A case of an adenoma of the nipple was reported. A 44-year old woman presented with bloody nipple discharge. No breast mass or skin involvement was observed. Ultrasonography revealed low echoic dilated duct and high echogenic mass inside. Cytological examination revealed a cluster of cells showing papillary growth. Microdochectomy was performed and histological examination revealed the mass being adenoma of the nipple. Clinical importance to avoid over-surgery and co-operation of surgeons and pathologists were discussed.

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We performed a breast conservation operation in 5 patients using a clinical pathway in 1995 and analyzed the effect on the patient's outcome. Compared to 5 patients without a clinical pathway during the same time period, the mean hospital stay decreased from 10.8 to 4.6 days and the amount of antibiotics decreased from 9.0 to 2.0g. A satisfactory effect was observed on the establishment of communication between staff and the standardized care of patients. Breast conservation operation seems to be a good candidate for the introduction of a clinical pathway. Further improvement could be obtained by reviewing the outcome of patients.

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Our breast quadrantectomy operative procedure and the clinical results are reported. We have performed this method in 19 patients with stage I and II breast cancer under general anesthesia. A negative margin of cancer was confirmed by intraoperative histological examination. Our method of quadrantectomy was performed without suturing both cut edges, which allowed interstitial fluid to collect. Of nineteen patients operated using this method, 17 were satisfied with the cosmetic results. Burn and infection were the causes of deformity of the preserved breast. Tight adaptation of the skin suture, avoiding burns due to electrocautery and suturing of the residual duct are recommended procedures for satisfactory results.

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A Case of hyperestradiolemia induced by Tamoxifen was reported. A 37-year old woman presented with right breast mass 3 days after delivery. The tumor, 1.2×1.0cm, was diagnosed to be cancer and quadrantectomy with axillar lymph node sampling was performed. Metastasis to the sampled lymph node (1/1) was observed. ER was negative but PgR was positive. Postoperative irradiation (50Gy) with adjuvant chemotherapy consisting of Epirubicin, CBDCA and 5FU was performed. After 2 months of Tamoxifen administration (20 mg/day), she developed vaginal bleeding and bilateral ovarian cysts with elevated serum level of estradiol (777 pg/ml). Tamoxifen for another month made the size of ovarian cysts larger and the concentration of estradiol higher (787 pg/ml). By discontinuing Tamoxifen, bilateral ovarian cysts disappeared and the level of estradiol recovered to normal in 3 months. The importance of careful observation of the hormonal environment of premenopausal breast cancer patient on Tamoxifen was discussed.

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十二指腸カルチノイド腫瘍は,比較的まれな疾患であるが,今回,びまん性脾転移をともない,その超音波像において高エコー結節像として検出された十二指腸球部カルチノイド腫瘍の1例を経験したので報告する.症例は,75歳の女性で左側腹部痛,体重減少を主訴に来院した.超音波検査で肝脾腫を認め,脾内にはびまん性に多数の小結節の集簇した腫瘤像を認めた.各種画像診断および腹水,肝,脾の穿刺細胞診を施行したが,確定診断の得られないまま入院後3ヵ月目に肝腎不全で死亡した.剖検を行ったところ,十二指腸球部に1.1cm大のカルチノイド腫瘍を認め,肝,脾,腎,肺,リンパ節など広範な転移を認めた.特に脾は著明に腫大し,内部にはびまん性に多数の小結節の集簇を認め,超音波像によく反映されていた.カルチノイド腫瘍の肝転移の超音波所見に関する報告は散見されるが,びまん性脾転移の超音波像に関する報告はなく,貴重な症例と考え報告した.

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Site planning for emergency temporary housing units is required to follow many rules and be suitable for site-specific conditions. To reduce the time for site planning, we have developed an automatic arrangement program that runs on BIM based on the concept that computers handle repetitive tasks that follow complicated rules, and humans handle unique tasks of adding conditions as appropriate. As a result, by using the developed program for a large site, we confirmed that it is possible to create site plans with the same number of temporary housing units as the conventional method in less than half the time.

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Laparoscopic cholecystectomy has proven to be a safe and effective treatment for symptomatic gall stone disease. However, laparoscopic cholecystectomy in hemodialysis patients is considered to be relatively contraindicated because of anemia and bleeding tendency. We performed laparoscopic cholecystectomy in three patients being treated by hemodialysis for chronic renal failure. No significant complications were observed after surgery. Laparoscopic cholecystectomy should be considered for hemodialysis patients requiring cholecystectomy.

