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A 71-year-old, right-handed woman was admitted to our hospital due to a sudden difficulty with conversation. On admission, she was alert, but had a euphoric mood, disorientation, and a disturbance of recent memory. Her speech was fluent. Her repetition and auditory word cognition were excellent, but she had a slight difficulty with naming visual objects. She frequently showed word-finding difficulty and irrelevant paraphasia during free conversation and a word fluency task. Her irrelevant paraphasia was observed more frequently when she was asked to explain her outbreak of anger at the hospital, i.e., it was situation-dependent. She also had anosognosia. MRI showed an infarct in the territory of the left tuberothalamic artery. Single-photon emission computed tomography revealed low-uptake lesions in the left thalamus and orbital frontal, medial frontal, and medial temporal lobes. The patient was diagnosed with non-aphasic misnaming. The clinical characteristics of patients with non-aphasic misnaming in the literature were reviewed. All of the patients with non-aphasic misnaming had word-finding difficulty and irrelevant paraphasia. Additionally, they had either emotional disturbance or anosognosia.

「とっておきの蔵出し症例」として, 脳血管障害で再帰性発話を呈した症例と, ジャルゴン様発話を呈した重度のアルツハイマー病の症例を報告した。再帰性発話については, その典型例や非典型例の発話記録を通して, 再帰性発話の成立基盤や病態機序について考察した。再帰性発話の背景に重度の失構音, 喚語困難や文構成障害, 自己発話のモニタリング障害があること, 再帰性発話は命題的発話あるいはその代用であり, 右半球仮説には疑義があることを述べた。重度アルツハイマー病の empty speech の背景には, 注意障害, 語彙や概念の不明瞭化などの言語周辺機能の低下とともに, 重度の喚語困難や文構成障害などの純粋な言語機能低下, 語間代に代表される反復傾向などが存在する。そして, 時には新造語ジャルゴンや再帰性発話様の発話も認められるが, 脳血管障害例における典型例とは異なることを指摘した。

Hand-assisted laparoscopic surgery is considered to provide the benefits of laparoscopic surgery in various diseases. However, limited information is available regarding the feasibility of hand-assisted laparoscopic distal gastrectomy (HALDG)-a subset of hand-assisted laparoscopic surgery-as a gastric cancer treatment. This study aimed to evaluate the usefulness of HALDG compared with laparoscopy-assisted distal gastrectomy (LADG). Consecutive patients who underwent HALDG (n=58) or LADG (n=90) for stage I gastric cancer between 2005 and 2016 were eligible. Operative time was significantly shorter and blood loss was significantly higher in HALDG than in LADG (P

An 80-year-old man was transferred to our institution with lower limb edema and worsening dyspnea following the administration of diuretic medication. Transthoracic echocardiography and computed tomography revealed a giant hepatic cyst (176×190 mm) compressing his right atrium and inferior vena cava (IVC). Laparoscopic cyst deroofing combined with omental packing and subsequent tube drainage immediately alleviated all his symptoms. The procedure was uneventful, and he was discharged without any complications on postoperative day 9; he had no recurrent symptoms or hepatic cysts at the postoperative 2-month follow-up. Therefore, a giant hepatic cyst can cause IVC syndrome, and laparoscopic deroofing is a beneficial approach for the treatment of accessible cysts.

OBJECTIVE: This study aimed to examine echolalia and its related symptoms and brain lesions in primary progressive aphasia (PPA). METHODS: Forty-five patients with PPA were included: 19 non-fluent/agrammatic variant PPA (nfvPPA), 5 semantic variant PPA, 7 logopenic variant PPA, and 14 unclassified PPA patients. We detected echolalia in unstructured conversations. An evaluation of language function and the presence of parkinsonism, grasp reflex, imitation behaviour, and disinhibition were assessed. We also measured regional cerebral blood flow (rCBF) using single-photon emission computed tomography. RESULTS: Echolalia was observed in 12 nfvPPA and 2 unclassified PPA patients. All patients showed mitigated echolalia. We compared nfvPPA patients with echolalia (echolalia group) to those without echolalia (non-echolalia group). The median age of the echolalia group was significantly lower than that of the non-echolalia group, and the echolalia group showed a significantly worse auditory comprehension performance than the non-echolalia group. In contrast, the performance of repetition tasks was not different between the two groups. The prevalence of imitation behaviour in the echolalia group was significantly higher than that in the non-echolalia group. The rCBFs in the bilateral pre-supplementary motor area and bilateral middle cingulate cortex in the echolalia group were significantly lower than those in the non-echolalia group. CONCLUSIONS: These findings suggest that echolalia is characteristic of nfvPPA patients with preserved repetition and impaired comprehension. Reduced inhibition of the medial frontal cortex with release activity of the anterior perisylvian area account for the emergence of echolalia.

Agrammatism is one of the core clinical features of non-fluent/agrammatic variant primary progressive aphasia, and it has traditionally been considered the hallmark of non-fluent aphasia in Western countries. However, agrammatic speech may remain undetected in Japanese patients because of the agglutinative structure of the language and high flexibility in word order. In the present study, we aimed to analyze agrammatism in the speech production of Japanese patients with aphasia due to neurodegenerative disease using an anagram test generated by our laboratory. Four patients were recruited from the dementia clinic at Tohoku University Hospital between December 2014 and August 2015: two patients with non-fluent/agrammatic variant primary progressive aphasia, one with semantic variant primary progressive aphasia, and one with probable Alzheimer's disease experiencing episodic memory impairment accompanied by transcortical sensory aphasia. All patients underwent thorough neurological and neuropsychological testing before performing a Japanese anagram task based on the Northwestern Anagram Test. Our findings indicated that the two patients with non-fluent/agrammatic variant primary progressive aphasia exhibited poorer performance on the anagram task than the remaining two patients. Therefore, the anagram test used in the present study may aid in detecting output aspects of agrammatism in Japanese patients with aphasia, although future studies are required to develop a standardized version of test.

