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A 60-year-old woman with an 8-year history of Cushing’s syndrome was evaluated. Biochemical data were consistent with those of Cushing’s disease. Plasma ACTH levels responded paradoxically to GnRH. MRI demonstrated a large tumor occupying the sphenoid sinus, which was enhanced by gadolinium diethylenetriamine pentaacetic acid (Gd-DTPA). The pituitary gland was normal in shape and was located in the sella turcica without dislocation. The pituitary gland and the sphenoid tumor could be distinguished by the obvious difference in their MRI intensities. Three consecutive partial resections of the sphenoid tumor were performed, but plasma ACTH and cortisol levels remained high just after the third operation. Histological studies revealed a chromophobe adenoma immunohistochemically positive for ACTH. However, adrenal crisis occurred 3 months after the third operation during reserpine administration ( 1.5 mg/day for approximately 2 mo) for the treatment of Cushing’s syndrome due to the residual tumor in the sphenoid sinus. Subsequent MRI showed no change in the tumor shadow, and the paradoxical response of plasma ACTH levels to GnRH remained unchanged. The fourth operation reconfirmed the existence of the ACTH-producing adenoma in the sphenoid sinus. There was no anatomical interaction between the sphenoid tumor and the pituitary gland, and, histologically, no tumor cells were present in the pituitary gland. These findings suggest that the tumor is an ACTH-producing ectopic pituitary adenoma arising from the sphenoid sinus. The patient has been in remission for 4 years on glucocorticoid replacement therapy. The factors responsible for the adrenal crisis were not well understood, although reserpine administration might have had some role.

A case of Takayasu’s arteritis with multiple aneurysms is reported. A 34-year-old woman was found to have an abdominal tumor incidentally by ultrasonography during pregnancy. The abdominal aneurysm measured 6 cm in diameter and was resected after delivery. The pathologic sections of the aneurysmal wall revealed chronic inflammation due to Takayasu’s arteritis. Involvement of branches of the aortic arch was not detected at that time. One year later, aneurysms of the right subclavian and vertebral arteries were found during follow-up. They were successfully managed surgically and pathologic examination of the specimens showed similar changes to the previous one. Stenotic lesions are predominant and aneurysm is infrequent in Takayasu’s arteritis. A brief review of the literature is given.

症例は74歳の男性で，数日前に突然右下腹部痛が出現し近医を受診後，当院に紹介となった．初診時，腹部は全体に膨隆しており，反跳痛を認めた．腹部CTで腹腔内中央部に辺縁が不均一に造影され内部が低濃度な300mm大の腫瘤，最大径40mm大の多発肝病巣，腹腔内に散在する小結節を認めた．以上より，多発肝転移・腹膜播種を伴う腹腔内腫瘍の切迫破裂と診断し開腹手術を施行した．主病変は小児頭大で幽門下部の大網付着部に基部を有する腫瘍および複数の小播種結節を認めた．主病変および周囲の粗大播種結節を切除した．主病変は300×280×80mm大で，重量は2,413gであった．病理組織学的に高悪性度大網原発線維肉腫と診断された．退院後，化学療法としてドキソルビシンを使用したが，術後7か月目に死亡した．大網に発生したきわめてまれな線維肉腫の1例を経験した．

後腹膜線維症を合併したIgG4関連硬化性胆管炎と考えられる1例を経験したので報告する．症例は82歳，男性．発熱と腹痛を主訴とし総ビリルビン，胆道系酵素の上昇，IgG4値の上昇を認めた．造影CT検査では総胆管，肝内胆管の拡張があり，上腸間膜動脈根部から末梢12cmの範囲にわたり動脈周囲を取り囲むような濃染像を認めた．胆道造影で総胆管拡張，下部胆管の狭窄像を認めたが，胆汁細胞診は陰性であり，上腸間膜動脈周囲の腫瘤にたいするEUS下穿刺吸引細胞診でも悪性所見は認められなかった．上記により後腹膜線維症を伴ったIgG4関連硬化性胆管炎を疑い，ステロイド治療を行った．腫瘤は縮小傾向を示すも胆管ステントの度重なる閉塞のため胆管空腸吻合を施行した．胆管内腔の生検では線維化とIgG，IgG4染色陽性の形質細胞の浸潤が認められ，悪性像は認められなかった．

Recently, solitary fibrous tumors occurring in spine-related lesions have been reported. However, the destruction of vertebral bodies by this type of tumor has not been reported. A 71-year-old female presented with pain from a mass on the right side of her neck. Plain radiographs of the cervical spine showed collapse of the C5 vertebral body and dislocation of the C4 vertebral body. The MRI image showed a large mass surrounding C4 and C5, which had low signal intensity in the T1W image and high signal intensity in the T2W image. At first, resection of the tumor and spinal fusion was performed by anterior approach. Histology revealed a solitary fibrous tumor with proliferating spindle cells. Immunohistochemistry showed positive stains for vimentin and CD34. One year postoperatively, a local recurrence manifested extensive destruction of the C4 and C5 vertebral bodies. Then, palliative surgery with posterior cervical instrumentation and radiation therapy were performed. Because the destruction proceeded and the rods were broken 2 years after, she underwent additional occipito-cervical instrumentation. This is the first report of a solitary fibrous tumor that involves the destruction of the spinal structure. An extensive destruction of the vertebral body by the solitary fibrous tumor needs to be aware in treating this tumor with spinal involvement.

