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Urinary tract infection (UTI) occurs in 25% of recipients of living-donor kidney transplantation (LDKT). Female sex, age, and anatomical abnormalities have been reported as recipient-related risk factors for UTI after LDKT; few studies have reported donor-related factors. We retrospectively examined UTI occurrence within 5 years of transplantation in recipients (n = 211) who underwent LDKT at our hospital between April 2011 and April 2021. All nephrectomies were performed using a retroperitoneal pure laparoscopic approach. The ureter was dissected at the lower level of the common iliac artery and trimmed to the shortest length, enough to reach the bladder using extra vesicular ureterocystoneostomy with a 3 cm submucosal tunnel. Twenty-nine recipients (13.7%) developed UTI within 5 years, and the median time to onset was 40.0 days. After adjusting for the well-known factors, including recipient sex, graft ureter length was an independent factor for UTI occurrence (HR 1.25, 95% CI 1.02∼1.53, p = 0.028) in the multivariate Cox regression analysis. The long ureter is usually trimmed, and the widest part is used for anastomosis, which may increase the possibility of reflux from the bladder to the ureter in the standard technique. The ureter length may be associated with the incidence of UTI after LDKT.

Background This study evaluated the changes in basal insulin secretion capacity (BISC) after pancreatectomy across two surgical procedures. We also investigated the association between decreased BISC and the introduction of postoperative insulin therapy. Methods The data on 110 patients who underwent pancreatectomy during October 2018–February 2022 at our hospital were retrospectively registered and analyzed. We focused on the C-peptide index (CPI) as an index for BISC. A decreased postoperative BISC was defined as a postoperative CPI (post-CPI)

This study evaluated the changes in basal insulin secretion capacity (BISC) after pancreatectomy across two surgical procedures. We also investigated the association between decreased BISC and the introduction of postoperative insulin therapy. The data on 110 patients who underwent pancreatectomy during October 2018–February 2022 at our hospital were analyzed retrospectively. We focused on the C-peptide index (CPI) as an index for BISC. A decreased postoperative BISC was defined as a postoperative CPI (post-CPI)

Once-daily extended-release tacrolimus (TACER) is commonly administered following kidney transplantation (KTx); however, its optimal dosage remains unknown.In this multi-center, randomized controlled trial, 62 living donor KTx recipients were assigned to either standard-exposure (SE; n = 32) or low-exposure (LE; n = 30) TACER (Graceptor®, Astellas Pharm Inc.) groups. All patients received basiliximab and mycophenolate mofetil (MMF). The primary outcomes were acute rejection, graft/patient survival, and the secondary outcomes were incidence of cytomegalovirus infection, and de novo donor-specific antibodies (dnDSA) production.The tacrolimus trough level and estimated area under the blood concentration-time curve (eAUC) were significantly higher in SE than in LE (SE vs. LE; 1 year: 5.0 ± 0.9 ng/ml and 206.9 ± 26.8 ng h/ml vs. 3.4 ± 1.0 ng/ml and 153.9 ± 26.4 ng h/ml; 2 years: 4.8 ± 1.0 ng/ml and 204.9 ± 30.1 ng h/ml vs. 3.8 ± 0.9 ng/ml and 164.4 ± 27.0 ng h/ml). In contrast, the dosage and eAUC of MMF did not differ between groups. Two-year graft and patient survival rates were 100% in both groups, and acute rejection rates were 0% and 10% in the SE and LE, respectively (p = 0.11). The mean estimated glomerular filtration rates did not differ between the groups. Cytomegalovirus infection was slightly lower in the LE (SE: 12.5% and LE: 6.7%, p = 0.37). In the LE, four cases of dnDSA were noted within 2 years of transplantation; no case was observed in the SE (p = 0.034).Although the LE TACER regimen showed similar rates of acute rejection, as well as graft and patient survival compared with SE after KTx, LE was significantly more associated with dnDSA. Further investigation of its long-term effect on graft survival is warranted. (University Hospital Medical Information Network Clinical Trials Registry ID: UMIN000033089).

