べーチェット病として経過観察中に巨大な食道潰瘍が出現し,その進展様式と治癒過程を観察し得た1例を経験した.症例は19歳,男性.昭和61年よりべーチェット病として経過観察中,平成2年5月に嚥下痛・胸骨後部痛が出現.内視鏡検査にて食道中下部にしもふり状のびらんを認めた.6月の内視鏡検査ではキッシング状の潰瘍となり,7月には厚い白苔に覆われたほぼ全周性の潰瘍へと進展した.また食道潰瘍の増大とともに白血球増多等の炎症所見を認め,回盲部病変も出現した.プレドニゾロンの投与にても改善はみられなかったが,Total parenteral nutrition(TPN)療法を開始したところ回盲部病変は改善し,また食道潰瘍は徐々に縮小し炎症所見の改善とともに治癒した.べーチェット病に伴う食道潰瘍は円形で浅いものが多数報告されているが,広範囲にわたる巨大なものも重症の難治例に報告されている.本症例でみられた食道潰瘍は,経過中多彩な像を呈し,ほぼ全周性の巨大潰瘍へと進展した.本症例に合併した食道潰瘍は広範囲にわたる巨大な潰瘍であったが,TPN療法が有効であり治癒せしめることができた.

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In bronchial, esophageal and gastric photodynamic therapy (PDT) we were dazzled by the reflection of red laser light during photoradiation, especially in the use of the pulse laser such as an excimer dye laser. Initially we placed a green filter on the eyepiece of the fiberscope to protect the naked eye from being dazzled during photoradiation. Later, we also inserted a green filter in front of the CCD-camera in an OES-TV system with a NTSC signal. The red spot of laser light could be observed clearly, but the mucosal image turned to green and the boundary between cancer and surrounding mucosa became unclear. We, therefore, developed a new device for endoscopic photoradiation that consists of a conventional fiberscope and a new OES-TV system which has a high resolution and sensitivity with automatic gain controller and the signal can be sent out by RGB. We inserted an interference filter specially made to order in front of the CCD which specifically absorbs a red light, whose transmissivity rate at 630 nm wavelength is 15% and the full width at half maximum is 26 nm, while an average transmissivity is 94%. In order to make an optimal balance between a white xenon light and the red laser beam, we also inserted a neutral density filter of ND-0.8 which transmits 16%. However, these filters were not enough to absorb the red laser beam. By this trial we could find the spectral specificity of the filter to make the optimal balance in the use of the excimer dye laser of 4mJ/pulse and 80Hz. In conclusion, the filter should be qualified the specifications as follows: an average transmittance requires more than 20%, the transmissivity rate at 630 nm should be less than 1%, and the rates between an average transmittance and the transmissivity rate at 630 nm should be more than 20 times.

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In the 1980's, we had treated thirty-seven patients with early gastric cancer by photodynamic therapy (PDT) with Photofrin I or H and an argon dye laser. The energy intensity was over 90 J/cm². However, the rates of cure were only 57%. In order to improve the therapeutic effectiveness of PDT, we started employing the pulse laser, such as an excimer dye laser (EDL; Hamamatsu Photonics, Hamamatsu, Japan) in 1990 and an optical parametric oscillator system pumped by a Q-switched Nd: YAG laser (YAG-OPO laser; Ishikawajima-Harima Heavy Industries, Tokyo, Japan) in 1995, because the pulse laser with extremely high peak power was expected to be more efficient at exciting HpD than a continuous wave laser. EDL has peak power of 400 kW and YAG-OPO laser 700 kW. We treated thirty-five patients with early gastric cancer using Photofrin^R and the EDL or the YAG-OPO laser, who were at poor risk for conventional surgery. The entire lesion, plus a 5-mm wide perimeter of mucosa, was irradiated uniformly with laser beams transmitted endoscopically. The energy intensity was over 60 J/cm². By employing pulse lasers, the rates of cure were markedly improved to 95%(18 of 19) in mucosal cancer, 71%(12 of 17) in submucosal cancer, 83% in total, including two cases that required the second session of PDT. With the YAG-OPO laser, a wide mucosal carcinoma was cured, whose size was 19 cm² in area, though the energy intensity was 48 J/cm². Concerning responses to PDT, signet-ring cell carcinoma and submucosal cancer had tendencies of resistance to the treatment by PDT. We treated five patients with advanced gastric cancer using Photofrin^R and the EDL and one patient with type 2' advanced MP' cancer, whose tumor was 13cm² in area, was cured completely. There were no serious side effects caused by PDT. In conclusion, a pulse laser with extremely high peak power had markedly improved cure rates of PDT for early gastric cancer and demonstrated the possibility of treatment of advanced gastric cancer in case of no metastasis using PDT in the future.

