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We describe life-threatening vasculitis of the small bowel following fulminant hepatitis. A 35-year-old man was admitted to our hospital due to consciousness disturbance and jaundice. He was diagnosed with fulminant hepatitis, and recovered after intensive medical care that included corticosteroid administration and artificial liver support. During reduction of the dosage of steroid, massive gastrointestinal hemorrhage occurred from the upper jejunum, revealed by arteriography. The hemorrhage could not be stopped, so a portion of the ileum, including the bleeding point, was excised. However, the intestinal hemorrhage continued from several small ulcers remaining outside the resected area. Pathological findings revealed an ulcerative region that was diagnosed as cytomegalovirus (CMV) vasculitis. His serum level of CMV (measured by real-time-detection polymerase chain reaction [PCR]) was high. Ganciclovir therapy was started, and manifestations of the CMV infection improved. In addition to CMV, PCR assay for hepatitis A virus (HAV), HBV, HCV, Epstein-Barr virus (EBV), human herpes virus-6 (HHV-6), and herpes simplex virus (HSV) was performed, but no viruses other than CMV were detected. We are the first to report such a case. We conclude that the possibility of CMV enteritis should be considered when patients present with unexplained fever and gastrointestinal hemorrhage following fulminant hepatitis, and we conclude that the early administration of ganciclovir should be considered.

BACKGROUND It has been reported that MUC1 is an important prognostic factor in several cancers. This study investigated the importance of MUC1 as a prognostic factor in mass-forming intrahepatic cholangiocarcinoma (m-ICC). METHODS In 50 patients with m-ICC who had undergone hepatectomy, expression of MUC1 was investigated. Expression of MUC1 was examined by immunohistochemical staining with monoclonal antibody HMPV, which recognizes the MUC1 core peptide. The immunohistochemical staining patterns of MUC1 were classified into three types: ductal type (the luminal surface membrane of neoplastic cells was stained), cytoplasmic type (the cytoplasm of neoplastic cells was stained dominantly), and negative type. RESULTS Expression of MUC1 was detected immunohistochemically in 38 (76%) of 50 cases of m-ICC (ductal type, 18; cytoplasmic type, 20; and negative type, 12). Seventy-five percent of patients with lymph node metastasis had the cytoplasmic type MUC1 expression. Lymph node dissection was performed in only 20 patients, but significant correlation was demonstrated between MUC1 expression and lymph node metastasis (P = 0.0227). The location of MUC1 expression correlated with surgical outcome in m-ICC. Patients with the cytoplasmic type expression showed significantly lower survival rates. Univariate analysis revealed that MUC1 expression was a statistically significant risk factor affecting outcome in m-ICC (P = 0.0028). Furthermore, expression of MUC1 was found to be a statistically significant independent risk factor in multivariate analysis (P = 0.0063). CONCLUSIONS The results suggest that evaluation of MUC1 expression may be very useful in predicting the surgical outcome in m-ICC. Cancer 2002;94:1770–6. © 2002 American Cancer Society. DOI 10.1002/cncr.10398

Background and Objectives Lymph node micrometastasis is frequently detected in resected specimens of esophageal squamous cell carcinoma (ESCC). The goal of this study was to evaluate the clinical implication of micrometastasis in patients with lymph node-negative (pN0) disease. Methods We examined the presence of micrometastasis in 2,511 lymph nodes from 53 patients with pN0 disease who underwent curative esophagectomy. All lymph nodes and the primary tumors were immunostained using an anticytokeratin antibody cocktail (AE1/AE3). Results Micrometastasis was detected in 18 lymph nodes (0.72%) from 14 patients (26.4%). Detection of micrometastasis was not associated with the depth of invasion or the differentiation or lymphatic invasion. Lymph nodes containing micrometastases were widely distributed, but the most frequently involved nodes were located along the lesser curvature of the stomach. Four patients with micrometastasis (29%) and the only two patients without micrometastasis (5%) had recurrence as lymph node metastases (P = 0.036). There were no significant differences in recurrence-free survival and disease-specific survival between patients with micrometastasis and patients without micrometastasis. Conclusions These results show that micrometastasis might increase the risk of lymph node recurrence, but does not influence the survival of patients with pN0 ESCC. J. Surg. Oncol. 2002;79:224–229. © 2002 Wiley-Liss, Inc.

Background: There is a high risk of anastomotic leakage after pancreaticojejunostomy after pancreaticoduodenectomy (PD) in patients with a normal pancreas because of the high degree of exocrine function. These PD are therefore generally performed using a stenting tube (stented method). In recent years, we have performed pancreaticojejunostomy with duct-to-mucosa anastomosis without a stenting tube (nonstented method) and obtained good results. Methods: The point of this technique is to preserve adequate patency of the pancreatic duct by carefully picking up the pancreatic duct wall with a fine atraumatic needle and monofilament thread. The results of end-to-side pancreaticojejunostomy of the normal pancreas were compared between the nonstented method (n = 109) and the stented method (n = 39). Results: There were no differences in background characteristics between the groups, including age, gender and disease. The mean duration to complete pancreaticojejunostomy was 26.6 min in the nonstented group and 29.2 min in the stented group. The mean durations of surgical procedure and intraoperative blood loss were also similar in the groups. Morbidity rates due to early postoperative complications were 20.2 and 23.1%, with pancreatic leakage occurring in 7.3 and 7.7% of patients, respectively. These differences were not statistically significant. One patient in the stented group died of sepsis following leakage of pancreaticojejunostomy. There were also no significant differences in the mean time to initiation of solid food intake or postoperative hospital stay. Conclusion: We conclude that a stenting tube is unnecessary if the duct-to-mucosa anastomosis is completely performed. This operative technique can be considered a basic procedure for pancreaticojejunostomy because of the low risk.

