Search

症例は76歳女性で糖尿病，慢性膵炎の既往がある．第12胸椎の圧迫骨折のため脊椎短縮術，後方固定，後側方固定術を施行された．腹臥位で，手術時間6時間20分であった．麻酔覚醒後から腹痛が出現し，術後1日目も腹痛は強く，膵酵素，WBC，CRPの上昇を認め，予後因子スコア5点で重症急性膵炎と診断．造影CTでは膵頭部の腫大および膵頭部内の造影不良域を認め，右腎下極以遠までの滲出液貯留を認めたため，造影CT grade 2と診断．蛋白分解酵素阻害薬・抗菌薬膵局所動注療法などの治療を行った．術後16日目の造影CTでは膵頭部の造影不領域が増大し，右後腹膜膿瘍も増大した．十二指腸の壁構造は消失し，十二指腸壁の壊死と考えられた．術後18日目に膵頭十二指腸切除術（PD）を行った．手術では十二指腸は広範に壊死に陥り，後腹膜膿瘍を形成していた．術後は縫合不全など大きな合併症はなく，PD術後101日に退院した．

はじめに: センチネルリンパ節（sentinel node；以下，SNと略記）同定のトレーサーは，一般的に色素やradioisotope（以下，RIと略記）が用いられる．しかし，色素の粒子径は小さく，生体内で癌細胞の動態を反映するか疑問が残る．また，RIは特殊施設を要する欠点がある．癌細胞に近い粒子径で使用が簡便である蛍光ビーズを色素法（Indocyanine Green；以下，ICGと略記）と併用し，胃癌におけるSN同定の有用性を検討した．対象と方法: 蛍光ビーズ使用に同意を得たcN0の胃癌31例を対象とした．蛍光ビーズは，術前日内視鏡下に病変粘膜下に注入した．ICGは術中漿膜側から注入し，5～15分で緑色に染まったリンパ節および紫外線照射で蛍光発光したリンパ節をSNとした．SN摘出後は標準郭清を行い，摘出標本に紫外線照射し発光したリンパ節を検索した．結果: 早期癌に限ると同定率は蛍光ビーズ法のみで76%（19/25），併用法で92%（23/25），ICG法のみで60%（15/25）であった．平均SN個数はそれぞれ2.3個，3.1個，2.3個であった．同一リンパ節に両トレーサーを認めるリンパ節も7例あった．蛍光ビーズの分布は第1群リンパ節に限らず第2群にも認めた．結語: 早期胃癌症例で蛍光ビーズは色素と併用することでSN同定率を向上させることが可能であった．

Background Rikkunshito, a traditional Japanese (Kampo) medicine, is widely prescribed as an oral preparation for the treatment of functional dyspepsia (FD). In our previous study, we reported that extracorporeal ultrasonography (US) is a useful technique for the assessment of the gastric accommodation reflex (AR) and duodenogastric motility. In this study, we examined the effects of Rikkunshito on the gastroduodenal function in patients with FD. Methods Sixteen FD patients (median age, 45 y) underwent US, before and after 14 days of treatment with Rikkunshito (7.5 g b.d.). For assessment of the AR, a cross-sectional area of the proximal stomach was measured after incremental ingestion of a liquid meal up to 400-mL. The expansion rate was used as the parameter to determine the AR. Then, the gastric emptying rate (GER), motility index (MI), and reflux index (RI) were evaluated using previously reported methods. Results Although no significant changes were observed in the total score of the Gastrointestinal Symptom Rating Scale (GSRS), the scores of 3 of the 15 symptoms of GSRS decreased significantly after treatment with Rikkunshito. The expansion rate of the proximal stomach was significantly greater after treatment with Rikkunshito than before the treatment. Although the GER and MI increased significantly, no significant differences in the RI were observed after treatment with Rikkunshito. Conclusion These observations suggested that Rikkunshito may be beneficial for the treatment of FD patients with impaired AR and gastric motility. These results also suggested that Rikkunshito has a therapeutic potential for FD and GERD.

症例は55歳，女性．貧血の精査のため腹部超音波検査，腹部CT検査を行い，小腸腫瘍が指摘された．当院を紹介受診し，精査加療目的で入院した．小腸内視鏡で，空腸に管腔半分を占める弾性軟の隆起性病変を認めた．生検で低分化のcarcinoma cellが認められ小腸腺癌が疑われたため，空腸切除術を行った．摘出した空腸腫瘍は乳白色の隆起性病変で，腸間膜リンパ節転移，腹膜播種を伴っていた．病理組織学的に空腸カルチノイドと診断された．本邦で小腸カルチノイドは，小腸腫瘍のうち1.38％と非常に少なく，また全消化管カルチノイドにおける臓器別発生頻度でも3.8％と稀な疾患である．小腸内の発生部位は回腸に多く，空腸発生は稀である．本症例は空腸原発のカルチノイドでリンパ節転移，腹膜播種を伴っていたため，術後の厳重な経過観察が必要である．

