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The effect of adjuvant radiation therapy (RT) in extrahepatic bile duct (EHBD) cancer patients with microscopic-positive resection margins (R1 resection) is still controversial.Between January 2000 and March 2010, 52 patients with EHBD cancer underwent surgery at our institution, of whom 36 were subjected to a retrospective analysis. Eleven patients received adjuvant RT after resection [surgery (S)+RT group], which included 9 patients with R1 resection and 2 with para-aortic lymph node metastasis. Their oncological outcomes were analyzed and compared with those of the 25 patients with R0 resection who did not receive adjuvant RT (S group).Patients in the S+RT group had significantly more advanced disease than those in the S group. However, there was no significant difference in disease-free survival or overall survival between the 2 groups. Median survival times for the S+RT and the S groups were 44 and 47 months, respectively, whereas the 5-year survival rates were 38.9% and 46%, respectively (P=0.707). Locoregional recurrence was less frequent in the S+RT group as compared with the S group, but the incidence of distant metastasis was unaffected by the adjuvant RT.Our results support the beneficial effect of adjuvant RT in EHBD cancer patients with R1 resection. This effect seems to result from an improved control of the locoregional tumor by adjuvant RT.

Introduction Until now, no data have been available on the incidence of chylous ascites after laparoscopic colorectal surgery. Methods From January 2007 to December 2011, 137 patients with colorectal cancer underwent laparoscopic surgery at our institution. The clinical data of the patients with postoperative chylous ascites were compared with those of the patients without chylous ascites. Results Chylous ascites developed in 9 of the 137 patients (6.5%). Blood loss, operative time, tumor location, and extent of lymph node dissection were not associated with postoperative chylous ascites. Mean postoperative hospital stay for patients with chylous ascites was significantly longer than that for patients without any complications (14 days vs 10 days; P

Introduction The feasibility, safety and oncological outcomes of laparoscopic surgery for transverse and descending colon cancers in a community hospital setting were evaluated. Methods Twenty-six patients with transverse or descending colon cancers who underwent laparoscopic surgery at our hospital were included in this retrospective analysis (group A). Their outcomes were compared with those of 71 patients who underwent laparoscopic surgery for colon cancer at other tumor sites (group B). Results There were no significant differences between the two groups in terms of operative time, estimated blood loss, postoperative hospital stay and morbidity rate. Extended lymphadenectomy was performed more frequently and the number of harvested lymph nodes was significantly higher in group B than in group A. However, no recurrence developed in group A, while recurrence occurred in four patients from group B. The 3-year disease-free survival rates were 100% for group A and 93.5% for group B. The 3-year overall survival rates were 100% for group A and 91.6% for group B. Conclusions Laparoscopic surgery for transverse and descending colon cancers can be performed safely with oncological validity in a community hospital setting, provided there is careful selection of the patients and adequate lymphadenectomy considering the clinical stage of their disease.

症例は71歳，男性．検診で胸部異常影を指摘され，当院受診．肺結節精査目的のPET検査で偶然十二指腸乳頭部付近に高集積像（SUV 7.1）を認めた．悪性腫瘍の可能性を考えさらに精査を進め，十二指腸乳頭部癌と診断．幽門輪温存膵頭十二指腸切除，D2リンパ節郭清を行った．病理組織診断は0.6cm pT1（Du0 Panc0）H0P0N0M(-) pEM0 stage Iであった．十二指腸乳頭部癌は乳頭部周囲腫瘍の中では比較的早期に発見され，切除を行うことにより，予後の期待できる疾患である．画像診断の進歩により早期発見が可能になりつつあるが，十二指腸乳頭部癌ではPETが有用であるとの報告もある．今回われわれはPETを契機に診断された十二指腸乳頭部癌の1例を経験したため，若干の文献的考察を加えて報告する．

症例は57歳の男性. 10年前よりC型肝炎ウイルス陽性を指摘されていた. 腹部超音波検査にて肝S2に径2.6cmの腫瘍を認め血管腫として経過観察されていた. 7カ月後やや増大傾向を認めたため, 精査入院となった. CTでは単純で低吸収域, 造影では不均一に造影された. 血管造影では左葉に淡い濃染を認めた. 画像診断にて肝細胞癌 (以下HCC) を否定できず, 肝外側区域切除術を行った. 腫瘍は脂肪, 平滑筋, 血管の3種の成分からなり, 肝血管筋脂肪腫 (以下肝AML) と診断された. 肝AMLは臨床上HCCとの鑑別は非常に困難である. 本邦報告79例を検討したところ, 増大傾向を示す肝AMLは11例で, 全例HCCの否定ができず切除となっていた. 本症例のように慢性肝炎を合併し, 増大傾向を示す場合は, 切除し確定診断を得ることが必要と思われた.

