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OBJECTIVES: Magnifying narrow-band imaging (M-NBI) is more accurate than white-light imaging for diagnosing small gastric cancers. However, it is uncertain whether moving M-NBI images have additional effects in the diagnosis of gastric cancers compared with still images. DESIGN: A prospective multicenter cohort study. METHODS: To identify the additional benefits of moving M-NBI images by comparing the diagnostic accuracy of still images only with that of both still and moving images. Still and moving M-NBI images of 40 gastric lesions were obtained by an expert endoscopist prior to this prospective multicenter cohort study. Thirty-four endoscopists from ten different Japanese institutions participated in the prospective multicenter cohort study. Each study participant was first tested using only still M-NBI images (still image test), then tested 1 month later using both still and moving M-NBI images (moving image test). The main outcome was a difference in the diagnostic accuracy of cancerous versus noncancerous lesions between the still image test and the moving image test. RESULTS: Thirty-four endoscopists were analysed. There were no significant difference of cancerous versus noncancerous lesions between still and moving image tests in the diagnostic accuracy (59.9% versus 61.5%), sensitivity (53.4% versus 55.9%), and specificity (67.0% versus 67.6%). And there were no significant difference in the diagnostic accuracy between still and moving image tests of demarcation line (65.4% versus 65.5%), microvascular pattern (56.7% versus 56.9%), and microsurface pattern (48.1% versus 50.9%). Diagnostic accuracy showed no significant difference between the still and moving image tests in the subgroups of endoscopic findings of the lesions. CONCLUSIONS: The addition of moving M-NBI images to still M-NBI images does not improve the diagnostic accuracy for gastric lesions. It is reasonable to concentrate on taking sharp still M-NBI images during endoscopic observation and use them for diagnosis. TRIAL REGISTRATION: Umin.ac.jp UMIN-CTR000008048.

As improvements in the diagnosis and treatment of malignant tumors extend the average length of patients' lives, the incidence of multiple primary malignant tumors has been increasing. As a result, incidents of triple cancer are frequently found and even quadruple cancers are observed occasionally. However, a case in which radical operations can be performed for all the tumors of quadruple cancer is still rare. We report an unusual case of metachronous quadruple cancers, which included triple cancers in the head and neck region, where it was possible to perform surgery on all the primary lesions.

症例は51歳,女性.48歳時に急性網膜中心動脈閉塞症の既往があり,全身倦怠感,黄疸を主訴に入院.各種ウイルスマーカー陰性,高γグロブリン血症(2.8g/dl),抗核抗体陽性(160倍)を認め,本邦厚生省研究班ならびにInternational Autoimmune Kepatitis Groupの診断基準を満たしたことより,急性肝炎像にて発症した自己免疫性肝炎(AIH)と診断された.肝炎は入院後に重症化したために,prednisolone (30mg/日)の投与と血漿交換療法を施行したところ奏効し軽快した.肝生検では広範な肝細胞の壊死脱落を伴った急性肝炎(confluent necrosis type)と診断された.さらにその既往歴やIgM抗cardiolipin抗体(IgM-aCL)陽性などから,抗リン脂質抗体症候群(APS)の合併が疑われた.APSと急性肝炎との合併例の報告はなく,この合併により予想される病態や検査の上での問題点ならびに重症肝炎時に検出するaCLの意義について文献的考察を加え報告する.

We present a rare case of leiomyoma arising in an accessory right bronchus in a 55-year-old man who had been treated for bronchial asthma. Diagnosis was established on the results of bronchoscopic biopsy. An emergency operation was performed because the patient had begun to complain of severe dyspnea. The tumor was completely removed by electrocautery with a wire snare by rigid bronchoscopy. Postoperative bronchoscopic findings revealed a tracheal bronchus arising above the carina, and the root of the tumor existed in the orifice of the branch. Final histology revealed a leiomyoma.

Primary mediastinal liposarcoma is an unusual variant of mediastinal neoplasms. We describe a long-term survivor who underwent repeated operations. After resections through a posterolateral thoracotomy and median sternotomy, a third operation was performed for recurrent bilateral huge tumors through a clamshell incision, and both tumors were removed en bloc. Results of pathologic examination showed that both tumors were well-differentiated liposarcoma. The patient is currently well 16 years after the first operation. Aggressive surgical intervention whenever possible appears to improve the quality of life and prolong the survival of patients with mediastinal liposarcoma.

