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Owing to the advantages of a laparoscopic approach, laparoscopic cholecystectomy (LC) is thought to be the treatment of choice in gallbladder disease, even in cases of suspected malignancy. However, it is difficult to differentiate between cholecystitis and gallbladder carcinoma (GBC). We performed radical hepatectomy in patients with pT2 GBC diagnosed by full-thickness frozen biopsy. A 75-year-old Japanese man presented to our hospital with discomfort in the right upper quadrant of the abdomen. This patient was diagnosed with suspected GBC and was scheduled to undergo LC and intraoperative histological examination. Following the procedure, we made a diagnosis of GBC with negative invasion of the cystic duct stump. We converted the laparoscopic procedure to an open surgery involving wedge liver resection with lymphadenectomy. The patient was discharged from our hospital in remission 14 days following the radical hepatectomy. Histological examination showed that the GBC had invaded the liver (T3a), but there was no lymph node metastasis (N0): stage IIIA. Between April 2009 and September 2018, 580 patients underwent cholecystectomy for gallbladder disease at our hospital. Among these, 8 (1.4%) were suspected to have GBC preoperatively and underwent laparoscopic excisional cholecystectomy. We performed elective surgery in the early stage in two patients and second-look surgery in two patients recently. We were able to perform what we termed a laparoscopic excisional cholecystectomy, involving LC with a full-thickness frozen biopsy, even in situations where intraoperative histological examination was not available. Altogether, laparoscopic excisional cholecystectomy is an effective surgical treatment for suspected early GBC.

Introduction and importance: Granular cell tumor (GCT) is a benign, mesenchymal tumor that originates from Schwann cells. Case presentation A 75-year-old Japanese woman was referred to our hospital due to epigastric discomfort. Upper gastrointestinal endoscopy revealed an ulcerated cancer lesion, approximately 1.2 cm in diameter, at the angle of the stomach in the posterior gastric wall and a yellowish submucosal tumor, 5 mm in diameter, near an anal ulcerated lesion. Based on these findings, the patient was scheduled for laparoscopic distal gastrectomy and lymph node dissection. The pathological diagnosis was a moderately differentiated tubular adenocarcinoma invading mucosal stroma without lymph node metastasis and GCT in the stomach. Tumor cells were positive for S-100 and were consistent with the characteristics of GCT. Clinical discussion To the best of our knowledge, this is an extremely rare case with reports of only 6 cases of such a combination, including our case. Conclusions We believe that the coexistence of a GCT and gastric cancer in our patient was accidental and that there was no relation between them.

Highlights • A 76-year-old Japanese man had invasive intraductal papillary carcinoma (IPMC). • IPMC recurred in the remnant pancreas five years after initial pancreaticoduodenectomy. • Most likely, recurrence was due to multifocal disease that developed a new cyst. • Remnant pancreatectomy is the preferred approach for remnant pancreatic carcinoma due to better median long-term survival outcome., Introduction and importance The prognosis of non-invasive intraductal papillary mucinous neoplasma (IPMN) is better than that of pancreatic cancer. However, if the first surgical finding revealed an invasive IPMC, the risk of recurrence was found to be 7–21%. Case presentation A 76-year-old Japanese man had undergone subtotal stomach-preserving pancreaticoduodenectomy for intraductal papillary mucinous carcinoma non-invasive type at our hospital. No signs of adenocarcinoma at the resection margin were found by pathological examination of frozen sections. Five years later, a blood analysis showed increased serum CA19-9 level. A contrast-enhanced computed tomography scan of the abdomen revealed a mass adjacent to the pancreaticogastrostomy anastomosis. The patient underwent a total pancreatectomy. The tumor was identified as a recurrent IPMC with subserosal invasion, but without nodal involvement. The resection margins were negative. The patient’s postoperative course was uneventful, and he was discharged after 12 days. He is being followed up without adjuvant chemotherapy. Discussion The prognosis of IPMN is better than that of pancreatic cancer. However the risk of recurrence in invasive IPMC was found to be 7–21%. Therefore, IPMC must be surveilled every three months using tumor markers and imaging. Local recurrence in remnant pancreas is usually treated with systemic therapy. The median long-term survival after total pancreatectomy (range 7–24 months) was shown to be better than when chemotherapy alone was used (range 10–13 months). Conclusion We chose secondary surgery in term of survival time although there are quality of life drawbacks that currently make total pancreatectomy more inappropriate in patients than chemotherapy.

