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We have investigated flux flow dissipation in typical two kinds of HTS tapes, i.e., a Bi-2223 multi-filamentary tape and a RE-123 coated conductor (CC) from the view point of heat load under over current conditions. Based on systematic measurements on current-voltage characteristics, the nonlinear flux flow dissipation has been described analytically by taking into account current sharing in metallic sheath or stabilization layer. Flux flow dissipation in the RE-123 CC shows much steeper temperature dependence than that of the Bi-2223 tape. As a result, attainable cooling power becomes smaller in the RE-123 CC in comparison with that of Bi-2223 tape even if the same cooling condition. In other word, acceptable temperature rise in the RE-123 CC is small at over current condition, whereas moderate temperature dependence in the Bi-2223 tape allows stable operation even if the bias current exceeds the critical current. Influence of spatial inhomogeneity in the both HTS tapes has also been investigated. Longitudinal variation of local critical current, Ic, and its statistical behavior have been characterized by use of reel-to-reel scanning Hall probe microscopy. It has been found that the flux flow dissipation is possibly localized more than one order higher than that of the average value due to discrete local Ic drops.

Purpose: Increased vascular endothelial growth factor (VEGF) expression is associated with colorectal cancer liver metastases. It is reasonable to expect that measurement of VEGF in liver metastases would provide the best prediction of therapy benefit for VEGF-targeted drugs, such as bevacizumab (Avastin). In this study, we evaluated how VEGF mRNA level in primary colorectal cancer was related to that in corresponding liver metastases. Thirty-one pairs of primary colorectal cancer and corresponding liver metastases were analyzed. Experimental Design: Formalin-fixed, paraffin-embedded tumor specimens were dissected by using laser-captured microdissection. RNA was extracted and cDNA was prepared by reverse transcription. Quantitation of VEGF and internal reference gene (β-actin) was done using real-time PCR (Taqman PCR). Results: There was no difference between median VEGF mRNA levels of primary colorectal cancer and liver metastases (median value 3.79 versus 3.97: P = 0.989). On an individual basis, there was a significant correlation in VEGF mRNA expression between primary colorectal cancer and corresponding liver metastases (rs = 0.6627, P < 0.0001). In addition, the VEGF mRNA levels of the patients who had two or more liver metastatic tumors were significantly higher than those of the patient who had solitary liver metastatic tumor in both primary cancer (5.02 versus 3.34: P = 0.0483) and liver metastases (4.38 versus 3.25: P = 0.0358). Conclusion: Good prediction of VEGF mRNA levels in liver metastases can be obtained by measuring those of primary colorectal cancer. The risk of multiple liver metastatic tumors might be predictable by measuring VEGF mRNA expression in primary colorectal cancer. Further study is required to confirm these preliminary results.

Purpose: Cyclooxygenase-2 (COX-2) is generally elevated in tumors compared with normal tissue and apparently has an important role in tumor development. A number of studies have found high expression of COX-2 to be an unfavorable prognostic factor for overall survival in several cancers. However, the influence of COX-2 expression levels on tumor response to chemotherapy has been relatively little studied. The purpose of this study was to ascertain if COX-2 gene expression is associated with tumor response in the clinical treatment of colorectal cancer with the fluoropyrimidine-based therapy S-1. Experimental Design: Patients with advanced (stage IV) colorectal cancer were treated with S-1 twice daily based on the patient's body surface area (BSA; BSA < 1.25 m2, 80 mg/d; 1.25 m2 ≤ BSA < 1.5 m2, 100 mg/d; BSA ≥ 1.5 m2, 120 mg/d) for 28 days followed by a 2-week period rest. mRNA was isolated from paraffin-embedded pretreatment primary tumor specimens and expression levels of COX-2 relative to β-actin as the internal reference gene were measured using a quantitative reverse transcription-PCR (Taqman) system. Results: The overall response rate in a group of 44 patients treated with S-1 was 40.9%. Sufficient tumor tissue was available from 40 of these patients for COX-2 mRNA quantitation. COX-2 gene expression was significantly lower in the responding tumors compared with the nonresponders (P = 0.012, Wilcoxon test). Patients with COX-2 values above the cutoff value of 3.28 × 10−3 had a significantly shorter survival than those with COX-2 gene expressions below the cutoff value (adjusted P = 0.031). Conclusions: Intratumoral COX-2 gene expression is associated with likelihood of response to chemotherapy with S-1 and is a prognostic factor for survival of patients after the start of S-1 chemotherapy.