Hassall's corpuscles are regular structures in the medulla of the normal thymus and in non-neoplastic thymic conditions, e.g. in multilocular thymic cysts. In thymomas, however, they are inconsistently found, and are believed to indicate medullary differentiation of WHO type B1-3 thymomas. We present five organotypical thymomas resembling WHO type B2 and B3 thymomas, but with an abundance of Hassall's corpuscles. We wonder whether this exceedingly rare observation might herald a distinct entity. Four tumors were asymptomatic, incidental findings and of low Masaoka stage (I or II) [20] . One patient suffered from myasthenia gravis which disappeared upon surgical removal of the thymus, while all other patients had no concomitant autoimmune disease. Two patients had a relapse-free follow-up of 12 and 2 years, respectively, upon curative surgery, and another tumor was an autopsy finding; follow-up data of two more recent cases was not yet available. The neoplastic epithelium other than Hassall's corpuscles was arranged either in a cortical type B2 pattern or in type B3 solid cords. In all examples, there was cyst formation, inflammatory reaction and repair, indicative of a long-standing condition. Immature T cells were present in all instances. “Corpuscular thymomas” morphologically resemble WHO type B2 and B3 thymomas, but appear biologically indolent and are rarely associated with myasthenia gravis. Whether they qualify for a separate entity has to be proven by larger series, including genetic studies.

Pancreatic cancer is a rare cause of gastrointestinal bleeding, and it is extremely rare for hematemesis to be the initial manifestation of invasive pancreatic cancer. We report the case of a 67-year-old man with hematemesis who was found to have invasive pancreatic cancer with a bleeding duodenal ulcer. The patient was not icteric, but repeated sudden hematemesis. An urgent pancreatoduodenectomy was performed with a favorable outcome. Microscopic examination revealed that an adenocarcinoma originating from the pancreatic head extended to the muscularis propria of the duodenum. Furthermore, an exposed vessel and narrow fistula were found. The diagnosis, pathological findings, preoperative events, and postoperative outcome in this unusual case are reviewed.

目的:若年性子宮内膜癌患者の妊孕性温存療法時における内膜細胞診の有用性とその臨床的対応を明らかにすることを目的とした.対象・方法:酢酸メドロキシプロゲステロン (MPA) と内膜全面掻爬による温存療法を施行した若年性子宮内膜癌12例中, 内膜細胞診・組織診を同時に施行した6例28回の検査時の細胞・病理学的変化と細胞診判定の正診率を検討した.結果: いずれの症例もMPA投与により異型増殖症, 内膜増殖症を経て, 萎縮状内膜へと変化した. 同時に施行した内膜組織診の正診率は25/28 (89%) であった.結論:若年性子宮内膜癌の診断・治療効果判定に, 細胞診判定のみによる対応では変性した複雑型内膜増殖症の誤判定があるものの, 内膜細胞診は大多数有用であった.

We report an unusual case of a large solitary fibrous tumor (SFT) in the retroperitoneum. A 53-year-old man was referred to our hospital for surgical treatment of a swelling in the right flank with dull pain. Abdominal computed tomography (CT) and echograms showed a large encapsulated tumor compressing the right kidney and liver. At laparotomy, the tumor was found to be encapsulated but fixed to the capsule of the right kidney within a small area. Therefore, complete removal was achieved. The resected specimen was an encapsulated elastic hard tumor, 14 x 13 x 10 cm in size. Immunohistochemical studies revealed reactivity for CD34 and vimentin, but no staining for keratin, S-100, or alpha-smooth muscle actin, confirming a diagnosis of SFT. Although SFT is usually associated with a favorable prognosis, close follow-up is recommended because of the limited information on its long-term behavior.

症例は89歳の女性で,血便を主訴として近医を受診し当科を紹介された.注腸造影検査および大腸内視鏡検査により直腸Rs領域に40mm大の2型腫瘤影を認め,生検の結果,高分化腺癌と診断された.このため直腸癌の診断にて手術を施行した.腫瘍は盲腸,右尿管・卵管に癒着しており,直腸低位前方切除術に加え,回盲部切除,右尿管部分切除,右卵巣卵管切除を行った.切除標本で,腫瘍は虫垂から直腸を貫くように発育していた.病理組織検査では粘液嚢胞腺癌で,これに接する直腸壁は正常であった。以上の所見より,原発性虫垂癌の直腸穿通と診断した.自験例は特異な発育進展形態のため,直腸癌と術前診断したが,術後の検索で原発性虫垂癌の直腸穿通と診断されたまれな症例である.

1 Dodick DW. Thunderclap headache. JNNP J Neurol Neurosurg Psychiatry, 2002;72:6–11. 2 De Bruijn SFTM, Stam J, Kappelle LJ. Thunderclap headache as first symptom of cerebral venous sinus thrombosis. Lancet, 1996;348: 1623–1625. 3 Chilvers E, Rudge P. Cerebral venous thrombosis and subarachnoid haemorrhage in users of oral contraceptives. BMJ, 1986;292:524. 4 Dindar F, Platts ME. Intracranial venous thrombosis complicating oral contraception. Can Med Assoc J, 1974;111:545–548. 5 den Heijer M, Blom HJ, Gerrits WB, et al. Is hyperhomocysteinaemia a risk factor for recurrent venous thrombosis? Lancet, 1995;345:882–885. 6 Pinto AN, Canhao P, Ferro JM. Seizures at the onset of subarachnoid haemorrhage. J Neurol, 1996;243:161–164. 7 Minadeo JP, Karaman BA. Headache: cortical vein thrombosis and response to anticoagulation. J Emerg Med, 1999;17:449–453. 8 Sztajzel R, Coeytaux A, Dehdashti AR, et al. Subarachnoid hemorrhage: a rare presentation of cerebral venous thrombosis. Headache, 2001;41: 889–892.

