Search

A 59-year-old woman's father and paternal grandmother died of colorectal cancer and her paternal uncle died of pancreatic cancer. She was positive for fecal occult blood and underwent colonoscopy. The colonoscopy revealed a type 0-Ⅱa+ Ⅱc lesion in the transverse colon suspected to be submucosal deep invasion, and the biopsy revealed poorly differentiated adenocarcinoma. Contrast-enhanced CT showed no regional lymphatic metastasis or distant metastasis. She was diagnosed with transverse colon cancer, T1N0M0, cStage Ⅰ, and laparoscopic partial colectomy and D2 lymphadenectomy were performed. Histopathological examinations showed medullary carcinoma, pT2(MP), Ly1a, V0, BD1, Pn1a, pPM0, pDM0, pN0. She had 2 of the items in the revised Bethesda Guideline, and was suspected of having Lynch syndrome(LS). There is no definitive diagnosis of LS because she did not want MSI or other genetic testing. However, the surveillance should be required not only for recurrence of colon cancer but also for occurrence of LS-related tumors.

The patient was a 57-year-old man. Upper gastrointestinal endoscopy revealed a 0- II c lesion at the anterior wall of the greater curvature in the lower third of the stomach, and the biopsy of this tumor gave the diagnosis of tubular adenocarcinoma. Abdominal contrast-enhanced computed tomography revealed many enlarged regional and non-regional lymph nodes. Because there was no definite evidence of lymph node metastasis, distal gastrectomy with D2 was performed. Histopathological examinations found the sarcoid reaction(SR)in lymph nodes, but could not demonstrate any cancer cells. SR is the epithelioid cell granuloma in lymph nodes found in patients without systemic sarcoidosis but with cancer. Early gastric cancer with SR is rare, with only 22 reported cases in Japan. SR is considered as one of the differential diagnoses when we find many enlarged lymph nodes in patients with early gastric cancer.

症例は25歳の女性で, 下腹部痛, 嘔吐, 発熱を主訴に近医を受診し急性虫垂炎の診断で当院に紹介された. 約1か月間インドに旅行しており帰国直後であった. 来院時下腹部全体に激しい自発痛および圧痛を認めた. 腹部CTと超音波検査で臍方向に向かう腫大した虫垂を認め, 急性虫垂炎と診断し虫垂切除術を施行, 8.5×2.5cmのフランクフルトソーセージ様に発赤腫大した虫垂を認めた. 術後再度腹痛と下痢, 白い膿状の便汁を認め, 39℃台の発熱も続いたため精査を行い腹部CTで上行結腸の著明な壁肥厚, 大腸内視鏡で白苔付着を伴い多発し散在する類円形のびらんと深掘れの潰瘍を認めた. その後, 大腸生検組織および虫垂切除組織から栄養型アメーバが検出されたため, アメーバ性大腸炎と診断しメトロニダゾールの内服を開始した.開始後より解熱し症状も消失した. 海外渡航歴があり急性虫垂炎の症状のある患者では赤痢アメーバなども念頭において原因の検索を行わなくてはいけないと考えられた.

軟骨肉腫のなかで肋骨を原発とするものは約2%と比較的稀である.今回われわれは右第5肋骨に発生した肋骨原発軟骨肉腫の1例を経験したので,文献的考察を加えて報告する.症例は64歳,女性.右乳房の腫瘤を主訴に来院したが,超音波検査で腫瘤は肋骨と連続性があり,細胞診にて軟骨肉腫と診断された.腫瘤を含む広範囲胸壁切除, Marlex meshによる胸壁再建を施行した.術後の病理検査ではGrade Iの軟骨肉腫と診断した.術後16カ月現在,再発の兆候は認めていない.軟骨肉腫の治療は化学療法や放射線療法が無効のため, safety marginを十分にとった広範囲切除が重要であると考えられた.

Dynamic contrast-enhanced magnetic resonance imaging (CE-MRI) has emerged as a promising diagnostic modality in various breast cancer treatments. However, little is known about the correlation between the pattern of time to signal intensity curves (TIC) on the CE-MRI and clinicopathologic features. This study was designed to investigate these correlations and evaluate the predictive value of TIC on CE-MRI in order to identify high-risk patients.Between 2001 and 2003, 101 lesions were evaluated to detect malignancy on CE-MRI in 101 women who were suspected of having breast tumors based on either clinical findings or conventional imaging studies. Moreover, the clinicopathologic findings were compared with the pattern of TIC for the 69 surgically treated malignant lesions.In detecting malignancy, the sensitivity, specificity, and accuracy were 78.7%, 88.5%, and 81.2%, respectively, in the 101 breast lesions. Especially for the 69 surgically treated malignant lesions, in comparison with breast cancer tumors with the benign pattern of TIC, the breast cancer tumors with a malignant pattern were found more frequently in lymphatic invasion (P0.01) and lymph node metastasis (P0.005), although no statistical correlation regarding the histological type, tumor size, vascular invasion, extensive intraductal component, hormone receptor status, or pathological stage was noted between the two groups. According to a logistic regression model, lymph node metastasis was found to be a significant independent variable.The pattern of TIC could be used to predict lymphatic spreading associated with lymph node metastasis prior to surgery as well as to detect malignancy. Therefore, a more detailed evaluation should be made to identify the presence of lymphatic spreading in patients with a malignant pattern of TIC.

