経過追跡しえたlinitis plastica胃癌の1例

A Followed-up Case of Linitis Plastica Carcinoma

　臨床上linitis plastica胃癌における早期診断は極めて困難で，進展が早く，予後が極めて悪いことはしばしば経験するところである．私ども臨床医は日常の診療において，このlinitis plastica癌を見落とさないようにと日夜気にかけているつもりである．にもかかわらず，数年にわたる胃X線検査で突然leather bottleのX線像が出現し，愕然とすることがある．最近筆者らはX線，内視鏡検査で悪性とする異常所見を把握できず，1年後にlinitis plasticaの状態で手術された症例を経験したので，若干の検討を加え，報告する．

　症　例

　患　者：54歳男，警察官．

　主　訴：食欲不振．

　家族歴，既往歴：特記すべきことはない．

　現病歴および診断経過：1977年1月の胃集団検診にて異常を指摘され，1977年2月1日金沢市内の病院にて胃X線および内視鏡検査を施行するも，異常を指摘できなかった．1978年1月初旬ごろより食欲不振を認めるようになり，新野外科病院を受診，胃X線検査にてBorrmann 4型癌が疑われ，胃生検にて癌の確診を得たため，同年3月6日胃全剔術が施行された．入院時の検査成績には異常を認めなかった．

　Linitis plastica carcinoma of stomach is characterized by an insidious onset, a rapidly progressing cachexia and fatal determination. Although this condition is not rare, very few reported cases have been diagnosed at an early stage. In order to evaluate the early stage of this carcinoma, we made the retrospective study of our own case followed-up for about one year. A 54 year-old man visited our hospital for further workup because of being checked up some abnormalities by mass survey for gastric disease, but he was asymptomatic. Upper GI series showed a shallow depression of irregular shape at the anterior wall of angulus, accompanied by some nodular protrusions at the tips of convergent mucosal folds. Moreover, this revealed some rigidity along the greater curvature of its outline. Endoscopic view at that time revealed a shallow depression with convergency swollen abruptly. A Ⅱc-like depressed lesion was endoscopically overlooked then and he was followed-up without medications.

　About one year after the first examination he visited Shinno Hospital with complaints of loss of appetite, and second roentgenography taken at this time illustrated marked rigidity of the greater and lesser curvature, widening of the angulus. A diagnosis of linitis plastica carcinoma was made and total gastrectomy was performed. Gross picture disclosed slightly thickened pattern of rugal folds with edema and rigidity throughout the entire stomach except for pyloric antrum. Cancer cells infiltrated the entire gastric wall and the primary site was histologically confirmed to be a shallow ulcerating lesion at the anterior wall of the angulus.

　Of the greatest importance in establishing the roentgenographic and endoscopic diagnosis is the study of gastric mucosal abnormalities before occurring of rigidity of the gastric wall. Some abnormal findings of earlier stage of linitis plastica were obtained from retrospective study in this case, such as a Ⅱc-like depression with edematous neighboring mucosa, irregular elevation around the ulcer, and initial rigidity of gastric wall. As for the initial rigidity endoscopy is difficult to evaluate it, so that we should make the diagnosis comparing findings of endoscopy with those of roentgenography.