Search

Background : The aim of this study was to investigate quality of life (QOL) and night-time sleep disturbance in colon cancer patients with middle risk chemotherapy for proper antiemetic therapy. Methods : The study enrolled 139 patients with colorectal cancer. All patients received oxaliplatin or irinotecan-based chemotherapy. Patients completed a questionnaire about chemotherapy-induced nausea and vomiting and sleep disturbance. Sleep disturbance was checked, and the relationship between sleep disturbance and nausea was analyzed. Results : The prevalence of nausea was 48.9% (68 / 139). The degree of the nausea was slight / moderate / severe in 51 / 11 / 6 patients, and 12 patients had vomiting. Appetite showed no change / slightly decreased / half / one-fourth / none in 51 / 34 / 33 / 6 / 7 patients. There were significant differences in the mental component summary (MCS) score and the role-social component score (RCS). (MCS : nausea(+) vs nausea(-) 46.4 ± 1.1 vs 54.1 ± 1.1 p 0.01 RCS : nausea(+) vs nausea(-) 33.1 ± 2.1 vs 41.6 ± 2.1 p 0.01). Using the MCS with a cut-off score of 50, patients were divided into two groups, and nausea was significantly correlated with a low MCS score. Furthermore, patients were divided into two groups using a Pittsburgh Sleep Quality Index cut-off score of 6, and sleep disturbance was correlated with old age and second-line chemotherapy. Conclusions : Nausea affects QOL and night-time sleep of colon cancer patients with middle risk chemotherapy. J. Med. Invest. 67 : 338-342, August, 2020.

We clarified the safety and efficacy of preoperative chemoradiotherapy for locally advanced rectal cancer using a multidrug regimen (S-1 + oxaliplatin + bevacizumab). This multicenter phase II trial involved 47 patients with locally advanced rectal cancer. All patients received S-1 orally (80 mg/m2/day on days 1–5, 8–12, 15–19, and 22–26) and infusions of oxaliplatin (50 mg/m2 on days 1, 8, 15, and 22) and bevacizumab (5 mg/kg on days 1 and 15). The total radiation dose was 40 Gy delivered in daily fractions of 2 Gy via the four-field technique. The primary endpoint was the pathological complete response rate. The secondary endpoints were safety (incidence of adverse events) and clinical response, relapse-free survival, overall survival, local recurrence, R0 resection, downstaging, and treatment completion rates. All 47 patients received chemoradiotherapy, and 44 patients underwent curative resection. Two patients refused surgery and selected a watch-and-wait strategy. The pathological complete response rate was 18.2% in patients who underwent curative resection. The clinical response rate was 91.3% in 46 patients. Concerning hematotoxicity, there was one grade 4 adverse event (2.1%) and seven grade 3 events (14.9%). Diarrhea was the most frequent non-hematotoxic event, and the grade 3 event rate was 25.5%. Although preoperative chemoradiotherapy for patients with locally advanced rectal cancer using the S-1 + oxaliplatin + bevacizumab regimen did not achieve the expected pathological complete response rate, this regimen led to an improved clinical response rate.

According to the REGARD and RAINBOW trials, ramucirumab(RAM)was introduced as second-line therapy for advanced or metastatic gastric cancer. Endoscopic metallic stent placement and angiogenesis inhibitor administration carry the risk of gastrointestinal perforation. The outcomes of patients who undergo endoscopic placement of metallic stents during RAM treatment have not yet been fully assessed. A 60's man was diagnosed with advanced esophagogastric junction cancer(por) with Virchow's lymph node metastases. His tumor was classified as cT4a(SE), N1(#1), M1, stage Ⅳ. He received chemotherapy, but the size of the primary tumor and metastases increased. After stenting for gastric outlet obstruction, he received a paclitaxel(PTX)plus RAM regimen as third-line treatment. Because of CTCAE Grade 2 peripheral neuropathy, PTX was discontinued after 10 courses. For 11 months, tumor control without adverse events was maintained. The patient was then switched to CPT-11 as fourth-line treatment.

BACKGROUND/AIM Right aortic arch (RAA) is a rare abnormality of the aortic arch that forms a vascular ring. Oesophageal cancer (EC) accompanied with RAA is even rarer, and in such cases, it is very important to understand the anatomical structure in the upper mediastinum in order to perform a safe and curative operation. PATIENTS AND METHODS A 67-year-old man who presented with pharyngeal discomfort was admitted to our hospital. Further examinations revealed advanced thoracic EC accompanied with RAA and aortic diverticulum. RESULTS After neoadjuvant chemotherapy, we successfully and safely performed thoracoscopic oesophagectomy and lymphadenectomy using the prone positioning. CONCLUSION There exist only a few reports of thoracoscopic oesophagectomy for EC with RAA. Sufficient preoperative preparation and sharing an adequate strategy for the surgical approach with the surgical team are definitely necessary. Although the thoracoscopic approach for EC with RAA is useful, more considerations are needed for some issues.

