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OBJECTIVE Our goal was to ascertain the prevalence of pruritus in diabetic and nondiabetic subjects and the relevance of symptoms, signs, and nerve functions of diabetic polyneuropathy (DPN) of pruritus. RESEARCH DESIGN AND METHODS A large-scale survey of 2,656 diabetic outpatients and 499 nondiabetic subjects was performed. In diabetic subjects, the relationship between pruritus and age, sex, diabetic duration, A1C, Achilles tendon reflex (ATR), and abnormal sensation in legs was evaluated. In 105 diabetic subjects, nerve conduction studies, quantitative vibratory threshold (QVT), heart rate variability, and a fall of systolic blood pressure at a head-up tilt test (ΔBP) were performed, and the relationships between pruritus and nerve functions were evaluated. RESULTS Although the prevalence of truncal pruritus of unknown origin (TPUO) in diabetic subjects was significantly higher than that in age-matched nondiabetic subjects (11.3 vs. 2.9%, P = 0.0001), the prevalence of other pruritus was not different between the two groups. Multiple logistic regression analysis revealed that abnormal sensation and ATR areflexia were independent risk factors for TPUO in age, sex, duration of diabetes, and A1C. ΔBP in diabetic subjects with TPUO was significantly impaired compared with that in those without TPUO. Larger ΔBP was identified as a significant risk factor of TPUO independent of other nerve dysfunctions by multiple logistic regression analysis. CONCLUSIONS TPUO is significantly more frequent in diabetic than in nondiabetic individuals. TPUO is significantly associated with symptoms and signs of DPN, including impaired blood pressure response in a head-up tilt test. TPUO, therefore, might be a newly recognized symptom of DPN.

In order to clarify the predictors of postoperative respiratory complications in patients over 80 years old who had undergone gastrectomy for gastric cancer with lymph node dissection to the extent of group 1 or 2, 21 patients were divided into two groups according to postoperative respiratory complications, eight with and 13 without complications. Univariate analysis revealed %VC, VC/m2 and FEV1.0/m2 as the predictor for respiratory complications, and Nutritional Risk Index or performance status (PS) had a tendency to be the predictor. The following formula which means possibility of postoperative respiratory complications, Y=1.184+0.186×curability-0.645×VC/m2+0.216×PS was elicited by stepwise logistic analysis. Y value of 0.47 established as the cut off point obtained accuracy in 90.5%, sensitivity in 90.5% and specificity in 92.3%. In order to prevent postoperative respiratory complications, preoperative exercise of respiratory function to raise vital capacity should be involved and an adequate method of operation should be selected by taking PS and stage of gastric cancer into consideration.

A surgical resection of metastatic liver lesions from colorectal cancer contributes to an improved prognosis. However, the postoperative recurrence rate remains high, particularly in the residual liver. This is probably the result of the failure to detect small lesions. In the present study, we histologically examined the presence of intrahepatic micrometastases, which are considered to be related to recurrence in the residual liver. Intrahepatic micrometastases were histologically examined in 31 resected specimens of 25 patients undergoing a hepatic resection because of metastasis to the liver from colorectal cancer. Micrometastases were found in 14 of 25 cases (56.0%). They were located in the portal veins, central veins, sinusoid, and bile ducts. The longest distance from the main metastasis was 38.2 (mean 7.5 +/- 8.0) mm. The size of the macrometastases became larger, and the frequency of micrometastases and the distance of micrometastases from macrometastases had a tendency to increase. Continuous invasion of the macrometastases into the micrometastases through the vasculature or bile duct was also observed. These results suggested that some micrometastases observed in the metastatic liver from colorectal cancer were thus seeded from the primary lesions, while other micrometastases originated from the macrometastatic lesions as satellite lesions.

A 56-year-old man who had been operated on for a cancer of the thoracic esophagus was admitted to the hospital with a suspicion of pleural recurrence on February 28, 1996. On March 14, dyspnea along with hallucination and disorientation appeared. Since severe impaired ventilation was noted, endotracheal intubation was emergently performed and the patient was entered the ICU. At that time, Ca level was 18.6mg/dl, showing significant hypercalcemia, and the white blood cell count increased to 18, 100/mm8. PTH-rP level in blood was as high as 260Pmol/ml. The elevated Ca level gradually decreased with a combinated use of elsitonine and bisphosphonate and his clinical condition became better, however, the Ca level converted to increase gradually since April 7, and appearance of arrhythmia and aggravation of ventilatory impairment were associated. On May 8, the patient died of abrupt cardiac arrest, when the white blood cell count was 21, 600/mm3 and Ca level was 14.8mg/dl. It is thought that hypercalcemia in this case might be caused by pleural recurrence of the esophageal cancer based on an increase in PTH-rP, and the cause of his death might be due to hypercalcemia crisis because the increase in Ca level was correlated with the clinical symptoms.

