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Current techniques of laparoscopic colectomy require an abdominal incision for extraction of the specimen. Although this incision is smaller than that for open laparotomy incision, it may reduce the advantages of laparoscopic surgery. In totally laparoscopic sigmoid colectomy, intracorporeal anastomosis is technically difficult. A safe and simple technique for circularly stapled intracorporeal anastomosis is described. After mobilization of the colon and division of the mesentery, a semicircumferential colotomy is made at the anterior colonic wall just proximal to the transection site. The anvil of a circular stapling device, secured with a Prolene suture, is introduced via the colotomy. The suture is advanced anteriorly so that the center rod of the circular stapling device penetrates the colonic wall. The colon is staple-transected at this point to secure the anvil on the proximal colon. A grasping forceps is brought through the rectum, and the specimen is extracted through the colotomy made at the distal staple line. After the colotomy is reclosed with a linear stapler, anastomosis is established using a hemidouble stapling technique. Totally laparoscopic sigmoid colectomies were performed for 16 patients with colon cancers. All the patients were treated laparoscopically without any complications. The average operation time was 180 min. Although one patient experienced wound infection, no major complications occurred. There was no mortality in this series. The procedure of totally intracorporeal anastomosis combined with transanal extraction of the specimen can be performed easily, enabling surgeons to achieve minimal invasiveness comparable with that of hybrid natural orifice translumenal endoscopic surgery (NOTES).

進行癌に対する腹腔鏡下大腸切除術の短期および遠隔期手術成績を検討した．対象：腹腔鏡下切除術を施行した深達度pMP以深の進行大腸癌313例．開腹症例180例を対照とした．結果：腹腔鏡下手術群（LAC）の手術時間は209±70分，術中出血量120±219mlで，開腹術群（OC）と手術時間に有意差を認めず，出血量ではOCよりも有意に少なかった．検索リンパ節数はLAC 18.8±9.8個，OC 15.8±11.2個と有意差なし．術後合併症ではLACで縫合不全が多い傾向を認めたが統計学的な有意差を認めなかった．治癒切除症例295例中46例に再発を認めた（再発率15.6%）．再発型式は開腹例と有意差はなかった．LACの累積5年生存率は，Stage I 100%, Stage II 96.5%, Stage IIIa 85.1%, Stage IIIb 66.6%, Stage IV 49.3%（3年）でこれまでの当院の成績と同等と考えられた．まとめ：進行癌に対する腹腔鏡下手術の手術成績はこれまでの当院の成績と同等であり，腹腔鏡下手術導入による予後への悪影響は認められなかった．

大腸癌治療ガイドライン（以下，ガイドライン）では，内視鏡切除後にpSM癌のリンパ節転移のリスクを評価し，外科的追加切除の必要性を判定している．1991年から2008年までに当院で外科切除を施行したpSM大腸癌101例を対象とし，病理組織所見よりリンパ節転移に関与する因子を検討した．組織型，脈管侵襲（ly因子，v因子），sm浸潤距離に関し，リンパ節転移陽性群（以下，陽性群）とリンパ節転移陰性群（以下，陰性群）の間で比較した．陽性群は陰性群より，有意にly因子陽性率が高く，sm浸潤距離が大きかった．組織型およびv因子陽性率に関し，陽性群と陰性群の間で有意差を認めなかった．陽性群11例のうち1例は，リンパ節転移陽性であるにも関わらず，ガイドラインの外科的追加切除条件を満たさなかった．ガイドラインのリンパ節転移予知能は高感度，低特異度という特徴を理解して利用する必要がある．

Background: Laparoscopically assisted low anterior resection is difficult even for experienced surgeons because of difficulties in selecting the appropriate transection line and completing anastomosis in the narrow pelvic space. The prolapsing technique resolves these problems. We combined our new technique for intracorporeal anastomosis with this prolapsing technique and achieved a totally laparoscopic low anterior resection. Methods: After the total mesorectal excision, a semi-circumferential colotomy is made at the anterior colonic wall just proximal to the proximal transection site. The anvil of a circular stapling device, secured with a Prolene suture, is introduced via the colotomy. The suture is advanced anteriorly so that the center rod of the anvil penetrates the colonic wall. The colon is staple-transected at this point to secure the anvil on the proximal colon. The distal rectum is everted and pulled transanally outside the body using a grasping forceps inserted from the anus. Staple-closure and transection of the distal rectum is performed under direct vision. Anastomosis is established using the double-stapling technique. Results: Totally laparoscopic low anterior resections using this technique were performed for 7 patients with rectal cancer. There was no anastomotic leakage/stenosis. Conclusions: Our procedure can be performed easily, which enables surgeons to achieve minimal invasiveness compared with hybrid NOTES.

