Search

症例は65歳，女性．AL型アミロイドーシスによる腎不全のため透析中，2007年左乳癌に対しBtを施行した．補助化学療法としてPaclitaxel初回投与後11日目に腹痛出現，CTにてfree airを認め穿孔性腹膜炎との診断で緊急手術を施行した．開腹すると横行結腸左側に穿孔を認め，結腸左半を切除し肛門側断端は閉鎖，横行結腸を挙上しストーマを造設した．病理組織検査で炎症や腫瘍性病変は認めず，粘膜下層の小型血管から漿膜の中型動静脈において血管壁に好酸性の沈着物を認めCongo red染色において陽性所見を認めた．以上よりアミロイド沈着またはPaclitaxelによる血管の破綻，出血，循環不全などが穿孔の原因と考えられた．術後腹腔内に留置したドレーンより排膿を認め，造影したところ小腸が描出され消化管の再穿孔が示唆されたが，保存的治療で穿孔部は自然閉鎖し術後36日目に退院となった．

症例は69歳,女性.腸管Behcet病による回盲部潰瘍の増悪にてステロイドパルス療法を施行中であった.経過中消化管穿孔を認め緊急開腹術施行.回腸末端の穿孔があり回盲部切除・洗浄ドレナージ術を行った.病理診断にてサイトメガロウイルス感染による回腸穿孔と判明した.術後下血によりプレショック状態に陥ったが,ガンマグロブリン・ガンシクロビル投与後,下血が改善した.ステロイド加療中の膠原病患者における消化管穿孔・消化管出血症例においては,サイトメガロウイルス感染も念頭に置く必要がある.

乳癌消化管転移は初回転移では稀であり,消化管原発性腫瘍と鑑別が困難である.腹腔鏡下生検で鑑別可能であった乳癌大腸転移症例を報告する.症例は72歳,女性,腎結核による腎不全で透析中である.右乳癌(浸潤性小葉癌, T2N2MO: stage III) で胸筋温存的乳房切除術後9カ月目に右下腹部痛,便秘が出現した.注腸造影,消化管内視鏡,腹部CT検査で横行結腸転移が疑われたが確定診断は得られなかった.腹腔鏡で横行結腸脾彎曲部付近の壁硬化,腸間膜硬結,近傍リンパ節腫大を認め,腸問膜一部とリンパ節を採取した.組織検査から乳癌転移と診断した.乳癌大腸転移は初回診断が困難であり,内視鏡的生検でも鑑別不能な症例が多い.腹腔鏡下の漿膜側生検で診断確定できれば,速やかに化学療法を開始し侵襲が大きい手術を避けることが期待できる.

症例は54歳,女性.平成11年から左腎部褥創に対し,近医で治療を行っていた.平成14年7月23日,市内の形成外科病院にて褥瘡部の生検で腺癌と診断されたため,当科に紹介入院した.鼠径リンパ節転移を伴う痔瘻癌と考え,ストーマ造設後に術前化学療法を施行し,その後2期的に腫瘍切除,大殿筋皮弁による会陰部再建を行った.手術所見では,直腸癌 (Ra) と会陰部腫瘍には連続性はみられず,また同様の組織型であることから直腸癌の痔瘻転移であると考えられた.転移性痔瘻癌は,現在までに8例の報告があるのみで,非常に稀な症例であり,転移経路は口側の腫瘍からの痔瘻内へのimplantationが原因であると報告されている.予後は原発,転移巣の進展度によると考えられるが,本症例のように転移巣が大きな症例では外科的切除のみならず,集学的治療が必要であると考えられた.

症例は44歳の女性で, 平成9年4月, 左後腹膜腫瘍 (平滑筋肉腫) の診断で, 腫瘍, 左腎臓摘出術を施行した. 平成12年2月上旬, 肝転移に対してS2, S4の肝部分切除. また, 平成13年12月中旬, 残肝再発のため肝外側区切除施行した. いずれも病理組織学的に平滑筋肉腫の肝転移と診断された. 平成14年7月下旬, 腹痛の精査のため再入院した. 腹部CTにて膵尾部に2cm 大のlow density areaを認め, 平滑筋肉腫の局所再発と診断し, 8月下旬, 手術を施行した. 腫瘍は膵内に存在したため膵転移と診断し, 膵体尾部切除術を施行した. 後腹膜原発平滑筋肉腫の膵転移の切除例は今回検索しえたかぎりでは報告が見られず, 非常にまれな症例と考えられた. 転移性膵腫瘍において, 切除例に長期生存の報告もあり, 治療法の1選択肢として外科的切除も考慮すべきである.

