症例は76歳，女性．55歳時に左胸膜腫瘍に対して当センターにて切除術を施行されlocalized fibrous mesotheliomaと診断された．今回，健診にて異常を指摘され当センター呼吸器科紹介となる．CT検査の結果，両肺野の多発結節性陰影および肝S3に径18mmの腫瘍性病変を認めた．転移性腫瘍を疑い全身検索を行うも明らかな原発巣は発見できず，患者の希望で経過観察となった．9カ月後，肺腫瘍に変化はみられなかったが肝腫瘍は径31mmと増大したためS3部分切除術を施行した．病理組織学的検査の結果，孤立性線維性腫瘍（solitary fibrous tumor;以下SFT）と診断された．また20年前の切除標本も再検にて肝と同様SFTと診断され，胸膜SFTの肝および肺転移と診断した．SFTは長期間経過してから再発をきたす場合があるが局所再発が多く遠隔転移は稀である．初回切除後，20年を経過して肝・肺転移をきたしたSFTの1例を経験したので報告する．

OBJECTIVE:To study the relationship of anomalous right-sided round ligament with respect to branches of the portal vein.METHODS:We studied four patients of right-sided round ligament diagnosed radiologically in the last 5 years. 3-D volume rendered CECT abdominal images were analyzed for attachment of the round ligament in the liver in relation to portal venous anatomy and position of gallbladder.RESULTS:In all cases, a trifurcate pattern of portal venous branching was observed. Right-sided round ligament was attached at the point of divergence of the right anterior portal vein. The region to the left of the point of its attachment drained into the middle hepatic vein while the region to the right of the point of attachment drained into the right hepatic vein. The left portal vein branched into posterior and paramedian branches. Right, middle, and left hepatic veins were visualized having normal course in all cases. In all, the gallbladder was present to the left of the round ligament.CONCLUSIONS:Trifurcate pattern of portal vein branching in all four cases. Right-sided round ligament was attached to the bifurcation of the right anterior portal vein in all the cases. The left portal vein branched into posterior and paramedian branches.

Major hepatic resection for hilar cholangiocarcinoma is reportedly closely associated with severe postoperative complications. We performed a new limited resection that included total resection of the caudate lobe and anterior segment (ventral region of the right paramedian sector), and bile duct resection with hepaticojejunostomy in 3 patients with hilar cholangiocarcinoma that had not infiltrated the hepatic artery or portal vein. In all 3 patients, curative surgical resections were obtained and no serious complications were encountered. This new limited resection based on a reclassification of the liver may offer an effective procedure in limited patients with hilar cholangiocarcinoma.

Previously, computed tomography (CT) yielded cross-sectional images reconstructed from single-slice CT. However, the recently developed multidetector-row spiral CT provides isotropic voxel data sets, giving clear and precise three-dimensional images of the intrahepatic vascular structure. The vascular anatomy of the liver and relationship between liver tumors and intrahepatic vascular structure can thus be determined. We have developed software for an image-navigated surgery system with which vessels supplying blood to tumors and main hepatic vein drainage can be identified in patients preoperatively. Virtual liver resection can then be performed on a computer using this software. This simulation surgery contributes to making subsequent actual hepatic resection safer and less invasive.

Gallbladder involvement in patients with renal cell carcinoma (RCC) is extremely rare. We present a report of a 61-year-old man with a synchronous RCC metastasis to the gallbladder presenting as an intraluminal polypoid mass simulating primary gallbladder carcinoma. Enhanced abdominal computed tomography demonstrated a well-enhanced polypoid lesion in the gallbladder. Intraoperative rapid pathological examination of the gallbladder tumor showed clear cell-type cancerous cells. Microscopically, tumor cells of both the resected kidney and gallbladder had round uniform nuclei, clear cytoplasm, and well-defined cytoplasmic borders, forming alveolar patterns. Immunohistochemically, the tumor cells were negative for cytokeratin 7 (CK7) and carcinoembryonic antigen (CEA), which is usually positive in primary clear cell carcinoma of the gallbladder. Therefore, the final diagnosis was RCC with a synchronous gallbladder metastasis.

今回われわれは肝膿瘍を契機に発見された混合型肝癌の1例を経験した．稀な症例と考え報告する．症例:64歳，男性．主訴:上腹部痛，発熱．現病歴:2003年6月主訴出現し，当院受診した．初診時体温38.8度．血液検査所見:白血球10700/μl，CRP 20.5mg/dl．CEA 5.5ng/ml，AFP 215ng/ml，PIVKA II 777mAU/ml．造影CT:肝内側区域に長径7cmの腫瘤を認めた．一部膿瘍形成を認めた．門脈左枝に腫瘍栓を認めた．血液培養でKlebsiella. pneumoniaeを検出した．肝膿瘍を合併した肝細胞癌と診断．抗生剤による感染症治療の後，拡大肝左葉切除+リンパ節郭清術を施行した．病理組織学的検査所見:混合型肝癌．T4N1M0stageIVA．治癒度C．術後4カ月目に癌の残肝再発．肝膿瘍再発．抗生物質と肝動注化学療法により一時軽快するも術後7カ月目に肝膿瘍再燃して死亡した．