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From 1981 to 1990, we had treated thirty-seven cases with early gastric cancer by PDT with HpD (Photofrin ^RI) or DHE (Photofrin ^RII) and an argon dye laser (ADL). However, the rates of cure were only 59%(13 out of 22 cases) in mucosal cancer, 53%(8 out of 15 cases) in submucosal cancer, and 57%in total. In order to improve the therapeutic effectiveness of PDT with DHE for early gastric cancer, we employed an excimer dye laser (EDL; Hamamatsu Photonics, Hamamatsu, Japan) instead of an ADL in 1990, and then improved the EDL in 1993 to apply PDT to the wider lesion, whose size is within 4cm in diameter and 13 cm² in arca. The characteristics of an New EDL are as follows: wavelength, 630nm; pulse energy, 4 mJ; peak power, 400kW; pulse width, 10 nsec; frequency of repetition, 80Hz; average output, 320mW. The entire lesion, plus a 5-mm wick, perimeter of mucosa, was irradiated uniformly with an EDL beam transmitted endoscopically. The energy intensity of an EDL was over 60 J/cm². By employing an EDL, the rates of cure were markedly improved up to 93%(14 out of 15 cases) in mucosal cancer, 73%(8 out of 11 cases) in submucosal cancer, and 85%in total. It was thought that an EDL can penetrate deeper and activate DHE more efficiently than an ADL. Since 1995, we have been treating early gastric cancer by PDT with DHE and an optical parametric oscillator system pumped by a Q-switched Nd YAG laser (YAG-OPO laser; Ishikawajima-Harima Heavy Industries, Tokyo, Japan). It has a high peak power of 700kW though its average output is 250mW. By employing a YAG-OPO laser, a wide cancerous lesion was cured, whose size was 19cm² in area. In conclusion, PDT with a pulsed laser, which has a high peak power, is more effective for treating early gastric cancer than that with an ADL.

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Esophageal cancer reacts to photodynamic therapy (PDT) markedly and it necrotizes easily besides the ulcer after PDT repairs soon, because it is more sensitive to PDT than gastric cancer. In order to improve the therapeutic effectiveness of PDT with Photofrin II and laser light for superficial esophageal cancer, we employed an excimer dye laser instead of an argon dye laser since 1990. The characteristics of the current laser are as follows: wavelength, 630nm; pulse energy, 4mJ; peak power, 400kW; pulse width, 10nsec; frequency of repetition, 80Hz; average output, 320mW. The entire lesion plus a 5-mm wide perimeter of mucosa was irradiated with an EDL beam at 630nm wave length transmitted endoscopically.
In PDT for esophageal cancer, we had used a front-view fiberscope (model GIF-P10, GIF-XQ20, Olympus, Tokyo, Japan) for five cases with esophageal cancer according to the traditional method of diagnostic endoscopy until 1991. But uniform irradiation was difficult, especially with large lesions, because of esophageal peristalsis and respiratory movement. Since the first trial using a side-view fiberscope in PDT for esophageal cancer in 1992, we used a side-view fiberscope (model GF-20, Olympus, Tokyo, Japan) for five cases with esophageal cancer, not only in PDT, but also in pretreatment examinations and follow-up examinations. Two of them were located in abdominal esophagus (Ea) just above EC junction, where PDT had been considered out of application. In this procedure, patients with a lesion located on the right side can lie in a left lateral position as usual, whereas patients with a lesion located in the left side, especially from 7 to 10 o'clock, must lie in a right lateral position. This enabled photoradiation of esophageal cancer from a 90°angle without any difficulty, besides with less energy intensity of the irradiated laser light. Of these 10 lesions, 9 were cured by initial treatment and no recurrence was proved by endoscopy and biopsy. The final rate of cure was 90% (9/10).

