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症例は54歳男性. 2001年5月より歩行時の胸痛を自覚していた. 10月の胸部単純写真で左肺門部腫瘤影を指摘され, CTと併せ左肺門部癌が疑われた. またトレッドミル検査で心電図上ST低下を認め, 冠状動脈造影を施行したところ冠状動脈狭窄を認めた. PTCAを施行したが狭窄部を通過せず, 冠状動脈バイパス術の適応であった. 肺全摘術中・術後の循環動態の安定を考え, 一期的にCABGと肺全摘術を行う方針とした. 胸骨正中切開でアプローチし, 人工心肺下で3枝バイパス術を行い, その後左肺全摘術・縦隔リンパ節郭清を行った. 術後出血を認めたが, 輸血により術後2日目には止血した. 病理は低分化腺癌pT1N1M0病期IIaであった. 術後2年6ヵ月経過したが再発は認めていない. 肺癌に対する早期治療という点で, 今後も虚血性心疾患合併肺癌症例において一期的手術も考慮されるべきと思われた.

肺炎による急性炎症の発現にて発見されたCA19-9産生肺癌の1切除例を経験したので若干の文献的考察を加えて報告する.症例は72歳, 男性.全身倦怠感および発熱を主訴に来院した.胸部単純X線写真で右下肺野に浸潤影を認め, 肺炎の診断で内科的治療を行った.炎症所見の改善後も陰影が継続して認められたため, 経皮生検を行い腺癌と診断された.入院時の血清CA19-9は, 1, 977U/mlと高値を示したが, 肝, 胆, 膵及び消化管に異常を認めなかったため, 原発性肺癌の診断にて右下葉切除術を行った.病理組織学的には肺原発の高分化腺癌 (pT2N0M0) で, 免疫染色にてほとんどの癌細胞においてCA19-9の分布が確認された.術後, 血清CA19-9値は低下し, 1ヵ月後には18U/mlと正常化した.消化器系癌だけでなく原発性肺癌でも血清CA19-9値が高値を示すことがあり, その臨床的意義を認識する必要があると思われた.

BACKGROUND Vascular endothelial growth factor (VEGF), a recently identified growth factor with significant angiogenic properties, is a multifunctional angiogenic cytokine that is expressed in many tumors. High VEGF expression has been shown to correlate with the incidence of metastasis and poor prognosis in various cancers. In this study, the authors investigated VEGF expression and microvessel density (MVD) in ductal pancreatic adenocarcinoma and examined the correlations among VEGF expression, clinicopathologic factors, and clinical outcome. The authors especially focused on the correlation between VEGF expression and liver metastasis. METHODS Paraffin embedded tumor specimens of 142 surgically resected pancreas carcinoma were immunohistochemically stained for VEGF and MVD. The correlations among VEGF expression and MVD, clinicopathologic factors, and clinical outcome were then statistically analyzed. RESULTS One hundred thirty-two (93%) of 142 ductal pancreatic adenocarcinomas were positive for VEGF protein by immunohistochemistry. A significant correlation was observed between VEGF positivity and MVD (P < 0.0001). Multivariate logistic regression analysis indicated a significant association between high VEGF expression and liver metastasis (P = 0.010) but no other factors, such as age, tumor size, histologic type, lymph node metastasis, venous invasion, neural invasion, peritoneal metastasis, or local recurrence. Patients with tumors that showed moderate or high VEGF expression had significantly shorter survival than patients with low VEGF expression or none at all in their tumors (P < 0.05). CONCLUSIONS These results indicate that VEGF expression is closely correlated with MVD and seems to be an important predictor for both liver metastasis and poor prognosis in ductal pancreatic adenocarcinoma. Cancer 2000;88:2239–45. © 2000 American Cancer Society.

Gastric metastases to other organs are often unresectable, and even resectable caases have to have an extremely poor prognosis. This time we experienced a long-term survivor for 7 years and 2 months after the initial operation for gastric cancer; during of which multiple metachronous extraperitoneal metastases were successfully treated by operations, radiation and chemotherapy. The patient was a 56-year-old woman who had undergone a total gastrectomy with D2 lymph nodes dissection for advanced gastric cancer in July, 1990. Four years later, the patient was admitted to our department because of an umbilical tumor and was diagnosed as having an umbilical metastasis, socalled Sister Mary Joseph's nodule, from a previously-treated gastric cancer by fine needle aspiration cytology. She underwent an extirpation of the umbilical tumor. Three months later she noticed a swollen lymph node in the right axilla and several nodules suggesting intramuscular metastases in the abdominal rectus muscle. Furtheremore, 4 months after the extirpation of the axillary lymph node, which was histologically diagnosed to be metastatic gastric cancer, her right breast showed a cancerous skin change and bilateral inguinal lymph nodes enlarged. Therefore, radiation therapy at a total dose of 50Gy on both sites was added, followed by several courses of systemic chemotherapy using methotorexate and 5-fluorouracil. Our aggressive combined therapy was effective, and gave her a long-term surrvival without spoiling the quality of her life for as long as 7 years and 2 months.

