佳成 小野’s scientific contributions

1986年から1997年迄に名古屋大学医学部附属病院において,15人の進行性胚細胞腫瘍患者に後腹膜リンパ節郭清術を施行した.国際胚細胞腫瘍コンセンサス分類上,poor-risk症例8例と過半数を占めた.12例でマーカー正常化後に手術が施行されたが,3例では正常化しなかった.平均手術時間は510分,平均出血量は3,806gであった.手術時間,出血量は化学療法後も残存する体軸上の腫瘤の大きさに比例した.術中合併症は15症例中5症例に生じた.腎動脈損傷2件,腎静脈損傷1件,尿管損傷1件,総腸骨動脈損傷2件であった.術後合併症では,イレウスが2件,下大静脈切除による下肢浮腫が1件,創離開が1件に生じた.手術により完全に腫瘍が切除でき,病理学的にも壊死又は奇形腫であった8例中6例に癌なし生存が得られた.全ての腫瘍は取り除けなかったが病理学的には壊死又は奇形腫であった4例のうち,2例で癌なし生存が得られた We performed retroperitoneal lymph node dissection (RPLND) on 14 patients (IIA: 1, IIB: 4, IIIA: 3, IIIB2: 2, IIIC: 4) with testicular and one with retroperitoneal germ cell tumor at the Nagoya University Hospital between 1986 and 1997. According to the international germ cell consensus classification, 4 patients were classified as "good-prognosis", three as "intermediate-prognosis" and eight as "poor-prognosis". RPLND was performed on 12 patients with the tumor marker levels normalized preoperatively and on three without the marker normalization. The mean surgical time was 510 (195-1, 125) minutes and the mean bleeding volume was 3,806 (100-12,598) g. The surgical time and bleeding volume were correlated with the size of the tumor in the body axis. Intraoperative complications occurred in 5 (33%) out of 15 patients: injury of renal artery (2), renal vein (1), ureter (1) and common iliac artery (2). Postoperative complications occurred in 2 patients: ileus (2) and lower extremity edema resulting from resection of the inferior vena cava (1) and would dehiscence (1). Of the 8 patients whose completely resected retroperitoneal tumors were necrosis/fibrosis or teratoma (psCR), 6 achieved survival with no evidence of disease (NED). Among 4 patients, whose tumor was not completely resected but pathologically diagnosed as necrosis/fibrosis or teratoma (pCR), NED without recurrence was achieved in 2 and also in one with resection of relapsed teratoma 2.5 years after RPLND. All three patients with cancer tissues pathologically retained in the resected tumors (sCR or psIR), consequently died of the disease. In six patients with relapse, the initial sign was elevation of the tumor marker levels, which was noted more than 30 days postoperatively in 2 patients with psCR and 7 to 15 days in 4 patients without psCR. We believe that RPLND is needed to examine the pathology and to predict the prognosis of the poor-risk patients with NSGCT. Careful dissection of vessels is needed to reduce vascular complications.

症例1(53歳女)。肺結核治療中に腎腫瘍を指摘され, 治療目的で当科を受診した。左腎腹側に径9cm内側に2cm大, 背側と外側それぞれに1cm大の腫瘍を認めた。また, 右側に3×1.5×1cm大の腫瘍を認めリンパ節や他臓器転移は認めなかった。両側腎細胞癌T2N0M0と診断し腎機能温存で治療を進めるも, 腫瘍の大きさから左腎温存は不可能で右腎に体外での腫瘍核術, 自家腎移植術を行い, 腎機能温存を図り機能回復を確認した。術後3週間に腹腔鏡下根治的左腎摘除術を施行し, 術後14ヵ月経過して腎機能は良好で再発は認めていない。症例2(43歳女)。Von Hippel-Lindau(VHL)病の経過観察中に両側腎腫瘍を指摘され当科に入院となった。左腎髄質に径1.5cm大2つ, ほかに1cm大の腫瘍を認め, 腎細胞癌を疑い, 右腎に5cm大の腫瘍を認めた。リンパ節や他臓器転移は認めず術後臨床病期T1aN0M0と診断した。腎温存方向の治療として右腎は腫瘍径が5cm以下で悪性と断定できないため, 経過観察とし左腎腫瘍は腹腔鏡下左腎摘除術, 体外腫瘍核出術ならびに左腸骨窩自家腎移植術を施行した。術後9ヵ月を経て腎機能も良好で再発所見など認めていない。 Von Hipple-Lindau (VHL) disease is a rare familial cancer syndrome that is dominantly inherited and pre-disposes affected individuals to developing various tumors, including hemangioblastoma of the retina and central nervous system, and multicentric renal cell carcinoma. We report two cases of VHL disease with bilateral renal cell carcinoma. Case 1: A 53-year-old woman was referred to our hospital because of bilateral kidney tumor incidentally found. We performed left laparoscopic radical nephrectomy and laparoscopic nephrectomy, ex vivo excision and reconstruction, and autotransplantation for the right kidney. Case 2: A 43-year-old woman was referred to our hospital because of left kidney tumor incidentally found. Because the suspectious lesion in the right kidney was very small, we decided to follow it up with no treatment. We performed laparoscopic nephrectomy, ex vivo excision and reconstruction, and autotransplantation for left kidney.

