良性潰瘍との鑑別が問題となったびまん浸潤型胃癌の1例

A Gastric Ulcer Looked Like Benign Lesion Developing into Typical Diffusely Infiltrating Gastric Cancer After Three Months, Report of a Case

要旨●患者は70歳代，男性．急性心筋梗塞にてステント治療を受け，その3日後から上腹部痛が出現した．初回EGDでは，胃角上部の前壁小彎に潰瘍性病変を認めた．悪性所見に乏しく，抗血栓療法施行中のため鉗子生検を行わずに終了し，PPIを投与した．6週間後の第2回EGDでは潰瘍性病変は縮小し，白苔の周囲に再生上皮がみられた．初回より12週間後の第3回EGDでは白苔は消失し，瘢痕部は全体にやや隆起し，その周囲に褪色調粘膜と不整形陥凹を認めた．また，前回まで異常を認めなかった前庭部に伸展不良がみられた．鉗子生検ではGroup 5（sig）と診断された．胃X線造影では胃の遠位側を中心とした広範な硬化像がみられ，びまん浸潤型胃癌と考えられた．外科手術を施行したが非治癒切除となった．

　A man in his seventies was referred to our department complaining of upper abdominal pain. He had undergone coronary artery stenting for the treatment of acute myocardial infarction 3 days previously. The patient's first EGD revealed gastric ulceration anterior to the middle portion of the lesser curvature. The endoscopic finding of the ulceration showed no remarkable malignant appearance. Biopsy specimens were not taken at this time because of concurrent anticoagulant therapy, and a proton pump inhibitor was administered to the patient. A subsequent EGD（6 weeks after the first EGD）revealed a reduction in the extent of the lesion, and regenerative gastric mucosa was observed around the ulceration. The patient's third EGD（12 weeks after the first）revealed a slightly protruded cicatrix that was surrounded by whitish mucosa and an irregular depressed lesion. Poor extension of the antrum, which had not been previously noted, was also observed. Histological biopsy specimens taken from the whitish mucosa and irregular depressed lesion were diagnostic for signet ring cell carcinoma. Radiographic examination revealed diffusely poor extension of the distal gastric wall. From these findings, we diagnosed a diffusely infiltrating gastric cancer. Total gastrectomy was performed; however, tumor cells were histopathologically observed at the resected anal margin, as well as on the cytological examination of ascitic fluid.