癌性リンパ管症により周囲に特異な赤色・白色斑の集簇を認めた1型胃癌の1例

Papillary Adenocarcinoma of the Stomach with Marked Lymphangiosis Carcinomatosa, Presenting an Uncommon Aggregation of White and Red Speckles on the Mucosa around the Tumor, Report of a Case

要旨　患者は70歳の女性．Parkinson病の治療中に小球性低色素性貧血を指摘され紹介受診した．上部消化管X線検査で胃体上部前壁小彎側に3cm大の立ち上がり急峻なやや丈の高い扁平隆起性病変を認め，表面は小結節状で隆起表面に不整形の淡い陥凹を伴った．また隆起性病変周囲の噴門部から胃体上部前壁にかけて，ほぼ均一な顆粒状の透亮像が集簇し，その境界は不明瞭であった．この顆粒集簇像は上部消化管内視鏡検査では白色調ないし赤色調の透過を有するなだらかな小隆起の集簇として認められた．扁平隆起性病変の生検から乳頭腺癌の所見が得られ，胃全摘術を施行した．切除標本の病理組織学的検索では，隆起性病変はそのほとんどが粘膜から粘膜下層深部にとどまり，一部が固有筋層表層へ浸潤した乳頭腺癌の所見であった．その周囲には白色調ないし褐色調の小隆起がうろこ状に集簇しており，組織学的には粘膜固有層および粘膜筋板直下の高度のリンパ管侵襲とその著明な拡張，およびリンパ管内出血の所見であった．リンパ管侵襲は固有筋層から漿膜下層へ及び，第2群リンパ節への転移陽性であった．癌性リンパ管症を合併した1型胃癌として特異な発育形式を来した1例と考えられた．

　The patient was a 70-year-old woman, who presented microcytic hypochromic anemia and was referred to our hospital for further examination of the stomach. Upper gastrointestinal series and endoscopy showed a flat elevated lesion, approximately 3 cm in diameter, in the anterior wall of the upper gastric body. An uncommon aggregation of white and red speckles was also seen on the mucosa around the elevated lesion. A biopsy specimen of the elevated lesion showed papillary adenocarcinoma, so total gastrectomy was performed. Macroscopic examination of the resected tissue showed that the elevated lesion, measuring 36×29 mm in size, was surrounded by an aggregate of white and red speckles extending on the mucosa. Histologically, the elevated lesion was papillary adenocarcinoma invading the deep layer of the submucosa and focally involving the superficial propria muscularis, as well as being accompanied by prominent lymphangiosis carcinomatosa. Lymphatic vessels around the elevated tumor showed marked dilatation because of tumor thrombosis and hemorrhage especially in the propria mucosae, thus presenting such an uncommon aggregation of speckles.