著者らは1999～2004年の間に,術前診断で腎癌を疑い,腹腔鏡下腎部分切除術を24例に施行した.その手術方法について解説した.1)腫瘤径が小さく,腫瘤と腎杯,腎洞との距離が1cm以上ある場合は,超音波メス等の道具を用いて腎動静脈の血流遮断を行わずに腫瘤を切除し,12例中10例で成功した.2)腫瘤と腎杯,腎洞との距離が1cm未満で腎杯を切開する可能性が高い症例に対しては,腎血流を遮断した後に腫瘤を切離し,必要に応じて腎杯縫合,腎実質縫合を行った.3)血流遮断を行った症例での平均阻血時間は26分で,imperative caseでも術後の腎機能の低下は軽度であった.4)病理診断が腎癌であった症例の予後は,elective case 11例では再発はみられず,imperative case 6例のうち2例で局所再発を認めた We retrospectively reviewed the clinical results of 24 patients who underwent laparoscopic partial nephrectomy by a diagnosis of renal cell carcinoma (RCC) between 1999 and 2004, including 16 elective cases and 8 imperative cases. Twenty-two were successfully treated laparoscopically; two cases in the imperative group required conversion to open surgery because of uncontrollable bleeding. A vascular clamp was used in 12 cases for an average of 26 minutes. The creatinine clearance changed from 98 to 93 ml/min in the elective cases and from 49 to 44 ml/min in the imperative cases. Pathological evaluation revealed RCC in 10 elective cases and 6 imperative cases. Local recurrence (renal hilum lymph node and ipsilateral kidney) was found in 2 patients in the imperative group. Although laparoscopic partial nephrectomy is useful, long-term follow-up is necessary for evaluating the tumor control.

訪問看護ステーション40施設とその利用在宅高齢者2322名(男1023名,女1299名).尿道カテーテル留置者は225名(男97名,女128名)で,理由は尿排出障害62.5%,尿失禁25.3%であった.おむつ使用者は1301名(男533名,女768名)で,使用開始時期は在宅看護開始前が79.9%,理由は尿失禁11.6%,寝たきり67.0%,痴呆8.8%,尿失禁予防12.3%であった.清潔間歇導尿施行者は36名(男23名,女13名)で,理由は尿閉・残尿が88.9%,施行者は家族・介護者が63.9%であった.カテーテル留置の決定は医師84.7%,看護婦・保健婦30.6%で,清潔間歇導尿では医師86.9%,看護婦・保健婦21.8%であった.おむつ使用の決定は医師11.4%,看護婦・保健婦27.3%,家族64.2%,被看護者本人18.3%であった.専門家への受診は191名で,排尿管理別の受診割合はカテーテル留置者39%,おむつ使用者5.8%,清潔間歇導入施行者77.8%であった.専門医受診依頼は一般医よりなされるのが52%,ケースバイケースが36%であった A fact-finding inquiry was made on elderly people in home care, in order to investigate urinary management. A questionnaire survey was performed on 2,322 elderly people (1,023 male and 1,299 female) cared at home by 40 home nursing stations in Aichi prefecture. The survey focused on the urinary management and the practical problems at home. The number of the elderly managed by an indwelling catheter was 225 (9.7%) and 1,301 (56.0%) of the elderly wore diapers. The rates of the people managed by an indwelling catheter or diapers widely varied among the home nursing stations. In 25.3% of the people managed by an indwelling catheter, the catheter was used because of urinary incontinence, which should not normally be indicated. Diapers were unnecessarily used in 23.9% of people mainly for a protective purpose. The majority of the people whose voiding dysfunction was managed either by an indwelling Foley catheter or diapers had had this treatment started before discharge from hospital. Only 5.8% of the elderly wearing diapers received consultation from medical specialists. Intermittent catheterization was performed in 36 people (1.6%), and in 23 (63.9%) the catheterization was carried out by the care givers. We conclude that the urinary management in the elderly cared at home is insufficient and that standardization of the urinary management and creation of a network of care givers, nurses, general physicians, medical specialists and government representatives should be urgently needed to improve the quality in urinary management in the elderly.

