Lesser omental hernias are rare; however, they should be considered in symptomatic bowel obstruction subsequent to a subtotal or total colectomy. This report describes two cases of recurrent bowel obstruction secondary to lesser omental hernias after laparoscopic total colectomies for ulcerative colitis. Initially, these patients had been treated conservatively; however, due to symptom recurrence, surgical intervention was decided on. In both cases, laparoscopic surgery revealed lesser omental hernias. The small bowel, which had entered from the dorsal aspect of the stomach, was returned to the original position, and the lesser omentum was closed. The patients were discharged uneventfully, with no recurrent bowel obstruction during the follow-up period. These cases highlight the importance of including internal hernias in the differential diagnosis relative to recurrent bowel obstruction, in patient subpopulations with a prior history of a subtotal or total colectomy. Confirmation by computed tomography is preferable.

BACKGROUND AND AIM: Colitis-associated intestinal cancer (CAC) can develop in patients with inflammatory bowel disease; however, the malignant grade of CAC may differ from that of sporadic colorectal cancer (CRC). Therefore, we compared histological findings distinct from cancer stage between CAC and sporadic CRC to evaluate the features of CAC. METHODS: We reviewed the clinical and histological data collected from a nationwide database in Japan between 1983 and 2020. Patient characteristics were compared to distinguish ulcerative colitis (UC), Crohn's disease (CD), and sporadic CRC. Comparisons were performed by using all collected data and propensity score-matched data. RESULTS: A total of 1077 patients with UC-CAC, 297 with CD-CAC, and 136 927 with sporadic CRC were included. Although the prevalence of well or moderately differentiated adenocarcinoma (Tub1 and Tub2) decreased according to tumor progression for all diseases (P < 0.01), the prevalence of other histological findings, including signet ring cell carcinoma, mucinous carcinoma, poorly differentiated adenocarcinoma, or squamous cell carcinoma, was significantly higher in CAC than in sporadic CRC. Based on propensity score-matched data for 982 patients with UC and 268 with CD, the prevalence of histological findings other than Tub1 and Tub2 was also significantly higher in those with CAC. At pT4, mucinous carcinoma occurred at a significantly higher rate in patients with CD (45/86 [52.3%]) than in those with sporadic CRC (13/88 [14.8%]) (P < 0.01). CONCLUSION: CAC, including early-stage CAC, has a higher malignant grade than sporadic CRC, and this difference increases in significance with tumor progression.

INTRODUCTION: The aim of this study was to evaluate the effect of biologics on the risk of advanced-stage inflammatory bowel disease (IBD)-associated intestinal cancer from a nationwide multicenter data set. METHODS: The medical records of patients with Crohn's disease (CD) and ulcerative colitis (UC) diagnosed with IBD-associated intestinal neoplasia (dysplasia or cancer) from 1983 to 2020 were included in this study. Therapeutic agents were classified into 3 types: biologics, 5-aminosalicylic acid, and immunomodulators. The pathological cancer stage was compared based on the drug used in both patients with CD and UC. RESULTS: In total, 1,042 patients (214 CD and 828 UC patients) were included. None of the drugs were significantly associated with cancer stage in the patients with CD. In the patients with UC, an advanced cancer stage was significantly associated with less use of biologics (early stage: 7.7% vs advanced stage: 2.0%, P < 0.001), 5-aminosalicylic acid, and immunomodulators. Biologic use was associated with a lower incidence of advanced-stage cancer in patients diagnosed by regular surveillance (biologics [-] 24.5% vs [+] 9.1%, P = 0.043), but this was not the case for the other drugs. Multivariate analysis showed that biologic use was significantly associated with a lower risk of advanced-stage disease (odds ratio = 0.111 [95% confidence interval, 0.034-0.356], P < 0.001). DISCUSSION: Biologic use was associated with a lower risk of advanced IBD-associated cancer in patients with UC but not with CD. The mechanism of cancer progression between UC and CD may be different and needs to be further investigated.