Currently, complete surgical resection is the most effective and the only potentially curative treatment for gallbladder carcinoma (GBC). However, GBC frequently presents various manifestations as it progresses, including liver invasion, bile duct invasion, hepatoduodenal invasion, venous invasion, and lymphatic invasion. Although there is a clear need for effective chemotherapeutic methods in the management of GBC, no standard chemotherapeutic regimen for advanced GBC has been established to date, and the prognosis remains poor. Herein, we report a case of successful treatment in a patient with advanced GBC who showed a great response to combination chemotherapy and who was subsequently able to undergo curative resection. A 38-year-old Japanese woman was first diagnosed with unknown primary cancer with bilateral ovarian, hepatic, and peritoneal metastases. Combination paclitaxel plus carboplatin chemotherapy was started at a dose of 653 mg of carboplatin and 248 mg of paclitaxel once a week for 3 weeks. After 6 cycles, the tumor had shrunk in size and was detected as only a slightly contrasted lesion in Couinaud's hepatic segments 4 and 5. One month after the final cycle of chemotherapy, we performed cholecystectomy and right lobectomy of the liver with D2 lymph node dissection. The patient exhibited an uneventful postoperative course. Five months have passed since the operation, with no signs of recurrent disease. Our findings suggest that combination chemotherapy with paclitaxel and carboplatin may be effective against advanced GBC.

Highlights • IHPT is difficult to distinguish from malignant tumors • Knowledge of IHPT is necessary to allow for treatment, even without experience., Introduction Inflammatory hepatic pseudotumor (IHPT) is an important benign liver disease because it is difficult to clinically and radiologically distinguish from malignant tumors. Presentation of case Here, we describe a case of a 67-year-old male patient diagnosed with multiple inflammatory hepatic pseudotumors. The patient had undergone left hemicolectomy for descending colonic cancer (T3 N0 M0 stage IIA) 2 years prior. He underwent segment 6 and segment 7 partial hepatectomy because of suspected liver metastasis. The patient had an unremarkable postoperative course and was discharged 7 days after surgery. Marked infiltration of inflammatory cells was observed on histological examination. The patient was finally diagnosed with IHPT of the fibrohistiocytic type. Discussion Repeated imaging studies over 1 month showed the spontaneous regression of the hepatic tumors. Therefore, knowledge regarding this condition is necessary to allow for treatment, even in the absence of experience. During examination, it may be important to ascertain lesion size. Moreover, percutaneous needle biopsy and follow-up examinations are necessary for cases of suspected IHPT. Conclusion Hepatectomy should be considered if the lesion is suspected to be an IHPT.

Pseudomyxoma peritonei (PMP) is characterized by extensive mucinous ascites following rupture of mucinous neoplasms of an intra-abdominal origin, and contain secreted gel-forming mucins such as MUC2 and MUC5AC. We encountered a 66-year-old Japanese man complaining of abdominal distension. Ascites at the site was gelatinous upon gross examination, and needle aspirate smears showed histiocytes and many mucinous balls wrapped in spindle cells, which were positive for vimentin, pan-cytokeratin, and podoplanin. The cell block showed several adenocarcinoma clusters, which were positive for MUC2, MUC5AC, CK20, and CDX-2, and negative for CK7. From these findings, a diagnosis of PMP arising from colon cancer was indicated. Cytoreductive surgery was performed, and the cystic diverticulum was found to be infiltrated by tumor cells in the sigmoid colon that caused PMP. Mucinous balls surrounded by mesothelial cells and MUC2-positive adenocarcinoma cells are useful clues in the diagnosis of PMP. Diagn. Cytopathol. 2016;44:628-631. © 2016 Wiley Periodicals, Inc.