Highlights • Proton pump inhibitor (PPI) use is associated with the development of fundic gland polyps (FGPs). • Discontinuing PPI is associated with regression of FGPs, but not in patients with polycythaemia vera. • A rare case of non-respondent FGPs after discontinuing PPI use was successfully treated using APC. • The mechanism involved in the interaction between FGP and polycytheamia vera remains unknown., Introduction Proton pump inhibitor (PPI) use is associated with the development of fundic gland polyps (FGPs); discontinuing PPIs is associated with regression of FGPs. Here, we report a rare case of non-respondent FGPs after discontinuation of PPI that were successfully treated using an argon plasma coagulator (APC). Presentation of case We present the case of a 68-year-old woman with a history of polycytheamia vera. She also had gastroesophageal reflux disease (GERD) and had been taking 10 mg of omeprazole daily for the past three years. Esophagogastroduedenoscopy (GF) revealed over 100 pedunculated polyps in the gastric body and fundus. Histological examination of the specimens showed dilated oxyntic glands with flattened parietal and mucous cells. Based on these findings and the clinical history, a diagnosis of FGPs was made. Omeprazole use was then discontinued. Repeat GF performed 6 months and 1 year later showed a significant increase in the number and size of the polyps. APC treatment was performed every 6 months for 3 years. Further GF showed a significant decrease in the number and size of the FGPs 4 years after discontinuing PPI. Discussion We conclude that PPI use is a strong risk factor for the development of FGPs and discontinuing PPI is associated with regression of FGPs, but not in patients with polycythaemia vera. However, the mechanism involved in the interaction between FGP and polycytheamia vera remains unknown. Conclusion Non-respondent FGPs after discontinuation of PPI use may be successfully treated using APC.

Background and Purpose— Apraxia of speech (AOS) is a motor speech disorder, which is clinically characterized by the combination of phonemic segmental changes and articulatory distortions. AOS has been believed to arise from impairment in motor speech planning/programming and differentiated from both aphasia and dysarthria. The brain regions associated with AOS are still a matter of debate. The aim of this study was to address this issue in a large number of consecutive acute ischemic stroke patients. Methods— We retrospectively studied 136 patients with isolated nonlacunar infarcts in the left middle cerebral artery territory (70.5±12.9 years old, 79 males). In accordance with speech and language assessments, the patients were classified into the following groups: pure form of AOS (pure AOS), AOS with aphasia (AOS-aphasia), and without AOS (non-AOS). Voxel-based lesion–symptom mapping analysis was performed on T2-weighted images or fluid-attenuated inversion recovery images. Using the Liebermeister method, group-wise comparisons were made between the all AOS (pure AOS plus AOS-aphasia) and non-AOS, pure AOS and non-AOS, AOS-aphasia and non-AOS, and pure AOS and AOS-aphasia groups. Results— Of the 136 patients, 22 patients were diagnosed with AOS (7 patients with pure AOS and 15 patients with AOS-aphasia). The voxel-based lesion–symptom mapping analysis demonstrated that the brain regions associated with AOS were centered on the left precentral gyrus. Conclusions— Damage to the left precentral gyrus is associated with AOS in acute to subacute stroke patients, suggesting a role of this brain region in motor speech production.

Key Clinical Message Xanthogranulomatous pyelonephritis (XGP) is an uncommon inflammatory disease of the kidney 1. Diffuse XGP is a rare condition which may spread into the pelvic cavity leading to fatal complications from a psoas muscle abscess and/or renocolic fistula 2. In diffuse type, nephrectomy and excision of the fistula is the recommended treatment.

Highlights • Protein induced by vitamin K absence or antagonist II (PIVKA-II) is a newly recognized tumor marker for hepatocellular carcinoma. • It is proposed that PIVKA-II may be useful primarily as a prognostic biomarker, predicting rapid tumor progression and poorer prognosis. • PIVKA-II-producing colon cancer is an extremely rare subtype of colon cancer., Introduction Protein induced by vitamin K absence/antagonist-II (PIVKA-II) is an abnormal protein, and several reports have demonstrated the efficacy of PIVKA-II in the diagnosis of hepatocellular carcinoma (HCC). We report an extremely rare case of adenocarcinoma of the colon with a high serum PIVKA-II level. Presentation of Case A 95-year-old woman presented with right lower quadrant pain and appetite loss. An abdominal computed tomography scan and ultrasonography showed an ascending colon tumor and multiple metastatic tumors in the liver. The serum level of PIVKA-II was extremely high, 11,900 ng/mL. Colonoscopic examination revealed a tumor accompanied by an ulcer in the ascending colon, which was highly suspicious for malignancy. Multiple biopsies showed well-differentiated adenocarcinoma of the colon, which was evaluated as colon cancer, stage IV. PIVKA-II-productive colon cancer was confirmed. Chemotherapy with TS-1 was administered. The patient died 3 months after initial admission. Discussion The expression of PIVKA-II was detected in non-cancer areas, with non-specific expression observed in plasma cells in our case. There might be some possibility that hepatoid differentiation exists in other regions of the colon tumor or in the liver tumor, parenchymal cells or lung metastases, which were composed of PIVKA-II-positive and AFP-negative cells. Conclusion To the best of our knowledge, high serum levels of PIVKA-II resulting from colon adenocarcinoma have not been reported previously. We report this rare case together with a review of the literature.