Background: Postoperative cholangitis is a late complication of pancreaticoduodenectomy (PD). This study aimed to elucidate the pathogenesis of post-PD cholangitis (PPDC) and explore its optimal treatment.Methods: We retrospectively analyzed 210 patients who underwent PD at our institute between 2009 and 2018. Patients who underwent follow-up for less than one year or had cholangitis caused by cancer recurrence, were excluded from the analysis. Diagnostic criteria for cholangitis and its severity were determined based on the classification of acute cholangitis provided by the 2018 Tokyo Guidelines (TG18).Results: PPDC occurred in 19 (11%) of the 176 included patients. Of these 19 patients, nine experienced more than one episode of cholangitis (total episodes, 36). For 14 patients (74%), the first episode of PPDC occurred within two years after surgery. Based on the TG18, 21 episodes were mild and 15 episodes were moderate; none were severe. Blood culture test results were positive for 16 of 24 episodes. Most patients were hospitalized and treated with intravenous antibiotics (median, seven days). The blood test values improved promptly after treatment was started. Four patients with recurrent cholangitis underwent endoscopic examination, and three of them had anastomotic stenosis of the hepaticojejunostomy. The univariate and multivariate analyses did not indicate any significant predictive factors for PPDC development.Conclusion: Mild and moderate PPDC occurred and improved with short-term antimicrobial treatment. Temporary reflux into the intrahepatic bile ducts may have been the cause of PPDC while anastomotic stenosis may be involved in recurrent cases.

Introduction The Living Kidney Donor Profile Index (LKDPI) was recently proposed in the United States to evaluate living donor quality. Japan has a largely different renal transplant circumstance, such as a high ABO incompatibility rate. The aim of this study was to validate the LKDPI among the Japanese population and adjust the score. Methods We performed a retrospective analysis of 133 living donors in renal transplant in our institution. We analyzed the clinical characteristics and outcomes, and created a modified LKDPI score considering the favorable ABO incompatible kidney transplant outcomes in Japan. Results Median (interquartile range [IQR]) donor age was 59 (51 to 65) and median (IQR) body mass index was 22.9 kg/m2 (20.9 to 25.2). ABO incompatibility rate was 28.5%. Median (IQR) donor estimated glomerular filtration rate (eGFR) (Chronic Kidney Disease Epidemiology Collaboration equation) was 108.7 mL/min/1.73 m2 (99.9 to 115.5). The 1-year graft survival rate was 98.5%, and the 3-year graft survival rate was 97%. The incidence of antibody mediated rejection was 5.2%. The median (IQR) LKDPI score was 30.2 (11.8 to 46.8). This was significantly higher than the previously reported score in the United States, which was 12.8 (-0.8 to 27.2). The modified LKDPI (mLKDPI) score was 23.2 (4.1 to 35.1). LKDPI and mLKDPI did not show a diagnostic value in graft survival; however, LKDPI and mLKDPI showed significant diagnostic value in eGFR at 1 year (area under the curve [AUC]=0.627, P = .017; and AUC=0.673, P = .01). Conclusion Our outcomes had better survival even though with higher ABO incompatibility rate. According to original LKDPI, our donor pool is higher than the general US population. In this study, lower LKDPI tended to be associated with good allograft function, and mLKDPI has better diagnostic value than LKDPI. To compare internationally, an adjusted model for Japan might be necessary based on the outcomes of a large population.

Although distant metastasis from pancreatic ductal adenocarcinoma (PDAC) has a dismal prognosis, some single center studies reported that lung metastasis has a favorable prognosis. The aim of this study is to evaluate the prognostic value of site-specific metastasis after pancreatectomy for PDAC, with a focus on lung metastasis.Data from 117 cases of lung metastasis after pancreatectomy were collected retrospectively from 23 institutions in Japan. To compare the sites of metastasis we also collected the data of 134 patients with liver only metastasis, 67 patients with peritoneal only metastasis and 121 patients with locoregional recurrence alone.In patients with lung only metastasis, the median time from recurrence to death (RTD) was 23.1 months, which was better in comparison to other sites of recurrence. In lung metastasis group, the patients who underwent pulmonary resection had better long-term outcomes in comparison to those who did not. (RTD: 29.2 vs 15.2, P .001). In the multivariate analysis, solitary metastasis (HR 5.03; 95% CI 1.195-21.144, P = .022) and postoperative chemotherapy (HR 14.089; 95% CI 1.729-114.77, P = .023) were identified as significant prognostic factors after lung resection.Surgical resection is a favorable option for selected patients with a solitary lung metastasis and for whom adjuvant chemotherapy can be administrated.

