Search

Highlights • A resection of a thoracic duct cyst in the right upper mediastinum resulted in post-operative chylopericardium. • Chylous complications in thoracic duct cysts are frequent when intraoperative diagnosis is not reached, such as in cases with anomalous cyst location. • A review on post-surgical chylopericardium is performed, which will provide information for future management of this rare complication., Introduction Thoracic duct cysts are very rare, and diagnosis is often difficult. We report a rare case of chylopericardium following thoracic duct cyst resection. There are no established guidelines on the management of such cases. We reviewed the literature on postoperative complications after thoracic duct cyst resection, and conducted the first thorough review of the etiology and management of chylopericardium in surgical cases. Presentation of case A 54-year-old male presented with cardiac tamponade due to chylopericardium. He had undergone resection of a thoracic duct cyst 2 years previously, which was complicated by postoperative chylothorax. Chyle accumulation resolved with conservative treatment. Discussion Chylothorax is a frequent complication following thoracic duct cyst resection, especially in cases where no intraoperative diagnosis is reached. Diagnosis may be difficult due to anomalous location of the cyst, as in our case. Chylopericardium is rarely reported, and may have occurred in our case because of prior pleurodesis. Chyle accumulation can reportedly be managed with diet restrictions in over half of reported cases, especially in cases of lung or mediastinal tumor resection. Conclusion The most important points highlighted by this rare case of chylopericardium secondary to thoracic duct cyst resection are: 1) pedicles should be ligated in cyst resections, regardless of location; 2) careful assessment in the initial surgery may help identify the point of leakage; 3) low-fat diet is the first choice in the initial management of postoperative chylopericardium, but surgical repair may be considered in cases with no response after > 2 weeks of conservative treatment.

目的．悪性胸膜中皮腫に対する胸膜肺全摘術の意義を明らかにすることを目的として，その手術成績および予後因子について後ろ向きに検討した.対象．われわれの多施設共同研究グループで胸膜肺全摘術を行った悪性胸膜中皮腫32例を対象とした．結果．症例の内訳は，男性31例，女性1例，平均年齢55.4歳であった.術後合併症は膿胸，横隔膜再建パッチの脱落などがみられ，発症率は56.3%であった.術死は2例（6.3%）にみられた.併用療法は胸腔内灌流温熱化学療法，全身化学療法などを13例（40.6%）に行った.全例の術後累積生存率は，2年および3年がそれぞれ40.1%，16.0%で，中間生存期間は16.2ヵ月であった.予後因子に関する多変量解析では，performance status（Eastern Cooperative Oncology Group）0，N0，手術時間600分未満の3因子が独立した有意の予後良好因子であった.これら3因子を全て持った症例の術後2年および3年生存率は，それぞれ64.8%，51.9%であった．結論．悪性胸膜中皮腫に対する胸膜肺全摘術は患者選択によっては良好な成績が期待できる.

背景．自然気胸を初発とする肺癌は稀であり，自然気胸を契機に発見された微小肺癌症例を経験したので報告する．症例．53歳，男性．2006年5月，呼吸困難感を自覚し，前医を受診した．左自然気胸と診断され，当院紹介となり，胸腔ドレナージが施行された．自然気胸は改善したが，胸部CTにて左S1＋2胸膜直下に胸膜陥入を認め，周囲にGGOを伴った径10 mmの結節影を認めた．2ヶ月の経過観察にて結節影は消退せず，充実部分の増大および胸膜陥入の増悪傾向がみられたため，同年7月胸腔鏡下肺生検を施行し，肺腺癌と診断した．左肺上大区域切除およびリンパ節郭清術を引き続き行い，病理組織学的には腫瘍径7×7×5 mmの，高分化型腺癌pT1N0M0 stage IAと診断した．結論．近年，CT画像の向上とともに微小肺癌が発見される機会が増えつつあり，自然気胸症例といえどもCTの画像評価は，腫瘍性病変を見落とさないように慎重に行うべきである．周囲にGGOを伴う結節性小型病変は，悪性である可能性があり，経過観察にて消退しない場合，肺癌の可能性を念頭において精検すべきである．