Although previous reports have shown similar recurrence rates and patterns between laparoscopic and open surgery for colorectal cancer, precise data regarding recurrent cases are lacking.From January 2007 to December 2011, 137 Patients with colorectal cancer underwent laparoscopic surgery at our hospital. Of the 137 patients, 7 patients with recurrence were analyzed for oncological factors. Their outcomes were compared with those of 13 patients with recurrence of 160 patients who underwent open surgery for colorectal cancer between January 2005 and December 2006.In the laparoscopic group, 1 of 37 patients (2.7%) with pathological Stage II (pStage) and 6 of 37 (16.2%) with pStage III experienced recurrence; in the open surgery group, 4 of 56 patients (7.1%) with pStage II and 9 of 63 patients (14.3%) with pStage III experienced recurrence. Although majority of recurrent patterns was distant metastasis, peritoneal metastasis was observed in 2 patients with pT3 tumors in the laparoscopic group. In contrast, all 3 patients with peritoneal recurrence in the open surgery group had pT4 tumors. In the laparoscopic group, 2 patients with peritoneal metastasis were pT3N1M0, and 1 of them revealed peritoneal carcinomatosis 6 months after surgery and developed chylous ascites as a postoperative complication.Although the recurrence rates and sites were similar between the laparoscopic and open surgery groups, peritoneal recurrence developed only in patients with pT3 tumors in the laparoscopic group. Exfoliation of tumor cells from divided lymphatic vessels might lead to development of peritoneal recurrence after laparoscopic surgery.

乳腺アポクリン癌からの化生を示唆する紡錘細胞癌の1例を経験した.症例は78歳の女性で,左乳房腫瘤を主訴に来院した.術前はアポクリン癌を疑い術中迅速病理診断にて癌を確認し胸筋温存乳房切除術(Bt+Ax+Ic)を施行した.組織学的には紡錘型細胞よりなる肉腫様部分とアポクリン化生を示す癌腫部分がほぼ半分の領域を占め,さらに両者の漸次移行部も認められた.アポクリン化生癌からさらに紡錘細胞癌が発生したものと思われた.リンパ節転移なし,ホルモン・リセプター(ER・PgR)はいずれも陰性であった.術後8年1カ月経過するが再発兆候は認めない.

今回われわれは, S状結腸腹膜垂が索状となった絞扼性イレウスの1例を経験したので報告する.症例は71歳,女性.下腹部痛にて近医を受診,入院のうえ保存的に経過をみていたが,症状軽快せず, CTで右下腹部腸管の膨隆を認め,腹水もみられたため,絞扼性イレウスの診断にて当科紹介され,転院となった.当科入院後の腹部超音波検査でも右下腹部の腸管が限局して緊満しており腹水も認め,腸管の絞扼が疑われたため,同日緊急手術を施行した.開腹したところ, S状結腸腹膜垂が膀胱前壁と癒着して索状となり,回腸末端より40cmから130cmの腸管が絞扼されていたため,同部回腸を切除した.術後経過は順調であった.腹膜垂が原因となってイレウスをきたした症例は極めて稀と考えられ,本邦報告例を集計し文献的考察を加えたので報告する.

症例は64歳の男性. 幽門狭窄を伴う進行胃癌に対し開腹手術を行ったが膵臓への浸潤が高度で非切除, 胃空腸吻合術のみとなった. TS-1を用いた化学療法を開始し, 1サイクル後のCTでは胃前庭部の腫瘤, 周囲リンパ節とも縮小し, PRと判定した. 3サイクル後はCT上, 胃の腫瘤および周囲リンパ節とも指摘できずCRとなった. 1年間CRを持続した後, 再度の開腹手術で幽門側胃切除術を行った. 病理組織学的検索では切除標本に癌細胞の遺残はみられなかった. TS-1は経口であるため外来投与可能であり, 患者のQOLを損なわない化学療法である. 今回, 初回手術時には非切除となった高度進行胃癌に対して経口化学療法剤であるTS-1を投与してCT上, CRとなり, 再手術を行い病変部を切除しえた. 病理組織学的検索では切除標本に癌細胞の遺残はみられず, 今後切除不能例を含めた高度進行胃癌に対してTS-1が有用となる可能性が示唆された.