SAMは腹部大動脈から分岐する臓器動脈に動脈瘤が多発し,破裂する疾患である.今回われわれは腸間膜出血をきたしたSAMの1例を経験したので報告する.症例は59歳男性.腹痛にて救急外来受診.血液検査では貧血と炎症所見を認め, CTでは腸間膜血腫を認めた.腹部血管造影では上腸間膜動脈分枝に動脈瘤を20個認め,右結腸動脈に破綻した血管像が認められた.活動性の出血所見は認めなかったが,同領域の腸管虚血が疑われた.以上から右結腸動脈瘤破裂により血腫を形成し,また腸管壊死の可能性があると考え緊急手術を施行した.腸間膜に小児頭大の血腫を認め,血腫から流出する腹腔内出血を認めた.腸管に虚血性変化を認め,右半結腸切除を行った.病理所見では腸間膜動脈血管の中膜が変性をきたしておりSAMと診断した.1年経過した現在,再破裂認めず健在である. SAMは急性腹症の鑑別に際し念頭に置くべき疾患であると考えられる.

高分化型脂肪肉腫の亜分類である脱分化型は,高分化型脂肪肉腫の5%以下と稀な組織型である.今回われわれは,後腹膜に発生した巨大な脱分化型脂肪肉腫に対して,手術切除を行った症例を経験したので報告する.症例は58歳,女性. 2004年腰痛にて近医受診し,腹部エコーにて右側腹部に巨大な腫瘤を指摘される.穿刺吸引細胞診にて間葉系悪性腫瘍との診断を得たため,手術切除を施行した.腫瘍は12×16×8.5cm, 1,120gの充実性の腫瘍であったが高度の中心性壊死を示していた.組織所見では,高分化型脂肪肉腫の部分と短紡錘型細胞が目立ち,悪性線維性組織球腫様所見を呈した充実部分とが認められ,脱分化型脂肪肉腫と診断した.脱分化型脂肪肉腫は,他の組織型に比べて予後不良である.治療の第一選択は他の脂肪肉腫と同じく,外科切除となる.化学療法・放射線療法などの補助療法の有効性は定まったものはない.

大腸癌の異時性脾転移の1例を経験した.症例は76歳の男性で, 平成5年4月他院で上行結腸癌に対し結腸右半切除術施行した.平成15年10月近医でCEA高値, 腹部超音波検査にて脾臓に直径10cmの腫瘤を指摘され紹介となった.腹部CTで腫瘤はlow density で, 横隔膜, 左腎臓に浸潤が疑われ, 左腎静脈背側にリンパ節腫脹を認めた.以上より, 大腸癌脾転移を疑い, 平成16年1月脾臓・左腎臓・左副腎摘出術と横隔膜合併切除術を施行した.摘出標本で脾転移巣は高度壊死に陥り, 左腎臓, 左副腎, 横隔膜に直接浸潤し, 組織学的に高分化から中分化腺癌であり, 大腸癌の孤立性脾転移が他臓器に浸潤したと考えられた.大腸癌の孤立性脾転移は非常にまれで, 術後10年目に再発した症例は報告がない.大腸癌術後でも長期フォローが必要で, CEA上昇を来した場合, 再発・転移巣の検索対象に脾臓も考慮にいれるべきと考えられた.

今回われわれは, von Recklinghausen病(以下, R病)に乳癌と褐色細胞腫を合併した1例を経験した.症例は63歳,女性.左乳房のしこりを自覚し近医受診,当院紹介となった.精査の結果,乳癌と診断し手術を予定したが,術前に行った腹部超音波検査で右副腎に腫瘤を認め,また全身の皮膚にcafe au lait spotと軟らかい多発性の腫瘤を認めた.精査の結果, R病に合併した左乳癌と右副腎褐色細胞腫と診断した.褐色細胞腫に起因する高血圧による術中,術後管理のリスクを考慮し,まず褐色細胞腫に対し腹腔鏡下右副腎摘出術を施行後,乳癌に対し左乳房部分切除術を行った.病理組織学的には浸潤性乳管癌でt2n1 (2/8) m0 stage IIB, ER(-), PR(-)であった. R病は悪性腫瘍をしばしば合併するが,上皮性の腫瘍は比較的少ない.文献的考察を加え報告する.

目的)膿胸に対する有茎性大網法につき,有用性,限界を検討する.方法)閉鎖困難な有瘻性症例,大きな腔を有するが十分な筋肉弁を作成困難な症例,菌陰性化しない症例,胸郭成形術を避けたい症例を有茎性大網法の適応とし,有茎性大網法を行った膿胸10例につき,背景因子,術式,術式選択理由,治療成績,腹部合併症を検討した.結果)全例一度治癒退院したが,醸膿胸膜が遺残した2例が,晩期再発した.有瘻性症例,菌陰性化しない症例,腔遺残した症例,一期的手術も成功率が高かった.腹部合併症は軽度であった.結論)瘻孔閉鎖が成功しやすい,非耐性菌であれば菌陰性化を要さない,腔遺残しても治癒率が高いなどの利点から膿胸治療上有茎大網法は成功率が高く有用である.一方,膿胸壁残存症例で晩期再発を認めた.限界を理解した上で適応,治療手順を考え,有茎性大網法を施行することが重要である.