背景．胸腺癌は比較的稀な腫瘍であり，特に進行期症例では，その治療法は未だ確立されていない．症例．55歳男性．職場健診にて胸部異常影を指摘され当科紹介となった．胸部X線写真では左肺門部に巨大な腫瘤影を認め，CTでは前縦隔から左胸腔内に大きく突出する長径9.5 cmの腫瘤影を認めた．腫瘤は左腕頭静脈，大動脈，肺動脈起始部と接して存在しており，各々への浸潤を疑った．また腫瘍マーカーはAFP：24.9 ng/ml，NSE：26.0 ng/ml，CYFRA：34.0 ng/mlと高値を示しており前縦隔腫瘍の診断にて入院となった．入院後，経皮的吸引細胞診及び組織診を行い，胸腺癌（正岡III期）と診断した．CDDP＋VNRによる化学療法を2コース施行したところ著明な腫瘍の縮小を認め，腫瘍マーカーも正常範囲となったため，腫瘍を左肺上葉とともにen blocに摘出した．病理診断は胸腺未分化癌であった．術後放射線治療及び化学療法を施行し，現在術後12ヶ月が経過したが再発なく，元気に社会復帰している．結論．進行期胸腺癌症例では，術前化学療法に外科切除術の併用が治療の1選択肢となる可能性が示唆された．

Introduction:A subset of non–small-cell lung cancer (NSCLC) patients with malignant pleural effusion and/or malignant pleural nodules is now classified as stage IV and is generally considered a contraindication to surgery. However, several reports have demonstrated that the prognosis of patients with pleural carcinomatosis first detected at thoracotomy is relatively favorable. The aim of this study was to describe the results of surgical intervention in NSCLC patients with pleural carcinomatosis in Japan.Methods:In 2010, the Japanese Joint Committee of Lung Cancer Registry conducted a nationwide registration of lung cancer patients who underwent surgery in 2004. Using this database, we performed a retrospective study focused on pleural carcinomatosis. We examined the clinicopathological features, the current status of therapy, and surgical outcomes in patients with pleural carcinomatosis.Results:Among the 11,420 registered NSCLC patients, 329 (2.9%) patients had pleural carcinomatosis. The median survival time and 5-year survival rate of 313 patients without other metastatic disease were 34.0 months and 29.3%, respectively. Primary tumor resection was performed in 256 (81.8%) patients, and macroscopic complete resection was achieved in 152 (48.6%) patients, with 5-year survival rates of 33.1% and 37.1%, respectively. Multivariate analysis revealed that Eastern Cooperative Oncology Group performance status (p < 0.001), best stage nodal status (p = 0.002), and the presence or absence of gross residual tumor (p = 0.013) were independent predictors of survival.Conclusion:In our surgical registry for NSCLC, patients with pleural carcinomatosis accounted for 2.9%, and macroscopic complete resection for them was associated with better survival.

目的:下咽頭癌は早期に特異的な症状が発現しにくいため, 確定診断時に進行癌であることが多く早期発見が望まれている.早期下咽頭扁平上皮癌発見における喀痰細胞診の有用性の評価を目的とし, その細胞像について検討した.対象と方法:平成5-15年度の喀痰集検受診者11万237人からの発見癌201例のうち, 下咽頭扁平上皮癌が確定診断された8例を対象とした.同症例の蓄痰標本に出現した中等度異型以上の異型扁平上皮細胞, および扁平上皮癌細胞について細胞学的検討を行った.成績:発見された下咽頭癌の病期は, I期: 3例, III・IV期: 5例であった.喀痰中の異型上皮細胞および癌細胞数は, I期: 50.8個, III期: 333.3個, IV期: 427.4個で, I期癌では進行期癌と比較し有意に少数であった (P

