鯉沼 広治

We report the first case of sigmoid volvulus after laparoscopic surgery for sigmoid colon cancer. The patient is a 75-year-old man who presented with the sudden onset of severe abdominal pain. He had undergone laparoscopic sigmoidectomy for cancer 2 years before presentation. CT scan showed a distended sigmoid colon with a mesenteric twist, or "whirl sign." Colonoscopy showed a mucosal spiral and luminal stenosis with dilated sigmoid colon distally and ischemic mucosa. The diagnosis of ischemic colonic necrosis due to sigmoid volvulus was established. Resection of the necrotic sigmoid colon was performed and a descending colon stoma was created. A long remnant sigmoid colon and chronic constipation may contribute to the development of sigmoid volvulus after laparoscopic sigmoidectomy. Prompt diagnosis is essential for adequate treatment, and colonoscopy aids in the diagnosis of ischemic changes in patients without definitive findings of a gangrenous colon.

A 64-year-old man received mFOLFOX6+bevacizumab chemotherapy for metastatic lung cancer after rectal cancer resection( Stage IV). After 28 courses, he had an abdominal pain with fever, and computed tomography showed pelvic abscess with stercolith of appendix. He was diagnosed as acute appendicitis with intra-abdominal abscess, and emergency appendectomy with drainage was performed. Two days after the operation, he was suspected to have a sutural leakage as was suggested from the properties of his drainage, therefore re-operation was performed. A small hole of the ileum, about 2mm in diameter, was observed. The margin of the hole showed neither inflammatory nor neoplastic change, and a suturing closure of the hole was performed. The post-operative course was uneventful. Histopathological findings of the resected appendix suggested that the perforation was caused by necrosis of metastatic cancer cells penetrating the appendiceal wall. This is a case of a bevacizumab-related metachronous perforation that occurred in different gastrointestinal origins within a very short term.

BACKGROUND: Lynch syndrome, also referred to as hereditary nonpolyposis colorectal cancer, is the most common form of hereditary colorectal cancer, and is associated with a high incidence of multiple primary neoplasms in various organs. METHODS: A 79-year-old woman (patient 1) diagnosed with ascending colon cancer had a history of previous carcinomas of the uterus, stomach, uroepithelial tract, and colon. One year later, she developed a brain tumor (glioblastoma). A 54-year-old female (patient 2) was diagnosed with endometrial cancer and sigmoid colon cancer. Both patients underwent genetic evaluations independently. RESULTS: No mutations were found in an exon-by-exon analysis of genomic DNA by polymerase chain reaction (PCR) and reverse transcription (RT)-PCR. However, multiplex ligation-dependent probe amplification (MLPA) identified genomic duplication spanning from exon 7 to exon 14 of the MSH2 gene in both patients. Due to the presence of this characteristic gene duplication, their pedigrees were investigated further, and these showed that they are paternal half-sisters, consistent with paternal inheritance. CONCLUSION: Large genomic duplication from intron 6 through intron 14 in MSH2 is a very rare cause of Lynch syndrome and is difficult to identify with conventional methods. MLPA may be an alternative approach for detecting large-scale genomic rearrangements.

We report a rare case of acute mastitis caused by enteric organisms passing through a cystoperitoneal shunt catheter, which had penetrated into the colon. The patient is a 56-year-old woman who underwent shunt placement for cyst formation after surgery for meningioma at the age of 29. After 26 years, she suffered from a brain abscess and an attempt was made to surgically remove the indwelling catheter. Only part of the catheter could be removed, leaving a divided and ligated catheter in situ. A year later, she described right-breast pain. CT showed that the catheter had migrated into the colon, followed by colonoscopy confirming that the catheter had indeed penetrated the colon. The breast to the abdomen segment of the catheter was exteriorized through the right-anterior chest wall without laparotomy. A patient who presents with acute mastitis and has previously undergone shunt surgery should have a careful assessment of the entire catheter.

