胃底腺粘膜領域から発生したⅡc型早期胃癌で術後2年4ヵ月に著明な骨髄転移を来した1剖検例

Intramucosal Carcinoma of the Stomach, Having Arisen from the Fundic Gland Mucosa and Its Recurrence with Marked Bone-marrow Metastasis, Two Years and Four Months after Operation: Report of an Autopsy Case

要旨　54歳，女性．胃集団検診にて巨大皺襞を指摘され，精査の結果，胃体上部前壁側大彎寄りの深達度mの未分化型Ⅱc型早期胃癌と診断された．切除胃の組織学的検索にて粘膜筋板直下のリンパ管内への癌の浸潤を1カ所認めた．また，3，4，6，9番の領域リンパ節への転移が認められた．術後経過良好にて退院，以後外来にて経過観察していたところ，術後2年ごろよりALPが上昇，骨X線検査にて広範な骨転移が認められ，化学療法が行われた．術後2年4カ月に腹部圧痛，高度の貧血を主訴に再入院となるも，DICを併発し当日死亡した．病理解剖により，骨髄に高度の癌の転移が認められ，また組織学的には食道空腸吻合部領域，肝，肺，リンパ節に転移が認められた．肝・腎の微小血栓形成と，後腹膜出血，皮膚，消化管粘膜の点状出血，血性心囊水・胸水などの出血素因が認められ，死因はDICによる出血と考えられた．

　A 54 year-old housewife was admitted to our hospital complaining of dull back pain.

　An x-ray examination of double contrast of the stomach showed a shallow depressed lesion with interruptions of the mucosal folds in the anterior wall of the gastric corpus near the greater curvature (Fig. 1 a, b). An endoscopic examination also revealed a depressed lesion of irregular shape and rough surface in the same location (Fig. 2 a, b). She was diagnosed as having type Ⅱc of early cancer.

　Biopsy materials revealed mucocellular adenocarcinoma (Fig. 3). In the resected stomach, the lesion showed a typical type Ⅱc of undifferentiated carcinoma, measuring about 3×3 cm in dimensions and located in the anterior wall of the gastric corpus near the greater curvature (Fig. 4 a, b). The lesion was histologically diagnosed as undifferentiated adenocarcinoma of the stomach having arisen from the fundic gland mucosa, limited to the mucosa (Fig. 6 b, 7) and metastatic to the regional lymph nodes. Further histological study by serially cutting the carcinoma was done in order to know the vertical depth of cancer infiltration, and a cancer nest permeating into a lymph vessel was disclosed just beneath the muscularis mucosae (Fig. 6 a, 8).

　Two years after operation, she was diagnosed as having vertebral cancer metastasis. After anti-cancer chemotherapy was performed, she rapidly went a down-hill course and expired of respiratory failure.

　At autopsy, lymphogenous metastasis was seen in the mediastinal, pulmonary hilar and retroperitoneal lymph nodes. Diffuse metastasis to the bone-marrow was observed, especially marked in the vertebrae, and microscopical metastasis was also noted in the lung and liver.