Background Sclerosing hemangiomas of the lung are uncommon tumors and are thought to be benign. However, the histogenesis and clinicopathological features of these tumors have not been elucidated. Methods We analyzed the clinicopathological features of 26 sclerosing hemangiomas. The immunoreactivity for Ki-67 and p53 of sclerosing hemangiomas was determined and compared with that of pathological stage 1 pulmonary papillary adenocarcinomas. Results The patients of sclerosing hemangioma were predominantly female. Eighteen patients were detected as a result of routine medical examinations and 15 were nonsmokers. Seven patients underwent tumor enucleation, 10 underwent a wedge resection, and 9 underwent a lobectomy. The mean tumor size was 2.2 cm (range 1 to 5 cm). Pathological findings demonstrated a papillary pattern in 23 cases, sclerotic pattern in 26 cases, hemorrhagic pattern in 22 cases and a solid pattern in 25 cases. Twenty-five cases had an excellent prognosis with no evidence of recurrence following surgery. However, 1 patient who had undergone a wedge resection developed a local recurrence and required an additional wedge resection. The Ki-67 labeling index of sclerosing hemangiomas was significantly lower than that of adenocarcinomas, whereas the Ki-67 labeling index of the recurrent case was 0.4%. No significant immunohistochemical staining for p53 was observed in sclerosing hemangioma cases. Conclusions Sclerosing hemangioma exhibits various histologic findings. Although we experienced one case with a recurrent tumor, sclerosing hemangiomas did not exhibit malignant behavior.

A 67-year-old man was admitted to our hospital because of an abnormal chest echoic lesion detected incidentally by echocardiography. A chest roentgenogram showed the presence of a giant mass, and computed tomography of the chest confirmed the presence of a mass with a nonhomogeneous density in the left mediastinum, just adjacent to the left ventricle of the heart. Percutaneous aspiration cytology of the mass showed benign fibrous cells and a small amount of lymphocytes. The preoperative diagnosis of the tumor suggested a thymoma, and the patient underwent a thoracotomy. A pedunculated tumor arose from the visceral pleura of the left upper lobe of the lung, and it was capsulated within the pleura. The tumor measured 15 x 12 x 8 cm in size and it was successfully resected. The pathological diagnosis of the tumor was benign localized fibrous tumor of the pleura.

胸部外傷に伴う気管支損傷を経験したので報告する.症例1は20才男性.整備中の車が胸部に落下し受傷した.右気管支上幹の完全断裂を来し, 緊急入院となった.他臓器損傷は軽微.発症23時間後に手術施行した.右肺上葉は挫傷高度であったため肺葉切除となった.経過良好にて術後19病日退院した.症例2は20才男性.10tの重量物に挟まれ受傷.右気管支上幹完全断裂にて緊急入院となった.他臓器損傷は軽微.受傷9時間後に手術施行した.肺挫傷は比較的軽度で肺動脈 (truncus superior) の損傷無く, 端々吻合にて右上幹を再建した.経過良好にて術後21病日退院した.外傷性気管支損傷は気管分岐部近傍の主気管支横断裂が多数を占め, 本例の如く右上幹が引き抜かれるように損傷することは稀である.また外傷性気管気管支断裂は他臓器損傷を合併することが多く死亡率も高いとされるが, 本2症例のように他臓器の損傷が軽微な場合は救命の可能性があり, 積極的な外科療法がなされるべきと考える.なお, 術式の選択は肺損傷の程度を考慮して決定するべきである

Objective: Failure or prolongation of treatment for refractory thoracic empyema by the current chesttube drainage technique is often due to sterilization difficulties. Insufficient sterilization prolongs hospitalization, and is often associated with life-threatening complications and/or additional invasive surgical procedures. A new chest-tube sterilization technique aimed at making it less invasive and shortening the therapy is proposed.Methods: Following pretreatment for complications including loculation, bronchopleural fistula, or corticated lung, a double-lumen trocar catheter was introduced at the bottom of the empyemic cavity through the lateral chest wall. Then, a Foley balloon urethra-catheter was inserted and attached just inside the anterior chest wall at the top of the cavity for the evacuation of intrathoracic air. After irrigation of the cavity with distilled water once or twice, the cavity was completely filled with a bactericidal solution which was left in place for 30–60 minutes, followed by an antibiotic solution for more than 20 hours.Results: Among the five treated post-lobectomy or pneumonectomy cases, sterilization was obtained after only one treatment in four cases and after two courses in the other. Catheterization duration from the initial treatment was 2–13 days. Neither recurrence nor treatment-related major complications were observed.Conclusions: This balloon-tube thoracostomy technique is simple, minimally invasive and cost-effective, due to shortening of the treatment time with minimal manpower and equipment requirements. It is thus a promising therapeutic approach to thoracic empyema and has the potential for application to other intrathoracic disorders.

