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Background The role of elastography for breast tumors is still ambiguous. The purpose of this study was to inquire how effectively elastography can be used in the diagnosis of breast tumors.

症例は68歳，男性．不消化性の下痢，曖気の精査加療目的で入院となった．腹部CTで下行結腸～脾彎曲にかけて13cm大の腫瘤性病変を認めた．下部消化管内視鏡検査では下行結腸に隆起を主体とする5型病変を認め，ファイバーは潰瘍底より容易に胃内へと挿入された．腫瘍からの生検で高分化型腺癌と診断された．胃結腸瘻を形成した進行下行結腸癌と診断し，左半結腸切除術，D3リンパ節郭清，胃全摘，膵尾部・脾臓合併切除術を施行した．最終診断はmuc，si，n0，ly0，v0，ow(－)，aw(－)，stageIIで，手術根治度Aであった．われわれは内視鏡が通過することで診断できた胃結腸瘻を形成した下行結腸癌の1例を経験したので，自験例を加えた本邦報告25例の集計および文献的考察を行った．

症例は41歳，女性．妊娠28週目に腹痛を認めたため，前医を受診した．精査にて横行結腸癌を疑われたため，当科紹介となった．大腸内視鏡検査にて横行結腸腫瘍を認め，生検にてtub2と診断された．明らかな遠隔転移は認めなかったため，産科医および小児科医との相談の上，妊娠29週であることから，帝王切開術および横行結腸切除術を施行した．帝王切開にては1,280gの女児（Apgar score 8/9）を出産した．病理組織検査にて横行結腸癌（tub2，ss，n2，ly0，v1，H0，P0，M0，Stage IIIb）と診断した．妊娠中に消化器癌を合併する頻度は非常に少なく，なかでも大腸癌は妊娠10万例に1～2例といわれ，非常に稀である．治療方針は妊娠時期や患者および家族の意思を考慮する必要がある．今回妊娠中に切除した横行結腸癌の1例を経験したので，若干の文献的考察を加えて報告する．

症例は63歳男性で，急性膵炎を発症し，精査の結果膵体部の主膵管に腫瘍性病変が認められた．膵管内腫瘍または小膵癌の診断のもと膵体尾部切除およびリンパ節郭清を行った．切除標本において，主膵管内に充満するやや白色調の10mm大の腫瘍を認めた．腫瘍内部は異型細胞がスリット状の管腔を有しながら増殖しており，周囲の膵管に乳頭状隆起を伴っていた．膵管内乳頭粘液性腺癌との鑑別に苦慮したが，膵管内管状腺癌と診断した．膵管内管状腫瘍は，2010年に出されたWHO分類ではIntraductal papillary mucinous neoplasm（IPMN）とは別にIntraductal tubulopapillary neoplasm（ITPN）として新しく定義されるようになったが，膵癌取扱い規約第6版では膵管内乳頭粘液性腫瘍に含まれており，その位置づけは明確にされていない．本邦では膵管内管状腺癌は自験例を含め13例の報告をみるにすぎず，臨床病理学的に不明な点が多い．今後さらに症例を蓄積し，病態の検討を重ねていく必要があると考えられた．

症例は58歳，女性．他院にて上行結腸のポリープに対し，大腸内視鏡下ポリープ切除術を施行された．当日夕より腹痛と嘔吐を認めた．間欠的な腹痛の増悪を認めるため，翌日朝に当院救急外来を受診した．来院時の腹部CT検査では明らかなイレウス像を認めなかったが，嘔気と腹痛が持続していたため，経過観察目的にて入院となった．同日夕に腹痛の増悪を認めたため，入院時CT検査より10時間後に腹部CT検査を再度施行した．骨盤内に小腸のループ形成を認め，腹水の貯留も認めたため，内ヘルニアによる絞扼性イレウスの診断にて同日緊急手術を施行した．左子宮広間膜の異常裂孔に小腸が迷入し，終末回腸近傍の小腸が嵌頓しており，虚血性変化をきたしていた．子宮広間膜裂孔を開放し，回盲部切除を行った．大腸内視鏡を契機として発症したと考えられるまれな子宮広間膜ヘルニアの1例を経験したので，若干の文献的考察を交えて報告する．

単孔式のストーマの造設術は，消化器外科手術，とくに大腸外科領域においては基本となる手術手技である．手術手技については施設，術者によって種々報告されているが，明確なエビデンスにもとづいた「標準」といったものはない．現時点での標準と考えられる，単孔式ストーマ造設手術手技について解説する．合併症の少ない，管理しやすい良好な消化管ストーマを造設することは,患者および家族にとってとても重要であり，すべての外科医が会得すべき手技である．

