廣 純一郎

47歳女性,血便精査の大腸内視鏡検査でS状結腸に粘膜下腫瘤(submucosal tumor:SMT)様隆起に連なる潰瘍病変を認め,HE染色で低分化腺癌と診断された.画像上,S状結腸以外にも骨盤内に多数腫瘤を認め,腫瘍マーカーはCA125が高値であった.免疫染色でCK7(+),CK20(-),Pax-8(+)と判明し,婦人科癌の転移と診断した.審査腹腔鏡を行い,卵巣に異常を伴わない腹膜播種の所見であったため,腹膜癌(高異型度漿液性腺癌)と診断した.化学療法3コース後にdebulking surgeryを実施したところ,卵巣に同様の腺癌を認め,卵巣癌の診断に至った.骨盤内腫瘤を伴う大腸腫瘍では免疫染色を考慮することが有用である.(著者抄録)

The outer mucus layer of the colorectal epithelium is easily removable and colonized by commensal microbiota, while the inner mucus layer is firmly attached to the epithelium and devoid of bacteria. Although the specific bacteria penetrating the inner mucus layer can contact epithelial cells and trigger cancer development, most studies ignore the degree of mucus adhesion at sampling. Therefore, we evaluated whether bacteria adhering to tissues could be identified by removing the outer mucus layer. Our 16S rRNA gene sequencing analysis of 18 surgical specimens of human colorectal cancer revealed that Sutterella (P = 0.045) and Enterobacteriaceae (P = 0.045) were significantly enriched in the mucus covering the mucosa relative to the mucosa. Rikenellaceae (P = 0.026) was significantly enriched in the mucus covering cancer tissues compared with those same cancer tissues. Ruminococcaceae (P = 0.015), Enterobacteriaceae (P = 0.030), and Erysipelotrichaceae (P = 0.028) were significantly enriched in the mucus covering the mucosa compared with the mucus covering cancers. Fusobacterium (P = 0.038) was significantly enriched in the mucus covering cancers compared with the mucus covering the mucosa. Comparing the microbiomes of mucus and tissues with mucus removed may facilitate identifying bacteria that genuinely invade tissues and affect tumorigenesis.

OBJECTIVES: To determine whether the tongue menthol test, which measures the cold sensation detection threshold (CDT) of the tongue, used before and after oxaliplatin administration is an objective evaluation method for oxaliplatin-induced peripheral neuropathy (OPN). METHODS: The tongue menthol test was administered to patients both before and after undergoing chemotherapy containing oxaliplatin for colorectal cancer. The tongue menthol test was conducted by applying a menthol solution (a selective agonist of transient receptor potential cation channel subfamily M member 8 [TRPM8]) to the tongue and measuring the CDT. RESULTS: The mean CDT before the first dose of oxaliplatin was 0.34% (0.005%-1%; n=38), and the mean CDT after the first dose was 0.32% (0.005%-1%; n=38). The CDT appeared to decrease after the first dose, but this difference was not significant. In patients who received five courses of oxaliplatin, changes in CDT values were compared before and after the five courses. In patients with Neurotoxicity Criteria of Debiopharm (DEB-NTC) grade 2 neuropathy, the pre-oxaliplatin administration CDT was compared between before grade exacerbation and when exacerbation occurred, and was found to decline when grade exacerbation occurred. Moreover, when the CDTs before and after administration were compared before grade exacerbation, there was a significant decrease in CDT after administration (P=0.04). CONCLUSIONS: By performing a menthol test in oxaliplatin-treated patients, it may be possible to objectively predict the exacerbation of peripheral neuropathy at an early stage.

Obesity has been considered a risk factor for postoperative complications following colorectal cancer surgery. However, the usefulness of a combination of intracorporeal anastomosis and preoperative weight reduction for severely obese patients with colon cancer remains unclear. A 66-year-old man with a body mass index (BMI) of 43 kg/m2 presented with abdominal pain and iron deficiency anemia. Colonoscopy and computed tomography revealed advanced ascending colon cancer with regional lymph node metastasis and excessive abdominal fat. Preoperative diet-induced weight reduction was performed for severe obesity, which decreased his BMI to 39.7 kg/m2 after 1 month. Thereafter, curative resection was performed using intracorporeal anastomosis for reconstruction to achieve minimal colon and mesentery mobilization and a shorter incision. The patient was discharged from the hospital without complications. Laparoscopic right hemicolectomy combining intracorporeal anastomosis and preoperative weight reduction was extremely useful in the current patient with severe obesity and ascending colon cancer.

