Vol.35(6),Jun.1993 症例 村 田裕彦 1365 ほか Figure 1 Initial barium enema shows flat-elevated lesion with smooth surface on Sep. 10, 1990 (left) Tumor had enl
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1 Gastroenterol Endosc 1993 ; 35 : Yuhiko MURATA A case Primary Malignant Lymphoma Presenting Rapid Morphological Changes in a Relatively Short Period
2 Vol.35(6),Jun.1993 症例 村 田裕彦 1365 ほか Figure 1 Initial barium enema shows flat-elevated lesion with smooth surface on Sep. 10, 1990 (left) Tumor had enlarged and become lobular surface on Jan. 29, (right) Figure 4 Microscopic section the partially diffuse lymphoid the adventitia. view lymphoid Gastroenterological Endoscopy cells shows picture tumor shows infiltration from the (top, infiltration cells. (bottom, H. cross- follicular and mucosa to E.) High-power medium-sized H. E. ~ the beyond 100)
3 1366 症例 Figure 5 positive Table 1 Results Immunostaining for CD 20 (B immunostaining frozen 村田裕彦 1) and frozen sections monoclonal ほか shows Vol.35(6),Jun.1993 most proliferation sections. lymphoid IgM あ り,Naqvi分 lambda cells to be. ( ~ 100) 類StageIで あ った. 術 後 経 過:切 除 断 端 陽 性 が 強 く疑 わ れ た た め 術 後 COP+Epirubicin療 部 照 射(40Gy)を 法(CHOPに 準 ず)Gク ール,骨 盤 行 っ た.術 後 に行 った骨 髄 生 検,Gaシ ンチ で は異 常 な く術 後1年8カ 月 の現 在再 発 の徴 候 な く 健 在 で あ る, Ⅲ考 按 消化 管 原発 の悪性 リンパ 腫 の診 断 基準 とし てDawson ら は,1)表 在 リンパ 節 の 腫大 を認 め な い,2)胸 線撮 影 で縦 隔 リンパ節 の腫 大 を認 め な い,3)末 血球 数,分 類 に異常 が無 い,4)消 リ ン パ 節 郭 清 お よ びS状 切 除 標 本:腫 結腸 人 工肛 門造 設術 施 行. 瘍 は 径31 26mmで 状 の 隆 起 性 病 変 で,小 表面は小結節分葉 潰 瘍 を 伴 う.潰 腸 粘 膜 に 覆 わ れ て い た(Figure3カ 病 理 組 織 学 的 所 見:HE染 てsmall cleaved ラ ー 附 図). 色 で は 粘 膜 か ら外 膜 に か け cellが 濾 胞 を 形 成 し浸 潤 増 殖 し て い る. 周 囲 に は 正 常 リ ン パ 濾 胞 の 残 存,形 (Figure4).新 1)の 瘍 部 以 外 は正 常 直 質 細 胞 の浸 潤 伴 う 鮮 凍 結 標 本 で の 免 疫 染 色 で は表(Table ご と く で あ り,IgM,λ-chainが で,follicular type(lsg分 陽 性(Figure5) lymphoma,medium-sized 類)と る とPO,HO,M(-),深 診 断 さ れ た.大 cell,,b-cell 腸 癌 取 扱規 約 に準 ず 達 度a2,INFβ,1yo,v2,ow (-),aw(-),ew(+),n(-),stageⅢ,r2,non-curaで 部X 梢血白 化 管 病 変 が主 体 で あ り所 属 リンパ 節 の み に転移 が見 られ る,5)肝,脾 に腫 瘍 を認 め な い,以 上5項 目 を あげ て い る.自 験 例 は これ らを満 た してお り,さ らに骨 髄 生検,Gaシ ン チに 異常 所 見 な く直 腸 原 発悪 性 リンパ 腫 と診断 した. 大腸 悪 性 腫瘍 にお け る悪 性 リンパ 腫 の頻 度 は極 め て低 くJinnaiら に よる と本邦 で は19.850例 の癌 に対 して悪 性 リ ンパ 腫130例(0.65%),Perryら は直 腸 癌2,940例 に対 して悪性 リンパ腫7例(0.2%)で あ った と報 告 して い る.大 腸 で の 発 生 部 位 別 頻 度 は 回 盲 部 が 最 も多 く 71.5%,次 い で直 腸16.9%,上 行結 腸6.2%の 順 で,盲 腸 に高 頻 度 に発 生 す るの は リンパ組 織 が よ く発 達 して い るた めで あ り,ま た直 腸 は腸 内容 が貯 留 す る部 位 で あ る ことが 好 発の 一 因 にな ってい るので は と考 えられている. Gastroenterological Endoscopy
4 Table 2 Reported cases primary malignant lymphoma the rectum in Japan. ( )?;not described, ML;malignant lymphoma, ML?;ML suspected, JP;juvenile polyp, SMT;submucosal tumor, CA;carcinoma, LH;lymphoid hyperplasia, MLe;malignant lesion, P;protruded type, U;ulcerative type, D;diffusely infiltrating type, DL;diffuse large cell, DM;diffuse medium-sized cell, DS;diffuse small cell, DMx;diffuse mixed, FL;follicular large cell, FM;follicular medium-sized cell, FW;follicular well diff erenciated, LI;large cell immunoblastic, ILL;intermediate lymphocytic lymphoma, B;B cell type. Gastroenterological Endoscopy
5 1. Dawson IMP, Comes JS, Morson BC. Primary malignant lymphoid tumours the intestinal tract. Br J Surg 1961; 49 : Jinnai D, Iwasa Z. Watanuki T. Malignant lymphoma the large intestine : Operative results in Japan. Jpn J Surg 1983 ;13 : Perry PM, Gross RM, Morson BC. Primary Malignant lymphoma the rectum. Proc. R. Soc. Med. 1972: 65 : 72.
