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This patient was a 96-year-old woman. She was referred to our hospital with abdominal pain and vomiting. The levels of the tumor markers CEA and CA19-9 were elevated, at 39.47 ng/mL and 918.5 U/mL, respectively. She was diagnosed with peritonitis with digestive tract perforation by abdominal CT and an emergency operation was performed. At laparotomy, dirty ascites was observed in the peritoneal cavity. A perforation, 1 cm in diameter was found in the jejunum 15 cm from the Treitz ligament, and a mass, 2 cm in diameter was also palpated on the mesentery side. We performed jejunectomy including the tumor. The submucosal tumor was 2 cm in size and the mucosal surface of the perforation was ulcerated. Pathohistological inspection of the extracted sample revealed no heteromorphism in the small intestine mucosal plane. A moderately differentiated adenocarcinoma was diagnosed in the submucosal layer of the heterotopic pancreas of Heinrich typeⅡ. No tumor cells were found in the perforation. Thirteen previous cases of ectopic pancreatic cancer have been reported and this was the 14th case.

症例は23歳の女性. 平成13年7月4日より腹痛嘔吐が出現し7月7日当院を受診した. 触診上, 左下腹部に圧痛を伴った鶏卵大腫瘤を触知した. 腹部エコー, CT検査において左下腹部にターゲットサインを認め, また上部小腸の拡張を認めた. 小腸重積症の診断で高圧注腸を試みたが, 整復が困難であったため緊急手術を行った. 回腸末端部より90cm口側の回腸が約15cmにわたって重積を起こしており, 約40cmの回腸を切除した. 重積回腸先進部の粘膜面に径約3cmの腫瘍を認めた. 病理組織学的には, 粘膜下組織と筋層内に平滑筋組織と混在する導管構造を認め, 迷入膵Heinrich分類III型と診断した. 迷入膵は胃, 十二指腸, 空腸などの膵の近傍に好発する疾患で, 回腸に発生することは比較的まれである. 回腸迷入膵は腸重積を引き起こし発症することが多く, 高圧注腸による整復が困難で腸切除を余儀なくされることが多い. 発生部位は回腸末端部より100cmまでの下部回腸に好発する.

症例は41歳の男性で左側胸部痛,嘔吐,呼吸困難を主訴とした.胸部X線,胸部CT,上部消化管造影検査より,全胃が胸腔内へ脱出した傍食道型裂孔ヘルニアと診断し,開腹下に根治術を施行した.また,症例は以前より皮膚の過伸展,関節の過可動性,血管の脆弱性を認め,何らかの結合織疾患を疑い,皮膚生検を行った.その結果,膠原線維の若干の細小化と弾性線維の密度の上昇および断片化を認め, Ehlers-Danlos症候群と診断した.自験例のように,比較的若年発症の食道裂孔ヘルニア症例を経験した際には,本疾患の関与も念頭に置く必要があると思われた.

The aim of this study was to elucidate the risk factors for recurrence of Stage IIIa colon and rectosigmoid cancer.The subjects were 93 patients with Stage IIIa colon and rectosigmoid cancer who underwent radical colectomy in this department between 2001 and 2011. Various risk factors for recurrence were examined.The overall recurrence rate was 18% (17/93 cases). Univariate analysis identified a risk factor for recurrence: depth of tumor invasion( ≥serosa exposed[ SE])(hazard ratio[ HR] 10.04, 95% confidence interva[l CI] 3.26-30.89, p0.0001). The rate of 1, 2, and 3-year relapse-free survival of patients with respect to the depth of tumor invasion( ≥SE) were 76%, 61%, and 56%, respectively.Tumor depth SE or serosa infiltrating( SI) was a risk factor for the recurrence of Stage IIIa colon and rectosigmoid cancer.

We report a case of lethal interstitial pneumonia that occurred after neoadjuvant chemotherapy for advanced gastric cancer. A 76-year-old man with no history of interstitial pneumonia received 2 courses of S-1 (100 mg/body) following 1 course of S-1 plus cisplatin( CDDP) from June 2012. He complained of dyspnea on exertion 6 days after completion of the treatment. Chest radiography and computed tomography (CT) revealed diffuse interstitial lesions in bilateral lung fields. Bronchoalveolar lavage( BAL) revealed an increased number of lymphocytes and leukocytes. Transbronchial lung biopsy (TBLB) revealed interstitial pneumonia with fibrous thickening in the alveolar septum. The drug lymphocyte stimulation test (DLST) was positive for S-1 and negative for CDDP. These results suggested that S-1 had induced interstitial pneumonia. Steroid therapy( 40 mg/day prednisolone following 500 mg methylprednisolone pulse therapy) and an antibiotic agent were administered but were ineffective. He rapidly developed respiratory failure and required tracheal intubation and mechanical ventilation on hospital day 24, and died on hospital day 38.

Angio CT施行時に肝内に門脈CTで楔状の低吸収(wedge-shaped defect;以下WD),動脈CTで同部の濃染という特異な像を呈する場合がある.肝転移巣の詳細な評価のためにangio CTを施行した大腸癌肝転移41例を対象とし, WDの臨床的意義について検討した. 8例に12箇所のWDを認めたが, 8例は全て同時性肝転移症例であった.原発巣の手術日からangio CTまでの期間はWDを認めなかったWD (-)群に比べWDを認めたWD (+)群が有意に短期間で,同時性肝転移症例のみに限った検討でもWD (+)群が有意に短期間であった. WDについて切除肝の病理学的検討を行い得た3例では, 1例に門脈血栓, 1例に門脈血流の一時的停止を示唆する所見である再生結節性過形成性変化を認めた. Angio CTによりWDを認めたのは原発巣切除後早期にCTAPを施行した症例に限られることから,肝内楔状病変の原因は原発巣切除の影響の可能性が高いと思われた.