目的. 印環細胞型腺癌成分を含む原発性肺腺癌について臨床病理学的な検討を行った. 対象・方法. 最近12年間で生検にて印環細胞型腺癌成分を確認した4例を対象とした. 臨床事項として, 年齢, 性別, 喫煙歴, 臨床もしくは病理病期, 手術適応, 予後, および画像病理学的事項として, サイズ, 局在, 病変の内部および辺縁性状, 血管集束の有無, 分化度, 隣接臓器への進展および遠隔転移の有無を検討した. 結果. 同時期の肺腺癌に占める頻度は, 0.82%(4/488) で, 性別は男性3例, 女性1例. うち1例は39歳の若年者であった. 2例は中枢発生, 2例が末梢発生であった. 画像上は, 充実性で境界は明瞭, 辺縁はnotchもしくはspiculaを呈し, 周囲にすりガラス状の領域はみられなかった. 4例中3例は検診指摘例であったにもかかわらず, いずれも隣接臓器への浸潤もしくは遠隔転移を伴い, 手術施行例は1例のみであった. 手術不適応例は数ヶ月以内に癌死し, 手術施行例も術後11ヶ月で癌死した. 考察. 今回の検討では, 症例数が限られているが, 画像上, 充実性, 境界明瞭, 辺縁不整な性状を呈し, 周囲にすりガラス領域はみられなかった. 所属リンパ節転移もしくは局所浸潤/遠隔転移を伴い, 悪性度の高い性格が示唆された. また生検組織診断の結果, 転移性肺腫瘍疑いとされ, 肺以外の全身検索を施行した. 印環細胞型腺癌は最近改訂されたWHO分類の肺腺癌Variantsの中にも記載されており, 正しい認識が必要であり, 今後の症例の蓄積と更なる臨床病理学的検討が望まれる.

Stereotactic radiosurgery is an encouraging approach to deliver higher doses of radiation boost for malignant gliomas safely and precisely. The purpose of this study was to investigate the radiation response and histological changes of malignant astrocytic tumors after stereotactic linac radiosurgery (SLRS). We studied an autopsy case of recurrent glioblastoma multiforme (GBM) and two surgical cases with gross total removal of recurrent GBM and anaplastic astrocytoma transformed from fibrillary astrocytoma treated with SLRS. Destructive changes, such as the disappearance of viable cells, coagulation necrosis, and fibrinoid degeneration of vascular walls, were observed in the center of the target of SLRS, which showed histologically similar radiobiological reactions to well-known delayed central nervous system radiation necrosis caused by conventional radiotherapy. The region showing such radiation necrosis was within the area irradiated with approximately 15–20Gy or more by SLRS; however, dense viable tumor cells remained in the periphery that was irradiated with less than 15 Gy. In a comparative immunohistochemical study of the tumors before and after SLRS, neither MIB-1 and p53 labeling indices nor immunoreactivity for GFAP represented any persistent tendencies. There were very few TUNEL-positive cells in either tumor before and after SLRS. These results showed that radiosurgery for malignant gliomas leads to earlier radiation necrosis than conventional radiation and that it is useful in eradicating tumor cells in the center of the target. However, some viable tumor cells may remain in the periphery irradiated with an insufficient dose for cell death and may be partly transformed in character by DNA damage due to radiation. Proton magnetic resonance spectroscopy (MRS) was suggested to characterize the radiation response in radiosurgery tumor targets for correlation with histological findings.

A nondissecting aneurysm of the distal descending thoracic aorta, 55 mm in diameter, in a 35-year-old woman who was undergoing 24-year steroid therapy of systemic lupus erythematosus was successfully resected and replaced with a tube graft. The suture line of the aortic wall was reinforced with a polytetrafluoroethylene felt strip. Histologically, the media and adventitia contained numerous lymphoplasmacytic infiltrates that consisted of b and activated t cells mixed with plasmacytes. These findings would have been in accordance with active aortitis. Systemic lupus erythematosus was suggested as possibly associated with nondissecting thoracic aortic aneurysm, especially in patients undergoing chronic steroid therapy in which inflammation continued. (J Vasc Surg 2002;35:801-4.)

【緒言】胸壁の良性脂肪腫が33年間に6回の手術を施行される間に悪性化し,脂肪肉腫となった症例に関し,後半の18年間を追跡しえたのでその経過を報告する.【症例】80歳,女性. 1967年と1974年に左胸部に生じた手拳大の脂肪腫を某医で切除された. 1982年には同部に再出現した腫瘍に対し当科で手術を行った.診断は良性脂肪腫であった. 1988年に再度腫瘍は増大し前回腫瘍の再発と考えた.腫瘍は大胸筋へ癒着していたので,一部合併切除し,腋窩リンパ節郭清を行った.診断は紡錘型細胞脂肪腫であった. 1991年にも再発し,前回同様紡錘型細胞脂肪腫と診断された. 1997年より左肩部に腫瘍が増大し, 2000年には左胸壁にも腫瘍が出現し急速に増大するため通算6度目の手術を施行し,高分化型脂肪肉腫と診断された.【考察】本症例では良性脂肪腫が歳月と再三の手術の影響でその性質を変え,紡錘型細胞脂肪腫からさらには分化型脂肪肉腫へと推移していったものと判断した.