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症例は57歳男性.25歳時,食道アカラシアの手術既往がある.べーチェット病,糖尿病にて経過観察中,特に誘因なく心窩部痛と39度の発熱が出現.上部消化管内視鏡検査にて胃体上部後壁に緊満感を有する粘膜下腫瘤様の病変を認め,中心陥凹部より自色膿性物の流出を認めた.膿性物の細胞診では悪性細胞は認めず,多数の好中球を認め培養ではStreptococcus属を認めた。画像検査とあわせて胃壁膿瘍と診断,抗生物質の投与により腹部症状,炎症所見ともに改善した.初回より50日後の内視鏡検査にて食道胃粘膜接合部直上後壁に直径5mmの開孔を確認,胃体上部後壁の粘膜下腫瘤は瘢痕化しており中心陥凹部と食道開孔部との瘻孔を確認した.約4年間の経過観察にても瘻孔の閉鎖傾向は認められていない.

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Photodynamic therapy (PDT) is a new endoscopic method for treating malignant tumors using a photosensitizer and a laser. We employed a new pulse laser as the excitation light source for PDT to treat early gastric cancer, which is an optical parametric oscillator system pumped by a Q-switched Nd: YAG laser (YAG-OPO laser; Ishikawajima-Harima Heavy Industries, Tokyo, Japan). It has a high peak power of 700 kW and its average output is 250 mW. Because of the tunability of wavelength which is between 620-670 nm enables it to be used for various kinds of new photosensitizers.
From June 1995 until December 1997, we performed a cooperative clinical trial of PDT for early gastric cancer with Photofrin Injection^R and the YAG-OPO laser. Fifteen patients were enrolled and 12 were evaluable for response. Complete responses (CR) were obtained in 75% of twelve patients, including two cases that required the second session of PDT. According to the depth of the lesion, CR was observed in all cases with mucosal carcinoma and 63% with submucosal carcinoma One case, whose tumor was 19cm² in area, was ineligible because of its large size but the cancerous lesion was cured completely. Regarding toxicity, mild photosensitivity was seen in one case and it lasted several weeks. Another major side effect was the decrease of total protein, which was observed in six patients (40%) and it lasted several months. There were no serious abnormalities in symptoms or laboratory tests.
We conclude that YAG-OPO laser has the capability of acting as the excitation light source for PDT.

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We have been performed PDT with a gold vapor laser (GVL) since 1988 and with a excimer dye laser (EDL) since 1994 for inoperable gastric cancer. We have treated 21 early gastric cancer lesion (18 cases) by only PDT with GVL. The rate of cure for mucosal carcinomas was 81.3% (13/16), that of submucosal carcinomas was 60% (3/5). Eight of 10 Ul (+) II c (superficial depressed type with ulcer) lesions were cured by PDT. Recently endoscopic mucosal resection (EMR) has been performed for the treatment of early gastric cancer in general. However, we designed a new therapy named“endoscopic combined therapy”combined PDT with Nd: YAG and electrocoagulation. This therapy is useful for some type of advanced gastric cancer. These results suggested that a role of PDT is treatment of early gastric cancer which doesn't apply to EMR. And PDT is one of useful treatment for some type of advanced gastric cancer.

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　症例は56歳の男性.完全型Behcet病にて加療中,口腔内の疼痛および嚥下痛を訴えたため,上部内視鏡検査を施行したところ,口腔内アフタ,食道上部から中部にかけて多発性の浅い潰瘍を認めた.同時に皮膚,外陰部病変が増悪し, Behcet病に伴う食道病変と診断した.食道および皮膚病変はコルヒチンの増量で軽快したが,19カ月後に再発した. Behcet病に伴う食道病変は稀であり,貴重と考え報告する.