BACKGROUND Normal bronchial epithelium gradually acquires cellular and genetic changes that result in the formation of invasive tumors. The objective of this study was to evaluate the degree of proliferative change and the amount of neovascularization in both normal and preneoplastic lesions in smokers who were at high risk for developing lung carcinoma. METHODS The authors studied bronchial biopsy specimens from 7 nonsmokers and 52 smokers. Immunohistochemical staining of the specimens with antibodies for the presence of p53 protein, Ki-67 and CD34 antigens, and vascular endothelial growth factor was performed. The proliferation index (PI) was assessed by immunohistochemical staining for Ki-67 antigen. RESULTS Overexpression of p53 protein was observed frequently in regions of squamous dysplasia and in squamous cell carcinoma tissue. The PI of normal epithelium from smokers was increased compared with nonsmokers, and the difference was statistically significant (P < 0.05). The microvessel count (MC) in normal mucosa obtained from smokers was higher compared with the MC in normal mucosa obtained from nonsmokers (P < 0.05). A significant difference in MC also was observed between regions of squamous metaplasia or dysplasia with projections of capillary loops into the bronchial mucosa and similar lesions without capillary loops (P < 0.005); however, there was no difference in either the PI or the incidence of p53 overexpression between these groups. CONCLUSIONS These results show that smoking appears to induce both a proliferative response and neovascularization in bronchial mucosa. The projection of capillary loops into the bronchial mucosa also may be a result of neovascularization occurring within the lamina propria of the bronchial wall. Cancer 2002;95:1539–45. © 2002 American Cancer Society. DOI 10.1002/cncr.10850

Therapeutic principles for managing subclinical pleural cancer found unexpectedly during intraoperative examination are unclear. We analyzed prognostic factors including the tumor proliferative marker Ki-67 in these circumstances.The cases of 65 surgically treated patients with lung cancer and subclinical T4 pleural cancer, microscopic in 25 and macroscopic in 40, were reviewed.The overall 5-year survival rate of patients undergoing lobectomy was 14.3%. For patients with T4 NO disease, the 5-year survival rate was 46.7%. In patients with a low Ki-67 labeling index, the 5-year survival rate was 28.6%. The Ki-67 labeling index was a significant (p0.05) indicator of survival. Multivariate analysis demonstrated Ki-67 labeling index, lymph node involvement, and tumor differentiation to be the most influential prognostic factors for postoperative survival (p0.01).In the treatment of lung cancer patients with subclinical pleural cancer found at thoracotomy, tumor resection is not necessarily contraindicated. Resection appears to be beneficial in patients with no nodal involvement or a low tumor Ki-67 labeling index. This index is a good therapeutic indicator for lung cancer patients.

A 30-year-old woman was admitted to our hospital for investigation of an abnormal shadow in the right pulmonary hilus on a chest X-ray film. A percutaneous needle biopsy was performed, which revealed pulmonary blastoma. A right upper lobectomy was performed and the pathological stage was confirmed to be IIIa (T3N0M0). An analysis of preoperative cytological specimens showed that epithelial tumor cells with thin cytoplasm were either tubular or papillary, while some mesenchymal tumor cells with elliptic and spindle-shaped nuclei were also found in the necrotic background. Thus, pulmonary blastoma should be considered when a two-cell pattern consisting of both epithelial and mesenchymal components is observed. DNA analysis was performed on previously identified areas of the epithelial or sarcomatous components, using a microdissection method. An analysis of the p53 gene by the single-strand conformation polymorphysm method showed an abnormal band with shifted mobility of exon 8 in only the sarcomatous component.

胸腔鏡下気胸手術は自然気胸に対する第一選択の手術手技として世に広く普及しているが, 術後の気胸再発が少なくないという点が新たに問題となっている.我々の施設における VATSによる自然気胸手術症例の再発率につき検討すると30例中3例 (10%) であり, これは従来の手術成績に比較し高率であった.最近経験した胸腔鏡下手術後1ヵ月以内の早期に気胸の再発をきたし, 開胸術により再手術を行った2症例の開胸所見では自動縫合器による前回の肺切除線に接して小嚢胞を認めたが, 胸腔鏡下手術時には同部に明らかな嚢胞を認めておらず, 術後新たに嚢胞が形成されたものと考えられた.自動縫合線近傍での嚢胞の新生が, 自然気胸に対する胸腔鏡下手術後の気胸再発の一因である可能性を示すものと考えられた.

