Suenaga Mitsukuni, Ohta Kei-ichiro, Toguchi Masataka, Sato Takahiro, Ohyama Shigekazu, Yamaguchi Toshiharu, Muto Tetsuichiro, Yanagisawa Akio, Kato Yo
Division of Gastroenterological Surgery, Cancer Institute Hospital, Tokyo, Japan.
Gastric Cancer. 2003;6(4):270-6. doi: 10.1007/s10120-003-0260-5.
A 73-year-old man presented with an abnormal gastric shadow during a check-up of atomic bomb survivors. Radiological examination and endoscopy of the upper gastrointestinal tract revealed a protruding tumor, type 0-I+IIa, on the lesser curvature of the midstomach. An initial diagnosis of early gastric cancer was made and a segmental gastrectomy was planned. However, distal gastrectomy with D3 lymph node dissection was necessary, because intraoperative frozen section showed that the paraaortic lymph nodes (N3) were positive for cancer. The tumor in the resected specimen was, microscopically, a well-differentiated tubular adenocarcinoma (tub1) with pT2 (MP), pN3, ly2, and v1, in final (f) stage IV. The tumor cells of the type 0-I segment appeared as gastric phenotype and those of the type 0-IIa segment as intestinal phenotype. The border between the two was distinct. The tumor had focally invaded the muscularis propria where only the gastric phenotype was shown and the histological type became less differentiated. Thus, special attention should be paid to possible unexpected deep-wall invasion and lymph node metastasis in well-differentiated adenocarcinomas of the gastric phenotype. Further, in this patient, diffusely proliferating low-grade lymphoma was also observed incidentally in the gastric mucosa within and around the carcinoma. This was diagnosed as mucosa-associated lymphoid tissue (MALT)-type lymphoma with aberrant expression of BCL10. Finally, this case was considered to be a colliding gastric and intestinal phenotype well-differentiated adenocarcinoma of the stomach developed in an area involved by MALT-type lymphoma. Because no Helicobacter pylori was detected throughout the mucosae and the patient had no history of its infection, the three tumors may have developed under the same conditions as those seen in Helicobacter pylori infection, but without this infection.
一名73岁男性在原子弹爆炸幸存者体检时发现胃影像异常。上消化道的放射学检查和内镜检查显示胃中部小弯侧有一突出肿瘤，0-I+IIa型。初步诊断为早期胃癌并计划行胃部分切除术。然而，由于术中冰冻切片显示主动脉旁淋巴结（N3）癌转移阳性，故需行D3淋巴结清扫的远端胃切除术。切除标本中的肿瘤，显微镜下为高分化管状腺癌（tub1），pT2（MP），pN3，ly2，v1，最终（f）分期为IV期。0-I型节段的肿瘤细胞呈胃型表型，0-IIa型节段的呈肠型表型。两者之间的边界清晰。肿瘤局部侵犯固有肌层，此处仅显示胃型表型，组织学类型分化程度降低。因此，对于胃型高分化腺癌，应特别注意可能出现的意外深壁侵犯和淋巴结转移。此外，在该患者中，还偶然在癌内及癌周的胃黏膜中观察到弥漫性增生的低级别淋巴瘤。这被诊断为伴有BCL10异常表达的黏膜相关淋巴组织（MALT）型淋巴瘤。最后，该病例被认为是在MALT型淋巴瘤累及区域发生的胃和肠型碰撞的高分化胃腺癌。由于整个黏膜均未检测到幽门螺杆菌，且患者无幽门螺杆菌感染史，这三种肿瘤可能在与幽门螺杆菌感染相同的条件下发生，但无该感染。