Background/Aims: Although the interlobar arterial collateral of the liver has been thoroughly analyzed, few reports have described the intersegmental arterial collateral between the medial and left lateral segments. Methods: The hepatic arterial system of the left liver was evaluated using 12 latex resin cast specimens in which latex resin was injected into the left hepatic artery after ligation of the right hepatic artery. Results: In all 12 livers, an intersegmental collateral between the medial and left lateral segments was detected. These collaterals were extrahepatically located in the umbilical plate and gave rise to branches traveling to the bile duct of the left liver. Conclusions: The present study showed that the communicating arcade between the middle and left lateral hepatic arteries was consistently present in the umbilical plate and played an important role not only in the intersegmental arterial collateral system of the left liver but also in the blood supply to the bile ducts.

Sarcomatous hepatocellular carcinoma is a rare neoplasm of the liver. A 79-year-old man with a liver tumor was admitted to our hospital. Enhanced computed tomography and magnetic resonance imaging revealed a cystlike lesion, whereas abdominal ultrasonography revealed a solid tumor. The patient underwent medial segmentectomy of the liver for the presumptive diagnosis of atypical hepatocellular carcinoma. Microscopically, the tumor was diagnosed as hepatocellular carcinoma with sarcomatous change. Although anticancer therapy is presumed to be a cause of sarcomatous change in hepatocellular carcinoma, some cases in which patients had not previously undergone anticancer therapy have been reported. Here we report a case of sarcomatous hepatocellular carcinoma without previous anticancer therapy and present a review of the literature.

BACKGROUND/AIMS:Pancreas-sparing duodenectomy (PSD) represents an attractive operation for benign or premalignant duodenal disease. However, use of PSD is controversial for indications that include malignancy.METHODOLOGY:The present study investigated 16 patients who underwent PSD for duodenal neoplasms including adenoma, cancer, carcinoid and non-epithelial tumor. Indications for PSD were divided into 3 categories: early stage neoplasms; isolated duodenal neoplasms in high-risk patients; and duodenal involvement from adjacent organ malignancies. This study classified PSD into 4 types based on the resected portion of the duodenum, as used in gastrectomy (total, subtotal, distal, and proximal) and we experienced pancreas-sparing proximal duodenectomy and pancreas-sparing distal duodenectomy.RESULTS:Pancreatic fistula or anastomotic leak occurred in 2 patients, and were closed with nonoperative management. Although 1 patient with gallbladder cancer died postoperatively due to the results of a concomitant operation, no postoperative deaths or re-operations related to PSD were encountered. Mean duration of follow-up was 65 months. Three patients died as a result of distant metastases from primary cancer without local recurrence, and 2 patients died from other causes. The remaining 10 patients are well, with no symptoms related to the hepatobiliary and pancreatic systems.CONCLUSIONS:Good results after long-term follow-up suggest that PSD represents an attractive option for duodenal neoplasms. Moreover, absence of local recurrence suggests that PSD may also be acceptable for selected duodenal malignancies.

症例は70歳の女性で, 2001年9月, 他院において肝右葉の肝内胆管癌の診断で肝右葉切除術を受けた. 初回手術時進行度はt2, n0, m0, stage IIであったが, sm (+)となった. 術中に癌露出部は癌細胞の遺残を疑い, マイクロウェイブにて焼灼された. 術後6か月経過した2002年3月, 残肝切除断端の再発を疑われ当院紹介受診. 術後の変化とも考えられ経過観察していたところ, 1年後には病変部の増大を認めた. 他病変を認めないことから残肝再発に対して2003年4月, 肝S4+S1の亜区域切除+肝外胆管切除術を施行. 肉眼的には前回手術時右グリソン断端部に一致して長径2.5cmの境界明瞭な白色結節を認めた. 病理組織学的検索では中分化型腺癌s0, n0, vp0, va0, b0, sm (+)であった. 肝内胆管癌再発と診断した. 術後2年11か月経過したが再々発を認めない.

症例は73歳, 女性. 健診での腹部超音波検査にて肝腫瘍を指摘され, CTにて胆嚢腫瘍, 膵頭部後面リンパ節の腫大も認められ, 当センター紹介入院となる. 初診時腫瘍マーカーはAFP 8,856ng/ml, CEA 7.5ng/ml, PIVKA-II 133AU/mlと高値を示した. 腹部CT, 血管造影検査の結果, 胆嚢癌および肝転移, リンパ節転移の診断となり手術を施行した. 病理検査では胆嚢腫瘍は肝細胞癌類似の像や乳頭状腺癌の像がみられ肝様腺癌と診断した. また, 胆嚢癌, 肝転移およびリンパ節転移のすべてで抗AFP染色および抗CEA染色陽性であった. 術後, AFPは正常値に復し, 現在10カ月無再発生存中である.