大腸癌の予後および治療法の選択は深達度と密接に関係している.CT colonographyでは,MDCTの技術革新に伴って,短時間で仮想内視鏡像や仮想注腸像,MPR像といった様々なpost processing imageの作成が可能となった.一方,大腸内視鏡や注腸造影検査においては,これまでに培われたそれぞれの診断基準が存在する.CT colonographyにおける大腸癌の深達度診断においては,得られた様々なpost processing imageに,従来のモダリティで培われた診断基準を用いて,総合的に診断することで的確な深達度診断が可能と考える.(著者抄録)

We report a case of spontaneous regression of pulmonary metastases from a malignant phyllodes tumor. A 50-year-old woman was diagnosed with a breast phyllodes tumor. Computed tomography and positron emission tomography revealed multiple lung metastases. She underwent a mastectomy to control the pain of the enlarging breast mass. Histopathologic examination diagnosed a malignant phyllodes tumor. Without the administration of any adjuvant therapy, the follow-up chest computed tomography scan and positron emission tomography scan showed disappearance of the lung metastases 2 months after surgery.

Between 1989 and 2009, 10 patients with small bowel adenocarcinoma were treated in our hospital. These tumors appeared in the jejunum in 6 patients and in the ileum in the remaining 4 patients. All patients had some symptoms. The median size of the tumors was 50mm(30-110mm). All tumors were advanced type 2 lesion with severe stricture. Histologically there were 8 well, 1 moderately and 1 poorly differentiated adenocarcinomas. There were 8 tumors invading the serosa and 2 tumors invaded other organs. Positive lymph nodes were identified in 6 cases. Liver metastasis and peritoneal dissemination were identified in 3 and 4 cases, respectively. Eight cases were diagnosed as small bowel adenocarcinoma preoperatively by double balloon endoscopy. The 4 patients with stage II tumor and 2 patients with stage III tumor underwent curative-intent surgery. The 4 patients with stage II tumor are all surviving without evidence of disease now.

症例は53歳の女性．2006年頃から腹部膨満感を自覚した．2008年5月，近医での腹部超音波にて巨大な腹腔内嚢胞性病変を指摘され当科を受診した．腫瘍マーカーは基準値内であり，画像検査では肝左葉由来の単房性嚢胞性病変を認め，多数の壁在結節を有していた．胆管嚢胞腺癌の術前診断で，当院外科にて肝左葉切除術を施行した．病理組織学的検査にて乳頭状隆起は粘液円柱上皮で構成され，分裂像，核異型を認め，胆管嚢胞腺癌と診断した．卵巣様間質や胆管との交通は明らかでなかった．免疫染色ではMUC5ACがびまん性に陽性，MUC1は一部陽性で，MUC2とMUC6は陰性であり，胃腺窩上皮細胞の粘液形質を有していた．過去の報告例の検討でも同様に胃腺窩上皮細胞の粘液形質を示す傾向を認めた．<br>

症例は53歳，男性．7カ月前より下血と肛門痛が出現し，当院を受診した．肛門後方に痔瘻を認め，肛門縁より5cmの直腸に腫瘤を触知した．大腸内視鏡検査で下部直腸に全周性2型腫瘍を認め，直腸腫瘍と痔瘻2次口から突出した硬結部の生検結果は，いずれも高分化型腺癌であった．直腸癌および転移性痔瘻癌と診断し，腹会陰式直腸切断術，D3郭清を施行した．直腸癌は中分化型腺癌で，直腸癌と離れた痔瘻1次口部，2次口部と括約筋間に中分化型腺癌を認めた．原発巣と組織が同一であることから，直腸癌からの管腔内転移を来たした転移性痔瘻癌と診断した．<br> 痔瘻は日常診療でしばしば遭遇する疾患であるが，大腸癌との合併例では転移性痔瘻癌も念頭に置き，通常の痔瘻と異なる所見に注意し，とくに瘻管内の硬結に対しては積極的な生検が必要と考えられる．反対に，痔瘻癌と診断された症例では，大腸の精査を必ずすべきである．<br>