Objective: Contrast-enhanced magnetic resonance imaging (CE-MRI) has emerged as a new diagnostic technology in various breast cancer treatments. However, little is known about the correlationbetweenintraductalspreadonCE-MRIandclinicopathologicfeatures.Thisstudywas designed to evaluate these correlations for the surgical planning of breast cancer. Methods: Twenty-six breast cancer lesions (in 26 female patients) treated by breast conserving surgery between March 2001 and March 2003 were evaluated retrospectively. CE-MRI was performed with a 1.5 T unit using a dedicated bilateral breast coil. Results:In detecting intraductal spread of breast cancer, the sensitivity, specificity and accuracy of CE-MRI were 82.4%, 60.0% and 77.3%, respectively. On mammography (MMG), these were 21.1%, 100.0% and 42.3%, respectively. Therefore, CE-MRI has a higher sensitivity and accuracy, although with a lower specificity than MMG. Compared with breast cancer lesions without intraductal spread on CE-MRI, lesions with intraductal spread on CE-MRI were found more frequently in larger-sized tumors (P = 0.0088). Conclusion: Preoperative evaluation for intraductal spread by CE-MRI should be more useful than by MMG for breast cancer. When making the surgical decision regarding excision range, particular attention should be paid to this consideration for patients with larger-sized cancer tumors.

背景. 比較的稀とされる肺門縦隔リンパ節のみに癌を認め, 原発巣不明な症例を2例経験したので, 本邦報告例66例の検討とともに報告する. 症例. 1例目は68歳, 女性, 右肺門から縦隔リンパ節腫大を認め他部位には異常を認めなかった. 肺門縦隔リンパ節郭清と右肺中下葉切除を施行したが肺内に癌はなくリンパ節の病理組織像は中分化腺癌であった. 術後再発なく4年後他病死した. 2例目は54歳, 男性, 検診で肺門リンパ節腫大を発見されたが他に異常所見を認めなかった. 肺門縦隔リンパ節郭清, 右肺上葉切除を施行し, リンパ節には大細胞癌を認めたが肺内に癌は認めなかった.10ヶ月後縦隔, 胸膜再発をきたし, 術後17ヶ月癌死した. 結論. 原発巣不明肺門縦隔リンパ節転移の2症例に対しリンパ節切除と肺切除を施行した. リンパ節の切除あるいは郭清のみを行い肺切除は不要とする意見も多いが結論はなく, 肺切除の適応は病変の存在部位等により十分なインフォームドコンセントのもとに決定すべきである. 予後は比較的良いとされ, 切除可能であれば切除が第一選択と考えられる.

症例は62歳,女性.近医の血液検査で,貧血を認め, 2000年10月紹介となった.入院時血液検査で著明な貧血と血小板減少および血清CEAの高値を認めた.精査にて, ITPを合併したS状結腸癌と診断した.術前γ-globulin製剤,濃厚血小板を投与し, 2000年10月23日S状結腸切除,脾摘を施行した.術後血小板数は回復したが,その効果は一時的であった. 2001年6月, 2002年5月にプレドニゾロンによるパルス療法を施行したが,その効果は一時的であった.その後プレドニゾロン10mgにて維持療法を施行し,その間血小板数は2×104～6×104/μlを推移した. 2003年11月Helicobacter pyloriに対する除菌療法を施行したところ,治療2カ月後には血小板数, PA IgGは正常化し, ITPに対して除菌療法が著効を示した症例を経験した.今後, ITPを合併した消化器癌患者の治療方針を考える上で貴重な症例と考え文献的考察を加え報告する.

胆嚢原発の内分泌細胞癌は稀であり,確立された有効な治療法のない予後不良の疾患である.今回われわれは, 40歳女性の胆嚢原発内分泌細胞癌症例を経験したので報告する.平成13年12月29日右季肋部痛を主訴に近医に緊急入院した.加療にて胆嚢炎は改善したが,胆嚢頸部に腫瘤残存し,平成14年1月16日当院に紹介された.精査で胆嚢頸部に30mm大の腫瘤,膵胆管合流異常を認め,胆嚢癌の診断にて同年2月6日術中病理でNo.13aリンパ節転移を認めたため肝S4a+S5切除,膵頭十二指腸切除およびD3リンパ節郭清を施行した.腫瘍は胆嚢頸部から体部に存在し,術中迅速病理にて内分泌細胞癌と確定診断された.病理でt3(se), hinf0, binf0, n2(+),免疫組織化学染色chromogranin A(+), synaptophysin (-), EMA(+), NSE(+)であった.集学的な治療が望まれるが,転移病巣の早期発見,慎重な経過観察が必要である.

降下性壊死性縦隔炎(descending necrotizing mediastinitis;以下DNMと略)は重篤化し易く,致命率の高い疾患であり迅速な治療方針の決定が必要である.今回われわれは重篤化したDNMに対し,従来の治療方針に持続縦隔洗浄を加え,救命しえた1例を経験したので報告する.患者は54歳,男性.平成13年5月4日,咽頭痛を主訴に近医受診. 5月7日,胸部X線写真で左膿胸を指摘され,トロッカーを挿入し胸腔ドレナージ術を施行された.しかし同日, DICおよびseptic shock状態を呈したため当院紹介となった. CTで縦隔内に膿瘍があり,気管分岐下から後縦隔下方まで進展していたため,緊急右開胸縦隔ドレナージ,深頸部膿瘍切開ドレナージ術を施行した.縦隔組織の壊死が著明であったため,右開胸で到達可能な範囲にデブリードメントを行った.炎症反応が持続し縦隔に遺残膿瘍をみたため, 5PODより更に両側頸部からトロッカーを縦隔(両側傍気管)に留置し持続縦隔洗浄開始した. 14POD軽快傾向にて持続洗浄中止し, 62POD軽快にて退院となった. DNMは,口腔および咽頭部感染が縦隔に波及して発症する重篤な疾患であり,迅速な診断と適切なドレナージ術が不可欠である.また,低侵襲を追求するあまり不充分なドレナージは致命的となり得るため,術後のドレナージ効果を十分に評価し,効果不十分の場合は,頸部および開胸による縦隔ドレナージを追加することを躊躇すべきではない.更に,持続縦隔洗浄の併用も有用であると思われた.

