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Morphologically, liver metastases from colorectal carcinoma usually form as nodular tumor masses, whereas intraductal papillary growth in the bile duct is rare. A 65-year-old man underwent right hemicolectomy for advanced colon carcinoma, and histology of the primary carcinoma confirmed moderately differentiated adenocarcinoma with subserosal invasion, no vascular infiltration, and no lymph node metastasis. A liver tumor was found in the right paramedian Glisson pedicle and intraductal growth of cholangiocarcinoma was seen on imaging. We performed right hepatectomy and macroscopically, the resected specimen contained a growth in the bile duct lumen similar to cholangiocarcinoma. Histological examination revealed intraductal papillary proliferation of well-differentiated adenocarcinoma without vascular infiltration or lymph node metastasis in the hepatic hilum. Immunohistochemical staining revealed that the tumor cells were negative for cytokeratin-7 and positive for cytokeratin-20. Based on these findings, liver metastasis from colon carcinoma was diagnosed. Liver metastasis from colorectal carcinoma rarely arises as intraductal papillary growth in the bile duct, but the possibility of liver metastases with unusual morphology must be borne in mind for patients with a history of carcinoma in the digestive tract., Surgery Today, 41(2), pp.276-280; 2011

症例は45歳の男性で, 生体腎移植後12年経過していた. 腹痛で発症し, 白血球増多の進行のため腹部CTを行ったところ, 後腹膜気腫と腹腔内遊離ガスを認めた. 穿孔部位はS状結腸であり, ハルトマン手術を行った. 病理学的検査では憩室穿孔の疑いであった. 術前, シクロスポリン, ミゾリビン, メチルプレドニゾロンによる3剤併用免疫抑制療法を受けており, 術後早期も調節し続行した. 重篤な合併症は起こさず救命し, また移植腎機能も温存された. 腎移植後は拒絶反応抑制のため, 免疫抑制剤を使用しており免疫不全状態となっていることや, 副腎皮質ステロイドによる組織の脆弱性, 低腎機能による組織治癒能の低下など, 治療を行ううえで, 通常とは異なる病態がみられる. 本邦での腎移植後の大腸穿孔の報告は, 本例を含め12例あり, 生存9例 (うち移植腎機能喪失1例), 死亡2例であった. 男性・献腎移植例・S状結腸に多い傾向があった.

症例は急性進行性糸球体腎炎のためステロイド治療中の71歳の女性で, 下腹部痛のため緊急入院した. 体温38.8℃, 脈拍数115/分, 下腹部に筋性防御を認め, 白血球数1,900/mm3で, 腹部CTにより直腸穿孔と診断された. ハルトマン手術を行った後, 持続的血液濾過透析とレスピレーター管理により順調に経過していたが, 術後8日目に突然全身倦怠感を訴え, モニター上心室頻拍が出現した. リドカイン静注後の心電図でII, III, aVF, V2～V6と広範囲にST上昇がみられ, 心エコーでは心基部の過収縮と中部から心尖部にかけてのバルーン状拡張がみられ,“たこつぼ型心筋症” と診断された. 左室内圧較差は60～130mmHgで, これによる低心拍出が心室頻拍の原因になった可能性が示唆された. 心エコーを中心に厳重な経過観察を行ったところ, 発症2日目より徐々に壁運動の改善がみられ, 21日目には左室内圧較差も軽快した. 本症の原因として消化器外科手術は重要で, 消化器外科医にとって周知しておくべき術後合併症の1つである.

