佐久間 康成

膵頭十二指腸切除術(PD)を施行し術後胆管炎に、ダブルバルーン内視鏡逆行性胆道造影(DBERC)を施行した13例34回を対象とした。PDを施行した244例中20例(8.2%)に術後胆管炎を認め、反復する胆管炎症例も7例存在し、延べ合計47件の術後胆管炎を認めた。胆管狭窄を伴うものは11例で、吻合部再発をきたしたものは2例、術後胆管炎による死亡例は認めなかった。DBERCは13例、合計34件の術後胆管炎に実施し、肝門部へ到達できなかったのは1件のみで、97%の到達率であった。この1例は、後日再度DBERCを施行した際には到達できた。到達できた際には、造影やステント留置などの胆管内治療も全件において成功した。DBERC関連合併症による胆管炎の悪化や死亡例を認めなかった。

十二指腸乳頭部がんの外科治療において最も問題となるのは,深達度が乳頭部粘膜内にとどまる(T1a)か,Oddi筋に達する(T1b)かで,T1a以浅とT1b以深とでは治療の考え方が大きく異なる.Stage0〜IAの乳頭部がんの中には,内視鏡的,外科的乳頭切除術で治癒する症例は存在するが,『エビデンスに基づいた胆道癌診療ガイドライン改訂第2版』(2014年)で推奨される標準治療は,StageIB〜IIIと同様に,(幽門輪温存,亜全胃温存)膵頭十二指腸切除術である.(著者抄録)

Unilateral multiple adrenocortical micronodules (UMNs) constitute a rare subset of primary aldosteronism (PA) characterized by the hypersecretion of aldosterone derived from multiple small nodules in the zona glomerulosa of the unilateral adrenal grand. This case study describes a 49-year-old man with PA and UMNs who presented with muscle cramps at rest due to hypokalemia. The patient had a 6-year history of hypertension treated with antihypertensive drugs. Imaging studies revealed bilateral adrenal nodules as large as 5 mm. Adrenal venous sampling confirmed unilateral PA; therefore, the patient underwent the removal of the affected adrenal gland. Macroscopically, the removed adrenal gland exhibited irregular adrenocortical thickening accompanied by ill-defined, adrenocortical macronodules as large as 6 mm. The zona glomerulosa was histologically hyperplastic. However, an immunohistochemistry test of the steroidogenic enzymes revealed that these macronodules and the hyperplastic glomerular layer tested negative for CYB11B2. Moreover, we observed adrenocortical micronodules as large as 0.5 mm that tested immunohistochemically positive for CYP11B2 and HSD3B2 but negative for CYP17A1 and CYP11B1. Thus, UMNs were diagnosed. This case instructively indicates that a grossly or histologically detectable nodular lesion is not necessarily a culprit lesion for PA. Therefore, functional histopathology is indispensable for the correct subclassification of PA.

Pathological complete response (pCR) is considered to be a useful prognostic marker for neoadjuvant chemotherapy to improve the survival rate of patients with operable breast cancer. In the present study, we identified differentially expressed microRNAs (miRNAs) between pCR and non-pCR groups of patients with human epidermal growth factor receptor 2 (HER2)-positive breast cancer who received neoadjuvant chemotherapy with trastuzumab. Expression profiles were examined by miRNA microarrays using total RNA extracted from formalin-fixed, paraffin-embedded tissues from pretreatment biopsy specimens. Significant differences were observed in miRNAs associated with pCR between the luminal B-like (HER2-positive) and HER2-positive (nonluminal) subtypes, which were further classified according to their estrogen receptor (ER) status. Prediction models constructed with differentially expressed miRNAs performed well. In conclusion, the combination of miRNA profiles and ER status may improve the accuracy of pCR prediction in patients with HER2-positive breast cancer and enable the development of personalized treatment regimens.

