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The present study reports the outcomes of chemotherapy using nab-PTXplus RAM in 6 patients with metastatic gastric cancer as recommended in the JGCA guidelines for special conditions. Four cases exhibited Grade 3 neutropenia, 1 exhibited Grade 3 hypertension, and no case developed febrile neutropenia; however, the adverse events were tolerated. One case showed partial response, 1 showed stable disease, 2 cases showed non-complete response/non-progressive disease, and 2 cases could not be evaluated. These results suggest that this treatment may be performed safely in ambulatory patients.

Therapy-related leukemia(TRL)is a distinctive clinical syndrome that occurs after exposure to chemotherapy or radiotherapy. We report a case of suspected TRLafter chemotherapy in a patient with breast cancer. A 61-year-old woman underwent total mastectomy and sentinel lymph node biopsy(negative)for her breast cancer. Histopathologic analysis showed invasive ductal carcinoma, pStage I. Her subtype histology was Luminal B-type, and postoperative adjuvant chemotherapy and endocrine therapy were administered. Four years after chemotherapy, a blood examination showed pancytopenia. Bone marrow examination showed acute promyelocytic leukemia. She was treated with chemotherapy and achieved complete remission. Breast cancer provides long-term survival after treatment. Attention should be paid to the occurrence of TRLin breast cancer surveillance.

肝細胞癌と胆管細胞癌が併存する混合型肝癌は比較的稀である. その再発時は胆管細胞癌あるいは肝細胞癌どちらの再発も起こりうる. 混合型肝癌術後10年目に肝細胞癌成分の再発を経験したので報告する. 患者は68歳の男性, 10年前にS4の肝腫瘍を指摘され中央2区域切除を施行された. 切除後の病理診断は混合性肝癌の診断であった. 今回, 肝腫瘍指摘され当科に紹介された. 外側区域の肝腫瘍を認め外側区域切除を施行した. 病理診断で肝細胞癌であり前回に認めた肝細胞癌の成分と同様の所見であった. 以後, 2年間再発を認めていない. 混合性肝癌は血行性・リンパ行性に転移し予後不良であるといわれる. 今回、 混合性肝癌の初回手術後10年後に残肝再発をきたし再切除可能であった症例を経験しその再発形式に興味がもたれたので文献的考察を交えて報告する.

In October 2012, a man in his 60s was hospitalized for the examination of ascites, and was diagnosed with gastric cancer and carcinomatous peritonitis. S-1+cisplatin (CDDP) therapy was administered as neoadjuvant chemotherapy; however, during therapy, he developed cerebral infarction. We suspected that the cerebral infarction was caused by a coagulation disorder owing to Trousseau's syndrome. After completing 5 courses of chemotherapy, total gastrectomy was performed. Thereafter, the treatment was changed to S-1+docetaxel(DTX), followed by nab-paclitaxel (PTX). Although cerebral infarction did not relapse after the administration of an anticoagulant agent, the patient died of gastric cancer 1 year and 5 months after the operation. Trousseau's syndrome is a coagulation disorder in cancer patients. Cerebral infarctions caused by Trousseau's syndrome have a high tendency to relapse, and the prognosis is poor. This syndrome should be kept in mind when treating cancer patients.

近年本邦においても術後肺血栓塞栓症(以下PE)は増加傾向にあり，その予防は重要である。2003年7月から2004年8月まで我々は203例の全身麻酔下手術患者に対して，弾性ストッキング(以下CS)と間欠的圧迫器(以下IPS)を用いた周術期管理を行なった。我々の管理の効果とPE予防との関連において，PE発生率，予後，合併症およびコスト，利益等について検討した。この結果，致死的PE発生は無かった。1人の患者において術後SpO2低下，呼吸困難をきたしたが肺血流シンチ検査でPEは否定された。合併症として，2人にCSによる接触性皮膚炎，ほか持続硬膜外麻酔カテーテルを留置した1人にヘパリン投与後一過性の対麻痺をきたした。2004年4月より肺血栓塞栓症予防管理料加算が認められるようになり，ガイドラインも示されている。CSとIPCを用いた周術期管理は一定の予防効果が期待された。しかしヘパリン投与は重篤な合併症発生の可能性があり十分注意すべきである。