Background and Methods: Clinicopathological analysis of 346 patients with gastric cancer was made retrospectively and new criteria for the indication of a limited operation using endoscopic ultrasonography (EUS) was developed. Suggested new criteria for selecting gastric cancer patients for the limited operation were: (i) the cancer is located in the mucosa and the lymph nodes are not involved as indicated by EUS examination; (ii) the maximum size of the tumour is less than 2.0 cm; (iii) there are no multiple gastric cancers or simultaneous abdominal cancers; and (iv) the mucosal cancer of elevated type less than 2.0 cm is excluded because there are good indications for endoscopic mucosal resection. Results and Conclusions: We applied these new criteria to 262 patients and found that the patients who had limited operation had the same prognosis and a better quality of life compared with patients who had the conventional operation. ©1999 Blackwell Science Asia Pty Ltd

Gastric perforation in early gastric cancers is relatively rare and often demands an emergency surgery. We describe a case of early gastric cancer with gastric perforation, in which an elective radical surgery for the gastric cancer was performed following a successful conservative treatment. A 49-year-old woman was seen at the department because of abrupt left hypochondoric pain. A plain abdominal X-ray photograph showed free air under the diaphragm and perforation of the upper gastrointestinal tract was suspected. The patient underwent conservative treatment for the perforation. Fiberscopy revealed an early gastric cancer of type IIc+III at the greater curvature of the fornix 10 days after the conservative treatment for the perforation. Histological diagnosis of biopsy specimens was signet-ring cell carcinoma. She underwent a total gastretomy with D2 lymphadectomy. The invasion of the cancer was within mucosa histopathologically. The final diagnosis was gastric perforation underlying early gastric cancer. No recurrent disease has been detected as of 1 year and 3 months after the operation. Fifty cases of gastric perforation underlying early gastric cancer seen in the Japanease literature are also reviewed.

We report herein the case of a 61-year-old man found to have a rare nonfunctional paraganglioma of the pancreas. Interestingly, the preoperative data and images showed similar characteristics to neuroendocrine tumors of the pancreas. Both paragangliomas and neuroendocrine tumors of the pancreas belong to the category of Amine Precursor Uptake and Decarboxylation (APUD) tumors (APUDomas). Thus, it is important to examine the serum level of pancreatic endocrine hormones and a variety of peptides to differentiate paragangliomas of the pancreas from other pancreatic tumors. Paragangliomas of the pancreas grow slowly, so radical resection is recommended to achieve curability with a good prognosis.

Oral administration of a single dose of triphenyltin compounds induces diabetes with decreased insulin secretion in rabbits and hamsters after 2-3 days without any morphological changes in pancreatic islets. In the present study, to test the possibility that the impaired insulin secretion induced by triphenyltin compounds could result from an impaired Ca2+ response in pancreatic beta-cells, we investigated the effect of triphenyltin-chloride (TPTCl) administration on the changes in the cytoplasmic Ca2+ concentration ([Ca2+]i) induced by secretagogues, such as glucose, high K+, gastric inhibitory polypeptide (GIP), and acetylcholine (ACh) in hamster pancreatic beta-cells. TPTCl administration caused partial suppression in 10 mM K+-induced rise in [Ca2+]i without suppressing the increase in [Ca2+]i evoked by 20-50 mM K+. Administration of TPTCl strongly inhibited the rises in [Ca2+]i induced by 27.8 mM glucose, 100 microM ACh in the presence of 5.5 mM glucose, and by 100 nM GIP in the presence of 5.5 mM glucose. In the ACh-induced response, TPTCl administration strongly suppressed the late sustained phase, while weakly suppressing the initial rise in [Ca2+]i. TPTCl administration significantly suppressed the rise of cAMP content in islet cells induced by 100 nM GIP with 1 mM 3-isobutyl-1-methylxanthine in the presence of 5.5 mM glucose (P0.01, N = 5-11). TPTCl administration also impaired the insulin secretion in islet cells induced by 27.8 mM glucose, 100 nM GIP in the presence of 5.5 mM glucose, and 100 microM ACh in the presence of 5.5 mM glucose (P0.05, N = 9-16). We conclude that the pathology of triphenyltin-induced diabetes in hamsters involves a defect in cellular Ca2+ response due to a reduced Ca2+-influx through voltage-gated Ca2+ channels.