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肝転移を伴う巨大直腸平滑筋肉腫を経験し, Miles手術および拡大左葉切除にて切除しえたので報告する.
症例は67歳,男性.排便障害・下血を主訴に来院した.注腸,内視鏡にて下縁が肛門縁より5cmに存在する潰瘍を伴う直腸粘膜下腫瘍と診断.針生検によって平滑筋肉腫と確診した.CT検査では骨盤内腔を占拠する巨大直腸腫瘍と肝S₄に単発性のSLOが認められた. Miles手術および二期的に施行した拡大左葉切除にて切除した腫瘍は原発巣: 13×12cm, 肝転移巣: 10×9cmで,ともに中心壊死を伴っていた.
直腸平滑筋肉腫は比較的まれな疾患であり,多くは管外性に発育するためその症状の発現が遅い.それゆえ原発巣の早期発見とそれに対する根治的手術および肝転移の積極的切除が予後の重要な因子と考えられる.

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We report a case of Mirizzi's syndrome managed by extracorporeal shock wave lithotripsy and endoscopic sphincterotomy. An 84-year-old man who was suspected of choledocholithiasis but preferred non surgical treatment was transfered to our hospital. The stone impacted in the dilated cystic duct was removed by endoscopic sphincterotomy after fragmentation by extracorporeal shock wave lithotripsy. Endoscopic retrograde cholangiography revealed that the dilated cystic duct branched into the lower common hepatic duct. Long-term results should be assessed carefully, but extracorporeal shock wave lithotripsy in combination with endoscopic sphincterotomy for Mirizzi's syndrome should be actively attempted because it is a non-invasive and effective technique.

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4例の十二指腸カルチノイドを経験したので術式選択について文献的考察を加えて報告する.症例1:53歳女性.過形成性ポリープの術前診断で十二指腸部分切除を行った.術後経過は良好である.症例2:47歳男性. Zollinger-Ellison症候群の術前診断で膵頭十二指腸切除を行った.リンパ節転移を認め現在生存中であるが肝転移を認めている.症例3:51歳男性.十二指腸ポリープの術前診断で十二指腸部分切除を行った.リンパ節転移を認め経過観察中である.症例4:69歳男性.十二指腸カルチノイドの術前診断で十二指腸部分切除を行った.術後経過は順調である.自験例4例を含めた89例の腫瘍径,深達度と転移の関係を調べた結果,腫瘍径20mm以上もしくは深達度pm以上では転移は著増し膵頭十二指腸切除を行うべきであると考えられた.また局所切除においても十二指腸授動を行いリンパ節転移を確認すべきであると考えられた.

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消化管平滑筋肉腫は比較的稀であるが,近年は報告例が増加してきている.本症は肝転移が多いという特徴をもち,予後不良なことから,転移性肝平滑筋肉腫に対して手術的治療が施行されることは少なかった.今回,直腸を原発とする平滑筋肉腫の術後,腹部CT検査にて肝右葉にlow density areaを認め,肝転移と考え,肝右葉部分切除を施行し,組織学的にも平滑筋肉腫の肝転移と診断された症例を経験した.本症の術前診断は臨床症状や臨床検査でも特異的なものがないため,一般的に困難であり,経過観察中に超音波検査やCT検査等により,肝転移を早期に発見する必要があると考えられた.また,平滑筋肉腫の肝転移巣に対する可及的な腫瘍切除術は,十分に延命効果が期待されるので,外科的療法の可能性を考慮すべきであると考えられた.

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腫瘤摘出術9年後に死亡した直腸平滑筋肉腫の1例を報告する.患者は52歳女性,肛門部腫瘤を主訴に来院した,肛門縁より6cmの直腸に鶏卵大の腫瘤を認め,摘出術を施行した.組織所見では細胞密度は高いが細胞異型は軽度で核分裂像もごく少数であり良悪性の診断は困難であったが,平滑筋肉腫と診断した.4年後に局所再発がみられ,腹会陰式直腸切断術を施行した.肝右葉に径2cmと1.5cm,左葉に1.5cmの転移を認め,Adriacin総量180mg,Picibanil総量40KEを全身投与し,6年後Adriacin総量120mgの肝動注を施行したが,著効はみられず摘出術9年後に死亡した.平滑筋腫瘍の良悪性の鑑別は時に困難で,そのような症例には積極的な手術適応と長期に渡る厳重な経過観察が必要と思われた.

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In recent years, interactive design platforms called “generative design” in which a computer performs parameter optimization for a parametric design model and a designer provides feedback, have begun to attract attention. The purpose of this study is to create a tool that automatically generates volumes of apartment buildings on an arbitrary site using a design co-creation environment, and to present a method for doing so. The tool includes two models: “the basic model” that is highly versatile for the site geometry, and “the kd-tree model” that can represent a variety of forms.

