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症例は44歳の女性で, 平成9年4月, 左後腹膜腫瘍 (平滑筋肉腫) の診断で, 腫瘍, 左腎臓摘出術を施行した. 平成12年2月上旬, 肝転移に対してS2, S4の肝部分切除. また, 平成13年12月中旬, 残肝再発のため肝外側区切除施行した. いずれも病理組織学的に平滑筋肉腫の肝転移と診断された. 平成14年7月下旬, 腹痛の精査のため再入院した. 腹部CTにて膵尾部に2cm 大のlow density areaを認め, 平滑筋肉腫の局所再発と診断し, 8月下旬, 手術を施行した. 腫瘍は膵内に存在したため膵転移と診断し, 膵体尾部切除術を施行した. 後腹膜原発平滑筋肉腫の膵転移の切除例は今回検索しえたかぎりでは報告が見られず, 非常にまれな症例と考えられた. 転移性膵腫瘍において, 切除例に長期生存の報告もあり, 治療法の1選択肢として外科的切除も考慮すべきである.

糖尿病を合併した直腸癌術後骨盤内膿瘍から発症したFournier's gangreneの1例を経験したので報告する.症例は50歳,男性でRbを主座とする進行直腸癌の診断で腹会陰式直腸切断術を施行した.術後仙骨前面に膿瘍を形成し,約2カ月後に臀部から右大腿,躯幹に及ぶ発赤,腫脹が出現した. CTにて軟部組織に異常ガス像を認めたため広範囲に切開, debridementを行ったが術後に敗血症から多臓器不全に陥り,救命できなかった.直腸癌にFournier's gangreneを合併した例は検索しえた限り本邦で5例目であった.本症は重篤な経過を辿ることがあるため,躯幹に及ぶ以前に診断して早期に切開,排膿と壊死物質の除去,洗浄を行うと同時に,原疾患の治療および血糖を含めた適切な全身管理を行うことが肝要であると思われた.

To evaluate the ganciclovir pharmacokinetics and clearance during continuous venovenous hemodiafiltration.Case report.General intensive care unit of a tertiary care emergency department.A 63-yr-old female who has a history of active behçet's disease that has been controlled with oral prednisolone, and who has chronic renal failure.None.A 5-mg/kg dosage of ganciclovir was administered intravenously over a 60-min period under continuous venovenous hemodiafiltration. Samples from the arterial and venous blood catheters and from the ultradiafiltrate were collected over the next 12 hrs to calculate pharmacokinetic parameters and clearance of hemodiafiltration. The pharmacokinetic parameters were as follows: half-life of elimination phase 12.6 hrs; total clearance 0.55 mL/min/kg; and volume distribution of steady state 27.07 L. The clearance of hemodiafiltration was 0.63 mL/min/kg.Continuous venovenous hemodiafiltration is effective in removing ganciclovir from the blood.

To determine the roles of tissue factor and thrombin on the systemic inflammatory response syndrome (SIRS) in posttrauma patients, as well as to investigate the relationship between SIRS and sepsis.Prospective, cohort study.General intensive care unit of a tertiary care emergency department.Forty trauma patients were classified into subgroups, according to the duration of SIRS: non-SIRS patients (n = 9); patients with SIRS for2 days (n = 15); and patients with SIRS for3 days (n = 16).None.Tissue factor antigen concentration, prothrombin fragment F1+2, thrombin antithrombin complex, fibrinopeptide A, and cross-linked fibrin degradation products (D-dimer) were measured on the day of admission, and on days 1 through 4 after admission. Simultaneously, the number of SIRS criteria that the patients met and the disseminated intravascular coagulation score were determined. The results of these measurements, frequency of acute respiratory distress syndrome (ARDS), multiple organ dysfunction syndrome, sepsis, and outcome were compared among the groups. The values of all five hemostatic molecular markers in the patients with SIRS for3 days were significantly more increased than those molecular marker values measured in the other groups on the day of admission. These values continued to be markedly high up to day 4 of admission. The occurrence rates of disseminated intravascular coagulation in these patient groups were significantly higher than those rates in the other two groups (p = .0001), and the disseminated intravascular coagulation scores did not improve during the study period. The occurrence rates of ARDS (p.05) and multiple organ dysfunction syndrome (p.01) were higher in patients with SIRS for3 days compared with those rates in the other groups, and the patients with SIRS for3 days had a poor outcome. No significant difference was noted in the frequency of sepsis among the groups.Sustained SIRS is the main determinant for ARDS, multiple organ dysfunction syndrome, and outcome in posttrauma patients. Disseminated intravascular coagulation associated with massive thrombin generation and its activation is involved in the pathogenesis of sustained SIRS. Sepsis has a small role in early posttrauma multiple organ dysfunction syndrome.