‹はじめに›肝細胞癌では病理学的に門脈侵襲, 肝静脈侵襲に比べ, 胆管侵襲は比較的稀である. 胆管侵襲を伴う肝細胞癌症例につき臨床病理学的検討を行った. ‹検討対象›当院で1986年から2002年までの切除肝細胞癌1452例のうち病理学的に胆管侵襲陽性であった40例を対象とした. ‹結果›胆管侵襲を伴う肝細胞癌は以下の特徴を認めた. 1. 肉眼型で単純結節型の割合が少ない. 2. 門脈肝静脈侵襲を保有する率が高い. 3. 被膜形成を伴わないものが多い. 4. 病理診断上, 細胞異型度が低～中分化のみで肉芽様変化や淡明細胞等, 特殊型が多くみられる. 5. リンパ節転移率が高く, 術後のリンパ節再発, 肝外再発が多い. 6. 生存率は不良である. ‹結論›胆管侵襲を伴う肝細胞癌は胆管侵襲を伴わない肝細胞癌と異なる特異な臨床病理学的特徴を有する.

膵管内乳頭粘液性腫瘍 (IPMT) の自然経過を知る上で, 興味深い症例を経験した. 症例は57歳男性. 50歳時まで急性膵炎で他医に入退院を繰り返していた. この際のERCPで, 主膵管の拡張, 陰影欠損を伴う膵頭部分枝膵管の嚢胞状拡張が認められていたが, 外科的処置は行われていなかった. 2001年10月, 他医で慢性膵炎, 閉塞性黄疸と診断され胆嚢摘出術, 胆道バイパス術 (肝管空腸吻合) を施行. その後の当院入院精査で, 胃・十二指腸に瘻孔形成を伴う膵管内乳頭腺癌由来の浸潤癌と診断し, 2001年12月6日, 膵頭十二指腸切除術を施行した. 摘出標本では, 膵頭体部に径6.6×6.1cm, 内部に結節状隆起を伴う嚢胞性腫瘍を認め, 嚢胞内にはゼリー状の粘液が充満していた. 病理組織所見では, 印環細胞を含む粘液結節を広範囲に認めた. 膵管内には粘液産生を伴う乳頭状の腺癌部分がみられ, 浸潤部はほとんど粘液結節として存在し, 膵管内乳頭腺癌由来の浸潤癌 (粘液癌) と診断された.

Thymidylate synthase (TS), the target enzyme of the fluoropyrimidine class of drugs, has a 28-bp repeat polymorphism in the promoter region that has been associated with response of tumors to 5-fluorouracil-based therapy. Patients homozygous for the double repeat (2R/2R) in the TS gene have an overall better outcome from treatment than patients homozygous for the triple repeat (3R/3R). However, due to loss of heterozygosity at the TS locus on chromosome 18 in cancer cells, heterozygous 2R/3R individuals can acquire the 2R/loss or the 3R/loss genotype in their tumors. The purpose of this study was to determine whether the response of colorectal cancer to fluoropyrimidine therapy is associated with the resulting tumor TS genotype when loss of heterozygosity occurs in tumor DNA. A total of 30 colorectal cancer patients treated with the fluoropyrimidine-based combination S-1, all of whom had stage IV disease, were studied. The response rate to S-1 in this group of patients was 13 of 30 (43%). The heterozygous 2R/3R genotype was found in 22 of 30 normal tissues, whereas 10 (45%) of the matched cancer tissues showed only the 2R-sequence band (2R/loss), and 7 cancer tissues (32%) showed only the 3R-sequence band (3R/loss). The response rate of the 2R/loss tumor genotype patients was 80% (8 of 10) compared with 14% (1 of 7) in the 3R/loss genotype group (P = 0.029). Patients with tumor 3R/loss genotypes had significantly lower survival than 2R/loss genotypes. Heterozygous patients with a 2R/loss tumor genotype had the same survival as 2R/2R patients, whereas patients with a 2R/3R tumor genotype had a short survival similar to homozygous 3R/3R genotypes. These results show that: (a) response to 5-fluorouracil-based therapy is determined by tumor genotype; and (b) the 3R repeat is a direct negative determinant of outcome.