Apolipoproteins in the cerebrospinal fluid (CSF) play important roles in lipid metabolism in the central nervous system. Although it has been demonstrated that apo E is synthesized in the neuron, the synthesis of apo A-I has only been determined in fish and chicken. It was demonstrated that apo A-I concentrations in the CSF were increased in poliovirus-infected macaques, however, the origin of the CSF apo A-I was not determined. The present immunohistochemical study provided evidence that apo A-I was localized within the nerve cell body of the rat spinal cord. In situ hybridization also showed that apo A-I mRNA was predominantly expressed in the neurons. As a further experiment, we compared apo A-I levels in the spinal cord from control rats and rats with experimental allergic encephalomyelitis (EAE), which was induced by sensitization with myelin basic protein. Although no significant changes in serum apo A-I levels were observed, apo A-I levels in the spinal cord were significantly elevated in EAE rats. Furthermore, apo A-I in the spinal cord of rats with EAE was not seen in the nerve cell body, but at the interstitium, particularly in lesions where inflammation had occurred. The current study clearly demonstrated that apo A-I is synthesized in the neurons of the rat spinal cord and the synthesis was suppressed in EAE rats.

A 52-year-old woman was found to have a liver tumor during treatment for a liver abscess. The tumor was diagnosed as intrahepatic cholangiocarcinoma by closer examinations, including a percutaneous needle biopsy. Ten years previously, she had undergone excision of a choledochal cyst, with reconstruction by Roux-en-Y hepaticojejunostomy, as treatment for Todani's type Ia congenital biliary dilation, which had been confined only to the extrahepatic bile duct. The significant association between congenital biliary dilation and hepatobiliary malignancies is well known. Some patients have been reported to develop biliary cancer long after the excision of the entire extrahepatic bile duct and hepaticoenterostomy. However, in these patients, the development mostly took place in the remnant choledochal cyst, the anastomotic site, or in the dilated intrahepatic bile duct of Todani's type IV-A congenital biliary dilation. The development of intrahepatic cholangiocarcinoma after operation has not been reported previously in a patient with Todani's type I congenital biliary dilation. This case suggests that the entire biliary tree may have a high risk of field cancerization, even in extrahepatic congenital biliary dilation.

Background: Endotracheal/endobronchial metastases (EEMs) from nonpulmonary neoplasms are rare. However, their definition and developmental modes have not yet been fully elucidated. Methods: EEMs were defined as documented nonpulmonary neoplasms metastatic to the subsegmental or more proximal central bronchus, in a bronchoscopically visible range. The clinical and pathologic features of 16 cases were reviewed, with special emphasis on the developmental modes based on five criteria: location in the tracheobronchial tree, number of lesions, laterality of lesions, depth of lesions, and relationship with the associated bronchus. Results: The developmental modes were proposed on the basis of the above five criteria as follows: type I, direct metastasis to the bronchus; type II, bronchial invasion by a parenchymal lesion; type III, bronchial invasion by mediastinal or hilar lymph node metastasis; and type IV, peripheral lesions extended along the proximal bronchus. Primary tumors included colorectal in six patients, breast in three patients, uterus in two patients, osteosarcoma of the bone in two patients, and maxillary, larynx, and parotid carcinoma in one patient each, respectively. The mean recurrence interval was 65.3 months. The developmental modes were as follows: type I, five patients; type II, one patient; type III, four patients; and type IV, nine patients. Three patients underwent surgical resection. One patient has remained well for 5 years after operation. Median and mean survival times were 9 months and 15.5 months, respectively. Conclusion: The mean recurrence interval was long at 65.3 months, but the mean survival time was short at 15.5 months. Type I accounted for only 5 of 16 patients. Type II was found in only one patient. It is thought that this type is a rare form. Type IV affected nine patients. Treatment plans must be individualized, because in some cases, long-term survival can be expected. (CHEST 2001; 119:768‐775)

症例は14歳の女児.発熱を主訴に近医を受診した.胸部X線写真で左上肺野に無気肺像を認め, 精査目的にて当院小児科へ入院した.胸部CT所見では左主気管支上葉支分岐部において気管支内外へ発育する腫瘍を認めた.気管支鏡で左主気管支内腔に径約10mmの易出血性腫瘤を認めた.腫瘍の気管支外発育及びそれによる無気肺のため手術適応と判断され, 当科転科となった.術中, 左上葉に完全無気肺を認め, 左主気管支壁は硬く肥厚しており腫瘍の浸潤が疑われたため, 左上葉管状切除術を施行した.切除標本の病理学的診断は粘表皮癌であり, 組織学的にリンパ節転移は認めなかった.気管支腫瘍の大部分はカルチノイドであり, 比較的稀な小児に発生した粘表皮癌の一手術例を報告する.

