鯉沼 広治

Metastatic squamous cell carcinoma (SCC) from an unknown primary site to the colon has not been reported previously. A 75-year-old woman presented with a mass in the left submandibular region. Biopsy revealed a Class V lesion, but the histologic type was undetermined. Surgical resection of the left submandibular gland with cervical lymph node dissection was performed. However, SCC was seen in the lymph nodes only, with no tumor in the submandibular gland. Three months after surgery, computed tomography revealed that the preoperatively diagnosed lesion in the transverse colon had grown considerably. A laparoscopic right hemicolectomy was performed. Histological examination showed features of SCC, similar to the findings in the cervical lymph nodes. We report a rare case of synchronous metastatic SCC to the colon and cervical lymph nodes from a carcinoma of unknown primary site.

症例は80歳女性で、79歳時に右乳癌で右乳房温存術を施行した。術後ホルモン療法と右残存乳房に放射線治療を施行した。右乳癌術後経過観察中のCTにて上行結腸の壁肥厚を指摘され、下部消化管内視鏡検査で、上行結腸癌と診断された。労作時の息切れを認めたため、精査目的に入院とした。下部消化管内視鏡検査では、上行結腸に半周性2型の腫瘍を認め、病理検査にて腺癌と診断された。呼吸機能検査では、軽度閉塞性障害を認めた。病歴や画像所見や喀痰検査から、放射線療法による特発性器質化肺炎(COP)と診断した。画像上肺炎像が悪化したため、パルミコート(ブデソニド)吸入ステロイド薬による加療を行った。3ヵ月間ステロイド吸入による加療を行い、画像所見・呼吸機能は改善した。腹腔鏡下結腸右半切除術を施行した。周術期に呼吸器症状なく、術後9日目に退院した。COPの再燃及び呼吸器症状なく経過している。

症例は65歳,男性.排便困難と肛門痛を主訴に近医を受診した.大腸内視鏡検査で下部直腸癌と診断され,当科を紹介受診.腹部CTで前立腺および肛門挙筋への浸潤,直腸周囲の膿瘍形成,側方リンパ節の腫脹を認めた.外来精査中にイレウスとなり,緊急で双孔式S状結腸人工肛門造設術を施行した.抗菌薬投与を行い炎症所見が消退した後,術前化学放射線療法(UFT 500mg/LV 75mg,総線量50.4Gy)を行い,腫瘍の著明な縮小を認め,骨盤内臓全摘術を施行した.術後に癒着性イレウスを発症したが保存的加療で軽快し,術後51日目に退院となった.切除標本では直腸病変は瘢痕化しており,病理組織学的検査では腫瘍細胞を認めず,化学放射線療法の効果はGrade3,病理学的完全奏効(pCR)と診断された.膿瘍形成を伴う高度進行直腸癌に対し術前化学放射線療法が奏効しpCRを得た症例を経験したので報告する.(著者抄録)

A 48-year-old man underwent laparoscopic sigmoid colon resection for cancer and surveillance colonoscopy was performed annually thereafter. Five years after the resection, a submucosal mass was found at the anastomotic staple line, 15 cm from the anal verge. Computed tomography scan and endoscopic ultrasound were not consistent with tumor recurrence. Endoscopic mucosa biopsy was performed to obtain a definitive diagnosis. Mucosal incision over the lesion with the cutting needle knife technique revealed a creamy white material, which was completely removed. Histologic examination showed fibrotic tissue without caseous necrosis or tumor cells. No bacteria, including mycobacterium, were found on culture. The patient remains free of recurrence at five years since the resection. Endoscopic biopsy with a cutting mucosal incision is an important technique for evaluation of submucosal lesions after rectal resection.

Purpose: Endocrine cell carcinoma, according to the Japanese classification criteria for colorectal cancer, corresponds to neuroendocrine carcinoma (NEC) and mixed adenoneuroendocrine carcinoma (MANEC), as defined in the 2010 World Health Organization (WHO) classification. We retrospectively reviewed the clinical features of patients with these tumors diagnosed and treated at our institution. Methods: The clinicopathological features of endocrine cell carcinomas of the colon and rectum diagnosed by neuroendocrine markers from January 2000 to December 2012 were retrospectively evaluated in 12 patients. Results: Surgical specimens were obtained from eight of the 12 patients. MANEC was diagnosed in six patients and NEC in one. One tumor was unclassifiable. The tumors were not resected in four patients, and all died within 3 months. Of the eight patients who underwent resection, four received an R0 resection, two of whom underwent adjuvant chemotherapy and survived more than 5 years. One patient who underwent an R2 resection and continuous chemotherapy survived for 53 months. One patient with NEC underwent surgery and radiotherapy, and died 17 months later. Conclusion: Most endocrine cell carcinomas of the colon and rectum reviewed were MANECs. Though their prognosis was generally poor, chemotherapy may be effective in some patients.