The clinical characteristics and results of surgical treatment in patients with double carcinomas of the lung and other organs were evaluated using 73 patients with pathologically confirmed double carcinomas out of a total of 1279 lung carcinoma patients resected from 1980 to 1996. The double carcinomas were divided into three groups according to anatomical conditions and environmental factors including smoking habits; Group A; laryngopharynx and esophagus; Group B: gastroduodenum, hepatopancreas, kidney and urinary bladder; Group C : colorectum, breast, uterus and other organs. Clinical features revealedsignificant differences in the gender distribution and smoking indices of Groups A, B and C. The re-occurrence interval also demonstrated a significant difference between Groups A and C. However, no significant differences were observed in age distribution, the histologic types of the lung carcinoma, or the pathological stages of the lung carcinoma. The overall 5-year survival rates from lung resection inGroups A, B and C were 61.5%, 46.6% and 68.7%, respectively. There was a significant difference between Groups B and C (p

症例は16歳, 女性.主訴は胸部異常陰影.1996年5月, 学校健診の胸部X線写真にて左中肺野に縦隔に接する腫瘤影を指摘され, 紹介受診, 精査加療目的にて入院.術前行った肺動脈造影, 大動脈造影では異常動脈は確認されなかったが, 肺分画症, 縦隔腫瘍などを疑い8月15日に手術を施行した.腫瘤は左上葉S3と前縦隔の間に存在し, 有茎性に肺門部と連続していた.茎部には左肺動脈主幹から流入する動脈と左上肺静脈への還流静脈が確認された.内部は嚢胞が大部分を占め, 正常気管支との交通はなく, 肺葉外肺分画症の診断にて摘出術を施行した.同部位に発生する肺葉外肺分画症は比較的稀で術前診断の面からも興味ある症例であり報告した.

We report a case of giant mediastinal neurinoma with expansion into the intraspinal canal. We resected the tumor safely with the two-stage operation. The patient was a 52-year-old male. An abnormal shadow in the left lung field was pointed out at a mass survey. The tumor shadow was 15 cm in size, and extended into the intraspinal canal on chest X-ray, CT, and MRI. It was diagnosed as neurinoma by percutaneous fine needle biopsy (PCNB). First we resected the intraspinal portion of the tumor by the posterior route.Subsequently, the remaining intrathoracic portion of the tumor was resected and reconstruction of the spinal column was performed via the postero-lateral route six weeks later.Pathological diagnosis was benign neurinoma. The patient improved neurologically, discharged on his foot and had been well after two years.

原発1生肺非小細胞癌47例につきPCR-SSCP分析をもちいp53遺伝子突然変異の検出を試みた.12例 (25.5%) に遺伝子変異を認め, うち3例は喫煙との関係が示唆されているG-T Transversionであった.p53遺伝子の変異の有無とT, N, M各因子とのあいだに有意な相関は認められず, p53遺伝子変異群に有意に扁平上皮癌が多く認められた.また47症例中, 正常組織原発巣, 転移リンパ節組織がともに得られた8例に対しそれぞれ変異の検出を行った.2例において原発巣および転移リンパ節に変異が検出されたが, 正常クローンと変異クローンの比率を比較するために原発巣, 転移巣それぞれにつきp53の正常バンドと変異バンドのシグナルの比率を測定した.結果は2例ともに原発巣, 転移巣のあいだに差を認めなかった.p53の変異の有無は進行度, 転移と明確な関係はないものと思われた.

縦隔気管支嚢胞と併存し, さらにそれとの交通を認めた限局性蜂窩肺の一手術例を経験したので報告する.症例は14歳女性, 感冒様症状を主訴に近医を受診し, 胸部異常陰影を指摘された.胸部CTにて, 右上葉S3に蜂窩状陰影および気管右側にそれと併存する径3cm大の嚢胞状陰影を認めたため, 縦隔気管支嚢胞およびそれと交通する右上葉限局性蜂窩肺と診断し, 嚢胞および右上葉合併切除を施行した.嚢胞は縦隔内に存在するものの, 奇静脈弓下より右主気管支と併走する異常気管支を通じ蜂窩肺と交通しており, 病理組織学的には, 蜂窩肺は強い炎症像を示したが, 縦隔嚢胞には炎症性変化をほとんど認めず気管支嚢胞と診断された.本例は末梢気管支に発生した気管支嚢胞が, 奇静脈により肺内と縦隔に分離された発生異常の可能性が高いものと考えられた.