Intestinal intussusption is primarily a disease of infants and occurs in adult in a relatively low frequency. Recently we experienced an adult case of idiopatic intussusption of the intestine. A 20-year-old man was seen at the hospital because of right lower quadlant pain. There was tenderness in the same region and a most probable diagnosis was appendicitis. With abdominal ultrasonography a diagnosis of iliocecal intussusption was made. During operation it was found that the cecum and terminal ileum was investigated into the ascending colon, but it was sponteniously released. We were not able to rule out a possible organic disease as a cause of the condition, and performed an ileocecal excision. No any lesion was detected in the excised intestine histopathologically. In a recent 11-year-old period a total of nine adult patient have been treated at the hospital, and two patients of them had an unknown cause. Eight out of nine patients underwent laparotomy, all of whom were definitely diagnosed as having an intestinal intussusption by preoperative abdominal ultrasonography. The importance of abdominal ultrasonography as a diagnotic tool should be emphasized.

We report a case of breast cancer with severe respiratory dysfunction due to multiple lung metastases, which was recovered by treatment with weekly trastuzumab administration. A 47-year-old woman with breast cancer had received a folk remedy from a general practitioner for 4 years. However, she was delivered to a hospital because of severe dyspnea, and intubation was found to be needed and performed. She was diagnosed with left breast cancer with skin and pleural wall invasion, and multiple lung metastases. Pathological examination showed invasive ductal carcinoma which was ER-postive, PgR-negative, and HER2-postive. After transfer to our hospital, treatment with trastuzumab(4mg/kg/weekly for the first course, and 2 mg/kg/weekly thereafter)was administered. Respiratory function improved gradually, and ventilator weaning was successful at 53 days after trastuzumab administration. CT examination also showed a remarkable reduction of lung and lymph node metastases and pleural effusion. She was discharged from our hospital 80 days after treatment, and her treatment with trastuzumab and capecitabine has been ongoing at an outpatient clinic.

Until now, no data have been available on the incidence of chylous ascites after laparoscopic colorectal surgery.From January 2007 to December 2011, 137 patients with colorectal cancer underwent laparoscopic surgery at our institution. The clinical data of the patients with postoperative chylous ascites were compared with those of the patients without chylous ascites.Chylous ascites developed in 9 of the 137 patients (6.5%). Blood loss, operative time, tumor location, and extent of lymph node dissection were not associated with postoperative chylous ascites. Mean postoperative hospital stay for patients with chylous ascites was significantly longer than that for patients without any complications (14 days vs 10 days; P0.001). Recurrence was observed in two of the nine patients with chylous ascites; it developed locally and in the liver in one patient, and peritoneal dissemination was seen in the other. The recurrence rate in the chylous ascites group (22.2%) was significantly higher than that in the non-chylous ascites group (3.9%; P = 0.016). The 3-year disease-free survival in the chylous ascites group (76.2%) was significantly lower than that in the non-chylous ascites group (93.4%; P = 0.020); however, the 3-year overall survival rates did not differ between the groups (87.5% vs 94.4%, respectively; P = 0.332).Chylous ascites are not a rare complication of laparoscopic colorectal surgery. It was managed conservatively in all cases but was associated with longer hospital stays. We recommend careful tissue dissection at a suitable plane and meticulous clipping during lymphadenectomy to prevent chyle leakage when lymphatic invasion is suspected.