The recurrence rate after surgery in patients with hepatocellular carcinoma (HCC) is very high, while prognosis is quite poor. However, there is no standard treatment to prevent recurrence of HCC after a curative operation. In this study, we investigated the clinical utilization of an autologous tumor lysate-pulsed dendritic cell vaccine plus ex vivo activated T cell transfer (ATVAC) in an adjuvant setting for postoperative HCC as a non-randomized controlled trial. Ninety-four patients with invasive HCC received informed consent information regarding the study, and 42 opted to have the ATVAC after surgery. Their recurrence-free survival (RFS) and overall survival (OS) were measured after 5 years and compared with those of 52 patients who selected to have the curative operation alone. The median RFS and OS were 24.5 months and 97.7 months in the patients receiving adjuvant ATVAC and 12.6 months and 41.0 months in the group receiving surgery alone (P = 0.011 and 0.029). In the treated group, patients with positive delayed-type hypersensitivity (DTH) had a better prognosis (RFS P = 0.019, OS P = 0.025). No adverse events of grade 3 or more were observed. A postoperative dendritic cell vaccine plus activated T cell transfer would be a feasible and effective treatment for preventing recurrence in HCC patients and achieving long-term survival especially in DTH positive patients.

Background: There has been no comparative study of the clinicopathological features of HCC patients who are seropositive for α-fetoprotein (AFP) alone and those who are seropositive for des-γ-carboxy prothrombin (DCP) alone. The authors, thus, performed this comparative study. Methods: The clinicopathological features of patients with solitary hepatocellular carcinoma (HCC), who underwent a hepatectomy were compared among the four below groups according to the seropositivity of AFP and DCP: group A, seronegative for both AFP below 20 ng/mL and DCP below 40 mAU/mL; group B, seropositive for AFP above 100 ng/mL and seronegative for DCP; group C, seronegative for AFP and seropositive for DCP above 100 mAU/mL; and group D, seropositive for both AFP and DCP. Results: Group B patients showed a higher incidence of HCC with an indistinct margin, and a somewhat higher incidence of small HCC less than 2 cm in greatest dimension compared with group C patients. By contrast, group C patients had a higher frequency of HCC with a distinct margin compared with that of an indistinct margin, large tumors more than 3 cm compared with that of small tumors less than 2 cm, and a somewhat higher frequency of moderately to poorly differentiated HCC compared with that of well-differentiated HCC. Our HCC cases showed advanced clinicopathological features in the order of group C, group B and group A. Groups C and D patients showed similar characteristics. Conclusions: Hepatocellular carcinoma patients who were seropositive for AFP alone demonstrated clinicopathological features of less advanced HCC compared with those who were seropositive for DCP alone.

We report a case of living-related partial liver transplantation for decompensated hepatitis B without reactivation of hepatitis B in the following 30 months, and we analyze the factors that indicate a favorable prognosis for transplantation. The 42-year-old female patient received continuously administered lamivudine before transplantation, and hepatitis B virus immunoglobulin (HBIG) from the anhepatic phase to the present. Currently, she shows a normal aminotransferase level and is negative for hepatitis B surface antigen and hepatitis B virus (HBV) DNA by polymerase chain reaction amplification. Sequence analysis was performed. The entire precore/core region and part of the polymerase region of HBV were sequenced by a direct sequencing method after polymerase chain reaction. No specific mutation was found in these regions. These observations show that the key factors in the long-term successful treatment of this patient appear to be the combination therapy of lamivudine and HBIG that the patient received from around the time of the transplantation. Furthermore, the lack of specific mutations, including lamivudine resistant-mutations, is likely to represent an additional factor in the effectiveness of this treatment.

We present a rare case of eight multicentric hepatocellular carcinomas (HCCs) occurring in the same segment of the liver. In a 66-year-old Japanese man, multiple liver tumors were detected during follow-up of chronic hepatitis C infection, and he was admitted to our hospital in 1995. Ultrasonography (US) showed eight tumors, each measuring between 10 and 15 mm in diameter, in the right lobe, and a 10-mm tumor in the left lobe. Angio-ultrasonography (US) showed no enhancement of the tumors, and multicentric occurrence was suspected. Portal angio-US showed eight tumors in the right lobe located in the anterior segment. Accordingly, anterior segmentectomy and partial resection of the S3 subsegment were performed, in December, 1995. On histological examination, all eight tumors in the anterior segment and the tumor in the S3 subsegment were well differentiated HCC. The liver parenchyma showed cirrhosis. The grade and stage of hepatitis did not differ between the anterior segment and the S3 subsegment, but irregular regeneration of hepatocytes was more prominent in the anterior segment. The multicentric occurrence of HCCs in the anterior segment may be related to the more severe damage caused by chronic hepatitis in the anterior segment than in the left lobe of the liver.