直腸肛門部悪性黒色腫は比較的まれで, 極めて予後不良な疾患である. 今回, 比較的早期に発見された2症例に対し, 生検後の局所追加切除あるいは腹会陰式直腸切断により, 術後3年以上の長期生存をみているので, その概要を紹介し若干の文献的考察を加えた.症例1: 76歳の男性, 10mm大の直腸ポリープの診断にてポリペクトミーを施行したところ, 病理組織学的に低色素性黒色腫と診断された. 直腸切断術を勧めるも患者の強い希望で局所の追加切除のみにとどめたが, 術後8年目の現在無再発生存中である.症例2: 72歳の女性, 25mm大と10mm大の黒色腫瘤を伴う最大径48mmの黒色腫であった. 生検により診断確定し, 約4週後に腹会陰式直腸切断術 (D2) を施行した. 進行度はsm, v0, ly0, n (-) のStage Iであった. 術後4年1か月の現在, 無再発生存中である.

Angiogenesis is considered to play an important role in the development of malignant brain tumors, especially glioblastoma multiforme (GBM). Abnormal vascular construction with a glomeruloid appearance is characteristic of GBM. beta-catenin is known as one of the adhesive molecules associated not only with cell adhesion and cell polarity, but also with carcinogenesis. We postulated the relevance of beta-catenin to vigorous endothelial proliferation in human GBM because the vascular cells (VCs) are apt to lose their cell polarity. The object of this study is to compare the immunohistochemical localization of beta-catenin in VCs between GBMs and normal brain tissues. Immunohistochemical analysis of beta-catenin for VCs in 32 GBMs and 10 normal brain tissues was performed. beta-catenin was found concentrated in the areas of vascular cell-cell junction and internal surface of the vascular lumen in all normal brains. In contrast, beta-catenin, in proliferating VCs in GBMs, was stained homogeneously and intensely in the cytoplasms of 26 cases (81.3%), in which nuclear staining of beta-catenin was also recognized in four cases (12.5%). In conclusion, the intracellular localization of beta-catenin in VCs of GBMs was found to be different from that of normal brain tissues. The changes of expression of beta-catenin may be associated with the angiogenesis or transformation of the VCs in human GBM.

We report herein the case of a 69-year-old man in whom rapid growth of a retroperitoneal rhabdomyosarcoma occurred following hemicolectomy for ascending colon cancer. On his first admission for surgery, a small lesion, 1.5 cm in diameter, was detected adjacent to the inner side of the left kidney by abdominal axial computed tomography (CT), which was initially suspected to be a benign lesion; however, a postoperative follow-up CT scan done 5 months later revealed that the lesion had enlarged remarkably to 8 cm in diameter. Thus, total resection was performed under the presumed diagnosis of a malignant retroperitoneal tumor. The tumor was found to be adjacent to the inner portion of the left kidney and covered by Gerota's fascia. As it involved the ileolumbar muscle and had a metastatic lymph node, complete resection was performed. The resected specimen was 8.5 x 6.5 x 5 cm in size and was histologically confirmed as a retroperitoneal rhabdomyosarcoma of embryonal type. Two courses of adjuvant chemotherapy with adriamycin, vincristine, and cyclophosphamide were given, and the patient has shown no signs of recurrence for 2 years since his second operation.

We report herein the case of a patient in whom a giant adrenocortical carcinoma was found to have recurred in the contralateral adrenal gland and intrapelvic cavity 6 years after his initial operation. A 52-year-old man had consulted our hospital complaining of right upper abdominal pain and weight loss, and was subsequently diagnosed as having a giant adrenal tumor by computed tomography scans and echography. A laparotomy was performed and the tumor, located in the right retroperitoneal cavity and infiltrating the liver and right kidney, was surgically removed. The lesion, 29 x 19 x 10 cm in size and 4700 g in weight, was histopathologically diagnosed as an adrenocortical carcinoma. Adjuvant chemotherapy with mitotane was given for 3 months and his postoperative course was uneventful until a recurrence in the contralateral adrenal gland and peritoneal cavity was found 6 years later. The second resection was successful, and he is currently alive with no further sign of recurrence 8 years after his first operation. We report this unusual case as it provides much useful information on the biological features of adrenocortical carcinomas and the state of tumor dormancy.

急性腹症と発熱にて発症し, 手術後施行した検査にてAIDSと診断された腸結核の1例を経験したので報告する.症例は22歳の女性. 40℃の発熱と軽い腹痛にて当院を受診した. 腎盂腎炎と診断され治療を受けたが発熱は軽快せず, 右下腹部に強い痛みが出現したため当科を受診した. 右下腹部に強い筋性防御を認め, 腹部超音波検査にて同部に低エコー腫瘤を認めた. 膿瘍を伴った虫垂炎を疑い手術を施行した. 回腸末端は手拳大に腫大し, 腸間膜リンパ節は大動脈周囲まで腫大していた. 悪性腫瘍が否定できず, 同部に通過障害を認めた事から回盲部切除術を施行した. 病理組織学的には類上皮細胞を伴った乾酪壊死をみとめ, 喀痰および便の培養検査にて結核菌が検出されたことから腸結核と診断した. 術後も高熱が続き, HIV検査を施行したところ陽性反応を認めた. 結核治療を開始したが発熱が続いたため, 患者は第25病日, AIDS拠点病院へ転送された.