症例は77歳の女性で,6年前より痔瘻,痔核を指摘されていたが放置していた.難治性痔瘻の診断にて腰椎麻酔下に痔瘻根治術を施行した.瘻孔内に粘液様物質を認め,これを迅速病理診断に提出したところ粘液癌の診断であったため,臨床的に痔瘻癌の診断にて根治術として二期的に全身麻酔下に腹会陰式直腸切断術を施行した.ところが術後病理診断にて痔瘻癌の診断(P, 5, a2, P(-), HO, n(-), M(-)stage II)とともに皮膚切除断端に悪性細胞(Paget cell)陽性であったため,皮膚科にてmappingの上,後日皮膚,皮下脂肪織追加切除を行い根治を得た.慢性炎症を伴う痔瘻は癌の合併に注意が必要である.今回,肛門周囲Paget病に関して,その拡がりの評価にmappingが有用であった.

今回われわれは胃切除術後40年目に発症した腸重積症の1例を経験したので報告する.症例は75歳,男性.突然の腹痛と嘔吐を主訴に近医より当院に絞扼性イレウスの診断で救急搬送された.既往歴として約40年前に胃潰瘍に対して胃切除術(BillrothII法)を受けていた.入院時現症は左上腹部に腫瘤を触知し同部に圧痛,反跳痛,筋性防御を認め,腹部CT検査にてtarget signを認め腸管内に重積腸管の横断面が層状構造を呈して描出された.腸重積と診断,緊急開腹手術を施行した.開腹所見として輸出脚空腸が逆行性にBraun吻合を通り3筒性に重積を起こしていた. Hutchinson手技にて整復するも腸管の色調が悪かったため,空腸切除術を付加した.胃切除術後の腸重積症は稀な疾患であるが,術後の腸閉塞の診断においては本症も念頭におき, CT検査などを有効に用い早期に適切な治療を行う必要があると考えられた.

An 18-year-old Jehovah's Witness injured in a traffic accident developed hypovolemic shock. Total blood loss due to a crushed pelvic fracture and degloving injury of the lower limb was estimated at more than 3, 000ml and the patient's hematocrit fell to 10.8%. The patient refused blood transfusion on religious grounds, virtually ensuring death. Failing to provide blood transfusion involved the following potential problems: i) the truck driver hitting the patient could charged with homicide rather than unintentional infliction of injury, and ii) the hospital could be sued by the patient's family or the truck driver for not providing reasonable treatment. Blood on these considerations, we transfused the patient with 30 units of blood before obtaining consent. The patient recovered uneventfully thanks to the blood transfusion followed by embolization of the iliac artery and surgery. Fortunately, neither the patient nor his family complained about treatment, and even thanked us.

症例は62歳男性.主訴は心窩部痛.精査にて胆嚢結石症と診断された. 23歳時に十二指腸潰瘍に対し幽門側胃切除, Billroth II法再建を施行されていたため内視鏡逆行性膵胆管造影(endoscopic retorograde cholangiopancreatography,以下ERCP)は困難であり胆道系の詳細な情報は術前には得られなかった.手術は,胃切の既往があることを考慮し開腹下に胆嚢摘出術を行った. Calot三角部に胆嚢管,胆嚢動脈が確認されたが,さらに術式をすすめていくうちにそれとは別に胆嚢頸部より肝門部へと走向する索状物が存在した.この索状物より術中造影を行ったところ右肝管根部付近が造影され,肝管と交通があることが確認されたため,重複胆嚢管と確診し,今回は結紮切離した. 胆道系手術に占める重複胆嚢管の割合は0.03%と非常に稀ではあるが,術後胆汁瘻を防ぐため,その存在の可能性を念頭に置き手術操作をすすめていく必要があると思われる.

This study was made to explore correlations of telomerase activity with a variety of biological factors in breast tumors. Telomerase activity was examined using the TRAP assay in 59 breast tumors including 45 breast cancers, eight fibroadenomas, four mastopathies and two phyllodes tumors which were surgically resected between 1996 and 1999. The correlations of telomerase activity with various biological factors such as DNA ploidy pattern and cell cycle phase were investigated. As far breast cancers, clinicopathological findings such as tumor diameter, axillary lymph nodes metastasis, clinical stage, histologic type, and hormone receptors were studied retrospectively in terms of correlation with telomerase. The telomerase activity was significantly higher in breast cancers than in benign tumors (P=0.0108), and correlated with Sphase of cell cycle phase. In breast cancers, the larger in size and the more advanced in clinical stage, telomerase activity was significantly higher, though there were no significant differences in histologic types. And in case of positive lymph nodes metastasis, telomerase activity tended to be higher. These results indicate a possibility that telomerase activity may be one of useful plognostic indicators.

