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Patients after esophagectomy for esophageal squamous cell carcinoma (SCC) occasionally develop metachronous SCC in the residual esophagus. Although most of these second primary lesions are detected as superficial cancer at follow-up endoscopy, it is often difficult to perform endoscopic resection for these lesions near the site of anastomosis. The objective of this study was to evaluate the effectiveness of argon plasma coagulation (APC) for superficial SCC in the residual esophagus after esophagectomy. Twelve patients (involving 15 s primary lesions) received APC for superficial SCC in the residual esophagus after esophagectomy. These lesions were difficult to perform endoscopic resection and they were treated using APC. There was no treatment-related complication. Complete remission (CR) was achieved in 13 (86.6%) of the 15 lesions: CR was achieved in 11 lesions (73.3%) after the first APC course, and in another 2 lesions (13.3%) after two or more APC courses. Of the 2 patients with persisting residual tumor, 1 patient received 12 times repeated-APC courses over 6 years, and eventually achieved local control without metastasis, the other patient received radiotherapy and cervical esophagectomy after treatment failure with APC. All patients survived except for one patient who died of old age and another patient who died of tongue cancer. APC was a safe treatment that was easy to perform. APC was concluded to be an effective treatment for superficial SCC in the residual esophagus after esophagectomy when endoscopic resection was difficult.

The tumor immune response is dependent on the interaction between tumor cells and the T-cell subset expressing the T-cell receptor (TCR) repertoire that infiltrates into the tumor microenvironment. The present study explored the diversity and shared TCR repertoires expressed on the surface of locoregional T cells and identified the T lymphocyte subsets infiltrating into esophageal squamous cell carcinoma (ESCC), in order to provide insight into the efficiency of immunotherapy and the development of a novel immune-oriented therapeutic strategy. A total of 53 patients with ESCC were enrolled in the present study, and immunohistochemical analysis of CD3, CD8, CD45RO, FOXP3, CD274, HLA class I and AE1/AE3 was performed. Digital pathological assessment was performed to evaluate the expression level of each marker. The clinicopathological significance of the immuno relation high (IR-Hi) group was assessed. Adaptor ligation PCR and next-generation sequencing were performed to explore the diversity of the TCR repertoire and to investigate the shared TCR repertoire in the IR-Hi group. Repertoire dissimilarity index (RDI) analysis was performed to assess the diversity of TCR, and the existence of shared TCRα and TCRβ was also investigated. Further stratification was performed according to the expression of markers of different T-cell subsets. Patients were stratified into IR-Hi and immuno relation low (IR-Lo) groups. Cancer-specific survival and recurrence-free survival rates were significantly improved in the IR-Hi group compared with in the IT-Lo group. The diversity of the TCR repertoire was significantly higher in the IR-Hi group. TCR repertoire analysis revealed 27 combinations of TCRα and 23 combinations of TCRβ VJ regions that were shared among the IR-Hi group. The IR-Hi group was divided into three clusters. Overall, the current findings revealed that the IR-Hi group maintained the diversity of TCR, and a portion of the IR-Hi cases held the T cells with shared TCR repertoires, implying recognition of shared antigens. The prognosis of patients with ESCC was affected by the existence of immune response cells and may possibly be stratified by the T-cell subsets.

Mucinous gastric carcinoma (MGC) is a rare histological subtype of undifferentiated gastric carcinoma, accounting for ~2.6-6.6% of all gastric cancer cases. The clinicopathological characteristics and prognosis of MGC are controversial. The present study aimed to determine the clinicopathological characteristics and prognosis of patients with MGC. We retrospectively compared the characteristics and postoperative survival of 70 patients with MGC and 2,492 non-MGC (NMGC) cases who underwent surgical resection between 1990 and 2010. MGC was characterised by larger tumor size, macroscopic Borrmann type 2 and 3, T4 invasion of the gastric wall, positive N2 and N3 lymph node metastasis, positive lymphatic vessel invasion, positive venous invasion, peritoneal metastasis and advanced tumor stage III and IV. The prognosis of MGC patients was worse compared to that of NMGC patients, as the former group consisted of more advanced-stage cases. When patients with similar disease stages were compared, the incidence of peritoneal metastasis was significantly higher among MGC patients. However, hepatic metastasis was found significantly more often in NMGC patients. Otherwise, the prognosis of MGC and NMGC patients with similar disease stages was not significantly different. Therefore, our findings indicated that, although MGC is more rare and mostly detected at an advanced stage, the diagnosis of the mucinous histological subtype was not an independent prognostic factor.