目的:Systemic inflammatory response syndrome (SIRS)症例に合併したdisseminated intravascular coagulation (DIC)に対するnafamostat mesilate (FUT)投与が凝固線溶系マーカーに与える影響の検討と,これらの症例に対するFUT投与の妥当性の考察。対象と方法:DICを合併したSIRSの16症例を対象とした。さらに16症例をDIC改善の有無で2群に細分し検討を加えた(改善群;n=7,非改善群;n=9)。DICの診断後FUTの投与前,治療開始後1, 3, 5病日に採血し,fibrinopeptide A (FPA), fibrinopeptide Bβ15-42 (FPBβ15-42), D-dimer, tissue plasminogen activator (t-PA)とplasminogen activator inhibitor-1 (PAI-1)の活性および抗原量を測定した。また背景因子,重症度,不全臓器数,転帰等を検討した。結果:SIRS症例のDICではFPAが著増しトロンビン産生が増加していたが,FUTの投与に伴いFPAは有意に低下した。さらにt-PA活性を認めずt-PA抗原量が増加,両者が解離し,PAI-1は抗原量・活性ともに増加していた。これは線溶抑制活性が亢進していることを示している。この線溶抑制活性の増加にもかかわらず,FPBβ15-42・D-dimer(二次線溶)の高値が全病日持続した。DIC改善の有無によるサブグループ間で比較検討すると,DIC非改善群のFPAはFUT投与にもかかわらず高値が持続し,PAI-1活性はDIC改善群に比較して有意に高値となった。さらにDIC非改善群は改善群に比較して,不全臓器数が多く転帰が不良であった。しかし,両群間のFPBβ15-42・D-dimerの推移に差は認めなかった。これらの結果をもとにSIRS症例のDICに対するFUT投与の妥当性を考察した。結論:SIRS症例に合併したDICに対してFUTは有効な抗凝固薬と考えられる。しかし,本症例のDICでは線溶抑制活性の増加が著しく,FUT投与にもかかわらずトロンビン産生が持続する症例も存在する。これらの症例に対するFUT投与の有効性に関してさらなる検討の必要性を強調した。

Objectives a) To investigate the relationships between tumor necrosis factor-alpha (TNF-alpha), interleukin-1 beta (IL-1 beta), plasminogen activator inhibitor-1, and disseminated intravascular coagulation (DIC); b) to determine the influence of DIC on the mortality rate, adult respiratory distress syndrome (ARDS), and multiple organ dysfunction syndrome; and c) to find a useful prognostic index for outcome. Design Prospective, case-control study. Setting General intensive care unit (tertiary care center) in a city hospital serving a population of 1.5 million people. Patients Fifty-eight trauma patients; 22 of the patients with DIC and 36 of the patients without DIC. Interventions None. Measurements and Main Results TNF-alpha, IL-1 beta, plasminogen activator inhibitor-1 activity, and plasminogen activator inhibitor-1 antigen concentration were measured on the day of the injury, and on days 1, 3, and 5 after admission. The results of these measurements, demographic data, severity of illness score, mortality rate in the intensive care unit and frequencies of ARDS, multiple organ dysfunction syndrome, and sepsis were compared according to the occurrence of DIC. DIC patients were classified into subgroups of survivors and nonsurvivors, and the changes in plasminogen activator inhibitor-1 between subgroups were studied. The Acute Physiology and Chronic Health Evaluation II scores, the Injury Severity Scores, and the frequency of ARDS and multiple organ dysfunction syndrome were higher in the DIC patients. The mortality rate of the DIC patients was higher than the rate of the non-DIC patients (59.0% vs. 13.8%; p equals .0009). TNF-alpha and IL-1 beta concentrations increased more in the DIC patients than in the non-DIC patients. Plasminogen activator inhibitor-1 activity and plasminogen activator inhibitor-1 antigen concentrations in the DIC patients, especially those values in the nonsurvivors, continued to be markedly high up to day 5 of admission. The most favorable prognostic value of plasminogen activator inhibitor-1 for the prediction of death in all of the trauma patients and the DIC patients was determined on days 3 and 5, respectively. No significant correlation was noted between the two cytokines and plasminogen activator inhibitor-1. Conclusions In the patients with trauma, DIC is a predictor of ARDS, multiple organ dysfunction syndrome, and death. TNF-alpha and IL-1 beta might be one of the causes of DIC, while plasminogen activator inhibitor-1 may be one of the aggravating factors of ARDS and multiple organ dysfunction syndrome. Plasminogen activator inhibitor-1 is a good predictor of death for posttrauma DIC patients.