BACKGROUND AND AIM Various randomized clinical studies have suggested that short- and long-term outcomes of laparoscopic surgery (LAP) for colorectal cancer are comparable with those of open surgery (OP). However, these studies were performed in high-volume hospitals. The aim of the present study was to compare the outcomes of LAP versus OP for colorectal cancer in rural hospitals. METHODS This was a multicenter retrospective propensity score-matched case-control study of patients who underwent colorectal surgery from January 2004 to April 2009 in 10 hospitals in Japan. All patients underwent curative surgery for pathologically diagnosed stage II or III colorectal cancer. The primary end point was 5-year overall survival (OS). The secondary end points were disease-free survival (DFS) and postoperative complications. RESULTS In total, 319 patients who underwent LAP and 1020 patients who underwent OP were balanced to 261 pairs. There was no significant difference in the OS and DFS between two groups. The operation time was significantly shorter for OP than for LAP. Blood loss was significantly lower in LAP than in OP. There was no difference in intraoperative morbidity between the two groups. The postoperative morbidity was significantly lower in LAP than in OP. The hospital stay was significantly shorter in LAP than in OP. There was no significant difference in 90-day postoperative mortality. CONCLUSIONS Laparoscopic surgery may be a feasible option for colorectal cancer in rural hospitals.

We devised a method for confirming the position of mesh placed during transabdominal preperitoneal repair (TAPP) of an inguinal hernia. The preperitoneum is sufficiently detached, and the mesh is fixed in place as usual. Before completely closing the peritoneum, pressure is applied from outside the body and inside the abdominal cavity to remove as much air as possible from the detached preperitoneum; the peritoneum is then sutured using a V-Loc(TM) closure device so that it does not constrict. By releasing the pressure all at once, the airtightness of the preperitoneum is maintained, and the position of the mesh can be observed through the translucent peritoneum. This method, called Mesh-Airtight-Preperitoneum (MAPP), could become widely used as a simple technique for confirming mesh position in TAPP. J. Med. Invest. 63: 270-273, August, 2016.

Introduction We evaluated 3-D CT imaging for preoperative classification of the left gastric artery and vein in patients with early gastric cancer and estimated its clinical benefit. Methods Between April 2009 and March 2014, 279 patients underwent preoperative 3-D CT using a 64-row multi-detector CT scanner, followed by laparoscopy-assisted distal gastrectomy. The 3-D CT images of the arterial and portal phases were reconstructed and fused. The operative outcomes were compared between patients who had not undergone 3-D CT (2007–2008) and who had undergone 3-D CT (2009–2011). Results According to Adachi's classification, the numbers of type I, II, III, IV, V, and VI arterial patterns were 253, 15, 1, 3, 3, and 1, respectively. Three cases could not be classified. According to the Douglass classification, the left gastric vein flowed into the portal vein, splenic vein, junction of the portal vein and splenic vein, and left branch of the portal vein in 119, 111, 36, and 5 patients, respectively. The left gastric vein could not be visualized in six patients, and two patients could not be classified. In addition, the relation was absent for an Adachi type I vein and one of the “other” types of veins. The total operative time was significantly shorter with 3-D CT than without it (P = 0.01), and the degree of lymph-node dissection was significantly higher (P = 0.01). Inflammatory parameters and operative morbidity tended to decrease with 3-D CT. Conclusion Three-dimensional CT is a useful modality to visualize the vessel anatomy around the stomach, and it improves clinical effectiveness and reduces the invasiveness of surgery.

Laparoscopy-assisted distal gastrectomy (LADG) for gastric cancer is safe and feasible. In contrast, no prospective study evaluating the safety and efficacy of laparoscopy-assisted total gastrectomy (LATG) or laparoscopy-assisted proximal gastrectomy (LAPG) has been completed. We conducted a single-arm confirmatory trial to evaluate the safety of LATG/LAPG for clinical stage I (T1N0/T1N1/T2N0) proximal gastric cancer. The extent of lymphadenectomy was selected based on the Japanese Gastric Cancer Treatment Guidelines. The mini-laparotomy incision was required to be ≤ 6 cm. The primary endpoint was the proportion of grade 2–4 (CTCAE ver. 4.0) esophagojejunal anastomotic leakage. The planned sample size was 245 considering a threshold of 8% and one-sided alpha of 2.5%. Between April 2015 and February 2017, 244 eligible patients were enrolled. LATG/LAPG was performed in 195/49. The proportion of conversions was 1.7%. Clinical T1N0/T1N1/T2N0 was 212/9/23. The extents of lymphadenectomy were as follows: D1+: 229; D2: 15. The median operation time was 309 min (IQR 265–353). The median blood loss was 30 ml (IQR 10–86). Grade 2–4 esophagojejunal anastomotic leakage was 2.5% (6/244; 95% CI 0.9–5.3). The overall proportion of in-hospital grade 3–4 adverse events was 29% (71/244). The proportions of intraabdominal abscess and pancreatic fistula were 3.7% and 2.0%, respectively. There were no treatment-related deaths. This trial confirmed the safety of LATG/LAPG. After the non-inferiority of LADG is confirmed in our phase III trial (JCOG0912), LATG/LAPG is expected to be established as one of the standard treatments for clinical stage I gastric cancer.

