Search

原発性自然気胸の治療とその成績を検討した.対象は, 1999年1月より2001年12月まで,初回治療例59例67側(両側8例).平均30.1歳.治療方針は,入院時,胸部X線写真とCTにてブラの有無を判定.原則として全例胸腔ドレナージ.気漏がなければ3日目にドレーン抜去し,翌日に退院.気漏が続けば手術.再発例は,気漏の有無に関わらず手術.手術は,胸腔鏡下ブラ切除術.【結果】(1)初回治療:安静のみ2症例.胸腔ドレナージ57例, 65側(両側8例)で,手術なしで退院したのは, 43側であった.手術を行ったのは, 22側であった. (2)胸腔ドレナージのみの再発率は, 27.9%であった.ブラの有無別再発率は,ブラあり40.7%,ブラなし11.1%.再発例には,全例手術を施行した. (3)手術成績:初回入院時と再発時合わせて35側に胸腔鏡下ブラ切除を施行した.術後再発率は, 8.6%であった.以上より,ブラが明らかな症例に対しては,初回時に手術を勧めても良いと考える.

Objective: We investigated the mechanism involved with the initial drop and subsequent recovery of exercise capacity in the early postoperative period of thoracotomy patients. Methods: Sixteen patients (13 who had undergone lobectomy, 3 who had undergone pneumo- nectomy) underwent a routine pulmonary function test (PFT) and a cardiopulmonary exercise test preoperatively, within 14 postoperative days (POD; post-1; mean 6 SD, 9 6 2 POD), and after 14 POD (post-2; mean, 26 6 12 POD). Results: After surgery on post-1, PFT results of FVC, FEV1, and maximum ventilatory volume (MVV) significantly decreased. Oxygen uptake (VO2) at a venous blood lactate level of 2.2 mmol/L (La-2.2), which was adopted as the empirical anaerobic threshold, and maximum VO2 (VO2max) decreased significantly to 88.2 6 7.9% and 73.1 6 15.4% of the preoperative values, respectively. La-2.2 min ventilation (VE)/ MVV and maximum VE (VEmax)/MVV increased significantly from 0.36 6 0.08 to 0.66 6 0.20 and from 0.58 6 0.14 to 0.80 6 0.09, respectively. On post-2, though La-2.2 VO2 did not change, VO2max improved significantly to 81.5 6 19.7% of the preoperative values, in association with significant increases in maximal tidal volume and VEmax, which were produced by significant increases in the PFT results. La-2.2 VE/MVV also decreased significantly to 0.49 6 0.13, which indicated a sufficient recovery of respiratory reserve at submaximal exercise. Conclusions: The initial drop of exercise capacity after lung resection seems to be derived from both circulatory and ventilatory limitations. Further, the subsequent recovery within 1 month seems to be produced by an improvement in ventilatory limitation, which was caused by the surgical injury to the chest wall. (CHEST 2000; 118:384 -390)

症例は74歳の女性.胸部X線にて異常陰影を指摘され当科に紹介された.胸部CT, MRIでは均一な内部構造を有する充実性の腫瘍が椎体に接して認められた.1998年5月15日, 腫瘍摘出術を施行した.腫瘍は3.3×2.0×1.0cm大で, 壁側胸膜に覆われ, 表面平滑, 弾性軟で, 割面は黄褐色であった.病理組織検査では, 血管, 平滑筋細胞, 脂肪組織の3成分からなる良性腫瘍であり, 血管筋脂肪腫と診断された.血管筋脂肪腫は腎に発生することが多い間葉系の良性腫瘍で他臓器の発生は稀である.縦隔原発例は, これまで本邦において自験例を含め5例が報告されているのみである.

症例は, 82歳, 男性血痰と咳嗽を主訴に近医受診.胸部異常陰影を指摘され, 当院を紹介された.胸部X線と胸部CTでは, 右卜葉S1に50×45mm大の腫瘤を認めた.気管支鏡下生検で肺癌との診断を得たため, 平成11年1月26日, 右上葉切除+リンパ節廓清術を施行した.腫瘍は, 60×50mm大で, 病理組織学的検査では, 腫瘍は大小不同の異型細胞よりなり, 著明な管腔形成を認めた.鍍銀染色とFactor VIII, CD34の免疫組織染色にて, 肺血管肉腫との診断を得た.根治術を行うことができた症例であるが, 術後6カ月目に多発性骨転移にて死亡した.本症例は, 稀な疾患で, 本邦報告例は, 自験例を含めたll例であった.

