radical operation, if necessary, is very useful, because needle biopsy is not effective, and open lung biopsy and radical pleuropneumonectomy are extremely invasive. Furthermore, the recurrence rate of localized mesotheliomas has been reported to be over 5% and clinical manifesta-tions of the disease are not adequate for predicting whether the tumor is malignant or not.
This patient has been followed for 1 year and 6 months, so far. He is doing well, but we will continue to monitor his condition carefully.

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A 73-year-old man, who had a blunt trauma on the left chest 41 years before which was treated conservatively, was admitted to the hospital because of bloody sputa and hemoptysis. The patient had been asymptomatic until recently. X-ray examination revealed a mass lesion occupying almost entire the left pleural cavity. No definite diagnosis was achieved for the lesion. The lesion was excised under a diagnosis of intrathoracic tumor. The excised tumor was a huge hematoma covered with fibrous capsule, and contained stratified organized tissue and fresh hemorrhage. Histopathologically it was hematoma composed of fibrin and red-blood-cells. The diagnosis of “chronic expanding hematorma” caused by the past thoracic injury was made.
The growing character of the chronic expanding hematoma that must often be indistinguishable for clinicians from malignant neoplasms has nerve been clearly explained. Our histological picture which showed abnormal multiplication of endothelial cells may support a theory that perpetuating bleeding and expanding of the lesion are resulted from development of damaged microcapillaries induced by chronic inflammation.

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This paper reports a case of traumatic diaphragmatic hernia, presenting with intestinal obstruction, which occurred 30 years after an accident.
An 89-year-old woman referred to the hospital because of abdominal distension, vomiting and dyspnea. There was a previous history of meeting with an accident at a coal mine 30 years before when she had chest contusion and a rib fracture. Chest X-ray showed an intestinal gas shadow in the left lung field. On laparotomy, there was a defect of 10cm in diameter at the central tendon of the left diaphragm. And the stomach, small intestine and transverse colon were escaped into the thoratic cavity. The defect was repaired with direct suture. From the previous history of trauma, the location of the defect, and the lack of the hernia sac, the patient was diagnosed as obstructive phase of traumatic diaphragmatic hernia. It is considered that a laparotomy is preferable as the first acsess in obstructive phase.

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A 72-year-old female was admitted to the hospital because of upper abdominal pain and vomiting.
A chest plain film demonstrated dextrocardia and bowel gas at the left phrenic o-costal angle. An upper GI barium series and barium enema revealed that the antrum portion of the stomach and transverse colon were incarcerated in the left thoracic cavity.
Surgery was carried out using the trans abdominal approach.
The operative findings included that the hernia sac contained the greater omentun, stomach and transverse colon; and that the liver and gallbladder were found in the left side of the abdominal cavity, the spleen was in the right side of it. Moregagni hernia has been reported in around 3% of all diaphrag-matic hernias, but we could not find any literature concerning this disease associated with situs inversus.
The most valuable diagnostic approaches were chest X-ray, CT, or MRI scan and barium GI series.
She was discharged in satisfactory condition on the 14th postoperative day uneventfully.

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A 52-year-old woman was admitted because of dysphagia and an oppressive feeling in the chest. Chest X-ray, esophagogram, esophagoscopy, EUS, CT, MRI, bronchoscopy and bronchial artery angiography findings led to a diagnosis of middle to posterior mediastinal tumor (bronchogenic cyst). At surgery, a mass originating in the muscle coat of the esophagus was identified and successfully removed along with a part of the esophageal mucosa. The resected specimen was a solid mass and 7×5×5cm in size. Microscopically, the tumor was composed of spindle cells in irregular fascicles, reminiscent of Antoni A type tissue. Immunohistochemically, tumor cells were positive for S-100 protein staining but negative for muscle specific actin (HHF35) staining and desmin staining. The final diagnosis was neurinoma of the esophagus.
Neurinoma of the esophagus is an extremely rare disease. To our knowledge, this is the seventh case of neurinoma of the esophagus reported in the Japanese literature.