An ulcer occasionally develops in the gastric tube as an esophageal substitute after esophagectomy. The aim of the present study was to investigate the risk factors for a gastric tube ulcer. We reviewed the medical records of all 826 patients who underwent esophageal reconstruction using a gastric tube following esophagectomy, in Kurume University Hospital between 1985 and 2010. Potential risk factors for a gastric tube ulcer were investigated by comparing the clinical characteristics between patients with a gastric tube ulcer and those without, using a multivariate logistic regression model. Among the 826 patients, 30 patients (3.6 %) developed a gastric tube ulcer. In 19 cases without any signs or symptoms, the ulcer was found using upper endoscopy. In the other 11 patients, there were symptoms including hematemesis, chest pain, and/or abdominal pain. In 3 cases, the patient developed a severe complication from the ulceration such as perforation. Of these 3 cases, one patient died of massive bleeding from the left brachiocephalic vein. The multivariate analysis revealed that (1) a past history of a peptic ulcer, and (2) the period of treatment (meaning the more recent period after the introduction of systematic prevention and treatment for a gastric tube ulcer) were the only two risk factors for a gastric tube ulcer (p

A 54-year-old man was admitted at our hospital with a complaint of sudden anterior chest pain. At 1 year previously he had undergone right transthoracic esophagectomy for cancer followed by reconstruction using a gastric tube through a posterior mediastinal route. Upper gastrointestinal endoscopy confirmed a gastropericardial fistula. He was therefore given emergency intensive proton pump inhibitor together with gastric tube decompression using a nasogastric tube. Transabdominal pericardial drainage was surgically performed through a retrosternal space at 4 days after the onset. On the 22nd day after the drainage operation, upper gastrointestinal endoscopy showed healing of the gastropericardial fistula, and he was discharged on the 38th postoperative day. A gastropericardial fistula in the gastric tube following esophagectomy for cancer could be treated with less-invasive procedures including surgical pericardial drainage. Our procedure may be recommended as initial emergency treatment before more invasive procedures such as gastric tube resection and muscle flap plombage.

Purposes The aim of this study was to determine the prognostic factors in salvage surgery following definitive chemoradiotherapy (dCRT) for esophageal cancer.

Situs inversus totalis (SIT) is a rare congenital anomaly in which the positions of the abdominal and thoracic cavity structures are reversed. The reported incidence of SIT is one in 10,000 to 50,000 live births. There are few reports of gastric cancer in individuals with SIT or of the potential complications of surgical intervention in such cases. We report the case of a 79-year-old woman with SIT who underwent surgical treatment for advanced gastric cancer at our hospital and review the pertinent literature. Prior to surgery, abdominal computed topography angiography with 3-dimensional reconstruction was performed to uncover any variations and to verify the exact structures and locations of vessels. Total gastrectomy with D2 lymphadenectomy and cholecystectomy were performed safely and with careful consideration of the mirror-image anatomy.

Mucosal (T1a) and submucosal (T1b) squamous cell carcinoma of the esophagus (ESCC) have often been analyzed together and are staged as the same category in the UICC/TNM staging system. The difference in surgical outcomes between T1a and T1b ESCC therefore remains unclear. The purpose of this study was to examine the differences in surgical outcomes between T1a and T1b ESCC, and to investigate the prognostic factors in T1 ESCC.A prospectively maintained database identified 145 previously untreated patients with pT1 ESCC who underwent radical transthoracic (n = 134) or transhiatal esophagectomy (n = 11). Median follow-up was 108 months.Of the 145 patients, 35 (24 %) had pT1a cancer and 110 (76 %) had pT1b cancer. Lymph node metastasis was present in 45 patients (31 %): 3 patients with pT1a cancer and 42 patients with pT1b cancer (P = 0.0003). The 5-year survival rate for the whole group was 77 %. The 5-year survival rate of the T1a patients was 94 % compared with 72 % for the T1b patients (P = 0.0282). In multivariate analysis, only the depth of tumor invasion (pT1a vs. pT1b) was an independent prognostic factor (hazard ratio 2.358; 95 % confidence interval 1.009–5.513; P = 0.0477).After esophagectomy, the prognosis of patients with pT1b ESCC is significantly worse than that of patients with pT1a ESCC. Infiltration into the submucosa is the only independent prognostic factor affecting survival. These findings suggested that T1a and T1b ESCC could be staged separately in the next version of UICC/TNM staging system.