乳癌化学療法施行患者と未施行患者とを比較しその総合的健康状態を把握することを目的としQOL評価を行なった。2004年6月から8月に当科で乳癌化学療法施行(以下化療群)および外来経過観察(非化療群)の患者16名にアンケート方式で調査した。調査票はFunctional Assessment of Cancer Therapy Scale General(FACT-G)を改良したものでMann-Whitney検定を行なった。化療群は8名，非化療群は8名であった。化学療法の内訳はエピルビシン＋シクロフォスファミド(EC)療法6名，ドキソルビシン＋ドセタキセル(AT)療法1名，シクロフォスファミド＋メトトレキセート＋フルオロウラシル(CMF)療法1名であった。身体症状および精神的状態では，化療群が有意に悩んでいた(p＜0.05)。社会的および家族との関係では両群間に差はなかった。活動状況では非化療群が有意に活動的であった(p＜0.05)。特に治療の副作用，自分を病気と感じること，死ぬことや病気の悪化の心配などにおいて化療群は有意に敏感であった(p＜0.05)。非化療群では有意に生活を楽しみ良好なQOLを得ていた(p＜0.05)。 乳癌化学療法施行において，一過性であっても身体症状および精神的状態のQOLが不良であった。今後はこうした点でのサポートも重要であると考えられた。

症例は52歳, 男性, 左小胸筋下から第一肋間を貫通し胸腔内に発育した腫瘤の切除目的で入院となった.左襟状切開に第3肋間までの胸骨正中部分切開を加え前胸壁側と胸腔内から剥離を進めて腫瘍を完全切除した.病理組織診断はInfiltrating typeのintramuscular lipomaであり, 砂時計型経胸壁型成人脂肪腫と診断した.砂時計型経胸壁型成人脂肪腫は本邦で3例の報告が認められるのみである.本腫瘍は再発の可能性があるため脂肪腫といえども完全切除が必要である.また, 今回用いたアプローチは前胸部上部の胸壁内外に存在する腫瘍切除に有用と考えられた.

症例は84歳,女性.平成15年4月,上行結腸癌の診断のもと右半結腸切除術〈D2〉施行.術後病理ではmucinous adenocarcinoma, ss, n2(+), ly2, v0, P0, H0, M(-), Stage-IIIbと診断された.同年8月,外陰部の腫瘤を主訴に精査加療目的に入院.理学的所見では,左外陰部に約3 cm大の可動性を有する疼痛を伴わない弾性硬腫瘤を触知した.血液生化学的検査では軽度貧血を認める以外,腫瘍マーカーを含めて異常は認められなかった. CTでは左外陰部に造影効果のある腫瘤を認めた.以上より,外陰部腫瘤の診断のもと腫瘤切除術を施行.術後病理では転移性皮下腫瘍と診断された.術後1年経過した現在も再発の兆候を認めず,当科外来で経過観察中である.結腸癌の転移部位としては稀であるが切除により長期予後を期待できる症例もあるため積極的切除を考慮すべきと思われる.

術前診断された魚骨穿通による腹腔内膿瘍を経験した. 症例は38歳男性. 下腹部痛をきたし, 近医より当院を紹介受診した. 腹部腫瘤を認めCTおよびMRI検査で魚骨を含む腹腔内膿瘍と診断され手術を行われた. 術中魚骨による大網に囲まれた膿瘍を認めた. 穿通部はS状結腸であった. 魚骨除去, 大網膿瘍切除およびドレナージ術を行った. 術後経過良好で術後21日目に軽快退院した.魚骨による消化管穿通による腹腔内膿瘍は比較的まれであり, その術前診断は困難であるが, CTスキャンは有用であった.