PURPOSE: Recently, a new certification system called the Endoscopic Surgical Skill Qualification System (ESSQS) has been launched in Japan to improve surgical safety. This study aimed to determine whether ESSQS-qualified surgeons affect the short- and long-term outcomes of laparoscopic right hemicolectomy. METHODS: A total of 187 colon cancer patients who underwent laparoscopic right hemicolectomy at Kindai University Hospital between January 2016 and December 2020 were enrolled. These patients were divided into two groups based on surgeries performed by ESSQS-qualified surgeons (QS group) and non-ESSQS-qualified surgeons (NQS group). The short- and long-term outcomes were compared between the two groups before and after propensity score matching (PSM). RESULTS: After PSM, 43 patients from each group were included in the matched cohort. In the short-term outcomes, the total operative time was significantly longer in the NQS group than in the QS group (229 vs. 174 min, p < 0.0001). However, there were no significant differences in the two groups regarding blood loss (0 vs. 0 ml, p = 0.7126), conversion (0.0% vs. 7.0%, p = 0.0779), Clavien-Dindo ≥ 2 complications (9.3% vs. 7.0%, p = 0.6933), mortality (2.3% vs. 0.0%, p = 0.3145), and postoperative hospital stay (9 vs. 9 days, p = 0.5357). In the long-term outcomes, there were no significant differences between the two groups in the 3-year overall survival (86.6% vs. 83.0%, p = 0.8361) and recurrence-free survival (61.7% vs. 72.0%, p = 0.3394). CONCLUSION: Laparoscopic right hemicolectomy performed by ESSQS-qualified surgeons contributed to shorter operative time. Under the supervision of ESSQS-qualified surgeons, almost equivalent safety and oncological outcomes are expected even in surgeries performed by non-ESSQS-qualified surgeons.

BACKGROUND: Patients with longstanding inflammatory bowel disease are at high risk of developing intestinal cancers. In this study, we aimed to elucidate the differences between intestinal cancers associated with ulcerative colitis and Crohn's disease. METHODS: Intestinal cancers in ulcerative colitis and Crohn's disease patients treated between 1983 and 2020 at 43 Japanese institutions were retrospectively analyzed.. RESULTS: A total of 1505 intestinal cancers in 1189 ulcerative colitis and 316 Crohn's disease patients were studied. Almost all of ulcerative colitis-associated cancers (99%) were in the colon and rectum, whereas half of Crohn's disease-associated cancers (44%) were in the anus, with 11% in the small intestine. Ulcerative colitis-associated cancers were diagnosed more frequently by surveillance (67% vs. 25%, P < 0.0001) and at earlier stages (stages 0-1, 71% vs. 27%, P < 0.0001) compared with Crohn's disease-associated cancers. Colorectal cancers associated with Crohn's disease showed a significantly worse 5-year overall survival rate than those associated with ulcerative colitis (stage 2, 76% vs. 89%, P = 0.01, stage 3, 18% vs. 68%, P = 0.0009, and stage 4, 0% vs. 13%, P = 0.04). Surveillance correlated with earlier diagnoses for ulcerative colitis- and Crohn's disease-associated intestinal cancers, whereas shorter intervals between endoscopic examinations correlated with an earlier cancer diagnosis in ulcerative colitis patients but not in Crohn's disease patients. CONCLUSIONS: The clinical and oncological features of ulcerative colitis- and Crohn's disease-associated cancers were very different. Crohn's disease-associated cancers were diagnosed at more advanced stages and were detected less frequently by surveillance. Additionally, they showed a significantly poorer prognosis.

The use of temporary diverting stoma has become more common in low colorectal anastomosis to reduce anastomotic complications. Surgical site infection (SSI) at the stoma closure site has been one of the most frequent postoperative complications. The aim of this study was to compare the short-term outcomes between conventional primary suture closure and negative pressure wound therapy with instillation and dwelling (NPWTi-d) therapy following purse-string suturing, using propensity score matching analysis. We retrospectively evaluated the medical records of 107 patients who underwent stoma closure between January 2016 and October 2020. The primary outcome was the proportion of SSI. The secondary outcome was the day of postoperative length of stay. Propensity score matching with one-to-one match was performed for reducing treatment selection bias. Of a total of 107 patients, 67 patients had been treated with conventional primary closure and 40 with NPWTi-d therapy. The propensity score matching derived 37 pairs. The respective SSI proportions were 0% and 16.2% in the groups with NPWTi-d and primary closure (P = 0.025). The respective median days of postoperative hospital stay were 9.0 and 10.0 in the groups with NPWTi-d and primary closure (P = 0.453). NPWTi-d therapy with purse-string suturing was effective in reducing SSI after stoma closure.