Interval appendectomy or non-operative management is commonly performed for complicated appendicitis in adult patients. However, these treatments are still controversial because the incidence rate of appendiceal tumors recognized after interval appendectomy is reportedly higher than that after emergency appendectomy. Thus, this study aimed to compare the appendiceal tumor rates between uncomplicated and complicated appendicitis.This study was a retrospective review of patients with appendicitis who underwent surgical removal at a single institution over 7.5 years. The primary objective was the comparison of the incidence rate of appendiceal tumors using propensity score matching, and the secondary objective was the same comparison among older patients, defined as patients aged ≥ 60 years.A total of 1277 patients were included. Of these patients, 297 (23.3%) were preoperatively diagnosed with complicated appendicitis. Moreover, 22 (1.7%) patients, including 14 cases of complicated appendicitis and 8 cases of uncomplicated appendicitis, were diagnosed with appendiceal tumors based on pathological examination. No significant difference was found in the incidence rate of appendiceal tumors between the two groups after matching for patients' background, including age, sex, and history of appendicitis by propensity score matching (P = 0.073). However, among patients aged ≥ 60 years, the incidence of appendiceal tumors was significantly higher in complicated than in uncomplicated appendicitis (P = 0.006).Although the overall risk of appendiceal tumors did not differ between complicated and uncomplicated appendicitis when analyzed by the propensity score matching, in older patients aged ≥ 60 years, the risk increased among those with complicated appendicitis. Therefore, although the incidence is low, complicated appendicitis, particularly, among older patients, should be examined carefully and be performed IA when unusual findings exist.

BACKGROUND Approximately 8300 hemophiliacs are registered in Japan, but no comprehensive reports on hepatobiliary and pancreatic surgery (HBPS) have been conducted. This report investigates the current status of HPBS in hemophilia patients in Japan. METHODS The subjects were hemophiliac patients seen between January 1 2007, and December 31 2017, at facilities participating in this study among the facilities for performing high-difficulty cases nationwide designated by the Japanese Society for HBPS. A retrospective examination of short-term outcomes in 49 cases was conducted to assess patient background, disease, surgical procedure, and complications. RESULTS The types of hemophilia were A: 43 cases, B: four cases, and von Willebrand disease: two cases (hemophilia severity: mild 32, moderate seven, severe 10). The target malignant diseases for surgery were hepatocellular carcinoma (HCC) in 20 cases, intrahepatic cholangiocellular carcinoma (CCC) in four cases, combined HCC-CCC in two cases, hilar CCC in two cases, and pancreatic cancer in four cases. As for the surgical procedure, limited resection (subsegmentectomy and partial hepatectomy) was performed in 16 cases of HCC even with normal liver function tests. Pancreaticoduodenectomy and distal pacreatectomy were performed for pancreatic cancers as in the standard procedure. Postoperative complications were postoperative bleeding in two cases after hepatectomy and one after pancreatectomy in one case. When compared with Japanese National Clinical Data base, the complication rates after hepatectomy and pancreatectomy were not conspicuous in hemophilic patients. CONCLUSIONS As long as they are performed in qualified centers, complication rate is not increased in hemophilic patients undergoing HBPS.

BackgroundPreoperative characteristics of living kidney donors are commonly considered during donor selection and postoperative follow-up. However, the impact of preoperative uric acid (UA) levels is poorly documented. The aim of this study was to evaluate the association between preoperative serum UA levels and post-donation long-term events and renal function.MethodsThis was a single-center retrospective analysis of 183 living kidney donors. The donors were divided into high (≥5.5 mg/dl) and low (ResultsIn total, 44 donors experienced 52 adverse events over 5 years. The incidence of adverse events within 5 years was significantly higher in the high UA group than in the low UA group (50% vs. 24%,p = 0.003); this was true even after the exclusion of hyperuricemia-related events (p = 0.047). UA emerged as an independent risk factor for adverse events (p = 0.012). Donors with higher UA levels had lower eGFRs after donation, whereas body mass index, hemoglobin A1c, blood pressure, and low-density lipoprotein cholesterol did not have any impact on the eGFR.ConclusionsThe findings suggest that preoperative UA levels should be considered during donor selection and postoperative follow-up.