近年、内視鏡的治療の進歩により、慢性膵炎およびその合併症(膵石症、膵仮性嚢胞、internal pancreatic fistula(IPF:膵性胸腹水)、胆道狭窄)に対して、膵管ステント留置、経胃的ドレナージなどの難易度の高い内視鏡手技が開発され、その低侵襲性から多くの病態では第一選択の治療となっている。しかし、すべての例で内視鏡的治療が実施できる訳ではなく、奏効率、長期成績では外科的治療に劣る部分もあり、どのようなタイミングで外科的治療を行うかを常に念頭に置いて治療計画を検討することが重要である。治療コンプライアンスの悪い症例などでは外科的治療を第一選択とすることも選択肢として、施設の熟達度を考慮し、十分なインフォームドコンセントを行ったうえで治療法を決定する必要がある。(著者抄録)

BACKGROUND: Long-term term survival in patients with pancreatic neuroendocrine tumors has been reported, even in patients with metastatic disease. Metastases to the spleen are extremely rare, but have been reported from a number of primary malignancies, such as breast cancer, lung cancer, melanoma and ovarian cancer. This is the first report of a splenic metastasis from a primary pancreatic neuroendocrine tumor. CASE PRESENTATION: The patient presented as a 53 years old white male with anemia and fatigue. Physical examination revealed a left upper quadrant fullness and computed tomography showed a 24 cm left upper quadrant mass with multiple liver metastases, splenomegaly and a 1 cm mass in the spleen. Resection of the primary pancreatic tumor (T4N0M1) was accompanied by gastrectomy, splenectomy and resection of adherent bowel. The spleen contained a metastatic lesion 1.0 cm in diameter, consistent with a primary neuroendocrine tumor of the pancreas. This operation was followed 8 months later, by delayed resection of liver metastases. The patient receives monthly administration of somatostatin long-acting analogue and has undergone several ablations of liver lesions with percutaneous radiofrequency ablation as well as a second liver resection. The patient is alive seven years after initial presentation, with no evidence of disease on imaging studies. CONCLUSIONS: This is the first report of a splenic metastasis from a primary pancreatic neuroendocrine tumor. The patient initially presented with synchronous multiple liver metastases and a single splenic metastasis. After resection of the primary tumor and spleen, the patient has undergone aggressive cytoreductive surgery/ablation of liver lesions and somatostatin therapy with resulting long-term survival.

INTRODUCTION: Pancreatic neuroendocrine tumors are rare. Treatment includes aggressive local management of the primary lesion and metastases, and systemic somatostatin. This is the first report of an isolated metachronous metastasis to the adrenal gland from a pancreatic neuroendocrine tumor that presented 90 months after the primary tumor. PRESENTATION OF CASE: The patient presented as a 53yo man with a left upper quadrant mass and synchronous metastases to the spleen and liver (pancreatic neuroendocrine tumor T4N0M1, Stage IV), which were resected (CD56-, synaptophysin+, chromogranin+, Ki-67<1%). Over the next 90 months, he underwent five procedures to treat hepatic recurrences (2 liver resections and 3 percutaneous radiofrequency ablations). Serum PIVKA levels were elevated prior to treatment of four of six lesions and returned to baseline after therapy. He presents now, asymptomatic, with a right adrenal mass found on routine imaging and no other lesions. Serum PIVKA was elevated to 44mg/dL. The adrenal gland was resected and shown to be a metastasis (CD56+, synaptophysin+, chromogranin+, Ki-67 15-20%). DISCUSSION: This patient's clinical course reflects aggressive local therapy of the primary lesion and multiple metastatic lesions to three organs (liver, spleen, adrenal) over nearly eight years. The utility of serum PIVKA levels in patients with pancreatic neuroendocrine tumors is not previously reported and needs further investigation. CONCLUSION: This patient has a pancreatic neuroendocrine tumor with metastases to the spleen, liver and adrenal gland and elevated PIVKA levels with recurrent disease. These unique clinical features add to the diversity of clinical presentation of these rare tumors.

慢性膵炎の疼痛治療として、まず内科的治療が行われる。外科的治療は内科的治療無効例に対して適応が検討される。膵管拡張例には膵管ドレナージ術が適応になり、術式としては主にPartington手術とFrey手術が行われる。膵切除術は、膵管拡張がなく病変が頭部もしくは体尾部に限局した症例が適応になるが、術後の膵内分泌機能低下が必発であり、それを上回る利点があると判断された症例に実施すべきである。膵全摘術、腹腔神経叢ブロック、(胸腔鏡下)内臓神経切除術は限られた症例のみが適応となる。慢性膵炎の疼痛治療は、症例により所見、疼痛の状態はさまざまで、慢性膵炎が良性疾患であることも考慮して、治療方針を決定する必要がある。外科的治療の実施にあたっても、断酒・禁煙を中心とする生活指導は重要で、治療コンプライアンスの高い症例に対してのみ治療を行うことが推奨される。(著者抄録)