BACKGROUND: Complete mesocolic excision (CME) with central vascular ligation (CVL) for colon cancer is an essential procedure for improved oncologic outcomes after surgery. Laparoscopic surgery for splenic flexure colon cancer was recently adopted due to a greater understanding of surgical anatomy and improvements in surgical techniques and innovative surgical devices. METHODS: We retrospectively analyzed the data of patients with splenic flexure colon cancer who underwent laparoscopic CME with CVL at our institution between January 2005 and December 2017. RESULTS: Forty-five patients (4.8%) were enrolled in this study. Laparoscopic CME with CVL was successfully performed in all patients. The median operative time was 178 min, and the median estimated blood loss was 20 g. Perioperative complications developed in 6 patients (13.3%). The median postoperative hospital stay was 9 days. According to the pathological report, the median number of harvested lymph nodes was 15, and lymph node metastasis developed in 14 patients (31.1%). No metastasis was observed at the root of the middle colic artery or the inferior mesenteric artery. The median follow-up period was 49 months. The cumulative 5-year overall survival and disease-free survival rates were 85.9% and 84.7%, respectively. The cancer-specific survival rate in stage I-III patients was 92.7%. Recurrence was observed in 5 patients (11.1%), including three patients with peritoneal dissemination and two patients with distant metastasis. CONCLUSIONS: Laparoscopic CME with CVL for splenic flexure colon cancer appears to be oncologically safe and feasible based on the short- and long-term outcomes in our study. However, it is careful to introduce this procedure to necessitate the anatomical understandings and surgeon's skill. The appropriate indications must be established with more case registries because our experience is limited.

BACKGROUND: Temporary stomas have been widely used to avoid the risk of complications such as anastomotic leakage after colorectal resection. Stoma closure is relatively easy; however, postoperative surgical site infection (SSI) may be a problem. Various methods have been used to reduce the incidence of SSI. We aimed to evaluate a new technique for stoma wound closure. METHODS: We enrolled patients who underwent stoma closure at our hospital between September 2019 and May 2020. We selected patients who lived far from our hospital and had difficulty visiting the hospital regularly and who agreed to undergo this surgical technique. We used negative pressure wound therapy with instillation and dwelling (NPWTi-d) and delayed primary closure for these patients. RESULTS: Four patients underwent NPWTi-d and delayed primary closure without the occurrence of SSI. The median postoperative hospital stay was 9 days (range: 7-14 days), and the median number of days to confirmation of epithelialization was 11.5 days (range: 10-16 days). CONCLUSION: The combined use of NPWTi-d and delayed primary closure for the stoma wound was very effective. This method may be a valuable new technique for wound management after stoma closure.

Intraoperative visualization of lymphatic flow could guide surgeons performing laparoscopic colon cancer surgery on the extent of intestinal resection required. The purpose of this study was to investigate indocyanine green fluorescence imaging for intraoperative detection of lymphatic flow and nodes in such patients. All patients undergoing elective laparoscopic surgery for colorectal cancer from October 2016 to July 2017 were included in this study. Indocyanine green was injected submucosally around the tumors via a colonoscope and lymphatic flow assessed with a laparoscopic near-infrared camera system intraoperatively. Lymphatic flow was visualized perioperatively in 43 of 57 patients (75.4%). The rate of visualized lymphatic flow was significantly higher in patients with a lower clinical stage than in those with a higher clinical stage (p = 0.0103). Among the 14 patients in whom lymphatic flow was not visualized, 10 (71.4%) had cStage III or IV cancer. Our results indicate the potential role of intraoperative navigation in colon cancer surgery in early-stage colon cancers. This method allows the surgeon to clearly identify lymphatic flow during surgery and allows the determination and individualization of the lymph node dissection range.

We present a case of locally advanced anal fistula cancer that was resected by total pelvic exenteration with genitalia resection and extensive perineal skin tissue resection. The patient was a 56-year-old man with a history of anal fistula treated at another hospital 15 years earlier. He was referred to our hospital for intractable anal fistula exacerbation and presented with many fistulas and drainage from the buttocks to the scrotum and penis. He was diagnosed with anal fistula cancer by biopsies from a fistula in the posterior wall of the anal canal. Preoperative CT and MRI revealed small bowel fistulas and suspected fistulas involving the urethra and bladder, which caused severe inflammation in the perineum. We performed sigmoid colostomy to improve his general condition prior to curative surgery. The patient then underwent total pelvic exenteration with genitalia resection, extensive perineal skin tissue resection, and treatment with a rectus abdominis musculocutaneous flap. He is currently alive without evidence of recurrence 19 months after surgery. For locally advanced anal fistula cancer with massive invasion into surrounding tissues and perineal skin, a wide en bloc resection including external genital resection is the preferred treatment.