進行胃癌に対する自律神経系(とくに交感神経系)を温存した大動脈周囲リンパ節(No.16)郭清の意義を検討した. 過去5年間にNo.16郭清を施行した進行胃癌115例(H0P0深達度mp以深)を対象とした. 左右大小内臓神経(SN), 両側腹腔神経叢(CP), SMA神経叢(SMA)を完全温存した全温存61例, SMAと右側のSN, CPを温存した右温存47例, SMAと左側のSN, CPを温存した左温存4例, すべての神経および神経叢を切除した全切除3例であった. 深達度ss以深ではNo.16転移率が20%を越えており, No.16郭清の適応と思われた. No.16転移個数15個以上, あるいはNo.16a2, b1の全領域転移例にはNo.16郭清の意味はなかった. H0P0se, H0P0siに対するD4はD2よりhistoricalに良好な成績であった. CP, SMA, SNを温存した(全温存, 右温存)No.16郭清は術後難治性水様下痢の発症が4%以下で, No.16の単独再発もなく郭清効果は満足できるものと考えられたが, 男性の射精機能が犠牲となっていた.

胃癌大動脈周囲リンパ節郭清78例に, CH40を投与し, リンパ流とリンパ節転移との関連を検討した.転移陽性リンパ節の黒染率は46.7%で陰性の55.4%に比較し有意に低率だった.リンパ流はA領域でNo.3→7, 8a→9→16, 4d→6→14v→16が多く, No.16a1の黒染率が最も高かったが, n1 (+) では通常のリンパ流がブロックされ, No.5, 6へ直接流入するリンパ流が増加した.また, M領域ではNo.3→7→9→16が多かったが, n1 (+) ではNo.5, 4sa, 2へ直接流入した.C領域ではNo.2→16, 4sa→10, 11→16が多く, No.16a2lateroの黒染率が高かった.No.8p, 12, 14vの黒染率は低く, n1 (+) ではNo.7へ直接流入した.跳躍転移例とn0症例のリンパ流は変化なく, 跳躍転移という概念は現行取扱い規約から生じる歪みと考えられた.リンパ節の群別化を解剖学的にではなく, 転移程度や郭清効果に準じ分類し, リンパ流を考慮した術式が治療成績向上に重要である.

A 47-year-old man was pointed out having a retroperitoneal tumor on ultrasonography at a medical checkup in March 1993, and was kept under medical observation. In May 1994 the patient was referred to the department because of an enlargement of the tumor. On preoperative imaging diagnosis, the tumor positioned on the left side of the aorta and at the inferior margin of the pancreas, and was 50 mm in longer diameter, almost spherical in morphology and cystic with a solid part. The feeding vessels were branched from the dosal pancreatic artery. During surgery, it was found that the tumor continued to the superior mesenteric plexus. The tumor was extirpated by resecting a part of the plexus. Histologically, it revealed findings of paraganglioma that the tumor was positive for two staining methods, and that polymorphologic cells with hranular cytoplasm solidly proliferated associating with small vessels. This paper describes this very rare case of retroperitoneal paraganglioma together with a review of the Japanese literature.

In order to clarify the predictive risk factors of postoperative pulmonary complications after surgery for esophageal cancer, 33 cases undergoing esophagectomy under thoracotomy were evaluated using univariate analysis and stepwise logistic regression analysis. In our department, postoperative pulmonary complications are defined as those demanding respiratory management for more than one week or those needing oxgen administration for more than 2 weeks. Postoperative pulmonary complications were observed in 9 cases (27.3%). With univariate analysis, FEV1.0/m2, MVV/m2 and bledding volume during surgery were significantly different between the cases with and without pulmonary complications, with stepwise logistic regression analysis, FEV1.0/m2, bleeding volume during surgery and duration of thoracotomy were selected as predictive factors of pulmonary complications. Risk score=0.742+0.0001517×bleeding volume during surgery+0.002655×duration of thoracotomy-0.796×FEV1.0/m2 was obtained by multivariate statistical analysis. Significantly high incidence of pulmonary complications was observed in patients with risk socre more than 0.36, These results suggested that to prevent postoperative pulmonary complications, over surgery should be avoided especially in the patients with obstructive pulmonary dysfunction.

The aim of this study is to evaluate the usefulness of intraoperative continuous hyperthermic peritoneal perfusion therapy (CHPP) combined with paraaortic lymph node dissection for the patients with serosal exposed gastric cancer. The survival and recurrent rates between CHPP combined (CHPP(+)) group (n=29) and CHPP not combined (CHPP(-)) group (n=35) were discussed. In 7 peritoneal disseminated cases the apoptosis index before and after CHPP were examined at several lesions of peritoneal dissemination. The 3-year survival rates were 42.6% in CHPP(+) group and 46.4% in CHPP(-) group and the rates in n4(-) cases were 72.5% and 48.1% respectively. The rates of peritoneal recurrence were 31.0% in CHPP(+) group and 34.3% in CHPP(-) group. Especially in the n4(-) cases, the rates were 16.7% in CHPP(+) and 30.8% in CHPP(-). And no peritoneal recurrence was observed in n4(-) cases with the mean intraperitoneal temperature was more than 42°C. The apoptosis index was 3.5±2.3% before CHPP or 51.5±7.5% after CHPP. In conclusion, CHPP is effective as a local therapy and paraaortic node dissection combined with CHPP is useful for the patients with no paraaortic lymph node metastasis and those whose mean intraperitoneal temperature had been maintained at more than 42°C.

