Contribution of transcranial color-coded real-time sonography to the etiopathogenetic classification of middle cerebral artery stenosis

Transcranial color-coded real-time sonography (TCCS) and cranial computed tomography were applied to patients with middle cerebral artery (MCA) stenosis to evaluate whether these techniques may disclose additional aspects of the pathophysiology of the stenotic lesion. In 15 patients with MCA stenosis identified by transcranial Doppler sonography, the echogenicity of the stenotic segment was estimated subjectively by TCCS. The density of the stenotic segment, prior to being detected by TCCS, was quantified by computed tomography. In 5 of the 15 patients, transcranial image-directed Doppler sonography identified a hyperechogenic lesion in association with the stenotic vascular segment; computed tomography demonstrated a "dense" artery (Hounsfield units [HU] > 120) in the corresponding vascular segment. In 10 patients the echogenicity of the stenotic segment was found to be normal, with a computed tomography density of < 100 HU in the corresponding segment. Hyperechogenic and hyperdense stenotic vascular segments in TCCS and computed tomography, respectively, may indicate an arteriosclerotic vascular lesion with calcium deposits. Normal echogenicity and normal to slightly elevated computed tomography-density of a stenotic vascular segment may suggest the presence of a thrombotic/embolic lesion.     

Appearance of the resection area of brain tumors in intraoperative MRI imaging

During MRI-controlled resection of brain tumors using an open MRI system, operation-induced alterations may occur, especially enhancement of the resection cavity wall. This may simulate tumor areas, resulting in false assessment of the resection or resection of non-tumorous areas. Based on 42 MRI- and biopsy-controlled brain tumor resections in an 0.5 T open MRI (Signa SP, GE), the appearance and origin of operation-induced reactions are analyzed. In our opinion, there is a superposition of preformed peritumoral reactions by operation-induced microcontusions. The beginning of the cavity wall enhancement needs at least 10-15 min. MRI-controlled analysis of the intraoperative steps by the neurosurgeon and neuroradiologist allows discrimination of operation-induced reactions from tumor areas and leads to safe operation.     

Tectal tumors of childhood: clinical and imaging follow-up

PURPOSE: This study was done to determine which clinical and imaging findings best correlate with outcome in children with tectal tumors. METHODS: A retrospective review was done of the medical records and imaging studies of 32 children (16 boys and 16 girls; mean age, 8 years) with tectal tumors. Eight children had CT, 11 had MR imaging, and 13 had both CT and MR studies. Findings from surgical and pathologic reports as well as from follow-up examinations (mean follow-up period, 5 years; range, 3.6 months to 17 years) were included in the review. RESULTS: All patients had hydrocephalus and all but one required CSF diversion. The tectum was the center of the tumor in all cases and the majority of the tumors appeared isodense on CT scans, isointense on T1-weighted MR images, and hyperintense on T2-weighted images. Twenty patients required no further treatment. In this group, the mean maximum tumor diameter was 1.8 cm and enhancement occurred in two cases. At follow-up, 18 patients had stable tumor size, one had an increase in tumor size with cyst formation but no worsening of symptoms, and one had a decrease in tumor size. Twelve patients required further treatment (excision and/or radiotherapy) because of progression as indicated by either increased tumor size or worsening of symptoms. In this group, the mean maximum tumor diameter was 2.5 cm and contrast enhancement occurred in nine cases. Further follow-up in this group showed decreased tumor size in eight and stable residual tumor in three. CONCLUSION: Tectal tumors in childhood have variable behavior. MR imaging assists in the clinical determination of which children need treatment beyond CSF diversion. Larger tumor size and enhancement are radiologic predictors of the need for further treatment.     