Key Clinical Message NOMI is mesenteric hypoperfusion with reactive vascular spasms. Changes in the color of the mucosa may reflect the severity of the ischemia of the colon and the severity of prognosis. Even with surgery, the mortality rate is 75%. Diagnosis requires a high degree of clinical suspicion.

Background Achalasia is a rare disease with a morbidity of 1 in 100,000, for which the exact mechanism of pathogenesis has not been clarified due to the small total number of patients. We herein report on our experience with two cases of familial achalasia in which the involvement of genetic inheritance was suspected. Case presentation These cases consist of a man in his thirties and his mother in her sixties. The son consulted the Department of Gastrointestinal Medicine at our institute with dysphagia, and an upper gastrointestinal endoscopy revealed a gastric submucosal tumor with a maximal diameter of approximately 50 mm. Achalasia was also strongly suspected due to the enlargement of the esophagus to the maximum transverse diameter of 55 mm by esophagography along with delayed clearance of barium. A detailed interview revealed prolonged mild dysphagia in his mother. Therefore, high-resolution manometry was carried out in both patients. As a result, peristaltic disorder was observed in the esophageal body in both the mother and son, leading to a definitive diagnosis of achalasia. For the son, total gastrectomy including the lower esophagus with Roux-en-Y reconstruction was performed. His postoperative course was uneventful, and the patient was discharged from hospital in remission on the 9th day following surgery and is currently undergoing follow-up as an outpatient. Conclusions We hereby report on a very rare case of familial achalasia that we experienced which may suggest a genetic element in the onset of achalasia, and reviewed the literature.

A 78-year-old woman was admitted to another hospital with vomiting. Chest X-ray showed an abnormal shadow in the lower right lung field, and CT indicated a Morgagni hernia containing the stomach and transverse colon. The patient was transferred to our hospital and underwent laparoscopic surgery. After the hernia contents were repositioned into the abdominal cavity, we repaired the hernia orifice with a prosthetic mesh to achieve a tension-free repair. There were no complications after the surgery, and there has been no recurrence. The patient has remained free of clinical symptoms since 10 months after the surgery. Laparoscopic repair with a prosthetic mesh for Morgagni hernia is a simple and safety procedure for elderly patients.

We appreciate the letter by Terao et al1 on our recent publication. The posterior wall of the precentral gyrus corresponds to the primary motor cortex or Brodmann’s area 4 at its mid to dorsal parts and to the premotor cortex or Brodmann’s area 6 at its ventral part. The region associated with apraxia of speech in our study, which …

Rhabdomyolysis associated with fenofibrate monotherapy is extremely rare. Here, we report a rare case of rhabdomyolysis of the psoas muscle in an 82-year-old man with chronic myelogenous leukemia (CML). He was prescribed fenofibrate because of a hypertriglyceridemia. The patient reported generalized muscle pain and right abdominal pain while receiving fenofibrate monotherapy. An abdominal computed tomography scan and an abdominal ultrasound showed a large and low attenuation and high echogenicity, respectively, in the right middle abdominal area. Laboratory values included a serum creatine concentration of 4.1 mg/dl and a creatinine phosphokinase concentration of 5,882 IU/l. During laparotomy, a large hematoma and necrotic mass was identified in the right psoas muscle. Histological examination revealed that the resected specimens were of the psoas muscle with irregular fiber sizes, degenerating fibers surrounding the inflammatory reaction, and fiber necrosis that is typical for polymyositis. Based on these findings and the clinical history, a diagnosis of fenofibrate-induced rhabdomyolysis was made. To the best of our knowledge, no patient has ever been diagnosed with fulminant psoas rhabdomyolysis due to a fenofibrate monotherapy. This report details the rare case of rhabdomyolysis in a patient with CML associated with fenofibrate monotherapy and offers a review of the literature.

Carbohydrate antigen 19-9 (CA 19-9) is a sensitive marker for pancreatic and hepatobiliary malignancies. The highest frequency of elevated serum CA 19-9 levels is found among patients with pancreatic cancer. CA 19-9 has recently been demonstrated to be a marker of digestive tract malignancies. We report the case of a patient with a gastric cancer and a very high serum CA 19-9 level. During laparotomy, a large mass was found in the antrum. A distal gastrectomy with D2 dissection of the lymph nodes was performed. Histological examination, including immunohistochemistry, revealed an adenocarcinoma of the stomach producing CA 19-9. To the best of our knowledge, no patient with an extremely high serum CA 19-9 level resulting from a gastric adenocarcinoma has been reported previously.