Assessment of malignant potential in gastrointestinal stromal tumors (GISTs) is still problematic. The maximum tumor diameter and the mitotic index are generally used as an index of malignancy of GISTs. The Ki-67 labeling index has recently been used as an index of cell growth, and the prognosis of GISTs was reported to be significantly poor when the value of this index was 10% or higher.Clinicopathological and immunohistological factors were analyzed in 15 patients who underwent surgical resection of gastric stromal tumors at our department between April 1997 and July 2002. The patients were divided into "metastasis/recurrence" and "benign" groups. Also, the relationship of changes in the Ki-67 labeling index to the degree of malignancy in recurrent lesions was assessed in an 84-year-old woman who underwent five reoperations because of recurrences in the peritoneum.Significant differences were noted between the metastasis/recurrence and benign groups in relation to the mean maximum tumor diameter (186.7 +/- 80.8 mm vs 41.3 +/- 22.9 mm), mitotic index (88.3 +/- 5.0/50 high-power fields [HPF] vs 3.0 +/- 2.9/50 HPF), and the Ki-67 labeling index (11.4 +/- 2.5% vs 0.01 +/- 0.51%). In the patient who had metastasis to the liver 3.5 years after initial operation and underwent five reoperations before death, the intervals until detection of recurrence tended to be shortened gradually. The Ki-67 labeling index varied with each operation, and tended to be higher at the time of reoperations than at the initial operation.The maximum tumor diameter, mitotic index, and Ki-67 labeling index were useful as an index of malignancy for gastric stromal tumor. The efficacy of surgical resection alone may be insufficient in patients with disseminated metastasis to the peritoneum.

糖尿病を合併した直腸癌術後骨盤内膿瘍から発症したFournier's gangreneの1例を経験したので報告する.症例は50歳,男性でRbを主座とする進行直腸癌の診断で腹会陰式直腸切断術を施行した.術後仙骨前面に膿瘍を形成し,約2カ月後に臀部から右大腿,躯幹に及ぶ発赤,腫脹が出現した. CTにて軟部組織に異常ガス像を認めたため広範囲に切開, debridementを行ったが術後に敗血症から多臓器不全に陥り,救命できなかった.直腸癌にFournier's gangreneを合併した例は検索しえた限り本邦で5例目であった.本症は重篤な経過を辿ることがあるため,躯幹に及ぶ以前に診断して早期に切開,排膿と壊死物質の除去,洗浄を行うと同時に,原疾患の治療および血糖を含めた適切な全身管理を行うことが肝要であると思われた.

Liver abscess successfully treated by hepatic resection in a case of acute leukemia was reported in this paper. The case was a 33-year-old man. In the previous hospital, multiple liver and splenic abscesses were recognized after chemotherapy for acute myelomonocytic leukemia. The patient received various antibiotics and antifungal agents followed by splenectomy, but the liver abscess, almost localizing at the dome of liver, was still detected by CT and MRI. The patient was referred to our department. After partial hepatectomy, the clinical course was uneventful and inflammatory signs were improved. Liver abscess associating with leukemia is often multiple, and no clinical case of hepatic resection of liver abscess with acute leukemia has been reported. This case has suggested that such hepatic resection can be safely done in a stage of complete remission of leukemia. We think that hepatic resection should be an available alternative to conservative treatments for liver abscess associated with leukemia, if it offers resistance to the conservative ones.

Transcatheter arterial embolization (TAE)が奏効した21歳,男性の動門脈瘻を伴う外傷性肝動脈瘤破裂の1例を報告した.本症例は腹部刺創にて肝縫合術後,肝膿瘍が出現し経皮ドレナージを行なったが受傷4カ月目に突然吐下血をきたした.右肝動脈瘤破裂および動門脈瘻による門脈圧亢進症(門亢症),胆管瘻による胆道出血と診断された.炎症性臓器癒着,門亢症による易出血性の為一期的肝切除が困難でありTAEが施行された.TAE後門亢症,胆道出血は消失しCT上も仮性動脈瘤腔の縮小,器質化を認め現在経過観察中である.動門脈瘻を伴う外傷性肝動脈瘤は発生,破裂までに不定の潜伏期間を有し,また重篤多彩な臨床症状を呈することからその診断,治療上に多くの問題点を有している.臨床経過ならびに画像診断所見より本病態の成立過程を推測し,治療法としてのTAEの有用性を強調した.

In a 72 years old woman, abdominal computed tomography (CT) disclosed multicentric hypervascular tumor in S4 of the liver, and it was T1.T2 by the MRI, and a high signal was presented together. Stenosis was shown by ERCP at the same site. Cholangiocellular carcinoma was suspected before operation, but malignant change was not recognized by frozen section, so the operation was finished. Later, a diagnosis of solitary necrotic nodule of the liver was established by pathological diagnosis. Solitary necrotic nodule of the liver is a benign tumor.