6 13. Kim TH. Michel RP, Melnychuk D, Freeman CR. Non-Hodgkin's lymphoma in Couples. Cancer 1982 ; Hirakata K, Nakata H, Kajiwara Y, Kuroda Y. Primary malignant lymphoma the rectum. Pediatr Radiol 1989 :19 : HTLV- TŠ õ Ç Ì a Ô Æ ušw.ˆãšw Ì ä Ý 1987:142: Figure 2-a Initial endoscopic view shows a flat elevated varices-like submucosal tumor which rise up smoothly from the surrounding mucosa without redness, discoloration or erosion on Oct. 2, Figure 2-b An elevated lesion with reddish erosion surrounded by normal mucosa is seen on Jan. 17, Biopsy was negative. Figure 2-c Tumor has enlarged and shows lobular surface. Reddish erosion has reduced on Feb. 2, Figure 2-d Tumor has protruded sharply from surrounding mucosa further more with central ulcer is seen on Feb. 8, Figure 3 Surgical specimen shows lobular protrudent tumor with small central ulcer in the lower rectum measuring 31 ~ 26mm in size.,
7 A CASE OF PRIMARY MALIGNANT LYMPHOMA PRESENTING RAPID MORPHOLOGICAL CHANGES IN A RELATIVELY SHORT PERIOD Yuhiko MURATA, Takasi WATANABE, Noriaki TAMURA, AND Osamu KIMURA *Department Surgery, Saihaku Hospital. **Department Internal Medicine, Saihaku Hospital. ** The First Department Surgery, Tottori University School Medicine. A rare case primary malignant lymphoma the rectum presenting rapid morphological changes observed by sequential endoscopic studies is reported. A 46-year-old female complaining vague epigastric pain was diagnosed as having a rectal flat-elevated varices-like submucosal tumor and seropositive for HTLV-1 antibody. Approximately 3 months after the initial endoscopy, she complained bloody stools. The second endoscopy showed the lesion seen previously growing to a protruded tumor with reddish erosion. Biopsy was negative for malignancy. Two weeks later, the third endoscopy showed a loburated enlarged tumor. Biopsy revealed malignant lymphoma. One more week later, the forth endoscopy showed the lesion protruded more sharply from the surrounding mucosa with a central ulcer. Abdominoperineal excision the rectum with R2 lymph node dissection was performed on Feb. 15, Surgical specimens showed a lobular protuberant submucosal tumor. Histopathological study showed a follicular lymphoma, medium-sized cell type accoording to LSG classification. Immunostaining the frozen sections showed positive for B-cell markers and producing monoclonal IgM lambda-chain. Involvement the regional lymph nodes and distant metastasis were not identified. Postoperative chemotherapy and irradiation for the involved field were done for suspicion residual tumor cells at the surgical stump. The patient is well free from disease for 20 months after surgery. With regard to family history, her husband and mother-in-law with whom she had been live for nearly 20 years also died malignant lymphoma the stomach and tonsil, respectively. The familial clustering this disease and seropositiveness HTLV-1 antibody suggests an infectious agent and/or environmental factor may play a role in the etiology malignant lymphoma. Gastroenterological Endoscopy
8 Yukiya Hakozakiほ か 論 文 附 図 本 文 掲 載 頁:p, Figure-1 Yuhika Murataほ Figure-2 か 論 文 附 図 本 文 掲 載 頁:p Figure-2 Figure -3 Figure-4
401 Table 1 Laboratory data on admission 2 Abdominai CTscan reveals a large SMAG shows no nor tumor stain. abnormal vessels solid 3 mass. 注 腸X線 所 見(4):横 行結 腸 に,管 腔 を ほ とん ど占 め る腫 瘤 に よ る と思 わ れ る陰 影 欠
Summary We reported a 75-year-old male patient, who had a large tumor mass, about 5 x 7 x 4 cm, on the left lower eyelid. Histopatholgically, this was
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Gastroenterol Endosc 1997 ; 39 : 2272-78. Toru HIYAMA A Case of Primary Gastric T-cell Malignant Lymphoma. 2274 ガド伊1 日li亨 ほ カ πol.39(11i,n{ v.1997 ab Figure2a,blEndoscopicfindingof1.hestomachshowsanirregu且arexcavatedlesionwith
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