症例は74歳の女性. 右卵巣嚢腫, 胆嚢ポリープの診断で経過観察中. 平成6年8月28日, 腹部超音波検査で脾に径20×20mmの低エコー病変を認めた. 症状はとくに無く病変も小さいことから経過観察とした. 10月9日再検で脾病変は38×45mmと増大していたため, 精査を勧めたが本人の希望で経過観察とした. 左側腹部痛が出現したため12月12日当院受診, 再検で腫瘍は68×67mmと更に増大していた. 腹部CT, 腹部血管造影, 67Gaシンチグラフィーなどの画像診断から脾原発悪性リンパ腫を疑い, リンパ節郭清を伴う脾摘出術を施行した. 病理組織学的所見はmalignant lymphoma, diffuse lymphomalarge cell typeと診断された.術後化学療法は行っていないが, 3年を経過した現在, 再発の兆候なく経過観察中である.

BACKGROUND Multiple chondromatous hamartomas of the lung, which are very rare, are a feature of Carney syndrome. The relation between the two entities is not clear. METHODS A patient with multiple chondromatous hamartomas of the lung is described in this article. The literature was reviewed with special reference to the relation between multiple chondromatous hamartomas of the lung and Carney syndrome as well as the triad of gastric epithelioid leiomyosarcoma, functioning extra-adrenal paraganglioma, and pulmonary chondroma. RESULTS A total of 15 cases of multiple chondromatous hamartomas of the lung have been published worldwide. Two cases exhibited two other features of Carney syndrome, namely, gastric leiomyogenic neoplasms and extra-adrenal paragangliomas, and three other cases demonstrated only gastric leiomyomatous neoplasms. These five patients were all young females. CONCLUSIONS Some patients with multiple chondromatous hamartomas of the lung have a history of Carney syndrome. Patients with multiple chondromatous hamartomas require further examination of other sites, particularly the stomach and nervous system. Cancer 1999;85:2557–61. © 1999 American Cancer Society.

視触診法のみの乳癌検診では検診効果が低いことが指摘されているが, 当院では1986年より受診者全例に視触診とともにセクター方式超音波検査 (以下, US) を併用する乳癌検診を行っており, 総受診者50,378名のうちから61例, 0.121%の乳癌を検出した。このうち, 検診医も精検担当医もともに腫瘤・抵抗を触知しない非触知TO乳癌症例は16例を数え, そのうちの3例は乳頭異常分泌により検出され, 他の13例はUSのみで検出された直径10mm以下の微小腫瘤径乳癌であった。そのうちの非浸潤癌Tis症例は3例, 18.7%のみで他の13例, 81.3%はすべて浸潤癌症例であり, USを併用する乳癌検診では乳房撮影 (以下, MG) を併用する乳癌検診と比較して, 悪性度の高い乳癌をより多く検出していることが示唆された。USのみで検出された13例のTO症例は61例の検診発見乳癌のうちの21.3%に相当し, 視触診法のみの検診では見落とされることとなるが, 同様にMGのみの検診でもこの13例のTO症例のうち4例, 30.8%がMGで「所見なし」であったので見落とされることとなる。全例がnOであったものの, そのうちの3例, 23.1%がリンパ管侵襲陽性(ly1～ly2) であり, 4例, 30.8%が脂肪織浸潤陽性であったことから, 触知し得ない微小腫瘤径乳癌であっても看過できないことが判明した。また, USのみで発見された13例のTO症例のうち11例, 84.6%が毎年繰り返し再診例であり, 平均3.5回で直径10mm以下の微小腫瘤径乳癌がUS上の低エコー像のみで検出されていた。有意に有効な生存率を示す乳癌検診を行うためには, 受診者全例にUSを併用する乳癌検診を毎年繰り返して行うことの重要性が示唆された。

Ischemic stricture ofthe small intestine is a rare entity. We experienced a case of ischemic stricture ofthe small insestine after abdominal angiography. A 72-year-old man was admitted tothe hospital forthe purpose of transarterial embolization (TAE) for hepatic cancer which was detected during observation of clinical course of liver cirrhosis. On abdominal angiography, selective insertion of a chateter was impossible and we could not perform TAE. Afterthe angiography, he developed an abdominal pain. Abdominal CT scan on the next day revealed splenic infarction and bilateral renal infarction.The abdominal pain sustained, and gaseous distention and air-fluid level formation were intensified with time. Fluoroscopic study of the small intestine on 69th day after the angiography revealed a stricture about 7cm in length at the middle of the small intestine. Based on his clinical course, ischemic stricture of the small intestine due to embolus was diagnosed, and the patient was operated on. At operation, the stricture was present about 2cm oral from the terminal ileum, and an excision of the small intestine includingthe stricture was performed.The resected material disclosedthickenning of the wall at the stricture. Histopathological study revelaed ulcer extending to submucosa and ulcer scars. We must entertain a possibility of ischemic enteritis in the treatment of acute abdomen following angiography.