Gastrointestinal stromal tumor(GIST)に対するimatinib mesylate(IM)の抗腫瘍効果は60%以上と優れているが,頻度的に少ない大腸GISTに対する効果,neoadjuvant(NA)の有効性など不明な点も多い.今回,大きさ,部位的に切除困難が予想された若年者直腸GISTに対してIMによるNAを行い,容易に切除可能となった症例を経験したので報告する.症例は32歳,男性で便通異常を主訴に近医を受診した.直腸巨大GISTと診断されたが,切除困難を理由に当院に紹介された.直腸,膀胱を圧排する長径10cm超の直腸GISTを認めた.IMによるNAを6カ月間行い,腫瘍は23.8%縮小した.手術は腹会陰式直腸切断術を施行したが,ひとまわり縮小したために切除は容易で下腹:神経,骨盤神経叢も確認・温存できた.本症例はIMのNAによりresectabilityの上昇,神経温存などの点でNAの利点を十分享受できたと考えられた.

The carcinogenic potential of 9-(4’-aminophenyl)-9H-pyrido[3,4-b]indole (aminophenylnorharman: APNH), a newly identified heterocyclic amine, was evaluated in a rapid production model for pancreatic duct adenocarcinoma in hamsters. In experiment 1, the initiation potential of APNH was examined. Hamsters received corn oil, 30 mg/kg body weight N-nitrosobis(2-oxopropyl)amine (BOP) or APNH (totally 50 and 100 mg/kg) as initiators followed by two cycles of augmentation pressure for pancreatic duct carcinogenesis and were sacrificed 75 to 78 days after the beginning of the experiment. Ductal hyperplasia and atypical hyperplasias developed in hamsters receiving APNH but their numbers and incidences did not differ from the corn oil case. In experiment 2, promoting potential of APNH for pancreatic duct carcinogenesis was examined. Hamsters received 30 mg/kg body weight BOP as an initiator followed by augmentation pressures and thereafter diet containing 0, 25 or 50 ppm APNH for 50 days. All hamsters were sacrificed 100 days after the beginning of the experiment. The numbers and incidences of ductal lesions, including adenocarcinomas, did not differ among the experimental groups. The results suggest, APNH may not have initiation or promotion potential for pancreatic duct carcinogenesis in hamsters.

高齢人口の増加とともに大腸癌手術症例のうち高齢者の占める割合は増加の一途をたどり,当科では高齢者 (75歳以上)は20%を越えた.そこで高齢群(75歳以上)(240例) と非高齢群(41～50歳)(155例)を臨床病理学的に比較し高齢者の特徴を検討した.他病死を含めた累積生存率は高齢群で不良であった.術後早期死亡例の検討では高齢群といえども非高齢群と変わらず安全に手術が行われていた.両群間の腹膜播種,肝転移,リンパ節転移,壁深達度には有意差はみられず高齢者に進行例が多いとはいえなかった.組織学的分化度の検討では高齢群は高分化型が多いという傾向はみられず,一般的に高齢者癌は悪性度が低いという印象があるが,大腸癌にっいては非高齢者と変わらなかった.腫瘍占居部位は高齢群女性で右側結腸に発生する頻度が高かった.死因では他病死の占める割合が多く,併存疾患,余命を考慮した手術が行われるべきである.

脾原発inflammatory pseudotumorの2 例を経験したので報告する. 症例1は53歳の男性で, 胃癌にて遠位側胃切除術を施行後, 腹部超音波検査にて脾腫瘤を指摘され入院した. 腹部CT検査で脾内に被膜を有する低吸収値の腫瘤を認め被膜のみに造影効果を認めた. 胃癌の孤立性脾転移, 脾過誤腫などを疑い摘脾術を施行した. 症例2は40歳の女性で, 6 年前に子宮全摘の既往があり, 胃粘膜下腫瘍の経過観察中に腹部超音波検査にて脾腫瘤を摘摘され入院した. 腹部CT検査で等吸収値の腫瘤を認め, MRI検査ではT1, T2強調像とも低信号で, ガドリニウム負荷にて内部が淡く造影された. 症例1の経験からinflammatory pseudotumorも疑い摘脾術を施行した. いずれも病理組織学的に脾原発in-flammatory pseudotumorと診断した. 本例は2例とも開腹手術の既往があり, 開腹操作が本症の発生に関与している可能性が示唆された.

