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Macrocystic serous cystadenoma (MSC) of the pancreas is a rare benign neoplasm with varied imaging appearances. We describe an intriguing case of a surgically resected and histologically proven giant MSC, developed in the pararenal space. Ultrasonography (US) revealed a large, oligocystic mass around the lower pole of right kidney. Like US, computed tomography, and magnetic resonance imaging were unable to detect the origin of the lesion, which was only verified at surgical exploration. A bizarre finding was the unusual location of the pancreatic tumor growing seemingly apart from the pancreas itself, with no obvious connection to it.

A great deal of clinical experience has firmly established the concept of the sentinel lymph node (SN) in breast cancer. SN biopsy allows treatment without axillary lymphadenectomy and has made it possible to perform a surgical intervention via just a small skin incision. In partial resection of the breast (quadrantectomy), we use a double retractor to form a workspace under the skin via a small axillary incision. Resection does not require a large incision even in cases in which the cancer lesion is located in the upper inner or lower inner quadrant of the breast, as the endoscope allows the surgeon to see the workspace formed by the double retractors.

Neck endoscopic surgery is likely to prove less invasive and more cosmetically advantageous than conventional methods. The surgical procedure used for 42 consecutive patients undergoing video-assisted thyroidectomy by the anterior chest wall approach is described herein. A 3-4 cm incision was made at the anterior chest wall 2 cm below the clavicle on the tumor side. Two Kirshner wires connected to a winching device were horizontally inserted beneath the skin in order to lift the neck skin. Specially made retractors were passed through the chest wall wound to the lateral neck bilaterally. Strap muscle on the tumor side was retracted laterally and the thyroid tumor was retracted medially. A suitable working space was thus created using this modified neck lifting method without gas insufflation. All patients underwent video-assisted thyroidectomy utilizing an anterior chest wall approach without conversion to open thyroidectomy. Mean operative time from incision to removal of the tumor was 145 min. Mean tumor size was 4.1 cm (range: 2.0-7.5 cm). The advantage of our approach is that the scar below the clavicle is invisible under normal clothing. In addition, conventional instruments for open thyroidectomy can be used. In our method, the thyroid tumor and trachea are palpable and some parts of the operation can be conducted under direct visualization if the assistant retracts the anterior chest wall wound upward. Video-assisted thyroidectomy utilizing an anterior chest wall approach is cosmetically less invasive, particularly for women who are frequently nervous about operative scars on the neck.

Background. Recently, eicosapentaenoic acid (EPA) was found to have an anti-inflammatory effect attributable to diminished synthesis of arachidonic acid metabolites that initiate acute lung injury. We evaluated the ability of dietary EPA supplementation to prevent endotoxin-induced acute lung injury in rats. Materials and methods. Rats fed a standard diet were divided randomly into two groups: for 2 weeks one group additionally was fed 1000 mg/kg/day of EPA ethyl ester emulsion (EPA rats), while in the other group the diet was supplemented with vehicle alone (control rats). Fatty acid components of alveolar macrophages (AM) were measured, as well as leukotriene (LT) B 4 and LTB 5 production by AM exposed in vitro to calcium ionophore A23187. Plasma concentrations of thromboxane (Tx) B 2 , a stable metabolite of TxA 2 , were examined 1 h after inducing lung injury with endotoxin (2 mg/kg iv). At 6 h, wet/dry (W/D) weight ratios were calculated for the lungs to assess pulmonary edema, and neutrophils were counted in pulmonary parenchyma and peripheral blood. Results. Arachidonic acid content and LTB 4 generation in AM were significantly lower in EPA rats than in controls; conversely, EPA content and LTB 5 generation in AM were significantly higher in the EPA group. Neutrophil counts in lung parenchyma and peripheral blood did not differ between groups, but W/D and plasma TxB 2 concentrations were significantly lower in EPA rats. Conclusions. EPA supplementation depressed arachidonic acid content and LTB 4 generation in AM and plasma TxB 2 in our model, leading to decreased pulmonary edema.