It remains unclear whether human T-cell lymphotropic virus type-I (HTLV-I) infection is associated with an increased risk of malignancies other than adult T-cell leukemia/lymphoma.The authors investigated the geographic distribution of the incidence of adult T-cell leukemia/lymphoma and other malignancies in Nagasaki Prefecture, Japan, where HTLV-I is endemic. The world age-standardized incidence rates of adult T-cell leukemia/lymphoma and five cancers of other sites were calculated in 15 areas, using the data from the Nagasaki Prefectural Cancer Registry (1985-97).The incidence of adult T-cell leukemia/lymphoma was found to be positively correlated with that of biliary tract cancer in men (person-years-weighted r = 0.49, P = 0.06) and liver cancer in women (r = 0.56, P = 0.03), but not with cancer of the stomach, lung or cervix uteri.The results may not support the hypothesis that HTLV-I infection is strongly associated with an increased risk of cancer of the stomach, lung or cervix uteri. The association between HTLV-I infection and cancer of the biliary tract and the possible interaction between hepatitis C virus and HTLV-I in the development of liver cancer should be evaluated by prospective cohort studies.

The serum levels of sialyl Lewisa (CA19-9), sialyl Lewisx (SLX), sialyl Tn (STN) and carcinoembryonic antigen (CEA) in peripheral venous blood and tumor drainage venous blood of

In order to know in more detail the clinicopathological features of Crohn's disease (CD), the vascular patterns were morphologically investigated by microangiography of surgical specimens. Six patients with CD treated by surgical resection were subjected to this study. 1) Although the microangiographic pattern of CD varies with the histologic features, the morphological basis for the vascular change of CD were mainly vascular disarrangement by inflammatory reaction of lymphoid tissue. Hypervascularity with widening of the submucosa was considered to be the eariest form. Section through an aphthoid ulcer showed vascular convergence to a surface of the ulceration. 2) The variable vascuar patterns with abnormal vascularity disarranged by degrees of inflammatory response was observed in the cobblestone area. 3) The vessels in the area with thickening of the bowel wall were greatly altered, tortuous and irregularly narrowed by fibrosis of all layers, resulted with a lack of normal vascular patterns. 4) In the part of intestine with longitudinal ulceration, the vessels were severely altered across all layers of the bowel wall, as abnormality of the extra-intestinal vessels, i.e., a narrowing and/or abrupt of vasa recta. The vascular patterns of CD, in which the vessels of all layers were disarranged with the disproportionate proliferating inflammation, appeared to be an important factor affecting the improvement of the lesions.

In order to know the clinicopathological features of ulcerative colitis (UC) in more detail, the vascular patterns were morphologically investigated by microangiography of surgical specimens. Seven patients with UC treated by surgical resection were subjected to this study. 1) The vascular disarrangement of UC were mainly mucosal and submucosal vessels. Muscular and/or subserosal layers maintained the normal vascular patterns even though the muscular and submuscular vessels were extremely disarranged. The lack of convergent vascular coursings toward the surface of ulceration in UC was observed. 2) Inflammatory polyps, in which there were the penetrating vessels originated from muscularis propria, were classified into 2 groups, i.e., proliferative inflammatory polyp and mucosal tags formed by the ulceration. 3) Pseudopolyposis types of UC were composed of the proliferative inflammatory vessels, whereas the vessels of atrophic types were greatly altered, tortuous and irregularly narrowed in reflection to pathologically muscular thickness. Toxic megacolon showed thin proper muscle layer, mucosal tags with normal vascular pattern and the lack of mucosal vessels in ulcerated zones. 4) The vessels beneath mucosa in zones of healed ulcer still remained dilated and proliferative, which was suspected a factor affecting the ulcer recurrence. The vascular patterns of UC appeared to be a response to the inflammatory component of UC and to affect promotion or improvement of colitis in relation to the pathogenesis of the disease.

