菊夫 岡村’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.

1)TUR-P術前に尿路感染症のない前立腺肥大症患者を対象に,注射剤と経口剤の感染予防効果を比較検討するため,multicenter prospective randomized studyを施行した。2)注射剤としてcefotiam(CTM),経口剤としてtosufloxacin(TFLX)を用いた。手術当日より7日間,CTM 4g/日あるいはTFLX 300mg/日投与の無作為割り付けをした。3)登録は150症例であったが,124例は術前のカテーテルかつ尿路感染の既往なしのlow risk groupであった。Low risk groupでは発熱の頻度の差は,点推定でTFLX投与群がCTM投与群より4.4%少なかったが,統計学的に有意な差ではなかった。4)複雑性尿路感染症発症率は,術後4～5日目,9～12日目,23～27日目および37～40日目の各検査時でCTM投与群,TFLX投与群両群間に有意な差を認めなかった。Low risk groupの感染率はCTM投与群で,それぞれ8.3%,16.4%,25.0%および23.9%またTFLX投与群で6.7%,16.7%,29.6%および36.7%であった To compare the prophylactic effect of oral and intravenous antibiotics against postoperative fever and urinary tract infection (UTI) after transurethral resection of the prostate (TUR-P), we conducted a multi-center prospective randomized study. The incidence of pyrexia over 38 degrees C was defined as the primary endpoint. One hundred and fifty patients with sterile urine before TUR-P were entered into this study. The patients were allocated randomly into the two arms; arm A cefotiam 4 g a day for 7 days, arm B tosufloxacin 300 mg a day for 7 days, based on the stratification into the 4 groups determined with/without preoperative indwelling catheters and with/without the history of preoperative UTI. Of these patients, 143 were eligible. We divided 124 patients without preoperative UTI and without indwelling catheters as the "low risk group", and the other 19 patients with preoperative UTI and/or with indwelling catheters as the "high risk group". In the low risk group, 9 patients out of 63 (14.3%) in arm A and 6 out of 61 (9.8%) in arm B had pyrexia during 7 postoperative days. The incidence of fever in arm B was 4.4% less than that in arm A and the 95% confidence limit was from -7% to 16%. In the high risk group, 4 out of 11 (36.4%) patients in arm A and none of 8 in arm B had fever but the difference was not significant. The incidence of post operative UTI in the low risk group on the 4 to 5, 9 to 12, 23 to 26 and 37 to 40 postoperative days was 8.3, 16.4, 25.0 and 23.9% in arm A and 6.7, 16.7, 29.6 and 36.7% in arm B, respectively. The prophylactic effect of oral administration of tosufloxacin is equivalent to that of the intravenous administration of cefotiam. The use of oral antibiotics is beneficial to reducing the cost of medication.

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.

1984年7月から同11月までの間に当大学および関連19施設で経験した難治性の複雑性尿路感染症64例を対象として,新しく開発されたquinolone carboxylic acid系薬剤のNFLXを投与し,臨床効果を検討した.なお起炎菌が証明されなかったり,真菌の検出された20例は除外し,計44例を検討対象とした.投与方法は1日600 mg(分3),14日間とした.効果判定はUTI薬効評価基準に準じて行ない,MICも測定した.疾患別の有効率は単独感染62.1%,混合感染60.0%で,単独感染のカテーテル留置例の有効率は50%であった.従来の本剤による報告では有効率が52%～85%であり,今回の成績が平均61%とやゝ低いが,G-1, G-5のカテーテル留置例が多かった結果と考えられる.従ってカテーテル留置群を除くと有効率は67%となり,経口剤単独治療としては満足できるものといえた.細菌学的効果は分離株61株中65.6%に効果を認め,既存の抗菌剤より優れていた.最も多く分離されたP. aeruginosaのMIC分布をみると,MIC 3.13以下に効果を認め,評価できる結果であった.副作用は軽度の胃腸障害を4例に認め,GOTの上昇を1例に認めたに過ぎない.以上の成績より,NFLXは経口抗菌剤として複雑性尿路感染症に有効かつ安全性の高い有用な薬剤といえる The new chemotherapeutic agent NFLX was orally administered 600 mg a day for 5 consecutive days in 44 cases having complicated urinary tract infection, and its clinical efficacy was evaluated. They consisted of 8 marked effective cases, 19 moderately effective cases and 17 ineffective cases, and its overall clinical efficacy was 61%. The bacteria disappeared in 10 cases, and decreased in 9 cases. Thirteen cases showed bacterial alternation, and 12 cases remained unchanged. By type of disease group, the efficacy was slightly inferior in the indwelling catheter group compared with that of the nonindwellt group.