1968年から1994年に経験した同時性多発胃癌447例を対象にその特徴と治療について検討した. 多発胃癌の頻度は6.7%であり, 単発胃癌に比べて高齢者, 男性に多く主病巣の特徴は早期癌, 分化型腺癌, 隆起型の割合が高かった. 主病巣と副病巣の関係は早期癌同士, 分化型同士が多く, 同一領域または隣接領域に存在するものが約9割を占めていた. 多発胃癌の副病巣は腫瘍径10mm以下で粘膜内癌の頻度が高く, 術前診断率は40%と低かった. 多発胃癌の進行度別5年生存率は単発胃癌と同程度であり, 残胃の癌の発生頻度 (4.7%) は単発胃癌 (1.7%) と有意差を認めたが, 5%に満たない値であった. 多発胃癌の治療は, 単発胃癌と同様に主病巣の深達度および占居部位に応じた切除範囲, また根治度A, Bを目指したりんぱ郭清でよいと考えられ, 術後, 残胃の厳重なfollow upが重要であると思われた.

腎癌は転移しやすい癌であり,しかも10年以上の年月を経て転移巣が出現するなど,長期経過観察を要する疾患である.肝転移をきたした場合,ほとんどが多発で外科的切除は不能であるが,腎摘後11年を経て単発の肝転移をきたした症例に対し,肝切除術を施行し,術後4年間無再発生存をえた.病理組織学上も原発巣と同じ乳頭状腎細胞癌と診断された.乳頭状腎細胞癌は非乳頭状腎細胞癌に比べ予後良好な疾患であり,肝転移巣に対しても積極的な切除が有効と考えられた.

はじめに: 肝腫瘍に対してグリソン鞘一括処理による系統的肝切除を行うためには, 腫瘍の局在区域を同定することが不可欠である. 今回, 肝細胞癌の術前局在区域診断能について検討した. 方法: 術前診断としてUS, CT, angiographyを施行し, さらにportal angio-echo (以下, PAE) を行った肝細胞癌111結節を対象とした. グリソン鞘一括処理による系統的肝切除の術中所見を正診として, 肝3区域分けを基本とした区域境界を3箇所に設定し, 境界別, 検査別の局在区域診断正診率とPAE誤診例について検討した. 結果: 局在区域診断正診率は, PAEが90.1%で他の検査との間で有意差を認めた. しかしながら, 区域境界別では中区域右区域の下領域境界ではPAEと他の検査間に有意差を認めず, また他のいずれの検査においてもこの境界の正診率が最も低くかった. PAE誤診例は11結節認めたが, 8結節が中区域右区域の下領域境界であった. 考察: portal angio-echoは肝細胞癌局在区域診断に有用である. しかしながら, 中区域右区域の下領域境界診断に関しては中区域切除標本の検討から, 右葉肝門側亜区域を支配するグリソン鞘3次分枝に多くの分岐形態を認めるため, この境界の局在区域診断には注意を払う必要があると思われた.

Background: The pathologic mechanism of idiopathic portal hypertension (IPH) is unknown. Because cytokines and the balance of T helper (h) 1 and Th2 CD4+ T cells have been reported to be important for regulating the immune response, in the present study we investigated the role of cytokines and the distribution of cytokine-producing cells in IPH patients. Methods: Serum levels of tumor necrosis factor (TNF)-α, soluble TNF receptor-I, -II, interferon (IFN)-γ and interleukin (IL)-4 were measured in IPH patients, fatty liver patients, chronic hepatitis patients and control subjects. The percentages of Th0, Th1 and Th2 CD4+ T cells were examined in peripheral and spleen lymphocytes in IPH patients by intracellular staining. Results: Serum levels of TNF-α, soluble TNF receptor-I, interferon-γ and IL-4 of IPH patients were not increased in comparison with control subjects. Only the mean value of soluble TNF receptor-II was significantly higher than that of control subjects and fatty liver patients. The ratios of Th1 and Th2 in both peripheral and spleen lymphocytes of IPH patients were significantly increased compared with the ratios found in peripheral lymphocytes of control subjects. The increase in the ratios was due to a decrease in the percentage of Th2 CD4+ T cells. Conclusions: These results suggest that the imbalance of Th1 and Th2 CD4+ T cells and TNF may be associated with the pathogenesis of IPH.

In 115 patients (68 with liver cirrhosis and 47 without) who underwent curative resection of hepatocellular carcinoma (HCC) caused by hepatitis C virus (HCV)-related chronic liver diseases, we separated the liver into three segments (right, middle, and left) according to the three secondary branches of the Glissonean pedicle. We examined the weight of each resected segment. We also examined the histological findings of the segments in the same liver in 24 other patients with HCV-related chronic liver diseases. The average weight of the segments did not vary significantly in patients without liver cirrhosis. However, the average weight of the segments was significantly different in patients with liver cirrhosis (P = 0.0414) and the weight of the middle segment was lower than that of the other segments. In another group, of 246 patients with curative resection of HCC, of the 90 patients with single nodular HCCs, 45 nodules (50%) were located in the middle segment (P = 0.0004); in the 156 pa-tients with synchronous multicentric HCCs (total, 401 nodules), 220 nodules (54.9%) were located in the middle segment. In 74 of the 156 patients with synchronous multicentric HCCs (47.4%), the HCCs were located in the same segment. The grade, stage of hepatitis, and number of sites of irregular regeneration were significantly different in each segment (P < 0.05), and the middle segment had more advanced hepatitis than the other segments. The rate of occurrence of HCC in the middle segment was higher than that in the other segments. The difference among the segments of the liver in regard to the degree of damage done by hepatitis may be related to the differences in HCC occurrence among the liver segments.