The aim of this study was to investigate the clinical characteristics and outcomes of elderly patients (≥ 70 years old) undergoing curative hepatectomy for hepatocellular carcinoma (HCC).Clinicopathological data and treatment outcomes in 100 elderly patients (≥ 70 years old) and 120 control patients (≤ 70 years old) with HCC who underwent curative hepatectomy between 2000 and 2011 were retrospectively collected and compared.The overall survival rate was similar between the two groups, but the disease-free survival rate was worse in the elderly group when compared with the control group. Prognostic factors for overall and disease-free survival were the same when comparing the two groups. The elderly group had higher rate of females (p = 0.0230), higher hepatitis C virus infection rate (p = 0.0090), higher postoperative pulmonary complication rate (p = 0.0484), lower rate of response to interferon (IFN) therapy (p = 0.0203) and shorter surgical time (p = 0.0337) when compared with the control group. The overall recurrence rate was higher in the elderly group than in the control group (p = 0.0346), but the rate of recurrence within 2 years after the operation was similar when comparing the two groups.The survival of elderly patients with HCC was similar to that of younger patients. However, the disease-free survival was worse in elderly patients than in younger patients. Aggressive antiviral therapy (e.g. IFN therapy) may be necessary to improve the disease-free survival, even in elderly patients. Additionally, clinicians should be aware of the risk of pulmonary complications in elderly patients after hepatectomy.

症例は80歳女性．近医で肝機能障害を指摘され，当科受診．AST 423 IU/l ， ALT 222 IU/l ，ALP 481 IU/l ，T-Bil 6.7 mg/dl と上昇，抗核抗体が160倍と陽性，IgGが3238 mg/dl と上昇し，またIgM-HA抗体が陽性であった．自己免疫性肝炎（AIH）の国際診断基準によるスコアが12点疑診であることから，背景にAIHの存在が示唆された．またRT-PCR法で血清HAV-RNAが検出されたことよりA型肝炎ウイルス（HAV）感染の存在も示唆された．安静にて経過観察を行ったが，AST，ALTの上昇が持続していたため，肝生検施行した．結果，AIHと矛盾しない組織所見であった．その後，プレドニゾロンの内服を開始し，速やかに肝機能の改善を認めた．背景に存在したAIHの急性増悪にHAV感染が併存したと考えられる高齢女性の一例を経験したので報告する．

Hepatocellular carcinoma (HCC) shows a high rate of recurrence after hepatectomy; predictive factors for early recurrence would help determine optimal therapeutic and management strategies. Among 163 patients with HCC undergoing hepatectomy with curative intent, 46 patients developed recurrence within 1 year. Clinicopathological data were retrospectively analyzed to identify predictive parameters for early recurrence. Survival rates in cases of recurrence within 1 year were worse than those of no recurrence within 1 year or recurrence after 1 year. Protein induced by vitamin K absence/antagonist II (PIVKA-II) greater than 150, positive fucosylated alpha-fetoprotein (L3-AFP), and deviancy from Milan criteria (MC) on preoperative imaging were associated with high risk of early recurrence and total number of these three risk factors predicted the survival. With multivariate analysis, 1) preoperatively, positive factors of two or more among three items of PIVKA-II, L3-AFP, and deviancy from MC; 2) and postoperatively, pathological cancer spread (microscopic vascular invasion and/or intrahepatic metastasis) both represented risks for early recurrence. A combination of three preoperative factors, PIVKA-II, L3-AFP, and MC status, in conjunction with the postoperative factor of cancer spread status represents a significant indicator for recurrence within 1 year. Improving the prognosis of patients with HCC would depend on how to adequately treat those at high risk of early recurrence.