Ciliated muconodular papillary tumor (CMPT) is an extremely rare pulmonary tumor and the clinical characteristics are still unknown. We report the preoperative long-term clinical course and changes in computed tomography (CT) findings of CMPT. A 60-year-old man underwent lower bilobectomy for squamous cell carcinoma in the right lower lobe 18 years before the surgery for CMPT. Twelve years before the surgery for CMPT, a 4-mm small ground glass nodule arose in the left lower lobe. The nodule gradually grew and became dense over time. Because it became mostly solid with central cavities, the patient underwent wedge resection and the tumor was diagnosed as CMPT. There were no recurrences 20 months after surgery. The preoperative CT findings of CMPT were similar to progressive preinvasive lesion, whereas it followed the benign clinical course. To the best of our knowledge, this is the first report on long-term preoperative follow-up of CMPT.

A 36-year-old man, who had never been detected abnormalities on an annual chest X-ray check up, presented with a sudden onset of right-sided chest pain and fever. Contrast-enhanced computed tomography showed an anterior mediastinal mass with necrosis or hemorrhage and right pleural effusion. Neither computed tomography-guided biopsy nor video-assisted thoracic surgery (VATS) yielded definitive histological diagnosis due to insufficiency of the sample. For diagnosis and treatment, we performed thymectomy. Histopathologically, the tumor was almost entirely necrotic with few viable tumor cells on periphery. A diagnosis of B2 thymoma was rendered.

BACKGROUND Adequate renal perfusion at the time of unclamping is important because it has been known to affect outcomes in renal transplantation. Nevertheless, the ideal intraoperative systolic arterial pressure (SAP) has not been well defined. METHODS We performed a retrospective analysis of 106 living donor renal transplants performed at our center from June 2010 to May 2019. We divided the cohort into 2 groups according to our center's goal SAP of ≥150 mm Hg: 57 patients had SAP ≥150 mm Hg and 49 patients had SAP

Background The renal function of the remaining kidney in living donors recovers up to 60~70% of pre-donation estimated-glomerular filtration rate (eGFR) by compensatory hypertrophy. However, the degree of this hypertrophy varies from donor to donor and the factors related to it are scarcely known. Methods We analyzed 103 living renal transplantations in our institution and divided them into two groups: compensatory hypertrophy group [optimal group, 1-year eGFR ≥60% of pre-donation, n = 63] and suboptimal compensatory hypertrophy group (suboptimal group, 1-year eGFR n = 40). We retrospectively analyzed the factors related to suboptimal compensatory hypertrophy. Results Baseline eGFRs were the same in the two groups (optimal versus suboptimal: 82.0 ± 13.1 ml/min/1.73m2 versus 83.5 ± 14.8 ml/min/1.73m2, p = 0.588). Donor age (optimal versus suboptimal: 56.0 ± 10.4 years old versus 60.7 ± 8.7 years old, p = 0.018) and uric acid (optimal versus suboptimal: 4.8 ± 1.2 mg/dl versus 5.5 ± 1.3 mg/dl, p = 0.007) were significantly higher in the suboptimal group. The rate of pathological chronicity finding on 1-h biopsy (ah≧1 ∩ ct + ci≧1) was much higher in the suboptimal group (optimal versus suboptimal: 6.4% versus 25.0%, p = 0.007). After the multivariate analysis, the pathological chronicity finding [odds ratio (OR): 4.8, 95% confidence interval (CI): 1.3–17.8, p = 0.021] and uric acid (per 1.0 mg/dl, OR: 1.5, 95% CI: 1.1–2.2, p = 0.022) were found to be independent risk factors for suboptimal compensatory hypertrophy. Conclusion Chronicity findings on baseline biopsy and higher uric acid were associated with insufficient recovery of the post-donated renal function.