【目的】10mm以下の大腸SM深部浸潤癌が，内視鏡所見から診断できるか検討すること．【方法】当施設で大腸内視鏡検査が行われ，切除標本の病理組織検査で，腫瘍径10mm以下，SM深部浸潤（1,000μm以上）癌と診断された9病変を対象とし，その内視鏡写真を評価した．通常内視鏡所見では，明らかな陥凹，襞のひきつれ，表面凹凸不整，潰瘍・びらん，易出血性，緊満感の有無，拡大内視鏡所見ではピットパターンを評価項目とした．【結果】明らかな陥凹5例（56％），襞のひきつれ4例（44％），表面凹凸不整5例（56％），潰瘍・びらん2例（22％），易出血性3例（33％），緊満感3例（33％）を認めた．拡大観察では7例中4例（57％）にVN型ピットを認めた．9病変中8病変でいずれかの内視鏡所見が陽性であった．【結論】10mm以下のSM深部浸潤癌の多くは，通常内視鏡観察と拡大観察により診断可能と考えられた．

Evaluation of pathologic predictors of metastases in T1 stage colorectal cancer may be difficult with hematoxylin and eosin (HE) staining alone. The aim of this study was to clarify the role of pathologic predictors by using immunohistochemical staining and Elastica van Gieson (EVG) staining. One hundred and twenty-four patients who underwent bowel resection for single T1 stage colorectal cancer from 1990 to 2004 in 1 institution were studied. D2-40, EVG staining, and CAM5.2 were used to detect lymphatic invasion, venous invasion, and tumor budding, respectively. These 3 factors were separately evaluated based on HE staining. Histology was reviewed by 1 pathologist. Lymph node metastases in the surgical specimen were the standard reference, and distant metastases were identified by periodic computed tomography for 2 years or more after surgery. A logistic regression model was applied to analyze risk factors for lymph node metastases and a Cox regression model for distant metastases. In predicting lymph node metastases, univariate analysis demonstrated significance for all predictors except venous invasion by HE staining. Multivariate analysis showed that venous invasion by EVG and tumor budding by HE showed significance as predictors. In predicting distant metastases, univariate analysis showed significance for lymphatic invasion shown by D2-40, tumor budding shown by CAM5.2 and HE, and lymph node metastases. Multivariate analysis showed only venous invasion by EVG stain as being significantly associated with distant metastases (P=0.001). In conclusion, venous invasion evaluated shown by EVG staining is a useful pathologic predictor for metastases in T1 stage colorectal cancer.

The purpose of this study was to screen for genes involved in ovarian carcinogenesis in an attempt to develop an effective molecular-targeted therapy for ovarian cancer. We constructed retroviral expression libraries for the human ovarian cancer cell lines SHIN-3 and TYK-CPr, and performed a focus formation assay with 3T3 cells. As a result, proteasome subunit beta-type 2 (PSMB2), ubiquitin-specific protease 14 (USP14), and keratin 8 (KRT8) were identified from SHIN-3, and polymerase II RNA subunit (POLR2E), chaperonin containing T-complex polypeptide 1 subunit 4 (CCT4), glia maturation factor beta (GMFB), and neuroblastoma ras viral oncogene homolog (NRAS) from TYK-CPr. NRAS gene analysis revealed a CAA --> AAA substitution at codon 61, resulting in a Glu --> Lys change at position 61. When the mutant NRAS was introduced into fibroblasts for its expression, many transformed foci were generated, confirming the transforming ability of the mutant NRAS.

BACKGROUND: The diagnostic accuracy of conventional endoscopy for small colonic polyps is not satisfactory. Optimal band imaging (OBI) enhances the contrast of the mucosal surface without the use of dye. OBJECTIVE: To evaluate the diagnostic accuracy for the differentiation of neoplastic and non-neoplastic colorectal polyps by using magnified OBI colonoscopy. DESIGN: An open prospective study. SETTING: Jichi Medical University, Japan. PATIENTS: A total of 133 colonoscopy cases. MAIN OUTCOME MEASUREMENT: A comparative study of the overall accuracy, sensitivity, and specificity for the differentiation of neoplastic and non-neoplastic colorectal polyps < or =5 mm in size by capillary-pattern diagnosis by using conventional colonoscopy, capillary-pattern diagnosis in OBI, and pit-pattern diagnosis in chromoendoscopy with low magnification. RESULTS: A total of 107 polyps, composed of 80 neoplastic and 27 non-neoplastic polyps, were evaluated. OBI clearly showed the capillary network of the surface mucosa of neoplastic polyps at low magnification, whereas the surface mucosa of non-neoplastic polyps showed up as a pale lesion. The capillary pattern in conventional colonoscopy had 74% accuracy, 71% sensitivity, and 81% specificity for neoplastic polyps. The accuracy and sensitivity were significantly lower than those that used the capillary pattern in OBI (accuracy 87% and sensitivity 93%) and the pit pattern in chromoendoscopy (accuracy 86% and sensitivity 90%). There were no significant differences in specificity (OBI 70% and chromoendoscopy 74%). The kappa analysis indicated good agreement in both OBI and chromoendoscopy. CONCLUSIONS: Capillary-pattern diagnosis in OBI is superior to that in conventional endoscopy and is not significantly different from pit-pattern diagnosis for predicting the histology of small colorectal polyps.