症例は7歳,男児で右下腹部痛で発症した.保存的治療で症状は改善せず,発症後4日目に急性虫垂炎疑いで手術を行った.手術所見はMeckel憩室炎であった.術後も腹痛が持続し,術後3日目に関節痛と紫斑を認めた.血管性紫斑病の診断でジピリダモール内服を開始し,以後経過良好で軽快退院した. 急性虫垂炎の診断は臨床所見のみならず,超音波検査やCT検査により向上しているものの今なお約15～30%のnegative appendectomyの報告がある. Meckel憩室炎および血管性紫斑病は代表的な急性虫垂炎の鑑別疾患だが,両疾患を合併した症例は非常に稀で,その症例を呈示すると共に,急性虫垂炎との臨床的相違点について報告する.

We report a rare case of acute appendicitis which was probably caused by a fish bone. The patient was a 21-year-old woman, who was examined at our hospital with the chief complaints of right lower abdominal pain and diarrhea. At the time of examination, localized pain, tenderness, and mild muscular defense were observed in the right lower abdomen. In the hematological examinations, the leukocyte count was 13900/μl and CRP level was 1.0mg/dl. As an abdominal CT demonstrated swelling of the appendix vermiformis and a linear high-density area, fecalith was suspected. Based on the above findings, an operation was performed with a diagnosis of acute appendicitis. The postoperative pathological diagnosis was phlegmonous appendicitis, and a fish bone of 1cm in length was found in the excised appendix lumen. Appendicitis was thought to have developed from obliteration of the appendix lumen, which was caused by a fish bone, and accompanying bacterial infection and induction of inflammation.

The purpose of this study was to analyze the collagens in aortic aneurysm walls and to investigate the mechanism of the formation of calcified abdominal aortic aneurysms (AAAs). Collagens were extracted from human aneurysmal aortic walls obtained during surgery, and from human nonaneurysmal aortic walls obtained at autopsy, using pepsin-acetic acid digestion. Electrophoresis and immunoblotting were performed. Type III collagen was found to be reduced in the arteriosclerotic aneurysmal aortic walls. The alpha1 chain of type II collagen/alpha1 chain of type I collagen ratio was 0.35+/-0.11 in the aortic aneurysms and 0.68+/-0.11 in the nonaneurysmal aortic walls (P=0.0111). All the calcified aneurysms were associated with type III collagen fragments having molecular mass of approximately 70 kDa and 30 kDa as estimated by sodium dodecyl sulfate-polyacrylamide gel electrophoresis. Thus, we concluded that AAAs with calcification may be caused by an abnormal degradation of type III collagen.

In many cases of long-gap congenital esophageal atresia, direct anastomosis is difficult. In these cases, the esophagus is first lengthened by myotomy before anastomosis. We determined the degree of submucosal blood flow and/or approximation force at the site of anastomosis in rabbits after (1) separation of the esophagus from the outer membrane, (2) 1 cm and 2 cm resection of the esophagus, and (3) circular or spiral myotomy of the esophagus after 2 cm resection. In the first experimental group, submucosal blood flow volume115.2 ml/min/100 g resulted in anastomotic leakage. In the second experimental group, a 1 cm resected esophagus with an approximation force of 33.3 +/- 8.2 g did not result in leakage, while a 2 cm resected esophagus with an approximation force of 111.7 +/- 13.3 g resulted in leakage. It was found that leakage occurred when the approximation force was higher than 49.1 g even if submucosal blood flow volume was greater than 131.8 ml/min/100 g. In the third experiment, both circular and spiral myotomy reduced the approximation force. Although there was no difference in the changes in submucosal blood flow volume between the two types myotomy, circular myotomy was superior to spiral myotomy in the reduction of the approximation force at the site of anastomosis. We conclude that both approximation force and submucosal blood flow are important factors in preventing anastomotic leakage.