A case of Schwannoma of the left brachial plexus that extended into the thoracic cavity and caused fracture of the left first rib is presented. A 33-year-old woman suffered from a sudden onset of left shoulder pain at coughing. Chest X-ray film revealed fracture of the left first rib and a left apical mass. The tumor was subcapsularly resected with thoracoscopic surgery. The resected tumor was Schwannoma arisen from the brachial plexus of nerve trunk. After the operation, the patient developed a mild motor inpairment of the muscles controlled by median and ulnar nerve. This postoperative neurological problem was improved in 6 months. It should be kept in mind that tumors arising in the brachial plexus are a probable differential diagnosis for tumors at the pulmonary apex, even if no neurological symptoms are seen in the upper extremities.

We describe a rare case of adenoma with a few foci of severe atypia arising from the cystic duct in a 68-year-old woman, initially diagnosed by the presence of intracholecystic tumefactive sludge on abdominal ultrasonography. Endoscopic retrograde cholangiography (ERC) disclosed a tuberous filling defect at the orifice of the cystic duct. Pathology examination of the biopsied specimen obtained from ERC disclosed not a cancerous but an adenomatous lesion. Macroscopically, the resected specimen showed a superficially spreading and shallowly elevated lesion extending from the cystic duct to the common bile duct. Although a few sporadic foci of severe atypia were observed, microscopy did not reveal any cancer findings, but confirmed the tumorous lesion as benign adenoma, showing mild-to-moderate atypia. Postoperative immunohistochemistry revealed no expression of p53 protein. We briefly refer to the rarity of adenoma in the biliary tract and discuss the difficulty of differential diagnosis of neoplastic lesions in the extrahepatic biliary tract.

We have experienced a resected case of intrahepatic cholangiocellular carcinoma of peripharal type oc-curred 9 years after an operation for synchronous double cancer of the stomach and pancreas. A 74-year-old man revealed an increase in level of a tumor marker (CA 19-9:267IU/ml) during medical ovservation following the operation for the double cancer on an ambulant basis. Abdominal CT scanning visu-alized a tumor 3cm in diameter presenting an irregular low density area in the anterior and superior segment of the right lobe (S 8) of the liver. From findings of CT, ultrasonography, and angiography, we found a great deal of difficulty in differentiating whether the hepatic tumor was metastatis of the former gastric or pancreatic cancer or intrahepatic cholangiocellular carcinoma. But we first considered it as intrahepatic cholangiocel-lular carcinoma because it was solitary and 9 years had elapsed after the inital operation, and performed a segmentectomy (S 8) of the liver. The resected material also demonstrated intrahepatic cholangiocellular carcinoma of peripheral type, histopathologically. It is very rare that metachronous triple cancer appears in such combination as early gastric cancer, pan-creatic cancer and intrahepatic cholangio-cellular carcinoma, and hence this case is presented here.

We treated a patient with primary carcinoma of the appendix showing a chronic clinical onset. This paper presents this case with a review of 144 cases found in the Japanese literature in the past two decades. A 71-year-old man was admitted because of right lower quadrant pain with first onset occurring about a decade before, three subsequent hospitalizations and eventual relief conservative. A knuckle sized tumor was found in the right lower quadrant. Abdominal ultrasonography and computed tomography suggested a cystic lesion. A barium enema showed an extraluminal lesion in the distal cecum, without demonstration of the appendix. Because of an elevated serum CEA level (41.5 ng/ml), we suspected a malignant lesion and performed laparotomy. At operation, the appendix was not identified, however, a white-yellowish cystic tumor was found in the distal cecum, and ileocecal resection was performed. Postoperative pathological diagnosis was mucinous cystadenocarcinoma of the appendix. We recommend that, in view of the present case, caution should be exercised in diagnosing appendicitis, particularly, in elderly patients with chronic onset.

