Achalasia術後のBarrett型食道に発生した悪性絨毛上皮腫の1剖検例

Choriocarcinoma Arising from Barrett's Esophagus after the Esophagus after the Esophagocardiectomy for Achalasia, Report of an Autopsy Case

要旨　患者は45歳の男性．生来健康であったが，1964年achalasiaの診断で下部食道胃噴門部切除術が施行された．1977年吻合部付近に腺癌が発生し　，再び食道胃部分切除術が施行された．組織学的には，粘膜内にとどまる未分化腺癌であったが，その癌は前回手術の食道胃吻合部より口側にあった．しかもその周囲は円柱上皮によって被われていたため，Barrett型食道に発生した早期腺癌と診断された．このとき悪性絨毛上皮腫の所見は認められなかった．1982年7月ごろより悪心，嘔吐が出現．精査の結果，癌の再発と診断され同年11月全食道および残胃切除術が施行された．組織学的に腫瘍の大半は食道にあり，その一部，リンパ節転移巣に腺癌と共存して，悪性絨毛上皮腫類似の組織像が認められた．この部分はPAP法でHCG陽性であった．1983年2月ごろより咳漱が出現．胸部X線写真上，多数の結節状腫瘤影が認められた．またこのころより睾丸の萎縮と女性化乳房が出現し，血中HCG値も12,000mIU/mlと高値を示した．MFC療法が無効であったため，ACT-D，MTX，Vinblastinに変更したところ肺転移巣の縮小と血中HCG値の減少が認められ，同年6，月には280mIU/mlまで低下した．しかし同年9月肺炎の合併と全身転移のために死亡した．剖検検索では壊死性，出血性の転移結節が肺，肝，腎およびリンパ節広範に多数認められた．組織学的にはすべて悪性絨毛上皮腫であった．

　The patient was well untill 1964, when lower esophagocardiectomy was performed under the diagnosis of achalasia. He complained of refiux esophagitis thereafter. In July 1977, partial esophagogastrectomy was done because of development of cancer near the anastomotic site. Histologically, poorly differentiated adenocarcinoma without submucosal infiltration was seen at the oral side of the previous anastomosis. There was no choriocarcinomatous structure. The lower esophagus around th ecancer was covered by columnar epithelium with focal epithelial dysplasia. Accordingly, the cancer was considered to have arisen from Barrett's esophagus. He was readmitted in September 1982 complaining of dysphagia. Total esophagogastrectomy was performed in November because of a large tumor at the site of anastomosis. Histological examination revealed adenocarcinoma and choriocarcinomatous structure, which was positive for HCG by PAP-method, mostly involving the esophagus with lymph node metastases. A small area of remaining Barrett's esophagus was identified near the tumor. In February 1983, multiple nodular shadows were found in both lung fields on chest x-ray films. In spite of MFC-therapy, the lung shadows rapidly enlarged along with testicular atrophy, gynecomastia and markedly elevated serum HCG level (12,000 mIU/ml). Vinblastin, Actinomycin-D and MTX-therapy resulted in diminished size of the lung shadows and lowered serum HCG level (280 mIU/ml). However, re-growth of the lung tumors was observed since July and he died of respiratory failure on September 11, 1983, at the age of 45.

　Autopsy disclosed metastatic choriocarcinoma in the lungs, liver, kidney and lymph nodes.

　This is the first case of esophageal choriocarcinoma arising from Barrett's esophagus recorded in the world literature.