A 27-year-old woman seen for irregular menstruation, and found to have a right ovarian cyst became pregnant and underwent laparotomy during the 18th week of pregnancy. Instead of an ovarian cyst, she was found to have a 13cm spindle-shaped tumor of the appendix, necessitating appendectomy and partial ceacal resection to avoid possible perforation during pregnancy. The surgical specimen proved histologically to be an appendiceal mucinous cystoadenoma. The patient and fetus had an uneventful postoperative course followed by a natural childbirth. We review the literature on appendiceal mucocele in pregnant women and its features. © 2009 The Japanese Society of Gastroenterological Surgery.

Colorectal carcinoma (CRC) remains the major cause of cancer death in humans. Although chromosomal structural anomaly is presumed to play an important role in the carcinogenesis of CRC, chromosomal copy number alterations (CNA) and loss of heterozygosity (LOH) have not yet been analyzed extensively at high resolution in CRC. Here we aim to identify recurrent CNA and LOH in human CRC with the use of single nucleotide polymorphism-typing microarrays, and to reveal their relevance to clinical outcome. Surgically resected CRC specimens and paired normal mucosa were obtained from a consecutive series of 94 patients with CRC, and both of them were subjected to genotyping with Affymetrix Mapping 50K arrays. CNA and LOH were inferred computationally on every single nucleotide polymorphism site by integrating the array data for paired specimens. Our large dataset reveals recurrent CNA in CRC at chromosomes 7, 8, 13, 18, and 20, and recurrent LOH at chromosomes 1p, 4q, 5q, 8p, 11q, 14q, 15q, 17p, 18, and 22. Frequent uniparental disomy was also identified in chromosomes 8p, 17p, and 18q. Very common CNA and LOH were present at narrow loci of <1 Mbp containing only a few genes. In addition, we revealed a number of novel CNA and LOH that were linked statistically to the prognosis of the patients. The precise and large-scale measurement of CNA and LOH in the CRC genome is efficient for pinpointing prognosis-related genome regions as well as providing a list of unknown genes that are likely to be involved in CRC development.

A 74-year-old man with diabetic nephropathy developed epigastric pain and high fever after endoscopic submucosal dissection (ESD) for early gastric cancer. Gastroscopy, endoscopic ultrasonography and computed tomography showed ulceration with a purulent lake, thickened entire gastric mucosal layers suggesting focal abscess formation, leading to the diagnosis of phlegmonous gastritis. He underwent total gastrectomy as an emergency. Histological findings of the resected specimen showed severe inflammatory cell infiltration and multiple focal abscess formation spreading to the entire gastric wall. In patients with poorer general conditions, phlegmonous gastritis should be considered as a serious complication after ESD, indicating a requirement of antibiotic prophylaxis.