Large cell neuroendocrine carcinoma (LCNEC) は, Travisらが提唱した肺原発の神経内分泌腫瘍で, 一般に予後は不良であるが, 補助療法の効果に関しては, 比較的めずらしい腫瘍でもあり十分な検討がなされていない.今回我々は, 術前治療としてconcurrent chemoradiotherapy (CCRT) が有効と考えられたLCNECの1例を経験した.症例は49歳, 男性.主訴は咳嗽.画像上, 左肺門から前縦隔に11×6cmの腫瘍を認めた.腫瘍マーカーは, AFP1,314ng/ml, CEA35.7ng/ml, NSE13.1ng/mlと高値で, 開胸生検でLCNECと診断された.肺動脈幹への浸潤の可能性が考えられたため, CDDP+Vp-16 (CVp) を2クール行った.しかし腫瘍の増大を認めたため, CCRT (RT : 40Gy, CVpx2) を行った.CCRTの奏効度はPRで, AFPも148.4ng/mlに低下し切除術を行った.腫瘍は広範囲に心外膜に浸潤あるも, 心嚢内には浸潤なく左肺全摘+心外膜合併切除+R2aの治癒切除を行った (pT3N0M0).術後12ヵ月の現在再発なく経過良好である.

A rare case of giant intracystic and non-invasive carcinoma of the male breast is reported. A 76-year-old man was seen at the hospital because of a left breast mass. A huge and hard mass, mesuring 10 by 10cm in size, was located in the entire left breast. An aspiration cytologic examination revealed class IV. A ultrasonography revealed a multi-cystic tumor and a mixed pattern. These findings offered a suspicion of breast carcinoma. An intraoperative frozen section diagnosis after tumorectomy indicated ductal carcinoma. Therefore, a modified radical mastectomy was performed. Postoperative pathological examination revealed noninvasive ductal carcinoma. He has been recurrence free for 4 months after the operation without any adjuvant therapy.

肺癌肺切除患者において, どのレベルの縦隔リンパ節を術中迅速診断すればp-N1以下と診断しうるか検討した.[retrospective study] p-N2肺癌55症例の分析より, p-N2診断率の最も高い原発肺葉毎のリンパ節の組み合わせは, 右上葉は#2, 3, 4, 左上葉は#4, 5, 7, 右下葉は#3, 7, 8, 左下葉は#4, 7, 8, で各々100, 91, 91,100%のp-N2が診断できた.[prospective study] 肺癌61例に対して上記3レベルの郭清を行い, 各レベルで最も転移の疑われるものを1個つつ迅速診断 (f-N) し, 続いて行ったR2a以上の固定標本による診断 (p-N) と比較した.39例がf-N1以下・p-N1以下で, 16例がf-N2・p-N2以上で一致した.6例がf-N1以下, p-N2以上で不一致であったが, 内4例は郭清3レベル内の微小転移であった.肺癌原発肺葉毎に上記3レベルの術中迅速診断を行い, 転移を認めない症例においては高い精度でp-N1以下と診断できた.また, これらの症例には3レベルまでの縮小縦隔郭清が適応できると思われた.

症例は75歳女性.stage I肺扁平上皮癌に対する右下葉切除の2年後に気管癌を発症し, 気管管状切除を行った.組織型は肺癌と同じく扁平上皮癌であったが臨床的に重複癌と診断した.気管癌は気管分岐部の上3cmの部位から声門側3.5cmを占めており, 右開胸による手術も可能と思われたが前回手術による胸腔内の癒着を考慮し, 胸骨正中切開と頚部襟状切開でアプローチした.縦隔リンパ節郭清による癒着はあったが気管周囲の授動とsuprahyoid release で8気管軟骨輪を切除し端々吻合を行うことが出来た.大網被覆により吻合部の治癒は良好であったが, 患者は術後9ヵ月, 局所再発により死亡した.右下葉切除後の気管形成においては, 肺靱帯・下肺静脈の切離により右胸腔内の授動は終了しており, 上部気管の授動としてsuprahyoid releaseが有用と思われた.

縦隔奇形腫は前縦隔発生の頻度が高く, 後縦隔のものは稀である.われわれは後縦隔に発生した奇形腫の1手術例を経験したので報告する.症例は46歳の男性.胸部X線にて左後縦隔の腫瘤陰影を認め, 胸部CT, MRIでは腫瘍は不均一な内部構造を有し, 石灰化が認められた.大動脈造影にて, 第8～12肋間動脈からの栄養血管が確認された.経皮針生検にて毛髪が確認され, 奇形腫と診断された.1993年10月22日, 左第7及び第10肋間開胸にて腫瘍摘出術を施行した.腫瘍は横隔膜上にあり16×10×9cm大で周囲組織と強固に癒着していた.栄養血管を処理し, 腫瘍を摘出した.腫瘍は頭側半分は骨および気管支様の構造が散在する脂肪組織で, 尾側半分は毛髪を含んだ泥状物で満たされた嚢胞であった.病理組織では, 悪性所見はなく, 気管支, 脂肪組織, 毛髪, 角化した重層扁平上皮など3胚葉成分からなり, 成熟奇形腫と診断された.

