越智 隆之

OBJECTIVE: This study was performed to demonstrate the clinical application of duodenum-preserving pancreatic head resection (DPPHR) as a surgical treatment for pancreatic neuroendocrine tumors (PNETs) in terms of both curability and maintenance of postoperative quality of life. METHODS: Seven patients diagnosed with PNETs underwent DPPHR from January 2011 to December 2021 at our institution. We investigated the clinical relevance of DPPHR based on the patients' clinicopathological findings. RESULTS: The median operative time was 492 min, and the median blood loss was 302 g. Postoperative complications were evaluated according to the Clavien-Dindo classification, and postoperative intra-abdominal bleeding was observed in one patient. Pathological examination revealed a World Health Organization classification of G1 in six patients and G2 in one patient. Microvascular invasion was observed in two patients (29%); however, no patients developed lymph node metastasis or recurrence during the follow-up period. A daughter lesion was observed near the primary tumor in one patient. All patients achieved curative resection, and no tumor specimens showed positive margins. CONCLUSIONS: DPPHR facilitates anatomical resection of the pancreatic head in patients with PNETs as well as detailed pathological evaluation of the resected specimen. Therefore, this surgical procedure is an acceptable alternative to pancreaticoduodenectomy or enucleation for patients with PNETs.

症例は68歳男で、19年前に膵体部IPMNに対して膵中央切除+膵管-膵管吻合(Martin手術)を施行された。今回、心窩部痛を主訴に受診し、CTで膵管吻合部から尾側に乏血性腫瘤を認め、残膵癌が疑われた。諸検査の結果から、膵管吻合部に発生したDe novo膵癌が強く疑われたため、残膵切除術を行うこととした。膵切離を行い迅速病理に提出したところ腺癌陽性と診断されたため術式を膵全摘に変更し、術後経過は良好であった。

We report a case of a woman in her 70s who underwent conversion surgery after FOLFIRINOX, followed by radiation therapy for initially locally advanced unresectable pancreatic cancer. She visited her local doctor with a chief complaint of upper abdominal pain. Contrast-enhanced CT scan of the abdomen revealed an irregular mass invading the superior mesenteric artery, and the first and second jejunal arteries(>180°)in the pancreatic uncinate region. Based on imaging, she was diagnosed as UR-LA(sm), cT4N0M0, cStage Ⅲ pancreatic cancer, and underwent 5 courses of modified FOLFIRINOX. Radiation therapy of 50.4 Gy was added for local control, and CA19-9 decreased from 394.1 U/mL to 10.5 U/mL. The treatment effect was judged as RECIST: partial response. The tumor was considered to be potentially curative, and a subtotal stomach preserving pancreaticoduodenectomy was performed 8 months after the initial treatment. The tumor was found to be 3× 2 mm in size, pStage ⅠA, R0, and the response to preoperative chemotherapy: Evans Grade Ⅲ. The patient is alive at 5 months postoperatively without recurrence.

We report a case of a patient with sigmoid colon cancer and multiple liver metastases who underwent hepatectomy after chemotherapy and pathological results showed complete remission. However, after chemotherapy was discontinued, the patient developed a local recurrence of the liver metastasis and underwent rehepatectomy. The patient came to our hospital with lower abdominal pain. Colonoscopy revealed a circumferential type Ⅱ, well-differentiated adenocarcinoma. Laparoscopic sigmoidectomy with lymph node dissection was performed. Postoperative CT scan showed multiple liver metastases at S5, S7, and S8. 11 cycles of bevacizumab plus modified FOLFOX(mFOLFOX)were subsequently performed. The liver metastases shrank at all sites, and the patient underwent right hepatectomy. The resected specimen was considered to be in complete remission, with no evidence of viable malignant cells. Postoperatively, bevacizumab plus mFOLFOX was resumed for 6 cycles and the patient remained in remission. However, 3 months after stopping chemotherapy and 1 year and 6 months after hepatectomy, a follow-up CT scan showed local recurrence of the liver edge, and a diagnosis of local recurrence of liver metastasis was made, and a partial hepatectomy was performed. The patient is recurrence-free and resuming modified FOLFOX 9 months after surgery.

症例は61歳女性。肝機能障害に対する精査中に肝病変が検出され当院に紹介された。血液検査でγ-GTP、ALT、可溶性IL-2受容体高値を認め、腫瘍マーカーは正常範囲内にあり、HBV表面抗原とHCVコア抗体は陰性であった。腹部造影CTでは肝後区に13cm大の病変がみられ、右肝動脈に付着しており、肝門部周囲から傍大動脈領域にビーズ様に肥大するリンパ節を認めた。また、MRIではT1強調像とT2強調像にて低信号を示す境界明瞭な表面不規則な病変が検出された。悪性疾患を疑いCTガイド下リンパ節生検を行ったところ悪性所見は認めず、腹腔鏡下アプローチにて診断的治療を行う方針とした。術中病理所見では腫瘍はみられず、拡張リンパ脈管の増殖はリンパ管腫または反応性リンパ管拡張を示唆するものであり、腹腔鏡下拡大肝後区域切除と右肝静脈切除術を施行した。肝後区域Glissonian茎の結紮、頭尾方向の虚血線に沿った肝切除、結紮Glissonian茎と肝静脈末梢部の分割、右肝静脈主幹部の露出、後腹膜からの肝病変の摘出を行った。切除検体の組織診では上皮細胞はみられず、びまん性の病変内線維化が生じており、小血管の増殖、血管拡張、ヘモジデリン沈着、リンパ球、形質細胞優位の炎症細胞浸潤が認められ、炎症性偽腫瘍と最終診断した。術後16日目に退院となり、その後2年、無症状で経過している。