表層型早期胃悪性リンパ腫の1例―早期診断への手掛かり

Malignant Lymphoma of the Stomach: A characteristic finding for early detection

　胃悪性リンパ腫の診断学的特徴像については従来より種々の報告がなされてきたが，これらの多くは，進行胃癌との鑑別診断を主体としたものであり，早期診断指標となり得る所見について言及したものは少ない．そこで，われわれは光島¹⁾が既に早期診断指標として報告した“溝状びらんに囲まれた粗大顆粒の集簇像”を典型的に示した1例を提示し，若干の考察を加え報告したい．

　症　例

　患　者：52歳，女．

　主　訴：胃病変の精査．

　診断経過：1979年2月集団検診を受診．間接X線フィルム上，胃角より角上部小彎にかけて広汎な粗大顆粒像が指摘され，悪性リンパ腫を疑われ同年4月2日当センター紹介受診．4月6日の胃X線検査，4月13日の胃内視鏡検査にて早期悪性リンパ腫を疑われ，同時に行われた胃生検にて確診された．

　A 52 year-old woman with no particular complaint was admitted to the National Cancer Center Hospital for the exact examination of the gastric lesion which had been detected in mass survey.

　With the precise roentgenographic and endoscopic observations, this lesion was revealed as variedly sized and smooth-surfaced granules surrounded by sulcuslike erosion. This mucosal irregularity extended from the lesser curvature of the middle body to the anterior wall of the antrum.

　From this particular mucosal pattern this case was diagnosed as malignant lymphoma preoperatively and histological confirmation was made on the biopsy specimens. Total gastrectomy with extended lymph node dissection was performed. The gross appearance of the resected specimen corresponded to the findings shown in x-ray and endoscopic examinations.

　On the histological examination the case presented was diagnosed as a diffuse type of PDL (Poorly differentiated lymphocytic lymphoma). The depth of invasion was limited within mainly mucosal partially submucosal layer (so called early gastric lymphoma) and five lymph nodes out of 38 were involved.

　Numerous papers to date, have described the characteristic findings of macroscopic appearances in gastric lymphoma. Previous literature, however, has been limited in its description and prediction of early detectable lesion seen as only mucosal irregularity.

　In this paticular case the macroscopic appearance shows no ulcerating and tumorous component but only reveals superficially granular and erosive mucosa. This appearance had been already reported as one of the characteristics in malignant lymphoma of the stomach (Cobblestone-like appearance: Mitsushima).

　Hence, for the early detection of the gastric malignant lymphoma it is important to make precise observation not only to the ulcerative or tumorous finding but to the superficial irregularity of the gastric mucosa as shown in the case presented.