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This paper reports a case adenoid cystic carcinoma of the esophagus. A 74-year-old man was admitted to the hospital because of discomfort in swallowing. Polypoid lesion was found in the middle third of the esophagus and an adenoid cystic carcinoma was suspected by biopsy. Subtotal esophageal resection was performed. The resected specimen was 25×22mm in size. Histological studies revealed that the specimen had cribriforme and tubular pattern, and mucinous substance in the interstitum and cystic space was positive in alcian-blue stain. We diagnosed as pure adenoid cystic carcinoma. His-tologically it was sm, n (-), ly (+), v (+), in stage I. In a review of the Japanese literature, 43 cases including this case were clinically analyzed. When compared with squamous cell carcinoma, this adenoid cystic carcinoma was common in women and had a poorer prognosis. The 43 cases of patients with adenoid cystic carcinoma in the Japaneses literature were reviewed. The rate of woman was less and prognosis was worth than squamous cell carcinoma. Histologically pure cases of adenoid cystic car-cinoma represented 59% of all cases and the tumor must have origniated from the esophageal gland.

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Small cell carcinoma of the esophagus has a poor prognosis. It has been reported that the mean survival period is 5.3 months. Recently we experienced two resected cases of small cell carcinoma of the esophagus survived more than two years after surgery. Both patient had a stage I carcinoma and underwent thoracic esophagectomy with R3 lymph node dissection. In a review of literature, all survivors for more than 2 years had no distant metastasis and underwent the multidisciplinary therapy comprising of radical resection of the tumor with lymph node dissection and some adjuvant therapy. However, overall prognosis of small cell carcinoma of the esophagus is very poor, and there is no effective treatment for improving the prognosis. In the present state of treatment, early diagnosis before distant metastasis occur and multidisciplinary treatment consisting of radical resection and combined therapies such as chemotherapy and irradiation are the treatment of choice.

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A 61-year-old man with synchronous triple cancer involving the esophagus, stomach and colon underwent attempted curative resection.
Surgical resection was performed for the thoracic esophageal cancer and gastric cancer, and the colon cancer was resected by endoscopic polypectomy.
The patient died of pleuritis cartinomatosa 120 days after surgery.
A total of 8 cases of synchronous triple cancer of the esophagus, stomach and colon have been reported in Japan, including 5 in which cancer resection was attempted and 1 in which the patient lived for longer than 1 year after resection.

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A 52-year-old man underwent gastrectomy because of a perforated gastric ulcer. Gross observation of the resected specimen showed a normal gastric mucosa but perforated ulcer. Histological examination, however, revealed many lymphoid follicles without atypia, which were proliferated ranging from the mucosal to the subserosal layer of the gastric wall. Immunohistochemically, the infiltrated lymphocytes among the lymphoid follicles did not have monoclonal B-cell or T-cell proliferation, and lymphoid follicles did not show monoclonality for the stainings of light chains of immunoglobulin. This study enabled us to make the final diagnosis of this case as reactive lymphoid hyperplasia of the stomach. The patient is now free of recurrence as of 2 years and 5 months after the surgery.
Most of the cases diagnosed as reactive lymphoid hyperplasia of the stomach in Japan were low grade malignant lymphoma, so benign lymphoid hyperplasia like this case is rare.

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Two cases of intractable complete external pancreatic fistula following pylorus preserving pan-creatoduodenectomy (PpPD) were successfully treated by fistulogastrostomy. Cases: PpPD was perfor-med in two cases of early duodenal cancer and lower bile duct cancer. Insufficient pancreatojejunostomy resulted in complete external pancreatic fistula. Fistulography after conservative treatment revealed complete obstruction at the anastomosis. Fistulograstrostomy was performed 8 months and 6 months after the initial operation, respectively. Method: Skin incision was placed around the external orifice. The fistula was dissected carefully from surrounding tissue until the minor curvature of the stomach appeared. The fistula of 3cm in length was obtained and a 6 Fr drainage tube was inserted into the fistula. Seromytomy was placed on the anterior wall of stomach, tip of the fistula was sutured to the stomach mucosa, and the fistula was covered by seromuscular layer. The drainage tube was extracted through the anterior wall of stomach. Result: Postoperative course was uneventful in both cases with no abnormal elevation in serum amylase nor formation of pancreatic pseudocyst. This procedure is easy to perform and useful in the treatment of complete external pancreatic fistula following PpPD.