The aim of this study was to investigate the association between psychotic symptoms in dementia with Lewy bodies and brain perfusion on single photon emission tomography. Based on factor analysis in 145 patients, psychotic symptoms were classified into five symptom domains (factor 1 to 4-related symptoms and delusions). The relationship between each symptom domain and brain perfusion was assessed in 100 patients with dementia with Lewy bodies, while accounting for the effects of age, sex, dementia severity, parkinsonism and dysphoria. Factor 1 symptoms (Capgras syndrome, phantom boarder, reduplication of person and place and misidentification of person) represented misidentifications, and were significantly related to hypoperfusion in the left hippocampus, insula, ventral striatum and bilateral inferior frontal gyri. Factor 3 symptoms (visual hallucination of person and feeling of presence) represented hallucinations of person and were related to hypoperfusion in the left ventral occipital gyrus and bilateral parietal areas. Delusions of theft and persecution were associated with relative hyperperfusion in the right rostral medial frontal cortex, left medial superior frontal gyrus and bilateral dorsolateral frontal cortices. This study revealed that different psychotic symptoms in dementia with Lewy bodies were associated with distinguishable cerebral networks. Visual hallucinations were related to dysfunction of the parietal and occipital association cortices, misidentifications were related to dysfunction of the limbic-paralimbic structures and delusions were related to dysfunction of the frontal cortices. Our findings provide important insights into the pathophysiological mechanisms underlying psychotic symptoms in dementia with Lewy bodies.

全体的行動の変容である取り繕い反応，代表的な行動心理症状である物盗られ妄想，精神医学と神経心理学の接点ともなっている妄想性人物誤認などを中心に認知症の症候論を論じた。こうした症状は神経ネットワークの障害にだけは帰せられず，困難な状況に直面した患者の全人的反応であり，患者の心理状態を考慮した対応が必要である。神経心理学は認知障害の分析や認知症の疾患診断には必須であるが，認知症をもつ人の「こころ」に寄り添うためには神経心理学的アプローチだけでは限界があることを論じた。

発話開始困難と中断が目立つ非流暢性失語症を呈したが，その他の言語症状は軽微であった症例について，その非流暢性の原因を検討した。症例は83 歳，右利きの女性。左中前頭回後部から中心前回前部にかけての脳梗塞を発症，第１病日はごく軽度の失構音があり，非流暢性が著明であった。語列挙や文の構成障害がなく，発話衝動は保たれ，失構音は速やかに改善したにも関わらず，自由発話における発話開始困難と中断が遷延した。非流暢性発話の二大要因である失構音と言語発動性の低下を欠き，本症例における非流暢性の原因として，前頭葉由来の思考障害，思考の言語化の障害，選択肢が多い場合の語句の選択の困難さが考えられた。本症例の病巣は，多くの典型的 Broca 失語の病巣に含まれることから，本症例の非流暢性発話の原因が，典型的 Broca 失語の非流暢性発話の一因となっていることが予想される。

Aims: To identify the neural correlates of impaired performance in the clock-drawing test (CDT) in patients with dementia with Lewy bodies (DLB). Methods: Cerebral blood flow was measured by single photon emission computed tomography in patients with clinically diagnosed DLB, and was compared between impaired CDT (n = 30) and normal CDT (n = 30) subgroups. Results: DLB patients with impaired CDT performance showed significantly lower cerebral blood flow in the bilateral frontal eye fields, supplementary eye fields, right posterior putamen and the right ventrolateral part of the thalamus relative to the normal CDT subgroup. Performance in other visuospatial/attentional tasks (trail making test part A, copying a cube, semantic fluency, and block design) was also poorer in the impaired CDT group than the normal CDT group. Conclusions: This study indicates that impaired performances on the CDT and some visuospatial/attentional tasks by DLB patients are closely related to dysfunctions of the frontal-subcortical network relevant to control of visuospatial attention and arousal, involving the frontal eye fields, supplementary eye fields and the thalamus. Our findings provide evidence that cognitive performance in DLB reflects the pathological involvement of both cortical and subcortical regions, and suggest that the neurophysiological basis underlying impaired CDT in DLB may be different from that in Alzheimer disease.

乳腺内視鏡手術は内視鏡手術手技により手術創の縮小化と移動を実現し整容性と手術効果の両面を満足させることができる乳房温存手術であり，日本で独自に開発された術式である．各術式は腋窩アプローチ法，傍乳輪アプローチ，外側アプローチ法，乳房下アプローチ法に分類され，それぞれ完全内視鏡手術と内視鏡補助手術が行われている．腫瘍径 2 cm 以上では何らかの乳房の変形が生じるため再建術の併用が必要と思われた．当科では現在セルロース，コラーゲンによる充填法を施行しており良好な成績を得ている．乳腺内視鏡手術は無作為比較試験による直接的証明はされていないものの従来法と同等の手術効果と安全性を持ちかつ整容性の面では優れている事から今後の普及が期待される術式である．しかしその最大の目的である整容性を保持するためには厳格に適応を守り，内視鏡手術特有の合併症について十分な対策を立てておく必要がある．

Objectives: To explore the neural substrates corresponding to the perseverative errors in the Wisconsin Card Sorting Test (WCST). Methods: The study examined the correlations between the WCST performances and the SPECT measurements of regional cerebral blood flow (rCBF) in subjects with neurodegenerative dementia. Negative non-linear correlations between the rCBF and the two different types of the perseverative errors ("stuck-in-set" and "recurrent" perseverative errors) were calculated on a voxel basis and volume-of-interest basis in the mixed groups of 72 elderly and dementia patients. Results: The stuck-in-set perseverative error was associated with the reduced rCBF in the rostrodorsal prefrontal cortex, whereas the recurrent perseverative error was related to the left parietal activity but not to the prefrontal activity. Conclusions: These findings augment evidence that the rostrodorsal prefrontal cortex crucially mediates attentional set shifting, and suggest that the stuck-in-set perseverative errors would be a true pathognomonic sign of frontal dysfunction. Moreover, this study shows that the recurrent perseverative errors may not be associated closely with the prefrontal function, suggesting that this error and the stuck-in-set error should be differentially estimated in the WCST.