Background and Objectives To improve the survival rate of patients with colon cancer, liver metastases must be eradicated in a clinically occult state. This study was designed to find a predictor for potential liver metastases or micrometastases in colon cancer. Methods Peripheral blood samples and tumor specimens were obtained from 36 patients with colon cancers. The blood samples were subjected to reverse transcriptase-polymerase chain reaction (RT-PCR) analysis, and the expression of sialylated carbohydrates was also investigated in the tumors immunohistochemically. Results A carcinoembryonic antigen (CEA)-specific signal in the blood was detected in 9 of 12 (75%) patients with liver metastasis and in 8 of 24 (33%) patients without liver metastasis, respectively (P < 0.05). The positive rates of sialyl Lewis A (sLeA) and sialyl Lewis X (sLeX) were 36.3% and 40% in tumors without liver metastasis vs. 58.3% and 100% with liver metastasis, respectively. Within a year after surgery, liver metastases became clinically evident in three of the four patients without liver metastasis who showed a CEA-positive signal in their blood preoperatively and who had tumors with a strong expression of sLeX. Conclusions A combination of both markers may provide prognostic information for liver metastases in colon cancer. J. Surg. Oncol. 2000;75:98–102. © 2000 Wiley-Liss, Inc.

Dermatomyositis is one of the auto-immune diseases and is associated with cancer at a high rate. In many cases, upon its detection the cancer is already advanced. Recently we have experienced two cases associated with carcinoma. The first case was associated with a duplicate cancer of the breast and stomach, and in both of them the cancer was early. After a radical operation, the symptoms were made less severe by prescribing steroid, and the prognosis was good. The second case was associated with an advanced cancer of the colon. About two months after the diagnosis of dermatomyosis, a radical operation had been performed and the symptoms had temporarily become less severe and the patient had left the hospital. But they soon recurred and the prognosis was not good. It seems that early detection is very important for improvement of the prognosis and the examination should be made with the possibility of duplicate cancer in mind.

A 41-year-old woman with chronic idiopathic colonic pseudo-obstruction (CICP) underwent partial colectomy two times after various conservative therapies were not entirely effective. Subtotal colectomy including dilated colon reduced the abdominal complaint. CICP is characterized by massive dilatation of the colon without any organic obstruction. The etiology of this disease is unknown and is an isolated condition rather than a part of chronic intestinal pseudo-obstruction (CIIP), in which abnormal motilities appear throughout the entire gastro-intestinal tract. Twenty-nine cases between 1981 and 1997, including our case, were retrospectively reviewed from the Japanese literature. Either total or subtotal colectomy is required when conservative managemant, such as colonic decompression or medical treatment fails.

Mesenteric panniculitis is a rare inflammatory process of mesenteric fat tissue with unknown etiology. Two patients with mesenteric panniculitis are presented. The first patient developed ischemic colitis and mesenteric panniculitis 5 months after descending colectomy and required a sigmoid end-colostomy after several times of non-operative therapies. The second patient presented with small intestinal obstruction with per-sistent leukocytosis resulting in endotoxin septic shock. Despite the benign clinical course and favorable outcome of this disease, careful observation is necessary, because some complications such as ischemic enteritis and septicemia can be critical. Ninety cases of meseoteric panniculitis collected from the Japanese literature. together with two cases from the author's source, are reviewed.

Since most problems in distribution lines are ground faults, the technology to distinguish the causes in the distribution lines will be very useful in preventing faults beforehand or, at least finding any problems at an early stage. The waveforms of ground faults which were collected from data concerning problems in the distribution lines and ground fault experiment are analyzed. The technology which could predict classified groups drawn from the scale of I0 (the waveform of ground fault current) and V0 (the waveform of ground fault voltage), and both of them in the ground faults is studied. The results demonstrated that I0 could be classified into three groups, that is, leaking ground faults are sine curve shaped, gap discharge ground faults are triangular, and intermittent discharge ground faults are needle shaped. Also, simulated equivalent impedance of the causes of ground faults by EMTP is calculated. Furthermore, the influence caused by the condition of the distribution lines is investigated. With these results, a technique is proposed which could predict the cause of problems in ground faults.

Recently sigmoid-visceral fistula which is a candidate for surgical treatment is increasingly encountered, with an increase in the frequency of sigmoidal diverticulitis. In patients complaining of bladder distress and intestinal dysfunction, the early diagnosis with barium enema and cystoscopic examination is important, bearing in mild a possible occurrence of sigmoid-visceral fistula. Careful attitude is mandatory to rule out probable association of malignant disease from the overlapping of the sigmoid colon in barium enema examination and the inflammatory changes in cystoscopic examination. As for the operation, an one stage procedure consisting of resection of the fistula with the bowel is recommended. Partical cystectomy was not necessary in two cases experienced. This paper reports a case of sigmoid-visceral fistula with a review of the literature.

術前に診断困難であった出血性Meckel憩室症例を紹介する.患者は22歳の女性で17歳時より間欠的に原因不明の消化管出血を繰り返していた.その度, 専門施設にて消化管の精査および99mTcphytate腹部スキャン, 99mTcpertechnetate腹部スキャン, 血管造影などの精査が行われたが, 99mTcphytate腹部スキャンにて下腹部に集積像が認められた以外には所見なく, 経過観察を受けていた.1989年8月再度大量下血にて入院.出血部位は特定できなかったが, 出血性Meckel憩室などを疑って開腹術を施行した.回腸末端より50cmの小腸に4×3cmのMeckel憩室を認め, 切除した.異所性組織を持たないMeckel憩室で, 底部近くに輪状潰瘍を伴っていた.若年者で, 繰り返す原因不明の消化管出血では, 99mTc phytate腹部スキャンで下腹部に集積像が認められれば, 出血性Meckel憩室を疑って開腹術を考慮すべきであろう.

