Ⅱc型微小早期胃癌と接吻潰瘍の合併症例

A Case of Minute Ⅱc Type Early Cancer of the Stomach Associated with Kissing Ulcers

　胃疾患診断学の進歩は漸次，微細な病変へと目を向けさせ，胃癌についていえば，癌巣の拡がり，深達度ともに極めて軽微な微小癌と称されるものが臨床診断の対象となるに至った．しかし，微小胃癌の診断には従来の早期胃癌の診断の要点をそのままあてはめることが無理な例が多く，未解決の課題は多い．

　筆者らは，胃体部に良性の接吻潰瘍を合併した，角上部前壁の微小胃癌（4×5mm）を経験したので，臨床診断の要点に若干の考察を加えて報告する．

　A man 58 years of age visited our hospital complainng of unpleasant sensation in the epigastrium along with loss of appetite. In the course of treatment for kissing ulcers found in the gastric body, a minute Ⅱc type cancer was detected on the anterior wall of the angle region. The clue that led us to examine the stomach in great detail was a slight stricture of the lesser curvature above the angle as revealed by a barium-filled picture. In double contrast study the tiny Ⅱ c lesion was seen as a thin barium fleck with spots of denser shadow among it. On the greater curvature side the margin of the thin barium fleck was accompanied with a shadow suggestive of a small elevation bordered by sulcus-like shadows. On the distal side was seen sharply outlined rugal convergency.

　By x-ray alone it was hard to tell whether or not it was Ⅱc or ulcer scar. The utmost we could do then was to suspect Ⅱc. Endoscopy too did not reveal any finding suggestive of malignancy. It was biopsy that clinched the qualitative diagnosis: In two of three specimens was adenocarinama revealed.

　Even macroscopically the resected stomach hardly displayed any chang that suggested cancer. It was only after histologic study of serial sections of the specimens that we were able to further confirm the diagnosis. It was adenocarcinoma tubulare, CAT 2, SAT 2, m, with a size of 4×5 mm, located on the margins of the central portion of an ulcer scar.

　The positive rate of accurate diagnosis for minute cancer achieved by x-ray is said to be 23.0 per cent, by endoscopy 29.1 per cent, and when both are coemployed it is held to be 39.3 per cent. Biopsy shows the poorest results: it is no more than 7.6 per cent. Altogether diagnosis of minuie carcinoma is hard to make accurately. In view of slight constriction on the lesser curvature above the angle in the present case that resulted in preoperative diagnosis by x-ray and endoscopy, careful evaluation even of a slightest change seems essential for the diagnosis of minute cancer. Also indispensable are appropriate various combinations of various examination procedures.

　Kissing ulcers in the body proved to be of benign nature and was almost in scarring stage. Both lesions on each side of the wall were diagnosed as Ul-Ⅲ ulcer.