As there was no nationwide database for gastrointestinal surgery in Japan at the time, in 2006, a Clinical Database Committee was established in the Japanese Society of Gastrointestinal Surgery (JSGS) to create a clinical database in Japan. The Committee first organized preliminary nationwide Japanese surveys in gastrointestinal surgery in 2006 and 2007. Data from more than 770 000 patients were accumulated from these web-based surveys, including 333 627 patients in 1039 institutions in 2006 and 440 230 patients in 1464 institutions in 2007. The mortality rate was stratified by organ, surgical procedure and hospital volume without using risk-adjustment techniques. The overall mortality rate was 0.95% in the 2006 survey and 0.92% in the 2007 survey. The organ-based analysis found that the mortality rates were almost similar in 2006 and 2007. Hospital volume influenced the mortality rate in six major surgical procedures, namely esophagectomy, gastrectomy, total gastrectomy, low anterior rectal resection, hepatic resection and pancreaticoduodenectomy. A risk reduction of 30–80% was noted in each surgical procedure, at least in our non-risk-adjusted analysis, in hospitals with a high volume of operations. These preliminary surveys indicate that hospital volume might influence the mortality rate after major abdominal surgery. Further analysis using risk-adjustment techniques should be conducted to understand the specific contribution of hospital volume to surgical mortality. A nationwide database of patients who have undergone gastrointestinal surgery and risk-adjustment analysis of the data are currently planned in Japan. (Cancer Sci 2011; 102: 226–230)

Acta Medica Nagasakiensia. 1992, 37(1-4), p.195-200

上部胃癌切除294例について, 占居部位・漿膜面浸潤・組織学的壁深達度別に所属リンパ節の転移を検索し, 術式の選択・適応について検討した.切除全胃癌中21.3%を占め, 男女比は2.7: 1, 平均年齢は60.0歳であった.胃癌取扱い規約によれば, Cに限局するものは129例で, 早期癌は15.0%であった.術式は胃全摘214例, 噴切52例, その他28例であった.リンパ節転移は, 早期癌ではn (-) であったが, pmで#2・3に7.7, 30%, ssβで#1・3に40%, #7・9に20%, #6・10・11・13・14に10%, ssγでは#4s・4d・16に37.5, 12.5, 12.5%の転移をみた.Cの漿膜面浸潤と#4d・5・6の転移は, S0S1はn (-) であったが, S2ではそれぞれ2.8, 11.1, 5.6%の転移をきたし, S3では21, 4, 14.2, 7.1%であった.5年および10年生存率は全摘で43.1%, 40.9%, 噴切で32, 5%, 27.5%で, 全摘が優れていたが有意差はなかった.以上より上部胃癌の噴切の適応はS1までのもの, 組織学的にはssγまでにとどまるものである.

To clarify the differences in prognosis of colorectal cancer patients based on the expression of sialyl Lewisaa sialyl Lewisx and sialyl Tn antigens in serum and tumor tissue.Preoperative serum levels (by radioimmunoassay) and tumor tissue expression (by immunohistochemistry) of these antigens were simultaneously determined in 52 patients. For each antigen, patients were classified into one of four groups: Group S-/T-, S-/T+, S+/T- and S+/T+. (S denotes serum, T denotes tumor tissue, and negative and positive represent expression).For sialyl Lewisa antigen, the survival time of Group S+/T+ was significantly shorter than Group S-/T- or Group S-/T+ (p=0.027 or p=0.032, respectively). For sialyl Lewisx antigen, the survival time of Group S-/T+ was significantly shorter than Group S-/T- (p=0.048).Increased expressions of sialyl Lewisa antigen in serum and sialyl Lewisx antigen in tumor tissue may be associated with poor prognosis in colorectal cancer patients.

To investigate numerical aberrations of chromosome 17 and the p53 locus in early stages of hepatocellular carcinoma (HCC), 12 fresh-frozen specimens of small HCCs (less than 30 mm in size) were examined by dual-color fluorescence in situ hybridization. We used a chromosome 17 alpha-satellite DNA probe and a p53 locus-specific DNA probe. We also performed immunohistochemical analysis for p53 protein in the same cases. Gain of chromosome 17 was the most frequently observed anomaly, present in 58% of cases, and deletion of the p53 locus was observed in 50% of cases. The combination of chromosome 17 gain and p53 locus deletion was observed in 33.3% of cases. However, overexpression of p53 protein was not observed in any specimens. Our results suggest that gain of chromosome 17 and deletion of the p53 locus could represent early genetic events, prior to overexpression of p53 protein due to mutation, in early stage HCC.

