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〈目的〉各種気管病変による気管壁の異常所見は，通常のCT検査および内視鏡検査で確認するのにとどまってきた。通常のCT検査に呼吸運動を加えたdynamic CT検査が，気管病変の診断に新たな情報をもたらすか否かを検討した。〈対象および方法〉dynamic CT検査は，通常の胸部CT画像から壁運動が最も異常を示すと思われる部位で深呼吸時に，1秒スキャン1秒インターバルでデータ収集を行った。連続的に作成した画像をシネモードにして気管壁の動きを観察した。対象は2000年8月～2002年4月の間に検査された気管病変9例で，その内訳は，年齢28～86歳，男女比5：4で，A群：気管壁伸展例2例（気管憩室1例，皮膚弁による気管壁欠損部補填1例），B群：腫瘍あるいは損傷による気管狭窄例7例（悪性腫瘍による気管狭窄4例，気管損傷3例）の2群に分類して検討した。〈結果〉dynamic CT検査は気管壁を動的にとらえることができた。気管壁が軟弱となっている気管憩室と皮膚弁による気管形成術後の2例では，吸気終末あるいは呼気終末時に続く最後の怒責によって気道内圧が上昇したときに，軟弱部が外側に膨隆することにより著明な気道腔開大が認められた。一方，腫瘍性狭窄例では全例で呼気時の狭窄が著明となり，腫瘍浸潤のために気管壁の動きが不良となった範囲とその程度を明示することができた。〈結論〉気管におけるdynamic CT検査は，病変の範囲および進行状況を把握するのに有用であり，さらに治療法を検討する上での一助になると思われた。

症例は2歳8ヵ月の男児で, 咳嗽, 呼吸困難のために当院に入院.胸部X線, CTで左上葉の過膨脹を認めた・全身麻酔下の気管支鏡検査で左上葉支のチェックバルブ状の狭窄を認め先天性肺葉性肺気腫と診断した.治療は左上葉切除を行い, 術後経過は順調であった.病理検査では左上葉気管支壁に異常は認めず, 原因不明であった.手術時の体重は正常下限であったが, 術後1年4ヵ月には体重は平均値にまで増加し, 先天性肺葉性肺気腫が患児の正常な成長に障害となっていた可能性が示唆された.

薄壁空洞を形成した原発性肺腺癌を経験した.症例は59歳, 男性.咳嗽, 血痰, 発熱を主訴に近医受診, 胸部X線写真およびCT写真上, 右上葉に直径約6.5cm大の薄壁空洞を伴う陰影を認め当院紹介となった.精査にて原発性肺腺癌と診断, 右上葉切除術を施行した.病理診断で低分化型腺癌と診断 (P-T3NOMO), また空洞壁内には壊死組織凝血壊死像やfibrinの析出を認めた.空洞形成の原因は腫瘍内部の壊死によると考えられた.術後5カ月目に左肺野に同様の薄壁空洞が多数出現し転移と診断, その後も空洞は急速に発育し, 10カ月目に癌死した.肺癌における薄壁空洞形成は比較的稀である.自験例における空洞形成の成因は病理所見, 臨床経過などから癌細胞自体から分泌される蛋白分解酵素によるCell Autophagism説が疑われた.文献的考察を加え報告する.

Controversy exists regarding the relationship of the degree of c-erbB-2 amplification to other prognostic factors in breast cancer. To determine the degree of amplification of c-erbB-2 exactly, a sensitive and quantitative method is required. We have developed a competitive PCR method to quantitatively determine the amplification of the c-erbB-2 oncogene. Using this method, we evaluated DNA from 27 breast cancer tissue specimens and DNA from peripheral blood leukocytes from a normal individual. Regarding the relationship between the degree of c-erbB-2 amplification and clinicopathological factors, we found a greater degree of amplification of the c-erbB-2 oncogene in estrogen receptor- negative or progesterone receptor-negative specimens than in positive ones and in lymph node metastasis-positive specimens than in negative specimens, in stages II, III, and IV of disease compared with stage I disease, and in samples with positive lymphatic vessel invasion than with no lymphatic vessel invasion. Generally, these factors were seen in the group of patients who had a bad prognosis. By univariate analysis and multivariate analysis, reverse correlation was observed between amplification of c-erbB-2 and overall survival. Regarding disease-free survival, these relationships were observed only with univariate analysis in our group of patients.

症例は64歳男性で血疾を主訴に近医を受診し胸部X線写真上, 前縦隔に巨大な腫瘍を指摘され精査目的で当院に1994年10月27日に入院した.CTガイド下生検で胸腺癌 (扁平上皮癌) と診断され, 静脈造影検査では左腕頭静脈の狭窄像を認めたため正岡III期と診断した.腫瘍の完全切除が可能となるよう腫瘍の縮少と微小遠隔転移の制御を目的として術前化学療法を施行した.CDDP 80mg/m2×2, VDS 3mg/m2×2を1クール, CBDCA 200mg/m2, VDS 2mg/m2を1クール施行したところ腫瘍は30%に縮少した.1995年1月25日に胸骨正中切開下に左上葉部分切除, 左腕頭静脈合併切除を併用して腫瘍を完全に切除し, 併せて縦隔リンパ節郭清も行った.切除検体内にviableな細胞を認めたため術後縦隔に60Gyの放射線療法を施行後退院し, 術後2年の現在再発なく健存中である.胸腺癌は比較的血行性転移が多く, 進行例に対しては術前の腫瘍の縮少化と微小遠隔転移の制御のために術前化学療法が有効となる可能性が示唆された.