Here we report on a 54-year-old man who had undergone left pneumonectomy for a primary lung cancer 25 years earlier and who underwent salvage blunt esophagectomy for a recurrent esophageal cancer after definitive chemoradiotherapy. The patient received chemoradiotherapy for a cancer in the upper thoracic esophagus at the clinical stage IA (T1bN0M0) because of a past history of left pneumonectomy for lung cancer, and the esophageal cancer showed complete response. At 1 year after chemoradiotherapy, local recurrence was found in the upper thoracic esophagus. Although chemotherapy using docetaxel was administered, this was not effective. Transhiatal esophagectomy as salvage surgery was successfully done by a combination of laparo-mediastinoscopy assisted blunt dissection with the eversion stripping method. The postoperative course was uneventful. The patient died of lung and brain metastasis at 23 months after the salvage surgery. Transhiatal esophagectomy may be an option as a salvage esophagectomy in cases with a history of major lung surgery.

Recently, several immune checkpoint inhibitors have been developed and are being used to treat malignant melanoma, lung cancer, and other cancers. Several reports have indicated that tumor-infiltrating lymphocytes (TILs) are associated with clinical and histopathologic risk factors in various cancers. However, the role of TILs in esophageal squamous cell carcinoma (ESCC) has not been well studied. This study aimed to investigate the perilesional status of TILs in ESCC and to show associations between TILs and clinical variables. The study enrolled 277 ESCC patients. Evaluation of TILs was performed according to the criteria of the International TILs Working Group 2014, and associations between TIL and clinicopathologic variables were examined. Most of the clinicopathologic factors were not statistically associated with TIL status. The number of patients who received adjuvant therapy was significantly larger in the TIL-negative group. Cancer-specific survival (CSS) of patients in the TIL-positive group was significantly better than in the TIL-negative group. Among the patients who received adjuvant therapy, CSS was significantly better in the TIL-positive group than in the TIL-negative group. Uni- and multivariate analyses identified tumor depth and TIL status as independent prognostic factors for CSS. Among the other clinicopathologic variables, TIL status was the strongest CSS indicator. Tumor-infiltrating lymphocyte status is a strong predictor of good prognosis for ESCC patients.

OBJECTIVE The aim of this study was to assess the relationship between fluorine-18 fluorodeoxyglucose (F-FDG) uptake and molecular biological markers in esophageal squamous cell carcinoma (ESCC) patients. METHODS Our patient population included 51 patients who underwent F-FDG PET/computed tomography before surgery. Excised tumor tissue was analyzed immunohistochemically using monoclonal antibodies for glucose transporter-1 (GLUT-1), GLUT-3, CD34 [microvessel density (MVD) marker], CD68 (macrophage marker), and CD163 (tumor-associated macrophage marker). The relationships among pathological factors [pathological T stage (p-T stage), pathological lymph node status (p-N status), pathological stage (p-stage), and pathological tumor length], the maximum standardized uptake value (SUVmax), and these molecular biological markers were evaluated using Spearman's rank test and the Kruskal-Wallis test. RESULTS GLUT-1, GLUT-3, CD34, and CD163 significantly correlated with SUVmax (r=0.547, P

A 29-year-old woman who swallowed oil cleaner (strong hydroxide: NaOH) by mistake received conservative therapy because of having neither mediastinitis nor peritonitis. She complained of dysphagia 1 month after ingestion. Upper gastrointestinal series showed severe stricture in the middle and lower thoracic esophagus and in the antrum of the stomach. Gastrostomy and jejunostomy were performed on the 87th day after ingestion. Transthoracic subtotal esophagectomy and total gastrectomy followed by esophageal reconstruction using the colon with microvascular anastomosis through a retrosternal route was performed on the 148th day after the ingestion. On open thoracotomy, although dense mediastinal adhesions were found around the esophagus, esophagectomy could be achieved successfully. She was discharged 22 days after the second surgery without postoperative complication.

Reflux esophagitis (RE) is a known complication disturbing patients' quality of life after esophageal resection. It is generally recognized that bile reflux as well as acid reflux cause RE. However, the clinical influence of acid and bile reflux, and Helicobacter pylori (H. pylori) infection on RE in the cervical esophagus after esophagectomy is not yet clarified. Sixty patients who underwent cervical esophagogastrostomy following esophagectomy were enrolled in this study. They underwent examination for H. pylori infection, endoscopic examination, and continuous 24-hour pH and bilirubin monitoring, at 1 month after surgery. The influence of acid and/or bile reflux, H. pylori infection, and others on the development of RE were investigated. RE was observed in 19 patients (32%) at 1 month after esophagogastrostomy, mild RE in 16 (27%), and severe RE in 3 (5%). The percentage of time duration of both acid and bile reflux into the cervical esophagus was higher in patients with RE than in those without (P = 0.027, P 0.14 between non-RE and mild RE (P = 0.017). Acid and/or bile reflux was observed in 31 patients (52%), acid-only reflux in 6 (10%), bile-only reflux in 15 (25%), and acid-and-bile reflux in 10 (17%). Severe RE was observed only in patients having acid-and-bile reflux. On the univariate analysis, no infection of H. pylori, acid reflux, and bile reflux were determined to be the influencing factors to RE among the clinical factors including age, gender, route of esophageal reconstruction, H. pylori infection, and acid-and-bile reflux. In the subanalysis using the logistic model, there were significant correlations between bile reflux and RE irrespective of the presence of H. pylori infection (P = 0.016, P = 0.007). On the other hand, there was a significant correlation between acid reflux and RE only in patients without H. pylori infection (P = 0.039). In the early period after esophagogastrostomy, bile reflux could cause RE irrespective of H. pylori infection, while acid reflex could cause RE only in patients without H. pylori infection. There is a possibility that bile reflux plays an important role in the development of RE after esophagectomy.