多形性腺腫は唾液腺の中では一般的な腫瘍である。大唾液腺, 特に耳下腺にしばしば発生する。小唾液腺においては, 普通は口蓋に発生し, 口唇の発生は比較的まれである。上唇に発生した多形性腺腫の3例を報告した。それらは, 境界明瞭で可動性であり, 局所麻酔下に容易に切除できた。再発は認めなかった。病理組織学的に多形性腺腫と診断された。日本語文献上われわれが渉猟しえた限りでは, 小唾液腺腫瘍919例のうち上唇多形性腺腫は39例 (4.2%) であった。口唇の術後の変形や機能障害が起こることを考慮して安全域を設定する必要がある。

We report here a case of chronic eosinophilic pneumonia with significant endobronchial involvement. A 59-year-old man was admitted complaining of fever, productive cough, wheezing, and dyspnea. There were ground-glass opacities in bilateral upper fields and tram track shadows in the left lower lung field on chest x-ray, and ground-glass opacities in bilateral upper lobes, thickening of the bronchial walls, and centrilobular nodules on computed tomographic scan of the chest. There was marked eosinophilia in the peripheral blood and bronchoalveolar lavage fluid and was diagnosed as chronic eosinophilic pneumonia. Bronchoscopy also revealed white nodules at the orifice of the right S and the left S bronchi. The histologic examination of these nodules revealed eosinophilic inflammation into the bronchial wall. This is a rare case of chronic eosinophilic pneumonia with endobronchial eosinophilic involvement.

Narrow-band imaging (NBI) is useful for detecting superficial oropharyngeal lesions. However, the diagnostic and treatment guidelines for NBI are not established. The aim of the present study was to evaluate the treatment strategy for these microlesions.From October 2008 to September 2009, 68 flat-type brownish microlesions were observed in the orohypopharynx using NBI. Lesions were examined via magnifying NBI (M-NBI) and followed up without biopsy or endoscopic resection for12 months. To clarify the characteristics, lesions were compared with the endoscopic characteristics of flat-type lesions diagnosed by biopsy and endoscopic resection as squamous cell carcinoma and high-grade intraepithelial neoplasia.The average diameter of the 68 lesions was 1.6 mm (range, 0.5-5 mm). At the 1-year follow up, 19 lesions had disappeared. No size increases or morphological changes wereobserved among 49 lesions followed for1 year. At 2 years, 10 patients had dropped out and 11 lesions had disappeared. No changes were observed among 28 lesions followed for2 years. Of the flat-type lesions as squamous cell carcinoma and high-grade intraepithelial neoplasia, a distinct border and irregular distribution of atypical vessels were observed in all cases using M-NBI. These findings were observed in two of 68 flat-type brownish microlesions during follow up.Although there is some possibility of squamous cell carcinoma or high-grade intraepithelial neoplasia, flat-type microlesions of ≤5 mm diameter in the orohypopharynx may be followed for up to 2 years without biopsy or endoscopic resection.

Patients with bone metastasis originating from gastric cancer experience complications from DIC. They are treated with anticoagulation therapy or platelet transfusion, but their prognosis is poor. Our case was a 50-year-old male who had undergone distal gastrectomy for early gastric cancer[pT1a(M)N0M0, pStage I a]ten years previously. He was admitted to our hospital complaining of backache. As a result of his examination, he was diagnosed with disseminated carcinosis of bone marrow with DIC as a postoperative recurrence of gastric cancer. The patient was treated with combination chemotherapy of S-1 and cisplatin(S-1 80 mg/body, po, day 1-21 and cisplatin 50mg/body, iv, day 8). After one course of treatment, DIC was resolved and his pain was relieved. He survived for about nine months. S-1 and cisplatin are considered to be effective for disseminated carcinosis of bone marrow.

There are few reported cases of intrathoracic Ewing's sarcoma, a very rare malignant neoplasm. We report a surgical case of extraskeletal Ewing's sarcoma that had been followed-up as a stable sized tumour for many years, which then grew rapidly within a year. A 27-year old female patient with a rapidly growing abnormal shadow on chest roentgenogram was admitted to our department. She had undergone periodic examinations including chest computed tomography (CT) scans for 6 years since a small nodule in her chest had been pointed out by chest roentgenogram. The initial CT demonstrated a solitary nodule with a diameter of 20 mm on the parietal pleura that covered the V rib of the posterior chest wall. For 5 years the tumour's size did not change noticeably but it suddenly grew to about 90 mm diameter in a year. The tumour volume doubling time was calculated to be 17 days.

