菅野 敦

胆嚢は壁構造の特異性から，癌が周囲臓器に浸潤しやすい．胆嚢癌の予後は，胆嚢周囲進展度とリンパ節転移に規定される．腹部超音波や超音波内視鏡は，胆嚢内腔を詳細に観察することが可能であり，胆嚢癌の壁深達度診断に有用である．ERCPは，肝十二指腸間膜浸潤の診断や胆汁細胞診に有用である．CTは，客観性のある画像を得ることができるため，胆嚢癌の進行度診断には必須である．MRIは拡散強調画像や肝細胞特異的造影剤の開発から，その有用性が増している．FDG-PETはリンパ節転移など遠隔転移の診断に有用である．各々の画像診断の特徴を理解し，組み合わせて総合的に胆嚢癌の進行度を診断することが重要である．<br>

A 50-year-old woman had undergone left nephrectomy for renal cell carcinoma 13 years previously. Ten years later, a solitary metastatic tumor had been detected in the pancreatic tail and she had undergone subsequent resection of the pancreatic tail and spleen. Three years after surgery, she was admitted to our hospital for severe anemia resulting from gastrointestinal tract bleeding. Esophagogastroduodenoscopy revealed a 3-cm solid tumor at the oral side of the papilla of Vater. Histology of the bioptic duodenal tissue revealed inflammatory granulation without malignancy. Computed tomography showed a well-contrasted hypervascular tumor in the descending portion of the duodenum. We diagnosed the patient with metachronous duodenal metastasis of renal cell carcinoma and performed a pancreaticoduodenectomy. An ulcerated polypoid mass was detected at the oral side of the papilla of Vater. Histology revealed clear cell carcinoma coated by granulation tissue across the surface of the tumor. Immunohistology demonstrated that the cells were positive for vimentin, CD10 and epithelial membrane antigen and negative for CK7. After a repeated pancreatectomy, the patient had no symptoms of gastrointestinal bleeding and maintained good glucose tolerance without insulin therapy because the remnant pancreas functioned well. In conclusion, for the diagnosis of patients who have previously undergone nephrectomy and present with gastrointestinal bleeding, the possibility of metastasis to the gastrointestinal tract, including the duodenum, should be considered. With respect to surgical treatment, the pancreas should be minimally resected to maintain a free surgical margin during the first surgery taking into account further metachronous metastasis to the duodenum and pancreas.

症例は40代，女性．幼少期にNeurofibromatosis type I（NF1）と診断された．貧血，黒色便にて他院を受診した．カプセル内視鏡にて小腸出血と診断され当院紹介となった．腹部造影CT検査では，多発する腫瘤を空腸および膵頭部近傍に認め，EUS-FNAにて多発消化管GISTと診断し，膵頭十二指腸切除術，小腸部分切除術を行った．文献的検討によると，NF1関連性GISTは散発性GISTとは異なる臨床的特徴を有し診療上注意を要すると考えられた．<br>