早期十二指腸癌―症例報告および文献的考察

Early Duodenal Cancer, a Case Report with a Review of Its Literature

　原発性十二指腸癌は比較的まれな疾患であり，全剖検例の中，欧米ではMateer¹⁾らによれば0.06～0.2％を占め，本邦では石原，長与³⁾らの0.1～0.2％という報告がある（表1）．最近臨床的にも，原発性十二指腸癌の手術成功例の報告が散見されるようになったが，これらはすべて漿膜浸潤高度な進行癌であり，この部分の早期癌の報告には未だ接しないようである．われわれは最近十二指腸水平部末端に発生した病変で，切除標本の組織所見から粘膜層に限局した早期十二指腸癌と診断された貴重な一症例を経験したので，若干の文献的考察を加えて報告する．

症例

　患　者：H. K.　67歳，女性．

　主　訴：上腹部とう痛，胃部膨満感，嘔吐．

　家族歴：特記すべきことはない．

　既往歴：1年前から膝関節ロイマチス，下肢静脈血栓症あり．

　現病歴：昭和46年6月上旬より，軽い上腹部痛，食後の胃部膨満感をきたすようになったので，6月中旬当外科を受診，胃X線検査および胃カメラが施行されたが，胃幽門部の胃周囲炎によるくびれを指摘されたのみで，他に特に異常は認められなかった．しかし患者はその後も上腹部痛があり，6月末頃から朝食べたものを夕方嘔吐するようになったので，7月上旬当内科を受診し，貧血を指摘され，精密検査をすすめられて入院した．

　The patient: a 67-year-old housewife.

　Chief complaints : pain in the upper abdomen and vomiting.

　Present history : Since the beginning of June 1971 the patient had slight epigastralgia and full sensation of the stomach after meals. X-ray examination done in the middle of the same month revealed no abnormality. As the pain in the upper abdomen persisted and since the end of June she began to have bouts of hematemesis and vomiting in the evening, she visited our hospital. She was admitted for further check-up because of noticiable anemia.

　Observations at admission : The patient was rather small of stature and slightly undernourished. Conjunctivae were rather anemic, but sclerae showed no jaundice. The abdomen was flat with no palpable liver or spleen. The epigastrium and left lower quadrant were very tender on palpation and resistent. The feces after admission was strongly positive for occult blood. In the upper x-ray G-Ⅰ series no abnormality was seen in the stomah, but in the duodenum abnormal course and dilation of the mucosal folds were seen in the second portion. In addition, an irregular constriction was noticed in the terminal end of the third portion. Hypotonic duodenography revealed there a flat-tipped elevation with granular surface associated with partial ulceration. The elevation was seen as an irregular shadow defect, measuring about 4 cm long. It was highly suggestive of malignancy. Endoscopy was not performed, however.

　Findings at operation : The first and second portions of the duodenum were markedly dilated, and in the terminal part, corresponding to the Treitz's ligament, was a hard tumor palpated in the duodenal wall, the serosa strongly adhering to the mesenterium. Under a diagnosis of malignant growth of the duodenum we resected the second portion in its entire length, followed by sied-to-end duodenojejunal anastomosis. Gross specimen of the resected duodenum showed a granular, flat-tipped protrusion of irregular shape about 5 cm long, extending over the entire circumference of the intestinal wall. A shallow depression of some extent was seen in the center of the lesion, with a perforation 0.8 mm in diameter a little to one side. Histology revealed a well-differentiated papillotubular adenocarcinoma still in the stage of mucosal cancer. It encircled almost the whole of the central ulcer, which was Ul-IV. No cancer invasion was seen beyond the muscularis mucosae. The present case is possibly the first report of early cancer of the duodenum, for we could not find any in the literature available for us.