術後13年で残胃に再発をみた膠様腺癌の1例

Mucinous Adenocarcinoma of the Remnant Stomach Relapsing 13 Years after Subtotal Gastrectomy, Report of a Case

要旨　患者は70歳，男性．13年前にBorrmann3型胃癌で胃亜全摘術(Billroth Ⅰ法)を受けており，腹痛，嘔吐を主訴に近医を受診，当院を紹介された．上部消化管X線検査では残胃の中央に淡いバリウム斑を伴う境界が比較的明瞭な隆起性病変と，十二指腸側の圧迫像で吻合部に接して中央に淡いバリウム斑を伴う境界明瞭な隆起性病変を認めた．胃内視鏡検査で残胃吻合部小彎線に黄白色の白苔に覆われた不整陥凹を伴う境界明瞭な隆起性病変と，それと連続するように十二指腸側に周囲の隆起した不整陥凹を認めた．胃側も十二指腸側も生検で中分化型腺癌を認め，残胃の亜全摘を施行した．切除胃固定標本では吻合部小彎線にまたがる隆起性病変を認め，多くは正常粘膜に覆われているが，吻合部を挟んで胃側に7×7mm，十二指腸側に10×3mmの不整形の陥凹を認めた．病理組織学的には潰瘍周辺で中分化型腺癌を認めたが，粘膜下の腫瘍組織のほとんどが初回手術時同様，膠様腺癌の像を呈していた．本症例では結合織の増生の少ない膠様腺癌のため興味ある表面形態をとり，悪性リンパ腫との鑑別が困難であった．進行胃癌切除後13年を経て吻合部に再発した胃膠様腺癌の1例を報告した．

　A 70-year-old man who had undergone subtotal gastrectomy (Billroth Ⅰ) because of advanced gastric carcinoma of Borrmann 3 type 13 years ago visited a practitioner with chief complaints of abdominal pain and vomiting. He was referred to our hospital. Double contrast picture in the left anterior oblique position showed a sharply demarcated nodular tumor with a barium fleck on the lesser curvature of the remnant stomach. Prone compression film of the duodenum revealed a clearly demarcated nodular tumor with an irregularshaped barium fleck adjacent to the anastomosis. Gastroscopy revealed a sharply demarcated nodular tumor with irregular dents coated with yellow-whitish fur on the lesser curvature of the remnant stomach and a nodular tumor with irregular dents on the duodenum adjacent to the remnant stomach. Both biopsy specimens from the gastric remnant and the duodenum showed moderately differentiated tubular adenocarcinoma. And subtotal remnant gastrectomy was carried out. Resected specimen of the remnant stomach, after fixation, showed a nodular tumor with an irregular dent, 7 × 7 mm in size, overlying the lesser curvature of the anastomosis and another irregular dent, 10 × 3 mm in size, in the duodenal side. These were mostly coated with normal mucosa. Pathohistological examination revealed moderately differentiated tubular adenocarcinoma in the circumference of the ulcer and mucinous adenocarcinoma in the submucosa as observed at the initial operation. In this case, an interesting surface morphology was created by mucinous adenocarcinoma with minimal hyperplasia of the connective tissue. This in turn made it difficult to be differentiated from malignant lymphoma. Finally we reported a case of mucinous adenocarcinoma which relapsed at the anastomosis 13 years after gastrectomy because of advanced carcinoma.