消化器癌に対するロボット支援下手術(RS)は、2018年4月に胃癌に対する腹腔鏡下胃切除術(幽門側胃切除術)、腹腔鏡下噴門側胃切除術、腹腔鏡下胃全摘術の他に、食道癌に対する胸腔鏡下食道悪性腫瘍手術、直腸癌に対する腹腔鏡下直腸切除・切断術が保険収載され、今後ますます普及、発展していくことが予想される。RSで使用されるda Vinci Surgical Systemの利点として、手振れ防止機能、高解像度の3D内視鏡、多関節の鉗子、縮尺機能などがあげられる。一方、触覚がない、高額であるなどの欠点が指摘されているが、様々な科学技術の発展とともにRSも進歩していくことが期待される。消化器癌に対するRSに関して、一般的には時間はかかるが、出血量は少なく、合併症も低減できる可能性が報告されている。しかし、始まったばかりの手術であるため、エビデンスはまだ不十分であり、今後は、安全に行っていくともにエビデンスを構築していくことが求められている。(著者抄録)

Mesenteric cysts are rare intra-abdominal masses. They do not show classic clinical findings and are detected incidentally during imaging because of their absent or nonspecific clinical presentation. We herein report 2 cases of mesenteric cysts that were successfully diagnosed and resected through a laparoscopic approach. In a 35-year-old man underwent a comprehensive medical checkup at another hospital, during which ultrasound incidentally revealed a cystic mass in his right retroperitoneum. The patient was referred to our hospital for surgical treatment. He was asymptomatic and his medical history was unremarkable. Physical examination revealed no palpable abdominal mass, and all laboratory test results were within normal ranges. Contrast-enhanced computed tomography showed a 7.2-cm-diameter smooth-surfaced, well-demarcated mass behind the right colon without a contrast effect (Fig. 1). We considered the cyst to be benign and localized in the mesentery of the ascending colon. In one patient, the cyst was located in the mesentery of the ascending colon and removed via a right hemicolectomy; in the other patient, the cyst was located in the sigmoid mesentery, which was completely resected through the operative wound under an open procedure after laparoscopic mobilization of the sigmoid mesentery. We chose the laparoscopic approach in both cases because the cysts were considered benign, noninfectious, and nonhemorrhagic. Histologic examination revealed cystic lymphangioma in both cases. For mesenteric cysts, laparoscopy could be a preferred approach in properly selected patients.

We report a relatively rare case of cecal cancer with dermatomyositis. An 81-year-old man was diagnosed with dermatomyositis associated with the symptoms of eruption, limb muscle weakness, and difficulty swallowing. Colonoscopy revealed a type 2 tumor in the cecum. The patient underwent laparoscopic ileocecal resection. Although it was impossible for the patient to stand before the surgery, he could stand 10 days after the surgery and walk without assistance 14 days after the surgery. In addition, the eruption disappeared, and the preoperatively high creatine kinase(CK)value normalized. Dermatomyositis with malignant tumor has been reported to be associated with poor prognosis. Symptoms related to dermatomyositis may be improved by the resection of the associated tumor. Therefore, it is important to treat the malignant tumor when the patient's condition permits.

A 67-year-old woman presented with bloody stools and constipation. A rectal digital examination revealed a smooth and elastic hard tumor in the posterior wall of the rectum. We diagnosed the tumor as rectal GIST measuring 5 cm in diameter. Because the patient desired anal preservation, neoadjuvant imatinib mesylate(IM)(400mg/day)treatment was administered. Although the diameter of the tumor reduced to 2 cm in the third week of administration, the patient experienced erythema-type drug eruption(Grade 3). We discontinued the IM treatment and initiated steroid therapy. After the eruption had disappeared, IM treatment was resumed, initially with half doses. Local transanal resection was performed 36days after the neoadjuvant IM treatment. Currently, the indication and the administration period of IM for preoperative treatment is not clear. It may be necessary to accumulate cases to evaluate neoadjuvant IM therapy.

症例は66歳女性．直腸S状部（RS）癌に対し腹腔鏡下直腸高位前方切除術（DST再建，R0，根治度A）．術後病理診断でpStage IIであった．外来経過観察中血便を認め，直腸診で吻合部に腫瘤を触知，精査にて吻合部再発（tub2），側方リンパ節（LLNs）再発を認めた．局所および全身制御を目的として，術前mFOLFOX6を6コース施行し，内視鏡検査にて腫瘍の著明な縮小を確認，CT・MRI検査でもLLNsの縮小を認めた．初回手術後16ヵ月で直腸低位前方切除術（DST再建），LLNs郭清を施行した．切除標本の病理診断で組織学的効果判定はgrade3であり，LLNsも陰性でpCRであった．術後mFOLFOXを6コース施行し，現在再発巣切除術後3年無再発生存中である．局所制御に化学療法のみでもpCRがえられ，術後吻合部再発に対する治療として有用な選択肢になりうる可能性がある．