Preoperative chemotherapy using 5-fluorouracil and cisplatin is a standard treatment for stage II/III esophageal squamous cell carcinoma (ESCC) in Japan. However, stronger therapies are needed for advanced ESCC. This retrospective study aimed to evaluate the feasibility and safety of neoadjuvant chemoradiotherapy with R-DDP. Patients diagnosed with clinical stage II/III ESCC and initially treated with preoperative R-DDP were enrolled. R-DDP comprised intravenous docetaxel (40 mg m−2 day−1 on day 1), oral doxifluridine (800 mg m−2 day−1 on days 1–7), low-dose cisplatin (5 mg m−2 day−1 on days 1–5), and concurrent radiation (2 Gy day−1 on days 1–5), which were repeated weekly for 3 weeks (maximum total radiation: 30 Gy). If clinical stage T4 was suspected, another week of the regimen was added (maximum total radiation: 40 Gy). After therapy evaluation, patients underwent esophagectomy with 2 or 3 fields of lymphadenectomy. Between April 2003 and March 2011, 19 eligible patients were enrolled (treatment completion rate: 89.5 %). Complete or partial response was obtained in 17 cases (89.5 %), and 8 cases (42.1 %) involved downstaging. In resected specimens, the primary tumor’s histopathological grade was 1, 2, and 3 in 3, 11, and 5 cases. Although 42.1 % of patients developed grade 3+ adverse events, there were no severe perioperative complications. Three- and five-year overall survival rates were 42.1 and 36.1 %, with a 23-month median progression-free survival. Although this treatment had good antitumor effects, it did not necessarily confer prognostic improvements. R-DDP could become a therapeutic strategy for locally advanced ESCC.

The purpose of this study was to investigate the oncologic outcomes of laparoscopic distal gastrectomy (LDG) for advanced gastric cancer (AGC). Between April 2003 and March 2014, LDG was performed for 392 patients, 91 patients (23.2%) had histopathologically diagnosed AGC beyond T2 depth. The clinicopathological features, postoperative outcomes, mortality, morbidity, recurrence rate, and survivals of those patients were reviewed. The TNM stages of the tumor were IB in 26 patients (28.5%), IIA in 20 (21.9%), IIB in 18 (19.7%), IIIA in 13 (14.2%), IIIB in 6 (6.5%), IIIC in 6 (6.5%), and IV in 2 (2.1%). Major morbidity occurred in 14 patients (15.3%), with no postoperative mortality. Median follow-up was 24.5 months ; 10 patients developed recurrence during the follow-up period, and 10 patients died, including 6 cancer deaths. The 5-year overall and disease-free survival rates were 76.8% and 72.6%, respectively. By stage, OS/DFS was 92.3%/91.8% in stage IB, 85.4%/85.4% in stage II, and 49.3%/26.9% in stage III. Oncologic outcomes were good in patients with AGC, especially with stage IB-IIB, who underwent LDG. LDG appears to be an effective approach for treating stage IB and II gastric cancer.

Background: Preoperative chemoradiotherapy (CRT) with 5-FU has been widely used to improve local control of disease and to preserve anal sphincter in the treatment of rectal cancer. UFT and S-1 as oral dihydropyrimidine dehydrogenase (DPD)-inhibitory fluoropyrimidines enhance the therapeutic effect of 5-FU by modulating its metabolic pathways. The purpose of this study was to evaluate the efficacy and toxicity of CRT using UFT versus S-1 in patients with locally advanced rectal cancer. Methods: Fifty-nine patients who received preoperative CRT (40 Gy radiotherapy) were randomly assigned to either UFT or S-1 groups. UFT and S-1 were administered during the radiotherapy course. Response to CRT was determined using a histopathologic examination and RECIST of surgically resected specimens and classified as responders (CR, PR and grade 2, 3) or nonresponders (SD, PD and grade 0, 1). Results: All patients were randomly allocated to S-1 group (n = 30) or UFT group (n = 29). Pathological response rate (Grade2 and Grade3) was 57% in the S-1 group and 45% in the UFT group (p = 0.36). Pathological complete response (CR) rate (Grade3) was 7% in the S-1 group and 4% in the UFT group (p = 0.98). There was no statistically significant difference between the two groups in regard to the response rate of RECIST (p = 0.52). There was no statistically significant difference between the groups based on the downstaging rate, resection of tumor, sphincter preservation and marginal invasion. The incidence of Grade 3 diarrhea was significantly more frequent in the S-1 group (7%) compared with the UFT group (0%) (p = 0.02). Conclusion: The results supported the conclusion that CRT using UFT or S-1 is effective and feasible for patients with locally advanced rectal cancer.

