十二指腸・主膵管・総胆管の表層拡大型十二指腸乳頭部癌の1例

Superficial Spreading Carcinoma of the Papilla of Vater, Report of a Case

要旨　十二指腸・主膵管・総胆管の表層拡大型乳頭部癌の1例を経験した．患者は61歳，女性．心窩部痛を主訴として1993年10月4日初診．十二指腸内視鏡検査およびX線検査で十二指腸第2部に乳頭の腫大と表面小結節状の広汎な丈の低い隆起病変を認めた，主乳頭前壁側に粘膜下腫瘍(SMT)も副病変として認めた．生検，ERCP，EUS所見も総合し乳頭部癌と診断した．1994年3月11日，膵頭十二指腸切除，および同年5月26日，膵体部追加切除を行った．病病理組織学的にOddi筋に達しない十二指腸粘膜内（m），主膵管内，総胆管内表層の分化型腺癌で，大きさは十二指腸粘膜面で52×40mmであった．

　A 61-year-old female who had been suffering from occasional pain in the epigastrium for the past 10 years and who was diagnosed as having chronic pancreatitis by other clinicians, visited our hospital on Oct. 4, 1993. Duodenoscopy revealed a wide superficial elevated lesion with a white and fine nodular surface involving a swollen major papilla and a submucosal tumor in the second part. Roentgenogram of the second part of the duodenum showed a wide superficial elevation with irregular nodular surface including the swollen papilla and the submucosal tumor. CT and EUS demonstrated dilatation of the main pancreatic duct. ERCP disclosed an irregular obstruction of the common bile duct and an tapering of the main pancreatic duct of the pancreatic head. EUS showed the tumor-like lesion, measuring 15×10 mm in diameter, in the main pancreatic duct of the pancreatic head. Macroscopic view of the duodenum of the surgical specimen showed the wide superficial elevation with fine nodular surface, measuring 52×40 mm in diameter, in which the swollen major papilla was located. Histologic findings disclosed well differentiated tubular adenocarcinoma of the papilla of Vater, superficially invading into three dimensions, i.e. the duodenal mucosa, the main pancreatic duct near the pancreatic body and the common bile duct. In addition, the submucosal tumor of the duodenum was histologically proved to be a heterotopic pancreas. Although such a lesion has been found in the stomach and colorectum, superficial spreading carcinoma of the papilla of Vater such as is reported here is a rare disease.