A case of ampullary carcinoma with a jumping metastasis to the paraaortic lymph node is presented. A 51-year-old woman was admitted to the hospital because of epigastrial discomfort. Liver dysfunction had been noticed since one year before without a history of jaundice. CA 19-9 level elevated. Intrahepatic bile duct dilatation was detected by ultrasound and computed tomography. Hypotonic duodenography showed a protruded mass, 4cm in size, which was well differentiated adenocarcinoma by endoscopic biopsy. There was no ascites, liver metastasis or peritoneal dissemination on laparotomy. An elastic hard tumor was palpable at the second portion of the duodenum without any invasion to the serosa. A pylorus-preserving pancreatico-duodenectomy was performed with extended lymph node dissection including paraaortic regions, and with intraoperative radiation. The mass was an exposed protruding type, invading the submucosa of the duodenum. The only one paraaortic lymph node was metastasized of all 55 dissected lymph nodes. We conclude that there is a direct stream of lymph from the papilla to paraaorta and that the paraaortic lymph node dissection would be mandatory for surgery of ampullary carcinoma even in an early stage.

Background The clinical course of patients with carcinoma of the gallbladder depends on the depth of tumour invasion. This study was conducted to clarify the prognostic factors affecting survival and appropriate surgical strategy based on depth of invasion of gallbladder carcinoma according to the pathological tumour node metastasis (pTNM) classification. Methods A total of 70 patients who underwent surgical resection were reviewed retrospectively with regard to the type of operation, histopathological findings of the resected gallbladder carcinoma and clinical follow-up after operation. Results Twelve patients with pT 1 gallbladder carcinoma fared favourably following cholecystectomy or extended cholecystectomy. In 13 of 26 patients with pT 2 gallbladder carcinoma, lymph node metastasis was evident: pN 1 in eight and pN 2 in five. The 3-year survival rate of patients with pT 2 gallbladder carcinoma was 28 per cent after cholecystectomy, 91 per cent after extended cholecystectomy and 67 per cent after hepatectomy. In 21 of 28 patients with pT 3 or pT 4 gallbladder carcinoma, surgical margins were affected by malignant cells. The 1-year survival rate of patients with pT 3 or pT 4 gallbladder carcinoma was 24 per cent, even after hepatectomy. Significant prognostic factors were age, macroscopic type, histological grade, depth of invasion, lymph node metastasis, pathological stage, lymphatic invasion, venous invasion, perineural invasion and involved surgical margins. Conclusion Cholecystectomy was adequate for pT 1 gallbladder carcinoma. Extended cholecystectomy or hepatectomy with extrahepatic bile duct resection and lymph node dissection (pN 1 and pN 2 ) were justified for pT 2 gallbladder carcinoma. The survival of patients with more advanced gallbladder carcinoma remains dismal.

胃重複症は先天性の奇形で消化管重複症の1つである. 自験例を含め, 本邦で74例の報告を見るに過ぎない. 今回, 2つの嚢腫を有した胃重複症を経験したので報告する. 症例は40歳の女性で, 1991年12月腹部エコー, CT検査で左横隔膜下, 膵背側に嚢胞性腫瘤を指摘された. 1992年4月, 膵嚢胞の疑いで手術を受けた. 左横隔膜下に径8cm, 膵体尾部背側に10cmの嚢腫が存在し, おのおの別個に胃体上部大彎側との強固な壁の連続を認めた. 病理組織学的所見で2つの嚢腫は共に消化管壁に類似した構造を持ち, またその筋層は本来の胃の筋層と連続しており, 胃重複症と診断した. 胃重複症は無症状で経過し成人で偶然発見されることも多い. 診断には胃透視, 腹部CT検査, 超音波内視鏡が有用であり, また重複胃よりの癌発生の報告もあるため治療は外科的治療が第1選択と考えられる. 腹腔内に嚢胞性腫瘤がある場合には胃重複症も念頭に置くことが大切である.

Diversion colitis (DC) すなわち空置腸管に発生した腸炎に関する本邦での報告はまれである. 今回, 高度の貧血を伴ったDCの1例を経験したので報告する. 症例は33歳の男性で1994年6月悪性リンパ腫による小腸閉塞症のため回盲部切除, 回腸人工肛門造設, 上行結腸による粘液瘻造設術を施行した. 化学療法で完全寛解が得られたため, 1995年3月腸瘻閉鎖目的で入院したが, 血色素6.4g/dlと貧血が高度であった. 粘液瘻部より血性分泌液の排泄があり大腸内視鏡を施行したところ, 粗造な粘膜に発赤, 出血を認めDCが疑われた. 回腸上行結腸吻合術施行後, 炎症所見は速やかに改善し, 血性粘液の排泄は消失し貧血も改善した. 文献上も腸瘻閉鎖により腸管の連続性を回復することが最も効果的とされている. 空置大腸がある場合には, 定期的, 積極的に内視鏡検査を行いDCを早期発見し, また他の炎症性腸疾患と鑑別するよう努めることが大切である.