Among various tumors of the small intestine which lack in specific clinical manifestations, leiomyomas or leiomyosarcomas often present as melena and anemia as the chief complaints. Six cases of leiomyoma or leiomyosarcoma of the small intestine, including 2 of leiomyosarcoma and 4 of leiomyoma, experienced at our department in a past 6-year period were clinically studied. A close examination of the small intestine is needed for a patient complaining of melena and anemia but revealing no lesion on the upper digestive tract or colon. Angiography can offer valuable informations of the size or site of a tumor; whether it is multiple; invasion into the surrounding tissues; and existence of liver metastasis. Moreover, it will enable to detect such tumors in early stages. When we must determine whether a tumor is benign or malignant, careful attention should be paid not only for a pattern of karyomitosis but also for other factors such as diameter of the tumor. A case having some factors indicating poor prognosis needs a careful follow-up, as well as aggressive treatments, especially for liver metastasis.

A 73-year-old woman was suspected to have gallstone ileus from abdominal simple X-ray film and ultrasonography. Preoperative alimentary examination revealed a cholecystoduodenal fistula, and freeing of the ilues was successfully performed. Gallstone ileus commonly occurs in aged people and we often have difficulties in diagnosis because its ileus condition prevent from sufficient preoperative diagnosing. Abdominal simple X-ray film and ultrasonographic examination are simple methods to offer some convincing holds suspecting the disease. For this disease conservative treatment is first selected, however, the majority of cases demaned surgical operation. Radical treatment for internal biliary fistula is not always necessary if biliary residual stones are not found. In this case which had no residual stones but had high risks, no biliary radical operation was carried out.

Few reports are currently available on the surgical management of bronchiectasis. We report our experience with 8 cases of bronchiectasis. The indications of pulmonary resection were recurrent pneumonia and/or hemoptysis in spite of medical treatment and the extent mainly limited to the unilateral lung. With the exception of one patient, who died from postoperative pneumonia, all patients showed improvement in symptoms. However, in two cases, hemoptysis recurred; these patients had cystic bronchiectasis, Pseudomonas aeruginosa infections and minimal disease in the contralateral lung, which accounted for the recurrence of hemoptysis. A few reports indicated that cystic bronchiectasis and incomplete resection were adverse prognostic factors and that Pseudomonas aeruginosa infections were related to the development of new bronchiectasis. However, according to some other reports, these factors were not adverse prognostic factors. It is thought that the analysis of many cases is required to determine the indication of lung resection and the appropriate type of resection for bronchiectasis; however, it is difficult to conduct randomized control studies. Since the accumulation of case reports is also considered to be important, we report our series of cases.

A 75-year-old woman with Mycobacterium avium complex (MAC) pulmonary disease who had been treated by drug therapy for 7 years was admitted on an emergency basis for hemoptysis. Through the previous 7 years, her sputum cultures had been positive for MAC, and her clinical symptoms and examinations, such as chest X-ray and computed tomography, revealed that her condition had worsened. The lesions spread over the right middle lobe, segment 3 (S3) in the right upper lobe, and segment 6 (S6) in the right lower lobe, however, no lesions were present in the left lung. Since we believed that the disease was localized unilaterally, surgical treatment was selected. The surgical procedures that were employed included right middle lobectomy, right S3 segmentectomy and partial resection of right S6 by thoracoscopy. Sixteen months postoperatively, the sputum culture is negative for MAC. Our procedure enabled the preservation of effective lung function and was successful in controlling MAC pulmonary disease. It is believed that surgery for MAC pulmonary disease should be evaluated in more patients to decide the appropriate surgical indication and procedure.

We encountered a case of occult contralateral breast cancer, previously undetected by conventional imaging such as mammography (MMG) and ultrasonography (US), but incidentally detected by contrast-enhanced magnetic resonance imaging (CE-MRI). We present it here with a review of the literature. A 67-year-old Japanese woman was referred to our hospital in October 2000 because of a 1.5 cm right breast lump detected in a medical checkup. MMG, US and fine needle aspiration cytology revealed a cancerous lesion during the right breast. No mass lesion was palpable nor was any detected by MMG or US in the left breast. Bilateral breast CE-MRI was performed for more detailed evaluation. Consequently, an occult contralateral breast cancerous lesion was detected incidentally by CE-MRI, with the images showing rapid initial enhancement of time to signal intensity curves. Before surgery, bilateral breast lesions were diagnosed as invasive ductal carcinoma by open biopsy. She underwent bilateral breast conserving surgery with bilateral axillary lymph node dissection. The postoperative course was uneventful and no recurrence has been noted as of January 18th, 2004. CE-MRI of the contralateral breast should be of value as a routine screen in those patients with a known or suspected malignancy in one breast considering the limits of breast cancer detection by such conventional modalities as MMG and US.

We report a case of lung adenocarcinoma with stromal bone formation. A 73-year-old woman was incidentally found to have a coin lesion in the left lower lung field on a chest roentgenogram and computed tomography showed a nodular lesion containing a few coarse high density areas in the left lower lobe. Since transbronchial cytology revealed adenocarcinoma, left lower lobectomy was performed. Histologically, the tumor was a papillary-tubular adenocarcinoma, and fragments of osseous tissue were found within abundant fibrous stroma. Bone formation in primary lung adenocarcinoma is a very rare condition, and only 7 other cases have been reported in the literature.