Pilocytic astrocytomas of the posterior fossa. A follow-up study in 33 patients

The extent of resection in pilocytic astrocytoma of the posterior fossa often remains undefined and the indications for further treatment in incompletely resected tumours are a matter of debate. It has been also realized that the problem of hydrocephalus in patients with pilocytic astrocytoma of the posterior fossa has not yet been solved and the diagnostic impact of postoperative CT findings remains questionable. We retrospectively reviewed the data from 33 patients harbouring a pilocytic astrocytoma of the posterior fossa to evaluate the impact of surgical technique in terms of radicality and of postoperative imaging results upon prognosis and adjunctive treatment. In addition, the issue of hydrocephalus was considered and related to different treatment modalities. Thirty patients underwent surgical treatment whereas 3 had open biopsy of the tumour. Macroscopically gross total resection of the tumour was performed in 20 patients, whereas resection was partial in 10. Follow-up was obtained in 29 patients for a period which ranged between 2 and 184 months (85 months +/- 56 months). Outcome was good in 24 patients who had only slight neurological deficit and poor in 3 patients, who were severely disabled. Two patients died during the follow-up period. Recurrent tumour growth occurred in 2 cases with incompletely resected tumours. From the series presented, it was concluded that long-term follow-up with CT seems mandatory in cases with contrast-enhancing residual tumour. Recurrent tumour growth should be assumed in postsurgical patients with an enlarging area of enhancement shown in follow-up CT studies. Permanent ventriculoperitoneal shunting is required in certain patients with pre- or postoperative hydrocephalus.(ABSTRACT TRUNCATED AT 250 WORDS)     

Functional results and survival probability of tumor patients after reconstruction of the mouth cavity and oropharynx using a microvascular radial forearm flap

In tumor surgery of the oral cavity and oropharynx function and quality of life should be maintained and large resection margins to avoid recurrences. For these purposes the radial forearm flap has proved to be a versatile tissue transfer since it is thin and pliable and has a long vascular pedicle. From 1987 to 1991 we used the radial forearm flap in performing 70 reconstructions of the oral cavity and oropharynx after resection of squamous cell carcinomas. Forty-six patients had carcinomas of the oropharynx, while 24 patients had carcinomas of the oral cavity. The indications for these reconstructions were tumors of the oral cavity and oropharynx greater than T2 which after resection were not suitable for primary closure of the defect. Thirty-seven patients died during the follow-up period, with 36% dying within the first 2 years after operation. Fifty-five percent of these patients died of recurrences, 17% of metastases and 11% of intercurrent diseases. In 17% of cases the cause of death was unknown. The 2-year survival probability was 52% (Kaplan Meier). Our results show that reconstructions with the radial forearm flap do not improve survival rates when compared to the general survival rate in these cases despite a possibly larger resection margin allowing a more radical tumor resection. Thirty-one of the 33 patients still alive underwent following examinations. Forty-six percent of the patients with tumors of the oropharynx and 57% of the patients with tumors of the oral cavity had severe difficulties in swallowing.(ABSTRACT TRUNCATED AT 250 WORDS)     

Results of salvage abdominoperineal resection for anal cancer after radiotherapy

PURPOSE: Nonsurgical treatment of anal cancer by radiotherapy alone or combined with chemotherapy is the standard therapy for epidermoid carcinoma of the anal canal. Surgery is only recommended for treatment failures. Very few studies have been devoted to the outcome of this salvage surgery. The aim of this study is to evaluate these results. METHODS: A retrospective review from 1986 to 1995 revealed 21 patients with residual or recurrent anal canal carcinoma after initial radiotherapy, operated on by abdominoperineal resection. Patients were reviewed as to age, gender, initial treatment, any symptoms of recurrence, duration until recurrence, any diagnosis imaging, treatment, and outcome. RESULTS: None of these 21 patients had known lymph node involvement or metastases at radiotherapy or at salvage abdominoperineal resection. Eleven patients had residual disease (positive biopsy less than 6 months after the end of radiotherapy) and 10 had tumor recurrence (more than 6 months after cessation of treatment). Recurrence occurred at a mean of 15 (range, 9-41) months after radiotherapy. All 21 patients underwent an abdominoperineal resection. Pathologic examination of the 21 specimens showed complete excision in all cases except one and lymph node metastases in two cases. There was no perioperative mortality. The mean follow-up after surgery was 40 months; no patients were lost to follow-up. Of the 21 patients, 10 died and 11 lived, of whom 9 are disease free. The overall survival rate at three years after salvage abdominoperineal resection was 58 percent. The overall survival rate for patients with residual disease (vs. recurrence) at three years was 72 percent (vs. 29 percent) and at five years was 60 percent (vs. 0 percent; P = 0.06). CONCLUSIONS: Salvage abdominoperineal resection for anal cancer can be expected to yield a number of survivors from residual disease, but the low rate of survival after abdominoperineal resection for recurrent disease suggests the need for additional postoperative treatment if salvage abdominoperineal resection is performed.     

