Search

A 76‒year‒old man was introduced to our hospital after being suspected of having early gastric cancer with an upper gastrointestinal endoscope that was performed to find the cause of anemia. Two cancers were revealed: type 0‒Ⅱa+Ⅰ lesion in the lesser curvature of the upper body and type 0‒Ⅱa+Ⅱc lesion in the greater curvature of the middle body. The blood test showed abnormalities(hemoglobin, 6.8 g/dL; platelets, 26,000/μg). Thus, myelodysplastic syndrome(MDS) was suspected, and since this was prioritized over gastric cancer, the patient was transferred to the hematology department. As high risk MDS was diagnosed, azacitidine therapy was initiated. After 2 cycles of treatment, the blood abnormalities improved(hemoglobin, 11.3 g/dL; platelets, 254,000/μg). ESD was performed in our department for the 2 lesions. Histopathological examination showed that both lesions represented well‒differentiated adenocarcinoma, and so radical resection was performed. Since MDS occurs due to aging and is common among patients, we believe that timely treatment is necessary.

A 69-year-old woman presented with persistent nauseous, underwent upper gastrointestinal endoscopy, and was diagnosed with type 2 advanced gastric cancer at the antrum. Abdominal contrast CT image data revealed that there was a large, swollen, pancreatic superior lymph node invading the common hepatic artery. We determined that the tumor was unresectable and systemic chemotherapy was performed using S-1 plus oxaliplatin(SOX)therapy. After 5 courses of chemotherapy, the abdominal contrast CT image data indicated reduction of both the primary lesion and lymph node metastasis. A laparotomy was performed. As the No. 8a lymph node was forming hard scar tissue, we could not dissected clearly it from the common hepatic artery wall. We strongly suspected that cancer tissue remained at the artery wall. A distal gastrectomy and Roux-en-Y reconstruction were performed. Histologically, the resected specimen was determined to be Grade 3, with a pathological complete response(pCR). The patient was administered S-1 for 6 months after the operation and has enjoyed 2.5 years of recurrence-free survival. SOX therapy for unresectable gastric cancer and surgical intervention as conversion surgery were effective. This case demonstrated the possibility of life prolongation using these therapies.

症例は77歳，男性．1992年（64歳時）に胆嚢摘出術を受けている．2006年3月近医で黄疸を指摘され当院紹介．画像検査で上部胆管に楔状の狭窄を認めたが，胆管壁の不整は無かった．拡張した上流胆管（肝内胆管）内に多数の小結石を認めた．胆汁細胞診はClassIIであった．良性胆管狭窄および胆道結石症の診断で内視鏡的治療を試みたが不成功のため開腹手術を行った．胆管狭窄部を切除し結石を除去した後，肝管空腸吻合を施行した．狭窄部には肉眼的にも腫瘍を認めず，慢性胆管炎による胆管狭窄であった．なお，術後胆管狭窄の原因で最も多いとされる初回手術中の胆管損傷の有無は本症例では不明である．

症例は67歳の女性で, 近医に高血圧, 糖尿病で通院中であった. 血糖コントロールの悪化と, 腹部超音波検査で膵腫瘍を指摘され紹介入院となる. 血液検査所見ではエラスターゼ1が900ng/dlと高値であった. 腹部超音波検査所見では主膵管の閉塞と末梢膵管の拡張を認めた. MRCP所見では膵体部にて膵管は途絶し, 末梢膵管は拡張していた. ERCP所見でも, 膵体部にて膵管は途絶していた. 腹部CT所見では明らかな腫瘤は同定できなかった. その他, 上部消化管内視鏡検査, 下部消化管造影検査にて, 異常所見はなかった. 以上より, 通常の膵管癌を疑い, 平成17年2月, 膵体尾部切除術を施行した. 術後の病理組織学的検査にて, 同腫瘍細胞は卵円形細胞が充実性結節状, 胞巣状に増殖し, chromogranin染色陽性であった. また, 各種ホルモンの染色ではserotoninのみ陽性であり, 膵内分泌腫瘍と診断した.