p59fyn, a protein tyrosine kinase belonging to the src-family, is involved in the regulatory mechanism of acute response to ethanol in the central nervous system. A previous report showed an association between src-family kinase activity and fatty acid oxidation, and it also reported that hepatic free fatty acid levels were low in Fyn−/− mice. We examined, using Fyn−/− mice whether Fyn is also involved in fatty acid metabolism and the development of pathological changes in the liver in response to chronic ethanol consumption. C57BL/6J Fyn−/− and Fyn+/+ mice were fed for 8 weeks with either a liquid diet comprising ethanol or one in which the calories from ethanol were replaced with carbohydrates. Chronic ethanol consumption for 8 weeks resulted in remarkable hepatic steatosis in Fyn+/+ mice but not in Fyn−/− mice. Chronic ethanol consumption induced a significant decrease in hepatic FFA and triglyceride levels in Fyn−/− mice. Levels of interleukin-6, which is associated with the enhancement of fatty acid oxidation, was also increased significantly in the livers of ethanol-fed Fyn−/− mice. The results suggest that Fyn is involved in the enhancement of fatty acid oxidation and the development of hepatic steatosis caused by chronic ethanol consumption.

Nonalcoholic steatohepatitis (NASH) can develop into end-stage disease such as cryptogenic cirrhosis and hepatocellular carcinoma. Hence, it is important to understand the pathogenesis of NASH. In general, the "two-hit theory" has prevailed as a pathogenic mechanism of NASH. According to this theory, lipopolysaccharides (LPS) contained in normal portal blood are the "second hit," but their role is not completely understood. Based on this theory, we evaluated the role of LPS in NASH pathogenesis. For the first hit to develop metabolic abnormalities, a synthetic diet rich in disaccharide (synthetic diet: 12.1 cal% disaccharide) was fed to Zucker (fa/fa) rats for 12 weeks. For the second hit, 100 microg/kg LPS was injected intraperitoneally once daily for 2 weeks. Synthetic diet-fed rats treated with LPS showed an increase in the triglyceride content and higher expression of profibrogenic mRNAs in the liver. Plasma alanine aminotransferase levels were significantly elevated using this protocol. Furthermore, histological examination demonstrated that this protocol induced mild hepatic fibrosis and focal necrosis in the livers of all rats. Synthetic diet-fed Zucker (fa/fa) rats treated with LPS could be useful for understanding the development of hepatic fibrosis in the two-hit theory.

Reported herein is a case of focal hepatic steatosis surrounding a metastatic insulinoma in the liver of a 69-year-old woman. The patient complained of losing consciousness after meals, and hypoglycemia and hyperinsulinemia were confirmed. On CT and abdominal angiography a mass, 1 cm in diameter, was seen in the tail of the pancreas. In the early phase of dynamic CT a mass, 5 mm in diameter, was seen in the liver. In the late phase this mass appeared to be 3 cm in diameter. An arterial calcium stimulation/venous sampling test showed insulin levels after calcium injections in the hepatic artery to be extremely high. Thus, the liver tumor was diagnosed as a metastatic insulinoma, and distal pancreatectomy and partial resection of the liver were performed. The pancreatic tumor cells were immunohistochemically positive for insulin. The liver tumor was pale yellow. A white area surrounded the tumor. Histologically, the liver tumor was an insulinoma and the white area was focal fatty change of the liver. High insulin levels are said to inhibit oxidation of free fatty acids into triglycerides, causing free fatty acids to accumulate in hepatocytes. Focal hepatic steatosis caused by the local effects of insulin can present as a focal rim surrounding a metastatic insulinoma.