Sensitivity of computed tomography in detecting local recurrence of prostatic carcinoma following radical prostatectomy

The aim of this study was to evaluate CT imaging in the post-operative follow-up and in the detection of recurrence after radical prostatectomy in cases of prostatic carcinoma. In over 500 patients undergoing radical prostatectomy for prostatic carcinoma, 22 cases with local recurrence were found. CT examinations of the pelvis were retrospectively evaluated in these patients. Local recurrence was detected by PSA uptake and confirmed by transrectal ultrasound (TRUS) in combination with guided biopsy. In 22 cases of confirmed local recurrence, positive results on CT were found in eight patients (36%) and negative results in nine patients (41%). In the remaining five cases (23%), no distinction could be made between scar and local recurrence. All cases definitively classified as recurrent tumour disease showed a soft tissue mass of 2 cm or more. CT sensitivity in local recurrence of prostatic carcinoma after surgery is low. Even in a very careful follow-up, the understaging would be up to 41%. In comparison, PSA, TRUS and needle biopsy are the methods of choice and are superior to CT imaging. Based on these results, there would be no reason for including pelvic CT examinations in the follow-up of prostatic carcinoma after radical prostatectomy.     

Pleural lipoma: report of a case

We report herein the unusual case of a 45-year-old Japanese man whose chest X-rays revealed an abnormal shadow, increasing in size. A chest wall tumor was suspected, based on the findings of computed tomography (CT) of the thorax, the CT number of which was -137, chest roentgenogram, and an echograph. An open biopsy was performed to establish the final diagnosis. The resected tumor was a pedunculated pleural mass, yellowish in color, the pathological diagnosis of which confirmed a lipoma. Intrathoracic lipomas are rare, but pleural lipomas are seen even less frequently. CT, echography, and percutaneous needle biopsy have been found useful for diagnosing intrathoracic lipomas, but these examinations are not always adequate for confirming the final diagnosis. Consequently, tumor resection is essential for obtaining a pathological diagnosis.     

Postoperative follow-up of juvenile nasopharyngeal angiofibromas: assessment by CT scan and MR imaging

The purpose of this study was to assess the radiological findings after surgical removal of juvenile nasopharyngeal angiofibromas (JNA). The postoperative CT and MRI scans of ten patients were reviewed. The cured group included six patients. The non-controlled group included six patients with eight recurrences. Two patients belonged to both groups as they were also followed and cured after surgery for relapse. Four recurrences were asymptomatic and diagnosed by imaging. The imaging patterns were matched to the patients clinical status and endoscopic findings. In the cured group, non-enhanced residual soft tissue masses were seen in all cases. In the non-controlled group, recurrence was always demonstrated on early postoperative CT or MR as a dramatically enhanced mass. The recurrence was located in the lateral or superior aspect of the nasopharynx (n = 3), deep to the fossa of Rosenmuller (n = 4) or out of the nasopharynx (n = 1). In two cases a remaining enhanced mass disappeared spontaneously on iterated examinations. Because of numerous asymptomatic relapses, a radiological workup is recommended four months after surgery, even in patients with normal endoscopy, to rule out posterolateral or extranasopharyngeal recurrences. Spontaneous evolution of residual masses must be appreciated on iterated imaging examinations.     

Aggressive fibrous dysplasia of the maxillary sinus

Fibrous dysplasia is usually a slowly progressive, benign disease that develops over several years and presents with deformity or mild symptomatology. Five of 34 patients (ages 4-21 years), who were subsequently diagnosed histologically as having fibrous dysplasia of the maxillary sinus, rapidly developed soft tissue masses of the malar region over a period of less than 4 months with accompanying pain (2 patients) and nasal obstruction and exophthalmos (2 patients). Each was clinically suspected of having a sarcoma; two had been thought to have an "osteofibrosarcoma" on initial biopsy at outside hospitals. After resection, all lesions developed regrowth. At histopathologic examination, both initial and recurrent masses proved to be typical fibrous dysplasia with spicules of woven bone in cellular, sometimes vascular, fibrous tissue. No malignant degeneration was found. On conventional radiography, aggressive fibrous dysplasia produced opacification and expansion of the maxillary sinus and apparent disruption of its wall with an associated soft tissue mass. Computed tomography (CT) demonstrated voluminous heterogeneous masses with "ground glass appearance", calcifications, areas of enhancement, low attenuation, cystic areas, and a thinned, sometimes interrupted, maxillary wall. Despite the aggressive clinical course for both initial and recurrent lesions, the CT findings of a "ground glass" mass with calcifications surrounded by a maxillary sinus wall, even if incomplete, can suggest the diagnosis of aggressive fibrous dysplasia.     