Two cases of anorectal malignant melanoma are reported. Malignant melanoma of the digestive tract is rare and the prognosis is dismal. Both a 70-year-old woman (case 1) having a left inguinal lymphadenopathy and an 80-year-old woman (case 2) having multiple metastatic shadows on a chest x-ray film were admitted to the hospital with a year's history of blood stools. A digital examination easily revealed a bleeding ulcerating tumor in the anterior wall of the anal canal in case 1, and in the left posterior wall of the rectum close to the anal verge in case 2. The biopsy specimens of both cases were diagnosed as malignant melanoma histologically and immunohistologically. An abdominoperineal resection (APR) was performed, followed by adjuvant immunochemotherapy with DAV and interferon-β in case 1. Case 2 did not receive chemotherapy because no enlargement of metastatic lesions in the lung occurred during her hospitalization. In this paper some problems in the diagnosis and treatment of the disease are discussed based on our cases together with previous cases in the literature. We would emphasize the importance of our surgeons careful attention to the possible presence of the disease and early detection based on macroscopic findings to improve the prognosis.

Two cases of retroperitoneal leiomyosarcoma are reported. Patient 1, a 68-year-old man, was admitted to the hospital because of a left upper abdominal mass.Abdominal echo and CT scan showed giant masshaving necrotic change. The tumor 16×15×19cm in size and developing in the retroperitoneum was removed with the body and tail of pancreas, and spleen tran-speritoneally.Patient 2, a 65-year-old man, was admitted to the hospital because of tarry stool and fatigability.Abdominal echo and CT scan showed a well demarcated large abdominal mass accompanying with colonic gas. Intraoperative findings showed that the tumor invaded the second portion of duodenum and pancreas head. The tumor 13×7×6cm in size, was removed by partial resection of the duodenum and pancreas tran-speritoneally.The pathological diagnoses of case 1 and 2 were retroperitoneal leiomyosarcoma.Postoperative courses of both patients were uneventful.Histological grading is the Determinant prognostic factor for retroperitoneal sarcomas.We would emphasize the importance of early detection and if necessary, radical resection as much as possible which is the most effective and available treatment.

We experienced a rare case of malignant melanoma metastasized to the small intestine. A 59-year-old man, who had been diagnosed as having a malignant melanoma of the nasal cavity two years earlier, had been admitted to the Department of Otorhinolaryngology in our hospital several times for anticancer drug treatment. On November 6, 1994, he was seen at the Department of Surgey in the hospital because of upper abdominal pain. He had a protuberant tense abdomen with slight tenderness and bilateral nasal bleeding with anemia. Plain abdominal roentgenograms showed multiple, small fluid levels of the small bowel. These findings were suggestive of obstruction of the small intestine. Nasogastric long tube suction was continued and intravenous hyperalimentation was given. After relief of the intestinal obstruction, an abdominal firm mass was palpated and a barium meal study demonstrated a filling defect in the ileum. The preoperative diagnosis was made as metastatic malignant melanoma to the ileum. At operation, endoscopic examination of the small intestine showed a 3.0×3.0 cm nodular mass in the ileum with no other lesions. Partial resection of the ileum with the tumor was performed. Macroscopic examination of the resected specimen revealed a brown nodular mass with an ulcer, 2.5×2.5 cm in size, which occupied most of the intestinal wall area. In immunohistological stainig, S-100 antibody was positive. The histological diagnosis was thus established as metastatic malignant melanoma to the ileum. The patient was discharged on the 14th day after the surgery following an uneventful postoperative course. However, he died of metastatic lung cancer with no abdominal complaints one year after the operation.

We report a case of adenosquamous carcinoma of the stomach which involved only the mucosa and submucosa, but was found to have already metastasized to a regional lymph node and the liver at surgery. Adenosquamous carcinomas of the stomach are rare and usually invade deeply into the muscular layer. Those limited to the mucosa and submucosa are extremely rare, and only seven cases have been reported to date. It was interesting that in our case, 80% of the tumor in the stomach and lymph node was composed of squamous cell carcinoma and 20% consisted of adenocarcinoma, whereas the metastases in the liver consisted entirely of adenocarcinoma. The literature on this type of gastric carcinoma is reviewed and the possible histogenesis of this tumor is discussed.

The aim of this study was to examine whether the type of bilioenterostomy enhances biliary carcinogenesis in the hamster model. Syrian hamsters were divided into the following groups ; simple laparotomy (control group), cholecystoduodenostomy with dissection of the extrahepatic bile duct on the distal end of the common duct (CDDB group) and cholecystoileostomy with dissection of the extrahepatic bile duct on the distal end of the common duct (CIDB group). Following these procedures, all hamsters received N-nitrosobis(2-oxopropyl)amine. The diameter of the extrahepatic bile duct and plasma levels of cholecystokinin (CCK) were measured and the number of neoplastic lesions was counted microscopically. Proliferative effect of the procedures on the biliary epithelium was examined by proliferative cell nuclear antigen. In the CDDB group the extrahepatic bile duct was significantly dilated and carcinogenesis of the gall-bladder and extrahepatic bile ducts was enhanced. In the CIDB group the CCK bioactivity was stimulated and intrahepatic biliary duct, but not gall bladder and extrahepatic bile duct, carcinogenesis was promoted more than that observed in the CDDB group. Proliferation of the biliary duct epithelium was enhanced in both the CDDB and CIDB groups. Cholecystoduodenostomy enhanced intra- and extrahepatic bile duct carcinoma, whereas cholecystoileostomy promoted only intrahepatic bile duct carcinoma. Some factors in the intestinal juice seem to play a role in the promotion of biliary tract carcinoma.