An attempt was made to visualize minute intraductal lesions using helical CT in patients with abnormal nipple discharge.Galactography was performed, immediately followed by CT (ductal CT examination). Based on the image data obtained, ductal images were constructed on a workstation using a Pegasus viewer (ductal CT imaging). Since no criteria for diagnosis by this method are available, ductal CT images were diagnosed by reference to the known ductal fiberscopic findings.Ductal CT examination was performed in 10 cases, in 9 of whom ductal CT images were successfully constructed. Pathological examination was performed in 8 cases. It was possible to observe the structure of the luminal surface on the constructed ductoscopic images from all directions, but the color tone or the presence or absence of hemorrhage could not be observed.In the examination for abnormal nipple discharge, ductal CT examination was useful for intraductal observation. Currently, it is a method that allows for observation of the most minute intraductal lesions. However, some issues still remain unresolved. The results of this study suggest that further studies with more cases hold the promise of making ductal CT imaging a useful examination method.

In order to explore the factor structure of a modified version of the Wisconsin Card Sorting Test (mWCST) and to identify the dimensions of deficit in patients with Alzheimer’s disease (AD) and mild cognitive impairment (MCI), conventional mWCST scores in 55 AD patients, 17 MCI patients, and 22 controls were subjected to factor analysis. Three factors, perseveration, inefficient sorting, and nonperseverative error, were obtained. Perseveration score was significantly poorer in both AD and MCI than in controls. By contrast, the MCI group showed significantly poorer scores on the nonperseverative error factor than did the AD patients, and the controls yielded intermediate values between the two patient groups. The perseveration factor was significantly correlated with the other estimates of executive function. This study suggested that the many mWCST scores could be reduced to three major factors, and that the perseveration score may effectively represent an aspect of executive dysfunction in AD and MCI patients.

A 16-year-old girl was operated on for unknown perforation of the transverse colon on May 14th, 1995. Her family has a kindred of familial adenomatous polyposis (FAP), however, she had no polyps of the colon. After the surgical treatment, we adopted unresectable tumors in the mesenterium of the small intestines. A biopsy of the tumors showed fibromatosis (desmoid tumor). In the knowledge that breast cancer as well as desmoid tumor is dependent on hormone, we instituted the same endocrine therapy against the desmoid tumors; goserelin acetate (3.6mg/month), tamoxifen (20mg/day) and fadrozole hydrochloride (2mg/day). We recorded the tumor's fluid degeneration and a decrease in size over an 8 month period. Desmoid tumors are pathologically benign, but locally invasive and said to be recurrent in a high rate after the surgical treatments. We got sufficient response to treat the desmoid tumor by endocrine therapy without severe side effects. Henceforth, endocrine therapy rather than surgery will be one of the strategies against desmoid tumors.

Background/Aim: An angiolipoma is a common benign neoplasm with a characteristic vascular component that occurs in the subcutaneous tissue and rarely in the gastrointestinal tract. We report on a 69-year-old man with a submucosal angiolipoma in the cecum. Methods: This patient was treated with a laparoscopy-assisted ileocecostomy, and a side-to-side anastomosis was performed extracorporeally. Results: A light microscopic study supported the diagnosis of an angiolipoma of the colon. After 5 years of follow-up, the patient has no symptoms or signs of recurrence. Conclusion: The colonic angiolipoma was successfully removed using a minimally invasive laparoscopic technique.

A 62-year-old woman was found having type A gastritis and multiple carcinoids on the upper body of stomach on an endoscopic study. The patient was associated with bronchial asthma which initiated at the age 60. Urinary 5-HIAA and blood serotonin levels were normal. Each tumor was minite and it appeared possible to resect endoscopically. However, a total gastrectomy was counducted, because of her backgroung factors of type A gastritis and multiple occurrence, and a character of the disease that the tumor can invade the submucosal layer in an early phase. After the operation her asthma disappeared. A possibilty can be considered that the tumor in this patient might be positive for anti-histaminic antibody and bronchial asthma might arise from the tumor. And another possibility was thought that, since the tumor was minute, hypergastrinemia with gastritis type A might stimulate minute endocrine cell foci to provoke histamin production, inducing bronchial asthma. In a review of the Japanese literature as possible as we could, there have been no cases of gastric carcinoid in which associated bronchial asthma disappeared after the operation. This case which was thought valuable is presented here.

心嚢液中に子宮頸部扁平上皮癌細胞が出現することは比較的まれであり, 今回一見すると腺癌細胞と誤りやすい, 球状の集塊を呈して認められた扁平上皮癌細胞の1例を経験したので報告する. 症例は30歳女性. 不正性器出血を主訴として当院を受診し, 子宮頸部擦過細胞診および生検組織診にて子宮頸部扁平上皮癌と診断された. 広汎子宮摘出術後, pT1bN1M0, Stage Ibの病期にて放射線療法および化学療法が施行された. しかし, 術後1年半後に呼吸困難が出現し, 再入院, 心嚢液の貯留が認められ, 血性心嚢液が採取され細胞診検査を実施した. 心嚢液中の細胞所見は, 腺癌との鑑別を要する球状の集塊がみられたが, 球状の集塊を構成する細胞の多くは核中心性の扁平な細胞であり, 同心円状に配列していた. 細胞質縁は厚く, 細胞間橋が明瞭に認められた. PAS染色では, 細胞質が穎粒状に一部びまん性に陽性を呈し, アルシアン青染色は陰性であった. また, 免疫組織学的検索にてケラチン (K-13) 抗体が陽性であった. 以上の所見から, 腫瘍細胞は扁平上皮癌細胞と判定され, 子宮頸癌の心外膜転移と診断された, 再入院から約1ヵ月後に死亡し剖検が施行され扁平上皮癌以外に癌は認められなかった.