Recurrent left-sided heart leiomyosarcoma: should heart transplantation be legitimate?

Leiomyosarcoma of the heart is an uncommon primary malignant tumor with poor postoperative survival that may be measured in months. A leiomyosarcoma of the left atrium was diagnosed in a 47-year-old man. Initial admission was for acute pulmonary edema requiring emergency surgery. The tumor involved the left atrial cavity, and a radical resection was performed. Six months later an isolated myxomatous recurrence was detected. Heart transplantation was then performed. The patient is in good health 20 months after operation with no evidence of residual disease or recurrence. The literature has been reviewed. Surgical resection is not an adequate treatment for leiomyosarcoma of the left atrium and early heart transplantation probably offers the only hope for these patients.     

Computed tomography in the postoperative patient

Nine cases of patients in whom intracranial infection was suspected after operation are presented. Lesions with ring enhancement were seen in all of these patients. The differentiation of enhancement, seen as a normal postoperative phenomenon, from residual neoplasia and cerebral abscess can be difficult. This can be resolved by serial and sequential-delayed CT, and thus unnecessary re-exploration may be prevented.     

Inverted papilloma of the nasal cavity and the paranasal sinuses: using CT for primary diagnosis and follow-up

OBJECTIVE: Morphologic criteria for the diagnosis of primary and recurrent inverted papilloma as revealed on CT were evaluated in a large series. MATERIALS AND METHODS: Findings of 121 CT examinations that had been performed in 32 patients with histologically proven inverted papilloma were retrospectively analyzed using the following morphologic criteria: localization, size, surface configuration, and bony changes. RESULTS: Unilateral tumor localization involving the lateral nasal wall and the middle meatus was the feature that best correlated with the finding of primary inverted papilloma. A lobulated surface pattern was another typical sign, which was revealed on 19 of the 29 CT scans of patients with primary inverted papilloma. Although tumor localization and the finding of a newly grown soft-tissue mass were less reliable criteria to differentiate between recurrent inverted papilloma and postoperative complications or concomitant inflammatory disease, a lobulated surface pattern was seen on 26 of the 28 CT scans of patients with tumor recurrence but on only three of the 64 follow-up CT scans of patients without recurrent inverted papilloma. CONCLUSION: A unilateral mass within the nasal cavity or paranasal sinuses with a surface configuration that appears lobulated on CT is, to our knowledge, a new sign that strongly suggests inverted papilloma as a primary diagnosis and also suggests inverted papilloma in patients with tumor recurrence.     

Mixed oligoastrocytomas: a survival and prognostic factor analysis

Seventy-one patients with supratentorial mixed oligoastrocytomas underwent surgery only (5 patients) or surgery with postoperative radiation therapy (66 patients) between 1960 and 1982. The median survival for these 71 patients was 5.8 years and the 5-, 10-, and 15-year survival rates were 55, 29, and 17%, respectively--values significantly different from those of an age- and sex-matched normal reference population. Uni- and multivariate survival analyses were applied to 14 possible prognostic factors, including the following: patient factors--age, sex, and seizures; tumor factors--site, size, side, computed tomographic enhancement, and calcification; pathological factors--tumor grade and dominant cellular component; and treatment factors--extent of surgical resection, lobectomy, and radiation dose and field. Of these factors, tumor grade, as determined by the Kernohan method, was the most strongly associated with survival. The 60 patients with Grades 1 and 2 tumors had a median survival of approximately 6.3 years and 5- and 10-year survival rates of 58% and 32%, respectively, compared with 2.8 years (36 and 9%, respectively) for the 11 patients with Grades 3 and 4 tumors. Age < 37 years, gross total resection, partial brain radiation, and radiation dose > or = 5000 cGy were other factors significantly associated with improved survival in both uni- and multivariate models. Three of five patients not receiving postoperative radiation therapy experienced tumor recurrence and died. Seven of eight patients from whom tissue was obtained at the time of tumor progression demonstrated anaplastic transformation.(ABSTRACT TRUNCATED AT 250 WORDS)     

Radiologic evaluation of gastrointestinal leiomyosarcomatosis

A 68-year-old woman who had previously undergone small intestinal resection because of leiomyosarcoma was referred to our clinic with epigastric pain. A double-contrast barium study and the subsequent abdominopelvic CT and abdominal MRI examinations demonstrated multiple extraluminal growing tumors arising from the walls of stomach, small bowel, and colon. A CT-guided aspiration biopsy revealed malignant mesenchymal tumor. The presence of disseminated intra-abdominal masses without concomitant ascites and invasion of tissue planes on CT in a patient operated on prior because of a leiomyosarcoma led to the diagnosis of gastrointestinal leiomyosarcomatosis. In this report we discuss the radiological approach to this rare entity.     

