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Solids with competing interactions often undergo complex phase transitions with a variety of long-periodic modulations. Among such transition, devil's staircase is the most complex phenomenon, and for it, CeSb is the most famous material, where a number of the distinct phases with long-periodic magnetostructures sequentially appear below the Neel temperature. An evolution of the low-energy electronic structure going through the devil's staircase is of special interest, which has, however, been elusive so far despite the 40-years of intense researches. Here we use bulk-sensitive angle-resolved photoemission spectroscopy and reveal the devil's staircase transition of the electronic structures. The magnetic reconstruction dramatically alters the band dispersions at each transition. We moreover find that the well-defined band picture largely collapses around the Fermi energy under the long-periodic modulation of the transitional phase, while it recovers at the transition into the lowest-temperature ground state. Our data provide the first direct evidence for a significant reorganization of the electronic structures and spectral functions occurring during the devil's staircase., Comment: 22 pages, 5 figures

We use a surface-selective angle-resolved photoemission spectroscopy and unveil the electronic nature on the topmost layer of Sr_{2}RuO_{4} crystal, consisting of slightly rotated RuO_{6} octahedrons. The γ band derived from the 4d_{xy} orbital is found to be about three times narrower than that for the bulk. This strongly contrasts with a subtle variation seen in the α and β bands derived from the one-dimensional 4d_{xz/yz}. This anomaly is reproduced by the dynamical mean-field theory calculations, introducing not only the on-site Hubbard interaction but also the significant Hund's coupling. We detect a coherence-to-incoherence crossover theoretically predicted for Hund's metals, which has been recognized only recently. The crossover temperature in the surface is about half that of the bulk, indicating that the naturally generated monolayer of reconstructed Sr_{2}RuO_{4} is extremely correlated and well isolated from the underlying crystal.

Background Acute acalculous cholecystitis (AAC) is a relatively rare disorder of the gallbladder. Breast cancer recurrence more than 10 years after curative surgery is also infrequent. Case presentation Here, we report a case of a 59-year-old woman who presented with right flank pain. Her medical history included a lumpectomy for cancer of the left breast 12 years prior. Laboratory tests showed a severe inflammatory reaction and mild liver function abnormalities. Ultrasonography and computed tomography revealed an enlarged gallbladder and inflammation of the surrounding tissues; however, no gallstone was present. She was diagnosed with AAC. We performed an emergency laparoscopic cholecystectomy, and histopathological examination revealed a poorly differentiated adenocarcinoma in the cystic duct. Both metastatic and primary tumor cells were positive for estrogen and progesterone receptors on immunohistochemistry. The final pathological diagnosis was acute cholecystitis due to breast cancer metastasis to the cystic duct. Conclusion Although AAC secondary to metastatic breast cancer is rare, it should be included in the differential diagnosis for abdominal pain in patients with a previous history of breast cancer.

症例は68歳の女性で，66歳時，左肝管内に限局する乳頭状隆起性病変を認め，術中の胆道鏡では，右肝管，総胆管内には病変を認めなかったため，左葉切除を施行した．病理組織学的には，胆管被覆上皮の乳頭状増殖を示すものの浸潤性増殖像は認めず，胆管乳頭腫症と診断された．退院後半年に1度，CTでフォローしていたところ，2年後のCTで下部胆管に淡い造影効果を示す結節陰影を認めた．Endoscopic Retrograde Cholangiograpy（ERC），Magnetic Resonance Cholangiopancreatography（MRCP）で下部胆管内に12 mm大の不整形の隆起性病変を認めたため，下部胆管に発生した胆管癌を疑い，膵頭十二指腸切除を施行．病理の結果，病変は前回と同様に乳頭状増殖を示し胆管乳頭腫症と診断された．胆管乳頭腫症は胆道の良性疾患として分類されているが，悪性転化の報告があり，癌に準じた根治的切除が必要と考えられているが，本症例のように根治的切除がなされた後でも異時性に発生することもあり，注意深い観察が必要と考えられる．

