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症例は59歳，男性．2003年2月，下部直腸癌に対して，術前化学放射線療法を施行した後，同年3月に低位前方切除術を施行した（pStageIIIa）．術後吻合部縫合不全を生じ，人工肛門造設術を施行した．ドレーン抜去部が糞瘻となっていたが自然閉鎖した．縫合不全が画像上認められないことを確認して，2004年5月，人工肛門を閉鎖したところ，2005年4月，左下腹部のドレーン抜去部に直腸皮膚瘻が再燃した．経皮的なフィブリノーゲン注入では閉鎖しないため，経下部消化管内視鏡的にERCP用の造影カテーテルを瘻孔内へ約5cm挿入し，シアノアクリレートを注入した．瘻孔は閉鎖し，3年10カ月後の現在再燃を認めない．特に放射線治療後は，消化管術後縫合不全により生じる瘻孔が難治性となり，治療に難渋することがあるが，本症例では経内視鏡的シアノアクリレート注入が有効と考えられた．

症例1は79歳，男性．CTで胃軸捻転症と診断し，減圧目的に胃管を挿入した．上部消化管内視鏡で胃粘膜の血流障害を認めたため，緊急手術を施行した．胃は腸間膜軸方向に捻転しており，胃全摘術を施行した．症例2は79歳の女性．CTで胃軸捻転症と診断し，減圧目的に胃管を挿入した．上部消化管内視鏡で胃粘膜の虚血性変化は認めなかったが，整復困難であったため，緊急手術を施行した．食道裂孔ヘルニア内に胃の前庭部が捻転を伴い，嵌頓していた．用手的に胃を還納し，捻転を解除した．一般に胃軸捻転症は，CT検査でその診断はほぼ可能である．治療は，胃管を挿入し減圧を図った後，上部消化管内視鏡を実施し，胃粘膜の観察と捻転の解除を試みる．捻転が解除できない場合や，粘膜の血流不全が認められる場合は緊急手術を施行する．胃軸捻転症は比較的まれな疾患であるが，上記の治療アルゴリズムにより，その診断，治療は適切に実施できると思われた．

58歳男性．検診の上部消化管造影検査にて，胃の異常陰影を指摘され当院受診．上部消化管内視鏡検査にて幽門部後壁にIIc病変を認めた．同部位からの生検にて胃癌（低分化腺癌）と診断され当科紹介．術前診断T2(MP)N0M0，StageIBにて幽門側胃切除術を施行した．術後の病理検査所見で索状・敷石状構造を示す部位を認めた．同部はsynaptophysin陽性であり胃小細胞癌と診断された．深達度はSMで早期癌であったが，No.6に2個の微小リンパ節転移を認めた．胃小細胞癌は極めて予後不良であり，早期より脈管侵襲や転移を起こしやすいことが，その一因と考えられている．本症例は早期癌であったが，リンパ節に微小転移をきたしていた．胃小細胞癌においては，早期癌であっても微小転移が存在している可能性が高いと考え，治療することが必要と考える．

症例は65歳，女性．近医で検診目的に腹部エコーを施行．左上腹部に腫瘤を指摘され当院紹介．精査を行ったところ，脾に38mm大の腫瘤を認めた．画像上，確定診断はつかなかったが，明らかな悪性所見はなく，症状もないことから経過観察となった．1年4カ月の経過で，この腫瘤は約60mmと増大傾向を認め悪性腫瘍が否定できず，脾摘出術を施行した．病理検査の結果は脾原発の炎症性偽腫瘍であった．脾原発の炎症性偽腫瘍は稀な疾患であり，画像所見での確定診断は困難である．基本的に予後良好な良性疾患であり，術前に確定診断がつけば，経過観察が可能な例もでてくると思われる．しかし，最近では炎症性偽腫瘍の疾患概念の中には真の腫瘍性病変も併存しているとの報告もあり，術前に確定診断がつかなかったり，悪性が否定できない場合には診断も兼ねた手術も必要と思われる．

目的: 自動縫合器を用いた機能的端端吻合の普及にともない，吻合部再発の報告が増加している．吻合部再発の原因の1つと考えられる腸管内遊離癌細胞の存在について検討した．対象と方法: 2005年11月から2007年8月までに当科で開腹手術を施行した大腸癌67例を対象とした．病変部腸管を摘出後，口側，肛門側腸管内をpovidone-iodine綿球を用いて3回清拭し，その前後で吻合部腸管粘膜面の擦過細胞診を施行した．さらに，2006年10月以降は，癌細胞の術中腸管内散布を防止する目的で開腹直後に癌部の口側，肛門側の腸管を結紮した．細胞診でclass IV, Vとされたものを癌細胞陽性とした．結果: 腸管粘膜面の癌細胞の検出率は，清拭前には口側断端12.5%，肛門側断端21.2%であった．一方，清拭後には，全例がclass Iで癌細胞陰性であった．癌細胞の検出率は，腸管結紮の有無，癌の占居部位，深達度，肉眼型，腸管切除断端までの距離では有意差を認めなかったが，肛門側腸管では，腫瘍径が50mm以上あるいは腫瘍の環周率が80%以上の群で有意に癌細胞が検出される頻度が高かった．術前腸管処置の有無でみると，肛門側では前処置としてニフレック®を服用しなかった群で癌細胞の検出率が高い傾向がみられた．考察: 大腸癌切除時の吻合部再発の原因の1つと考えられる腸管内遊離癌細胞が存在することが明らかとなった．遊離癌細胞が断端腸管粘膜面の清拭により除去された．大腸癌切除時の腸管内腔の清拭は吻合部再発の予防に極めて有用である．