Thymidylate synthase (TS) is the target enzyme of 5-fluoropyrimidines. The TS gene promoter enhancer region (TSER) possesses tandem, repeated, regulatory sequences that are polymorphic in humans. This polymorphism has been reported to influence TS expression in vitro and in vivo. In this study, we assessed whether or not the TSER genotype is an efficacious marker for tumor sensitivity to 5-fluorouracil (5-FU)-based oral adjuvant chemotherapy for colorectal cancer. One hundred and thirty-five Japanese patients who received curative resection and 5-FU-based oral adjuvant chemotherapy were studied. TSER genotypes of the tumors were analyzed by PCR. The numbers of repeated sequences of representative bands were determined by direct sequence. The genotypes of two-/two-repeats (TSER 2/2), two-/three-repeats (TSER 2/3), three-/three-repeats (TSER 3/3), and three-/five-repeats (TSER 3/5) were found in 11 (8.1%), 32 (23.7%), 85 (63.0%), and 7 (5.2%) tumors, respectively. Patients were classified into two groups: TSER 2/2 or 2/3 group; and the TSER 3/3 group. The relationship between the TSER genotype group and disease-free intervals was analyzed by univariate and multivariate analyses. Five-year disease-free survivals of the TSER 2/2 or 2/3 group and the TSER 3/3 group were 77% and 75%, respectively (P = 0.89). Multivariate analysis revealed that stage was the only independent prognostic factor and that the TSER genotype did not have a prognostic significance (hazard ratio for TSER 3/3, 0.91; P = 0.84). In conclusion, TSER genotype is not an efficacious marker for tumor sensitivity to 5-FU-based oral adjuvant chemotherapy for Japanese colorectal cancer patients after curative resection.

BACKGROUND: Altered expression of blood group-related carbohydrate antigens such as sialyl Lewis (Le)xantigen in tumours is associated with tumour progression behaviour and subsequent prognosis. However, the prognostic value of the expression of Le-related antigens in colorectal tumours remains unclear.PURPOSE: To clarify the prognostic value of Lea, sialyl Lea, Lexand sialyl Lexexpression in colorectal carcinomas as prognostic factors after surgery.PATIENTS AND METHODS: Colorectal carcinoma samples from 101 patients with primary colorectal carcinoma who underwent surgical resection were subject to immunohistochemical analyses for Lea, sialyl Lea, Lexand sialyl Lexexpression with the respective monoclonal antibodies.RESULTS: Lea, sialyl Lea, Lexand sialyl Lexwere expressed in 69 (68.3%), 73 (72.3%), 66 (65.4%) and 76 (75.3%) carcinomas, respectively. The patients with sialyl Lex-expressing tumours had more advanced cancer than those with nonsialyl Lex-expressing tumours (P=0.0029). The survival time after surgery of patients with Lex- or sialyl Lex-expressing tumours was significantly shorter than the survival time of those with non-Lex- or nonsialyl Lex-expressing tumours, respectively (P=0.023 and P=0.0001, respectively). Cox’s regression analysis revealed that Lexand sialyl Lexexpression, separate from stage and histological type, were prognostic variables for patient survival (hazard ratio [HR] for sialyl Lex-positive expression to sialyl Lex-negative expression 2.90; HR for Lex-positive expression to Lex-negative expression 12.76 in stage I/IV, 0.63 in stage II and 1.69 in stage III).CONCLUSIONS: Lexexpression and sialyl Lexexpression in colorectal carcinomas are each associated with poor prognosis. These variables should be considered in the design of future trials.