A 55-year-old woman developed cholestatic hepatitis of unknown origin and suffered from repeated jaundice. There was a previous history of undergoing cholecystectomy for cholelithiasis. Thereafter, she complained of general fatigue and fever associated with jaundice. She was diagnosed as amputation neuroma or benign tumor of the biliary tract from the findings of retrograde cholangioscopy. On laparotomy, we found that a 2.0×1.1cm elastic hard tumor extended from the confluence to common hepatic duct and that the liver was dark red in colour. Resection of the bile duct including the tumor and hepaticojejunostomy were performed. Histological examination revealed amputation neuroma of the bile duct resulting from the cholecystectomy. Cholestatic hepatitis was improved after the previous operation. In this paper, we also reviewed amputation neuromas associated with jaundice in Japan.

BACKGROUND/AIMS Similar oncological outcomes of laparoscopic and open surgery for advanced colon cancer have been reported by several large-scale studies. Whether those results are applicable to community hospitals is questionable. METHODOLOGY From January 2007 to December 2010, 95 patients with colon cancer underwent laparoscopic surgery at Seirei Mikatahara General Hospital. Of these, 40 patients with pathological stage II/III colon cancer were subjected to this retrospective analysis (laparoscopic resection (LAP) group). Their outcomes were compared with those of 58 patients with pathological stage II/III colon cancer who underwent open surgery between January 2005 and December 2006 (open resection (OP) group). RESULTS Surgical complications were significantly less frequent in the LAP group than in the OP group. Three-year disease-free survival (DFS) and overall survival (OS) for stage II colon cancer were 88.9% and 100% in the LAP group, and 90% and 86.7% in the OP group (p=0.976 and p=0.285), respectively. Three-year DFS and OS for stage III colon cancer were 85.4% and 86.9% in the LAP group, and 75.3% and 83.8% in the OP group (p=0.613 and p=0.837), respectively. CONCLUSIONS Laparoscopic surgery for advanced colon cancer seems feasible and the oncological outcome is adequate in a community hospital setting.

We have experienced 56 cases of advanced and recurrent colorectal carcinoma treated with 5-Fluorouracil (5-FU)/l-Leucovorin (LV) therapy from January 2000 to March 2005. The RPMI regimen was employed, but 5-FU was administered at the dose of 500 mg/body for the first cycle and 750 mg/body for subsequent cycles, thanks to its safety, economy, and simplicity. l-LV was administered at 375 mg/body for all cycles. An average of 3.6 cycles were given, and the average 5-FU dose was 427.7 mg/m(2). The probability of the toxicities (Grade 3 or 4) tended to be less frequent compared with that observed in multi-center cooperative studies in Japan, although the frequency of nausea and vomiting was similar. Responses were CR 0/56, PR 16/56, NC 23/56, and PD 17/56, and the overall response rate was 28.6%. The median progression-free survival time was 6.0 months, and the median overall survival time was 14.0 months, which was longer than that achieved in multi-center studies in Japan. These data suggest that new regimens such as FOLFOX 4 and infusional 5-FU/l-LV therapy can be administered at lower doses of anti-cancer drugs with less toxicity and possible longer survival time.

Long-term observations, considered to be necessary for obtaining information on the progressive growth course of esophageal cancer, have been rarely reported. We have experienced a patient, a 76-year-old man, for whom it was possible to make retrospective roentgenological observations over a four-year period. In this case, roentgenological findings revealed a growth progression of 5mm in longer diameter during the three-year period for which the cancer was considered to be a superficial cancer, and 7mm during the one-year period for which it could possibly be considered an advanced cancer. Pathological findings revealed marked cellular infiltration, mainly of lymphocytes, into the periphery of the lesion, a factor suggestive of good prognosis. Moreover, growth progression of the esophageal cancer and the interstitial response to the cancer were also investigated.

We have investigated the accuracy of preoperative ultrasonography in detecting lymph node metastasis due to either esophageal or gastric cancer. Ultrasonograms of 236 gastric cancers and 63 esophageal cancers with pathological confirmation are reviewed retrospectively in this report. Correct diagnosis by preoperative US examination was obtained in 61% and 75% of the gastric and esophageal cancers respectively. Node involvement located around the celiac artery and in the lessor curvature were especially well demonstrated by ultrasonography as compared to those in the major curvature of the stomach. According to the analysis of false negative cases, the detection rate of lymph node metastasis smaller than 15mm in diameter located in the greater curvature tended to be low. In addition, histological examination revealed that lymph node metastasis due to poorly differentiated adeno carcinoma with diffuse spreading were not well detected by US.