Patients with advanced colorectal cancer (CRC) have increased risks of brain metastases (BMs), which are associated with poor clinical outcomes. In a study of 25 patients with multiple brain lesions, we identified prognostic factors relevant to local treatment for BMs. After BMs onset, continued systemic chemotherapy might improve survival in cases of advanced CRC. Background: Increased rates of long-term survival after CRC diagnosis are accompanied by increases in the incidence of BMs. Here, we retrospectively evaluated the outcomes of patients with BMs from CRC. Materials and Methods: We reviewed the records of 1364 patients with CRC treated between January 1999 and December 2010 at Kinki University Hospital in Japan. Twenty-five of these patients developed BMs. Log-rank tests and Cox regression analyses were used to assess potential prognostic factors for survival. Results: Among the patients with BMs, BMs developed a median of 25.3 (range, 11.4-111) months after primary CRC surgery. There was a median of 2 BMs per patient. Eleven patients had solitary BMs. Concomitant extracerebral metastases, particularly lung metastases, were found in 23 patients. Twenty-three patients were receiving systemic chemotherapy at the time of diagnosis with BMs. After the development of BMs, the median survival time (MST) was 2.8 months. The MST was 4.8 months among patients who underwent neurosurgical resection (n = 6) or stereotactic surgery (n = 9, including combined therapy in 2 patients) and 1.5 months among patients who underwent whole-brain radiotherapy only or best supportive care (n = 12). In multivariate analysis, single BMs and additional systemic chemotherapy after BMs diagnosis were significantly associated with overall survival (P = .022 and .023, respectively). Conclusion: Our results suggest that advancements in continuing systemic chemotherapy prolong survival among patients with BMs from CRC. Clinicians should be especially aware of BMs in patients with lung metastases.

Background: Intersphincteric resection (ISR) has been used to avoid permanent colostomy in very low rectal cancer patients. This study aimed to assess the surgical safety and oncologic and functional outcomes of ISR. Methods: The records of 30 consecutive very low rectal cancer patients who underwent ISR without neoadjuvant therapy were retrospectively analyzed; survival and locoregional recurrence rates were calculated by the Kaplan-Meier method. Incontinence was assessed by a functionality questionnaire and the Wexner score. Results: The median distance between the distal margin of the dentate line was 10 mm. A total of 12, 4, and 14 patients underwent partial ISR, subtotal ISR, and total ISR, respectively. The mean distal resection margin was negative in all cases, and circumferential resection margin was positive in two cases. Morbidity was 33.3%: anastomotic stricture in seven patients, colonic J-pouch prolapse in two patients, and an anovaginal fistula in one patient. During the median, 56.2-month follow-up period, local, distant, and combined recurrences occurred in four, three, and two patients, respectively. The 5-year overall and disease-free survival rates were 76.5% and 68.4%, respectively. Local recurrence rates were 5.2% for the patients with Tis-T2 tumors as compared with 45.5% for those with T3 tumors (P = 0.008). The mean Wexner scores and stool frequencies, 12 months after stoma closure in 19 patients, were 11.5 and 6.6 per 24 h, respectively. Significant differences were not seen in the Wexner scores between partial ISR and subtotal/total ISR (11.8 +/- 2.6 and 9.1 +/- 5.6). Stool frequency (P = 0.02), urgency (P = 0.04), and fragmentation (P = 0.015) were worse in patients with anastomotic stricture than in those without; there was no symptom improvement in patients with anastomotic stricture. Conclusions: The anastomotic strictures in patients undergoing ISR may have negatively affected anal function. For total ISR patients, at least, informed consent stating the possibility of a permanent colostomy is necessary.

症例は71歳，女性. 既往歴は51歳時に子宮頸癌（扁平上皮癌）に対する広汎子宮全摘術および術後放射線療法（50Gy）が施行された. 14年後（65歳時）に直腸癌（中分化腺癌）に対し高位前方切除術を施行され，術後５年間無再発であった．今回，子宮頸癌治療後20年目に下腹部正中に皮膚の発赤および掻痒感が出現した．腹部骨盤CT検査で同部の皮下から腹直筋にかけて７cm大の腫瘤が認められた．生検組織の病理診断は低分化腺癌の疑いであったため，直腸癌の腹壁再発としてmFOLFOX6およびCPT-11による化学療法が施行された．治療効果がPDであったため，生検組織の免疫組織学的検査による再検討を行ったところ，ビメンチンのみ陽性で未分化な肉腫と診断された．その後アドリアマイシンによる化学療法が行われたが，皮膚症状出現後１年４カ月後に死亡した．今回，子宮頸癌治療後に放射線誘発と考えられた直腸癌および腹壁肉腫の１例を経験したので文献的考察を加え報告する.