症例は56歳, 男性. 急性腹症で発症し上腸間膜動脈 (superior mesenteric artery : 以下SMAと略す) 解離と診断され, 同時に総肝動脈瘤も指摘されていた. 保存的治療で軽快し2年間, 経過観察中であったところ, 下血により胃癌が発見された. 今回, われわれは, 胃癌に対しては幽門側胃切除術を, 総肝動脈瘤に対しては瘤切除および血行再建術を行った. SMA解離は血栓化しているためそのままとした. 大動脈解離を伴わない孤立性のSMA解離は極めて稀な疾患である. また, 近年, 画像診断の進歩により総肝動脈瘤の発見は増えつつあるものの症状に乏しいため診断されにくく, 破裂時には救命率が低いと報告されている. われわれは, 孤立性上腸間膜動脈解離や, 総肝動脈瘤といったその一つのみを有していても稀な疾患を重複併存した胃癌手術症例を経験したので報告する.

われわれは腸石嵌頓を伴った盲腸壊死の稀な1例を経験したので報告する.症例は70歳,女性.右下腹部痛を自覚したため近医を受診するも軽快せず,精査のため当科に紹介受診となった.腹部X線写真, CTにてバウヒン弁近傍に3cm大の腸石を伴うair fluid cystic lesionを認め,腸石嵌頓による急性憩室炎の膿瘍形成が疑われたため,緊急手術となった.術中,回盲部の腫大と変色壊死を認めたため回盲部切除を行った.病理所見は盲腸壁全層の出血壊死であった.回盲部に明らかな憩室は認められず,盲腸壊死は腸石の嵌頓による可能性が高いと考えられた.術後の腸石の成分分析では炭酸カルシウム53%, 燐酸カルシウム47%であり,患者の15年間に及ぶ健康食品(サンゴカルシウム)の誤った摂取方法が原因ではないかと考えられた.

局所進行大腸癌は解剖学的特性により,腹壁や小腸,膀胱,生殖器など近接他臓器にしばしば浸潤するが,腎に直接浸潤するものは比較的稀である.下行結腸癌が左腎に直接浸潤し,合併切除により治癒を得た.症例は51歳,女性.発熱を主訴に受診し,腹部超音波検査で左腎腫瘍を疑われた.精査にて下行結腸に全周性の進行癌を認め,結腸癌が腎に浸潤したものと考えられた.下行結腸癌は左腎に強固に癒着し,左腎合併切除を含む左半結腸切除(D3郭清)を施行した.病理組織所見では下行結腸癌および左腎腫瘤は共に中分化型腺癌であり,結腸癌の腎直接浸潤と診断した.結腸癌は他臓器浸潤例においても治癒切除例では良好な成績が報告されており,積極的な浸潤臓器の合併切除が予後を改善すると考える.

ショック状態に至った大腸穿孔例は予後不良であるが,今回われわれは腎移植患者において1救命例を経験した.患者は52歳女性で, 1993年3月に生体腎移植を受けている. 1999年11月2日に急激な腹痛を生じ,約10時間後に当院を受診,血圧52/13mmHgで,腹部緊満著明であった.胸部単純X線で腹腔内遊離ガス像を認めたため,緊急開腹手術を行った.横行結腸脾彎曲部付近の腸間膜付着部反対側に直径約3cm大の穿孔を認め,同部および肛門側には,腫瘍を認めなかった.病変部横行結腸を局所切除・吻合し,口側横行結腸にストーマを設置した.術後にエンドトキシン吸着を2度行った. 術後graft lossに陥ることもなく,第131病日に退院した.病理組織学的所見上穿孔以外には明らかな所見はえられなかった.致死率の高い病態を腎移植患者に合併しながら救命し,さらにはグラフト機能を温存しえた症例であった.

Internal hernias are not common cause of intestinal obstruction. Among of those hernias, a very rare internal herniation through an abnormal defect in the broad ligament of the uterus is reported. A 54-year-old woman was admitted to the hospital because of abdominal pain and vomiting. She was treated conservatively with a long tube, but no symptomatic remission was obtained except evacuation. As a stenosis of the ileum was detected on a long tube enterogram, an operation was performed on the 11th hospital day. At laparotomy, the ileum, approximately 25cm proximal to the ileocecal valve, was herniated through an abnormal defect in the broad ligament of the uterus. Following a reduction of the incarceration, the hiatus was sutured. This disease presents difficulty in preoperative diagnosis. When we encounter multiparous patient with intestinal obstruction without any previous surgical history, a possibility of this disease must be kept in mind.

