Pancreas divisumに発生し，2年6か月間の経過観察をした膵癌の1例

Pancreatic Cancer with Divisum Followed Up for Two Years and Six Months, Report of a Case

要旨　63歳，女性．手術2年6か月前に心窩部の激痛があり，血清，尿アミラーゼは著しい高値を示した．胃X線検査で胃体部小彎に胃外性圧排がみられた．副乳頭挿管によるERCPで，divisumを伴う背側膵炎と診断した．手術1か月前，心窩部痛が再来し背部痛，食欲不振を伴った．血清，尿アミラーゼともに低値を示し胃外性圧排も前回より著明となった．ERCPで頭部と体部の2か所に主膵管の不整狭窄がみられ，重複膵癌と診断．CT，血管造影でも切除可能な重複膵癌と診断し，膵全摘を施行した．病理検索では体尾部から頭部まで拡がった1つの膵癌であった．膵管癒合不全例に発生し，2年6か月の観察を行った例でERCP像，胃体部圧排，アミラーゼ値の経過を中心に報告した．

　A 63 year-old woman had severe epigastric pain four years and seven months before operation. Two years later, the same pain recurred. She visited a clinic and was examined with UGI series and amylase level in serum and urine. UGI series showed extra-gastric compression of slight degree at the lesser curvature of the gastric body. Serum and urinary amylase level was extremely high. She was referred to our hospital for detailed examination of pancreatic disorder. The first ERCP cannulating into major papilla revealed only the normal bile duct system.

　The second FRCP was attempted five days later in order to observe the pancreatic duct system by cannulation of minor papilla. With use of a metal tip catheter, chronic pancreatitis of moderate degree was diagnosed. US and CT scan performed at the same period showed nothing abnormal. Due to absence of signs of malignancy in morphological examinations and improving symptom, she discontinued her visits to our hospital.

　Two years and six months later, epigastric pain radiating to the back and anorexia occurred. She visited our hospital again and was checked with UGI series, amylase level and ERCP. UGI showed extragastric compression on the lesser curvature of the gastric body more markedly than on the previous time. Serum and urinary amylase levels were low at this time. ERCP cannulating into minor papilla showed irregular stenosis of the main pancreatic duct and was diagnosed as pancreatic cancer. Subsequent US, angiography and CT scan also indicated cancer of the pancreas.

　On laparotomy, two hard masses were felt at the head and body of the pancreas. These were considered to be double cancer. In spite of invasion to mesocolon, ligament of Treitz and gastric wall, total gastrectomy+total pancreatectomy+splenectomy was carried out. Pathological analysis showed that the carcinoma was single with a lesser amount of the cancer nest at the neck of the pancreas. Pancreatic cancer observed in divisum has rarely been reported and no follow-up cases were found in literature.

　A rare case of pancreatic cancer, as well as diagnostic ability of extra-gastric compression on UGI series and amylase level in initial stage of pancreatic cancer, is reported.