4028Background: Laparoscopy-assisted distal gastrectomy (LADG) for gastric cancer is safe and feasible. Several phase III studies try to confirm non-inferiority of LADG to open surgery for early di...

4007Background: Although postoperative adjuvant chemotherapy with S-1 is among the standard treatments for curatively resected pStage II/III gastric cancer (GC) in Asia, the outcome of pStage III G...

症例は50歳，女性．健診で胃粘膜下腫瘍を指摘され当院へ紹介となる．術前CT検査では胃後壁に壁外発育を示す6cm大の類円形腫瘍を認め胃GISTと診断された．腫瘍は胃体部大彎から有茎性発育をきたしており，腹腔鏡補助下に茎付着部より2cm離しstaplerを用いて胃全層を含めた胃部分切除術を行った．腫瘍は紡錘形細胞の増殖を認め免疫組織化学染色ではc-kit(+)からGISTと診断された．核分裂はほとんど認めず1>/50HPFであった．術後約12カ月経過した現在も無再発生存中である．壁外有茎性発育した胃GISTは本邦では過去に31例と比較的稀である．一般的な胃GISTに比べ壁外有茎発育性胃GISTは腫瘍径の割に予後は良好であるが，治療の第一選択は手術であり術式は胃正常部を含めた胃部分切除術が望ましい．

症例は66歳の男性で, 慢性B型肝炎のため経過観察中, 2006年2月,#12腹腔内リンパ節腫大を指摘され, 内視鏡検査で胃噴門直下に4cm大の1型腫瘍を認め乳頭状腺癌と診断された. 腫瘍マーカーはAlpha-fetoprotein (以下, AFP) が333ng/mlと高値であった. T2N3M0: stage IVの診断で化学療法を行った. TS-1(120mg/日)をday 1～14, day 1およびday8にDo-cetaxel(60mg/日), CDDP (10mg/日) をday1～5, 8～12に経静脈投与した. 画像上PRが得られ, AFP値も45ng/mlと低下し, 胃全摘を行った. 病理組織学的診断では原発巣に癌の遺残はなく, 郭清リンパ節にもGrade 2の効果が得られた. そのうち, 1個にのみ腫瘍の残存を認め, AFP染色陽性であった. TS-1による補助化学療法を3コース施行し, 術後14か月経過した現在再発はない. 化学療法が奏効したAFP産生胃癌の1例を報告する.

Congenital defects of the pericardium are rare. This report describes a young woman with a congenital complete pericardial defect who developed a giant pulmonary cyst. After operation the patient experienced chest pain caused by myocardial ischemia due to cardiac displacement. It is important to note that heart lability in patients with congenital pericardial defects may cause grave complications after thoracotomy associated with volume loss of the residual lung.

Various randomized clinical studies have suggested that short- and long-term outcomes of laparoscopic surgery (LAP) for colorectal cancer are comparable with those of open surgery (OP). However, these studies were performed in high-volume hospitals. The aim of the present study was to compare the outcomes of LAP versus OP for colorectal cancer in rural hospitals.This was a multicenter retrospective propensity score-matched case-control study of patients who underwent colorectal surgery from January 2004 to April 2009 in 10 hospitals in Japan. All patients underwent curative surgery for pathologically diagnosed stage II or III colorectal cancer. The primary end point was 5-year overall survival (OS). The secondary end points were disease-free survival (DFS) and postoperative complications.In total, 319 patients who underwent LAP and 1020 patients who underwent OP were balanced to 261 pairs. There was no significant difference in the OS and DFS between two groups. The operation time was significantly shorter for OP than for LAP. Blood loss was significantly lower in LAP than in OP. There was no difference in intraoperative morbidity between the two groups. The postoperative morbidity was significantly lower in LAP than in OP. The hospital stay was significantly shorter in LAP than in OP. There was no significant difference in 90-day postoperative mortality.Laparoscopic surgery may be a feasible option for colorectal cancer in rural hospitals.

In our hospital, a clinical trial on the effects of preoperative 2-week S-1 administration for advanced gastric cancer is being conducted. A7 5-year-old man presented to our hospital with a type 2 tumor(poorly differentiated adenocarcinoma)in the pyloric antrum. Subpyloric lymph node enlargement and a c-T2(MP), N1, M0, Stage II A tumor (according to the gastric cancer handling agreement, 14th edition)were diagnosed, and S-1(100mg/day)was subsequently administered for 14 days. On day 15, we performed laparoscopy-assisted distal gastrectomy, with D2 dissection. Analysis of the resected specimen, ie the primary tumor and metastatic lymph nodes, confirmed the effect of the treatment as Grade 2, and revealed a type 2 gastric cancer of 30×20mm in size; this tumor was downstaged to yp-T1b(SM), N1, Stage I B. No adverse events associated with perioperative S-1 were observed, and the postoperative course was good. At the latest follow-up(6 years after treatment), no recurrence was observed.