【目的】胃原発広義GISTの手術適応におけるKITレセプターの臨床的意義を検討した.【対象】1987年～2001年に切除した胃原発広義GIST75例.【方法】LSAB法にてα-SMA, s-100蛋白, KITレセプターの免疫染色を行った.【結果】(1) Rosai分類いずれの群にも悪性例を認めた.(2)腫瘍径4 cm未満の症例に約40%の悪性例を含む.(3)全症例の76%がKITレセプター陽性.(4) KITレセプター陰性例に悪性例なく,陽性例中63%が悪性例.(5)再発8例全例にKITレセプター陽性.【結論】広義の胃GISTは腫瘍径で手術適応を判断してきたが, KITレセプター陰性症例に悪性例を認めない結果より生検可能であればKITレセプター染色性により手術適応を判断でき,特に腫瘍径の小さい粘膜下腫瘍の手術適応の判断に有用である.

症例は75歳の男性で, 外側区の肝細胞癌に対し他医にてTAE, 経皮的エタノール注入療法をくり返し施行されていたが, 再発をくり返すため当院紹介となった. 再TAE施行するも腫瘍の縮小効果が得られず再入院となったが, 入院当日に黒色便と貧血を認め突然の上腹部痛, 嘔気が出現した. 腹部超音波, CT検査にて肝外側区域に胆管内腫瘍栓を認めその末梢胆管の拡張を認めた. 血管造影検査では外側区域に腫瘍濃染像を認め, 経皮経肝胆道造影では左胆管が造影されず総胆管末端に血腫によると思われる透亮像を認めた. 以上より肝細胞癌の胆管内腫瘍栓からの胆道内出血と診断した. 開腹すると左胆管内に腫瘍栓があり腫瘍栓からの出血と胆管内の凝血塊を認め, 肝左葉尾状葉切除, 総胆管血腫掻爬を施行した. 病理組織像はsar-comatous changeを伴う低分化型肝細胞癌であった.

症例は71歳,女性. 1994年右耳下腺癌(腺様嚢胞癌)の診断にて右耳下腺拡大全摘出術を受けた.局所再発を認めず経過したが1998年超音波検査にて肝右葉に10cm大の腫瘍を指摘された.超音波および腹部CT検査にて腫瘍中心部を走行する門脈枝を認め,ドップラー超音波検査にて車軸状血流を認めfocal nodular hyperplasia (以下FNH)が疑われた.腫瘍生検の結果耳下腺癌肝転移と診断され肝拡大右葉切除術が施行された.再発なく経過するも2003年12月超音波検査にて腹腔内腫瘍および肝転移を指摘された.耳下腺癌の化学療法の奏効率は低く切除を考えて開腹したが,腹膜播種の状態にて切除不能であった.本症例は原発巣術後4年で肝転移,さらに5年後に腹膜播種をきたした.長い経過で遠隔転移を呈する耳下腺癌の特徴を考慮し,長期間にわたる慎重な全身follow upの必要性が示唆された.

症例は65歳,男性.突然の下腹部痛を訴え救急車にて来院. 4年半前にC型慢性肝炎と巨大肝癌にて右三区域切除施行していた.病理所見は索状型中低分化型肝細胞癌, vp1 vv0 b0 tw0 im2で非癌肝は硬変肝であった.その後に残肝再発に対して1回の再切除と3回の焼灼療法を行っていた.来院時下腹部に圧痛と軽度の膨隆を認めたが反跳痛,筋性防御はなかった. CTにて小骨盤腔に造影効果のある腫瘤と大量の腹水を認めた.その直後出血性ショックとなり緊急手術となった.腹腔内には大量の凝血塊と小骨盤腔内右精嚢腺浸潤する直径3cm大,弾性軟の腫瘍からの出血があり腫瘍摘出術を施行した.術後13日目に軽快退院された.病理組織では好酸性異型細胞が索状に増生する中分化型肝細胞癌で, hepatocyte染色陽性であった.肝細胞癌術後の急激な下腹部痛,腹部膨満感では本症を疑い,適切かつ迅速な診断,治療が重要であると考えられた.

