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A 72-year-old woman had a history of chronic hepatitis C virus (HCV) infection previously treated with interferon to achieve a sustained virologic response. Thereafter, she developed polyarthritis and purpura of the lower extremities as well as progressive renal dysfunction with hypertension and proteinuria that had occurred in the last three months. Laboratory investigations revealed seropositivity for cryoglobulin but negative findings for HCV RNA. She was ultimately diagnosed with cryoglobulinemic glomerulonephritis complicated by monoclonal gammopathy of undetermined significance (MGUS) based on the pathological findings of the kidney and bone marrow, indicating that MGUS-induced cryoglobulinemic vasculitis may occur even after HCV elimination.

Feline calicivirus (FCV) is frequently used as a surrogate of human norovirus. We investigated eligibility of FCV for anti-viral assay by investigating the stability of infectivity and pH sensitivity in comparison with other viruses. We found that infectivities of FCV and murine norovirus (MNV) are relatively unstable in infected cells compared with those of coxsackievirus (CoV) and poliovirus (PoV) , suggesting that FCV and MNV have vulnerability. Western blotting indicated that inactivation of FCV was not due to viral protein degradation. We also demonstrated sensitivity of FCV to low pH, the 50% inhibitory pH value being ca. 3.9. Since human norovirus is thought to persist longer, in infectivity and to be a resistant virus, CoV, which is robust and not restrained in use as PoV, may be more appropriate as a test virus for disinfectants, rather than FCV and MNV.

Treatment-related quality of life (QOL) is an important aspect of diabetes management. However, no studies have compared the influence of dipeptidyl peptidase-4 inhibitors versus alpha-glucosidase inhibitors on treatment-related QOL. This prespecified sub-analysis of the Linagliptin Study of Effects on Postprandial blood glucose (L-STEP) compared the effects of linagliptin (5 mg once daily) and voglibose (0.2 mg/meal thrice daily) on treatment-related QOL in Japanese patients with type 2 diabetes (T2DM) inadequately controlled with diet and exercise therapy. Among 366 subjects in the original study, 182 in the linagliptin group and 173 in the voglibose group were included in this analysis. The outcome of this study was change in QOL as assessed by the Diabetes Therapy-Related Quality of Life 17 (DTR-QOL17) questionnaire from baseline to week 12. Compared with baseline data, total DTR-QOL17 scores were significantly higher after 12 weeks of linagliptin and voglibose treatment. The change in the total DTR-QOL17 score and the score of one domain, burden on social activities and daily activities, was significantly greater in the linagliptin group than in the voglibose group. In addition, only linagliptin treatment was identified as a factor associated with an increased total DTR-QOL17 score. Linagliptin is superior to voglibose in terms of improving treatment-related QOL in Japanese patients with T2DM.

Background This study assesses the safety and effectiveness of endoscopic biliary sphincterotomy (ES) in the treatment of papillary stenosis (PS) with and without biliary stones. Methods The records of all patients who had endoscopic retrograde cholangiopancreatography (2,689 patients) from January 1, 1991, to August 1, 2010, were reviewed. There were 117 patients with PS who had ES. Results All patients had biliary pain, a dilated common bile duct (CBD) with a maximum diameter of 10 to 25 mm, and elevated liver function tests. There were 46 patients who had prior cholecystectomy of whom 20 patients had CBD stones. The remaining 71 patients had no prior biliary surgery; there were no biliary stones in 14 patients. All patients were symptom free after ES with or without CBD stone retrieval. Conclusions ES is the optimal treatment for PS in patients with or without biliary stones. ES eliminates pain, corrects CBD dilation, and restores LFTs to normal.

Background and Aims: The most effective treatment would be neoadjuvant chemoradiotherapy (NACRT) plus surgery with three-field lymphadenectomy, if tolerability and complications are acceptable. The aim of this prospective study was to evaluate the tolerability of NACRT+ systematic three-field lymphadenectomy. Methods: A total of 127 cases of advanced esophageal carcinoma were objected, among which 32 had NACRT, being the cases suspected to cT3–T4 or

T4 esophageal cancer is defined as the tumor invading adjacent structures, using tumor–node–metastasis (TNM) staging. For clinically T4 thoracic esophageal carcinoma, multimodality therapy, that is, neoadjuvant chemoradiotherapy (CRT) followed by surgery or definitive CRT, has generally been performed. However, the prognosis of patients with these tumors remains poor. Another strategy is needed to achieve curative treatment. In the present article, the treatment strategies employed to date are reviewed. Furthermore, the strategies for these malignancies are reassessed, based on our experiences. R1/2 and R0 resections are regarded as those with residual and no tumor after surgery. The present data show that patients who underwent R1/2 resection after neoadjuvant CRT experienced little survival benefit, while complete response (CR) cases after definitive CRT had comparatively better results. Therefore, curative surgery should not be attempted without down-staging, and definitive CRT should be the initial treatment. Then surgery is indicated for the eradication of residual cancer cells. Close surveillance is essential for early detection of relapse even after CR, because the operation will gradually become increasingly difficult due to post-CRT fibrosis. In conclusion, multimodality therapy consists of definitive CRT followed by R0 resection, which can be the treatment of choice for T4 esophageal carcinoma. These challenging treatments have the potential to constitute the most effective therapeutic strategy. (Cancer Sci 2007; 98: 937–942)

We report a case of abdominal wall abscess caused by diverticulitis of the jejunum penetrating through the abdominal wall. A 53-year-old Japanese woman visited a local hospital complaining of abdominal pain and a mass in the left lower abdomen. An abdominal computed tomography scan showed a tumor with isodensity in the left lower abdominal wall. Magnetic resonance imaging showed a mass in the abdominal wall with isointensity in the T1-intensified image and high intensity in the T2-intensified images. The mass was heterogeneous inside and protruded partially toward the intraperitoneal cavity. Ultrasound examination showed a heteroechoic mass extending into the intraperitoneal cavity. Laparotomy revealed a tumor in the abdominal wall with a fistulous tract extending to the jejunum. We resected the abdominal wall tumor with partial resection of the small intestine. The resected specimen contained a tumor with a fistulous tract passing through the abdominal wall. Histological examination revealed remarkable infiltration of neutrophils and a bacterial mass in the abdominal wall tumor, with a fistulous tract connected to the area adjacent to the mesenteric border of the jejunum. These findings suggested that diverticulitis of the jejunum had penetrated through the abdominal wall, leading to the formation of an abscess. We report this case to highlight the need for complete gastrointestinal evaluation with gastrointestinal barium studies and imaging analysis to examine extension of intra-abdominal lesions in patients with an unexplained abdominal wall abscess.