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We report a case of hydronephrosis associated with appendicitis.
A four-year-old girl was admitted to our hospital on August 21, 1994 with right flank pain and fever. We suspected appendicitis, but abdominal ultrasound demonstrated appendical abscess and hydrone-phrosis on the right side. IVP revealed hydronephrosis and hydroureter on the same side. Surgery was performed with a diagnosis of hydronephrosis associated with appendicitis.
Appendiceal abscess was confirmed. IVP performed 3 weeks later revealed a normal urogram. A total of 9 cases in the Japaanes literature, including this case, were reviewed to examined clinical differences.

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Mucocele of the appendix is rare, especially that causing intussusception. We present a case of adult intussusception caused by malignant mucocele of the appendix concomitant with an ascending colon cancer. A 67-year-old woman was seen at the hospital because of lower abdominal pain. Abdominal ultrasonography and computed tomography revealed a target-like mass with a cystic lesion in its central area. Barium enema showed a crab-finger defect at the hepatic flexure, and we diagnosed as intussuscep-tion, but this intussusception was reduced by slowly increasing hydrostatic pressure. Extraluminal suppression to the cecum and an elevated lesion of the ascending colon were visualized. The patient was diagnosed as having intussusception caused by mucocele of the appendix and an ascending colon cancer. Right hemicolectomy was performed. Histological examination revealed synchronous cancers of mucinous cystadenocarcinoma of the appendix and well differentiated adenocarcinoma of the ascending colon. This paper also presents a review of 10 cases of mucocele or mucinous cystadenocarcinoma associated with a colon cancer in the Japanese literature. It is supposed that we should examine the entire colon in a case of mucocele of the appendix, because some mucocele of the appendix are often associated with a colon cancer.

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Acute colonic pseudo-obstruction (ACP) is characterized by prominent gaseous colonic dilatation without organic lesions.
This syndrome should be treated carefully because it resembles paralytic ileus but is far different from the latter in etiology and clinical course. We report a case of ACP in a 61-year-old man who had past history of left nephrectomy 20 years ago and underwent partial descending colectomy for colonic cancer. His early postoperative course was uneventful, but mild abdominal distention and gaseous colonic dilatation developed about 10 days after the operation. When nasogastric suction therapy failed to dissolve the progression of the abdominal distention and colonic gaseous dilatation, cecostomy was performed on day 22. Prompt improvement was observed after cecostomy, and a contrast study of the entire colon via the cecostomy revealed no evidence of mechanical obstruction, including adhesions, colonic torsion or anastomotic failure.

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We report a resected case of liver metastases of colon cancer. The metastasis was found directly invading the duodenum. The patient was a 63-year-old female. One year and two months previously, sigmoidectomy and cholecystectomy had been performed for Dukes' C colon cancer and cholecystoli-thiasis. During follow up, an extrahepatically protruding tumor was found on the lower surface of the right lobe of the liver. In January 1993, extended posterior segmentectomy of the liver, pylorus-preserving pancreatoduodenectomy and regional lymph node dissection were performed. The largest metastasis was 8.0cm×7.0cm×7.0cm in size. Histologically, it was well-differentiated adenocarcinoma compatible with the primary colon cancer.
To the best of our knowledge, this is the first case of the liver metastasis treated by hepatopan-creatoduodenectomy. We think that combined resection, such as pylorus-preserving pan-creatoduodenectomy, is useful in treating liver metastasis invading neighboring organs or structures, if macrocopically curative resection has been achieved.

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A 61-year-old female was referred to the hospital for the surgical treatment of a carcinoma of the rectum. There was a past history of receiving irradiation for an advanced cancer of the cervix uteri 19 years before. As abdominal symptoms of radiation-induced colitis increased in degree for those several months, the patient was investigated through the barium study and colonoscopy. Carcinoma was pointed out at the rectosigmoid colon, then a radical operation was performed. The adhesion was so strong inside the pelvis. The main tumor was resected and Hartmann's operation was performed. Mucinous carcinoma with its subserosal invasion without lymph node metastases was observed pathologically.
Although the effectiveness of the irradiation for the cancer of the cervix uteri is today undoubtful, the radiation-induced colorectal cancer has been increasingly reported than before. Since our case satisfies some important factors of the criteria of the radiation-induced cancer proposed previously, it is reported with some review of the literature.