Background. Chemotherapy is an important component of the multimodal approach to the treatment of advanced esophageal squamous cell carcinoma. Methods. We investigated the associations between p53, p21 (Waf1), bcl-2, and bax expression and response to chemotherapy (cisplatin + 5-fluorouracil + leucovorin) in 43 patients with advanced esophageal squamous cell carcinoma. The expression of p53, p21 (Waf1), bcl-2, and bax proteins was analyzed immunohistologically in pretreatment biopsy and post-treatment resected specimens. Results. The 23 patients who had objective evidence of either a complete response (CR) or a partial response (PR) to chemotherapy survived for significantly longer than the 20 patients who had no response (NR). The expression of p53, p21 (Waf1), bcl-2, and bax was detected in 26 (61%), 12 (28%), 6 (14%), and 19 (44%) of the pretreatment biopsy specimens, respectively. The response to chemotherapy was not independently associated with the expression of any of these proteins. However, in the 26 patients with p53-expressing tumors, the response rate was 80% in patients whose tumor also expressed p21, whereas it was 19% in those whose tumor did not coexpress p21. No change in p53 expression was observed before and after chemotherapy, except in 1 patient; however, p21 expression appeared to be induced by chemotherapy in 5 patients. Patient survival was also not independently associated with the expression of any of these proteins. However, patients with p53-negative or p21-positive tumors had a better response to chemotherapy and survived for longer than those with p53-positive and p21-negative tumors. Conclusion. p53 and p21 expression in biopsy specimens obtained before chemotherapy could be useful predictors of response and survival in patients with advanced esophageal squamous cell carcinoma.

BACKGROUND Des-γ-carboxy prothrombin (DCP) is an established marker for hepatocellular carcinoma (HCC), but the conventional enzyme immunoassay (EIA) kit lacks adequate sensitivity. Thus, a revised EIA kit with increased sensitivity has been developed. In this kit, the sensitivity has increased while high specificity to HCC has been maintained. The authors have already reported the clinical usefulness of this revised EIA kit. In this study, they examined the serum levels of DCP measured by this revised EIA kit in relation to the clinicopathologic features of solitary HCC. METHODS Fifty-six patients with solitary HCC who underwent hepatectomy were studied. The relation between the greatest dimension and the histologic differentiation of HCC was investigated in these 56 patients, as were the serum levels of DCP measured by the revised EIA kit (Sensitive DCP), α-fetoprotein (AFP), and DCP measured by the conventional EIA kit (DCP). The cutoff value for Sensitive DCP was set at 40 mAU/mL, and the values for AFP and DCP were 20 ng/mL and 100 mAU/mL (0.1 AU/mL), respectively. RESULTS The positivity rates for Sensitive DCP, AFP, and DCP (n = 56) were 53.6%, 53.6%, and 35.7%, respectively, and the rate was 73.2% when Sensitive DCP was used in combination with AFP (Sensitive DCP + AFP). The positivity rates for these markers were as follows: 1) When the greatest dimension of HCC was more than 3 cm (n = 16) and less than 2 cm (n = 23), the rates were 81.3% and 30.4% for Sensitive DCP, 68.8% and 39.1% for AFP, 56.3% and 13.0% for DCP, and 93.8% and 56.5% for Sensitive DCP + AFP. 2) When HCC was moderately to poorly differentiated (n = 41) and well differentiated (n = 15), the rates were 68.3% and 13.3% for Sensitive DCP, 61.0% and 33.3% for AFP, 48.8% and 0% for DCP, and 85.4% and 40% for Sensitive DCP + AFP. 3) When HCC was either more than 3 cm or moderately to poorly differentiated (n = 42) and either less than 2 cm or well differentiated (n = 27), the rates were 69.0% and 29.6% for Sensitive DCP, 61.9% and 37.0% for AFP, 47.6% and 11.1% for DCP, and 85.7% and 51.9% for Sensitive DCP + AFP. CONCLUSIONS DCP measured by the revised EIA kit with increased sensitivity has a stronger correlation than AFP with size and histologic differentiation of HCC. This Sensitive DCP is a very useful marker for HCC and should be used in combination with AFP. Cancer 2000;88:544–9. © 2000 American Cancer Society.

経皮的マイクロ波凝固療法 (PMCT) を施行した肝細胞癌273結節200症例を対象とし, 遺残率と局所再発率を腫瘍側因子の腫瘍径と治療側因子のapproachから比較し, 腫瘍増大例と合併症も加えてPMCTの適応を検討した. 腫瘍径別では20mm未満で良好な結果を得た. approach別では全身麻酔下が局所麻酔下より効果的であった. 腫瘍増大例は9例で全例半年以内に平均腫瘍径が23.1mmから53.3mmとなり, 広範囲門脈腫瘍栓を7例に, 塊状発育を5例に認めた. 追加治療奏功例はTAEの1例のみであった. 重篤な合併症の門脈出血, 胃壁腸管損傷は局所麻酔下に多く, グリソン鞘2次分枝近傍腫瘍に胆管狭窄を認めた. 肝細胞癌に対するPMCTは腫瘍径20mm未満がよい適応で, 局在部位が肝門部や肝表面で消化管と接する部位では特に注意を払う必要がある. また全身麻酔下では効果的な局所治療と合併症の回避が可能であり, 初回治療時に確実な完全凝固治療を目指すことが重要と思われた.