Typically, the diagnosis of gastric anisakiasis is made at endoscopy with the identification of anisakis larvae. We report a case of gastric anisakiasis presenting as pneumoperitoneum. A 70-year-old Japanese woman was admitted to our hospital with abdominal fullness and pain. Plain chest X-ray in the upright position showed the presence of free gas below the diaphragm. A tentative diagnosis of perforation peritonitis was made and an emergency laparotomy was performed. At laparotomy, a 4 cm, circumscribed red mass was noted on the anterior wall of the upper body of the stomach near the lesser curvature and a partial gastrectomy was carried out. The histological diagnosis showed a foreign body, assumed to be a part of anisakis larvae, seen in the centre of the granuloma. On the serosal aspect, there was histological evidence of peritonitis with fibrin and neutrophils. In addition, an antianisakis larvae immunoglobulin G antibody test was positive. Chronic gastric anisakiasis was suspected because of the presence of eosinophilic granuloma in the resected area and denatured anisakis larvae. Thus, we interpret this case as gastric perforation acutely based on chronic gastric anisakiasis.

症例は77歳の女性で, 心窩部不快感を主訴に近医受診し, 上部消化管内視鏡検査にて胃体中部前壁に壁外からの圧迫所見を認め当院紹介受診となった. 腹部超音波検査にて, 肝左葉外側区域(S2)に39×30mmの等から高エコー腫瘤を認めた. 腹部造影CTでは, 同部の辺縁部から内部に向けて, 不均一な造影効果を認めた. 腹部MRIではT1強調像で低信号, T2強調像で高信号, dynamic studyにて内部が不均一に造影された. その他, 消化管精査で異常はなかった.第1に海綿状血管腫を疑ったが, 画像所見上, 肝内胆管癌, 転移性肝癌などとの鑑別は困難であった. 平成16年7月, 腹腔鏡補助下肝部分切除術を施行した. 病理組織学的検査では線維性結合組織と海綿状血管腫が混在し, 肝硬化性血管腫と診断した. 肝硬化性血管腫の報告はまれであり, 検索しえたかぎり9例を認めるのみであった.

非機能性膵島腫瘍が原発巣切除後9年を経て肝転移を来たし, 肝切除後1年間以上再発なく経過している1例を経験した. 症例は65歳の男性. 1987年, 膵外発育型膵島腫瘍に対し腫瘍を含めて膵尾側部分切除術を施行した. 以後, 近医にて経過観察していたが, 1996年7月, 腹部エコーにて肝右葉に多発腫瘤を認め, 当科再入院となった. 腹部CTでは周囲が良好に造影され, 中心部に壊死を思わせる低吸収域を伴っていた. 他に原発と思われる病巣が存在せず, 膵島腫瘍の肝転移再発を疑い, 肝右葉切除術を施行した. 病理組織学的所見より, 非機能性膵島腫瘍の肝転移再発と診断したが, 興味深いことに核DNA量解析では原発巣がdiploidであったのに対し, 転移巣ではaneuploidyを呈した. 術後2年を経過するも再発なく生存中であり, 膵島腫瘍は発育速度が緩徐であるため, 転移巣に対しても積極的な外科的切除にて良好な予後が期待できると思われた.

肛門外脱出を来した直腸癌を2例経験した. 症例1は51歳の男性で, 直径4cm大で腫瘍が肛門縁から5cmの部位に存在した. 直上にBorrmann 1型の腫瘍を併発しており, 2群リンパ節郭清を伴う超低位前方切除を施行した. 病理組織検査ではm癌であった. 症例2は68歳の女性で, 直径約6cm大の腫瘍が肛門縁から3cmの部位に存在した. 超音波内視鏡でsm癌と診断し経肛門的に切除した. 病理組織検査でもsm癌であった. 切除断端には癌組織を認めなかった.大腸癌が肛門脱出を来す機序としては有茎性腫瘍が脱出する場合と直腸脱に伴う腫瘍脱出があるが, 前者の場合は腫瘍の大きさにかかわらず早期癌である可能性が非常に高い. 自験例では2例とも前者の機序と考えられた.

A 73-year-old woman with a tentative diagnosis of gallbladder cancer had undergone cholecystectomy with liver resection and dissection of regional lymph nodes. Pathological examination of the resected specimen revealed well-differentiated papillary adenocarcinoma of the gallbladder with subserosal invasion. No evidence of metastasis was noted in the dissected lymph nodes. After surgery, she had been disease free in the follow-up study. Ten years after surgery, however, carcinoma arising from the common bile duct was newly found, and pancreaticoduodenectomy with regional lymph nodes dissection was performed. Histological examination confirmed well-differentiated adenocarcinoma of the common bile duct. Lymph nodes had no evidence of malignancy. The patient has been doing well with no evidence of recurrence 20 and 10 years after each operation, respectively. Apparently, these two cancers occurred independently and each surgical treatment for this patient was successful.