皮膚筋炎を合併した早期食道癌の1例

Early Esophageal Carcinoma Associated with Dermatomyositis, Report of a Case

要旨　皮膚筋炎と食道癌の合併は少ない．本邦では7例の報告があるのみで，いずれも進行癌である．今回われわれは早期食道癌と皮膚筋炎の合併例を経験したので報告する．患者は56歳の男性で，1981年末ごろより前額部，頸部ならびに前胸部にびまん性の紅斑が出現し，本院に入院した．項部や背部には浮腫性紅斑があり，爪床に毛細血管拡張を認めた．上肢帯や大腿の筋肉には筋力低下が認められた．臨床検査成績はGOT 85U/l，LDH 488U/l，CPK 345U/l，ESR 28mm（1時間値），筋電図はmyogenic patternであった．前胸部からの皮膚生検では表皮の萎縮，真皮上層の浮腫と血管周囲のリンパ球浸潤を認めた．以上より皮膚筋炎と診断し，内臓悪性腫瘍の検索のために上部消化管透視と内視鏡検査を施行した．Im右後壁に隆起性病変を認め，表在隆起型食道癌と診断し，根治手術を施行した．腫瘍は丈の低い隆起が主体で，大きさは15×15mmであった．表面は結節状不整で中央に陥凹を伴っていた．切除標本の病理組織学的検索では深達度smの中分化型扁平上皮癌で，リンパ節転移や脈管侵襲は認められなかった．術後経過は順調で，皮疹もステロイド治療に反応したが，1983年3月に頸部上縦隔リンパ節再発をみた．本症例ではリンパ節転移や脈管侵襲がなかったので，術後経過観察としたが，腫瘍の肉眼的ならびに組織学的所見からは高い悪性度が予想され，十分な術後合併療法をすべきであったと老えられた。

　Coincidence of esophageal cancer with dermatomyositis is rare. Only seven cases have been reported for these 25 years in Japan. In this paper, we report the first case of early esophageal carcinoma associated with dermatomyositis.

　A 56 year-old man was admitted to our hospital with a complaint of diffuse erythema on the forehead, neck and upper chest since Dec. 1981. Also he had edematous erythema on the nape and back, teleangiectasis on the nail bed and muscle weakness of the shoulder girdle and thigh. Laboratory examinations were following; SGOT 85 U/l, LDH 488 U/l, CPK 345 U/l, ESR 28 mm in first hour, myogenic pattern in electromyogram. A biopsy specimen of the erythema taken from the upper chest showed atrophic epidermis, edema in the upper part of the corium and mild infiltration of lymphocyte at perivascular area.

　Roentgenological and endoscopical examinations of the esophagus revealed a well-defined superficial elevated lesion on the right side of the posterior wall of Im region (middle thoracic esophagus). It was diagnosed as esophageal cancer. The tumor was surgically resected.

　In the resected specimen, the lesion was 15×15 mm in diameter and had nodular surface with central depression. Histopathological examinations confirmed the lesion to be a superficial elevated type early esophageal cancer which was moderately differenciated squamous cell carcinoma and limited to the mucosa and submucosa with no lymph node metastasis.

　After operation, erythema was improved by oral administration of gluco-corticoid. The patient has not been treated by any anti-cancer therapy because of no evidence of the invasion into blood vessels and lymphatics. Thirteen months later, the recurrence was found on cervical and mediastinal lymph nodes. Even though there was no evidence of metastasis at the surgical resection, clinical courses are suggesting us the necessity of anti-cancer therapy after surgical resection especially in the case of moderate differenciated early esophageal cancer.