回腸膀胱では残尿が50 ml以下ならば間欠的導尿を行わないで経過をみているが,長時間経過した場合,reservoirの過伸展による腸管壁の変化,およびそれにともなうreservoir容量の変化が,今後の問題点となりうる From September 1989 to March 1990, 6 male patients with invasive bladder cancer, 49 to 70 years old in age, underwent bladder replacement with the ileum (the urethral Kock pouch) after radical cystectomy. Follow up ranged between 3 and 9 months. Urodynamic evaluation showed the ileal bladder to be a low pressure reservoir with a capacity that increased to more than 250 ml. The ileal bladder was emptied by straining without significant residual urine in all patients except one who was performing intermittent self-catheterization. All patients were continent in the daytime. However, all patients required pads at night because of occasional loss of a little urine. Excretory urograms revealed excellent upper tract function. The procedure is suitable whenever the urethra can be preserved after cystectomy for cancer.

1988年より1996年迄に,名古屋大学医学部附属病院泌尿器科においてpoor-risk非セミノーマ胚細胞腫瘍の11例を治療した.化学療法施行中に縦隔原発腫瘍の2例が死亡.腫瘍容積の大きな縦隔腫瘍の治療では輸液量を最低限にする必要がある.導入化学療法によりマーカーが正常化したのは3例.導入化学療法中或いは後,マーカーが上昇した3例は結局全例癌死した.導入化学療法ではマーカー正常化をみなかった7例中5例で,救済化学療法によってマーカーが正常化し,そのうちの2例が長期に生存している.救済化学療法後,8例に残存腫瘍摘出を施行した.残存腫瘍の病理検査で壊死,線維組織であった5例中,2例で術後早期にマーカーの上昇をみた.結局,11例中8例にCRが得られたが,長期NEDは5例に達成されたのみであった Between 1988 and 1996, we treated 11 poor-risk patients with non-seminomatous germ cell tumors (NSGCT) at Nagoya University Hospital. "Poor-risk" was defined as i) advanced disease equal to or greater than class 7 of the Indiana University Classification (7 patients), ii) primary mediastinal extragonadal NSGCT (2), iii) tumor markers not normalized by the induction chemotherapy (1) or iv) primary retroperitoneal NSGCT with multiple lung metastases (1). Two patients with mediastinal tumors died during the chemotherapy. The minimal volume of fluid must be administered to patients with giant mediastinal tumors. The tumor marker normalized during the induction chemotherapy in only three patients. Three patients, whose tumor markers elevated during or one month after the induction chemotherapy, eventually died of cancer. The tumor markers in five of the seven patients which had not normalized during the induction chemotherapy, had decreased to the normal range during the salvage chemotherapy and two of the five subsequently achieved the status of "no evidence of disease" (NED). Six patients with and two without normalized tumor markers underwent retroperitoneal lymph nodes dissection and/or resection of residual tumors. Pathological examination of the resected tumors showed necrosis/fibrosis in five patients and two had elevated tumor markers immediately after the surgery and eventually died of the disease. Overall, eight (73%) of 11 poor-risk patients achieved a complete response but only five (45%) eventually achieved a NED status that was maintained (6.6 +/- 3.0 years). Our results were not satisfactory, and we believe that new strategies, such as early high-dose chemotherapy, are required for poor-risk patients, who are not likely to respond well to the induction chemotherapy.

1996～1999年1に治療した胚細胞腫瘍15例を対象に検討した.施行した化学療法は22回で,骨髄回復期に43回の末梢血幹細胞採取を施行した.2回の大量療法に必要なCD34陽性細胞数を4×1000000/kgとするとBEP療法4回で必要量の幹細胞を採取できなかった.しかし,nadirにおける末梢白血球数が2000/ml以上であっても必要量の採取は可能であった.BEP療法時にはday 14,15から5μg/kgのG-CSFを採取日まで投与し,day 19～21にアフェレーシスを行うのが良いと考えられた.VIP療法では1回のアフェレーシスあたり1.7×1000000/kgのCD34陽性細胞しか採取できなかった.大量エトポシド療法は骨髄回復期のばらつきが少なく,1回のアフェレーシスあたり7.9×1000000/kgのCD34陽性細胞を採取できた.大量エトポシド療法はBEP,VIP中に必要量が採取できない場合には,極めて有用な幹細胞動員方法であると考えられた From January 1996 to December 1999, fifteen patients with germ cell tumors underwent peripheral blood stem cell harvest during 15 courses of bleomycin, etoposide, cisplatin (BEP), 4 courses of etoposide, ifosfamide, cisplatin (VIP) and 3 courses of high-dose etoposide mobilization at Nagoya University Hospital. We performed 29 aphereses during BEP, eight during VIP, and six during high-dose etoposide. Although we were able to harvest 4.4 x 10(6)/kg of median CD34 positive cells per apheresis during BEP, the number of stem cells (more than 4 x 10(6)/kg of CD34 positive cells), which are needed for tandem high-dose chemotherapy, could not be obtained during four courses of BEP. For three patients in whom white blood cell counts at nadir were 2,000/microL or more, however, the required number of CD34 positive cells were harvested. VIP provided only 1.7 x 10(6)/kg of median CD34 positive cells per apheresis, while, 7.3 x 10(6)/kg of CD34 positive cells were harvested during high-dose etoposide mobilization. The dose of G-CSF was a significant factor for the number of CD34 positive cells harvested during BEP (p = 0.02); however, there might be some relationship between the harvest and the number of the peripheral white blood cells on the day of apheresis (p = 0.08), the day to start G-CSF (p = 0.13), or the day to initiate apheresis (p = 0.27). Based on our experience, it is recommended that 5 micrograms/kg of G-CSF should be started from the 14th or 15th day of BEP until the last apheresis and that aphereses should be performed between the 19th and 21st day, especially at the days when the peripheral white blood cell count increases beyond 10,000/microL.