This study was designed to clarify the clinical and pathologic features of diffusely infiltrative squamous cell carcinoma of the esophagus. Diffusely infiltrative squamous cell carcinomas were classified grossly into two types, namely, scirrhous carcinoma and nonscirrhous carcinoma. There were seven patients with the former type and three with the latter type. Scirrhous-type carcinoma was associated with a prominently thickened esophageal wall with strictures, whereas nonscirrhous-type carcinoma demonstrated thickening of the esophageal wall without strictures. Microscopically, all patients had lymph node metastases and lymphatic invasion. Blood vessel invasion was found in seven patients and extranodal invasion was found in seven. The prognosis of patients with both types of carcinoma was extremely poor. Only two patients who underwent curative surgery as well as chemoradiotherapy survived for more than 1 year. Therefore, further morphological studies on the early stages of diffusely infiltrating esophageal carcinoma should be performed. New treatment strategies such as intensive preoperative chemoradiotherapy based on sensitivity tests in individual patients will be required for treating the advanced stages of this disease.

胸部食道に対する頸部郭清の適応について, 鎖骨上と反回神経沿いリンパ節の術前超音波診断ならびに手術成績の面から検討した. 対象は1986年から93年にcl以上の切除を行った胸部食道癌136例 (3領域郭清105例, 2領域郭清31例) とした. 3領域郭清例において, 術前に鎖骨上リンパ節転移陰性とした84例中7例 (8.3%) に組織学的に転移が認められた. False negative 7例中5例は反回神経沿いに術前超音波診断および術中に転移を認めた. したがって, 術前超音波診断による鎖骨上リンパ節の転移の有無のみで頸部郭清を省略するのは危険であるが, 反回神経沿いリンパ節の術前・術中診断を加味すると97.6% (82/84例) の症例で頸部郭清の適応を術前診断にて判断可能であった. また術前に鎖骨上・反回神経沿いに転移陰性としたmp以上の症例における5生率は頸部郭清の有無に関係なく37%であった. 術前診断による鎖骨上または反回神経沿い転移陽性症例が頸部郭清の適応である.

A series of 335 patients with squamous cell carcinoma of the thoracic esophagus undergoing resection and reconstruction via a right thoracotomy and laparotomy with cervical anastomosis between 1973 and 1990, were reviewed. Prior to 1982, the removal of lymph nodes was limited to the nodes in the mediastinum below the tracheal bifurcation and upper abdomen (142 patients). Nodal metastases were found in 89 of these patients at operation. The upper abdominal nodes were the most frequent sites of metastasis (47.2%). None of the 38 patients with positive nodes sampled from the neck and superior mediastinum survived for more than 45 months. In the 50 patients with recurrences, 30 were in the neck and/or superior mediastinum. During or after 1983, the superior mediastinal nodes, particularly the bilateral recurrent nerve nodal chains, were routinely removed (193 patients). Nodal metastasis was proven in 131 of the 193 patients, in whom 87 (45.1%) had metastasis in the neck and superior mediastinum. Eleven of these 87 patients survived for 45 months or more. In the 61 patients with recurrences, 20 were in the neck and/or superior mediastinum. These data suggest that recurrent nerve nodal chains should be removed to improve survival in patients with esophageal carcinoma.

胸部食道癌根治手術例で右開胸開腹, 頸部吻合, 胸骨後あるいは後縦隔経路再建の285例を対象とし, 再建術後の問題点と対策を検討した. 反回神経リンパ郭清を行わなかった1982以前の88例 (First Gr.) と, それ以降の197例 (Latter Gr.) の, 非再発死亡と再発例の生存率では, First Gr.で非再発死亡の生存率が再発例より有意に良好であった. しかし, Latter Gr.ではその有意差は消失し, 非再発死亡の66.7% (30/45例) は肺炎, 全身衰弱, 突然死であった. Latter Gr.の胸骨後再建80例と後縦隔再建117例では, 退院時の体重, 肺活量, 1秒量は後縦隔経路で有意にその落ち込みが少なく, 退院後3年の体重も良好に維持された. 術後3～5年経過例のアンケート結果でも後縦隔再建例で食物のつかえ感や誤飲, 腹痛, 息切れを訴える症例が少なかった. 消化器・呼吸器症状が少なく, 術後長期の栄養状態も良好な後縦隔経路は, 食道癌根治手術におけるfirst choiceの再建経路と考えられる.

