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Two-thirds of early gallbladder carcinomas are classified as superficial macroscopic type. Most pathologic T1b (pT1b) gallbladder carcinomas spread only locally. As lymph-vascular invasion and nodal metastasis are rarely found in pT1 tumor, postoperative diagnosis of early gallbladder carcinoma does not warrant additional radical resection when surgical margin is cancer-free. No nodal disease or a single positive node indicates a favorable outcome after resection, whereas radical lymph node dissection is effective for selected patients with multiple positive nodes, provided that an R0 resection is feasible. Direct liver invasion and portal tract invasion are the main modes of hepatic spread from resectable gallbladder carcinoma. Portal tract invasion mainly results from lymphatic spread within the portal tracts. The mode of hepatic spread and residual tumor status, rather than the type of hepatectomy, is the most important predictor of survival after resection for gallbladder carcinoma with hepatic involvement. The correlation between gross depth of direct liver invasion and distance of portal tract invasion may be useful clinically for estimating adequate hepatectomy margins, since partial hepatectomy involving the gallbladder bed is a critical part of the resection for gallbladder carcinoma.

症例は55歳の男性で,心窩部痛を主訴とし,当科入院後の検査で肝内直接浸潤と大網浸潤を有する胆嚢癌と診断された.また,B型肝炎ウイルスによる肝硬変を合併していた.癌浸潤のある大網とともに肝S4a+S5部分切除術を行い,肝外胆管切除・胆道再建術を併施した.少量の腹水貯留を認め,リンパ節郭清はD_1郭清に留めた.病理組織学的には高～中分化管状腺癌から成るpT_4, pN_0, pM(-), fStage IV aの胆嚢癌であり,pHM_2のため非治癒切除となった.再発を危ぐし,補助化学療法として低用量Gemcitabine(以下,GEM)療法を施行した.術後1年目はGEM 400mg/回/週,3週投与1週休薬を継続し,以後は隔週投与とした(総投与量48,800mg).5年経過した現在,再発なく社会復帰している.胆道癌切除例に対する低用量GEM化学療法は,quality of lifeを損なうことなく継続可能な補助療法の一つとして期待できる

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The nodular umbilical metastasis of the visceral carcinoma has been termed the “SisterMary Joseph’s nodule” (SMJN), and is one of signs of a terminal condition. There are variousroutes of metastasis according to anatomical and embryological specificity. We reporttwo cases of metastatic adenocarcinoma of the umbilicus, and also reviewed the 108 cases ofSNJN that have been reported in Japan.The patients were 49 year-old man and 84 year-old woman who were referred to ourhospital with umbilical nodules. Examination by computed tomographies, a biopsy and anextirpation of umbilical nodules showed that the primary malignancies were the pancreascancer and the gallbladder cancer.Of 110 SMJN cases in Japan, thirty-one were men and seventy-six were women, and theprimary focus was found in the stomach (45/103 : 39%), ovarium (18/103 : 13%), pancreas (14/103 : 15%) or colon (11/103 : 12%). In fifty-two cases (52/94 : 55%), initial presentation of theinternal organ carcinoma was an umbilical nodule.It is generally reported that the prognosis of the patient with SMJN is extremely poor,but a few cases get the long survival after extirpation of SMJN. In order to decide propertreatment and prognosis, it is necessary us to further examine the primary malignancy andthe route of metastasis for the SMJN patient.

The usefulness of ultrasonography (US) as a screening examination for the early diagnosis of gallbladder cancer was evaluated. US findings of polypoid lesions of the gallbladder comfirmed histologicaly were classfied into 3 types: peduncular type, papillary type and nodular type. In 28 cases with benign polypoid lesions of the gallbladder, 21 cases showed peduncular type, 5 cases showed papillary type and only 2 cases showed nodular type. In 12 cases with gallbadder cancer locarized in the gallbladder, 8 cases showed nodular type, 2 cases showed papillary type. From these results, a flow chart for screening for gallblader cancer was maked out. Twenty-two patients with gallblladder cancer locarized in the gollbladder who had undergone curative resection were classfied into 3 groups as follows. A group (9)：patients with symptom diagnosed gallbladder cancer befor operations, B group (8)：patients undergone operations for another disease (cholelithiasis etc.) and C goup(9)：patients without symptom who had been screeninged using ultrasonography. Five-year survival rate was 33% in A group, 50% in B group and 89% in C group. A significant difference (p

The mortality rate for the biliary tract cancer (BTC) in Niigata Prefecture is the highest in Japan. It is shown that the higher incidence of gallbladder cancer (GBC) rather than extrahepatic bile duct cancer(BDC) may account for BTC in Niigata. In order to explain the geograhical clustering of deaths from GBC and to search for the presence of genetic difference, a study of HLA typing of the patients was under taken. Forty patients of GBC and 32 cases of BDC were extracted from the patients admitted to five hospitals in Niigata Prefecture from 1987 to 1989. The control subjects were selected from employees in a steel-manufacturing company located in Niigata City. The HLA antigens were examined by the Terasaki-NIH standerd method. Statistical analysis of difference in frequencies of phenotypes between the cases and the controls was undertaken by Fisher's exact test of probabihty. Concerning the HLA-A, B, C antigens, none of them was associated with the GBC and BTC. The positive association was found only in the DR locus in GBC. The DR4 frequency of 60.0% (24/40)in GBC was statistically higher than that of the control group at the probability level of 0.00646 by Fisher's exact test. The relative risk and its 95% confidence limits were 3.5 and 1.4～8.7, respectively. The value of etiologic fraction was 0.429, that is, the HLA-DR4 attributed 42.9% to the occurrence of GBC in terms of the genetic susceptibility. in the case of the BDC, the frequency of DR4 was 28.1% (9/32) and not different from the control group.

Niigata prefecture gives very high mortality rate for the bilialy tract cancer. Recent studies to explore this epidemiologic characteristics showed a significant correlation between the standerdized mortality ratio (SMR) for the biliary tract cancer and the amount of certain agricultural chemicals consumed. We detected agricultural chemicals in cholesterol gallstones of 99 patients, including 11 patients of gallbladder cancer, in order to clarify the possibility that these chemicals could be excreted into the bile and play a role in the etiology of the biliary tract cancer in this high risk area. DLD, pp'-DDT, β-BHC and PCB were detected in the gallstones, even though epidemiological study showed no positive correlation between them and the SMR for the biliary tract cancer. MCPA, MCPB, CNP, simetryn that showed significant correlation to the SMR were not detected. Further investigation on the biliary excretion of the metabolites of these chemicals is indicated.