膵癌・大腸癌患者において燃蛋白に対する免疫応答を検討した. 血清中の抗ras抗体陽性率は正常人の5% (2/40) に対し, 大腸癌で40% (51/150, p

マトリックスメタロプロテアーゼ (MMP)-2, 7, 9のmRNA発現を, 大腸癌手術標本を用いて観察した.その結果, MMP-7 (マトリライシン) mRNAは, 癌組織にのみ特異的に強く発現し, その発現量は大腸癌の進展度に伴い増加し, 肝転移巣においても非常に強く発現していた.そこで, マトリライシンmRNAに対するアンチセンスオリゴヌクレオチドを設計, 合成し, 大腸癌の浸潤, 増殖に及ぼす影響を検討した.アンチセンスオリゴはマトリライシン産生直腸癌細胞株CaR-1のマトリライシンmRNA発現を特異的に抑え, 濃度依存性にその浸潤および増殖能を抑制した.以上の臨床および基礎データから, マトリライシンは大腸癌の浸潤, 転移に関わるものと考えられ, 現在, マトリライシンmRNAのアンチセンスオリゴを肝動注投与することにより, 微小肝転移の増殖抑制および肝内への浸潤抑制の可能性について検討している.

症例は49歳の男性で心窩部痛を主訴に来院, 胃内視鏡検査で胃角部後壁の0' (IIc+III) T2型胃癌と診断した.CT検査でNo.7と16b1リンパ節の腫大を認め, 血清alpha-fetoprotein (AFP) 値は3.0ng/mlと正常であったが, carbohydrate antigen 19-9 (CA19-9) 値は490ng/mlと高値を呈した.胃全摘術および膵体尾部・脾臓・左副腎・胆嚢合併切除によるD4郭清を施行した.原発巣は深達度ssの低分化型腺癌でNo.7と16b1の転移リンパ節にのみ肝様腺癌を認めた.AFPおよびCA19-9染色は原発巣ではともに陰性であったが, 転移リンパ節の肝様腺癌ではAFP陽性細胞が散在性に認められ, CA19-9染色はすべての細胞がびまん性に染色された.以上より本例は転移リンパ節の肝様腺癌がCA19-9を産生したまれな症例と思われた.肝様腺癌はAFP産生胃癌に特徴的な組織型であるが, 本例のようにCA19-9値が高値の肝様腺癌は広範なリンパ節転移をきたすので十分なリンパ節郭清が必要である.

We studied the effects on survival time of postoperative immuno-chemotherapy, including the streptococcal preparation OK-432, in patients with gastric cancer and synchronous peritoneal dissemination. The patients were prospectively randomized and a valid statistical assessment could be made for 109. Patients randomized to group B received therapy that is widely used in Japan to treat patients with gastric cancer: mitomycin C (MMC) and UFT, a combination of tegafur and uracil in a molar ratio of 1:4, for 1 year. Patients randomized to group A received the same drugs as were given to group B patients plus OK-432 i.p. for 7 days, beginning on postoperative day 0, and OK-432 by intradermal injection for 1 year, at 2-week intervals. There were no differences between the two groups in any known prognostic factor or in the dose of any drug administered except for OK-432. There was no difference in the toxicity rate between the groups. In this negative trial, there was no improvement in survival time with the addition of OK-432 to MMC and UFT for patients with gastric cancer and peritoneal dissemination.

症例は左側腹部痛と粘血便を主訴とした69歳の男性で,注腸X線検査および大腸内視鏡検査の結果,下行結腸に浅い小潰瘍を伴う大きさ4×3cmの粘膜下腫瘍を認め,左半結腸切除術および横行結腸直腸端々吻合を施行した,標本は組織学的に反応性のリンパ球増殖であるのか悪性リンパ腫なのか通常の染色では診断に苦慮した.そこでリンパ球の各抗原に対するモノクロナール抗体を用いたAvidin-Biotin-Colnplex法によって免疫組織学的検索を行った,パラフィン切片では膜抗原の保存性が悪く,凍結切片を用いることにより,λ-chainだけからなるIgMを産生するモノクローナルなB細胞の瀰慢性増殖を示す悪性リンパ腫であると診断できた.またこの悪性細胞はintermediateB細胞,matureB細胞およびlarge non-cleavedcellの一部にみられるB2抗原が陽性であった.

大腸癌根治手術後の再発の防止および早期発見による治療成績の向上を目的として治癒手術後3年以上経過例における再発について検討を行った. 再発は415例中145例 (34.9%) にみられ約80%は2年以内, 約90%は3年以内にみられた. 再発形式は結腸癌では肝再発が半数をしめ, 直腸癌では局所再発が最も高頻度であった. 再発後5年生存例は3例のみであり, 再発死亡例129例の平均生存期間は11.6ヵ月であった. carcinoembryonic antigen, computed tomographyの導入により特に肝再発の切除率の向上がみられ, 再発巣の切除により生存期間が延長したと考えられる症例もあり, 腫瘍マーカー測定や画像診断などによる定期的なフォローアップを行い早期に再発を診断することが重要であると考えられた.