肝門部に主座を置く嚢胞性腺癌の1例 [in Japanese] CYSTIC ADENOCARCINOMA POSITIONED IN THE PORTA HEPATIS : REPORT OF A CASE [in Japanese]
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症例は64歳女性.人間ドックで肝機能異常を指摘.腹部超音波, CTで肝門部に充実性成分を有する3.5cm大の多房性嚢胞性腫瘍を認めた. ERCでは右肝管は造影されず,右肝内胆管拡張と左肝管圧排伸展像を認めた.腹部血管造影では尾状葉枝の圧排伸展像を認めた.画像所見から肝門部に主座を置く嚢胞性腺癌を最も疑い,経皮経肝門脈塞栓術後,拡大右葉切除,胆管切除,左肝管空腸Roux-Y吻合術を行った.腫瘍は右肝管を巻き込み,一部右肝管腔内に突出するが,大部分は左右肝管合流部から右肝内第1次分岐部までの胆管壁外に存在し,病理組織学的に高分化型乳頭状腺癌で嚢胞内に限局していた.肝門部に主座を置く嚢胞性腺癌は自験例を含めて5例を数えるに過ぎず稀である.左右肝管は肝実質に接し肝内胆管と連続しているため,原発部位が不明瞭になることも少なくない.治療は腫瘍と十分な距離をもった肝切除,胆管切除,リンパ節郭清が必要と思われた.
A 64-year-old woman who was pointed out impaired hepatic function at a medical checkup was seen at the hospital. Abdominal ultrasonography and CT revealed a multilocular cystic tumor 3.5cm in size involving solid component at the porta hepatis. With ERC the right hepatic duct did not visualized, and dilated right intrahepatic bile duct and compressed and extended left hepatic duct were shown. Abdominal angiography revealed a compressed and extended caudate lobe branch. From these imaging findings, a most probable diagnosis of cystic adenocarcinoma positioned in the porta hepatis was made, and the patient was operated on. Operative procedures included percutaneous transhepatic portal embolization followed by extended excision of the right lobe, excision of the bile duct, and left Roux-Y hepatocholangiojejunostomy. The tumor had enrolled the right hepatic duct, and the major part of the tumor existed in the bile duct extramurally covering from the confluence of the right and left hepatic ducts to right intrahepatic first branch, though a part of it protruded into the right hepatic ductal space. Histopathologically it was well differentiated papillary adenocarcinoma limiting in the cyst.<br> Cystic adenocarcinomas positioned in the porta hepatis are so rare that four cases in addition to this case have been reported so far. Since the right and left hepatic ducts are adjacent to the hepatic parenchyma and connect to the intrahepatic bile duct, the primary site can not be determined in not a few cases. In the treatment of the disease, hepatectomy with a sufficient distance from the tumor, excision of the hepatic duct and lymph nodes dissection are neceessary.
- The journal of the Japanese Practical Surgeon Society
The journal of the Japanese Practical Surgeon Society 58(8), 1846-1851, 1997-08-25
Japan Surgical Association