今回, 我々はserrated adenomaの多発を認めた若年者大腸癌の1例を経験したので報告する. 症例は29歳の女性. 腹部腫瘤の自覚で近医を受診. 精査にて横行結腸に限局潰瘍型の腺癌とS状結腸から横行結腸にかけてポリープの多発を認めた.結腸右半切除術・D3のリンパ節郭清を施行した. 病理組織学的所見では限局潰瘍型病変は高分化腺癌 (壁深達度se, 脈管侵襲ly1, v1)) であった. 切除標本上の多数の小隆起性病変はhyperplastic polypとserrated adenomaであった.正常部・腫瘍部に対し遺伝子不安定性を検討したがreplication errorは認めなかった. 補助化学療法はテガフールーウラシル配合剤300mg/dayの経口投与を施行している. 術後経過良好にて軽快退院し, 術後18か月の現在, 癌の転移・再発, 第2癌の発癌は認めていない.

症例は69歳女性で,下腹部痛・血便を主訴に来院した.注腸造影大腸内視鏡にて2型進行S状結腸癌と診断し,S状結腸切除術を施行した.病理学的には,ss,n1(+)の中分化腺癌であった.他院での2回の注腸造影写真をretrospectiveに検討すると,23カ月前に,ほぼ同一の部位に長径0.6cmのIsp型隆起性病変を認め,また8カ月前には,同部位に長径3.1cmの隆起性病変を認めていた.tumor doubling time(DT)は全経過で76.4日と極めて短期間であり,また前半で64.4日,後半で117.9日とむしろ後半で延長していた.分子生物学的検査では,p53蛋白の異常蓄積を認め,Ki-67が強陽性であり,急速な発育との関連が示唆された.今後は,遡及的検討例において,DTと分子生物学的検査との相関についてさらに集計・検討が必要と考えられた.

1980年から1991年の間に切除された全周性大腸癌は107例であり, このうちA群 (イレウスを伴った症例 : 16例), B群 (軽度の閉塞症状を伴った症例 : 37例), C群 (閉塞症状をまったく有しなかった症例 : 54例) に分類し, A群の臨床病理学的特徴および予後に関して他の2群と比較検討した. 年齢, 性別, 肉眼型, リンパ節転移度, 脈管侵襲および組織学的進行度では3群間に有意差は認められなかった. 腫瘍径ではA群はC群に比べ縦径は有意に短く (P

Recently colorectal carcinomas have been increasingly reported, multiple carcinomas of the colon and rectum are not rare, and the hereditary factor seems to be involved in the etiology of such multiple occurrence. Thirty-seven cases of multiple colorectal cancers experienced at the department in a recent 14-year period were clinicopathologically studied. Of these 37 patients, seven patients (15 lesions) had a family history of colorectal cancer within the first degree relatives (positive group) and the remaining 30 patients (65 lesions) had no family history (negative group). Patients in the positive group were younger than those in the negative group. Carcinomas of the positive group were located in more prpximal colon than those of the negative group. Histological examination revealed that most of the first lesions in the positive group were moderately differentiated adenocarcinomas while the second lesions were commonly well differentiated adenocarcinomas. Presence of associated adenomatous polyps was more common in the negative group than in the single carcinomas. The cumulative 5-year survival rate was 62.5% in the positive group and 42.0% in the negative group. All patients in the positive group satisfied the diagnosis criteria of HNPCC (hereditary nonpolyposis colorectal cancer), but the negative group may include initiator of HNPCC.