INTRODUCTION: Isolated vaginal metastases from colorectal cancer are extremely rare. There are only a few reported cases in the English literature, and the characteristics of such cases of metastasis remain relatively unknown. PRESENTATION OF CASE: We present a case of isolated vaginal metastasis from rectal cancer in a 78-year-old female patient. The patient had no symptoms related to vaginal tumor. Magnetic resonance imaging (MRI) showed thickening of the middle rectum and a vaginal tumor. Biopsy from the vaginal tumor showed adenocarcinoma, similar to the rectal lesion. Low anterior resection with ileostomy, hystero-oophorectomy, and transvaginal tumor resection was performed. After nineteen months, computed tomography scan revealed multiple lung metastases and recurrent tumor in the pelvis. The patient refused chemotherapy and is alive three months after developing recurrent disease. DISCUSSION: Most cases of primary vaginal carcinoma are squamous cell carcinoma. Other histologic types such as adenocarcinoma are usually metastatic lesions. Primary lesions associated with metastatic vaginal adenocarcinoma are most often the uterus, and are very rarely from the colon or rectum. We review previous case reports of isolated vaginal metastases from colorectal cancer and discuss their symptoms, treatments, and outcomes. CONCLUSION: We should keep the vagina within the field of view of pelvic MRI, which is one of the preoperative diagnostic tools for colorectal cancer. If female patients show gynecological symptoms, gynecological examination should be recommended. Isolated vaginal metastases are an indication for surgical resection, and adjuvant chemotherapy is also recommended.

症例は54歳の女性．近親者の大腸癌罹患による不安から近医を受診した．大腸内視鏡検査は挿入困難であった．注腸検査で上行結腸癌を疑われ精査加療目的に当院へ紹介となった．ダブルバルーン内視鏡検査で上行結腸癌と診断された．3D-CT angiographyではSMV rotation signを認め，腸回転異常症を伴う上行結腸癌の診断で開腹回盲部切除術を施行した．手術所見では，上行結腸は後腹膜に固定されておらず，小腸は十二指腸尾側より肝下面に内ヘルニアをきたし，paraduodenal hernia typeの腸回転異常症と診断された．郭清は回結腸動脈を根部で切離してD3とした．内ヘルニアの小腸は右上腹部で後腹膜に強固に癒着しており，これまで無症状であったことから整復は行わなかった．内ヘルニアを伴う腸回転異常症に併存する大腸癌は稀であり，文献的考察を含めて報告する．

INTRODUCTION: Neuroendocrine tumors of the colon and rectum are relatively rare compared to sporadic colorectal carcinoma. There are few reports of neuroendocrine tumors of the colon and rectum in patients with ulcerative colitis. PRESENTATION OF CASE: A patient with sigmoid colon carcinoma with focal neuroendocrine features is presented. A 32-year-old man, who had been followed for ulcerative colitis for 14 years, was found to have carcinoma of the sigmoid colon on routine annual colonoscopy, and he underwent laparoscopic total colectomy. Pathologic examination showed sigmoid colon adenocarcinoma with focal neuroendocrine features. DISCUSSION: Most colorectal carcinomas associated with inflammatory bowel disease are histologically similar to the sporadic type, and tumors with neuroendocrine features are very unusual. CONCLUSION: Very rare case of sigmoid colon carcinoma with neuroendocrine features arising in a patient with UC was described.

症例は57歳の女性.右下腹部腫瘤の精査で盲腸癌と診断された.術前の腹部超音波検査で肝S2に径10mmの境界明瞭で内部不均一な低エコー腫瘤を認めた.CT検査では淡い低吸収域として認め,造影効果は認めなかった.MRI検査ではT1強調で低信号,T2強調で軽度高信号を示し,superparamagnetic iron oxide(SPIO)造影後T2強調で明瞭な高信号として描出され,拡散強調画像で拡散の低下を認めた.盲腸癌・転移性肝癌と診断し,回盲部切除術と肝部分切除術を施行した.病理組織学的所見で肝reactive lymphoid hyperplasiaと診断された.術後8年再発なく経過している.肝reactive lymphoid hyperplasiaは良性疾患とされているが,術前検査で悪性腫瘍との鑑別が困難であり,外科的切除が行われることが多い.診断,治療の現状と問題点を考察した.(著者抄録)

It has been suggested that total cholesterol levels and the use of statin medications are associated with the incidence of complications after gastrointestinal surgery. The aim of this study was to determine if preoperative total cholesterol levels are associated with a higher risk of postoperative infections and mortality. A total of 2211 patients undergoing general surgical procedures between December 2006 and November 2008 at Iizuka Hospital and between January 2010 and March 2012 at Jichi Medical University Hospital were reviewed. Multiple logistic regression models were used to evaluate serum total cholesterol and other variables as predictors of postoperative nosocomial infections. Serum total cholesterol concentrations lower than 160 mg/dl were associated with an increased incidence of superficial and deep incisional surgical site infections. Serum total cholesterol levels showed a reverse J-shaped relationship with the development of organ space surgical site infection and pneumonia. There was no discernible effect of serum cholesterol levels on the postoperative mortality observed in this cohort of patients. Decreased serum albumin was one of the strongest risk factors for the development of nosocomial infection after surgery. Postoperative pneumonia was not observed in patients taking statin medications whose cholesterol levels were <200 mg/dl. Serum total cholesterol may be a valid predictor of surgical outcome. Preoperative statin use may affect the development of postoperative pneumonia in patients with total cholesterol levels below 200 mg/dl.