Pseudomyxoma peritonei is generally caused by appendiceal and ovarian tumors. Other primary sites have been rarely reported. We describe herein the second reported case of pseudomyxoma peritonei due to mucinous cystadenocarcinoma of the urachus. A 54-year-old man was admitted with a left inguinal hernia that had developed several months prior to his admission. During herniorrhaphy, we found a large amount of gelatinous mucinous material in the indirect-hernia sac and made a diagnosis of pseudomyxoma peritonei on cytological grounds. At re-operation, the origin of the pseudomyxoma peritonei proved to be a ruptured urachal cyst. The urachal cyst and the dome of the urinary bladder were excised. In addition, we removed as much of the gelatinous material as possible. On histological examination, a unilocular cyst was found to consist of noninvasive mucinous adenocarcinoma. We succeeded in removing the rest of the mucinous material by postoperative intraperitoneal lavage with dextran solution, and have observed no evidence of recurrence for 7 years since the operation.

An 81-year-old man with a mass in the lower abdomen and symptoms of ileus was admitted to the hospital. On physical examination, a hard, fixed mass was palpable in the lower abdomen. CT (A) revealed an intrapelvic tumor with nonuniform internal structure, and both ureters were displaced laterally causing bilateral hydronephrosis. Abdominal MRI (B) disclosed a tumor that was relatively smooth in the margin and had a capsule. The tumor, comprised of cystic and nodular parts, displaced the bladder anteriorly. Abdominal angiography revealed several feeders from the internal iliac artery toward the tumor, suggesting the presence of a retroperitoneal tumor such as malignant schwanoma or malignant fibrous histiocytoma. At operation, a smooth-surfaced tumor occupied the inside of the pelvis, displacing the sigmoid colon to the right (C) and affecting the bladder and bilateral ureters. Because the tumor showed relatively slight adhesion to the surrounding tissues, dissection was mainly performed manually, with some sharp dissection, along the tumor capsule to isolate a potbelly-shaped tumor 18 cm maximum diameter, weighing 1,340 g (D). Observation of cut surfaces showed irregularly mixed cystic parts containing serous substance and white, hard, nodular parts (E). Solitary fibrous tumor was diagnosed by histopathologic examination. Immunohistochemical staining tests for CD34 and bcl-2 protein were positive, and these findings were useful for differentiation from other spindle-cell neoplasms. Solitary fibrous tumor, reported for the first time by Klemperer and Rabin in 1931, is a mesenchymederived benign tumor. It usually develops in the pleura in adults; rarely is the retroperitoneum the site of origin. Nakatani and colleagues reviewed 25 patients with solitary fibrous tumors arising in the retroperitoneum. They were ages 17 to 82 years (mean 49.0 years), and their tumors ranged from 2 to 26 cm diameter (mean 10.6 cm). The tumor was found incidentally in eight patients. It was manifested by abdominal pain and the “symptom of hypoglycemia” in three patients each, attributed to insulin-like growth factor produced by tumors (incidence about 5%). Aside from one patient showing infiltration-type tumor growth, the tumors had capsules, and a diagnosis of malignancy was made by A

A 64-year-old-male had recurrent paraaortic lymph node and liver metastases eight months after total gastrectomy and with distal pancreatectomy and splenectomy for advanced gastric cancer. Combined chemotherapy with 5-FU and a low-dose of CDDP was effective and the both lesions disappeared. Thirteen months later, a second recurrence of anterior mediastinum lymph node metastases occurred. After the same protocol, the lesions showed a partial response and lymph node dissection was performed. Histopathological examination showed that the resected lymph nodes had 99% necrosis and fibrotic change. Immunohistochemical examination of p53 of the primary gastric cancer showed negative staining. The patient has been followed for three years after the operation, and has no recurrent lesions.

Ninety-nine patients with unresectable primary liver cancer were treated with ligation of the hepatic artery (LHA), intra-arterial infusion chemotherapy (IAIC) or transcatheter arterial embolization (TAE) between 1960 and 1983. A statistical study was made of therapeutic effects and prognosis. The results are as follows: The mean survival time of 14 patients treated with LHA was about 5 months. The survival time of the LHA + IAIC with mitomycin C group was not prolonged as compared with that of the LHA group, but LHA + IAIC with Adriamycin (doxorubicin) group showed a significant prolongation of survival time over the LHA group. In the LHA + IAIC with Adriamycin group, the mean survival time was 12.8 months and the 1-year survival rate was 37.5%. Factors including age, presence of liver cirrhosis, number of involved segments, and degree of anaplasia graded on Edmondson's criteria did not influence survival time.