To our knowledge, only a few cases of thyroid carcinoma with an extensive tumor thrombus in the atrium have been reported in literature. We describe a unique case of papillary carcinoma of the thyroid with extensive tumor thrombus in the atrium. A 74-year-old man consulted our hospital because of thyroid carcinoma with an extensive tumor thrombus in the atrium. Computed tomography (CT) revealed a 2-cm tumor with extensive continuous tumor thrombus in the left jugular vein, innominate vein, superior vena cava, and atrium. The tumor was resected to reduce the risk of sudden death from tumor embolism into the pulmonary arteries. Histologically, the diagnosis was papillary carcinoma of the thyroid. Thyroid carcinoma, especially papillary carcinoma, rarely develops a macroscopic tumor thrombus. Patients with an extensive tumor thrombus generally have poor prognoses and high mortality. This patient has been followed for 7 months after successful operation without recurrence.

十二指腸狭窄を伴った黄色肉芽腫性胆嚢炎の1例を経験したので文献的考察を加えて報告する．症例は51歳，男性．2カ月前より食欲低下が出現し，前医で上部消化管造影検査にて十二指腸の狭窄を指摘され，当科紹介となった．腹部CT検査にて胆嚢壁の肥厚が著明で，胆嚢周囲の肝組織の濃度上昇を認めた．腹部血管造影検査にて胆嚢動脈の屈曲，蛇行，不整を認めた．胆嚢癌の肝浸潤，十二指腸浸潤を疑い，開腹手術を施行した．術中迅速組織診断にて黄色肉芽腫性胆嚢炎と診断した．十二指腸狭窄は胆嚢炎の炎症波及によるものであった．術後吻合部潰瘍を併発し治療を要したが，保存的治療にて軽快し退院となった．

症例は83歳の女性．突然の吐血を主訴に当科紹介となった．腹部造影CTにて膵頭部に血腫および内部に動脈瘤を認めた．血管造影検査にて膵十二指腸動脈瘤破裂と診断された．腹腔動脈領域はすべて上腸間膜動脈より膵頭部動脈アーケードを介して造影された．動脈塞栓術ではcoiling困難であったため，緊急開腹手術を施行した．正中弓状靱帯によって腹腔動脈起始部が顕著に圧迫されており，腹腔動脈起始部圧迫症候群（CACS）と診断した．正中弓状靱帯を切離することにより腹腔動脈の血流が再開し，求肝性に保持可能であったため，幽門輪温存膵頭十二指腸切除術（PpPD）を施行した．術後経過は良好であった．腹腔動脈起始部に狭窄を伴う膵頭部動脈瘤破裂症例においては，CACSの可能性を念頭に置くことと，肝動脈血流量を測定しながら膵頭切除等の手術操作を進めることが重要であると考えられた．

肝細胞癌 (hepatocellular carcinoma ; 以下, HCC) の再発時に偶然発見された, HCCの転移性胃腫瘍の1切除例を報告する. 症例は70歳, 男性. 3年前のHCCの初発時に肝部分切除が行われた以降, 再発を繰り返していた. 平成16年11月にHCC再発と診断され, 貧血の原因精査のための上部消化管内視鏡検査にて胃体中部大彎に2型腫瘍を指摘された. 組織診断と免疫染色にてHCCの胃転移と診断され, 同年12月に胃局所切除およびラジオ波焼灼術が施行された. 胃漿膜面は平滑で可動性を有する隆起性の円形腫瘤を認めた. 術後組織診断上, 粘膜層から粘膜下層にかけ境界明瞭な充実性病変で, 静脈浸潤を認めた. HCCはEdmondson IV型であった. 以上からHCCの血行性胃転移と診断された. HCCの胃転移は稀で, 中でも血行性転移は本邦での報告は極めて稀である. 自験例に文献的考察を加えて報告する.

症例は74歳の男性で, 主訴は全身倦怠感. 内視鏡検査で, 噴門より胃体下部に及ぶ2型病変を認めた. 生検の結果, 腺癌と診断したが, 一部の検体では扁平上皮癌を認めた. 腹部CTで膵臓への直接浸潤ならびにリンパ節#12Pに転移を認めた. Downstagingを目的にTS-1/CDDPによる術前化学療法を3コース施行した. CT画像による効果判定はNCであった. 胃全摘, 脾摘, 膵体尾部切除術を施行. 膵への直接浸潤を認めたが, 腹膜播種を認めず, Stage IV, 根治度はBであった. 病理組織学的検査では, 扁平上皮癌成分のみ認め, 腺癌成分を認めず, 腺扁平上皮癌の腺癌成分が術前化学療法により消失したものと考えられた. 腺癌成分と扁平上皮癌成分では, 化学療法に対する感受性が異なる可能性が示唆された.