教室では1983年以降, 胸部食道癌に対して積極的に3領域リンパ節郭清を施行してきた.最近, 高齢者の食道癌切除症例が増加しているが, 果たして高齢者に対しても3領域リンパ節郭清が有効であろうか? c1以上の切除症例251例を対象に, 70歳以上の高齢者群 (65例) と70歳未満の非高齢者群 (186例) に分け検討した.その結果, 1) 術前併存症は高齢者群に有意に多かった.2) 術後合併症は高齢者特有の合併症はなかったが, 不整脈やせん妄が多くみられた.3) 3領域郭清群に合併症が多く認められた.4) 人院死亡率は両群間に差を認めなかった.5) 2領域郭清例の相対5生率は両群間に差はないが, 3領域郭清例では高齢者の5生率は8.0%で, 非高齢者群の35.9%に比べて有意に低かった.高齢者胸部食道癌の外科治療に対しては, 画一的な術式の選択よりも, 臨床的に癌をとり残さないことを最低条件とした合理的なリンパ節郭清が必要である.

A solitary well-demarcated tumor was found in the left lung of a 53-year-old man. It was located in the posterior region of the lower lobe just adjacent to, but apart from, the pleura. It was resected by video-associated thoracic surgery. Macroscopically, the tumor was a whitish solid nodule without hemorrhage or necrosis, and it was 1.5 cm in diameter. Histologically, the tumor consisted of a proliferation of fibromuscular tissue in interlacing fascicles in which many tubular or cleft-like epithelial inclusions were involved. The epithelial inclusions showed cystic changes with goblet cell metaplasia in part, but no atypical changes. Other mesenchymal components such as cartilaginous, myxomatous or adipose tissues were not seen. The patient had no history of neoplasm, including smooth-muscle tumor. Thus, we diagnosed this tumor as a "true" fibroleiomyomatous hamartoma, as distinct from so-called fibroleiomyomatous hamartoma or benign metastasizing leiomyoma, which are usually found in the lungs of women who have had hysterectomies, as multiple fibromuscular nodules. We report here this rare case and we review and discuss published reports of fibromuscular tumors of the lung.

Galectin-3 is a member of the β-galactoside-binding protein family that plays an important role in cell-cell adhesion and in cell-matrix interaction. We have examined the expression of galectin-3 in normal, adenomatous, and malignant thyroid tissues and also in metastasic lesions. Galectin-3 was rarely expressed in normal thyroid tissue but was abundant in the cytoplasm of the neoplastic lesions. Among neoplastic lesions, galectin-3 was expressed to a greater extent in follicular carcinomas than in follicular adenomas and was present in greater amounts in papillary carcinomas than in follicular adenomas or carcinomas. Primary lesions of papillary carcinoma with metastasis contained significantly higher concentrations of galectin-3 than tumors of this type without metastases. However, the expression of galectin-3 was significantly decreased in metastasic lesions in the lymph nodes compared with their primary lesions. From these results, we assumed that galectin-3 works in different ways at different stages of thyroid neoplasm proliferation. Among primary tumors, galectin-3 expression is significantly different in 3 histological types. However, the continuity of progression among these tumors is not yet proven. In later stages, decreased expression of galectin-3 may aid the release of cancer cells from the primary lesions for invasion and metastasis.

BACKGROUND The aim of this study was to establish whether the site of lymph node metastasis influences the survival of patients with carcinoma of the thoracic esophagus. METHODS A series of 159 patients with lymph node metastasis who underwent right transthoracic R0 esophagectomy was analyzed retrospectively. Sites of the nodal metastasis were divided into two regions; the neck and/or upper mediastinum above (upward metastasis) and the abdomen and/or lower mediastinum below (downward metastasis) the tracheal carina. RESULTS Univariate analysis of prognostic factors revealed the tumor location, distant lymphatic metastasis, number of metastatic nodes and upward metastasis influenced survival, but downward metastasis did not. Multivariate analysis showed that the number of metastatic nodes and upward metastasis were also significant prognostic factors. Thirty-one (33.3%) of the 93 patients with, but only 6 (9.1%) without, upward metastasis had recurrences in the neck and/or upper mediastinum (P = 0.0002). Eighteen (60.0%) of the 30 patients with extranodal invasion in the neck and/or upper mediastinum had recurrence in these regions. CONCLUSIONS Nodal metastasis in the neck and/or upper mediastinum was a significant risk factor for prognosis, the same as the number of metastatic nodes.

