Journal Article 葉間進展形態を呈し緩徐に進行した原発性肺腺癌の1切除例
A Surgical Case of Pulmonary Adenocarcinoma with Slow Interlobular Progression

加藤, 陽介  ,  松本, 勲  ,  吉田, 周平  ,  竹村, 博文  ,  笠原, 寿郎  ,  西川, 晋吾

56 ( 5 )  , pp.368 - 372 , 2016-11-01 , 日本肺癌学会 = The Japan Lung Cancer Society
Background. Primary lung cancers commonly invade the lung parenchyma and, on reaching the visceral pleura, cause pleural dissemination. We herein report a surgical case of primary lung cancer which showed a unique growth pattern of spreading predominantly within the interlobular pleura. Case. A 65-year-old male patient was referred to our department because of an abnormal shadow in the right middle lung field detected on chest X-ray film during the follow-up period of angina. Contrast-enhanced computed tomography revealed slightly enhanced nodule shadows with a beaded appearance in the right minor and major fissures. During the observation period, the size of this abnormal shadow increased slowly with no evidence of lymph node enlargement or distant metastasis. Therefore, the patient underwent surgical resection (right upper and middle lobectomy with partial resection of the right lower lobe) for diagnostic and therapeutic purposes, and lymph node dissection was performed. On a histopathological examination, the tumor was found to be located only partly within the lung parenchyma of the upper lobe but predominantly within the interlobular pleura. The tumor cells were arranged in a tubular or papillary pattern, and immunohistochemical examinations revealed the tumor cells to be positive for TTF-1 and SP-A, leading to a diagnosis of primary pulmonary adenocarcinoma (pT3N0M0). In addition, EML4-ALK translocation was positive, whereas EGFR mutation was negative. The patient received adjuvant chemotherapy with the oral administration of UFT for two years after surgery with no evidence of recurrence. Conclusion. The invasive growth of primary lung cancer within the interlobular pleura is a rare form of progression. In our present case, it was difficult to distinguish between primary lung cancer and other lesions of pleural origin. 背景.原発性肺癌は一般に肺実質内を進展し,胸膜に浸潤した場合,胸膜播種を起こすことが多い.今回我々は,主に葉間胸膜内を進展する,特異な発育形式を示した原発性肺腺癌の1切除例を経験したので報告する.症例.65歳男性.狭心症の経過観察中に右中肺野の異常陰影を指摘され,当院紹介となった.造影CT検査にて右小葉間裂,大葉間裂に淡い造影効果を伴う連珠状の腫瘤影を認めた.経過で緩徐な増大を示しており,診断および治療目的に切除の方針とした.手術は,右肺上中葉切除および下葉部分切除にND2a-1リンパ節郭清を追加した.病理組織学的に,腫瘍は主に葉間胸膜内に存在していたが,部分的に上葉肺実質内にも分布していた.腫瘍細胞は管腔状や乳頭状に増生しており,免疫染色にてTTF-1陽性,SP-A陽性であったため原発性肺腺癌(pT3N0M0)と診断した.また,EGFR変異陰性,EML4-ALK転座陽性であった.補助化学療法としてUFT内服を継続中であり,術後2年経過し再発を認めていない.結論.原発性肺癌が胸膜内進展形態をとることは稀であり,本症例においては胸膜由来病変との鑑別が困難であった.
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