前立腺癌に対する内分泌療法 (抗アンドロゲン剤, LH-RHアゴニスト) 後に発症した男性乳癌の1例を経験したので, 文献的考察を加えて報告する. 症例は88歳, 男性. 平成12年前立腺癌に対して手術を施行され, 術後内分泌療法としてLH-RHアゴニストと抗アンドロゲン剤が投与された. 平成14年頃より両側乳房腫脹が出現し, 平成15年左乳房腫瘤のため当科受診. 穿刺吸引細胞診にて左乳癌と診断. 左乳房切除および大胸筋合併切除, 腋窩リンパ節郭清術を施行した. 病理組織診断はInvasive ductal carcinoma, papillo tubular carcinomaであった. 術後抗エストロゲン剤および5'-DFURの内服を開始したが, 術後8カ月目に局所再発し, 術後26カ月目で永眠された.

We report a 72-year-old man who was diagnosed by gastroscopy as having a type III poorly differentiated adenocarcinoma in the lesser curvature, with the longest diameter being 10 cm. An abdominal computed tomography (CT) scan revealed multiple liver metastases, thickening of the gastric wall, and an enlarged paraaortic lymph node. The serum carcinoembryonic antigen (CEA) level was 60 ng/ml and the carbohydrate antigen (CA) 19-9 level was 1355 U/ml. The patient received combined chemotherapy with doxifluridine (800 mg/body per day) and paclitaxel (one course comprised three weekly infusions at a dose of 70 mg/m(2) followed by 1-week rest). After the completion of three courses, the patient achieved a complete response (CR), with complete disappearance of the primary tumor, the metastatic foci in the liver, and the enlarged abdominal lymph nodes; as well, the tumor markers were normalized. Adverse effects included only mild anorexia that was limited to grade 1. He maintained a CR for 1 year and 2 months. Combination chemotherapy with paclitaxel and doxifluridine can be an effective treatment for unresectable advanced gastric carcinoma.

Even for patients with multiple pancreaticoduodenal aneurysms, successful treatment with noninvasive operative procedures can be employed, if intraoperative devices are considered. A 73-year-old man, without any symptoms, was admitted to our hospital and had computed tomography (CT) scanning to examine his liver for hepatitis C virus (HCV). Selective superior mesenteric artery (SMA) angiography confirmed multiple aneurysms in the anterior inferior pancreaticoduodenal artery (AIPDA), one aneurysm in the posterior inferior mesenteric artery (PIPDA), and another in the occluded celiac trunk, all with severe calcification. All of the aneurysms were thought to communicate with each other. With the celiac artery occlusion, the right hepatic artery (RHA) was revealed to be supplied by collateral arteries from the aneurysms in the AIPDA, and the left hepatic artery was shown to be supplied by collaterals from the left gastric artery. Intraoperative Doppler echography, at the time of the clamping of both IPDAs, demonstrated a marked decrease of blood velocity in all aneurysms (before clamping, >50 cm/s; after

PURPOSE: Metastasis to regional lymph nodes through the lymphatic vessels is a common step in the progression of cancer. Recent evidence suggests that tumor production of vascular endothelial growth factor-C (VEGF-C) promotes lymphagiogenesis, which in turn promotes lymphatic metastasis. Nitric oxide (NO) may also increase metastatic ability in human cancers. EXPERIMENTAL DESIGN: Nitrite/nitrate levels and VEGF-C production were assessed in MDA-MB-231 breast cancer cells after induction and/or inhibition of NO synthesis. Formation of nitrotyrosine, a biomarker for peroxynitrate formation from NO in vivo, was analyzed in primary human breast carcinoma with long-term follow-up. The relationship between nitrotyrosine levels and lymph node status, VEGF-C immunoreactivity, and other established clinicopathologic variables, as well as prognosis, was analyzed. RESULTS: Production of nitrite/nitrate and VEGF-C in MDA-MB-231 cells was increased by treatment with the NO donor DETA NONOate. The NO synthase inhibitor N(G)-nitro-l-arginine methyl ester eliminated this increase. High-grade nitrotyrosine staining was observed in 57.5% (65 of 113) of the invasive breast carcinomas. Nitrotyrosine levels were significantly correlated with VEGF-C immunoreactivity and lymph node metastasis. Survival curves determined by the Kaplan-Meier method showed that high nitrotyrosine levels were associated with reduced disease-free and overall survival. In multivariate analysis, high nitrotyrosine levels emerged as a significant independent predictor for overall survival. CONCLUSIONS: Our data showed a role for NO in stimulating VEGF-C expression in vitro. Formation of its biomarker nitrotyrosine was also correlated with VEGF-C expression and lymph node metastasis. Furthermore, high nitrotyrosine levels may serve as a significant prognostic factor for long-term survival in breast cancer.

