浅野 之夫

This study aimed to validate the DFS (direct fast scarlet) staining in the diagnosis of EC (eosinophilic colitis). The study included 50 patients with EC and 60 with control colons. Among the 60 control samples, 39 and 21 were collected from the ascending and descending colons, respectively. We compared the median number of eosinophils and frequency of eosinophil degranulation by HE (hematoxylin and eosin) and DFS staining between the EC and control groups. In the right hemi-colon, eosinophil count by HE was useful in distinguishing between EC and control (41.5 vs. 26.0 cells/HPF, p < 0.001), but the ideal cutoff value is 27.5 cells/HPF (high-power field). However, this method is not useful in the left hemi-colon (12.5 vs. 13.0 cells/HPF, p = 0.990). The presence of degranulation by DFS allows us to distinguish between the groups even in the left hemi-colon (58% vs. 5%, p < 0.001). DFS staining also enabled a more accurate determination of degranulation than HE. According to the current standard to diagnose EC (count by HE staining ≥20 cells/HPF), mucosal sampling from left hemi-colon is problematic since the number of eosinophils could not be increased even in EC. Determination of degranulated eosinophils by DFS may potentiate the diagnostic performance even in such conditions.

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。

55歳の女性.検診で膵尾部の腫瘍を指摘され,腹腔鏡下膵体尾部切除術が施行された.病理検査の結果,PanNET G3(Ki-67指数>20%)と診断された.術後7ヵ月で胆管拡張と肝機能異常(AST:171U/l,ALT:86U/l)を認めた.腹部造影CTで主膵管内から十二指腸乳頭に充満する腫瘍を認め,上部消化管内視鏡検査では,Vater乳頭から赤色で白苔を有する乳頭状腫瘍の露出を認めたため,残膵全摘出術を施行した.免疫染色ではsynaptophysin,chromogranin Aが陽性で,Ki-67指数は30～40%であり,PanNET G3の再発と診断された.患者は2回目手術から24ヵ月無再発生存中である.(著者抄録)

In this review article, we focus on recent papers on organ-preserving pancreatectomy procedures published since 2010. When comparing central pancreatectomy (CP) and distal pancreatectomy (DP), most studies have concluded that the CP group exhibited significantly lower incidence of new-onset diabetes or diabetes exacerbation than the DP group postoperatively. However, because of increased incidence of morbidities such as pancreatic fistula, the surgeon faces a considerable trade-off between increased short-term morbidity and long-term preservation of endocrine function. When the outcomes of two types of spleen-preserving DP (Kimura and Warshaw procedures) are compared, most studies mentioned the low incidence of postoperative gastric varices and splenic infarction with the Kimura procedure. Although there are several reports regarding the effect of spleen preservation on prevention of postoperative infections, no report on the contribution of spleen preservation to the prevention of overwhelming post-splenectomy infection is seen. The advantages of duodenum-preserving pancreatic head resection (DPPHR) concerning endocrine and exocrine functions continue to be subjects of discussion, mainly due to the limited number of institutions that have adopted this approach; however, DPPHR should be presented as an option for patients due to its low incidence of postoperative cholangitis. Organ-preserving pancreatectomy requires meticulous surgical techniques, and postoperative complications may increase with this surgery compared with standard pancreatectomy, which may be influenced by the surgeon's skill and the surgical facility where the procedure is performed. Nonetheless, this technique has significant long-term advantages in terms of endocrine and exocrine functions and its wider adoption in the future is expected.