症例は62歳，男性．37年前に十二指腸潰瘍に対して胃切除術の既往がある．1カ月前から嘔気・嘔吐を認めるようになり近医受診した．腹部CTで吻合部に腫瘤影と輸入脚の著明な拡張を認めた．同日の上部消化管内視鏡検査では吻合部に全周性の3型腫瘍を認め，残胃癌による輸入脚閉塞症と診断し緊急手術を施行した．前回手術はBillroth-II法の結腸後経路で再建されており，Treitz靱帯から吻合部の空腸は暗赤色を呈し著明に拡張していた．残胃全摘術，膵尾部・脾臓合併切除術を施行した．治癒切除であったが，術後3カ月で胃癌死された．残胃癌による輸入脚閉塞症の本邦論文報告7例について，集計および文献的考察を行った．

目的:大腸癌待機手術における術前機械的腸管処置（MBP:mechanical bowel preparation）の有無による術後合併症の発生の検討を行い，その必要性を明らかにする．対象:2003年5月から2007年10月の間に当科で待機手術を行った，結腸癌切除症例および直腸癌前方切除症例467例を対象とした．方法:術前に，MBP施行群と非施行群に無作為に患者の割り付けを行った．MBPの有無と，主な術後合併症として，創感染，縫合不全，腸閉塞の発生との関連を検討した．また，手術時間，出血量との相関をみることにより，手術操作への影響を検討した．結果:全症例，結腸癌症例，直腸癌症例，腹腔鏡補助下手術症例のいずれの群においても，MBPの有無による術後合併症の発生および，手術時間，出血量に有意差はみられなかった．結論:大腸癌の待機手術症例では，MBPは必ずしも必要ではないことが示唆された．

潰瘍性大腸炎に対して，待機例は腹腔鏡下（LA-RPC）もしくは用手補助腹腔鏡（HALS）大腸全摘術，緊急例でも全身状態が安定している準緊急手術はHALS結腸全摘術を選択し，その妥当性を検討した．2001年7月∼2008年9月の腹腔鏡手術74例と1997∼2001年の開腹術56例とを比較検討した．待機例でのLA-RPCは開腹術と比べ，手術時間は延長するものの，出血量は有意に少なく，術後在院日数も短かった．準緊急例についてはHALS群で手術時間がやや長かったが，出血量は有意に少なく，術後在院日数も有意に短かった．今後，さらなる検討が必要であるが，待機例での腹腔鏡手術，とくにLA-RPCは手術時間は延長するものの，術後回復も早く，低侵襲手術のひとつのオプションとなりうる可能性が示唆された．準緊急手術に対するHALSも手術時間の延長もわずかで，術後回復も早いことから，低侵襲手術のひとつとして有用な可能性が示唆された．

症例は67歳の女性,下腹部痛と血便を主訴に受診し入院となった. CT検査にて骨盤腔内にガスと液体貯留を有する嚢腫様病変と,それに接するS状結腸壁の壁肥厚を認めた.入院翌日に下腹部激痛を訴え, X線写真で両横隔膜下に遊離ガス像を認めた. S状結腸膀胱痩とそれに起因する汎発性腹膜炎を疑い手術を行った.術中所見では多量の膿性腹水を認めたが膀胱は正常であり子宮体部に穿孔を認めた. S状結腸に腫瘍を認め子宮体部背側に癒着していたが浸潤の有無は不明であった. S状結腸癌に伴った子宮留膿腫破裂による汎発性腹膜炎と診断し,単純子宮全摘術・S状結腸切除術を施行した.病理組織学的には,子宮は炎症著明であったが子宮内膜・筋層にS状結腸癌の腫瘍細胞を認めなかった.本症例はS状結腸癌に伴った子宮留膿腫破裂による汎発性腹膜炎をきたした稀な症例であった.

症例は96歳の男性.開腹の既往歴はない.心窩部痛を主訴に来院し,腹部単純X線と腹部CT検査で小腸の拡張を認めイレウスの診断で入院となる.イレウス管を留置し,保存的治療を行うも症状が改善しないため入院9日目に開腹術を施行した. S状結腸間膜左葉に直径2cmの欠損を認め,回盲部より約40cm口側の回腸がRichter型に嵌頓していた.用手的に嵌頓を解除し,嵌頓部の腸管は損傷を認めず切除を要しなかった.ヘルニア門は切開開放とし手術を終了した. S状結腸間膜内ヘルニアは腹腔内ヘルニアのなかでも稀で,その本邦報告例は自験例を含め22例であった.入院から手術までの期間は平均9.39日であり,術前に診断し得たのは1例のみであった. S状結腸間膜内ヘルニアを含む内ヘルニアの診断は極めて困難であり,原因不明のイレウスでは可及的早期の手術を考慮する必要があると考えられた.