多発性大動脈瘤症例を対象とし, その形態, 部位, 手術時期, 合併症等につき検討した. 当科で経験した多発性大動脈瘤14例を対象とした. 男性10例, 女性4例で平均年齢は66歳であった. その内訳は弓部-胸腹部1例, 弓部-腎動脈下6例, 胸部下行-腎動脈上1例, 胸部下行-腎動脈下5例, 胸腹部-腎動脈下1例であった. 瘤径は胸部63±13mm, 腹部54±13mmであった. 一期的手術を施行したのは胸腹部-腎動脈下の1例のみであった. 二期的手術を施行したのは8例で, 弓部-腎動脈下5例, 胸部下行-腎動脈下2例, 弓部-胸腹部1例であった. これらのうち弓部優先3例, 腹部優先5例であった. 術後合併症は脊髄麻痺1例, 腸管壊死1例, 腎障害2例, 呼吸障害2例, 肝障害1例であった. 手術死亡なく遠隔期に3例の死亡を認めた. 多発性大動脈瘤の手術には, 瘤径の大きいほうを優先し二期的に手術を行うほうが望ましい.

A 47-year-old woman was admitted to our hospital with a giant spinal arteriovenous malformation (AVM) causing heart failure and thoracic myelopathy. Angiography revealed that the spinal AVM had multiple feeding vessels branching from the 5th through 12th intercostal arteries. The drainage vein flowed to the azygos vein and superior vena cava. The AVM destroyed the 7th thoracic vertebra. The cardiac output was 16.7l/min and the shunt ratio was 64% before treatment. Embolization with cyanoacrylate was performed because the operation was considered to be associated with a significant risk of paraplegia and organ ischemia. The cardiac output decreased to 11.6l/min and the shunt ratio was reduced to 32%. After embolization the patient demonstrated no symptoms of either heart failure or sensory deficits. During embolization, provocative tests using sodium amytal and lidocaine with magnetic stimulation were also performed. The above findings suggest that provocative tests and magnetic stimulation are useful to predict paraplegia, which could result from embolization while, in addition, embolization is considered to be a useful treatment for multiple shunt and nidus in this region.

Systolic ankle pressure was measured in limbs in the extended and 90 degrees-flexed positions in three groups of patients who had undergone below-knee femorodistal arterial bypass. Group 1 consisted of eight limbs in seven patients who had received an autologous saphenous vein (ASV) graft; group 2 consisted of seven limbs in seven patients who had received a ringed expanded polytetrafluorethylene (ePTFE) graft; and group 3 consisted of five limbs in five patients who had received a reinforced biosynthetic borine collagen vascular (Omniflow) graft. Intravenous digital subtraction angiography was performed within 3 months of implantation. The ankle/brachial index (ABI) was significantly lower when the knee was flexed than when it was extended in group 1 and 3, but not in group 2. The ABI flexion in group 1 was similar to that in group 2. Morphologic changes such as kinking were demonstrated angiographically in groups 1 and 3. Given that the ABIs in groups 1 and 2 were similar with the knee flexed, despite the morphologic changes in group 1, we concluded that saphenous vein and ringed ePTFE grafts are more durable when subjected to acute knee flexion than Omniflow grafts. Thus, as graft failure is unlikely to result from kinking as a result of knee flexion alone, further clinical studies are required to elucidate the precise causes of graft failure.

1975年1月から1991年4月までに経験した急性動脈閉塞症例37例を血栓症と塞栓症別に比較検討した. 血栓症16例17肢中4例が退院時死亡, 6肢が切断となったが, 塞栓症21例25肢では死亡2例, 肢切断1肢と血栓症に比し予後は良好であった. 血栓症例16肢に手術が施行され血栓除去した6肢中3肢は閉塞, うち1肢は最終的に肢切断となったがバイパス術を行った5肢は全例救肢した. また塞栓症例22肢に手術が施行され肢切断した1肢を除き塞栓除去18肢, バイパス術3肢の肢救済に成功した. 以上より血栓症にはバイパス術, 塞栓症には塞栓除去が第一選択と思われた.

