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Gastric gastrointestinal stromal tumor(GIST)is rarely accompanied by lymph node metastasis. Therefore, partial gastrectomy generally proceeds with good indication for laparoscopic surgery. However, surgical procedures can be complicated by the tumor location or growth type. Furthermore, laparoscopy and endoscopy cooperative surgery(LECS)has recently been developed, with good results. In this study, we aimed at determining the applicability of various types of laparoscopic surgery to gastric GIST based on the tumor location and growth type. Between 2005 and 2020, 52 patients underwent surgery for preoperatively suspected or pathologically confirmed GIST. Tumors were found in the upper, middle, and lower portions of the stomach of 32, 16 and 4 patients, respectively. The types of tumor growth were intraluminal, extraluminal, and mixed for 21, 14, and 17 patients, respectively. The surgical procedures were open and laparoscopic for 26 patients each. After the laparoscopic surgery, the surgical duration, blood loss, and tumor size were significantly lower, while the hospital stay was significantly shorter. For the laparoscopic surgery, we adopted simple wedge resection, transillumination and serosal dissection methods(TSDM), or LECS. Two patients underwent TSDM using single incisional laparoscopic surgery(SILS)for tumors with intraluminal growth in the cardiac region, while 7 underwent LECS. The selection of the method for laparoscopic surgery was based on the tumor location or growth type, resulting in good outcomes.

症例1:35歳,男性. 主訴:特になし. 現病歴:平成16年1月,人間ドックの腹部エコー検査にて 膵頭部に嚢胞性病変を指摘された.3月精査目的で当科紹 介となった. 既往歴:7歳 脾門リンパ節炎,14歳 十二指腸潰瘍,24歳 気管支喘息. 現症:腹部は平坦,軟. 入院時検査所見:血液,生化学検査では異常を認めなかっ た.腫瘍マーカーにおいては,CEA 1.1ヘ/ml DUPAN-2 25未満U/mlで正常であったが,Span-1が58U/ml,CA19-9 が139.2U/mlと上昇を認めた. 腹部US所見:膵頭部~体部に直径47.6mm大の多房性の嚢 胞性腫瘍を認め,一部は壁在結節様であった. EUS 所見:膵頭部の腫瘍は44×49mm大で隔壁を持つ嚢胞 性病変として描出された.内部は不均一であった. 腹部CT所見:膵体部頭側に突出して5×5cm大の多房性 嚢胞性病変を認めた.比較的厚い被膜,隔壁を有している が,内部に明らかな充実部分は認めなかった.Dynamic study にて隔壁に早期濃染を認めた(図1a). MRI(MRCP)所見:膵体部の頭側に径46mm大の分葉状の 腫瘤性病変を認めた.T1強調像にてやや高信号,T2強 調像にてやや低信号を呈していた.信号強度から嚢胞内の 性状は比較的粘稠度が高いと考えられた.主膵管との連続 性は指摘できず,主膵管の拡張も見られなかった. 血管造影:腫瘍濃染などの異常は認めなかった. 膵リンパ上皮嚢胞の2例 濱 野 亮 輔*,稲 垣 優,木 村 裕 司,磯 田 健 太, 北 田 浩 二 ,西 江 学,野 村 長 久,徳 永 尚 之, 高 橋 健 司 ,宮 宗 秀 明,常 光 洋 輔,大 塚 眞 哉, 三 好 和 也 ,岩 川 和 秀,高 橋 正 彦,岩 垣 博 巳

We experienced 20 patients with distal bile duct carcinoma from May, 1997 to December, 2007. The male/female ratio was 11/9 and the average age was 69.6 years. The operative procedures were as follows : pancreaticoduodenectomy (PD), 9 ; pyrolus preserving pancreaticoduodenectomy (PPPD), 8 ; subtotal stomach preserving pancreaticoduodenectomy (SSPPD), 2 and hepatico-jejunostomy without resection, 1. We performed a clinicopathological study on 16 patients with distal bile duct carcinoma, excluding 3 operation-related deaths and 1 unresectable case. The cumulative survival rate was 70% at 3 years and 11% at 5 years. The 3-year survival rates at fStageII, fStageIVa and fStageIVb were 100%, 80% and 0%, respectively. Log-rank analysis revealed that pathological pancreatic and duodenal invasion and curative resectability may be prognostic factors, while lymph node metastasis and perineural and stump invasion did not affect prognosis. Six recurrences in the 11 curative resection cases (54.5%) were observed ; therefore, postoperative systemic chemotherapy is warranted to curtail recurrence in advanced distal bile duct carcinoma.