Operative breast cancers were subjected to a serological and immunohistochemical evaluation of sialyl Lewisx antigen as a tumor-associated one, where a new monoclonal antibody CSLEX1 which reacts with sialyl Lewisx antigen was used. Percent positive of sailayl Lewisx in sera of 30 patients with breast cancer was 30%(9/30), which was better than those of any other tumor markers such as CEA, CA19-9, CA15-3 and SLX. Percent positives, according to clinical stages, were 20.0%, 37.5%, 40.0% and 50.0% in stage I, II, III and IV respectively. Immunohistochemically, the expression of a sialyl Lewisx in the normal ductal epithelium and carcinoma cells of 41 breast cancers demonstrated 95.5%(21/22) and 65.9%(27/41) respectively. Although the immunohistochemical experssion of sialyl Lewisx antigen indicated a low cancer specificity, comparatively high positive rates in stage I and II were obtained in sera of cancer patients. It has been suggested that sialyl Lewisx antigen is useful as a tumor-associatd antigen in breast cancers.

To obtain symptomatic remission, five patients with severe dumping syndrome have received reoperations. The patients, including two males and three females, had undergone gastrectomy when they were from 25 to 50 years old because of gastric ulcer (in 4 cases) or gastric cancer (in one). The first surgical procedures were pylorous-side gastrectomy in 4 and pylorous-side subtotal gastrectomy in one case. Four cases of gastric ulcer or one of gastric cancer received Polya or Billroth I anastomosis respectively. Excepting one case, dumping syndrome occurred around postoperative 3 weeks to one month, and a difficuty to work and a weight-loss due to malnutrition were noted. They have been sufering from the syndrome for 3 to 27 years. Preoperative X-ray examination and gastric scan revealed a significantly stimulated exhausion of the stomach in each case. In the reoperation, the jejunum, 5-9cm, was placed antiperistaltically between the residual stomach and duodenum, and vagotomy was added to the residual stomach. Though one case needed the third sugical treatment, symptomatic remisson was noted in all cases and scintigram revealed a shortening of exhausion time of the stomach.

Colorectal cacinomas of 58 patients aged 75 years or over who recieved bowel resections, were clinicopathologically studied compared with those of 373 patients aged 40 to 74 during 22 years from 1965 to 1986. Cancers in older patients indicated following features: (1) higher frequency in right sided colon, localized carcinoma and pm invased cancer, (2) variety in histological classification, (3) lower frequency in degree of matastasis and advanced stages, (4) satisfactory resectability (90.6%), operative mortality (5.3%), and 5-years survival (74.9%). These data suggest that radical surgery for colorectal carcinoma in aged patients is justificable.

新しいモノクローナル抗体CSLEX1によって認識される糖鎖抗原sialylated Lewisxを, 大腸癌手術症例63例の血清を対象に, EIA法にて測定し, 腫瘍マーカーとしての有用性を検討した. 陽性率は23.8% (15/63) で, Dukes A・Bの早期においては0%・8.7%と低値で, 早期診断は困難であるが, Dukes C・Dの進行癌での陽性率は33.3%・50.0%で, 非治癒切除例・非切除例での陽性率は50.0%・66.7%と高率であり, 術前の根治度の判定が可能であると考えられ, 転移形式のうち肝転移とリンパ節転移因子に関連性を有する.また, 限局型癌・粘液癌に陽性率が高い. 以上より, 大腸癌患者血清中sialvlated Lewisx抗原は, 新しい腫瘍マーカーとして臨床的に有用であることが示唆された.