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A case of focal nodular hyperplasia (FNH) of the liver is reported.
A 30-year-old man was admitted to our hospital because of an epigastric tumor. Palpation revealed a 9×9cm tumor. Abdominal CT and echography demonstrated a tumor in the left lobe of the liver. Hepatic angiography revealed a hypervascular tumor. Left hepatic lobectomy was performed. The resected mass measured 9×9×7cm and weighed 310g. FNH was confirmed histologically. The postoperative course was uneventfully and the patient is well six months after surgery.

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We report a case of cholangiocarcinoma of the liver coexisting with a huge cyst. A 23-year-old woman came to Tottori University Hospital complaining of an upper-abdominal mass. Ultrasonography showed a huge cystic lesion in the left lobe of the liver. A CT scan revealed not only the multilocular cyst but a low density area in the liver adjoining the cyst. Percutaneous drainage of the cyst and 100% ethanol injection therapy were preferred because the lesion was initially judged to be benign. The low density area in the liver was larger in the follow-up CT scan, and was diagnosed as malignant by aspiration biopsy cytology. Laparotomy revealed a liver tumor with a cyst, and peritoneal and lymph node metastases. Palliative left lobectomy of the liver was performed, and the patient died 259 days after surgery. Histologic examination revealed cholangiocarcinoma of the poorly differentiated type. Surgery is highly recommended for such cystic lesions of the liver when malignancy has not been ruled out.

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A 67-year-old woman was pointed out having a lesions in the pancreas during the treatment for tuberculosis of the lung with INH/RF/EB. Abdominal ultrasonography showed a low echoic lesion, sized 20×17mm, in the body of the pancreas, in which high echoic spot without acoustic shadow was seen. The lesion was recognized to be a low density area in CT. In MRI, it was low intensity area in T1, and high intensity area in T2 weighted image. In ERP, the main pancreatic duct was slightly pressed. Abdominal angiography revealed a slightly stained lesion. Cystic pancreatic disease or localized pan-creatitis was suspected. On laparotomy, the body of the pancreas was localized hard and adhered to the surrounding tissue. Resection of the body and tail of the pancreas with spleen was performed. Path-ologically, most of the lesion was composed of hyalinized, organized, and granulated serous cystadenoma. Localized pancreatitis was existed in contact with it. We supposed that localized pancreatitis was caused by the existence of serous cystadenoma, and then the inflammation spread to the adenoma.

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A case of cecum cancer metastasizing to the spleen ten months after a radical operation which was detected by elevated serum CEA is reported.
A 56-year-old woman developed a cecum carcinoma with high serum level of CEA. Although serum CEA level had been almost normalized after right hemicolectomy, it elevated again during the follow-up period. Splenic tumor suggestive of recurrent cecum cancer was pointed out by CT scan and angiogram. Splenectomy, sampling of lymph nodes, and resection of peritoneal nodules were performed at the 2nd operation. In histology, they were moderately differentiated adenocarcinoma consistent with the primary tumor. Tumor thrombus was observed in the splenic sinus.
Detection of splenic metastasis from colonic carcinoma is extremely rare during clinical course, since most splenic metastasis is found as a part of wide-spreaded metastasis in autopsy studies. Although prognosis of the patient with splenic metastasis is very poor, solitary metastasis will be indication for splenectomy. In this case hematogenous metastatic pattern was suggested.

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This paper describes a resected case of heterochronous metastases to the lung and left adrenal gland from a rectal cancer.
A 64-year-old man underwent an amputation of the rectum for a rectal cancer in December, 1990. The excised tumor was Borrmann type 2, Ra, b, Cir, H0, P0, N0, and A2 in Stage II. Histologically it was well differentiated adenocarcinoma. In November, 1992, a chest X-P prevealed a tumor in the right lung. Under a diagnosis of metastasis of the rectal cancer, right lower lobectomy was carried out. In clinical course general fatigue enhanced and CEA increased to 14.1ng/ml. Abdominal CT visualized a left adrenal tumor. Needle biopsy cytology resulted in Class 5. Adrenal metastasis of the rectal cancer was suspected from various examinations. In September, 1993, excision of the left adrenal tumor was performed. The excised tumor was 6.5×8.5×5.0cm in size and 160g in weight. Histologically it showed features suggestive of metastasis of the rectal cancer. Postoperative course was uneventful. General fatigue disappeared and CEA level decreased to 5.2 ng/ml from a preoperative level of 144.7ng/ml.

