経十二指腸的乳頭切除術後に再発した早期乳頭部腺癌の1例  [in Japanese] Recurrence of early carcinoma in the ampulla of Vater after transduodenal ampullectomy: a case report  [in Japanese]

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Author(s)

    • 安次富 裕哉 Ashitomi Yuya
    • 山形大学医学部外科学第一講座(消化器・乳腺甲状腺・一般外科学分野) First Department of Surgery (Department of Gastroenterological, Breast, Thyroid and General Surgery), Yamagata University Faculty of Medicine
    • 木村 理 Kimura Wataru
    • 山形大学医学部外科学第一講座(消化器・乳腺甲状腺・一般外科学分野) First Department of Surgery (Department of Gastroenterological, Breast, Thyroid and General Surgery), Yamagata University Faculty of Medicine
    • 平井 一郎 Hirai Ichiro
    • 山形大学医学部外科学第一講座(消化器・乳腺甲状腺・一般外科学分野) First Department of Surgery (Department of Gastroenterological, Breast, Thyroid and General Surgery), Yamagata University Faculty of Medicine
    • 渡邊 利広 Watanabe Toshihiro
    • 山形大学医学部外科学第一講座(消化器・乳腺甲状腺・一般外科学分野) First Department of Surgery (Department of Gastroenterological, Breast, Thyroid and General Surgery), Yamagata University Faculty of Medicine
    • 手塚 康二 Tezuka Koji
    • 山形大学医学部外科学第一講座(消化器・乳腺甲状腺・一般外科学分野) First Department of Surgery (Department of Gastroenterological, Breast, Thyroid and General Surgery), Yamagata University Faculty of Medicine
    • 菅原 秀一郎 Sugawara Shuichiro
    • 山形大学医学部外科学第一講座(消化器・乳腺甲状腺・一般外科学分野) First Department of Surgery (Department of Gastroenterological, Breast, Thyroid and General Surgery), Yamagata University Faculty of Medicine
    • 岡崎 慎史 Okazaki Shinji
    • 山形大学医学部外科学第一講座(消化器・乳腺甲状腺・一般外科学分野) First Department of Surgery (Department of Gastroenterological, Breast, Thyroid and General Surgery), Yamagata University Faculty of Medicine

Abstract

80歳女性.他疾患の経過観察CTで総胆管の拡張を指摘された.上部消化管内視鏡検査で十二指腸乳頭部に径約3 cmの腫瘍を認め,生検で腺癌と診断された.高齢なことやEUSやIDUSから腺腫内癌が示唆されたことから経十二指腸的乳頭切除術を施行した.病理組織学的にはadenocarcinoma(tub1~tub2)in tubulovillous adenomaで早期乳頭部癌であったが,一部Oddi筋への浸潤が認められた.断端は十分に確保されており,pEM0の切除であった.退院後外来で経過観察していたが,術後3年目に膵頭部背側,大動脈周囲,上縦隔に多発リンパ節転移をきたし,術後4年目に死亡した.十二指腸乳頭部の早期癌に対しては縮小手術も考慮されるが,今回の症例では術後病理検査でOddi筋浸潤を認めており,早期癌と考えられた症例でも縮小手術の適応は慎重に判断する必要があると考えられた.

Dilation of the common bile duct was detected by computed tomography (CT) scan in an 80-year-old woman. Upper gastrointestinal endoscopy revealed a tumor of 3 cm in diameter in the papilla of Vater, and a carcinoma was proven by tumor biopsy. Transduodenal ampullectomy was performed, considering the patient's age and the clinical findings for suspecting early carcinoma. Histopathological examination demonstrated adenocarcinoma (tub1- tub2) in tubulovillous adenoma, with partial invasion into Oddi's muscle. Follow-up CT 3 years after surgery showed recurrence in the lymph nodes at the head of the pancreas, and also the para-aortic and upper mediastinal nodes. The patient died four years after initial surgery. Pancreatoduodenectomy is a standard operation for early stage carcinoma of the ampulla of Vater; however, according to clinical practice guidelines for the management of biliary tract and ampullary tumors, limited resection can be considered for intramucosal carcinoma. However, accurate preoperative diagnosis of intramucosal carcinoma is usually difficult and in our case, the tumor invasion to the Oddi's muscle was detected by postoperative histological examination. Therefore, the indication of limited resection should be strictly judged.

Journal

  • Tando

    Tando 29(2), 279-284, 2015

    Japan Biliary Association

Codes

  • NII Article ID (NAID)
    130005078010
  • Text Lang
    JPN
  • ISSN
    0914-0077
  • Data Source
    J-STAGE 
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