今回われわれは稀な骨盤腔後腹膜に発生した巨大な悪性末梢神経鞘腫瘍（MPNST）の1例を経験したので報告する．症例は74歳，男性．右下腹部腫瘤を主訴に2006年3月来院．CT検査，MRI検査にて骨盤腔内後腹膜に境界明瞭な約15cm大の腫瘍を認め，2006年5月手術施行した．腫瘍は巨大で骨盤腔右側を占めていたが，周辺臓器への浸潤は認めず，経腹的に腫瘍を完全摘出した．摘出腫瘍は大きさ15.0×10.0×8.5cmで重量640gであった．病理組織学診断で長紡錘状腫瘍細胞の粗な増殖がみられ，核異型，分裂像を認めた．免疫染色でS-100は陰性であったが，NSE，vimentin，MIB-1が陽性を示していたことからMPNSTと診断された．術後経過は良好で術後17日目に退院となった．術後2年経過した現在再発は認めていない．

We report a rare case of a very large nonfunctioning endocrine tumor of the pancreas without malignant histological features. A 63-year-old woman referred for appetite loss and general fatigue was found to have a tumor in the pancreas head. Computed tomography demonstrated a well-defined pancreatic tumor 45mm in diameter with hypervascular staining in the pancreas head. Angiography showed a hypervascular tumor of the pancreas head and a dilatation of the anterior superior and posterior superior pancreaticoduodenal arteries. The preoperative diagnosis was an endocrine tumor of the pancreas, with undeniable malignancy. Pylorus-preserving pancreaticoduodenectomy was performed. The histopathological diagnosis was a benign nonfunctioning endocrine tumor of the pancreas based on immunohistochemical staining for Chromogranin A, Synaptophysin, and NSE, but not for hormones. The tumor revealed a low labeling index (

Colovesical fistula (CVF) resulting from colon diverticulosis is a comparatively rare disease, and neither the diagnosis nor treatment has been established. Our experience with CVF due to sigmoid diverticulitis over a 9-year period was reviewed to clarify the clinical presentation and diagnostic confirmation. Ten patients with CVF were identified in this period, and chief complaints, laboratory findings, presenting symptoms, diagnostic investigations, and subsequent treatments were reviewed. Preoperative urinalysis showing bacteriuria (100%) was the most common presentation, followed by fecaluria (40%), abdominal pain (40%), pneumaturia (30%), hematuria (30%), pain on urination (30%), pollakiuria (10%), and dysuria (10%). The abilities of various preoperative investigations to identify CVF were: computed tomography (CT), 88.9%; magnetic resonance imaging, 40%; cystoscopy, 30%, and gastrografin irrigoscopy, 22.2%. Colonoscopy (0%) was not diagnostic. Bowel resection was performed in nine of ten patients. When inflammation was intense, covering ileostomy was performed, and an omental plasty was placed between the bowel anastomosis and bladder. When CVF is suspected, we recommend CT followed by colonoscopy and cystoscopy as a first-line investigation to rule out malignancy as a cause. Other modalities should only be used if the diagnosis is in doubt or additional information is needed to plan operative management. Primary colic anastomosis appears to be safely performed by applying omental plasty and covering ileostomy.