Background: Paclitaxel is an effective agent in the treatment of metastatic breast cancer. The aim of this study was to evaluate the safety and efficacy of weekly paclitaxel-based preoperative chemotherapy in patients with large operable breast cancer. Methods: Patients initially received paclitaxel as a 3-hour infusion at 175 mg/m 2. Three weeks after initial administration, two cycles of three weeks of paclitaxel 80 mg/m 2 over a 1 hour infusion followed by a one week break were given. Of 22 patients, 9 had stage 11 (tumor diameter greater than 3 cm), 4 stage IIIA 7 stage IIIB, and 2 stage IV (with ipsilateral supraclavicular lymph node metastasis) cancer, respectively. Results: Excluding stage IV patients, the overall response rate to paclitaxel chemotherapy was 80%. Four of the 20 patients (20%) showed a clinical complete response (cCR). Two of these showed pathologic complete response and the other 2 had only the ductal component remaining. The primary tumor response and axillary lymph node downstaging following preoperative chemotherapy tended to be related in 16 patients with clinically positive nodes. Breast conserving surgery was performed as a result of downstaging in the 9 stage 1] patients. Grade 3 neutropenia occurred in one patient when 175 mg/m 2 of paclitaxel was administered, but no serious side effects developed during the weekly administration of paclitaxel. Conclusion: The use of weekly paclitaxel-based preoperative chemotherapy appears to yield a significant anti-tumor effect without inducing serious drug-related adverse effects. Furthermore, the effectiveness of this treatment appears to result in a higher frequency of breast conserving surgery.

近年乳癌で細胞周期調節に関与するcyclin Eの異常が有用な予後因子として注目されているが,その意義は確立されていない.10年以上の長期観察がなされている乳癌185例を対象に,免疫染色からcyclin Eならびに癌抑制遺伝子p53発現異常さらには乳癌治療に重要な因子であるHer2発現を解析し,それら分子生物学的因子の異常ならびに従来の臨床病理学的因子に基づき乳癌の予後を検討し,それらの長期予後因子としての有用性について研究した.185例中cyclin E陽性は69例(37%)にみられ,Her2陽性,p53陽性はそれぞれ22%,32%に認められた.cyclin E過剰発現とHer2過剰発現は核分裂像および核異型度と有意な関連がみられ,またHer2発現はホルモンレセプターと逆相関を示した.しかしp53発現はいずれの臨床病理学的因子とも関連は認められなかった.予後との解析から,腫瘍の分子生物学的因子であるcyclinE,Her2,p53発現などは独立した乳癌予後因子となり得なかった.しかしながらリンパ節転移ならびに核異型度は独立した長期予後因子であった.cyclin EおよびHer2発現の乳癌のリスク因子としての有用性は示唆されたが,予後の異なる乳癌集団でのリンパ節転移や核異型度の有用性と比べ,分子生物学的因子としての有用性は低いと考えられた.

エリスロポエチン(EPO)は赤芽球前駆細胞の細胞膜上に存在する特異的受容体であるエリスロポエチンレセプター(EPOR)と結合し赤芽球系細胞の分化および増殖を促進する.おもに腎や胎児の肝において分泌されるが他の組織でも分泌され,血管内皮細胞やニューロンなどの正常細胞,髄膜腫,子宮癌,卵巣癌,乳癌などの悪性腫瘍細胞においてもEPOやEPORの存在が報告されている.本研究では,原発性胃癌を対象として,腫瘍組織,正常組織,患者および正常人血清中のEPO値を測定し各々の比較検討を行った.さらに,ヌードマウスに原発性胃癌組織を移植しEPOR拮抗剤(EMP9)を投与し移植腫瘍に対するEPO情報遮断の影響について評価した.血清EPO値は胃癌症例で有意に高値を示した.リンパ節転移の有無と有意に相関した.組織中のEPO値は腫瘍および正常組織間に有意差を認めなかった.ヌードマウス移植腫瘍においてはEMP9投与群で有意にEPOR陽性細胞および新生血管数が減少していた.また,その40%に石灰沈着像を認める結果となった.EPO値は原発性胃癌において,リンパ節転移と有意な相関を認め,EPO-EPOR情報伝達を阻害することにより腫瘍細胞の増殖および血管新生を抑制する可能性を有することが示唆された.