We examined the clinical results of 15 patients treated with imatinib mesylate for metastatic or recurrent gastrointestinal stromal tumors(GIST)at the Osaka City General Hospital. Treatment with imatinib was initiated at 400 mg daily; however, in case of severe adverse events, the dose was gradually reduced to 300 mg or 200 mg to reach a tolerable dose so that administration could be continued for as long as possible. Assessments were performed according to the Response Evaluation Criteria in Solid Tumors(RECIST)and Choi criteria. According to the assessment by the RECIST criteria, clinical response(CR)was observed in 1 patient; partial response(PR), in 5 patients; stable disease(SD), in 6 patients; and progressive disease(PD), in 3 patients; the response rate was 40%. However, as per the Choi criteria, CR was observed in 1 patient; PR, in 11 patients; SD, in 1 patient; and PD, in 2 patients; the response rate was 80%. The median period of progression-free survival was 2,031 days and the 5-year survival rate was 80.0%. Grade 3 or higher adverse reactions observed included leukopenia(1 case), neutropenia( 2 cases), and anemia(1 case). In 6 patients(40%), the dose of imatinib was reduced to 300 mg or less; however, no significant difference in progression-free survival was observed between the 200/300mg group and 400/800mg group. Choi criteria are useful in assessing the response of advanced GIST to imatinib mesylate, and reducing the dose of imatinib mesylate to 200/300mg daily might be sufficient for treating patients who experience severe adverse reactions.

Recently, it has been reported that cyclin D1 plays a major role in oncogenesis in various cancers; however, there have been few studies on the association of cyclin D1 overexpression and prognosis of patients with malignant tumors. We evaluated the prognostic significance of cyclin D1 overexpression in colorectal adenocarcinoma. One hundred twenty-three specimens resected from patients with colorectal adenocarcinomas were investigated by staining with a monoclonal antibody against cyclin D1. As a result, both overall survival and disease-free survival were significantly poorer in the patients with tumors strongly positive for cyclin D1 than in those with cyclin-D1-negative or weakly positive tumors. The 5-year survival rate of the patients with tumors strongly positive for cyclin D1 was 53.3%, while the 5-year survival rates of patients with cyclin-D1-negative and weakly positive tumors were 96.2 and 78.8%, respectively. Moreover, multivariate analysis indicated that cyclin D1 overexpression is an independent predictor of disease recurrence in our patients. In conclusion, cyclin D1 overexpression may be useful as a predictor of disease recurrence in colorectal adenocarcinoma.

A 57-year-old female was seen at another clinic because of diarrhea and abdominal pain in July, 1994. Since abnormal findings were pointed out in the blood examination, she was referred to the hospital and was diagnosed as acute promyelocytic leukemia (APL). After one course of BHAC-DMP therapy, fever raised up to 38_??_39°C and CRP also raised up. With abdominal US and CT, she was diagnosed as multiple splenic abscesses and cholecystolithiasis. Splenectomy and cholecystectomy were performed on November 25, 1994. Liver biopsy was also performed during the operation, since a lot of small indurations similar to those of the spleen were recognized in the liver. The weight of the spleen was 260 g and multiple small abscesses which sized 5_??_10 mm were also recognized in the section. They were pathologically diagnosed as fungal splenic and hepatic abscesses. After the operation, antifungal agent was also administrated systemically for the rest abscesses in the liver and the patient was discharged from the hospital on the postoperation day 10. We successfully treated a case of fungal hepatic and splenic abscesses occurred during the chemotherapy for leukemia and systemic administration of antifungal agent, for which there has been no established definitive therapy as yet.

大腸癌肝転移症例に対する治療成績を予後を中心に検討した.大腸癌肝転移症例99例を対象にし, I群 : 肝切除群16例, II群 : 肝切除+肝動注リザーバー群10例, III群 : 肝動注リザーバー群19例, IV群 : one shot肝動注あるいはTAE群14例, V群 : 抗癌剤全身投与群21例, VI群 : 非治療群19例の6群に分け, 予後について比較検討した.II群の肝切除+肝動注リザーバー群の予後が最も良好で, 1年, 3年生存率とも100%と, 他のいずれの治療群に対しても有意差を認めた.次にI群の肝切除群の予後が良好で, 累積生存率は1年75.0%, 3年39.3%, 5年29.5%であった.III群, IV群, V群, VI群の予後は非常に悪く, 1年生存率はそれぞれ, 44.2%, 28.6%, 38.1%, 26.3%であった.以上より, 肝切除後肝動注リザーバーによる反復動注が予後の延長に有用である可能性が示唆された.