前立腺癌臨床病期stage A2, B, Cの症例44例について検討した. 1)術後の5年生存率は,リンパ節転移陽性例で77%,陰性例で90%であり,5年の術後無病率は,リンパ節転移陽性例で54%,陰性例88%であった.根治的前立腺全摘除術及び骨盤内リンパ節郭清術は,臨床病期stage C以下の前立腺癌症例に対して有用な方法と考えた. 2)臨床病期stage D1症例に対する根治的前立腺全摘除術の是非については,QOL等を含めたrandomized studyによる確認が必要と考えた. 3)リンパ節転移陽性の14例32%の転移部位は,閉鎖節8例57%,内腸骨節6例43%,外腸骨節6例43%,総腸骨節4例29%,正中仙骨節2例4%であった Between September, 1987 and September, 1993, a total of 44 consecutive patients had undergone radical retropubic prostatectomy and pelvic lymphadenectomy for the treatment of prostate cancer. The patients were between 56 and 77 years (mean, 68 years). Eleven patients had clinical state A2 disease, 21 had stage B disease, and 12 had stage C disease. Fourteen of the 44 patients (32%) had positive lymph node metastases. The 5-year survival rate for patients with pT1, pT2 and pT3 was 100%, 71% and 87%, respectively. It was 77% in patients with positive node disease and 90% in patients with negative node disease. The 5-year disease-free survival rate for patients with pT1, pT2 and pT3 was 82%, and 78%, respectively. It was 54% in patients with positive node disease and 88% in patients with negative node disease. In 14 positive node patients, metastases were located in obturater nodes in 8 patients (57%), hypogastric nodes, in 6 patients (43%), external iliac nodes in 6 patients (43%), common iliac nodes in 4 patients (29%) and presacral nodes in 2 patients (14%). We confirmed that radical retropubic prostatectomy is effective treatment for locally confined prostate cancer and removal of obturater, hypogastric lymph nodes and the internal chain of external iliac lymph nodes is important in detecting metastases.

Three females with urinary retention caused by uterine leiomyoma are reported. The patients were 35, 48 and 50 years old. In each patient, transabdominal ultrasonography showed a large and homogeneous mass located in the retrovesical space, compressing the bladder. Pre-operative computed tomographic (CT) scan and magnetic resonance (MR) imaging revealed uterine leiomyoma which severely compressed the bladder from the posterior wall to the urethra. The urinary symptoms completely resolved in all patients following total hysterectomy, and postoperative uroflowmetry demonstrated normal voiding.

Neobladder replacement has become an important procedure in the patient undergoing radical cystectomy for invasive bladder cancer. It yields postoperatively excellent quality of life in these patients. The indications of the patients selection have not been established, since long-term clinical results have not been presented and some issues such as urethral recurrence of the original disease, growth of the cancer from the neobladder made of the gastrointestinal tract and influences arising from orthotopic micturition are still unclear. We reviewed the reports describing neobladder replacement in the patients undergoing cystectomy for the bladder cancer. At present the criteria of patients selection described by most authors can be summarized as follows, (1) male patients, (2) patients having an available gastrointestinal tract for reconstructing the neobladder, (3) patients having a good renal function and liver function and could tolerate for the surgery and (4) patients with no evidence of disease in their urethra and prostate (direct invasion of the disease). As to carcinoma in situ within the bladder, some authors included their indication and the others contraindication.

