結果的に5年間経過観察された胃細網肉腫の1症例

A Case of Gastric Reticulum-cell Sarcoma: Follow-up study with X-ray, gastroendoscope and gastric biopsy during the past five years

　胃疾患診断学の進歩により，胃の悪性リンパ腫の診断は従来より容易となったが，その早期診断については今なお困難な点が多い．われわれは初診時良性の多発性胃潰瘍と診断し，その後約5年間経過観察を行ない，結果的に悪性リンパ腫（細網肉腫）であった1症例を経験したので報告する．

症例

　患　者：77歳（手術時）女性，農業

　主　訴：心窩部痛，吐血，下血

　家族歴：特記すべきものなし

　既往歴：高血圧．40歳頃より食欲不振，胃部膨満感等の胃症状を訴えていた．

　現病歴：1970年3月，下血，顔面浮腫，貧血，脱水等にて来院検査の結果多発性潰瘍として3カ月入院し，保存的療法にて軽快退院した．その後1972年9月と1973年8月にも下血をきたし，入院治療を繰り返している．初回入院時は多発性胃潰瘍と診断し治療を行なったが，その後の経過で，胃X線，内視鏡所見が多彩な変化を示したことより，臨床的に悪性リンパ腫を疑った．しかし生検の結果では組織学的に悪性細胞が認められず，RLHとして経過を観察した．1975年3月大量の吐血，下血にて緊急入院した．

　Case : a 77 years old female at the time of operation.

　In March 1970, she visited Tone Hospital complaining of melena, anemia and facial edema. A diagnosis of multiple ulcers of the stomach was made after detailed examination. Although malignant lymphoma was suspected later, endoscopic biopsy failed to show malignant aspects, so that we carried on five years long follow up under a diagnosis of RLH (Reactive lymphoreticular hyperplasia).

　X-ray and endoscopic examinations were performed every three to six months, including endoscopic biopsy (four times), but no malignant findings could be confirmed histologically. Final endoscopic biopsy just before the operation led us to a diagnosis of malignant lymphoma of the stomach.

　According to the reports in the literature observing the progress of lymphoma, a sudden change and clinical signs and symptoms were said to appear within a short time. This case likewise showed recurrence of multiple ulcers and variegated mucosal changes, such as Ⅱc-like depressions or irregular unevenness of the mucosal surface. However, at any time of the follow-up was it difficult to determine whether or not the lesions were malignant. Final examination before the operation impressed us with highly suspicious malignant lymphoma because multiple elevations similar to submucosal tumors were detected in the pyloric and antrum region.

　As diagnosis by endoscopic biopsy was also malignant lymphoma, operation was performed.

　According to the classification proposed by the Sano group, macroscopic appearance of the superficial type of malignant lymphoma resembles that of early cancer. It becomes then all the more difficult to differentiate this type of malignant lymphoma from RLH. The only way to do so would be to perform gastric biopsy. Still, even histologically it is considered sometimes difficult to tell them apart.

　On this account, if there be a firm clinical suspicion of RLH, the patient should preferably undergo surgical exploration even when the diagnosis by gastric biopsy be negative as it was inthis case.