The SMAD-2 gene, which is located at 18q21, has been identified as a candidate tumour-suppressor gene from work on colorectal cancers. The aim of the present study was to determine the clinical alterations and the significance of its mutations in a series of colorectal cancers previously examined for SMAD-4/DPC-4 gene. Mutation analyses of the SMAD-2 gene were carried out on cDNA samples from 36 primary colorectal cancer specimens using a combination of the polymerase chain reaction (PCR), single-strand conformation polymorphism (SSCP) and DNA sequencing. Only one missense mutation (2.8%), producing an amino acid substitution in the highly conserved region, and two homozygous deletions (5.5%) of the total coding region of the SMAD-2 gene were detected in the 36 cancers. The SMAD-2 gene may play a role as a candidate tumour-suppressor gene in a small fraction of colorectal cancers. However, allelic loss at 18q21 is very often seen in this type of tumour. Even in combination with changes in SMAD-4, the observed frequency was not sufficient to account for all 18q21 deletions in colorectal cancers. Thus, another tumour-suppressor gene, such as DCC, discovered as the first tumour-suppressor candidate in the region may also exist in this chromosome region. Images Figure 1 Figure 2

Background and Objectives: Lymph node metastasis is known as a significant predictor of prognosis in colorectal cancer patients. Recently, reverse transcriptase polymerase chain reaction (RT-PCR) has been applied to detecting micrometastasis. To assess the risk of recurrence and accurately determine the spread of tumor cells, we examined lymph node micrometastases in a series of colorectal cancer patients. Methods We examined 202 lymph nodes obtained from 13 colorectal cancer patients who underwent curative operation and were histologically diagnosed to be node-negative, using RT-PCR to amplify mRNAs for two epithelial markers, carcinoembryonic antigen (CEA) and cytokeratin 20 (CK-20). Results All the cases, including early stage patients, had micrometastases. A total of 102 among 202 lymph nodes (50.5%) were positive for either CEA or CK-20, or both (47.0, 40.1, and 36.6% respectively). Positive lymph nodes were spread along the courses of vascular trunks as well as being located in more distant regions. Conclusions Even in histologically negative lymph nodes, there is a considerable possibility that micrometastases may exist. Their detection by RT-PCR may improve clinical staging and indications for cancer therapy. We should also take care in the choice of surgical approach. J. Surg. Oncol. 1998;68:34–40. © 1998 Wiley-Liss, Inc.

We have demonstrated that the dynamic study for breast lesions by magnetic resonance Imaging (MRI) can differentiate benign from malignant lesions objectively. The cases were57 histopathologically appraised breast lesions, including 20 cases of breast cancer, 28 cases of mastopathy, 8 cases of fibroadenoma and 1 case of intraductal papillomatosis. We plotted time-signal intensity ratio curves and then determined 95% confidence intervals, plotting the signal intensity ratio for both breast cancer and mastopathy every 30 seconds during dynamic magnetic resonance mammography (MRM) after gadolinium-diethylenetriamine pentaacetic acid (Gd-DTPA) administration, and further established cut-off points to differentiate between them. We then tried of estimate objectively the benign-malignant differentiation to breast lesions by confirming their signal intensity ratio to be more or less than the cut-off points. We advocate this procedure, and call it the “dynamic ratio method.”As a result, we found highly significant differences between breast cancer and mastopathy at 30 and 60 seconds after Gd-DTPA administration (P

直腸癌を合併した成人腸回転異常症の2例を経験した.症例1は57歳の女性で, 肛門痛と出血を主訴として来院.直腸鏡検査にて2型の直腸癌と診断され, 注腸造影で腸回転異常が認められた.開腹時, 回盲部, 上行結腸は正中部に存在しており, 小腸は右側に大腸は左側に偏位しており無回転症と診断した.直腸癌に対してはD2郭清を伴う腹会陰式直腸切断術を施行した.腫瘍は6.2×3.8cm大でstage Iの腺扁平上皮癌であった.症例2は62歳の女性で, 血便を主訴として来院.直腸Ra部に腫瘍が認められ, 注腸造影にて腸回転異常が疑われた.開腹時, 症例1と同様の所見が認められ無回転症と診断した.直腸癌に対してD3郭清を伴う低位前方切除術を施行した.腫瘍は52×47mm大の2型の直腸癌でstage IIIaの中分化型腺癌であった.2例とも腸回転異常に対しては, 予防的虫垂切除術のみを施行した.腸回転異常症は併存病変の診断治療を困難にする可能性があり, 本症を念頭に置く必要があると考えられた.

A 53-year-old man was admitted to the hospital because of left flank dull pain. Abdominal US revealed a dilatation of the pelvis of the left kidney. DIP showed left non-function kidney and CT combined DIP revealed air density in the dilated pelvis. When percutaneous pelvic drainage was conducted, pus discharge was observed, and a catheterography performed at that time visualized that a contrast material entered the descending colon. We diagnosed the case as renocolic fistula. Pus discharge and high grade fever persisted and so a lapalotomy was performed 5 days after drainage. Left nephrectomy and partial resection of the colon were performed. A histological study revealed squamous cell carcinoma, grade 1, INFα, pT (colon), pR0, pL0, pV0. It has been reported that squamous cell carcinoma of the renal pelvis grows invasively. This case in which the carenoma directly invaded the colon to form fistula is very rare.

A 63-year-old woman was admitted to the hospital because of hematochezia. Severe anemia and thrombocytopenia were noted (red blood cell 248×104/mm3, hemoglobin 5.8g/dl, hematocrit 19.6%, platelet count 0.8×104/mm3). The patient was diagnosed as sigmoid colon cancer associating with idiopathic thrombocytopenic purpura (ITP). Transfusion of 25 units of platelet was performed and a large dose of globulin 20g/day for 5 days, methylprednisolon 500-1000mg/day, and prednisolone 50mg/day were administered. When the platelet count increased to 25.2×104/mm3, splenectomy and sigmoidectomy with lymphnode dissection (D2) were carried out. After the surgery, abnormal bleeding did not occur and the postoperative course was uneventful. After discharge, the patient has been followed at outpatient clinic as of 6 month after the operation, and the plateletcount is kept at good level of 25.2×104/mm3 without taking predonisolone.The large dose gulobulin regimen appears an extremely safe and useful method in preoperative management of surgical patients with ITP. It is possible to keep increased platelet level by splenectomy.