症例は53歳男性, 嚥下障害を主訴に近医受診, 食道癌の疑いで紹介入院となった.全身検索の結果, 原発性食道癌, 原発性肺腺癌及び転移性脳腫瘍と診断されたが症状緩和のため食道癌の切除を計画, 同一術野にて肺切除も可能と判断し食道亜全摘術及び左下葉切除術を施行した.術後病理検査により肺の腫瘍は原発性低分化型腺癌, 食道の腫瘍は肺からの転移と診断された.原発性肺癌の食道転移は剖検例においては比較的稀ではないとされているが, 手術報告例は少なく自験例を含め3例にすぎない.また一期的手術施行例は1例のみで自験例が2例目であった.

一時的バイパス設置下に切除し得た大動脈漫潤肺癌2例を経験した.症例1は64歳男性, 左上葉大細胞癌。腫瘍は下行大動脈に浸潤しており, 左鎖骨下動脈一下行大動脈間にバイパスを設置し大動脈の外膜のみを剥離して, 左上葉切除によって摘出した.症例2は48歳男性, 左下葉腺癌.腫瘍は下行大動脈に浸潤しており, 腫瘍を挟み下行一下行大動脈間にバイパスを設置して大動脈環状切除を行い, 左下葉切除によって摘出した.肺癌の大動脈浸潤例に対する一時的バイパスの設置は補助循環を使用する事なく簡便でかつ安全な方法であると考えられた.

This paper descibes a case of recurrent pneumothorax two months after a thoracoscopic bullectomy for spontaneous pneumothorax which needed another bullectomy. A 25-year-old man was seen at the male visited our hospital because of right chest pain and was admitted with a diagnosis of right spontaneous pneumothorax. We successfully performed a thoracoscopic bullectomy and the patient was discharged from the hospital. However, on the 67th postoperative day, the patient was re-admitted because of recurrent pneumothorax, and on the 77nd postoperative day, we performed another bullectomy via axillary thoracotomy. At the re-operation, one bulla measuring about 1.5 cm which was located from near the staples of th first operation was found to be ruptured. It is thought that a major cause of such a recurrent case is oversight of bullae and neoplasms or their enlargement. Mechanisms and causes of recurrent pneumothorax should be further investigated.

In case of sternal resection, it is necessary to preserve bone material indispensable for the stability of the anterior chest wall and air tightness of the thoracic cavity, and the support of the chest wall integrity must be restored by some means. Various techniques have been applied to the reconstruction of the chest wall following resection. During the last 10 years, we have performed reconstructive operation for 6 cases of the chest wall following resection of the sternum in recurrent cases of breast cancer or invaded case of primary breast cancer. In these patients, the chest wall was reconstructed using a rib-latissimus dorsi osteomyocutaneolus flap or a latissimus dorsi myocutaneous flap. The sternum was totally resected in 3 cases, and in all 3 cases, reconstructed using a rib-latissimus dorsi osteomyocutaneous flap. Although postoperative pulmonary function decreased, all cases could be relieved from endotracheal intubation within 17 hours after operation, and had no problems in activities of daily living or occurrence of chest flailing or paradoxical movement of the chest. An artificial material (expanded polytetrafluoroethlene patch) was used in only one patient for the reconstruction of the osseous thorax, but this case developed infection during postoperative chemotherapy. After this experience, we used only biological materials for the reconstruction of the chest wall and postoperatively performed radiotherapy and/or chemotherapy on all cases. We have observed no flap infection or detachment since then. One characteristic of using the latissimus dorsi myocutaneous flap is that it is easily elevated and rarely causes serious postoperative esthetic or functional problems. The flap is also easily utilized to reinforce the osseous thorax because ribs immediately below the latissimus dorsi muscle are readily mobilized as a pedicle graft. Reconstruction of the chest wall following resection of the sternum, described in this report, allowed us to perform radiotherapy and/or chemotherapy without serious postoperative complications on the cases relapsing after treatment of breast cancer. The 2-year survival rate is 50% and one of these cases survived up to 10 years after resection of the sternum. Thus we prefer to perform resection of the sternum for sternal recurrence of breast cancer if there are no metastatic lesions in other organs.

A 74-year-old woman complained of a small nodule in the outer lower quadrant of her left breast. On physical examination, a 0.9 x 0.8 cm, round-shaped and firmly elastic nodule was palpated. Excisional biopsy was performed. Histologically, the tumor was separated into, with a bicellular pattern, containing both numerous glandular structures and numerous spindle-shaped cells. Immunohistochemical staining for EMA and cytokeratin showed strongly positive immunoreactivity for epithelial cells. Staining foraipha;-SMA showed strongly positive immunoreactivity for myoepithelial components. Staining for keratin and S-100 protein showed weakly positive immunoreactivity for myoepithelial cells. Microscopically, the tumor was diagnosed as adenomyoepithelioma of the breast. Immunohistochemical examination is needed to distinguish epithelial cell proliferation from myoepithelial cell proliferation. Immunohistochemical examination using antibodies against EMA, alpha-SMA, Keratin, cytokeratin and S-100 protein, is indispensable.