われわれは喀痰中に腫瘍細胞が認められた悪性中皮腫の1例を経験した. パパニコロウ染色標本に見出された喀痰中の腫瘍細胞を電顕にて観察し, 悪性中皮腫細胞であることを確診し得た. 症例は, 67歳のアスベスト曝露歴のある男性で, 職場検診にて胸部異常陰影を指摘されて平成6年7月入院し, 胸水貯留が認められ胸水細胞診にて悪性中皮腫が疑われた. 治療により軽快退院したが翌年3月悪化して再入院し, この時喀痰細胞診にて腫瘍細胞が, 平面的で結合性の疎な集団として発見された. 腫瘍細胞はライトグリーン好性の重厚で豊富な細胞質と, 円形で中心性の核を有し, 明瞭な核小体が1ないし2個認められた. 電顕にて腫瘍細胞を観察した結果, 細胞膜表面の長いmicrovilliと核周囲の中間径線維が認められ, 悪性中皮腫細胞と確診された. 死亡時の胸膜穿刺生検から作成された標本では, 線維性結合織中に腫瘍細胞の蜂巣状増殖が認められ, 腫瘍細胞はアルシアン青およびコロイド鉄染色陽性で, ピアルロニダーゼにより消化された. このような所見および免疫組織化学的所見から, 病理組織学的にも悪性中皮腫と診断された.

Among torsions of the omentum, spontaneous torsion of the omentum which is not associated with any organic disease is a relatively rare entity and has been reported in only 39 cases in Japan. Recently we experienced a case of the disease which was definitively diagnosed at laparotomy with a preoperative diagnosis of acute appendicitis. A 45-year-old man was seen at the hospital because of right lower quadrant pain. With a preoperative diagnosis of acute appendicitis, a laparotomy was performed. On laparotomy, it was found that the greater omentum was twisted clockwise by 6 turns. The patient was diagnosed as spontaneous torsion of the omentum, and underwent a resection of necrosed part of the omentum and appendectomy. This disease often presents with a right lower quadrant pain and almost 80% of the cases are diagnosed as appendicitis preoperatively. The usefulness of abdominal ultrasonography and abdominal CT findigns characteristic of the disease in the preoperative diagnosis have been reported. We think that it is not always impossible to make the preoperative diagnosis of spontaneous torsion of the omentum based on those imaging findings. We should entertain the existence of the disease as a possible diagnosis for acute abdomen. This disease has a good prognosis. There has been no report that the disease caused a death.

石灰化上皮腫に穿刺吸引細胞診が施行され, その細胞像を観察する機会をえたので報告する.症例は9歳女児で, 左眉毛の上の結節に気づいていたが増大したように感じられたため, 日之影町国民健康保険病院を受診し, 結節の穿刺吸引細胞診が施行され, 標本が中央微生物検査所に送られてきた.標本を観察した結果, 良性疾患と考えるが組織診の推定は困難であると判定したため, 結節は摘出され, 組織学的に石灰化上皮腫と診断された.細胞診標本上には, 裸核様細胞が結合性の疎な不規則な集団を形成して多数認められ, 核は円ないし類円形で大小不同は軽度であり, クロマチンは細穎粒状で均等に分布し, 明瞭な核小体を有する細胞も存在した.同時に, ライトグリーンで縁どられた, 境界の比較的明瞭な, 無構造で不透明な物質が認められた.組織像と対比した結果, 前者は好塩基性細胞, 後者は陰影細胞であろうと考えられた.

結核予防会大阪府支部では, 平成5年度の老人保健法に基づく肺癌検診で, 6,464件の喀疾細胞診が実施された.その結果, Eと判定された症例8例中, 胸部X線像に異常陰影なしと判定されていた症例は6例あり, そのうち5例は喀疾細胞診で扁平上皮癌と判定されており, 残りの1例が本症例で, 腺癌と判定された.本症例は58歳の女性で, 検診1ヵ月後に精密検査が行われた. 他院で撮影されたCTでは左肺尖部に小結節陰影が認められたが, 肺結核の既往歴があったためそれによる陰影と診断された.同時に行われた喀疾細胞診がやはり陽性であったため, 左上葉の気管支擦過細胞診および気管支肺胞洗浄細胞診が施行されたがいずれも陰性であった. その後, 喀疾細胞診は, ほぼ毎月施行されたが陰性が続いた. 検診から1年7ヵ月後, 喀疾細胞診が再び陽性と判定されたのでCTが施行され, 左肺尖部の病巣は肺癌が疑われた. 気管支擦過細胞診は陽性であり, 手術の結果, 組織学的に高分化乳頭型腺癌と診断された. 組織標本における腫瘍径は15×12mm, 術後病期はpTlN0M0であった.本症例は, 術後16ヵ月の現在も再発の徴候はなく生存中である. 本症例は腺癌の早期発見でも喀疾細胞診が有用であることを示した症例といえる.