We report here a case of pulmonary benign metastasizing leiomyoma (BML) from the uterus. A 48-year-old woman was admitted to our hospital because of multiple pulmonary nodules on the chest radiograph 7 years after total hysterectomy with removal of the left ovarium for uterine leiomyoma. A specimen of the lesion obtained by a thoracoscopic lung biopsy was consistent with leiomyoma. Histological re-evaluation of the uterine myoma showed similar histology as compared with the lung tumor. Immunohistological staining for both estrogen and progesterone receptors on the lung tissue was positive. Based on these results, we diagnosed the pulmonary lesions as BML. The patient received no treatment and has shown no evidence of exacerbation of disease during 6 years of follow up.

In biopsy specimens with low grade adenomas, it is often difficult to identify the presence of high grade adenomas or early carcinomas and low grade adenomas preoperatively, and clear guidelines have not yet been defined for the applicability of endoscopic treatment to low grade adenomas identified in biopsy specimens.We aimed to clarify the usefulness of magnifying endoscopy with narrow band imaging (NBI) compared to conventional white light endoscopy for diagnosing actual high grade adenomas or early carcinomas with low grade adenomas, using the VS (microvascular pattern [V] and microsurface pattern [S]) classification for low grade adenomas in biopsy specimens. The study cohort consisted of 135 patients who were diagnosed with low grade adenomas in preoperative biopsy specimens and received endoscopic submucosal dissection.In the elevated type of lesion, magnifying endoscopy with NBI diagnosed high grade adenomas or early carcinomas at a higher sensitivity and specificity than conventional white light endoscopy (82.4 vs. 70.6%, P = 0.391, 97.3 vs. 54.7%, P 0.0001). In the depressed macroscopic type of lesion, magnifying endoscopy with NBI also diagnosed high grade adenomas or early carcinomas at a higher sensitivity (95.5 vs. 68.2%, P = 0.0459) than conventional white light endoscopy. Although the specificity was high, at 100%, the difference when compared to conventional white light endoscopy was not significant (100 vs. 100%, P 0.99).For low grade adenomas in biopsy specimens, it is vital to take sufficient consideration of endoscopic findings and not take action based only on the biopsy results. If a decision is made using the VS classification with magnifying endoscopy with NBI, actual high grade adenomas or early carcinomas can be differentiated from low grade adenomas so that endoscopic treatment can be performed more strictly.

腺様嚢胞癌は, 頭頸部のいかなる部位にでも発生するが, その発生頻度は比較的まれな腫瘍である。特に, 舌下腺原発腺様嚢胞癌の症例報告はまれである。本報告では, 高齢者に発生した舌下腺原発腺様嚢胞癌を報告した。80歳・男性が左側口底から舌にかけての知覚麻痺と硬結を主訴として来科した。左側口底に, 約27×15mmの弾性硬, 不動性の腫瘤を認めた。臨床診断を左側口底悪性腫瘍とした。試験切除時の病理組織像は, 腺様嚢胞癌であった。全身麻酔下に, 気管切開術・局所拡大切除術・上頸部郭清術をおこなった。術中, 神経周囲浸潤が疑われたため, 舌神経および舌下神経を切除した。また, 顎下およびオトガイ下リンパ節転移が認められたが, 高齢者であったため, 上頸部郭清にとどめた。欠損腔は残存舌にて閉鎖した。術後, 放射線治療が選択された。局所および頸部リンパ節は制御されたが, 術後観察中に多発性微小肺転移が認められた。摘出物の病理組織像は, リンパ節転移・静脈侵襲・神経周囲浸潤を伴った舌下腺原発腺様嚢胞癌であった。本邦における文献では, 本症例を含めて18例の舌下腺原発腺嚢胞癌が報告されている。一般的に, 舌下腺原発腺様嚢胞癌は, 頸部郭清術と局所拡大切除がおこなわれている。しかし, 高齢者では術後の合併症や機能障害の防止のために, 局所切除および頸部郭清は制限される。

高分化型扁平上皮癌の1亜型である疣贅状癌は, 1948年にAckermanによって最初に報告された。日本においては, 1990年に浅海らが52例を報告している。われわれは, 頬粘膜, 舌, 下顎歯肉の3例の疣贅状癌を報告した。頬粘膜および舌の2例は切除し, 下顎歯肉の1例はレーザー切除と蒸散をおこなった。本腫瘍においては, 未分化転換がしばしば起こるため, 化学療法と放射線治療は一般的には行なわれない。われわれの3例では, 外科療法が選択され, 局所制御が得られた。

We describe herein the case of a 2-year-old girl found to have a pulmonary blastoma (PB). The child was admitted to our hospital with the chief complaints of coughing and left-sided chest pain. On admission, a chest X-ray revealed a large mass in the left lung, which measured 10 cm in diameter. Computed tomography and magnetic resonance imaging showed a marginally and heterogeneously enhanced tumor filling the left hemithorax. Pathologic findings of the fine-needle aspiration were suggestive of neuroblastoma. Subsequently, a left pneumonectomy with lymph node dissection was performed and histopathological examination confirmed that the tumor was a PB (type III). After the definitive diagnosis was made the patient received combination chemotherapy, and no evidence of recurrence has been seen in the 5 months since surgery.