最近24年間にわれわれの施設において経験した腺様嚢胞癌切除11例の診断, 外科治療成績につき検討した. 内視鏡所見は本腫瘍に特徴的で内視鏡下生検により全例で術前診断が得られた. また内視鏡所見は腫瘍の浸潤様式を推定するのに有効であった. 気管発生の腺様嚢胞癌4例では術前に内視鏡下レーザー照射による気道開大術が臨床症状の改善および手術術式の決定に有効であった. 気管および主気管支発生例では, 手術術式は気道形成術が施行されたが, 切除断端陽性例が多数を占めた.断端陽性例にたいしては60Gy程度の術後放射線照射により良好な局所コントロールが得られた. 手術予後はおおむね良好で, 気管分岐部切除後に縫合不全を来した1例を除く5年生存率は100%, 平均生存期間は89.8月であった.

術後鎮痛の目的で, バルーンリザーバー式持続法入器による鎖痛薬硬膜外持続投与法の有用性を間欠投与法と比較検討した.対象は当施設において開胸術をうけた患者46例で, A群24例, B群22例に無作為に割り付けた.ブプレノルフィンを生食水にて希釈し硬膜外カテーテルよりA群ではバルーソリザーバー式持続注入器にて持続投与, B群では12時間毎に間欠投与した.ペインスコアの平均ではA群1.62±0.19に対し, B群は1.79±0.24とB群が有意に高かった (p

左上葉転位亜区域気管支より発生した肺扁平上皮癌の一切除例につき報告する.症例は52歳の女性.血疾を主訴に近医を受診し, 胸部X線写真上, 左上肺野に腫瘤影を指摘された.気管支鏡検査で左B1+2aが左主気管支より分岐する転位気管支を認めた.腫瘍は異常気管支領域に存在し, 生検で扁平上皮癌と診断された.また胸部CTにて左肺尖部に著明な気管支拡張所見が認められた。臨床病期c-T2N2M0, StageIIIAと診断し, 左肺全摘除術を施行した.切除標本の病理学的検索では腫瘍は中分化型扁平上皮癌と診断され, また腫瘍より末梢の肺尖部の多数の拡張した気管支の上皮に癌細胞の浸潤を認め, さらに切除肺葉内転移も認められ, 術後病理病期はp-T2NIM1 (pm1), stageIVであった.術後, 10ヵ月現在経過良好にて外来通院中である.

肺癌の外科治療に際して, 術前の画像解析では診断できず, 開胸時に発見された少量の胸水に対して術中迅速細胞診を施行した. 対象は最近10年間の開胸手術例321例で, 組織型の内訳は腺癌179例, 扁平上皮癌109例, 大細胞癌11例, 小細胞癌6例, その他16例である. その結果細胞診陽性と判定された症例は49例 (15.3%) で, 組織型は腺癌が46例 (94%) と大多数を占めた. 胸水とともに肉眼所見で胸膜播種巣が発見された症例は31例で, 残る18例 (37%) は細胞診のみで癌性胸膜炎が証明された. 切除標本による検討では細胞診陽性症例ではP1-2症例が84%, N2-3症例が65%と多数を占めた. 悪性胸水症例では標準的な肺葉切除術に加えてリンパ節郭清, 可及的胸膜播種巣切除, および閉胸時に抗癌剤による胸腔内洗浄を施行した. 胸水細胞診施行例の術後5年生存率は, 陽1生例20%, 陰性例60%で, 陽性例は陰性例に比較して有意に術後生存率が低下していた (p

