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It has been known that intrahepatic cholelithiaiss is frequently associated with cholangiocarcinoma and the prognosis is very poor in that case. We have experienced such a case surviving for more than three years after operation. A 55-year-old woman complaining of an upper abdominal pain was found having intrahepatic gallstones by endoscopic retrograde cholangiography and abdominal computed tomography. The lateral segment of the left lobe of liver was resected and histologic sections revealed associated chlangiocarcinoma whitch extended to surgical margin. Forty-three days later, the medial segment of the left lobe was resected to remove residual carcinoma, though cancerous tissue was not detected histologically. The patient has been well for more than three years after the operation. Significance of exact clinical investigation and pertinent operation should be emphasized in the management of intrahepatic cholelithiasis with a long history of the disease, especially in a case with recurrent infections.

今回われわれは虫垂杯細胞カルチノイドの2例を経験したので報告する.症例は46歳の男性と41歳の男性である.2例とも虫垂炎の診断で虫垂切除術を行った.術後の病理検査で虫垂杯細胞カルチノイドと診断されたため, ともに右半結腸切除術を追加した.しかし, 切除標本には腫瘍細胞を認めず, リンパ節転移も認めなかった.2例は術後約2年2か月, 約2年を経過しともに再発の徴候はない.虫垂の杯細胞カルチノイドはまれな疾患である.本邦ではわれわれの症例を含めて31例が報告されている.多くの症例は急性虫垂炎の診断で手術されているが進行した症例では回盲部腫瘍と術前に診断されていた症例も認められる.治療は虫垂切除術のみで経過観察されている症例と回盲部切除術や右半結腸切除術が行われた症例に分けられるが, 転移, 再発を認めた症例が多く, 病期によっては積極的な外科治療が必要と考えられる.

We experienced a case of rectal cancer with Fournier's gangrene. A 56-year-old man was seen at the hospital because of swelling and pain of the scrotum. With digital examination of the rectum a tumor was palpated. The patient was suspected to have a rectal cancer with Fournier's gangrene and admitted to the hospital. Abscess in the scrotum was confirmed. Lavage was performed by inserting a drain, but inflammatory findings did not show any remission. Bilateral resection of the testes and abcess drainage were carried out. After inflammatory findings were improved and surgical wounds were cured, barium enema was done. And an elevated lesion was detected in the rectum Rb. Under a diagnosis of rectal cancer, abdominoperineal excision of the rectum was carried out. Histopathologically the tumor cells infiltrated into the striated muscle and in its surrounding the abscess existed. There has been no sign of recurrence, as of about 4 years and 7 months. It has been reported that anal diseases caused Fournier's gangrene in 29 out of 68 cases (42.6%). It is rare that lower rectal cancer causes perianal abscess and this case in which rectal cancer caused Fournier's gangrene is the first report in Japan.

Malignant lymphomas arising in the breast are rare. We experienced a case of malignant lymphoma arising in the bilateral breasts heterochronously. The case involved a 65-year-old woman. In January 1988 she underwent radical mastectomy for a tumor in the right breast. She was diagnosed as having a malignant lymphoma and underwent chemotherapy and radiotherapy after the operation. In July 1990 the patient was seen at the hospital because of a tumor in the left breast. Under a diagnosis of malignant lymphoma modified radical mastectomy was carried out. Histological picture was the same as the former. In March 1992 she had a recurrence in the left hard palate which was successfully managed by chemotherapy and radiotherapy, however, died of other disease in April 1993. Malignant lymphoma of the breast is characterized by its bilateral occurrence in a relatively high rate. So in a case of the disease arised in the lateral breast, the counterlateral breast should be carefully followed up. Most heterochronous bilateral cases have been treated by bilateral mastectomies, but recurrence have occurred in many of them. It is though that the disease should be dealt with as a systemic disease and aggressive cheomotherapy is important.

We experienced a case of gastric leiomyosarcoma, with calcification and ossific nest, complicated by duodenal Brunnerioma. A 66-year-old male patient was found to have a tumor in the anterior wall of the upper body of the stomach, showing a mixed type of Skandalakis classification with dimensions of 120×80×70mm. Ultrasonography and CT-scan examinations were useful for the diagnosis of calcification. The tissue findings indicated a formation of bone surrounded by osteoblasts. We have so far had reports of 22 such cases of gastric myogenic tumor accompanied by calcification in Japan, in which the tumors were not so big (mean diameter of 47mm). The ratio of males to females was 6:14, notably more for females. Some endocrine factors were considered to have participated in the mechanism of calcification. Furthermore, a probable participation of an unknown humorla activator was suspected in the growth of the tumors.

Comparative study of image diagnosis of ultrasonography (US) by linear electronic scanner, computed tomography (CT), and adrenal scintigraphy was performed in 14 patients with Cushing's syndrome. Adrenal imaging by scintigraphy was performed at the 5th and 6th day or further 7th day following the injection of 1 mCi of Adosterol. Cushing's disease (11 cases) US failed to detect the adrenals in 4 cases examined. Measurement of the adrenals on CT film demonstrated the enlargement of adrenals (greater than mean + 2SD) in 6 of 7 cases (85.7%). Scintiscanning showed the increased uptake of bilateral adrenals in 4 of 10 cases (40%). Adrenal scintigraphy with dexamethasone pretreatment (DP) still demonstrated the isotope uptake of bilateral adrenals in all of those 4 cases tested, although the other 6 cases were not studied with DP. From these findings, it was suggested that the measurement of adrenal size by CT was useful for the additional image diagnosis of Cushing's disease, and the adrenal scintigraphy with DP was also available for complementary study of Cushing's disease. Cushing's syndrome due to adrenocortical adenoma (3 cases) In one case examined by US, which had the smallest adenoma (0.6 X 1.0 X 2.0 cm) in this syndrome, the adenoma was not detected. All of 3 adrenal adenomas (2.6 X 2.6 X 2.2 cm to 0.6 X 1.0 X 2.0 cm) were detected by CT. Adrenal scintigraphy demonstrated good uptake by adrenal adenoma but no visualization of the contralateral adrenal in every case.