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症例は64歳女性,便秘の精査のため入院.精査の結果,上行結腸下部に進行癌と,その背側に鶏卵大の嚢胞を認めた.手術所見は潰瘍浸潤型の上行結腸癌(高分化型腺癌)に接して,単房性嚢胞が併存し,一部で癌が嚢胞内に穿破していた.嚢胞の内面は単層の細胞で覆われ,免疫組織学的検討では,ケラチン,ビメンチンが陽性,CEA,第Vm因子関連抗原が陰性であり中皮性嚢胞と判明した.大腸癌に中皮性嚢胞を併存した報告はなく,本例は腹腔内中皮性嚢胞の発生機作を検討する上で興味ある症例と考え報告した.

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症例は53歳，女性．腹痛，吐血を主訴に救急車で搬送された．腹部CTにて腹腔内遊離ガスを認め，上部消化管穿孔の診断にて，緊急手術を施行した．開腹所見で胃癌穿孔，膵臓浸潤，腹膜播種と診断し大網充填術，胃空腸吻合術を施行した．術後TS-1，TS-1+CDDP，TS-1+CPT-11を施行し，4年以上の長期生存を得られている．胃癌穿孔・非切除例の長期生存の報告はなく，貴重な1例を経験したので報告する．

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　背景・目的:赤外線内視鏡検査は白色光よりも組織透過性のよい近赤外光を光源に用いることで,通常観察では見えない粘膜の下の血管をとらえ消化管癌の深達度や拡がり診断を行うものである.今回われわれは2波長赤外線内視鏡を用いて胃癌に対する診断能を検討した.　対象と方法:当センターで外科手術もしくはEMRを行った早期癌病型の陥凹型胃癌30例を対象とした.これらに2波長赤外線内視鏡検査を行い,病巣部が染まらない“不染所見” もしくは病巣全体が淡く均一に染まる“淡染所見” を呈するもの,ICGが病巣周囲に点状に貯留する“pooling所見” を呈するもの,病巣の一部に濃く貯留する“ 濃染所見” を呈するものに分類し,癌の深達度との関連を検討した.　結果:2波長赤外線内視鏡検査で“ 不染所見”,“ 淡染所見” が得られた23例中21例(91%)がmもしくはsm　1,000mより浅いsm癌で,“pooling所見”,“ 濃染所見” が得られた7例中7例がsm　1,000mより深いsm癌であり,その正診率は93%であった.特に通常内視鏡検査やEUSでの診断が困難とされているUI(+)の病巣でも95%(18/19例)の病巣で深達度を正診できた.　結語:赤外線電子内視鏡はUlの有無に関わらず,陥凹型早期胃癌の診断に有効と考えられた.

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目的: 局所切除後の大腸sm癌に対するリンパ節郭清の適応基準を明らかにすることを目的として臨床病理学的因子を検討した.対象と方法: リンパ節郭清を伴う腸切除を施行した大腸sm癌113例を対象とし, リンパ節転移と臨床病理学的因子13項目との関連性を検討した. 結果: リンパ節転移率は12.4%であった. 単変量解析からリンパ節転移の有無は, sm垂直浸潤距離 (以下, depth), sm水平浸潤距離 (以下, width), 簇出, リンパ管侵襲 (ly) の各因子に有意差を認め, 多変量解析では, lyと簇出が選択された. また, lyと簇出は有意に相関した. 肉眼型別浸潤量の比較では表面型においてdepth, widthはリンパ節転移例に有意に多い結果となった.考察: sm浸潤距離がdepth 1mm以下でwidth 3mm以下であれば, リンパ節転移, ly, 簇出はなく, 浸潤距離がこの範囲内であれば腫瘍切除で根治性がえられることが示唆された. また, 簇出はリンパ節転移の予知因子として重要な因子と考えられた.

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症例は62歳女性.嘔気嘔吐,食欲不振,味覚障害,頻回の水様性下痢にて他院入院.その後低蛋白血症,脱毛,爪甲脱落を認め,精査加療のため当院紹介転院.胃に多発性隆起性病変を認め,小腸及び大腸には隆起性病変は認めなかったが,Cronkhite-Canada症候群と診断した.ステロイド,抗プラスミン剤の併用により自覚症状,外胚葉系の変化(脱毛,爪甲異常,皮膚色素沈着),消化管ポリポーシスのすべてにおいて著明な改善を認めた.