A rare case of hemophagocytic syndrome (HPS) associated with B-cell lymphoma is reported. A 38-year old female with dyspnea and fever developed a subcutaneous nodule with purpuric erythema on her right thigh and consulted our department on September 2, 1991. The histologic picture of this nodule revealed a dense infiltration of atypical lymphocytes into the dermis and subcutaneous tissue. A surface marker study of these atypical cells were CD22, CD74, and HLA-DR positive, indicating a B-cell origin for these cells. Normal histiocytes phagocyting erythrocytes were mixed with the infiltrating cells. The patient also had pericardial effusion, liver dysfunction, hepatosplenomegaly, and bleeding tendencies. The diagnosis was HPS associated with B-cell lymphoma. She died of DIC on November 8, 1991.

胆嚢原発の内分泌細胞腫瘍は極めて稀で,その予後も不良といわれている.今回,肝右3区域切除を行うも,早期に再発をきたした胆嚢原発内分泌細胞癌の1例を経験した. 症例は59歳,女性.肝機能障害と腹部USで肝腫瘤を指摘され入院となった.腹部US, CTでは肝右葉に多発する巨大な腫瘤とS4にも5cm大の腫瘤を認めた.胆嚢は壁が全周性に肥厚しており,結石もみられた.胆嚢癌の肝転移と考え,右3区域切除術を行った.切除標本の割面では腫瘍は膨隆していたが明らかな皮膜はみられず,黄色部と白色部が混在していた.病理検査では胆嚢および肝の腫瘍は共に壊死,線維化を伴った悪性細胞がみられ,免疫組織染色ではNSE染色とchromogranin A染色で陽性であり,胆嚢原発内分泌細胞癌と診断した.術後2カ月半後のCTで残肝に腫瘤が多発しており, CPT-11, CDDPの肝動注療法を行うも1カ月後に永眠した.

単純性潰瘍は回盲部に好発する大型の打ち抜き様潰瘍を特徴とする原因不明の炎症性腸疾患である.症例は43歳,女性.主訴は腹痛であった.平成16年3月の大腸内視鏡検査で,回盲部に深い打ち抜き様潰瘍を認め,再発を繰り返した.臨床症状と病理像から単純性潰瘍と診断し,ステロイド投与を含めた内科的治療を行った.しかし,治療抵抗性であったために平成17年2月に腹腔鏡下回盲部切除術を施行した.術後経過は良好で,現在のところ再発は認めていない.単純性潰瘍は稀な疾患で,その病態の解明や治療法の確立は成されていない.また,しばしば難治性で,経過中に出血や狭窄,穿孔などをきたすこともある.その累積手術率は高く,術後再発率も非常に高いことが知られている.今回われわれが行った腹腔鏡補助下回盲部切除術は低侵襲であり,癒着のリスクも低いことから複数回の手術の可能性のある本疾患に対して選択されるべき術式であると考える.

症例は48歳の男性で, 2004年4月下血および肛門部痛を主訴に近医を受診し, 痔瘻, 直腸癌疑いで当院に紹介となった. 痔瘻は肛門左側に開口し, 15mm大の顆粒状の硬い結節として触れた. なお, 同部位からの生検では悪性所見はなかった. 直腸診では肛門輪より4cmの直腸後壁を中心に硬い腫瘤を触れた. 血液一般検査で特記事項は認めず, CEAは19ng/mlと高値を呈していた. 精査の結果, 痔瘻を伴う直腸Rb中分化型腺癌の診断のもとで, 腹会陰式直腸切断術, D3郭清を施行した. 会陰操作では痔瘻を完全切除し, 型のごとくS状結腸に人工肛門を造設した. 術後会陰創の一部.開を認めた以外経過は良好であった. 病理組織診断で中分化型腺癌a2, n1 (+), ly1, v2でstage IIIaであった. 痔瘻開口部からも同様の組織が確認でき, 直腸癌からの管腔内転移と診断した. 転移性痔瘻癌の報告はまれであり文献的考察を加え報告する.

2004年10月より進行,再発大腸癌に対してweekly CPT-11/UFT/LVを9例に施行した.投与スケジュールはCPT-1160mg/m2を第1, 8, 15に外来において点滴静注し,経口薬UFT (300mg/body/日)と経口Leucovorin (75mg/body/日)を21日間連日投与し, 7日間休薬の28日間を1コースとした.治療効果はPR 5例, SD 4例であり,奏効率56% (5/9), tumor control rateは100%であった. Grade3以上の副作用は倦怠感33%,白血球減少11%,嘔気11%で,下痢は1例(Grade2)のみであった.これらの結果は既報告と比較し,有害事象発生率が低く,奏効率56%と満足できるものであった.外来におけるCPT-11/UFT/LV療法は,有効性,安全性, QOLの面からも,進行再発大腸癌に対するfirst lineとして有用な治療法であると考えられた.