過去16年間に当科で手術を施行した75歳以上の高齢者大腸癌は60例で,50歳以上70歳未満の対照者群319例,39歳以下の若年者群18例の内,主に単発癌を比較の対象とし臨床的特徴と遠隔成績を検討した.高齢者群は,(1)占拠部位では右側結腸に有意に多かった.(2)壁深達度は,漿膜内にとどまる症例が多く比較的浅い傾向.(3)リンパ節転移陽性率は低い傾向.(4)手術直接死亡例はないが他病死例が多く,他病死を除いたら5年生存率は対照者群と比べて差はなかった.高齢者大腸癌は,壁深達度は浅く,リンパ節転移率も低い傾向にあり,D2もしくはD3の適切なリンパ節郭清にて根治度AまたはBの切除が可能であり,高齢といえども患者の状態の許す限り積極的に対照者群と同様の郭清を伴った根治切除術を心がけるべきである.高齢者では術前より全身状態の悪い症例が多く,合併疾患の術前後の管理を充分に行えば対照者群と同等の成績が期待できる.

Angle-resolved photoemission spectroscopy using tunable low energy photons allows us to study the quasi-particle (QP) dispersions of the inner and outer CuO2 planes (IP and OP) separately in the tri-layer cuprate Bi$_2$Sr$_2$Ca$_2$Cu$_3$O$_{10+\delta}$ (Bi2223). The kink energy of the OP band is $\sim$ 70 meV, as observed in various high-$T_c$ cuprates, while that of the IP band is as large as 100 meV in the superconducting (SC) state. This large kink energy is attributed to the $\sim$ 35 meV buckling mode plus the large ($\sim$ 60 meV) SC gap of IP. The IP band also shows a weak kink feature at 70 meV in the SC state. The latter feature can be explained either by the 70 meV half-breathing mode or by the $\sim$ 35 meV buckling-phonon mode plus the $\sim$ 40 meV SC gap of OP if interlayer scattering of QP is involved., Comment: 5 pages, 2 figures

The patient was a 77-year-old woman admitted for nausea and abdominal pain. Computed tomography (CT) revealed advanced ascending colon cancer with liver metastasis. After operation, we started combination chemotherapy of S-1 and irinotecan (CPT-11); S-1(80 mg/m²) administered orally for consecutive days followed by 14 days rest.CPT -11 (100 mg/m²) was given as a 2-hour infusion on day 1 and 15. The patient complained of high fever and subsequent dyspnea with severe hypoxemia after the first course of combination chemotherapy of S-1 and CPT-11.CT scan showed diffuse interstitial lesions with ground glass opacity on both lungs. Steroid pulse therapy with oxygen therapy remarkably improved her symptoms, and abnormal findings on CT scan also resolved. Drug lymphocyte stimulation test was positive against S-1 and negative against CPT-11. These findings were consistent with S-1-induced lung injury. Drug -induced pneumonia needs to be considered in the differential diagnosis when patients treated with S-1 and CPT-11 combination therapy present high fever and dyspnea.

The patient was a 75-year-old man who was admitted because of diarrhea and anemia. Endoscopic examination revealed advanced sigmoid colon cancer. Serum CEA levels were markedly elevated. In July 2007, surgery was performed, but the sigmoid colon cancer was unresectable. After surgery, the patient was treated with chemotherapy and concurrent radiotherapy. The chemotherapy consisted of oral UFT (420 mg/body/day)and Leucovorin (75 mg/body/day) administered for 6 weeks. Radiotherapy at 2 Gy/day was administered 30 times (total dose 60 Gy). The tumor decreased slightly in size and serum CEA levels also decreased. The patient refused surgery as an additional therapy. In August 2007, we started combination chemotherapy using oral S-1 (100 mg/body/day, day 1-14) and intravenous CPT-11 (140 mg/body/day, day 1 and 15) as one course for 4 weeks. After 4 courses, serum CEA levels were normal, the sigmoid colon cancer was not found by endoscopy and a biopsy specimen revealed no malignant cells. Moreover, after 8 courses, the tumor disappeared, as confirmed by computed tomography (CT) and positron emission tomography-CT, representing a complete response. Chemoradiotherapy using UFT and Leucovorin, and chemotherapy consisting of S-1 and CPT-11 as an additional therapy may be effective for treating unresectable advanced sigmoid colon cancer.