右腋窩,大胸筋に発生した筋肉内粘液腫の1例を経験したので報告する.症例は75歳,男性,主訴は右腋窩の腫瘤であった.初診時,右腋窩に弾性硬で周囲との境界明瞭な腫瘤を認めた.血液検査所見にて異常を認めず, CTにて脂肪より高CT値,筋より低CT値の腫瘤を右大胸筋外側に認め,浸潤傾向を認めなかった.手術は,腫瘤の辺縁を約5mmの切除marginをおき摘出した.大胸筋との間にstalkを認めたが,切離することにより摘出が可能であった.病理組織検査の結果,筋肉内粘液腫と診断した.術後10カ月の現在,再発はなく経過は良好である.

胸骨後で再建した有茎空腸が胸腔内にヘルニアを来したまれな1例を経験した. 症例は62歳の男性で, 30歳時に十二指腸潰瘍穿孔に対し幽門側胃切除術 (Billroth II法) を施行した. 平成12年, 胸部食道癌に対し術前放射線化学療法後に食道亜全摘, 有茎空腸胸骨後再建, microsurgery下に血行再建術を施行した. 術後経過は良好であったが, 2か月後より嘔吐と嚥下困難を来した. 胸部X線写真とCTにて縦隔右側に鏡面像を伴う. 胞様構造を認めた. 食道透視にて. 胞状に拡張した挙上空腸を認め, 右胸腔内ヘルニアと診断. 保存的治療で一時的に改善するも, 増悪を繰り返し手術を施行. 胸骨下半T型切開を加え, 屈曲蛇行した余剰空腸を切除し端側吻合した後, 前縦隔に縫着固定した. 術後経過は良好で嚥下困難は消失した. しかし, 初回手術から1年2か月後, 多発性骨, 肺, 脳転移にて死亡した.

Purpose: To prospectively assess the forward shift of the cornea after laser in situ keratomileusis (LASIK) in relation to the residual corneal bed thickness. Setting: Miyata Eye Hospital, Miyazaki, Japan. Methods: Laser in situ keratomileusis was performed in 164 eyes of 85 patients with a mean myopic refractive error of −5.6 diopters (D) ± 2.8 (SD) (range −1.25 to −14.5 D). Corneal topography of the posterior corneal surface was obtained using a scanning-slit topography system before and 1 month after surgery. Similar measurements were performed in 20 eyes of 10 normal subjects at an interval of 1 month. The amount of anteroposterior movement of the posterior corneal surface was determined. Multiple regression analysis was used to assess the factors that affected the forward shift of the corneal back surface. Results: The mean residual corneal bed thickness after laser ablation was 388.0 ± 35.9 μm (range 308 to 489 μm). After surgery, the posterior corneal surface showed a mean forward shift of 46.4 ± 27.9 μm, which was significantly larger than the absolute difference of 2 measurements obtained in normal subjects, 2.6 ± 5.7 μm (P

患者は65歳,女性.乳癌および胆嚢結石症の手術既往あり.腹部CT検査にて総胆管結石,肝内結石を指摘. MRI, ERC検査にて肝内胆管B3の拡張を認めた.腹部血管造影にて悪性所見を認めず,血清CEA, CA19-9値も正常であった. 2001年2月,総胆管切石,肝外側区域切除術を施行した.術中迅速組織検査にて胆管癌で断端陽性との結果であった.肝S4区域切除およびリンパ節郭清を追加し,左肝管断端陰性を確認した.組織診断は胆管細胞癌で12aリンパ節に転移を認めた.原発性肝癌取扱い規約による組織学的所見はIg, Fc (-), S0, Vp0, B1, IM0, SM (-), NL, N1であった.術後17カ月で肝門部再発をきたし,外来にて温熱化学療法施行中である.肝内結石症の手術時には,術中迅速病理検査により肝内胆管癌の併存の有無を検索することが重要であると思われた.また胆管断端陰性であっても胆管切除すべきであったと考えられた.

Expression of angiogenic and lymphangiogenic factors by tumors may influence the route of metastatic spread. The angiogenic factor vascular growth factor-C (VEGF-C) is implicated in the development of lymphatic vessels and promotion of lymphatic metastasis. The purpose of this study was to determine whether VEGF-C correlates with lymph node metastasis or prognosis. We assessed VEGF-C expression using immunohistochemistry in 123 invasive breast carcinomas with long-term follow-up. The relationship between VEGF-C expression and lymph node status and other established clinicopathological parameters was assessed. Whether VEGF-C expression plays a prognostic role in breast cancer was also investigated. VEGF-C expression was identified in 103 cases (83.7%). Positive VEGF-C was significantly correlated with lymph node metastasis (P = 0.0131). Survival curves determined by the Kaplan-Meier method and univariate analysis demonstrated that positive VEGF-C was associated with both disease-free survival (P = 0.0165) and overall survival (P = 0.0175). On the basis of our findings, VEGF-C plays a crucial role in lymph node metastasis and may be a significant prognostic factor for long-term survival in breast cancer.