症例は84歳の女性.主訴は右季肋部痛.Computed tomographyにて膵頭部に腫瘤を認め, 血管造影にて同部に淡いtumor stainあり.十二指腸粘膜下腫瘍の診断で膵頭十二指腸切除術施行.摘出腫瘤は径8cm大, 十二指腸壁より壁外性に発育し, 内部に出血壊死を認めた.組織学的にはH.E.染色でリンパ球浸潤が多く, 紡錘型の腫瘍細胞が束状に配列し, 核のpalisadingを示すAntoniA型の組織型を部分的に認めた.銀染色では, 繊細な好銀線維が, 線維末端まで不規則に分枝していた.免疫染色ではS-100蛋白, desmin, neuron specific enolase, actinすべて陰性であった.Mitosisは少なく, 良性もしくは低悪性度の神経鞘腫と診断された.しかし, 35か月後, 肝転移再発により死亡した.十二指腸神経鞘腫の本邦報告は20例のみで, なかでも悪性は3例であった.本例は免疫染色を用いても, 平滑筋腫瘍との鑑別が困難で, H.E.および銀染色所見より神経鞘腫と診断し, 臨床経過より悪性と判断した.

ss胆嚢癌切除例は31例でssα, β22例, ss-γ9例, 根治切除例はそれぞれ18例, 6例であった.ssα, β22例とssγ9例の組織学的リンパ節転移, 静脈浸潤, 神経周囲浸潤の各頻度は前老32%, 18%, 23%で後者の78%, 67%, 67%に比較して有意に低率でおのおのの4年生存率68%, 23%に有意差がみられた.ssα, β 根治切除例18例のうち再発死亡は局所再発が3例で, 現在生存の11例には主としてS5, 4下肝亜区域切除+R2+16番リンパ節郭清術 (以下, 拡大胆摘術) が施行され肝外胆管切除, 膵頭十二指腸切除が併施された.一方, ssγ6例にも同様の根治手術が行われたが全例再発死亡し5例が局所再発に加えて遠隔転移を伴っていた.したがってss癌と診断された症例には拡大胆摘術を行い, 腫瘤の局在とリンパ節転移状況により肝外胆管切除, 膵頭十二指腸切除を併施する.さらに術後ssγ と診断された症例には, 免疫化学療法を主体とした補助療法を付加するのがよいと考える.

To evaluate the incidence and period of gallstone formation after gastrectomy for a carcinoma, questionnaire survey has been conducted in 316 patients. Replies were obtained through 81% of the patients. Except for 48 unknown cases, 31 (15%) out of the 209 patients had gallstones. Additionally, 5 patients had gallbladder debris, 3 had cholesterol polyp, and one had acute cholecystitis. Overall 40 patients (19%) had some gallbladder disease. In 50 patients undergoing total gastrectomy, 13 (26%) had gallstones, and 17 (34%) had some gallbladder diseases. Gallstone was found within 5 years after gastrectomy in 14 cases, between 5 to 10 years in 12 cases, and after 10 years in 5 cases. In 26 cases (84%), gallstone was found within 10 years. Cholecystectomy was done in 13 patients, but 18 patients had no symptom and have been periodically checked at the outpatient clinic. In 13 cholecystectomised patients, 9 had black stone, and 2 had bilirubin stone. In the remaining 2 cases, nature of the stone was unclear. There was no cholesterol stone. In follow up of postgastrectomy patients with gastric cancer, special attention should be given to gallstone formation as well as recurrence. In such situation, the adequacy of prophylactic cholecystectomy would be a further problem to be solved.

慢性膵炎の自然歴を考えればどの様な術式の選択を行うとも外科的治療は姑息的である.しかし外科的治療は現時点では疼痛消失が早いことと合併症の治療が可能な事から,膵管病変と膵実質病変を十分に把握し,手術適応例であれば術後早期から確実にかつ持続的に疼痛除去が期待できる膵管空腸側側吻合術か膵頭切除術を選択することが重要である.さらに術後は禁酒を含めた生活指導を徹底し,厳重なfollow upを続けることが大切である.