BACKGROUND It has been reported that MUC1 is an important prognostic factor in several cancers. This study investigated the importance of MUC1 as a prognostic factor in mass-forming intrahepatic cholangiocarcinoma (m-ICC). METHODS In 50 patients with m-ICC who had undergone hepatectomy, expression of MUC1 was investigated. Expression of MUC1 was examined by immunohistochemical staining with monoclonal antibody HMPV, which recognizes the MUC1 core peptide. The immunohistochemical staining patterns of MUC1 were classified into three types: ductal type (the luminal surface membrane of neoplastic cells was stained), cytoplasmic type (the cytoplasm of neoplastic cells was stained dominantly), and negative type. RESULTS Expression of MUC1 was detected immunohistochemically in 38 (76%) of 50 cases of m-ICC (ductal type, 18; cytoplasmic type, 20; and negative type, 12). Seventy-five percent of patients with lymph node metastasis had the cytoplasmic type MUC1 expression. Lymph node dissection was performed in only 20 patients, but significant correlation was demonstrated between MUC1 expression and lymph node metastasis (P = 0.0227). The location of MUC1 expression correlated with surgical outcome in m-ICC. Patients with the cytoplasmic type expression showed significantly lower survival rates. Univariate analysis revealed that MUC1 expression was a statistically significant risk factor affecting outcome in m-ICC (P = 0.0028). Furthermore, expression of MUC1 was found to be a statistically significant independent risk factor in multivariate analysis (P = 0.0063). CONCLUSIONS The results suggest that evaluation of MUC1 expression may be very useful in predicting the surgical outcome in m-ICC. Cancer 2002;94:1770–6. © 2002 American Cancer Society. DOI 10.1002/cncr.10398

1968年から1994年に経験した同時性多発胃癌447例を対象にその特徴と治療について検討した. 多発胃癌の頻度は6.7%であり, 単発胃癌に比べて高齢者, 男性に多く主病巣の特徴は早期癌, 分化型腺癌, 隆起型の割合が高かった. 主病巣と副病巣の関係は早期癌同士, 分化型同士が多く, 同一領域または隣接領域に存在するものが約9割を占めていた. 多発胃癌の副病巣は腫瘍径10mm以下で粘膜内癌の頻度が高く, 術前診断率は40%と低かった. 多発胃癌の進行度別5年生存率は単発胃癌と同程度であり, 残胃の癌の発生頻度 (4.7%) は単発胃癌 (1.7%) と有意差を認めたが, 5%に満たない値であった. 多発胃癌の治療は, 単発胃癌と同様に主病巣の深達度および占居部位に応じた切除範囲, また根治度A, Bを目指したりんぱ郭清でよいと考えられ, 術後, 残胃の厳重なfollow upが重要であると思われた.

腎癌は転移しやすい癌であり,しかも10年以上の年月を経て転移巣が出現するなど,長期経過観察を要する疾患である.肝転移をきたした場合,ほとんどが多発で外科的切除は不能であるが,腎摘後11年を経て単発の肝転移をきたした症例に対し,肝切除術を施行し,術後4年間無再発生存をえた.病理組織学上も原発巣と同じ乳頭状腎細胞癌と診断された.乳頭状腎細胞癌は非乳頭状腎細胞癌に比べ予後良好な疾患であり,肝転移巣に対しても積極的な切除が有効と考えられた.

はじめに: 肝腫瘍に対してグリソン鞘一括処理による系統的肝切除を行うためには, 腫瘍の局在区域を同定することが不可欠である. 今回, 肝細胞癌の術前局在区域診断能について検討した. 方法: 術前診断としてUS, CT, angiographyを施行し, さらにportal angio-echo (以下, PAE) を行った肝細胞癌111結節を対象とした. グリソン鞘一括処理による系統的肝切除の術中所見を正診として, 肝3区域分けを基本とした区域境界を3箇所に設定し, 境界別, 検査別の局在区域診断正診率とPAE誤診例について検討した. 結果: 局在区域診断正診率は, PAEが90.1%で他の検査との間で有意差を認めた. しかしながら, 区域境界別では中区域右区域の下領域境界ではPAEと他の検査間に有意差を認めず, また他のいずれの検査においてもこの境界の正診率が最も低くかった. PAE誤診例は11結節認めたが, 8結節が中区域右区域の下領域境界であった. 考察: portal angio-echoは肝細胞癌局在区域診断に有用である. しかしながら, 中区域右区域の下領域境界診断に関しては中区域切除標本の検討から, 右葉肝門側亜区域を支配するグリソン鞘3次分枝に多くの分岐形態を認めるため, この境界の局在区域診断には注意を払う必要があると思われた.