Splenic artery aneurysm is considered to be a relativery uncommon disease. However, it is the most frequent of all abdominal splanchic artery aneurysms, and the recent development of diagnostic imaging has resulted in an increasing number of reported cases.We report the case of a 60-year-old man who visited the hospital with a chief complaint of epigastric pain. Gastric endoscopy demonstrated a submucosal tumor-like semispherical mass, 5×5cm, in the posterior wall of the middle part of the gastric body. On endoscopic ultrasonography, the mass was found to be a compression from outside the gastric wall, and celiac angiography led to the diagnosis of splenic artery aneyrysm originating from the main splenic artery. In operation, only aneurysmectomy was carried out and splenectomy was not performed. The patient was discharged with a complete cure on the 17th hospital day.Histologically, there was no arteriosclerotic change in the wall of the aneurysm, and etiologically, an aneurysm of Group I in the Stanley classification was considered.

The image diagnoses of a case of so-called "nonfunctioning" adrenal adenoma, weak mineralocorticoids producing adrenal carcinoma, congenital adrenogenital syndrome due to 21-hydroxylase deficiency--simple virilizing form--, and 5 cases of pheochromocytoma were studied. In a patient with so-called "nonfunctioning" adrenal adenoma (2.3 X 3.0 X 3.3 cm), in which steroids biosynthesis was confirmed, computed tomography (CT) delineated the tumor shadow with extremely low density, and ultrasonography (US) demonstrated the round tumor echo with homogenous and low echogenicity at the superior region of the right renal pole. Adrenal scintigraphy also showed the tumor image. A weak mineralocorticoids-producing left adrenal carcinoma (3.5 X 3.5 X 3.0 cm) was shown as a heterogenous round tumor at the left lateral portion of the vertebra by CT. On adrenal scintigraphy under dexamethasone pretreatment, there was good uptake in the tumor and disappearance of the contralateral. Both bilateral adrenal images on CT in a patient with congenital adrenogenital syndrome were linear-shaped and markedly enlarged. The enlarged right adrenal was clearly demonstrated by US with an electronic sector scanner but not with an electronic linear scanner, although the left one was hardly shown by either US instruments. Three of 4 patients with pheochromocytomas examined by US were correctly detected, while in the remaining one the tumor image was judged to be a retroperitoneal tumor. CT also correctly demonstrated the former 3 pheochromocytomas, but misjudged the latter one as a pancreatic cancer. Good uptake of Adosterol by bilateral adrenals was shown in a case of extra-adrenal pheochromocytoma. Three of 4 cases of adrenal pheochromocytoma showed the isotope uptake of the contralateral normal adrenal alone. In another case of right adrenal pheochromocytoma, isotope accumulation in the colon obscured whether the isotope uptake in the right adrenal was shown or not.

The shape and size of the adrenals in control subjects without adrenal disorders were studied by computed tomography (CT), and a comparative assessment of diagnostic values of ultrasonography (US) by electronic linear scanner, CT, and adrenal scintigraphy was made on 9 patients with primary aldosteronism. Adrenal imaging by scintigraphy was performed on the 5th and 6th day, or further on the 7th day after the injection of 1 mCi of Adosterol. CT findings of the adrenals in control subjects: Eighty-two % of 100 control right adrenals, and 89% of 100 control left adrenals were detected by CT. Seventy-seven % of the right adrenals were in linear-shape, and the others were in V-shape. The shape of the left adrenals could be classified into triangular-shape (54%), Y-shape (28%) and V-shape (18%). The mean width and thickness of the right adrenals were 28.6 +/- 7.5 mm (M +/- SD) and 3.8 +/- 1.4 mm, respectively. Those of the left ones were 19.4 +/- 5.5 mm and 5.3 +/- 1.8 mm. Image diagnosis of primary aldosteronism: In 2 out of 3 patients examined by US, aldosteronomas were detected. In these 2 patients, one had 2 adenomas 2.8 X 1.7 X 1.2 cm and 1.0 X 1.0 X 2.0 cm in size, and the other had one adenoma 0.8 X 1.0 X 2.0 cm in size. On adrenal scintiscanning under dexamethasone pretreatment (DP), the isotope uptake of aldosteronoma was still seen with the disappearance of the contralateral adrenal in 7 out of 9 cases. In these 7 cases, the laterality of the tumor was confirmed. In one of the remaining 2 cases, the bilateral adrenal images were obtained regardless of DP. In the other case, of which aldosteronoma was the smallest (0.6 X 0.6 X 0.8 cm), the image of the affected adrenal with adenoma as well as the contralateral adrenal disappeared under DP. CT delineated all aldosteronomas in 8 cases examined including 2 cases in which adrenal scintiscanning failed to elucidate the localization of aldosteronoma. These results indicated that the combination of these 3 new image diagnostic methods was available for the detection of aldosteronomas of various sizes.