症例は50歳の男性で, 腹痛, 発熱を主訴として来院し, 諸検査の結果, 重症急性膵炎と診断され, ICU管理のもとで輸液, 薬剤, 高圧酸素療法を行う. その結果, 全身状態と臨床検査成績は急速に改善の方向に向かった. しかし, 入院3週目より, 再び腹痛, 高熱力が出現し, WBC15,500, CRP強陽性, computed tomographyによる画像所見の増悪傾向を示したので, 感染性膵壊死の診断で開腹した. 手術は後腹膜ルートで膵を含む後腹膜腔に存在する融解した感染壊死組織を用手的に除去し, 術後に持続的後腹膜灌流を行った. 後腹膜灌流期間は8週を要した. なお, 壊死巣よりStaphylococcus aureusを検出した. 本法は今までに例をみない新しい術式であり, その意義は後腹膜の感染壊死巣の浄化とともに, 術後に新しく産生される感染壊死物質や生物学的活性物質の排除であり, その結果, 創傷治癒が促進され, 全身状態が改善される.

肝内結石症に対する肝外側区域切除術の10年後に胆管細胞癌と診断され, 特異な経過をたどった1例を報告する.症例は57歳の男性.47歳の時, 急性胆嚢炎の診断により胆嚢摘出術を施行されたが, その後も胆管炎症状が持続.精査の結果, 肝左葉の肝内結石の診断により同年, 肝外側区域切除を施行された.51歳の時, 総胆管結石の診断で内視鏡的乳頭切開術をうけた後は無症状にて経過していた.今回, 発熱および心窩部痛にて発症.心窩部には外胆汁瘻の形成を認めた.精査の結果, 肝断端付近に発生した腫瘍が腹壁, 横隔膜などに広範囲な浸潤をきたしていた.入院後, 腹腔内膿瘍が心嚢へ穿破し, 化膿性心外膜炎, 心タンポナーデを併発し, 入院後3か月で死亡した.肝内結石症の診療に際しては, 同時性および異時性の胆管癌合併を常に考える必要があり, 肝内胆石症に対する手術においては, 拡張胆管を含めた肝切除術が必要であると考えられた.

A 72-year-old man was admitted to our hospital because of upper abdominal pain and weight loss. Abdominal ultrasonography revealed a 4×4 cm hypoechoic tumor in the head of pancreas. Selective celiac angiography showed encasement of the posterior superior pancreatoduodenal artery. Pancreatoduodenectomy was carried out under a diagnosis of pancreatic cancer. The resected specimen showed that the tumor was stony-hard and 4 cm in diameter. Histological examination denied pancreatic cancer and demonstrated severe chronic pancreatitis. We report a case of so called “tumor forming pancreatitis” which is occasionally differentiate from pancreatic cancer.

245例の肝細胞癌 (HCC) 中40歳未満の若年者症例を13例 (5.3%) 認めたのでその特徴について検討した. 13例中肝疾患の既往, 家族歴, HBs抗原陽性の3因子をいずれも欠くのは3例のみであった. 非若年者に比べ若年者HCCでは肝硬変の合併率が53.8%と有意に低かったが, 逆にHBs抗原陽性率は66.7%と有意に高かった. 血清alpha-fetoprotein値400ng/ml以上の頻度が75%と有意に高く, 3分の1の症例で10,000ng/ml以上の異常高値を示した. 切除例の病理組織所見で両者に違いはなかったが, 若年者HCCの核DNA量はanueploidが80%を占めていた. 若年者HCCは非若年者に比べ進行例が多い傾向を示したが, その予後に有意な差はなかった. 非切除例の予後は不良であったが, 切除例では長期生存も得られており, 早期発見・早期治療が望まれた. そのためにはHBキャリアーの厳重な経過観察が重要であると考えられた.

症例は52歳の男性でアルコール性慢性膵炎の診断をうけ当科を紹介され入院した.画像診断上は著明に拡張した主膵管および, 多数の膵石が認められるも, 膵癌を示唆するような腫瘤像は得られず, 慢性膵炎の診断であった.しかし, 血中CA19-9, CA50, Dupan-2, Elastase-1などの腫瘍マーカーはすべて正常値をこえて上昇していた.しかもこの患者のLewis血液型はLe (a-, b-) であった.Dupan-2を除くほかの腫瘍マーカーは膵管空腸側側吻合術後に正常値に復した.悪性疾患では血液でLe (a-, b-) 型でも血中CA19-9が上昇する例はしばしば遭遇するが, 良性疾患での報告は少ない.興味ある本症例の報告を行うとともにCA19-9上昇の機序を併せて検討した.