Recent observations suggest that an immune response is involved in the development of chronic pancreatitis. We report a case of autoimmune pancreatitis in a patient who showed complete obstruction of the lower common bile duct. A 63-year-old man was admitted to a local hospital, complaining of appetite loss and back pain. The patient had obstructive jaundice, and percutaneous transhepatic gallbladder drainage was performed. Fluorography through the biliary drainage catheter showed complete obstruction of the lower common bile duct. The patient had no history of alcohol consumption and no family history of pancreatic disease. Physical examination revealed an elastic hard mass palpable in the upper abdomen. Abdominal ultrasound and abdominal computed tomography (CT) scans showed enlargement of the pancreas head. While autoimmune pancreatitis was highly likely, due to the patient's high serum immunoglobulin level, the possibility of carcinoma of the pancreas and/or lower common bile duct could not be ruled out. Laparotomy was performed, and wedge biopsy samples from the pancreas head and body revealed severe chronic pancreatitis with infiltration of reactive lymphocytes, a finding which was compatible with autoimmune pancreatitis. Cholecystectomy and biliary reconstruction, using choledochojejunostomy, were performed, because the complete bile duct obstruction was considered to be irreversible, due to severe fibrosis. After the operation, prednisolone (30 mg/day) was given orally for 1 month, and the entire pancreas regressed to a normal size. Complete obstruction of the common bile duct caused by autoimmune pancreatitis has not been reported previously; this phenomenon provides an insight into autoimmune pancreatitis and provokes a controversy regarding whether biliary reconstruction is needed for the treatment of complete biliary obstruction caused by autoimmune pancreatitis.

後縦隔腫瘤として発見され, 原発部位の診断が困難であった食道原発gastrointestinal stromal tumor (GIST) に対し食道切除術を施行. 腫瘍細胞の染色体異常が証明された. 症例は58歳, 男性. 無症状. 検診の胸部X線写真で異常陰影を指摘されるも放置. 1年後, 検診で再度異常陰影を指摘され当科受診. 胸部CT上, 後縦隔右側に中～下部食道, 右肺, 気管, 左右主気管支に接し奇静脈を外側に圧排する最大径13cmの腫瘍を認めた. 平滑筋腫, 神経鞘腫, 平滑筋肉腫, 悪性神経鞘腫, 悪性線維性組織球腫等を考慮し, 後縦隔腫瘍と診断し手術を施行した. 術中所見から腫瘍は食道原発GISTを考え, 食道亜全摘, 右肺部分切除, 奇静脈, 迷走神経合併切除術にて完全切除し得た. 組織学的に腫瘍は不規則に配列した紡錘形細胞よりなり, 食道筋層内に連続していた. 免疫染色で筋原性及び神経原性マーカーが陰性, CD34とc-kitが陽性を示し, 食道原発のGISTと診断した. 核分裂像は2個/400倍50視野に認められたのみであったが, 染色体解析にて核型は47-48, XY, +mar1×2 [cp6] /47-48, idem, add (5) (p15) [cp4] であり, 悪性化に関与するとされる5pの増幅を認めた. 腫瘍径が10cm以上であることと合わせ, 本腫瘍はmalignant potentialを有する可能性が示唆された.

We report a patient with rectal stenosis caused by peritoneal recurrence 8 years after a curative resection of advanced stage gastric carcinoma; the recurrence was effectively treated with the weekly administration of paclitaxel. The patient was a 66-year-old Japanese woman who was admitted to our hospital complaining of abdominal pain and frequent bowel movements. She had undergone total gastrectomy, due to advanced-stage gastric carcinoma with extensive lymph node metastasis, 8 years before, and had taken an oral anticancer agent, fluoropyrimidine, for 4 years after the operation. Colonofiberscopy performed on admission revealed circumferential rectal stenosis located 10 cm from the anal verge. Barium enema study demonstrated extensive poor expansion of the upper and lower rectum and irregularity of the descending colon. Abdominal computed tomography (CT) scanning revealed wall thickening in the rectum and descending colon. These findings were compatible with rectal stenosis caused by the peritoneal recurrence of gastric carcinoma. Weekly administration of paclitaxel was started. The abdominal symptoms soon disappeared when the second cycle of paclitaxel was completed, and they have not appeared since then. The rectal stenosis was attenuated, as confirmed by imaging analyses. Weekly paclitaxel has been effective for more than 13 months, suggesting that the patient is in a state of tumor dormancy of recurrent gastric carcinoma.

目的: 大動脈周囲, 特に大動脈裂孔周囲リンパ節の解剖所見を解剖体と手術所見で比較し, その相違について検討した. 対象と方法: 38体の医学教育研究用に献体された成人解剖体と大動脈裂孔周囲のリンパ解剖が観察できた16例の胃癌手術例を対象とし, 大動脈裂孔周囲の腰リンパ本幹の経路, 乳糜槽との関連を検討した. 結果: 解剖体では, 左の腰リンパ本幹は平均2.07 (1～3) 本, 右は1.16 (1～2) 本で, 腰リンパ本幹はしばしば大動脈裂孔を通して縦隔へ達し, そこで胸管を形成していた. 大動脈裂孔以外を通るリンパ管は細いリンパ管で4例 (13%) あった. 乳糜槽の形成は, 2例 (5%) に認められた. 手術所見では全例に太い腰リンパ本幹を認めた. 大動脈裂孔を通らない症例も存在した (4例25%). 大動脈裂孔を通してのリンパ経路が主であった. 考察: 腹部大動脈周囲リンパ節から胸管へ流れる経路は, 大動脈裂孔を通る経路が主流と考えられた. したがって, 大動脈周囲リンパ節郭清に際しては, 左右腎動脈背側にある大動脈裂孔を意識することが重要と考えられた. しかし, 横隔膜の内側脚と中間脚の間へ流れる経路が併存しうることも留意する必要がある.