OBJECTIVE: To evaluate the efficacy of ultrasonography for the diagnosis of cervical lymph node metastasis in esophageal carcinoma. SUMMARY BACKGROUND DATA: Ultrasound (US) examination is useful for diagnosing lymph node metastasis. However, few reports have examined its role in the decision to perform cervical lymph node dissection in esophageal carcinoma. METHODS: Ultrasound examination was performed to evaluate cervical lymph node metastasis in 519 patients with esophageal carcinoma. The patients were divided into 5 groups according to treatment received: group 1, 153 patients who underwent curative resection of primary tumor by right thoracotomy and complete bilateral cervical lymphadenectomy; group 2, 112 patients who underwent curative resection of primary tumor by right thoracotomy but without cervical lymphadenectomy; group 3, 78 patients who underwent esophagectomy by left thoracotomy or blunt dissection with or without removal of cervical lymph nodes; group 4, 76 patients with palliative resection without cervical lymphadenectomy; and group 5, 100 patients without any surgical treatment. US diagnosis was compared with histologic findings or cervical lymph node recurrence. RESULTS: Lymph node metastasis was detected in 30.8% of patients (160/519). The sensitivity, specificity, and accuracy of US diagnosis in group 1 were 74.5%, 94.1%, and 87.6%, respectively. Cervical lymph node recurrence was seen in 7 patients (4.6%) in group 1, in 4 patients (3.6%) in group 2, and 3 patients (3.8%) in group 3. Although the incidence of cervical lymph node metastasis as determined by US examination was high in groups 4 and 5, almost none of the patients died of cervical lymph node metastasis. CONCLUSIONS: Ultrasound examination plays a useful role in the decision to perform cervical lymph node dissection in patients with esophageal carcinoma, particularly in those with potentially curative dissection.

Endoscopic mucosal resection (EMR) has recently been standardized for mucosal cancer of the esophagus. It may be hypothesized that EMR may be considered to be curative for superficial esophageal cancer (SEC), if the possibility of lymph node metastasis can be excluded beforehand. Ninety patients with p-T1 tumours who underwent esophagectomy were studied. Their primary lesions were stained with anti-Desmoglein 1 antigens using the ABC method. The p-T1 tumors were subdivided into three categories: carcinoma limited to the lamina propria mucosae (19 patients, SEC1), carcinoma invading the lamina muscularis mucosae or with invasion just into the submucosa (27 patients, SEC2), and carcinoma definitely invading the submucosa (44 patients, SEC3). Lymph node metastasis was not observed in the SEC1 patients but was observed in 19% of the SEC2 patients and 41% of the SEC3 patients. None of the SEC1 or SEC2 patients had lymph node metastasis when preserved Desmoglein 1 expression was obtained. The EMR appears to be appropriate therapy for SEC1. Our findings indicate that, for SEC2, preserved expression of Desmoglein 1 may be a helpful aid to exclude the possibility of lymph node metastases. Transthoracic esophagectomy with lymphadenectomy should be selected in the SEC3 patients.

We retrospectively analyzed the clinicopathologic findings, treatment and outcome of 22 patients with synchronous or metachronous carcinomas of the esophagus and head and neck. The patients with metachronous cancers in whom esophageal cancer occurred first had either an early-stage esophageal carcinoma or only one positive lymph node. Similarly, five of 10 patients with metachronous cancers in whom head and neck cancer was the first tumor had early-stage esophageal carcinomas. The esophageal lesion was mucosal carcinoma in four patients which was found by endoscopy with the iodine dye method. In the patients with synchronous cancers either one or both carcinomas were advanced, and the prognosis of these patients was poor compared with those of patients with metachronous carcinomas. Accordingly, endoscopic surveillance for early detection of metachronous lesions are encouraged.

We investigated extranodal connective tissue involvement (ECTI) in 39 patients with oesophageal carcinoma. Both the primary tumour and ECTI were immunohistochemically examined using the monoclonal antibody 32-2B for desmosomal glycoprotein 1 (DG1). Connective tissue carcinoma deposits were identified as cells within small lymph nodes, as lymphatic or venous vessel invasion or as widespread invasion beyond the capsule of metastatic lymph nodes. These histological findings were present in at least one area in 20 of 39 patients (51.3%). DG1 immunostaining intensity by tumour was graded as DG1 (++), DG1 (+) or DG1 (-). DG1 (+) or DG1 (-) primary tumours demonstrated lymph node metastases and ECTI more frequently than DG1(++) tumours (P