In order to determine the means of monitoring the immunological status of allograft recipients in miniature swine, an assay was developed to measure interleukin (IL)-2 production in vitro by pretreatment of donor peripheral blood lymphocytes (PBL). Miniature swine were given 0 to 4 weekly intravenous transfusions of 5-10 X 10(7) donor PBL incompatible at major histocompatibility complex (MHC) and assayed in vitro for donor specific immune IL-2-like activities. The results are summarized as follows: (1) IL-2-like activity in 24 hr and 48 hr supernatants from mixed lymphocyte cultures (MLC) with MHC-incompatible PBL was detected without pretreatment. The 48 hr MLC supernatant exhibited a high IL-2-like activity compared with the 24 hr; (2) IL-2-like activity after only one transfusion with MHC-incompatible PBL was higher than that without pretreatment; (3) IL-2-like activity in 4 weekly transfusions was detectable slightly earlier than that without pretreatment or three transfusions with MHC-incompatible PBL.

原発性肝細胞癌切除例のうち術前リピナドール (Lp) 併用肝動脈塞栓術 (Lp-TAE) 施行後にcomputed tomography (Lp-CT) を行った30例について検討した.男性27例, 女性3例であり, 平均年齢は59.5歳であった.肝硬変の併存は24例 (80%) に認めた.Lp-CTにて腫瘍内のLp集積像は4型に分類できた.I型: びまん性集積型 (16例), II型: 斑状集積型 (7例), III型: 点状集積型 (4例), IV型: 微少集積型 (3例).I型は小結節に, IV型は大結節に多い傾向であった, Lp-TAE前後での50%以上の血清alphafetoprotein減少率の頻度はI型80%, II型50%, III型80%, IV型50%であった.平均腫瘍壊死率はI型79.6%, II型52.1%, III型13.8%, IV型63.3%であったが, I型にのみ100%の完全壊死を7例に認め腫瘍壊死効果が良好であった.腫瘍の組織型では索状型の場合腫瘍壊死効果が良好で, 充実型, 偽腺管型では不良となる傾向であった.Lp-TAE後のLp-CT像からLp-TAEの効果判定がある程度可能であると考えられた.

黄色肉芽腫性胆嚢炎 (xanthogranulomatous cholecystitis) は胆嚢癌との鑑別が困難とされているが, 超音波検査ならびにcomputed tomography (CT) 検査など画像診断にて鑑別が可能であった症例を経験したので報告する.症例は54歳女性.右季肋部痛の消腿後に, 胆嚢に腫瘍性病変を指摘されて来院した.超音波検査では胆嚢底部に全周性に壁肥厚を認め, 胆嚢内腔は狭小化していた.肥厚した胆嚢壁内には結節性にhyperechoic lesionを認め, 同部は造影CTでlow density areaとして描出された.また, 胆嚢頸部には最大径約5cmの結石を認めた.血管造影では胆嚢動脈は拡張し, 肥厚した胆嚢壁に沿って屈曲蛇行した細動脈の増生がみられたが, encasementは明らかでなかった.以上より, 胆嚢癌を否定し, XGCの診断のもとに胆嚢摘出術を施行した.切除標本の胆嚢壁内には黄色の結節を認め, 組織学的には同部にxanthoma cells, リンパ球および異物型巨細胞を認めた.

1969年10月より1990年10月までに経験した膵頭領域癌 (十二指腸癌, 原発不明癌を除く) 切除例114例の予後および予後に関与する因子について検討した.症例の内訳は膵頭部癌55例, 乳頭部癌34例, 下部胆管癌25例であり, 平均年齢はそれぞれ64.0±11.7歳, 59.3±12.3歳, 62.1±11.5歳であった.このうち膵頭部癌の予後が最も悪く (p

教室例を含めて文献上報告されている肝内胆管癌 (CC) 合併肝内結石症 (IHS) の90例を集計し臨床病理学的に検討した.その結果は,(1) CCの合併はIHS全体の1.5～9.4%を占めた.(2) CC合併IHSは男性に多くみられた.(3) 一般に40歳以上にみられ, 60歳代に最も発生頻度が高かった.(4) 20年以上にわたる病悩期間を有する症例が36%を占めた.(5) CC合併の術前診断率は41%にすぎず, 臨床症状や画像所見およびtumor markerを含めた検査所見に特異的なものはなかった.(6) CCの主占居部位は左肝内胆管系が多かった.(7) IHSとCCの占居部位はきわめて高率に一致または近接していた.(8) 治療として肝葉切除や区域切除が42例に施行された.(9) 外科的治療を受けた75例の累積1, 3, 5年生存率は29, 8.6, 8.6%であった.以上より長期間にわたる胆管炎がCCの発生を促す可能性が考えられ, IHSの治療にあたっては早期に胆汁うっ滞及び感染を除去できる肝切除などを考慮すべきである.