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Adrenocortical tumors, usually adrenocortical carcinoma, producing hormonal symptoms are very rare in children. A 4-year-old girl with acne, general obesity, moon face and hypertrichosis was admitted to our hospital. Hormonal studies demonstrate high urinary excretion of 17-OHCS and 17-KS, and a high serum testosterone concentration. The serum ACTH concentration low was and the cortisol level was within the normal range.
A right adrenal tumor was detected by CT scan, MRI and ultrasound. Complete extripation of the tumor, weighing 126g, was carried out successfully. Pathologically a diagnosis of adrenocortical car-cinoma was made because of the presence of venous and capsular invasion by the tumor cells.
It is very difficult to make a pathological diagnosis in this tumor. Although prognosis of adrenocor-tical carcinoma is poor, the patients is doing well with no signs of postoperative recurrence.

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A 78-year-old woman who had no past of abdominal surgery or injury came to our hospital because of pain and vomiting. On admission her abdomen was distended and tender. Abdominal X-ray films revealed dilated loops of small intestine in the upper abdomen, and a CT scan showed an intestinal shadow in the omental bursa. An ileus long tube was inserted, but the intestinal shadow did not resolve and we operated suspecting internal hernia. At laparotomy defect in the lesser omentum was found to be a hernia orifice, and 30cm of small intestine were incarcerated. The small intestine was not necrotic, so the lesser omentum was partially resected and the small intestine was reduced. The postoperative course was good, and the patient was discharged after 4 weeks.
Internal hernia is rare in ileus, and we have reported an even rarer case of lesser omental hernia along with a review of the literature. There are many unkown aspects of the predisposing causes of lesser omental hernia, but treatment is the same as in any other type of ileus. When caring for ileus patients, the possibility of internal hernia should be kept in mind. We should be alert to the characterisitc X-ray and findings.

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Primary torsion of the omentum presenting with acute abdomen is a relatively rate entity. There are only 33 cases which had no organic disease in the Japanese literature. This paper describes such a case of primary torsion of the greater omentum.
A 54-year-old female was admitted to the hospital because of a severe abdominal pain localized in the right upper quadrant. On physical examination, tenderness and muscle defense were noted in the region of right hypochondrium. She had high fever and leukocytosis. An emergency operation was performed under a diagnosis of suspicion of perforative peritonitis. At laparotomy, a 5.6×3.8×2.5cm dark-red omental mass was found associated with a few bloody ascites. It was a part of the greater omentum and infarcted by torsion (2.5 times in a clockwise rotation). The affected omentum including normal surround-ing tissue was resected. Histological findings showed necrotic change of the omentum with hemorrhage and mild inflammatory cells infiltration. The postoperative course was uneventful.
Thirty four cases including our case in the Japanese literature are reviewed.

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Retroperitoneal serous cyst is extremely rare, and 49 cases have been reported in the domestic literature. This paper describes a case of retroperitoneal serous cyst, with a review of the pertinent literature.
A 62-year-old female was seen at the hospital because of right lateral abdominal discomfort. In abdominal ultrasonography and computed tomography, cystic mass including homogeneous content of watery density was detected locating inferior to the right kidney, measuring 10×7×6cm in size, and was diagnosed as retroperitoneal cyst preoperativelly. The cyst was revealed in the retroperitoneal space, locating inferior to the right kidney and dorsal to the ascending colon besides. Gross findings of the specimen included smooth surface, thin and transilluminated capsule, measuring 10×6×5cm in size. Cross section view of the cyst revealed monoloculated, and yellowish serous fluid was standed in the cyst, measuring 230ml in quantity. Histologically, the epithelial component of cyst wall was simple cuboidal epithelium mingled cilliated cells, and strikingly resembled the ovarian tube epithelium. Accordingly, the origin of the cyst was guessed that the retroperitoneal mesothelium was metaplastically transformed to the muellerian cell system, and the definite diagnosis was made with retroperitoneal serous cyst. The patient has been in good health without a sign of recurrence for 8 months after the operation.