Doxifluridine (5'-DFUR)が効率良く5-FUに変換されるためにはthymidine phosphorylase (TP)の発現が誘導される必要がある.進行胃癌を対象にDocetaxel (TXT)および5'-DFURによるTP・dihydropyrimidine dehydrogenase (DPD)の発現誘導を検討した.研究1 (n=11)はTXT 20mg投与前および1週後の癌および正常粘膜のTP, DPD量を測定した.研究2 (n=14)は5'-DFUR 1,200mg/日2日間投与前後の癌および正常粘膜のTP, DPD量を測定し,同患者に対しTXT 40mgおよびその5日後より5'-DFUR 1,200mg/日2日間投与しTXT投与1週後の癌および正常粘膜のTP, DPD量を測定した.癌組織のTP発現はTXT 40mg投与により誘導された(p=.0052)が,正常粘膜のTPは変動しなかった. DPD発現はTXT投与により癌組織では影響を受けなかったが,正常粘膜では40mg投与で低下(p=.0092)した. TP/DPD比はTXT投与により癌組織で上昇した(p=.0303).癌および正常粘膜におけるTP, DPDの発現は5'-DFUR投与による影響を受けなかった.胃癌症例においてTXTと5'-DFURの併用は相乗的な抗腫瘍効果の増強が期待できる.

A 64-year-old man with a chief complaint of melena visited our emergency outpatient clinic. After several examinations, he was diagnosed as a gastrointestinal stromal tumor (GIST) with liver metastasis. Surgical resection of the jejunal lesion and postoperative adjuvant therapy with STI571 for one year was performed. Due to recent immunohistological studies and introduction of STI571, the diagnosis, treatment, and prognosis of GIST are about to change profoundly. Further accumulation of cases is necessary to investigate the diagnosis, treatment, and prognosis of GIST.

今回われわれは輸血を要する大量下血を呈した小腸GISTの2例を経験したので文献的考察を加え報告する.症例1は64歳,男性.ショック状態での来院時, Hb 2.1g/dlにて赤血球濃厚液20単位を輸血した. CTで右下腹部に8×6cm大の分葉状の腫瘤,肝S8に2cm大の腫瘤を認めた.肝病変の針生検ではGISTの転移であった.手術は回腸切除,播種腹膜切除,肝部分切除を行った.術後STI571を投与中で術後15カ月の現在,再発なく経過観察中である.症例2は67歳,女性. 1年前に下血による貧血にて赤血球濃厚液8単位を輸血していた.以後下腹部膨満感を認め,腹部CTにて骨盤内に10×6cm大の腫瘤を認め紹介となった。血管撮影にて回腸動脈より支配される腫瘤濃染像を認めた.小腸GIST疑いにて回腸切除を行った.病理組織所見では小腸GIST, smooth muscle typeであり,術後30カ月の現在,再発は認めていない.

症例は70歳,男性.上腹部痛,嘔気,嘔吐を訴え来院し,上部消化管内視鏡検査で食道胃接合部より3cm口側の食道に,粘膜下腫瘍様の小隆起病変(0-Isep)を指摘された.生検では低分化型扁平上皮癌が疑われた. 14カ月前に受けた上部消化管内視鏡検査でも同様の所見を指摘されていた.根治術として右開胸中下部食道切除術,胸腔内胃管再建術を施行した.病理組織所見では,腫瘍部分の粘膜固有層内に大型の異型細胞からなる癌胞巣がみられたが,表層の扁平上皮に異型性は認められなかった.癌胞巣周囲にリンパ球の浸潤が顕著で,リンパ瀘胞の形成も伴っており,リンパ球は癌胞巣内にまで浸潤していた.深達度はmであり, infα, ly0, v0, n0であった.本症例は組織学的に低分化型で増殖能の高い腫瘍であると考えられたが, 14カ月の間腫瘍が増大しなかった理由として,浸潤したリンパ球により腫瘍の増大,転移が抑制されていた可能性が考えられた.

背景. 肺癌副腎転移は剖検例では高頻度に見られるが, 治癒切除可能な症例は少なかった. しかし近年画像診断の進歩により転移発見動機が増加し, 外科治療の結果長期生存が得られたとの報告例も散見される. 今回, 我々は肺癌手術後の副腎転移2例に対し摘出術を行ったので報告する. 症例1. 68歳男性.66歳時, 右上葉切除術を施行した. pT1N0M0, stage LAであった. 1年3ヵ月後の定期的なCT検査にて左副腎腫瘍があり, 転移と考えたが本人の希望で経過観察していた. その後他疾患で開腹術の際, 同時に副腎摘出術を行った. 病理診断で肺癌の転移と診断された. 副腎摘出術後3年9ヵ月経過し, 再発を認めていない. 症例2. 65歳男性.64歳時, 右中下葉切除術を施行した. pT1N2M0, stage IILへであった. 1年後, 右側腹部痛があり, CTにて右副腎腫瘍を発見した. 副腎単独転移と診断, 摘出術を施行した. その7ヵ月後, 胸部の広範囲に再発, 最終的に副腎摘出術から1年3ヵ月後死亡した. 結論. 副腎単独転移の場合, 摘出術によって長期予後が得られることがあり, 可能ならば手術も積極的に選択すべきである.