We report a rare case of pneumothorax caused by metastatic carcinoma of the breast, in a 69-year-old woman who was admitted to our hospital with severe chest pain. Four years previously, she had undergone modified radical mastectomy for a left breast tumor. Chest X-ray examination and computed tomography (CT) scan on current admission revealed right pneumothorax and bilateral pulmonary tumors. Although operation is not usually indicated in such circumstances, the patient had persistent air leakage for 7 days, despite receiving effective closed cather drainage, making right thoracotomy necessary. During the operation, an open bronchopleural fistula in the metastatic tumor of the upper lobe, infiltrating close to the visceral pleura, was observed. Wedge resection, including the necrotic tumor, was thus performed. Microscopic examination of the resected specimen showed poorly differentiated adenocarcinoma, consistent with metastasis from breast carcinoma. This is the second reported case of pneumothorax caused by metastatic carcinoma of the breast.

Accessory parotid tumors comprising about 1% of all primary parotid neoplasms. This disease is usually present with asymptomic buccal mass.The age at diagnosis varied from 8 to 73.The spectrum of tumors arising in accessory parotid gland is similar to that of tumors arising in the main parotid gland.Although more than half of the accessory parotid tumors are malignant.Masses arising in accessory parotid glands usually occur along the central third of the alar region, parallel to Stenon's duct.Sialography and CT scanning are occasionaly required for diagnosis.A 56-year-old female complained of an asymptomatic mass in her right preauricular region. After many investigations, clinical diagnosis was a benign tumor arising in the accessory parotid gland.Under general anesthesia, the facial nerve was exposed by elevating the temporal-pre-auricular-cervical flap and the tumor was resected.Pathological examination in the operation revealed a picture of adenoid cystic carcinoma.Local wide resection was done and the facial nerve branch near the tumor was resected.The resected nerve was reconstructed by nerve transplantation with the greater auricular nerve.After the operation, radiotherapy was done.We found no evidence of reccurence or metastasis.

血管筋腫は1937年, Stoutが最初に報告した良性腫瘍である。血管筋腫は口腔領域に発生することはまれである。下唇に発生した血管筋腫の1例を報告し, 文献的考察を行った。30歳の男性が左側下唇の腫瘤を主訴として当科を受診した。同日, 局所麻酔下にて腫瘍摘出術を施行した。病理組織学的診断は血管筋腫であった。本邦における口腔領域においての本腫瘍の報告例は, 本症例を含めて65例であった。

Study Design. Case report. Objectives. Lumbar paraspinal myonecrosis after abdominal vascular surgery. Summary of Background Data. Lumbar paraspinal myonecrosis does not appear to have been reported previously. Methods. A patient who had severe back pain after abdominal vascular surgery was observed with computed tomocrsphic scans and histologic examination of a specimen obtained in open biopsy. Resuits. Computed tomographic scans of the lumbar region demonstrated muscie swelling of the unilateral paraspinal compartment. Histologic examinations of affected muscle revealed fresh ischemic necrosis. A compartmental syndrome was considered from the patient's clinical presentation and radiographic and histologic features. An accompanying secondary infection led to an extensive abscess in the paraspinal compartment. The patient resumed active daily lite after aggressive debridements of infected and necrotic muscles. Conclusions. A compartmental syndrome in the paraspinal muscie should be kept in mind as a potential cause of acute back pain especially after abdominal vascular surgery.