局所進行切除不能膵癌に対してFOLFIRINOX+放射線療法を行った後,conversion surgeryを施行した1例について報告する。症例は70歳代,女性。食後の腹痛を主訴に近医を受診し,腹部造影CTを撮影したところ,膵鉤部に上腸間膜動脈,第1空腸動脈,第2空腸動脈浸潤(>180°)を伴う不整形腫瘤を認めた。画像上,UR-LA(sm),cT4N0M0,cStage IIIの膵癌と診断され,mFOLFIRINOX 5コース施行した。その後,局所制御を目的として,放射線療法50.4Gy(三次元原体照射)を追加した。CA19-9は394.1U/mLから10.5U/mLへ低下した。治療効果はRECIST:partial responseと判定した。この後,根治術可能と判断し,初回治療から8ヵ月後に亜全胃温存膵頭十二指腸切除術を施行した。腫瘍は3×2mm相当とごくわずかな範囲に認められ,pStage IA,R0,術前化学療法の治療効果判定はEvans Grade IIIであった。患者は術後5ヵ月無再発生存中である。(著者抄録)

S状結腸癌および多発肝転移に対して化学療法後,肝切除術を施行し病理結果で完全寛解を得たが,化学療法中止後肝局所再発を来したため再肝切除を行った1例を報告する。下腹部痛で当院救急外来を受診した。大腸内視鏡では全周性のII型腫瘍を認め生検にて高分化型腺癌と診断された。根治目的にて腹腔鏡下S状結腸切除+D3リンパ節郭清を施行した。術後CTにてS5,S7,S8に肝転移を認め,Bev+modified FOLFOX(mFOLFOX)を11サイクル施行した。肝転移はいずれの部位でも縮小し肝右葉切除術を施行した。切除標本からはviableな癌組織は認めず完全寛解と考えられた。術後Bev+mFOLFOXを6サイクル再開し寛解を維持していたが,化学療法を中止した3ヵ月後,肝切除後1年6ヵ月後のフォローアップCTにて肝断端の局所再発を認め,肝転移局所再発と診断し開腹肝部分切除を行った。患者は術後9ヵ月現在,無再発生存中でありmFOLFOXを再開している。(著者抄録)

局所進行切除不能膵癌に対してFOLFIRINOX+放射線療法を行った後,conversion surgeryを施行した1例について報告する。症例は70歳代,女性。食後の腹痛を主訴に近医を受診し,腹部造影CTを撮影したところ,膵鉤部に上腸間膜動脈,第1空腸動脈,第2空腸動脈浸潤(>180°)を伴う不整形腫瘤を認めた。画像上,UR-LA(sm),cT4N0M0,cStage IIIの膵癌と診断され,mFOLFIRINOX 5コース施行した。その後,局所制御を目的として,放射線療法50.4Gy(三次元原体照射)を追加した。CA19-9は394.1U/mLから10.5U/mLへ低下した。治療効果はRECIST:partial responseと判定した。この後,根治術可能と判断し,初回治療から8ヵ月後に亜全胃温存膵頭十二指腸切除術を施行した。腫瘍は3×2mm相当とごくわずかな範囲に認められ,pStage IA,R0,術前化学療法の治療効果判定はEvans Grade IIIであった。患者は術後5ヵ月無再発生存中である。(著者抄録)

S状結腸癌および多発肝転移に対して化学療法後,肝切除術を施行し病理結果で完全寛解を得たが,化学療法中止後肝局所再発を来したため再肝切除を行った1例を報告する。下腹部痛で当院救急外来を受診した。大腸内視鏡では全周性のII型腫瘍を認め生検にて高分化型腺癌と診断された。根治目的にて腹腔鏡下S状結腸切除+D3リンパ節郭清を施行した。術後CTにてS5,S7,S8に肝転移を認め,Bev+modified FOLFOX(mFOLFOX)を11サイクル施行した。肝転移はいずれの部位でも縮小し肝右葉切除術を施行した。切除標本からはviableな癌組織は認めず完全寛解と考えられた。術後Bev+mFOLFOXを6サイクル再開し寛解を維持していたが,化学療法を中止した3ヵ月後,肝切除後1年6ヵ月後のフォローアップCTにて肝断端の局所再発を認め,肝転移局所再発と診断し開腹肝部分切除を行った。患者は術後9ヵ月現在,無再発生存中でありmFOLFOXを再開している。(著者抄録)

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.