The prognosis for patients with unresectable intrahepatic cholangiocarcinoma(ICC) is extremely poor. Case 1 was a 65- year-old woman who had an ICC of 9 cm in diameter (mass-forming type) in the right lobe with portal trunk invasion. She was treated with hepatic arterial infusion chemotherapy[cisplatin(CDDP)/5-fluorouracil(5-FU)/l-leucovorin(l-LV)] and radiation therapy (total dose, 50 Gy). After 6 months, abdominal computed tomography (CT) revealed that the tumor had regressed. She survived for 7 years without recurrence of the ICC; subsequently, she died of peritoneal cancer. Case 2 was a 59-year-old woman who had an ICC of 8 cm in diameter (mass-forming type) in the left lobe with lymph node metastasis in the hepatoduodenal ligament; the right hepatic artery was involved by the metastatic lymph nodes. She was treated with hepatic arterial infusion chemotherapy(CDDP/5-FU/l-LV) and radiation therapy(total dose, 30 Gy). After 10 months, abdominal CT revealed that the tumor had disappeared, but paraaortic and mediastinal lymph node metastases were detected. She was therefore treated with systemic chemotherapy. Treatment with systematic chemotherapy enabled her to survive for over 5 years with a good performance status.

We report a patient who had a complete response by treatment with 200 mg of imatinib mesylate daily for peritoneal recurrences of gastrointestinal stromal tumor(GIST)of the stomach. On March 2007, a 68-year-old woman underwent distal gastrectomy for GIST of the stomach. On May 2007, peritoneal recurrences were recognized on CT scan, and treatment with 400 mg daily of imatinib mesylate was started. Because grade 2 systemic edema and rash developed one week later, the imatinib mesylate dose had to be reduced to 200 mg daily from July 2007. After reduction of imatinib mesylate, the adverse reactions resolved. Peritoneal dissemination disappeared on CT scan from April 2010, and complete response has been maintained for 18 months.

腹膜偽粘液腫は虫垂や卵巣を原発としてみられるが結腸原発は稀である,患者は71歳,男性.平成2年7月から腹部膨満感が増強し,同年10月入院となった.入院時腹部は腹水貯留を認め,右下腹部に手拳大の腫瘤を触知した.またCEA,CA125の上昇を認めた,注腸検査にて上行結腸に巨大腫瘤陰影を認めた.腹部CT検査にて右横隔膜下に肝弯入像と腫瘤周囲,脾周囲,ダグラス窩に腹水のCT値に近い病変部を認め,上行結腸癌原発腹膜偽粘液腫と診断された.開腹所見にて,上行結腸に手拳大の腫瘤を認め,腹腔内全体に粘液腫瘤塊が認められた.組織学所見では,結腸漿膜面を越えて浸潤する粘液癌であった,術前腹部CT検査にて診断された稀な結腸原発腹膜偽粘液腫の1例を報告した.

腸間膜脂肪織炎は原因不明の稀な非特異性炎症疾患である.われわれは結腸腸間膜に発生した本症の1例を報告するとともに,本邦報告例の文献的考察を加える.症例は73歳,男性.下腹部痛を主訴に,注腸造影検査,大腸内視鏡検査,CT検査,腹部エコー検査より直腸から下行結腸の腸間膜に発生した脂肪織炎と診断し,保存的治療を試みたものの,腸管狭窄の改善を認めず,外科的切除を施行した,自験例を含む,記載の充分な本邦報告49例の検討では,中年以上の男性に多く,部位では大腸腸間膜例が34例と多く,腹部の外傷歴や手術歴を有する症例は18例であった.本症の診断には腹部CT検査が有用であると思われた.32例に病変部の摘出術が施行され,17例に保存的治療がなされている.自験例のように保存的治療に抵抗し,著明な腸管狭窄を示すような症例では,腸管切除を考慮する必要があろう.

大腸癌肝転移症例24例を対象として原発巣および肝転移巣でのSPan-1抗原およびCEAの発現を検討した.原発巣におけるSPan-1抗原,CEAの陽性率は,それぞれ87.5%,91.0%と高率であった.次に,原発巣および肝転移巣の組織発現の程度を比較検討したところ,SPan-1抗原は原発巣陽性例21例中10例の47.6%に肝転移巣における発現の増加を認め,総計学的に有意な差を認めた(p

Injuries penetrating into the floor of the mouth in the oral cavity caused by chopsticks are rare. We report a case of neck impalement injury caused by a wooden chopstick fragment penetrating all the way through the base of the tongue. An 18-month-old boy fell off his chair when he was biting on a wooden chopstick. Four centimeters of the chopstick broke off but could not be found, so he was brought to our emergency department with minor bleeding from the tongue. Computed tomography (CT) revealed that the fragment had penetrated through the tongue into the neck. Ultrasonography (US) revealed that the fragment was in close proximity to the common carotid artery. Surgery for the removal of the chopstick tip was uneventful, with minimal soft tissue trauma. Postoperative progress was satisfactory and without complications. Of particular interest is the sensitivity of US in outlining the broken chopstick fragment lodged in the neck. It is noteworthy that the contrast of the chopstick greatly varied between CT and US.