61歳,女性.右乳癌に対して平成1年5月, Bt+Ax+Ic+Mj施行.病理診断は硬癌, n1β(4/9), ER(+), PgR(-).術後3年間, UFTとTAMを内服.平成11年5月に左腸骨の骨転移を認めた. CEF 4クール,放射線治療(42Gy)を施行し, CEAは9.0ng/mlから6.4ng/mlに低下.その後, docetaxel 30mg/週×10回を施行, CEAは2.3ng/mlまで低下.平成13年9月に右大腿骨頸部に骨転移による圧迫骨折を認め,人工骨頭置換術施行.原発巣,転移巣ともにHerceptest 2+であったため, trastuzumab 90mg, paclitaxel 60mgを2週に1回投与し, CEAは13.5ng/mlから2.2ng/mlと正常化.骨シンチ上は転移巣の完全消失を認めないが, 20カ月後の現在も,新たな転移巣を認めず,痛みも消失し元気に日常生活を送っている.乳癌術後多発性骨転移にtrastuzumab, paclitaxelの併用が奏効した1例を経験した.

症例は55歳,男性.主訴は嚥下困難.食道胃透視,内視鏡検査にて食道癌(MtUt, 3型, 12cm長),胃癌(M, IIa+IIb, 3 cm大)と診断. CT検査にて食道癌の右肺浸潤が疑われT4と診断し,放射線(40Gy)化学療法(CDDP, 5'-DFUR)を施行した.終了2週目に発熱と,胸部X線にて右下葉肺炎を認めた.食道造影にて右下葉B6と膿瘍腔が造影され食道肺瘻と診断した. covered EMSを挿入し,肺炎の改善を図り, 19日後に手術を施行した.食道と右肺は固く癒着し,食道および右肺下葉を一塊として切除した.病理診断は,高分化扁平上皮癌, pT3, pN0, stage IIで,肺浸潤や瘻孔は明らかでなかった.食道気管支瘻を形成した食道癌に対するcovered EMS挿入は,肺炎の治療に有効であるとともに,術前処置としても有用な方法と考えられた.

症例は63歳,男性.上腹部痛,背部痛,および微熱のため当科に入院した. CT検査にて左葉胆管のび漫性の拡張を認め,超音波検査で拡張胆管の中枢側に腫瘤陰影がとらえられた.血管造影で門脈左枝の狭窄を認めた. ERCPでは肝内胆管の部分的狭窄と嚢腫状拡張を認め,胆汁細胞診はclass IIであった.胆管癌の疑診にて肝左葉切除,右肝管空腸吻合,リンパ節郭清術を施行した.しかし,病理組織学的に悪性所見はなく,胆管周囲には著明な繊維化とリンパ球や形質細胞などの炎症細胞の浸潤を認め,原発性硬化性胆管炎(以下PSC)と診断した. PSCと胆管癌の鑑別は困難であるが,切除により良好な予後がえられることや胆管癌との合併の可能性を考慮すると,限局型PSCでは病巣部の切除が望ましいと考えられた.

症例は52歳,男性. C型慢性肝炎の既往あり.胆石症による閉塞性黄疸にて緊急入院.経皮経肝胆道ドレナージ(PTBD)を上前区域枝(B8)より施行したが, PTBD後21日目に胆道出血を認めた.手術は胆嚢摘出・総胆管切石・Tチューブ留置術を施行した.手術後第18病日に嘔吐とともにTチューブからの動脈性出血を認め,自然止血したが, 1～3日間隔で反復した.肝動脈前区域枝をgelfoamにて塞栓し止血しえた.血清総ビリルビン値は30mg/dlを超え黄疸が遷延した.希薄胆汁であったが, Tチューブを閉鎖し胆汁の体外排出を止めることにより黄疸は改善した.PTBD後の遠隔期胆道出血は比較的稀と考えられ,また術後の遷延性黄疸は胆汁の体外排出を止めることにより改善した.これらは同様の症例の治療において重要と考えられたので,文献的考察を加え報告する.