自然尿および膀胱洗浄液 (以下洗浄液) 細胞診がともに施行された膀胱の移行上皮癌患者66名のべ81例を対象として, その細胞診成績および細胞所見を比較検討した. 自然尿の陽性例は33例 (40.7%), 洗浄液の陽性例は59例 (72.8%) で, 洗浄液細胞診の方が有意に陽性率が高かった. 洗浄液において, Grade1の膀胱癌8例 (66.7%) およびGrade2の膀胱癌35例 (66.0%), 乳頭状腫瘍の48例 (70.6%) および非乳頭状腫瘍の11例 (84。6%), 浸潤癌の51例 (72.9%) および非浸潤癌の8例 (72.7%), 再発例の29例 (80.6%) がおのおの陽性であった. 他方, 自然尿においてはGrade1の膀胱癌2例 (16.7%) およびGrade2の膀胱癌16例 (30.2%), 乳頭状腫瘍の27例 (39.7%) および非乳頭状腫瘍の6例 (46.1%), 浸潤癌の30例 (42.8%) および非浸潤癌の3例 (27.3%), そして再発例の12例 (33.3%) がおのおの陽性であった. 発育様式をGrade別に分け, 自然尿および洗浄液細胞診の成績を比較すると, 乳頭状浸潤型膀胱癌Grade2において両者の陽性率に有意差が認められた. 細胞所見については, 洗浄液では多数のよく保存された細胞が出現し, また自然尿にみられる細胞より大きく, 核縁は薄く核内構造も明瞭に観察できた.

Background Abnormal cardiac uptake of 123I-metaiodobenzylguanidine (123I-MIBG) is a diagnostic marker of Lewy body diseases (LBDs), e.g., Parkinson’s disease (PD) and dementia with Lewy bodies (DLB). Planar imaging is generally used to assess cardiac sympathetic dysfunction in 123I-MIBG scintigraphy; however, its clinical utility requires further improvement. We hypothesized that the co-registration of single-photon emission tomography (SPECT) and computed tomography (CT) images would improve the diagnostic accuracy of 123I-MIBG cardiac scintigraphy for LBDs. This study sought to evaluate the effects of SPECT/CT imaging on 123I-MIBG cardiac scintigraphy for diagnosing LBDs. Methods We retrospectively investigated data of 54 patients (consecutive 18 patients in each PD, DLB, and idiopathic normal pressure hydrocephalus [iNPH] groups) who underwent 123I-MIBG cardiac scintigraphy (planar and SPECT/CT) because of suspected LBDs at the Tohoku University hospital from June 2012 to June 2015. We compared the diagnostic accuracies of the conventional planar 123I-MIBG method and SPECT/CT methods (manual and semi-automatic). Results In the conventional planar analysis, 123I-MIBG uptake decreased only in the DLB group compared with the iNPH group. In contrast, the SPECT/CT analysis revealed significantly lower 123I-MIBG uptake in both the PD and DLB groups compared with the iNPH group. Furthermore, a receiver operating characteristic analysis revealed that both the manual and semi-automatic SPECT/CT methods were superior to the conventional planar method in differentiating the 3 disorders. Conclusions SPECT/CT 123I-MIBG cardiac scintigraphy can detect mild cardiac sympathetic dysfunction in LDBs. Our results suggest that the SPECT/CT technique improves diagnostic accuracy for LBDs.

大阪肺癌集検研究班では, 1981年より胸部X線撮影と喀痰細胞診による肺癌検診を実施しているが, 1990年までの10年間に, 喀痰細胞診でDあるいはEと判定された症例の, 精検および追跡調査の結果について報告する. 喀痰を提出した高危険群所属者は, 男女合計16,992人で, 有効喀痰は16,795人が提出した. 要精検者は402例, 原発性肺癌患者は28例であり, したがって陽性反応適中率は6.97%となった. 要精検者のうち判定D群は53例で, 発見された肺癌患者は14例, 陽性反応適中率は26.42%であった. 一方, 判定E群は14例で, 発見された肺癌患者は9例, 陽性反応適中率は64.29%であった. 臨床病期1期肺癌の比率は, 判定D群14例中12例85.7%と, 判定E群6例中2例33.3%よりかなり高かった. また, 判定D群14例中10例は喀痰細胞診単独発見例であり, すべて臨床病期1期であった. 肺癌または喉頭癌以外の判定D群37例, 判定E群3例を追跡し, 5年以上追跡しえた判定D群の16例, 判定E群の2例からは肺癌を発見しえず, Eと判定した2例はfalse positiveと考えられた

We report on a patient with a gastric leiomyosarcoma that had a giant cystic component and very high levels of ferritin in serum and cystic content. A 38-year-old man presented with an upper abdominal mass. Upper gastrointestinal series and gastroscopy revealed a submucosal tumor showing central retraction in the upper part of the stomach. Abdominal computed tomography as well as ultrasonography showed the tumor as a huge cyst with multiple septa. Selective arteriography demonstrated a tumor of the stomach. Histological examination suggested a highly malignant leiomyosarcoma, extending beyond the stomach, the serum ferritin level was very high: 307.8 ng/ml in serum and 22,800 ng/ml in the cystic content. This has, to our knowledge, not been reported before.