Among 205 cases of cancer of the sigmoid colon were operated on in the department from 1972 to 1990, adhesion of the sigmoid colon to bladder was noted in 9 cases (4.4%). An average age of the 9 patients was 59.6 years. The male-to-female ratio was 6:3. Most of the carcinomas were large (an average diameter of the tumors was 7.2cm) and the tumors in 8 of 9 cases were circular. The lesions of adhesion or infiltration to the bladder were at the appex of the bladder in 4 cases, the left posterior wall in 3 and the fundus in 2. Six of 9 patients were diagnosed as cancer invasion positive to the bladder wall at the operation. So, Hartmann's operation with partial cystectomy was performed in 2, sigmoidectomy with partial cystectomy in 3 and low anterior resection with total cystectomy in one. But, only three of them showed microscopic invasion to the bladder wall. It is said that there are some cases judged invasion negative (false negative) even if examination with an intraoperative frozen section is carried out. So another new examination methods at operation are desired.

家族性大腸腺腫症,大腸多発癌および大腸癌局所切除例を除き,大腸癌腹膜転移の有無が確定された985例を対象として,腹膜転移例の79例(P群)と腹膜転移のない906例(N群)を比較するとともに,P群を2年未満に死亡した群(Pa群;63例)と2年以上生存した群(Pb群;16例)に分けて比較検討した.N群とP群の性別には差はみられなかったが,年齢はP群では有意に低かった.右側結腸癌の腹膜転移率は17.5%と腹膜転移頻度は最も高かった.しかし,腹膜転移例の大腸癌切除率は右側結腸では74.2%と比較的良好な値を示した.肝,リンパ節転移はそれぞれN群では9.4%,46.4%,P群では46.8%,94.1%とP群はそれぞれ高率であった.P群のうち相対非治癒症例は11例あり,累積生存率は4年45.5%,5年で22.7%と比較的良好であった.以上より,腹膜転移陽性例では相対非治癒手術の可能な場合には,腹膜転移巣を含めた積極的な外科的切除が重要であると思われた.

CASE 1: A 67-year-old man had advanced gastric cancer with lymph node metastasis (cT3N1M0, cStage IIIA). S-1 120 mg was administered for 21 days as neoadjuvant chemotherapy (NAC). A month later, total gastrectomy (with splenectomy) was performed. Histopathological examination revealed no cancer cells in the gastric wall and dissected lymph nodes. CASE 2: A 62-year-old man had advanced gastric cancer with lymph node metastasis (cT4aN2M0, cStage IIIB). He was treated with daily oral administration of S-1 120 mg (28-day administration followed by 7-day rest, and then 14- day administration) as NAC. A month later, total gastrectomy was performed. Histopathological examination revealed no cancer cells in the gastric wall and dissected lymph nodes. In both cases, the pathological effect was judged as grade 3. This suggests that NAC with S-1 mono-therapy can have a distinct therapeutic value for advanced gastric cancer.

Guidelines for breast cancer patient follow-up have not been widely adopted in Japan. To assess our intensive follow-up program, we evaluated first relapse and its indicators in patients with breast cancer. Of 964 patients, 126 relapsed and 43 died in the median follow-up term of 45 months. Follow-ups were scheduled every 6–12 months for imaging and tumor marker (TM) evaluation. Of 126 relapsed patients, 30 (23.8%) had symptoms of relapse. First indicators of relapse in 96 asymptomatic patients were physical examination in 24 patients (19%); imaging, 57 patients (45.3%); and TMs, 15 patients (11.9%). The most sensitive indicators were physical examination for local relapse, ultrasonography for regional lymph nodes, scintigraphy for bone, computed tomography for lung, and TMs for liver metastasis. During intensive follow-up, 43% of relapsed patients were identified by symptoms or physical examination. These patients had poor prognosis compare to patients identified by imaging or TMs in overall survival and post-relapse survival (p = 0.009 and 0.019, respectively). In all 964 patients, the relapse rates for stage I, IIA, IIB, and III tumors were 7.4, 7.9, 19.9, and 43.5%, respectively. The percentage of first relapse detected by imaging or TMs for stage I, IIA, IIB, and III were 4.7, 5.1, 11.8, and 19.8%, respectively. The cost of our follow-up program for 10 years was approximately 290,000 yen per patient. A routine intensive follow-up program involving imaging and evaluation of TMs in all patients has low efficacy and high expenditure.