The performance of the base Mobile IP handover algorithm for moving the Mobile Node's network layer point of attachment from one subnet to another has been recognized as a potential performance bottleneck for some time. In this paper, we discuss a collection of algorithms that use a link synchronous approach to Mobile IP handover. In the link synchronous approach, information on the progress of switching the link is used to drive handover at the IP level. We present a comprehensive analysis of handover packet drop, and develop analytical models of how the link synchronous algorithms help to mitigate it. We use data from a handover emulator to test the analytical models, and to compare the performance of the different algorithms under a variety of link conditions. Data from implementations on IS-2000 and 802.11b show how the link synchronous algorithms behave on real radio protocols. The results indicate that the link synchronous algorithms can reduce packet loss substantially, with best results possible if the link layer provides information on the move prior to the link switch.

There are currently no universally accepted indications and criteria for additional surgical resection of the colorectum after endoscopic resection of the submucosal invasive cancer. The purpose of the present study is to establish accurate indications and criteria for additional surgical resection of the colorectum, based on the prediction of lymph node metastasis, after endoscopic resection of the submucosal invasive cancer. We investigated 140 submucosal invasive colorectal cancers and analyzed the pathologic factors of lymph node metastasis. The tumors were evaluated for pathologic factors in the invasive area of the submucosal carcinoma and were compared between the cases with lymph node metastasis and those without lymph node metastasis. Lymph node metastasis was observed in 13 cases (9%). Univariate logistic regression analysis showed that the depth of invasion, cribriform-type structural atypia, absence of lymphoid infiltration, lymphatic permeation, and venous permeation were statistically significant as risk factors for lymph node metastasis. Multivariate logistic regression analysis showed that the important risk factors included, in decreasing order, lymphatic permeation, absence of lymphoid infiltration, cribriform-type structural atypia, venous permeation, and depth of invasion. Submucosal invasion of 2 mm or more, and/or, depth of lymphatic permeation of 2 mm or more are risk factors for lymph node metastasis. The pathologic criteria based on our results for additional colectomy enables greater accuracy selection of patients who will undergo further surgical treatment after endoscopic resection.

Recently, embedded assembly programs have properties dependent on hardware (direct operation of address spaces, memory mapped I/O, interruption, etc.) in the process of development. Thus, demands about the established method of formal verifications corresponding to those properties are increasing from the point of view of shorter development and high reliability. Our work aims at enabling formal verification for embedded software. We propose the detailed verification method with SMT-Based BMC for the Assembly Code Block (ACB). In addition, we have developed the automatic verification. Our method is based on the verification for the assembly program [1] and the verification using SMT-Based BMC for the embedded ANSI-C program [2] [3]. In this paper, we have developed the parser and the model converter for source codes of assembly program (assembly codes). Moreover, we show the validity of our method by experiments.

症例は52歳,女性.右下腹部の鶏卵大腫瘤の精査のために入院した.注腸造影検査では,盲腸を下方から圧排する管外性腫瘤が認められた.内視鏡検査では盲腸底部内側に表面平滑な粘膜下腫瘍様の隆起性病変が認められた.悪性腫瘍の可能性も否定できないため,回盲部切除術が施行された.盲腸前面内側に,虫垂および大網が強固に癒着し,一塊となり,硬い腫瘤を形成していた.切除標本の検索では,盲腸,虫垂および大網の癒着部を主座とする黄色肉芽腫性炎が盲腸の粘膜下層に波及し,隆起性病変を形成していた.黄色肉芽腫性炎が盲腸に粘膜下腫瘍様の病変を引き起こすことは稀であるが,回盲部腫瘤の鑑別疾患に加える必要があると考えられる.

We report the case of a 55-year-old Japanese woman with adult onset Still's disease in whom hemophagocytic syndrome and severe liver dysfunction developed. High serum levels of ferritin, macrophage colony stimulating factor and interferon-gamma, which imply the presence of hemophagocytic syndrome, were detected. It is known that hemophagocytic syndrome is associated with adult onset Still's disease. In our case, many markedly swollen Kupffer cells with phagocytized red blood cells were found in the liver, as well as macrophages in the bone marrow and spleen. Accordingly, we believe that severe liver dysfunction in this case may have been related to hypercytokinemia due to hemophagocytic syndrome.