腺房細胞癌は唾液腺に発生するまれな腫瘍であり, 全耳下腺腫瘍の2～4%を占める。上唇粘膜に発生した腺房細胞癌の1例を報告し, 文献的考察を行った。44歳の男性が右側上唇の無痛性腫脹を主訴として当科を受診した。局所のリンパ節腫脹は認められなかった。腫瘍は初診時に約20×20mmの大きさであり, 病理組織学的には腺房細胞癌であった。全身麻酔下に, 腫瘍を口腔内より根治的切除し, 分層植皮にて再建した。術後, 再発および転移は認めていない。1955年から1991年までの, 日本での文献では54例の小唾液腺由来の腺房細胞癌が認められた。好発部位は口蓋 (19例) であった。次いで, 臼後三角部 (9例) , 口唇 (7例) , 頬粘膜 (7例) , その他 (12例) に発生していた。文献例による再発率は21.6%であった。

Amyloid deposition in the hepatic parenchyma and portal tracts in the liver is well known in systemic amyloidosis. We recently experienced an autopsy case of systemic amyloidosis presenting the amyloid deposits in the intrahepatic biliary tree. This experience prompted us to survey 19 autopsy cases of systemic amyloidosis. Amyloid deposition was found just under the lining epithelium of the intrahepatic large bile duct in 10 of 19 cases and around the peribiliary glandular acini in 7 of the 19 cases, respectively. Amyloid deposition in the intrahepatic large bile duct and peribiliary glands was positively correlated with the degree of amyloid deposition in the liver but not with type of amyloid protein. Double-staining of amyloid and vascular endothelium disclosed that amyloid deposition was more closely related to the inner part of the peribiliary vascular plexus and to the vascular plexus encircling the peribiliary glands than the lining biliary epithelium and peribiliary glandular acinar cells themselves. The exact pathogenesis of amyloid deposition in these anatomical components, however, remains unclear. Although our cases failed to show any overt clinical symptomatologies related to amyloid deposition in these biliary components, it seems conceivable that more massive amyloid deposition in these anatomical components could give rise to some clinical symptoms. (HEPATOLOGY 1990;12:743–746).

Three cases of an unusual diffuse sclerosing variant of papillary carcinoma were found among 370 consecutive malignant tumors of the thyroid gland retained in the surgical pathology files of Kanazawa University Hospital over the last 10 years. The tumors were characterized by diffuse involvement of one or both lobes of the thyroid, dense fibrosis, papillary carcinoma with marked squamous metaplasia and abundant psammoma bodies, heavy lymphocytic infiltration and extensive lymphatic permeation. In two cases, the neoplasms showed more aggressive regional lymph node metastases and local invasion; the patient in the first case underwent surgery three times after initial radical surgery because of regional lymph node recurrences, and the second case showed direct invasion of the thyroid tumor to the larynx and distant metastasis to the lungs. Although the number of examined cases was small, the findings suggest that the diffuse sclerosing variant type has a less favorable prognosis and should be differentiated from papillary carcinomas with excellent prognosis.

Mucoepidermoid carcinoma is one of the tumors originating from the salivary glands and classified as a malignant tumor by many authors. This tumor usually occurs in the parotid gland and the hard palate but rarely in the buccal region.A case of this tumor in the buccal mucosa was reported. A 30-year-old female complained of a mass in her left buccal region. The mass was resected under local anesthesia. Histopathological examination revealed a picture of mucoepidermoid carcinoma.The lesion was then reconstructed with extended resection and D-P Rap.

Necrotizing sialometaplasia is an ulcerating, self-limiting inflammatory lesion of the salivary gland. The most common site of occurrence is reported to be the minor salivary glands of the hard palate. It is often misdiagnosed clinically and histopathologically, as malignant lesions such as a squamous cell carcinoma or a mucoepidermoid carcinoma. A case of this disease, occurred after an intra-oral anesthesia, was reported.A 29-year-old Japanese man noted a painless ulcer and swelling of his hard palate after an infiltrating anesthesia for pulpectomy of the left maxillary second premolar. An excisional biopsy of the lesion revealed a picture of necrotizing sialometaplasia. The lesion healed completely 6 weeks after the biopsy and no evidence of recurrence was noted.

Gingival cysts in adults arise from odontogenic epithelial remnants and are most commonly seen in the canine-premolar region of the mandible. The condition is rare. In Japan, an extensive review of the literature revealed only one reported case to date. We have encountered such a case, and report it here. A 22-year-old man was referred to our department on March 27, 1998 because of gingival swelling in the canine region of the right side of the mandible. He had previously consulted a dental clinic because of tenderness in the same region. The gingival swelling had a diameter of about 3 millimeters. It was hemispheric, the border was clear, and the color was similar to that of the normal gingiva. The patient had no spontaneous pain, only tenderness. The surrounding teeth were all vital, and had no pain on percussion or mobility. A radiographic examination showed no abnormalities. We clinically suspected the swelling to be a gingival tumor. We extirpated the lesion on April 28, 1998 under local anesthesia. A 1-mm margin of normal gingiva was resected concurrently. It was pathologically diagnosed as a gingival cyst in an adult. The postoperative course has been good.