Resection, biopsy, and survival in malignant glial neoplasms. A retrospective study of clinical parameters, therapy, and outcome

Between July, 1984, and October, 1988, 263 patients (163 male, 100 female), aged from 4 to 83 years (mean 52 years), with malignant brain gliomas underwent surgical procedures: stereotactic biopsy in 160 and resection in 103 patients. There were 170 grade IV astrocytomas, 17 grade IV mixed oligoastrocytomas, 44 grade III astrocytomas, 22 grade III mixed oligoastrocytomas, and 10 malignant oligodendrogliomas. Overall median survival time was 30.1 weeks for grade IV gliomas, 87.7 weeks for grade III gliomas, and 171.3 weeks for malignant oligodendrogliomas. Multivariate analysis in 218 newly diagnosed cases revealed that the variables most strongly correlated with survival time were: tumor grade, patient age, seizures as a first symptom, a Karnofsky Performance Scale score of less than 70%, tumor resection, and a radiation therapy dose greater than 50 Gy. The proportions of patients receiving tumor resection versus biopsy in each of these prognosis factor groups were similar. Since most of the 22 patients with midline and brain-stem tumors were treated with biopsy alone, these were excluded. Considering 196 newly diagnosed patients with cortical and subcortical tumors, grade IV glioma patients undergoing resection of the contrast-enhancing mass (as evidenced on computerized tomography and magnetic resonance imaging) and postoperative external beam radiation therapy lived longer than those undergoing biopsy only and radiation therapy (median survival time 50.6 weeks and 33.0 weeks, respectively; Smirnov test, p = 0.0380). However, survival in patients with resected grade III gliomas was no better than in those with biopsied grade III lesions (p = 0.746). The authors conclude that, in selected grade IV gliomas, resection of the contrast-enhancing mass followed by radiation therapy is associated with longer survival times than radiation therapy after biopsy alone.     

Spinal subdural enhancement after suboccipital craniectomy

PURPOSE: To characterize transient intraspinal subdural enhancement (potentially mimicking the subarachnoid spread of tumor) seen on MR images in some children after suboccipital craniectomy for posterior fossa tumor resection. METHODS: Radiologic and medical records of 10 consecutive children who had MR imaging for spinal staging after resection of posterior fossa tumor during a 9-month period were reviewed retrospectively. In addition, one case with similar findings of intraspinal enhancement on spinal staging MR images obtained at another institution was included in the review. RESULTS: Intraspinal enhancement thought to be subdural was seen in four of 10 patients undergoing spinal staging MR imaging 6 to 12 days after surgery. In these four patients, MR studies 50 to 18 days later, without intervening treatment, showed resolution of the abnormal enhancement. A fifth patient (from another institution) with similar intraspinal enhancement underwent CT myelography 4 days later, which showed no subarachnoid lesions. No metastases have developed in any of these five patients during the 2.5- to 3.5-year follow-up period. conclusions: From analysis of the MR appearance and on the basis of prior myelographic experience, we suggest an extraarachnoid, probably subdural, location of this enhancement. Awareness of this phenomenon will reduce the rate of false-positive diagnoses of metastatic disease. Preoperative spinal staging should be considered for patients undergoing suboccipital craniectomy.     