Purpose To compare the efficacy of low- and high-molecular-weight sodium hyaluronate in protecting corneal endothelial cells during phacoemulsification. Setting Miyata Eye Hospital, Miyakonojo, Miyazaki, Japan. Methods One hundred forty-nine eyes of 136 cataract patients were randomly assigned to have cataract surgery using sodium hyaluronate 1% with a low molecular weight (0.6 to 1.2 million d, Opegan®) or sodium hyaluronate 1% with a high molecular weight (4 million d, Healon®) during phacoemulsification. Each group was divided into 2 subgroups depending on the amount of ultrasound (% min) used during phacoemulsification, which was defined as the mean phacoemulsification energy (%) multiplied by phacoemulsification time (minutes). Corneal endothelial cell density was examined preoperatively and 3 months after surgery. The rate of cell loss was compared between the subgroups in the Opegan group and the Healon group. Results In the subgroups with ultrasound of 50% min or less, the mean rate of endothelial cell loss 3 months after surgery was 3.2% ± 4.1% (SD) in the Opegan group and 5.9% ± 5.3% in the Healon group ( P = .0214). In the subgroups with ultrasound over 50% min, the mean rate of endothelial cell loss 3 months after surgery was 7.5% ± 10.6% in the Opegan group and 14.8 ± 9.0% in the Healon group ( P = .0029). Conclusions The results suggest that Opegan is more effective than Healon in protecting corneal endothelial cells during phacoemulsification regardless of the amount of ultrasound energy used.

はじめに: 膵癌術後の胆汁中CEA値が肝転移再発の予測マーカーとなりうるか否かを検討した.方法: 膵癌治癒切除21例を対象とした. 肝転移群は13例 (6か月以内の早期肝転移群6例, 6か月以降の晩期肝転移群7例), 非肝転移群は8例であった. 術前, 術後の胆汁採取は胆管ドレナージチューブより行い, 胆汁中CEA値を測定した.結果: 病理組織学的諸因子と肝転移再発に相関を認めなかった. 術前胆汁中CEA値は, 肝転移群 (41±89ng/ml), 非肝転移群 (12±14ng/ml) で有意差を認めなかった. 術後胆汁中CEA値は, 肝転移群は295±432ng/mlで, 非肝転移群の67±62ng/mlより高値の傾向を示した. 早期肝転移群7例の術後胆汁中のCEA値は, 肝転移群は476±572ng/mlで, 非肝転移群に比べて有意に高値であった. また, 第14病日と, 第28病日の2回にわたって胆汁中CEA値を測定した13例の胆汁中CEA値の推移を検討すると, 早期肝転移群は, 術後経時的に胆汁中CEA値が増加した.結論: 胆汁中CEA値は膵癌術後早期の肝転移再発の予測マーカーとなりうることが示唆された.

症例は15歳の女性. 主訴は下腹部痛. 13歳時, 腹痛にて施行したCT検査で脾腫 (容積1,150cm3) を指摘されるも位置異常を認めなかった. 今回, ジェットコースターに乗った後に下腹部痛を来し来院.CT検査にて脾臓を正位に認めず, 下腹部に腫瘤 (容積810cm3) を認めた. 超音波検査, 血管造影にて広範な脾梗塞を伴う遊走脾と診断し, 腹腔鏡下脾臓摘出術を施行した. 術中所見では脾周囲靭帯は欠失し, 脾臓は腹腔内に遊離していた. 脾動静脈をEndo GIA40mmR にて切離後, 腹腔内で脾臓をTissue MorcellatorR を用いて粉砕し摘出した. 手術時間は145分, 出血量は50mlであった. 病理所見は梗塞を伴った正常脾であった. 第6病日に退院し, 術後2年目の現在経過良好である. 遊走脾に対する腹腔鏡下手術の報告は自験例を含め5例で, メッシュによる脾固定3例, 脾摘2例であった. 自験例は広範な脾梗塞と脾腫をともなっていたため, 脾摘を行った.

The origin and evolution of photosynthesis have long remained enigmatic due to a lack of sequence information of photosynthesis genes across the entire photosynthetic domain. To probe early evolutionary history of photosynthesis, we obtained new sequence information of a number of photosynthesis genes from the green sulfur bacterium Chlorobium tepidum and the green nonsulfur bacterium Chloroflexus aurantiacus . A total of 31 open reading frames that encode enzymes involved in bacteriochlorophyll/porphyrin biosynthesis, carotenoid biosynthesis, and photosynthetic electron transfer were identified in about 100 kilobase pairs of genomic sequence. Phylogenetic analyses of multiple magnesium-tetrapyrrole biosynthesis genes using a combination of distance, maximum parsimony, and maximum likelihood methods indicate that heliobacteria are closest to the last common ancestor of all oxygenic photosynthetic lineages and that green sulfur bacteria and green nonsulfur bacteria are each other's closest relatives. Parsimony and distance analyses further identify purple bacteria as the earliest emerging photosynthetic lineage. These results challenge previous conclusions based on 16 S ribosomal RNA and Hsp60/Hsp70 analyses that green nonsulfur bacteria or heliobacteria are the earliest phototrophs. The overall consensus of our phylogenetic analysis, that bacteriochlorophyll biosynthesis evolved before chlorophyll biosynthesis, also argues against the long-held Granick hypothesis.