Adenovirus-mediated wild-type p53 gene transfer induces apoptosis in a variety of human cancer cells. Although clinical trials have demonstrated that a replication-deficient recombinant adenovirus expressing the wild-type p53 gene (Ad-p53) is effective in suppressing growth of non-small cell lung cancer (NSCLC), we often experienced late resistance to this treatment. To elucidate the mechanism of late resistance to Ad-p53 in human lung cancer cells, we generated 5 different resistant variants from p53-susceptible H1299 NSCLC cells by repeated infections with Ad-p53. We first examined the transduction efficiency of adenoviral vector by Ad-LacZ transduction followed by X-gal staining in parental and 5 resistant H1299 cell lines. Their sensitivity to viral infection decreased in correlation with the magnitude of resistance, and Ad-p53-mediated tumor suppression could be restored by dose escalation of Ad-p53 in the resistant variants. The expression of Coxsackie and adenovirus receptor (CAR) and alphaV integrins, which are cellular receptors for attachment and internalization of the virus, respectively, was next investigated in these cell lines. Flow cytometry revealed that alphaVbeta3 and alphaVbeta5 integrin expression was consistent, while p53-resistant cell lines showed that diminished CAR expression correlated with the magnitude of the resistance. Our results demonstrated that decreased CAR expression could be one of the mechanisms of late resistance to Ad-p53, which may have a significant impact on the outcome of adenovirus-based cancer gene therapy.

症例は48 歳の男性で, 嘔吐, 右上腹部痛出現し, 腹部超音波検査にて胆石胆嚢炎と診断された. 入院の上, 内視鏡的逆行性膵胆管造影 (endoscopic retrograde cholangiopancreatogra-phy; 以下, ERCPと略記) を施行した結果, 総胆管および右肝管に合流する重複胆嚢管と診断し, 開腹下に手術を施行した. 胆嚢およびCalot 三角の炎症は高度で, 胆嚢頸部より造影し重複胆嚢管であることを確かめ胆嚢摘出術を行った. 総胆管結石も認められたため, 載石後Tチューブを留置した. 一般に胆嚢管走向異常症例はA 型からG 型の9 つに分類される. E 型である重複胆嚢管に関してMEDLINE (インターネット接続) での英語文献検索を行ったところ過去の報告数は12例のみであり極めてまれである. 胆嚢管の走向, 合流形式には種々の異型が存在し, 手術に際しては胆道損傷を避けるためにこれら異型の存在を念頭におくことを忘れてはならない. 今回, ERCPが非常に有用であり術前に重複胆嚢管と診断でき, 安全に手術できたので報告する.

今回われわれは,後腹膜原発extragonadal germ cell tumor (以下EGCT)の1例を経験したので報告する.症例は29歳の男性.平成9年2月より左上腹部痛,食欲不振出現し, 5月8日当院を受診.左上腹部に境界明瞭で,可動性のない手拳大の有痛性腫瘤を触知した.腹部CTでは左腹部を占拠する約10cmのtumorが尿管を左上方に圧排していた. tumorによる消化管通過障害が出現したため, 5月30日手術を施行した.左腹腔内に手拳大の突出した巨大な後腹膜腫瘍を認めた.圧排された尿管には浸潤はなく鈍的に剥離し,また大腰筋および大動脈の一部に浸潤を認め鋭的に剥離し16b1のリンパ節とともに摘出した.切除標本は, 12×8.5×5cmで表面平滑,弾性硬,組織はembryonal carcinoma, choriocarcinoma, teratomaが混在する複合組織型であった.経過は良好で術後high dose VIP療法施行し,現在HCG-βは正常化している.

A Case of Resected Cholangiolocellular Carcinoma during Treatment for Lung Cancer Cholangiolocellular carcinoma is an extremely rare malignant primary liver tumor, accounting for less than 1% of primary liver tumors. We herein report a case of cholangiolocellular carcinoma during treatment for lung cancer. A woman following up after operation for lung cancer was found to have a solitary hepatic tumor in the left lobe of the liver at an abdominal computed tomography checkup. It showed early enhancement with hypovascular area of the center in the arterial phase and enhancement contrast retention in the delayed phase. The tumor was seen as a hypointense nodule in the hepatocellular phase of EOB magnetic resonance imaging. We diagnosed liver metastasis of lung cancer with differential diagnosis of cholangiocellular carcinoma. We performed extended left lobectomy of the liver. Histological and immunohistochemistry findings were compatible with cholangiolocellular carcinoma./p>