A randomized controlled clinical trial was conducted to compare the use of Farmorubicin (FARM) and Adriamycin (ADR) in Lipiodol transcatheter arterial chemoembolization (L-TAE) as a treatment of hepatocellular carcinoma. In all, 192 hospitals participated, and 415 patients were enrolled in the study during the period from October 1989 through December 1990, and their data were collected. The patients were randomly allocated to group A (FARM) or group B (ADR) by a central telephone registration. Several clinical characteristics were slightly worse in group A than in group B, but there was no statistically significant difference. The actual doses of FARM and ADR were 72 mg/body and 48 mg/body, respectively. Additional treatments, including repeated TAE or surgery, were given to 248 patients. The 1- and 2-year survival rates were 69% and 44% for group A and 74% and 57% for group B, respectively. The difference was marginally significant (P value in the log-rank test, 0.038). When each group of patients was classified into two subgroups, i.e., high-risk and low-risk categories, based on the severity index calculated by the Cox regression model from significant prognostic factors, the ADR subgroup was significantly superior to the FARM subgroup in the low-risk category, but there was no significant difference between the subgroups in the high-risk category. The change in the serum alpha-fetoprotein level, the extent of Lipiodol accumulation in the tumor, and the extent of tumor reduction did not show any significant difference between the groups. At the above-mentioned doses, ADR seemed to have efficacy almost the same as or slightly superior to that of FARM in L-TAE for the treatment of hepatocellular carcinoma.

A randomized clinical trial comparing L-TAE with Farmorubicin (FARM) and L-TAE with Adriamycin (ADR) in the treatment of hepatocellular carcinoma was conducted from October 1989 through December 1990. In all, 192 hospitals participated in this study and 117 patients were entered. The patients were randomly allocated to group A (L-TAE+FARM) or group B (L-TAE+ADR). There was no significant intergroup difference in background factors. Additional treatment consisting of repeated TAE or surgery was given to 66 patients. Four factors were analyzed in this study: the percentage of reduction in tumor size, the change in the AFP level, lipiodol accumulation, and survival. None of these factors differed significantly between the two groups. The final evaluation of this study will be based on differences in survival after a long-term follow-up. Toxic effects manifested less frequently in group A than in group B, and the decrease in the platelet count in the peripheral blood was significantly lower in group A than in group B. These results suggest that FARM exerts a more favorable effect than does ADR in the treatment of hepatocellular carcinoma.

Liver abscess successfully treated by hepatic resection in a case of acute leukemia was reported in this paper. The case was a 33-year-old man. In the previous hospital, multiple liver and splenic abscesses were recognized after chemotherapy for acute myelomonocytic leukemia. The patient received various antibiotics and antifungal agents followed by splenectomy, but the liver abscess, almost localizing at the dome of liver, was still detected by CT and MRI. The patient was referred to our department. After partial hepatectomy, the clinical course was uneventful and inflammatory signs were improved. Liver abscess associating with leukemia is often multiple, and no clinical case of hepatic resection of liver abscess with acute leukemia has been reported. This case has suggested that such hepatic resection can be safely done in a stage of complete remission of leukemia. We think that hepatic resection should be an available alternative to conservative treatments for liver abscess associated with leukemia, if it offers resistance to the conservative ones.