症例は28歳女性.2000年11月より全身倦怠感, 左眼瞼下垂が出現した.近医にて画像上, 前縦隔及び右胸腔内 (前胸部, 横隔膜上) の腫瘤, 右胸水貯留を認め, 12月8日入院となった.入院8日後, 急速に呼吸状態が悪化し, 人工呼吸管理となった.重症筋無力症の急性増悪としてAnbenonium 20mg/dayの投与と二重濾過血漿分離交換法を行うも人工呼吸器離脱には至らなかった.経皮的針生検にて胸腺腫との診断を得, 正岡臨床病期分類StageIVaと考えられた.術前化学療法を1クール行い, 2001年2月14日拡大胸腺摘出術を施行した.術後Anbenonium及びPrednisolone (PSL) の投与, 免疫吸着療法を行うも著変なく, 4月26日よりTacrolimus (FK-506) 3mg/dayを開始した.投与後より徐々に呼吸状態は改善し5月28日呼吸器より離脱した.術後前縦隔へ計50Gy照射を行った.2003年4月現在, 胸腺腫再発の兆候認めずFK-5063mg/day, Anbenonium 25mg/day, PSL 5mg隔日投与にて筋無力症状はほぼ消失している.

症例は73歳の男性で, 主訴は下血. 既往歴として2か月前より, 肺線維症にてプレドニゾロン (以下, PSL) 5mg/日内服中であった. 下血および血液検査上著明な汎血球減少 (WBC2.5×103/mm3, Hb 5.9g/dl, 血小板1.0×103/mm3)がみられ当院内科に緊急入院した. 精査の結果, 特発性血小板減少性紫斑病 (idiopathic thrombocytopenic purpura: 以下, ITP) を合併した横行結腸癌と診断した. ステロイド投与開始するもコントロール不良であり, 腹鏡鏡下用手的手術(hand-assisted laparoscopic surgery: 以下, HALS)にて1期的に摘脾およびD2郭清を伴う横行結腸切除を施行した. 術後経過は良好で, 術後第13病日に退院し, 以後特に異常なく現在外来通院中である. ITP合併横行結腸癌の報告例はまれであり, 1期的に摘脾および横行結腸切除術を施行しその術式にHALSを用い良好な結果が得られたので報告した.

門脈圧亢進を伴う消化管出血で胃食道以外から来たすことはまれである. 今回, 空腸静脈瘤破裂にて緊急手術に至った症例を経験したので報告する. 患者は59歳の男性で, 以前より肝硬変および肝癌にて治療中であった. 下血, ショックにて近医に受診し, 上部・下部消化器内視鏡を施行したが, 出血源を特定できず, 当院に搬送された. 出血シンチグラフィ, 血管造影を施行し, 上部小腸からの出血が疑われ, 緊急開腹手術を施行した. Treitz靭帯よりやや肛門側の空腸に静脈瘤が認められた. 胃を切開し, 挿入した内視鏡検査にて同部位に出血点を確認した. 静脈瘤を空腸壁外より縫合結紮した. 術後一時期肝不全に陥ったが, G. I療法, 血漿交換により救命し, その後は経過良好にて退院した.

症例は43才女性, 2年前より前胸部の圧迫感を自覚, 徐々に症状が頻回となったため, 1998年12月, 精査目的で当院受診となった.頸部MRIにて左頸部から前縦隔にかけて, T1強調画像でlow, T2強調画像でhigh intensityの腫瘤陰影を認めた.echoではhypoechoicに描出され, 穿刺吸引細胞診で, 線毛円柱上皮を多数認めた.嚢胞性疾患を考え, 確定診断目的で手術施行.手術所見で嚢腫は胸腺左葉と連続しており, 胸腺左葉と共に嚢腫を切除した.病理所見で嚢腫周囲はハッサル小体を含む胸腺組織に覆われ, 又, 嚢腫内腔は一層の線毛円柱上皮で被われ, 胸腺嚢腫と診断した.加えて, 嚢腫壁に接して副甲状腺組織も認め, これは原基の移動途中に迷入したものと考えられた.今回, 胸腺嚢腫の嚢腫壁内に副甲状腺組織を認めた稀な頸部胸腺嚢腫の一切除例を経験した.