One hundred-three consecutive patients who had sustained blunt hepatic trauma since 1965 were reviewed. Fifteen patients who were conservatively treated were also clinically analyzed with reference to current diagnostic methods. 1) In the previous series, 58 patients (96.7%) underwent laparotomy, whereas 13 patients (30.2%) were conservatively managed in the recent series. The extent of liver injury was classified into three types according to severity. 2) All patients who were conservatively managed were diagnosed and followed up by US or CT. Patients who had suffered subcapsular rupture and laceration with grade I or II were mainly selected for conservative therapy. 3) One patient with central rupture of grade III died following hepatic failure, while the other 14 patients did well. Follow-up study by CT showed that the intrahepatic hematoma was spontaneously resolved 6 to 12 months after injury. The following indications for conservative management of blunt hepatic trauma might be considered; a) Vital signs stable or stabilized by transfusion. b) No significant injuries associated with intraperitoneal organs. c) Nature and extent of injuries to the liver are subcapsular rupture or lacerations of grade I or II of no active bleeding. In these patients follow-up by US or CT is needed until the hematoma is completely resolved.

直腸腫瘍に対する局所切除術15例について臨床病理学・細胞核DNA量の両面から検討し, 早期直腸癌の局所切除術の適応について考察した. 広基性m癌, 絨毛腺腫, 扁平腺腫の各1例の術後経過・予後とも良好で, 良い適応と考えられた. 進行癌には適応はないと考えられるが, 姑息的治療として3例に採用した. sm癌7例のうち, 中分化腺癌・脈管侵襲陽性・sm massive invasion・DNA aneuplodyの1例に再発を経験し, 他の6例はすべて5年生存を得た. 以上より, sm癌にも適応があるが,(1) 隆起潰瘍型IIa+IIc型,(2) 高分化腺癌以外,(3) sm massive invasion,(4) 脈管侵襲陽性,(5) DNA aneuploidyのrisk factorがある場合は, 本術式は避けるべきで, 術後適応外と判断された場合は, 再根治手術を行うべきである.

胃癌患者60例の末梢血好中球polarizationを測定し, 胃癌の病態因子別に検討を加えた.胃癌患者の好中球polarizationは対照群に比べ有意に低下していた.stage IV, n3, 深達度ssで示される進行胃癌患者で有意な低下を認めた.術後感染症合併例では, 他群に比較して差を認めなかった.死亡例では有意な低下をみた.C領域癌, Borrmann 3型癌, por (低分化腺癌) 癌で有意な低下を示した.これらの成績から進行胃癌患者では, 一連の好中球機能の過程で最も初期に位置するpolarizationという機能においてその低下が示され, 担癌患者での好中球機能不全が示唆された.

n3 (+) 早期胃癌5例の原発巣と転移リンパ節の核DNA量をフローサイトメーターを用いて測定し, 特に核DNA量の面からリンパ節転移の特徴を検討した. n3 (+)早期胃癌には深達度sm, 占居部位A, 肉眼型IIa+IIcが多い傾向が認められ, 第3群リンパ節の中では12番リンパ節に転移の頻度が高く, その予後は著しく不良であった. また原発巣の核DNA量はn-numberの増加に伴って, DNA aneuploidyが優位となり, n3 (+)症例では3例すべてDNA aneuploidyであった. n3 (+)症例における原発巣と転移リンパ節のDNA index値は3例中2例で一致したが, 1例では転移リンパ節においてDNAmultiploidyを示した.

急性腸間膜血管閉塞症15例の原因別にみた病態と治療について検討し.本邦例を集計して考察を加えた.1) 塞栓症8例, 血栓症7例で, 塞栓症の全例に心疾患併存を認めた.血栓症は5例が動脈硬化症, 2例がイレウスに起因した.2) 全例24時間以上経過して腸切除し, 14例に腸管大量切除した.血栓症は4例救命しえたのに対し, 塞栓症は重症例が多く, 7例が2日から3ヵ月で循環障害で死亡した.3) 術後2例のアミノ酸分析から本症の術後肝障害が示唆された.4) 本邦例では約45%の救命率で, 多くは併存する循環器疾患で死亡している.本症は閉塞因子, 閉塞部位などで病態が異なるが予後不良である.病態を考慮した適切な診断と治療の必要性を強調した.