S-1 is an oral formulation combining tegafur (FT), 5-chloro-2,4-dihydroxypyridine (CDHP), and potassium oxonate (Oxo) in a molar ratio of 1:0.4:1. We examined whether Oxo reduces the immunosuppression induced by 5-fluorouracil (5-FU) in the rat. The body weight of rats treated with S-1 (FT + CDHP + Oxo) for seven consecutive days was significantly higher than that of rats treated with a combination of FT plus CDHP (FT + CDHP) for a similar period. The number of peripheral leukocytes was significantly higher in the S-1-treated rats (S-1 group) than that in the FT + CDHP-treated rats (FT + CDHP group). There was no apparent difference between the two treated groups in phenotypic changes of CD3-, CD45-, CD4-, or CD8-positive cells from the spleen or mesenteric lymph nodes. However, the natural killer activities of both spleen cells and mesenteric lymph node cells were significantly higher in the S-1 group than in the FT + CDHP group. Interleukin (IL)-2 production by spleen cells stimulated with concanavalin A was significantly lower in the FT + CDHP group than in the S-1 group. Although IL-2 production by mesenteric lymph node cells in the S-1 group was lower than that in untreated rats, it was higher than that in the FT + CDHP group. These findings suggest that Oxo in S-1 may reduce the suppression of antitumor immunity induced by 5-FU.

Little is known about the clinicopathological features of intermediate-stage T2 gastric cancer, defined as tumors invading the muscularis propria or subserosa.Of 808 patients with gastric cancer, 210 patients (25.9%) who underwent gastrectomy for T2 gastric cancer were selected for this retrospective study. The clinicopathologic findings of these patients were analyzed retrospectively from their hospital records.Of all 808 patients with gastric cancer, 73 patients (9.0%) had tumors invading the muscularis propria (mp). The remaining 137 patients (16.9%) had tumors invading the subserosa (ss). Compared with ss gastric cancer, mp gastric cancer was associated with smaller tumor size, an absence of lymphatic spreading, and hematogenous and late recurrence [disease-free interval: 654.5 days (mp) vs. 365.5 days (ss)]. Univariate analysis of cases with curative operations showed that lymphatic invasion, and lymph node metastasis were significant prognostic factors in patients with T2 gastric cancer. Further examination by multivariate analysis demonstrated that pN2 or higher as classified by both the JCGC (Japanese Classification of Gastric Cancer) and the TNM lymph node staging systems was a predictor of poor prognosis.JCGC and TNM lymph node staging systems were the most reliable prognostic factors for T2 gastric cancer. Close follow-up should be required for patients with stage pN2 or higher gastric cancer. Long-term follow-up should be required for mp cancers, in particular.

Although extended lymphadenectomy for thoracic esophageal cancer is widely practiced in Japan, solitary supraclavicular lymph node recurrence (SCLR) has often become a problem. This study was designed to evaluate the survival and clinical benefit of salvage cervical lymphadenectomy.Between 1989 and 2001, 153 patients underwent esophagectomy for esophageal cancers. SCLR was identified in 5 (3.7%) patients and these five patients were examined retrospectively.Surgical treatment was performed intensively for all patients. Two patients showed longterm survival for 7 years 3 months and 4 years, respectively. Four patients belonged to the good prognostic group but the other patient had poor prognosis from the viewpoint of both the pathological metastatic lymph node number and disease-free interval (DFI). There were no local recurrences but were a recurrent laryngeal nerve palsy in three patients associated with treatment.Salvage cervical lymphadenectomy for SCLR should be performed positively by selecting each case carefully. Indication must be weighed against increased morbidity considering such indicators as the extent of metastatic lymph node numbers and DFI.

Objective: A phase I study of weekly intravenous paclitaxel combined with a fixed dose of S-1, a dihydropyrimidine-dehydrogenase-inhibitory oral fluoropyrimidine, was conducted for patients with advanced or recurrent gastric cancer (ARGC). Endpoints of this study were to examine the toxicity profile of this regimen and to determine the recommended dose (RD) of paclitaxel. Methods: S-1 was fixed at a dose of 80 mg/m2 per day and was administered for 2 weeks (days 1–14) followed by a 2-week rest. Two dose levels of paclitaxel (level 1: 60 mg/m2, level 0: 50 mg/m2) were studied. Paclitaxel was infused over 1 h on days 1, 8, and 15. Plasma sampling was performed to characterize the pharmacokinetics and pharmacodynamics of paclitaxel in some patients. Fifteen patients were enrolled (6 patients in level 1, and 9 patients in level 0). Dose-limiting toxicities were defined as grade 4 hematological (including grade 3 febrile neutropenia) and grade 3 non-hematological (except anorexia, nausea, vomiting and depilation) toxicities. Results: Three of 6 patients in level 1 developed grade 4 neutropenia or grade 3 febrile neutropenia, and 1 of them also showed grade 3 diarrhea, which settled the maximum-tolerated dose at this level. At level 0, 2 of 9 patients developed grade 4 neutropenia or grade 3 febrile neutropenia, and the RD of paclitaxel for this protocol was set at this level. Pharmacologic studies demonstrated the persistence of significant serum paclitaxel levels over 24 h after drug administration at both levels. Objective responses according to Response Evaluation Criteria in Solid Tumors were observed in 3 of 6 patients who had measurable disease. Conclusion: A combination of S-1 and weekly paclitaxel was feasible and well tolerated, and is suggested to produce a worthwhile response in ARGC. These results warrant further investigation, and a phase II study has already been started.