A total of 103 patients with unresectable hepatocellular carcinoma (HCC) treated in the Second Department of Surgery, Nagasaki University Hospital from September 1969 to December 1987 were reviewed. Unilateral ligation of the hepatic artery was done on 9 patients, unilateral ligation of the portal vein branch on 3, catheterization into the hepatic artery for infusion of anticancer drugs on 16, transcatheter arterial embolization (TAE) on 23 and other treatment with or without systemic chemotherapy on 52. The one, two or three year cumulative survival rate of the total cases was 14%, 9% or 4% respectively. The outcome of the 23 patients treated with TAE was better than that of the other patients. Macroscopic stage classification and clinical stage classification reflected the prognosis of the disease. However, the factors with or without hepatitis B-antigen, liver cirrhosis or high levels of serum AFP before the treatment did not influence the prognosis. Recently, we have done a combination therapy with TAE, tumor reduction surgery and infusion therapy via both hepatic artery and portal vein on 4 patients with unresectable HCC. The average survival period of these patients were better than that of other patients, but not significantly.

手術後に発生した広範囲肝梗塞の2例を経験したので報告した.症例1は62歳男性で肝門部胆管癌に対する門脈合併切除を伴う肝左葉兼尾状葉切除後にS8領域に発生した肝梗塞であり, 症例2は46歳男性で胃癌再発例に対する門脈, 肝動脈合併切除兼再建を伴う膵頭十三指腸切除後に発生したものである.前者は術後1か月目に肝不全にて失ったが後者は救命しえた.また肝梗塞の発生機序として, 症例1は剖検により門脈再建部は良好に開存しているのが確認されたが, 右肝動脈前枝が腫瘍に巻き込まれていたため結紮切除しており, その支配領域 (S8) が広範囲に肝梗塞に陥っていた.症例2は胆管空腸吻合部の減圧目的として挿入したretrograde transhepatic biliary drainage tubeで肝内血管を損傷し, その肝内血管支配領域に肝梗塞が発生したと考えられた.これら肝梗塞の診断, および反省点について考察を加え報告した.

多中心性乳頭状胆管癌の切除例を経験したので胆管多発癌の外科的治療, 特に胆管切除範囲を中心に報告する.症例は67歳の男性で発熱を伴う上腹部痛にて発症した.経皮胆道ドレナージ後, 術前画像診断より肝門部を中心とした多発胆管癌と診断し, 肝拡大右葉切除兼尾状葉切除術 (胆嚢・総胆管切除), 左肝管空腸吻合術 (Roux-en-Y) を施行した.切除標本の肉眼所見は下部胆管より左肝管起始部, 右肝内胆管を中心として乳頭状腫瘤が散在し, 組織学的には乳頭腺癌であった.本症における癌遺残防止のため, 多発病巣の検索と切除範囲の決定において高周波数探触子による術中超音波検査が有用であった.また自験例では第2群リンパ節に転移を認め, 十分なリンパ節郭清の必要性が示唆された.

Purpose: XAGE-1 was originally identified by the search for PAGE/GAGE-related genes using expressed sequence tag database and was shown to exhibit characteristics of cancer/testis-like antigens. Four transcript variants XAGE-1a, XAGE-1b, XAGE-1c, and XAGE-1d have been identified thus far. We recently identified XAGE-1b as a dominant antigen recognized by sera from lung adenocarcinoma patients. We here investigated the mRNA expression of four XAGE-1 variants and XAGE-1 protein expression in non–small cell lung cancer (NSCLC). Humoral immune response to XAGE-1b was also evaluated in patients. Experimental Design: Forty-nine NSCLC specimens were analyzed for the expression of four XAGE-1 transcript variants by conventional 30-cycle and real-time reverse transcription-PCR and XAGE-1 protein expression by immunohistochemistry. Sera from 74 patients were analyzed for XAGE-1b antibody production by ELISA and Western blot. Results: XAGE-1b and XAGE-1d mRNA were detected in 15 and 6 of 49 lung cancer specimens, respectively. No XAGE-1a or XAGE-1c mRNA expression was observed. XAGE-1b mRNA expression was observed in 14 of 31 (45%) adenocarcinoma and 1 of 18 (6%) lung cancer with other histologic types. Immunohistochemical analysis using a XAGE-1 monoclonal antibody showed that 14 of 15 XAGE-1b mRNA-positive and 3 of 34 XAGE-1b mRNA-negative specimens expressed XAGE-1 protein. Seropositivity was observed in 5 of 56 patients with adenocarcinoma, whereas none of 18 patients with other histologic types produced XAGE-1b antibody. Conclusion: XAGE-1b is highly and strongly expressed in lung adenocarcinoma and immunogenic in patients, suggesting that XAGE-1b is a promising antigen for immunotherapy against lung adenocarcinoma.