The status of Fas and Fas ligand (Fas L) expression was investigated in this study for 103 hepatocellular carcinomas (HCC). We studied the expression of the following three factors, Fas and Fas L expression in carcinoma cells and Fas L expression in stromal mononuclear cells (defined as stromal Fas L index). Fas expression in HCC cells was significantly decreased in cases with poor differentiation (P< 0.0001) and of larger size (P = 0.0058). Fas L expression in carcinoma cells was observed exclusively in moderately or poorly differentiated cases. Furthermore, each factor had prognostic significance for disease-free survival (DFS) (P< 0.0001, P = 0.0222 and 0.0027 respectively). We then scored the results of each factor and defined the total score as ‘Fas-Fas L risk score’. The P -value of the score for DFS was even lower than that of the clinical stage by multivariate analysis. These results suggest that the evaluation of Fas and Fas ligand expression potentially has a significant prognostic value for DFS of HCC patients, in addition to the clinical stage, and can be regarded as a new prognostic marker. © 2000 Cancer Research Campaign

消化管出血により出血性ショックに陥った膵頭部動静脈奇形 (AVM) に対し, 緊急幽門輪温存膵頭十二指腸切除術を行い救命しえた1例を経験した. 患者は57歳の男性. 繰り返す十二指腸潰瘍からの出血と腹痛の精査目的のため施行した腹部血管造影検査にて膵頭部AVMと診断された. 他院にてAVMへの塞栓術を2回施行するも症状軽快せず, 当院に転院. 手術待機中に大量吐血からショック状態に陥り緊急手術となった. 胃十二指腸動脈の結紮にても出血を制御できず, 救命のため幽門輪温存膵頭十二指腸切除術を施行した. 病理組織検査にて膵周囲から十二指腸粘膜下層にかけての大小不同の動静脈および潰瘍底に露出する静脈が認められた. 術後は多臓器不全, DICに陥ったが, 回復し, 第76病日に退院した. 術後19か月の現在, 再発を認めない. 膵AVM報告66例中の膵頭十二指腸切除施行例は12例であるが, 緊急手術による救命例は自験例のみであった.

A rare case of primary clear cell adenocarcinoma of the retroperitoneum is reported. A 58-year-old woman, who underwent total hysterectomy and bilateral salpingo-oophorectomy for cervical carcinoma at the age of 44 years old, was pointed out having a tumor of the ascending colon. On close examination, an 8×6cm huge pelvic tumor was found out by computed tomography. Transrectal needle biopsy of the tumor showed adenocarcinoma of unknown origin. She underwent an ileocecal resection and a resection of the retroperitoneal tumor. The tumor was located in the retroperitoneal cavity at the left side of the rectosigmoid. It was adherent to the rectal mesocolon, stump of the vagina and bladder. Histological examination showed clear cell adenocarcinoma of the retroperitoneum, and the colon tumor was revealed to be well differenciated adenocarcinoma, m, n0. The patient received chemotherapy for ovarian carcinoma because both this tumor and ovarian clear cell adenocarcinoma seemed to be of miillerian origin. There have been no signs of recurrence as of 14 months after the surgery. As far as we could review, no such case as clear cell adenocarcinoma arising from the retroper-itoneum like our case has been reported in Japan.

In this study, we investigated the proliferating cell index by the percentage of Ki-67 expressing cells (Ki-67 LI) and the apoptotic index (AI) by the number of morphologically apoptotic cells per 1000 carcinoma cells in haematoxylin and eosin sections of 76 hepatocellular carcinomas (HCC). Both indices showed excellent correlation with each other (P < 0.0001) and were significantly higher in cases of poor differentiation, of advanced stages, with portal invasion and with intrahepatic metastasis. Furthermore, cases with higher Ki-67 LI or higher AI displayed poor outcomes for disease-free survival (P = 0.0001 and P = 0.0005) by univariate analysis. By multivariate analysis, both indices could be regarded as independent prognostic factors. These results strongly suggest that Ki-67 LI and AI have very similar clinical significance, reflecting the existence of biologically aggressive phenotypes and poor disease-free survival rate in HCC. © 1999 Cancer Research Campaign

It was previously found that a cationic amphiphilic peptide, Ac-(Leu-Ala-Arg-Leu)3-NHCH3 (4(3)), caused the destabilization of a phospholipid membrane and showed strong antibacterial activity [Lee et al. Biochim. Biophys. Acta 1986; 862: 211-219]. In order to investigate the effect of changing alpha-helix propensity, hydrophobicity and basicity in 4(3) on the peptide conformation and activity, the 4(3) analogs, [Gly (or Val)6]4(3), [Gly (or Val)2,6]4(3), [Gly (or Val)2,6,10]4(3), [Gln3]4(3), [Gln3,7]4(3) and [Gln3,7,11]4(3) were synthesized. Except for [Val2,6]4(3) and [Val2,6,10]4(3), which mainly formed a beta-structure, other peptides formed an alpha-helix and showed moderate membrane-perturbing activity toward neutral and acidic lipid vesicles. All the peptides other than [Val2,6,10]4(3) and [Gln3,7,10]4(3) had the antibacterial activity comparable with that of 4(3). The relationship between the membrane-perturbing activity and the antibacterial activity was not always parallel. Conclusively, the Ala-->Val substitution in 4(3) causes the change of peptide conformation and the presence of a cationic amino acid residue is necessary for the antibacterial activity.