Aortic complications after esophageal cancer surgery are rare and usually fatal. Here, we report three patients who underwent thoracic endovascular aortic repair (TEVAR) for aortic complications after esophagectomy for cancer. In the first case, aortic rupture was caused by pyothorax due to residual tumor after esophagectomy. In the second case, aortic rupture was caused by pyothorax due to anastomotic leakage. In the third case, a pseudoaneurysm was caused by surgical injury during esophagectomy. TEVAR was safe and effective for severe aortic complications when graft infection was avoided. The first case died of sepsis on the 84th postoperative day, and the other two cases have survived 4 years and 2 years to date.

The aim of this study was to determine the factors influencing acidity in the gastric conduit after esophagectomy for cancer. Acidity and bile reflux in the stomach and in the gastric conduit were examined by 24-h pH monitoring and bilimetry in 40 patients who underwent transthoracic subtotal esophagectomy followed by esophageal reconstruction using a gastric conduit, which was pulled up to the neck through a posterior mediastinal route in 17 patients, through a retrosternal route in 10 patients, and through a subcutaneous route in 13 patients. They were examined at 1 week before surgery, at 1 month after surgery, and at 1 year after surgery. Helicobacter pylori infection was examined pathologically and using the (13) C-urea breath test. The factors influencing acidity of the gastric conduit were analyzed using the stepwise regression model. Gastric acidity assessed by percentage (%) time of pH 0.14 into the lower portion of the gastric conduit was significantly increased after surgery throughout the period from 1 month after surgery to 1 year after surgery. Multivariate analysis showed that the acidity in the gastric conduit was influenced by H. pylori infection and DGR at 1 month after surgery, and by H. pylori infection and the route for esophageal reconstruction at 1 year after surgery. Acidity in the gastric conduit was significantly decreased after surgery. Acidity in the gastric conduit for esophageal substitutes is influenced by H. pylori infection and surgery. DGR influences the gastric acidity in the short-term after surgery, but not in the long-term after surgery.

【背景】食道癌は重複癌を合併することが多く，とくに頭頸部癌や胃癌の合併が多い。食道癌術後の長期生存例が増加するとともに，胃管癌症例も増加している。【対象と方法】1982～2001年に食道癌手術 (胃管再建術) を施行した608例中，異時性胃管癌を発症した13例 (2.1％) を対象とし，治療成績について検討した。【結果】胃管癌発症時の年齢中央値は66歳，全例男性だった。食道癌手術から胃管癌発見までの期間は中央値6.5年だった。食道癌術後の再建経路は，胸壁前3例，胸骨後2例，後縦隔8例だった。胃管癌発見の契機は，定期的内視鏡検査9例，症状3例，検診異常1例だった。胃管癌の深達度は，T1が8例，T2が2例，T3が1例，T4が2例だった。治療法は，胃部分切除術3例，幽門側胃切除術2例，胃全摘術1例，内視鏡治療6例，ステント留置術1例だった。胃管癌治療後の5年生存率は29.6％だった。現在，5例が生存中で8例が死亡した。死因は，胃管癌死2例，肺癌死1例，手術死亡1例，他病死4例だった。【まとめ】食道癌術後は，長期生存例でも定期的な内視鏡検査が重要である。定期的内視鏡検査により胃管癌を早期に発見し，内視鏡治療にて治療することが肝要であると考える。