We report a case of left inguinal lymph node metastasis of anal canal carcinoma, treated effectively with chemotherapy consisting of S-1 and CDDP combined with radiotherapy. In February 2006, a 76-year-old woman underwent resection of a tumor diagnosed as squamous cell carcinoma of the anal canal. The patient refused additional surgical therapy. In August 2007, a painful lymphnode swelling was noticed in the left inguinal region. Biopsy was performed, and specimens were shown to include squamous cell carcinoma cells. The patient was treated using chemotherapy concurrent with radiotherapy. The chemotherapy consisted of oral S-1 (80 mg/body/day; 5 days/week) and intravenous CDDP (5 mg/body/day; 5 days/week), both administered for 4 weeks. Radiotherapy at 2 Gy/day was administered 25 times (total dose 50 Gy). The metastatic tumor in the lymph node responded well to the treatment and decreased remarkably in size by December 2007. After chemoradiotherapy, the oral administration of S-1 alone (80 mg/body) for 2 weeks followed by a 2-week rest period as one course was continued for 1 year. The lymph node metastasis had disappeared 1 year after chemoradiotherapy, as determined by computed tomography (CT) and positron emission tomography-CT, representing a complete response. Chemotherapy consisting of S-1 and CDDP concurrent with radiotherapy maybe effective for treating metastatic lymph node metastasis of anal canal carcinoma.

We report a rare case of neurofibromatosis type-2 (NF-2) associated with a chest wall schwannoma that was initially suspected of being a breast tumor. The patient was a 28-year-old female who was diagnosed as having NF-2 at 19 years old. At that time, she noticed a mass in the upper lateral region of her left breast but did not have it examined. The mass grew and became painful, and she was therefore referred to our department. Results of the initial examination indicated the possibility of a breast tumor, but a diagnosis of extramammary tumor of the major pectoralis major muscle was made on the basis of the results of ultrasonography and 3-dimensional computed tomography (3D-CT). An endoscope-assisted extirpation of the tumor was performed. Histologically, the tumor was an Antoni type A and B neurilemoma and was diagnosed as a schwannoma.

Inflammatory fibroid polyps (IFPs) are rarely found in the gastrointestinal tract. The majority of IFPs are sessile-pedunculated or pedunculated polypoid lesions, whereas a polyp presenting like a Borrmann type II lesion is extremely unusual. This report describes the case of a 74-year-old man with a history of intussusception, in whom a preoperative diagnosis of a cecal tumor of the ileocecal valve was made. A laparotomy subsequently revealed a lesion similar to a Borrmann type II tumor located 15 cm above the ileocecal valve, but not at the valve. The lesion was diagnosed as an IFP which had been caused by repeated colostomy irrigation. The aim of the present report is to draw attention to this entity, which should be included in the differential diagnosis of intussusception and small bowel obstruction.

Purpose FOLFOX is a standard combination chemotherapy regimen for metastatic colorectal cancer (CRC). 5-Fluorouracil (5-FU) is infused continuously through a pump for 46 h; therefore, replacement of infused 5-FU with oral S-1 would be more convenient for patients. We investigated the efficacy and safety of S-1/oxaliplatin (SOX) plus bevacizumab regimen in a community setting. Methods We conducted a phase II clinical study in Hiroshima, Japan. We enrolled individuals aged 20–80 years who had metastatic CRC, an Eastern Cooperative Oncology Group performance status of 0 or 1, assessable lesions, and not received previous chemotherapy. Eligible patients were administered SOX plus bevacizumab (S-1 80 mg/m2/day, day 1–14 orally; and oxaliplatin 130 mg/m2 day 1 i.v., bevacizumab 7.5 mg/kg, day 1 i.v. q3w). The primary endpoint was response rate (RR), and the secondary endpoints were progression-free survival (PFS), overall survival (OS), and safety. Results Between May 2011 and January 2014, 55 patients (mean age 64 years) were enrolled at 12 institutions. Median follow up duration was 20.2 months (range 1.3–47.1 months). RR was 47.1 % [95 % confidence interval (CI) 33.7–60.6 %]. Median PFS and OS was 9.2 months (95 % CI 7.6–10.8) and 22.5 months (95 % CI 19.4–25.9), respectively. Major adverse events (grade 3/4) were neutropenia (9.3 %), thrombocytopenia (5.6 %), anorexia (18.5 %), and sensory neuropathy (16.7 %). Conclusion These data suggested that SOX plus bevacizumab is effective and capable of being managed in metastatic CRC patients in our community clinical practice.