Expression of cell-cycle modulators at the G1-S boundary, retinoblastoma gene product (pRb), p21, p16, p27, p53, cyclin D1, and cyclin E was investigated with 104 hepatocellular carcinomas (HCC), as well as 90 of their adjacent noncancerous lesions and 9 normal liver control specimens. The labeling indices (LI) of pRb, p21, p16, and p27 were higher in HCC lesions than in the adjacent noncancerous lesions and normal controls. Especially, p27 LI in noncancerous lesions was significantly higher than that in normal livers (P =.011). Aberrant p53 expression and cyclin D1 and E overexpression were observed exclusively in HCC lesions. pRb was positive in 85.6% of the HCC cases and was not related to any clinicopathological parameters. The p21 LI was generally low (average, 5.5 +/- 9.8). Although a negative regulator, p21 LI was higher in cases with intrahepatic metastasis (P =.0359). The p16 LI was significantly decreased (P =.0121) in cases with advanced stage. p27 LI was significantly decreased in cases with portal invasion (P =.0409), poor differentiation (P

食道癌切除後の乳糜胸に対し, OK-432とミノサイクリンの投与が有効であった1例を経験した. 患者は62歳の男性. 胸部中下部食道癌に対し右開胸開腹にて胸腹部食道切除, 胸腔内食道胃管吻合, リンパ節郭清を施行した. 第1病日より右胸腔ドレーンから1,400～2,000ml日の排液を認めた. 摂食にて排液は白濁し, 乳糜胸と診断. 排液量が減少しないため, 第13病日より3日間, 胸腔内にOK-43210KEとミノマイシン200mgを投与した. 排液は著減し, リンパ管造影にてTh10で造影剤の途絶を確認した. 第18病日に胸腔ドレーンを抜去した. 隔壁化された胸水の貯留を認めたが, 徐々に減少し, 第51病日には胸水をほとんど認めなくなった. 食道癌切除後の乳糜胸に対する胸膜癒着療法の本邦報告例は4例で, 排液は500～2,200ml日, 第11～20病日に胸膜癒着剤が投与され, 全例治癒していた.

Papillary thyroid carcinoma is a frequent thyroid cancer. Many factors have been reported to be of prognostic importance, but the significance of biologic factors suggesting aggressiveness and proliferating activity has not been sufficiently documented. Conventional prognostic factors such as age, extrathyroidal invasion, lymph node and distant metastasis, and biologic factors including histologic differentiation, DNA ploidy, S-phase and G2M-phase fractions, and expression of CD44 variant 6 (CD44-v6) obtained from 131 patients who underwent surgery for papillary thyroid carcinoma at Osaka Police Hospital were analyzed retrospectively. Age was closely related to extrathyroidal invasion, G2M-phase fraction, and CD44-v6 expression. Extrathyroidal invasion was independently related to age, gender, and lymph node metastasis. The grade of lymph node metastasis was related to extrathyroidal invasion, gender, distant metastasis, and CD44-v6 expression. Distant metastasis was associated with aneuploid tumors. Cause-specific survival was independently related to biologic factors including extrathyroidal invasion, distant metastasis, DNA ploidy and S-phase fraction. These results suggest that biologic factors indicating aggressiveness and proliferating activity are important for papillary thyroid carcinoma.

Bile duct cancers are still difficult to cure, and even if curatively resected locoregional recurrences are frequent. Biologic proliferative activity of the cancer may influence postoperative recurrence and the prognosis. A retrospective study was performed with the medical records of 44 consecutive patients who underwent surgery for histologically extrahepatic bile duct cancer (stage 3 or 4) at Osaka Police Hospital during the period 1980 to 1992. Univariate analysis suggested that the stage according to the UICC classification, curability, DNA ploidy, proliferating cell nuclear antigen (PCNA), S-phase and G2M-phase fractions, and histologic differentiation were significant prognostic factors. The Cox's proportional hazard model indicated that PCNA and histologic differentiation were independent prognostic factors for crude and cause-specific survival. When PCNA was omitted from the analysis, DNA ploidy and histologic differentiation were independent prognostic factors for both crude and cause-specific survival. These results suggested that proliferative activity influenced the postoperative prognosis of extrahepatic bile duct cancer.