Esophageal cancer patients with distant organ metastasis have usually been treated only to palliate symptoms without multimodality therapy. The current study evaluates the role of multimodality therapy in esophageal squamous cell cancer patients with distant organ metastasis. Between February 1988 and January 2007, 80 esophageal squamous cell cancer patients with distant organ metastases were treated at our institution. Multimodality therapy was performed in 58 patients: 43 patients received chemoradiotherapy, 13 underwent surgery followed by chemotherapy and/or radiation therapy, and two received chemotherapy or chemoradiotherapy followed by surgery. Thirteen patients received single-modality therapy; chemotherapy, radiotherapy, or surgery alone. The remaining nine patients received best supportive care alone. The metastatic organ was the liver (n= 40), the lungs (n= 33), bone (n= 10), and other (n= 6). Nine patients had metastasis in two organs. There was no difference in the median survival among the sites of organ metastasis, lung, liver, or bone (P= 0.8786). The survival of patients treated with multimodality therapy was significantly better than that of the patients who received single-modality therapy or best supportive care alone (P < 0.0001). In patients treated with multimodallity therapy, there was no difference in survival for patients treated with surgery compared with patients treated without surgery (P= 0.1291). This retrospective study involves an inevitable issue of patient selection bias. However, these results suggested that multimodality therapy could improve survival of the esophageal squamous cell cancer patients with distant organ metastasis.

SUMMARY Esophageal small cell carcinoma (SmCC) has been regarded as a rare and aggressive tumor with early metastasis. The optimal treatment has not yet been established, and the role of surgery has remained controversial. In this retrospective study, we report seven cases studies of SmCC of the esophagus and analyze the clinical outcomes after surgery. Between 1986 and 2007, there were seven patients with esophageal SmCC treated surgically in our institution. All the patients with clinically limited disease underwent transthoracic esophagectomy with lymphadenectomy. Lymph node involvement was found in all cases irrespective of the depth of tumor invasion. Three of the seven patients were diagnosed as having an extensive disease on pathological examination after esophagectomy. Five patients received postoperative chemotherapy. Two patients are alive with no recurrence at 16 months and at 45 months after surgery. Another one without chemotherapy survived 93 months and died of another disease. The remaining four patients died of recurrent disease or another disease. The median overall survival to date of these patients was 16 months (range 12–93 months). Esophagectomy with lymphadenectomy resulted in a relatively better survival in some patients with esophageal SmCC. We concluded that surgery may be helpful as part of multimodality treatment in selected patients with esophageal SmCC.

Reflux esophagitis (RE) and columnar-lined esophagus (CLE) are frequently observed after esophagectomy. The incidence of these conditions according to time and to the route of esophageal reconstruction after esophagectomy remains unknown. The aim of this study was to clarify any changes and differences of the incidence of RE and CLE in patients who underwent gastric tube reconstruction after esophagectomy. A hundred patients who underwent cervical esophagogastrostomy after resection of the thoracic esophagus were included in this study. We reviewed their endoscopic findings at 1 month, at 1 year and at 2 years after surgery, and compared the incidence rates of RE and CLE with the passage of time and among the three reconstruction routes; a subcutaneous route, a retrosternal route, and a posterior mediastinal route. The incidence rate of RE was 42%, 37% and 38%, at 1 month, 1 year and at 2 years after surgery, respectively. There was no significant difference in the incidence of RE according to the time after surgery. The incidence rate of severe RE (Grade C and D in the Los Angeles Classification) was 9% percent at 1 month after surgery, 18% at 1 year after surgery and 22% at 2 years after surgery, significantly increasing with passage of time. The incidence rate of CLE was 0% at 1 month after surgery, 14% at 1 year after surgery and 40% at 2 years after surgery, significantly increasing with passage of time. No difference was observed in the incidence of RE and that of CLE among the three routes of esophageal reconstruction. Severe RE and CLE increase with passage of time after cervical esophagogastrostomy. Therefore, careful endoscopic follow-up is necessary for such patients irrespective of the route of esophageal reconstruction.

The quality of life in patients who have undergone surgery for esophageal cancer is frequently disturbed by postoperative gastroesophageal reflux disease or pharyngolaryngeal reflux disease. Recently, there have been many reports on gastroesophageal reflux disease after esophagectomy, and only a few on pharyngolaryngeal reflux disease. There is not yet any convenient endoscopic classification of reflux pharyngolaryngitis. We designed a new classification for reflux pharyngolaryngitis based on endoscopic findings. Our new classification consists of the five grades from 0 to IV based on (i) the extent and severity of erythema and/or edema in the pharynx and the larynx, and (ii) the extent and severity of granulation or scarring stenosis in the vocal cords. Ninety-three patients after cervical esophagogastrostomy after esophagectomy (the CEG group) and 28 patients after intrathoracic esophagogastrostomy (the TEG group) were reviewed in this study. We investigated the relation between the severity of reflux pharyngolaryngitis and clinical symptoms in these patients, and the correlation between this new classification of reflux pharyngolaryngitis and the Los Angeles classification of reflux esophagitis. Reflux esophagitis was more severe in the TEG group than in the CEG group, while there was no difference in the grading of reflux pharyngolaryngitis between the two groups. The pharyngolaryngeal symptoms and F-scale scores were not correlated with the severity of reflux pharyngolaryngitis in each group. The grading of reflux pharyngolaryngitis and that of reflux esophagitis was correlated in each group (P