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症例は67歳の男性で, 主訴は検診での異常. 平成9年11月に検診の胃内視鏡検査で胃体下部大彎側に2型の胃癌を認め, 平成10年1月に幽門側胃切除術, D2郭清, Billroth II法再建が施行された. 進行度はmp, n2, H0, P0のstage IIIAであった. 術後療法としてUFT300mg/日が投与された. 術後1年目のCTで, 30×25mmの傍大動脈リンパ節の腫大を認め, CEAは207. 2ng/dlと上昇していた. 胃癌の再発の診断で, 平成11年2月に当科入院, 放射線化学療法が施行された. 放射線照射は計30Gy施行し, 同時にlow-dosecis-diamminedichloroplatinum (以下, CDDP)+UFT療法が併用された. 治療開始約1か月半後のCTでpartialresponse (以下, PR) と判定された. 平成11年6月にCEAが陰性化し, CT上明らかなリンパ節を認めず, completeresponse (以下, CR) と判定された. その後, 現在まで約6年の間CRが継続している. 本症例は限局性再発であったため, CDDPを用いた放射線化学療法のよい適応であると考えられた.

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症例は64歳の男性. 幽門狭窄を伴う進行胃癌に対し開腹手術を行ったが膵臓への浸潤が高度で非切除, 胃空腸吻合術のみとなった. TS-1を用いた化学療法を開始し, 1サイクル後のCTでは胃前庭部の腫瘤, 周囲リンパ節とも縮小し, PRと判定した. 3サイクル後はCT上, 胃の腫瘤および周囲リンパ節とも指摘できずCRとなった. 1年間CRを持続した後, 再度の開腹手術で幽門側胃切除術を行った. 病理組織学的検索では切除標本に癌細胞の遺残はみられなかった. TS-1は経口であるため外来投与可能であり, 患者のQOLを損なわない化学療法である. 今回, 初回手術時には非切除となった高度進行胃癌に対して経口化学療法剤であるTS-1を投与してCT上, CRとなり, 再手術を行い病変部を切除しえた. 病理組織学的検索では切除標本に癌細胞の遺残はみられず, 今後切除不能例を含めた高度進行胃癌に対してTS-1が有用となる可能性が示唆された.

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顆粒細胞腫は皮膚,食道,舌に好発するが,大腸での報告例は稀である.われわれは盲腸に発生した多発顆粒細胞腫の1例を経験したので報告する.症例は44歳女性,大腸内視鏡検査にて盲腸に2個の粘膜下腫瘍を認め,腹腔鏡下に切除した.腫瘍細胞は好酸性の顆粒を含む胞体を有し,その顆粒はPAS染色陽性であり,ジアスターゼ消化に抵抗性であった.免疫組織学的染色ではS-100蛋白陽1生であり,顆粒細胞腫と診断した.

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症例は63歳の男性で, 上腹部痛を主訴に来院された. 上部消化管造影検査と内視鏡検査にて胃体下部に3型腫瘍を認めた. また, 腹部造影CTと腹部超音波検査にて肝S4に30mm大の肝転移を認めた. 単発性肝転移を伴う進行胃癌の診断にて術前化学療法を施行した. TS-1 100mg/body/dayを3週投与2週休薬, CPT-11は80mg/bodyを第1日目と15日目に点滴静注し, これを1コースとした. 2コースを終了後, 肝転移巣の著明な縮小を確認し, 開腹手術を行った.術中超音波検査にて肝転移巣は確認されず, 幽門側胃切除術, 胆.摘出術, リンパ節郭清D2+α, R-Y再建を施行した. 術後補助化学療法としてTS-1を1年間継続し, 術後3年経過した現在無再発生存中である. 同時性肝転移を伴う進行胃癌は肝病変が切除可能であれば, まず外科的治療が優先されることが多い. しかし, 本症例は術前化学療法が有効である可能性を示唆した.

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