We aimed to identify prognostic factors after pulmonary metastasectomy for colorectal cancer and propose the clinical application of them. Furthermore, we endeavored to provide a rationale for pulmonary metastasesectomy.Several prognostic factors have been proposed, but clinical application of them remains unclear. Moreover, there is no theoretical evidence that pulmonary metastasectomy is indicated for colorectal cancer.We retrospectively analyzed 1030 patients who underwent pulmonary metastasectomy for colorectal cancer from 1990 to 2008. Prognostic factors were identified and the relationship of recurrent sites after pulmonary resection to pulmonary tumor size was assessed.Overall 5-year survival was 53.5%. Median survival time was 69.5 months. Univariate analysis showed tumor number (P0.0001), tumor size (P0.0001), prethoracotomy serum carcinoembryonic antigen (CEA) level (P0.0001), lymph node involvement (P0.0001), and completeness of resection (P0.0001) to significantly influence survival. In multivariate analysis, all remained independent predictors of outcome. In patients whose recurrent sites extended downstream from the lung via hematogenous colorectal cancer spread, pulmonary tumor size was significantly larger than in those with recurrent sites confined to the lung and regions upstream from the lung.We should utilize these prognostic factors to detect patients who might benefit from surgery. Therefore, we should periodically follow up advanced colorectal cancer patients by chest computed tomography to detect small pulmonary metastases before serum CEA elevation. Metastases to the lung or organs upstream from the lung are regarded as semi-local for colorectal cancer. This concept provides a rationale for validating surgical indications for pulmonary metastases from colorectal cancer.

原発性肺癌切除例353例を用いて, 高齢者肺癌の外科治療における免疫能の低下の問題点と免疫賦活の意義につき検討した.PPD, Candida およびSK/SD抗原による遅延型皮膚反応では3種の抗原とも加齢と共に陽性率は低下し, 特にSK/SD抗原では59歳以下と60歳代および70歳以上で推計学的に有意差が認められた.呼吸器系合併症はSK/SD陰性例で, 特に70歳以上の例に有意に多くみられたことからSK/SD遅延型皮膚反応は高齢者肺癌の術後呼吸器系合併症の予測因子として有用であると考える.またSK/SD遅延型皮膚反応は高齢者の, 特にIII期例の生存率と関連し, TF投与例は非投与例より推計学的に有意に良好な生存率がえられた.高齢者肺癌の外科治療に際しては可能な限り免疫賦活を計ることが治療成績向上に重要である.

肺硬化性血管腫の術後再発例を経験したので報告する. 症例は41歳女性. 胸部X線写真で左上肺野に銭型陰影を指摘され, 経皮的針生検で肺硬化性血管腫と診断された. 腫瘍摘出術が施行され, 摘出標本でも同様の病理診断がなされ悪性所見は認められなかった: 2年後, 再び同部位に銭型陰影が出現し増大傾向を示した. 経皮的針生検により前回と同様の診断が得られたので肺部分切除術が施行された. 初回および再発時の病理組織像を比較検討すると, 両者とも乳頭状増生を示す部分と充実性部分から成る特徴的な組織像を呈しており, 核異型, 分裂等の悪性所見は認められなかった. 再発時の組織像では初回に比して充実性部分の硬化像が少なく胞体の明るい細胞が多く認められた. また, ケラチンおよびサーファクタントアポプロテインを用いた免疫組織化学の結果より, 乳頭状部分を被覆する細胞はII型肺胞上皮細胞への分化を示すものと考えられ, 電子顕微鏡所見でも裏付けられた. 本例は肺硬化性血管腫の病因の解明の一助になるものと考えられる.

症例は55歳男性. 肺線維症の診断にて薬剤治療を受けていたが, 喀痰細胞診で扁平上皮癌と診断された. 胸部X線写真では, 右下肺野に輪状網状影を認めたが明らかな腫瘤影は認められなかった. 平成3年2月12日, 右中下葉切除及び右S2部分切除術を施行した. 切除標本の肉眼所見では, 右S9～S10を中心とした蜂窩肺に一致して, 末梢肺組織にびまん性の硬化巣のみが認められ, 肉眼的に原発巣を特定することは困難であった. 病理組織学的所見では, 拡大した気腔とその隔壁の著明な線維化を認め, その構造中に散在性に異型扁平上皮化生と扁平上皮癌組織が存在した. また, その一部には, 両者の移行像も認められた. 特発性問質性肺炎に合併した扁平上皮癌がこのような増殖形態を呈したものは稀であり, multi-focalな癌発生の可能性も示唆される症例と考えられた.