Two cases of relatively rare spindle cell carcinoma (SpCC) are described here. Case 1: A 55-years-old woman was found having a 10×12cm tumor in the left breast and underwent left radical mastectomy. The tumor was ultrastructurally diagnosed as SpCC. The spindle cell component was immunoreactive for carcinoembrionic antigen (CEA), epithelial membrane antigen (EMA) and Keratin. The pathological stage was T4nomo. The patient died of bilateral lung metastase 20 months after the operation. Case 2: An 86-years-old woman was found having an 8×8cm tumor in the right breast and underwent right modified radical mastectomy. Ultrastructural study did not reveal the epithelial component. With immunoreac-tivity of the spindle cell component for CEA, the tumor was diagnosed as SpCC. The pathological stage was T3n0m0. The patient has been free from recurrence, as of 3 months after the operation. Fifty three cases collected from the Japanese literature including these cases were reviewed, especially, in terms of histological diagnosis with immunohistochemisty.

A 51-year-old patient had recurrent breast cancer with liver metastases. After mastectomy, she received CEF and many kinds of hormone therapy and chemotherapy after recurrence. Her liver metastases had been controlled by CMF therapy for 9 months. CMF therapy is good at maintaining the QOL of recurrent patients during treatment because of less toxicity and is even useful for multidrug-resistant tumors like this patient with liver metastases after anthracycline and taxane treatment. CMF is thought to be still useful after development of new drugs for recurrent breast cancer.

A 77-year-old woman had a subcutaneous mass in the anterior chest wall for 2 months duration. She underwent an open drainage at another hospital, but it was unsuccessful. She was refered to the hospital for persistent bleeding and wound pain. On physical examination, there was a 2.5×2cm subcutaneous mass with reddish skin on her anterior chest wall. Histological diagnosis based on an excisional biopsy of the tumor was angiosarcoma. Wide excision was performed without bony chest wall resection. No adjuvant therapies such as radiation were added. She had complained of back pain since 2 months after the operation. Bone scintigram revealed multiple bone matastases. Bearing bone metasatases. She is alive 9 months after the operation.

Fistula between the trachea and esophagogastric anastomosis after esophagectomy is rare. We successfully treated a 75-year-old woman with such a lesion by single-stage repair. The patient had undergone radical esophagectomy 20 years ago, and repeatedly developed aspiration pneumonia for recent 5 years. Radiological and endoscopic examinations demonstrated the fistula between the trachea at the level of sternal notch and esophagogastric anastomosis. The fistula was separated and the defects on both sides were closed. A sternocleidomastoid muscle flap was inserted between the two structures. The postoperative course was uneventful.

We report herein the case of a 48-year-old man with malignant schwannoma of the intrathoracic vagus nerve associated with von Recklinghausen's disease. Malignant intrathoracic vagal tumors are extremely rare and to our knowledge, only four other cases have been documented in the literature, none of which were associated with von Recklinghausen's disease.

Intrabronchial capnography was applied in 11 lung cancer patients to investigate the effects of lobectomy on regional lung function. Spirometry and intrabronchial capnography were performed before surgery (PRE), and during the early (POST1,19 +/- 5 POD) and late (POST2, 184 +/- 98 POD) postoperative periods. End-tidal carbon dioxide concentration (EtCO2) and Smidt's velocity profile index (V-index) were calculated from each lobar capnogram obtained bronchoscopically. The V-index of lobes without cancer on the operated-on side increased after surgery (PRE, 10.7 +/- 5.0%; POST1, 14.3 +/- 9.4%, NS; POST2, 16.8 +/- 8.6%, p0.05), while the V-index on the unoperated-on side decreased after surgery (PRE, 10.5 +/- 5.3%; POST1, 7.9 +/- 3.5%, p0.05; POST2, 7.2 +/- 2.9%, p0.05). EtCO2 after surgery was lower on the operated-on side (POST1, 5.1 +/- 1.1%; POST2, 4.6 +/- 1.1%) than on the unoperated-on side (POST1, 5.4 +/- 0.9%, p0.05; POST2, 5.0 +/- 0.9%, p0.01). Since the V-index and EtCO2 are compatible with the expiratory flow rate and the perfusion/ventilation ratio, respectively, we concluded that the air flow decreased on the operated-on side and increased on the unoperated-on side postoperatively and that perfusion on the operated-on side was more severely reduced than ventilation. These findings suggest that intrabronchial capnography is useful for assessing the ventilation and perfusion of the individual lobes as single units.

肺癌切除後の脳転移例19例の臨床像と治療成績を検討した.診断は全例, 頭痛などの症状の出現後に脳CTによりなされた.脳転移巣が単発で脳以外の他臓器転移のない症例の予後が良好であった.単発性転移の8例に開頭脳転移巣切除を行い, 単発または多発性転移の9例に放射線+化学療法を行った.中間生存期間は手術群で14ヶ月, 放射線治療群で3ヶ月であった.単発性脳転移例には, 外科的切除が勧められる.