We report our second patient treated successfully with a new combined chemotherapy regimen of intra-arterial pirarubicin and nedaplatin plus intravenous methotrexate and vincristine for squamous cell carcinoma (SCC) of the bladder. A 57-year-old man consulted our hospital in September 2005 for treatment of bladder tumors diagnosed in another hospital. Magnetic resonance imaging (MRI) showed an extravesical invasive tumor on the anterior wall of the bladder, and clinical stage T2bN0M0 was diagnosed. Transurethral cold-cup biopsy was performed, and pathological examination revealed SCC. After he received two courses of this new combined intra-arterial chemotherapy regimen using nedaplatin, tumors were detected in MRI and cystoscopy. We performed partial cystectomy in January 2006. Postoperative pathological examination revealed no tumor cells (pathological CR). There were no severe adverse reactions by this chemotherapy regimen. He has been alive without evidence of disease.

A 43-year-old woman had experienced recurrent right pneumothoraces at the beginning of her menstrual period. Thoracoscopically, multiple small fenestrations were widely found over the tendinous part of the diaphragm. Multiple purple colored nodules were seen on the visceral surface of upper lobe containing intralobar lesions, and about 100 ml blood was pooled in the thoracic space. We performed a video-assisted thoracoscopic resection of the pleural nodule suspected to be the cause of the hemothoraces. Histologically, the resected nodule had intra-alveolar hemorrhage not seen in common endometriosis. Pleurodesis with mechanical abrasion of parietal pleura and the diaphragm was performed. Chemical pleurodesis, with minocycline hydrochloride and distilled water was applied.

A case of odontogenic maxillary sinusitis with many antroliths is reported. A 52-year-old woman was introduced to our hospital for evaluation of an abnormal image on an X-ray film. Computed tomography showed a calcified mass in the right maxillary sinus and thickening of the antral mucosa. Under a clinical diagnosis of odontogenic maxillary sinusitis with antroliths, Caldwell-Luc operation was performed. On opening the right maxillary sinus, turbid and yellow fluid containing many stones shaped like polyhedrons was found. The 47 stones consisted of Ca, P, Mg, Na, S, I, K, Al, and the main component was CaPO4.

Chronic sclerosing sialadenitis (CSS) is a cryptogenic tumor-like condition of the salivary gland(s). While immune-mediated processes are suspected in its pathogenesis, and CSS is occasionally reported to be associated with sclerosing pancreatitis, an IgG4-related disease, the exact immunopathologic processes of CSS remain speculative. In this study, we examined the clinicopathologic findings of CSS (12 cases) in comparison with sialolithiasis (8 cases) and Sjogren's syndrome (13 cases), and tried to clarify whether CSS is an IgG4-related disease or not. Submandibular gland(s) were affected in all cases of CSS. CSS cases could be divided into two types: 5 cases were associated with sclerosing lesions in extrasalivary glandular tissue (systemic type), while only salivary gland(s) were affected in the remaining 7 cases (localized type). In the former type, which showed male predominance, bilateral salivary glands were frequently affected, and eosinophilia and elevations of gamma-globulin and IgG in serum were frequently found. Histologically, all cases of CSS showed marked lymphoplasmacytic infiltration admixed with fibrosis and the destruction of glandular lobules. Obliterative phlebitis was found in the affected salivary glands in all cases of CSS. Immunohistochemically, the proportion of IgG4/IgG-positive plasma cells was more than 45% in CSS, while it was less than 5% in controls. The resemblance of the clinicopathologic features of CSS with those of sclerosing pancreatitis suggests the participation of a similar immunopathologic process with IgG4 disturbance in CSS. The abundance of IgG4-positive plasma cells in the lesions would be useful for distinguishing CSS from other forms of sialadenitis.