症例, 73歳, 女性. 肝右葉を置換するように高度に増殖した胆管細胞癌症例の左葉に典型的な結節性再生性過形成がみられた. 結節性再生性過形成の発生機序は門脈枝閉塞による肝内血流の不均等がもたらす肝細胞の萎縮とそれに対する代償反応であると一般に考えられているが, 本症例では門脈枝の病変はごく軽度であった. これに対して, 肝静脈枝は胆管細胞癌の侵襲とそれによると考えられる内膜肥厚のために狭窄, 閉塞していた. したがって, 本症例の結節性再生性過形成の発生には, 右葉の癌置換による肝細胞消失に対する代償性の左葉肝細胞の増生と, 左葉肝静脈枝の癌侵襲による狭窄, 閉塞の結果としての肝内血流の不均等が関与していると考えられた.

症例は69歳, 女性. 左顔面の鈍痛, 左眼瞼下垂および下垂体機能低下で発症し. 頭蓋骨, 下垂体に原発不明の癌転移が認められ, 剖検によって胆管細胞癌と判明した症例を報告した. その転移経路は, 肺には肺動脈末梢枝にごく少量の癌塞栓がみられるのみであり, 外椎骨静脈叢に高度の癌塞栓がみられたことから, Batsonの提唱した椎骨静脈系を介するものと考えられた. すなわち, 門脈に侵入した胆管細胞癌が奇静脈に流入し, 椎骨静脈系, 脳底静脈叢および海綿静脈洞を経て下垂体および頭蓋骨に転移したと推測される. 胆管細胞癌が椎骨静脈系を介する経路で頭蓋骨および下垂体に転移することは稀であるが, 肺転移のみられない症例ではこのような可能性を念頭において原発巣を検索する必要がある.

A 75-year-old woman developed depression in 2010 and was treated with oral medications at our Department of Psychiatry. Since she showed no tendency toward improvement, she underwent modified electroconvulsive therapy (mECT). Later, she developed severe liver injury that was presumably induced by the propofol used for mECT. Propofol is an intravenous anesthetic agent that reportedly can be used relatively safely in the presence of liver dysfunction. We herein report the first case of propofol-induced liver injury definitively diagnosed based on positive drug lympocyte stimulation testing (DLST).

When hepatectomy is used as a primary treatment for liver metastasis from colorectal cancer (CRCLM), the balance between surgical curability and functional preservation of the remnant liver is of great importance. A total of 108 patients who underwent initial hepatectomy for CRCLM were retrospectively analyzed with respect to tumor extent, operative method, and prognosis, including recurrence. The 1-, 2-, 3-, and 5-year overall survival rates (OS) for all patients were 90.5%, 77.8%, 63.2%, and 51.6%, respectively. Multivariate analysis indicated serum carbohydrate antigen 19-9 (CA 19-9) level after hepatectomy (

Background Hepatectomy is recommended as the most effective therapy for liver metastasis from colorectal cancer (CRCLM). It is crucial to elucidate the prognostic clinicopathological factors. Methods Eighty-three patients undergoing initial hepatectomy for CRCLM were retrospectively analyzed with respect to characteristics of primary colorectal and metastatic hepatic tumors, operation details and prognosis. Results The overall 5-year survival rate after initial hepatectomy for CRCLM was 57.5%, and the median survival time was 25 months. Univariate analysis clarified that the significant prognostic factors for poor survival were depth of primary colorectal cancer (≥ serosal invasion), hepatic resection margin (< 5 mm), presence of portal vein invasion of CRCLM, and the presence of intra- and extrahepatic recurrence. Multivariate analysis indicated the presence of intra- and extrahepatic recurrence as independent predictive factors for poor prognosis. Risk factors for intrahepatic recurrence were resection margin (< 5 mm) of CRCLM, while no risk factors for extrahepatic recurrence were noted. In the subgroup with synchronous CRCLM, the combination of surgery and adjuvant chemotherapy controlled intrahepatic recurrence and improved the prognosis significantly. Conclusions Optimal surgical strategies in conjunction with effective chemotherapeutic regimens need to be established in patients with risk factors for recurrence and poor outcomes as listed above.