成人鼠径ヘルニアに対するmesh plug法やProlene hernia systemを用いた手術法(以下mesh法)が本当に簡便で再発率が低いかにつき従来法と比較検討を行った.対象は1984年5月から2002年7月までに当科および関連施設で治療された鼠径ヘルニア患者537症例579病変で,従来法が303症例325病変, mesh法が233症例253病変である.両群間で手術時間は差がなかったが,術後疼痛期間,術後入院期間はmesh法が有意に短く(P

To test the clinical usefulness of hepatic asialogycoprotein receptor analysis in liver surgery, we have conducted univariate and multivariate analysis for the detection of cirrhotic patients and prediction of morbidity after hepatic resection. Liver scintigraphy using technetium 99m-labeled asialoglycoprotein analog (TcGSA), ICG test, and CT hepatic volumetry were undertaken in 158 surgical patients including 111 who underwent hepatic resection. Hepatic functional parameters including Child-Pugh score, indocyanine green retention at 15 minutes (ICG-R15), clearance index (HH15), receptor index (LHL15), receptor concentration ([R]0), total hepatic receptor amount (R0) and hepatic parenchymal volume (HPV) were compared among patients with normal, cirrhotic, and non-cirrhotic damaged liver. Preoperative hepatic functional parameters, resected parenchymal fraction (RPf), operative blood loss, and total receptor amount of the remnant liver (R0-remnant) were compared between patients with and without signs of postoperative liver failure. All parameters but HPV were significantly different among patients with normal, cirrhotic, and noncirrhotic damaged liver. The multivariate analysis selected two significant (p0.05) parameters, [R]0 and Child-Pugh score for the detection of liver cirrhosis. Of the 111 patients who underwent resection, 14 developed transient signs of postoperative liver failure. Of the parameters tested, presence of liver cirrhosis, LHL15, R0, intraoperative blood loss, and R0-remnant were significantly different between patients with and without signs of postoperative liver failure (p0.05). The multivariate logistic regression analysis selected only R0-remnant as a significant (p = 0.022) parameter for the prediction of liver failure. The morbidity rate in patients with R0-remnant under 0.05 mmoles was 100%, and the rate decreased in inverse proportion to R0-remnant. In conclusion, combining the ASGP-R concentration ([R]0) and the Child-Pugh score best detected liver cirrhosis in surgical candidates. Cirrhotic patients and patients with a low R0-remnant are at higher risk for postoperative liver failure. The present study confirms the usefulness of hepatic asialogycoprotein receptor analysis in liver surgery.

Background/Purpose: We investigated the molecular mechanisms of carcinogenesis in the biliary epithelium in patients with pancreaticobiliary maljunction. Methods: Point mutations of the K-ras gene and the p53 gene, and the overexpression of p53 gene products were examined in the cancerous and noncancerous biliary epithelium of 37 patients with pancreaticobiliary maljunction, with or without biliary dilatation. Results: In the gallbladder epithelium of 5 patients with pancreaticobiliary maljunction associated with biliary carcinoma, K-ras gene mutations were detected in 3 (60%), p53 gene mutations in 3 (60%), and the overexpression of p53 gene products in 4 (80%), while in the bile duct epithelium of these patients, these features were found in 2 of 3 (66.7%), in all of 3 (100%), and none of 3 (0%) specimens, respectively. In the gallbladder epithelium of patients with pancreaticobiliary maljunction without biliary carcinoma, K-ras gene mutations were detected in 8 of 24 (33.3%) specimens, p53 gene mutations were detected in 16 of 27 specimens (59.3%), and the overexpression of p53 protein was detected in 5 of 27 (18.5%) specimens, while in the bile duct epithelium of these patients, these features were found in 10 of 25 (40%) specimens, 14 of 25 (56%) specimens, and 6 of 24 (25%) specimens, respectively. Conclusions: These results suggest that noncancerous lesions of the biliary epithelium in patients with pancreaticobiliary maljunction have mutations of the K-ras gene and/or the p53 gene, which provides genetic evidence that biliary epithelium has high carcinogenic potential.

Although retroperitoneal or psoas abscess is an unusual clinical problem, the insidious and occult characteristics of this abscess sometimes cause diagnostic delays, resulting in considerably high morbidity and mortality. In particular, psoas abscess caused by perforated colon carcinoma is uncommon. We report a case of psoas abscess caused by a carcinoma of the cecum. A 72-year-old Japanese woman was admitted to our hospital, with pain in the right groin and buttock. The pain had appeared 6 months before admission, and the symptoms had then been relieved by oral antibiotics. On March 25, 1999, inflammatory signs in the right buttock indicated localized cellulitis, and incision and drainage was performed at a local hospital. The patient was referred to our hospital on the same day. On admission to our hospital, computed tomography (CT) scan revealed a thick right-sided colonic wall and enlargement of the right ileopsoas muscle. Barium enema and colonofiberscopy revealed an ulcerated tumor occupying the entire circumference of the cecum. A retroperitoneal abscess and fistula had been formed by the retroperitoneal perforation of cecum carcinoma: surgical resection was performed after remission of the local inflammatory signs. Operative findings indicated that the cancerous lesion and its surrounding tissues were firmly attached to the right iliopsoas and major psoas muscle, and en-bloc resection, including adjacent muscular tissue, was performed. The fact that carcinoma of the colon could be a cause of psoas abscess and cellulitis in the gluteal region should be considered when an unexplained psoas abscess is diagnosed.