目的：食道癌治療における化学放射線療法（chemoradiotherapy；以下，CRT）の増加に伴い，CRT後の遺残・再発に対するsalvage食道切除例が増加している．当科のsalvage食道切除の治療成績を検討し，治療適応を考察した．方法：1986～2008年に，50 Gy以上のCRT施行後の遺残・再発に対し食道切除を施行した18例を対象とした．結果：cStage I-III（nonT4）/cStage III（T4）-IVaのCRTの効果は，有効6例/7例，無効1例/4例で，CRT終了から手術までの期間は，中央値6か月/2か月だった．前者/後者の手術根治度は，治癒切除2例/4例，姑息切除5例/7例だった．前者の術後1年生存率は，14％で2年生存例はなかった．後者の術後1, 3, 5年生存率は，おのおの36％，18％，9％だった（p＝0.5725）．治癒切除例の術後1, 3, 5年生存率は，おのおの83％，33％，17％だったが，姑息切除例では，1年生存例はなかった（p＝0.0005）．CRT有効例の術後1, 3, 5年生存率は，おのおの39％，15％，7％だったが，無効例では，1年生存例はなかった（p＝0.0106）．手術合併症は，17例（94％）に認め，重篤な合併症は姑息切除例での発生が多かった．salvage食道切除例の予後は，CRTの効果と手術根治度が関与しており，CRT前の進行度は予後に関与なかった．考察：salvage食道切除はCRTが有効な症例の再発で，治癒切除可能例においてのみその手術の意義があると考えられた．

症例は67歳の男性で，手指，顔面の紅斑と四肢の脱力感を主訴に近医を受診した．抗Jo-1抗体陽性のため皮膚筋炎と診断され，当院内科を紹介された．全身の悪性腫瘍検索のため施行した上部消化管内視鏡検査で，胸部食道扁平上皮癌が発見された．右開胸開腹食道亜全摘，3領域リンパ節郭清，胸壁前食道胃管吻合術を施行した．食道癌の最終診断は，T3N4M0, Stage IVaで，CDDP/5-FU少量連日投与による術後化学療法を施行した．化学療法中に手指の色素沈着および掻痒感が出現し，皮膚筋炎が増悪したため，2か月間の休薬期間を要し，化学療法を完遂した．しかし，食道癌の再発とともに皮膚筋炎が再燃し，術後1年2か月で癌死した．皮膚筋炎は悪性腫瘍を高率に合併するが，食道癌合併例の報告は少ない．文献的考察を加え報告する．

A case of esophageal stricture with Barrett’s esophagus after total gastrectomy is reported herein. A 72-year-old woman was referred to our hospital because of dysphagia due to a stricture in the esophagus for 5 years. She had earlier undergone total gastrectomy followed by Billroth II reconstruction consequent to a gastric ulcer at the age of 49 years. She was diagnosed as having an esophageal stricture with Barrett’s esophagus. The 24-h pH monitoring indicated significant reflux of alkaline duodenal contents into the esophagus. The patient underwent duodenal diversion with Roux-en-Y reconstruction. The postoperative course has been uneventful, with no dysphagia and no dilatation. No change in the extent of Barrett’s esophagus has been observed to date at 7 years postoperatively. This case presented with development of Barrett’s esophagus and subsequently of esophageal stricture solely by duodenal reflux. Duodenal diversion was concluded to have been effective for esophageal stricture with Barrett’s esophagus after total gastrectomy.

A 62-year-old woman was referred to our hospital with presenting pigmentation and/or dermal thickening in the nucha, face, axilla, abdomen, and hands. She also presented a history of weight loss of 4 kg during the previous 3 months. She was pathologically diagnosed as having acanthosis nigricans by skin biopsy. She subsequently underwent 18F-FDG-PET, CT, and upper gastrointestinal endoscopy, and then was diagnosed as having malignant acanthosis nigricans with squamous cell carcinoma in the esophagus at the clinical stage of T3, N0, M0, stage IIA in the UICC stage classification. She underwent subtotal esophagectomy through a left thoracotomy with thoracoabdominal two-field lymphadenectomy and esophageal reconstruction using a gastric tube through a retrosternal route. The postoperative course was uneventful, and she was discharged at 26 days after the surgery without any adjuvant therapy. At 6 months after the surgery, the dermal thickening and the pigmentation of the acanthosis nigricans were completely relieved. She is well without recurrence at 1 year to date after surgery. Although acanthosis nigricans is frequently associated with malignancy, malignant acanthosis nigricans with squamous cell carcinoma in the esophagus has been rare.