MBE-grown CdTe/InSb/CdTe single quantum wells were characterized by TEM, FTIR and photoconduction. Even in the presence of In, Te related compounds and CdTe buffer-width dependent Fabry-Perot interference, a step-like quantum size effect was observed in the SQW FTIR data. The photocurrent peaks are also attributable to quantum well intersubband transitions due to higher subband energy levels. With the improvement of the CdTe/InSb interface in mind, we studied the characteristics of α-Sn layers grown on top of CdTe. TEM pictures show that the propagation of dislocation planes originating from the CdTe buffer layer is stopped at the α-Sn/CdTe heterointerface.

Recently, intraductal papillary-mucinous tumor (IPMT) of the pancreas has increasingly been recognized. However, differential diagnosis between benign and malignant IPMT is often difficult using conventional imaging modalities. The purpose of this study was to retrospectively investigate the value of endoscopic ultrasonography (EUS) for differentiating malignant from benign IPMT.A total of 51 patients with IPMT were preoperatively examined by EUS. The endosonograhic findings were compared with histopathological findings of the resected specimens.In main duct type IPMT, the diameter of the main pancreatic duct (MPD) wasor =10 mm in seven of the eight malignant tumors, compared with two of the seven benign tumors (p0.05). In branch duct type IPMT, three of the four large tumors (40 mm) with irregular thick septa were malignant lesions. In both main duct type IPMT and branch duct IPMT, eight patients had large mural nodules (10 mm); seven of the eight tumors were malignant and one of the eight tumors was benign. When the tumor was diagnosed as malignant according to above three findings, EUS was able to differentiate between malignant and benign IPMT with an accuracy of 86%.Main duct type tumors withor =10 mm dilated MPD, branch duct type tumors (40 mm) with irregular septa, and large mural nodules (10 mm) strongly suggest malignancy on EUS. EUS would be a useful modality for differentiating between benign and malignant IPMT.

We evaluated the MR imaging features of adenomyomatosis of the gallbladder with particular emphasis on Rokitansky-Aschoff sinuses.MR images of 17 patients with histologically proven adenomyomatosis were retrospectively reviewed. The presence of Rokitansky-Aschoff sinuses was evaluated and analyzed; four T2-weighted (fast spin-echo with a surface coil, with or without breath-holding, fast spin-echo with a phased-array coil with breath-holding, and half-Fourier rapid acquisition with relaxation enhancement with breath-holding) and two contrast-enhanced dynamic pulse sequences were studied. These six pulse sequences were separately rated on a 5-point scale by two radiologists for comparison. Interobserver differences were evaluated. Other MR findings were also analyzed.Among the six pulse sequences studied, three T2-weighted with breath-holding sequences were found to be superior to the other three sequences in showing Rokitansky-Aschoff sinuses. In particular, the half-Fourier rapid acquisition with relaxation enhancement was scored the highest by the two observers and received the highest kappa coefficient in our statistical analysis of the scoring. Diffuse-type adenomyomatosis typically showed early mucosal and subsequent serosal enhancement. Localized adenomyomatosis exhibited homogeneous enhancement, showing smooth continuity with the surrounding gallbladder epithelium.MR imaging may be able to provide important information in the diagnosis of adenomyomatosis.

An inflammatory polyp of the gallbladder is a rare variant of benign gallbladder polyp. Differentiation between an inflammatory polyp and polypoid gallbladder carcinoma is difficult when the polyp is more than 1 cm in diameter. We report a rare case of a large inflammatory polyp of the gallbladder masquerading as gallbladder carcinoma in a 37-year-old Japanese woman who was incidentally diagnosed with a large gallbladder polyp, measuring 1 cm in diameter, by ultrasonography. She was asymptomatic and physical examination was unremarkable. Abdominal ultrasonography and endoscopic ultrasonography revealed three polypoid lesions in the gallbladder. One lesion was an isoechoic polyp, measuring 15 x 8 mm, showing a nodular surface and located in the fundus of the gallbladder. The other two lesions were hyperechoic polyps, measuring 5 x 5 mm, in the body of the gallbladder. Computed tomography and magnetic resonance imaging revealed marked enhancement of the largest polypoid lesion by dynamic study, and no lymph node enlargement was noted. Endoscopic retrograde cholangiography revealed a 12 x 8 mm polyp with an irregular surface in the fundus of the gallbladder. Superselective angiography of the cystic artery revealed neovascularity and a tumor stain in the fundus of the gallbladder. Cholecystectomy with lymph node dissection was performed. Intraoperative frozen section diagnosis of the largest polyp was an inflammatory polyp of the gallbladder. The other two polyps were cholesterol polyps. Inflammatory polyp should be considered as a differential diagnosis of hypervascular gallbladder polyps that measure more than 1 cm in diameter.