BACKGROUND Des-γ-carboxy prothrombin (DCP) is an established marker for hepatocellular carcinoma (HCC), but the conventional enzyme immunoassay (EIA) kit lacks adequate sensitivity. Thus, a revised EIA kit with increased sensitivity has been developed. In this kit, the sensitivity has increased while high specificity to HCC has been maintained. The authors have already reported the clinical usefulness of this revised EIA kit. In this study, they examined the serum levels of DCP measured by this revised EIA kit in relation to the clinicopathologic features of solitary HCC. METHODS Fifty-six patients with solitary HCC who underwent hepatectomy were studied. The relation between the greatest dimension and the histologic differentiation of HCC was investigated in these 56 patients, as were the serum levels of DCP measured by the revised EIA kit (Sensitive DCP), α-fetoprotein (AFP), and DCP measured by the conventional EIA kit (DCP). The cutoff value for Sensitive DCP was set at 40 mAU/mL, and the values for AFP and DCP were 20 ng/mL and 100 mAU/mL (0.1 AU/mL), respectively. RESULTS The positivity rates for Sensitive DCP, AFP, and DCP (n = 56) were 53.6%, 53.6%, and 35.7%, respectively, and the rate was 73.2% when Sensitive DCP was used in combination with AFP (Sensitive DCP + AFP). The positivity rates for these markers were as follows: 1) When the greatest dimension of HCC was more than 3 cm (n = 16) and less than 2 cm (n = 23), the rates were 81.3% and 30.4% for Sensitive DCP, 68.8% and 39.1% for AFP, 56.3% and 13.0% for DCP, and 93.8% and 56.5% for Sensitive DCP + AFP. 2) When HCC was moderately to poorly differentiated (n = 41) and well differentiated (n = 15), the rates were 68.3% and 13.3% for Sensitive DCP, 61.0% and 33.3% for AFP, 48.8% and 0% for DCP, and 85.4% and 40% for Sensitive DCP + AFP. 3) When HCC was either more than 3 cm or moderately to poorly differentiated (n = 42) and either less than 2 cm or well differentiated (n = 27), the rates were 69.0% and 29.6% for Sensitive DCP, 61.9% and 37.0% for AFP, 47.6% and 11.1% for DCP, and 85.7% and 51.9% for Sensitive DCP + AFP. CONCLUSIONS DCP measured by the revised EIA kit with increased sensitivity has a stronger correlation than AFP with size and histologic differentiation of HCC. This Sensitive DCP is a very useful marker for HCC and should be used in combination with AFP. Cancer 2000;88:544–9. © 2000 American Cancer Society.

経皮的マイクロ波凝固療法 (PMCT) を施行した肝細胞癌273結節200症例を対象とし, 遺残率と局所再発率を腫瘍側因子の腫瘍径と治療側因子のapproachから比較し, 腫瘍増大例と合併症も加えてPMCTの適応を検討した. 腫瘍径別では20mm未満で良好な結果を得た. approach別では全身麻酔下が局所麻酔下より効果的であった. 腫瘍増大例は9例で全例半年以内に平均腫瘍径が23.1mmから53.3mmとなり, 広範囲門脈腫瘍栓を7例に, 塊状発育を5例に認めた. 追加治療奏功例はTAEの1例のみであった. 重篤な合併症の門脈出血, 胃壁腸管損傷は局所麻酔下に多く, グリソン鞘2次分枝近傍腫瘍に胆管狭窄を認めた. 肝細胞癌に対するPMCTは腫瘍径20mm未満がよい適応で, 局在部位が肝門部や肝表面で消化管と接する部位では特に注意を払う必要がある. また全身麻酔下では効果的な局所治療と合併症の回避が可能であり, 初回治療時に確実な完全凝固治療を目指すことが重要と思われた.

We report two cases of hepatic infraction after percutaneous microwave coagulation therapy (PMCT) for hepatocellular carcinoma.(Case 1) A 58-year-old man was diagnosed recurrence tumor 2.5 cm in diameter after right lobectomy. TAE was no effectiveness, and we performed PMCT under general anesthesia. After treatment, the patient had a high fever and a high AST/ALT level of 1779/1360 IU/L.(Case 2) A 69-year-old man was diagnosed multiple recurrence tumor after right lobectomy. We performed TAE and PMCT under general anesthesia for 15 mm (S4), 12 mm (S3) and 11 mm (S3) in diameter. After treatment, the patients had a high fever and a high AST/ALT level of 712/428 IU/L. In patients, CT scan revealed hepatic infraction in the proximal liver area.The patients had a high fever and a high AST/ALT level, but discharged into the 10 days after PMCT.