We report a case of a 74-year-old woman with an esophageal gastrointestinal stromal tumor (GIST). Endoscopic examination suggested a submucosal tumor in the middle-lower thoracic esophagus. Computed tomography showed a solid mass 95 × 56 × 44 mm in size, suggesting an esophageal mesenchymal tumor. Endoscopic ultrasonography-guided fine-needle aspiration biopsy was positive for c-kit and CD34, and negative for both S-100 and desmin, on immunohistochemical examination, confirming this to be a GIST. The patient underwent transthoracic esophagectomy with esophageal reconstruction using a gastric tube through the subcutaneous route. The tumor was completely resected, and there was no lymph node metastasis. The pathological examination confirmed the tumor to be at high risk for recurrence because of its size and the presence of necrosis. We are carefully following the patient conservatively with no adjuvant chemotherapy such as imatinib mesylate.

顆粒細胞腫の表面に併存した食道表在癌を経験したので報告する．症例は50歳の男性で，表在型食道癌の診断で当院紹介となった．上部消化管内視鏡検査で，長径12 mm大の粘膜下腫瘍様の病変で，頂部にヨード不染を示すびらんを認め，生検で高分化型扁平上皮癌と診断された．超音波内視鏡検査では，sm3の診断であった．食道癌Lt，0-Isep，T1bN0M0 Stage Iと診断し，根治的化学放射線療法を施行した．治療後，頂部のルゴール不染は消失したが，粘膜下腫瘍様の腫瘤は，丈は低くなったものの残存した．超音波内視鏡検査にて残存腫瘤は粘膜下層主体の粘膜下腫瘍と診断し，内視鏡的粘膜切除術を施行した．病理組織学的検査より食道顆粒細胞腫と診断された．最終的に顆粒細胞腫の表面に0-IIc型食道癌を合併したものと診断した．

症例は45歳の女性で，1年前に腹部食道癌に対し，左開胸開腹下部食道噴門側胃切除術を施行．術後診断はpT3N0M0 Stage IIで根治度Aであった．経過観察中，CTで気管前リンパ節の腫大を認めた．確定診断のため，胸腔鏡補助下リンパ節摘出術を施行した．組織学的には，強い中心乾酪壊死を伴う類上皮細胞肉芽腫とLanghans型巨細胞を認め，リンパ節結核の所見であった．結核菌の検出は確認できなかったが，術後に施行したツベルクリン反応は強陽性であり，病理組織学的検査よりリンパ節結核と診断した．抗結核薬を6か月間内服し，その後の経過は良好であった．現在，食道癌手術後3年，結核の診断後2年経過しているが，ともに再発・再燃は認めていない．腹部食道癌術後の上縦隔リンパ節再発，特に“気管前リンパ節再発”はまれであり，術後経過中に，この部位のリンパ節腫大を認めた場合は，癌以外の疾患，特に縦隔リンパ節結核も鑑別の一つとして考慮すべきである．

はじめに：食道手術における結腸再建術は，従来より高率に発生する縫合不全が問題となっていた．我々はこの克服のため1989年以来血管吻合を付加した結腸再建術を行ってきたので，その治療成績を報告する．対象と方法：1981年から2007年までに当科で施行した結腸再建例86例（食道癌；77例，良性；9例）を対象とし，1988年までの血管吻合を付加しない結腸再建術24例（以下，通常群）と1989年以降の血管吻合を付加した62例（以下，血管吻合群）の2群に分け，その手術成績を比較検討した．結果：主な合併症は通常群，血管吻合群ともに縫合不全で，発生率を比較すると通常群は63％（15例），血管吻合群は23％（14例）と血管吻合群が有意に少なかった（p=0.0003）．また，通常群では食道結腸吻合部の縫合不全は13例（54％）に認め，そのうち7例で再手術を要したのに対し，血管吻合群では同部の縫合不全は6例（10％）で，全例保存的に治癒した．手術関連死亡率は通常群が17％（4例），血管吻合群が2％（1例）と血管吻合群が少なかった（p=0.007）．また，血管吻合群を動静脈とも吻合した症例（動静脈群）51例，静脈吻合のみの症例（静脈群）11例に分け縫合不全発生率を比較すると，動静脈群が6％（3例），静脈群が27％（3例）と動静脈群が良好な成績だった（p=0.03）．考察：血管吻合付加により結腸再建例の治療成績は向上し，その有用性が示された．また，血管吻合法は，動静脈双方の吻合が静脈のみの吻合に比べより有効である可能性が示唆された．

Background There remains controversy over what constitutes the optimal rational extent of lymphadenectomy, in other words, the concept of rational lymphadenectomy, for cancer of the cervical esophagus. The purpose of this study was to propose the concept of a rational N category for cancer of the cervical esophagus that indicates more clearly which cluster(s) of lymph nodes should be resected during resection of a cancer of the cervical esophagus.