We report two cases of hepatic infraction after percutaneous microwave coagulation therapy (PMCT) for hepatocellular carcinoma.(Case 1) A 58-year-old man was diagnosed recurrence tumor 2.5 cm in diameter after right lobectomy. TAE was no effectiveness, and we performed PMCT under general anesthesia. After treatment, the patient had a high fever and a high AST/ALT level of 1779/1360 IU/L.(Case 2) A 69-year-old man was diagnosed multiple recurrence tumor after right lobectomy. We performed TAE and PMCT under general anesthesia for 15 mm (S4), 12 mm (S3) and 11 mm (S3) in diameter. After treatment, the patients had a high fever and a high AST/ALT level of 712/428 IU/L. In patients, CT scan revealed hepatic infraction in the proximal liver area.The patients had a high fever and a high AST/ALT level, but discharged into the 10 days after PMCT.

高分化型肝細胞癌切除71例を腫瘍最大径により大型12例 (3cm超) と小型59例 (3cm以下) に分け, 臨床病理像を比較検討した. 背景では年齢, 性, 肝炎の罹患率に差は認められなかった. 大型は肝硬変の併存率が有意に少なく (P=0.0329), AFP20ng/ml以下の症例が多く (P=0.0254), 血管造影では全例腫瘍濃染像を認めた (P

Postoperative complications were investigated in 72 patients who received neoadjuvant therapy with esophagectomy. Preoperative chemotherapy consisted of 5-fluorouracil (700 mg/m2/day, on days 1 to 5), cisplatinum (70 mg/m2/day, on day 1), and leucovorin (20 mg/m2/day, on days 1 to 5). Preoperative chemoradiotherapy consisted of cisplatinum combined chemotherapy and radiotherapy (total dosage of 30–70 Gy). The incidence of postoperative pneumonia (16%) and anastomotic leakage (24%) in the preoperative chemotherapy group was slightly higher than that in the control group (n = 506), and mortality (6.0%) after esophagectomy in the preoperative chemotherapy group was higher than that (2.4%) of the control group. Postoperative morbidity and mortality were observed more frequently in patients who received two cycles of the chemotherapy than those receiving only one cycle. Postoperative complications occurred more frequently in patients suffering high grade toxicities due to the preoperative chemotherapy. The highest preoperative serum creatinine value correlated to that of postoperative period (r = 0.6494). The use of the preoperative chemoradiotherapy with a total exposure dosage of 60 Gy or more significantly increased the postoperative pneumonia rate (67%; p < 0.05) compared to the group receiving 40 Gy or less. The mortality rate (33%) also increased. The second cycle of the preoperative chemotherapy should be cancelled if patients suffer high grade toxicities during or after the first cycle, and the total exposure dosage of the preoperative chemoradio-therapy should be limited to 40 Gy or less.

Background: Lymph node metastasis is a significant prognostic factor in intrahepatic cholangiocarcinoma. This study was aimed at investigating lymph node metastasis in intrahepatic cholangiocarcinoma and to examine whether the extent of metastasis affects outcomes after surgery. Methods: From 1980 through 1996, 70 patients with intrahepatic cholangiocarcinoma underwent hepatectomy, with a 50% curative resection rate. Lymph node dissection was performed in 51 patients, and the presence of lymph node metastasis was examined microscopically. The metastatic nodes were divided into groups N1, N2 or N3 using the classification proposed by the Liver Cancer Study Group of Japan. Results: Twenty-three patients had lymph node metastasis. Metastasis was to N1 nodes in 10 patients, to N2 nodes in nine patients and to N3 nodes in four patients. Nineteen patients had metastatic nodes in the hepatoduodenal ligament, which was the most common metastatic site regardless of tumor location. The five-year survival rate in patients with lymph node metastasis (0%) was significantly lower (p < 0.0001) than that in patients without lymph node metastasis (51%); however, five-year survival rates did not differ between patients with metastases to N1, N2 and N3 nodes. Conclusions: Lymph nodes in the hepatoduodenal ligament may be sentinel nodes for intrahepatic cholangiocarcinoma, and outcomes after surgery for patients with lymph node metastasis are poor regardless of the sites of nodal metastasis.

The relationship between aplastic anemia and viral hepatitis is well recognized, and such patients usually have a high mortality. We successfully treated a case of aplastic anemia following living-related orthotopic liver transplantation (LROLT) for non-A, non-B, non-C hepatitis. A 2-yr-old boy with fulminant hepatic failure from non-A, non-B, non-C hepatitis received LROLT. Before transplantation, he had pancytopenia which was probably hepatitis associated, and viral suppression was suspected after bone marrow (BM) biopsy. After the transplantation, he developed progressive pancytopenia and a diagnosis of aplastic anemia was made via BM biopsy. With immunosuppressant agents (cyclosporine, methylprednisolone), cytokine therapy (granulocyte-colony stimulating factor (G-CSF), macrophage-colony stimulating factor (M-CSF), recombinant human erythropoietin (rhEPO)) was effectual and the patient recovered from pancytopenia. He was discharged from the hospital 57 d after the liver transplantation and remains well 1 yr after LROLT. Combined cytokine therapy with high doses of G-CSF, M-CSF and rhEPO appeared to be effective in the treatment of aplastic anemia following liver transplantation for non-A, non-B, non-C hepatitis. Since M-CSF activates macrophages, it may have contributed to the graft rejection. Careful consideration should be given to the use of high-dose M-CSF in liver transplant patients.