Eight patients with inoperable advanced gastric cancer were treated with combination chemotherapy of S-1, low-dose cisplatin(CDDP)and Lentinan. S-1 80 mg/ m² was orally administered for 2 weeks followed by 1-week rest, CDDP 15 mg/ m² and Lentinan 2 mg/body were given intravenously on day 1 and 8. One complete response and four partial responses were observed for an overall response rate of 63%(5 of 8 patients). Only one patient developed over grade 3 toxicity leukocytopenia. Many patients could be maintained by long-term continuous treatment. Since combination chemotherapy of S-1/low-dose CDDP/Lentinan for advanced gastric cancer was very tolerable, it could be used for a long time.

絶対治癒切除大腸癌39例を対象として,核DNA ploidy patternとAgNORs数を測定し,これらと臨床病理学的所見および予後との関連について検討した.核DNA ploidy patternは臨床病理学的所見とは明らかな関連性はみられなかったが,予後の面ではdiplo1d型症例はaneuploid型症例に比べて有意に予後が良好であった.癌細胞核の平均AgNORs数は,そのcut off値を3.00とすると,臨床病理学的所見とは一定の関連性はみられなかったが,AgNORs数が低値の症例は高値の症例に比べて有意に予後が良好であった,aneuploid型症例においてもAgNORs数の低値群は高値群に比べて有意に予後が良好であった.以上の結果から,核DNA ploidy patternおよびAgNORs数は大腸癌の予後を反映する因子となると考えられ,核DNA ploidy patternとAgNORs数を組み合わせることにより,より鋭敏に予後を反映すると思われた.

Pure extragonadal tumors are rare in adult males. A 24-year-old male with an extremely high level of serum &#102 -fetoprotein (32.795 ng/ml) was diagnosed by abdominal computed tomography as having a retroperitoneal tumor. A case of primary retroperitoneal pure yolk-sac tumor in an adult male is described.

To evaluate the liaison-clinical pathway for patients with breast cancer introduced since May 2008, the data from a questionnaires survey of 56 clinics and 105 patients were reviewed. Half of the clinics specialized in internal medicine. 93% of physicians recognized the utility of the pathway while 24% made the most of the pathway. About 40% of the clinics wished to enlarge both the patient number and treatment materials. Half of the patients were employed. 55% of patients valued the pathway as helpful. And 29% of patients used the patient booklet at all times. 8% of patients replied they had complaints went to clinics. There has been no serious problem in using the pathway. Countermeasures to electronic health records in clinics, and responses to requests from each patient will be needed.

A liaison-clinical pathway for patients with stageI to III gastric cancer after curative operation has been introduced and managed in our hospital from July 2009. We made two kinds of liaison-clinical pathway in the presence or absence of postoperative adjuvant therapy. The duration of follow-up was 5 years in proportion to the Guidelines for Diagnosis and Treatment of Carcinoma of the Stomach. We held a briefing session for practicing physicians involved after liaison-clinical pathway making, conducted a questionnaire, and judged whether induction was possible. The liaison-clinical pathway consists of a chart for practicing physicians, leaflets with checklists for the patients, and other documents. We began to use them in July, 2009, and involved patients are 11 to date. Because postoperative treatment planning became clear by using the liaison-clinical pathway, we were able to relieve the anxiety of patients with cancer, and it seemed that it was easy to facilitate to perform cancer cooperation by the practicing physicians. For the introduction and management of this pathway, a thorough explanation to the patients with gastric cancer and good communication is required with the practicing physicians in cooperation with the coordinator.

We reported a patient with advanced gastric cancer successfully treated with S-1 chemotherapy for three weeks. The patient was a 67-year-old man who had gastric cancer clinically diagnosed as cT3N1H0P0M0, stage IIIA. His treatment was supposed to be daily oral administration of 120 mg S-1 for 28 days. At 21 days, this treatment was stopped due to severe appetite loss. The histological diagnosis of the resected stomach revealed complete disappearance of cancer cells in the stomach and the regional lymph nodes. Our report suggested that S-1 may have a potent therapeutic effect in neoadjuvant chemotherapy for advanced gastric cancer.

腸重積を呈した大腸癌の2例を報告し, 文献的考察を加えた. 症例1は22歳, 女性. 主訴は腹痛, 下血. 腹部超音波および注腸検査にて右側横行結腸部に腸重積を認め, 非観血的に整復. 再度施行した注腸検査, 大腸内視鏡検査にて盲腸に腫瘤形成型の癌腫を認め, 根治手術を施行した. 症例2は75歳, 男性.主訴は下血. 注腸検査にて腫瘤形成型のS状結腸癌と診断.その後に腹痛が出現し, 大腸内視鏡検査にて癌による腸重積を認め, 整復せずに根治手術を施行した. 自験例を含めた1981～1990年までの本邦報告37例と同時期の当科での切除単発結腸癌症例259例を比較検討した. 腸重積を呈した結腸癌37例の検討では発生部位はS状結腸に51.4%と最も多く, 次いで盲腸癌が32.4%を占めた. また腫瘤径は腸重積の発生要因とはならず, 壁深達度では早期癌で比較的, 腸重積を起こしやすく, 肉眼型別では限局型腫瘤が腸重積を呈しやすかった.