間歇性跛行症状を客観的, 定量的に評価することは難しく, このため重症度の比較や治療効果判定は容易でない. 今回われわれは, Lipo PGE1の治療効果をトレッドミルを用い客観的に判定しようと試みた. 閉塞性動脈硬化症による間歇性跛行肢20症例に対し, Lipo PGE1を one shot 静注 (10μg, 1回/日, 1週間投与) し, トレッドミルを用いた運動負荷を行った. 疼痛出現距離 (m) は, Lipo PGE1投与前72.5±41.4, 投与1週間後92.0±53.7と有意に延長した. しかし, 運動負荷により歩行不能に至る距離, 安静時API, 運動負荷前後の足関節部血圧差は, Lipo PGE1投与によって有意な変動を示さなかった. 間歇性跛行症状を客観的に評価する1方法として, トレッドミルを用いた跛行距離の測定は, 疼痛出現距離をマーカーとして用いれば有用であった.

Pulmonary arteriovenous fistula is a relatively rare disease, but recently case reports of this disease can be increasingly seen.A 54-year-old male was admitted to the hospital because of chest abnormal shadow. The CT, MRI and pulmonary arterial angiography revealed a simple pulmonary arteriovenous fistula on the left lower lobe. An excision of the fistula was tried, but the fistula was too large to excise completely and left lower lobectomy was added. Postoperative course was uneventful and the patient was discharged from the hospital on the 32nd postoperative day.Lobectomy and segmentectomy have been widely performed on this disease. Recently an excision or occlusion of the fistula is coming to be a best procedure in order to prevent the lung function. However, any recurrence and remainance of the fistula should be avoided even if this disease is benign.We emphasize the necessity of lobectomy and segmentectomy in some cases.

The authors report the cases of 2 infants with congenital diaphragmatic hernia (CDH) treated without extracorporeal membrane oxygenation (ECMO) therapy who were discovered to have hearing loss at 1 year of age. Both boys had been diagnosed as having CDH antenatally and were treated with surgery and high-frequency oscillatory (HFO) therapy. The patterns of hearing loss were consistent with sensorineural deafness and believed to be associated with HFO therapy, prolonged mechanical ventilation, and a high pH.

A case of goblet cell carcinoid of the appendix is reported. A 67-year-old female was admitted to our hospital complaining of right lower abdominal pain. Clinical symptoms and examinations revealed acute appendicitis and an appendectomy was performed. A histologic examination revealed a goblet cell carcinoid of the appendix. The patient recovered well, and is strictly followed up by blood, urine and CT examinations.Our experience of this case has emphasized the necessity of histologic examination after appendectomy even if a patient was diagnosed as acute appendicitis clinically.A total of 14 cases of goblet cell carcinoid of the appendix in Japan was also reviewed.

Remnant sciatic artery or its aneurysm is extremely rare because the sciatic artery is the main blood pathway in the initial term of embryonal period, and only 14 cases have been reported in Japan. This time we experienced a case of remnant sciatic artery aneurysm presented with right sciatica-like symptom.A 71-year-old woman complaining of right lower leg pain at exercise was referred to our clinic because of a right gluteal aneurysm diagnosed by CT at her near practitioner. Digital substraction arteriogram showed that an enlarged right internal iliac artery passed posteriorly across the right hip and down the posterior aspect of the femur to the popliteal artery. With a diagnosis of persistent sciatic artery a bypass grafting between external iliac artery and popliteal artery using ringed EPTFE graft was performed. As the blood flow of the popliteal artery was supplied by persistent sciatic artery, the proximal and distal sides of the aneurysm were ligated. The aneurysm remained opened. Pathological examinaiton indicated an atherosclerotic aneurysm.