肝細胞癌129結節 (初回治療75結節, 切除後再発54結節) を対象とし, 血管造影所見および腫瘍径とTAEによる治療効果の関係を検討した. 血管造影所見としては, 腫瘍と非腫瘍の境界 (明瞭, 不明瞭), 腫瘍濃染の均一性 (均一, 不均一), 腫瘍濃染の程度 (強, 弱) について行い, TAE後1年経過後もviable lesionの出現を認めない結節を完全壊死結節とした. 完全壊死率は境界明瞭結節で61%, 均一濃染結節で57%, 強濃染結節で40%と有意に良好であり, 腫瘍径別検討では初回例では20mm～30mm, 再発例では10mm～20mmの腫瘍径において治療効果は最も良好だった. また, 境界明瞭, 均一濃染, 強濃染を示す結節の頻度は, 再発例において高く, 初回例では20%, 再発例では41%が完全壊死となり再発例の方が総じて治療成績は良好だった. 血管造影所見と腫瘍径を考慮して適応症例を選べばTAEの治療成績の向上が期待できる.

1996年までに切除した浸潤性膵管癌438例のうち, 5年以上長期生存した長期生存群17例と, 根治度A, B がえられたものの1年未満で癌再発死亡した早期 (再発) 死亡群29例を対象とし, 膵後方浸潤 (rp) の有無別に組織学的所見, 術式, 再発様式, quality of life (QOL) について比較検討した. rp (-) 例では, PL郭清を伴うD1+αが多かったが, ともに, 膵外神経叢浸潤 (p1) は陰性で, 長期生存群でりんぱ節転移n (+) が33%と少なかった. 早期 (再発) 死亡群では肝転移が75%であった. rp (+) 例では, PL郭清を伴うD1+αまたはD2が行われ, 長期生存群でn (+) が38%と少なく, 乳頭腺癌や高分化型管状腺癌が75%と多かった. 早期 (再発) 死亡群では肝転移, 後腹膜再発が68%, 40%で, 再発に伴うQOLの低下がみられた. 以上より, rp (-) 例ではD1+α以下の術式と効果的な肝転移対策, rp (+) 例ではPL郭清を伴うD2と局所制御のための補助療法, 効果的な肝転移対策が膵癌長期生存には必要と考えられた.

過去10年間の大腸sm癌外科切除104例の中で, 6例(5.8%)に術後転移再発を認めた. 局所・リンパ節再発は4例で, 直腸3例, 下行結腸1例であった. 組織型は中分化腺癌が3例, 高分化腺癌が1例で, 4例中3例はリンパ節転移陽性, 全例リンパ管侵襲陽性であり, 壁深達度細分類ではsm3であった. 3例に再切除を行い, 2例生存中である. 肝再発は2例で, 横行結腸1例, 上行結腸1例であった. 2例とも単発肝再発であり, 血中CEA値の上昇で, 肝再発を指摘しえ, 肝部分切除後無再発生存中である. 大腸sm癌の初回手術時の病理所見で中分化腺癌, リンパ節転移陽性例, リンパ管侵襲陽性例は, 局所・リンパ節再発のhigh risk groupとして, より入念な経過観察が必要である. 肝再発の予測は困難であるが, 肝転移を念頭においた術後の経過観察が重要であると思われた.

症例は58歳, 女性. B型慢性肝炎の経過観察中に肝細胞癌を指摘された. 他医にて肝動脈塞栓術および動注ポート挿入による化学療法を施行するも, 腫瘍壊死効果が得られず増大傾向を認めたため当院入院となった. 画像診断にてS5とS8に直径35mmと20mmの病巣を認めた. 患者が開腹治療を拒否したため経皮的マイクロウェーブ凝固壊死療法 (PMCT) を施行した. PMCT後の腹部CTでは腫瘍は早期相平行相とも低吸収領域となり凝固壊死と判断した. しかしPMCT後7カ月目の腹部CTにて, 急激に塊状発育した局所再発巣を認めたため, 右葉切除術を施行した. 病理組織所見ではtrabecular～tubular typeの低分化型肝細胞癌でvv2, vp1, b0, tw0, im2であった. しかしながら術後5カ月目に多発残肝再発と腹膜播種, リンパ節再発により死亡された. PMCTは肝癌の局所治療として有効であるがときに不充分な治療から腫瘍の急激な進展を示す場合もあり, 示唆に富む症例と考え報告した.

In 177 patients with hepatic tumor (245 nodules) undergoing percutaneous microwave coagulation therapy (PMCT), tumor persistence and local recurrence were compared with regard to tumor size and the method of treatment in order to identify suitable candidates for PMCT. Tumors measuring less than 20 mm in diameter showed a good response to PMCT. And the therapy was more effective under general anesthesia than under local anesthesia. PMCT is best indicated for tumors less than 20 mm in diameter. And under general anesthesia, effective local treatment are possible. Therefore, it seems important to achieve reliable and complete coagulation at the initial treatment session.

We experienced a case of solitary splenic metastasis after hepatectomy for hepatocelluler carcinoma. The case was a 69-years-old female without liver cirrhosis or hepatitis. She underwent “so called Right Liver Trisegmentectomy” for large hepatic tumor on November 16, 1993. Pathological findings revealed trabecular type moderately differentiated hepatocellular carcinoma. fc (+), fc-inf (+), Vp0, Vv0, b0, tw (-), im 1. Seven months later, we observed multiple liver metastasis and a low density splenic tumor of 2cm diameter by computed tomography. We perfomed Trans arterial embolization on the liver metastasis, but the splenic tumor had enlaged to 4cm diameter. We diagnosed the splenic tumor as metastasis of hepatocellular carcinoma. She underwent splenectomy on March 20, 1995. Before and during the operation, we found other evidence of metastatic tumors except for those detected in the liver and spleen. Immunological competence levels were within the normal range. There had been 8 cases of solitary splenic metastasis of hepatocellular carcinoma reported in Japan, and only 2 were resected.