大阪肺癌集検研究班が, 1981-1990年の10年間に行った肺癌検診において, 高危険群所属者22,753人 (受診者の24.5%) に喀痰容器が配布されたが, 回収率は87.3%, 有効検体率は98.7%であった. 精検は76人 (0.4%) で, 精検受診率は98.7%, 精検完了率は96.0%であった.高危険群所属者で, 喀痰細胞診により発見された肺癌は29人 (中心型扁平上皮癌は21人) で, このうち喀痰細胞診のみによる発見は15人 (中心型扁平上皮癌は13人) であった. 中心型扁平上皮癌の, 経年受診7人中6人, その他の受診14人中9人が臨床病期1期であった.喀痰細胞診により発見された肺癌の切除率は48.3%, 絶対的治癒切除率は27.6%であった. 1981-1983年, 1984-1986年, 1987-1990年の3時期にわけて男性中心型扁平上皮癌の標準化発見比を算出した結果, それぞれ1.595, 1.189および0.680となった.

In order to clarify the relation between cigarette smoking and lung cancer, a case-control study was conducted. The case series consisted of 1,376 lung cancer patients (1,082 males and 294 females) who were newly diagnosed and admitted to eight hospitals in Osaka during 1986-88. Smoking histories were compared with those of 2,230 controls (1,141 males and 1,089 females) admitted to the same hospitals during the same period without established smoking-related diseases. Odds ratios of current smoker versus nonsmoker were 18.1, 1.9, 21.4, and 3.8 for squamous, adeno, small, and large cell carcinoma, respectively, for males, and 9.7, 1.3, 12.1, 3.7, respectively, for females. Compared to the results from previous studies in Japan, the magnitude of the odds ratios for squamous and small cell carcinoma is approaching the level of Western Europe in the late 1970s. Population attributable risk of exsmokers has also been increasing to the level of Western Europe. Among male current smokers, smoking intensity, such as number of cigarettes per day or fraction smoked per cigarette, seemed to have a slightly greater influence on squamous cell carcinoma than adenocarcinoma, while factors associated with the spread of cigarette smoke, such as inhalation, seemed to have greater influence on adenocarcinoma. The difference in the distribution of these smoking characteristics between Japan and Western Europe could not fully explain the difference in lung cancer incidence and distribution of histologic types between the two areas.

Gastric cancer with an extraluminal growth is infrequently encountered. This paper presents a case of gastric cancer with an extraluminal growth directly invading the lateral segment of the liver. A 59-year-old man was admitted to the hospital because of epigastralgia. On physical examination a 10×5cm immovable and elastic-hard mass was palpated in the left upper abdomen. Gastric fluoroscopy and endoscopy revealed an elevated lesion with an irregular surface and gaiant ulcer in the lesser curvature involving from upper to middle body of the stomach. Computerized tomography of the abdomen showed a low density area in the lateral segment of the liver. The serum CEA level was high, 62ng/ml. The pathological finding of biopsy specimen turned out group V. When the abdominal cavity was opened, an extrasgastric tumor developing to the liver was found. Total gastrectomy with lateral segmentectomy (D2 resection) was performed. Pathologically it was extraluminally growing gastric cancer with ulcer which perforated into the liver. There were no lymph node involvement in the resected specimen.

組織学的に甲状腺癌が確認された112例に対する穿刺吸引細胞診の成績は, 陽性94例 (83.9%) であった. これに対し, 触診, 超音波検査, X線検査の診断率は, それぞれ67.9%, 58.6%, 50.0%であり, 穿刺吸引細胞診の成績が最も優れていた. 特に乳頭癌の陽性率は87.1%で, ほかの診断法に比しはるかに優れており, 触診, 超音波検査, X線検査のいずれもが癌の所見を示さず, 穿刺吸引細胞診のみが陽性であった症例が10.9%にみられた.穿刺吸引細胞診が疑陽性あるいは陰性であった症例について標本の再検討を行い, 組織所見と対比した結果, 乳頭癌で細胞判定に問題があったと考えられる症例は4例あり, 1例は核内細胞質封入体と変性空胞との鑑別に困難を感じた例であり, ほかは乳頭癌の特徴的な細胞所見が認められなかった. 組織所見に問題があったと考えられる症例は5例あり, 乳頭癌が濾胞腺腫とともに存在した例, follicular valiantを示した例があり, また腫瘍組織の石灰化の著明な例が3例みられた.濾胞癌の陽性率は25%と低く, 穿刺吸引細胞診による濾胞腺腫との鑑別はきわめて困難であ

Introduction Gastric tumors in patients affected by neurofibromatosis type 1 are usually carcinoids or stromal tumors, and rarely adenocarcinomas. Case presentation We report a case of an adenocarcinoma of the stomach in a 53-year-old Japanese man with neurofibromatosis type 1. An abdominal computed tomography scan and ultrasonography showed tumors in his liver. Gastric fibroscopy revealed a Borrmann type III tumor on his cardia that had spread to his esophagus and was highly suspicious for malignancy. Multiple biopsies showed an adenocarcinoma of the stomach, which was evaluated as gastric cancer, stage IV. Chemotherapy with TS-1 was performed. Our patient died four weeks after initial admission. Histological examination of a liver needle biopsy showed metastatic adenocarcinoma in his liver. Conclusion To the best of our knowledge, high serum levels of α-fetoprotein, carcinoembryonic antigen, and carbohydrate antigen 72-4, resulting from gastric adenocarcinoma, have not been reported previously in a patient with neurofibromatosis type 1. We report this rare case along with a review of the literature.