Transcatheter arterial embolization (TAE)が奏効した21歳,男性の動門脈瘻を伴う外傷性肝動脈瘤破裂の1例を報告した.本症例は腹部刺創にて肝縫合術後,肝膿瘍が出現し経皮ドレナージを行なったが受傷4カ月目に突然吐下血をきたした.右肝動脈瘤破裂および動門脈瘻による門脈圧亢進症(門亢症),胆管瘻による胆道出血と診断された.炎症性臓器癒着,門亢症による易出血性の為一期的肝切除が困難でありTAEが施行された.TAE後門亢症,胆道出血は消失しCT上も仮性動脈瘤腔の縮小,器質化を認め現在経過観察中である.動門脈瘻を伴う外傷性肝動脈瘤は発生,破裂までに不定の潜伏期間を有し,また重篤多彩な臨床症状を呈することからその診断,治療上に多くの問題点を有している.臨床経過ならびに画像診断所見より本病態の成立過程を推測し,治療法としてのTAEの有用性を強調した.

A 64-year-old-male had recurrent paraaortic lymph node and liver metastases eight months after total gastrectomy and with distal pancreatectomy and splenectomy for advanced gastric cancer. Combined chemotherapy with 5-FU and a low-dose of CDDP was effective and the both lesions disappeared. Thirteen months later, a second recurrence of anterior mediastinum lymph node metastases occurred. After the same protocol, the lesions showed a partial response and lymph node dissection was performed. Histopathological examination showed that the resected lymph nodes had 99% necrosis and fibrotic change. Immunohistochemical examination of p53 of the primary gastric cancer showed negative staining. The patient has been followed for three years after the operation, and has no recurrent lesions.

Pyrimidine nucleoside phosphorylase (PyNPase) is the enzyme that converts 5'-deoxy-5-fluorouracil (5'DFUR) to 5-fluorouracil (5FU). Its activity in cancer tissue may correlate with the selective antitumor activity of 5'DFUR in breast cancer.Two hundred and sixteen T2 breast cancer patients were treated consecutively with surgery followed by 5'DFUR (600 mg/body/day) + tamoxifen (20 mg/body/day) for 2 years. PyNPase activity in breast cancer tissue, determined by high-performance liquid chromatography, ranged from 4.2-626.0 micrograms FU/mg protein/hr (mean +/- SD, 203.5 +/- 122.4), and the examined patients were divided into two groups: group A (high PyNPase group), cases with the PyNPase activity equal to or more than the mean value of 203.5 micrograms FU/mg protein/hr, and group B (low PyNPase group), cases with activity less than the mean value.Although there was no difference in relapse-free survival (RFS) between groups A and B, among node-positive patients (n = 83) those in group A tended to have a longer RFS. When divided into subgroups according to estrogen receptor (ER) status, among node-positive and ER-positive tumors (n = 49), the RFS was significantly better in group A than in group B (p0.05).Intratumoral PyNPase activity might be of use as a predictor of the effect of adjuvant 5'DFUR on breast cancer.

Background: To investigate the role of plasma neutrophil elastase (elastase-α1-proteinase inhibitor complex), plasminogen activator inhibitor-1 (PAI-1), and disseminated intravascular coagulation (DIC) in patients with posttraumatic acute respiratory distress syndrome (ARDS) and to explore the time course of the changes of these factors after trauma, we performed a prospective case-control study. Methods: The study subjects consisted of 41 trauma patients, 5 with ARDS, 7 at risk for but not developing the syndrome, and 29 control patients without or with no risk for ARDS. Plasma neutrophil elastase, PAT-1 activity, and PAI-1 antigen concentration were measured on the day of the injury and on days 1, 3, and 5 after admission. DIC was measured on the basis of the DIC score. The results of these measurements and demographic data were compared among the three groups. Results: Neutrophil elastase, PAI-1 activity, and PAT-1 antigen concentration for the ARDS patients continued to be mark- edly high until the fifth day of admission, and the values on the fifth day were significantly higher than those of the other two groups. All patients with ARDS developed DIC. A decrease in the DIC score was found for the control patients and also for the patients at risk for ARDS; however, for the patients with ARDS, the DIC score did not improve during the study period (p = 0.5809). Conclusion: We provide precise information on the time course of neutrophil elastase, PAI-1, and DIC in trauma patients with ARDS and those at risk of developing this syndrome. Neutrophil activation and persistent intravascular coagulation as well as impaired fibrinolysis may play a role in the pathogenesis of posttraumatic ARDS.