膵頭部癌に対する全胃幽門輪温存膵頭十二指腸切除 (PpPD) の適応を, 十二指腸第1部または胃への癌の直接浸潤を認めず, 胃周囲リンパ節 ((3), (4), (5), (6), (7)) への転移を認めないこととした1989年以降の膵頭部浸潤性膵管癌切除例154例を対象に, PpPD66例と胃切除を伴う膵頭十二指腸切除 (胃切除PD) 88例の2群に分け, 比較検討した. 拡大手術は, ともに約80%に安全に行われ, 進行度, 根治度もPpPDと胃切除PDで差はなかった. 5生率, 平均生存期間もともに差はなく, PpPDでおのおの, 35%, 15.0か月であった. 再発様式はともに後腹膜再発, 肝転移が多くを占め, PpPDで胃周囲リンパ節再発例はなかった. Performance, Statusと体重変動からみた術後のQuality of Life (QOL) もPpPDと胃切除PDに差はなく良好であった. 以上より, 上記の適応基準を用いれば, 根治性, 安全性, 術後QOLを損なうことなく, 膵頭部癌に対する基本術式としてPpPDを導入できると考えられた.

胸部食道癌の占居部位別, 深達度別至適リンパ節郭清領域を転移頻度や治療成績などを考慮して検討した. 頸部郭清は, n (+) のIm例で上縦隔リンパ節転移が無い症例のみで有効 (p

症例は71歳の男性. 1983年 (60歳), 他医にて肝後区域の門脈腫瘍栓を有する径5.5cmの肝細胞癌に対し動注化学療法が施行され腫瘍は消失た. 1991年 (68歳), 肝前区域に肝癌再発. 胆管細胞癌の術前診断で肝右葉切除が施行された. 径3.5cmの肝細胞癌 (低分化型, 索状型) と, 径3.0cmの胆管細胞癌 (中分化型管状腺癌) が衝突する肉眼像を呈し, 混合型肝癌 (combined type) と診断された. 1994年 (71歳), 術後3年目, 左頸部に径6.0cmのリンパ節転移が発見され頸部リンパ節摘出術が施行された. リンパ節の組織所見は索状および管状に増殖する腺癌で組織学的および免疫組織学的所見より胆管細胞癌からのリンパ節転移と診断された. 臨床的にはその他の部位への再発は見られず, 混合型肝癌術後左頸部リンパ節にのみ転移再発した症例と考えられた.

Intrahepatic metastasis via the portal venous system and bloodborne distant metastasis are common in hepatocellular carcinoma. However, lymph node metastasis after resection of hepatocellularcarcinoma is rare. and recurrence of lymph node metastasis after surgical resection is also rare. On the other hand, detection of lymph node metastasis has been reported in about 30% of autopsy cases. We carried out this clinicopathological study to assess patients positive for lymph node metastasis among those who underwent surgical resection of hepatocellular carcinoma. A total of 951 patients underwent resection of HCC in our department during the period from 1983 to 1995, and 57 of them, the lymph nodes were dissected or the hepatoduodenal liga-ment and superior pancreatic rim alone were sampled intraoperatively because lymph node enlargement was noted during surgery. Histological examination showed lymph node metastasis in 7 patients. The carcinomas were larger than 4cm in diameter in all 7 patients and had invaded other organs in 3 of them. Many metastic lymph nodes were detected in cases 8 and 12. Lymph node metastasis was associated with cirrhosis in one of them. All 7 patients had poorly-differentiated HCC, with extensive interstitial invasion. We analyzed the correlation between lymph node metastasis and levels of carcinoembryonic antigen (CEA), tumor grade and liver tissue. There was a significant correlation between these facters and lymph node metastasis (p

手術治療を行った単発の原発性肝細胞癌534例を対象として術後10年間の生存曲線, 無再発生存曲線を生存分析パラメトリックモデルへ当てはめた. 3年-5年-10年の生存率, 無再発生存率はそれぞれ76-60-34%, 46-32-16%であった. ワイブルモデルあるいは対数ロジスティックモデルが生存曲線, 無再発生存曲線をよく説明することが明らかとなった. 生存曲線に影響を及ぼす有意な因子は術前ICG R15値と腫瘍径であり, 術前ICG R15値が低値で, 腫瘍径の小さなものほど良好な生存率が期待された. 無再発生存曲線については術前ICG R15値, 腫瘍径, 切除区域であり, 術前ICG R15値が低値, 腫瘍径の小さなもの, 切除区域の大きな症例ほど長期の無再発が期待される結果となった. 切除域の拡大は無再発期間の延長に繁がるが, 長期の生存には切除域の拡大は影響せず, 肝機能が良好であることがむしろ重要であり, 切除と肝機能温存のバランスを取ることの重要性が再確認された.