健常女性と乳癌患者の血中エリスロポエチン(EPO)値及び腫瘍組織内とその周囲の乳腺組織内におけるEPO値をELISA法を用いて定量し,又,ヌードマウスに原発性乳癌組織を移植して得られた移植腫瘍に対しEPO様物質(EMP1),EPOR阻害剤(EMP9)を投与して,移植腫瘍への影響を検討した.血中EPO値は健常女性に比べ乳癌患者が有意に高値を示したが,臨床病理学的因子との間には相関関係は認めなかった.組織におけるEPO蛋白含有量では乳癌組織に比べ,周囲の乳腺組織が有意に高値を示した.ヌードマウスにおける移植腫瘍におけるEPO応答細胞の局在を抗特異的受容体(EPOR)抗体で検出したところ,腫瘍細胞と血管内皮細胞がEPOR陽性反応を示した.よって,EPOは乳癌における診断及び腫瘍増加や転移等の悪性度の判定基準となり,EPOR阻害物質であるEMP9が抗腫瘍効果を有することが示唆された

165個の癌関連遺伝子を一度に発現解析できるmembrane-based hybridization array法を用いて42例の正常乳腺組織と乳癌組織での遺伝子発現を比較し, 発現異常遺伝子を同定するとともに発現異常遺伝子間の関連性を検討した.正常組織と比べ癌組織で5培以上の発現上昇あるいは発現低下がみられた遺伝子を高発現または低発現遺伝子とすると, 症例間での変化した発現遺伝子数に相違がみられ, 1症例につき平均13遺伝子が高発現で19遺伝子が低発現であった.42例中7例以上の症例で高発現あるいは低発現であった遺伝子に限定すると, 12遺伝子が高発現で21遺伝子が低発現であった.高発現遺伝子のなかでは細胞外マトリックス分解酵素(MMPs)が多く, MMP-2,MMP-9,MMP-11は高発現で, うちMMP-9とMMP-11の発現に有意な相関が認められた.しかしMMP-7は低発現遺伝子で, 他のMMPsと発現に相関はなかった.低発現遺伝子ではアポトーシス関連遺伝子が多く見られ, caspase-2発現低下はBad低発現と有意な関連が認められたが, Fas発現低下との関連はみられなかった.臨床病理学的因子の関連からFGFR-2発現低下は腫瘍径の増大と有意な相関がみられた.本法による遺伝子発現解析から乳癌の生物学的多様性が示唆され, 同時に本法によって乳癌の新しい生物学的予後因子が同定できる可能性がある.

症例は56歳の男性で,15年前より痔瘻と診断され近医で加療されていた.難治性痔瘻増悪の診断で当科を紹介受診された際には,臀部から陰嚢および陰茎にかけて多数の瘻孔と排膿が認められた.肛門管後壁の瘻孔からの生検にて痔瘻癌と診断した.また,腸管同士の瘻孔形成を認め,尿道・膀胱への瘻孔形成が疑われた.痔瘻は広汎かつ深部に及び,会陰部の炎症が強いため,まずS状結腸人工肛門造設術を行い,全身状態と会陰部の炎症所見を改善させたうえで,外性器を含む広汎な会陰皮膚組織切除を伴う骨盤内臓全摘を行い,会陰欠損部に対して腹直筋皮弁形成術を施行した.現在,術後19ヵ月無再発生存中である.本例のように,腸管や尿道・膀胱への浸潤に加え,広汎な会陰部の皮膚浸潤が疑われる局所進展痔瘻癌に対しては,根治のために外性器切除を含めた広範囲の一塊切除が必要であると考えられる.(著者抄録)

郭清すべきリンパ節領域の同定が可能か検討するために、腹腔鏡手術予定の結腸癌患者50例を対象に、カラー蛍光内視鏡システムであるPINPOINTシステムを用いて、術中蛍光リンパ流・リンパ節診断を行い、臨床病理因子と比較検討を行った。手術前日あるいは前々日の内視鏡検査時に、インドシアニングリーンを腫瘍直下の粘膜下に局所注射を行った。経口リンパ流の有無については、手術開始時の蛍光状態で判定した。その結果、手術前日あるいは前々日の内視鏡検査による有害事象は認めなかった。手術開始時の蛍光リンパ流は、50例中39例で確認することができた。上行結腸癌13例では、蛍光リンパ流に沿った領域リンパ節に転移をきたす可能性が示唆された。横行結腸癌8例でも、同一の腫瘍局在であっても、症例ごとに異なる領域リンパ節に移転する可能性が示唆され、病理学的に転移陽性であった。術前の画像検査にてリンパ節腫大を認めない28例中、蛍光リンパ流を確認できなかったのは4例で、リンパ節腫大を認めた22例では7例であった。