Although hemihepatic portal vein embolization (PVE) has been used preoperatively to extend indications for hepatectomy in patients with colorectal metastases, the effects of this procedure on tumor growth and outcome remain controversial. To address this issue, we assessed the proliferative activity of intrahepatic metastases after PVE and the long-term outcome of this procedure. Eighteen patients with colorectal metastases underwent preoperative PVE between 1996 and 2000 (PVE group). Twenty-nine patients who underwent major hepatic resection without PVE served as control (non-PVE group). The hepatic parenchymal fraction of the left lobe had significantly increased from 38.1 +/- 3.2% to 45.9 +/- 2.9% 3 weeks after PVE (+20.5%, P

With carcinoma of the thoracic esophagus, clinical evidence of invasion of adjacent organs (T4) indicates a highly advanced stage, and most surgeons avoid esophagectomy. Although the therapeutic strategy for such disease is generally selected based on preoperative evaluation and intraoperative inspection, their accuracy and the relation to survival outcomes after esophagectomy have seldom been analyzed on the basis of exact histopathologic evidence. We performed esophagectomy, with perioperative adjuvant therapy when possible, on patients with clinical-T4 tumors unless absolutely unresectable conditions were detected. Among the 500 patients who underwent esophagectomy, the 78 patients whose tumors were confirmed to be T4 pathologically were compared with patients whose tumors were assessed as T4 preoperatively or intraoperatively to evaluate the role of esophagectomy for clinical-T4 carcinoma. Esophagectomy was possible for 99% of the pathologic-T4 tumors preoperatively assessed as resectable, but the resection was grossly incomplete in 35%. The true-positive rates in tumors preoperatively and intraoperatively assessed as T4 were 51% and 84%, respectively. The hospital mortality rate in patients with pathologic-T4 tumors was 4%. The overall 5-year survival rate for patients with pathologic-T4 tumors was 14%, compared with 60% for those with tumors assessed as T4 intraoperatively but not pathologically. Esophagectomy with perioperative adjuvant therapy yielded occasional cure with an acceptable mortality rate for patients with pathologic-T4 tumors assessed as technically resectable. Preoperative assessment and intraoperative macroscopic inspection had limitations for predicting pathologic-T4 disease and incomplete resection. Only patients with definitive evidence of unresectability should be excluded from esophagectomy.

While gallbladder carcinoma is occasionally associated with pancreaticobiliary maljunction, spontaneous necrosis of carcinoma is extremely rare. We herein present a case of spontaneous necrosis of gallbladder carcinoma associated with direct invasion of viable cancer cell nests to the muscularis propria and subserosal layer located beneath the primary nodules. A 65-year-old Japanese man was admitted to a local hospital, complaining of repeated discomfort in the right hypochondrium. Ultrasonography and computed tomography scanning revealed cholecystitis associated with gallstones. Cholecystectomy was performed, and operative cholangiography demonstrated pancreaticobiliary maljunction. The resected gallbladder showed multiple mixed stones filled with necrotic debris and bile sludge. Scrutiny of the mucosal surface revealed multiple small necrotic nodules in the fundus, which were histologically confirmed to be necrotic remnants of a cancerous glandular structure. Small nests of papillary adenocarcinoma were found beneath the nodules in the muscularis propria and in the venous structure located in the connective tissues next to the divided margin of the gallbladder bed. Resection of S4a and S5 of the liver and resection of the extrahepatic bile duct was then performed to remove the remaining cancerous tissues and/or micrometastasis in the liver and bile duct. The biliary tree was reconstructed with a hepaticoduodenostomy. No cancer nests or any precancerous lesions were found in the additionally resected specimens. This case indicates a unique morphological feature of gallbladder carcinoma associated with pancreaticobiliary maljunction, which provides some insight into the pathogenesis of spontaneous necrosis of gallbladder carcinoma.

We report a case of gastritis cystica polyposa (GCP) that developed in association with a small stump carcinoma. The patient had had distal gastrectomy for peptic ulcer 33 years prior to the present illness. Total gastrectomy was carried out for the stump carcinoma of the remnant stomach, followed by Roux-en-Y anastomosis. Histological examination revealed that the cancer was associated with a GCP lesion in its neighborhood. The resected stomach was subjected to a cell kinetics study and p53 gene analysis, as GCPs are thought to have a high potential for carcinogenesis. The GCP mucosae, as well cancer tissues and remnant mucosae obtained from the same specimens, were investigated and compared. We found that cell kinetics, as measured by a Ki-67 labeling index count, was more accelerated in the GCP than in the remnant mucosa, and that p53 gene aberrations, including both mutations and deletions, took place in the GCP lesion. As the p53 gene is considered to be recessive, in principle, its tumor suppressive activity is lost only when gene aberration, either mutation or deletion, occurs concurrently or successively in both alleles. It was of interest to us that a benign lesion such as GCP had, in this instance, already developed both gene aberrations, strongly suggesting a precancerous nature for this disease.

We report a case of hyperplastic polyp of the gallbladder in a 6-year-old girl, successfully treated by laparoscopic cholecyctectomy after a 2-year follow-up from the original diagnosis. On her first admission, serum amylase level was very high, so that congenital pancreaticobiliary maljunction (PBM) was suspected. Although it became clear afterwards that the high serum amylase level was derived from a mumps infection, the diagnosis of PBM was not excluded until intraoperative cholangiography was conducted. The tumor in the gallbladder had doubled in size in 2 years. It was not possible to obtain biopsy specimens for histological diagnosis, so the risk of the tumor being malignant could not be completely excluded until surgical resection had been carried out. In spite of the rapid tumor growth, no neoplastic features were seen in the tumor by histopathological examination of the resected specimen; thus, a diagnosis of a hyperplastic polyp of the gallbladder was made.

Despite the relatively common incidence of sacrococcygeal dermoids, rectal cysts are uncommon. We report the case of a submucosal dermoid cyst occurring in the rectum. A 30-year-old woman visited the Gynecology Department because of pregnancy. A pelvic tumor was accidentally found during the checkup after miscarriage. A barium enema showed an anterior shift of the rectum by the presence of the tumor. Computed tomography and magnetic resonance imaging revealed a tumor located posterior to the rectum occupying almost the entire pelvic cavity, and the tumor was resected. The tumor was located in the submucosal layer of the posterior rectal wall and was well circumscribed. The resected tumor was a cyst entirely covered with a fibrous and firm capsule, which was filled with an amorphous white creamy substance. The histological findings showed the cyst consisting of a keratinizing stratified squamous epithelium with sebaceous gland and hair follicles, which was compatible with benign cystic teratoma. Primary rectal teratoma is very rare and only 36 cases have been reported in the literature worldwide. Furthermore, while the majority of cases were polypoid-shaped dermoid cysts protruding into the rectal lumen, only 3 cases were submucosal dermoid cysts. Therefore, such cases are considered to be extremely rare.