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We investigated the in vivo antitumor effect of recombinant human interferon-α, γ (IFN-α, γ) and/or recombinant human tumor necrosis factor-α (TNF-α) against human colon cancer cells (LoVo) transplanted into nude mice. LoVo cells were very sensitive to IFN-γ and slightly sensitive to IFN-α and resistant to TNF-α in vitro by dye uptake method. Intravenous administration of IFN-γ significantly inhibited tumor growth transplanted subcutaneously into nude mice, but IFN-α and/or TEN-α did not show any antitumor effect. Labeling index on staining with bromodeoxyuridine and mitotic index of LoVo cells treated with IFN-α, γ or TNF-α differed slightly from those of the control group. We previously reported that the synergistic antitumor effects on the three cell lines could be examined by the combined use of IFN-α and TNF-α and the mechanism of the synergism was arrested in the S phase of cell cycle of target cells. However in the case of LoVo cells, the combined use of IFN-α and TNF-α was not effective and did not arrest the cells in the S phase of cell cycle. Therefore, arrest in the S phase was suspected to be responsible from the synergistic antitumor activity of IFN-α and TNF-α on the sensitive targets.

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症例は88歳女性で, 肝左葉外側区より発生した単純性巨大肝嚢胞例である. 嚢胞は最大径22cmで左腹腔内全体を占め左腎及び左腎への脈管を圧迫し左腎機能障害を惹起していた. 嚢胞治療後左腎機能は回復 (腎シンチによる分腎機能: L-GFR4.8ml/min→19.1ml/min) した. 肝嚢胞により左腎機能障害を来した報告は本邦では本例が初めてである. 嚢胞は単房性で, 嚢胞壁は平滑で一部石灰化を伴っていた. 嚢胞液が初回1680ml排液され, 嚢胞液中のCA19-9, CEA, TPAが著明な高値を示したが, 性状は黄褐色漿液性であり, 悪性細胞や腫瘍細胞を認めず細菌培養及び寄生虫検索のいずれも陰性であった. 嚢胞腔はドレナージチューブ留置下の無水エタノール頻回注入により著明に縮小したが, 嚢胞腔消失には塩酸ミノサイクリンの追加注入が必要であった. 嚢胞腔内へのエタノール注入後のエタノール血中濃度が注入回数の増加に伴い低下したことより, エタノール注入を繰り返すことで嚢胞壁よりのエタノール吸収効率が低下することが推測された.

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In this study, we improved the developed automatic arrangement program for the site planning of emergency temporary housing that runs on BIM mainly for the following two points.

1.　The location of housing units and parking lots has been optimized with GA.

2.　The operation of drawing a surface has been replaced with the operation of arranging points and lines.

As a result, the number of housing units and parking lots in the new program increased by an average of 12% and 26% respectively, and the time for the site planning was shortened by an average of 37%.

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(背景と目的) 悪性腫瘍の増加に伴い, 重複癌の報告も多く認められるが, 臨床経過中の腎細胞癌に関する重複癌の纏った報告は無い. 男女に区分してその臨床的特徴を解析した.
(症例と方法) 804例の腎細胞癌中38例 (4.7%: 25例, 女性13例) の重複癌に関して臨床的特徴を男女に区分して検討した.
(結果) 全体としてみた場合, 胃癌が最も多く14例 (36.8%), 続いて肺癌, 前立腺癌,膀胱癌, 子宮癌がそれぞれ3例 (7.9%), 直腸癌, 甲状腺癌が2例 (5.3%), 咽頭癌, 食道癌, T-cell lymphoma, 慢性リンパ性白血病 (CLL), 腎盂癌, S状結腸癌, 脳腫瘍, 大腸癌が各々1例 (2.6%) ずつであった. この内男性では, 胃癌10例 (2例直接死因: 20%), 肺癌3例 (2例直接死因: 66.7%), 前立腺癌3例 (2例直接死因: 66.7), 膀胱癌3例 (1例直接死因: 33.3%), その他, 咽頭癌 (直接死因), 食道癌, T-cell lymphoma, CLL, 腎盂癌, S状結腸癌 (直接死因) が各々1例ずつであった. 女性では, 胃癌4例 (全て直接死因), 子宮癌3例 (全て直接死因), 直腸癌2例 (全て直接死因), 甲状腺癌2例 (1例直接死因), 脳腫瘍1例, 大腸癌1例であった. 加えて, 重複癌の発見の時期を検討した結果, 男性は同時性が10例 (40%) を占めたのに比較して, 女性は同時性の症例は認められ無かった.
(結論) 男女とも胃癌が重複として最も頻度が高かっが, 女性では重複癌による死亡が多く, 加えて同時性発見例がみられなかった.

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