Background and Objectives Survival after surgery for intrahepatic cholangiocarcinoma (ICC) is usually poor. The objective of this study was to investigate whether the gross appearance of ICC indicates postoperative prognosis. Methods Seventy patients with ICC underwent hepatectomy, with a 50% curative resection rate. Tumors were classified according to gross appearance [mass-forming (n = 28), periductal-infiltrating (n = 14), intraductal growth (n = 10), and mass-forming plus periductal-infiltrating (n = 18)], and the presence of lymph node or intrahepatic metastasis was studied microscopically. Results The incidence of positive lymph nodes was significantly higher in the patients with mass-forming plus periductal-infiltrating tumors than in those with intraductal growth tumors (P = 0.0089). The curative resection rate was significantly lower in patients with mass-forming plus periductal-infiltrating tumors than in those with either mass-forming or intraductal growth tumors (P = 0.0001, P = 0.0048, respectively). The 5-year survival rate after surgery in patients with mass-forming plus periductal-infiltrating tumors (0%) was significantly lower than that in patients with mass-forming tumors (39%) or intraductal growth tumors (69%) (P = 0.0036, P = 0.0011, respectively). Multivariate analysis using Cox's hazards model revealed that lymph node metastasis (P = 0.0109) and curative resection (P = 0.0315) were statistically significant independent prognostic factors; however, macroscopic types were not. Conclusions Patients with mass-forming plus periductal-infiltrating ICCs have a poor prognosis; however, the macroscopic types may not be a statistically significant independent prognostic factor. J. Surg. Oncol. 1998;69:162–167. © 1998 Wiley-Liss, Inc.

Background. There is a potentially significant risk to the donor in living-related liver transplantation. Methods. We analyzed surgical risk and stress to 35 donors in living-related liver transplantation with special reference to the types of donor hepatectomy. Donor surgery was performed in one of three ways: (1) lateral segmentectomy without ligation of the middle hepatic vein (MHV) in the remnant liver (group 1, n=21); (2) lateral segmentectomy with ligation of MHV in the remnant liver (group 2, n=6); and (3) left lobectomy with MHV (group 3, n=8). Results. No critical complications were observed in any group. The postoperative enzyme levels in group 2 were significantly higher than those in groups 1 and 3 (P

This study describes the clinicopathologic features of minute intrahepatic cholangiocarcinoma (ICC) and clarifies the relation between minute nodular ICC and hepatitis viral infection.The presence of hepatitis C virus antibody (anti-HCV) and hepatitis B surface antigen (HBsAg) was examined in the serum of 50 patients with ICC who underwent hepatectomy from 1990-1996. The ICCs included 12 minute tumors (3 cm in greatest dimension), 6 of which were nodular type and 6 others were nonnodular type (5 of periductal spreading or infiltrating type and 1 of intraductal type).Of these 50 patients with ICC, 16 (32%) were positive for anti-HCV, 5 (10%) were positive for HBsAg, and 1 (2%) was positive for both. The prevalence of hepatitis viral infection in cases of minute nodular-type tumor (83%; 5 patients positive for anti-HCV) was significantly higher than that in cases of minute nonnodular-type tumor (0%; P0.05). These minute nodular-type tumors were detected during follow-up of patients with chronic hepatitis or cirrhosis. All patients were treated with hepatectomy alone. At last follow-up, 3 patients had been free of disease for5 years after surgery. However, 1 patient died 2 years after surgery because of remnant liver and lymph node recurrence.Minute nodular ICC appears to be related to hepatitis viral infection and could be detected at an early stage, similar to hepatocellular carcinoma, by following up cases of chronic hepatitis or cirrhosis.

We performed endoscopic ultrasonography (EUS) to assess the therapeutic efficacy of thoracic esophageal carcinoma treatment and compared this assessment with that of histology. The subjects were 43 patients who underwent surgical resection following preoperative chemotherapy for advanced thoracic esophageal carcinoma. The region of maximal thickness and the cross-sectional area of the tumor were measured, and the percent reduction was taken to be the degree of reduction. Total assessment of metastatic lymph nodes was made on the basis of the degree of reduction in the major axis and cross-sectional area, and the three elements of morphology, border echo and inner echo. The histological findings were classified into Grades 0 through 3 according to criteria for the management of esophageal carcinoma and compared with the EUS findings. The reduction in tumor thickness was 30% or less in 16 patients, 14 (87.5%) of whom had Grades of 0 to 1. The degree of reduction was greater than 50% in 17 patients, 15 (88.2%) of whom had Grades 2 to 3. The degree of reduction was 60% or greater in eight patients, six (75%) of whom had a Grade of 3. Reduction in the cross-sectional area was less than 50% in 19 patients, 16 (84.2%) of whom had Grades of 0 to 1. Of the 19, all who showed a reduction of 30% or less had Grades of 0 to 1. The reduction in cross-sectional area was greater than 50% in 24 patients, 20 (83.3%) of whom had Grades of 2 to 3. A significant difference was noted in the correlation between reduction in thickness and histological assessment between Grades 0 to 1 and Grade 2 (p

膵動静脈奇形は非常にまれな疾患で, 外科的切除にて根治できた1例を経験したので, 文献的考察を加え報告する. 症例は49歳の男性, 心窩部痛, 背部痛を主訴に当院受診し, 疼痛の増悪を認めたため入院となった. 入院後超音波検査にて膵頭部に低エコー域を認め, ドップラーエコーにて同部に拍動性の速い血流を認めた. MRCPにて総胆管末端の狭窄を認めたため, ERCPを施行し, 胆道出血と総胆管末端の狭窄を確認した. またdynamic CTでは膵頭部に蛇行した血管の増生と同時相の門脈早期濃染を認めた. 腹部血管造影検査では動脈相早期より膵頭部に網状新生血管が描出され, 門脈の早期描出も認めたことから, 膵頭部動静脈奇形と診断し, 疼痛除去と胆管狭窄改善目的に全胃幽門輪温存膵頭十二指腸切除術を施行した.病理標本においても拡張した細動静脈を認めた.術後経過は良好であり, 疼痛も完全に除去することができた.