Metabolic function-morphologic correlation throughout whole-body sections with F-18-FDG PET/CT scan is an excellent tool for diagnosis and treatment strategy of malignancies of various organs. As well as in other regions, the recent systemic review and meta-analysis of accumulated experiences over the world has comprehended the utility of this technique in diagnosis and treatment strategy of abdomino-pelvic tumors. Especially, the panel recommends the physicians to use this technique for initial staging, therapeutic response assessment, re-staging and detection of recurrent or progressive lesions after surgery or chemo-radiation therapy, and for prediction of prognosis. On the other hand, the panel has clarified some limitations of this technique for differential diagnosis and accurate assessment of local tumor extension and lymph node metastasis, and recommends the combined use of other imaging modalities. This second chapter describes the utility and limitation of FDG PET/CT scan in esophageal and gastric cancer, gastrointestinal stromal tumor (GIST), primary and metastatic liver tumors, biliary ductal tumors, pancreatic and splenic tumors and colorectal cancers, based on systemic review of recent literatures.

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Through clinically safe procedures, medicine is about to provide the patients with highly qualitative outcomes. But we also know that actions by the today's management procedure are not enough. In this issue, I address that it is critical to introduce underlying problems about taking or injection of drugs for improvement of clinical safety

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Nutrition management, an important aspect of care, is undertaken by the nutrition support team (NST) at our hospital from an early stage of care. For many patients, ingestion is possible when performing percutaneous endoscopic gastrostomy (PEG), but it sometimes causes aspiration pneumonia by gastro-esophageal reflux in such patients. Furthermore, the dose of the enteral diet into the stomach creates a difficult case of leakage of nutrients from gastro-cutaneous fistula. Such cases necessitate the use of a transgastric jejunal catheter. Generally, the insertion technique includes oral insertion of an endoscope and guidance to the duodenum using a guidewire with forceps. However, we use a bronchoscope directly from the gastro-cutaneous fistula. This safe technique imparts little pain to patients and the insertion of the devices can be done in a short time. If diagnostic instruments and a bronchoscope can be manipulated easily, the procedure can be performed at a general hospital and reports it because it is a manual skill useful at all.

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Recently, breast cancers have increased in Japan. Sometimes, we meet women who develop breast cancer in both breasts. From 1990 to 2005, 618 women were treated for primary operable breast cancers in our hospital, 14 of them were developed bilateral primary operable breast cancers. 9 patients developed synchronous bilateral breast cancers, 5 patients developed metachronous. We compared them about age at operation, histology, hormone receptor status and survival. In synchronous cases, the mean age of diagnosis was about 57 years old. In metachronous cases, the mean age of diagnosis of the first cancer was about 61 years old. The mean age of the second cancer was about 70 years old. The mean interval between first cancer and second cancer was 115±44 months. In all cases most popular histologic type was scirrhous carcinoma. In our study, only 2 cases were matched histologic status in both. The lack of histologic correlation in bilateral cancers has been reported. Hormone receptor status was not matched in both breasts, too. Synchronous and metachronous bilateral breast cancers show almost the same for postoperative survival rate. Breasts are bilateral and symmetric organ. So we must try to follow closely for our patients of breast cancer.

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Based on recent 7 elderly cases (2 males and 5 females aged 80-88) those required artificial ventilation management after emergency abdominal surgery, the indications and usefulness of postoperative respiratory management were evaluated. Diagnosis were as follows: 2 bowel obstruction cases caused by small intestinal adhesions, 1 perforated duodenal ulcer case, 2 colonic or rectal cancer cases with perforation, 1 superior mesenteric artery obstruction case and 1 intraperitoneal abscess case. The etiology of postoperative respiratory dysfunction included respiratory failure due to shock and electrolyte abnormality, and the postoperative artificial ventilation management period was 2 to 99 days. Patients with a postoperative PaO₂/FiO₂ ratio of less than 200 required a longer artificial ventilation accompanying pneumonia, pleural effusion and SIRS. The cases with superior mesenteric artery obstruction and with intraperitoneal abscess died. The PaO₂/FiO₂ ratio just after surgery was useful for the prognosis of postoperative artificial ventilation management. When the pathologic condition is eliminated by operation and postoperative treatment, the prognosis of the elderly patient with prolonged artificial ventilation might be better.

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We describe a 49-year-old woman who underwent low anterior rectal resection for rectal cancer and radiofrequency ablation (RFA) for liver metastasis in June 2005, followed by oral administration of TS-1. In August 2005, although the patient's CEA level was elevated, abdominal CT revealed no recurrence. In December 2005, CT and PET revealed local recurrence in the liver, for which RFA was performed, followed by partial hepatic resection in May 2006. Adjuvant chemotherapy with FOLFOX was administered, followed by UFT/leucovorin starting in May 2006, followed by UFT alone from January 2007. In August 2007, elevation of the CEA level was again observed, and CT and PET revealed a tumor in the pelvic cavity. TS-1 was therefore administered again. In January 2008, as CT and PET revealed enlargement of the tumor, bilateral oophorectomy was performed. The postoperative pathologic diagnosis indicated that the tumor was a metastasis of the rectal cancer to the ovary. At the time of writing in May 2008, the patient remains disease-free after the ovarian surgery. If an ovarian metastasis of rectal cancer can be removed completely, surgical resection combined with chemotherapy is recommended to improve the prognosis.

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