malignant cycle症例

malignant cycle

　主に内視鏡像にて，良性潰瘍→縮小・瘢痕化→Ⅱc＋Ⅱa→良性潰瘍，という変化を観察し得た，Ⅲ＋Ⅱcの1例を報告する．

　症　例：63歳　男子

　経過観察期間：約7カ月．

　A case of Ⅲ＋Ⅱc is endoscopically described through its vicissitudes from benign ulcer to its diminution and scarring, to Ⅱc＋Ⅱa and again to benign ulcer.

　The case: 63-year-old of observation: about 7 months.

　One year before he had been diagnosed as gastric ulcer, and he had been advised to undergo operation. A short time before he felt pain in the upper abdomen. As a niche was found at the gastric angle by a gastric mass survey, he visited our department for thorough examination.

　As is shown in Fig. 1, the initial endoscopy picture revealed an ulcer with marked marginal swelling. Diagnosis then was benign ulcer. Although not completely satisfied, we placed him under medical management with a tentative diagnosis of benign ulcer, and chiefly antacids were given. The picture in Fig. 2 taken one month later shows that the white coat over the ulcer floor has considerably dwindled, with the nature of the ulcer floor becoming more distinct now. Slightly reddened, islet-like protrusions on its oral side, club-like swollen mucosal tips and shallow Ⅱc-like erosions really looked malignant. In the Fig. 3 taken about one and half a month later the white coat on the ulcer floor had almost fallen off, and the ulcer was now cicatricized. However, mucosal folds converging toward the scar were of uneven size with islet-like protrusions in the center. We nevertheless decided to follow him up for another month because Ⅱc-like erosions seen in the last picture had disappeared.

　The next endoscopy picture revealed four reddened islet-like elevations in the center of ulcer scar, surrounded with typically Ⅱc-like erosions. The folds were also characteristic of early gastric cancer. Gastric biopsy done at the same time proved positive for cancer. It was diagnosed as adenocarcinoma. However, perhaps because subjective sympotoms had subsided, the patient refused to undergo operation, so that we had to wait for another two months. In the third month of follow-up, he had such a large amount of bloody discharge that he was immediately admitted as an emergency case. On the fourth day of bleeding, the endoscopy was performed, revealing, surprisingly enough, a more gentle picture of benign ulcer with no trace of former Ⅱc lesion. We presumed that eroded parts typical of former Ⅱc lesion had fallen off because of large amount of hemorrhage. Even in the resected specimen (Fig. 6) it was hard to tell benignancy from malignancy. Histopathologically, however, cancer was seen in parts oral and anal from the ulcer. It was early gastric cancer (m), Ⅲ＋Ⅱc, measuring 17×16 mm.