腸管悪性リンパ腫の治療と予後

Treatment and Prognosis of Primary Malignant Lymphoma of the Intestinal Tract

要旨　原発性腸管悪性リンパ腫32例の内訳は，十二指腸1例，空腸4例（含，他臓器重複），回腸16例（含，他臓器重複），大腸11例（含，他臓器重複）であった．腸管多発悪性リンパ腫は4例あり，12.5％を占め，他臓器重複例は10例，31.3％に認められ，主に胃や他の消化管であった．腸管悪性リンパ腫の治療は，根治手術が13例（41％）に施行され，残り19例が姑息手術に終わった．その理由は大動脈周囲リンパ節（n₄＋）転移陽性が13例（68％）に認められ，腹膜播種5例，肝転移2例もn₄＋例と重複して認められた．他の6例は局所所見のためであった。肉眼分類では小腸は壁肥厚型が多く，大腸では潰瘍型が多かった．組織型はLSG分類でdiffuselarge cell型が多かった．腸管悪性リンパ腫が臓器原発か，全身性の一部分症かを手術前に明確にするのは困難であるが，いずれにしても消化管症状を取るため可及的に切除すれば，姑息手術に終わっても，化学療法（AVCP，EMLP，CHOP，VEPAMなど）を施行し，CRを認め5年以上生存例を2例も経験しているので，腸管原発例では姑息手術でも腸管切除を行うことは有意義であり，化学療法で初回寛解導入が得られれば長期生存が期待できよう．

　Thirty-two cases of primary malignant lymphoma of the intestinal tract were classified into one case of duodenal lesion, four cases of jejunal lesions (including duplication in other organs), 16 cases of ileal lesions (including duplication in other organs), and 11 cases of large intestinal lesions (including duplication in other organs).

　Four cases had multiple malignant lymphoma of the intestinal tract (12.5%) and ten cases (31.3%) had concomitant lesions of other organs, mainly the stomach and other parts of the alimentary tract. Thirteen cases (41%) were curatively operated on for the treatment of maiignant lymphoma of the intestinal tract, and nine cases were palliatively operated on. The reason for this was that paraaortal lymph node (n₄) metastases were positive in 13 cases (68%), and, among the n₄ positive cases, five cases of peritoneal dissemination, and two cases of hepatic metastasis were noted to be duplicated. In six cases, localized findings were the reason. By LSG classification, diffuse large cell type claimed a great portion of all histological types.

　It is difficult to clarify preoperatively whether or not a malignant lymphoma of the intestinal tract originates in an organ or is a partial manifestation of a systemic disease. Whatever the case may be, as far as possible, resection is indicated so as to eliminate some alimentary symptoms. If this is done, according to our experience, a palliative operation with chemotherapy (AVCP, CHOP or VEPAM) would bring about CR and a 5-year or longer survival.

　This makes it meaningful to resect the intestinal tract in a case of primary malignant lymphoma involving the tract even in palliative operations. If initial relief ensues chemotherapy, long-term survival can well be anticipated.