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A retroperationeal cavernous hemangioma especially accompanied with Kasabach-Merrit syndrome has been rarely reported.
A 68-year-old woman was admitted to the hospital because of abdominal fullness. On physical examination, she appeared healthy except for a first sized elastic hard tumor palpated in the left hypochondrium. Laboratory studies including tumor markers were all negative. CT and magnetic reso-nance imaging (MRI) studies revealed a well demarcated tumor near the left iliolumbar muscle, 10 by 10cm in size, containing a cystic component and calcification in part. After admission, thrombocytopenia with bleeding tendency was developed. Anti-DIC therapy was started, which however, was not effective. Eventually, emergent life saving surgery was performed under thrombocyte transfusion, because the mass lesion which might have caused DIC was suspected to be malignant. She recovered from DIC state immediately after the tumor extirpation. She was doing well, when discharged on the 20th postoperative day. Pathological diagnosis was defined to be carvenous hemangioma with intravascular papillary endothelial hyperplasia. The pathogenesis of Kasabach-Merritt syndrome related to the cavernous hemangioma was also considered in this case.

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A case of giant lymphocyst in the retroperitoneum in a 41-year-old woman is reported. This patient had undergone hysterectomy and lymph node dissection for a uterine cancer one year before. Postoper-ative course was uneventful except that a lymphocyst was recognized in the right retroperitoneum. Thereafter leg edema, right lower abdominal pain and fever developed and became severe gradually. The patient was admitted to another hospital. Conservative treatment with antibiotics and ureteral catheter-ization by transurethra for hydronephrosis failed to provide any symptomatic remission. The patient was referred to the hospital and was operated on an abscess formation in the right retroperitoneum. The patient was managed in ICU because of severe infected retroperitoneal lymphocyst and re-expansion pulmonary edema in the right lung. Postoperative course was good. No reccurence has been recognized for one year after the operation.

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We encountered a case of malignant fibrous histiocytoma (MFH) originating in the retroperitoneal region, in which the tumor was surgically resected but pancreatic and pulmonary metastases occurred two years after the first operation, and the metastatic foci were resected. The patient was a 56-year-old woman whose course after retroperitoneal MFH resection had been followed up at the outpatient clinic. The patient began to complain of epigastralgia two years after the operation. Pancreatic and pulmonary metastases were detected on detailed examination, and the metastatic foci were resected simultaneously. The tumor was histopathologically diagnosed as metastatic malignant fibous histiocytoma.
MFH originating in the retroperitoneal region is rarely accompanied by subjective symptoms, and is often detected as a huge mass. Accordingly, the incidence of local recurrence and metastasis is higher than MFH originating in other regions, resulting in a worse prognosis. Preferential sites of metastatic foci include the lung, liver and bone. Pancreatic metastasis, as observed in our patient, is extremely rare. Accessory therapies such as radiotherapy and chemotherapy have been performed more frequently, but no established therapy is available. Effects for early detection of the recurrence should be made through careful postoperative follow-up, in order to resect the metastatic foci in the earliest stage possible.

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A 47-year-old asymptomatic man visited a near by hospital for a routine physical examination. A huge abdominal tumor as large as infant's head sized was detected, and he was admitted to our hospital for further examination and treatment. After several examinations, the tumor was identified as a retroperitoneal multicystic tumor, but no definite diagnosis could be made. The tumor was in contact with pancreas, left adrenal and left kidney but was easily removed without resecting other organs. The resected specimen was 19cm in diameter and weighed 1950g. Histopathologically, Antoni A and B regions were observed and a ganglion was noted adjacent to the tumor.
Immunologically, S-100 protein stained positive and ultimately the tumor was diagnosed as an ancient schwannoma. Retroperitoneal ancient schwannomas are rare and the lesion in this case was the largest found in a review of the literature.

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This paper describes our experience with a case of adult presacral epidermoid cyst. The patient was a 54-year-old woman. She was followed on an ambulant basis after gastrectomy for a gastric cancer. In July, 1992, she was pointed out having a tumor by digital examination and was admitted to the hospital for examination and treatment. The tumor was diagnosed as presacral teratoma by retrograde colonogra-phy, colonoscope, pelvic computed tomography and Magnetic resonance image. She was operated on by using a sacral approach. Pathologically the inside of the cyst was polylayerd squamous epithelium with keratinization and bulged to inner space. No sebaceous gland, sweat gland and hair were found. Pathological diagnosis was epidermoid cyst.
Adult presacral tumors are rare, especially epidermoid cysts. Only four sach cases have been reported in Japan.
Though the diagnosis should be made totally by digital examination and a variety of imagings, the definite diagnosis relies upon pathological examination. The tumor has sometimes a malignant potential, and so surgical resection is recommended.

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