An operated case of bile duct stone enclosing dead ascaris as a core is reported, with a review of the literature. A 38-year-old man was admitted to the hospital because of upper abdominal pain and nausea. Endoscopic retrograde cholangiopancreatography (ERCP) demonstrated a string like translucency in the bile duct. It was diagnosed as biliary ascariasis and anthelmintic treatment for ascariasis was administered. But ascarid body was not found. Because of ineffectiveness of oral anthelminitics administration and persistent upper abdominal pain, choledochotomy, choledochostomy and cholecystectomy were performed. Two cholesterol stones which were spindle-shaped with a white surface and brown content, were found in the bile duct. One stone was found in the gallbladder. The scanning microscope revealed the female imaginal ascaris body in the bile duct stones. Most of stones of enclosing ascaris that have been reported so far were bilious stones, and our case is considered to be rare.

To evaluate the effectiveness of radiofrequency ablation (RFA) for liver metastases of colorectal cancer.RFA was used to treat 31 tumors (median diameter 1.5 cm, range 0.5-3.9 cm) in 13 patients of liver metastases of colorectal cancer. The median number of tumors treated per patient was 2. 9 (range, 1-10).Two patients had complications; bleeding and liver dysfunction. Four (12.9%) of 31 lesions developed a local recurrence after the treatment. We achieved a local control in 2 (92.6%) of 27 lesions3.0 cm in diameter. In 4 (30.8%) of 13 patients, new metastases were observed at follow-up. One year survival rate from the initial ablation was 92.3% and 2-year was 46.2%. One year total local recurrence rate from the initial ablation was 55.6%.In the case of tumor greater than 3 cm, RF ablation is an effective method to treat hepatic metastases from colorectal carcinoma.

A 69-year-old woman was admitted to our hospital with complaint of epigastric discomfort in February 2006. The detailed examination had revealed type 4 advanced gastric cancer. An exploratory laparotomy was performed for the unresectable case due to peritonitis cartinomatoza. Postoperative S-1 monotherapy (100 mg/body, 4 weeks on, 2 weeks off) was started as an outpatient in April 2006. After 3-course, partial response (PR) was observed for the primary lesion by gastrointestinal endoscopy. In April 2007, the regimen was changed to S-1 (100 mg/body, 3 weeks on, 2 weeks off)+CDDP (60 mg/m2, days 8) combined chemotherapy, then the primary lesion showed a slight increase. Thereafter, the regimen was changed to S-1 monotherapy in March 2008, and S-1+CDDP combined therapy in July 2008 again. PR was kept observed for three years successfully after the exploratory laparotomy. A case of type 4 unresectable gastric cancer was reported that the postoperative chemotherapy of S-1 was effective.

The patient was an 85-year-old man who underwent a rt-hemicolectomy, cholecystectomy and choledocholithotomy for cecum cancer and bile duct stone. The tumor was a well differentiated adenocarcinoma, type 2 in the Japanese classification of colorectal carcinoma. The tumor was considered to be in stage II (ss, ly2, v0, n (-), P0, H0, M (-)). He did not receive any adjuvant chemotherapy. After 2 years and 3 months from the surgery, an abdominal MRI and an abdominal CT scan revealed a 30 mm hepatic nodule lesion. We diagnosed with liver metastasis of the cecum cancer. The patient refused both surgery and radio-frequency ablation therapy. We chose radiotherapy for liver metastasis. He was given a total dose of 50 Gy/25 fractions. After 3 months from the radiotherapy, the tumor was reduced gradually and tumor marker (CEA) was normalized. The disease was diagnosed as CR because no tumors were detected. There has been no liver recurrence. But after 4 years and 6 months from the surgery, 20 mm lung nodules in rt-lower lung were revealed by chest X-ray. Once more, we chose radiotherapy for lung tumor. He was given a total dose of 66 Gy/33 fractions. At present, the tumor was reduced gradually. There has been no recurrence since his irradiation. If the case was made a good choice, radiation therapy appears to be effective for liver and lung tumors from the colorectal cancer.

We report two cases of advanced gastric cancer with severe postoperative complications after neo-adjuvant chemotherapy (NAC). The first case is a 60-year-old man who was diagnosed as a type 2 advanced gastric cancer with paraaortic lymph node metastases and the elevation of serum CA19-9 level. NAC was started, but no reductions were noted after 3 courses. Palliative total gastrectomy with distal pancreatectomy, splenectomy, cholecystectomy, and partial hepatectomy for T4 gastric cancer exhibiting obstruction were performed in June 2007. On postoperative day 10, abdominal CT scan revealed left subphrenic abscess, then CT-guided percutaneous drainage was performed. A culture of the abscess yielded Candida albicans and Candida glabrata. The second case is a 58-year-old man who was diagnosed as a type 2 advanced gastric cancer with multiple lymph node metastases and the elevation of serum CA19-9 level. NAC were performed, but no reductions were noted. A distal gastrectomy was performed in January 2008. On the first postoperative day, a severe abdominal distension was appeared suddenly and increasingly. An emergency laparotomy was undergone, but no findings of the bowel obstruction were observed. On postoperative day 2, a rise of serum beta-D-glucan level was recognized. Both cases were improved by an antifungal drug therapy.