SummaryHypoxia and ischaemia influence blood coagulation and fibrinolysis. This study has been made to determine whether human cardiopulmonary arrest causes fibrin formation and reduction of fibrinolysis. Serial levels of fibrinopeptide A (FPA), fibrinopeptide Bβ15-42 (FPBβ15-42), D-dimer, tissue plasminogen activator antigen concentration (t-PA antigen), t-PA activity, plasminogen activator inhibitor-1 antigen concentration (PAI-1 antigen), and PAI-1 activity were determined in 63 patients with out-of-hospital cardiopulmonary arrest. In the resuscitated patients, the markedly elevated FPA (194.8 ± 54.2 ng/ml) at the beginning of cardiopulmonary resuscitation (CPR) significantly decreased to 32.4 ± 9.1 ng/ml at 24 h after admission (p

To investigate the relationships between tumor necrosis factor-alpha (TNF), interleukin-1 beta (IL-1 beta), soluble thrombomodulin (TM), and disseminated intravascular coagulation (DIC) in patients with systemic inflammatory response syndrome (SIRS), twenty-nine SIRS patients were classified into three groups; 4 patients without DIC, 8 DIC patients who recovered, and 17 DIC patients who did not recover. Serum TNF, IL-1 beta, and soluble TM were measured on the day of the diagnosis of SIRS, and also on the 1st, 3rd, 5th days. All of the DIC patients had multiple organ dysfunction syndrome (MODS) and the number of the dysfunctioning organs showed significant differences between the groups (p = .0017). All of the patients who did not recover from DIC died. The serum soluble TM level was higher in the patients without DIC recovery than in either the DIC recovery patients or the non DIC patients throughout the study period. In DIC patients who did not recover, there were significant correlations between soluble TM and TNF (r2 = 0.205, p = .0003) or IL-1 beta (r2 = 0.157, p = .0036). In conclusion, the DIC being associated with endothelial injury is an important pathogenetic factor for MODS and is a main determinant of the outcome of SIRS patients. TNF and IL-1 beta might be involved in the cause of this endothelial injury. The soluble TM is a good predictor of organ dysfunction and also of a poor prognosis.

Objective : Our goal was to investigate the role of soluble thrombomodulin (TM) and neutrophil elastase in patients with trauma. Design : This study is a prospective case-control study. Materials and Methods : Forty-seven trauma victims, 14 with disseminated intravascular coagulation (DIC), 5 with multiple organ dysfunction syndrome (MODS), and 28 control patients without DIC or MODS were the participants. Soluble TM and neutrophil elastase (elastase-α 1 -proteinase inhibitor complex) were measured on the day of the injury, and on the first, third, and fifth days after admission. The results of these measurements and demographic data were compared among the groups, and correlations between the soluble TM and the neutrophil elastase were examined. The DIC patients were classified into subgroups of survivors (n = 5) and nonsurvivors (n = 9), and the changes of the soluble TM between the subgroups were then studied. Measurements and Main Results : A high incidence of DIC patients encountered MODS complications (12 of 14, 86%). The DIC patients had higher Injury Severity Scores (ISSs) than the other patients. The levels of soluble TM and neutrophil elastase significantly increased on the day of admission in the patients with DIC and also in those with MODS (p < 0.05 vs. control patients) and continued to show markedly high values until the fifth day of admission in the patients with DIC. In the DIC patients, the levels of soluble TM were higher in the nonsurvivors than in the survivors (p < 0.05 on the third and the fifth days of admission). In all patients, there was weak but statistically significant correlation between peak levels of soluble TM and ISS (r 2 = 0.125, p < 0.025). Comparison of the levels of soluble TM and neutrophil elastase in the patients with DIC or MODS demonstrated an excellent correlation (r 2 = 0.718 and r 2 = 0.714, respectively). Conclusions : Soluble TM as a novel endothelial cell injury marker increases in patients with DIC and also in those with MODS after trauma. Neutrophil elastase may be involved in the pathogenesis of the injury. Soluble TM is a marker of the severity of injury and is a good predictor of MODS.