Background Compensation of contralateral kidney function after living-donor kidney donation is well known, and many predictive factors have been proposed. However, no prediction model has been proposed. This study was performed to establish a tool with which to estimate the degree of compensation of the contralateral kidney after living-donor kidney donation. Methods We retrospectively analyzed 133 living donors for renal transplantation in our institution. We defined a favorable compensation as a post-donation estimated glomerular filtration rate (eGFR) at 1 year (calculated by the Chronic Kidney Disease Epidemiology Collaboration equation) of > 60% of the pre-donation eGFR. We analyzed the living donors’ clinical characteristics and outcomes. Results The median (range) donor age was 59 (24–79) years, median (range) body mass index was 22.9 (16.8–32.7) kg/m2, and median (range) body surface area was 1.6 (1.3–2.0) m2. All donors were Japanese, and 73% of the donors were biologically related. The median (range) donor pre-donation eGFR was 108.7 (82–144) ml/min/1.73 m2, and the median (range) post-donation eGFR at 1 year was 86.9 (43–143) ml/min/1.73 m2. Eighty-six percent of donors had compensatory hypertrophy. In the univariate analysis, age, female sex, history of hypertension, body surface area, and pre-donation eGFR were significantly associated with hypertrophy (p

We previously reported that allografts from living donors may have pre-existing histopathological damages, defined as the combination of interstitial fibrosis (ci), tubular atrophy (ct), and arteriolar hyalinosis (ah) scores of ≧1, according to the Banff classification. We examined preoperative characteristics to identify whether the degree of these damages was related to metabolic syndrome-related factors of donors. We conducted a single-center cross-sectional analysis including 183 living kidney donors. Donors were divided into two groups: chronic change (ci + ct ≧ 1 &cap, ah ≧ 1, n = 27) and control (n = 156). Preoperative characteristics, including age, sex, blood pressure, hemoglobin A1c (HbA1c), aortic calcification index (ACI), and psoas muscle index (PMI), were analyzed. Comparing the groups, the baseline estimated glomerular filtration rate was not significantly different, however, we observed a significant difference for ACI (p = 0.009). HbA1c (p = 0.016) and ACI (p = 0.006) were independent risk factors to predict pre-existing histopathological damages, whereas PMI was not. HbA1c correlated with ct scores (p = 0.035), and ACI correlated with ci (p = 0.005), ct (p = 0.021), and ah (p = 0.017). HbA1c and ACI may serve as preoperative markers for identifying pre-existing damages on the kidneys of living donors.

症例は46歳，男性．上腹部痛を主訴に当院消化器科を受診した．画像検査上膵頭部に4cm大の内部が不均一でhypovascularな腫瘤が存在し肝内にはいくつかの小結節性病変を認めた．膵腫瘤，肝内の多発結節はサイズが徐々に増大し，入院後10日，膵頭部腫瘤が破裂出血したため，緊急に止血ドレナージ術を行った．術後6日には肝内多発結節のサイズが増大，S3のものが破裂出血しており，一時的な止血救命を目的にTAEを行った．術後10日（入院後22日）肝不全のため死亡．剖検病理所見では肝血管肉腫と診断された．診断に苦慮し，膵頭部腫瘤を契機に発見されるという非常に稀な肝血管肉腫を経験した．若干の文献的考察を加え報告する．

憩室炎に起因するS状結腸膀胱瘻に対して，腹腔鏡下手術を行った5例について文献的考察を加え報告する．全例男性，平均年齢は60.0歳，主訴は気尿，混濁尿であった．確定診断にはCTにおける膀胱内air像が有効で，注腸透視や大腸内視鏡検査では憩室は確認できたが瘻孔は描出されなかった．術式は，全例腹腔鏡下に瘻孔を切離しS状結腸切除を行い，膀胱に対する特別な処置は加えなかった．平均手術時間は280分，出血量は43g，尿道バルーン留置期間および術後在院日数は，1例を除きそれぞれ7日，10～11日であった．手術関連死はなく，術後合併症として結腸吻合部の縫合不全を1例に認めた．また，切除標本はすべて病理学的検索を行い悪性所見のないことを確認した．結腸膀胱瘻に対する手術は，リンパ節郭清は不要で腹腔鏡下手術のよい適応である．また，腹腔鏡下手術が完遂できれば低侵襲で，患者にとっては大きな福音となると考えられた．