上部進行胃癌では膵脾合併切除や脾摘のかたちで脾門リンパ節郭清が行われるが, リンパ流の観点からすると小彎領域からの脾門リンパ節転移は考えにくい. 小彎病変に脾門リンパ節郭清が必要かを検討した. 脾門リンパ節郭清を伴う上部胃癌根治切除515例のうち, 脾門リンパ節転移陽性は68例, 13.2%で, 転移陽性例の腫瘍占居部位は, 大彎を占居する, または大彎側に病変が及ぶ症例が57例 (83.8%) と多数であった. 小彎側のみを占める症例を11例 (16.2%) と少数ながら認めたが, 小彎病変11例は全例に小彎リンパ節転移を認め, うち10例は転移の所見が著明であった. また11例中, 腫瘍径40mm未満の病変は1例のみで, この1例には明らかな小彎リンパ節転移を認めた. 以上より胃上部小彎病変では, 小彎リンパ節に明らかな転移を認めず, 腫瘍径40mm未満の場合は脾門リンパ節郭清の省略が可能と考えられた.

患者は70歳の男性. 右下腹部痛を主訴に当院受診し精査治療目的に入院. 諸検査にて腫瘍は直腸Rb前右側に位置し, 潰瘍を伴う粘膜下を主体とした腫瘍であった. 経肛門的needle biopsyにて間葉系腫瘍でありいわゆるGISTと診断, Miles手術を施行した. 光顕上腫瘍は紡錘形の核を有する細胞質に乏しい細胞から成り, 索状に配列し, 核異型, 核分裂像はほとんど認められず, 免疫組織学的にvimentin, CD34, NSE陽性, desmin, muscle-actin 陰性で, 加えてc-kit抗体陽性であることからGISTと診断した.

食道癌術後再建挙上胃管癌が発生しこれを切除, その後この挙上胃管癌の異時性単発肺転移を来し, これを切除しえた一例を経験した.患者は63歳男性, 食道癌術後7年6ヵ月後挙上胃管癌にて幽門側胃管部分切除術を施行した.その2年2ヵ月後胸部CTにて右肺S1に径5mmの結節陰影を認めた.3カ月後の胸部CTにて結節陰影は12×10mmと増大した.病理組織学的診断はないものの臨床経過と画像所見より挙上胃管癌の単発肺転移と診断し右再開胸による右肺部分切除術を行なった.切除標本は病理組織学的に挙上胃管癌の肺転移と診断された.挙上胃管癌の症例報告は年々増加しつつあるが, 肺転移切除症例は検索しえた限りでは本邦のみでなく海外を含め報告はなく本症例が初めてである.

癌の口側がEi以下で, m3以深の胸部食道癌で頸胸腹郭清を行った31例を検討し, 胸部下部 (Ei) 癌の手術では頸部郭清は不必要か否かを検討した.頸部転移は6例 (19%) で認め, その中で4例 (13%) は頸部単独領域転移であった. 転移部位は頸部操作で郭清し得る頸胸境界部の反回神経リンパ節に多かった.m3～sm1, 4例中1例 (25%), sm2～sm3, 7例中1例 (14%), mp～a2, 19例中2例 (11%) が頸部単独領域転移であり, 表在癌でも頸部単独転移はまれではなかった. 手術操作による反回神経麻痺は4例 (13%) にあり, いずれも6か月以内に症状は改善した. 頸部再発は1例あり, 初回手術時に郭清を省略した下内深頸リンパ節に再発した. 頸部単独転移例の予後は良好であった.頸胸境界部の確実な郭清には頸部操作が必要であり, Ei以下の表在癌においても頸部郭清が望ましい.

早期胃癌における至適リンパ節郭清範囲の解析を目的に, Roviere, Collerらにならい, 胃を左胃動脈領域, 右胃動脈領域, 右胃大網動脈領域, 脾動脈領域の4領域に分け, 各領域に転移を認める早期胃癌の分布を検討した. 対象は, 腫瘍径4cm以下の早期胃癌単発リンパ節転移例84例である. その結果, 左胃動脈リンパ領域が幽門前庭部, 胃上部大弯を除くほぼ全胃を占め, 胃角上より肛門側の幽門部全体を占める右胃大網動脈のリンパ領域と広く重なりがあることが明らかとなった. 一方, 右胃動脈, 脾動脈領域はおのおの幽門前庭部小弯, 胃上部大弯の狭い範囲であった. これらは, 胃中下部では, 複数の方向にリンパ節転移が起こることを示している. したがって, 早期胃癌の縮小手術に当たっては上記の動脈リンパ領域を考慮にいれリンパ節の郭清範囲を決定すべきである.

Gastritis cystica polyposa (以下GCP)を伴った残胃初発癌の3症例の経験を報告した.症例1は67歳男性で,胃潰瘍術後30年で吻合部大彎側半周に芋虫状に隆起したGCPと,その大彎線上に中分化腺癌を認め,深達度はseであった.症例2は60歳男性で十二指腸潰瘍術後33年で吻合部ほぼ全周に無茎性に隆起したGCPが存在し,その大彎部分に中分化腺癌,深達度mpを認めた.症例3は36歳男性.胃潰瘍術後24年で吻合部全周および小彎縫合線に沿って脳回転様に隆起したGCPが存在し,吻合縫合両線の交点部に低分化腺癌,深達度mpを認めた.病理組織学的にはいずれのGCPも腺窩上皮の過形成,偽幽門腺の嚢胞状拡張,粘液腺の粘膜下層侵入などの特徴を備えていた.これら3例のp53染色では癌部は全例陽性,非癌非GCP結膜では全例陰性であったのに対し, GCP結膜では粘膜中層に限局して陽性細胞が散見され,発癌との関連が示唆される所見と考えた.