症例は71歳,女性. 既往歴は51歳時に子宮頸癌(扁平上皮癌)に対する広汎子宮全摘術および術後放射線療法(50Gy)が施行された. 14年後(65歳時)に直腸癌(中分化腺癌)に対し高位前方切除術を施行され,術後5年間無再発であった.今回,子宮頸癌治療後20年目に下腹部正中に皮膚の発赤およびそう痒感が出現した.腹部骨盤CT検査で同部の皮下から腹直筋にかけて7cm大の腫瘤が認められた.生検組織の病理診断は低分化腺癌の疑いであったため,直腸癌の腹壁再発としてmFOLFOX6およびCPT-11による化学療法が施行された.治療効果がPDであったため,生検組織の免疫組織学的検査による再検討を行ったところ,ビメンチンのみ陽性で未分化な肉腫と診断された.その後アドリアマイシンによる化学療法が行われたが,皮膚症状出現後1年4ヵ月後に死亡した.今回,子宮頸癌治療後に放射線誘発と考えられた直腸癌および腹壁肉腫の1例を経験したので文献的考察を加え報告する.(著者抄録)

近年，網羅的遺伝子解析の手法によって癌関連抗原が数多く同定されてきた．RNF43，TOMM34は大腸癌に高発現（80％以上）しているが，正常粘膜にはほとんど発現のみられない遺伝子である．われわれは進行・再発大腸癌に対してこれら２種の新規癌関連遺伝子由来のペプチドと経口抗がん剤UFT/LV併用療法の第Ⅰ相臨床試験を行い，安全性ならびに臨床効果を検討した．登録された23例中21例がプロトコールを完遂したが重篤な有害事象なく，安全に施行することが可能で，生存期間中央値（MST）も24.4カ月と良好であった．しかも，RNF43，TOMM34両方にCTL活性が誘導された群が最も生存期間が長く，次いでどちらか一方に活性が得られた群，いずれの活性も得られなかった群は最も生存期間が不良であった．この結果から，今後さらに大規模な臨床研究を行う価値があると考えられた．

胃粘膜下腫瘍切除時、膵体部にしょう液性嚢胞腺腫を認めていたが放置した。1年後腫瘍の増大傾向を認め切除した。

乳房温存手術に対し，乳輪切開によるwide local excisionと内視鏡下腋窩郭清についてビデオ供覧を行った．

乳癌に対する色素法とラジオアイソトープ併用センチネルリンパ節生検の有用性について報告を行った．

乳腺造影CTと共に乳管の造影を行い，腫瘍の局在把握，切除範囲決定の有用性を報告した．

高齢者では安全性を優先し側方郭清、骨盤内臓全摘、肝切除を控える一方で、pouch operationと自律神経温存で積極的に機能温存が行われる。但し、社会生活レベルと将来の介護の可能性を考慮してハルトマン手術は選択される。

J型結腸嚢再建の術後機能は従来の端々吻合より良いが大きな結腸嚢作製は排便困難をもたらす。大きな結腸嚢作製でみられる排便困難に術後1年までにおこる結腸嚢長軸の水平化が関与する。

適応は肛門縁から吻合部までの距離が8cm以下であり、特に４cm以下の超低位吻合には必須である。術後5年でも従来のストレート再建より機能良好である。

J型結腸嚢再建を用いた低位前方切除の排便機能は良好であるが、大きな結腸嚢作製は排便困難の原因となる。大きな結腸嚢作製でみられる排便困難に術後1年までにおこる結腸嚢の過膨張が関与する。

結腸癌切除152例のリンパ節転移をクリアリング法で調べた。規約（転移の広がりで分類）はTNM（1992年版：転移の数と広がりで分類、1997年版：転移の数で分類）より症例数分布と5年生存率がwider rangeでありかつ郭清すべき領域を示すので臨床的に有用である。

さまざまな乳腺疾患に対しMultislice CTを利用した術前診断の有用性について検討を行った．

cDNAアレイを用いて遺伝子発現から乳癌の分子生物学的特性に基づく乳癌分類を試みた．