症例は65歳の女性で，左上腹部痛を主訴に近医を受診．諸検査にて異常は認められないとされたが症状改善はなく，1カ月後よりspike feverが出現，精査加療目的に当院紹介となった．US，CT，MRIにて膵尾部に接する脾嚢胞性病変様の所見を認めた．膵癌，もしくは膵炎に起因したもの，あるいは脾原発の悪性リンパ腫などが鑑別にあげられた．開腹所見では膵尾部に脾臓，腎臓，結腸間膜に浸潤している腫瘤を認め，膵癌と診断し左腎臓，左副腎の合併切除を伴う膵体尾部切除術を施行した．術後病理組織学的診断では膵尾部癌の脾臓浸潤と脾臓の膵酵素暴露による好塩基性変化を認めた．膵疾患による脾合併症は比較的まれであり，膵尾部癌の脾浸潤による脾臓の凝固壊死は検索した限りでは報告例がなく，極めてまれであると考えられる．脾臓の部分的凝固壊死を契機に発見された膵尾部癌について文献的考察を加え報告する．

症例は58歳の男性で，検診で直腸Rbに粘膜下腫瘍を指摘された．直腸カルチノイドの診断でendoscopic submucosal dissection（ESD）を行った．病理組織学的検索では腫瘍径は4 mmで，垂直・水平断端はともに陰性であったが微小脈管侵襲が認められた．十分なインフォームドコンセントの後，追加手術を行ったところ，251番リンパ節に転移を認めた．直腸カルチノイドでは，径10 mm以上，深達度mp以深，中心陥凹，表面の凹凸不整像，脈管侵襲陽性などの所見があれば，追加切除や厳重な経過観察が必要とされている．腫瘍径5 mm以下では，リンパ節転移のない症例がほとんどであること，手術によりquality of lifeが損なわれる可能性があることから，追加切除の是非についてはいまだにコンセンサスが得られていない．しかし，本症例のごとく微小病変であっても脈管侵襲陽性例は追加手術，あるいは厳重な経過観察が必要と考えられた．

症例は55歳，女性．平成12年に子宮頸癌に対して子宮全摘術を施行され，その後術後補助化学療法，放射線療法を施行された．平成20年5月下旬，右下腹部痛が出現し救急外来を受診した．腹部全体に圧痛を認め，腹部レントゲン写真でFree airを認めた．CT上，腹水の貯留も認めたため，同日，上部消化管穿孔の疑いで緊急手術を施行した．術中所見では無臭で黄色透明の腹水貯留を認めたが，消化管の穿孔は認めなかった．術後3日目，尿道バルーンカテーテルを抜去した後，尿量の減少と黄色透明な腹水の増加を認めた．再度バルーンカテーテルを留置すると尿量の増加と腹水の減少を認め，放射線治療後の膀胱自然破裂と診断した．バルーン抜去後，定期的自己導尿を行い症状改善し術後28日に軽快退院となった．放射線治療後の膀胱自然破裂の報告は散見されるが，Free airを伴った症例は非常に稀であり，文献的考察を加えて報告する．

The clinical indications for hepatectomy and extrahepatic bile duct resection (EBDR) for pT2 gallbladder carcinoma (GBC) remains controversial. The aim of this study is to elucidate the therapeutic effect of hepatectomy and extrahepatic bile duct resection on the surgical treatment of pT2 GBC. Ninety-four patients with pT2 GBC who underwent a potentially curative resection were retrospectively analyzed regarding their pathological findings, surgical procedures, and survival. The most powerful predicting factor for the survival is the nodal status. The 5-year survival rate was 87.1% for the pN0 patients and 55.7% for the pN1 patients. With respect to surgical procedures, the 5-year survival rate was 73.3% for the 51 patients with hepatectomy, and 87.2% for the 43 patients without hepatectomy. In addition, the 5-year survival rate was 66.7% for the 11 patients with EBDR, and 81.1% for the 83 patients without EBDR. When restricting the patients to those with pN1 disease, the 5-year survival rate of the patients who received these procedures did not surpass that of the patients who did not. There is no positive therapeutic effect besides providing surgical margins in hepatectomy and EBDR in the surgical treatment of pT2 GBC whereas lymph node dissection is most effective procedure for improving survival. Provided that the negative surgical margins are secured, a hepatectomy and an EBDR can therefore be withheld in the surgical treatment for the pT2 GBC.

