2)白血病

Gastrointestinal Lesions in Leukemic Patients

　白血病の消化管病変は，白血病細胞の消化管浸潤によるもの，化学療法による直接ないし間接的毒性によるもの（necrotizing enterocolitis等），白血病自体や白血病治療薬による免疫状態の変化によるもの（日和見感染等），消化性潰瘍に大別される．本稿では以下の4項目に分けて検討を加えた．（1）白血病の消化管浸潤による病変では，ATL/L（成人T細胞性白血病/リンパ腫）消化管浸潤の自験例，22例34病変を解析し，本邦報告例の文献的考察を加え，併せてATL/L以外の消化管原発悪性リンパ腫と比較検討した．ATL/Lでは，食道1例，胃15例，小腸10例，大腸8例に浸潤がみられ，消化管病変は決してまれではないことが判明した．ATL/Lの消化管浸潤病変は，他の悪性リンパ腫に比べて，多発性，びまん性の傾向がみられ，特に小腸では，多発する小隆起という形態が，全体の70％を占め，ATL/Lの小腸浸潤の典型像と思われた．ATL/L以外の白血病では，本邦報告例における消化管浸潤病変の肉眼所見の特徴を中心に述べ，自験例を呈示した．白血病の消化管浸潤の特殊な病態である，granulocytic sarcoma（chloroma：緑色腫）についても欧米の報告例における臨床像，肉眼形態を分析し，自験例を呈示した．（2）白血病の経過中にみられるnecrotizing enterocolitisのうちneutropenic enterocolitisについて，欧米の報告例における臨床像，肉眼形態を中心に述べた．（3）日和見感染については，別項にて詳述されるため，ATL/Lの自験例の分析にとどめた．（4）消化性潰瘍については，CML（慢性骨髄性白血病）において，合併頻度が高いとされているが，文献例の検討を中心に述べた．

　Pathogenesis of gastrointestinal lesions of leukemia could be broadly classified as follows ; Firstly, direct or indirect toxicity of chemotherapy such as necrotizing enterocolitis and, secondly, decreased immunity due to leukemia itself or to medication used for leukemia resulting in opportunistic infection, and peptic ulcer. In this paper analysis was made on four subjects as follows.

　1. Concerning lesions due to gastrointestinal infiltration of ATL/L (adult T-cell leukemia/lymphoma). A total of 34 lesions in 22 cases with ATL/L at our institute were studied and comparision with primary gastrointestinal malignant lymphoma unrelated to HTLV-1 was carried out with reference to the Japanese literature. Tumor cell infiltration was seen in only one case in the esophagus, in 15 cases in the stomach, in 10 cases in the small bowel and in 8 cases in the large bowel. As a result, we concluded that gastrointestinal lesions associated with lymphoma are not rare. As for the site of involvement, an esophageal lesion has been seen in only two cases including our own case, but when compared this data with the data of autopsy cases, the low frequency of reported esophageal involvement was thought to be due to the difficulty of clinical detection. Gastrointestinal lesions of ATL/L were more likely to be multiple and diffuse than those of HTLV-1 unrelated malignant lymphoma. Above all, 70 ％ of small intestinal lesions revealed multiple small elevations which were thought to be typical features of infiltration in the small bowel. As for gastrointestinal lesions of leukemia other than ATL/L, characteristics of macroscopic features of reported cases in the Japanese literature were analyzed. In addition, clinical manifestations and macroscopic features of granulocytic sarcoma (chloroma), which is a specific pathologic feature of gastrointestinal infiltration of leukemia, were analysed with reference to the medical literature of Europe and America.

　2. Necrotizing enterocolitis seen during the clinical course of Leukemia includes neutropenic enterocolitis, pseudomembranous colitis and ischemic colitis. In this paper, clinical manifestations and macroscopic features of reported cases in European and American literature concerning neutropenic enterocolitis, which is a characteristic complication of leukemia, were described.

　3. As details of opportunistic infection are described elsewhere by other authors, we analyzed only our own cases.

　4. The part of our paper on the reports that peptic ulcer is frequently complicated with CML (chronic myelogeneous leukemia), consists mainly of a description and analysis of the medical leterature on the subject.