胃癌に併存した胃の限局性サルコイドの1例

A Case of Local Sarcoid of the Stomach Coexiting with Carcinoma of the Stomach

　近年，サルコイドージスは全身性疾患として注目され，肺門リンパ節，肺，眼，皮膚，表在リンパ節，骨，神経，唾液腺などに好発すると言われている¹⁾．消化管，とくに胃のサルコイドージス（または胃の限局性サルコイド）についての報告は少なく，欧米ではSchaumann（1936）²⁾の報告以来34例をWadina（1966）³⁾が，本邦では長村（1960）⁴⁾に始まってわずか7例^5)～9)を集めるにすぎない．最近われわれは良性胃潰瘍の診断で手術した胃を精査した結果，病理組織学的に胃癌に胃サルコイドと思われる病変が共存していたので報告し，併せて文献的考察を行なってみる．

　The patient: a 32-year-old man. Chief complaints: epigastralgia and tarry stool. Since three years before he had been under medical management for gastric ulcer.

　X-ray examination of the stomach revealed (1) a niche on the lesser curvature of the angle with mural rigidity around it, and (2) prominent abnormal patterns of the large mucosal folds, or giant rugae, on both walls extending from the middle to lower corpus. Endoscopy also disclosed (1) a small, crescent-shaped ulcer with thin, white exudate over it likewise on the lesser curvature at the angle, together with (2) giant folds taking unusual courses in the mid-body and lower corpus, associated with poor distensibility of the gastric wall despite a great amount of air introduced. Gastrectomy was therefore done under a diagnosis of benign gastric ulcer and giant mucosal folds.

　In the gross specimen of the resected stomach (1) a shallow ulcer was seen in the lesser curvature side on the anterior wall of the lower corpus. It measured 8×6 mm，with a limited area of Ⅱc-like depression directly on its oral side. The specimen also disclosed (2) giant mucosal folds extending to lower corpus.

　Histopathologically, (1) the depression as a whole was Ul-Ⅳ ulcer encircled by a cancerous area, measuring 5.0×3.0 cm, with sm degree of depth invasion. It was adenocarcinoma mucocellulare scirrhosum. The area of Ⅱc-like depression as confirmed macroscopically did not coincide with that of cancer infiltration. (2) On both walls of the lower body, almost over the whole circumference of the gastric wall was seen an epithelioid granuloma in the muscularis propriae. Histological characteristics of the granuloma itself along with the distribution of the tumor and cancer infiltration led us to the diagnosis of sarcoid of the stomach. The same variety of granuloma was likewise seen in the subpyloric lymph node. The giant rugae were interpreted as resulting from fibrosis due to granuloma and superficial gastritis. Kveim reaction was negative, while tuberculin test was positive.

　Only seven cases of sarcoid of the stomach have been reported so far in our country. Of great importance is its differentiation from early gastric cancer of ulcer and scirrhus types.