A case is reported herein of intrahepatic cholangiocarcinoma (ICC) with multicystic, mucinous appearance and oncocytic change. Because of liver dysfunction, a 73-year-old woman was hospitalized in early October 2003. She was diagnosed as having ICC of the right hepatic lobe with occlusion of the hilar and perihilar bile ducts by imaging examination. Extended right lobectomy was performed but the patient died of liver failure on the next day. In surgically resected specimens, the tumor (3 x 3 cm) was mainly located in the right lobe, and tumors infiltrated along the biliary tree as well as invading into the adjacent hepatic parenchyma. The tumor mass had a sponge or honeycomb appearance. Microscopically, these tumors were composed of multiple microcysts filled by abundant mucin and lined by micropapillary adenocarcinoma cells. Their cytoplasm was acidophilic, appearing as an oncocyte, and carcinoma cells were positive for mitochondrial antigen in addition to biliary cytokeratins. There were no ovarian-like stromas around these cystic tumors, and communication of the biliary lumen with these carcinomatous cysts was not evident, thus different from biliary mucinous cystadenocarcinoma and intraductal papillary neoplasm of the liver. This is the third case of multicystic mucinous ICC and the present case might have been derived from intrahepatic peribiliary glands.

The small intestine is rarely involved with metastatic tumors from outside the abdomen, and few case reports have been documented in the literature. We describe herein what to our knowledge is the third case of a solitary metastasis from squamous cell carcinoma (SCC) of the esophagus being found in the jejunum, causing small intestinal obstruction.

We performed extended resection of primary mediastinal undifferentiated carcinoma, together with the superior vena cava and the upper lobe of the right lung, after effective induction chemoradiation therapy based on the results of a chemosensitivity test. Pathological examination of the resected specimen revealed that almost all of the tumor cells had died. The patient received adjuvant chemotherapy and has remained free from disease progression for 27 months since his operation. Our experience supports the effectiveness of an aggressive approach, in the form of chemosensitivity test-guided induction therapy, to treat this high-grade malignant disease, despite the risk of cancer dissemination.

A case of solitary fibrous tumor (SFT) in the pelvic cavity with hypoglycemia is reported. The patient was a 60-year-old man who was referred to our hospital for a closer examination of hypoglycemia. Computed tomography demonstrated a mass, measuring 14 x 9 cm in size, in the pelvic cavity. Magnetic resonance imaging showed the mass to have a low signal intensity on T1-weighted images and a high intensity on T2-weighted images. Laparotomy revealed no peritoneal dissemination nor lymph node metastasis. An en bloc excision of the tumor was performed with a good recovery, and the hypoglycemia disappeared. Histologically, the tumor was composed of spindle-shaped and oval cells in sarcoma, based on a moderate mitotic rate and cellularity. Immunohistochemically, the tumor was positive for CD34 and negative for keratin, alpha-smooth muscle actin, desmin, S100 protein, c-kit protein, and epithelial membrane antigen. Based on these findings, the tumor was diagnosed to be malignant SFT in the pelvic cavity.

Superficial non-ampullary duodenal epithelial tumor (SNADET) is defined as a sporadic tumor that is confined to the mucosa or submucosa that does not arise from Vater's papilla, and it includes adenoma and adenocarcinoma. Recent developments in endoscopic technology, such as high-resolution endoscopy and image-enhanced endoscopy, may increase the chances of detecting SNADET lesions. However, because SNADET is rare, little is known about its preoperative endoscopic diagnosis. The use of endoscopic resection for SNADET, which has no risk of metastasis, is increasing, but the incidence of complications, such as perforation, is significantly higher than in any other part of the digestive tract. A preoperative diagnosis is required to distinguish between lesions that should be followed up and those that require treatment. Retrospective studies have revealed certain endoscopic findings that suggest malignancy. In recent years, several new imaging modalities have been developed and explored for real-time diagnosis of these lesion types. Establishing an endoscopic diagnostic tool to differentiate between adenoma and adenocarcinoma in SNADET lesions is required to select the most appropriate treatment. This review describes the current state of knowledge about preoperative endoscopic diagnosis of SNADETs, such as duodenal adenoma and duodenal adenocarcinoma. Newer endoscopic techniques, including magnifying endoscopy, may help to guide these diagnostics, but their additional advantages remain unclear, and further studies are required to clarify these issues.

Idiopathic portal hypertension (IPH) is characterized by dense fibrosis of portal tracts and portal venous obliteration. Little is known about the etiopathogenesis of IPH. Association of various autoimmune diseases such as systemic lupus erythematosus in IPH suggests that IPH may share immunological disturbances with such autoimmune diseases. We recently experienced two autopsy cases presenting with both diffuse scleroderma and IPH. Dense fibrosis was found in both the dermis and intrahepatic portal tract of these cases. In addition, small vascular damages were commonly observed to various degrees in these fibrotic areas of both organs. The activation of fibroblasts and vascular damages mediated by various growth factors and cytokines reportedly involved in the dermis in scleroderma might have also been operative in portal tracts in these two cases of IPH. A review of literature disclosed eight overlapping cases of IPH and scleroderma (middle- to old-aged females), and scleroderma was diagnosed earlier than IPH. These findings suggest that similar pathogenetic processes are operative in the dermis as well as in the portal tracts of the liver in these cases.