A 52-year-old man with a past history of a pituitary adenoma and hyperparathyroidism due to a parathyroid adenoma was admitted because of a solitary tumour of the pancreas revealed by ultrasonography. His family history was unremarkable. Plasma glucagon levels were slightly elevated (280 ng/l, normal range, 40-180 ng/l) with decreased plasma amino acid levels. Plasma glucagon levels disclosed an exaggerated response during an arginine infusion test and paradoxical elevation during a 75 g oral glucose tolerance test. Endoscopic ultrasonography revealed a monolocular cystic mass of about 3 cm in diameter in the body of the pancreas. A pancreatic tumour was diagnosed before surgery as a cystic glucagonoma. Intra-operative ultrasonography showed one cystic mass in the body of pancreas and two other solid tumours, about 1 cm and 0.5 cm in diameter, in the tail of the pancreas. Histologically, all three tumours showed neoplastic epithelial cells with round nuclei forming cords and/or a ribbon-like arrangement. They showed positive staining for Grimelius' silver stain and immunopositive cells for glucagon. Genetic analysis of the main cystic tumour revealed loss of heterozygosity (LOH) on chromosome 11. After the operation, the responses of plasma glucagon to arginine infusion and oral glucose became normal. Here we describe the usefulness of these provocation tests for early diagnosis and post-operative follow-up in a rare cystic glucagonoma associated with multiple endocrine neoplasia type 1 (MEN 1) which had LOH on chromosome 11.

Thirty-five patients with prostate cancer were examined for micrometastases to the bone marrow using reverse transcription-polymerase chain reaction (RT-PCR) with primers specific for the prostate-specific antigen (PSA) gene. Of nine patients with bone metastases detectable by bone scan imaging, five patients had PSA mRNA expression in the bone marrow detectable by RT-PCR. Of 26 patients with negative bone scan findings, seven patients had PSA mRNA expression detectable in the bone marrow. RT-PCR could detect micrometastatic prostate cancer cells in the bone marrow that were not detectable by bone scan imaging. Of 16 patients with a serum PSA concentration of 25 ng ml(-1) or greater, only nine (56.3%) had bone metastases detected by bone scans. Of the remaining seven patients, five had micrometastases to the bone marrow detected by RT-PCR. Overall, 14 of 16 patients (87.5%) with a serum PSA concentration of 25 ng ml(-1) or greater had metastatic bone diseases including bone marrow micrometastases. Of 19 patients with a serum PSA concentration of less than 25 ng ml(-1), two (10.5%) had only micrometastatic disease detected by RT-PCR. A significant correlation was observed between the incidence of bone involvement and the serum PSA concentration. This study suggests that RT-PCR will potentially develop into a relevant tool to assess bone involvement including bone marrow micrometastases and establish a precise correlation between serum PSA concentration and metastatic bone disease in patients with prostate cancer. Images Figure 1

We report a very rare case of primary retroperitoneal Castleman's lymphoma accompanied with myastenia gravis. A 57-year-old male was admitted to the 1st department of medicine in our hospital because of dysphagia and speech disturbance and was diagnosed as myastenia gravis. After admission a retroperitoneal tumor was found by abdominal computed tomography and echogram. He was transferred to the department for operation. Upon laparotomy a 58×48×30mm tumor, rich in blood supply, was located beside the left kidney and showed good movability. In addition a feeding artery from the abdominal aorta and a draining vein to the testicular vein were seen. He also had a hemangioma, angiolipomyoma of the right kidney and left renal cyst. The tumor was diagnosed as Castleman's lymphoma based on pathologically findings of lymphadenoid tissue with germinal centers following hyalinization and an increase of capillary vessels. Our case is considered the forth report in the world as far as we could review. A remission of subjective achieved to some extent, but the sign were unchanged after the operation. Therefore, the relationship between Castleman's lymphoma and myastenia gravis is still obscure.

We have revealed that a dynamic study of the breast using MR Imaging technique can estimate objectively benign-malignant differentiative diagnosis. Subjects were 41 cases of breast lesion, including 13 cases of breast cancer, 21 cases of mastopathy, six cases of fibroadenoma and one case of intraductal papillomatosis, and the results of them were investigaged in comparison with histopathological diagnosis. As so the method, we drew up time-signal intensity ratio curve plotting signal intensity ratio at each 30 second of dynamic MR mammography after Gd-DTPA administration. We found a especially high significant difference between breast cancer and mastopathy, within 90 second after Gd-DTPA administration (p=0.0000). Still more, we established cut off point concerning with establishment of 95% confidence interval, that is, at 30 second after Gd-DTPA administration the point equivalent 1.53 at 60 second equivalent 2.00, at 90 second equivalent 2.47, and about this estimating maneuver using the cut off point we named Dynamic ratio method. We can estimate preoperatively not only benign-mallignent differentiative diagnosis with breast tumor, but also neighboring infiltration and lymph node metastasis of breast cancer using this Dynamic ratio method. Over again, Dynamic ratio method provides fine information to preoperative decision of resecting region for breast conserving surgery. The efficiency of this method is sensitivity=92.3%, specificity=89.3% and positive predictive value=80.0%