高分化型肝細胞癌切除71例を腫瘍最大径により大型12例 (3cm超) と小型59例 (3cm以下) に分け, 臨床病理像を比較検討した. 背景では年齢, 性, 肝炎の罹患率に差は認められなかった. 大型は肝硬変の併存率が有意に少なく (P=0.0329), AFP20ng/ml以下の症例が多く (P=0.0254), 血管造影では全例腫瘍濃染像を認めた (P

Background: Lymph node metastasis is a significant prognostic factor in intrahepatic cholangiocarcinoma. This study was aimed at investigating lymph node metastasis in intrahepatic cholangiocarcinoma and to examine whether the extent of metastasis affects outcomes after surgery. Methods: From 1980 through 1996, 70 patients with intrahepatic cholangiocarcinoma underwent hepatectomy, with a 50% curative resection rate. Lymph node dissection was performed in 51 patients, and the presence of lymph node metastasis was examined microscopically. The metastatic nodes were divided into groups N1, N2 or N3 using the classification proposed by the Liver Cancer Study Group of Japan. Results: Twenty-three patients had lymph node metastasis. Metastasis was to N1 nodes in 10 patients, to N2 nodes in nine patients and to N3 nodes in four patients. Nineteen patients had metastatic nodes in the hepatoduodenal ligament, which was the most common metastatic site regardless of tumor location. The five-year survival rate in patients with lymph node metastasis (0%) was significantly lower (p < 0.0001) than that in patients without lymph node metastasis (51%); however, five-year survival rates did not differ between patients with metastases to N1, N2 and N3 nodes. Conclusions: Lymph nodes in the hepatoduodenal ligament may be sentinel nodes for intrahepatic cholangiocarcinoma, and outcomes after surgery for patients with lymph node metastasis are poor regardless of the sites of nodal metastasis.

肝細胞癌129結節 (初回治療75結節, 切除後再発54結節) を対象とし, 血管造影所見および腫瘍径とTAEによる治療効果の関係を検討した. 血管造影所見としては, 腫瘍と非腫瘍の境界 (明瞭, 不明瞭), 腫瘍濃染の均一性 (均一, 不均一), 腫瘍濃染の程度 (強, 弱) について行い, TAE後1年経過後もviable lesionの出現を認めない結節を完全壊死結節とした. 完全壊死率は境界明瞭結節で61%, 均一濃染結節で57%, 強濃染結節で40%と有意に良好であり, 腫瘍径別検討では初回例では20mm～30mm, 再発例では10mm～20mmの腫瘍径において治療効果は最も良好だった. また, 境界明瞭, 均一濃染, 強濃染を示す結節の頻度は, 再発例において高く, 初回例では20%, 再発例では41%が完全壊死となり再発例の方が総じて治療成績は良好だった. 血管造影所見と腫瘍径を考慮して適応症例を選べばTAEの治療成績の向上が期待できる.

1996年までに切除した浸潤性膵管癌438例のうち, 5年以上長期生存した長期生存群17例と, 根治度A, B がえられたものの1年未満で癌再発死亡した早期 (再発) 死亡群29例を対象とし, 膵後方浸潤 (rp) の有無別に組織学的所見, 術式, 再発様式, quality of life (QOL) について比較検討した. rp (-) 例では, PL郭清を伴うD1+αが多かったが, ともに, 膵外神経叢浸潤 (p1) は陰性で, 長期生存群でりんぱ節転移n (+) が33%と少なかった. 早期 (再発) 死亡群では肝転移が75%であった. rp (+) 例では, PL郭清を伴うD1+αまたはD2が行われ, 長期生存群でn (+) が38%と少なく, 乳頭腺癌や高分化型管状腺癌が75%と多かった. 早期 (再発) 死亡群では肝転移, 後腹膜再発が68%, 40%で, 再発に伴うQOLの低下がみられた. 以上より, rp (-) 例ではD1+α以下の術式と効果的な肝転移対策, rp (+) 例ではPL郭清を伴うD2と局所制御のための補助療法, 効果的な肝転移対策が膵癌長期生存には必要と考えられた.