1979年4月から1984年3月までに,名鉄病院泌尿器科にて施行された手術に関して統計的観察をおこなった.1)この間の手術総数は967,各年度とも約200件で,年度間に大きな差はみられなかった.2)男女比は,男:846 (87.5%)であった.3)部位別にみると,腎:67 (6.9%),尿管:94 (9.7%),膀胱:232 (24.0%),前立腺:239 (24.7%),尿道,陰茎,陰嚢内容:304 (31.4%),その他:31 (3.2%)であった.4)もっとも多くおこなわれた手術はTUR-Pの114 (11.8%)であり,ついでTUR-Bt:88 (9.2%).尿管切石術:60 (6.2%),睾丸固定術:58 (6.0%)であった A five-year statistical observation was made on operations and patients examined and treated surgically at our Department. Methods and numbers of operations are shown and discussed briefly. The total number of operations was 967, and the male/female ratio was 7.0:1. The most frequent operation was TUR-P (114, 11.8%) and the second was TUR-Bt (89, 2.2%).

Clinical effect of Estracyt was investigated in prostatic cancer patients. Twenty seven patients had been previously treated and 20 had not received prior treatment. Improvement rate of subjective symptoms was 85% in the previously untreated patients and that of objective findings was 85%, while those rates were 44% and 50% in the previously treated patients, respectively. Most of the adverse reactions were changes in mamma and mammary papilla which were considered to be due to the estrogenic activity.

種々の原因による閉塞性腎疾患48例51腎に対し,IVP, 99mTc-DTPA利尿レノグラム,99mTc-DMSAレノシンチグラフィーを施行した.1)利尿レノグラムのパターンが1→3a→3b→4となるに従い,水腎臓症の程度は高度になった(P<0.005).利尿レノグラムのパターンは尿流障害の程度を示す良い指標であると考えた.2)水腎症の程度が高度になるに従い,99mTc-DMSA腎摂取率は低下したが有意ではなかった.3)利尿レノグラムのパターンと99mTc-DMSA腎摂取率との関係では2a型は有意に腎摂取率は低かった.3aと3b型をあわせた3型の腎摂取率は1型に比し有意に低かったが,3a, 3b間には有意差を認めなかった.4)O'Reillyの2型は基本的には低下した腎機能を示すものであり,2a型は高度の腎機能障害を有するに対し,2b型は疝痛発作後にみられるもので可逆性の機能障害である可能性が高い 99mTc-DMSA and diuretic 99mTc-DTPA renoscintigraphy were performed on 51 kidneys suspected of obstructive nephropathy based on excretory urography to evaluate the residual renal function and the degree of urinary flow impairment respectively. We classified the response to diuretics into 6 patterns: I. normal, IIa. severely damaged renal function, IIb. slow RI excretion without urinary tract visualization (pattern II had no response to furosemide), IIIa. rapid elimination of tracer from the obstructed upper tract, IIIb. slow elimination, and IV. gradual tracer accumulation in the pelvicalyceal system with fairly well preserved renal function but no response. Hydronephrosis varied according to pattern type, in the ascending order of I, IIIa, IIIb and IV (p less than 0.05). Degree of hydronephrosis was inversely related to 99mTc-DMSA uptake, but without statistical significance. 99mTc-DMSA uptake was lower for pattern III as a whole (IIIa + (IIIb) than for pattern I (p less than 0.005), but there was no difference between IIIa and IIIb. Pattern IIa exhibited a significantly lower uptake than any of the other groups. (p less than 0.005) In contrast to previous views, we believe that pattern IIIa indicates a mild obstruction of urinary flow and impaired renal function. Consequently, assessment of obstructive nephropathy should not be based only on urodynamic study but also on differential renal function test.