鼠径リンパ節郭清を施行した肛門管腺癌のうち、鼠径リンパ節転移(鼠径転移)陽性11例と陰性62例の治療成績を比較した。鼠径転移陽性例は陰性例に比して高齢で、術前血清CEAおよびCA19-9が高値で、非分化型腺癌、T4b、高度リンパ管侵襲例が多く、間膜内の転移リンパ節数および側方の転移リンパ節数が有意に多かった。鼠径転移陽性例の根治度A手術の施行率は63.6%(7例)と陰性例(93.5%)に比べて有意に低率であるが、Stage III症例では鼠径転移陽性例と陰性例で再発率、予後に差を認めなかった。鼠径転移陽性例では初再発部位として鼠径リンパ節(2例)、全再発部位では骨盤内再発(4例)が陰性例に比べて有意に高率であった。Stage III肛門管腺癌では鼠径転移陽性の治療成績は鼠径転移陰性と同等だが、鼠径リンパ節および骨盤内再発に注意した術後フォローアップが必要と考えられた。(著者抄録)

We reviewed clinical records of 73 cases with anal canal adenocarcinoma who underwent bilateral inguinal lymph node (ILN)dissection. Eleven patients with positive ILN metastasis(ILNM)were compared with 62 patients with negative ILNM in clinicopathological items and treatment outcomes to evaluate the effectiveness of ILN dissection. Positive ILNM were older, higher preoperative serum levels of CEA and CA19-9, more frequencies of undifferentiated carcinoma, T4b and severe lymphatic invasion than negative ILNM. And the number of mesorectal and lateral node metastasis were significantly more in positive ILNM than negative ILNM. Although the frequency of curability A surgery was significantly less in positive ILNM (63.6%)than negative ILNM(93.5%), there were no significant differences in recurrence rate and prognosis between positive ILNM and negative ILNM in Stage Ⅲ cancer. Recurrence in ILN occurred significantly more in positive ILNM (2 cases) than in negative ILNM(0 case)as initial recurrent site. And recurrence in pelvic local site occurred significantly more in positive ILNM(4 cases)than in negative ILNM(6 cases). Although there was no significant difference in oncological outcome in Stage Ⅲ anal canal adenocarcinoma, ILN recurrence and pelvic local recurrence should be cared for positive ILNM in postoperative follow-up.

症例は81歳男性。腹痛と嘔吐を主訴に当院を受診した。腹部所見は平坦やや硬で,腹部全体に圧痛と反跳痛を認めた。腹部CT検査では上腹部を中心に腹腔内遊離ガスと膀胱壁在気腫を認めた。上部消化管穿孔による汎発性腹膜炎を疑い,同日緊急手術を施行した。腹腔鏡下で腹腔内を観察すると淡血性の混濁した腹水を中等量認めるも,消化管に明らかな穿孔所見を認めなかった。膀胱右側壁に径1cmの穿孔所見を認め,膀胱破裂に伴う腹膜炎と診断した。穿孔部を縫合閉鎖し腹腔内を洗浄して手術を終了した。術後明らかな合併症を認めなかったが,廃用症候群が進んだためリハビリテーションを行い第35病日に退院した。膀胱破裂の際に腹腔内遊離ガスを伴うことがあり,消化管穿孔との鑑別が困難である。今回,消化管穿孔を疑い緊急手術を施行した気腫性膀胱炎に伴う膀胱破裂の1例を経験したので報告する。(著者抄録)

Purpose: The clinical significance of the platelet count × C-reactive protein level multiplier (P-CRP) in patients with locally advanced rectal cancer (LARC) undergoing neoadjuvant chemoradiotherapy followed by curative surgery has not been fully evaluated. Methods: In this retrospective study, the correlation between the P-CRP and prognosis was evaluated in 135 patients with LARC. We also performed a subgroup analysis limited to patients with pathological TNM stage III [ypN(+)] LARC. Results: The cut-off value of the P-CRP for prognosis was set at 4.11. The high and low P-CRP groups comprised 39 (28.89%) and 96 (71.11%) patients, respectively. Among the investigated clinicopathological factors, the serum carcinoembryonic antigen level and presence of recurrence were significantly associated with the P-CRP value. In the Kaplan–Meier analysis, both overall survival (OS) and disease-free survival (DFS) were shorter in the high P-CRP group (p &lt 0.0001 and p = 0.0002, respectively log-rank test). Multivariate analysis using a Cox proportional hazards model showed that a high P-CRP was an independent prognostic factor for OS [hazard ratio (HR) 29.20 95% confidence interval (CI), 3.42–294.44 p = 0.0024] and DFS (HR 5.89 95%CI 1.31–22.69 p = 0.023) in patients with LARC. In addition, a high P-CRP predicted poor OS and DFS in patients with pathological TNM stage III [ypN(+)] LARC (p = 0.0001 and p = 0.0012, respectively log-rank test). Conclusions: The P-CRP is a promising predictor of survival and recurrence in patients with LARC treated by neoadjuvant chemoradiotherapy followed by curative surgery.