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症例は49歳の女性で，近医で肝機能異常とCA19-9の高値を認め腹部CT施行，胆嚢腫瘍と左卵巣腫瘍を指摘され精査加療目的に当科紹介された．腹部CT, MRIで胆嚢に不整な壁肥厚と乳頭状隆起を認め，骨盤腔内に14 cm大の多房性嚢胞を認めた．胆嚢と卵巣の重複癌の診断にて開腹手術を施行したが，胆嚢癌は腹膜転移を伴っており総肝動脈幹リンパ節のサンプリングと両側附属器切除のみを施行した．手術時に採取したリンパ節と左卵巣腫瘍はともに腺癌で，免疫組織染色検査にていずれもCA19-9陽性，cytokeratin 7陽性，cytokeratin 20陽性，p53陽性であり，一元的に胆嚢癌のリンパ節転移，卵巣転移と診断した．消化管腫瘍の卵巣転移のうち，胆嚢癌由来はまれである．本例はジェムシタビン，TS-1による化学療法を行い，術後21か月生存した．

A 69-year-old man diagnosed as having gallbladder cancer with liver invasion and metastasis to Couinaud's hepatic segment 8 (S8) was referred to our hospital. Because of the presence of liver metastasis, gemcitabine administration was chosen. Although gemcitabine was effective for the liver metastasis, his serum carcinoembryonic antigen (CEA) level had gradually increased after 12 cycles of gemcitabine administration. There was no distant metastasis other than the liver metastasis (manageable with gemcitabine) on detailed radiological examination. Therefore, we performed surgery for the primary lesion, after obtaining informed consent. Pathological examination demonstrated viable cancer cells with necrosis and fibrosis in the gallbladder, and fibrosis without viable cancer cells in the induration in liver S8. Gemcitabine was re-administered as postoperative adjuvant chemotherapy. Twenty months after the surgery, there was no sign of recurrence. In selected patients, gemcitabine treatment may be effective against gallbladder cancer with metastasis.

Lack of effective adjuvant therapy against advanced extrahepatic biliary tract carcinoma (BTC) requires that new therapeutic methods, such as molecular targeted therapy, be developed. The mitogen-activated protein kinase (MAPK) and Akt signaling pathways, which activate cell proliferation and suppress apoptosis, respectively, may function as important targets for such therapies. The aim of this study was to examine the expression patterns of phosphorylated MAPK (p-MAPK) and phosphorylated Akt (p-Akt) proteins in BTC cell lines and clinical specimens. Expression of p-MAPK and p-Akt proteins in four human BTC cell lines and in frozen sections of 20 advanced extrahepatic BTC specimens was analyzed by Western blotting. Thirty formalin-fixed BTC specimens were immunohistochemically stained for p-MAPK and p-Akt using labeled streptavidin–biotin conjugates. Expression of p-MAPK was observed in three of four (75%) BTC cell lines, whereas no expression of p-Akt was observed. Twenty-three of 30 formalin-fixed specimens stained positive for p-MAPK (77%), whereas only 47% stained positively for p-Akt. Expression of p-MAPK relative to that of p-Akt was also seen more frequently in the frozen specimens. The results of this study suggest that MAPK is activated more frequently than Akt in extrahepatic biliary tract carcinoma.

Background. Although bacterial translocation is a sig- nifi cant problem in patients with obstructive jaundice, how translocation is promoted in this situation is not clearly understood. We previously reported the recov- ery of gut mucosal T-lymphocyte numbers in jaundiced rats following internal biliary drainage. This suggests that bile in the intestinal lumen promotes T-lymphocyte redistribution into the gut mucosa. To test this hypoth- esis, we have examined the expression patterns of che- mokines that play an important role in lymphocyte recruitment into the small intestine. Methods. Four groups of rats receiving one of the following surgical procedures were studied: a sham operation (SHAM), common bile duct ligation (CBDL), CBDL followed by external drainage, or CBDL followed by internal drain- age. Expression levels of intestinal mRNAs encoding TECK, MECK, and LARC chemokines were assessed using real-time polymerase chain reaction. Distribution of chemokine mRNA in the rat ileum was examined using in situ hybridization (ISH). Results. Following surgery, the expression levels of TECK mRNA decreased signifi cantly in the CBDL group compared with in the SHAM group. While TECK expression did not recover after external drainage, it recovered to a near-normal level after internal drainage. Expression levels of MECK and LARC mRNAs were similar among all groups. ISH confi rmed strong expression of TECK mRNA in the epithelial cells of the small intes- tine. Conclusions. These results indicate that bile may contribute to high expression levels of TECK/CCL25 mRNA in the small intestine. Bile may also have a role in regulating the distribution of gut mucosal T lympho- cytes by promoting TECK production from epithelial cells.

A 67-year-old woman was referred to our hospital for investigation of epigastric discomfort. Computed tomography (CT) showed dilatation of the intrahepatic bile duct in the left lobe of the liver, endoscopic cholangiography showed complete stenosis of the left main branch of intrahepatic bile duct, and CT during angiography showed decreased portal blood flow to segment 3 of the liver. Based on these findings, we suspected intrahepatic cholangiocarcinoma and performed left lobectomy of the liver. However, pathological examination revealed fibrosis and infiltration of inflammatory lymphoid cells around the stenotic bile duct and periportal area, without any evidence of malignancy. Since these findings were compatible with sclerosing cholangitis and the patient did not have a disorder that would cause secondary sclerosing cholangitis, the final diagnosis was primary sclerosing cholangitis (PSC). It is difficult to distinguish segmental PSC from cholangiocarcinoma; thus we think surgical resection is an appropriate therapeutic and diagnostic procedure for segmental intrahepatic bile duct stenosis.