患者は67歳, 男性. 検診で胆石を指摘され, 胆石胆嚢炎の診断で腹腔鏡下胆嚢摘出術 (laparoscopic cholecystectomy : 以下, LC) を行った. LCから2年4カ月後, 右季肋下のポート部瘢痕に有痛性の腫瘤を認めたため再手術を行った. 病理学的検索の結果, ポート部再発および腹膜播種と診断された. 手術前後の検索では原発巣は特定できず, 摘出した胆嚢を再検索し腺管構造を有する大きさ2mmの微小高分化腺癌 (深達度m) が認められ, 潜在胆嚢癌のポート部再発および腹膜播種と考えられた. ポート部位再発はほとんどの場合, 潜在胆嚢癌に対してLCを行った場合に発症している. 自験例の如く, たとえ微小癌であっても再発する場合があるので, 潜在胆嚢癌の存在を念頭においた慎重な対応が必要である.

A 52-year-old male visited a local clinic with a subjective complaint of pain in the left side of his abdomen. Abdominal CT revealed the presence of a pancreatic body tumor. On EUS, the tumor presented hypoechoic signals with an obscure boundary, which continued from the pancreatic parenchyma to the inside of the main pancreatic duct. Abdominal contrast CT revealed a hypervascular tumor with densely stained pancreatic parenchyma. ERP findings revealed that main pancreatic duct invasion was suspected based on partial radiolucency in the duct. Distal pancreatectomy was performed, and a definitive diagnosis of pancreatic neuroendocrine tumor (WHO class G1) was made histopathologically.

It was once considered that the T cell response is an all or nothing type event, but recent studies have clearly indicated that T cells show many different types of activation in recognition of altered ligands for T cell receptors (TCR). In this review, we summarize our recent findings on the response of human CD4+ helper T (Th) cell clones to altered peptide ligands (APL); peptides carrying single or multiple residue substitutions in antigenic peptides. The extensive analyses revealed that TCR-antagonism and partial agonism are frequently observed by the stimulation with APLs substituted at particular amino acid residues of antigenic peptides. We observed unique partially agonistic APLs inducing prolongation of T cell survival without cell proliferation. Superagonistic APLs stimulated enhanced proliferation and production of cytokines in Th cell clones reactive to tumor-associated antigens. The other APL induced enhanced production of interleukin-12 by antigen presenting cells and subsequent enhancement of IFN-gamma production by T cells reactive to allergens. By utilizing an HLA-DR-restricted T cell epitope library generated by mutated invariant chain genes, it was revealed that human Th cell clones recognize a more diverse array of peptides with multiple and simultaneous amino acid substitutions in an antigenic peptide. APLs also induced altered intracellular signaling events including intracellular calcium increase and phosphorylation of signaling molecules. This information provides basic knowledge regarding the characteristics of antigen recognition by human Th cells and the subsequent activation, and a novel method for manipulation of human Th cell responses by APLs, as a possible candidate for antigen-specific immuno-potentiating or immunosuppressive therapy.

症例は24 歳の女性で, 職場の健康診断で施行された腹部超音波検査にて6cm 大の肝右葉の腫瘤性病変を指摘され当院に紹介された. CT にて腫瘤は中心性瘢痕の部分を除いて強い早期濃染を示し, Superparamagnetic iron oxide (SPIO)-enhanced MRI では取込みを認めず著明な高信号を呈しfibrolamellar carcinoma (FLC) が疑われた. 肝右葉切除が行われ, 病理組織学的に強い好酸性を示す大型の腫瘍細胞が層状の膠原線維により区画されておりFLCと診断された. FLC は通常型肝細胞癌とは異なる臨床病理学的特徴を有し, 肝硬変のない若年者に好発する. しばしばリンパ節転移を伴う事から治療にあたっては肝切除に加えリンパ節郭清を行う必要がある. FLC に関する本邦報告例の集計52例を含め文献的考察を加えて報告する.

