随伴Ⅱb型早期胃癌の1例

A Case of Ⅱb Early Gastric Cancer Attending on Another Ⅱc+Ⅲ

　直視下生検法の普及した今日でも，癌病巣部と周囲粘膜との間に形態的な差が余りなく，輪廓の明瞭でないⅡb型早期胃癌は，診断面でもまた治療上にも多くの課題を提起している．随伴Ⅱb型（白壁ら¹⁾の定義による）の1例における経験を，内視鏡診断を中心に外科医の立場からふりかえってみたい．

　A description is given about the difficulty of diagnosing Ⅱb encountered in a case of an extensive early cancer of this variety concomitant with another Ⅱc+Ⅲ lesion. To determine how far cancer has spread toward the cardiac side carries great weight in deciding to what extent a given segment is to be excised. The present case was first suspected of cancer at a gastric mass screening, and later confirmed as Ⅱc+Ⅲ lesion alike by roetgenography, endoscopy and biopsy. Before the operation was presumed to have spread to an extent toward the cardiac side, but we were unable to confirm the extent of coexisting Ⅱb-like lesion, which had in fact spread as near as 4 mm to the esophagogastric junction, a fact postoperatively made clear by histological examination. At first subtotal gastrectomy was carried out, but gross observation of the resected specimens cast a doubt on the integrity of the remnant. Indeed frozen sections were positive for cancer, so that additional resection was performed. On looking back, the conspicuous Ⅱc+Ⅲ forming the core of the extensive lesion led us astray. Prior to operation the extent of cancer spread was not confirmed. The delineation of the upper segment was unsatisfactory, and its interpretation, insufficient. Although observing endoscopically Ⅱb-suggesting cancer spread, we failed to appraise correctly what was obtained by color spray method. All was to blame on our neglecting biopsy to dermine how far cancer had extended. We should always taken into account the possibilities of cancer extension beyond an apparent border. Roentogenography and endoscopy cannot be done too carefully. We must also see to it that biopsy is effectively employed.