PURPOSE: This study was designed to confirm the safety of not removing small adenoma in patients who undergo colorectal cancer surgery. METHODS: Patients who underwent surveillance colonoscopy after surgery were enrolled. The study was approved by our institutional review board. Colonoscopy was performed with magnification chromocolonoscopy. Benign adenomas of 6 mm or less in size, diagnosed based on both nonmagnified and magnified observation, were left unresected with a maximum of three polyps per patient. The sites of the polyps were marked by tattooing. Interval colonoscopy was performed predominantly yearly or biennially. Increase in size by 2 mm or larger was defined as significant. In follow-up, polyps were removed if they grew larger than 6 mm, were suspicious for high-grade dysplasia, or the patients requested to have polyps removal. RESULTS: Five hundred polyps in 284 patients met the above criteria and were not resected, and 412 polyps were followed by repeat colonoscopy. The mean observation period was 3.6+/-2.2 years and the mean number of repeat colonoscopy was 3.6+/-1.6. At the final colonoscopy, 71 percent of 412 polyps showed no change in size, 15 percent increased, 3 percent decreased, and 11 percent could not be identified. Eighty-eight polyps were resected endoscopically, and histology showed neither cancer nor adenomas with high-grade dysplasia. Two hundred fifty-five polyps detected in the same patient cohort during index/repeat colonoscopy were removed, including four adenomas with high-grade dysplasia and two T1 cancers. CONCLUSIONS: Leaving small polyps is safe even in patients who have undergone colorectal cancer surgery, provided that careful observation is guaranteed.

PURPOSE: Our purpose was to study the characteristics of colorectal neoplasms in patients with gastric cancer (GC). METHODS: The study group comprised GC patients who underwent colonoscopy before resection of their GC. We examined the prevalence, site, and histology of colorectal neoplasms, as well as the clinicopathological features and treatment of the patients who had synchronous colorectal cancers (CRC). The logistic regression model was applied to investigate the features of the GC patients with concurrent CRC. RESULTS: We studied 466 GC patients (mean age 64.5 years; 147 women, 319 men), 143 (31%) of whom had a family history of gastrointestinal cancer. Synchronous colorectal adenoma and cancer were detected in 182 (39%) and 18 (4%) patients, respectively. Among the 18 synchronous CRCs, 11 were in the early stages and 10 of these were resected endoscopically. The other eight required simultaneous open radical surgery. All the GC patients with synchronous CRC were older than 50 years. Statistical analysis did not show a significant difference between the features of the patients with and those without concurrent CRC. CONCLUSIONS: The possibility of synchronous colorectal neoplasms in GC patients cannot be disregarded in clinical practice; however, screening of the large bowel may not be necessary in GC patients younger than 50 years.

目的 : 回腸ストーマ閉鎖術における器械吻合と手縫い吻合の安全性と経済性についてprospective studyを施行した.<br>方法 : 器械吻合はfunctional end-to-end吻合, 手縫い吻合はlayer-to-layer吻合を行った. 器械吻合群は外科臨床経験2年以上の医師, 手縫い吻合群は4年以上で腸管の手縫い吻合の経験のある医師を術者とした.<br>結果 : 器械吻合群 (10例) と手縫い吻合群 (10例) の術者の平均臨床経験年数はそれぞれ3±1, 7±3年 (p<0.05) であった. 平均吻合時間は24±6, 58±16分 (p<0.05), 平均手術時間は96±21, 127±26分 (p<0.05) であった. 術後合併症は創感染が機械吻合群に1例, 手縫い吻合群に4例認められたのみで, 縫合不全やイレウスはなかった. 術後平均在院日数は10±3, 11±1日 (n.s.) であった. 手術材料費は器械吻合で32,000円, 手縫い吻合は24,827円であった.<br>結論 : 器械吻合は経験の少ない術者でも短時間で安全に施行可能で, コスト面でも手縫い吻合と大きな差は認められなかったため標準術式として妥当であると考えられた.

Sox9 is a member of the Sry-type HMG-box (Sox) gene family. It encodes a transcription factor and is thought to be important for sexual differentiation in chicken. In the present study we have isolated Sox9 cDNAs from quail and duck, and examined the expression patterns of the corresponding genes in early embryonic gonads by whole-mount in situ hybridization. We developed a polymerase chain reaction-based protocol to identify the sex of quail and duck embryos before its morphological manifestation. Sox9 expression was first detected on days 5 and 7 in the gonads of male quail and duck embryos, respectively, and was not apparent in female gonads at these stages. These expression patterns are similar to that of chicken Sox9. Our results thus suggest that the expression of quail and duck Sox9 is associated with testis differentiation.