67歳男性．検診にてCA19-9の上昇を指摘された．造影CTにて左前縦隔に8×6×4 cm大の石灰化を伴う多房性嚢胞性病変と一部に充実部分を認め，FDG-PETでは充実部に一致した異常集積を認めた．胸骨正中切開下に腫瘍を含めた胸腺左葉+左肺上葉部分切除を施行した．最終病理診断は胸腺の嚢胞性病変より発生したmucinous adenocarcinomaであった．術後放射線治療60 Gyを追加し現在外来にて経過観察中である．

Two cases of medullary microcarcinoma of the thyroid are reported. The tumours were identified incidentally in a 60- and a 66-year-old woman each with a thyroid adenoma. These tumours were 0.8 cm and 0.5 cm in size, respectively, and located in the central portion of the right lateral lobe. In neither patient was there a family history of medullary thyroid carcinoma. Although medullary microcarcinoma with associated C-cell hyperplasia in familial form has been reported, sporadic medullary microcarcinoma is rare.

57歳，男性．重症筋無力症合併浸潤性胸腺腫症例．腫瘍は右肺，心膜浸潤の他に胸腺静脈を介して有茎性に上大静脈内へ発育·進展していた．手術は拡大胸腺-胸腺腫摘出術+右肺上葉合併切除+心膜合併切除および血管内腫瘍摘出術とした．血管内腫瘍は先端が肥大した巨大マッチ棒状の形態で，被膜に覆われ上大静脈内膜への浸潤·癒着は認められなかった．人工血管置換なしに左右腕頭静脈および上大静脈を遮断し，左腕頭静脈壁とともに容易に摘出し得た．本症例は腫瘍が胸腺静脈を介して上大静脈内腔へ発育した貴重な症例と考えられた．

A 40-year-old woman had experienced monthly right thoracic pain and productive cough occurring at the beginning of her menstrual period. X-ray findings indicated a diagnosis of catamenial pneumothorax. The serum CA125 level was very high at 159.6 U/ml. Thoracoscopy showed multiple dark cherry-colored nodules with neovascularization on the diaphragm. Following partial resection of the diaphragm thoracic endometriosis was diagnosed. Immunohistochemical staining of these endometrial cells showed antibodies to CA125. She has been well without recurrence for 15 months, and her serum CA125 level was within the normal range after operation.

We herein report the rare case of a patient suffering from lymphoepithelioma-like poorly differentiated squamous cell carcinoma of the esophagus. The patient was a 74-year-old woman in whom an esophageal tumor was found during an operation for thyroid cancer. After performing a subtotal thyroidectomy and cervical esophagectomy, esophageal reconstruction was performed using a free jejunal graft. Based on the results of the pathological examination, the esophageal tumor was diagnosed to be primary lymphoepithelioma-like esophageal cancer, not metastasis of either unknown nasopharyngeal cancer or thyroid cancer. Since surgery, she has survived postoperatively for more than 4 years with no evidence of recurrent disease.

限局性細気管支肺胞上皮癌はすりガラス影の結節としてCTで認められ，緩徐な増大傾向や濃度上昇を呈することが知られている．今回我々はHRCTにて4ヶ月の間に陰影が淡くなった限局性細気管支肺胞上皮癌の1例を経験したので報告する．

Non-cirrhotic, long-standing portal hypertension of unknown aetiology is being re-evaluated histopathologically and clinically. In this study, we examined 107 livers with this condition (92 wedge biopsy and 15 autopsy specimens) from five institutions in Japan. These cases were histologically categorized into four groups: idiopathic portal hypertension (66 cases), nodular regenerative hyperplasia (14 cases), partial nodular transformation (two cases), and incomplete septal cirrhosis (25 cases). These four groups shared several histological features: dense portal fibrosis with portal venous obliteration and intralobular slender fibrosis. In addition, the histopathological features characteristic of one group were also found to a mild degree in other groups. The histopathological lesions preceding portal venous obliteration remain speculative. However, the portal venous obliteration may be responsible for the occurrence of sustained portal hypertension and several of the pathological changes in these livers. It seems likely that idiopathic portal hypertension, nodular regenerative hyperplasia, partial nodular transformation and incomplete septal cirrhosis comprise a family of non-cirrhotic, long-standing portal hypertension in Japan, and the histological differences between them may reflect chronological progression of a single disease.