原発巣の直接浸潤は粘膜下層 (sm) に留まりながら胃壁内の著明な癌性リンパ管症を呈した胃癌の1例を経験したので報告する. 症例は70歳の女性. 胃内視鏡検査にて噴門部から体中部小彎に陥凹性病変を認め, 生検の結果Group Vであり加療目的にて当院に紹介された. 術前は表層拡大型早期胃癌と診断し胃全摘術を施行した. しかし, 病理組織診断では, 直接浸潤以外に固有筋層 (mp) から漿膜下層 (ss) までリンパ管侵襲による進展が認められ, 癌性リンパ管症を呈していた. 画像所見を再検討すると, X線検査にIIc面より広範囲に胃壁の浮腫状変化と思われる “しめ縄状” の粘膜ひだを認めた. これは, 癌細胞がリンパ管内で腫瘍塞栓を起こし, リンパのうっ滞が起こるために生ずるもので, 胃壁内に進展した癌性リンパ管症に特徴的であると考えられる.

T-cells that recognize mutated p21 Ras are relevant to immune surveillance systems against cancer. We report here evidence that immune responses of a T-cell clone recognizing mutated p21 Ras can be augmented by an analog peptide. Using spleen cells from a gastric cancer patient, we established the CD4+ alpha beta Th1-like clone C27 that recognizes wild-type (3EYKLVVVGAGGVGKS17) and mutated p21 Ras protein molecules and peptides, in an HLA-DR1-restricted manner. C27 responded prominently to mutated Ras peptides carrying Val or Ala at position 12, as compared to wild-type and other mutated peptides. C27 also exhibited a much stronger response to a mutated p21 Ras whole-protein molecule-carrying Val at position 12, as compared with the wild-type protein. The proliferative response and production of GM-CSF, TNF-alpha, and IFN-gamma by C27 were further augmented by replacing the possible first DR anchor 4Tyr of the mutated Ras peptide with Trp, a more potent anchor residue for the DR1 molecule. Enhancement of peptide antigenicity by substituting the HLA anchor residue of an antigenic peptide recognized by tumor-reactive T-cells may prove to be a novel strategy for antigen-specific cancer immunotherapy.

A 58-year-old man visited a local clinic after experiencing epigastric and dorsal pain. A computed tomography scan revealed a hypovascular mass in the pancreatic tail. T1-weighted magnetic resonance imaging (MRI) of the tumor showed a heterogeneous isointense signal and T2-weighted MRI showed a hyperintense signal. Contrast studies revealed contrast enhancement, showing a cystic wall and parts of a septal structure and lumen. Endoscopic ultrasonography revealed a multilocular hypoechoic tumor containing large quantity of debris. We experienced difficulty arriving at a diagnosis and are reporting this case of a pancreatic dermoid cyst, which was diagnosed based on pathological findings.

Intraductal tubulopapillary neoplasm (ITPN) is a rare pancreatic tumor belonging to a newly recognized entity that is coined in the 2010 WHO classification. We present a case of ITPN-associated microinvasive adenocarcinoma that developed in an asymptomatic 78-year-old patient. The tumor demonstrated all the clinical, radiological, and pathological characteristics of ITPN, but it differs from other reported cases of ITPN in molecular analysis, which revealed a somatic mutation in BRAF (c.1799T>A; p.V600E) but no mutation in PIK3CA. Post-operative recurrence was discovered 34 months after tumor resection with negative margins and a 6-month course of adjuvant chemotherapy. To the best of our knowledge, this is the first case of ITPN with BRAF mutation. This case suggests that an activation of RAS-mitogen-activated protein kinase signaling pathway may play a role in development of some of ITPNs. A possible mechanism of tumor recurrence in ITPN is also discussed. Further case series with molecular study are awaited to delineate the clinicopathological and molecular characteristics of ITPN.