症例は49歳の男性で, 1997年9月頃より嚥下困難出現し, 近医で食道潰瘍の診断を受け, H2-blockerおよびproton pump inhibitor内服で約6年ほど保存的加療を行っていたが軽快せず, 狭窄症状が出現したため, 2003年7月当院紹介となった. 当院にて精査したが, 逆流性食道炎は存在せず, また24時間pH測定検査でも酸の逆流はなく, 食道潰瘍の原因は判明しなかった. 潰瘍は次第に悪化し, 狭窄が強くなっていることから手術を勧めたが, 患者は手術を拒否し, 以来内視鏡下バルーン拡張術にて経過観察していた. 2007年8月, 背部痛が出現し, 精査にて, 食道潰瘍穿通による縦隔炎と診断し, 右開胸による食道切除術を施行した. 潰瘍周囲は強固に癒着しており, 潰瘍底は大動脈であった. 術後経過は良好で, 第27病日に退院した. 難治性食道潰瘍が穿通し縦隔炎を併発した症例に対し食道切除を行い良好な経過を得たので報告する.

症例は67歳，男性．腹部大動脈周囲リンパ節を含む多発リンパ節転移を伴う進行胃癌を認め，根治切除困難と考え，5-Fu 500mg+CDDP 10mg/day投与（day1～5，8～12），2週休薬を2コース施行した．さらに，TS-1 120mg/dayを21日間投与とCDDP 40mg/dayをday8，15，22に投与した．原発巣は肉眼所見で潰瘍瘢痕となり，生検では癌細胞は検出されなかった．リンパ節腫大はCT上完全に消失した．奏効度CRと判断し，幽門側胃切除術+リンパ節郭清（D2+No.16のサンプリング）を施行した．術後病理組織学的診断では胃および摘出リンパ節に癌細胞は認められず，組織学的効果判定Grade3と判断した．術後は，TS-1の内服（4週内服2週休薬）を1年行い，現在術後2年経過にて再発の徴候はない．大動脈周囲リンパ節転移陽性進行胃癌に対する術前化学療法が有効で根治手術が可能であった1例を経験したので報告する．

症例は87歳, 男性. 血便, 肛門痛を主訴に当院受診となった. 32歳時に痔瘻を指摘され切開の既往があった. 3時, 9時方向に痔瘻の手術瘢痕と2次口を認め, 直腸指診では肛門管の6時方向に母指頭大の疼痛伴う弾性硬な腫瘤を触知した. また肛門縁より約4cmの直腸左側壁より前壁にかけて可動性のない硬結伴う腫瘤を触知した. 瘻孔からの排膿は認めなかった. 精査の結果, 直腸Rb腫瘍の生検で中分化型腺癌の診断を得た. 痔瘻部結節からの生検では悪性所見は認めなかった. 痔瘻を伴う直腸癌の診断で腹会陰式直腸切断術, D2郭清を施行した. 病理組織診断で直腸癌は中分化型腺癌2型, 40×45mm, pA, pN1 (1/7), sH0, cP0, cM0, fStage, IIIa, であった. 痔瘻部には粘液癌を認め, 直腸癌と痔瘻癌は組織学的にも連続性は認められなかった. 今回, 直腸と痔瘻部の重複癌の1例を経験した. 直腸癌と痔瘻癌の重複は稀であり文献的考察を加え報告する.

The most suitable management of recurrent abdominal desmoid tumor is still unclear. A case of recurrent huge abdominal desmoid tumor successfully treated by hyperthermia therapy is described. A 63-year-old man was operated upon for desmoid tumor in the retroperitoneum involving pancreas, posterior wall of the stomach and transverse mesocolon in 2007. In 2008, the tumor recurred and could not be resected because of the patient refused the operation. Several therapies using tamoxifen, anastrozole, imatinib mesylate and radiotherapy were all ineffective. The tumor grew bigger and bigger during a treatment period. Finally, hyperthermia treatment was applied to the tumor. The size of the recurrent desmoid tumor reduced 75% by hyperthermia treatment for 46-month. Base on this experience, we recommend hyperthermia as the treatment for patients with recurrent abdominal desmoid tumor that several therapeutic strategies did not achieve a remarkable response.

This case report describes a small cell carcinoma in the esophagus with a squamous cell carcinoma that developed multiple fistulae. Autopsy findings demonstrated that both the primary tumor and the metastatic lymph nodes became necrotic and caused an abscess cavity spreading into the mediastinal, retroperitoneal, and subcutaneous spaces. An esophageal stent was effective for palliation.