Background and Objectives: In carcinoma of the thoracic esophagus, most surgeons consider that esophagectomy is contraindicated in patients with clinical evidence of major extraesophageal involvement in the lower neck or peritracheal regions. However, metastases to these regions are commonly found even in early phases of carcinoma invasion. With recent progress in preoperative assessment, operative technique and adjuvant therapy, esophagectomy could possibly benefit appropriately selected patients. Methods: We retrospectively analyzed results in 42 patients who had major involvement in the neck or upper mediastinum and who underwent esophagectomy with systematic lymph node dissection. We operated upon patients unless lesions were assessed as definitely unresectable. Preoperatively, 32 had enlarged peritracheal nodes greater than 15 mm in diameter on computed tomography, 18 had hard unmobile tumors in the lower neck, 9 had recurrent laryngeal nerve palsy, and 10 had findings suggestive of tracheal invasion. Preoperative radiotherapy and/or chemotherapy was given to 32 low-risk patients. Results: The hospital mortality rate was 4%. Bowel reconstruction was completed in all cases. No macroscopically recognizable lesion remained after operation in 35 patients. Eight patients were alive 5 years after esophagectomy, including 2 who had had tracheal invasion and I with recurrent nerve palsy. The cumulative 5-year survival was 38%. Conclusions: Evidence of major involvement of the neck and/or upper mediastinum does not always contraindicate resection. Aggressive esophagectomy combined with perioperative adjuvant therapy yielded acceptable palliation and occasional cure in cases with technically resectable lesions.

A 49-year-old woman, who had a pectoral muscle preserving mastectomy for a right breast cancer, revealed a swelling of supraclavicular lymph node and an increase in CEA level during clinical observation after the operation. Abdominal ultrasonography showed a mass with heterogenous echo level and 8cm in diameter at the hilum of spleen. So the patient was admitted to the hospital for close examination. Abdominal CT revealed a 14×10×8cm mass in the spleen, which was intensified but showed low density compared with that of parenchyma of the spleen. Abdominal magnetic resonance imaging (MRI) revealed iso-to mildly low signal on T1-weighted image and low signal with a high signal area on T2-weighted images. On Gd-DTPA T1-weighted image, it was a mass showing low signal in an arterial phase but slightly high signal in equilibrium phase. Angiography revealed a hypovascular tumor. Based on these imaging methods, a diagnosis of metastatic splenic tumor rather than primary tumor was made, and a splenectomy was conducted. On the resected material, the spleen was 580g in weight, 10×8×6cm in size, and yellowish white in colour which was sharply demarcated from the normal spleen. Histopathologically, the mass was mainly composed of growth of collagen fiber with infiltration of plasmacytes and lymphocytes, and no angitis nor possible malignant cells were demonstrated. The definite diagnosis of inflammatory pseudotumor was made.

The coexistence of bile duct carcinoma in choledochal cysts is well known. With large number of cases of congenital bile duct dilatation and pancreaticobiliary maljunction (PBM), it is now apparent that gallbladder carcinoma is more frequent in PBM without bile duct dilatation. The incidence of Gallbladder cancer in choledochal cyst and bile duct cancer in PBM, regardless of the presence of bile duct dilatation is significantly higher than that in control patients with biliary cancer but without PBM. A recent survey shows that the incidence of bile duct cancer in PBM without dilatation is equivalent to that of gallbladder cancer and bile duct cancer in patients with choledochal dilatation. Pathology in PBM is a result of reflux of pancreatic juice and stasis of the mixture in the biliary system. Carcinogenic factors thus present in the biliary contents induce epithelial changes in the biliary tract. In the biliary contents, activated pancreatic enzymes and secondary or deconjugated bile acids are markedly increased and they irritate the biliary mucosa. Mutagens are proven to form in the bile of PBM. In the epithelia of PBM, hyperplasia, metaplasia, and dysplasia are often found, and proliferative activity is increased; furthermore, K-ras gene mutation and overexpression of p53 protein are demonstrated. As for treatment of PBM, whether it is symptomatic or not, an operative procedure, is necessary, to prevent carcinogenic changes in the gallbladder and bile duct. Regardless of whether dilatation is present or not, total excision of the extrahepatic bile duct, along with gallbladder, is the treatment of choice, followed by hepaticojejunostomy or hepaticoduodenostomy.

End-to-side choledochoduodenostomy was originally used for reconstruction between the duodenum and the biliary tree in iatrogenic bile duct stricture. However, we believe the procedure could be applied for various biliary disorders. We have recently shown the high carcinogenicity of biliary epithelium in patients with pancreaticobiliary maljunction, and consequently we recommend excision of the bile duct, along with appropriate reconstruction of the biliary system to divert the flow of pancreatic juice from bile fluid, to prevent carcinoma in biliary epithelium even in patients without dilatation of the bile duct. The conditions causing primary or recurrent bile duct stones must be removed. We employed this procedure for biliary reconstruction in 42 patients with pancreatico-biliary maljunction and in 30 patients with various benign biliary diseases, such as bile duct stones and benign biliary stenosis. We also used the procedure for palliation in 6 patients with malignant tumors around the head of the pancreas. Among these 78 patients over 20 years, we experienced 5 cases of reflux cholangitis with anastomotic stenosis, for which conservative dilatation was required. This procedure of end-to-side choledochoduodenostomy could be widely applicable for biliary reconstruction in terms of its being simplicity, minimal invasiveness and the establishment of a single physiological route for bile flow into the duodenum.

