Search

症例は70歳，女性．平成4年10月に原発巣が不明の多発肝転移およびリンパ節転移の診断を受けていたが，経過観察となっていた．平成5年1月に，腹痛のため当院を救急受診し，汎発性腹膜炎にて緊急手術となった．回腸末端部約20cmにわたって壁の肥厚，硬化および膿苔の付着がみられたため，同部の穿孔と考え回盲部切除を行った．術後の病理検査でびまん浸潤型の回腸癌（中分化腺癌）と診断した．小腸癌はほとんどが輪状に発育し，本症例のように腸管の長軸に沿ってびまん性の発育をしめした症例は，過去に報告がなく極めて稀であり，若干の文献的考察を加え報告する．

今回，膵癌の小腸転移により小腸穿孔を来した1例を経験したので本邦文献報告例の検討および文献的考察を加え報告した．症例は84歳，女性．急性腹症の精査にてFree airおよび膵尾部腫瘍を指摘された．開腹所見では空腸に全周性腫瘍が存在し，同部で穿孔を認めた．空腸部分切除および腫大した幽門上リンパ節（#5）のサンプリングを行なった．術後病理所見にて小腸腫瘍および#5リンパ節は中分化腺癌で同一の組織像であり，小腸腫瘍は転移性腫瘍の形態を示したことから膵原発と考えられた．膵癌からの小腸転移は極めて稀である．我々が検索しえた限り，膵癌小腸転移の本邦文献報告例は自験例を含めわずか6例であった．平均年齢66.2歳，男性5例，女性1例であった．転移は全例空腸であり，穿孔例は3例で，5例で小腸切除がなされていた．転移経路は血行性3例，播種性3例であった．全例とも予後不良であった．

Correlations between preoperative carcinoembryonic antigen (CEA) levels of peripheral (p-CEA) and draining blood (d-CEA), the CEA gradient between d-CEA and p-CEA (d-p CEA gradient) levels, and survival after resection of cancer lesions were examined in 94 patients with colorectal cancer. Survival rates of patients with normal p-CEA and d-CEA levels and d-p CEA gradient levels (less than 5 ng/ml) were significantly better than those of patients with abnormal levels (greater than or equal to 5 ng/ml), and the 5-year survival rates were, respectively, 62%, 69%, and 72% in the former and 42%, 41%, and 35% in the latter. The differences in the 5-year survival rates between patients with normal and abnormal d-p CEA gradient, d-CEA, and p-CEA levels were 37%, 28%, and 20%, respectively. Furthermore, the positive rates of d-CEA levels (64%) and d-p CEA gradient levels (48%) were higher than that of p-CEA levels (36%). However, some significant differences in background variables also were found between the respective groups of patients with normal and abnormal p-CEA and d-CEA levels and d-p CEA gradient levels. These results suggest that patients with poor prognoses are examined more effectively by determining their d-p CEA gradient and d-CEA levels than their p-CEA levels, and that CEA may be expressed as a quantitative sum total of various pathophysiologic variables of patients with colorectal cancer but not as an independent prognostic variable.

The correlation between CA19-9 levels of portal and peripheral venous blood, and immunohistochemical variables of cancer lesions was examined in 53 gastric cancer patients and eight patients with benign diseases. Immunohistochemically, CA19-9 was found in 33 (62.5%) of 53 primary lesions. The antigen was found in the cancer cells of invasive lymphatics and node metastases of every CA19-9 localized cancer, although the cancer cells in veins showed little or no CA19-9. There was little or no antigen in the cancer cells in veins, lymphatics, or metastases of 20 CA19-9 nonlocalized primary lesions. Patients with CA19-9 nonlocalized cancer or with benign diseases showed no elevation of the antigen levels in peripheral or portal blood. CA19-9 levels of portal blood (mean, 76.4 U/ml; positive rate, 33.3%) were not different from those of peripheral blood (mean, 91.5 U/ml; positive rate, 33.3%). Additionally, the antigen levels of the blood in patients with lymphatic invasion or node metastases were significantly higher than those in patients without the invasion or the metastases, and every patient without the invasion showed no elevation of the antigen. These results suggest that production of the antigen in cancer cells may be a premise of CA19-9 elevation in peripheral blood and that CA19-9 may be drained by the thoracic duct of the lymphatic system via node metastases or invasive lymphatics, but not by the hematogenous portal system.

過去14年間に教室で経験した大腸多発癌18例と単発癌291例を対比し, 多発癌の背景因子と臨床的・病理学的な特徴について検討を加え, 以下の結果と結論を得た.同時性多発癌は14例 (4.8%), 異時性多発癌は4例 (1.4%) であった. 背景因子として, 性・年齢・遺伝性素因並びにポリープ合併頻度が, 癌病巣の臨床病理学的所見として, 発生部位・肉眼型・深達度・組織型において多発癌と単発癌との間に生物学的な差があることを報告した. 同時に大腸多発癌について上のべについても文献的な考察を加え言及した.

Correlation between carcinoembryonic antigen (CEA) levels of peripheral and portal blood, and eight histopathologic variables, was examined in 66 patients with colorectal cancer. The change in CEA levels in the portal blood of 40 patients during operation was also examined in relation to histopathologic variables. CEA levels of portal blood (with a mean of 26.6 ng/ml and positive rate greater than 5 ng/ml, 59.1%) were significantly higher than those of peripheral blood (8.1 ng/ml, 33.3%). Elevation of CEA levels in portal and peripheral blood was most highly correlated with the venous invasion. Although the levels in the portal blood were related to six other histopathologic variables including tumor size, tumor differentiation, node metastasis, lymphatic invasion, invasive layer of the colorectal wall, and Dukes' classification except tumor location. CEA levels rose from 19.4 ng/ml and 40% to 43.6 ng/ml and 90.2% respectively following operative stimuli to cancer lesions with venous invasion. However, the levels did not rise in the lesions without the invasion. CEA levels of peripheral blood were as low as 5 ng/ml in three out of eight patients with liver metastasis. However, the levels in portal blood were much greater than 5 ng/ml in all of the patients. These results suggest that CEA may be hematogenously drained by the portal system via the draining vein from the cancer cells in the invasive veins but not by the thoracic duct of the lymphatic system.