"Japanese clinical guidelines for autoimmune pancreatitis" advised to carefully differentiate between two conditions: autoimmune pancreatitis (AIP) and associated sclerosing cholangitis (SC), and pancreatobiliary malignancy.We report a series of three cases for which differential diagnosis of pancreatobiliary carcinoma from AIP and associated SC was crucial.Three patients presented with biliary stenosis secondary to pancreatic swelling or mass lesion, followed by further examinations: Case 1 was first diagnosed as having tumor-forming pancreatitis associated with AIP but eventually proven to be pancreatic head carcinoma; case 2 was operated for suspected bile duct cancer combined with AIP and associated cholangitis, and early cancer was found in the resected specimen; case 3 was operated on for presumed cholangiocarcinoma combined with AIP-associated SC, but no malignancy was found.Current series of cases would raise an alert on diagnosis of AIP and associated SC, and pancreatobiliary malignancy should be carefully excluded by any means. Surgical intervention would be required in selected cases of this clinical entity.

Nonalcoholic fatty liver disease (NAFLD) is a chronic liver disease, and is commonly observed in patients with obesity or type 2 diabetes. The pathogenesis of hepatic fibrosis is clinically important to the outcome of NAFLD, however, is not well understood. Since dietary habits are often considered to be responsible for NAFLD, we used a synthetic diet rich in disaccharides (12.1% calorie sucrose and lactose), which can be considered for human consumption. We examined the long-term (24 weeks) effect of this diet on the liver of Zucker (fa/fa) rats. The synthetic diet-fed Zucker (fa/fa) rats showed hepatic fibrosis during the development of NAFLD with no apparent infiltration of inflammatory cells. They showed significantly elevated hepatic mRNA levels of proinflammatory and profibrogenic cytokines. These findings suggest that excess long-term feeding of a diet similar to the synthetic diet used in our study leads to hepatic fibrosis during the development of NAFLD in patients with obesity or type 2 diabetes. Our results were different from NAFLD accompanied by infiltration of inflammatory cells. However, they also suggest that long-term feeding of this synthetic diet to Zucker (fa/fa) rats is useful for studying the hepatic fibrogenesis during the pathogenesis of NAFLD.

Reported herein is an autopsy case of primary hepatic neuroendocrine carcinoma associated with dermatomyositis. A 71-year-old Japanese man, who was diagnosed with dermatomyositis 5 months before death, had multiple tumors within a non-cirrhotic liver. Histopathologically, the tumors were composed of small- and medium-sized round cells with clear cytoplasm arranged in nests, sheets or rosettes. Immunohistochemically, the tumor cells were positive for chromogranin A, neuron-specific enolase and CD56 and were negative for synaptophysin. This tumor was diagnosed as a primary hepatic neuroendocrine carcinoma with metastasis to the lung, gallbladder and lymph nodes around the pancreas and aorta; no primary lesions were detected in any other organ. The tumor cells were also positive for cytokeratin 7, cytokeratin 19 and epithelial membrane antigen but were negative for anti-hepatocyte antibody and AFP. These findings suggest that the tumor originated in intrahepatic bile duct epithelium. Various cancers have been reported in patients with dermatomyositis, but only seven cases of dermatomyositis associated with primary liver cancer have been reported. To the best of the authors' knowledge, this is the first report of dermatomyositis associated with primary hepatic neuroendocrine carcinoma.