Purpose: To reevaluate postoperative radiotherapy for thoracic esophageal carcinoma. Methods and Materials: Reviewed were the outcome of 89 patients who underwent esophagectomy with systematic dissection of regional lymph nodes between 1988 and 1993. Of the 89 patients, 19 underwent no adjuvant treatment, 22 underwent adjuvant chemotherapy alone, and 48 underwent postoperative radiotherapy. Twelve of the 48 also underwent adjuvant chemotherapy. Results: All patients who experienced local-regional recurrence had lymph node metastases at the time of surgery. The acturial local-regional control rate at 2-year of follow-up was 94% for patients with lymph node metastatses at the time of surgery who underwent postoperative radiotherapy alone or plus chemotherapy, and 74% for those who underwent adjuvant chemotherapy alone. The local-regional control rate was significantly better for those who had undergone postoperative radiotherapy (p < 0.01). Conclusions: Postoperative radiotherapy still plays an important role as adjuvant treatment.

The inhibitory effects of somatostatin (SMS) and glucagon (Gn) on acute pancreatitis were evaluated in an experimental acute pancreatitis model in male Wistar rats. The effects of these agents were compared with those of nafamostat mesilate (NM). The acute pancreatitis was induced by four serial subcutaneous injections of caerulein. The rats were divided into four groups. The first group (n=28) received SMS daily, the second group (n=28) received Gn daily, and the third group (n=28) received NM daily after the first injection of caerulein. The fourth group (n=42) received caerulein alone and served as the control group. Animals were sacrificed 4, 6, 8, 12, and 24 h, and 3 and 7 days after the first administration of caerulein and the degree of severity of the acute pancreatitis was evaluated by serial morphological and histological examinations of pancreatic tissues, as well as in terms of the serum concentrations of amylase and lipase. The characteristic findings of acute pancreatitis in the animals of all groups treated with SMS, Gn, or NM were markedly attenuated at all time points after the treatments compared with findings in the controls (caerulein alone) in terms of wet weight of pancreas, serum concentrations of amylase and lipase, formation of intracellular vacuoles in acinar cells, interstitial edema, and infiltration of an inflammatory cell component. The inhibitory effects of SMS, Gn, and NM on acute pancreatitis were similar at the doses used. These results suggest that SMS and Gn are as useful as NM, they may be of value for the treatment of acute pancreatitis.

Two cases of retroperitoneal cystic lymphangioma which developed similar symptoms to acute appendicitis at their onsets and were operated on with a diagnosis of appendicitis at the other hospitals are reported. Case 1: A 22-year-old female visited another hospital because of a fever and right lower quadrant pain. Regional tenderness and muscle defense were noted. Leucocytosis was marked. She underwent surgery under a diagnosis of appendicitis but her illness persisted. Later, CT and ultrasonography revealed a large cystic mass in her retroperitoneum. Case 2: A 30-year-old man was seen at another hospital because of right lower quadrant pain when a cystic lesion in the left upper abdomen was confirmed. Eight days later he had a right lower abdominal pain again and was operated on with adiagnosis of appendicitis, but only slight inflammation was noted in his appendex. One month later he again developed severe abdominal pain with peritoneal irritation and bowel paralysis. Both patients were transferred to our hospital and underwent second operation with the diagnosis of retroperitoneal cystic disease. Histological study of the resected specimens revealed cystic lymphangioma.

A 45-year-old woman presented with a left breast mass. The painless solitary tumor was palpated in the A region of the left breast. Ultrasonography revealed an internally isoechoic mass with a regular margin. Mammography visualized a light spherous tumor with a smooth margin. Histopathologically, the excised specimen was 1.5×1.2cm in size and the section was milk-white in hue and hard. At low magnification, the tumor was relatively illdefined and localized but with no capsule. Mild compression of surrounding glandular ducts was also observed. At high magnification, smooth muscle fascicular or nerve fascicular structures were seen surrounding the ducts and framework. A biphasic pattern was clear in the duct itself and neither a cytological heterotype nucleus nor mytosis was seen in the duct and surrounding cells. Muscle-actin and α-smooth muscle actin staining showed strong positive responses in the cyto-plasms of tumor cells in the vicinity of the duct. These findings confirmed that this localized tumor, growing mainly in smooth muscle cells, was a muscular hamartoma.

To evaluate the effects of aggressive operation for esophageal cancer invading the trachea and main bronchi, we investigated retrospectively 62 patients with proven tracheobronchial involvement who underwent thoracotomy for esophagectomy between 1973 and 1993. We operated unless the tumor was assessed to be definitely unresectable. Esophagectomy was possible in 55 patients, and the resectability rate was 95% after preoperative computed tomography and bronchoscopy became routine. After esophagectomy, no residual cancer lesion was recognizable macroscopically in 53% of patients. The hospital mortality rate in esophagectomy cases was 7% in the past 8 years. The outcome in patients who underwent curative resection was significantly favorable (p0.0001), and the 2-year survival was 51%. The patients with nonresectable cancer all died within 6 months compared with a 23% 1-year survival rate for palliative esophagectomy cases (p0.006). Among patients with tracheobronchial involvement assessed as resectable on computed tomography and bronchoscopy, a considerable proportion benefited from aggressive therapy with esophagectomy. The possibility of complete cure was high, especially when the cancer responded well to preoperative therapy and no lymph nodes were involved.

The most effective treatment would be neoadjuvant chemoradiotherapy (NACRT) plus surgery with three-field lymphadenectomy, if tolerability and complications are acceptable. The aim of this prospective study was to evaluate the tolerability of NACRT+ systematic three-field lymphadenectomy.A total of 127 cases of advanced esophageal carcinoma were objected, among which 32 had NACRT, being the cases suspected to cT3-T4 or,cT3 with multiple lymph node metastasis. ≥ T2 of 95 cases were treated by surgery alone (NACRT [-] case). The effect of NACRT was evaluated by histological examination and corrected with the clinicopathologic factors, including postoperative prognosis. After reports JCOG9907, we treated eight cases with neoadjuvant chemotherapy at stages II and III. We examined Musashi-1 staining for these eight cases.Histological good response to NACRT group showed good prognosis. Lymph node metastasis is a predictive factor for prognosis. In this additional study, Musashi-1 was positive after neoadjuvant chemotherapy in three cases. The histological response was grade 1 in all of them and recurrence was observed within a short period of time. Two cases of grade 3 were negative staining to Musashi-1 and showed no recurrence.This study shows that NACRT plus surgery with three-field lymphadenectomy is a feasible therapeutic approach for the cases with multiple lymph node metastases. Prognosis was significantly better in cases with marked histological improvement. It is important to find the predictive factors of histological improvement. Musashi-1 might be a candidate maker for histological response and prognosis, and further studies are needed to prove it.