Recent pathological study demonstrated that extended lymphadenectomy is not always necessary for patients with early gastric cancer.Twenty-eight patients underwent pylorus-preserving gastrectomy. The clinicopathological findings of patients with pylorus-preserving gastrectomy were compared to those of 58 patients with conventional distal gastrectomy.There were no significant differences in surgical duration, blood loss, blood chemistry, food intake, and body weight loss. Regarding abdominal symptoms, early dumping syndrome was significantly higher in distal gastrectomy than in pylorus-preserving gastrectomy (35.6% vs. 12.0%, p0.05). Remnant gastritis was also significantly higher in distal gastrectomy (57.1% vs. 27.7%, p0.05). However, food residue tended to be more frequently seen in pylorus-preserving gastrectomy (33.3% vs. 61.1%, p=0.052). Based on questionnaire results, the rate of patient satisfaction with their surgical outcome tended to be lower in pylorus-preserving gastrectomy than in distal gastrectomy (84.0% vs. 95.6%, p=0.098). The tendency was more pronounced in patients over 70 years old (77.8% vs. 100%, p=0.065).Pylorus-preserving gastrectomy is superior to conventional distal gastrectomy in the prevention of dumping syndrome and reflux gastritis. However, since delayed emptying is frequently seen post pylorus-preserving gastrectomy, this procedure is not recommended for older patients under simplistic indications.

The reduction in the incidence of severe postoperative complications has resulted in a significant increase in the survival of patients with gastric cancer.A total of 879 patients undergoing gastrectomy for gastric cancer during the last decade were retrospectively evaluated for postoperative complications, mortality and associated risk factors.The most frequent complications were anastomotic leakage (3.0%) and wound infection (2.8%) followed by the development of pancreatic fistulae (2.2%) and intra-abdominal abscesses (1.5%). Multiple logistic regression analysis identified various independent risk factors including the extent of lymph node dissection (D1D2 vs. D3) for anastomotic leakage (RR 3.6, P0.05), splenectomy or distal pancreatosplenectomy for pancreatic fistulae (RR 27.4, P0.0001) and operative time (360 minor =) for intra-abdominal abscess (RR 4.8, P0.05). In total, fourteen patients (1.6%, n=879) died from postoperative complications, with 5 patients dying following non-curative gastrectomy (5.6%, n=90). The complications most associated with death were anastomotic leakage (4 patients) and pneumonia (2 patients).In view of the potential risk of complications, we should carefully evaluate the indications for aggressive lymph node dissection and/or combined resection of neighboring organs as well as non-curative gastrectomy.

BACKGROUND Amplification of DNA in certain chromosomal regions plays a crucial role in the development and progression of human malignancies, specifically when protooncogenic target genes within those amplicons are overexpressed. Comparative genomic hybridization studies have revealed frequent amplification at 20q in primary breast tumors. The aim of the current study was to identify specific genes in the 20q amplicon that were likely to have clinical significance. METHODS The authors examined 38 primary breast tumors by using a quantitative real-time reverse transcription–polymerase chain reaction assay to determine expression levels of 18 potential targets for amplification events involving 20q. Potential correlations between elevated expression of the genes in question and clinicopathologic parameters or clinical outcomes were analyzed. RESULTS Elevated expression of NABC1 was significantly associated with positive estrogen (P < 0.001) and progesterone (P = 0.027) receptors in breast tumors, and high expression of PTK6 was significantly correlated with positive estrogen receptor status (P = 0.022) and postmenopausal status (P = 0.008). Patients whose tumors showed elevated expression of NCOA3 (AIB1) had significantly shorter disease-free (P = 0.017) and overall (P = 0.0021) survival times after surgery than did other patients with breast tumors. Reduced disease-free survival, but not reduced overall survival, was associated with high expression of TOP1 (P = 0.035) and TFAP2C (P = 0.035). CONCLUSIONS TOP1, TFAP2C, and (particularly) NCOA3 may be prognostic indicators for patients with breast tumors. Cancer 2003;98:18–23. © 2003 American Cancer Society. DOI 10.1002/cncr.11482

The latest TNM classification (5th edition) changed the definition of nodal staging from the anatomical localization to the total number of metastatic lymph nodes. This study was designed to evaluate and compare the prognostic significance of nodal staging between the two widely known staging systems, the TNM classification (TNM) and Japanese Classification for Gastric Cancer (JCGC).A total of 582 patients who underwent curative gastrectomy with extended lymphadenectomy for gastric cancer were reviewed retrospectively from hospital records. Based on the localization of metastatic nodes according to the JCGC and the total positive node number according to TNM, the patients were divided into subgroups and their prognoses compared.Lymph node metastasis was found in 189 of the 582 patients (32.5%). Both nodal staging systems were found to be significant prognostic factors by multivariate analysis. A prognostic analysis of the patients by subdivision with the two staging systems indicated that the nodal staging system in TNM was more homogenous than that of the JCGC.The nodal staging system of the TNM classification is superior to that of the Japanese Classification of Gastric Cancer, because it is simple, reproducible and homogeneous.