診断困難な形態を示したスキルスの1例

A Case of Scirrhous Carcinoma of the Stomach Simulating a Submucosal Tumor

　わが国における胃病変の診断は，X線，内視鏡の普及とともに発展し，その質的診断も生検，拡大観察，実体顕微鏡観察，色素撒布などの補助手段の開発と相まって著しく進歩した．この経験の集積を通常のX線，内視鏡の判読の向上に役立てねばならない．今回われわれは臨床経過，検査成績，X線，内視鏡にて質的診断が困難な形態を示した症例を経験したので，その問題点について考察を加えて報告する．

症　例

　患　者：72歳　男性　会社役員

　家族歴：特記すべきものなし

　既往歴：62歳，急性肝炎の診断にて自宅療養し治癒．66歳，糖尿病を指摘され，現在食餌療法のみで可とされている．

　現病歴：約2年前より飲水時の前胸部閉塞感を自覚していたが，症状増悪しないままに放置していた．1977年6月，全身に皮疹を来たし，近医受診，同じ頃，心窩部鈍痛も自覚していたために，消化管透視を受け，慢性湿疹，胃潰瘍の診断を受け，通院開始した．2カ月後再び消化管透視を受け，Borrmann 1型胃癌と診断され，本院へ紹介された．これまでに食欲不振，体重減少はなく，便通異常，下血にも気付いていない．

　A report is made of a gastric cancer that could not be diagnosed by X-ray and endoscopy alone.

　A 72 years old man, a company executive, had consulted his family physician on account of rash on the skin and dull epigastric pain. He was referred to our hospital after he had been found to harbor Borrmann 1 type cancer of the stomach revealed by re-X-ray. Physical and laboratory examinations showed that rash was seen all over the body with a palpable tumor the size of an egg in the abdomen. Besides slight diabetes mellitus, considerable eosinophilia was noticed in the blood. X-ray examination of the stomach showed a protruding lesion with erosions at the tip, extending from the posterior wall of the angle down to the lesser curvature of the antrum. The protrusion was raised at a sharp angle. Endoscopy showed auricle-like reddening around the erosions. The surrounding mucosa looked like normal but the tumor itself was accompanied with bridging folds. By the findings of X-ray and endoscopy alone, it was hard to tell whether this tumor be a submucosal one or epithelial growth. Cancer we had naturally to take into account, Hodgkin's disease because of skin rash, eosinophilic granuloma as was suggested by the changes in the blood and so on.

　We were unable to arrive at an accurate diagnosis until biopsy disclosed undifferentiated carcinoma, which proved to be scirrhus by the histologic examination of the resected specimen.

　Although various ancilliary methods of diagnosis have been improved greatly, we must still endevor to reach such a time when we might be able to diagnose gastric lesions accurately by the usuall examination methods. One of the reasons for the difficulty of diagnosis in this case was that the tumor, developing mostly in the submucosa, grew as a tumor mass sharply circumscribed with the surrounding mucosa.

　Except for the part of erosions, it was covered with normal mucosa. Histologically it was scirrhus, but it would be false to conclude that scirrhus be cancer of Borrmann type 4. Such a conclusion would make the diagnosis of the present case much more difficult.