To investigate genetic features of esophageal cancer, we have examined 93 squamous cell carcinomas of the esophagus for loss of heterozygosity (LOH), using 41 restriction fragment length polymorphism (RFLP) markers representing all autosomal chromosomes. Allelic losses at frequencies of at least 30% were observed at loci on chromosomal arms 3p (35%), 3q (30%), 5q (36%), 9p (57%), 9q (60%), 10p (33%), 13q (43%), 17p (62%), 17q (46%), 18q (38%), 19q (32%), and 21q (37%). These results suggest that several putative tumor suppressor genes, in addition to the cyclin D and TP53 genes that are sometimes mutated in esophageal carcinomas, may be associated with development and/or progression of esophageal cancer. By a comparison of LOH on each chromosomal arm with clinicopathological parameters, we have found a significant correlation between LOH on 19q and regional lymph node metastases. Interestingly, the frequency of LOH on 17q was significantly higher in tumors in female patients (12 of 14 cases) than in those in male patients (20 of 56 cases) (P = 0.0009 by Fisher's exact test). Furthermore, we examined for mutations of the APC gene on chromosome arm 5q. Screening of nearly one third of the APC coding region, including the MCR (mutation cluster region), revealed no alterations. Therefore, although allelic loss at the APC locus is frequent in squamous cell carcinomas of the esophagus, it is likely that a gene on 5q other than APC is involved in esophageal tumorigenesis. Genes Chromosom Cancer 10:177–182 (1994). © 1994 Wiley-Liss, Inc.

We have experienced a case of mucinous cystoadenocarcinoma of the vermiform appendix presenting with intussusception. A 56-year-old woman was admitted to the hospital because of a sudden onset of abdominal pain in the right lower quadrant. Ultrasonography revealed a 3×3cm cystic lesion with target like appearance in the ileocecal region. An intussusception of the vermiform appendix brought about by appendical cyst was diagnosed by preoperative barium enema, total colonofiberscope, computed tomography and angiography. Right hemicolectomy with lymph node dissection was performed, because the polipoid lesion in the cyst was suspicious of malignancy. Histopathological examination showed mucinous cystoadenocarcinoma (m, ly0, v0, n0) of the appendix. In this case, abdominal ultrasonography contributed to establish the preoperative diagnosis.

A case of leiomyosarcoma of the stomach in a 79-year-old man in presented here. The patient underwent subtotal gastrectomy for a gastric leiomyosarcoma at another hospital in 1985. At the same hospital be underwent excisions two times for metastases to the mesentery, liver (S3 and S8), and abdominal wall in 1987. Thereafter the patient underwent excisions at the hospital for metastasee to the sigmoid colon in 1990; measenterium in 1991; liver (S8) and chest wall in 1992; liver (S8) in May and the same organ (S2 and S3), mesenterium, and retroperitoneum in July 1993. The patient is alive for 8 years after 7 times operations for metastatic foci following the first operation. When the primary and metastasized lesions were compared for the numbers of karyokinesis and Ag-NORs, the both numbers were higher in the metastatic lesions than those in the primary lesion. These findings indicated that the proliferation activity of the metastatic cells was accerelated.

For the treatment of patients with cancer of the thoracic esophagus, lymphatic spreading is one important factor to infer how advanced their cancer is. We introduced a one-dimensional scale based on lymphatic spreading patterns, the stage of cancer, to express how advanced their cancer is, and we proposed a method to infer each patient's stage from his lymphatic spreading pattern by applying a Bayesian model. Our Bayesian model was built based on the assumption that lymphatic spreading in cancer could be explained as what was brought about by the advance of stage. In the modeling, we introduced the probability of what stage each patient was in as a prior distribution. We also introduced distribution functions of Weibull distributions to express the relation between the advance of stage and the increase of the probability of metastasis. Our model was applied to the data of nodal involvement obtained from 103 patients with cancer of the thoracic esophagus and the parameters were estimated with the maximum likelihood method. AIC was used to check that the data had enough information to be divided into the stages of a clinically reasonable number. With the estimated parameters, we inferred the probability of metastasis to each lymph node in each stage and calculated by Bayes' theorem with 31 new patients the probability of what stage they were in. The results well represented some characteristics of the lymphatic spreading and suggested the appropriateness of our approach.

術後感染予防としての投生剤至適投与法を, 胆嚢摘除術に限定しCefotaxime (以下CTX) を用いて検討した.対象は胆嚢良性疾患58例で, 封筒法により3群にわけた.CTXの1回投与量は1g (点滴静注) として, A群は麻酔導入時1回のみ投与 (n=18), B群は麻酔導入時1回と術直後1回に加え以後12時間ごとに3日間投与 (n=20).C群は術後のみ術直後1回に加え以降12時間ごとに7日間投与とした (n=20).術野に関連した術後感染 (手術野感染) は全体で10.3%に認めた.A群で5例27-8%, B群で1例5.0%, C群で0%とA群の感染率が高く, A・C群間に有意差を認めた (p

A 60-year-old female, noted left lower quadrant abdominal pain and genital bleeding, visited a nearly clinic of Gynecology. she was underwent an operation under a diagnosis of adnexal tumor, but was judged to be unresectable. She was referred to the hospital for chemotherapy. CT scan revealed a huge tumor which compressed a kidney, aorta and intestine. Abdominal angiography showed a hypervascular tumor, feeded by right colic artery and ileal artery. On gastrointestinal series and barium-enema, small and large intestines were compressed, without obstruction. From these findings, the tumor was thought to be resectable. The tumor weighed 4800 g and was microscopically diagnosed as malignant fibrous histiocytoma. Further operations of 2 times were necessary in order to resect the local recurrences. It seems that the best treatment option is wide surgical excision because chemotherapy provides little help at present.