We previously reported that oesophageal squamous cell carcinoma (SCC) had a relatively high incidence of EGFR and HER-2 overexpression. Thus, anti-HER family targeting may become a promising approach to treat oesophageal SCC. In the present study, we investigated (a) the distribution of EGFR and HER-2 expression in oesophageal SCC (n=66) detected by immunohistochemistry and (b) cetuximab- and/or trastuzumab-mediated biological activity (antiproliferative effect by the MTT assay, apoptosis-inducing activity by the annexin V/propidium iodide assay, and antibody-dependent cellular cytotoxicity (ADCC) by the (51)Cr-release assay) against oesophageal SCC cell lines with various levels of EGFR and HER-2. Twelve of the 66 patients (18%) showed both EGFR- and HER-2 expression. Out of both EGFR- and HER-2-positive cases, nine cases (75%) showed EGFR and HER-2 expression in individually distinct regions. Furthermore, the combination of cetuximab and trastuzumab could induce synergistic antiproliferative effects and additional ADCC activities against not all, but several oesophageal SCC cell lines with EGFR and HER-2 expression. The combination of cetuximab and trastuzumab may be useful in the treatment of oesophageal SCC with EGFR and HER-2 expression.

金沢大学医薬保健研究域医学系, 医薬保健研究域・薬学系, This study was conducted to assess the frequencies of protein overexpression and gene amplification of Myc and to identify the mechanisms of Myc gene amplification, especially with regards to its possible coamplification with ERBB2 or EGFR in gastric adenocarcinomas. By immunohistochemical analysis of a total of 300 formalin-fixed and paraffin-embedded gastric adenocarcinomas, the nuclear overexpression of MYC was found in 47 tumors (16%). A fluorescence in situ hybridization (FISH) analysis revealed that nine (19%) of the 47 tumors with protein overexpression had cancer cells with high levels of Myc amplification, whereas only seven (6%) of the 122 tumors without protein overexpression showed high-level Myc gene amplification. Such Myc amplification was significantly correlated with positive nuclear protein overexpression. The coamplification of ERBB2 or EGFR with Myc that was found in six and four cases, respectively, is believed to be non-incidental because those frequencies were significantly higher than the individual frequencies observed for the total examined cases (ERBB2: 7%; EGFR: 4%). The high levels of gene amplification of these three genes, as visualized by FISH, could be broadly classified into two typical types, namely, 'multiple scattered signals' and 'large clustered signals'. Using two-color FISH, the coexistence of coamplified Myc and ERBB2, or Myc and EGFR, within single nuclei in various combinations of amplification types and copy numbers, could be ascertained in all nine cases, including one in which the synchronous 'multiple scattered type' coamplification of Myc and ERBB2 was observed. In three tumors, coamplification of ERBB2 and EGFR was found; however, ERBB2- and EGFR-amplified cell populations were separate and mutually exclusive. We propose that the non-incidental coamplification of Myc and either ERBB2 or EGFR occurred through translocation and subsequent rearrangement. © 2007 USCAP, Inc All rights reserved.

We present a case of simultaneous bilateral spontaneous pneumothorax caused by a pleuro-pleural communication formed from Nuss procedure for pectus excavatum. A 17-year-old man with a history of Nuss operation complained chest pain and dyspnea. A chest roentgenogram demonstrated a tiny bilateral pneumothorax and two metallic bars inserted at the Nuss procedure. Computed tomography revealed furthermore a bulla in the apex of the left lung. The bilateral pneumothorax critically deteriorated after 4 days from onset and urgent bilateral chest drainages were performed. Nevertheless the drainages the full expansion of both lungs was not obtained and air leakage only from left side was continued. A video-assisted left bullectomy was performed 9 days after the tube insertion. The two bars penetrating anterior mediastinal pleura were thought to be a cause of the simultaneous bilateral spontaneous pneumothorax.

Summary Topoisomerase II α (topoII α ) is an enzyme required for DNA replication and a molecular target for drugs called anthracyclines. The topoII α gene ( TOP2A ) is located close to the HER-2/neu oncogene ( HER2 ). We assessed gastric cancers to (1) clarify the relationship between gene amplification and protein overexpression of topoII α and HER2; (2) evaluate the correlation between gene amplification and protein overexpression of topoII α ; and (3) examine the relationship between the results of immunohistochemistry and Western blot analysis for topoII α . In a combined analysis of immunohistochemistry and fluorescence in situ hybridization on 552 formalin-fixed and paraffin-embedded gastric cancer tissues, 38 cases were found to have HER2 amplification. Further examination by fluorescence in situ hybridization revealed amplification of TOP2A in 13 of the 38 cases. No aberrations in the TOP2A gene were observed in cases without HER2 overexpression, except for one containing a gene deletion. The TopoII α protein-labeling index was not correlated with TOP2A amplification. Fluorescence in situ hybridization was performed on nuclear imprint specimens obtained from 9 cases using simultaneous probes for TOP2A , HER2 , and centromere 17. Of these 9 cases, 3 displayed coamplification of TOP2A and HER2 , and only 1 of the 3 cases revealed a high expression of topoII α in Western blot. Although patients having gastric adenocarcinoma with TOP2A amplification could be considered suitable for clinical trials, information involving anthracycline therapy is not firmly understood in regards to the status of TOP2A amplification or protein overexpression. Therefore, results of the current study will provide further insight for the clinical application of anthracycline in gastric cancers.