大腸リンパ管腫は比較的稀な疾患である.今回,われわれは内視鏡的に診断しえた2例の大腸リンパ管腫を経験した.症例1は51歳,男性で,脾彎曲部に13mm大のX線透過性の良いポリープを指摘された.大腸内視鏡ではcushion sign陽性の表面平滑な白色調亜有茎性腫瘤で,内視鏡的には大腸リンパ管腫と考えられ,内視鏡的ポリペクトミーを施行した.組織学的には海綿状リンパ管腫であった.症例2は50歳男性で,横行結腸に35×35mm,半球状の表面平滑な粘膜下腫瘍様の内視鏡所見を呈したが,周囲とくらべ透明感があった.cushion sign陽性で,生検鉗子にて穿破したところ,透明な液が流出し,隆起は消失し,リンパ管腫が疑われた.大腸リンパ管腫は良性疾患であり,本症を念頭においた注意深い観察により,術前診断も可能となり,合併症さえなければ内視鏡的にポリペクトミーや穿刺吸引あるいは経過観察で良いと思われた.

The effect of total parenteral nutrition (TPN) with fat emulsion was evaluated in 20 patients with liver disorders who showed Diabetes Mellitus (DM) type in preoperative oral glucose tolerance test (OGTT). The patients were divided into two groups according to Child's classification (Child A group; 10 cases, Child B group; 10 cases) and they underwent TPN after direct operation for esophageal varices. Blood glucose level in Child B group in the first to third days after operation was over 190 mg/dl and it was higher than that of Child A group during TPN. But blood glucose level of fat containing TPN cases in both groups tended to be lower than that of fat free TPN cases. There was no abnormal finding in liver function tests during TPN with or without fat emulsion after operation. It was indicated that fat containing TPN had little influences on the liver function in patients with liver disorders such as Child A and B who were classified in DM type in preoperative OGTT. Serum essential fatty acids level before operation was lower than normal level, and it further decreased after operation. The decrease was inhibited in patients of both groups undergoing TPN with fat emulsion. The plasma removal rates of fat emulsion (K2 values) during postoperative TPN were higher than those in preoperative period.It is concluded that the administration of fat emulsion is available to the patients with liver disorder accompanied with DM in OGTT during postoperative TPN.

A 61-year-old man with esophagus invasive advanced gastric cancer and peritoneum dissemination underwent three courses of S-1/CDDP/Lentinan (LNT) combination neoadjuvant chemotherapies (T3N1P1H0, Stage IV) (It is S-1 80 mg/m2,CDDP 15 mg/m2 and LNT 2 mg/body twice/week for two weeks) since down staging was obtained. We performed the surgery of total gastrectomy, splenectomy, D2 lymph node dissection, and Roux-en Y reconstruction in March 2008. With the surgical examination, there was no ascites and peritoneal dissemination. Although there was serious infiltration, we were able to remove it. In the histopathological effect judgment, it was Grade 1b. We changed the therapy to S-1 alone after the same chemotherapy for six months. One year after the operation, he is still alive one year after the surgery.

A liaison-clinical pathway for patients with stage I to III breast cancer undergoing adjuvant oral chemoendocrine therapy after curative operation has been introduced in our hospital since May of 2008. The form of this pathway was developed from the former cooperative treatment system between our hospital and local clinics. One hundred thirty four patients and 69 clinics have been using this pathway for 6 months. Our liaison-clinical pathway consists of a chart for the clinic-doctor, a leaflet with a checklist for the patient, and supplements. The aim of this pathway was care for patients with breast cancer in addition to total health care in a local clinic. Our pathway decreased patient anxiety and facilitated clinic-doctor acceptance for the cooperative cancer treatment system. A coordinator is a key person who constructs and manages this pathway. There has been no trouble in managing the pathway for 6 months. The liaison clinical pathway will be useful to reduce patient burden while maintaining treatment quality.

The clinicopathological studies on ovarian metastasis from the colorectal cancer were carried out. From 1972 to 1989, 385 female patients were managed by resection for primary colorectal cancer at our department. Six patients had ovarian metastasis from colorectal cancer (1.6%). The primary tumor was in the cecum in one case; in the ascending colon, two; in the sigmoid colon, two; and in the rectum, one. There was no relation between the location of the primary tumor and ovarian metastasis. An average age of six patients was 50.2 years, which was younger than that of female patients without ovarian metastasis. The primary lesions involved the serosa. Lymph node involvement and lymphatic invasion were present in all cases, and venous invasion and peritoneal disseminating metastasis were present in 4 and 3 of the 6 cases respectively. ER staining by immunohistological method was negative in all cases.