We investigated the relationship between surgical stress and tumor metastasis. The excessive surgical stress of a thoracolaparotomy enhanced tumor metastasis remarkably in an experimental model. We would like to propose that this phenomenon be termed "surgical oncotaxis". This effect has previously been attributed to some mechanisms of immunosuppression, excessive secretion of corticoids, and active oxygen production of granulocytes. An increase in lipid peroxide (LPO) in the liver was observed after a thoracolaparotomy, but a strong radical scavenger of a DL-alpha-tocopherol-L-ascorbic acid 2-0-phosphate diester (EPC-K1) restrained LPO levels in the liver and the effect of tumor metastasis in parallel. As clinical strategies for restraining the surgical oncotaxis, the control of any cytokine storm after surgery and/or the scavenging of active oxygen appears to be possible and hopeful, since it might be intermediated by cytokine. When pre-administration findings for EPC-K1 and methylpredonisolone were compared, EPC-K1 was found to be more suitable for restraining surgical oncotaxis, because serum LPO was only controlled with EPC-K1. The cytokine storm which occurs after surgery is augmented by a second stimulation, such as the administration of lipopolysaccharide, and no drug could control this well experimentally. Postoperative complications are a clinical model of a second stimulation (a so-called second attack). Our data showed the prognosis of a group with complications to be worse than that of a group without them even though no difference existed in the background of the esophageal cancer patients studied. Based on these results, safe surgery and the choice of minimally invasive surgery are the best ways to control surgical oncotaxis. Following a major surgical procedure, such as a thoracolaparotomy, the use of corticoids and/or radical scavengers can contribute to restraining surgical oncotaxis.

In order to assess the significance of changes in metalloproteinase activity in pancreatic carcinogenesis, the expression of matrix metalloproteinases 2 and 9 (MMP-2 and MMP-9, respectively), tissue inhibitor of metalloproteinase-1 (TIMP-1) and TIMP-2, and membrane-type 1 MMP (MT1-MMP) and MT2-MMP in ductal lesions in a rapid-production model for pancreatic duct carcinomas (PCs) in hamsters initiated with N-nitrosobis(2-oxopropyl)amine (BOP) and in subcutaneous transplantable tumors of hamster pancreatic duct carcinoma (HPDs) was investigated. Northern analysis revealed MMP-2, MMP-9, TIMP-2 and MT1-MMP mRNAs to be overexpressed in PCs. Immunohistochemically, elevated levels of MMP-2 were apparent in early duct epithelial hyperplasias and staining increased from atypical hyperplasias to carcinomas. Gelatin zymography demonstrated clear activation of proMMP-2 but not proMMP-9 in both of primary and HPD tumors, the MT1-MMP mRNA level and proMMP-2 activation being significantly correlated (r = 0.893, P < 0.001). In our rapid production model, 0.1 and 0.2% OPB-3206, an inhibitor of MMPs, given in the diet after two cycles of augmentation pressures for 48 days decreased the incidence and number of carcinomas. Gelatin zymography demonstrated that OPB-3206 inhibited activation of proMMP-2 in pancreatic cancer tissues. These results indicate that overexpression of MMP-2, TIMP-2 and MT1-MMP, and cell surface activation of proMMP-2 by MT1-MMP, are involved in the development of PCs, and that MMP-2 expression at the protein level appears in the early phase of pancreatic duct carcinogenesis. OPB-3206 may be a candidate chemopreventive agent for pancreatic ductal adenocarcinomas.

The methods we used to produce a carcinoma in the extrahepatic bile duct and gallbladder in hamsters are described along with the characteristics of the induced tumors. Female Syrian golden hamsters were first subjected to cholecystoduodenostomy with dissection of the extrahepatic bile duct on the distal end of the common duct (CDDB) and were, 4 weeks later, treated with weekly subcutaneous injections of N-nitrosobis(2-oxopropyl)amine (BOP) at a dose of 10 mg/kg body weight for 9 weeks. The animals were killed at the 12th, 16th and 20th week after the initiation of BOP treatment. Extrahepatic bile duct carcinoma developed in 16%, 24% and 41% and gallbladder carcinoma occurred in 58%, 81% and 82% of the hamsters, respectively, at the corresponding times of killing. The incidences were significantly higher than those in sham-operated controls (P < 0.01). The induced extrahepatic bile duct carcinomas were predominantly of the polypoid type and gallbladder carcinomas were of the papillary type in growth form, being morphologically similar to early stage biliary carcinoma in humans. Immunohistochemical staining using bromodeoxyuridine and anti-bromodeoxyuridine monoclonal antibody demonstrated that the CDDB procedure greatly accelerated the cell kinetic activity of the biliary epithelium, and this was considered to be a major factor promoting the development of biliary carcinomas in this hamster model. In conclusion, this new model provides a high incidence of tumor development at the extrahepatic biliary tract and is expected to be useful for clarifying the characteristics of this highly malignant tumor.