Thoracic actinomycosis: CT findings

PURPOSE: To characterize computed tomographic (CT) findings of thoracic actinomycosis. MATERIALS AND METHODS: Chest CT scans and radiographs obtained in 22 patients with histopathologically proved thoracic actinomycosis were retrospectively reviewed. All patients were immunocompetent; they were aged 12-73 years (mean, 42.6 years; 14 male, eight female). CT findings were correlated with histopathologic findings in nine patients who underwent surgery (lobectomy [n = 8] or segmental resection [n = 1]). RESULTS: All of the lesions were unilateral, with an average diameter of 6.5 cm (range, 2-12 cm). Patchy air-space consolidation (n = 20) or a mass (n = 2) was seen on CT scans. Fifteen (75%) of the 20 patients with air-space consolidation had central areas of low attenuation (5-30 mm in diameter) within the consolidation. Thirteen of the 15 patients underwent contrast medium-enhanced CT. Ten (77%) of the 13 patients showed ring-like rim enhancement. Adjacent pleural thickening was seen in 16 patients (73%). At histopathologic examination, central low-attenuation areas at CT were seen as microabscesses with sulfur granules or a dilated bronchus that contained inflammatory cells and Actinomyces colonies. Peripheral enhancement of the low-attenuation areas was wall of the microabscess or surrounding parenchyma composed of granulation tissue rich in vascularity. CONCLUSION: Findings of chronic segmental air-space consolidation that contained low-attenuation areas with peripheral enhancement or adjacent pleural thickening at CT were suggestive of thoracic actinomycosis.     

Quantitative imaging study of extent of surgical resection and prognosis of malignant astrocytomas

OBJECTIVE: This study used quantitative radiological imaging to determine the effect of surgical resection on postoperative survival of patients with malignant astrocytomas. Previous studies relied on the surgeons' impressions of the amount of tumor removed, which is a less reliable measure of the extent of resection. METHODS: Information concerning possible prognostic factors was collected for 75 patients undergoing magnetic resonance imaging or computed tomography preoperatively and within 10 days postoperatively. Image analysis of the neuroradiological studies was conducted to quantify pre- and postoperative total tumor volumes and enhancing volumes. Univariate and multivariate proportional hazards models were used to analyze the regression of survival regarding 22 covariates that might affect survival. The covariates that were entered included age, gender, tumor grade, cumulative radiation dose, chemotherapy, seizures as a first symptom, Karnofsky performance status at presentation, pre- and postoperative total and enhancing tumor volumes, ratio of pre- to postoperative total and enhancing tumor volumes, tumor location, surgeon's impression of the degree of resection, and subsequent surgery. RESULTS: There were 23 patients with anaplastic astrocytomas and 52 with glioblastomas multiforme. The estimated mean survival time was 27 months for patients undergoing gross total resection, 33 months for subtotal resection, and 13 months for open or stereotactic biopsy. Five factors that were significant predictors of survival in multivariate analysis were tumor grade, age, Karnofsky performance status, radiation dose, and postoperative complications (P < 0.05). In univariate analysis, tumor grade, radiation dose, age, Karnofsky status, complications, presence of enhancing tumor in postoperative imaging, and postoperative volume of enhancing tumor were significantly associated with survival (P < 0.05). CONCLUSION: We conclude that the most important prognostic factors affecting survival of patients with anaplastic astrocytomas and glioblastomas multiforme are tumor grade, age, preoperative performance status, and radiation therapy. Postoperative complications adversely affect survival. Aggressive surgical resection did not impart a significant increase in survival time. Surgical resection may improve survival, but its importance is less than that of other factors and may be demonstrable only by larger studies.     

A case of retroperitoneal extramedullary plasmacytoma

Extramedullary plasmacytoma (EMP) is a very rare disease and mainly arises in the head and neck area. We herein reported a case of EMP arising in the retroperitoneal space. A 46-year-old man was referred to our outpatient clinic in November 1989 with the complaint of flank pain on the left side. Radiological examinations showed a tumor formation in the retroperitoneal space, which involved the left kidney, spleen and pancreas. Immunoelectrophoresis showed an elevation of serum IgG level and a spike of M-protein was detected in the serum protein electrophoresis. No bone lesions were detected, and bone marrow aspiration showed no abnormal cells. US-guided needle biopsy of the tumor led to the histological diagnosis as plasmacytoma of the IgG-kappa type. Following three cycles of preoperative chemotherapy (a THP-COP regimen), which resulted in a size reduction of the tumor by 40%, extensive resection of the tumor including extirpation of the left kidney, spleen, and tail of pancreas was performed. Because of tumor extension into the posterior wall of the stomach, however, the surgery resulted in incomplete resection. A total of 11 cycles of postoperative chemotherapy (THP-COP) was performed periodically for the residual tumor in the stomach. Rapid tumor spreading in addition to re-elevation of the serum IgG level, however, developed after the 11th postoperative chemotherapy, which extensively involved the stomach and intestines. The patient died of the disease 33 months after the initiation of treatment.