The effects of endoscopic Nd:YAG laser surgery were studied in 36 patients with unresectable advanced primary and metastatic malignancies in the trachea with special reference to the factors influencing long-term survival. Overall effectiveness of YAG laser treatment was demonstrated in 34 of the 36 patients (94 per cent), while the overall 1, 3 and 5 year survival rates after the first laser treatment were 25 per cent, 13 per cent and 13 per cent, respectively. Neither histologic type nor the severity of clinical symptoms before laser treatment showed any significant influence on the survival curves, however, endoscopic findings of stenosis, the effect of laser treatment and irradiated longitudinal length were all significantly correlated with the survival curves. In other words, endoscopically protruding type tumors with a longitudinal length of irradiation of 3.0 cm or less, and good responses not only to laser treatment but also to other combined modalities are favorable factors for achieving long-term survival in patients with tracheobronchial malignancies undergoing endoscopic Nd:YAG laser treatment. Endoscopic Nd:YAG laser surgery is considered to be a promising part of the multi-modality treatment for unresectable advanced primary and metastatic malignancies of the trachea.

当施設において1977年以降外科的に切除され, 組織学的に硬化性血管腫と診断が確定した局所再発1例を含む14例を対象として, 術前診断, 組織像, 細胞像について検討した. 14病巣中, 術前, 術中に診断された症例は9例 (64%) で, 特に最近10年間の10症例での診断率は80%であった. 術前術中の診断法としては, 経皮針生検 (67%), 術中捺印細胞診 (80%) の診断率が良好で気管支鏡下生検の診断率 (8%) は低かった. 組織標本との比較検討では乳頭状発育パターンが優勢で充実部位の硬化が軽度な症例では, 小型円形核を有する上皮細胞に泡沫細胞が混じた多彩できわめて特徴的な細胞像が得られた. 乳頭形成が顕著でなく充実性発育が主体の症例では, 淡明細胞主体の細胞像で, 術前組織型診断の困難な症例も存在した. 抗keratin抗体, 抗surfactant apoprotein抗体を使用した免疫染色の結果は全例に陽性所見が得られた. 硬化性血管腫の術前診断は乳頭状発育の顕著な症例では典型的細胞像を呈し診断も比較的容易と考えられるが, 充実性発育が主体の症例では泡沫細胞も目立たないのでその診断には注意を要するものと考える. また免疫染色の併用は本腫瘍の組織型診断および腫瘍細胞の性格の解析に有用であることが示唆された.

症例は55歳, 男性.1990年7月, 右下葉の扁平上皮癌で右下葉切除術を施行, 術後病期はpT1N0M0Stage Iであった.約1年半後血痰が出現し, 気管支鏡検査にて, 右上葉支入口部から気管下部にかけて腫瘍性病変認め, 生検にて扁平上皮癌と診断され, 1991年3月手術を施行した.まず, 正中切開にて心嚢を開けて右肺動脈起始部を処理し, 続いて左側臥位とし, 気管は気管分岐部より3軟骨輪口側で, 左主気管支は分岐部の高さで切除し, 気管・左主管支を端端吻合する右completion sleeve pneumonectomyを行った.吻合部は胸腺の脂肪組織で被覆した.術後は特に合併症もなく, 第50病日に退院した.稀なcompletion sleeve pneurnonectomyの1例につき報告し, 致命的となる可能性もある肺動脈からの出血を回避するために, 正中アプローチによる肺動脈主幹の確保が有用であることを述べた.

25年もの長期にわたり無症状に経過した巨大縦隔奇形腫の一手術例について報告する.症例は55歳, 男性.主訴は労作時呼吸困難, 発熱, 咳噺.胸部X線写真では左胸腔内に巨大腫瘤陰影を認め, 呼吸機能検査では混合性障害を認めた.手術にあたって, 腫瘍摘出による術後の急激な循環動態の変動を来すことを避けるために, 術前に腫瘤内容物を吸引排出を行った.それにより全身状態の改善が得られ, 安全に腫瘤を完全摘出することができた.切除標本の病理組織学的検査では膵組織は存在せず, アミラーゼの上昇も見られなかった.このことが長期にわたり穿孔も来さず巨大腫瘤を形成し得た-因と考えられた.更に腫瘤内容物の親水性成分の検索では, LDH, CA125, CA19-9, CEA, HCG などの各種腫瘍マーヵーが高値を示した.