過去10年間の大腸sm癌外科切除104例の中で, 6例(5.8%)に術後転移再発を認めた. 局所・リンパ節再発は4例で, 直腸3例, 下行結腸1例であった. 組織型は中分化腺癌が3例, 高分化腺癌が1例で, 4例中3例はリンパ節転移陽性, 全例リンパ管侵襲陽性であり, 壁深達度細分類ではsm3であった. 3例に再切除を行い, 2例生存中である. 肝再発は2例で, 横行結腸1例, 上行結腸1例であった. 2例とも単発肝再発であり, 血中CEA値の上昇で, 肝再発を指摘しえ, 肝部分切除後無再発生存中である. 大腸sm癌の初回手術時の病理所見で中分化腺癌, リンパ節転移陽性例, リンパ管侵襲陽性例は, 局所・リンパ節再発のhigh risk groupとして, より入念な経過観察が必要である. 肝再発の予測は困難であるが, 肝転移を念頭においた術後の経過観察が重要であると思われた.

症例は58歳, 女性. B型慢性肝炎の経過観察中に肝細胞癌を指摘された. 他医にて肝動脈塞栓術および動注ポート挿入による化学療法を施行するも, 腫瘍壊死効果が得られず増大傾向を認めたため当院入院となった. 画像診断にてS5とS8に直径35mmと20mmの病巣を認めた. 患者が開腹治療を拒否したため経皮的マイクロウェーブ凝固壊死療法 (PMCT) を施行した. PMCT後の腹部CTでは腫瘍は早期相平行相とも低吸収領域となり凝固壊死と判断した. しかしPMCT後7カ月目の腹部CTにて, 急激に塊状発育した局所再発巣を認めたため, 右葉切除術を施行した. 病理組織所見ではtrabecular～tubular typeの低分化型肝細胞癌でvv2, vp1, b0, tw0, im2であった. しかしながら術後5カ月目に多発残肝再発と腹膜播種, リンパ節再発により死亡された. PMCTは肝癌の局所治療として有効であるがときに不充分な治療から腫瘍の急激な進展を示す場合もあり, 示唆に富む症例と考え報告した.

In 177 patients with hepatic tumor (245 nodules) undergoing percutaneous microwave coagulation therapy (PMCT), tumor persistence and local recurrence were compared with regard to tumor size and the method of treatment in order to identify suitable candidates for PMCT. Tumors measuring less than 20 mm in diameter showed a good response to PMCT. And the therapy was more effective under general anesthesia than under local anesthesia. PMCT is best indicated for tumors less than 20 mm in diameter. And under general anesthesia, effective local treatment are possible. Therefore, it seems important to achieve reliable and complete coagulation at the initial treatment session.

We experienced a case of solitary splenic metastasis after hepatectomy for hepatocelluler carcinoma. The case was a 69-years-old female without liver cirrhosis or hepatitis. She underwent “so called Right Liver Trisegmentectomy” for large hepatic tumor on November 16, 1993. Pathological findings revealed trabecular type moderately differentiated hepatocellular carcinoma. fc (+), fc-inf (+), Vp0, Vv0, b0, tw (-), im 1. Seven months later, we observed multiple liver metastasis and a low density splenic tumor of 2cm diameter by computed tomography. We perfomed Trans arterial embolization on the liver metastasis, but the splenic tumor had enlaged to 4cm diameter. We diagnosed the splenic tumor as metastasis of hepatocellular carcinoma. She underwent splenectomy on March 20, 1995. Before and during the operation, we found other evidence of metastatic tumors except for those detected in the liver and spleen. Immunological competence levels were within the normal range. There had been 8 cases of solitary splenic metastasis of hepatocellular carcinoma reported in Japan, and only 2 were resected.