胸腺内に発生した類表皮嚢胞壁内に微小なカルチノイドを認めた極めて稀な1例を神験したので報告する.症例は50歳, 女性で, 前胸部圧迫感を主訴とした.胸部X線上右第1弓に重なる縦隔腫瘤陰影を認め, 当科紹介となった.胸部CT及びMRIにて胸腺右上極に約2.5cm大の充実性腫瘤を認め, 胸腺腫の診断にて胸腺全摘術を行った.切除標本では胸腺右上極に2.5×2.3×2.0cm大, 境界明瞭, 表面平滑な球状腫瘤を認め, 割面では内腔に垢様角化物 (ケラチン) が充満する嚢胞であった.組織所見は類表皮嚢胞で, 嚢胞壁の被膜様結合組織内に微小な上皮性腫瘍細胞集団を認めた.これはHE染色で典型的なロゼット形成を認め, クロモグラニン及びNSE染色陽性で定型的カルチノイドと診断した.術後経過は良好で第12病日に退院, 外来経過観察中である.

We evaluated 3-D CT imaging for preoperative classification of the left gastric artery and vein in patients with early gastric cancer and estimated its clinical benefit.Between April 2009 and March 2014, 279 patients underwent preoperative 3-D CT using a 64-row multi-detector CT scanner, followed by laparoscopy-assisted distal gastrectomy. The 3-D CT images of the arterial and portal phases were reconstructed and fused. The operative outcomes were compared between patients who had not undergone 3-D CT (2007-2008) and who had undergone 3-D CT (2009-2011).According to Adachi's classification, the numbers of type I, II, III, IV, V, and VI arterial patterns were 253, 15, 1, 3, 3, and 1, respectively. Three cases could not be classified. According to the Douglass classification, the left gastric vein flowed into the portal vein, splenic vein, junction of the portal vein and splenic vein, and left branch of the portal vein in 119, 111, 36, and 5 patients, respectively. The left gastric vein could not be visualized in six patients, and two patients could not be classified. In addition, the relation was absent for an Adachi type I vein and one of the "other" types of veins. The total operative time was significantly shorter with 3-D CT than without it (P = 0.01), and the degree of lymph-node dissection was significantly higher (P = 0.01). Inflammatory parameters and operative morbidity tended to decrease with 3-D CT.Three-dimensional CT is a useful modality to visualize the vessel anatomy around the stomach, and it improves clinical effectiveness and reduces the invasiveness of surgery.

春季花粉症患者の漢方治療が有効であった69例 (男24名女45名) を, 有効方剤に基づき分類し, 花粉症発生時期, 自他覚症状などを比較し, それらの東洋医学的病態を分析する事で, 花粉症の病態像を検討した。その結果, 以下の3群と特殊な病態群 (4例) に分類された。すなわち, (1)辛温解表剤有効群 (23例)。本群は1月下旬より2月中旬に初発し, 多くは虚証の素因を有し, 風寒証の花粉症と考えられた。(2) 辛涼解表剤有効群 (22例)。本群は2月中旬以後の初発が多く, 外感風熱証症状を呈し多くは実証で, 温邪は弱く風邪が強い温病の風温証の花粉症と考えられた。(3) 混合群 (20例)。本群は辛温解表剤と辛涼解表剤の混合群であり, 虚証の素因は少なく, 辛涼群と辛温群の特徴が混在する寒熱錯雑症状を呈し, 温病の風温証に寒邪が客した兼証ではないかと考えられた。

症例は64歳, 女性.左背部胸壁の約15cm大の腫瘤を主訴とした.胸部CT検査では左背側胸壁に巨大な扁平腫瘤が広背筋, 前鋸筋の深層で, 骨性胸壁との間に認められた.手術は左後側方切開にて行った.腫瘤と周囲組織との剥離は容易であったが, 第5肋間に栄養血管が流入する腫瘤頚部を認め, 一部肋間筋を合併切除し腫瘤を摘出した.腫瘤割面は灰白調で壊死部分を認める不均一な充実性で, 重量は950g, 大きさは16×14×6cmであった.病理組織所見は線維芽細胞様のpatternless patternの増殖と, CD34, vimentinの免疫染色所見陽性より, solitary fibrous tumor (SFT) との診断を得た.根治を目的に腫瘤頚部の存在した第5, 6肋骨を含む骨性胸壁を第9病日に追加切除したが, 胸壁切離面及び胸膜面に腫瘍組織を認めず, 極めて稀な胸壁軟部組織由来のSFTと考えられた.胸壁切除術後2週にて退院し, 術後14ヵ月の現在, 再発, 転移を認めない.

Mammary fibromatosis is a rare entity. In Japan, only several cases have been reported. We present a case of mammary fibromatosis with a review of the Japanese literature. A 56-year-old woman was seen at the hospital because of a tumor of the left breast. The tumor measuring 6×4cm in diameter with an unclear border was palpated in the upper quadrant of the left breast with reddness and retraction of the overing skin. IN clinical, radiological and ultrasonographic examinations, it was difficult to distinguish from brest cancer. Cytologic examination was negative for malignant cells. Because we could not rule out a possible malignancy, quadrantectomy was carried out. So a diagnosis of mammary fibromatosis was made. There has not been evidence of recurrence, as of 27 months after the surgery. They are characterised by infiltrative growth and a tendency to recurrence even after resection, but they never metastasize. So follow-up should be especially vigilant.