大腸癌はほとんどが腺癌であり, 未分化癌の頻度は低い.われわれは1972年から1987年に経験した大腸未分化癌4例を対象に検討を行った。癌腫の占居部位は盲腸, 上行結腸, 横行結腸, 直腸がそれぞれ1例であった.リンパ節転移陽性は1例のみであり, 全例治癒切除が施行され, 術後良好な経過を示している.組織学的にはおおむね均一な細胞によるシート状ないし索状の配列が主で, 腫瘍細胞はN/C比が高く, 核分裂像があまりめだたなかった.Grimelius 染色で4例中3例に一部の細胞質内に陽性顆粒を認めたが, 粘液染色ではおおむね陰性であった.細胞核 DNA ヒストグラムは全例 diploid pattern を呈し, 良好な予後に支持を与えるものであった.組織学的に分化度が低いほど予後不良との報告もあるが, 自験例をみると大腸未分化癌は必ずしも悪性度が高いとはいえないと思われた.

1973年から1988年までに経験した大腸早期癌73例, 79病変を対象に臨床病理学的検討を行った.壁深達度別では, m癌37病変, sm癌42病変, 治療法別では内視鏡的ポリペクトミーが14病変 (13例), 局所切除術が5病変 (5例), 腸管切除術によるものが60病変 (57例) であった.早期癌の全大腸癌に占める割合は, 全期間では8.5%, 最近の4年問では15.0%であった.占居部位では, 早期癌の91.1%がS状結腸以下にみられた.肉眼形態では, Ip型29病変, Is型22病変, IIa型20病変, IIa+IIc型8病変であり, IIa+IIc型の8病変中7病変がsm癌であった.リンパ節転移はsm癌37病変のうち5病変 (13.5%) にみられ, IIa型, IIa+IIc型, 中・低分化腺癌, ly (+) の病変にその陽性率は高かった。治療成績では, m癌, sm癌それぞれ1病変に局所再発がみられたが, いずれも根治的再手術を施行することができた.残りの病変では再発は認めなかった.

A total of 773 cases of colorectal carcinoma were surgically treated in our department for the past 18 years, and 196 of those cases were performed non-curative resection (relative non-curative in 52 and absolute non-curative resection in 144), and 63 tumors were not resected. As regards tumor locations, the frequencies of the non-curative resection were as high as more than 30% in the descending colon, cecum and transeverse colon. Histologically, non-curative resection cases became predominant in moderately differentiated adenocarcinomas, mucinous carcinomas and signet-ring cell carcinomas. Factors related to relative non-curative resection were lymph node metastasis (N) in 45 cases, liver metastasis (H) in 3, peritoneal dissemination (P) in 3, and H with P in one. Factors related to absolute non-curative resection were cancer infiltration on the resected wall edge in 48 cases, H in 45, P in 18, N in 10, distant metastasis in 2, and concomitant over 2 factors in 21. The five-year survival rates were 82.9% and 52.4% in absolute and relative curative resections versus 44.8% and 8.0% in relative and absolute non-curative resections, respectively.

最近17年間の自験肛門管癌32例を対象として, リンパ節転移を中心とした臨床病理学的所見ならびに予後について検討した.肛門管癌32例中27例に腹会陰式直腸切断術が, 2例に局所切除術が施行された.直腸切断術例におけるリンパ節転移陽性率は42.3%であり, 転移方向では上方34.6%, 側方115%, 下方11.5%であった.直腸切断術例の5年生存率は49.2%であり, リンパ節転移陽性例のそれは13.6%と陰性例の67.9%とくらべ極めて不良であった.今後さらに徹底したリンパ節郭清に加えて, 照射療法, 化学療法などの併用を含めて治療成績の向上に努力せねばならない.

A case primary malignant lymphoma of the rectum in a 77-year-old woman was reported. The patient complaining of anal bleeding was found to have a tumor in the rectum. Preoperative biopsy revealed a malignant lymphoma. Miles' operation was perfomed. This lymphoma was classified histologically as diffuse medium size cell type. Immunohistochemical study showed the lymphoma to be of B cell type with IgA heavy chain and λ light chain. The 8.7% nuclei of tumor cells reacted positively with new monoclonal Ab-Ki-67. Now the patient is alive and well after 6 months of surgery. Seventy-five cases of malignant lymphoma of the rectum have been reported in Japan after Kuru and others in 1934. The male-to-female ratio of the patient group was 1:1.1 with the mean age of 62.5 years. Half of the masses were more than 5.0cm in diameter. Several percent of the patients who received curative operation died within one year after surgery. Thus, further studies are required for the developement of more effective and appropriate therapies.