膵頭部癌に対する全胃幽門輪温存膵頭十二指腸切除 (PpPD) の適応を, 十二指腸第1部または胃への癌の直接浸潤を認めず, 胃周囲リンパ節 ((3), (4), (5), (6), (7)) への転移を認めないこととした1989年以降の膵頭部浸潤性膵管癌切除例154例を対象に, PpPD66例と胃切除を伴う膵頭十二指腸切除 (胃切除PD) 88例の2群に分け, 比較検討した. 拡大手術は, ともに約80%に安全に行われ, 進行度, 根治度もPpPDと胃切除PDで差はなかった. 5生率, 平均生存期間もともに差はなく, PpPDでおのおの, 35%, 15.0か月であった. 再発様式はともに後腹膜再発, 肝転移が多くを占め, PpPDで胃周囲リンパ節再発例はなかった. Performance, Statusと体重変動からみた術後のQuality of Life (QOL) もPpPDと胃切除PDに差はなく良好であった. 以上より, 上記の適応基準を用いれば, 根治性, 安全性, 術後QOLを損なうことなく, 膵頭部癌に対する基本術式としてPpPDを導入できると考えられた.

胸部食道癌の占居部位別, 深達度別至適リンパ節郭清領域を転移頻度や治療成績などを考慮して検討した. 頸部郭清は, n (+) のIm例で上縦隔リンパ節転移が無い症例のみで有効 (p

症例は71歳の男性. 1983年 (60歳), 他医にて肝後区域の門脈腫瘍栓を有する径5.5cmの肝細胞癌に対し動注化学療法が施行され腫瘍は消失た. 1991年 (68歳), 肝前区域に肝癌再発. 胆管細胞癌の術前診断で肝右葉切除が施行された. 径3.5cmの肝細胞癌 (低分化型, 索状型) と, 径3.0cmの胆管細胞癌 (中分化型管状腺癌) が衝突する肉眼像を呈し, 混合型肝癌 (combined type) と診断された. 1994年 (71歳), 術後3年目, 左頸部に径6.0cmのリンパ節転移が発見され頸部リンパ節摘出術が施行された. リンパ節の組織所見は索状および管状に増殖する腺癌で組織学的および免疫組織学的所見より胆管細胞癌からのリンパ節転移と診断された. 臨床的にはその他の部位への再発は見られず, 混合型肝癌術後左頸部リンパ節にのみ転移再発した症例と考えられた.

Intrahepatic metastasis via the portal venous system and bloodborne distant metastasis are common in hepatocellular carcinoma. However, lymph node metastasis after resection of hepatocellularcarcinoma is rare. and recurrence of lymph node metastasis after surgical resection is also rare. On the other hand, detection of lymph node metastasis has been reported in about 30% of autopsy cases. We carried out this clinicopathological study to assess patients positive for lymph node metastasis among those who underwent surgical resection of hepatocellular carcinoma. A total of 951 patients underwent resection of HCC in our department during the period from 1983 to 1995, and 57 of them, the lymph nodes were dissected or the hepatoduodenal liga-ment and superior pancreatic rim alone were sampled intraoperatively because lymph node enlargement was noted during surgery. Histological examination showed lymph node metastasis in 7 patients. The carcinomas were larger than 4cm in diameter in all 7 patients and had invaded other organs in 3 of them. Many metastic lymph nodes were detected in cases 8 and 12. Lymph node metastasis was associated with cirrhosis in one of them. All 7 patients had poorly-differentiated HCC, with extensive interstitial invasion. We analyzed the correlation between lymph node metastasis and levels of carcinoembryonic antigen (CEA), tumor grade and liver tissue. There was a significant correlation between these facters and lymph node metastasis (p

手術治療を行った単発の原発性肝細胞癌534例を対象として術後10年間の生存曲線, 無再発生存曲線を生存分析パラメトリックモデルへ当てはめた. 3年-5年-10年の生存率, 無再発生存率はそれぞれ76-60-34%, 46-32-16%であった. ワイブルモデルあるいは対数ロジスティックモデルが生存曲線, 無再発生存曲線をよく説明することが明らかとなった. 生存曲線に影響を及ぼす有意な因子は術前ICG R15値と腫瘍径であり, 術前ICG R15値が低値で, 腫瘍径の小さなものほど良好な生存率が期待された. 無再発生存曲線については術前ICG R15値, 腫瘍径, 切除区域であり, 術前ICG R15値が低値, 腫瘍径の小さなもの, 切除区域の大きな症例ほど長期の無再発が期待される結果となった. 切除域の拡大は無再発期間の延長に繁がるが, 長期の生存には切除域の拡大は影響せず, 肝機能が良好であることがむしろ重要であり, 切除と肝機能温存のバランスを取ることの重要性が再確認された.