We studied the causative factor of increased incidence of digestive cancer and the appropriate methods of surgical management in our 12 hemodialysis patients with digestive cancers. The fact that they usually ate meals, which contained low fibrous and high fatty components is probably one of the main causes of the high incidence rate of colorectal cancer. Because the common subjective symptoms complained by these patients were often found in the unbalanced syndrome of chronic hemodialysis, it was difficult to distinguish these malignancies from a severe renal failure state. Thus, all cases were already in the advanced stages at the initial discovery point. Various risk factors (anemia, low serum protein, bleeding tendency, immuno-compromised state, etc.) caused postoperative complications, and preoperative appropriate adjustment of these abnormalities reduced the incidence of postoperative complications. Several modified therapeutic methods (hemodialysis without heparin, complete parenteral nutrition to recent advances in postoperative management of digestive cancers in chronic hemodialysis patients.

Two cases of thrombotic thrombocytopenic purpura (TTP) secondary to sepsis are reported. The pentad of consumptive thrombocytopenia, microangiopathic hemolytic anemia, fluctuating neurologic signs, fever, and renal disease appeared after sepsis in both patients. Except for thrombocytopenia, hemostatic studies were normal in one patient but prothrombin time was prolonged and fibrin/fibrinogen degradation products were slightly elevated in the other patient. Compelling evidence from the clinical, laboratory and pathologic findings suggests that disseminated intravascular coagulation (DIC) and TTP are separate entities. However, patients with TTP following sepsis may simultaneously develop DIC. We therefore emphasize the differential diagnosis of TTP and DIC in septic patients.

Malignant fibrous histiocytoma (MFH) of the retroperitoneum is rare in Japan. We have experienced one case of this disease. We present this case with a review and discussion of the literature. Case report 28-year-old woman presented with right hypochondralgia. She underwent cholecystectomy with the diagnosis of cholecystitis. The operative finding was a tumor, 10 cm in diameter, adjacent to the upper pole of the right kidney. She was referred to our hospital on Oct. 8, 1984, with a palpable tumor below the right subcostal margin. Laboratory data showed minimal changes. By angiography, A. capusularis of inf. adrenal artery were demonstrated to be the tumor's feeding vessels. On Nov. 6, 1984, she underwent tumor resection including the regional lymph-node. The pathological finding was MFH, of the retroperitoneum, without lymph-node metastasis. She was given postoperative chemotherapy, and was tumor-free 12 months after the operation. There have been 23 cases reported of MFH, of the retroperitoneum in Japan past 10 years. Among them, all 13 cases of urinary tract examination showed a variety of abnormalities. Computerized tomography demonstrated liver metastasis in one of 10 patients. Ultrasound sonography in two cases was also useful to detect the tumor's architecture. Angiography, performed in 13 cases, was the most important diagnostic tool in order to identify the origin of the tumor and assess resectability. Among 18 operative cases, 11 were combined with radiation and/or chemotherapy.

Ninety-nine patients with unresectable primary liver cancer were treated with ligation of the hepatic artery (LHA), intra-arterial infusion chemotherapy (IAIC) or transcatheter arterial embolization (TAE) between 1960 and 1983. A statistical study was made of therapeutic effects and prognosis. The results are as follows: The mean survival time of 14 patients treated with LHA was about 5 months. The survival time of the LHA + IAIC with mitomycin C group was not prolonged as compared with that of the LHA group, but LHA + IAIC with Adriamycin (doxorubicin) group showed a significant prolongation of survival time over the LHA group. In the LHA + IAIC with Adriamycin group, the mean survival time was 12.8 months and the 1-year survival rate was 37.5%. Factors including age, presence of liver cirrhosis, number of involved segments, and degree of anaplasia graded on Edmondson's criteria did not influence survival time.