The case of a 70-year-old Japanese woman with adenoid cystic carcinoma (ACC) of the esophagus is presented herein. The patient presented with progressive dysphagia, and an upper gastrointestinal series and esophagogastroscopy revealed a protruding tumor located in the middle portion of the esophagus. Ultrasonography (US) and computed tomography (CT) suggested a lymph node metastasis between the left lobe of the liver and the esophagocardiac junction. Histopathologic examination of a biopsy specimen showed squamous cell carcinoma (SCC) and a subtotal esophagectomy was performed under the preoperative diagnosis of esophageal carcinoma. However, the histopathologic diagnosis of the resected specimen proved to be ACC of the esophagus with a lymph node metastasis around the left gastric artery. We report the clinicopathological findings of this case and briefly discuss the clinical implications of ACC.

We herein describe a case of a gas-forming pyogenic liver abscess following transcatheter hepatic arterial embolization (THAE) for an iatrogenic intrahepatic pseudoaneurysm in a 74-year-old woman. Hemobilia developed 19 days after percutaneous transhepatic cholangio-drainage was performed for the purpose of percutaneous cholangioscopic lithotripsy for the treatment of post-gastrectomy choledo-cholithiasis. Celiac arteriography disclosed a saccular aneurysm in the right hepatic artery. The pseudoaneurysm was successfully occluded by THAE with gelatin powder and a stainless steel coil of the Gianturco type. Ten days after successful THAE, abdominal computed tomography revealed a gas-containing cavity, which suggested the presence of a gas-forming abscess, in the posterior hepatic segment, and percutaneous transhepatic abscess drainage was performed. Thus, impaired hepatic perfusion following effective THAE and coexisting cholangitis may play an important role in the development of a gas-forming pyogenic liver abscess.

The atomistic structure of crystalline Ge–Sb–Te thin film for phase-change optical recording was investigated using transmission electron microscopy and nanobeam electron diffraction. Nonradial diffuse streaks were observed in electron diffraction patterns obtained from laser-induced crystalline phases of Ge–Sb–Te thin films. The intensities of the diffuse streaks were pronounced in particular directions in this alloy. The diffuse streaks were due to low-frequency transverse lattice waves that occur along directions perpendicular to the near neighbor zigzag atomic chains.

This paper is concerned with the problem of the onset of buoyancy driven instability in a horizontal layer of binary fluid mixture which is heated internally by a uniform distribution of heat sources. The layer is bounded below by a thermal insulator and above by a rigid wall of constant temperature. Linear stability theory is applied to derive an eigenvalue system of eighth order which is then solved by the power series method. In order to reduce the amount of numerical work, Galerkin's method is also used. For wide ranges of various parameters, the conditions under which instability sets in are determined in detail.

The effect of a free surface deformation on the onset of surface tension driven instability in a horizontal thin liquid layer subjected to a vertical temperature gradient is examined using linear stability theory. Assuming that the neutral state is a stationary one, the conditions under which instability sets in are determined in detail. It is shown that when the upside of the liquid layer is a free surface the free surface deformation is important only for unusually thin layers of very viscous liquids. It is also shown that when the underside of the liquid layer is a free surface the free surface deformation plays an essentially important role and the presence of a vertical temperature gradient can stabilize the layer which, in case of no temperature gradient, is always unstable.

Domain structure of Rochelle salt has been studied by X-ray plane-wave topography. Fine stripe patterns of domain boundaries are found in topographs of a-plates in ferroelectric state. These patterns are caused by strains near the boundary, due to atomic displacements parallel to the boundary. For c-plates, separate three topographs have been obtained for three incident angles corresponding to three peaks in the rocking curve due to c-domain and to two sets of crystal orientation in b-domain.