55～83歳の前立腺肥大症患者35例において,本剤1.5 mg/日投与群と3.0 mg/日投与群とを比較したが,主治医による自覚症状改善度,他覚所見改善度,全般改善度,概括安全度,有用度の判定,並びに判定委員会による薬剤効果の判定において,両群間に統計学的有意差が認められず,初回投与量は1.5 mg/日が至適と考えられた.12週間投与した症例で特徴的な副作用はなかった.主治医判定における12週後の改善度は,4週後の改善度に比べ低かった.しかし判定委員会判定で自覚症状の重症度及び他覚所見は,12週後では4週に比べ,より改善が認められた Thirty-five patients with prostatic hyperplasia were entered into a randomized controlled study using bunazosin hydrochloride(alpha 1-adrenergic blocker). Eighteen patients were allocated to be treated with an initial dose of 1.5 mg/day (group 1) and 17 patients received an initial dose of 3.0 mg/day (group 2). Subjective symptoms and parameters of urodynamic studies were evaluated after 4 weeks and 12 weeks. There were 5 withdrawals or exclusions within 4 weeks and 6 within 12 weeks. Therefore, 15 patients in group 1 and 15 patients in group 2 were eligible for evaluation at 4 weeks, 12 patients in group 1 and 11 patients in group 2 were eligible for evaluation at 12 weeks. The rates of the improvement in subjective symptoms such as retarded urination, protracted urination, weakened urinary stream, abdominal straining on voiding, and sense of residual urine were 40%, 25% in group 1 and 46.7%, 36.4% in group 2, at 4 weeks and at 12 weeks, respectively. The rate of improvement in objective parameters of the urodynamic study such as voiding volume, residual volume, maximum flow rate and average flow rate were 26.7%, 16.7% in group 1 and 26.7%, 20.0% in group 2, at 4 weeks and at 12 weeks, respectively. Thus, these improvements were not correlated with the dosage of drug. Adverse effects such as diarrhea, mild headache, palpitation and gastric disturbance were observed in 2 patients in group 1, and 3 patients in group 2. In the 24 patients treated with the drug over 12 weeks, there were no specific adverse effects due to prolonged administration. These findings showed that bunazosin hydrochloride is beneficial for the treatment of prostatic hyperplasia, and could be safety administered for a prolonged period of time up to 12 weeks.

胚細胞腫瘍6例に末梢血幹細胞移植併用大量化学療法を施行した.2例が再発症例で,3例が導入化学療法に抵抗性と判断され,1例が残存腫瘍が切除不能の縦隔腫瘍症例であった.再発腫瘍の2例ではcPR,cCRが得られたが,結局再発癌死した.抵抗性の2例においてpCRが得られ,肺に残存した腫瘍は摘出しなかったが,23ヵ月,24ヵ月経過した現在も再発を認めていない.強化地固め療法として行った1例においても,24ヵ月PRを続けている Between January 1997 and December 1998, six patients with germ cell tumor were treated with high-dose CEC: carboplatin (1,500 mg/m2), etoposide (1,200 mg/m2) and cyclophosphamide (100 mg/kg), followed by peripheral blood stem cell transplantation (PBSCT) at Nagoya University Hospital. Four patients received one cycle of high-dose CEC and two received two cycles. The reasons why the high-dose CEC was administered included: 1) refractory to the induction chemotherapy (AFP/beta-HCG elevated during the induction chemotherapy or prolonged half-life of each marker) in three patients, 2) relapse in two patients, and 3) consolidation in one with unresectable mediastinal residual tumor. There were no treatment-related deaths and grade 1 hepatotoxicity occurred in one (17%) patient. The median duration (range) from PBSCT until a granulocyte count of 500/microL and a platelet count of 50,000/microL was 8.5 (8-11) and 11 (9-16) days, respectively. Of the six patients studied, 5 responded to the treatment; two achieved a complete response (CR) and three achieved a partial response (PR). One patient achieving a CR and two achieving a PR remained in complete remission after 23 to 24 months of follow-up, while the remaining patients with a CR, a PR and an incomplete response died of the disease. High-dose CEC could be administered without serious toxicity but the effectiveness of high-dose CEC for the poor-risk patients with germ cell tumor needs to be further investigated.

One hundred and three kidneys with calculi in 100 patients, were treated by conservative renal surgery from Jan., 1980 to Dec., 1982. The operative technique consisted of pyelolithotomy, extended pyelolithotomy, dismembered pyelolithotomy, nephrolithotomy (bivalve or anatrophic nephrolithotomy) partial nephrectomy and pyelo-nephrolithotomy. Intraoperative X-ray and coagulum lithotomy were employed when pyelolithotomy was performed. Thirty-five residual calculi in 20 kidneys were observed on postoperative X-ray film. The rate of residual calculi was 19.4%. Factors causing residual calculi, were analysed on these 103 kidneys. The factors were as follows; the shape of calculi: staghorn calculus with multiple small calculi, the shape of the renal collecting system: narrow pelvis with narrow caliceal neck and dilatated calices, and the operative technique: nephrolithotomy. These results suggested that it would be necessary to minimize residual calculi when performing nephrolithotomy.