We discuss the delivery of cacheable streaming content in a network with mobile nodes. Caching and regional replication are important techniques for traffic localization and reduction in load on the network and the content server. However traditional caching schemes alone cannot suffice for localization of streaming multimedia traffic in networks with mobile nodes. This is mainly because of limited geographical scope of caches. Mobile nodes can easily move out of such geographical scopes in the duration of a long session such as that of a typical streaming multimedia. In this paper we present a novel technique called cache handoff that allows a mobile node to keep switching to the most appropriate caching proxy as it moves, thus counteracting the adverse mobility effects and maximizing traffic localization. Simulation results show that this technique improves the average delay by almost 25% for a very low cache hit ratio of 0.1. This technique also gives increasingly better performance for larger session durations.

Service variability in IP networks creates the need for QoS (quality of service) assessment tools. These tools must provide estimations of the quality of service through different paths in the network. Some existing schemes require a large number of probe packets to be sent to achieve accurate estimates. Others use traffic monitoring with administrative control, the most adopted of which being SNMP (simple network management protocol) and RMON (remote monitoring). We propose a quality of service estimation mechanism for voice over IP (VoIP) that necessitates a small number of probe packets while adding simple queuing delay estimation functionality in core routers. The underlying concept is that variation in delay, jitter and available bandwidth, as seen by a voice application, is due to queuing variations at intermediate hops. Collecting and combining queuing delay estimates from core routers can therefore be used to obtain accurate QoS estimates. Our results indicate better performance than existing QoS estimation tools under similar conditions.

Mobile IP is focused on providing transparent connectivity to mobile nodes in an IP based network environment. While transparent mobility support is essential for compatibility with applications that are geared towards fixed network environment, it is a handicap for applications that can potentially benefit from mobility awareness. In this paper, we present Mobile IP API which is an interface between the applications and the mobility management module at mobile terminals and their correspondent nodes. Our main focus is basic Mobile IP API which primarily enables reading of mobility information for applications on mobile nodes and correspondent nodes. We present usage scenarios, design, and implementation of the API. We are also currently pursuing standardization of Mobile IP API through the IETF.

Seamless IP handoff is a crucial requirement to support real-time applications in mobile networks. In this paper, we aim to achieve seamless IP handoffs that are optimized for low latency and low packet loss in heterogeneous mobile wireless networks. We propose adaptive mechanisms that are distributed among heterogeneous network elements and mobile nodes. Adaptive process runs among geographically adjacent heterogeneous network elements and mobile nodes in the vicinity. The proposed mechanisms are devised to optimize IP handoff performances by attempting adaptive adjustment based on the local properties extracted through statistical processing.

Schwannoma is predominantly a benign neoplasm of the Schwann cells in the neural sheath of the peripheral nerves. Occurrence of schwannoma in parenchymatous organs, such as liver, is extremely rare. A 64-year-old man without neurofibromatosis was observed to have a space-occupying lesion of 23mm diameter in the liver during follow-up examination for a previously resected gastrointestinal stromal tumor (GIST) in the small intestine. He underwent lateral segmentectomy of the liver under a provisional diagnosis of hepatic metastatic recurrence of the GIST. Histological examination confirmed the diagnosis of a benign schwannoma, confirmed by characteristic pathological findings and positive immunoreactions with the neurogenic marker S-100 protein, but negative for c-kit, or CD34. The tumor was the smallest among the reported cases. When the primary hepatic schwannoma is small in size, preoperative clinical diagnosis is difficult. Therefore, this disease should be listed as differential diagnosis for liver tumor with clinically benign characteristics.

Since actinomycosis sometimes causes an abdominal tumor which mimics malignancy, treatment strategy varies from case to case. We herein report two cases which were treated with a combination of antibiotics and surgical intervention. Both patients presented with an intra-abdominal tumor lesion mimicking malignant disease after an appendectomy for acute appendicitis. Case 1 received surgical extirpation of the abdominal tumor in the liver and kidney twice since the clinical diagnosis of actinomycosis was not made. In contrast, case 2 was successfully treated by a combination of antibiotics and laparoscopic surgery following the experience of case 1. When a high probability diagnosis can be made, a laparoscopic approach is a useful and effective option to treat this condition.