清水 敦

症例は69歳，男性．CT，MRIで肝右葉に早期濃染される最大径15 cmの巨大腫瘍と外側区域と尾状葉に数個の小腫瘍を認め，PIVKAIIの高値と画像所見から肝細胞癌と診断した．総コレステロール855 mg/dl ，トリグリセリド753 mg/dl と著明な高脂血症も認めた．2年前の総コレステロールは250 mg/dl であった．胆汁うっ滞所見がなく，高脂血症の家族歴もなく，急激な上昇を認めていることから腫瘍随伴症候群による高脂血症と考えられた．右肝の主腫瘍切除後，総コレステロール・トリグリセリド値は急速に改善したが，術後早期に肝内再発をきたし，肝動脈化学塞栓療法を行うも著効なく，骨転移により急速な転帰をたどった．<br>

CONTEXT: Although surgical resection is the only curative therapeutic option for recurrent or metachronous pancreatic carcinomas, most such cancers are beyond surgical curability. We herein report on two rare cases of remnant pancreatectomy used to treat recurrent or metachronous pancreatic carcinomas. CASE REPORTS: CASE#1 A 65-year-old male developed weight loss and diabetes mellitus 83 months after a pylorus-preserving pancreaticoduodenectomy followed by two years of adjuvant chemotherapy (5-fluorouracil plus leucovorin plus mitomycin C) for a pancreatic carcinoma in the head of the pancreas (stage IA). An abdominal CT scan revealed a 3 cm tumor in the remnant pancreas which appeared as a 'hot' nodule on FDG-PET. A remnant distal pancreatectomy was performed and a pancreatic carcinoma similar in profile to the primary lesion (stage IIB) was confirmed pathologically. CASE#2 A 67-year-old male showed increased CA 19-9 levels 25 months after a distal pancreatectomy for a pancreatic carcinoma in the body of the pancreas (stage IA). An abdominal CT scan revealed a cystic lesion in the cut end of the pancreas which appeared as a 'hot' nodule on FDG-PET. A remnant proximal pancreatectomy with duodenectomy was performed and a metachronous pancreatic carcinoma (stage III) was confirmed pathologically. CONCLUSION: Remnant pancreatectomy can be considered a treatment option for recurrent or metachronous pancreatic carcinomas. FDG-PET can play a key role in detecting remnant pancreatic carcinomas.

膵温存十二指腸切除術には多彩な術式があり,十二指腸早期癌,十二指腸腺腫症,GIST(gastrointestinal stromal tumor)などの低悪性度腫瘍,他臓器からの癌浸潤,外傷などが適応となる.膵温存十二指腸第2・3部切除術では主乳頭・副乳頭の処理の有無や切除範囲によりその再建方法は異なり,多くの例で空腸空置が必要になる.合併症としては,吻合部狭窄(胃内容停滞),膵瘻,膵炎など膵に起因する病態に注意する必要がある.本術式は十二指腸,膵臓,胆管およびこれらの支配血管系の解剖を熟知すれば安全に施行できる手技であるが,根治性を損なわないことが重要で,症例選定のため十分な術前検討を行う必要がある.(著者抄録)