肺転移を伴った多発早期胃癌で胃切除に続き残胃全剔し1年後に肺切除した1例

Multiple Early Gastric Cancer Metastasized to the Lung, Report of a Case: Confirmed by lobectomy of right lung one year later after total gastrectomy following partial gastrectomy for three years

要旨　患者は68歳男性．約1カ月前より心窩部不快感と時々胸やけを認め来院した．4年前に胃腺腫を指摘され経過をみていた．上部消化管精査により，前庭部に不整な分葉状の隆起を認め，胃生検ではmild dysplasiaの所見であった．しかし4年前の所見と比べると，増大傾向があり，1980年5月28日胃部分切除が施行された．胃切除標本では前庭部に大きさ6.5×3.3cm，高さ1.0cmの隆起をみ，組織学的には巨大腺腫内に，多発性の癌巣を認めた．また偶然的な所見として，手術時肉眼的に認識しえなかった体中部切除断端近くに大きさ1.1cmの平坦型早期癌（Ⅱb型）が発見された．断端癌陰性でリンパ節転移もみられなかった．術後経過は良好で，無症状であったが，術後2年目に内視鏡にて残胃に新たにpolypoid cancerが発見された．1982年11月6日残胃全別術が施行された．その肉眼像は残胃前壁中心の表層性の隆起性癌（Ⅰ＋Ⅱa）で，一部穹窿部および噴門直下小彎にまで及んでいた．組織学的には乳頭状腺癌の像を呈し，粘膜下層にも大量の浸潤を伴っていた．2回目手術の術後経過良好であったが，1983年夏ごろより，持続性の咳漱と38℃前後の発熱をみ，当時気管支肺炎として抗生物質の投与により治療された．胸部X線所見では肺門部の結節性肺紋理の増強と右上肺に中等度のテント状の肋膜陰影をみ，喀痰検査にて悪性細胞を認めた．1983年11月2日，右肺葉切除とS₆，S₁₀の肺部分切除および肺門リンパ節郭清を施行，その切除標本では右肺に多発する孤立性の転移性結節をみ，組織学的に胃癌の肺転移と診断された．

　A 68 year-old man was first seen in our hospital because of epigastric discomfort and occasional heart burn of one month's duration. Four years prior to this admission, gastric adenoma was already checked up and he was followed-up elsewhere. The work-up of GI tract disclosed an irregularly lobulated elevation of flower bed shape on the antrum. Histologic examination of biopsy specimens demonstrated mild dysplasia. Nevertheless, on May 28, 1980 partial gastrectomy was done because of slow growth in size of tumor as compared with that of four years before. The gross specimen of the partially resected stomach showed a polypoid lesion on the antrum, measuring 6.5×3.3 in size and projecting 1. 0 cm above the mucosal surface. By histological investigation multiple foci of carcinoma were seen in the large flat adenoma. As an incidental finding, a superficial flat carcinoma (Ⅱb type) measuring 1.1 cm in diameter was detected near the surgical cut end of the midbody we were unable to identify at surgery. Surgical margin appeared cancer-free and no lymph node involvement was found. Postoperative course was uneventful and he remained asymptomatic for two years after surgery when a newly arising polypoid tumor on the remnant stomach was detected by endoscopy.

　On Nov. 9, 1982, total gastrectomy of the remnant stomach was carried out. The gross specimen of the remnant stomach showed superficial polypoid carcinoma (Ⅰ+Ⅱa) on the anterior wall extending into the fornix and the lesser curvature under cardia. Histology disclosed papillary adenocarcinoma massively invading the submucosal layer.

　After the second surgery he had a temporary recovery, but in summer of 1983 he began to notice persistent cough and spike fever around 38.0℃. He was treated for bronchopneumonia with antibiotics. The radiograph revealed a moderate amount of pleural tenting in the right lobe associated with nodular increase of the hilus. The cytology of sputum demonstrated malignant atypical cells. On Nov. 2 1983, lobectomy and partial resection of S₆ ＆ S₁₀ of the right lung were done with lymph node dissection of the hilus. The macroscopic findings showed isolated metastatic nodules in the right lung suggesting the metastases from primary carcinoma of the stomach.